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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Postoperative Pain Management and Patient Satisfaction in an Indian Tertiary Care Centre-A Prospective Observational Study
Correspondence Address :
Mohit K Srivastava,
Senior Resident (DM Pain Medicine), Department of Physical Medicine and Rehabilitation, AIIMS, Rishikesh, Dehradun-249203, Uttrakhand, India.
E-mail: rohitsriv14elec@gmail.com
Introduction: Despite various advancements over last two decades in pain medicine, postoperative pain remains inadequately addressed, even in a tertiary medical centre. There are very limited studies addressing postoperative pain management in India. Few published studies have assessed postoperative pain, but only at 24 hours intervals, and utilising tools focusing on any one parameter of pain. Hence, a holistic assessment using four different pain assessment tools should be done to get a wider overview of the condition.
Aim: To assess the intensity and severity of postoperative pain at 6, 12, 24 and 48 hours postoperatively for patients undergoing surgery for orthopaedics, gastrointestinal, general surgery, obstetrics and gynaecological ailments and patient satisfaction at 24 hours postoperatively.
Materials and Methods: A prospective observational survey was conducted at a tertiary care centre of New Delhi, India from October 2020 to October 2021. Three scales were used to determine the status of postoperative pain at 6,12,24 and 48 hours follow-up. The three different pain scales were Numerical Pain Rating Scale (NRS-pain) static and dynamic, Global Perceived Effect (GPE) and Neuropathic Pain System Inventory (NPSI).
Results: Total of 400 patients, with mean age of the study population was 43.26±4.98 years. Majority were males, 250 (60%) and of American Society of Anaesthesiologist (ASA) Grade I, 208 (52%). Significant improvement was observed in the NRS pain score at each follow-up among those undergoing orthopaedic surgery, general surgery, and gynaecological procedures. Improvement in the mean GPE scale was only seen for orthopaedic surgeries. There was a significant neuropathic pain component observed in all the surgeries except gynaecological surgeries. Majority 321 (80.25%) had received information about their pain treatment but only 174 (43.5%) were satisfied with their pain treatment.
Conclusion: A majority of the patients undergoing orthopaedic or general surgery, and gynaecological procedures had improvement in pain. This survey highlights the need for investigating future postoperative pain management protocols so that the intensity of postoperative pain, incidence of chronic persistent pain and resulting suffering, as well as disability, can be minimised to a large extent.
Global perceived effect, Numerical pain rating scale, Neuropathic pain system inventory
Pain is now the fifth vital sign according to the latest published clinical guidelines (1),(2), thus requires adequate clinical significance, good patient care, a quick response team, and a holistic management approach (3),(4),(5),(6). Pain management should not be considered a social commitment to the patient; it is an essential humanitarian need of every surgical procedure. Inadequate and under-treated pain may result in increased morbidity and mortality [7,8]. Postoperative pain gives the patient a traumatising memory and is equally dangerous as intraoperative awareness. As long as the surgery is successful, pain is considered a phenomenal event following surgery and is often neglected.
There have been worldwide surveys focusing on medical, ethical, and legal trends and initiatives related to the concept of pain management as a human right. Reasons for deficiencies in pain management include cultural, societal, religious, and political attitudes, including acceptance of torture (9). It was concluded in a multicentric study that, because pain management is the subject of many initiatives within the disciplines of medicine, ethics, and law, the authors are at an “inflection point” in which unreasonable failure to treat pain is viewed worldwide as poor medicine, unethical practice, and an abrogation of a fundamental human right (9). According to a survey conducted in Poland among seven hospitals in 2016, pain control seems to be unexpectedly poor in majority of centres (10). Thus, despite World Health Organisation (WHO) proclaiming pain relief as a fundamental human right, unfortunately, many surgical patients experience moderate to severe pain in the postoperative period.
Although worldwide attention is being paid to perioperative patient care, there is paucity of similar evidence from India. Few published studies have assessed postoperative pain, only at 24 hours intervals, and utilising tools focusing on any one parameter of pain (7),(8). Hence, a holistic assessment using four different pain assessment tools should be done to get a wider overview of the condition. Studies assessing the neuropathic components of postoperative pain,are also scarce in India. Moreover, very limited studies in the past have assessed postoperative pain at varying intervals-6, 12, and 24 and 48 hours but there were methodological flaws. Although a similar study has been reported from India, but pain beyond 24 hours was not assessed, and only neuropathic component of postoperative pain was studied using the NPSI (11).
