Journal of Emergency Medicine, Trauma and Acute Care - 2 - Qatar Health 2021 Conference abstracts, August 2021

It feels like yesterday that we wrote the editorial related to the previous issue of the Qatar Health 2020 Conference!¹. 2020 is clearly a year to remember globally as a challenging one and this probably contributed to time passing so rapidly, keeping everyone so busy caring for patients and conducting research². COVID-19 has had a big impact on all aspects of our lives, from the way we deliver patient care and work, to how we socialize and plan for the future in general. The past year has certainly provided an opportunity for the State of Qatar to demonstrate its resilience, its ability to rapidly adapt to new circumstances, and to find effective solutions to new problems^3,4. Although very concerned by the current pandemic, our focus needs to also concentrate on the forthcoming FIFA World Cup in 2022 and every possible health related aspects, to ensure the event is safely hosted for everyone’s enjoyment. This has been clearly reflected in the Qatar Health 2021 conference program and call for abstracts (Table 1) which was organized into four parallel tracks fully hosted online for everyone’s safety. This issue of the Journal of Emergency Medicine, Trauma and Acute Care contains an extensive selection of 38 out of the 94 abstracts that have been accepted for oral or poster presentation during the conference. The abstract themes are summarized in Table 2 and range from the impact of the pandemic on delivering primary care to Qatar’s preparedness to dealing with hazardous and chemical, biological, radiological and nuclear incidents^5,6. Notably 48 (51.06%) of the abstract titles contained the word COVID-19 or pandemic while only 4 abstracts (4.25%) were related to mass gatherings and sporting events. The later topics were primarily covered by multiple invited speakers with the relevant experience and proved to be the most attended conference sessions. It is worth noticing that the event attracted just over of 5,400 delegates and speakers from a total of 40 countries and has received highly positive feedback. We look forward to welcoming everyone again next year as we come closer to the FIFA World Cup 2022, with many more topics, partner organizations, and attendees.

Background: Diabetic patients are at significant risk of serious complications and higher mortality rates if they contract COVID-19^1,2,3. Primary Health Care Corporation (PHCC) in Qatar launched a Diabetes Teleconsultation Clinic to proactively support high risk diabetic patients with a hemoglobin A1c (HbA1C) superior or equal to 8 mg/dL and without a primary health care encounter in the last 2-12 months, in an attempt to support this high risk population and still provide continuity of care. Methods/Case presentation: Patients meeting the criteria were proactively contacted and received a teleconsultation call from a family medicine physician. During the call, family physicians and patients reviewed individual management plans, and if agreed and required changes, the patient management plans were adjusted and monitored. Patients were additionally supported by a wider team of professionals via teleconsultations, including dieticians, health educators and primary care psychology and psychiatry services. A paired sample T-Test (Table 1) was conducted to compare the HbA1c mean levels for patients before and after joining the PHCC Diabetes Management Teleconsultation Clinic, after a 4-month period. Results/Findings/Recommendations: There was a statistically significant difference in the results of mean HbA1c levels for patients before joining the Diabetes Management Teleconsultation Clinic and after the intervention. Of the 384 patients analysed, the average HbA1c level before the intervention was 9.49 mg/dL, and after the intervention the average was 8.83 mg/dL (p < 0.001). Conclusion: The use of teleconsultations, remote multidisciplinary team support, and collaborative patient management plans has had a positive impact on the health outcomes of 384 high-risk diabetic patients within primary care. This inclusive model of care will be replicated to support more patients as a preventative and supportive intervention not only during the COVID-19 pandemic but in the long term.

Background: As of 26 June 2020, the global number of infections caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), had reached 11 million, with more than 500 thousand associated deaths¹. Limited clinical information about COVID-19 on solid organ transplant (SOT) are available so far. We herein report our preliminary experience with COVID-19 in SOT recipients in the first few weeks of the outbreak in Qatar. Method: All SOT recipients with laboratory-confirmed COVID-19 up to 23 May 2020 were included. Baseline characteristics, antivirals and immunosuppressive management, complications, and outcomes were retrospectively extracted from the electronic health system. Categorical data are summarized as frequency and percentages, while continuous variables are presented as medians and ranges. Results: Twenty-four SOT patients with COVID-19 were included in this report (kidney: 16, liver: 6, heart: 1, and combined liver and kidney: 1). The median age was 57 years (range 24–72). Thanks to proactive screening, five (21%) asymptomatic cases were diagnosed (Table S1). Among the other 19 symptomatic patients, fever (15/19) and cough (13/19) were the most frequent presenting symptoms (Table S1). All patients were hospitalized; 5 (21%) required invasive mechanical ventilation in the intensive care unit (ICU) (Table S2 ). Eleven (46%) patients developed acute kidney injury as a complication, including 3 in association with drug-drug interactions involving investigational COVID-19 therapies (Table S2). Maintenance of immunosuppressive therapy was changed in 18 (75%) patients, but systemic corticosteroids were not withdrawn in any. After a median follow up of 43 days (26–89), 18 (75%) patients had been discharged home, 3 (12.3%) were still hospitalized, 2 (8.3%) were still in ICU, and 1 (4.2%) had died (Table S2).

Conclusion: Although higher mortality rates were observed in other reports,^2,3 our results suggest that asymptomatic COVID-19 is possible in SOT recipients and that overall outcomes are not consistently worse than other immunocompetent patients. The results require validation in larger cohorts.

Background: The new coronavirus disease 2019 (COVID-19) emerged in Wuhan, China, in December 2019. Researchers described COVID-19 mortality risk factors as being elderly, male, having comorbidities, and in some ethnicities. Some authors validated the use of first chest x-ray (CXR) severity scores (CSE) as an independent indicator of poor outcomes with COVID-19. Our objective was to evaluate the clinical and CXR findings as predictors of poor outcomes (death, needing intubation, Intensive Care Unit (ICU) admission) in patients with COVID-19. Methods: We performed a retrospective study of case-controls using a sample size of 60 patients admitted with the diagnosis of COVID-19 during the period of July-August 2020 to the Cuban Hospital in Qatar, as determined with the free online OpenEpi software (https://www.openepi.com/SampleSize/SSCC.htm). We defined cases as patients with a complication like death, needing intubation, ICU admission, or organ failure, and controls as patients who did not demonstrate the described complications. The dependent variables used were patient evolution divided into poor outcome or good outcome. The independent variables used were age, history of diabetes mellitus type II, and high blood pressure (HBP), CSE, and white blood count (WBC). The bivariate analysis was performed using the Chi-Square test or Fisher exact test. Multivariate analysis was done using binary logistic regression (IBM SPSS software 25). The results are expressed in Odds Ratio with p-value < 0.05 defined as statistically significant. Results: The bivariate analysis showed being older, having a history of HBP, diabetes, abnormal WBC, and high CSE were linked to poor outcome (p < 0.05) (Table 1). The multivariate analysis defined WBC and CSE with independent influence over the patient evolution (Table 2). Conclusion: We demonstrated that the value of WBC and CSE are predictors of poor outcome in patients with COVID-19. WBC increases the possibility of the described complications in COVID-19 patients 68,634 times and CSE 12,201 times.

Background: COVID-19 antibodies’ longevity following infection is still unclear. Early data brought hope that acquired immunity was possible¹ but subsequent studies suggested that immune protection might be short-lived. The results of recent studies provide greater insight into the human immune response to COVID-19^2,3. The Qatar Gas medical department’s strategy in preventing spread of infection among offshore and onshore workers consisted of maximizing the opportunities for COVID-19 polymerise chain reaction (PCR) and antibody testing. A large amount of data revealing the possible lifespan of COVID-19 antibodies in the study population was collected. Methods: Out of hundreds of employees who volunteered in this study about seroprevalance of COVID-19 antibodies, 52 whose results were reactive were tested for COVID-19 PCR before being selected. Employees with reactive or inconclusive PCR test results were excluded. Age, medical/surgical/social history, apart from past COVID-19 infection, were not selection criteria. We measured the period of time between the date of diagnosis and the antibody test result, segregating those still reactive from those who tested non-reactive at any point in time. The reactive group were retested for antibodies every 90 days as long as results continued to be reactive. Any cured employee was retested if they developed symptoms or was exposed to a confirmed positive case, to rule out the possibility of re-infection during this timeframe. Results: Only one employee was non-reactive after 110 days of COVID-19 PCR positive test result. 22 employees tested reactive although their PCR result had been negative. 30 employees tested reactive after a positive PCR with an average duration of 145 days, the shortest and longest being 24 and 223 respectively (Figure 1). Conclusion: We determined that antibodies’ longevity may extend to more than 6 months following COVID-19 infection and that there may be an early decay of antibodies in a limited proportion of the population, however further studies are recommended on larger populations. We noticed no cases of COVID-19 reinfection.

