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

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.