Hence, the aim of this study was to conduct a detailed 48-hour follow-up of patients undergoing different surgeries, to evaluate the postoperative pain management at the tertiary healthcare centre and assess the patient satisfaction as well as perception of the healthcare providers. The primary objectives were to assess the intensity and severity of postoperative pain at 6, 12, 24 and 48 hours postoperatively. The secondary objectives were to assess the presence, intensity, and severity of the neuropathic component of postoperative pain and assess the overall patient satisfaction at 24 hours postoperatively.
A prospective observational study was conducted at a University of Medical Sciences, Delhi, India from October 2020 to October 2021. This survey was conducted in compliance with the ethical standards of the Institutional Ethical Committee (HR/2020/37/5R).
Inclusion criteria: ASA (American Society of Anesthesiologists) grade I and II patients undergoing elective surgery for orthopaedics, gastrointestinal, general surgery, obstetrics and gynaecological ailments, consented to participate and cooperated, were included in the survey.
Exclusion criteria: Patients with age <18 years, requiring Intensive Care Unit (ICU) care, with co-morbidities like diabetes mellitus, hypertension, bronchial asthma, renal disease, and cardiac diseases, underwent multiple surgical operations and incidence of infections were excluded.
Sample size calculation: For calculating sample size, the formula used was X=Zα/22 *p(1-p)/d2, where Zα/2 is the critical value of the normal distribution at α/2 (for a confidence level of 95%, α=0.05 and the (value is 1.96), p is the prevalence of moderate postoperative pain {Numerical Rating Scale (NRS)=4-6.5} (40.83%) observed at fifth postoperative hour, d is the Margin of error for 5% level of precision, the final sample is 390 patients (11). Total 400 subjects were enrolled in this study.
Procedure
Tools for data collection: The doctors taking the survey were not involved in any form of intervention like administrating analgesics, thus minimising bias. Patients were explained about the survey and a Patient Information Sheet (PIS) in English and Hindi was handed over to them before taking their complete written informed consent. Strict confidentiality was assured to the patients. Those who signed the consent were taken-up for the survey and were asked a few questions regarding the presence or absence of pain, the intensity of pain, type of pain, and other associated symptoms.
Questionnaire: It was prepared according to the American Pain Society Patient Outcome Questionnaire-Revised (APS-POQ-R) (12-Parameter considered) (6). It included three different pain scales keeping in mind different types of pain:
1) Numerical Pain Rating Scale (NRS-Pain) (12);
2) Global Perceived Effect (GPE) (13); and
3) Neuropathic Pain System Inventory (NPSI) (12-Parameter considered) (14).
The patient proforma was filled by doctors and hence designed in one language only, i.e., English. The participants were assessed at different time intervals-6 hour, 12 hour, 24 hour, and 48 hour postoperatively for pain severity, type, associated with body movements like sitting, changing posture on bed, standing, walking, and going to the toilet. A pretested semi-structured questionnaire was used to assess patients’ level of satisfaction.
Statistical Analysis
All data were analysed in Statistical Package for Social Sciences (SPSS) 20.0. Descriptive summary using frequencies, percentages, graphs, mean, and standard deviation will be used to present study results. Probability (p) will be calculated to test statistical significance at the 5% level of significance. Categorical variable will be analysed using Chi-square test. Continuous variable will be calculated using independent t-test. Regression analysis will be done to establish association between independent and dependent variables.
Among the 400 patients in this study, mean age was 43.26±4.98 years. Majority was males 250 (60%) and of ASA Grade I 208 (52%). A majority had undergone 150 (40%) orthopaedic surgery followed by gastro-surgery and obstetrics and gynaecology surgery 100 (25%) (Table/Fig 1).