Background: The rapid spread of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and its resulting disease (COVID-19) is one of the greatest global public health crisis of the recent decades¹. The COVID-19 Biorepository is a national project aimed to support the high demand of biomedical research by multiple groups and the need to have access to high quality, curated clinical data, and specimens contributing to the understanding of, and response to, the COVID-19 pandemic and its impacts in Qatar^{2, 3}. Methods/Case presentation: Patients with a laboratory diagnosis of COVID-19, who were Qatar residents that could communicate in Arabic, English, Hindi, and Urdu were eligible to participate in the study. COVID-19 diagnosed patients were recruited at the time of their disease period from the main three public hospitals (Communicable Disease Center, Cuban, and Hazm Mebaireek Hospitals) serving as isolation facilities of symptomatic patients in Qatar, during a 7-month period from March 2020 until September 2020. Consented participants were followed up on a weekly basis until recovery, and then monthly for a year. Sociodemographic and clinical data were collected in electronic questionnaires via a face-to-face interview by trained Qatar Biobank (QBB) staff. Results: A total of 2097 consented participants were recruited up to September 2020, males (N = 1050) and females (N = 1047), with a mean age of 41 years (SD: 15.5). 61.0% of the participants had at least one follow up while 27% adhered to monthly follow up visits. Data was collected for 99.7% of the participants, while the follow up process is still ongoing. In total there are 107,171 high quality specimens in the biorepository including plasma, erythrocytes, buffy coat, serum, PAXgene whole blood, nasopharyngeal secretions, and DNA. Conclusion: The COVID-19 Biorepository is a national asset to illuminate the pathophysiological and identify markers of disease prognosis as well as to describe the clinical features and epidemiology of COVID-19 in Qatar and worldwide.

Background: COVID-19 pandemic created an unprecedented demand for reagents and diagnostic tools to confirm COVID-19 cases. Thus, the development of a robust in-house diagnostic test is considered of high importance. Within a few days after exposure, the human body produces specific antibodies that recognize the surface proteins of the invading SARS-CoV-2 virus¹. Therefore, virus specific immunoglobulins are neutralizing antibodies and their appearance in the blood is a good sign of immunity². The aim of this study was to develop an in-house COVID-19 serology ELISA test to quantify induced antibody responses. This test can help identify convalescent plasma donors with high antibody titers that can be used to treat other patients. Methods: Spike protein antigen is highly expressed in SARS-CoV-2³. Recombinant protein corresponding to the spike receptor-binding domain (RBD), which binds to specific antibodies circulating in COVID-19 patients’ blood was used as the antigen in this colorimetric ELISA test. Briefly, a 96-microtiter well plate was coated with RBD protein, where serum dilutions were added. Antibody titers were detected using an anti-human IgG- peroxidase labelled antibody and the substrate o-phenylenediamine dihydrochloride; measured at optical density (OD) of 450 nm (Figure 1). Results: The in-house quantitative serology test was validated using serum samples collected from severe COVID-19 patients (n = 282) admitted to the intensive care unit at Hamad General Hospital. Serum samples from non-COVID-19 (n = 10) were used as a negative control. We detected high antibody titers in ~90% of COVID-19 sera. In contrast, no SARS-CoV-2 specific antibodies were detected in the serum of non-infected subjects (n = 6), pooled human serum collected before 2019, or Middle East Respiratory Syndrome (MERS) infected subjects (n = 3) confirming the specificity and the sensitivity of this in-house serology test. Conclusion: This in-house quantitative serology test is sensitive, specific, and inexpensive. The test can address the rising issue of COVID-19 supply chain globally and foster the capacity-building efforts envisioned by Qatar University.

Background: Lung tomography is used to evaluate the lung parenchyma in diffuse interstitial lung disease. This type of injury can be caused by COVID-19 which emerged in Wuhan China, in December 2019.¹ Typical Computed Tomography (CT) findings in individuals with COVID-19 are ground glass opacities, particularly in the peripheral and lower lobes, and bilateral multiple lobular and subsegmental areas of consolidation.² The authors validated the use of baseline chest x-ray severity scores as an independent prognostic indicator of outcomes in COVID-19 patients.³Objective: To describe tomographic, radiological, clinical, and laboratory findings associated with worse evolution in COVID-19 patients. Methods: This is a descriptive observational study based on 15 patients infected with COVID-19 in the Cuban Hospital, in Qatar, between March and June 2020, and for whom a CT scan of the chest was performed. The facility was mainly dedicated to treat COVID-19 patients. Poor outcome was defined as patient needing intubation, Intensive Care Unit (ICU) admission, or death. Variables such as age, gender, nationality, body mass index (BMI), smoking habit, presence of comorbidities, laboratory tests (leukogram (WBC), lactate dehydrogenase (LDH), c-reactive protein (CRP), and glycemia), and the severity of radiological and tomographic findings were collected. The quantitative variables were dichotomized according to their values. Results: The outcome of our patients based on the variables collected is shown in Table 1. Diabetes mellitus and obesity were common comorbidities associated with poor patient outcome. The evolutive abnormal leukogram, glycemia, C-reactive protein were more abundant in patients with poor outcome. Regarding radiographic variables, 5 affected quadrants was the most observed radiological finding (Figure 1). In the chest tomography the most described was mild severity followed by severe score (Table 1). Conclusions: This sample is too small to make sound conclusions regarding our observations so a larger sample size study is required to confirm these results.

Background: In response to the COVID-19 global pandemic the Primary Health Care Corporation (PHCC) in Qatar recognized the need to limit face-to-face consultations within health centers in order to prevent unnecessary spread of the virus by offering an alternative solution for patients to access primary health care^1,2. PHCC responded by establishing teleconsultation services (telephone and video) within health centers and establishing a community call center offering teleconsultations for family medicine, ophthalmology, and dentistry services, with a nursing tele-triage service operating 24 hours a day, 7 days a week³. Methods: All previously booked appointments within health centers were converted to outbound telephone consultations. The community call center was widely advertised and received incoming patient inquiries. This led to an analysis of the teleconsultation service utilization on a daily, weekly, and monthly basis. Results: The 27 health centers successfully provided 703,845 teleconsultations (via video and telephone calls) between 1st April and 31st October 2020 compared to 964,285 in-person consultations (Table 1). A significant percentage of patients continue to opt for a telephone consultation rather than a face-to-face visit. Between 29th March and 28th November 2020, the community call center received a total of 159,137 calls with 61% of calls managed and resolved by a nurse, without the need for a consultation by a physician. Conclusion: The rapid response by PHCC to find alternative means to offer primary health care services during a pandemic was activated early and the public responded positively. Teleconsultation services within Qatar have been widely accepted by patients who have more choices to access primary care services. Since April 2020, when teleconsultations were fully implemented in PHCC, to October 2020, 42% of all consultations have been via teleconsultation (Table 1). Teleconsultation services both within health centers and the community call center, offer an alternative means of care delivery, empowering patients.

Background: Transport and retrieval of patients on extracorporeal membrane oxygenation (ECMO) support can be hazardous to patients and healthcare workers (HCWs)¹. COVID-19 is highly contagious and can be transmitted by contact, droplet, or airborne route. Transport of COVID-19 patients exposes HCWs and the public to infection risks, hence strict measures must be in place to ensure everyone's safety². ECMO cannulation and transportation is considered an aerosol generating procedure and can pose significant risks to HCWs³. In addition, close contact with the patient in the confined space of the ambulance may put HCWs at increased risk of exposure and infection. Methods: Between March 1st and September 30th 2020, a total of 32 episodes of COVID-19 ECMO transport were undertaken by the Medical Intensive Care Unit (MICU) and Ambulance Service. We reviewed the incidence of COVID-19 infection among HCWs involved in these missions. The transport clinical team is composed of ECMO consultant, two ECMO nurses, a perfusionist and a Critical Care Paramedic (CCP). Due to staff shortage and clinical needs, a respiratory therapist did not attend to the majority of cases. A crew of two paramedics supports the clinical team with their intensive care ambulance. Results: The number of clinical staff involved in the COVID-19 ECMO transport during that period is shown in Table 1. The duration of clinical staff’s exposure to the infected patient in the back of the ambulance is demonstrated in Table 2. MICU staff underwent COVID-19 serology tests every 2 weeks as per local policy. None of the clinical staff involved in these transfers and retrievals of COVID-19 positive patients tested positive after 2 weeks of transport. Conclusion: Strict infection prevention and personal protective measures are mandatory to avoid cross-infection and were carefully adhered to during all the missions. They translated into the well-being of the clinical staff involved in the transfer and retrievals of COVID-19 positive patients.

