Breaking barriers: Exploring the Full Cup Test (FCT) pain scale at a tertiary care hospital.

Background and Objective: Pain assessment plays a vital role in the management of patients across various healthcare settings. Accurate and reliable pain evaluation tools are essential for effective pain management and improving patient outcomes. The objective of this study was to assess ease of Full Cup Test (FCT) as a pain scale and to compare use of FCT with Visual Analogue Scale (VAS) for pain evaluation. Methods: A cross-sectional study carried out at a tertiary care hospital from December 2021 to July 2022 on individuals with pain at various body locations. Pain severity was evaluated using two pain assessment tools, the FCT and the VAS. The main objectives of the study were to assess correlation and agreement between the FCT and VAS; using Kappa statistics. Results: Of the total 288 subjects, median age was 42.5 years (IQR: 13-78), and median duration of pain was four months (IQR: one day to forty years). Analysis revealed significant positive correlation (r=0.577) between the Full Cup Test (FCT) and the Visual Analog Scale (VAS), indicating a relationship between both pain assessment tools. Significant agreement was also observed between FCT and VAS, with a kappa value of 0.596 (p<0.0001). Results however indicated that illiterate patients found it easier to understand FCT compared to VAS. Conclusion: The Full Cup Test (FCT) emerged as a potentially valuable tool for assessing pain severity in a diverse range of patients. Regardless of age, gender, education level, and ethnicity, FCT demonstrated utility with ease in detecting pain severity.

"Underneath the visible" - COVID-19 Risk prediction tools in a high-volume, low-resource Emergency Department.

Objectives: Patient risk stratification is the cornerstone of COVID-19 disease management; that has impacted health systems globally. We evaluated the performance of the Brescia-COVID Respiratory Severity Scale (BCRSS), CALL (Co-morbid, age, Lymphocyte and Lactate dehydrogenase) Score, and World Health Organization (WHO) guidelines in Emergency department (ED) on arrival, as predictors of outcomes; Intensive care unit (ICU) admission and in-hospital mortality. Methods: A two-month retrospective chart review of 88 adult patients with confirmed COVID-19 pneumonia; requiring emergency management was conducted at ED, Indus Hospital and Health Network (IHHN), Karachi, Pakistan, (April 1 to May 31, 2020). The sensitivity, specificity, receiver operator characteristic curve (ROC) and area under the curve (AUC) for the scores were obtained to assess their predictive capability for outcomes. Results: The in-hospital mortality rate was 48.9 % with 59.1 % ICU admissions and with a mean age at presentation of 56 ± 13 years. Receiver operator curve for BCRSS depicted good predicting capability for in hospital mortality [AUC 0.81(95% CI 0.71-0.91)] and ICU admission [AUC 0.73(95%CI 0.62-0.83)] amongst all models of risk assessment. Conclusion: BCRSS depicted better prediction of in-hospital mortality and ICU admission. Prospective studies using this tool are needed to assess its utility in predicting high-risk patients and guide treatment escalation in LMIC's.

Combining Non-invasive Ventilation with timed position change in the Emergency Department to improve oxygenation and outcomes in patients with COVID-19: A prospective analysis from a low resource setup.

Background: Moving away from invasive ventilation towards timed position change and non-invasive ventilation is especially of benefit in low and middle income countries, where judicious use of the available healthcare resources is the need of the day. Our study was conducted prospectively to develop strategies for non-invasive ventilation in combination with timed position change of patients to see its impact on their outcome. Objectives: Non-invasive ventilation has proven to be of benefit in COVID-19 related acute lung injury. The objective of this prospective, cross sectional study was to develop a protocol for the use of non-invasive ventilation with timed position change to improve COVID-19 patients' outcomes in the Emergency Department (ED). Methods: All patients presenting with confirmed or suspected COVID-19 were enrolled in the study from March 2020 to October 2020. Data was collected to see the effect of timed position change and non-invasive ventilation on these patients and its effect on delaying or avoiding invasive ventilation. Results: Of the 207 COVID-19 patients presenting to the IHHN ED, 109(52.7%) had oxygen saturation in the nineties in supine position followed by right lateral in 37(17.9%), sitting up in 30(14.5%), left lateral in 29(14%) and prone position in 2(1%). Maximal oxygenation was achieved with non rebreather mask (NRM) and nasal prongs in 87(42%) of the patients, followed by the use of continuous positive airway pressure (CPAP) in 29(14%). Conclusion: Most of the patients preferred to stay in the supine position and described it as the position of comfort. When used in combination supine position, patients on NRM with nasal prongs and on CPAP, had oxygen saturation in the nineties. Central obesity was found to be the prime reason for the inability to prone our patients. This needs to be followed up in the current fourth wave of COVID-19 to see the effectiveness of the said modalities.

