Barriers to safe anaesthesia care in South Asian countries: a virtual focus group discussion.

Objective: To identify barriers to safe anaesthesia practice across the South Asian region. METHODS: The qualitative study was conducted from September 2020 to August 2021 at the Department of Anaesthesiology at a leading medical university after getting exemption from the ethics review committee of the Pakistan Society of Anaesthesiologists. The sample comprised anaesthetists from 6 countries of the South Asian Association for Regional Cooperation. Data was collected through a focus group discussion held virtually using the Zoom app on September 22, 2020. The proceedings were transcribed and the data was subjected to thematic analysis. RESULTS: Of the 12 anaesthetists, 4(33.3%) were from India, 3(25%) from Pakistan, 2(16.7%) from Bangladesh, and 1(8.3%) each from Sri Lanka, Nepal and Afghanistan. There were 2 main themes identified; Safe anaesthesia and barriers to safe anaesthesia. They had 4 and 6 subthemes, respectively. The participants agreed that fresh medical graduates were not choosing anaesthesia as a preferred career specialty. One major concern raised was that qualified anaesthetists were leaving their countries for better-paid jobs abroad. Conclusion: The lack of a definition describing qualified anaesthetists in South Asian countries was pointed out. Lack of basic monitoring and drugs, brain drain, lack of ownership, lack of training programmes, lack of accountability, weak leadership, and disconnect between professional societies and governments were identified as the main barriers to safe anaesthesia.

What happens when private general practitioners receive incentivisation offers from pharmaceutical sales representatives? A qualitative study in Pakistan.

OBJECTIVES: Pharmaceutical incentivisation of physicians for profit maximisation is a well-documented health system challenge. This study examined general practitioners' (GPs) reactions to pharmaceutical incentivisation offers in one region in Pakistan. METHODS: We used the Standardised Pharmaceutical Sales Representative (SPSR) method and qualitative interviews with GPs. SPSRs were field researchers representing mock pharmaceutical companies who recorded their observations of 267 GPs' responses to pharmaceutical incentivisation offers. We triangulated SPSR data using qualitative interviews with a subset of the same GPs to gather information about how they interpreted different interaction outcomes. RESULTS: We found four major outcomes for GPs being offered incentives by pharmaceutical companies for prescribing medications. GPs might agree to make incentivisation deals, reject incentivisation offers, disallow PSRs to access them, or remain indeterminate with no clear indication of acceptance or rejection of incentivisation offers. GPs rejecting SPSRs' incentivisation offers indicated having active commitments to other pharmaceutical companies, not being able to work with unheard-of companies, and asking SPSRs to return later. CONCLUSIONS: The GP-pharmaceutical sales representative interaction that centres on profit-maximisation is complex as offers to engage in prescribing for mutual financial benefit are not taken up immediately. The SPSR method helps understand the extent of distortion of practices impacted by incentivisation. Such an understanding can support the development of strategies to control unethical behaviours.

Incentivisation practices and their influence on physicians' prescriptions: A qualitative analysis of practice and policy in Pakistan.

Focus on profit-generating enterprise in healthcare can create conflicts of interest that adversely impact prescribing and pricing of medicines. Although a global challenge, addressing the impacts on quality of care is particularly difficult in countries where the pharmaceutical industry and physician lobby is strong relative to regulatory institutions. Our study characterises the range of incentives exchanged between the pharmaceutical industry and physicians, and investigates the differences between incentivisation practices and policies in Pakistan. In this mixed methods study, we first thematically analysed semi-structured interviews with 28 purposively selected for-profit primary-care physicians and 13 medical sales representatives from pharmaceutical companies working across Pakistan's largest city, Karachi. We then conducted a content analysis of policies on ethical practice issued by two regulatory bodies responsible in Pakistan, and the World Health Organization. This enabled a systematic comparison of incentivisation practices with what is considered 'prohibitive' or 'permissive' in policy. Our findings demonstrate that incentivisation of physicians to meet pharmaceutical sales targets is the norm, and that both parties play in the symbiotic physician-pharma incentivisation dynamics. Further, we were able to categorise the types of incentive exchanged into one of five categories: financial, material, professional or educational, social or recreational, and familial. Our comparison of incentivisation practices with policies revealed three reasons for such widespread incentivisation linked to sales targets: first, some clear policies were being ignored by physicians; second, there are ambiguous or contradictory policies with respect to specific incentive types; and third, numerous incentive types are unaddressed by existing policies, such as pharmaceutical companies paying for private clinic renovations. There is a need for policies to be clarified and updated, and to build buy-in for policy enforcement from pharmaceutical companies and physicians, such that transgressions on target-driven prescribing are seen to be unethical.