Background: Transport and retrieval of patients on extracorporeal membrane oxygenation (ECMO) support can be hazardous with complications reported for up to 27% of patients¹. Transport of COVID-19 patients on ECMO requires appropriate training, resource allocation, meticulous planning, effective communication and co-ordination. Strict adherence to infection control procedures and appropriate use of personal protective equipment is recommended². The Extracorporeal Life Support Organisation registry reports 43% in-hospital mortality of COVID-19 patients supported on ECMO. This includes in-house and retrieval ECMO cases³. Methods: Between March 1st and September 30th 2020, 32 confirmed COVID-19 positive patients underwent peripheral cannulation followed by transportation to the Medical Intensive Care Unit (MICU) at Hamad General Hospital. Mobile ECMO is complex and time consuming. Following arrival at the bedside and thorough clinical assessment, the ECMO consultant may decline, recommend optimisation of the care provided, or opt for cannulation and initiation of ECMO. Cannulation can be performed at the bedside or in the operating room. Following stabilisation, the patient is transferred for computed tomography imaging and then transported by ambulance to hospital (Figure 1). Finally, another transfer from hospital entrance to the MICU takes place. All these phases pose risks for errors and complications unless vigilance, teamwork and continuous effective monitoring and co-ordination is observed. Patients were evaluated for age and severity of illness (Table 1). In addition, all major transport-related adverse events were reported and analysed. Major transport events are cardiac arrest, ECMO emergencies (membrane or mechanical failure, air embolism, accidental decannulation, or significant cannula dislodgement), significant arrhythmia, severe bleeding or cardio-respiratory instability, and vehicle breakdown/malfunction. Findings: The majority of our patients were critically ill with high probability of mortality as depicted by SOFA and APACHE2 score. 29 out of 32 patients were male. None of our patients suffered major complications during transportation. Conclusion: This small case series demonstrates transport and retrieval on ECMO for COVID-19 positive patients can be safely undertaken provided appropriate expertise, protocols and resources are used.

Background: A rising number of bariatric surgeries (BS) are associated with a rise in medical complications including protein malnutrition and neuromuscular complications (NM). Although BS were minimized during the COVID-19 pandemic, the number of admissions due to complications continued to increase. Proper outpatient follow-up was negatively affected during the pandemic. We aim to address the rising rate of post-BS admissions during COVID-19 pandemic compared to the previous six years' admissions with a similar diagnosis. Methods: This is a retrospective observational study of 33 patients admitted with malnutrition and/or NM complications post-BS at Hamad General Hospital, Qatar, from 1st Jan 2014–30th Aug 2020. Patients’ data were retrieved from the electronic medical records and bariatric patients’ database. Malnutrition was evaluated using serum albumin, total protein, minerals, and vitamins. Nerve conduction study/electromyography confirmed NM complications. Risk factors addressed were interval between BS and admission, gastrointestinal symptoms, total weight loss (TWL %), excess weight loss (EWL %), and irregular multivitamins intake. Results: The study included 21 patients, admitted from 1st Jan 2014-31th Dec 2019, compared to 12 patients during the period 1st Jan-30th August 2020. The patients’ mean age was 26.90 ± 9.81 years, and females were 18 (59%). The mean pre-operative weight, Body Mass Index (BMI), post-operative weight, BMI were: 123.48 kg, 44.37 kg/m² and 84.61 kg – 30.67 kg/m², respectively. The mean weight loss, EWL% and TWL% was 38.04 kg, 73.26%, and 30.57%, respectively. The time interval between BS and admission was 7.18 ± 8.99 months. Seventeen patients (51.5%) had malnutrition, while 16 (58.5%) had NM complications, 87.9% were off multivitamins, and 66% had gastrointestinal symptoms. All patients showed minerals and vitamins deficiencies, especially for vitamin D (81.8%) and potassium (30.3%). Conclusion: Despite a reduction in the number of BS during the COVID-19 pandemic, an increase in the rate of hospital admissions with medical complications after BS was observed.

Background: Hamad Medical Corporation (HMC) is providing dialysis treatment to approximately 1050 patients. COVID-19 started from China in December 2019^1,2, and the first case in Qatar was confirmed on 27^th February 2020. There were challenges to provide dialysis treatment for COVID-19 positive and negative patients during the pandemic due to severe staff shortage³, staff fear and psychological distress, workload, lack of dialysis slots, prolonged working hours and staff fatigue. Some staff were even deployed to COVID-19 facilities (modular dialysis services, hotel and quarantine facilities) to provide treatment. Methods:

1. 1) A COVID-19 management committee was established
2. 2) An on-call team was assigned to manage new cases and review dialysis slots availability.
3. 3) Staff performance and adherence to safety measures was monitored.
4. 4) A hierarchy model was implemented for COVID-19.

1.  – Confirmed COVID-19 patients were not to receive dialysis at Ambulatory Dialysis centres.
2.  – Unit meetings were only held online.

1.    – Dialysis services were to be provided in HMC dialysis facilities, COVID-19 hospitals, and isolation/quarantine facilities (home/hotels).
2. – Administrators with chronic disease worked from home.

1. – Reduce number of chairs in tearoom and waiting area
2. – Rearrange offices, working spaces, and conference room to keep everyone 2 meters apart.

1.   – Staff, patient and family education
2.   – Screening by using visual triaging scale
3.   – Deployment of staff
4.   – Managing staff mental health and psychosocial well-being

Background: During the COVID-19 pandemic response, Qatar Gas implemented a multi-layer integrated physical barrier system in the field based on an interrelated meshwork of dimensions. It involved the utilization of fiberglass partitions, air purifiers, and dedicated transportation vehicles for suspected cases besides the traditional measures of physical distancing of at least 2 meters between employees, wearing face masks, and hand hygiene. Methods: We evaluated the impact of these measures by comparing the prevalence of upper respiratory tract infections (URTIs), other than COVID-19, compared to the same time the previous year. In addition, we compared the number of sick leave days issued in 2020 to those issued during the previous year in the same time period and after stratification of other confounding or contributing factors. Results: Mechanistic studies found that surgical masks could prevent transmission of human coronavirus and in-fluenza virus infections if worn by infected persons¹. The number of other URTIs were statistically significantly lower after COVID-19 prevention measures were implemented (Figures 1 and 2)². A simultaneous significant decline in the number of sick leaves issued (51.7% decline) was observed over the same period of the decline of URTI visits (sick leave rate declined from 1.3% in 2019 to 0.77% in 2020, p value ≤  0.05) (Figure 1). Conclusion: A clinically and statistically significant decline was observed in the incidence of URTI cases and the rate sick leaves between 2019 and 2020. This observation correlates with the start of the implementation of COVID-19 preventive measures. We recommend to consider continuation of the same precautionary measures as far as reasonably applicable, for critical workers in the field.

Background: Throughout COVID-19, complex therapeutics and medication protocols left clinicians overwhelmed by contradicting information leading to drug-related problems (DRPs) potentially leading to ineffective pharmacotherapy and drug-related morbidity and mortality^1,2. DRPs queries are time consuming, utilize numerous resources, and require skills and experience to provide accurate answers³. Quick answers are paramount in the Emergency Department (ED) especially during a pandemic period. Clinical pharmacists (CP) can identify and resolve DRPs but are only available in the ED during daytime hours. We set up an out-of-office CP service for ED DRPs. This study aimed to assess the capacity of the service to capture 100% of calls received and to measure the time taken to resolve DRP queries compared to the international standard³. Methods: A dedicated ED CP on-call phone line and rota until 10 pm daily was arranged by the Hamad General Hospital Pharmacy (Doha, Qatar). Data was documented in a logbook and within the Electronic Medical Records (EMR) and analysed using predefined parameters. Results: Between March-September 2020, 133 DRPs calls were received and resolved by a CP. 38% were related to drug interaction/safety (often about medications used in COVID-19 treatment protocols), adverse drug reactions, dose-adjustments, drug allergies and drug in pregnancy. 30% were about medication administration, such as infusion rates, titration, and intravenous compatibility. Those questions were mostly from nurses (Figure 1). Appropriate dose selection and appropriate indication represented 21% and 11% respectively (Figure 2). Caller's acceptance rate to responses provided by CP was 100%. Responses were documented in the patients’ EMR. The call-history-log showed an average duration of 4.66 minutes per call which is below the average standard of 15-30 minutes³. Conclusion: The availability of clinical pharmacists to provide quick, acceptable, responses to DRPs queries is crucial given the complexity and diversity of ED patients. During COVID-19, an on-call clinical pharmacy service has proven its capability to resolve DRPs and support the clinical decision-making process in a relatively short time.

