Journal of Emergency Medicine, Trauma and Acute Care - 1 - Qatar Health 2022 Conference abstracts, January 2022

Welcome to this special issue of JEMTAC dedicated to the selection of 74 abstracts submitted to the Qatar Health 2022 online conference. The years are passing and the COVID-19 pandemic situation has not changed much globally. Although new vaccines have been developed and several restrictive measures have been rolled out in most countries to protect people, thousands are still succumbing to the effects of COVID-19^1,2. Similar to the Qatar Health 2021 conference³, among the abstract submissions, there is still much emphasis on how healthcare systems and services are dealing with the situation to mitigate the spread of the disease among patients and healthcare professionals, while still trying to deliver physical or mental care to those in need^4–6. It is also important to point out that the same needs and concerns apply to both the general public as well as the healthcare workforce^7,8. From a preparedness point of view, continuing professional development and testing of new processes and facilities are key to ensuring clinicians are ready to take on new roles in new environments, and that technology can play a significant role in a pandemic context^9–11. This is not only true in relation to clinical facilities, but as Qatar prepares to host the 2022 World Cup, it is also highly relevant to sporting events, during which multiple agencies need to work together collaboratively and as a multidisciplinary team as per the theme of Qatar Health 2022 and the 2^nd Qatar Public Health Conference^12–13.

The online conference has again been organized into four parallel tracks. It is dedicated to showcasing the work and opinions of leaders in their respective domains as well as the 112 abstracts that have been accepted for oral or poster presentation. The abstract themes are summarized in Table 1, and most of the corresponding abstracts are published in this special issue of JEMTAC. Submissions related to mass gatherings and sporting events were shy again this year, but it is expected to be a highly prominent topic for the next edition of the conference, after the 2022 World Cup. We hope you enjoy this early content preview of the conference and that it will make it even more engaging for everyone at the time of the question and answer sessions and on the poster boards. See you all online on the 10^th-12^th of February 2022!

Background: Hosting 2022 FIFA World Cup (WC2022) in Qatar is a mega event that can shape a country's development¹. Partnerships as preparedness efforts for mass gatherings within the health system can ensure a safe and efficient practice in hosting countries^2,3. This work aims to provide an analysis of the existing literature around partnership frameworks to inform the development of an innovative partnership framework for Primary Health Care Corporation (PHCC). In addition, it also discusses the preparedness plan at PHCC for the WC2022 to promote staff and national resilience. Methods: Various databases such as Academic Search Complete, Education Research Complete, Medline and Web of Science were used to search for relevant studies from 2010 to 2021. The search strategy consisted of search terms including partnership, framework and health. Moreover, searching was conducted by title, abstract, and full texts, and was limited to studies in English language. The content analysis was performed to analyze the relevant publications. Results: A total of 18 studies were considered. The related literatures were analyzed to present the emerging themes which revealed four major themes: collaboration, engagement, transformation, and risk mitigation. Leveraging the current primary care partnership framework will influence the ability of healthcare professionals to adapt and respond to the upcoming mass gathering. National and international partners must recognize and embrace the need for diverse training programs during the WC2022. The preparedness for the WC2022 calls upon clear assessments from various stakeholders at PHCC that are tied to the needs for emerging roles and services. Conclusion: This work offers a new perspective on the current PHCC partnership framework and provides some recommendations for infrastructure, commissioning, and engagement pathways among future public and private partners. Leveraging PHCC partnership framework and transforming it into a holistic framework of national resilience during mass gathering is of significance.F0001 F0002a F0002b F0002e F0002d F0002e

Background: International sporting events such as the World Athletics (WA) competition require proper medical coverage to ensure the wellbeing of athletes, support teams, and spectators¹. Several factors may have an impact on people's requirements for medical attention such as the climate, altitude, and intensity of the sporting competition on the athletes^2,3. The International Association of Athletics Federations (IAAF) held its 2019 competition in Doha, Qatar, and this study reports on the medical resources deployed to cover the event based on risk assessment. Case presentation: Although the competition was held for 10 days across two venues. The medical cover started 3 days earlier and also encompassed warm-up/training venues and official hotels (Table 1). It involved multiple healthcare organizations providing equipment, manpower, medical tents/clinics, and vehicles in case of transportation to the hospital was required. Results: Resources were allocated to various locations based on the risk assessment (Table 1) and depending on the number of people competing, training, or attending, and the size of the venue. Environmental factors were accounted for with the provision of cold-water immersion recovery baths at multiple locations and ample manpower with rostering of clinical staff from various relevant healthcare professions (Table 2). All resources were deployed on a rotational shift basis in the official locations well ahead of the start of each event until an hour or two after the completion of the event. Conclusion: Proper planning, communication, and collaboration among organizers, hosts, medical services providers, and other authorities play a vital role in the safety of athletes, support team members, and spectators. Such large events impose huge strain on the resources which can impact aspects of daily healthcare delivery to the rest of the community and hence need to be carefully considered. It is worth noting that the medical coverage provided was not overwhelmed by patient demand, hence; the medical coverage was appropriate.

Background: Sudden Cardiac Arrest (SCA) is defined as the abrupt loss of heart function as an occurrence without physical contact (absent commotio cordis). SCA's morbidity ratio is 1:50,000 of all deaths. The published estimates on SCA suggest that 11% of all victims have a normal heart. Current screening investigations include electrocardiography (ECG), echography, 24-hour ECG monitoring, eliciting stress history, and cardiac Magnetic Resonance Imaging. Some cardiac pathologies screened have never been detected. Athletes who experienced SCA had a survival rate of 50-60% over 30-days, and this rate might reach up to 80-89% in some cohort studies. The survival factors are based on regular and thorough screening checks, and better observation that enables quicker pickups. Players vary in cardiopulmonary resuscitation (CPR) performance and are emotionally involved, as was reported recently with footballer Christian Eriksen in the 2021 European Championship¹. However, anyone trained in CPR, not just medical professionals, can assist in resuscitation (Figure 1). Evidence-based studies show that Basic Cardiac Life Support (BCLS) is more effective on the sports field than Advanced Cardiac Life Support². The objective of this literature review is to make recommendations to effectively respond to SCA during football tournaments. Methods: PubMed database was used to retrieve articles published in English between 2018 and 2021 related to SCA during football games. Results: There are limited publications in this specific domain. Reports from 67 countries account for 617 players (mean age 34 ± 16 years, 96% men) suffering from SCA or traumatic sudden death during football activities between 2014 - 2018, of whom 142 players (23%) survived¹. CPR resulted in a survival rate of 85% with the use of an automated external defibrillator (AED) compared to 35% without. Conclusion: Key recommendations from this literature review are listed in Table 1. These are important steps needed to improve survival chance from SCA³. Qatar, hosting the Football World Cup 2022, can put in place additional measures to promote effective SCA resuscitation and ensure the safety of all players.

Background: Regular physical activity (PA) is an effective preventative measure for diverse health risks among all age groups ¹. Global PA guidelines provide recommendations on the required levels for active lifestyle based on evidence-based behavioral benchmarks to increase awareness and reduce overall morbidity and mortality rates ². The Qatar National Physical Activity Guidelines (QNPAG) were first developed in 2014. The recently released QNPAG-2021 provides an updated evidence-based practical guide on PA prescription for practitioners, physicians, educators, and individuals who wish to engage in regular PA. This review aims to provide a summary of how the second QNPAG was developed. Methods: QNPAG was developed by Aspetar Orthopaedic and Sports Medicine Hospital in collaboration with key stakeholders in Qatar; such as the Ministry of Public Health, Qatar University, Hamad Bin Khalifa University, Hamad Medical Corporation, Primary Health Care Corporation, Naufar and others. The steering committee formed a technical advisory group of local and international sport medicine scientists, epidemiologists, and public health experts. Recent literature and global guidelines were evaluated and synthesized. Specific health outcomes and population groups were then proposed taking into consideration the prevalence of diseases, culture, and geographical location. Results: Three main chapters were added on PA benefits and sedentary behavior-associated risks for healthy population; people with medical conditions; and people with special challenging conditions. QNPAG 2021 included additional sections on pandemics, outbreaks and quarantine; humidity and air pollution; substance use; and locations for PA in Qatar. Other topics were added targeting obesity, osteoporosis, cancer, disabilities, mental health disorders, and down's syndrome. Detailed exercise prescription (Frequency/Intensity/Time/Type), and relevant examples were provided together with safety tips. Conclusion: The updated QNPAG is expected to raise awareness and help increase PA levels in Qatar. However, more emphasis on PA recommendations and strategical implementation is required through promotion, practice, and policies within the different sectors in the country.

Background: Inter-professional education (IPE) highlights collaborative practices aimed at promoting the working relationship between two or more healthcare professions¹. IPE achieves together more than what individuals can achieve to improve healthcare practices at an organizational level¹. In order to reduce the risk of injury during positioning and transfers of children admitted in the Almaha units, nursing, physical therapy, and occupational therapy professionals designed and implemented a competency training program to improve safe handling and mobilization of children.

The novelty in this program is that the training was conducted in the wardrooms with the children where the actual practice occurs². This context-specific training was designed after careful assessment of the real-time environment, complex needs of our children, and the presence of cumbersome life-saving equipment connected to their bodies. The education was delivered by rehabilitation professionals on five topics for a total of 134 nurses in Almaha units. Each session lasted 60 minutes with hands-on practice with a real patient. Methods: A pre-test/post-test design was used on a convenience sample of nurses for this pilot study. An observation-based checklist was designed by the authors to measure the nursing competencies in five tasks: Chair positioning, Bed positioning, Bed-to-chair and Chair-to-bed transfers, splint application, and utilizing powered wheelchairs. A rehabilitation professional completed the checklist for all participants by observation before the education. The same checklist was completed for 30 nurses, 6 months after the training. Results: The mean percentage scores improved for all tested patient handling competencies (Table 1; Figure 1). The mean percentage in improvement was 61.2% for the task of bed positioning. No further statistical tests were performed due to the small sample size. Conclusion: Inter-professional education provided in real-life settings was found to be effective in improving the safe handling and mobilization of children with complex needs.

Background: Complementary medicine therapies are used globally. Around 88% of the countries that are members of the World Health Organization (WHO) reported using such practices while there is no information reported from the remaining 12% of countries ¹. Cupping therapy is an ancient therapy trending to be used among athletes ². Other complementary medicine therapies such as chiropractic are also used in sports medicine ³. This narrative review aims to provide an update on the current status of complementary medicine therapies used in sports medicine. Methods: A comprehensive search using three medical databases (PubMed, Cochrane, TRIIP) was conducted using this search Boolean: (“cupping therapy” + “sports medicine”), (“complementary medicine” +” Sports medicine”), (“cupping therapy” + “athletes”), (“complementary medicine” + ”athletes”) from inception to June 2021. Inclusion criteria were: articles in English language, systematic reviews, reviews, and clinical trials which are in direct relation to the aim of this narrative review. Results: From the 725 retrieved results, only 17 articles were included in this narrative review after excluding duplicates, non-relevant articles, and applying inclusion/exclusion criteria (Figure 1). Cupping therapy, chiropractic, and acupuncture were identified for their use in sports medicine (Table 1). Complementary medicine therapies were used among a variety of sports such as football, basketball, and martial art players for treating pain, musculoskeletal disorders, and rehabilitation. The use of complementary medicine modalities for sports performance had controversial results. Conclusion: Complementary medicine modalities such as cupping therapy, acupuncture, and chiropractic are used by a variety of athletes with promising effects. The current evidence is still limited. Hence; conducting high-quality clinical trials is highly encouraged.

Background: The ongoing coronavirus disease 2019 (COVID-19) pandemic has resulted in a global health emergency. With incomplete vaccination and incomplete protection of the vaccinated population, there remains an urgent need to develop drugs to treat COVID-19. Our previou in silico analysis suggested vulnerability of SARS-CoV-2 to inactivation by the endogenous reactive metabolite, methylglyoxal (MG), by modification of arginine residues in the functional domains of viral spike and nucleocapsid proteins^1–3. In this study, the antiviral activity of MG against wild-type SARS-CoV-2 using in vitro assays was evaluated. Methods: Wild-type SARS-CoV-2 with titers of multiplicities of infection (MOI) 0.8, 0.2, 0.02, and 0.01 were incubated with 2-fold serial dilutions of MG (7.8 μM to 500 μM) in infection medium for six hour. MG-treated and untreated control SARS-CoV-2 were incubated with confluent cultures of Vero cells in vitro for one hour, cultures were washed and then incubated in a fresh infection medium at 37°C for 4 - 5 days until 70% of virus–infected cells displayed cytopathic effect (CPE). The antiviral activity of MG was judged by assessing virus replication using quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) and median tissue culture infectious dose (TCID50) assays. Results: MG inhibited virus replication as measured by PCR and CPE of SARS-CoV-2 in vitro, with TCID50 increasing with increasing MOI. MG was most potent at MOI 0.02 and 0.01 where EC50 of MG was 49.6 ± 4.7 μM and 28.5 ± 1.3μM; respectively. Similar findings were also found for a shorter incubation period (3 hours) of MG and virus. Conclusion: MG has inhibitory activity against wild-type SARS-CoV-2 for virus exposure in the cell-free systems at low MOI. However, the antiviral activity of MG against other SARS-CoV-2 variants including alpha- and beta-variants is being investigated. Drugs increasing cellular concentration of MG to viricidal levels may have anti-COVID-19 activity.