Safety and effectiveness of ultrasound guided peripheral nerve blocks: Audit at tertiary care hospital.

OBJECTIVE: To assess the safety and effectiveness of peripheral nerve blocks using ultrasound. METHODS: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of all patients who received peripheral nerve blocks as part of anaesthesia care between January 2015 and January 2017. The data included outcomes of peripheral nerve block effectiveness, complications and limb conditions after the block. Peripheral nerve block effectiveness was assessed by monitoring pain scores at rest and on movement, and the requirement of co-analgesia. Complications, like numbness, motor block, metallic taste, hypotension and respiratory depression, were also assessed. Data was analysed using SPSS 19. RESULTS: There were 299 patients who received ultrasound-guided peripheral nerve blocks. The overall mean age was 44.57±16.64 years. Of the total, 140 (47%) received transversus abdominis plane block, followed by supraclavicular block 49(16.7%). The most common complication in the recovery room was numbness 19 (6.2%). Overall, 70% patients remained pain-free, while 16% had moderate pain on movement 12 hours postoperatively. CONCLUSIONS: Ultrasound-guided regional anaesthesia was found to provide effective analgesia during and after surgery. Nerve blocks proved to be safe when used with ultrasound.

Post-operative pain management modalities employed in clinical trials for adult patients in LMIC; a systematic review.

BACKGROUND: Unrelieved postoperative pain afflicts millions each year in low and middle income countries (LMIC). Despite substantial advances in the study of pain, this area remains neglected. Current systematic review was designed to ascertain the types of clinical trials conducted in LMIC on postoperative pain management modalities over the last decade. METHODS: A comprehensive search was performed in June 2019 on PubMed, Cochrane Library, CINAHL Plus, and Web of Science databases to identify relevant trials on the management of postoperative pain in LMIC. Out of 1450 RCTs, 108 studies were reviewed for quality evidence using structured form of critical appraisal skill program. Total of 51 clinical trials were included after applying inclusion/exclusion criteria. RESULTS: Results are charted according to the type of surgery. Eleven trials on laparoscopic cholecystectomy used multimodal analgesia including some form of regional analgesia. Different analgesic modalities were studied in 4 trials on thoracotomy, but none used multimodal approach. In 11 trials on laparotomy, multimodal analgesia was employed along with the studied modalities. In 2 trials on hysterectomy, preemptive pregabalin or gabapentin were used for reduction in rescue analgesia. In 13 trials on breast surgical procedures and 10 on orthopaedic surgery, multimodal analgesia was used with some form of regional analgesia. CONCLUSION: We found that over the past 10 years, clinical trials for postoperative pain modalities have evolved in LMIC according to the current postoperative pain management guidelines i.e. multi-modal approach with some form of regional analgesia. The current review shows that clinical trials were conducted using multimodal analgesia including but not limited to some form of regional analgesia for postoperative pain in LMIC however this research snapshot (of only three countries) may not exactly reflect the clinical practices in all 47 countries. Post Operative Pain Management Modalities Employed in Clinical Trials for Adult Patients in LMIC; A Systematic Review.

Managing acute pain in HIV+/AIDS patients: knowledge and practice trends among emergency physicians of major tertiary care centers of a developing country.

OBJECTIVE: To assess knowledge and practice trends in managing acute pain in patients infected with human immunodeficiency virus (HIV+) or having acquired immunodeficiency syndrome (AIDS) among emergency physicians of four tertiary care hospitals. Acute pain management in such patients is complex because of multiple concomitant painful conditions related to their disease. After obtaining ethical approval and written informed consent, emergency physicians were requested to fill out a questionnaire. RESULTS: Out of 84 physicians who participated, 49 had managed HIV+/AIDS patients during the preceding year. Out of the 49, 30 (61.2%) physicians stated that they used a combination of analgesics for acute pain in these patients. Forty-two (50%) out of the 84 participants believed that routine doses of opioids were adequate for pain relief, while 42 (50%) agreed that pain management was more complex in these patients mainly due to presence of multiple coexisting problems and psychological issues. Only 26 (31%) respondents considered that pain was under-reported and under-treated in these patients, mainly because physicians were more focused on patients' other disease related complications and issues. Formulation of guidelines are recommended for effective acute pain management in these patients encompassing associated issues, including concomitant painful conditions, opioid dependence, psychiatric problems, etc.

Analgesic Effect Of Bilateral Subcostal Tap Block After Laparoscopic Cholecystectomy.