Background: After a long, unprecedented pause, sporting events were cautiously resumed in Qatar in September 2020. With the persisting COVID-19 uncertainties, characterizing the COVID-19 risks related to sports activities remains to be examined, making it difficult to give clear messages ¹. This report describes some of the key challenges and opportunities for communicating COVID-19 risks associated with sporting events. Methods: The outbreak investigation report for COVID-19 cases related to the Asian Federation Cup (AFC) Champions League-West hosted in Qatar Sep 14th to Oct 3rd, 2020 was interpreted and taken as a case study. Results: The outbreak investigation reports, which involved approximately 74 COVID-19 cases is shown in Figure 1 and constituted the main subject to communicate the risks of the infection. The investigation teams were engaged in person-to-person communication, reviewing the history of the possible risk exposure and explaining the recommended measures. Clubs’ physicians and delegations besides the local organizing committee seem to have played a pivotal role as a credible source of information to the players and media about the possible case scenarios and the control measures^2,3. The yet unclear mode of transmission may have contributed to the poor risk perception and the compliance with the unfamiliar preventive recommendations^2,3. Conclusion: The profound evolution of the pandemic has already offered a unique opportunity to overcome the ‘lack of attention’ in the communication of communicable diseases. Using the epidemiological findings to communicate COVID-19 risks during sporting events seemed to be beneficial to explain the virus characteristics, emphasizing the role of the epidemiological approaches to improve the risk perception and the compliance with the public health advice.

Background: During the COVID-19 outbreak, Qatar Biobank (QBB) adapted its services to collect, process, and store high-quality data and specimens. This transformation period brought opportunities, risks, and challenges. Methods: QBB holds College of American Pathologists (CAP) accreditation and International Organization for Standardization (ISO) certification for Quality Management (9001:2105) and Information Security Management Systems (27001: 2013)¹. These standards helped to effectively convert its operations to facilitate the COVID-19 national project². The COVID-19 Biorepository is a National Disease-based study aiming to collect adequate health information and biological samples from Qatar residents infected by SARS-CoV-2 virus to enable evidence-based research towards the discovery and development of novel healthcare interventions and to facilitate research projects related to the COVID-19 pandemic. QBB IT Department used open-source Onyx (ObiBa) software to newly develop a COVID-19 electronic system and interface for various clinical devices and Laboratory Information Management System. QBB operational services were adapted to accommodate the COVID-19 project by providing training to the personnel (n = 20; i.e. nurses, research assistants etc.) and developing work instructions (n>5) for the participants’ recruitment process, data and specimen collection in the different hospitals. A COVID-19 portal was also developed by QBB to facilitate data access for researchers from Qatar and worldwide⁴. Results: Within 5 weeks QBB transformed to accommodate a disease/virus-based biorepository. At an operational level, multi-adjustments were implemented. QBB IT department developed an electronic system for the data collection and specimen traceability³. Clinically trained staff were transferred to different healthcare facilities to recruit COVID-19 positive patients. QBB laboratory designed special collection kits. QBB Medical Review Office and Scientific and Education departments managed the recruitment process, set up of the study and provided training to the staff. The Communications and Participants Recruitment Department transformed its operations to fit the needs of the COVID-19 initiative. The Research Access Office designed the COVID-19 access portal and supported the project through purchasing of personal protective equipment and other administrative tasks. Conclusion: It is now time to consider lessons learned, as many countries have been affected by this pandemic, and to understand that biobanks are an asset for a country and there is a need to integrate them into a new standard with their sustainability in mind. Qatar Biobank is a good showcase of how a biobank can successfully assist in the collection of important data related to different health crises such as the COVID-19 pandemic.

Background: Case investigation and surveillance is a key step in managing any epidemic. This report aimed to identify the main challenges faced by COVID-19 case investigators in Qatar and to suggest possible solutions to improve the case investigation process in managing future pandemics. Methods: Purposive sampling was used to select 40 COVID-19 case investigators posted at the Ministry of Public Health, Qatar. Interviewees were from diverse educational and cultural backgrounds and had been investigating COVID-19 cases for more than 6 months, at the time of interview. Face-to-face semi-structured interviews were done to collect data which was anonymized before analyzing for the purpose of this qualitative study. Results: The most common concern faced in conducting case investigations was language barrier, given the multinational and diverse diasporas Qatar is host to. Authenticity of the investigation was a matter of suspicion for many patients; whereas the majority of the investigators opined that multiple calls received from different healthcare departments asking for information overwhelmed many patients. Laborers/migrant workers often did not divulge information due to fear of repercussions from their supervisors. Social stigma associated with COVID-19¹ caused reluctance to reveal the index case and close contacts. Information regarding social gatherings attended and public places visited was often concealed (Figure 1). Cultural differences as well hindered smooth investigation in a few cases. Rising case load at times put restraints on improved coordination between different health departments² and structured guidance for investigators³ about the pandemic response system, which could help to deliver appropriate health services more efficiently. Comprehensive orientation in using the Electronic Surveillance database could also improve the efficacy of epidemiological analysis for improved public health outcomes. Conclusion: Addressing these challenges will help the public health team in Qatar to increase preparedness and efficiency in managing potential future outbreaks, especially in view of upcoming mass gathering events such as the FIFA 2022 World Cup.

Background: A novel coronavirus (SARS-CoV-2) has captured global recognition in a short period of time by dramatically impacting people's everyday lives and emerged as a public health emergency. Undoubtedly, it shows that lessons learned from past coronavirus epidemics such as the Middle East Respiratory Syndrome (MERS) and the Serious Acute Respiratory Syndrome (SARS) were not adequate and thus left us ill-prepared to deal with the challenges presently raised by the COVID-19 pandemic^1,2. Methods: COVID-19 adds to the list of previous outbreaks of infectious disease epidemics that try to remind us that we live in an ecosystem where the relationship between human and animal life, and the environment must be respected in order to survive and prosper. Rapid urbanization and our forestland invasion have created a new interface between humans and wildlife, and have exposed humans to unfamiliar species, frequently involving unfamiliar organisms and exotic wildlife^2,3. Findings: Every pandemic is nature’s way of reminding us that the interrelationship between all forms of existence needs to be recognized. To limit new infectious outbreaks, the transdisciplinary ‘One Health’ solution incorporating ‘Health in All Policy’ involving all stakeholders especially environmental health and social sciences is being advocated (Figure 1). Conclusion: Savings and investments should be made by everyone to meet the unexpected. Stigmatization and prejudice among individuals in the world should be discouraged. Special attention should be paid to the elderly, as their immune system is weak. Health and safety precautions such as physical distancing and health hygiene etiquettes should be considered as part of life. Global experience teaches that containment steps and active tracing of contacts are effective to minimize the economic burden of disease and enhance knowledge of disease processes, health issues, disease emergence, and re-emergence. These lessons will help us to battle future pandemics.

Background: Establishing a paediatric early warning system in a paediatric Emergency Department (ED) is a complex process and more so with the COVID-19 pandemic. PUMA (PEWS Utilisation & Morality Avoidance) is a qualitative system assessment survey tool which assesses the strengths and weaknesses of the patient care safety processes and systems within a department¹. This model draws together evidence from two theoretically informed systematic reviews^1,2. Methods: The Sidra Medicine ED Quality group surveyed online 200 staff from the department of physicians/nursing team focussing on processes of monitoring patients and documentation, communication amongst the team and with parents, staff empowerment, situational awareness, escalation processes and response to the deteriorating child in the three broad domains of Detect, Prepare, and Act, with a further seven smaller domains (monitor, record, interpret, review, prepare, escalate, and evaluate) (Figure 1). Survey analysis enabled to review current practice, identify areas that are working well and areas for improvement. Results and implications: The online survey helped achieve a 85% return rate and identify seven areas for improvement in the system. The spider diagram (Figure 2) illustrates the areas of strength and weakness in the seven domains with respect to Detect, Prepare, and Act. We collaborated with the Cerner team, created an automatic documentation of vital signs from triage and treatment areas to the patient’s Electronic Medical Record by associating patient’s cardiac monitors to reduce manual errors and for the timely monitoring of vital signs. A one-day “Back to Basics Training” refresher course for the nursing team was conducted. A senior nurse, as a watcher in the triage and treatment area, identified children at high risk of deterioration. A Pediatric ED Situational Awareness Tool (PEDSAT) was developed locally and is in trial to help manage sick children effectively. Conclusion: PUMA, a novel system assessment tool, empowered our ED to tailor a quality program with an aim to deliver effective and efficient patient care.

