Journal of Emergency Medicine, Trauma and Acute Care - 2 - International Conference in Emergency Medicine and Public Health-Qatar Proceedings, October 2016

Developing cultural competency in mental health provision became an imperative skill in the age of globalization. This involves the enhanced knowledge and attitudes of care givers (NKI). We will review the geodemographic, religious, linguistic, and family structure in the Middle East so we can understand some of the special approaches needed to achieve our goal. We evaluate the common pitfalls and caveats of our own practices starting with our formal western curriculum, the types of therapeutic approaches that we have gathered and learned, our biases and prejudices and all our educational, cultural, and life experience baggage. Also, we will go over the difficulty of applying diagnostic criteria applicable in the west to Middle Eastern pathologies, where albeit they carry the same name, the presentations are very different. A literature review of many documented experiences and research into the same issue was conducted, and we are including the most relevant findings and solutions to approach these practices. Many earnest efforts have been invested in building educational edifices and branches of international colleges in the Middle East that produce highly-educated and skillful professionals, yet the problem is the same for the curriculum that was given, as it was still a western plan tailored to a different society and culture.

Conclusion: Although it is a slow process, we have been able to identify some of the differences and as we go, we are applying the appropriate changes (Ex. Validated diagnostic scales, modified interviewing questions and better understanding the cultural idioms of complaints).

Background: Hamad General Hospital (HGH) houses the main Emergency Department (ED) in Qatar. This busy ED has a 27 bedded resuscitation area. Within a 24 hour period there could be any number between 1 to 10 cases that needed emergency or urgent intubation. Over the years, there has been multiple addition of new life saving devices to the resuscitation areas. All these devices add to the clutter of the already crowded resuscitation area, and may indirectly add to the chaos and occupational risk typically seen in a busy environment.

Methods: We aim to develop an airway trolley (by re-cycling available parts in the hospital) which can accommodate all standard airway equipment and all of our current difficult airway devices – Glidoscope, Stortz CMAC video laryngoscope and Stortz Flexible Intubating Video Endoscope.

Results: We created a robust and easy to clean trolley, with ample of work platform and storage spaces within easy reach. At the same time it is also small and mobile enough to tolerate our narrow resuscitation room floor space. It has multiple power sockets to charge all of the video intubating devices, and its main power cord is long enough to reach any wall socket without significantly obstructing medical staff movements.

Conclusion: With the help of the Engineering Department, we managed to create an airway trolley that fulfills our exact requirement more than what we can find in the current medical equipment market. At the same time we also declutter our busy ED resuscitation room.

Background: A minority of children attend an Emergency may have a serious underlying, systemic infection as a cause of fever. Blood culture remains the gold standard approach to establish the diagnosis and presence of pathogens in a child with suspected, serious bacterial infection. This study describes the proportion of positive blood cultures and correlation with a basic investigation (C-reactive protein, absolute neutrophil count) and clinical presentation in children visiting an emergency.

Methods: A retrospective study at Qatar- Al Wakra Hospital- pediatric emergency over one year. Patients younger than or equal to 3 months of age, patients with any form of immune deficiency and patient with no fever were excluded.

Results: A total 828 patients (mean age 3.83 years), presenting with fever or a history of fever, 121 (14.6%) admitted to the pediatric ward, 10 (1.2%) admitted to the pediatric intensive care unit, 1 (0.12%) admitted to the pediatric surgery. In total, 20 (2.4%) had positive blood culture, of these 20, 4 (20%) were admitted to the pediatric ward, and 9 (45%) were observed in the hospital less than 24 hrs, 7 (35%) were sent to their home after the investigations. We find no differences in the mean value of ANC (p = 0.934) or CRP (p = 0.572) in patient with positive or negative blood culture.

Conclusion: The yield of positive Blood Culture in routine care in an emergency department setting is low, 2.4%. There were no significant differences in associated clinical and laboratory investigations (ANC and CRP) between the groups with positive and negative blood cultures.

Background: Neurocysticercosis (NCC) is the most common parasitic disease of the central nervous system. On the basis of an incorrect assumption that human NCC does not occur in countries in which law prohibit swine breeding and consumption of pork, the disease has been considered rare in Arab world.

Materials and methods: A retrospective study carried out in Emergency Department, Alkhor hospital, HMC from April 2014 to May 2015 (14170/14). All patients above age of 18 yrs diagnosed to have neurocysticercosis from August 2005 to December 2013 were included. Data were retrieved from medical record department and electronic data base. This included baseline demography, clinical presentation and radiological findings.

Results: Out of a total of 137 subjects enrolled 9 were excluded. All the 128 subjects were male Majority of the subjects was in the age group 21–30 yrs (n = 86). Majority were from Nepal 76 (58.1%). 30 (20.3%) patients gave history of previous episodes of seizure, however only 8 of them were on antiepileptic medication. 107 patients presented to A&E with seizures (83.5%). Among which GTCS was the most common form 85%. Use of tobacco was seen in 20 subjects (13.6%) and alcohol in 10 (6.8%). Radiological examination, CT scan revealed solitary lesion in 84 (65.5%) subjects and majority were calcified. 114 patients were admitted to the hospital out of which 5 required ICU care. Anti-epileptic medication was initiated in all patients except 10 patients. Reason could not be identified. Except 13 patients all other patients received short course of oral steroids.

Conclusion: 1) Majority of the patients are young males from Asian countries, 2) GTCS is the most common mode of presentation, 3) Solitary lesion is the most common radiological finding. The increased ease of international travel and increasing number of immigration from developing countries have led to widespread recognition of NCC developed countries.

Background: Chickenpox is a contagious viral disease that affects any age group. Chickenpox is the most common infectious disease in Qatar. Most affected age groups in Qatar in the last three years are children. Chickenpox vaccination has been included in Qatar National Immunization Program in 2000.

Aim: To describe the epidemiological characteristics of chickenpox in Qatar in the year 2012–2014.

Methods: Descriptive analysis based on data retrieved from routine surveillance system, Qatar Information Exchange, Ministry Of Development Planning And Statistics and National Immunization Program. Incidence rate was calculated for each year by gender and age groups.

Results: Total number of chickenpox cases registered in Qatar in 2014 was 574 with the incidence (259.1 per 100,000) which was higher than 2012 (244.5) and 2013 (237.4). Most affected age groups in 2012 and 2013 were 5–9 years old (105.6 per 10,000) and (82.7 per 10,000) respectively while in 2014 age group 0–4 was most affected one (87.9 per 10,000). There was a remarkable increase in the incidence rate of chickenpox in the age groups 15–19, 45–49 and 50+ in 2014 comparing to 2012 and 2013. Although the number of affected cases was higher among men comparing to women, the incidence rate in men was lower.

Conclusion: Increase of incidence rate in 2014 comparing to 2012 and 2013 influenced by the increase of the incidence rate in middle and older age groups. Our results indicate that more evidence is needed to recommend use of varicella vaccine in adults and not only in children.

Background: Marked variations in the incidence and survival of particular types of childhood cancer exist between countries. This study is to explore epidemiology, survival and trends of pediatric cancers in Jordan 2001–2011.

Methods: Descriptive study done. Cases were identified from Jordan cancer registry. All Jordanian pediatric cancers which diagnosed during 2001–2011 were included. Data about age, sex, site, morphology, vital status (alive, dead), date of last visit were collected. SPSS software20 used for analysis & Kaplan Meier method was used to calculate five- and ten-year survival rate.

Results: There were 2267 (5%) registered malignant tumor during the period 2001–2011. Crude incidence rate for cancers is 99/million in children (111 for males and 85 for females). It is more common in males (57.8%), than in females (42.2%), M:F ratio 1.4:1, Median age was 5 years. The highest percent for pediatric cancers was seen in the age group 0–4 years 41.8%. The most common types of cancers were leukemia (31%), brain and CNS (16.5%), Lymphoma (15.9%). Five and ten years Survival rate for pediatric cancers is 70% and 65% respectively. Five Survival rate was best seen in eye cancer patients 91%, and the poorest survival rate was seen in neuroblastoma cancers patients (46%) leukemia (73%), brain CNS (58%) and lymphoma (86%).

Conclusion: The pattern of childhood cancer in Jordan seems to be similar to other countries in our region, where leukemia, lymphoma and brain & CNS were the most common cancers in Jordan and countries in the region, although survival rate is slightly better in Jordan than in other countries in the region.

Background: Standard Emergency Department (ED) operations goals include minimization of the time interval (hereafter tMD) between patients' initial ED presentation and initial physician evaluation.

Methods: The study was conducted using one month (May 2015) of an ED administrative database (EDAD), in HGH-ED, during the study month the ED saw 39,593 cases. The first step was generation of a multivariate model identifying the parameters associated with delay in tMD. In the second step, predictive marginal probability analysis was used to calculate the relative contributions of key covariates as well as demonstrate the likely tMD impact on modifying those covariates with operational improvements. Analyses were conducted with STATA 14 MP, with significance defined at p <  .05 and confidence intervals (CIs) reported at the 95% level.

Results: In an acceptable linear regression model that accounted for just over half of the overall variance in tMD (adjusted r2 .51), important contributors to tMD included shift census (p = .008), shift time of day (p = .002), and physician coverage n (p = .004). Marginal predictive probability analysis was used to predict the overall tMD impact (improvement from 50 to 43 minutes, p <  .001) of consistent staffing with 22 physicians.

Conclusions: The analysis identified expected variables contributing to tMD with regression demonstrating significance and effect magnitude of alterations in covariates including patient census, shift time of day, and physician n. Marginal analysis provided operationally useful demonstration of the need to adjust physician coverage numbers, prompting changes at the study ED.

Background: Age and sex are major determinants of cancer incidence. The objective of the study is to explore epidemiology of cancer in Jordan by age and sex for 2001–2011.

Methods: Descriptive study done, cases were identified from Jordan cancer registry (JCR), all Jordanian cancers patients that diagnosed and registered in 2001–2011 were included variables collected SPSS 20 used for analysis.

Results: Total number of cases in JCR were (45063), 22009 (48.8%) were males (23054) (51.2%) were females, M:F ratio 0.95:1. There is difference of distribution of cancer cases by age group, sex, (41.5%) of the cases in < 60 years, Male (57.7%) than female (42.3%), while females (60.1%) more common in the age group 30–59 years than males (39.9%), in the age>15 years males (57.8%) were more than female (42.2%). Top ten cancers in by different age groups: leukemia, lymphoma, and brain were predominant cancers in 0–19 years in both sexes, while breast cancer is the commonest cancer in female in 20–49 years then thyroid cancer. In males, lymphoma and colorectal are the commonest. In the age group < 50 years breast cancer (33.7%), again is the first in females followed by colorectal cancer (12.1%) while in males lung cancer (14.8%), colorectal (14.5%) and prostate cancers (11.6%) are the commonest.

Conclusion: There is variation of percentages of top ten cancers by different age groups in Jordan compared with other countries, efforts and attention to each age group and sex with type of cancer should be consider in cancer prevention. Further detailed studies about risk factors of cancer to age group and sex. Considering these data about age and sex in cancer screening programs in the future.

Background: To test the effectiveness of a school-based, peer-led smoking and asthma education program, known as the Triple A (Adolescent Asthma Action) in Jordan (TAJ), with an additional class smoke-free pledge strategy (TAJ-Plus) as compared to the TAJ alone on smoking-related knowledge and perception, nicotine dependence, and asthma control in male high school students in Jordan four months post-intervention.

Methods: In this cluster-randomized controlled trial, four public male high schools in Irbid, Jordan were randomly assigned to receive the TAJ-Plus (n = 215) or the TAJ (n = 218). TAJ educators were 3rd year male undergraduate nursing students (n = 9) who received training in a one-day workshop. These educators then trained senior students from the four schools to be Peer Leaders (n = 53), who then taught peers in grades 7 and 8 (n = 433). The Peer Leaders in the TAJ-Plus schools implemented the smoke-free pledge within the 7th and 8th graders, who voluntarily signed the pledge for four months. Data were collected from students in grades 7 and 8 using self-administered questionnaires at baseline and four months post-intervention.

Results: Students from the TAJ-Plus group reported significant improvements in smoking-related knowledge and perception (p < 0.001) and lower nicotine dependence (p < 0.001) as compared to the TAJ group. Improvement in asthma control was greater (p = 0.03) in non-smokers versus smokers.

Conclusions: Voluntary group commitment smoke-free through a pledge is feasible, and an incentive to motivate adolescents to abstain from smoking. Using social influences approaches in schools is useful in countering current aggressive tobacco marketing campaigns in Arab youth. TRN: NCT01938976

Objective: The study aimed to measure the status of cold chain management among primary health care professionals at primary healthcare centers (PHCC) in Qatar.

Methods: A cross-sectional design with pre-post-intervention study was conducted, and 570 primary health professionals were selected from 21 PHCCs using random sampling. A structured self-administered questionnaire was used to collect data regarding the status of cold chain system of healthcare workers before and after educational intervention.

Results: Of the 570 subjects, 492 (86.3%) participated in the post-intervention evaluation. cold chain management, before the intervention six elements were present in all of the PHCCs (100%), eight were present in >80%, another eight were present in 60–80%, while 13 were present in < 60%. These figures improved to 8, 13, 4, and 10, respectively, after the intervention.

Conclusion: In Qatar, The current status of cold chain status among primary healthcare workers had significantly improved after intervention. The practices of health professionals were also found to be adequate. Therefore, it is recommended that all health professionals working in PHCCs should receive mandatory cold chain management training to ensure delivery of safe and effective vaccines in Qatar.

Keywords: KAP, cold chain, primary health care center, immunization, PHC, Qatar

Background: Gestational diabetes mellitus is characterized by high blood glucose levels during pregnancy. The reported prevalence of GDM is 7% worldwide while 8% in Pakistan. About 19.5% of the women with GDM develop post-partum metabolic syndrome.

Methods: A prospective cohort study carried out at tertiary-care hospital in Lahore from Jan 2013 - Dec 2014 to determine the incidence of Mets in women with GDM. After informed consent, women with and without GDM were enrolled during 28th week of pregnancy. Demographic and personal data were recorded. Presence of Mets was evaluated 6 months after delivery measuring their blood pressure, anthropometry, fasting blood sugar (FBS) and triglycerides. Cumulative incidence of Mets, means of blood pressure, anthropometric measures were calculated. Comparisons of general characteristic and component of metabolic syndrome were done by student t-test.

Results: 102 women with GDM and 104 without GDM were followed. The Cumulative Incidence of Mets was 33% in GDM while 15.4% in non-GDM (P-value = 0.002). GDM group were significantly older than non-GDM group (P-Value < 0.001). In GDM group 29 (28.4%) had impaired FBS while in non-GDM group 7 (7%) had impaired FBS. Diabetes developed in 27 (26.5%) of GDM group while none of non-GDM group. BMI blood pressure fasting glucose, and triglycerides were significantly higher in GDM group than non-GDM group.

Conclusion: The study highlights that GDM group has more risk of developing Mets. They should be monitored as high risk for other cardiovascular diseases along with diabetes after delivery.

Keywords: metabolic syndrome, gestational diabetes mellitus, postpartum period

Background: Early identification and isolation of suspected communicable diseases are a major health concern, especially when there is an outbreak of a communicable disease. The ED is an essential component of the health care system and subject to workflow challenges, which may hinder ED personnel adherence to guideline based infection prevention practices.

Methods: In total, 993 suspected MERS-COV patients and their assigned nurses were screened, prospective data was recorded to study the compliance with set infection control practices. That is, hand hygiene (HH), proper use of personnel protective equipments (PPE), isolation techniques, and use of isolation indicators. Data was collected for a period of six months from Nov 2013 to April 2014. Data was then transferred into an excel sheet to calculate the percentage of compliance and non-compliance with each indicator. Each indicator was analyzed separately to find out the poor compliance.

Results: Out of 993 observations made 76.74% of nurses adhered to hand hygiene practices and 57.30% used proper PPE as recommended by CDC guidelines, 69.59% of suspected MERS-COV patients were isolated using the right technique and 73.31% used correct isolation indicators. The lowest indicator identified is in the use of proper PPE, were 42.70% of nurses are not complying with the standard.

Conclusion: Compliance with the infection control indicators showed improvement over time except in the use of proper PPE. Focused training, vigorous awareness campaigning is required to achieve a target of 100% compliance with infection control practices.

Background: Emergency Department (ED) is amongst the most crucial departments in the hospital. It receives around 1000 patient/day. ED overcrowding (EDOC) and increased Length of Stay (LOS) are key global issues for more than 20 years, as they have serious repercussions. No measurements have been done to assess the situation nationally.

Methods: The paper used direct observation for seven days to collect patient flow data on ED patients at a secondary care hospital in Kuwait. It calculated wait times and services to identify the major causes of EDOC and increased LOS.

Results: A total number of 6383 patient visits were registered, 1750 of them were referred to the ED observation room. Among these, 210 patients stayed more than 6 hours as a total ED visit time. The aggregated time of the 210 patients was 1918.95 hours. Further analysis revealed that they spent 1078.98 hours as wasted waiting time. (Waiting for a vacant in-patient bed) constituted 52% of that time, (waiting for a consultation reply) constituted 13.3% and (waiting for a radiology request to be executed) constituted 13.29%.

Conclusions: Around one-third of the ED design capacity was utilized by 12% of the ED patients. The wasted waiting time represents 56.2% of the aggregated LOS, and access block to inpatient wards was the primary cause of increased LOS and EDOC. A national-wide measurement project should be considered to assess the exact problem volume, its impact and test solutions, which should eliminate the waits before trying to reduce the service time.