Epidemiology of in-hospital cardiac arrest in a Pakistani tertiary care hospital pre- and during COVID-19 pandemic.

Objectives: To determine epidemiology of in-hospital cardiac arrest (IHCA) in a tertiary care hospital, pre- and during pandemic. Methods: This is a cross-sectional study of inpatients who experienced an in-hospital-cardiac arrest at a tertiary care hospital in Karachi between August 2019 and August 2020. Outcome variables were return of spontaneous circulation (ROSC) and survival to discharge (StD) and analysis was also done comparing pre- and during pandemic period. Results: A total of 77 patients experienced at least one IHCA event during the 1-year study period. Comparing pre- and during pandemic, ROSC for women was higher during the pandemic albeit not significant (43% vs 50%) in comparison to men (54% vs 10%, p<0.001). During the pandemic, women with IHCA were significantly younger than men (µ ± sd; 36.8 ± 15.3 vs 55.9 ± 12.7, p=0.001,) whereas pre-pandemic, there was no gender differences in mean age. Non-shockable rhythm was more common (92.2%) than shockable rhythm (6.5%). Pre- and during pandemic, there were significant differences in the cause of IHCA for 4H4T (87% vs 100%) and cardiac (36% vs 9%). The proportion of hypoxic patients increased from 50% during pre-pandemic to 91% during the pandemic period, whereas hypo/hyperkalemia decreased from 53% to 34%. Conclusion: Despite the limitation of a small sample size, our study has provided important information regarding the epidemiology and outcomes of IHCA pre- and during pandemic in a busy Pakistani tertiary care hospital. Our finding that gender differences exist in survival pre- and during pandemic needs to be explored further with more hospitals doing comparative studies.

Clinical spectrum and outcomes of patients with different resistance patterns of Salmonella enterica.

Background and Objective: Unceasing rise in cases of enteric fever, in particular extensively drug resistant (XDR) strain of Salmonella enterica, has led to a growing threat, leaving only carbapenems and azithromycin as the precious option. In this regard, we determined the burden and clinical course of XDR salmonella in comparison to multidrug-resistant (MDR) and drug sensitive (DS) strains. Methods: A retrospective chart review of 1515 Salmonella Typhi (S.typhi) culture positive patients was conducted at Indus Hospital and Health Network, Karachi from July 2017 to December 2018. Results: During our study, we observed children at the age of 5-6 years and adults at the age of 20-22 years were the chief targets of S.typhi. Further, we witnessed a rapid shift of drug resistance from MDR to XDR over the one year of study. Almost all patients presented with fever. However other signs and symptoms like malaise, body aches, anorexia, diarrhea, vomiting and abdominal pain were more common in XDR Typhoid patients. Further, the need of hospitalization, total hospital stay and mortality was also greater for XDR typhoid patients. Conclusion: There is a crucial requirement for consolidated steps to curtail the spread of XDR Salmonella tyhi disease as its management is challenging, and it is associated with increased morbidity and mortality.

Patient perception regarding privacy and confidentiality: A study from the emergency department of a tertiary care hospital in Karachi, Pakistan.

Background and Objective: Maintaining privacy and ensuring confidentiality with patients is paramount to developing an effective patient-provider relationship. This is often challenging in over-crowded Emergency Departments (EDs). This survey was designed to explore patients' perceptions on maintenance of privacy and confidentiality and their subsequent interactions with providers in a busy tertiary care hospital in Karachi. Methods: Trained nursing staff conducted structured interviews with 571 patients who presented to The Indus Hospital (TIH) ED from January to December 2020. All patients were 14 years of age or older, could speak and understand Urdu, and provide informed consent. Patients were asked about their perceptions of privacy and confidentiality in the ED and whether this affected their interactions with providers. Results: Respondents were primarily men (64%) under the age of 45 (62%) presenting for the first time (49%). The majority of patients felt that privacy and confidentiality were maintained, however 10% of patients reported that they had rejected examination due to privacy concerns and 15% of patients reported that they had changed or omitted information provided to a provider due to confidentiality concerns. There was correlation between privacy and confidentiality concerns and patient-provider interactions (p<0.0001). Conclusions: Despite the often over-crowded and busy environment of the ED, patients generally felt that privacy and confidentiality were maintained. Given the correlation between perception and behavior and the importance of an effective patient-provider relationship, particularly in the acute setting when morbidity and mortality is high, initiatives that focus on maintaining privacy and confidentiality should be pursued.

A review of clinical profile, complications and antibiotic susceptibility pattern of extensively drug-resistant (XDR) Salmonella Typhi isolates in children in Karachi.