Background: Community acquired pneumonia (CAP) is defined clinically as the presence of signs and symptoms of pneumonia in a previously healthy child due to an infection that has been acquired outside the hospital.^1,2 There is no previous data available from children in Qatar on CAP.³Objectives: To evaluate the incidence, clinical features, management, outcomes and, complications in infants and children presenting to Al Wakra Hospital, Qatar with CAP. Methods: This is a prospective, observational, non-interventional study that assessed all children aged 3 months to 14 years, during a period of 12 months, from November 2017 to November 2018. Results: The incidence of CAP was found to be 2.8 per 1000 of all patients presenting to Al Wakra Pediatric Emergency Department Qatar (328 of 116,761patients). The majority of cases were children 1-5 years (58.2%) (Table 1). Fifty-one percent and 61.3% of children admitted to inpatient wards had dyspnoea and tachypnea respectively. This is to be compared to 88.5% and 96.2% of patients respectively admitted to the Pediatric Intensive Care Unit (PICU) with dyspnoea and with tachypnea. C-reactive protein (CRP) more than 50 mg/L was noted in 48.2% of patients admitted to inpatient wards and 26.7% of patients admitted to PICU (Table 2). Oral amoxicillin was prescribed for 1.5% of patients, amoxicillin/clavulanic acid for 18% of patients, a further 18% had cefuroxime, and 29% had clarithromycin. Intravenous (IV) cefuroxime was the most used IV medication (29.6% of all patients). Nearly 50% of patients were admitted to inpatient wards, with 7.9% transferred to PICU, and only 39.3% discharged home without admission. Conclusion: Community acquired pneumonia represents 0.28% of all studied patients. More than 60% of the patients with CAP were admitted either to inpatient wards or to PICU.

Background: Urinary tract infection (UTI) is a common childhood disease with a prevalence of 7.8% that can lead to serious complications including renal scarring.¹ Approximately 80% of UTIs in children are caused by Escherichia coli that are unfortunately accompanied by an increased prevalence of extended-spectrum beta-lactamases (ESBL) - producing strains.^2,3 This study tries to determine the incidence of ESBL-producing Enterobacteriaceae (PE) UTIs among the pediatric population in Qatar, and predict the relation between multiple antibiotics exposure, antibiotic prophylaxis, recurrent UTIs, prior hospitalizations, prior urinary tract abnormalities as risk factors, and the development of ESBL-PE UTI in the same population. Methods: This is a retrospective case control and cross-sectional study conducted over a period of one year from January 2018 to January 2019. The inclusion criteria were infants and children from 0 month to 14 years old diagnosed with community-onset of urinary tract infection however, exclusion criteria were immunocompromised or cancer patients. Case group was defined as patients who developed ESBL-PE UTI (n = 135), while the control group were patients who developed sensitive Enterobacteriaceae UTI (n = 219). Results: 406 patients were included, 33% of them had ESBL-PE UTI (Figure 1) and 51 were excluded (infection caused by another organism) (Figure 1). Regarding antibiotics exposure during the preceding 6 months, 28% of the case group patients were prescribed multiple courses of antibiotics versus 10% in the control group. 21% within the case group patients received antibiotic prophylaxis versus 6% in the control group. Furthermore, 21% of case group patients were diagnosed with urinary tract anomalies versus 4.5% in the control group, however no significant statistical difference regarding UTI recurrence was found (p>0.05). 17% of case group patients were hospitalized previously versus 7% in the control group (Table 1). Conclusion: The study found that ESBL-PE UTI incidence among pediatric patients was high. Repeated exposure to antibiotics courses, antibiotic prophylaxis, previous hospitalization, and prior UT anomalies may have an impact on this resistance rate.

Background: Liver abscesses are common in the Emergency Department¹. A cross-sectional study conducted in Qatar showed pyogenic liver abscesses were more common than amebic abscesses². Spontaneous rupture of pyogenic liver abscess is a rare entity with serious complications. A rupture resulting in peritonitis requires urgent surgical intervention whereas localized abscesses are managed with surgical or image-guided percutaneous drainage in addition to appropriate antibiotics³. We report a case of spontaneous rupture of liver abscess presented to our Emergency Department that mimicked perforated hollow viscus. Methods/Case presentation: A 58-year-old male patient presented with fever, generalized weakness, anorexia, and abdominal discomfort for 2 weeks. The patient had a history of Type 2 diabetes mellitus and taking oral hypoglycemics. His initial vital signs revealed a temperature of 38.2°C, heart rate of 104 beats per minute, blood pressure of 150/74 mmHg, respiratory rate of 26 breaths per minute, oxygen saturation of 96% on room air. He appeared sick and dehydrated. Pertinent findings on abdominal examination were epigastric and right upper quadrant tenderness. The laboratory report showed leucocytosis and elevated transaminase. A chest X-ray was ordered and revealed air under the diaphragm (Figure 1).

Point of care ultrasound showed a right liver lobe hypoechoic lesion with internal echoes and surrounding free fluid (Figure 2).

A computed tomography of the abdomen showed a large hepatic lesion (11.5 x 8.5 x 9 cm), subcapsular in location, containing gas with dependent fluid, suggesting a gas-forming hepatic abscess, with the possibility of rupture and pneumoperitoneum. Results/Findings/Recommendations: The patient was admitted and underwent ultrasound guided drainage of the abscess. His blood and pus culture showed Klebsiella pneumonia and he received Ceftriaxone and Metronidazole intravenously (IV) for 14 days. He was discharged after 15 days with a favorable outcome. Conclusion: To the best of our knowledge, spontaneous liver abscess rupture resulting in pneumoperitoneum is rare. Chest X-ray findings may mimic perforated hollow viscus.

Background: Calcification is an abnormal deposition of calcium salts in vascular tissue, including valves, blood vessels, and the heart, which is highly prevalent in End Stage Renal Disease (ESRD) patients. Vascular calcification is an independent and important risk factor for cardiovascular events in hemodialysis patients and investigators have demonstrated that the extent and histo-anatomic type of vascular calcification are predictors of subsequent vascular mortality¹. Cardiovascular mortality risk is elevated 5-10-fold in ESRD patients compared to the general population². As we recognized the importance of early detection and delaying the complication of calcification, this study was initiated in March 2020 among 650 haemodialysis patients in Hamad General Hospital in Qatar. Methods: The haemodialysis multidisciplinary team identified patients with vascular calcification. Data was collected on available imaging study which included echocardiography, X-rays, and computed tomography (CT) to detect any kind of vascular calcification (e.g. valvular, calcified vessels). Our management protocol was updated to decrease the calcium load and active vitamin D. Abnormal serum calcium management was initiated to monitor and delay the progression of vascular calcification through interventions which included dietary control, medication, and dialysate bath. Results: We were able to screen 86% of dialysis patients (n = 559). Following the interventions, the percentage of patients with a calcium level of 2.1-2.55 mmol/l increased by 5 percentage points from 83% in March 2020 to 88% in September 2020 (p value =  0.004). Phosphorus level was maintained in the range of 0.81-1.8 mmol/l for 82% of patients (Figure 1) and parathyroid hormone (PTH) level in the range 150-400 pg/ml for 72% of patients (Figure 2). Conclusion: We implemented a successful screening program for vascular calcification in dialysis patients combined with specific interventions. Reduced hypercalcemia episodes can delay vascular calcification. Serum calcium level was improved and maintained within the target range (2.1 - 2.55 mmol/l) for a larger number of patients.