Background: Coronavirus Disease 2019 (COVID-19) was first discovered in China and resulted in a pandemic crisis.^1,2 Many agents were investigated with inconclusive outcomes.³ This study was conducted to compare the efficacy and safety outcomes of darunavir-cobicistat versus lopinavir-ritonavir in the treatment of patients with COVID-19. Methods: This retrospective, multicenter, observational study was conducted on adult patients hospitalized in COVID-19 facilities in Qatar. Patients were included if they had pneumonia and received darunavir-cobicistat or lopinavir-ritonavir for at least three days as part of their COVID-19 treatment. Data were collected from patients’ electronic medical records. The primary outcome was a composite endpoint of time to clinical improvement and/or virological clearance. Data were analyzed descriptively and inferential statistics were applied at alpha level of 0.05. Results: A total of 400 patients’ medical records were analyzed, of whom 100 received darunavir-cobicistat and 300 received lopinavir-ritonavir. The majority of patients were male (92.5%), with a mean (SD) time from symptoms onset to start of therapy of 7.57 days (SD 4.89). Patients who received lopinavir-ritonavir had a significantly faster time to the primary composite endpoint of clinical improvement and/or virological clearance than patients who received darunavir-cobicistat (4 days [IQR 3-7] vs. 6.5 days [IQR 4-12]; HR 1.345 [95%CI: 1.070–1.691], p = 0.011) [Figure 1]. Patients who received lopinavir-ritonavir had a significantly faster time to clinical improvement (5 days [IQR 3-8] vs. 8 days [IQR 4-13]; HR 1.520 (95%CI: 1.2–1.925), p = 0.000), and slower time to virological clearance than those who received darunavir-cobicistat (25 days [IQR 15-33] vs. 21 days [IQR 12.8-30]; HR 0.772 (95%CI: 0.607-0.982), p = 0.035) [Figure 2]. No significant difference in adverse events incidence or severity was observed. Conclusion: In patients with COVID-19, early treatment with lopinavir-ritonavir was associated with faster time to reach the primary composite endpoint of clinical improvement and/or virological clearance than treatment with darunavir-cobicistat. Future trials are warranted to confirm these findings.

Background: COVID-19 infection is caused by a novel coronavirus. It was identified initially in late 2019 as the cause of a cluster of pneumonia cases in Wuhan, China. It spread worldwide causing a pandemic. Since the start of the COVID-19 pandemic, multiple complications have been linked to COVID-19 infections, one of them being pleural effusion. To the best of our knowledge, only a few case reports have discussed the incidence of candida empyema in COVID-19 patients^1,2. Case Presentation: This work is reporting on a case of COVID-19 pneumonia, in a 52-year-old previously healthy male patient, who developed ARDS 2 days after diagnosis of COVID-19 pneumonia and was attached to mechanical ventilation. Unfortunately, he continued to progress with refractory hypoxemia despite the maximum support. Ultimately, the patient required veno-venous ECMO with ultra-protective lung ventilation until the gas exchange in his lungs has normalized. The patient received multiple treatments based on our local protocol that have immunosuppressive effects. Due to worsening pneumonia, bronchoscopy was done. The Bronchoalveolar lavage (BAL) showed Candida Albicans, which was complicated with left-sided candida empyema. The later was treated by antifungal, chest tube insertion, and finally with decortication. However, despite the maximum interventions, the patient has unfortunately passed away 2 weeks after the decortication due to sepsis and multi-organ failure, while he was on ECMO during the whole period. Recommendation: Given the immunosuppressive effect of many of the medications used for the treatment of COVID-19 infection, atypical and opportunistic infections should be carefully considered within the clinical context. Conclusion: Candida pneumonia/empyema is not very common in a healthy host, however, it is a serious and rare condition, commonly seen in immunocompromised patients and associated with a high mortality rate³. The immunosuppressive therapies that are used in COVID-19 are not completely safe and more atypical infectious agents have been considered as not suitable in several typical locations causing adverse outcomes.

Background: Paramedics are subjected to high levels of stress, which increase their risk of depression, burnout, quitting the profession, or even committing suicide.¹ Some recent studies have focused on the coping strategies used by nurses in response to the COVID-19 pandemic², but little is known regarding paramedics. This study explored the potential coping strategies used by Hamad Medical Corporation Ambulance Service (HMCAS) paramedics and critical care paramedics (referred to as “Paramedics”) in Qatar to manage the stress associated with their work before and during the COVID-19 pandemic. Methods: An online survey combining a validated tool (an adapted tool from the COPE [Coping Orientation to Problems Experienced] Inventory³) with additional questions were sent to all HMCAS emergency Paramedics (n = 1,100) in early 2021 with text message reminders, with the aim of recruiting 285 participants based on a sample size calculation with a 95% Confidence Interval. Results: Only the responses from staff who had started to work in Qatar before December 2019 were considered for inclusion in the study. As such, 274 valid responses were analyzed. The results show that the staff has used a variety of coping strategies that differed slightly before and during the pandemic (Figure 1). The percentage of paramedics using coping strategies due to work-related stress was 75.9% before COVID-19 and only 54.4% during the pandemic. This reduction is presented in Figure 2. Moreover, the results showed that the observed differences in coping strategies adopted before and during the pandemic were not always statistically significant. Conclusion: The use of coping strategies among HMCAS Paramedics generally decreased during the COVID-19 pandemic, especially those related to going out, meeting up with friends and relatives, and practicing a sport. This can probably be explained by their increased working hours during the pandemic and the precautionary measures limiting group activities and interactions, but regrettably, this can only exacerbate their level of stress.

Background: People respond to stressful situations differently based on their ethnicity.¹ This study explored the impact of ethnicity on coping strategies used to deal with work-related stress among Hamad Medical Corporation Ambulance Service (HMCAS) paramedics in Qatar before and during the COVID-19 pandemic. It is based on the associated work conducted by the same team.^2,3Methods: An online survey combining validated tools with additional demographic questions was sent to all HMCAS paramedics (n = 1,100) between January and May 2021. The survey collected demographic information and data regarding the coping strategies they used before and during the COVID-19 pandemic. Results: 274 valid responses were received and categorized into 5 ethnic groups. For statistical analysis purposes, only the three main groups with a sufficient number of participants could be considered; Arabian (n = 151), South Asian (n = 45), and Southeast Asian (n = 60) (Total n = 256). The other ethnic groups were represented by too few participants. Overall, stress levels were higher for all ethnicities during the pandemic compared to before (Table 1). However, stress levels were lower in the Southeast Asian subgroup before and during the pandemic as compared to South Asian and Arabian counterparts (Table 1). The usual coping strategies such as visiting the cinema, spending time with friends, and playing team sports decreased for all study subgroups during the pandemic (Table 2); likely due to restrictions imposed to control the pandemic. The practice of religious rituals as a coping strategy showed a significant decrease in the South Asian and Southeast Asian subgroups during the pandemic. Although not statistically significant, subgroup Arabian staff have reported smoking more cigarettes or shisha as a coping strategy during the pandemic and consumed more alcohol or recreational drugs than the other two groups. Conclusion: This study demonstrated that ethnicity has impacted the perceived work-related stress. Further, the coping strategies among the various ethnic groups also differed. Additional studies with larger sample sizes and in different settings are important to inform policy design related to work stress potentially considering staff ethnicity.

Background: Paramedics are at risk of burnout which represents a concern for the healthcare system and public health¹. In Italy, about 20% of health practitioners were infected, and some died during their work fighting against the COVID-19 pandemic², but little is known regarding paramedics. This study assessed the level of stress associated with the work of Hamad Medical Corporation Ambulance Service (HMCAS) paramedics in Qatar before and during the COVID-19 pandemic. Methods: An online survey combining validated tools including the Workplace Stress Scale³, with additional questions, was sent to all HMCAS frontline staff (n = 1,100) between January and May 2021 with text message reminders. The items upon which the level of stress of paramedics was determined before and during the pandemic are presented in Table 1. The level of stress was determined based on the responses to 9 questions. Results: 274 valid responses were received. The level of stress was then split into five categories, from low to dangerous. Based on the paramedics’ responses, their reported level of stress was in the moderate range before the pandemic and reached the severe level during the pandemic (Table 2). Conclusion: The reported level of stress among HMCAS paramedics was significantly higher during the COVID-19 pandemic compared to prior levels of stress. This can probably be explained by the very nature of their profession as frontline clinicians responding to emergency calls and being potentially exposed to the viral infection. Strategies need to be put in place to effectively mitigate the effects of increased stress levels experienced, so that paramedics remain safe and able to provide effective medical care rather than succumb to mental and physical illness related to stress.

Background: Internationally, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, causing corona virus disease (COVID-19), has increased the demand on healthcare services and resources¹. The proper use of personal protective equipment (PPE) by paramedics has recently become apparent². The risk of COVID-19 transmission has increased during prehospital life-saving procedures generating aerosols such as non-invasive ventilation, tracheal intubation, and external chest compressions, especially when working in a confined ambulance compartment³. Paramedics are encouraged to increase body-surface-isolation by donning additional PPE (high-filtration facemasks/face shields/surgical gowns/surgical hoods) during all patient encounters². This study aimed to better understand paramedics’ knowledge, attitude, and practice of PPE utilization in the State of Qatar during the COVID-19 pandemic. Methods: This prospective and quantitative study focused on the collection of descriptive data utilizing a purpose-designed online survey. Around 1300 frontline paramedics employed by Hamad Medical Corporation Ambulance Service (HMCAS) were invited via email to participate in the study. Results: 282 paramedics completed the survey. 90.4% were male and 78.7% had a bachelor's degree. 97.1% completed the mandatory HMCAS online infection control training program, 82.9% completed an N95 mask fit test in the last 5 years, and 91.5% completed the hand hygiene training program. The study found paramedics to be knowledgeable about COVID-19 and its transmission (98.2%) (Table 1). Paramedics’ attitude was mainly positive towards the use of PPE to prevent the spread of the virus which was synchronous with their practice. Conclusion: An effective model to curb the spread of COVID-19 amongst healthcare workers must consider the knowledge, attitude, and practice of first responders. This sample demonstrated a strong knowledge of COVID-19 and its transmission. Their overall positive attitude and good infection control practices were a demonstrative effort to mitigate risks associated with the spread of the virus in the prehospital setting.

Introduction: The COVID-19 pandemic had a significant impact on medical and maternity services across the world. The reported increase in maternal and neonatal morbidity and mortality is not only attributable to the disease itself but also the disruptions in the health services during lockdowns^1,2. Qatar maintained continuity of maternity services during the peak of the pandemic by telephone consultations³. It played a vital role in minimizing the community's spread of the disease. This study is a review to determine the frequency of patient contacts/visits during the COVID-19 pandemic and assessed pregnancy outcomes. Methods: A retrospective chart review was conducted at Al-Wakra Hospital using the electronic records of women who delivered between February-July 2020, during the peak of the pandemic in Qatar. COVID-19 positive patients were excluded. Data on the number of visits at Primary Health Care Corporation (PHCC) centers, Emergency Departments (ED), and Outpatient departments (OPD/Telephone consultations were collected. Pregnancy outcomes were noted and then compared with women who delivered pre-pandemic during a similar timeframe in the preceding year. Odds ratio was evaluated using MedCalcs’ online software. Results: A 40% increase in the number of births and an increase in patient visits to PHCC by 39.34% and ED by 44.04% were noted during the pandemic. Nearly all OPD consultations (3572) were performed by telephone in the study period during the pandemic (Figure 1). Rates of miscarriages and preterm birth, were unchanged (p>0.05). There were fewer admissions to Neonatal Intensive Care Unit (p < 0.05) as compared to the pre-pandemic period (Figure 2). Despite an increase in the number of births, there was no negative impact outcomes noted on neonatal during the pandemic. Conclusion: During the COVID-19 pandemic, poor pregnancy outcomes were noted across the world. In Qatar, the services were adapted to provide continuity of care. This presented challenges but there was no increase in adverse neonatal outcomes.

Background: In response to the declaration of COVID-19 reaching pandemic status, Mesaieed General Hospital (MGH) was commissioned in record time¹. A multidisciplinary team of healthcare professionals effectively worked together to confront the challenges and changing demands that arose due to the crisis². This work aims to describe the systematic approach used in our newly opened hospital in preparation for the national surges of COVID-19 cases. Methods: This is a clinical audit of MGH's preparation as a COVID-19 facility during the first and second waves of the pandemic in Qatar, utilizing the Comprehensive Hospital Agile Preparedness (CHAPs) tool³. The six essential domains of the tool are: workforce, infrastructure, supply and equipment, service reconfiguration, data and information technology, and communications (Table 1). Results: During the first wave, the multidisciplinary team and leaders encountered challenges in all domains of the CHAPs tool. These six key areas in preparing the hospital and the systems from the previous surge benefited us in managing the second wave which demonstrated significant improvements in five domains except for the workforce (Table 2). Despite having Corporate Nursing workforce in charge of the manpower pool from various facilities, temporary COVID-19 Registered Nurses and newly hired overseas staff have different nursing educational backgrounds, experience, and levels of expertise. This remains a challenge since most of the patients in the second wave were sicker and more critically-ill. It is essential to provide upskilling programs for nurses to improve their knowledge and abilities. Conclusion: This clinical audit concludes that the experiences and lessons learnt through MGH's COVID-19 pandemic preparation from the first to second wave have taught the team significantly to proactively address concerns to mitigate for similar pandemic situations in the future, particularly in preparation for the 2022 World Cup where influx of delegates and guests are expected to visit the country amidst the ongoing pandemic.

Background: Due to the COVID-19 pandemic, all out-patients clinics shifted to telehealth visits¹. However some patients still needed to be seen as face to face visit², mostly through the new urgent referrals which were overbooked in the clinics due to the limited availability of slots³. The aim of this quality improvement project was to decrease the percentage of re-booked urgent referrals for in-person visits in the general paediatric clinics from 60% to 30% within 2 months. Methods: An intervention study started in October 2020 until present at the Out-patient Paediatric Department, Hamad General Hospital, Qatar. It included all general paediatric clinics, targeting urgent referrals. The intervention was to standardize the triaging process of urgent referrals (Figure 1) to guide the general paediatric team for booking patients to in-person visits within two weeks. Patients were contacted to confirm the date, time, and location of their visits. Results: A total of 48 overbooking referrals in 11 clinics were screened with an average of 3 patients per clinic. 69% of the referral were re-booked to the next clinics. Implementing the above intervention methods, the number of re-booked urgent referrals went down to 28% (1 patient/clinic) within a 2-month period (Figure 2). Conclusion: During the unprecedented time of the pandemic, patients still need to access healthcare services safely and in a timely manner. This study showed that using a standardized pathway, the target of decreasing the need to re-book urgent visits for in-person evaluations was achieved. Standardization reduces wastes in processes (Figure 1) and decreases variations that may lead to overutilization of the limited resources and negatively affects patient care. Continuous monitoring and evaluation of the outpatient referrals processes are critical in ensuring the delivery of high-quality care.