Introduction: A mass casualty incident (MCI) or disaster can happen at any time. People at the extremes of ages are affected more especially children. Working in the nation's biggest Emergency Department (ED), Hamad General Hospital (HGH)-ED, staff preparedness is crucial to handle such unfortunate event or events. This study aims to assess the preparedness level, knowledge and the willingness of the HGH-ED staff to deal with MCI/Disaster involving children.

Methods: A prospective descriptive study design-using questionnaire to gather data. The study included a 21-item Questionnaire examining preparedness level, knowledge and the willingness of HGH-ED staff dealing with MCI/Disaster involving children. The questionnaire was send to 720 HGH-ED staff, descriptive statistics were used to describe study variables.

Results: Out of the total responders, 73.5% were ED nurse and 26.4% ED physician the average work experience was 7.81 ± 4.94 years. 74% reported that they have never been involved in disaster/MCI involving children's and 82% of the total responders they don't have any formal training in regard of dealing with pediatric victims of disaster. 64% where either unaware or uncertain about the existence of HGH-ED pediatric specific disaster plan.

Conclusion: The result of our study showed that the preparedness level and the knowledge to deal with disaster/MCI involving children in our ED staff were found to be low due to lack of knowledge of children special needs and lack of experience to deal with children involved in MCI and low level of training that ED staff had.

Background: Pesticide poisoning is a global public health problem. With growing population and rapid industrialisation in Qatar, there has been a natural increase in pesticide usage and hence, exposure amongst the workers handling them. It is therefore vital to understand existing knowledge, attitudes and practices about handling pesticides.

Methods: 100 municipality employees in Qatar who work with pesticides, were interviewed in person by trained bilingual staff using a structured questionnaire model.

Results: The mean age of the workers was 37.4 (SD-9.9) Of the interviewed workers, 81% did not know the contents or the name of the pesticides they were handling at work. Unsafe behaviours such as preparation of pesticides at the site of its usage rather than in a specified preparation room (29.6%), non-compliance with wearing protective clothing (38.8%), handling of drinking water (22%) and food (10%) on site where pesticides are used and not washing clothes every day after work (45.9%) were observed. Workers who received training in pesticides usage were more likely to be aware of its effects on the environment (61.6%) (OR-3.9), less likely to eat or drink while handling pesticides (83.6%) (OR-4.3) and more likely to give household members appropriate instructions prior to application of pesticides (90.4%) (OR-5.0). Workers who did not wear special protective clothes at work were found to be, more than twice as likely to visit hospitals per year, than those who wore (RR-2.2).

Conclusion: Unsafe practices were found to be significantly common amongst the personnel using pesticides. Workers who received prior training handled pesticides in a safer way.

Introduction: Sleeve gastrectomy has been a rising trend in management of morbid obesity in the Qatari population. National health insurance has included sleeve gastrectomy in the coverage scheme for patients with BMI of 40 or above, which has contributed to the consistent increase.

Objective: We aim to highlight one complication that we saw in our clinical practice of a 32 years old female who developed acute foot drop after sleeve gastrectomy. Clinical Scenario: We have been consulted to see a wheel chair bound 26 years old female who suffers from acute foot drop. The presentation was dramatic to the extent that hindered the patient from walking properly. Few weeks before this presentation, the patient has undergone a successful sleeve gastrectomy that was followed by a smooth period of convalescence and no reported post-operative complications.

Results and Conclusion: Sudden loss of popliteal pad of fat can fairly explain vague foot drop after sudden and rapid weight loss following bariatric surgery. Conservative management has proved to be effective saving the patient another surgical intervention.

Recommendations: Loss of popliteal pad of fat can fairly explain vague and sudden acute foot drop following rapid weight loss. Watchful waiting accompanied by physiotherapy proved to be effective management for this case and saved the patient surgical intervention of popliteal nerve decompression.

Background: Conventional endotracheal intubation (ETI) is challenging and requires high level of individual skills and experience. At the same time we are also committed to provide ETI training for Emergency Medicine Residents (EMR). Video laryngoscope (VDL) like the C-MAC (by Karl Storz) is designed to have a similar blade to the normal Macintosh blades (size 3 and 4). It has a bright light source and blade thickness that allow Direct Laryngoscopy (DL) and hence ETI under direct vision. We organised several sessions of ETI training using an intubating manikin. We found that the view from the C-MAC screen captured by the C-MAC video camera is the same view described by the operator doing the DL. There were enough consistencies reported during several training sessions that we decided to use the C-MAC for DL in real cases of ETI in the resuscitation room. We have done several ‘live’ cases and all intubations successfully as DL, with the added benefit of ‘video supervision’ and ‘video confirmation’ of the tube positioning. We also used the video recording and playback functions to give feedback to the EMR at the end of the procedure.

Methods (Case Report): In this educational poster, we describe a step-by-step laryngoscopic and ETI view seen on the C-MAC screen during one of our airway training session with the manikin. We also include several views of possible poor technique in laryngoscopy that may result in a failed intubation attempt.

Results: We discuss the potential safety and training benefits in conventional ETI using C-MAC VDL.

Conclusion: We conclude that promoting the use of this technique in ED, especially for ETI undertaken by a trainee improves patient safety and supervision.

Background: Obesity is a public health concern in both developed and developing countries, and it is a main risk factor for chronic diseases. Thus, Palestinian adults aren't spared from obesity and non-communicable diseases epidemic. This study aimed to assess the pattern of obesity among mothers in the Gaza Strip.

Methods: A cross-sectional study was conducted on of 357 mothers aged 18–50 years between April-October 2012 in the Gaza Strip. A structured questionnaire was used to collect sociodemographic information and the short form of the International Physical Activity Questionnaire (IPAQ) was used to assess the physical activity pattern. Mother's nutrition knowledge was evaluated using 16-item questionnaire. Anthropometric measurements were conducted among the mothers, and body mass index (BMI) ≥  30.0 kg/m² was computed to determine the prevalence of obesity. Multiple logistic regression was conducted to predict the associated factors of obesity.

Results: The prevalence of obesity among mothers was high (29.6%). About 78% of mothers were classified as moderately active, 21.6% of them were inactive, whereas, vigorous activity was not observed. Results revealed that as the age increased, the risk of mothers to be obese increased (OR: 1.11; 95% CI: 1.06–1.15; p < 0.001). Mothers with the medium education level have higher risks of being obese (OR: 2.39; 95% CI: 1.20–4.78; p = 0.013). Increased scores of nutrition knowledge to a participant increased the risk of being obese (OR: 1.17; 95% CI: 1.03–1.32.0; p = 0.013).

Conclusions: This study highlights obesity as a public health concern in the Gaza Strip. Age, educational level, and nutritional knowledge were found to have more influence on the prevalence of obesity. Community-based intervention programs should be applied to increase awareness among women and to help them to translate their nutrition knowledge into healthy dietary practices. In addition, effective program is required to increase physical activity levels for women.

Background: Worldwide ambulances are regularly involved in accidents as staff may not anticipate other drivers' actions, suffer from fatigue, or overestimate their driving privileges. An ambulance driving safety campaign started in June 2015 targeting some 935 registered HMCAS drivers. We aim to determine if our approach is effective in changing behaviours and believes, and reducing the number of accidents involving HMCAS vehicles.

Methods: This study was ethically approved as a quality improvement project and is still ongoing. The campaign made use of ambulance dashboard stickers and posters at ambulance stations' exits with respectively 4 and 6 key messages covering frequent issues resulting in collisions. An official circular also informed staff of the campaign. A month later a survey started to be distributed to staff.

Results: In two month, 189 anonymous online or paper questionnaires were fully completed. 69.2% of respondents had an HMCAS driving qualification (13.7% of qualified HMCAS drivers). On average, they reported having been involved in 0.90 accident requiring vehicle repair. Using a 5-point Likert scale (1 = very unsafe, 5 = very safe) respondents rated themselves as being safe drivers (4.24/5) and underestimated the monthly number of accidents with HMCAS vehicles to be 15.3 (Actual 21.2/month registered in 2014). Other data about self-reported driving behaviour and comparison between their perception about accidents and real data was analysed along with visibility and memorisation of the key messages.

Conclusions: Staff underestimated the number of accidents. Campaign material has been noticed by most staff except for the stickers inside the ambulances driving compartment which is not accessed by 23.2% of the respondents. Staff who saw the posters and stickers remembered nearly half of the information it contained. Although a significant decline accidents occurrences was noticed in September, the impact of the campaign cannot yet be reliably assessed over this relatively short period of time.

Infant mortality is a sensitive indicator of development of a country and investing in the health of children. Since 1997 Morocco has been engaged in a the program of the integrated care of the child. We evaluated the information system of the integrated child-care program and the opportunity for collecting reliable data and good quality necessary to identify priorities. We conducted an evaluation of the information system of the integrated child-care program performed at the province of Salé and that of Rabat. We included 135 health professionals. The evaluation was carried out according to World Health Organisation criteria. We used a comprehensive sample of Provincial Epidemiology Units' involved health professionals, Service Infrastructure and all Health Centers in the region involved in the integrated child-care program. We administered a questionnaire The Rate of participation 65s%. The system was considered easy by 72.7%. The reports were timely sent for 27.2%. These Reports we reproduced in 60% of health professionals involved in the integrated child-care program. The System was useful for 63.6%. The Data were only processed locally and in 27.2%. The Feedback was provided to the relevant structures in 9%. 81% have received training in the integrated child-care. This system is considered useful to estimate the burden of disease and allows the allocation of resources necessary for its operations, it is simple, relatively acceptable hence the need to provide significant efforts to improve the quality of the information produced: Generalizing the integrated child-care program to the entire region; Promoting the decentralization of the system at the regional level; Further developing the communication network between different levels: information and feedback; Adapting the system to the needs of users by simplifying collections of records and promoting the analysis of data collected.

Background: Vomiting is a symptom commonly encountered in emergency settings, with many differential diagnoses. In the following case, the diagnosis was nearly missed and the outcome could have been critical.

Methods: A case study was performed, supported by literature review. A 32 year-old lady presented to the Emergency Department with repeated vomiting for one day. She has had epigastric discomfort for several days. Her blood pressure was 119/74 mmHg, heart rate 118/minute, and she was afebrile. She had been under the in-vitro fertilisation program and received human chorionic gonadotrophin, oocyte retrieval and embryo transfer 8, 6, and 3 days respectively prior to presentation. On examination, her abdomen was soft, non-tender. Urinary pregnancy test was negative. Her sodium level was 131 mmol/l, Hb 17.0 g/dL, white cell count 20.5 ×  10*9/L, and platelet 485 ×  10*9/L. The rest of the renal and liver functions and amylase, were normal. She was admitted to the Emergency Ward with a working diagnosis of gastritis. On reassessment, her abdomen was noted to be slightly distended although no tenderness or guarding was elicited. Ovarian hyperstimulation syndrome was suspected, and gynaecology was consulted for further evaluation.

Results: Transvaginal ultrasound scan showed a normal-sized uterus with thickened endometrium and no intrauterine sac. Both ovaries were enlarged, left ovary 6.1 ×  4.3 cm and right ovary 5.0 ×  5.3 cm. Significant pelvic free fluid was present. The diagnosis was confirmed to be early ovarian hyperstimulation syndrome. Ovarian hyperstimulation syndrome is an iatrogenic complication from assisted reproduction technology. Following gonadotropin therapy, this condition usually develops several days after oocyte retrieval or assisted ovulation, with ovarian enlargement due to multiple ovarian cysts. Complications include ascites, haemoconcentration, hypovolaemia, and electrolyte imbalances.

Conclusion: Emergency physicians should consider ovarian hyperstimulation syndrome in patients who had received assisted reproduction presenting with repeated vomiting.

Background: Trauma is a major cause of death worldwide that can result death or permanent disability. Globally, 6–10% of all deaths are attributed to traumatic injuries. In Saudi Arabia, trauma is a public burden as a result of its socioeconomic impact. Our aim is to describe the pattern of traumatic injuries and predictors of in-hospital mortality among patients admitted through the ED of King Abdulaziz Medical City.

Methods: A retrospective cohort study was conducted on 3786 trauma-injured patients admitted from 2012 to 2014. Data on: patient characteristics, trauma characteristics and outcome characteristics, were extracted from a prospectively collected database. Logistic regression analysis and ROC curve were applied.

Results: Of 3786, (77.5%) of victims were males, (29.8%) injuries occurred in the age group (15–25 years). Blunt injuries constituted (87.1%), followed by burns (7%), intentional injuries (5%) and drowning & foreign body (1%). Data showed seasonal variation with two main peaks in March and August (p < 0.001). In-hospital mortality rate was (4.7%. Significant predictors of in-hospital mortality were age (p < 0.001), intubation need (p = 0.009), ISS (p < 0.001), RTS (p = 0.007), GCS (p = .004) and road traffic accidents (p = 0.001). The cut-off points for prediction of in-hospital mortality: were as follows: ISS = 22, AUC = 93%, ATS = 9, AUC = 78% and GCS = 8, AUC = 83%.

Conclusions: Our recommendation is targeted to ED policy makers to recognize the patterns of injury and the seasonal variation to structure and distribute the facilities and staff in a cost-effective manner. Also, enforcing trauma preventative measures should be encouraged. Secondly, for ED physicians to enhance the use of in-hospital predictors of mortality. Finally, educational programs targeting the general population are essential to cover all aspects.

Background: Patients experiencing psychiatric emergencies often require resources not available at the hospital to which they present and frequently require transfer to an appropriate psychiatric facility as it is the case at the Emergency Department of HGH. This typically involves being held in the Emergency Department (ED) until a psychiatric bed is available. Boarding of psychiatric patients, (defined as a length of stay greater than four hours after medical clearance), is ubiquitous throughout emergency departments nationwide (USA) and in Qatar.

Methods: The Emergency Department at HMC established in May 2014 an innovative and pioneering psychiatric liaison service based in ED, it is the first in the Gulf Area. In this study we are set to look at the difference in response time, boarding time, and disposition during the last six month compared to a similar period of a previous year.

Results: When initiated treatment in ED and mobilized the community based services available in Qatar, the preliminary results indicate a substantial decrease of total admissions, a similar decrease in overnight boarding and a shorter turnaround time to disposition. A 18% decrease of total admissions, and a 300% decrease in overnight boarding.

Conclusion: Having a dedicated psychiatric team embedded in a busy emergency department is conducive to providing a higher quality of mental health care, decrease the adverse occurrences associated with boarding the severely mentally ill. We established a training program (C&L Fellowship with one year ER psychiatry and educational modules for the medical ED Staff).

Background: Although Retropharyngeal Hematoma (RPH) has unknown frequency but considered a rare condition which can cause a life threatening airway obstruction. Various precipitating factors have been mentioned as causes of RPH as blunt head or neck trauma, whiplash injury, coagulopathy, central line insertion, stellate ganglion block, sneezing, severe coughing as well as spontaneous RPH.

Methods: We report a case of severe life threatening retropharyngeal hematoma secondary to a closed stable C5-C6 fracture that caused severe upper airway obstruction.

Results: As the RPH can develop hours or days, even after an apparently minor precipitating injury, in our patient it took almost 3 hours from time of accident till the development of severe upper airway obstruction (picture to be added in main poster). It was such a large collection hematoma that caused severe upper airway obstruction with cannot intubate cannot intubate situation.

Conclusion: RPH can cause a mechanical displacement of the pharynx & larynx making securing airway with ETT almost impossible with conventional laryngoscopy or even video-assisted techniques. On the other hand, the time taken for RPH to develop and to cause mechanical obstruction can be limited enough to allow proper preparations as well as availability of fiberoptic technique. We should keep a high index of suspicion of retropharyngeal hematoma and airway involvement in cases of cervical spine fracture, in order to help other physician to increase their awareness and anticipation of such life threatening & meantime avoidable condition.

Keywords: retropharyngeal hematoma, airway obstruction

Urticaria is a common presentation in Emergency Department. Most of the time its idiopathic or immune mediated. In a small proportion of cases it may be a symptom of serious medical illness. We report two case of urticaria with underlying medical causes.

Case 1: A 33-year-old female presented to emergency with recurrent urticaria, which started 5 months back. Even though it responded to antihistamines, symptoms recurred on discontinuing medicines. No other symptom and no other past medical illness. Clinical examination was unremarkable, except for extensive urticaria. Her laboratory evaluation showed hyperthyroidism, and deranged liver function test (LFT). She was started on carbimazole and symptoms improved after a few weeks. Symptom recurred after 3 months when dose was reduced and promptly relieved on restarting old dose. After few weeks she discontinued her medication and symptom recurred. On restarting the medicine she improved again. Her LFT also improved on follow up.

Case 2: One young female was seen in emergency with episodic urticaria for 6 months. She responded to antihistamines but recurred on discontinuing medicine. No significant illness in past. Clinical examination showed anaemia and generalised urticaria. Her laboratory test showed microcytic hypo chromic anaemia and her iron profile was suggestive iron deficiency. Urticaria symptoms improved after she was initiated on iron replacement.

Discussion: The above two cases represents two systemic causes of urticaria. Exact mechanism of how these disorder produce urticaria is unknown. In case of iron deficiency, iron therapy even in the absence of anaemia, is found to improve urticaria. The prevalence of thyroid autoimmunity is high in patients with chronic idiopathic urticaria. Mast cell over stimulation by thyroid hormone is thought to be the mechanism behind the urticaria in hyperthyroidism. Physicians should look for systemic causes when patients present with recurrent symptoms.

Introduction: Omental infarction is a rare cause of acute abdomen resulting from vascular compromise of the greater omentum. Vague symptoms and non-specific signs at presentation make the clinical presentation diagnostically challenging. Evidence to guide the management of omental infarct is still controversial and limited. However, general approach is to manage it conservatively and to consider surgery only if there is a deterioration in the clinical condition. We report a case of omental infraction presented to the ED with acute abdomen that showed fruitful recovery by conservative management without requiring surgery or prolonged hospitalization.