Background: Hamad General Hospital is the main provider of hemodialysis (HD) in Qatar, for approximately 650 patients per year. Over 60% of these patients have Diabetes Mellitus (DM) and 55% of them suffer from end stage renal disease (ESRD). 2% of ESRD patients develop DM after their first year of dialysis¹. The aims of this quality improvement study were early DM detection, risk factors modifications, and reduction of diabetes complications in our patients. Methods: A risk assessment tool was adapted to identify the risk level of HD patients to develop DM². They were screened to determine their risk score across 8 categories. Six categories (gender, history of gestational diabetes, family history of high blood pressure, diabetes, physical activity and smoking) were scored 0 to 1, age was scored 0 to 3, and relationship between weight and height scored 1 to 3. (Overall score range: 1-12). Patients were classified into two groups: a low-risk group (score < 5) and a high-risk group (score ≥ 5)³. Patients were referred to different medical specialties for further management according to the risk factor and a lifestyle modification management plan was set individually. Results: 189 non-diabetic dialysis patients were screened in the first quarter of 2020, their mean age was 51 years-old, and 69% were male. Forty-three percent of patients were found to be at high risk of developing DM. The most important risk factors were family history (55%), obesity (40%), age >60 years (32%), low physical activity (14%), and smoking (11%) (Figure 1). Thirty-seven percent of patients were referred to the obesity clinic, 10% to the smoking cessation clinic, 5% to physiotherapy, and 100% of patients were referred to the multidisciplinary care (Figure 2). Conclusion: Screening for diabetes is pivotal for early detection and risk factor modification in dialysis patients. We recommend quarterly data assessment and evaluation so patients can be managed according to the findings.

Background: Human immunodeficiency virus (HIV) infection remains a major health problem since discovery of the virus in 1981^1,2. Globally, since the introduction of antiretroviral therapy in 1996, acquired immunodeficiency syndrome (AIDS) related deaths fell by more than 25% between 2005 and 2011. HIV related opportunistic illnesses (OIs) are less common, especially with the use of prophylaxis³. This study aims to assess the incidence of HIV infection and related OIs in Qatar over a 17-year period. Methods: This is a retrospective cohort study of all HIV infected patients registered in Qatar from 2000-2016. Incidence of HIV infection and related OIs were calculated per 100,000 population. Demographic and clinical characteristics were compared between two groups of patients with and without OIs. Results: In 167 cases with HIV infection, 54 (32.3%) had OIs. The average incidence rate of HIV infection over 16 years is 0.69 per 100,000 population, and the incidence rate for OIs is 0.27 per 100,000 population (Figure 1). The most common OIs is pneumocystis jirovecii pneumonia (PCP), seen in 25% of cases, followed by cytomegalovirus (CMV) retinitis with 7.2%, tuberculosis 5.4%, toxoplasmosis 4.2%, and less than 2% for Kaposi sarcoma and cryptococcal infection. The treatment outcome of cases with OIs was: cure in 59.3%, failure in 3.7%. Mortality within 3 months of OIs was 3.7%, whereas 33.4% accounted for loss to follow up after starting the treatment due to patients leaving the country. Most patients in both groups were young males. The CD4 lymphocyte count and percentage (CD4%), CD4/CD8 ratio and viral load were statistically significant risk factors in cases with OIs (p < 0.05). Presence of comorbidities was lower in patients with OIs (p = 0.032) (Table 1). Conclusion: Qatar has a low prevalence rate for HIV infection and related opportunistic illness. Early diagnosis and use of antiretroviral therapy are important measures to decrease the rate of opportunistic illness.

Background:Candida auris, within the last decade, has emerged as a multidrug resistant public health threat that can lead to hospital outbreaks¹. It is an invasive fungal yeast resistant to multiple antifungal agents. The mode of transmission is through contaminated hospital items (including clothes and furniture) and interventions by staff. Two Candida auris outbreaks occurred in Qatar. The first outbreak was in Al Wakra Hospital (AWH), which is a facility of Hamad Medical Corporation (HMC), the principal public healthcare provider in the State of Qatar. As concluded by Eyre DW, et al. (2018), a series of interventions and environmental screening program may reduce the Candida auris outbreak². A screening toolkit that includes a checklist based on an existing protocol and operationally defined criteria is a key preventive measure for Candida auris identification. We aim to attain 100% compliance with screening suspected patients and preventing further outbreaks. Methods: A screening protocol toolkit was created for eligible patients that allowed early identification and prompt intervention therefore enhancing the provision of high-quality, efficient, cost effective, and safe patient care. Furthermore, implementation of an Outbreak Prevention Bundle had been proven effective in preventing the spread and comprised: (1) prophylactic contact precautions, (2) blanket screening of at risk/exposed patients, (3) environmental sampling, and (4) hydrogen peroxide disinfection. Results/Findings/Recommendations: In 2020, continuous screening was maintained for patients fitting the HMC criteria. The protocol for the management of outbreaks was implemented. The number of COVID-19 positive cases peaked during July - August 2020 when COVID-19 patients were transferred to AWH (Figure 1). Overall, AWH reached 407 cumulative days without Candida auris outbreak (Figure 2). Conclusion:Candida auris outbreak is preventable through early identification via screening and implementation of an Outbreak Prevention Bundle. This method has led to no active outbreak in AWH since August 2019 until October 2020.

Background: Optic neuritis is an acute demyelinating inflammation of the optic nerve that leads to acute loss of vision and eye pain worsened with eye movement¹. It is a relatively rare condition in the pediatric population². Pediatric optic neuritis usually arises following a viral illness. It can present as an initial feature of a systemic demyelinating disease such as multiple sclerosis or neuromyelitis optica, but can also occur as an isolated syndrome^2,3. We report a classic presentation of optic neuritis presented to our Emergency Department in Doha, Qatar. Case presentation: A 16-year-old female adolescent, of Asian descent, with no past medical history, presented with acute decrease in vision in her left eye associated with eye pain and mild headache for the past week. There were no other associated symptoms. Vital signs, systemic and neurologic examinations were normal. Pertinent ophthalmologic findings on her left eye examination were as follows: visual acuity: counting fingers at 3 meters aided, color vision 0/15; normal intra-ocular pressure, slight ptosis; sluggish pupil with relative afferent pupillary defect and funduscopy (Figure 1) showing hyperemic optic disc with blurring of the nasal margin, normal macula and retinal vessels. Laboratory reports were unremarkable. Head computed tomography (CT) scan showed asymmetric thickening of the left optic nerve with subtle surrounding fat stranding (Figure 2a). Brain and spinal cord magnetic resonance imaging (MRI) showed left optic nerve increased signal and thickness in the proximal segment and contrast enhancement in the optic nerve and optic nerve sheet (Figure 2b). Lumbar puncture was done. Cerebrospinal fluid (CSF) analysis and culture showed unremarkable results. The patient was admitted with a working diagnosis of optic neuritis for further investigations. Conclusion: The patient fully recovered after receiving steroid treatment for 5 days and was discharged subsequently. Optic neuritis can be seen among young patients, often female, with classic presentation of acute loss of vision and eye pain. It can be the primary manifestation of a chronic demyelinating process.

Background: There is substantial evidence that migration to Western countries is associated with an increased risk of metabolic syndrome (MetS)¹. However, there is a paucity of data on the incidence of MetS in migrants from different countries coming to Qatar. As a result, an important health problem is overlooked, and prevention measures are absent. This study aimed to investigate the effects of migration on the incidence of MetS following 24 months of residency in the Middle East (ME) among a group of migrants employed at Hamad Medical Corporation (HMC). Methods: This is a prospective longitudinal observational study. Migrants aged 18–65 years who joined HMC from June to December 2017 were invited to consent and participate. Baseline screening for MetS was conducted. Parameters included glycated hemoglobin (HbA1c), triglycerides (TG), high-density lipoprotein-cholesterol (HDL-C), blood pressure (BP), and waist circumference (WC) measurement. Migrants with normal metabolic parameters at baseline were invited to be rescreened 24 months post-migration. The International Diabetes Federation (IDF) Consensus Worldwide Definition of MetS was employed to diagnose MetS². Inferential statistics were applied to compare results before and after migration. Throughout the study, migrants with metabolic abnormalities were referred to physicians for further management. Results: Of the 1,379 screened migrants, 472 consented to participate. Of those, only 205 migrants had normal metabolic parameters. The incidence of MetS within the group with normal parameters rose to 17% (n = 27) after 24 months of residing in Qatar. Eighty-one percent (n = 129) developed at least one element of MetS. Migrants receiving medications that potentially induce MetS were more likely to develop MetS (odds ratio OR [(AOR 6.3, p < 0.001); 95% [CI], 0.07-0.59. p = 0.003). Conclusion: The incidence of MetS amongst migrants increases following residency in Qatar however, it is lower than that estimated in many developed countries (3, 4).