Background: The COVID-19 pandemic changed the way we deliver primary health care services for good. The need to protect staff and patients from the spread of infection while still providing essential healthcare services to the public was challenging but ignited innovations to facilitate healthcare delivery. International research supports the action of containing the spread of a virus by limiting the number of people co-located, if possible¹. The implementation of telephone and video consultations started in March 2020 in Qatar, within 4 weeks of COVID-19 being detected in the community, to support patient safety and provide primary health care services. Methods: Qatar's Primary Health Care Corporation (PHCC) implemented telephone consultations at 27 health care centers across general and specialty services to meet patients’ demands. Video consultations swiftly followed within an inbound community call center and 10 health care centers for general medicine, dental, and ophthalmology services. The latter then expanded to include, dermatology, and physiotherapy services. Results: Patients quickly adapted to attending telephone consultations as they understood the safety aspects of staying home unless a face-to-face consultation was absolutely necessary. The implementation of telephone and video consultations within PHCC has been successful as over 1,000,000 telephone consultations and more than 2,000 video consultations have been completed in one year. At the climax of the pandemic (around June 2020) approximately 50% of consultations were held virtually (Table 1: Telephone consultations versus in-person visits from April to July 2020). Conclusion: The implementation of telephone and video consultation services within PHCC, imposed by the pandemic, changed the way to connect and deliver services to patients. As the pandemic continues, this offers an alternative to face-to-face visits and is widely accepted by the public as a model of care delivery. The use of telephone and video consultations are widely implemented across the globe and both patients and clinicians have adapted well to such new ways of working^2,3.

Background: Since the 2020 COVID-19 Pandemic struck the healthcare industry, there has been a rapidly evolving and escalating situation across the globe that lead healthcare organizations to embrace changes at an accelerated rate¹. Hamad Medical Corporation (HMC) had to cope with an overwhelming number of patients being admitted to Acute Care areas during early 2021. When four HMC tertiary and secondary care hospitals were already at full capacity with COVID-19 patients, there was a need for another hospital like Al Wakra Hospital (AWH) to step up. AWH was a multi-specialty hospital attending to patients from all age groups with varying intensity levels in its Outpatient, Inpatient, and Critical Care Units. This article encompasses the journey of AWH from an acute care hospital to a COVID-19 facility receiving adult and obstetric COVID-19 patients from April 5th, 2021. Methods: The preparation involved rigorous risk assessment, brainstorming, and modification of patient care pathways and services (Table 1). A Series of Risk Assessment rounds were conducted.

The transformation encompassed areas inclusive of, but are not limited to, the creation and implementation of clinical pathways, drop off and pick up points for ambulances, wayfinding creation, online/point-of-care/face-to-face education, installation of antigen testing/Sharps box/wall-mounted hand rubs/ACRYLIC screens, staff exposure interviews and test scheduling, personal protective equipment (PPE) availability, H2O2 vapor disinfection, and healthcare-associated infections surveillance². Clinical pathways were well thought out to ensure the prevention of cross-contamination between patients³. Results: This transformation (Table1) demonstrated that successful change ensuring patient and staff safety can be achieved in a matter of days based on an organization's determination and comprehensive strategic planning, redesigning strategies that are effective, efficient, and befitting the need of time. Conclusion: A well-formulated infrastructure, prompt reallocation of resources, staff dedication, teamwork, proactive risk assessment, and continuous collaborative efforts paved the road to the successful clinical transformation of AWH.

Background: As the number of coronavirus disease (COVID-19) patients has rapidly increased around the world, the World Health Organization (WHO) declared the COVID-19 outbreak as a global pandemic in March 2020.¹ The pandemic created a global crisis affecting all countries, business sectors, and citizens around the world in their everyday lives.² Qatar's national policies and strategies focus on protecting the lives and the recovery of livelihoods. In line with this and to minimize the adverse impact on people's health and the environment, all types of wastes needed to be properly managed ³, especially at the time of a pandemic when everything might be contaminated. Methods: The Environmental Safety Section (ESS) under the Occupational Health and Safety (OHS) Department conducted a series of meetings with Hamad Medical Corporation (HMC) waste contractor and concerned departments to discuss the proper management of COVID-19 wastes generated from isolation and quarantine facilities. ESS staff provided training for nursing and housekeeping staff on the proper COVID-19 waste management from segregation, packaging, labeling, collection, and transport, and to strictly implement the System-Wide Incident Command Center (SWICC) memo.³Results: There was an increase in COVID-19 wastes from March to May 2020, with the highest amount recorded in the month of May as shown in Figure 1 due to the increase in COVID-19 patients, new COVID-19 facilities, improper segregation, and lack of training for the new staff and contractors. Conclusion: ESS-OHS collaborated with the COVID-19 management facilities for the proper waste collection and transportation. All applied strategies were effective and helped gradually to reduce the waste generated starting from August 2020.

Background: There is a paucity of robust, theory-based research investigating vaccination behavior.¹ Using Theoretical Domains Framework (TDF), the study aimed to explore the key behavioral determinants influencing vaccine behavior among pharmacy professionals in Qatar. Methods: A cross-sectional online survey of pharmacy professionals was conducted in April 2021. Survey items included questions related to demographics, vaccination behavior, and behavioral ‘determinants’ influencing vaccination (Likert statements, TDF items). The draft questionnaire was reviewed for face and content validity with experts and piloted among 80 participants. The sample size was calculated (n = 353) using the Raosoft online calculator. Data were analyzed using descriptive and inferential statistics and Principal component analysis (PCA) of TDF items.^2,3Results: The response rate was 37.40% (1,065/2,400). The majority expressed willingness to receive the COVID-19 vaccines. Participants who refused the influenza vaccine in the past were more likely to refuse the COVID-19 vaccines too (χ2(1) = 12.6, chi-square; p < 0.001). The mean (SD) overall percentage score of behavioral determinants influencing vaccine acceptance and advocacy were 31.2 ± 19.6 and 36.5 ± 28.2 (on a scale from -100 to 100). Vaccine acceptance was lower among those who refused any vaccines in the past (33.2 ± 18.9 vs 28.7 ± 20.1; p < 0.001) (Table 1). The main barriers to vaccine acceptance were safety, speed of development, and cultural influences. PCA identified ‘belief of consequence and emotions (fear and anxiety) as more negative determinant (-1.4 ± 42.1) potentially influencing vaccine acceptance behavior (Table 2). Although most participants considered it as their professional duty to advocate the use of vaccines, they were unsure if patients will accept their recommendations. Conclusion: Most participants expressed an interest to receive the COVID-19 vaccines and considered it as their professional duty to recommend the use of the vaccine. However, they were unsure if patients would accept their advice. Study findings will assist to develop behavior change interventions targeting individuals.

Background: Pharmacists are front-line healthcare workers who contributed to fighting the coronavirus disease 2019 (COVID-19) pandemic. Knowledge and attitude of both community and hospital pharmacists about COVID-19 were reviewed at different practice settings¹. This work aims to evaluate the knowledge and attitude of hospital pharmacists in Qatar about COVID-19. Methods: A descriptive cross-sectional web-based survey was distributed over 2 months. The study included Hamad Medical Corporation (HMC) pharmacists. The survey was developed based on the information available on the World Health Organization website, Qatar Ministry of Public Health, and HMC COVID-19 guidelines^2–3. The survey was piloted on 15 pharmacists. The required sample size (n = 289) was calculated based on a population of 564 pharmacists working at HMC hospitals and to achieve a 95% level of confidence, with a 5% margin of error and a design effect equivalent to 2 for cluster design. Results: The recruitment was 64.7% (n = 187) of the target sample size of 289 pharmacists. The overall level of knowledge was not affected by participants’ demographics (p-value ≥ 0.05). Pharmacists provided more correct answers to questions related to general knowledge about COVID-19 compared to questions about the treatment of the disease (Figures 1 and 2). Regarding attitude, frequencies, and percentages used to report data, more than 50% of participating pharmacists are using national resources as the main source of information related to COVID-19. Good health practices and attitudes regarding diseases control were reported by pharmacists including preventative measures implementation and self-isolation when needed. Around 80% were in favor of taking the influenza vaccine and COVID-19 vaccine. Conclusion: The required sample size was not met, limiting the reliability and validity of our reported findings. Hospital pharmacists’ knowledge about COVID-19 is good concerning the nature of the disease and its rapid transmission. Knowledge about treatment aspects needs further enhancement. Preventative measures implementation and self-isolation when needed were reported by pharmacists as good health practices and attitudes.

Background: COVID-19 has brought several patient challenges related to anxiety disorders impacting their wellbeing ¹. According to Vaartio-Rajalin et al., ², expressive art therapy (AT) has many advantages including mental health, physical, and social wellbeing. AT was introduced to COVID-19 patients on the 29^th of May, 2021 as part of our Patient Wellbeing Programme launched at Umm Salal Isolation Facility (USIF) in Qatar. USIF provided patients with drawing tools to potentially promote health, social engagement, reduce symptoms of anxiety, depression, fatigue as well as addressing social detriments such as loneliness and isolation ¹. Promoting group and individual identities was claimed advantageous when considering the multi-cultural and diverse patient groups housed in the facility ². The study was initiated by the nursing team to evaluate the effectiveness of the AT activity on patients’ feelings of isolation, loneliness, and depression. Methods: This was a prospective cohort mixed-method study. Art materials were provided to establish patients’ engagement. Art stations were set up at the patients’ facility where multi-language instructions explaining the activity were made visible. The artwork was collected from voluntary participants (907) once a week and evaluated during the study period (13 weeks) which provided quantitative data. An existing general patient experience questionnaire (PEQ) was used to collate qualitative data to support the aim of the study. Data analysis was completed using Excel. Results: 907 artwork submissions were collected from a total population of 1,600 COVID-19 patients. The average rate of participation was 8% weekly, over 13 weeks (Figure 1). 150 PEQ's were received from 907 patients where 98% of respondents felt that AT supports patients’ wellbeing in a confined facility like USIF. Conclusion: AT has been shown to improve patients’ perceived well-being by reducing feelings of isolation, loneliness, and depression. Participation remained very moderate and ways of promoting more engagement and a higher uptake need to be found.

Background: Home Health Care Services is a non-residential long-term care facility, part of Hamad Medical Corporation. It serves around 2,700 patients, the majority of which are elderly, with multiple co-morbidities and polypharmacy, and subsequently, an increased risk of drug-related problems and inappropriate medication use.¹ The clinical pharmacists’ ultimate focus is to provide effective pharmaceutical care to improve health outcomes and quality of life for these patients. Methods: As most clinical and medical services were delivered via telephone consultations, pharmacists were visiting elderly patients at home for Medication Therapy Management^2,3 taking appropriate measures to protect everyone. Their interventions included; medication reconciliation with appropriate identification of medication discrepancies, assessing compliance to prescribed medications ensuring safe and effective medication use; educating patients/families/caregivers about appropriate indication, dose, frequency, safe handling, and disposal, considering deprescribing of some medications that could negatively impact health outcomes using shared decision making in a very simple and raw language free from medical jargons, and recognizing any medications related problems (Figure 1). Results: Between January 2020 and December 2020, around 1,000 home visits were conducted, and 865 phone call consultations took place. The main challenges that were encountered were the language barriers of some caregivers as well as difficulty tracking some medications that have no clear indication. As a result, this work has created a long-term vision for aspirational and forward-thinking pharmacy practice models that resulted in improved clinical outcomes as well as increased patients’ and their caregiver's satisfaction about the clinical pharmacy services in Qatar (Figure 2). Conclusion: Clinical pharmacists played a major role during the COVID-19 pandemic as part of the multidisciplinary team providing unique, patient-centered, and high-quality pharmaceutical care. Through their visits and elderly patient and caregivers education, clinical pharmacists contributed significantly to keeping home healthcare elderly patients safe and well looked after despite the pandemic.

Background: In the data collected in the Hamad General Hospital (HGH), general pediatric in-patient unit, it was found that only 58% of medication orders were correctly prescribed by the resident physicians. This leads to patient care delays in a critical context and affects the discharge process^1,2.

By placing the correct order of medications, medication errors can be reduced. It prevents unnecessary calls being made to physicians by nurses and frequent calls from the pharmacy for verification in the pediatric in-patient unit, thus avoiding delays in-patient care. A quality improvement project was initiated in the pediatric in-patient unit, to improve the rate of correct medication prescriptions by pediatric resident physicians from 58% in February 2021 to 90 % by September 2021. Methods: Two main categories of change ideas were identified. Firstly, education and awareness, and secondly communication. For the two main change ideas, from April to September 2021, 7 Plan, Do, Study, Act (PDSA) cycles were conducted, each cycle with a different change idea (Figure 1). Educational sessions were implemented for resident physicians. Visual reminders were displayed on Workstation on wheels (WOW), educational material was posted in the residents’ lounge, weekly reminders were given through morning reports, monthly reminders were sent through e-mail, and twice-monthly updates were provided by the clinical pharmacist³. Results: There has been a gradual improvement in the percentage of correct medication order prescriptions from a baseline of 58% in February 2021 to 90% in September 2021 (Figure 2), hence meeting the objective of this quality improvement project. Conclusion: Gradual improvement was found in the medication order prescription by the pediatric physicians in the HGH pediatric in-patient unit from February 2021 to September 2021.

