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BACKGROUND: In the light of the impact that pain has on patients, emergency department (ED) physicians need to be well versed in its management, particularly in its acute presentation. The goal of the present study was to evaluate the prevalence of unrelieved acute pain during ED stay in a Moroccan ED, and to identify risk factors of unrelieved pain. METHODS: Prospective survey of patients admitted to the emergency department of Ibn Sina teaching university hospital in Rabat (Morocco). All patients with acute pain over a period of 10 days, 24 hours each day were included. From each patient, demographic and clinical data, pain characteristics, information concerning pain management, outcomes, and length of stay were collected. Pain intensity was evaluated both on arrival and before discharge using Numerical Rating Scale (NRS). Comparison between patient with relieved and unrelieved pain, and factors associated with unrelieved pain were analyzed using stepwise forward logistic regression. RESULTS: Among 305 patients who complained of acute pain, we found high levels of intense to severe pain at ED arrival (91.1%). Pain intensity decreased at discharge (46.9%). Unrelieved pain was assessed in 24.3% of cases. Patients with unrelieved pain were frequently accompanied (82.4% vs 67.1%, p = 0.012), and more admitted daily than night (8 am-20 pm: 78.4% vs 64.9%; 21 pm-7 am: 21.6% vs 35.1%, p = 0.031), and complained chiefly of pain less requently (56.8% vs 78.8%, p<0.001). They had progressive pain (73% vs 44.2%, p<0.001), and had a longer duration of pain before ED arrival (72-168 h: 36.5% vs 16.9%; >168 h: 25.5% vs 17.7%, p<0.001). In multivariate analysis, predictor factors of unrelieved pain were: accompanied patients (OR = 2.72, 95% CI = 1.28- 5.76, p = 0.009), pain as chief complaint (OR = 2.32, 95% CI = 1,25-4.31, p = 0.007), cephalic site of pain (OR = 6.28, 95% CI = 2.26-17.46, p<0.001), duration of pain before admission more than 72 hours (72-168 h (OR = 7.85, 95% CI = 3.13-25.30, p = 0.001), and >168 h (OR = 4.55, 95% CI = 1.77-14.90, p = 0.02). CONCLUSION: This study reported high levels of intense to severe pain at ED arrival. However, one quarter patients felt on discharge from the ED that their pain had not been relieved. The relief of pain in ED depend both sociodemographic, clinical, and pain characteristics factors.

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BACKGROUND: Measuring healthcare quality and improving patient satisfaction have become increasingly prevalent, especially among healthcare providers and purchasers of healthcare. Currently, research is interested to the satisfaction in several areas, and in various cultures. The aim of this study was; to confirm the reliability and validity of the Arabic version of the Emergency Department Quality Study (EDQS), to evaluate patient satisfaction with emergency care, and to determine associated factors with patient satisfaction. METHODS: A survey of socio demographic, visit and health characteristics of patients, conducted in emergency department (ED) of a Moroccan University Hospital during 1 week in February 2009. The EDQS was performed with patients who were discharged from ED. The psychometric properties of the EDQS were tested. Factors influencing patient satisfaction were identified using ordinal logistic regression. RESULTS: A total of 212 patients were enrolled. The Arabic version of the EDQS showed excellent reliability and validity. Sixty six percent of participants were satisfied with overall care, and 69.8% would return to our unit. The most patient-reported problems were about waiting time and test results. Variables associated with greater satisfaction with ED care were: emergent (OR: 0.15; 95% CI = 0.04-0.31; P < 0.001), or urgent patients (OR: 0.35; 95% CI = 0.15-0.86; P = 0.02) compared to non-urgent patients, and waiting time less than 15 min (OR: 0.41; 95% CI = 0.23-0.75; P = 0.003). Variables associated with lesser satisfaction were: distance patient's home hospital ≤10Kilometers (OR: 2.64; 95% CI = 1.53-4.53; P < 0.001), weekday's admissions (OR: 2.66; 95% CI = 1.32 to 5.34; P < 0.006), and educational level; with secondary (OR: 5.19; 95% CI = 2.04-13.21; P < 0.001) primary (OR: 3.04; 95% CI = 1.10-8.04; P = 0.03) and illiterate patients (OR: 2.53; 95% CI = 1.02-6.30; P = 0.03) were less satisfied compared to those with high educational level. CONCLUSION: Medical staff needs to consider different interactions between those predictive factors in order to develop some supportive tools.