BACKGROUND: Pain after laparoscopic cholecystectomy is mild to moderate in intensity. Several modalities are employed for achieving safe and effective postoperative analgesia, the benefits of which adds to the early recovery of the patients. As a part of multimodal analgesia, various approaches of Transversus abdominis plane (TAP) block has been used for management of parietal and incisional components of pain after laparoscopic cholecystectomy. This study was designed to compare the analgesic efficacy of two different approaches of ultrasound guided TAP block, i.e., Subcostal-TAP block technique with ultrasound guided Posterior-TAP block for postoperative pain management in patients undergoing laparoscopic cholecystectomy under general anaesthesia. METHODS: In this double blinded randomized controlled study, consecutive nonprobability sampling was done and a total of 126 patients admitted for elective laparoscopic cholecystectomy fulfilling the inclusion criteria were selected. After induction of general anaesthesia, patients were randomized through draw method and received either ultrasound guided posterior TAP block with 0.375% bupivacaine (20ml volume) on each side of the abdomen or subcostal TAP block bilaterally with the same. Up to 24 hours postoperatively, static and dynamic numeric rating pain scores were assessed. RESULTS: We found statistically significant difference in mean static pain scores over 24 hours postoperatively in subcostal TAP group, suggesting improved analgesia. However, mean dynamic postoperative pain scores were comparable between the two groups. Whereas, patients in both groups were satisfied with pain management. CONCLUSIONS: Ultrasound guided subcostal TAP block provides better postoperative analgesia as compared to the Posterior TAP block in laparoscopic cholecystectomy. Otherwise both of the approaches improve patient outcomes towards early recovery and discharge from hospital.

Urinary Retention in Unilateral Total Knee Arthroplasty: Comparison between Continuous Epidural Analgesia and Single-Shot Femoral Nerve Block.

OBJECTIVE: To compare the frequency of urinary retention and requirement of bladder catheterization in patients undergoing total knee arthroplasty while receiving either continuous epidural analgesia or single-shot femoral nerve block. STUDY DESIGN: Randomized controlled study. PLACE AND DURATION OF STUDY: Operating Rooms of Aga Khan University Hospital, Karachi, from January 2014 to January 2015. METHODOLOGY: Patients were randomized in two groups of 30 each, i.e. epidural group (group E) or femoral nerve block group (group F). Baseline parameters were recorded. Postoperatively, patients were followed for upto 24 hours to collect the data regarding urinary retention. Final outcome was taken at 24 hours postoperatively. Data was analyzed to compare the frequency of urinary retention between the two groups. RESULTS: The average age of the patients was 59.58 ±5.85 years. There were 28 (46.7%) male and 32 (53.3%) female patients. Frequency of urinary retention was significantly high in Group E than Group F (46.7% vs. 6.7%; p=0.0005). CONCLUSION: Single-shot femoral nerve block offers a more favorable profile in terms of postoperative urinary retention when compared to continuous epidural analgesia.

Palliative care in Pakistan.

Pakistan is a developing country of South East Asia, with all the incumbent difficulties currently being faced by the region. Insufficient public healthcare facilities, poorly regulated private health sector, low budgetary allocation for health, improper priority setting while allocating limited resources, have resulted essentially in an absence of palliative care from the healthcare scene. Almost 90% of healthcare expenditure is out of the patient's pocket with more than 45% of population living below the poverty line. All these factors have a collective potential to translate into an end-of-life care disaster as a large percentage of population is suffering from chronic debilitating/terminal diseases. So far, such a disaster has not materialised, the reason being a family based culture emphasising the care of the sick and old at home, supported by religious teachings. This culture is not limited to Pakistan but subsists in the entire sub-continent, where looking after the sick/elderly at home is considered to be the duty of the younger generation. With effects of globalisation, more and more older people are living alone and an increasing need for palliative care is being realised. However, there does not seem to be any plan on the part of the public or private sectors to initiate palliative care services. This paper seeks to trace the social and cultural perspectives in Pakistan with regards to accessing palliative care in the context of healthcare facilities available.

Assessment of patient satisfaction with acute pain management service: Monitoring quality of care in clinical setting.

BACKGROUND AND AIMS: Assessment of patient satisfaction is an important tool for monitoring the quality of care in hospitals. The aim of this survey was to develop a reliable tool to assess patient satisfaction with acute pain management service (APMS) and identify variables affecting this so that care can be improved. METHODS: A questionnaire was developed and administered to patients after being discharged from APMS care by an unbiased person. Data collected from record included patient demographics, surgical procedure, analgesic modality, co-analgesics and dynamic and static pain scores. Questions included pain expected and pain experienced, APMS response time, quality of pain relief with treatment, professionalism of APMS team, overall experience of pain relief and choosing/suggesting same modality for themselves/family/friends again. Five-point Likert scale was used for most of the options. Statistical analysis was done using SPSS 19. RESULTS: Frequency and percentages were computed for qualitative observation and presented on pie chart and histogram. Seventy-one per cent patients expected severe pain while 43% actually experienced it. About 79.4% would choose same analgesia modality in future for self/family/friends. Ninety-nine per cent found APMS staff courteous and professional. About 89% rated their experience of pain management as excellent to very good. CONCLUSION: The survey of patients' satisfaction to monitor the quality of care provided by APMS provided positive inputs on its role. This also helps to identify areas requiring improvement in care and as a tool to gauge the quality of care.