Case Report: A 23-year-old Ethiopian male patient, presented to the ED with colicky abdominal pain of few hours duration, which was sudden in onset and was increasing in the severity. The pain started in the right side of the abdomen just lateral to the umbilicus associated with anorexia. On the physical examination; he appeared to be in pain and on the palpation of the abdomen, there was tenderness and minimal rebound tenderness over the right iliac fossa and to a lesser degree over the right lumbar region. CT scan with contrast revealed an ill-defined focal area of increased fat stranding in the omental fat in the right lumbar region, anterior to the mid ascending colon, typical to that of focal area of omental infraction.

Conclusion: Omental infarction is a rare benign cause of acute abdomen. The widespread availability of CT allows us to recognize the cases while they are in the Emergency Department.

Background: The American Heart Association (AHA) recommends to treat cardiac arrest due to Torsade de Pointes (TdP) with 1–2 grams of intravenous (IV) magnesium over 5 minutes. A second dose can be repeated within 5–15 minutes, and a continuous infusion may be considered. In cases of TdP due to severe hypokalemia, the doses and rate of administration of IV potassium chloride (KCL) are not described explicitly in the guidelines.

Methods: In this case report, we describe a peritoneal dialysis (PD) patient who had a prolonged history of hospital stay with infected diabetic foot. He was on the medical ward, but recently admitted to the Intensive Care Unit with septic shock needing inotropic support. He developed a TdP cardiac arrest with a serum potassium of 2.4 millimol/litre. We managed the cardiac arrest according to AHA guidelines and also administered a total of 120 milliEquivalent (mEq) of KCL over 2 hours. The severe refractory hypokalemia improved, and the recurrent TdP subsequently stopped only after we urgently drained the PD fluid during the resuscitation as a last resort. We also avoided administration of sodium bicarbonate even though he was severely acidotic during and after the resuscitation.

Results: To compliment this case report, we reviewed the literature available on hypokalemia in PD patient, and also on the established treatment of TdP.

Conclusion: In cardiac arrest situation secondary to hypokalemia, repeated high doses of IV KCL, up to a total of 120 mEq may be required, provided point of care testing is available. Draining the PD fluid during resuscitation, might expedite the correction of the refractory hypokalemia and malignant arrhythmias.

Background: Abdominal pain is one of the most common presenting symptoms in Emergency Department. During a recent audit, it was found that Patients presenting to HGH emergency room with a chief complaint of abdominal pain are the most common patient's category to be delayed to disposition. Currently 62% of patients with abdominal pain admitted to Male Urgent Area in Emergency Department HGH were delayed to Disposition for more than 6 hrs.

Aim: To decrease the percentage of patients with abdominal pain delayed in Male Urgent Area ED, HGH for more than 6 hrs from 62% to 50% by May 2015 Project Scope; Project period: February 10th to 24th May 2015; Place: Male Urgent Area, Emergency HGH; Population: Male patients Expected Benefits of the project; Improve Patient Flow; Improve Patient safety; Improve patient Satisfaction.

Intervention: All abdominal pain patients must first be reviewed by the consultant of the See & Treat before transfer to male urgent area. Dedicated bed for reassessment of abdominal pain in Male Urgent Area. Flagging of patients when ready for reassessment.

Results: Post-intervention length of Stay Male Urgent Area has reduced by 2.28 hrs.

Conclusions: Early senior involvement has an impact on decreasing the Length of Stay in abdominal pain patients. Flagging patients for reassessment had an impact on the Length of Stay. It was very challenging to implement the changes and reach out to every staff being a big department.

Next steps: Quarterly Audit _ Publication of the Audit _ Continuous Education & Implementing to other Areas of the ED.

The present paper was designed to reflect the impact of conflict on the health situation in Yemen. A total of 2,305,048 people are displeased from their residences. The consequences of conflict permeate countless aspects of society, and are not limited to the mass causality (death and injured), inaccessibility to the health services and disturbance of health system. The most vulnerable group is the children who are highly affected by the current conflict, data shows that Acute malnutrition is dramatically increased in 2015 survey from 2014 survey, in Hodeida and Aden governorates GAM rates is 31% and 23 in 2015 respectively while in 2014 it was 18% in Hodeida and 10% in Aden. This analysis shows that the negative effect of war on health is particularly intense in the short term following the onset of a conflict, and children are the most affected group.

Background: Reports on burden of hepatitis C and hepatitis B virus (HCV/HBV) are a big challenge for district to minimize the transmission of associated risk factors. Study was conducted to know the prevalence of HCV/HBV infection in pregnant women and their blood donors attended a surgical referral clinic for cesarean delivery.

Objective: To determine the prevalence of HCV/HBV infection among pregnant women and their blood donors.

Methods: A cross-sectional analytical study (record review) of all pregnant women and their blood donors (family members) was conducted from 10th to 15th February 2015 at a private surgical clinic in district Naushahro Feroze. Data from 1st January to 31st December 2014 gathered on results of blood screening used by ELISA test.

Results: Of 175 women aged 15–52 years, 13% (n = 22) tested positive (13 HCV; 9 HBV) besides these a total of 656 blood donors aged 16–40 years reported for blood donations and were 22% (n = 145) tested positive (80 HCV; 65 HBV). The highest positivity rate was seen in women aged 25 years or less (26%) compared with those aged above 25 years (9%) OR = 3.02 (95% CI 1.03 to 9.98). Statistically significant difference was identified between ages of donors who were aged below 25 years were high positivity rate (30%) compared to above 25 years positive for hepatitis infection (24%) OR = 1.15. 02 (95% CI 1.01 to 2.34).

Conclusions: One in eight pregnant women attending surgical clinic for cesarean delivery and one in five blood donors who came to attend for bleed has evidence of HCV/HBV infection. These HCV/HBV positive mothers may be at increased risk of transmitting HCV/HBV infection to their unborn babies. We suggest that all pregnant women attending 1st antenatal care be tested for HCV/HBV infection; exposed babies need to receive HBV vaccines at birth. Further molecular studies on risk factors needed in these settings.

Background: Previous reports suggest prevalence of high stress levels and psychological morbidity among medical students. This study aimed to elucidate factors for Perceived Stress (PS), role of Emotional Intelligence (EI) in the experience of PS and its association with academic background and satisfaction with career choice among medical students.

Methods: A cross-sectional survey was conducted in Riyadh-Medical-College-Saudi-Arabia on First (n = 40) and Final year (n = 35) Female medical undergraduates during year 2015. Students were administered Schutte's Emotional Intelligence Inventory and Cohen's Perceived Stress Scale. Additional information was collected on participant demographics, previous qualification in higher education and career satisfaction level. Basic descriptive statistics –correlation & regression were used for data analysis.

Results: The survey had a 99% response rate. Seniors were more stressed than Juniors. Although there was no significant difference for EI scores between the two groups, still, there existed a ‘definite trend’ of ‘Low EI Scores’ being associated with ‘High Perceived Stress Levels’. ‘Low scorers’ on the EI were more likely to be (i) younger age group, (ii) without a previous higher education qualification (iii) not satisfied with their decision to study medicine (p < 0.01).

Conclusions: There is an inverse correlation between EI and PS. Significant predictors of PS are age, previous higher education qualification, satisfaction with the decision to study medicine and EI level. It would be interesting to explore by further research, if any possible difference exists between genders. The ‘t’ statistic indicates EI as a pivotal predictor of PS in medical profession. We suggest that health profession institutions could organize regular programs to enhance students' EI. Considering substantial previous research evidence on Stress and Professionalism being an interrelated phenomenon in Health professions, it would be logical to consider EI as a possible qualitative selection criterion for medical students to improve eventual outcomes.

Background: Utilization of primary health care services is an important determinant of health. Individuals who receive primary health care are generally healthier than those who do not. Despite the importance of primary health care use, there are many barriers to health care access that are experienced by populations in Arab countries. This study examined primary health-care use and accessibility among adolescents living in the United Arab Emirates.

Methods: In a cross-sectional study, we collected primary health-care use, sociodemographic and residential data for 6363 local and expatriate adolescents. Analysis consisted of descriptive statistics, and bivariate and multivariate analyses. Logistic regression modelling was employed to examine predictors of health-care use, specifically ‘not receiving care when needed’, ‘having a routine physical check-up without having a specific problem’, and ‘travelling for medication or treatment to other countries’.

Results: The most-consulted health professionals were dentists or orthodontists, family doctors and eye specialists. Local adolescents were more likely to attend public clinics or hospitals than private clinics or hospitals, while the opposite was true for expatriate adolescents. In the last 12 months 22.6% of participants had not obtained needed health care, and 19.5% had not had a routine physical health check-up. Common reasons for not obtaining care were busy schedules, dislike/fear of doctors and long waiting times. Predictors of not obtaining needed care included nationality and income, while those for having a routine check-up were mother's education and car ownership.

Conclusions: Improvements to the health-care sector are needed in order to increase health-care accessibility among adolescents.

Background: Urinary retention is a common presenting complaint in Emergency Department. Meningitis can be an unusual cause for this. This combination is referred to as Meningitis Retention Syndrome (MRS). We present 2 cases of MRS diagnosed in A&E, Alkhor.

Case 1: A 43-year-old male presented to ED with low grade fever, head ache of 10 days and dysuria of 2 days duration. Examination was unremarkable except for palpable bladder. Examination of CNS was normal. He was discharge on antibiotic after catheterisation of urinary bladder. He was readmitted to ED after few days with worsening of symptoms. Physical examination was unremarkable. CT head (contrast) showed meningeal enhancements and CSF study showed lymphocytic pleocytosis. He was initiated on anti-tubercular treatment (ATT). Patient improved and was discharged.

Case 2: A 42-year-old male presented to ED with fever and dysuria. He was managed as a case of urinary tract infection. He was readmitted to ED with fever and urinary retention. Physical examination was unremarkable except for temperature 38.5°C. Blood test and urinalysis were normal. He was discharged on medication. 2 days later he was admitted with altered sensorium high grade fever and clinical features of meningitis. CSF study showed lymphocytic pleocytosis. Patient was initiated on ATT. Patient had a prolonged and stormy hospital stay and later improved.

Discussion: Meningitis Retention syndrome is thought to be a very minute form of acute disseminated encephalomyelopathy. Urinary retention might reflect acute shock phase of this disorder. Most of the previously reported cases were due to aseptic meningitis but here we report two cases of MRS due to tuberculous meningitis Acute urinary retention can provide a critical clue to the diagnosis of meningitis as a cause of fever of unknown origin.

Background: Fibrous dysplasia affecting the spine is considered an uncommon entity in polyostotic fibrous dysplasia and aneurysmal bone cysts occurring in this setting is rare. Although, these are benign conditions, they may present with acute cord compression and fractures which necessitate emergency treatment.

Clinical course: Our patient is a 38-year-old Egyptian male who presented to the Emergency Department with a 2-week history of increasing pain over the thoracolumbar spine with acute bilateral lower limb weakness and difficulty walking. There was no history of trauma or fever. Physical examination revealed significant sensory loss below the level of the umbilicus with paraparesis of bilateral lower limbs. X-rays revealed large expansile lesion over the mid thoracic vertebrae and multiple expansile lesions involving the ribs. Subsequent CT and MRI showed features of multiple areas of polyostotic fibrous dysplasia with secondary cystic degeneration and aneurysmal bone cysts formation, worst at T6-7 complicated with severe central spinal canal stenosis, cord compression. The patient underwent urgent spinal cord decompression with laminectomy at T6 and T7 and hemilaminectomy at T4 and T5 with aneurysmal cyst curettage and fat graft placement and subsequent physiotherapy and rehabilitation with complete resolution of motor and sensory deficits.

Discussion: This case highlights the presentation of benign, non-malignant, non-infectious, and non-traumatic acute spinal cord compression in the Emergency Department. This case also showcases classical radiological images of a rare combination of polyostotic fibrous dysplasia of the spine with subsequent cystic degeneration and aneurysmal bone cyst formation causing acute spinal cord compression.

Background: While there are benefits for over-the-counter medication (OTC) use, there are serious risks associated with OTC usage. These include self-misdiagnosis, possible delay in receiving needed therapy, use of suboptimal therapy, and increased resistance to antimicrobial agents. The patterns of (OTC) usage among adolescents remains largely understudied. The objectives of this study are: (1) to determine the profile of OTC use among adolescents from the United Arab Emirates (UAE); and (2) to determine the biological or physical, psychological or behavioral, and social predictors of OTC use among the UAE adolescent population.

Methods: In a cross-sectional study, we collected data on the prevalence of OTC use for a sample of 6,363 adolescents aged 13 to 20 years. We also collected demographic, socioeconomic, residential, and behavioral data. Analysis consisted of descriptive statistics, and bivariate and multivariate analyses. Logistic regression modelling was employed to examine predictors of over-the-counter medication use.

Results: Overall, 51% of participants in this study reported OTC use. The most common form of OTC used was acetaminophen. Significant predictors of OTC use include nationality (UAE, GCC, Arab/Middle East, Arab/Africa, Western, Other), needed health care but did not receive it, sex (female), age (15–18 years), any medical diagnosis, unconventional drug use, spending more than 5 hours using TV and computer daily, and using prescription medicine.

Conclusions: Considering the high prevalence of OTC use among adolescents from the UAE, public health policies and strategies that promote appropriate use of OTC in this population are needed.

Background: Tobacco consumption among youth is a growing public health concern worldwide. This paper examines the prevalence, profile, and predictors of tobacco-use among expatriate and national adolescents attending secondary schools in the United Arab Emirates (UAE).

Methods: Using a cross-sectional study design, we collected data on the prevalence of tobacco-use for a sample of 6,363 adolescents aged 13 to 20 years, including current smoking of cigarettes, midwakh, shisha, and any other form of tobacco. We also collected demographic, socioeconomic, residential, and behavioural data.

Results: Results suggest that 8.9% of participants smoked cigarettes, 6.3% smoked midwakh, 7.4% smoked shisha, and 6.4% smoked any other form of tobacco in the past 30 days. Overall, 14.0% of adolescents were current smokers, defined as participants who reported occasional or daily use of at least one form of tobacco in the past 30 days. Results consistently indicate that the prevalence of tobacco use is higher among males than females, regardless of age and tobacco form. Among males, cigarette usage is the most popular whereas shisha is the most smoked tobacco form among females. Consistent predictors of tobacco smoking include being male, age, parents' marital status, ever using illegal drugs, exposure to smoking at home or with friends, ethnicity, and location of residence.

Conclusions: Findings of this study emphasize the need for continued public health strategies and education campaigns to discourage adolescents from using tobacco. Knowledge of predictors of tobacco-use can be used to target at-risk adolescents through various anti-tobacco use initiatives and tobacco control measures.

Background: Globally, almost half of all adolescent deaths occur due to injury. Injuries related to accidental fall, being struck by an object or person, and road traffic injury (RTI) are particularly relevant among adolescents. Accidental falls and RTI are the most common causes of injury among children and adolescents. This study examines the profile of injuries among adolescents in the United Arab Emirates (UAE), including motor vehicle injuries (MVI), and identifies related factors associated with injury.

Methods: A cross-sectional study design determined incidence of injury for a sample of 6,363 adolescents aged 13 to 19 years. Data collected information on injury in the past 12 months, socio-demographic, behavioral, sensory data, and traffic-related behaviors. Logistic regression modeling was used to examine predictors of physical injury for the past 12 months, including injuries from motor vehicle collisions.

Results: Among participants, 18% experienced injury; the three top causes include accidental falls (38%), being struck by an object or person (18%), and MVI (13%). Identified risk factors that are amenable for prevention include smoking behavior, exposure to smoking, physical activity profile, family income, and speeding behavior. In relation to MVI, significant predictors are attending private schools (OR = 2.58), physical activity (OR = 1.11), family income (OR = 16.25), and speeding (OR = 2.34). Additionally, expatriates were less likely to experience MVI than locals.

Conclusion: Our findings highlight the need for public health policies and education programs that reduce injury among the UAE adolescent population. Future studies should build upon these findings to plan and implement tailored injury prevention strategies for this sub-population.

Background: Tobacco consumption adversely affects cardiovascular (CV) disease (CVD) and risk profile, including hypertension. The long-term effect of cigarette smoking on blood pressure (BP) in adolescents is still, however, equivocal. Thus, the current study examined the CV hemodynamics in male adolescent cigarette smokers versus non-smokers.

Methods: Resting heart rate, systolic (SBP) and diastolic (DBP) BP, mean arterial pressure (MAP), pulse pressure (PP), and rate pressure products (RPP) were examined using automatic oscillatory method, while smoking status was determined with Youth Risk Behavior Survey (YRBS).

Results: After covariating for cofactors, the ANCOVA showed that CV hemodynamics were lower (p <  0.05), in the male adolescent smokers versus non-smokers. Additionally, regression showed that smoking predicted the reduction in SBP (20.6%), DBP (5.0%), MAP (13.4%), PP (7.5%), and RPP (13.4%).

Conclusion: The results suggest that cigarette smoking lowers CV hemodynamics in adolescent. However, more studies are needed to describe the mechanism(s) for lowering CV hemodynamics and explain the relationship of adolescent smoking with adulthood CVDs.

Background: Pulmonary infections caused by Pneumocystis in immunocompromised host can be associated with cysts, pneumatoceles and air leaks that can progress to pneumomediastinum and pneumothoraces. In such cases, it can be challenging to maintain adequate gas exchange by mechanical ventilation and at the same time prevent further barotrauma or ventilator-induced lung injury (VILI). We report a young HIV positive male with poorly compliant lungs and pneumomediastinum secondary to severe Pneumocystis jirovecii infection, rescued with veno-venous extracorporeal membrane oxygenation (V-V ECMO).