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BACKGROUND: The delay in diagnosis and treatment of tuberculous meningitis (TBM) is a major factor in the high mortality observed with this pathology. The distinction between bacterial meningitis (BM) and TBM by clinical features alone is often impossible, and the available biological resources remain inadequate or inaccessible, especially in developing countries. We attempted to develop a simple diagnostic algorithm on the basis of clinical and laboratory findings that could be used as an early predictor of TBM in adult patients in Morocco. METHODS: We compared the clinical and laboratory features on admission of 508 adults in a medical intensive care unit in Morocco who satisfied diagnostic criteria for tuberculous (n=274) or bacterial (n=234) meningitis. Features independently predictive of TBM were modeled by multivariate logistic regression to create a diagnostic rule, and by a classification and regression tree (CART). RESULTS: Six features were predictive of a diagnosis of TBM: female gender, duration of symptoms, the presence of localizing signs, white blood cell (WBC) count, the level of serum sodium, and the total cerebrospinal fluid WBC count. The sensitivity for CART was 87% and for a score >7 was 88%; specificity was 96% and 95%, respectively. The internal validation was excellent for both diagnostic methods, with a receiver operating characteristic (ROC) area of 0.906 bootstrap samples for a score >7 and 0.910 for CART. CONCLUSIONS: The clinical and laboratory parameters identified in this study may help the clinician with the empiric diagnosis of TBM and could be used in settings with limited microbiological diagnostic support.

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BACKGROUND: Health-related quality of life (HRQL) is a relevant outcome measures in intensive care unit (ICU). The aim of this study was to evaluate HRQL of ICU patients 3 months after discharge using the Arabic version for Morocco of the EuroQol-5-Dimension (EQ-5D), and to examine the psychometric properties of the questionnaire. RESULTS: The Arabic version for Morocco of the EQ-5D was approved by the EuroQol group. A prospective cohort study was conducted after medical ICU discharge. At 3-month follow up, the EQ-5D (self classifier and EQ-VAS) was administered in consultation or by telephone. EQ-VAS varies from 0 (better HRQL) to 100 (worst HRQL). An unweighted scoring for EQ5D-index was calculated. EQ5D-index ranges from -0.59 to 1. Test-retest reliability of the EQ-5D was tested using Kappa coefficient and intraclass correlation coefficient (ICC). Criterion validity was assessed by correlating EQ-VAS and EQ5D-index with the Short Form 36 (SF-36). Construct validity was tested using simple and multiple liner regression to assess factors influencing patients'HRQL. 145 survivors answered the EQ-5D. Median EQ5D-index was 0.52 [0.20-1]. Mean EQ-VAS was 62 ± 20. Test-retest reliability was conducted in 83 patients. ICCs of EQ5D-index and EQ-VAS were 0.95 and 0.92 respectively. For EQ-5D self classifier, agreement by kappa was above 0.40. Significant correlations were noted between EQ5D-index, EQ-VAS and SF-36 (p < 0.001). In multivariate analysis, factors associated with poorer HRQL for EQ5D-index were longer ICU length of stay (ß = -0.01; p = 0.017) and higher educational level (ß = -0.2; p = 0.001). For EQ-VAS men were associated with better HRQL (ß = 6.5; p = 0.048). CONCLUSIONS: The Arabic version for Morocco of the EQ-5D is reliable and valid. Women, high educational level and longer ICU length of stay were associated with poorer HRQL.

