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.