Case: A 26-year-old male with no significant past medical history was admitted with fever, cough and shortness of breath. He initially required non-invasive ventilation to reduce work of breathing. However, his respiratory function progressively deteriorated due to increasing pulmonary infiltrates and development of pneumomediastinum, eventually requiring endotracheal intubation and invasive ventilation. Despite attempts at optimizing gas exchange by ventilatory maneuvers, patients’ pulmonary parameters worsened and he developed severe type 2 respiratory failure necessitating rescue ECMO therapy. The introduction of V-V ECMO facilitated the use of ultra-lung protective ventilation and prevented progression of pneumomediastinum, maintaining optimal gas exchange. It allowed time for the antibiotics to show effect and pulmonary parenchyma to heal. Further diagnostic workup revealed Pneumocystis jirovecii as the causative organism for pneumonia and serology confirmed Human Immunodeficiency Virus (HIV) infection. Patient was successfully treated with appropriate antibiotics and de-cannulated after six days of ECMO support.

Conclusion: ECMO was an effective salvage therapy in HIV positive patient with an otherwise fatal respiratory failure due to Pneumocystis pneumonia.

Introduction: Tobacco consumption contributes substantially to cardiovascular (CV) diseases (CVD), including hypertension. However, the effect of waterpipe (WP) smoking on CV hemodynamics in adolescents is unknown. Thus, the current study investigated the relationship of WP smoking with CV indices.

Methods: Indices including heart rate (HR), systolic (SBP), and diastolic (DBP) blood pressures, mean arterial blood pressure (MAP), pulse pressure (PP) and rate pressure product (RPP) were obtained from 7th–10th grade male students.

Results: After controlling for confounding factors, SBP, DBP, MAP, and RPP were significantly lower (p < 0.05) in WP smokers versus non-smokers.

Conclusion: The results indicate that WP smoking lowers CV hemodynamics, which is perplexing given that tobacco smoking is associated with an immediate increase in CV hemodynamics and CVDs in adulthood. Therefore, future studies are needed to determine the mechanism(s) for lowered CV hemodynamics and the pathway between WP smoking and heightened risk of developing CV diseases adulthood, namely hypertension.

Introduction: Pain is a very common reason for presenting to the Emergency Department (ED). While the causes for pain are diverse, ranging from fractures and other injuries to chest or abdominal pain or headache, the provision of effective, timely analgesia should be one of the principal goals of emergency staff . Inadequate pain relief and poor treatment in pain management in ED was highlighted by Wilson and Pendleton and they coined the term oligoanalgesia to describe this phenomenon. They found that only 44% of patients with pain received analgesics in the ED, and sub therapeutic dosing was common.

Methods: This was a prospective observational study conducted in HGH ED after approval from Department of Emergency Medicine Audit & Ethical Committee, investigators were divided over shifts in ED for 2 weeks. Total of 448 patients were recruited. Inclusion criteria were any patient presented to Ed in acute pain over the last 24 hour, age >18 years old. Patients in life threatening conditions, major trauma, altered mental status or communication difficulties were excluded.

Results: Total of 448 patients were recruited. Of which 358 number were males, 90 Number were females. Trauma-related cases composed about 100 number (22.3%) of the pain cases. The number of pain medications prescribed to patients throughout the ED course and upon discharge was recorded.

Conclusion: The administration of pain-relieving medications in the ED was associated with significant pain reduction upon disposition. However, pain was still inadequately treated and scoring was not adequately recorded in patient files. Need for proper structured approach for pain management in HGH ED is warranted.

Background: Arterial punctures for monitoring respiratory problems are one of the most painful procedures in hospitalized patients. The knowledge regarding non-pharmacologic methods of pain management, including cold application is limited.

Objective: This aim of this study was to determine if the application of ice packs before the procedure would decrease the pain perception of patients during the arterial puncture.

Materials and methods: This experimental study was undertaken among patients admitted to emergency ward in a public educational center affiliated to Ilam University of Medical Sciences, Ilam/Iran. Sixty-one eligible subjects were randomly assigned to two groups. The treatment group (n = 31) received ice packs before arterial puncture, whereas the control group (n = 30) received no intervention for pain management. Pain immediately and 5 minute after the arterial puncture were scored on a visual analog scale (VAS) from 0 to 10.

Results: The mean of pain score immediately after the arterial puncture were 3.12 (1.68) and 4.6 (1.56) for treatment and control group, respectively (p < 0. 001). The mean pain score 5 minute after the punctures were 1.9 (1.51) for treatment group and 2.53 (1.85) for control group. This difference was not statistically significant. The mean of heart rate during the procedure were 75.45 (9.76) beats/min for the treatment subjects and 75.46 (9.36) beats/min for the control group (p>0.05). Patients with previous arterial puncture reported higher pain intensity.

Conclusion: Cold packs is a simple, non-invasive and inexpensive technique for pain management before the arterial puncture. However, there is a need for further research regarding this topic.

Background: The high prevalence of obesity was observed in numerous developed and developing countries. A reduce in energy expenditure due to the low physical activity level is a factor contributed to the increase in obesity. In the Gaza Strip there is a lack of studies on the pattern of physical activity among adults. The aim of this study was to determine the physical activity prevalence among mothers aged 18–50 years and its associated factors.

Methods: A mixed methods design was conducted using quantitative and qualitative methods. A total of 357 mothers were recruited from the Gaza Strip. The short form of the International Physical Activity Questionnaire (IPAQ) was used to assess the physical activity pattern. Focus groups discussion (FGDs) were conducted for qualitative study.

Results: The prevalence of physical inactivity was 21.6%, about 78% of mothers were classified as moderately active, while vigorous activity was not observed. Results revealed that, physical activity level decreased among mothers who lived in households with low income (OR: 2.30; 95%CI: 1.20–4.45; p = 0.013), and those with high nutrition knowledge were more likely to be physically inactive (OR: 1.15; 95%CI: 1.0–1.314; p = 0.040), while mothers who had low or medium education level were more active (OR: 0.31; 95%CI: 0.15–0.62; p = 0.001), or (OR: 0.47; 95%CI: 0.23–0.96; p = 0.039). The qualitative results showed that most of the mothers believed home chores are kind of exercises and could substitute for practicing sports. The main constraints to physical activity practice attributed to the sociocultural factors due to the limited availability of exercising facilities for Palestinian women and restrictions on their freedom.

Conclusions: Results of this study are important to monitor physical activity levels among mothers in the Gaza Strip. Effective community-based intervention programs should be implemented to improve physical activity levels among mothers in the Gaza Strip.

Background: The Emergency Medicine Residency Training Program (EMRTP) conducts weekly didactic teaching activities to deliver the curriculum for the Arab Board of Emergency Medicine. Traditional teaching methods often serve to deliver content to the learner passively, while an interactive model engages the resident, and aligns with principles of adult learning. With the accreditation of the EMRTP by the Accreditation Council for Graduate Medical Education - International (ACGME-I), the mode of teaching has also been modified to a more interactive model.

Methods: We analysed the EMRTP annual academic planner for 2015–2016 along with the format of teaching and broadly classified the topics and content into traditional vs interactive modes of delivery.

Results: The results showed that in 2012–2013, 75% of the content was through lectures but in 2015–2016 this had diminished to 21%, with the remaining 79% being delivered through various interactive means such as multidisciplinary grand rounds, joint conferences, morbidity & mortality meetings, journal clubs, oral board simulations, objective structured clinical examination (OSCE) slide presentations and faculty led clinical skills workshops.

Conclusion: The analysis showed an impressive reversal from a traditional to an interactive educational format with clear demonstration of adult learning principles.

Introduction: The Emergency Medicine Residency Training Program (EMRTP) in Qatar conducts weekly didactic teaching activities based on syllabus from the Arab Board of Emergency Medicine, but with the accreditation by Accreditation Council for Graduate Medical Education International (ACGMEI) in 2013, we set out to validate the teaching activities against an internationally recognized curriculum of the American Board of Emergency Medicine (ABEM) known as the EM Model.

Methods: We undertook a full review of all the teaching topics undertaken throughout the academic year of 2012–13 and found a moderate degree of compliance with the ABEM curriculum. Following this review, we identified developmental points addressed during the last three years. A further review was repeated for the academic year 2015–16 to ensure ongoing improvement.

Results: The results show improved content delivery. The overall compliance increased by 16% (58% to 74%) in the domain of medical knowledge and patient care and a staggering 48% (46% to 94%) in the other competencies.

Conclusion: On the whole the EMRTP annual curriculum has achieved a strong emphasis on the medical knowledge and patient care competencies (including procedures & skills). Further improvement was noted in other core competencies.

Background: Crowding in hospital Emergency Departments (EDs) is a commonly observed problem all over the world.

Objectives: To identify the factors related to patients’ unscheduled revisits to ED.

Methods: The Al Khor Hospital annual ED patient volume of 158,000. The census sample of patients who had revisited within 72 hours of discharge from the ED was recruited in the study. The CERNER system was utilized to collect all revisited patients’ data. Two experts from the pool of ED consultants reviewed the data independently.

Results: During the study period, 24,933 patients visited in ED, 849 revisited within 72 hours of their discharge, which accounts for 3.4%. The characteristics of revisited patients included young adults between 20–40 years of age (59.79%), mostly males (78.94%). Physician-related factors were: missed diagnosis (1.6%), adverse drug reaction (1.3%) and discharged without home medication (8.4%). Patient related, 60.26% (331) perceived that they were not improved with initial treatment. The vast majority of this patients (97.2 %) were discharged from the ED. Illness-related factors were the most common reason for revisits to ED; 52.9% (362) returned with same complaints while 21.3% (146) returned with related complaints, out of which 97.6% patients were discharged and 1.3 % (7) were admitted to the hospital. Of the remainder, 22.8% of the patients (156) reported to ED with new complaints. System related factors: 23.49% revisited patients lived in Al Khor or nearby, with their primary health center facility being 70 km away from their residential area.

Conclusion: From our study, we found the majority of revisits were due to illness or system-related factors. Effective educational program and initiation of telenursing service for discharged patients can prevent unnecessary ED visits.

Background: 75% of mental health illnesses and problems are treated in local communities in United Kingdom. There is a well-structured community service with a personal holistic management of these psychiatric problems patients and the arrangements are done according to needs and environment of the patient. However these services are not round the clock and they do not have an access to the acute psychiatric beds or any input for other medical problems. This is covered by Emergency Department of the country which has a 24 hours open access 7 days a week throughout the year. These patients are seen by Emergency Department clinicians and then managed in coordination with the psychiatric liaison nurses and on call psychiatric team.

Methods: We looked retrospectively to our practice in our two different trusts to see the actual increase in number of attending psychiatric patients in our emergency departments and the effect of these attendance and other related changes. Patients re-attending (Unplanned) in 72 hours are calculated separately.

Results: There is an increase of patients attending ED year after year with an average of 7.6% yearly increase. Over the last 5 years the overall increase of patient referral to PLS is 38.3%. Peak referral time is 0800—1000 and 1400–1500. 100% of ED doctors were aware of pathway for referral to PLS and could easily find it. All doctors were aware of the PLS point of contact and phone number. 90% of our ED doctors were happy with the initial management of these patients. 60% of junior and middle grade doctors have attended some kind of mental health teaching. 15% of these doctors were happy to discharge themselves the patient with low score (SAD PERSON Score).

Conclusions: Emergency physicians in collaboration with Psychiatric liaison service serve patients with mental health problems safe and effectively.

Background: Pain, a universal health problem, affects a substantive number of individuals in chronic or acute form. In the emergency and critical care settings, patients suffer moderate-to-severe acute pain from numerous sources. If not adequately managed, acute pain can transform to a chronic pain syndrome. The physical disabilities and psychological disorders associated with poorly controlled pain diminish patients' comfort and quality of life among the survivors. The study aimed at describing the knowledge and practices related to pain assessment, and perceived barriers among nurses caring for critically ill - adult patients (CIAP).

Methods: A descriptive cross-sectional design was employed to collect data from 170 nurses caring for CIAP in Uganda using a standardized survey tool.

Results: Nurses had adequate knowledge levels with gaps regarding the need for pre-emptive analgesia for painful procedures like airway suctioning, invasive line placement, and spontaneous breathing trial. Substantively, nurses did not know that the patient is the most accurate rater of their pain experience. Nurses reported poor pain assessment practices, including lack of use of pain assessment tools and guidelines, which were significantly associated with workload and the low priority set to pain assessment and management. Physicians' prescription of adequate analgesics was the only perceived enabler.

Conclusion: There is need to reprioritize pain management in emergency and critical care settings. This can be achieved through strategies that enhance the quality and quantity of resources for health care to reduce the perceived barriers and boost the enablers. Continuous professional education, provision of medication, human resources and guidelines for pain management can promote good pain assessment and management practices.

Background: Central Nervous system infections are associated with high morbidity and mortality. Initial presentation can be very non-specific, the classic triad of: fever, headache and altered mental status only found in 44% of patients with acute bacterial meningitis. In a recent study a delay in antimicrobial treatment of more than three hours after hospital admission was a strong and independent risk factor for mortality.

Methods: We reviewed case notes of patients presented with suspected meningitis or meningoencephalitis. We designed a Performa to collect information on presentation, clinical findings, investigation and management of these patients.

Results: 30 case notes were reviewed. 16 out of 30 patients had at-least 2 out of 3 classic features. Skin rash was not looked for in 53% patients. 83% patients had no documentation regarding presence or absence of papilledema. 75% of patients appropriately had CT Brain done before LP. 56% of patients had appropriate antibiotics in less than 3 hours. Mean time to perform LP was 10.38 hours. No patients had steroids before or along with antibiotics. One patient had CSF opening pressure checked on lumber puncture. In 10 patients paired serum sample was sent for glucose.

Conclusion: Major deficiencies are noted in documentation of key symptoms, signs investigations and management for CNS infection. We have planned three major interventions: 1) Senior physician review of all patients suspected of CNS infection within one hour. 2) All patients suspected of CNS infection have appropriate antibiotics administered within three hours of presentation. Steroids should be given along with first dose of antibiotic where indicated. 3) Implement LP sticker to improve documentation We will run few PDSA cycles of suggested interventions and study the results. Recommendations will be made based on PDSA results.

Background: Diabetes Mellitus is a worldwide disease that leads to several acute complications including diabetic ketoacidosis. Diabetic ketoacidosis is usually preceded by infection, acute myocardial infarction, stroke, or other dire events. There is one report where diabetic ketoacidosis was reported to be associated with acute arterial embolism. Acute arterial thrombosis is a rare disease that requires immediate treatment.

Methods: We present a diabetic patient who presented with acute arterial embolism and developed diabetic ketoacidosis. This is the first case in our hospital in which we have reported with acute brachial artery thrombosis and DKA.

Results: We present a 68 years old male chronic smoker with a 25 year history of type 2 Diabetes (non-compliant to medications), Peripheral vascular disease, dyslipidemia and transient ischemic attack. He experienced severe pain and numbness in his right arm and forearm with no wound, puncture lesion or ecchymosis. Forearm was cold, pale with delayed capillary refill on right hand. Right brachial, right radial and right ulnar arteries were not palpable. Strong pulsations of the right subclavicular and right carotid arteries were palpated. This led to a strong suspicion of an acute thrombosis of the right brachial artery. Emergency thrombectomy with +/ −  fasciotomy was planned. Patient was anticoagulated with intravenous heparin. Patient's blood sugar was persistently elevated and blood gases showed mild acidosis. Urinary examination confirmed presence of diabetic ketoacidosis.

Conclusions: A high index of suspicion of diabetic ketoacidosis in patients with acute arterial thrombosis may lead to early recognition and treatment, avoiding any adverse outcome.

Objective: Physician Associates were employed in a busy London Emergency Department to provide a new level of integrated Emergency Medical care.

Background: Physician Associates have proved invaluable in the USA medical field over the past 30 years and have been identified as a possible workforce solution in the UK1,2. There are currently 19 Physician Associates (PAs) working in Emergency Departments across the UK3, with the aim of improving the ED staffing crisis.

Case Description: Two Physician Associates were employed in a London Emergency Department 18 months ago, initially to assist in the Observation ward previously run by locum SHO's. As well as providing permanent, reliable junior staff members, this also alleviated the expenditure on locums in the Observation Ward at approximately half the cost per year. Despite initial skepticism, the role has developed following structured teaching sessions and reliable support from a designated consultant. A vigorous appraisal system was instigated with the clinical supervisor to ensure that the PAs’ clinical skills were developing appropriately and the PA's now see new unselected patients in the ED. The PAs also contribute to achieving CQUIN targets within the department by completing VTE assessments and discharge summaries. All patients in the observation ward now receive a senior review by either a Consultant or Registrar within 12 hours of admission - improving patient outcome. Research shows that patients do not mind whether they are seen by a PA4 and the role has been well received.

Conclusion: PAs have been so well received in the department that there has been a proposal to employ further individuals as a workforce solution. Doctors who work regularly with PAs are pleased with the role5. This model could be used in other hospitals to help with staffing pressures and also reduce cost of employing locums.

Background: On 3rd March the local newspaper published report regarding measles outbreak in Mansehra Colony Landhi, Karachi. In response to the report the Executive District Office health Karachi constituted a three members investigating team with the objectives to investigate the outbreak and propose recommendations for control of outbreak the affected Mansehra Colony Landhi having population of 600 households.

Methods: Investigation was carried out from 4th to 7th March, 2015. Case was defined as a child having 15 years of age residing in Mansehra Colony Landhi, with: a generalized rash and fever for three or more days and one or more of the associated symptoms, including cough, or coryza or conjunctivitis from 1st March to 7th March, 2015. Active case finding was carried out, line list maintained and six blood samples were taken and shipped to NIH Islamabad for lab confirmation.