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BACKGROUND: Withdrawing and withholding life-support therapy (WH/WD) are undeniably integrated parts of medical activity. However, Emergency Department (ED) might not be the most appropriate place to give end-of life (EOL) care; the legal aspects and practices of the EOL care in emergency rooms are rarely mentioned in the medical literature and should be studied. The aims of this study were to assess frequency of situations where life-support therapies were withheld or withdrawn and modalities for implement of these decisions. METHOD: A survey of patients who died in a Moroccan ED was performed. Confounding variables examined were: Age, gender, chronic underlying diseases, acute medical disorders, APACHE II score, Charlson Comorbidities Index, and Length of stay. If a decision of WH/WD was taken, additional data were collected: Type of decision; reasons supporting the decision, modalities of WH/WD, moment, time from ED admission to decision, and time from processing to withhold or withdrawal life-sustaining treatment to death. Individuals who initiated (single emergency physician, medical staff), and were involved in the decision (nursing staff, patients, and families), and documentation of the decision in the medical record. RESULTS: 177 patients who died in ED between November 2009 and March 2010 were included. Withholding and withdrawing life-sustaining treatment was applied to 30.5% of all patients who died. Therapies were withheld in 24.2% and were withdrawn in 6.2%. The most reasons for making these decisions were; absence of improvement following a period of active treatment (61.1%), and expected irreversibility of acute disorder in the first 24 h (42.6%). The most common modalities withheld or withdrawn life-support therapy were mechanical ventilation (17%), vasopressor and inotrops infusion (15.8%). Factors associated with WH/WD decisions were older age (OR = 1.1; 95%IC = 1.01-1.07; P = 0.001), neurological acute medical disorders (OR = 4.1; 95%IC = 1.48-11.68; P = 0.007), malignancy (OR = 7.7; 95%IC = 1.38-8.54; P = 0.002) and cardiovascular (OR = 3.4;95%IC = 2.06-28.5;P = 0.008) chronic underlying diseases. CONCLUSION: Life-sustaining treatment were frequently withheld or withdrawn from elderly patients with underlying chronic cardiovascular disease or metastatic cancer or patients with acute neurological medical disorders in a Moroccan ED. Religious beliefs and the lack of guidelines and official Moroccan laws could explain the ethical limitations of the decision-making process recorded in this study.

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INTRODUCTION: Anyone working in the hospital may become a victim of violence. The effects of violence can range in intensity and include the following: minor physical injuries, serious physical injuries, temporary or permanent physical disability, psychological trauma, and death. The aim of this study was to determine the frequency of exposure, characteristics, and psychological impact of violence toward hospital-based emergency physicians in Morocco. METHODS: This was a survey including emergency physicians who ensured emergency service during the last fortnight. The variables studied were those related to the victim (age and gender), and those related to aggression: assaulter gender, number, time, reason (delay of consultation and/or care, acute drunkenness, neuropsychiatric disease), and type (verbal abuse, verbal threat and/or physical assault). After the questionnaire was completed, State-Trait Anxiety Inventory (STAI) of Spielberg was applied to all participants. RESULTS: A total of 60 physicians have achieved permanence in emergency department during the 15 days preceding the questionnaire response. The mean age was 24 ± 1 year and 57% were male. A total of 42 (70%) had been exposed to violence. The violence occurred at night n = 16 (27%), afternoon n = 13 (22%), evening n = 7 (12%) and morning n = 6 (10%). Reasons for violence were: the delay of consultation or care in n = 31 (52%) cases, acute drunkenness in n = 10 (17%) cases and neuropsychiatric disease in n = 3 (5%) cases. Twenty eight (47%) participants stated that they experienced verbal abuse, n = 18 (30%) verbal threat and n = 5 (8.3%) physical assault. Exposure to some form of violence was related to a higher median [interquartile range, IQR] state anxiety point (SAP); (51 [46-59] vs 39 [34-46]; P < 0,001), and trait anxiety point (TAP) (48 [41-55] vs 40,5 [38-53]; P = 0,01). CONCLUSIONS: This study revealed a high prevalence (70%) of violence toward doctors in Morocco emergency departments. The exposure of physicians to some form of violence is greater among doctors with anxiety trait and was related to significant degree of anxiety state.