Introducing stickers on WOW highlighting awareness for orders created a positive impact on the residents while placing the orders. This positive outcome is expected to be sustained by regular performance monitoring and corresponding remediation interventions.

Background: Asthma is a leading chronic disease in children worldwide, which if left untreated or poorly controlled, can lead to altered lung function and poor quality of life.¹ Early detection and improved control of asthma are recommended to decrease utilization of emergency services and hospitalizations. Respiratory diseases are the most common conditions seen in Pediatric Emergency Centers (PECs) in Qatar.² The five PECs are an essential point of healthcare access for severely sick children, however, many people utilize them for potentially preventable reasons.³Methods: This was a quantitative retrospective observational study of children with asthma utilizing the five PECs during 2019. More than 18 variables were extracted from routine healthcare records, and data were analyzed via descriptive statistics using STATA to understand the characteristics of the population. Results: There were 41,343 visits to PECs due to asthma in 2019 from 18,382 children of more than 100 different nationalities. Around 60% were boys aged 2 to 13 years, with the peak of utilization in October and November (Figure 1) and during the day between 2:00 PM to 10:00 PM. The majority were seen in less than 30 mins (93%) and stayed in the PEC for 2 hours or less (84%) (Figure 2). Most did not have fever and 88% received Salbutamol. Around 900 children were admitted (1.6%) and almost 20 children attended once a month or more. Conclusion: From the severity of the cases, length of stay, prescriptions, and health care providers’ notes, it was clear that many PEC Emergency Department (ED) visits due to asthma were preventable. Hence; appropriate preventative medical care, education, and follow-ups are recommended to reduce hospital admissions and re-attendance. Understanding the characteristics and pattern of visits amongst this population will guide future qualitative research to explore reasons for attendance in more depth and identify potential opportunities for interventions to reduce ED attendances.

Background: Understanding the epidemiology of traumatic head injuries (THI) is essential to shape public health (PH) policies, implement prevention strategies, and justify the allocation of resources towards public safety, education, and research ¹. The World Health Organization (WHO) has recognized a gap in data and the high financial cost of THI's. Falls from shopping carts (SCs) are the most common cause of such injuries. This study aimed to investigate trauma related to SCs amongst children under 12 years of age, to help design safety strategies and effective intervention ². Methods: A systematic review was conducted using the search engines PubMed, Medline, Web of Science, and Cochrane Library databases between 1999 and 2020. A meta-analysis approach was adopted to evaluate the effect size, confidence level, and odds ratios of head and teeth injuries attributed to SCs. The search resulted in a total of 38,402 studies, of which 38,317 were excluded for not meeting the first level criteria. 7 out of 20 were further excluded due to primary outcome and variable relations. Results: 13 studies were subject to full meta-analysis (Table 1). The review involved an overall total sample of 180,857 children, the weight of 100%, and a confidence interval (CI) of 5.47 and 9.05 as the lower and upper limits; respectively. The result of the analysis showed the heterogeneity of the study was statistically significant at a 5% level (p = 0.000 < 0.05). There was a strong relation between falling from a shopping cart and head injuries (Figure 1) with high incidence rates (up to 72%). Conclusion: Trauma associated with SCs is a major PH concern, attributed to poor adult supervision, unrestrained child, or cart misuse. It is imperative to develop a national safety strategy plan to reduce or prevent serious injuries, involving public awareness through verbal prompts, posters, flyers, and stickers ³. Further investigation into associated dental trauma is needed.

Background: The Level 1 Trauma Center at Hamad General Hospital (HGH) offers world-class trauma services for Qatar, which also boasts the coveted Trauma Distinction Accreditation¹ award by Accreditation Canada. Consequently, HGH is expected to meet the Level 1 service specifications, which requires that an anesthetist should respond to Trauma 1 (T1) call within 15 minutes. Unfortunately, it was reported that this was not achieved in HGH, failing to fulfill the required compliance standard. In response to this, a new Trauma Anesthesia service was implemented, involving a pathway to deliver a 24/7 service by a designated team of Trauma Anesthetists taking part in all phases of trauma care (resuscitation, diagnosis, and treatment)^2,3 (Figure 1). This submission aims to describe the impact of this new service in providing timely care to trauma patients and thus meeting accreditation standards. Methods: This is a retrospective observational study primarily looking at the response time of the trauma anesthetists following a T1 call, which was recorded by the trauma nurses. Furthermore, the total number of trauma calls, proportional with T1 calls, and the number of trauma patients requiring anesthetic services were also collected. Data was collected from the Qatar Trauma Registry during the first six months (April to September 2020) of the new service. This data was then tabulated, analyzed, and expressed as a percentage (Table 1). Results/Findings: The study found that the service achieved a 100% (145) compliance rate for T1 anesthetic response time of 15 minutes. A total of 1029 trauma patients presented to HGH during the study period, of which 15% (145) were T1 admissions and about 10% (103) required surgical intervention. 25% (36) of T1 patients required anesthetic intervention. Conclusion: A 24/7 designated trauma anesthesia service provides high standards and continuity of care to trauma patients. The key anesthetic performance indicator for trauma accreditation was met.

Background: The evaluation of the pregnant trauma patient presents unique challenges. There are two patients potentially at risk; the mother and the fetus who both require evaluation and management.¹ Physiological changes like ligaments laxity, weight gain, and changes in the center of gravity make pregnant women at increased risk for trauma.² Knowing the other physiological changes is crucial for the adapted trauma management in pregnancy.³ This case study reports on major trauma in a pregnant woman that was under-evaluated at first assessment leading to maternal and fetal mortality. Case presentation: A 30-year-old pregnant lady (36 weeks) presented to a community hospital following a motor vehicle accident. She had sutures for a facial wound then she was sent home. A few hours later she presented to a tertiary hospital with hemoptysis. A Focused Assessment with Sonography in Trauma (FAST) ultrasound showed possible hepatic and splenic injuries and fetal death so she was transferred urgently to the operating room. Findings: The patient underwent laparotomy for the repair of the injured abdominal organs, in addition to a C-section complicated by uterine atony. After the failure of medical management, she underwent a hysterectomy then she progressed quickly into Disseminated Intravascular Coagulation (DIC) and passed away a few hours later. Conclusion: Trauma in pregnancy should always be taken seriously to avoid under-evaluation of major injuries. Basic principles of advanced trauma life support (ATLS) were not followed in this case and major injuries were missed. Patients in high-speed collisions should be referred to a trauma center instead of a community hospital in order not to lose the time window of the golden hour.

Background: The diaphragm is a musculotendinous structure providing a significant drive for respiration and lung expansion during inspiration. The other muscles aiding in ventilation are intercostal, abdominal, and accessory muscles, including sternocleidomastoid and scalene.¹ Direct neck trauma, either blunt or penetrating, potentially can contribute to diaphragmatic paralysis related to phrenic nerve palsy.² The use of ultrasound to confirm diaphragmatic paralysis is growing and becoming an alternative to conventional investigations, including fluoroscopy which is a gold standard.³Case presentation: A middle-aged man was found lying on the road with neck and upper back pain following a frontal collision with a bus. He was a restrained car driver at the time of the impact and was eventually brought by ambulance to the Emergency Department (ED). He had no breathing difficulty although, in the chest x-ray, the right hemidiaphragm was found to be raised (Figure 1). Bedside ultrasound showed no right hemidiaphragm movement assessed in B-Mode (Figure 2). In M-Mode, it showed a flat excursion and minimal change in thickness of the right hemidiaphragm compared to the left. He was managed conservatively with a cervical collar, analgesia, and admitted to the trauma ward for observation and discharged on day 5 with the diagnosis of transient right-sided diaphragmatic paralysis recovered fully as evident with reduced height differential between hemidiaphragm on repeat chest x-ray done one day before discharge, and C1 transverse process and C7 right lamina fracture. Recommendations: The use of bedside ultrasound is critical in suspected traumatic diaphragmatic paralysis during a secondary or tertiary survey to avoid high-risk transfers and the prevention of secondary injuries. Conclusion: Bedside ultrasound has characteristics that make it an ideal tool to use in ED to improve patient safety and optimize resource utilization. Hence; its use is highly recommended. However, further research is needed to determine its effectiveness in traumatic patients for diaphragm paralysis.

Background: Benign Prostatic Hyperplasia (BPH) is one of the most frequent diseases in men. The laser treatment for BPH has challenged TURP due to advances in laser technology, a better understanding of tissue-laser interactions, and rowing clinical experience.¹ The objective of this work is to evaluate the safety and efficacy of Holmium Laser Enucleation of Prostate (HoLEP) and compare it to Bipolar Transurethral resection of the prostate (TURP). Methods: This is a prospective study to evaluate the outcomes in BPH patients undergoing surgery by HoLEP and Bipolar TURP done between January 2018 to December 2019. A total of 80 Patients were enrolled, forty undergoing HoLEP and the other forty went for Bipolar TURP for BPH. All patients with symptomatic BPH and who were candidates for surgical treatment were included. Patients with previous prostate surgery, urethral surgery, history of prostate cancer, or neurogenic bladder were excluded.^1,2Results: Baseline parameters were almost similar between both groups in terms of age (years), International Prostatic Symptom Score (IPSS), Quality of life (QOL), Q max(ml/s), Post Void Residue (PVR), and gland size(grams) [Table 1]. Operative time and resected gland weight were more in HoLEP arm (p < 0.001). Catheter time and Hospitalization period were significantly lower in the HoLEP group (p < 0.0001). Haemoglobin drop was not significant between the two groups (p = 0.148). IPSS at three months was similar in both groups (p = 0.608). Qmax improved significantly in both groups, with 18.87 in TURP and 17.87 in HoLEP with a p-value of 0.261. PVR and QOL were similar between the two groups (P = 0.914 and P = 0.781) [Table 2]. Conclusion: Both Bipolar TURP and HoLEP were effective in relieving bladder outlet obstruction (BOO). HoLEP has equal efficacy compared to conventional bipolar TURP, with decreased hospital stay and catheter indwelling time.

Background: Mesaieed Hospital (MSH) was a COVID-19 center from the 7^th of February till the 28^th of June, 2021 with a high capacity and turnover. Therefore, timely discharge was crucial.¹ Before implementing the clinical pharmacy service, MSH discharge pharmacy was receiving discharge prescriptions from noon. Since clinical pharmacists did not review discharge prescriptions, errors identified by the discharge pharmacy resulted in further delays in patients’ disposition to quarantine facilities.^2,3

This project aimed to achieve a 100% clinical-pharmacist review of planned discharges before 15:00 by May 30, 2021 and decrease the time to bulk patients’ transfer to quarantine facilities to start from 16:00 instead of 19:00. Methods: As early as 09:00, clinical pharmacists sent the reviewed discharges to the discharge pharmacy for discharge medication preparation through Microsoft-Teams. The clinical pharmacists reviewed and solved all drug-related issues before 15:00. In addition, the clinical pharmacists reviewed planned patient discharges without medication orders, and discharge plans were documented on Cerner^®. The detailed process is shown in Figure 1. Results: Out of the 856 reviewed discharges during the project period, three prescriptions had pending Issues after 15:00 due to communication challenges with the prescribers because of the high turnover. Figure 2 illustrates the discharge rates before 16:00.

The discharge pharmacy started preparing medications 3 hours earlier (Figure 1). Accordingly, 100% of patients’ disposition was achieved by 16:00 instead of 19:00 before the new process. Additionally, sixteen pending discharges had their discharge medications proposed by clinical pharmacists and documented in Cerner^®. They were ready for dispensing once discharge was confirmed with no prescribing errors. Conclusion: The clinical pharmacy service within MSH enhanced the discharge process safety by ensuring a 100% review of the discharge prescriptions and more than 99% of the issues resolved before reaching the discharge pharmacy. Moreover, this process facilitated earlier patients’ disposition by about 3 hours. Further studies among HMC facilities are warranted.

Background: Overactive bladder (OAB), as described by the International Continence Society (ICS), is characterized by complex symptoms, which include urinary urgency (strong, sudden need to urinate that is difficult to delay) with or without urge incontinence that is usually associated with frequency (abnormally frequent urination) and nocturia (excessive urination at night).¹ The objective of this study is to assess the efficacy of mirabegron and tolterodine, comparing both drugs by International Prostate Symptom Score (IPSS), micturition episodes per 24 hours, nocturia, urgency, urge incontinence after 12 weeks of intervention among patients who presented with predominantly storage lower urinary tract symptoms (LUTS).^2,3METHODS: This is a prospective observational study conducted on 40 patients with overactive bladder over a period of 15 months, from January 2019 to March 2020. 20 patients received Mirabegron 50 mg (tablet) once daily (Group-M) and the other 20 patients received Tolterodine 4 mg (tablet) once daily (Group-T). RESULTS: The difference in urinary frequency episodes per 24 hours after 12 weeks in the Group-M was 2.75 ± 1.41, while that among Group-T was 1.15 ± 1.04 with significant p-value < 0.05. The difference of nocturia episodes after 12 weeks in the Group-M was 1.45 ± 0.88, while that in Group-T was 0.7 ± 0.65 with significant p-value < 0.05. The difference of urgency episodes after 12 weeks in Group-M was 1.65 ± 0.99, while that among Group-T was 1 ± 0.79 with significant p-value < 0.05. The difference of urge incontinence episodes after 12 weeks was not statically significant between the two groups (Table 1). The difference of IPSS after 12 weeks in the Group-M was 5.7 ± 3.65, while that among Group-T was 3.85 ± 1.27 with significant p-value < 0.05 (Table 2). CONCLUSION: Mirabegron improved urinary urgency, total number of micturition episodes/24 hours, nocturia, IPSS score more than Tolterodine in over active bladder patients. There was no statistical difference between Mirabegron and Tolterodine in terms of urinary incontinence episodes.