BACKGROUND: Enteric fever is a systemic infection caused by Salmonella enterica serovar Typhi and Salmonella enterica serovar Paratyphi A, B, and C. There is an emergence of Typhoid fever caused by extensively drug-resistant Salmonella Typhi strain called XDR S.Typhi. This strain is resistant to recommended first-line antibiotics and cephalosporins. WHO estimated 5274 cases of XDR S.Typhi in Karachi from November 2016 to December 2019. This study aims to determine clinical course, complications and response to treatment of XDR S.Typhi among the pediatric population coming to Indus Hospital. METHOD: We reviewed the records of children who had culture-proven XDR S.Typhi infection at Indus Hospital from July 2017 to December 2018. A pre-designed data abstraction form was used to record information about seasonality, demographic details, clinical features and course, treatment, complications and outcomes of the cases of XDR S.Typhi. RESULTS: The records of 680 children were reviewed. The median (IQR) age of the patients was 5 (2-8) years. More than half (n = 391, 57.5%) of the patients were males. The outcomes were recorded in 270 (40%) patients. Out of these, 234 (86.7%) children got cured within 14 days, while a delayed response to antibiotics was noted in 32 (11.9%) children. Seventy-six (29%) children recovered on a combination of meropenem and azithromycin, 72 (27%) got cured on azithromycin alone, while 15 (6%) responded to meropenem alone. CONCLUSION: Our review indicated that children under 5 years of age were affected more with XDR S.Typhi. Azithromycin alone or in combination with meropenem were effective antibiotics for treating XDR S.Typhi in children.

Frequencies and results of anti-nuclear, anti-dsDNA and anti-ENA in a tertiary-care hospital in Karachi, Pakistan.

OBJECTIVE: To analyse frequencies and results of anti-nuclear antibodies, anti-double stranded deoxyribonucleic acid and anti-extractable nuclear antigens tests ordered in a tertiary-care hospital. METHODS: The retrospective study was conducted at a tertiary care hospital in Karachi, and comprised all tests ordered for anti-nuclear antibodies, anti-double stranded deoxyribonucleic acid and anti-extractable nuclear antigens from March 2017 to January 2018. Data was retrieved from the institutional electronic database. The frequencies and results of the tests were determined. Anti-nuclear antibodies test was determined by indirect immunofluorescence, while the other two tests were determined by enzyme-linked immunosorbent assay. Patterns emerging from anti-nuclear antibodies tests were also analysed. RESULTS: Of the 1053 cases studied, 1000(95%) were tested for for anti-nuclear antibodies. The test was positive in 260(26%) patients, and was repeated in 8(3%) of the positive and 9(1.2%) of the negative patients. Anti-double stranded deoxyribonucleic acid test was ordered in 300(40.5%) and anti-extractable nuclear antigens test in 125(17%) patients who had tested negative for anti-nuclear antibodies. Among those who tested positive for anti-nuclear antibodies, the commonly observed patterns were homogenous 109(41.9%) and speckled 103(39.6%). Rod and ring pattern was seen in 10(3.8%) patients, and none of them were on anti-viral treatment. CONCLUSIONS: There was injudicious and unjustified ordering of auto-antibodies testing, indicating the need for greater physician education and cost-effective protocols.

Knowledge, Attitude and Practices of Labor Analgesia amongst healthcare workers and patients: a single center cross sectional study.

BACKGROUND AND OBJECTIVE: Childbirth ranks amongst the most painful experiences a woman has to endure. In developing countries issues related to awareness, acceptability and availability of analgesia exist. This study aims to assess the knowledge, attitude and practices for labor analgesia amongst healthcare workers and patients. METHODS: We performed a cross-sectional study conducted at Shaikh Saeed Memorial Campus of The Indus Hospital (TIH), Karachi. The study was performed in November 2016. Two surveys were conducted for this study; one for healthcare workers with patient interaction and second on patients attending their first antenatal clinic. The participants were asked to complete a survey following consent. RESULTS: A total of 71 healthcare workers and 1005 patients participated in the study. Among healthcare workers, 43.7% felt that pain relief should be administered, 14.1% believed analgesia had adverse effects on fetus and 11.3% reported increased risk of cesarean section. Results from patients showed 27.9% were aware of labor analgesia and when informed, 85.2% were willing to have labor analgesia. In 14.1% of patients, labor analgesia was unsupported as they stated being a mother meant to endure pain. CONCLUSION: There is a wide gap between knowledge and practice of labor analgesia. Healthcare workers have a role in educating women, to be advocates for labor analgesia and to educate patients timely for this service.

Synthesis of 4-substituted ethers of benzophenone and their antileishmanial activities.

Leishmaniasis is a vector-borne protozoan disease; it mainly originates from the bite of sandfly and initiated when parasite is transmitted to human at metacyclic flagellated promastigote form. In the current study, a synthesis of a series of 4-substituted benzophenone ethers 1-20 was carried out in good yields and their in vitro antileishmanial activities were also screened. Among synthetic derivatives, 15 compounds 1, 3, 5-12, 15 and 17-20 showed antileishmanial activities against promastigotes of Leishmania major with IC50 values in the range of 1.19-82.30 µg ml-1, and the values were compared with those of the standard pentamidine (IC50 = 5.09 ± 0.09 µg ml-1). Our study identified a series of new antileishmanial molecules as potential leads. Structures of these synthetic compounds were deduced by different spectroscopic techniques, such as 1H and 13C nuclear magnetic resonance, electron impact and high-resolution electron impact mass spectrometry and IR.