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BACKGROUND: The first case of 2009 pandemic influenza A (H1N1) virus infection in our center was documented on June 15. Subsequently, persons with suspected cases of infection and contacts of those with suspected infection were tested. Persons in whom infection was confirmed were hospitalized and quarantined, and some of them were closely observed for the purpose of investigating the nature and duration of the disease. The aim of the present study was to describe baseline characteristics, treatment, outcomes, hospital length of stay and mortality of the first 186 cases of influenza A (H1N1) virus infection, with special interest in those developing severe respiratory failure with intensive care unit (ICU) care requirement. METHODS: observational study of 186 consecutive cases of influenza A (H1N1) virus infection admitted in 3 departments that were reference centers for the care of patients with influenza A and 4 ICU in Ibn Sina university hospital (Rabat, Morocco) between June and December 2009. Real time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) testing was used to confirm infection. Demographic data, symptoms, comorbid conditions, illness progression, laboratory and chest radiologic findings, treatments, clinical outcomes and ICU care requirement were closely monitored. RESULTS: The mean age of the 186 patients was 17.6 ± 14.8 years, 47.8% had less than 14 years and 57% were male. The median duration of symptoms before hospital admission was 3 days (interquartile range (IQR): 2-5). The most common symptoms were fever (in 91.5% of the patients), cough in 92.5%, and nasal congestion in 62.4%. Twenty four percent of patients had comorbid respiratory disorders and 7.5% were pregnant. Abnormalities in chest radiography were detected in 26.3% of 186 patients on admission or after hospitalization. Twenty patients have required ICU care and 10 have required mechanical ventilation. The hospital length of stay was 5 days (IQR: 4-5). The following were risk factors of ICU admission: older age (p = 0.03), long duration of symptoms (p = 0.07), asthma (p = 0.01), obesity (P < 0.001), abnormalities of chest radiography (P < 0.001), leukocytosis (p = 0.005), and higher C-reactive protein (CRP) (P < 0.001). The ICU length of stay was 4 days (IQR: 3-6.7). The mortality rate was 3.5% among all patients and 30% among ICU patients. CONCLUSIONS: Close observation of patients infected with the 2009 pandemic influenza A (H1N1) virus infection provided us with several information. The influenza A (H1N1) virus infection affected young people particularly, with comorbid respiratory disorders. Risk factors of ICU admission were older age, long duration of symptoms, asthma, obesity, abnormalities of chest radiography, leukocytosis and higher CRP. Clinicians should be aware of complications of influenza A (H1N1) virus infection, particulary in patients with risk factors.

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BACKGROUND: Patients' satisfaction is an important indicator for quality of care. Measuring healthcare quality and improving patient satisfaction have become increasingly prevalent, especially among healthcare providers and purchasers of healthcare. This is mainly due to the fact that consumers are becoming increasingly more knowledgeable about healthcare. No studies of inpatients' satisfaction with hospital care have been conducted in Morocco. The first objective of the present study was to confirm the reliability and validity of the Arabic version of the EQS-H (Echelle de Qualité des Soins en Hospitalisation). The second objective was to evaluate patient satisfaction in an acute medicine department in Morocco by using the EQS-H questionnaire; and also to assess the influence of certain demographics, socioeconomics, and health characteristics in patient satisfaction. METHODS: it was a patient survey conducted in an acute medicine department of a Moroccan University Hospital. We surveyed their socio demographic status, and health characteristics at admission. We performed structured face to face interviews with patients who were discharged from hospital. The core of the EQS-H questionnaire was translated to Arabic, adapted to the present setting, and then used to measure patient satisfaction with quality of care. The internal consistency of the EQS-H scale was assessed by Chronbach's coefficient alpha. Validity was assessed by factor analysis. Factors influencing inpatients' satisfaction were identified using multiple linear regression. RESULTS: The Arabic version of EQS-H demonstrated an excellent internal consistency for the two dimensions studied (0.889 for 'quality of medical information' (MI) and 0.906 for 'Relationship with staff and daily routine' (RS)). The principal component analysis confirmed the bidimensional structure of the questionnaire and explained 60% of the total variance. In the univariate analysis, urban residence, higher income, better perceived health status compared to admission, better perceived health status compared to people of the same age, and satisfaction with life in general were related to MI dimension; Otherwise, mal gender, urban residence, higher income, staying in double room, better perceived health status compared to admission, and satisfaction with life in general were related to RS dimension. The multiple linear regression showed that four independent variables were associated with higher satisfaction in MI: More than 2 prior hospitalizations, a longer length of stay (10-14 days) (P = 0.002), staying in double room (P = 0.022), and better perceived health status compared to admission (P = 0.036). Three independent variables were associated with higher satisfaction in RS: a longer length of stay (10-14 days) (P = 0.017), better perceived health status compared to admission day (P = 0.013), and satisfaction with life in general (P = 0.006). CONCLUSIONS: Our current data assessing patient satisfaction with acute health care by the Arabic version of the EQS-H showed that the satisfaction rate was average on MI dimension; and good on RS dimension of the questionnaire. The majority of participants were satisfied with the overall care. Demographic, socioeconomic, and health characteristics may influence in-patients satisfaction in Morocco, a low/middle income country. An appreciation and understanding of these factors is essential to develop socio culturally appropriate interventions in order to improve satisfaction of patients.