Results: Sixteen cases were line listed, out of which 75% (n = 12) were females. Median age was 9 years (range: 3 to 13 years). All cases were from same family. Index case was 6 years old girl who visited her parents at Balochistan province (measles endemic) 6 days prior to development of sign symptoms. NIH Lab confirmed four cases positive out of six. As per EPI record all cases were fully immunized against measles.

Conclusion: Cases appeared in vaccinated children implicate that either there is some problem with the quality of vaccine, cold chain maintenance or vaccination techniques. Mopping -up activities conducted in Mansehra colony Landhi and surroundings, Health Education sessions conducted by Lady Health Workers on hygiene and disease prevention.

Keywords: measles outbreak, vaccinated, Health Education

Introduction: Diabetic foot is one of the most disabling complications with substantial morbidity. It remains the most common reason for hospital admission, impairs quality of life, engenders high treatment costs and is the most important risk factor for amputation.

Objectives: To determine the prevalence of diabetic foot among diabetic patients and the prevalence of main related risk factors.

Methods: A cross-sectional study was performed in Specialized Center for Diabetes in Baghdad - Iraq in which 410 diabetic patients age range 30–83 years were selected using convenient sample from 1st June - 31st September 2013. Data was collected by direct interview using a questionnaire, physical examination, patients' records and laboratory investigations. The data was analyzed using Minitab software version 16.

Results: Among 410 diabetic patients, females (56.83%) and males (43.17%). The prevalence of diabetic foot among diabetic patients was 19.27%. The following risk factors showed a statistically significant association with diabetic foot development: male gender (P = 0.047), duration of diabetes mellitus (P = 0.001), history of bare foot (P = 0.001), non-self-cleaning of foot (P = 0.001), hypertension (P = 0.006), irregular visits to diabetes center (P = 0.016) and uncontrolled level of HbA1c (P = 0.001). Applying binary logistic regression analysis revealed an independent significant association with diabetic foot development with: history of barefoot (AOR = 2.95), non-self-cleaning of foot (AOR = 2.24), male gender (AOR = 2.17), duration of diabetes mellitus (AOR = 1.37) and uncontrolled level of HbA1c level (AOR = 5).

Conclusions and recommendations: There is a high prevalence of diabetic foot among diabetic patients. The study recommends implementing the knowledge of main risk factors into preventive policies and investing more financial support on training programs in primary health care and specialized centers, patient education and DF problem awareness programs.

Background: It has been found that 89% of the ED staff in HGH has very low knowledge on the approach of SBAR, due to which they don't converse it accordingly with other staff especially during endorsements, face-face & critical call scenarios.

Aim: To increase and standardize the usage of SBAR as a communication tool among the clinical staff in the ED of high to 100% by FEB 2016.

Methods: The project was done in an iterative four-step continuous improvement method through careful monitoring in various areas of ED to collect the baseline data. SBAR champions were chosen from each area to facilitate and coordinate the project to most of ED. SBAR endorsement form was introduced for the nurses between shifts to notify information. Nurse educators & quality reviewers decided on educational sessions for the ED-nurses which consisted of role play, scenario based & simulation training for the nurses to make them understand the relevance of SBAR. A monitoring tool was developed for secret audit on SBAR usage to know the efficacy in the area.

Results: There has been a spike in the usage of SBAR by the nurses during the endorsement time and between the work schedules. With the help of the CN's and SBAR champions who regularly change from day to day, Careful monitoring has been placed in various areas of the ED which has led to such significant achievement. As of now the measurement and the testing has been done with the nurses, physicians, ECG technicians, respiratory therapists and also the quality reviewers. we are soon planning to include ems for the same training by end of February, we will make sure the whole ED will be talking & reporting in SBAR.

Conclusions: Interprofessional communication activity is needed at the entry level for all professionals. SBAR - teachable skill that is recognized by all healthcare workers as safe effective method of communicating among providers. We will soon spread this communication between units & during transfers also. Registration number: 0000-0003-0866-6512.

Background: Acute respiratory infections, including influenza, comprise a leading cause of morbidity and mortality globally. Influenza surveillance provides important information to inform policy on influenza control and vaccination. While the epidemiology of influenza has been well characterized in western countries, few data exist on influenza epidemiology in the Eastern Mediterranean Region. We describe the epidemiology of influenza virus in Oman.

Methods: Using syndromic case definitions and protocols, patients from four regional hospitals in Oman were enrolled in a descriptive prospective study to characterize the burden of severe acute respiratory infections (SARI) and influenza. Patients meeting the SARI case definition provided demographic information as well as oropharyngeal and nasopharyngeal swabs. Specimens were tested for influenza A and influenza B. Influenza A viruses were subtyped using RT-PCR.

Results: From January 2008 through June 2013, a total of 5,147 cases were enrolled and tested for influenza. Influenza strains were detected in 8% of cases for whom samples were available. Annual incidence rates ranged from 0.5 to 15.4 cases of influenza-associated SARI per 100,000 population. The median age of influenza patients was 6 years with children 0–2 years accounting for 34% of all influenza-associated hospitalizations. By contrast, the median age of non-influenza SARI cases was 1 year, with children 0–2 years comprising 59% of SARI. Compared to non-influenza SARI cases, a greater proportion of influenza cases had pre-existing chronic conditions and underwent ventilation during hospitalization.

Conclusions: Influenza virus is associated with a substantial proportion of SARI in Oman. Influenza in Oman approximately follows northern hemisphere seasonality, with major peaks in October to December and a lesser peak around April. The burden of influenza was greatest in children and the elderly. Future efforts should examine the burden of influenza in other potential risk groups such as pregnant women to inform interventions including targeted vaccination.

Background: This study used the 2012 London Olympic Games as the empirical context to examine how interagency collaboration took place among the diverse public health and safety agencies involved in this mass gathering event. In order to develop our understanding of how collaboration among the key stakeholders in a mass event may be improved, this study aims at capturing the components that affected the ability of interagency collaboration to deliver its potential.

Methods: An exploratory case study design was used. Data were collected before, during and after the Games through semi-structured interviews, direct observations and documentary analysis. Template analysis was used to analyze the interviews' transcripts, the field notes from observations and the documents. The analysis generated a framework of factors influencing interagency collaboration including leadership, communication, governance and knowledge.

Results: Leadership shaped interagency collaboration through several characteristics including processes, skills, behaviours and relationships. Findings indicated that accountability issues, the use of guidelines and legislation and the physical presence of the leaders were perceived as fundamental to the implementation of effective collaboration. Effective leaders were supportive, persistent, good listeners and easy to talk. Moreover, interpersonal trust formed the basis for positive interagency collaboration.

Conclusion: Recognizing and understanding the above leadership characteristics is an important step towards the support of the collaborative endeavours in mass gathering events.

Background: The aim of this study was to evaluate post-injury functional recovery over three years in patients with moderate and major trauma in Hong Kong.

Methods: This is a multicentre prospective cohort study conducted in Hong Kong. The inclusion criteria were: trauma patients admitted to one of three trauma centres, with age ≥ 18 years, injury severity score (ISS) ≥ 9, meeting Trauma Registry criteria, and surviving to 48 hours. Functional outcome was measured by the extended Glasgow Outcome Scale (GOSE) at 3 years post-injury. Good outcomes were defined as an extended Glasgow Outcome Scale (GOSE) ≥ 7, i.e. trauma patients' status rated as lower good recovery or upper good recovery categories.

Results: From 1st January 2010 to 30th September 2010, 400 patients were included. Mean age was 53.3 years; range 18–106 years; and 70% were male. 139 (35%) patients had ISS 9–15; 261 (65%) patients had ISS ≥ 16. Among those included, 38 % required ICU admission; and 58% had healthy pre-existing comorbidity status. For the GOSE analysis, the number of surviving responders at 3 years post-injury reaching a GOSE ≥ 7 was 86, which represented 54.1% of the 159 surviving responders, and 21.5% (86/400) of the original cohort. As there were no statistically significant differences between surviving responders and non-responders at baseline, the assumption is made that 54.1% of the 167 non-responders (N = 90) also reached a GOSE ≥ 7. The total number of cases reaching a GOSE ≥ 7 is therefore estimated to be (86+90), or 176, which is 44.1% of the original 400 cases.

Conclusion: The proportion of cases reaching a GOSE ≥ 7 at 3 years post-injury is 44.1%.

Background: There is little evidence of research outcome data or studies into self-reported back pain in Middle Eastern or Gulf region countries. Within HMC there is anecdotal evidence that suggests that back pain in nurses working in critical care environments accounts for a significant percentage of all sick cause leave. This has the potential to impact on productivity, patient care and quality of life in nurses working within critical care in environments.

Methods: A cross center mixed methodology study looking at back pain in nurses working in critical care environments data collection included demographic, occupational, and health characteristics and a Likert questionnaire. This comprised of 10 questions relating to manual handling education, equipment, staffing levels and ergonomics and was distributed in critical care and emergency departments across five hospital sites responses rate n = 450.

Results: Outcome data identified 65% of the respondents reported experiencing back pain over the last year with subsequent negative impact on quality of life. There was statically significant association between gender and quality of life p = 0.001; with more women verbalizing a negative impact on quality of life secondary to back pain. There were also statically significant relationships between age with younger age group reporting negative impact on quality of life p = 0.001 and length of time employed in HMC with respondents who have been employed between 1–5 years experiencing the greatest impact p = 0.001.

Conclusions: Back pain is an under reported occupational health concern that impacts on productivity and quality of life. Mandatory training in manual handling should feature in corporate educational agenda. Occupational health initiatives' are essential in the management of chronic health conditions.

Emergency Medicine (EM) is an officially recognized medical specialty in over 60 countries, with the rate of specialty recognition accelerating in recent years. EM care delivery systems are specifically focused on managing the acute consequences of non-communicable as well as communicable disease processes, and therefore represent an important public health tool for reducing the present and future global. According to the 2006 World Health Organization studies on the Global Burden of Disease, worldwide demographic and epidemiologic shifts now show non-communicable diseases to have become the single largest cause of morbidity and mortality worldwide. At Max Health Care, George Washington University started a 3 years Master course in Emergency (MEM International) since 2008.

Aim: Efficacy or value of Emergency Medicine (EM) as a medical specialty and of clinical care delivered by trained emergency physicians. Primary objective: Has MEM Educational program at Max Health Care brought an Improvement in patient care in Max Emergency Department? Secondary objective: Factors which can help in Improving Quality of course. Inclusion criteria: Consultants of any Specialty worked for more than 2 years in Max Health care. Exclusion criteria: Senior resident and Junior resident of other specialty Incompletely filled survey form.

Methods: It was an observational study and questionnaire in Annexure 1 was used for the survey. The questionnaire will be given to 49 consultants of various departments in Max Group. Data has shown that 91.86% of Consultants have accepted that the course has brought improvement. Private Health sector has accepted Emergency Medicine as an Individual Specialty. 4 areas of suggestion turned up at final assessment: More hands-on training in Ultrasound Gynecology, Pediatrics and Anesthesia - advised more dedicated training time in their specialties Internal Medicine and Critical Care suggested follow up till discharge. Increased emphasis on communication skills.

Oman has committed to the goal of eliminating measles, rubella and congenital rubella syndrome (CRS) by 2015 year. Elimination is defined as the absence of endemic measles and rubella transmission in a defined geographical area for ≥ 12 months in the presence of a well-performing surveillance system and for rubella without the occurrence of CRS cases associated with endemic transmission in the presence of high-quality surveillance system. Strategies to reach this goal included: a) achieving and maintenance high rates of vaccination coverage; b) syndromic surveillance programs to monitor fever and rash illness syndromes for effective detection of cases; c) and high-quality surveillance system, and sensitive for CRS. Measles and rubella was a leading cause of infant and child morbidity and mortality in Oman before the introduction of measles vaccine by 1975 and thereafter until 1994. With the introduction of a second dose of measles and first rubella vaccines in 1994, coverage for first and second doses of measles and rubella vaccines increased more than 95% in 1996 and has been sustained thereafter. A national measles and rubella immunization catch-up campaign targeting children ages 15 months to 18 years was conducted in 1994 that achieved 94% coverage. As a result, the incidence of measles and rubella have declined markedly in recent years, to ≤  1 case per million persons in 2012 and to zero cases for measles and rubella in 2013. Similarly, no case of CRS has been notified since 2007. Oman has made significant progress toward measles and rubella elimination and has met the regional elimination goals. However, new challenges faced by Oman, for instance with increased globalization, has led to issues such as outbreaks from imported cases. Additional challenges still remain with regard to increasing identification and immunization of unvaccinated non-Omani workers and their families.

Introduction: MVC accident is one of the major cause of mortality and morbidity in children. In 2010, road traffic accidents were the major cause of 228 deaths and 568 major injuries in Qatar.(4). Children in cars who are not restrained, have a great risk of being injured. Our aim from this study is to check parents' awareness of the important of using child restrain (car seat) and reasons behind preventing them from not using it.

Objectives: Check parents' awareness of using car seat in Qatar. And do they know related information about installing car seat in their car and how to use it? Methods: A prospective cross sectional qualitative survey study was conducted at PEC Alsadd of Hamad Medical Corporation from (May 1st 2015 to October 31st 2015). A total number of 212 sample questionnaires were filled by parents whom visited PEC because of their children illness. All have been given survey questionnaire to fill while they are in waiting area. Then research assistants collect filled questionnaires.

Results: Distribution of Male: female is 40.6% (86) and 59.4% (126) 70.8% (150) have car seat and 29.2% (62) have no car seat. The Qatari: non-Qatari population is 10% (21): 90% (121) in the study. Among the Qatari respondent, 85.7% (18) have car seat and 14.3% (3) have no car seats. 12% of cases were children with chronic illness. 84% parents have 4wd cars. 80% of parents have university certification, though only 65% of them who have car seat. And 31% of them who use always car seats.

Conclusion: This study showed the importance of doing more parents education about the importance of using car seats.

Background: Cranial computed tomography (CT) scan is a commonly performed neuroimaging prior to lumbar puncture (LP) in children with suspected meningitis to rule out intracranial hypertension or space occupying lesions. The purpose of this study was to assess the accuracy of physicians' prediction of CT abnormal cerebral findings in pediatric meningitis.

Subjects and methods: A prospective observational study design was performed over a 12-month period. Eligible patients were admitted to the Emergency Department (ED) where a structured questionnaire was filled independently by two physicians before undergoing cranial CT scan and prior to LP.

Results: In this study, 72 patients met the inclusion criteria with a mean age of 7.04 ± 3.38 years. The mean physicians' prediction score of abnormal CT findings was 6.0 ± 3.0 vs. 2.48 ± 2.01 of no abnormalities (difference 3.5 ± 1.0 (95% CI: 1.5, 5.5; p = 0.001). Relative risk of CT abnormalities associated with decreased level of consciousness was 7.33 (95% CI: 1.5, 33.67), Glasgow coma scale was 23.3 (95% CI: 7.7, 70.7), and abnormal posture was 8.9 (95% CI: 1.9, 41.7). Apart from mild headache (2.8%), vomiting (2.8%), dizziness (4.2%), no serious complications related to LP procedure have been reported.

Conclusion: Physician's clinical decision could predict absence of abnormal findings on cranial CT scan before LP in children with suspected meningitis. Our results suggest that LP could be performed with avoidance of CT scanning of the head in pediatric meningitis provided the presence of normal consciousness level, Glasgow coma scale ≥ 13 and normal neurologic examination.

Endoscopic third ventriculostomy (ETV) is a common minimal-invasive neurosurgical procedure with well-documented complications. We report the case of a 6-year-old female child who underwent ETV, external ventricular drainage (EVD) catheter insertion and biopsy for a tumour arising from the pineal gland causing obstructive hydrocephalus and raised intra cranial pressure (ICP). Vital signs were stable pre-operatively and anaesthesia was maintained using propofol infusion. The operative bed was irrigated with normal saline under pressure after ETV, which immediately resulted in sinus tachycardia intra-operatively and central neurogenic hyperventilation (CNH) with respiratory alkalosis and transient lactic acidosis an hour after the surgery. Only few case reports have been reported in adults with CNH and respiratory alkalosis. Hyperventilation resulting in lactic acidosis is a well-known entity but lactic acidosis following CNH due to transient hypothalamic dysfunction after endoscopic third ventriculostomy has not been reported previously. Our patient was managed with benzodiazepines and oxygen delivered by a rebreathing mask, which resulted in complete recovery within 12 hours. This case highlights the importance of ICP measurement and monitoring and assessment of the type, volume and pressure of fluid used for brain irrigation during ETV, to prevent complications. ETV may cause intra-operative hemodynamic disturbances such as tachycardia, hypertension and hyperthermia followed by post-operative transient hypothalamic dysfunction and CSF acidosis leading to sequelae of CNH with acute respiratory alkalosis and transient lactic acidosis. We emphasize the importance of ICP monitoring during neuroendoscopic procedures, as an inadvertant rise in ICP appears to be the central factor leading to the various ill effects encountered both intra and post-operatively. Moreover, although normal saline has been the irrigation fluid of choice for neurosurgeons, a multitude of laboratory studies suggest it being less ideal and it might be prudent to look into alternatives, namely artificial CSF and Ringer's Lactate.

Introduction: Proteinuria in burn patients is common, and it could be associated with acute kidney injury (AKI) with bad outcomes. We evaluated the incidences, outcomes, characteristics and determinants of proteinuria as a biomarker and its influence on AKI and outcomes in burn patients.