The mean NRS Pain score was observed to be lowest at 48 hours postoperatively and it was 5.56±1.23, 6.23±1.48, 5.23±0.54 and 5.89±1.82 in those with orthopaedic, gastro-surgery, general surgery and obstetrics and gynaecology at 48 hours. Significant improvement was seen in orthopaedic surgery, general surgery and obstetrics and gynaecology (Table/Fig 2). The mean global pain effect score was significantly improving in the patients who underwent orthopaedic surgery. The score was 6.86±0.12, 6.23±0.23, 5.89±0.86 and 4.23±1.04 at 6, 12, 24 and 48 hours, respectively (Table/Fig 3). The mean NPSI score was significantly improving in the orthopaedic surgery, gastro-surgery and general surgery (Table/Fig 4).
Majority patients (80.25%) had received information about their pain treatment but only 43.5% were satisfied with their pain treatment. 55.75% had participated in the decisions related to their pain management. 51.25% complained that postoperative pain prevented them from regular activities. 47.25% had worst pain in 24 hours (Table/Fig 5),(Table/Fig 6).
In the postoperative period following surgery, the patients experience pain of different types, magnitude and intensity depending on various factors. The postoperative pain can be acute or chronic. Acute pain is experienced immediately after surgery (upto 7 days) and pain that lasts for more than three months after surgery is chronic.
In the following study, the mean NRS Pain score was high at 6, 12 and 24 hours postoperatively while lowest was observed at 48 hours among those with orthopaedic, gastro-surgery, general surgery and obstetrics and gynaecology. Similarly in a study by Venkatesan U et al., severe pain was felt by nearly all (70%) among general surgery patients, 60% in orthopaedic surgery patients and 50% had moderate pain in urological surgery patients, respectively postoperatively (15). Subramanian P et al., also reported in their study that majority of respondents reported severe pain in the first 24 hour postsurgery (16). One study highlighted that high pain output scores might indicate that inadequate doses of analgesics were given to the patients after surgery (17). Poorly managed pain during postoperative period not only results in discomfort and suffering of patients, but also associated with many complications (18).
The mean global pain effect score was significantly improving in the patients who underwent orthopaedic surgery and the pain was significantly less after 48 hours postoperatively. Results of this study were inconsistent with study by Venkatesan U et al., also reported that majority (60%) of the patients who underwent orthopaedic surgery had severe pain postoperatively but 88% had a positive attitude towards pain management (15). This discrepancy in severity of pain and attitude has been explained by few researchers-there was a significant association with patient information about the disease and attention of operation theatre staff to the patients’ complains [15,19,20]. However, Venkatesan U et al., stated that that there was no relationship between severity of pain and type of surgery (15).
The present study reported neuropathic pain postoperatively among the patients who underwent orthopaedic surgery, gastro-surgery and general surgery, respectively and pain did not reduce significantly even after 48 hours. There is paucity of evidence regarding the neuropathic pain postoperatively. Due to central sensitisation, neuropathic pain takes time to relieve (2),(3).
Less than half (43.5%) patients in this study were satisfied with the postoperative pain management. This is very less in comparison to study by Bizuneh YB et al., who reported that overall patients who were satisfied with pain management service were 72.2%. The patient satisfaction can be gained by good caring attitude of healthcare professionals, preoperative pain education, presence of good communication, and providing frequent education on pain related issues from the ward nurses, especially focusing on the frequent measurement of pain assessment (21). Gordon B et al., has observed that satisfaction among patients on nursing care was reported as the most essential influencer of the overall satisfaction with hospital care and an important aim of any healthcare organisation (22). The strength of this study is that it has tried to study the relationship between severity of pain and type of surgery. Moreover, the neuropathic component of pain was studied in this research.
Limitation(s)
The patients were selected non randomly which poses the risk of selection bias and compromise of the external validity.
More than half the patients recruited had persistent postoperative pain of moderate intensity, reflecting that pain management after surgery is a neglected area in the healthcare system. This survey was conducted for investigating future postoperative pain management protocols so that the intensity of postoperative pain, incidence of chronic persistent pain and resulting suffering, as well as disability, can be minimised to a large extent.
DOI: 10.7860/JCDR/2023/60044.17903
Date of Submission: Sep 06, 2022
Date of Peer Review: Nov 29, 2022
Date of Acceptance: Jan 23, 2023
Date of Publishing: Apr 01, 2023
Author declaration:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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