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INTRODUCTION: Eosinopenia is a cheap and forgotten marker of acute infection that has not been evaluated previously in intensive care units (ICUs). The aim of the present study was to test the value of eosinopenia in the diagnosis of sepsis in patients admitted to ICUs. METHODS: A prospective study of consecutive adult patients admitted to a 12-bed medical ICU was performed. Eosinophils were measured at ICU admission. Two intensivists blinded to the eosinophils classified patients as negative or with systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, or septic shock. RESULTS: A total of 177 patients were enrolled. In discriminating noninfected (negative + SIRS) and infected (sepsis + severe sepsis + septic shock) groups, the area under the receiver operating characteristic curve was 0.89 (95% confidence interval (CI), 0.83 to 0.94). Eosinophils at <50 cells/mm3 yielded a sensitivity of 80% (95% CI, 71% to 86%), a specificity of 91% (95% CI, 79% to 96%), a positive likelihood ratio of 9.12 (95% CI, 3.9 to 21), and a negative likelihood ratio of 0.21(95% CI, 0.15 to 0.31). In discriminating SIRS and infected groups, the area under the receiver operating characteristic curve was 0.84 (95% CI, 0.74 to 0.94). Eosinophils at <40 cells/mm3 yielded a sensitivity of 80% (95% CI, 71% to 86%), a specificity of 80% (95% CI, 55% to 93%), a positive likelihood ratio of 4 (95% CI, 1.65 to 9.65), and a negative likelihood ratio of 0.25 (95% CI, 0.17 to 0.36). CONCLUSION: Eosinopenia is a good diagnostic marker in distinguishing between noninfection and infection, but is a moderate marker in discriminating between SIRS and infection in newly admitted critically ill patients. Eosinopenia may become a helpful clinical tool in ICU practices.

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Assessing pain in critically ill patients, particularly in nonverbal patients, is a great challenge. In this study, we validated a behavioral pain scale (BPS) in critically ill, sedated, and mechanically ventilated patients. The BPS score was the sum of 3 subscales that have a range score of 1-4: facial expression, upper limb movements, and compliance with mechanical ventilation. Two assessors observed and scored pain simultaneously with the BPS at rest and during painful procedures. The psychometric properties of the BPS that were studied were reliability, validity, and responsiveness. We achieved 360 observations in 30 patients. The BPS was internally reliable (Cronbach alpha = 0.72). The intraclass correlation coefficient to evaluate inter-rater reliability was high (0.95). Validity was demonstrated by the change in BPS scores, which were significantly higher during painful procedures, with averages of 3.9 +/- 1.1 at rest and 6.8 +/- 1.9 during procedures (P < 0.001), and by the principal components factor analysis, which revealed a large first-factor accounting for 65% of the variance in pain expression. The BPS exhibited excellent responsiveness, with an effect size ranging from 2.2 to 3.4. This study demonstrated that the BPS can be valid and reliable for measuring pain in noncommunicative intensive care unit patients.

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