Methods: This retrospective study was carried out on a group of patients with burn injuries admitted though Emergency Department to burn unit of Hamad General Hospital during a five-year period. Positive urine analysis (R/M) readings were defined as mild ( ±  or 1+) or heavy ( ≥  2+) proteinuria, and AKI was diagnosed and staged according to the Risk, Injury, Failure, Loss, End Stage (RIFLE) classification system. Patient characteristics, management and outcomes were evaluated as well for associations with proteinuria.

Results: Of the selected admitted patients to the burn unit during the study period (n = 249), 86 (34.5%) were classified as having proteinuria. In the patients whose total burn surface areas (TBSA) were > 30% (n = 50), 37 patients (74%) had proteinuria and 27 of these patients (72.9%) met AKI criteria. No patients without proteinuria developed AKI. Intensive care unit (ICU) mortality rates were 1%, 16 % and 30% (P <  0.001) in the groups with no, mild and heavy proteinuria, respectively.

Conclusions: We observed a high prevalence of proteinuria in patients with severe burns (>30% TBSA). Severely burned patients with proteinuria had a high risk of developing AKI and a poor prognosis for survival. This suggests that proteinuria should be used as a biomarker for identifying burn patients at risk of developing AKI.

Background: Ambulance services in Saudi Arabia are organised through the Red Crescent, the organisation that is responsible for ensuring adequate ambulance service for all communities in Riyadh. Paramedics are the first responders among the healthcare providers responsible for saving patients' live outside hospital settings. Work-related stress is a serious problem that affects the health and well-being of employees as well as the productivity of organisations. Stress has a huge impact on the performance and productivity of emergency health workers.

Objective: To explored the factors associated with stress and identified the effects of stress and burnout on Red Crescent ambulance workers.

Methods: This study explored the factors associated with stress and identified the effects of stress and burnout on Red Crescent ambulance workers. A cross-sectional study was conducted among ambulance workers at Saudi Red Crescent centers across four regions of the Ar-Riyadh province of Saudi Arabia. Questions about sociodemographic information, working conditions, level of burnout, and job stress were included in the questionnaires.

Results: Study sample responses regarding personal burnout level. The arithmetic mean, standard deviation, frequencies, and the responses (in %) to statements describing the personal burnout level are shown in Table 14.

Conclusion: Stress level and work-related burnout was a leading cause of poor performance and resulted in the inability of employees to perform assigned tasks.

Background/aims: Prognosis for patients with cirrhosis admitted to medical intensive care unit (MICU) is poor. The objective of this study was to assess the predictors for hospital mortality and admission of cirrhotic patients to MICU in Qatar.

Materials and methods: We conducted a retrospective cohort study of consecutive adult cirrhotic medical-ICU patients whom hospitalized from 2007 through 2012 to Hamad General Hospital-Qatar. We compared them to cirrhotic patients who admitted to medical wards during same period of time. All data were recorded and analyzed with respect to demographic parameters, clinical features and laboratory as well as radiology characteristics on day one of admission to MICU. Cirrhosis diagnosis was established either with a liver biopsy or the combination of physical, laboratory and radiologic findings. Predictors of mortality were defined by logistic regression analysis.

Results: The cohort comprised 109 cirrhotic MICU patients, 86.2% were males and their mean age ± SD = 51.6 ± 11.5. MICU-cirrhotic had longer hospital length of stay (LoS) than medical wards-cirrhotic (both for survivors and non-survivors). Mortality was higher for the MICU-cirrhotic group than medical wards group (27 (24.8%) deaths vs. 12 (5.3%) deaths, respectively, p = 0.001). In multivariate logistic regression analyses, older age >60 years (p = 0.04), APATCH-II score (p = 0.001) and MELD score (p = 0.02) were independent predicting factors for overall mortality. Furthermore, admission with severe hepatic encephalopathy, upper gastrointestinal bleeding and SOFA score were independent predicting factors for MICU admission.

Conclusion: Severe hepatic encephalopathy, upper gastrointestinal bleeding and SOFA score predict MICU admission of cirrhotic patients. Among MICU cirrhotic patients, older age, APATCH-II score and MELD score predict mortality.

Introduction: Use of ECMO has been shown to be an acceptable intervention for patients with respiratory failure refractory to optimal ventilator management. As experience with ECMO grows the indications for its use are also expanding.

Case: Our patient is a 20-year-old female who was found lying on the roadside after being hit by a moving vehicle. She was rushed into the trauma room where she was intubated for low Glasgow coma scale, CT head, chest, abdomen and pelvis showed severe head injury with possible diffuse axonal injury, blunt chest injury, blunt abdominal injury with splenic injury was admitted under the care of TICU, repeat CT head showed multiple hemorrhagic contusions. Ventriculostomy with ICP monitoring device was inserted. She was aggressively treated for severe brain injury by neuroprotective interventions. Over following days had severe ARDS. Despite appropriate antibiotic therapy, lung protective ventilation, HFOV, patient had severe hypoxemia. Patient was evaluated for ECMO despite her severe neurological injury with ICH, possible poor neurological recovery. After discussions involving primary team, ECMO was considered initiated using femoral-Jugular cannulation. No systemic anticoagulation was used. Tracheostomy was placed and was weaned off ECMO over next week. ECMO decannulation was performed on 7th day. Patient had multiple interventions by the orthopaedic, weaned off decannulation in 18 days and tracheostomy was closed. Patient had neurological recovery was discharged to the rehabilitation.

Discussion: ECMO is an established salvage therapy for profound respiratory failure and the need for systemic anticoagulation has often contraindicated its use in patients with severe intracranial pathology, and in particular, recent hemorrhage like our patient. Advances in circuit and oxygenator technology have challenged this concern and cases of ECMO support with intracranial pathology have been recently described. Risks and benefits of systemic anticoagulation need to be considered during ECMO support.

Conclusions: Extracorporeal membrane oxygenation is an acceptable therapy for patients with profound respiratory failure secondary to trauma and intracranial pathology contraindicating the use of systemic anticoagulation.

Background: Anticipating falls in the Emergency Department is a very challenging task as it's often the most unpredictable setting. Fall risk assessment tools used in inpatient units do not adequately capture the risk factors present in patients presenting to the Emergency Department. The MORSE scale is implemented only at a latter phase of patient admission to the inpatient unit. The purpose of this study is to develop and implement a simple, fast and effective tool to identify the risk of fall at the triage.

Methods: We designed a tool to identify patients at risk of fall. We planned to randomly assign 200 patients equally in to the test and control arm. We created the Fall Risk Assessment Tool specifically for the use in the Emergency Department. The study was conducted at Hamad General Hospital, Emergency Department triage area. If a patient was identified as at risk for fall, a Fall risk sticker was pasted on top of the ED paper to indicate the risk. Any patient identified as at risk was re-evaluated throughout their stay in the Emergency Department.

Results: Hundred patients identified as at risk for fall at the initial triage were re-evaluated for fall risk using standard MORSE scale. Reassessment showed 67% of the cases identified at the initial triage come under high risk category using Morse scale, 31% had moderate risk and only 2% had low risk. There were no reported cases of fall. Hundred patients, excluded as low risk for fall at the initial triage were re-evaluated for risk for fall using the standard Morse Scale. Reassessment showed 98% of the excluded patient's came in the low risk category and 2% had moderate risk as per the MORSE scale.

Conclusion: Our tool was as safe as and effective in predicting falls as the MORSE Scale.

The Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is an emerging infection that causes severe illness in patients, particularly those with comorbidities; and has a high mortality rate. Healthcare associated outbreaks have been reported across the Gulf region and the Republic of Korea. While there have been cases of MERS-CoV in Qatar, no healthcare associated outbreaks have been reported. The aim of this paper is to give a description of the infection prevention and control protocol implemented by the Primary Health Care Corporation to manage suspected or probable cases of MERS-CoV in the primary health care setting. This paper focuses on Alshahania Health Centre which is considered to be a high risk area due to its proximity to the camel shelter and race track. In order to gain an understanding of how patients visiting the health center are managed. Data was collected through a visit to the Alshahania Health Centre which included discussions with staff and documentation review. Our findings show that the infection control protocol implemented at Alshahania Health Centre is very robust and ensures that staff has clearly defined responsibilities in the management of a suspected case of MERS-CoV. A dedicated Isolation Team ensures a timely risk assessment is carried out which then triggers actions that reduce the risk of exposure to both patients and staff. The experience at Alshahania Health Centre also demonstrates that good communication and leadership are important factors in order to successfully embed infection control in clinical practice and prevent healthcare associated outbreaks of MERS-CoV.

Introduction: Despite the potential benefits of EMR systems to improve patient care, many attempts at implementing them have failed or met with high levels of user resistance, Implementations that failed have often been those with which the users were dissatisfied with the system.

Aim: The aim of this study is to assess the satisfaction of both the physicians and nurses with the newly introduced EMR system at the Emergency Department of Al Wakra Hospital, to find out if there was a significant difference between physician and nurse's perception to the system. And to determine which of the individual attributes of EMR were related to physician and nurse satisfaction.

Methods: Study design: cross sectional survey four month after of the introduction of the EMR system (Cerner) we surveyed 40 physicians and 96 nurses at the Emergency Department of Al Wakra Hospital. The questionnaire assessed: perceptions regarding EMR ease of use; concerns about impact upon work, and quality of patient care.

Results: The total satisfaction rate was 88.2%. 72.5% among the physicians and 94.5% among the nurses, both physicians and nurses were satisfied with the ease of use of the system, they find it generally to have a positive impact on their work, however both didn't find it to have an impact in reducing ED overcrowding.

Conclusion: Both physicians and nurses were satisfied with the EMR system.

Background: Non-adherence to antimicrobial guidelines is a major factor leading to emergence of antimicrobial drug resistance.

Objective: This study was carried out to investigate the adherence to local antimicrobial guidelines in the Emergency Department (ED) at Al Wakra Hospital in the state of Qatar.

Materials and methods: This cross-sectional, retrospective study was carried out in the Emergency Department of Al Wakra Hospital in Qatar. Prescriptions of 219 patients were investigated to study the adherence to antimicrobial guidelines. The relation of sex, age and emergency unit type to antimicrobial adherence as well as the appropriateness of antimicrobial prescribed on discharge were also evaluated.

Results: Overall adherence and non-adherence to local antimicrobial guidelines was found to be 41% and 59% of prescriptions respectively (P-value = 0.007). Participants had mean age of 42 ± 15.5. More adherence to guidelines was found among female patients and in critical care units. Furthermore, antimicrobial prescribed to patients on discharge was found to be appropriate in 60% of patients (P-value = 0.04).

Conclusion: Education of physicians and additional studies should be conducted in order to further investigate and improve adherence to antimicrobial guidelines.

Hospitals' track-and-trigger systems to identify and respond efficiently to patient's deterioration became an evidence base tool for patient safety and medical management worldwide. A prospective study about the Impact of Rapid Response Team Implementation in the Cuban Hospital was developed since September 2014 up to September 2015. The patients admitted in medical and surgical wards were screened upon admission and rescreened during every shift by nurses using the National Early Warning Score (NEWS), a multidisciplinary medical response team was designed and proper actions were done according to the acuity of illnesses and patient needs. The 100% of patients admitted were screened and properly followed during every shift, the system gave us the possibility for early detection of all the patients deteriorated, 9.9% in total, the 3.6% of patients admitted were transferred to ICU in deteriorated condition, decreasing to 0 the code blue activation and the unexpected mortality in wards. Early recognition and timely and competent clinical response gave us the opportunity to be proactive to protect our patients against life threatening situations. We recommend extend this result to all the hospital service using a wider system to include maternity and pediatric population, the implementation of the Qatar Early Warning System (QEWS) will be our next step to protect all the patients admitted in our Hospital.

Background: In 2011, HMCAS designed new Evidence-Based CPG. The previous protocols were not fit for purpose and not best practice. The service had multiple tiers of clinical practice among staff without standardization of care. CPG development is a knowledge management process to ensure standardization of care and a safer patient experience. This research sets out learning from two rounds of CPG development over 4 years.

Methods: The guidelines development process was mapped prior to starting in January 2015. CPG development and implementation went through 5 steps: 1. Scoping the guidelines: defining the purpose, the scope of service, and the end users of the guidelines. We conducted a staff survey to understand their views on presentation and purpose. 2. Establishing a working group to identify specific guidelines, clinical outcomes desired, and develop a writing template. 3. Conducting evidence reviews to draft the guidelines and then consulting with all role players to ensure guidelines are best practice and practical, and aligned to clinical pathways. 4. Guidelines publication considering ease of use, clarity, and balance between details and practicality. Finally, guidelines approval. 5. Guidelines implementation: Identifying champions to action alignment to systems (logistics/governance/management) and to redesign the corresponding educational curriculum.

Results: The development and implementation of the guidelines has resulted in significant changes within the Ambulance Service over 4 years. Reducing multiple tiers of care down to two tiers, standardized education of 900 existing and new clinical staff around guidelines, implementation of standardized pre-packed equipment within the ambulances, and standardized care to the community. This project was recognized by the MD's Stars of Excellence award 2013.

Conclusions: To implement standardized care and EBM, CPG are required. Guidelines development and implementation needs expertise, collaborative development, and champions who will undertake deliberate alignment of service activities and education to the guidelines.

Background: Hip fractures are very common in UK population (excluding Scotland) accounting for 64102 hospital admissions in 2014. FCIB is part of a best practice tariff and a quality indicator audited annually by the National Hip Fracture Database in UK, as part of NICE clinical guidelines. The ED protocol for fracture neck of femur (NOF) includes fascia Iliaca compartment block (FICB), which is a new service development as part of treatment.

Study objectives: To assess whether all patients with NOF were getting FICB prior to transfer from ED and to asses if FICB gave adequate pain relief.

Methods: A retrospective study new service evaluation was carried out on 58 patients admitted to orthopaedic ward from the ED with a diagnosis of fracture NOF. Exclusion criteria was contraindication to compartment blocks. This study focussed on the care received by the patients in the ED during the period from October 2014 to March 2015. A data collection spread sheet was developed with parameters based on the NICE guidelines, RCEM guidelines and the trust policy for performing FICB.

Results: Of the 58 cases, 51.72% of these received FICB and were documented. Of these 63.3% of patients had FICB performed within 4 hours of arrival to ED. The other 49% lacked evidence for FICB, assumed it was not done. Post-block pain scores were poorly documented. 82% of the blocks were performed by non-consultant doctors. One case of block failure and side effect.

Conclusion: This new service benefited patients with hip fracture, however has issues relating to compliance and consistency of service delivery and all efforts should be made to improve these.

Background: Spontaneous rupture of the renal pelvis is very rare and hence diagnosis may be delayed. Diagnosis of the rupture is best evaluated by CT and treatment is primarily removal of the underlying cause, followed by conservative management.

Presentation: An otherwise healthy 31-year-old male suffered abdominal pains and vomiting. His pain was at the right iliac fossa and suprapubic areas, which he rated as 7/10(NRS). He also reported dysuria of 2 days but with no other associated symptoms. On examination, Patient was vitally stable. On palpating his abdomen, there was right iliac fossa tenderness but no rebound tenderness, guarding nor rigidity, and the remainder of the examination was unremarkable. He received repeated analgesics; IV acetaminophen 1 g, 4 doses of IV fentanyl and in view of persistent pain and 2 additional doses of IV morphine. Abdominal ultrasonography were suggestive of distal right ureteric stone measuring 6 mm in diameter and mildly dilated upper and lower calyces with mild perinephric fluid. Along with, Tubular non-compressible structure 9 mm in diameter seen in RIF surrounded by minimal amount of fluid, giving an impression of query acute appendicitis with right distal ureteric stone. CT abdomen with double contrast revealed no features of acute appendicitis. However, there was a 4 mm stone in the lower end of the right ureter causing obstruction. Delayed series films showed rupture of the renal pelvis.

Conclusion: Rupture of renal calyx should be considered as one of the differential diagnosis for an unusual acute abdomen, not responsive to analgesics.

Background: Increasing levels of physical inactivity is associated with growing trends of childhood obesity as evidence suggests today's children physically inactive and unfit. The study aims to assess the effect of socio-demographic and lifestyle factors on mode of travel in school-aged children (10–15 years).

Methods: 4,497 school-aged children were selected from wave-1 of Understanding Society database in a multi-stage random sample with 81.8% response rate. Cross-sectional design was used to examine the relationship between active travel with demographic and lifestyle factors.

Results: Univariate analysis showed significant relation of age, region, smoking and eating fast food to the active commuter school-children. Multivariate adjusted analyses shows that children of ages 13 to 15 years were more likely to travel actively compared to those aged 10 to 12 years (OR = 1.92, 95%CI:1.65-2.23). Those engaged in sporting activity 3 times or more per week were more likely to be active travel compared to those less than twice per week (OR = 1.21, 95%CI:1.02-1.43). Children eating fast food once or less than per week were more likely to travel actively compared to unhealthy eaters. Most children living in their respective regions were less likely to travel actively.

Discussion: The positive association between active mode of travel and elder school children (13–15 years), who perform sport activities three times or greater per week and eating fast food once or less per week with active travel, reflect their free choice of mode of travel. Children who practiced sport more than three times per week and who ate less fast food showed healthy behaviors.

Introduction: Simulation is almost synonymous with computerised mannequins although they are not always essential components of the learning experience as what often matters most is the facilitation process of the learning experience rather than the technology.

Methods: We developed Visually Enhanced Mental Simulation (VEMS) for staff to demonstrate cognitive and decision making skills away from the practical context. Scenario participants are oriented by facilitators to the VEMS process which is a simulation approach that involves a whiteboard, laminated cards, and a poster to represent equipment and the patient. It requires participants to verbalise thoughts and actions including equipment settings, and actual communication with the patient and bystanders represented by the facilitators. Information like physiological parameters and interventions made by the participating crew are written on the whiteboard. Scenarios use the same scripts as what is prepared for full-scale simulation and are followed by a debriefing. It is complemented by parallel skills sessions, and ultimately both aspects are combined into full-scale scenario-based simulation.