Background: Antimicrobial resistance (AMR) determinants such as mobile colistin resistance (MCR-1) that encodes colistin resistance are increasingly spreading in healthcare-associated and community-acquired infections.¹ Colistin, a cationic peptide antibiotic, resistance is encoded by the MCR-1 gene that functions as phosphoethanolamine (PEA) transferase which adds a PEA moiety to lipid A head group rendering it resistant to host antimicrobial cationic peptides (AMPs).^2,3 The given hypothesis is that MCR-1 harboring bacteria survive longer in macrophages by evading AMPs. This study aims to investigate the role of MCR-1 in enhancing bacterial survival in macrophages. Methods: Eight E. coli strains were used in the study in which 4 strains were MCR-1 positive and 4 strains were negative. MCR-1 was confirmed by Polymerase Chain Reaction (PCR), and colistin and polymyxin minimal inhibitory concentrations (MICs) were determined using the microdilution method. Macrophage bactericidal assay was employed to examine bacterial survival using adherent murine RAW264 macrophages in an in-vitro bacterial infection model. Briefly, Macrophages were infected with E. coli strains at a multiplicity of infection (MOI) of 50 for 1 hour. The survival of bacteria associated with macrophages was quantified by agar plating method to calculate colony forming units (CFU/ml). Cytokines released from infected macrophages were quantified using ELISA method respectively. Results: Colistin MICs for MCR-1 positive E. coli strains were >25 μg/ml, whereas MCR-1 negative E. coli MICs < 6.2 μg/ml. E. coli strains encoding MCR-1 survived significantly more in association with macrophages (p = 0.024) compared to MCR-1 negative E. coli strains. Further, E.coli strains encoding MCR-1 induced slightly less IL-1β release from infected macrophages compared to E. coli strains without MCR-1 (p = 0.05). Taken together, the data suggest that MCR-1 enhanced bacterial survival in association with macrophages and modulated innate immune responses which may lead to treatment failure. Conclusion: MCR-1 encoding E. coli strains conferred resistance to colistin and survived more in association with macrophages.

Background: Group B Streptococci (GBS) or Streptococcus agalactiae colonize humans genitourinary and gastrointestinal tracts particularly in females¹. The pathogen is capable of causing invasive disease primarily in infants, pregnant and postpartum women as well as the elderly and patients with comorbidities². There is a paucity of studies on the disease with regional differences in prevalence and presentation of invasive bloodstream infection (BSI)³. In this study, we aim to assess the prevalence, microbiological characteristics as well as clinical outcomes of invasive GBS disease from all ages groups at Hamad Medical Corporation (HMC), Qatar. Methods: A retrospective study was conducted on all patients with microbiologically confirmed GBS bacteremia between January 2015–March 2019. Demographic, microbiological characteristics, as well as clinical data, were extracted from the hospital information system. Results: Out of the 196 confirmed cases of GBS bloodstream infections, 63.7 % were females (125/196) of whom 44.8 % were pregnant (56/125). There were three distinct age group populations: pediatric less than 4 years of age at 35.7 %, young adults 25-34 (20.9 %), and the elderly > 65 years (17.4 %). Presenting symptoms were fever in 53 % of the cases (104/196) (Table 1). Microbiological characteristics using disc diffusion tests demonstrated all isolates were universally sensitive to penicillin (100%, 196/196) with significant resistance to clindamycin at 28.6 % (56/196) and erythromycin at 49 % (96/196) of which 34.4 % (33/96) had inducible clindamycin resistance (Figure 1). The clinical outcomes showed a high cure rate of 87.25% (171/196) with low complications at 8.76 % (17/196) and 4% (8/196) 30-day mortality. Conclusion: Streptococcus agalactiae bloodstream infection in Qatar is common in females, affects the very young, and the elderly. The organism remains universality sensitive to penicillin with significant resistance to clindamycin and erythromycin. Patients present with mild symptoms have high cure rates, low complications, and safe outcomes for the majority of cases.

Background: Antimicrobial resistance (AMR) is a global threat to public health. There is a dire need for new antibiotics as AMR threatens our last-resort antibiotics efficacy.^1,2 Myrtle plants have been used in folk medicine for centuries. Essential oils from these plants demonstrated therapeutics effects. This study aims to examine the antibacterial activity of essential oils extracted from Myrtus communis L and Melaleuca leucadendron against clinically relevant bacterial pathogens.³Methods: Bacterial growth curves and bactericidal assays were performed on antibiotic-sensitive Staphylococcus aureus (SA) and antibiotic low and high resistant Methicillin-resistant Staphylococcus aureus (MRSA) strains; sensitive and resistant Klebsiella pneumoniae strains (KPS and KPR). Minimum bactericidal concentration (MBC) was performed on 4 strains of colistin sensitive E. coli and 4 colistin resistant E. coli strains. Results: Myrtle essential oils demonstrated a dose-dependent antibacterial activity against all tested strains and inhibited growth even after 24 hours. The tested oils dilutions ranged from 6.15 μl/ml up to 50 μl/ml and inhibited bacterial growth of both antibiotic sensitive and resistant strains of SA, MRSA (Figure 1), and Klebsiella. Further, the incubation of colistin sensitive and colistin-resistant E. coli strains with 50 μl/ml of Myrtle oil for one hour inhibited the growth of all tested strains. The viability of bacteria was tested by spotting on agar plates and further incubation overnight. The data suggest that Myrtle essential oils can effectively kill bacterial pathogens. Conclusion: Essential oils from Myrtus communis L. and Melaleuca leucadendron var. cajaputi possess potent antibacterial activity against antibiotic sensitive and resistant bacterial pathogens. There is a potential for utilizing these antibacterial oils as topical treatment of wound infections.

Background: The rise in antibiotic resistance requires prompt action to reduce the burden of untreatable bacterial diseases¹. Staphylococcus aureus is a human commensal and opportunistic pathogen that causes a broad range of diseases, from mild skin infections to infective endocarditis. The World Health Organization has placed S. aureus on the high-priority pathogen list due to its multidrug-resisting nature². The study aims to identify molecular targets for antibiotic adjuvants to restore antibiotic activity. Methods: Extensive blast search and computational analysis were employed to search published S. aureus genomes. The effect of suggested adjuvants was tested on sensitive and resistant S. aureus strains in-vitro. Bacteria were incubated in the presence of either an HDAC inhibitor (TSA) or an antibiotic (Cefixime), or a combination of both. Results: A gene that encodes a histone deacetylase-like enzyme (SA-HDAC) and shares high 3D-homology to human HDAC2 and HDAC8 was identified³. Using computational modeling, it was found that the SA-HDAC protein has an active catalytic pocket containing the highly conserved zinc-binding constellation, suggesting an HDAC-like activity. I-TASSER analysis revealed that HDAC inhibitors such as TSA, CRI, LLX, NHB, and B3N can bind to the catalytic core. From the growth curves generated using the in-vitro study, it was observed that while Cefixime alone had no effect, TSA had an inhibitory effect, and the combination showed an additive effect on both strains. Further, the effect was more evident in the sensitive strain as compared to MRSA. An extensive bioinformatics blast search showed that this gene is absent in most gut microbiota species but found in many pathogens that carry and spread multidrug resistance in healthcare settings as well as in community-acquired infections. Conclusion: SA-HDAC enzyme, which is absent in most gut microbiota, is a highly druggable target that can be utilized for novel adjuvant antibiotic discovery.

Background: Non-statin therapies (NSTs) have been shown to provide additional benefits for cardiovascular risk reduction among patients with type 2 diabetes mellitus (T2DM), but their economic merits have not been confirmed. The objective of this systematic review is to evaluate the cost-effectiveness of NSTs for primary and secondary prevention of cardiovascular disease (CVD) in T2DM patients.¹Methods: A literature search was systematically performed using MeSH terms (Table 1) from January 1990 to January 2021 in ten databases (e.g. MEDLINE, PubMed, and EconLit). Two reviewers independently screened the included studies that evaluated the cost-effectiveness of NSTs versus any comparator. Quality of Health Economic Studies (QHES) checklist was used for quality assessment.² Cost outputs were adapted to 2019 United States dollars (USD) to facilitate comparisons between studies.³Results: The search identified 21,182 records. Of which, 10,781 records were screened based on the title and abstract, and 185 articles based on the full text (Figure 1). After a full-text review, 12 studies were included in this study, where eight studies evaluated ezetimibe, four evaluated Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) inhibitors, two evaluated fenofibrate, one evaluated nicotinic acid, and one evaluated extended-release niacin/laropiprant (ER-ERN/LRPT). Six out of eight studies considered ezetimibe plus statin to be a cost-effective therapy for patients with T2DM and with or without CVD, three out of four studies suggested that PCSK9 inhibitors were not cost-effective. Fenofibrate, nicotinic acid, and ER- ERN/LRPT were cost-effective. Based on QHES, the majority of economic evaluations had good quality of reporting. The ICERs were consistent in the majority of studies after adaptation to 2019 USD values.^1–3Conclusion: The systematic review demonstrated that most cost-effectiveness studies considered NSTs to be cost-effective compared with standard care but not PCSK9 inhibitors for primary and secondary prevention of CVD in T2DM patients.

Background: Subclinical hypothyroidism (SCH) remains one of the most common biochemical manifestations of thyroid dysfunction.¹ Similarly, type 2 diabetes mellitus (T2DM) is considered the most common metabolic disorder in clinical practice.²Methods: This is a systematic review to ascertain the prevalence and optimum management approach for thyroid dysfunction in patients with T2DM. We conducted a search on PubMed and Google scholar (Figure 1) for articles published between 2010-2020 using the following keywords: subclinical hypothyroidism, type 2 diabetes mellitus, thyroid diseases, diabetic retinopathy, diabetic nephropathy, and diabetic complications. Results: The prevalence of SCH in T2DM patients ranges from 7.8% to 23 % (average around 13.4%). In comparison, the prevalence of SCH in the general population ranges from 6% to 10%. SCH has a higher prevalence in females, older age >60 years old, long duration of T2DM, positive thyroid autoantibodies, glycated hemoglobin (Hba1c) 8%, and obese patients (risk factors).³ The prevalence of SCH in patients with diabetic retinopathy (DR) ranges from 17.3% to 43.3%. Also, the prevalence of SCH among patients with diabetic nephropathy (DN) ranges from 18.1% to 36%. Screening for thyroid dysfunction in T2DM at diagnosis is recommended and justified (Table 1). If patients with SCH have a risk of cardiovascular disease (CVD), DR, DN, symptomatic, presence of goiter, pregnant women, and continuous sustained increases of thyroid-stimulating hormone (TSH) on follow-up, it is recommended to start low dose levothyroxine which improves morbidity. Conclusion: The prevalence of SCH is relatively high in T2DM patients. This supports routine screening of such patients for thyroid dysfunction especially in patients with risk factors and diabetic complications (DR, DN), and consideration of thyroxine replacement wherever warranted although more evidence from randomized controlled trials is needed to explore the possible causal relationships.

Background: Insulin therapy is commonly used to control hyperglycemia in hospitalized diabetic patients. There are different delivery devices of Aspart and Glargine insulin which are available in 1000 IU vial and 300 IU Flexpen. As per the manufacturer's recommendations, insulin pre-filled pens are designed for single patient use only, whereas the vial form is intended for multidose administration for different patients, therefore, the selection amongst both forms of insulin will certainly impact the consumption cost. According to our observation, there was an unjustified prescribing discrepancy between both forms. Several studies have shown a decrease in insulin wastage associated reduction in acquisition costs when switching from pre-filled pens to vials^1-3. Methods: This is a quality improvement project that aims to enhance prescribing insulin vials in acute medical units at Hamad General Hospital. Insulin consumption data were retrospectively reviewed between July 2020-May 2021. Data were obtained 3 months consecutively at baseline and post improvement interventions which consist of 2 steps. Step 1: educating physicians and nurses about the cost effectiveness of insulin delivery devices, and Step 2: Transitioning patients from insulin Flexpen to vials by an authorized pharmacist. The outcomes measures were related to insulin consumption and cost reduction. The process was measured by the amount of Flexpens dispensed. Results: From July-October 2020, 400 patients consumed 81500 IU of insulin Aspart and 58600 IU of insulin Glargine, with a total number of 297 Flexpens used. After implementing improvement intervention, insulin consumption for 551 patients from February – May 2021 reduced to 19200 IU (76.4%) for Aspart and 18900 IU (67.7%) Glargine (Figure 1), comparing with same interval period only 38 Flexpens were dispensed. Economically, the transition to insulin vials reduced the hospital cost by 71% (Table 1). Conclusion: Compared to Flexpen, insulin vial prescribing in hospitalized diabetic patients led to waste and cost consumption reduction of insulin.

Background: One of the most prevalent viruses among dialysis patients is Hepatitis C as it affects 8.4% of the dialysis patients in Qatar¹. It causes serious complications including end-stage liver disease. There is no available vaccine to protect against the transmission of the Hepatitis C virus (HCV). However, antiviral drugs lead to precious benefits including reducing the risk of morbidity/mortality, increasing life expectancy, and eventually nominating them for kidney transplant².

The Qatar National Plan for HCV control by 2020 was launched in December 2014. In 2017, the World Health Organization accepted to support the development and implementation of national multispectral policies and strategies for its prevention and control in Qatar³. The treatment of HCV in dialysis patients has been a challenge since its launch in 2020. Methods: This is a single-center cohort study, including a retrospective collection of data from 70 dialysis patients infected with Hepatitis C virus. 44 of them were treated with Ombitasvir 12.5 mg, Paritaprevir 75 mg, and Ritonavir 50 mg over 12 weeks and 12-week follow up period. As per all guidelines of the American Association for the Study of Liver Disease (AASLD), the European Association for the Study of the Liver (EASL), and the Asian Pacific Association for the Study of the Liver (APASL), sustained virological response indicates a patient has cured. Results: From the 70 HCV-positive patients, the 44 patients who received the 12-week treatments were cured (Figure 1). During the treatment phase, their biochemical values were normal (Figure 2). Conclusion: The outcome of the first phase treatment of Hepatitis C in dialysis patients is highly effective. Moreover, the successful HCV antiviral treatment will decrease the risk of infection transmission within dialysis patients and reduce the occurrence of complications occurring after kidney transplantation.