Post-operative analgesia for major abdominal surgery and its effectiveness in a tertiary care hospital.

BACKGROUND: Post-operative pain is often inadequately treated. Optimal utilization of the available resources is essential for improving pain management. AIMS: The aim of our study was to determine pain management strategies employed after major abdominal surgeries at our institute and their efficacy and safety. SETTINGS AND DESIGN: Prospective observational study conducted at a tertiary care hospital. MATERIALS AND METHODS: Patients undergoing elective major abdominal surgeries were included. Post-operative analgesic strategy, co-analgesics used, pain and sedation scores, motor block, nausea and vomiting were recorded and patient satisfaction was determined. RESULTS: Data was collected on 100 patients. Epidural analgesia was used in 61, patient controlled intravenous analgesia (PCIA) in 25 and opioid infusion in 14 patients. Multimodal analgesia was employed in 98 patients. The level of epidural was between L1-L3 in 31, T10-L1 in 20 and T8-T10 in 10 patients. Pethidine was used in 80% of patients receiving PCIA. Patients with epidurals at T8-T10 had lower pain scores. Fifteen patients had motor block, 73% of which were with epidural at L1-L3. Fourteen patients complained of nausea. Ninety nine out of 100 patients were satisfied with their analgesia. CONCLUSION: Epidural, PCIA and opioid infusions are used for pain relief after major abdominal surgeries at our hospital. Although there is limited drug availability, regular assessments and appropriate dose adjustments by acute pain management service (APMS) and use of multimodal analgesia led to a high level of patient satisfaction. We recommend that feedback to the primary anesthesiologists by APMS is of utmost importance to enable improvement in practice.

How we developed a bioethics theme in an undergraduate medical curriculum.

The 5-year undergraduate medical curriculum at Aga Khan University integrates basic sciences with clinical and community health sciences. Multimodal strategies of teaching and learning, with an emphasis on problem-based learning, are utilized to equip students with knowledge, skills, behaviours, attitudes and values necessary for a high-calibre medical graduate. Bioethics teaching was introduced in the medical curriculum in 1988 and has since undergone several changes. In 2009, a multidisciplinary voluntary group began review of undergraduate bioethics teaching and invested over 350 man-hours in curricular revision. This involved formulating terminal objectives, delineating specific objectives and identifying instructional methodologies and assessment strategies appropriate for the contents of each objective. Innovative strategies were specially devised to work within the time constraints of the existing medical curriculum and importantly, to increase student interest and engagement. The new bioethics curriculum is designed to be comprehensive and robust, and strives to develop graduates who, in addition to being technically skilled and competent, are well-versed in the history and philosophy of ethics and bioethics and are ethical in their thinking and practice, especially in the context of a developing country like Pakistan where health indicators are among the worst in the region, and clinical practices are not effectively regulated to ensure quality of care.

Informed consent and some of its problems in Pakistan.

Informed consent has become an essential element of human subject research. Certain components are essential for a well-understood informed consent. There are problems in procurement of a comprehensive and meaningful consent in the Pakistani research settings. The inefficient healthcare systems, low literacy rate with masses having no concept of individual rights, higher social status enjoyed by physicians inhibiting the patients from questioning them, and unwillingness to hear bad news are some of these factors. Establishing Bioethics education at all levels, encouraging the involvement of families in decision making, using improvisation in procurement of consent are suggested solutions. There needs to be a consideration for both beneficence and autonomy with emphasis on balancing and doing equal justice to both.

One standard of care for all is not always practical.

Multiple research guidelines address the issue of standard of care in international collaborative research. These guidelines fail to appreciate that differing standards may be present within the same country, which makes their application sometimes impracticable. In circumstances where ethics review committees follow one of these guidelines entirely and to the hilt, some relevant and useful research is rejected while the way for "me too" drug trials is paved. It should be acceptable to hold different researchers to separate standards of care on the basis of their intentions, their financial resources, their ultimate gains from the research, and subsequent utilisation of the results of the research, even when these researchers come from the same country where the research is being conducted.