Results: VEMS has been facilitated with uni/multi-professional teams of healthcare professionals for pre-hospital, interfacility, and handover scenarios. Comparison between VEMS and mannequin-based scenarios is ongoing and currently shows just a slightly less positive rating for VEMS although they advocate for this modality prior to full-scale simulation. VEMS reduces pressure on equipment demand and the staff engagement is such that similar clinical practitioner's mistakes are “observed” in both types of simulation approaches.

Conclusion: VEMS can be run almost anywhere as it requires a minimum of equipment but still requires time and experienced facilitators. Briefing about the process and expectations are as important as the preparation of the scenario script and clinical knowledge and facilitation style of the facilitators. VEMS can be very engaging for multiprofessional teams and address learning outcomes similar to what would be achieved in full-scale simulation.

Background: “Orientation” is an important phase when joining a new institution. It is the period when someone builds an understanding of their role/responsibilities in a new setting, and for colleagues to gauge someone's level of knowledge and competence. HMCAS recruits mostly overseas nursing qualified staff with variable experience and transforms them into Ambulance Paramedics (AP) all providing the same level of care in accordance to our Clinical Practice Guidelines.

Methods: Skills assessment using a 17–20 stations Objective Structured Clinical Examination (OSCE) process was introduced in the Training Department during a week-long instructor development workshop in 2013. Instructors were coached to develop practical/theoretical OSCE stations and took part in pilot sessions as examiners with new APs. The OSCE is now a core AP training programme component with weekly sessions to assess new staff on what they have been taught up to that point in time.

Results: Over 120 OSCE sessions have occurred in 2 years exposing about 600 staff to a minimum of 3 sessions each. A bank of over 40 stations has been developed and validated, and a team of trained examiners is used. As determined by the course evaluation form, although seen as a stressful experience, instructors and staff find it a very beneficial and effective assessment modality to prepare them for clinical practice. It motivates staff to study and they even request to have an OSCE per year as part of their continuing professional development.

Conclusion: We are committed and have processes in place to sustain the facilitation of OSCE sessions as it is a very practical way of assessing a wide range of skills over a set time period and gauging staff progress through consecutive sessions. The initial preparation is time consuming but we encourage other departments to explore this approach as part of their orientation/training programme.

Background: Whilst Head CT scanning carries an important role in the identification of clinically significant intracranial injuries, there are associated risks of radiation. Our initial audit of clinical notes and survey of EM physicians revealed a rate of 45% CT scans for pediatric minor head injuries with around half of requests not indicated. In 36% there were issues with documentation. The aim is to achieve a sustained compliance with Internationally acceptable guidelines of Head CT scanning for pediatric minor head trauma at Hamad General Hospital Emergency Department (ED).

Intervention: We conducted staff education through weekly program of Continuing Medical Education for emergency physicians, prominent display and availability of handouts of the International clinical decision rules (NICE guidelines, PECARN) in all clinical areas within the ED, encourage proper documentation for all head injury cases to meet JCI standards of documentation, and formulate a revised pediatric head injury guideline based on the international clinical decision rules.

Methods and results: The audit in August 2014 showed that 62 CT head were done, 45% of them were deemed unnecessary when measured against NICE guidelines. Also there was deficient documentation in 36% of cases due to the unavailability and difficulty accessing the guidelines. We supplied all areas in the ED with handouts of the guidelines, and conducted shop floor education for ED physicians. Regular sessions were conducted during educational activities and emergency seminars. The re-audit in January 2015 showed decreasing rate of CT scans at the rate of 22% achieving a reduction by 33% and improvement in the documentation by 31%. The overall reduction of and decreasing the percentage of unindicated CT head by around 30%.

Conclusion and recommendation: Managing minor head injury in pediatric age group becomes more safe by increasing the physician awareness about the evidence based updated guidelines.

Objective: The objective of this study was to collect feedback from Ambulance Paramedics (AP) with respect of their experience of using an External Chest Compression Device (ECCD) on cardiac arrest patients. Aspects of particular interest were ease of use and their perceived effectiveness of delivered CPR.

Background: HMCAS crews attend to several hundreds of cardiac arrests a year. To achieve Return of Spontaneous Circulation (ROSC), the key requirements are the provision of effective chest compressions delivering oxygen to the brain, maintaining coronary perfusion pressure, and priming the heart for successful defibrillation. Providing effective manual chest compressions in the austere Qatar pre-hospital setting with high temperatures is challenging, hence all HMCAS emergency vehicles have been equipped with ECCD.

Methods: HMCAS receives daily reports compiled by its Documentation Officers. These reports highlight specific cases in which use of the ECCD was indicated but not implemented. These cases are followed up and audited to assess if non-provision of automated chest compressions was clinically acceptable. HMCAS monitors specific key performance indicators, i.e. ’Use of the LUCAS™2 in Adult Medical CPR Cases’ as well as ’ROSC in Medical CPR’. Feedback was collected over a 3-month period using a 10-point Likert scale type questionnaire distributed to ambulance paramedic teams who had used the ECCD during a real medical cardiac arrest case.

Results: The results are based on 54 returned feedback questionnaires. Using a scale with 1 being very difficult and 10 being very easy, ambulance paramedics’ mean rating of the device's ease of use was of 8.8/10. Similarly, on a scale indicating perceived effectiveness, staff indicated that they found the chest compressions provided by ECCD to be highly effective (mean = 9.41/10).

Conclusion: HMCAS staffs are highly satisfied with making use of the device since it provides them with a safer work environment and they are less fatigued after finishing a CPR case, especially during the summer months.

Background: Breast cancer is the most common malignancy and leading cause of cancer mortality among females in Gaza. Most cases are diagnosed at late stage. Survival rates are persistently low in contrast to improved rates worldwide. Our study examined awareness, knowledge, attitude, practice and access to breast healthcare among both health professionals and women in Gaza.

Methods: In May and June 2014, using convenience and representative sampling, 100 health professionals from medical, surgical and obstetrics-gynecology completed a survey on basic knowledge of breast cancer, attitudes and practices. Structured interviews were conducted with 100 women 30 years and older across all districts and socioeconomic backgrounds. Women were interviewed about basic knowledge of breast cancer, self-exam, attitude and practice when a breast problem encountered, access, and barriers. Data was analyzed using excel to find frequency distributions.

Results: The health professional surveys showed: Only 15% offer breast exam to their patients, 13% believe mammography can cause cancer, 48% do not know that radiotherapy is not available in Gaza, 4% believe cancer breast is contagious. Health professionals expressed the need for standardized protocols and guidelines. Only 25% of surveyed women reported practice of self-examination, 87% had never had a mammogram or had been offered a breast exam, 26% think mammogram can cause cancer. However 80% were positive about seeking healthcare when needed. Most women accepted screening if affordable and were interested in receiving information about breast care.

Conclusion: Knowledge gaps in breast healthcare exist among healthcare professionals and women in Gaza strip. Awareness sessions, capacity building and specialized training of healthcare professionals are needed to improve quality of breast healthcare in Gaza. Increasing utility of mammography among women with access to multidisciplinary breast care may improve survival rate, particularly because most women in Gaza are keen on seeking medical care when needed.

Background: Intraosseous (IO) access are being widely used in resuscitation of patients with difficult intra-venous (IV) access. The United Kingdom Resuscitation Council guidelines recommend the use of IO access, after two minutes of failed IV access in adult patients or two failed IV attempts in pediatric patients. There are various complications associated with IO access such as extravasation of the infusion fluid or medications, bleeding, infection and pain1. Compartment syndrome is a rare complication associated with IO access. This is reported commonly in children where in certain cases the affected limb required amputation. We report a case where an adult patient developed compartment syndrome secondary to IO access.

Methods: A 52-year-old lady who was on dialysis for renal failure presented to the Emergency Department (ED) with septic shock. She was in peri-arrest and had a difficult IV access. Therefore an IO needle was inserted to her right tibia and resuscitation was carried out with fluids and medications. She required emergency intubation and ventilation and was later admitted to the Intensive Care Unit (ICU). The following day, it was found that she developed a compartment syndrome of the right lower leg where she had the IO access.

Results: Patient was taken to the theatre for an urgent fasciotomy of the affected leg by the orthopedic surgeons with input from plastic surgeons. She made a steady but full recovery and was discharged home later.

Conclusions: Compartment syndrome is a rare complication of IO access (0.6%) 1. Careful monitoring of the IO site is recommended. It is advisable to remove the IO needle once a definitive IV access is established.

1. Complication with Intraosseous Access: Scandinavian Users' Experience. Hallas et al. West J Emerg Med. 2013 Sep; 14(5): 440–443.

Background: Vaccine preventable diseases continue to kill large numbers of young children each year UNICEF estimates that 1.2 million deaths to children under five years of age could be prevented at low cost by vaccinating children. For example, it is estimated that measles related deaths have been reduced from about 2.5 million per year in 1980 to less than one million in 1990 (2)-a decline of more than 60 percent during the decade of the 1980s.

Purpose: Vaccinations are one of the most cost effective means to reduce morbidity and mortality associated with infectious diseases. The introduction of the vaccine has led to nearly a 90–100 percent reduction in target disease morbidity and mortality.

Methods: The information was collected used adopted WHO cluster survey 210 children to satisfy the research objectives_30 clusters with respondent in each were randomly chosen.

Findings: The result obtained showed that: Percentage of coverage with the BCG the number of vaccinated children by card (143) and from memory (12) with total percentage 74% and non-immunized (55) 26% for Penta3 and OPV3 the coverage was (57%) and the PCV3 coverage was (71%). The major reasons for non-immunization were unawareness of need for immunization or not able to return back to the second or third doses because of long distance and finance constrain. The study recommended that Strengthen social mobilization to increase routine immunization coverage and screening of defaulter children during the campaigns besides spending more efforts to decrease the dropout rate.

Conclusion: Darfur conflict during last decade, leads to massive population movement (nomads – refugees) that can threat the coverage all targeted children and reach every area but EPI in Sudan do effort to cover all population during campaign and routine immunization.

Introduction: The mechanism for carbamate toxicity is reversible cholinesterase inhibition, which leads to accumulation of acetylcholine at the neuromuscular junction.1 The cardiac manifestations of carbamate toxicity are rare. We report a case of carbamate toxicity with atrial fibrillation as the cardiac manifestation.

Case presentation: A 28-year-old patient, previously healthy, presented to the ED complaining of diplopia, dizziness, palpitation, and one episode of vomiting. The symptoms began two hours before when he was spraying pesticide at a farm. According to the patient he sprayed 9 liters of pesticide over a short period of two hours. The patient was not using any personal protective equipment. The pesticide used was later identified as Lannate, which contain Methomyl (carbamate). On examination, a chemical odor was noted. His initial vital signs were normal except heart rate of 134/min. The patient was decontaminated in the decontamination room to avoid further exposure. He had constricted pupils of 2 mm. There were no other signs of organophosphate or carbamate toxicity. His initial ECG showed atrial fibrillation (AF) with fast ventricular response rate. The pseudo-cholinesterase level was. The toxicology service was consulted, and they advised not to start antidote treatment only for the AF, as other signs and symptoms were absent. The cardiology on call assessed the patient and started amiodarone infusion presuming new onset of AF. The patient's rhythm reverted back to sinus 12-hour post-presentation. He was discharged next day with a diagnosis of paroxysmal AF secondary to carbamate poisoning.

Discussion: AF in carbamate toxicity is rare and only few cases have been reported in the literature.2,3 It is postulated that, enhanced nicotinic activity stimulates postganglionic sympathetic terminals and produces a dramatic release of norepinephrine.4 Norepinephrine mediates its arrhythmogenic effects by increasing automaticity of cardiac cells and by decreasing the cardiac muscle fibrillatory threshold.5

Backgrounds: Infection with Neisseria meningitides can produce a variety of clinical manifestations. Mortality and long-term morbidity can be very high in patients with invasive meningococcal disease if the infection is not treated appropriately. Our main objective was to evaluate mortality of all children admitted with acute meningococcal septicaemia (AMS).

Methods: We conducted a retrospective study of all paediatric-cases of acute meningococcal septicaemia admitted to Al-Nasser Paediatric Hospital, the largest paediatric hospital in Gaza Strip, between January-2009 and September-2015. All AMS cases were diagnosed based on the clinical presentation, skin smear and blood culture. Outcome measures were predicted mortality using Paediatric Risk of Mortality score III (PRISM III), actual mortality and standardised mortality ratio.

Results: A total of 240-children were admitted with proven AMS. Aged range from 1-month to 12-years, and 113 of them (47%) were male. The number of admitted children with AMS was decreased from 47–59 cases/year in the 2009–2011 period to 21–22 cases/year in the 2012-201. The total mortality predicted by PRISM III was 25.56%, however the actual overall mortality was 49 children (20.8%): 16(48.5%) aged less than-a-year, 17(22.1%) 1–3 year-old, 9(18.8%) 3–5 year-old and 7(8.5%) 5–12 year-old (p value = 0.00299). Standardised mortality ratio was 0.814. Forty-one children (82%) were died within the first 24-hours of admission. Sixty-nine (28.8%) children received corticosteroid, 85(35.4%) received inotropic medications and 46(19.2%) required mechanical ventilation for a median of 24-hours. In 75(31.3%) children, AMS was associated with meningitis. Multi-organ failure (n = 22, 9.2%) was the most common complication, followed by skin necrosis (n = 13, 5.4%), convulsions (n = 13, 5.4%), and disseminated intravascular coagulopathy (n = 10, 4.2%).

Interpretation: The mortality rate of the disease still high, however, this can be explained by the high predicted score of mortality, which reflect the severity of admitted cases. The mortality was significantly associated with younger age-group. New model of treatment (e.g. plasmapheresis) may be useful in decreasing mortality.

Background: Qatar is about to host the 2022 FIFA World Cup-WC, this can stress the public health system and resources of Qatar as hosting country. Reducing public health risks and ensuring people's safety at The Qatar 2022WC requires thorough planning and coordination. The aim is to obtain a comprehensive insight into the available practices concerning the infectious diseases preparedness and response for major Sporting events and to advise Qatar W.C-2022 health committee accordingly.

Methods: A desk review of WHO literature in public health considerations during mass gatherings was done, with particular focus on the Communicable Disease alert and response for mass gatherings.

Results: The literature suggests certain critical factors and preconditions for success that are common to most events as well as strategic, organizational, and tactical lessons learned that can be applied for Qatar WC 2022 includes, Comprehensive risk assessment should be conducted before the event, this will allows planners in Qatar to reduce the risk of communicable disease outbreaks associated with WC2022. Plans for risk management and risk communication need to be developed. New surveillance system should be in place for a sufficient length of time prior to the WC and this surveillance need to be divided into three phases, Pre-WC surveillance, WC-based surveillance and Post-WC surveillance.

Conclusion: The challenge for Qatar is to recognize the possible benefits from the outset of planning for the coming 2022WC and to build a positive and Strategic approach to communicable diseases issues into the earliest stages.

Background: The HGH Microbiology lab indicator showed that our blood culture contamination rate has been consistently higher than the international benchmark thereby we aim to reduce it in the critical area of Emergency Department by 50% by the end of July 2015 and at least 90% by end of February 2016.

Methods: A pilot area was chosen in the Emergency Department to do a study for 44 weeks after which blood culture kits (previously trolleys & trays were used) containing sterile gloves, masks, and blood culture supplies were introduced into the Critical area of ED-HGH in August 2015. Training included- new instructions to have two staff members present when drawing blood cultures (preceptor-preceptee methodology) thereby prohibiting drawing blood cultures from pre-existing lines and proper follow-up of every step. False positive blood culture rates were measured in the weeks preceding and the weeks following, this intervention.

Results: In the 8 weeks following the intervention, the average false positive blood culture contamination rate in HGH ED reached 1.9% (which was the benchmark) out of 318 blood culture samples. In the 6 months preceding, the blood culture contamination rates ranged from 4% to 1.5% each month.

Conclusions: Blood culture kits and educational training on proper technique resulted in significant reduction (>60%) in the false positive blood culture rate in the Critical areas of ED-HGH. Studies at other institutions have suggested that reducing the false positive blood culture rate could decrease costs by preventing unnecessary hospitalizations and administration of unnecessary antibiotics, as well as helping to prevent the development of multi-drug resistant organisms. 0000-0003-0866-6512 0000-0002-1057-2438.

To assess if stratification of patients based on clinical severity, laboratory markers and radiological findings at presentation would enable better prediction for the need for a surgical intervention. Single-centre retrospective cohort study done in the in-patient pediatric wards of a tertiary care centre in the State of Qatar. Participants – 56 children (aged 6 months – 14 years) with empyema or parapneumonic effusion, from July 2009- June 2013. Patients were classified into mild and severe clinical presentation based on the 2011 British thoracic society (BTS) pneumonia guidelines. Interventions were categorized as conservative (antibiotics only), non-conservative (antibiotic and surgical intervention). The values of CRP, ESR, WBC count, upon admission and follow up were also assessed, along with pleural fluid markers such as LDH, glucose and PH. The chest X-ray and chest USG were also assessed for severity and loculations. Of the 56 patients included, 29 (52%) had severe and 27 (48%) had mild clinical presentation. 26 patients (46.4%) were managed conservatively, while 30 patients (53.6%) required intervention. Younger patients (3.8 ± 3 years) tend to have increased risk for intervention, severe clinical presentation and loculations on USG. Age ≤  5 years, severe clinical presentation, serum WBC count ≥ 20,000/mm3, ESR ≥ 80 mm/hr, serum CRP ≥ 100 mg/dl, moderate to severe effusion on chest radiograph and presence of loculation on USG individually increased the likelihood for a surgical intervention in pediatric patients with parapneumonic effusion. Having ≥  4 out of 7 criteria accurately predicted a high risk for the need for surgical intervention (OR-6.93, 95%CI-1.2-37, p-0.023, sensitivity 72%, specificity 73%). Having ≥  4 out of 7 criteria accurately predicted a high risk for the need for surgical intervention. Prospective trials are recommended to see if this would enable homogeneity in deciding when to intervene in patients with parapneumonic effusion thereby reducing the LOS and cost-burden on the healthcare system.