Background: Hamad General Hospital (HGH) Nephrology Department is the main provider for dialysis services in Qatar, serving almost 900 patients. The introduction of the COVID-19 vaccination is a crucial step in protecting End Stage Renal Disease (ESRD) patients who are vulnerable and prone to infections due to their immunocompromised status.¹ They are at high risk because they are unable to practice adequate safe physical distancing as the majority of them are dependent on others due to age and the medical condition.

During the first wave of the COVID 19 pandemic, the mortality rate was 20-30% among the dialysis population.² Several challenges were faced since February 2020 to manage and control COVID-19 infection in dialysis units. Vaccination is the most important preventive measure in facing COVID-19. Hence, a multidisciplinary team was formulated in March 2020 aiming to raise the patients and staff awareness of the importance of COVID-19 vaccination. Methods: The assessment of dialysis patients’ knowledge and educational needs was done by conducting multidisciplinary focus group activities, providing educational materials in many languages, education through hospital TV channels, WhatsApp group activities with patient educators, and direct education during physicians’ monthly dialysis assessment. Monitoring the compliance rate was done by monthly data collection and targeting non-compliant groups. Results: After the implementation of COVID-19 immunization strategic plan by the end of June 2021, 75% (666 patients) out of 884 dialysis patients were vaccinated (Figure 1). The current vaccination update for over 16-year-old in Qatar is 62.8% ³. Moreover, COVID-19 positive patients were properly managed since the beginning of 2020 by following Ministry of Public Health (MOPH) guidelines to control the spread among the dialysis population and the successful initiation of COVID-19 vaccination program (Figure 2). Conclusion: Continuous educational activities and awareness campaigns have increased COVID-19 immunization percentage among the dialysis population and probably contributed to saving lives.

Background: Patient-centered care is a concept focussing on meeting the specific health needs of patients as expressed by them. Patients Reported Experience Measures (PREM) is another concept associated with patient-centered care. PREM surveys capture information about the healthcare experience as perceived by patients.¹ Its importance lies in the incorporation of patient feedback into the clinical decisions and service evolution.² Dialysis patients play an important role in their treatment and their voice matters to provide proper care. PREM was first conducted in 2019 in our dialysis unit. In 2020, the COVID-19 impacted dialysis services and resulted in many challenges including staff shortage and deployment. Yet, the patients’ feedback was evaluated continuously and compared with previous years before the pandemic. Methods: A validated questionnaire from the National Health Service in London was used.³ It consisted of 7 questions covering demographics, dialysis options, patient portal, patient's relationship with the staff, teamwork, and traveling abroad. The survey involved 317 randomly selected patients who have been at least one year on dialysis. A comparison between 2019 and 2020 results was conducted using the chi-square test. Results: A drop in patients’ experience was observed in many survey components like education on dialysis, medication side effects, access to the patient portal, access to physicians and nurses from home (Figure 2). However, in other areas, some positive experiences remained unchanged like communication and knowledge among the staff.:Conclusion: Patients’ reported experience helps in the evaluation of health services. After exploring dialysis patients’ experiences, it was possible to identify what is going well and how COVID-19 impacted the patients’ perspectives. The PREM survey conducted in this work showed a significant decline in many parameters likely attributed to COVID-19 consequences including the staff shortages.

Background: The D-dimer test has a diagnostic role in pulmonary embolism (PE) and deep vein thrombosis (DVT). In a low-risk patient with negative D-dimer, PE or DVT can safely be ruled out. This work aims at investigating whether the D-dimer has a similar role in cerebral vein thrombosis (CVT) diagnosis. Methods: A literature review was performed in PubMed, Google scholar, and BestBETs electronic resources to identify studies published from 1996 to July 2021 that assess D-dimer's diagnostic accuracy and report its sensitivity and specificity in CVT diagnosis. The AMSTAR tool was used to assess the quality of the included studies. Results: Out of 66 non-duplicated citations, 15 articles were relevant to our clinical question. Eight articles were included in one of the retrieved meta-analyses, and four articles were excluded during data collection because of unclear results. Two systematic reviews and meta-analyses^1,2 and one cohort study³ were included for the systematic review. The selection process is shown in Figure 1. The studies are reported with details of author, publication date, population details, and results are shown in Table 1. Most of the studies show that D–dimer has a high sensitivity which is estimated to be around 93% to 97% in CVT diagnosis. However, its sensitivity is affected by age, thrombus sizes, and the method used in D-dimer assay.

A review shows that more CVT extension and earlier presentation, prior to 2 weeks, were correlated with higher D-dimer levels. Unfortunately, most of the studies are not high-quality studies, with variable designs, population, and reference standard tests. The studies showed that D-dimer could help predict CVT in combination with risk factors and clinical presentation. Conclusion: Normal D-dimer only should not be used to exclude CVT. There is a probability of using D-dimer in CVT risk scoring and pre-imaging negotiation, and for that purpose, larger and higher-quality studies are needed.

Background: Clinical Pharmacists (CPs) have a vital role in the patient transition of care (TOC), including medication reconciliation and counseling upon admission, transfer, and discharge.¹ The Clinical Pharmacy Department at Al Wakra Hospital, Qatar, Hamad Medical Corporation (HMC), established a collaborative practice agreement with the Internal Medicine Department.² The post-discharge phone follow-up (PDPF) telehealth service aimed to maintain patient continuity of care post-discharge and ensure the safety and effectiveness of discharge medication therapy. This audit describes the implementation of a new TOC initiative. Methods: Criteria for PDPF service were developed and documented into a protocol. Patients discharged from medical wards with complex medication therapy or discharged without discharge medications counseling were contacted within 3 to 7 days from discharge. CPs provided phone medication reconciliation, counseling, lifestyle modification education, assessed medication adherence, and communicated identified medication errors to the primary physicians. Data collected from documented pharmacy interventions and PDPF service forms were used for descriptive analysis. Results: From December 2020 to March 2021, 429 patients met the inclusion criteria out of 1,117 discharged patients. CPs conducted more than 613 phone calls with an average of 15 minutes per patient. CPs reviewed 2,471 medications, found 638 pharmacy clinical interventions (Table 1), and approached more than 77 physicians. Out of the 276 patients who completed PDPF service (Figure 1), the average patients’ age was 52 years, 151 (51%) were females, and 85 (31%) were Qataris. Medication assessment by CPs revealed that 87% (n = 235) of the patients were adherent to medications, 20% (n = 56) were confused about discharge medication indications, and 13% (n = 30) experienced adverse drug reactions. Conclusion: There is no standardized or established TOC service utilizing telepharmacy; however, PDPF service expanded the clinical pharmacy role beyond the in-patient services.³ Our plan includes monitoring outcome-based parameters, including post-phone call readmissions rate, 60 days emergency visits, and patients’ satisfaction.

Background: For some time, paramedics and nurses of the National Ambulance Service in Qatar provided outpatient parenteral antimicrobial therapy (OPAT) to patients with the support of Family Physicians. Like in many other countries of the Middle East, there is a high prevalence of antimicrobial resistance which makes treating infectious conditions challenging. Methods: This is a retrospective cohort study of patients referred to the Ambulance Service – Mobile Healthcare Service from a public hospital acute facility for OPAT over 6 months in 2015. The study's primary aim is to determine whether the OPAT service had comparable outcomes to international reports with respect to unplanned hospital visits for acute care within 30 days of OPAT referral. A secondary aim of this work is to determine the effect of body fluid culture results on that outcome by comparing subgroups within the OPAT population, and the documentation of prevalence and types of antimicrobial resistance. Results: Between the 1^st of March and the 30^th of August 2015, 232 OPAT referrals were received. The most common referral diagnoses are reported in Table 1. Within 30 days of OPAT referral, 24.1% - 30.7% of patients required an unplanned hospital visit. This is at the high end of the range reported internationally for OPAT services.^1,2 Patients with resistant bacterial infections isolated from body fluid cultures experienced the worst outcomes. The prevalence of significant drug resistance among OPAT referrals was 28.0%, mostly extended-spectrum β-lactamase (ESBL) production. Conclusion: OPAT can be provided in the community.³ The rate of return to hospital for acute care within 30 days of OPAT referral was relatively high, however much of this can be accounted for by patients with resistant infections. They had worse outcomes than patients with non-resistant infections or those treated on an empiric basis. The prevalence of antimicrobial resistance was comparable with other recent Middle Eastern reports.

Background: Labour analgesia blocks the aggravated sympathetic overactivity due to labor pains in preeclampsia.¹ Performing regional anesthesia in obese parturients with severe scoliosis poses challenges due to technical difficulties and alterations in epidural space.²Case presentation: A 24-year-old primigravida (40 weeks, weight 111kg, Body Mass Index 41) presented to our emergency department with mild contractions and hypertension (156/110mmHg, proteinuria 3+). Systemic examination and laboratory tests including platelets were normal. Airway assessment showed Mallampati class 3. No prior Pulmonary Function Test or cardiologic evaluation was done. Xray of the abdomen showed altered thoracolumbar lordosis with double curve scoliosis (Figure 1). The thoracolumbar scoliosis was convex to left with cobb's angle 65° (severe >40°) and cervicothoracic scoliosis was convex to right (cobb's angle 40°). She was started on labetalol infusion, and the anesthesiologist was paged for labor analgesia. Using ultrasound guidance, the epidural space was reached at 8 cm, in a sitting position by orienting the needle towards the convexity of curvature in L3, L4 interspace. 10 ml 0.125% levobupivacaine with Fentanyl 2 mcg/ml was given as bolus and Patient Controlled Epidural Analgesia infusion started at 6 ml/hr, bolus 10 ml and lockout interval 20 minutes. The patient reported pain relief within 15 to 20 minutes and remained pain-free during her vaginal delivery keeping her blood pressure (BP) almost in a normal range. Findings/Recommendations: Working epidurals provide pain relief, minimize BP aggravations, and can be extended to provide anesthesia if a caesarean is needed.¹ This improves the uteroplacental blood flow and neonatal outcome. Epidurals mitigate the exaggerated cardiovascular response to intubation during difficult airway management in obese patients with Pregnancy Induced Hypertension (PIH). Conclusion: Epidural analgesia controls BP during labor in PIH. Ultrasound-guided technique is a highly reliable technique, especially in difficult cases like scoliosis.³ In scoliosis, neuraxial procedures warrant careful titration of drugs due to reduced subarachnoid space.

Introduction: Nearly 98% of women in developed nations benefit from antenatal services.^1,2 In Qatar, all pregnant women are provided with antenatal care services at primary and secondary care facilities. If indicated, they are referred or transferred to tertiary care hospitals.³ However, it was noted that a significant number of women opted not to avail of these services. This study is conducted to assess the prevalence of women with no/poor antenatal care and their neonatal outcomes. Methods: A retrospective chart review was conducted at a secondary care hospital. All women (n = 5,796) who gave birth in the year 2018 were included. Prevalence of women with poor/no antenatal care was noted. Neonatal outcomes of 248 women with poor antenatal care (Group A) were compared with 298 randomly selected women with antenatal care (Group B). Statistical analysis was performed with the MedCalc online software. Results: The prevalence of women with poor and no antenatal care was 12.54%. The prevalence of preterm birth was 23.79% versus 4.39% in Groups A and B; respectively (OR-6.79, 95% CI-3.62 to 12.73, P < 0.001). Large for dates and small for dates babies were observed in 14.92% versus 3.38% (OR-1.14 95% CI-0.67 to 1.92, P>0.05) and 12.5% versus 11.15% (OR-5.01, 95% CI-2.44 to 10.31, P < 0.001) in Groups A and B; respectively. Neonatal admissions at birth were 12.10% versus 6.76% (OR-1.89, 95% CI-1.05 to 3.44, P < 0.05) in Groups A and B. Higher prevalence of intrauterine fetal deaths was also noted in women with poor/no antenatal care with 3.32% versus 0.34% (OR-12.49, 95% CI-1.55 to 100.6, P < 0.05) (Figure 1, Table 1). Conclusion: A higher prevalence of women with poor antenatal care was noted as compared to data from developed nations. Poor neonatal outcomes were observed in these women. This study identified the need for future studies to determine why some women are not using maternity services in Qatar.

Background: Poor knowledge and attitude of postpartum complication (KAPC) among women delays their management and increases Maternal Mortality Ratio (MMR).¹ MMR in Lebanon increased from 24 deaths per 100,000 live births in 2005 to 29 in 2017.² This study aims to assess the perceived KAPC of Lebanese women and how it differs according to their level of education and age groups, in different regions in Lebanon. Methods: This community-based cross-sectional study was conducted among 500 women aged 17-50 years old from 2018 to 2020 regardless of having children or not. A questionnaire was developed, and its internal validity was found to be within the acceptable range (Richard's Kurdson = 0.75). The questionnaire was translated from English to Arabic and administered for data gathering through face-to-face interviews. Chi-square and ANOVA were applied to identify the statistical difference. A confidence interval of 95% was reported, and statistical significance was declared at p < 0.05. Results: The majority of women who regarded proteins and dairy products as essential are those living in Beirut [p = 0.020] [0.019]. Women who attended university demonstrated more knowledge of alarming urinary tract infection symptoms than those who attended secondary or high school level [p = 0.05]. Females living in Beirut knew better about deep vein thrombosis symptoms than those living in the South and Nabatieh [p = 0.047] (Table 1). Regarding the best method for breast emptying, 64.8% of women aged 36-50 chose continuous suckling compared to 47.2% of females aged 18-25 year-old (Table 2). Conclusion: KAPC among Lebanese women is distinct from one complication to another, and this is influenced directly or inversely by mainly the effect of the Lebanese geographical regions and educational level. Therefore, an awareness campaign must be implemented at several levels, targeting the most distant regions, especially the rural ones like Beqaa, and vulnerable age groups, particularly the young.