Synthesis of Thiocarbohydrazones and Evaluation of their in vitro Antileishmanial Activity.

BACKGROUND: Leishmaniasis is a protozoan parasitic vector-borne disease which is endemic in 88 tropical countries. Infected sandfly is the main vector of this disease, while there are several other vectors, parasites, and reservoirs involved in the transmission of this disease. Leishmania donovani, L. infantum, and L. chagasi are common disease causing species, transmitted through sandflies. Leishmaniasis is a neglected tropical disease with broad spectrum of clinical manifestations. Cutaneous leishmaniasis is prevalent in many countries, including Pakistan. METHODS: Thiocarbohydrazones (1-20) were synthesized through one pot method by refluxing thiocarbahydrazide with different substituted benzaldehydes in ethanol in the presence of acetic acid as a catalyst. These synthetic compounds were evaluated for their potential antileishmanial activity in vitro against Leishmania major promastigotes. RESULTS: Compounds 5-8, 11, 14, 16, 17, 19 and 20 were reported earlier, while compounds 2-4, 9, 10, 12, 13 and 15 were identified as were derivatives. Compounds 1-20 demonstrated antileishmanial activities with IC50 values between 1.63 ± 0.05 - 64.82 ± 0.17 µM, as compared to the standard drug pentamidine (IC50 = 5.09 ± 0.04 µM). Compounds 2 (IC50 = 1.63 ± 0.05 µM), 11 (IC50 = 2.33 ± 0.01 µM), 4 (IC50 = 11.03 ± 0.20 µM), and 10 (IC50 = 11.63 ± 0.06 µM) displayed comparable antileishmanial activities to the standard drug pentamidine. However, compounds 13, 15-17, and 20 with IC50 values 36.95 ± 0.025, 64.82 ± 0.17, 64.27 ± 0.38, 62.34 ± 0.38, and 40.47 ± 0.05 µM, respectively, showed a moderate antileishmanial activity. In contrast, compounds 1, 3, 5-9, 12, 14, 18, and 19 demonstrated less than 50% growth inhibition of promestigotes of L. major, and thus considered as inactive. CONCLUSION: In thiocarbohydrazone derivatives, different substituents at aryl part may be responsible for a varying degree of antileishmanial activity in vitro. Consequently, these compounds might have a potential for further studies as a new class of antileishmanial agents.

Antileishmanial diterpenoid alkaloids from Aconitum spicatum (Bruhl) Stapf.

The crude extracts of tubers of Aconitum spicatum (Bruhl) Stapf were investigated for in vitro antileishmanial activity against Leishmania major. The dichloromethane extract at pH 2.5 showed antileishmanial activity with IC50 value of 27.10 ± 0.0 µg/mL. Chromatographic purification of the dichloromethane extract led to isolation of three C-19 norditerpenoid alkaloids indaconitine (1), chasmaconitine (2) and ludaconitine (3). Compounds 3 and 2 showed antileishmanial activity with IC50 = 36.10 ± 3.4 and 56.30 ± 2.1 µg/mL, respectively. Compound 1 was less effective (IC50 > 100 µg/mL). The cytotoxicity of compounds 1, 2 and 3 studied against MCF7, HeLa and PC3 cancer cell lines and 3T3 normal fibroblast cell line did not show cytotoxicity at 30 µM.

4-Arylamino-6-nitroquinazolines: Synthesis and their activities against neglected disease leishmaniasis.

4-Arylamino-6-nitroquinazolines (2-25) were synthesized and evaluated for their leishmanicidal activities against Leishmania major promastigotes in vitro with IC50 values = 1.87-61.48 µM. Among the twenty four synthetic derivatives, 4-[4'-(methylsulfanyl)phenyl]amino-6-nitroquinazoline (21), and 4-(2'-methoxyphenyl)amino-6-nitroquinazoline (8) showed excellent antileishmanial activities with IC50 values 1.87 ± 0.31 and 4.37 ± 0.02 µM, respectively, more active than the standard drug, pentamidine (IC50 = 5.09 ± 0.09 µM). Compound 16 (IC50 = 6.53 ± 0.21 µM) displayed an activity comparable to the standard. Compounds 15 (IC50 = 9.04 ± 0.03 µM), 18 (IC50 = 12.28 ± 0.18 µM), 14 (IC50 = 19.87 ± 0.22 µM), and 5 (IC50 = 24.03 ± 2.71 µM) also showed good activities.