Background: Approximately 1,000 U.S. citizens suffer from sudden cardiac arrest daily outside of the hospital setting. Providing cardiopulmonary resuscitation (CPR) improves survival if appropriately administered; however, many are resistant to initiate mouth to mouth. Hands only CPR (HOCPR) was developed by the American Heart Association to improve technique retention and increase the willingness to administer CPR.

Methods: Participants watched a teaching video from the American Heart Association, followed by a mannequin demonstration. Participants then filled out a survey immediately after practicing HOCPR on the mannequin and at one month.

Results: 75 Subjects received HOCPR training and completed a survey and 44 (59%) of the subjects completed a one month follow-up survey. The initial survey revealed that 100% (n = 75) were able to correctly recall the HOCPR process and 79% (n = 59) were very likely to provide HOCPR to a person suffering from a cardiac episode. 76% (n = 57) were more willing to assist a person in need as a result of not having to provide breathes to the person in need. At the one month follow-up, 100% (n = 59) of the respondents remembered the order of steps and 73% (n = 32) were willing to provide HOCPR since no rescue breathing was required. After learning the material, 15% (n = 11) of the participants tried to teach their family and friends about HOCPR.

Conclusion: HOCPR is a simple method which the average person is able to recall after a brief training in proper technique. Subjects were more willing to provide HOCPR and teach family and friends.

Introduction: Pakistan has seen repeated outbreaks of the disease over the past decade or so. In 2011 the largest outbreak was seen in Punjab where 20,864 cases were reported. This study was conducted to estimate the disease burden and analyze epidemiological trends using data from the provincial Dengue Surveillance System, Punjab.

Methods: A descriptive analysis of data from January 1 to December 31, 2013, was undertaken. A case of dengue fever was defined as any person with fever from 2–10 days with any three of the following symptoms: headache, retro-orbital pain, myalgia, arthralgia, rash, hemorrhagic manifestation, leucopenia, abdominal pain and restlessness. Population estimates from Federal Bureau of Statistics were used to calculate attack rates.

Results: From January 1 to December 31, 2013, a total of 14,145 suspected cases were reported and 2,662 were confirmed. Out of cases 9,038 (69.3%) were males and 03 deaths were reported with CFR 0.11%. Mean age was 28.5 years (range 1–99 years). About 28 (0.2%) had previous history of dengue fever. Lahore was the most severely hit city (AR = 173/100,000) followed by Rawalpindi (AR = 52/100,000), Kasur (AR = 6.8/100,000) and Faisalabad (AR = 3.1/100,000). Most severely affected age group was 15–49 (AR = 30.8/100,000) followed by 50+ age group (AR = 15.5/100,000). Males were more affected (AR = 26.3/100,000) than females (AR = 11.8/100,000). The cases started increasing in August (1,128), peaking in November with 4,210 cases reported and then declining in December (758).

Conclusion: The analysis showed predominant involvement of adult males. Moreover highest number of cases was reported in the post-monsoon months of September through December. Age, gender specific health education and area specific larvae and vector control activities should be initiated. In 2014 there was significant decrease in dengue cases in Punjab and especially in Lahore where age and area specific targeted activities were conducted and AR was decreased to 21/100000.

Background: In April 2014, the South West London and Surrey Major Trauma Network entered its 4th year as an operational network, consisting of one Major Trauma Centre (MTC) and 7 acute Trauma Units (TUs) over a wide geographical area. In the year ending March 2014, 75% of the major trauma patients were taken to the MTC. However many patients with ISS >15 were admitted to TUs. Regular governance meetings are key to ensure these patients have received an appropriate level of care.

Case description: A service evaluation of care provided under governance framework, using the ISS as a guideline, was carried out. Patients who sustain traumatic injuries are managed in accordance with the Major Trauma Clinical Standards, the Trauma Audit and Research Network (TARN) measurable quality indicators and Trauma Quality Network System (TQuINS) recommendations. Available data indicates that there is a possibility that patients who present to a TU rather than a MTC may receive less than optimal care. In order to mitigate this difference it is necessary to have a governance system to ensure the patient care is optimal.

Methods: A proforma was developed for data collection with key trauma measures as quality indicators and the results collated in an Excel spreadsheet. A standard operating procedure and flow chart processes were developed to review major trauma cases. The TARN Office identified suitable patients and a multidisciplinary team reviewed the notes. Issues with care were formally registered with trust incident reporting system and registered in the trauma risk register. Findings were presented in the trust audit study day, in the Trust governance committee and disseminated for development.

Conclusions: Initiating a robust governance system and process will minimise substandard care and help standardise care across the network.

Background: Medical missions have become a part of the Global Health Programs at many academic institutions. Commonly these programs involve annual trips to locations in the United States and around the world. The University of Toledo Medical Center (UTMC) sought to develop a sustainable mission that has educational and clinical value to both the local community and academic institution.

Methods: The Department of Emergency Medicine at UTMC has worked with Salud Total, a small health clinic in La Ceiba, Honduras. Salud Total is staffed by a general practitioner, nurse and ancillary staff. During a mission the clinical volume increases over 100 patients a day. UTMC staff and senior ED residents see general medical complaints and perform small surgical procedures. Specialists, such as cardiologists and obstetricians see those needing specialty care. Education is provided in the form of bedside clinical teaching and materials distributed to staff and patients.

Results: This mission has provided clinical services to an underserved population, providing specialty medical care that otherwise was unavailable to these patients. Returning every 3 to 4 months allows the mission team to follow-up on treatment or procedures initiated on prior visits and provides the opportunity to advance clinical care through ongoing teaching and education.

Conclusions: Through our approach, we have enhanced clinical capabilities, increased the knowledge and skill set of the local practitioner as well as provided education to the patient and local community. Future expansion involves incorporation of telemedicine to provide real-time support for this clinic population and medical staff.

Introduction: Gallbladder volvulus is a rare entity, with a predilection for elderly women in their 7th or 8th decades of life. The condition results in rotation of the gallbladder on its mesentery along the axis of cystic duct and artery. Presence of redundant mesentery is a prerequisite. The disease is a frequent mimicker of acute cholecystitis, often difficult to diagnose preoperatively. Till date only about 300 cases have been reported in the literature, with children and adolescent presentations being exceedingly rare.

Case description: We report a case of an 18-year-old female who presented to emergency with right upper quadrant pain for a day associated with repeated vomiting. The patient was stable, had tenderness in right hypochondrium. Patient was evaluated as a potential case of acute cholecystitis. Laboratory investigations have shown normal white cell count, double normal liver function tests. Ultrasound showed that the gallbladder was out of the fossa with significant edema and wall thickness suggestive of gallbladder torsion. Further workup with MRCP was done, which showed retrohepatic gallbladder, with partial volvulus and hemorrhagic acalcular cholecystitis. The patient underwent laparoscopic detorsion and cholecystectomy and had an intraoperative evidence of gallbladder volvulus with gangrene with an uneventful course of hospital stay.

Conclusion: We believe that this may be the first documented case of this rare condition from Qatar. Gallbladder volvulus mostly occurs in elderly, but it might occur in young patients as well and should be included in differential diagnosis of abdominal pain. Ultrasound is a safe, feasible diagnostic tool, as sensitive as MRI in diagnosis of gallbladder volvulus.

Background/objective: Several inflammatory biomarkers of infection including procalcitonin (PCT) and C – reactive protein (CRP) have been shown to be useful in diagnosis of infection in different clinical settings. The purpose of this study was to determine the diagnostic value of serum PCT, CRP and White Blood Cells (WBC) as markers of sepsis in critically ill patients in Qatar.

Materials and methods: The PCT levels and other related inflammatory markers (CRP and WBC) were measured in 137 adult patients with a suspected diagnosis of sepsis and admitted to Internal Medicine inpatient service (i.e., Medical Wards and Medical Intensive Care Unit) at Hamad General Hospital, Hamad Medical Corporation-Qatar during the period from January 2011 to December 2013.

Results: The serum PCT was measured by chemoluminiscence immunoassay and the results were compared with other inflammatory markers between the patients with and without proven sepsis. A significantly higher PCT level was observed among patients with severe sepsis and septic shock compared to those without sepsis (19.34 ± 50 and 25.91 ± 61.3 vs. 4.72 ± 10, respectively; (p = 0.011). No significant differences were found in CRP and WBC between these groups. Non-survivors of both septic and non-septic groups had a mean PCT level of 22.48 ± 8.26 significantly higher than that measured in survivors of both groups (p = 0.01), a difference not evident in other inflammatory parameters.

Conclusion: PCT is a highly efficient inflammatory laboratory parameter for the diagnosis of severe sepsis and septic shock but WBC and CRP levels were of little value. PCT value assists in diagnosis of septic shock hence supporting appropriate disposition of patients. Levels of PCT also have prognostic implications with regards to mortality suggesting intensification of antibiotic therapy and supportive measures including appropriate family counseling.

Background: The last cholera epidemic in Sudan occurred in 2006/07, over 20,000 cases (4% case fatality rate) were recorded, index case was coming from South Sudan. In regard to recent outbreak in South Sudan June 2015, Sudan carried out preparedness procedures to prevent cholera spread. The uncontrollable open borders and the South Sudan refugees-over 198,000 – settled in Sudan poses a great cholera spread risk.

Objective: To illustrate cholera preparedness and response activities.

Methods: Comprehensive study utilize data collected from reports of cholera higher committee, investigation for cholera rumors, risk assessment missions for refugee camps and preparedness strengthening missions to States bordering South Sudan.

Findings: Higher committee was developed to undertake and follow preparedness activities under areas of surveillance, health promotion, environmental health, case management and points of entry (POE). Surveillance system was enhanced in all sentinel sites (1522) including refugee camps, daily zero reports were activated. Training for Rapid response teams and health cadres at hospital were achieved in all States with (70%) of the target. 39 rumors for cholera were investigated, laboratory test indicated negative results. Regarding case management; Cholera kits, protocols and leaflets were distributed to all States, isolation areas were established in Khartoum and bordering States. Preventative precautions at POE were implemented to rehabilitated isolation area at Khartoum airport and establish case referral system. Trips coming from South Sudan were observed throughout the period of the outbreak and leaflet distributed to passengers Actions were carried out urgently to allow chlorination of water in all States and provide deep trench latrines with 50% of target with focusing on refugee camps. Administration of cholera vaccine recommended by WHO assessment mission at refugee camps.

Conclusion: Significant government and partners commitment to avail resources was observed. Efforts done lead to reduce possibility of cholera spread especially at refugee camps.

Background: Multiple trauma patients are evaluated and managed by the Emergency Department (ED) in Al Wakra. The assessment, management, and disposition of this population have become a significant workload component. The aim of this study was to evaluate the trauma service at Al Wakra ED.

Methods: In our study, we aimed to collect data on the trauma patients, admitted between July 2014 and October 2015, who presented to the ED, at Al Wakra Hospital, and then transferred to the major trauma unit at Hamad General Hospital (HGH), Doha, if further subspecialty management was needed. The data analyzed was for demographic characteristics, triage categories, and need for transfer to the level one trauma center for further management.

Results: Total of 59 patients with multiple trauma were admitted to Al Wakra ED, with mean age of 28 ± 19 years. Of these 91% were male. Based on the trauma severity, majority of the cases were level 2 trauma (92.73%), while trauma level 1 and trauma level 3 were (5.45%) and (1.82%) respectively. The most frequent anatomical type was head trauma (62.71%) followed by extremities trauma (33.9%). Other types included chest trauma (23.73%), spinal trauma (18.64%) and abdominal trauma (15.25%). The most common consultation services requiring transfer to level trauma center at HGH, were the neurosurgery (59.32 %) followed by the orthopedics (33.9%). It was found that 61.2% of the patients were admitted. The mean length of stay (LOS) was 8.35 days, while the median LOS was 4 days.

Conclusions: The Emergency Department at Al Wakra Hospital was able to receive and do the initial stabilization of multi-trauma patients. However, lack of certain sub-specialties mainly neurosurgery required transfer of two thirds of the patients to level one trauma center for further management. This may point to the future need of implementing neurosurgery services at Al Wakra Hospital.

Background: Hepatitis C viral infection is a public health concern worldwide and a major cause of morbidity and mortality in several countries that supply the State of Qatar with many of its laborers. The objectives were to measure the prevalence of hepatitis C viral infection among single male laborers; detect the practices that may catalyze the spread of the infection; and assess the knowledge gap.

Methods: A cross-sectional study was conducted in 2014 and involved 504 expatriate single male laborers seeking health care in two Qatar Red Crescent health centers.

Results: Results showed that only 5% of the total participants have ever been tested for hepatitis C and positive serology was detected in 4 respondents (0.8%), three of them from Egypt and one from Nepal. Three out of the 4 positive cases did not know they were infected and 2.5% lived with someone harboring the infection. Respondents appeared to have varying healthcare needs with 57% subject to medical procedures outside Qatar. Various risk practices for hepatitis C infection were reported including ear/body piercing (21.9%), tattooing (13.3%), contact with blood (17.0%), sharing personal equipment (12.2%) and injecting with used needles or syringes (7.4%). Less than 40% of respondents had knowledge of all modes of hepatitis C transmission.

Conclusion: Further actions notably building HCV monitoring system, setting a prevention plan, building screening strategy were need to be complemented by a contract renewal or a 3-year screening policy.

Background: Hamad General Hospital (HGH) Emergency Department (ED) provided 465,942 patient visits in 2014. (ED) use has increased annually resulting in overcrowding, longer wait periods for service and increased stress on health care workers. Much attention has been paid to factors contributing to this increased usage such as the return visit of an (ED) patient within 48 hours of the initial visit. 48 hours is the benchmark time period used in measuring (ED) return visits utilized by many countries and it became a mandatory quality indicator of performance by the Supreme Council of Health in Qatar on April 2015. This study was conducted to identify factors associated with scheduled and unscheduled 48 hours return visits to serve as a basis for a Quality Improvement Project (QIP) for development of interventions to decrease unscheduled returns.

Methods: An exploratory quantitative study using a descriptive correlational design was performed. The sample consisted of all patients had a return visits to (ED) within 48 hours from the discharge time during January 2015 at the study facility. Data were abstracted from electronic patients’ records utilizing the data collection tool, all electronic records was reviewed by experienced emergency physicians.

Results: For the study month of January 2015 there were 1023 return visits within 48 hours from the discharge time (2%) out of 42981 (ED) patients. 906 visits (89%) was unplanned out of them 102 visits (11%) was clinically significant. 85 cases(9%) were admitted on the return visit and we had no mortality cases. Abdominal pain was the main presenting complaint (28%) of all revisits followed by musculoskeletal pain (13%) for patients whom presenting with the same complaint.

Conclusion: Abdominal pain is the most frequent complaint associated with unscheduled return visits. Further Study is important to design and implement interventions to decrease the frequency of unscheduled returns.

Background: Point-of-care ultrasound is an invaluable tool in the diagnosis and management of many conditions presenting to emergency departments across the world. It has also improved the success rate of invasive bedside procedures.

Objectives: This study aimed to investigate the current utilization of point of care ultrasound in a large tertiary care emergency department in the Middle East and to identify barriers to its utilization.

Methods: A cross sectional survey of emergency physician's experience with ultrasound was conducted, examining training, exposure and barriers to use. This paper-based survey was completed by the participants in the presence of study authors to improve compliance. Data was collected over a period of two months, from October to November 2014.

Results: One hundred and five (105) physicians participated in the survey. Fifty-six physicians had prior training in ultrasonography from courses approved by The Royal College of Emergency Medicine in the United Kingdom, and The Royal College of Physicians and Surgeons of Canada. Twenty-two physicians had undertaken other non-accredited ultrasound courses. All of them reported an improvement in their procedural skills by employing ultrasound. Perceived lack of time in the Emergency Department was the main barrier to scanning. Other hurdles included a deficiency of trained personnel for guidance, shortage of equipment and a lack of experience and interest. Hands on training were stated as the preferred method for enhancing ultrasonography skills.

Conclusions: There has been underutilization of point-of-care ultrasound by emergency physicians. Availability of dedicated time, equipment, supervision and training will help to increase its usage.

Background: The rate of patients who arrive at the Emergency Department (ED) but leave before being seen (LWBS) is considered an important marker of the quality of care.

Objectives: To evaluate the rate of LWBS at ED in Al Wakra Hospital (AWH) and to identify predictive factors associated with LWBS.

Methods: This was a retrospective study of patients who left the Emergency Department without being seen by physicians between January 1, 2015 and May 31, 2015. Factors associated with LWBS such as the age, sex, time of the day, day of the week, median ED waiting times and common ED presentation were analyzed.

Results: Out of 95,375 patient visits; there were 426 cases of LWBS over the 5-month period. The highest rate of LWBS was seen on the month of March. Independent factors associated with LWBS patients include patients who are middle age (19-43 years), female (56%), and patients being presented at non-critical areas (100%), night shift visits (46%), on weekend (52.8%). Musculoskeletal complaint was the most frequent complaint associated with LBWS (31%) and the median waiting time was 45 minutes among LBWS patients.

Conclusion: The rate of patients leaving without being seen at ED in AWH is very low. More investigations need to be conducted to improve LWBS rate during night and weekends.