Background: Early ambulation is considered as one of the post-operative interventions in Enhanced Recovery After Surgery protocol and women could be ambulated anytime from 6-8 hours post-surgery.¹ Early ambulation benefits patients by reducing the risk of deep vein thrombosis, improving breastfeeding rate, promoting better diet and nutrition, and improving their satisfaction.² A retrospective baseline data collection from December 2019 to February 2020 showed that only 6-7% of women were ambulated within 24 hours of surgery in the Obstetrics and Gynecology inpatient unit of Al Khor Hospital. Methods: A Quality Improvement (QI) project was conducted to deliver early ambulation in post-cesarean women using QI methodology from the 1^st of March, 2020 to the 31^st of July, 2021 with the aim to ambulate 100% of the women who underwent Lower Segment Caesarean Section (LSCS) within 12 hours of surgery. Patients received pre-and post-operative patient education, were reassessed by a physician within 6 hours post-surgery, and started oral intake. Women were assisted for post-surgery ambulation as required. They were offered multimodal analgesia to minimize the use of opioids and to enable them to mobilize without falling. Results: Results have suggested that 96% of women were ambulated within 12 hours of surgery at the end of the improvement cycle 1 and 100% of the women were ambulated by the 31^st of December, 2020 (Figure 1). Using opioids for pain relief during this period was reduced (Figure 2). Early oral intake increased from 17% to 92% and breastfeeding rate within 24 hours post-surgery increased from 25% to 85% by December, 2020. No fall incidences during ambulation were reported. The QI project is still under monitoring for evaluation of its sustainability. Conclusion: Early ambulation enables new mothers to mobilize within 12 hours of surgery and helps reduce the use of opioid drugs for pain, and increases compliance to breastfeeding and early oral intake.

Background: The majority of patients living in a Long-Term Care Unit (LTCU) have limited mobility.¹ Prolonged immobilization results in functional decline and increases the risk of other complications.² It was observed that there is a lack of a structured, evidence-based mobility program using mobility protocols and guidelines. As per a 6-weeks baseline data collection, out of the 36 patients in Rumailah Hospital's LTCU-2, 40% were bedbound and only 60% of them were engaged in any kind of “Out Of Bed Therapeutic Activities” (OOBTA) as of November 2020.The project aimed to increase patients’ participation in OOBTA from 60% to 80% by December 2021. Methods: A Mobility Task Force (MTF) was formed from a Multi-disciplinary Team (MDT). The Institute for Healthcare Improvement (IHI) Model of Improvement was utilized. A Cause and Effect Diagram with multi-disciplinary input identified potential causes limiting mobility and supported possible solutions for testing in a series of Plan-Do-Study-Act (PDSA) cycles (Figure 1). Each specialty evaluated and provided appropriate OOBTA based on their level of care. Results: This project helped the unit to promote a culture³ of early and safe patient mobility as shown by increased participation in OOBTA and zero falls, no pressure injuries, etc. As a result, it helped the unit to attain more than 80% of patient participation in OOBTA during their hospital stay (Figure 2). The team observed good multidisciplinary collaboration and engagement in developing this mobility program. Conclusion: Promoting early mobility is a cultural change that improved patients’ participation in OOBTA from 60% to 80% from July 2021, five months ahead of our target date and despite the COVID-19 pandemic situation.

Background: Early assisted patient discharge has been implemented in Qatar since 2014 through the introduction of a Mobile Healthcare Service (MHS) with family physicians, nurses, and paramedics doing home visits¹. Studies have explored the effect of Ramadan on Muslims, but findings have been variable^2,3. This research aims to study and quantify any effects of the Holy month of Ramadan, and other important Muslim Religious events, on MHS operations. Methods: Operational data was gathered and analyzed for the weeks of Ramadan, Eid Festivals, and ‘Normal’ working weeks, over 10 months in 2015, using descriptive statistics. Results: 5,863 interventions were extracted and grouped by time durations. The number of interactions per day ranged from 1 to 38, with the median gradually increasing throughout the duration of this study. Ramadan showed an average of 19 visits/day; Eid al Fitr: 16 visits/day; Eid al Adha: 20 visits/day. During Ramadan, call numbers often returned to zero at some point between 16:00-19:00 hrs, which corresponded to Iftar (breaking fast). There are outlying values in the weekly distribution, including a high number on the Sunday of Eid al Adha when many employees returned to work. Conclusion: Despite several possible confounding factors, Ramadan and other Holy events and holidays appear to affect the MHS demand. Although not statistically significant, a decrease in workload over the duration of Ramadan and Eid al Fitr was noticed. There is an approximately tri-modal distribution of interactions across all days, presumably reflecting the high proportion of patients requiring Intra-Venous antibiotics at set intervals and the effect of meal breaks. There is a marked dip between 11:00-12:00 hrs on Fridays, likely corresponding to Friday prayers. However, it is not clear how generalizable the observations are to other similar services in the Gulf countries or other Muslim populations.

Background: A significant number of offshore operations are carried out by Qatargas (QG) employees and contractors in multiple offshore locations, hence, people acutely ill require costly and risky Medical Evacuation (Medevac) undertaken by helicopter or boat.¹ This study aims to evaluate the impact of offshore fitness to work on reducing the number of preventable medevacs in QG compared to other oil and gas offshore organizations. Methods: This is a retrospective review of medevac data (2018-2020) in Qatargas offshore locations concerning the total yearly population. Employees’ records, human resource data, and medical screening data were used as a dominator for the population. It included analysis of pre-employment medical examination, periodic medical examination, medical screening programs, occupational vaccination, and fitness to return to work programs. Results: During the 3 years, 10 medevacs occurred for a total of 13,376 workers, resulting in a rate of 0.74 medevac cases per 1000 workers (Figure 1). This rate is remarkable compared to similar studies in other oil and gas offshore industries (4.97/1000²; 4/1000³). In addition, we have evaluated retrospectively the medical records of the medevac cases to identify those due to a medical reason (not injuries/trauma). Among the 6 medical cases, 1 worker had a pre-existing medical condition. Another finding was that the average age of the 3 medical medevac cases due to suspicious chest pain was 57 years old. All medevacs were male workers, mostly because of illnesses (60%) rather than trauma (40%) (Figure 2). Conclusion: This study provides a new benchmark medevac rate (0.74/1000). A robust fitness to work in an offshore program with the adequate implementation of other preventative measures (e.g., vaccination) is effective in reducing the number of preventable medical medevacs from offshore remote locations and hence, reducing the cost of both medevacs and lost working hours.

Background: Quality improvement has been well documented in various industries to improve safety and processes.¹ However, limited research has taken place within the pre-hospital sector in this regard. Various factors can be attributed to the delivery of effective services. Studies often investigate customer/patient perception and often sideline the importance of employee perception.² This study evaluates Qatar's Hamad Medical Corporation Ambulance Service (HMCAS) staffs’ perception on service delivery to patients they treat and transport. Methods: An online survey was designed and distributed to HMCAS staff working within the emergency section (N = 750). A 5-point Likert scale (1 = strongly disagree to 5 = strongly agree) was used. The SERVQUAL model consisting of 5 dimensions (RATER): Reliability, Assurance, Tangibility, Empathy, and Responsiveness was used.³ Two variables with the highest perception score were regarded as the drivers of service quality. A negative gap score (perception minus expectation) was used as the basis for the study recommendations. Results: As per the required calculated sample size to achieve a 95% confidence interval, 255 questionnaires were completed. Respondents were 79% Ambulance Paramedics, 18% supervisors, and 3% managers. The weights of each dimension's variables were calculated to obtain perception and expectation scores. Descriptive statistics and gap scores of the survey responses are presented in Table 1 for the two variables of each dimension. None of the gap scores were found to be statistically significant. The proposed recommendations generated from this study are presented in Table 2. Conclusion: A standardized staff quality perception tool can assist in identifying potentially missed quality-related service issue(s). In this study, the SERVQUAL model was easily adapted and applied to the pre-hospital Emergency Medical Service setting in Qatar and proved useful in identifying service delivery proponents needing attention. Overall and reassuringly, the staff believes that they provide quality service to their patients.

Background: The lack of healthcare quality management poses significant legal and financial implications^1,2. A proactive approach to systems improvement seems warranted and reasonable. It is not clear if current quality control measures are perceived by patients. The study aims to understand if any correlation exists in this respect in the context of patients using the Hamad Medical Corporation Ambulance Service in Qatar. Methods: A survey was distributed to adult patients transported by the Ambulance Service's emergency division to the Hamad General Hospital's See and Treat unit in Doha (n = 255). The patients had to be free from serious injury/illness, fully conscious, and with re-collection of the service received. The original SERVQUAL model³ consisting of 5 dimensions (Reliability/Assurance/Tangibility/Empathy/Responsiveness) was modified and a 6^th dimension (Quality Control) was added. The Spearman's rank correlation was used to test the strength between quality control (QC) and service quality responses. Results: The mean age was 33.46 years ( ± 9.62). Patients’ continent of origin distribution is presented in Table 1. The QC dimension was correlated with that of the SERVQUAL dimensions presented in Table 2. Most of the SERQUAL dimensions had strong correlations with QC. Interestingly, there was a weak correlation between Assurance/QC and a moderate correlation between Tangibility/QC. The results seem to be driven by providing service within promised timeframes, access to care, and patients’ perception of ambulance staff's willingness to help. Conclusion: An awareness of the variables with strong correlations is indicative of the significant impact QC measures have and the associated perception of importance held by patients. This study sheds light on the importance of evaluating quality processes and limiting internal costs. The number of patients by continent of origin did not enable valid statistical tests based on that variable. The Ambulance Service's QC measures appear to maintain favorable patients’ perceptions of services received.

Background: Across the world, the COVID-19 pandemic is causing unprecedented human and economic losses. The availability of safe and effective vaccines against the virus is instrumental in saving lives. Supply chain readiness is key to efficiently deliver vaccines to the target populations.¹ To control temperature excursions and equipment breakdowns with an upgraded cold chain system with the latest technology suitable in a hot country are challenging. Methods: Primary Health Care Corporation (PHCC) institutionalized a continuous temperature monitoring system using a specific Temperature Monitoring Device (TMD) called a Digital Data Logger (DDL) mounted on cold chain medical equipment like pharmaceutical refrigerators, freezers, and the pre-qualified iceboxes of the World Health Organization (WHO). The DDL devices were affixed to the medical equipment to monitor the temperature and are supported by sound alarm when there are temperature excursions. Results: PHCC Cold Chain Management Ecosystem (Figure 1) involves vaccine vials stored in pharmaceutical refrigerators with a temperature range between 2°C to 8°C and freezers with a temperature range between -10°C to -30°C and WHO prequalified iceboxes for short periods of transportation.² The DDL has a set point temperature measuring limit, measuring interval, and delay time (Table 1) defined for temperature monitoring.³

PHCC Bio-Medical Engineering Department has successfully institutionalized a 24-hour/7 day a week Cold Chain Management System across 27 PHCC health centers. Moreover, a Cold Chain Management System was arranged in an offsite facility within a short period of 72 hours at the Qatar National Convention Centre where the Covid-19 Mass Vaccination Program administered 650,000 doses over 4 months with Zero Wastage of Vaccines attributed to any temperature excursions. Conclusion: PHCC can rapidly deliver healthcare cold chain management solutions under any circumstances. To leverage economies of scale and utilize emerging technology, PHCC has envisioned a plan to migrate the cold chain medical equipment 24/7 temperature monitoring based on cloud services in 2022.

Background: Paramedics need a range of medications that are stored in bags for easy transportation to the patient's side and are exposed to temperature variations, especially in a hot country like Qatar¹. The thermal stability of some medications was examined in previous studies^2,3. Methods: A safe and practical solution had to be found and should be approved by the Production committee to investigate the thermal stability of a range of 13 medications over different periods of time (Table 1). Results: Six medication bags have been specially prepared with the drug samples presented in Table 1. While one data logger was fixed to the metal net divider at the back of the rapid response vehicle, each bag contained a radio-frequency identification (RFID) tag for tracing, two data loggers to measure the temperature and humidity every 10 minutes over a 3 to 12-month period, and an initial total of 15 drug samples (Table 1). The bags have been labeled “For research purpose” and placed at the back of rapid response vehicles (Figure 1). At collection times, 3 samples of each medication will be removed for analysis and replaced by new samples. Similarly, data loggers will be collected and replaced with new ones. As per Qatar Ambulance Service's standard operating procedures, paramedics are required to always keep their medication bag with them when they leave their vehicle for a break or to treat a patient, but for practical and safety reasons it will not be the case with the research samples. Although this means that the research bags will have less exposure to the outdoor environment, they will still be subjected to temperature variation in case the vehicle is parked without air conditioning¹. The collected samples will be kept at 4°C until analyzed by high-performance liquid chromatography. Conclusion: Based on the findings of this study, the results may have a significant impact on how some of the drugs are handled in the pre-hospital setting, especially, possible modification of the recommended expiration date specified by manufacturers to ensure patient safety.