Background: The emergency department (ED) is a complex environment presenting unique challenges for high-risk populations such as critically ill patients who often require the use of high-risk medications¹. One study suggests that clinical pharmacists (CPs) may improve the fulfillment of safety goals for the ED patient as per the Joint International Commission². Some published reports have asserted that ED-based CPs would have the potential to increase patient safety³. In our hospital, the number of CPs covering the ED increased from 2 to 9 starting from November 2019. Methods: This is a retrospective audit covering the period from January 1^st 2019 till October 25^th 2020 at Hamad General Hospital (HGH) in Doha, Qatar, to determine the impact of increasing the number of CPs covering the ED on the number of identified, solved, and documented drug related problems (DRPs) on the electronic medical records of ED patients. The interventions retrieved from pharmacy reports were analyzed and evaluated in terms of numbers by classification and percentages by the investigators. Results: A total number of 8,946 interventions covering 6,284 patients were carried out in 2020 compared with 1,515 interventions covering 1,001 patients in 2019 (Figure 1) which represents a 6-fold increment by increasing the CPs from 2 to 9. Even the detection of adverse drug reactions increased by 1.5 times with only 38 documented in 2019 compared to 64 in 2020. Classifications and quantities of interventions were also analyzed in detail (Table 1). Conclusion: This audit demonstrates that pharmaceutical intervention can positively contribute to the identification and resolution of DRPs. The benefit of CP involvement in patient care was observed based on the number of interventions that occurred. Studies are needed to assess the impact of those interventions on patients’ outcomes and cost effectiveness.

Background: Clinical trial registries ensure the transparency and accountability of clinical trials (CTs) internationally^1–2. It is important to safeguard the public's safety through the delivery of quality clinical research. Since the start of the COVID-19 pandemic there has been a tremendous increase in the number of CTs globally. The MENA region has an opportunity to increase its overall contribution to CTs, which is less than 1%³, in particular, through Qatar given its substantial economical growth and healthcare advancements. This review aims to explore the characteristics of clinical trials performed in Qatar, registered on ClinicalTrials.gov. Methods: The ClinicalTrials.gov registry was searched for trials conducted in Qatar using the appropriate keywords and advanced search options. Data retrieved was downloaded and sorted within Microsoft Excel then reviewed by two independent co-investigators. Results: The preliminary search yielded 143 entries with 32.1% (46) registered as multisite trials. The first trial in Qatar was registered in 2005. There has been a noticeable increase in CTs with its peak in 2020 (Figure 1), with currently 39.1% (9) of registered CTs on COVID-19; 83% of the completed studies were published, with the highest number of publications (8) in 2020 (Figure 1). Several specialties contributed to the CTs, with the highest participation and contribution rate of 31 CTs being in the field of pediatrics. Furthermore, some variations were found in recruitment status as reflected in Figure 2 with ∼65% (93) of studies being interventional and ∼35% being observational. Conclusion: The CTs conducted in Qatar are still relatively low despite the rapidly evolving healthcare system. Immediate updates and follow-ups could be considered by research investigators in Qatar with regards to CTs registration and updating. Further analysis is needed to elucidate the discrepancy of CTs reporting and to increase the contribution of CTs from Qatar to improve the health of its people.

Background: Hazardous Materials and Chemical/Biological/Radiological/Nuclear (HazMat-CBRN) incidents represent a serious threat to the population and the environment¹. They require a pre-hospital medical response system well equipped and supported with logistics and clinicians with appropriate knowledge and skills to prevent exposure and mitigate risks. Our aim is to determine if the Hamad Medical Corporation Ambulance Service (HMCAS) fulfils the pre-hospital readiness requirements for such incidents. Methods: This cross-sectional study was performed in HMCAS. An online survey assessed staff behaviour and knowledge in relation to HazMat-CBRN incidents. Responses were obtained on health risks and pre-hospital medical management of related threats in Qatar. Based on the results, a training module “HazMat Incident Management” was prepared with pre-/post-activity assessments. The results were explored using a multivariate linear regression and non-parametric Wilcoxon test for paired samples. Specialized Emergency Management (SEM) staff opinion about this training was assessed through an online survey. Both surveys’ validity and reliability tests were conducted. Ishikawa cause and effects diagram was built for the identification of the factors leading to a pre-hospital successful response to HazMat-CBRN incidents. Results: HMCAS has the proper logistics and plans to manage potential HazMat-CBRN incidents. The knowledge survey demonstrated that the pre-hospital medical staff information about this topic needs reinforcement. The multivariate linear regression (Table 1)and non-parametric Wilcoxon test (Table 2) demonstrated that this was obtained thanks to the implemented training module. The course satisfaction survey showed not only a big interest in this activity but also staff recommended more related topics². Earlier-RSDAT (Recognition, Safety, Decontamination, Antidot, Transport) is a tool proposed as a response acronym to build a successful risk-based response for HazMat CBRN incidents in pre-hospital setting³. Conclusion: HMCAS fulfills the readiness requirements for safe and effective response to potential HazMat-CBRN incidents in Qatar. The RSDAT response matrix might help in mitigating pre-hospital response risks.

Background: Sepsis is a major health burden. Guidelines call for healthcare providers to establish sepsis care improvement programs to enhance patient care and outcome^1,2. A comprehensive sepsis program has been developed at Hamad Medical Corporation (HMC) and implemented across its 13 facilities before embarking on a bigger journey. Methods: Senior leadership engagement and collaboration with pertinent departments are key to any initiative's success. A subject matter expert was appointed as Clinical Lead and Chair of the Program and held accountable to sponsors. Stakeholders were identified and invited to participate in the corporate steering group (Figure 1).

Given that facilities may have differing challenges, patient population, or resources, a facility-level sepsis committee was established adopting a similar structure to the corporate committee. Each facility committee reviewed, implemented, and reported to the respective local quality and safety committee. Training, reporting and monitoring were undertaken at the local followed by the corporate level (Figure 2a). Standardized sepsis pathways and guidelines were developed and implemented. Monitoring is crucial to ensure a program remains on track. This was attained using a corporate dashboard in which all cases of sepsis, irrespective of facility, time or age were reported and reviewed. Regular reports were sent to the Corporate Quality Improvement and Safety Committee. This, subsequently, is discussed at the Executive Management Committee. Findings: The implementation of a Corporate Sepsis Program was successful and extended to include other organisations (Sidra Medicine, Primary Health Care Corporation and the Qatar Red Crescent). An education subcommittee designed and delivered a nursing training program and e-learning as a collaboration between the Hamad International Training Centre (HITC), clinical and nursing informatics, and medical and nursing education. This resulted in timely and appropriate management (Figure 2b). Conclusion: HMC Sepsis Program improved sepsis outcome in Qatar³. A systematic approach, application of evidence-based practice, staff empowerment, senior leadership engagement, a clear structure of governance, quality assurance and reporting are critical elements of its success.

Background: The COVID-19 pandemic has been life-threatening for many people and as such, a contactless medical system is necessary to prevent the spread of the virus. Smart healthcare systems collect data from patients at one end and process the acquired data at the other end. The cloud is the central point and the communication happens through insecure channels¹. The main concern, in this case, is the violation of privacy and security as the channel is untrusted. Traditional methods do not provide enough hiding capacity, security, and robustness^2,3. This work proposes an image steganography method using the deep learning method to hide the patient's medical images inside an innocent cover image in such a way that they are not visible to human eyes which reduces the suspicions of the presence of sensitive data. Methods: An auto encoder-decoder-based model is proposed with three components: the pre-processing module, the embedding network, and the extraction network. Features from the cover image and the secret images are extracted and fused to reconstruct the stego image. The stego image is then used to extract the ingrained secret image. Figure 1 shows the overall system workflow. Results: Peak Signal-to-Noise Ratio (PSNR) is the evaluation metrics used. The ImageNet dataset was used for training and testing the proposed model. Figure 2 shows the image results of the proposed method. Conclusion: During a COVID-19 screening test, private patient data such as mobile number and Qatari identity card are collected, transferred, and stored through untrusted channels. It is of paramount importance to preserve the privacy, security, and confidentiality of the collected patient records. A secure deep learning-based image steganography method is proposed to secure the sensitive data transferred through untrusted channels in a cloud-based system.

