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

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.