Background: COVID-19 is a pandemic that had already infected more than forty-six million people and caused more than a million deaths by 1^st of November 2020. The virus pandemic appears to have had a catastrophic effect on the global population's safety. Therefore, efficient detection of infected patients is a key phase in the battle against COVID-19. One of the main screening methods is radiological testing. The goal of this study is using chest X-ray images to detect COVID-19 pneumonia patients while optimizing detection efficiency. Methods: As shown in Figure 1, we combined three methods to detect COVID-19 namely: convolutional neural network, transfer learning, and the focal loss¹ function which are used for unbalanced classes, to build three binary classifiers which are COVID-19 versus normal, COVID-19 versus pneumonia, and COVID-19 versus normal pneumonia (normal and pneumonia). The database used² includes a mixture of 400 COVID-19, 1,340 viral pneumonia, 2,560 bacterial pneumonia, and 1,340 normal chest X-ray images for training, validation, and testing of four pre-trained deep convolutional neural networks. Then, the pre-trained model that gives the best results was chosen to improve its performances by two enhancement techniques which are image augmentation, allowing us to reach approximately 2,500 images per class, and the adjustment of focal loss hyperparameters. Results: A comparative study was conducted of our proposed classifiers with well-known classifiers and obtained much better results in terms of accuracy, specificity, sensitivity and precision, as illustrated in Table 1. Conclusion: The high performance of this computer-aided diagnostic technique may greatly increase the screening speed and reliability of COVID-19 diagnostic cases. Particularly, at the crowded emergency services, it will be particularly helpful in this pandemic when the risk of infection and the necessity for prevention initiatives run contrary to the available resources.

Background: The COVID-19 pandemic has affected the world in every aspect. Many universities and education centres adapted their teaching to online education¹. Virtual simulation has been endorsed by stakeholders not only for teaching healthcare students and workers, but also to be counted as practice hours for students². We propose an approach to facilitate simulation-based education (SBE) online in an interactive manner for multiple participants. Methods: Visually enhanced mental simulation (VEMS) is a low fidelity yet very immersive and engaging educational activity used for participants to practise non-technical skills such as decision-making and communication while others observe³. Unlike ordinary mental simulation, participants can engage in VEMS as in a full-scale scenario-based simulation session, while being observed by peers. It is supported with visual elements such as a patient poster and laminated equipment cards for participants to illustrate the actions performed. Actions and patient parameters are also recorded with the timing by a facilitator on a white board. The scenario is followed by a debriefing involving all participants and observers. Recommendations: VEMS can be adapted to the online environment and be facilitated through platforms such as Microsoft Teams, Skype, Zoom, GoToMeeting, or Cisco WebEx easily using a shared screen with Microsoft PowerPoint and their associated chat function or the facilitator's web camera facing a noticeboard. A patient pictogram and transparent background equipment images can be used in PowerPoint to illustrate the actions verbalised by the participants. The facilitator can speak as the patient and illustrate and write down everything in PowerPoint as the participants engage in the scenario, so all the other session attendees can observe. Everyone can then attend the scenario debriefing online. Conclusion: Online VEMS offers an opportunity for participants to practise non-technical and communication skills. It is a low fidelity and low-cost approach to facilitating SBE that still needs to be tested with actual learners for ease of use, acceptability, and educational effectiveness.

Background: Sepsis is a medical emergency and a global economic and health burden. It is one of the leading causes of death worldwide with 1 death every 2.8 seconds and represents 20% of all deaths worldwide^1,2.

Sidra Medicine, the only pediatric tertiary care centre in the State of Qatar, in collaboration with Qatar’s Ministry of Public Health, Hamad Medical Corporation (HMC), and Hamad Healthcare Improvement Institute (HHQI) share the national goal of reducing mortality due to sepsis and septic shock through an increase in healthcare provider compliance to the sepsis six bundle of care from 0% to 95% by the end of 2022. Methods: A multifaceted, interdisciplinary, comprehensive education and training program was designed and provided to healthcare practitioners across Sidra and comprised:

• Pre-implementation education

• Multidisciplinary education sessions and workshops

• Train-the-trainer nurse educator workshop

• Bedside interdisciplinary simulation-based education

• Sepsis case discussions during morning reports, academic activities, grand rounds, and morbidity and mortality meetings

• Annual Qatar National Sepsis Symposium

• September Sepsis-Awareness Month

• Pediatric and women sepsis e-learning module

• National Patient Safety Collaborative (NPSC) training sessions and storyboards in collaboration with the Institute for Healthcare Improvement (IHI) and HHQI

 In addition, sepsis pathway posters, think-sepsis booklets and pocket cards, antibiotic preparation and administration cards, and family education materials in Arabic and English were produced and utilized. Results: Improved sepsis awareness and education was observed. 95% of providers successfully completed the e-learning module (Figure 1). Compliance to the sepsis six bundle of care subsequently reached 81%. Sepsis mortality rate was 1.8% in the first two quarters of 2020 which is well below international mortality rates. Conclusion: Since 2018, Sidra Medicine embraced sepsis education and care through a national evidence-based sepsis guideline for early recognition and treatment ³ which is positively reflected in low sepsis mortality rates for 2020.

Background: IoMT (Internet of Medical Things) devices (often referred to IoMT domain) have the potential to quickly diagnose and monitor patients outside the hospital by transmitting information through the cloud domain using wireless communication to remotely located medical professionals (user domain). Figure 1 shows the proposed IoMT framework designed to improve the privacy and security of the healthcare infrastructure. Methods: The framework consists of four modules:

1. Intrusion Detection System (IDS)¹ using deep learning (DL) to identify bluetooth-based Denial-of-Service (DoS)-attacks on IoMT devices and is deployed on edge-computing to secure communication between IoMT and edge.

2. IDS¹ is backed up with identity-based cryptography to encrypt the data and communication path.

3. Besides the identity-management system (to authenticate users), it is modeled with aliveness detection using face authentication techniques at the edge to guarantee the confidentiality, integrity, and availability (CIA) of the framework.

4. At the cloud level, another IDS² using MUSE (Merged-Hierarchical-Deep-Learning-System-with-Layer-Reuse) is proposed to protect the system against Man-In-The-Middle attacks, while the data is transferred between IoMT-EDGE-CLOUD. Results: These four modules are developed independently by precisely analyzing dependencies. The performance of IDS³ in terms of precision is 99% and for the identity-management system, the time required to encrypt and decrypt 256-bit key is 66 milliseconds and 220 milliseconds respectively. The true positive rate is 90.1%, which suggests real-time detection and authentication rate. IDS (2) using MUSE (12-layer) the accuracy is >95%, and it consumes 15.7% to 27.63% less time to train than the smaller four-layer model. Conclusion: Our designed models suit edge devices and cloud-based cybersecurity systems and support the fast diagnosis and care required by critically ill patients in the community.

Background: Virtual reality (VR) is still an evolving domain that presents a versatile medium to simulate various environments and scenarios that can be easily reset between users, which can be particularly useful for training purposes^1,2. In this pilot study, we recreated the interior of a modular ambulance patient compartment with elements that can be moved and also had access to the real physical ambulance with the same interior design and equipment. The primary objective of this study was to determine the usability of the VR patient compartment in terms of functionality and sense of presence. Methods: Paramedics were invited to take part in this pilot study which involved them attending a 15-minute presentation about ambulance safety and ergonomics, familiarise themselves with the VR equipment (Figure 1), position the modular elements of the ambulance patient compartment in the VR or real setting (and vice versa), and complete a questionnaire corresponding to the task completed and adapted from an existing tool³. They were unknowingly timed during the activities inside the real and VR ambulance for comparative purposes. Results: Twenty-seven participants were recruited, 77.8% of whom had no prior VR experience.

On the 7-point Likert scale questionnaire, the participants scored the various aspects of usability (ease of grabbing elements, ease of recognising fixed/movable elements, distinguishing close from far objects, ease of “playing” the game…) between 5.59 to 6.26 and their sense of presence as 6.11 (SD = 1.121). Participants were faster arranging the modular elements in the VR setting than in the real one (8.78 min, SD = 4.47 versus 13.05 min, SD = 5.04). Conclusion: VR technology and potential applications are still rapidly developing. This pilot study shows promising results in terms of ease of use and sense of presence for the paramedics. This demonstrates that VR can be used for interactive familiarisation with an environment such as an ambulance patient compartment and can be used to assist in their design.