Background: 0.9% sodium chloride (NaCl) fluid bags are commonly stored in ambulances. Despite that the ambulances normally use air-conditioning during operational shifts, NaCl bags are exposed to deviations from the controlled environmental conditions that could affect their integrity^1,2, as all ambulances are not constantly in use. Although stress tests performed in a laboratory Binder Convection Oven³ showed that NaCl maintained its stability, these findings need to be validated. This study aims to develop a protocol to evaluate the thermal stability of NaCl under real-life conditions in Qatar. Methods: Key aspects were considered to subject the research samples to the routine environmental conditions under which NaCl bags are stored in ambulances. The study bags are used for research purposes only, thus should not be used on patients (to avoid hindering the work of paramedics) and need to be tested after various exposure durations. Results: The agreed-upon study protocol is to be replicated on 5 ambulances over 12 months and includes 4 collection cycles of three 500 mL NaCl study bags and three 10 ml NaCl vials following different exposure durations (Table 1). Hence, 12 NaCl bags and 12 vials marked “for research-use-only” will be stored in a locked cabinet in the ambulance patient compartment alongside a temperature and humidity data logger taking measurements every 30 minutes (Figure 1). Control samples will be stored under manufacturer's recommended conditions. Following each collection cycle from the 5 ambulances and controls, samples will be stored at 4°C and protected from light until being visually inspected (for discoloration, turbidity, bulging), diluted, and tested using ion-exchange chromatography to measure sodium and chloride levels. Conclusion: This study performed under real-life conditions will help determine the effect of exposure to actual ambulance operational conditions on NaCl bags and may have a significant impact on how they are handled in the prehospital setting in countries with a hot/arid climate.

Background: In the pre-hospital context, paramedics carry medications in multi-compartment medication bags. However, these medications are occasionally subjected to temperature and humidity variations as they are being carried around by paramedics during their operational duties.^1,2 To develop a protocol to investigate medications’ stability inside these bags, a pilot study was needed to build a basic understanding of the temperature and humidity variations within both vehicles and bags and to guide the development of such a protocol. Methods: Data loggers, pre-programmed to record temperature and humidity every 5 minutes, were inserted inside two operational rapid-response vehicles and their respective medication bags for two full days (16-17/09/2020) when the outside temperature ranged from 30 to 40°C and the humidity ranged from 39% to 74%.³ Following this, 4 data loggers were installed for one month inside 4 different medication bags (28/09/2020-28/10/2020) in similar operational vehicles when the outside temperature ranged from 23 to 42°C and the humidity ranged from 18% to 80%.³ Logging data were extracted using special software (ElitechLog V6.0.3). Results: For the two-day study, temperature and humidity recordings were obtained (Figure 1). The mean (SD) temperature differences between both medication bags and their respective vehicles were -1.04°C (3.01) and 0.09°C (2.64).

Variations above and below the mean temperature difference were found to be random, and within the 3 sigma control limits, which demonstrates the stability and predictability of these temperature differences. Data from the one-month study showed similar recorded ranges (Figure 2). Conclusion: The findings illustrate that temperature readings inside air-conditioned vehicles and their respective medication bag were very similar in the context of Qatar. Therefore, it is possible and feasible to depend on recordings from either of them alone. These results will guide the development of a protocol for a future research project investigating drugs’ stability inside medication bags.

Background: Normal saline 0.9 % (NS) is the most widespread crystalloid used as a life-saving intravenous (IV) fluid.¹ NS contains sodium and chloride in equal concentrations and is subject to thermal stress conditions while stored and transported by clinicians in the pre-hospital environment.² This study aimed to investigate the effect of high-temperature exposure on NS bags used by the Hamad Medical Corporation Ambulance Service in Qatar. Methods: Five-hundred mL polyolefin NS soft bags (Qatar-Pharma, BN:1929013008) were divided into 4 groups of 24 each and stored at constant temperature (22, 50, or 70°C), or subjected to a temperature of 70°C for 8 hours followed by 22°C for 16 hours repeatedly over 28 days. Inspection and chromatographic analysis of the bags was performed at 0, 12, 24, 48, and 72 hours in the 72-hour study, and at 1, 2, 3, and 4 weeks in the 28-day study. Results: NS bags slightly bulged at 50°C and significantly bulged at 70°C or in the long experiment with temperature variation (Figure 1). During the exposure period, there was no discoloration, turbidity, or leaching of plastic components observed in the NS fluid. The pH readings were 5.59 ± 0.08 (22°C-Control sample), 5.73 ± 0.04 (50°C), 5.86 ± 0.02 (70°C), and 5.79 ± 0.03 following prolonged temperature variation. The sodium and chloride levels for the short-term study ranged from 100.2 ± 0.26% to 107.9 ± 0.75% and from 99.04 ± 0.76 to 102.11 ± 1.71%, and for the long-term study they ranged from 101.93 ± 0.90% to 111.27 ± 2.61 and from 99.05 ± 0.94% to 110.95 ± 1.63%; respectively (Figure 2) in comparison to manufacturer stated concentrations. Conclusion: There was no evidence to suggest that the NS fluid inside the PO bags is physically and chemically different when exposed up to 28 days to 50°C, 70°C, and prolonged temperature variations compared to 22°C. These simulated conditions are subject to further testing under real-life pre-hospital care emergency conditions in a hot country.

Background: Acute coronary syndrome (ACS) is one of the most common life-threatening diseases worldwide.¹ Early diagnosis, advanced cardiac life support, and rapid transportation to a cardiac center are essential to reduce mortality and morbidity. ST-segment elevation myocardial infarctions (STEMI) are life-threatening and are diagnosed with a 12-lead electrocardiogram (ECG). However, non-STEMI (NSTEMI) is not prioritized as a STEMI in the prehospital setting. Studies have confirmed that patients who are diagnosed with an ACS in the prehospital setting are more likely to survive.^2,3Method: A scoping review was conducted based on the above topic. Limited data is available on prehospital cardiac troponin tests for NSTEMI. Discussion: Paramedics from the national Ambulance Service in Qatar diagnose patients with ACS based on the findings of a 12-lead ECG, clinical presentation, abnormalities in vital signs, physical examination, and congruent history which is compatible with the American Heart Association and European Resuscitation Council recommendations. In a case of NSTEMI chest pain, the paramedic cannot rule out Acute Myocardial Infarction (AMI), yet the patient will be taken to the normal emergency department until further investigations are done.¹ ACS remains a challenge to diagnose in the prehospital setting as the diverse population in Qatar makes communication often difficult which would negatively impact the patient's assessment. Although the accuracy of prehospital Troponin tests done around 2010 was relatively encouraging², their sensitivity has now significantly improved and warrants further studies to highlight their benefit to patient care.³ The routing of patients with ACS (STEMI and NSTEMI) to the appropriate cardiac center is essential to assure they receive a rapid diagnosis and appropriate care. Conclusion: The enhanced diagnostic accuracy of ACS in the prehospital setting by using a rapid Troponin test is expected to accelerate the care of NSTEMI patients and should be explored in Qatar. This scoping review indicates that limited data is available on cardiac troponin tests for NSTEMI.

Background: Dapagliflozin has been shown to reduce the risk of heart failure hospitalization and cardiovascular mortality in patients with heart failure with reduced ejection fraction (HFrEF).^1,2 This work aims to determine the cost-effectiveness of dapagliflozin added to standard therapy versus standard therapy alone in patients with HFrEF, regardless of the presence or absence of type 2 diabetes mellitus (T2DM). Methods: A lifetime Markov model was constructed to compare the health outcomes and costs of dapagliflozin added to standard therapy versus standard therapy alone from a Qatari public healthcare perspective (Figure 1).² The cohort is comprised of HFrEF patients with left ventricular ejection fraction (LVEF) ≤ 40%, and New York Heart Association (NYHA) class II–IV with an average age of 65 years, based on Dapagliflozin and Prevention of Adverse-Outcomes in Heart Failure (DAPA-HF) trial (Table 1).^1,2 The model consisted of three health states: ‘stable’, ‘hospitalization for heart failure’, and ‘dead’. Clinical inputs were derived from the results of DAPA-HF trial and costs, and utilities were estimated from published sources as well as publicly available sources in Qatar.³ The main outcome was the incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year gained (QALY). All outcomes and costs were discounted at a rate of 3% annually. Sensitivity analyses were conducted to confirm the robustness of the results. The study was based on published data; therefore ethics approval was not required. Results: Dapagliflozin added to standard care prevented 112 heart failure hospitalization and resulted in an additional cost of QAR 33,890 (USD 9,309). This equated to an ICER of QAR 101,763 (USD 27,951) per QALY gained, below the US willingness-to-pay threshold of USD 150,000 per QALY gained. Sensitivity analyses showed the findings to be robust. Conclusion: Dapagliflozin in addition to standard care appears to be a cost-effective strategy for patients with HFrEF, regardless of the presence or absence of T2DM.

Background: Obesity is a chronic illness that affects a lot of health aspects¹. The general preparation for the bariatric surgery and the lengthy weight-loss time, particularly in individuals with many comorbidities, are challenging and a complex process². Successful control of such a process requires the integration of several domains of the healthcare system that includes surgical care, nutritional management³, social support, and medical management of such diseases. Thus, the present study was to identify the effect of the bariatric surgery on the absorption of various micronutrients. Method: This is an animal study on 20 albino rabbits sorted into control and experimental group (n = 10 each). All the rabbits followed the same diet, had the same living condition, and experienced physical activity opportunities. Then the blood samples were collected from all the rabbits after one month (each group) via the jugular vein. Also, several laboratory tests were performed (such as the levels of folate, iron, vitamins E, A, D, K, B-1, B-12, calcium, magnesium, and zinc). Results: The results showed that the percentage of the rabbits that had a deficiency in micronutrients after the bariatric surgery increased compared with the control group (Table 1). In addition, the mean laboratory results of micronutrients decreased in the rabbits after the bariatric surgery compared with the control group (Table 2). This was observed in folate (-0.023), vitamin D (-0.015), and zinc (-2.35) levels. Conclusion: Finally, the deficiency of the absorption of micronutrients resulted in a change in the anatomy of the gastrointestinal tract through the bariatric surgery, a surgery that altered the pH, changed the solubility, and caused the loss of some of the absorption transporters.

Background: The upper permanent canine tooth germ develops close to maxillary sinus (MS)¹ therefore, upper canine displacement and MS pneumatization may have a link.² This study aims to evaluate the MS dimensions, volume, and range of anterior and vertical MS pneumatization in bilaterally palatally (PDCs) and buccally displaced maxillary canine (BDCs) compared to normally erupted canine (NDCs) subjects. Methods: Cone-Beam-Computed-Tomography (CBCT) images of 167 patients (131 females/33 males, age averaged 18.88 ± 1.66 years) were included in the study. Maxillary canines were bilaterally displaced palatally in 60 patients, buccally in 57 patients, and normally erupted in 50 subjects. The following variables were measured: anterior, lateral, and vertical distance from canine cusp tip to MS wall, MS volume and dimensions, and MS anterior and inferior pneumatization. The paired sample t-test was applied to detect differences between the right and left sides. Differences between the three groups were assessed using Chi-square and ANOVA one-way analysis tests. Results: More anterior MS pneumatization was detected in maxillary displaced canines compared to NDCs’ subjects. MS was extended to the incisor region in 20%, 10%, and 4%, and to canine region in 10%,12%, and 24.5% in PDCs, BDCs, and NDCs subjects, respectively (X2 = 19.22, p = 0.014). Significant differences between the right and left sides were detected, subsequently, right and left sides values were averaged (Table 1). PDCs subjects had a smaller lateral distance from the canine tip to MS wall compared to BDCs subjects (p < 0.05) and a reduced average vertical position of the canine tip to MS compared to NDCs subjects (P < 0.001). BDCs subjects had a larger vertical distance from canine tip to MS (p < 0.001), an increased MS volume (p < 0.01), and a reduced MS width (p < 0.05). Conclusion: MS showed anterior pneumatization in subjects with maxillary displaced canines. In BDCs’ subjects, MS showed lateral pneumatization. MS width and volume were larger in BDCs subjects compared to PDCs and NDCs subjects.

Background: Following the World Health Organization (WHO) recommendations to seek efficiency in the learning process¹, the Primary Care Department of Paris-Est University (UPEC) has adopted a competency-based learning model. At the UPEC, clinical writing notes (CWN) are required from challenging clinical training situations faced by residents. This study aims to describe the relationship difficulties with the patients encountered by UPEC's Family Medicine residents, based on their CWN. Methods: This is a retrospective qualitative/quantitative study. The CWN of UPEC's Family Medicine residents of the same cohort (52 residents) were collected over their 3-year residency program in 6 different locations. At least two relationships difficulties notes for every 6 months of training were required by the residents. 734 notes of patient–resident relationship difficulties were analyzed. For each note, the main patient–resident relationship difficulty was identified and coded according to the French repository of 11 major families of clinical situations², then organized according to the encountered difficulties and training location. Results: The most frequent relational difficulty was related to the management of patients with unjustified requests. Request for prescription of sick leaves, antibiotics³, and investigations were frequently a source of relational difficulties (Table 1). The situations causing relational difficulties were facility-dependent. In the emergency department: inpatient patients and patients with non-urgent medical conditions. In inpatient department: workload and lack of supervision. In Ambulatory clinic: unjustified patients’ requests for prescription and patients questioning the legitimacy of the resident as a physician. Faced with their difficulties, the residents described 3 types of patients: introverts, extroverts, and uncivil. The residents adopted a two-step strategy: the involvement phase, and then in case of failure, the detachment phase (Table 2). Conclusion: The relational difficulties encountered by Family Medicine residents at UPEC with their patients are facility dependent and frequently related to patients’ unjustified requests.

Background: Clinical reasoning is described as a reflective process that enables health care practitioners to collect data, solve problems, and make decisions and judgments to enhance patient outcomes and patient safety ¹. To avoid practice mistakes, healthcare professionals should possess or develop effective clinical reasoning skills. To develop effective clinical reasoning skills, enough exposure to various experiences is required. Practicing and developing clinical reasoning skills can be achieved in both clinical and simulated settings ². Using structured clinical reasoning models could enhance effective clinical reasoning development ³. This review aims to explore the current clinical reasoning models. Methods: A scoping review was undertaken to answer the question; what are the best available clinical reasoning models to enhance clinical reasoning in clinical and simulated settings? The following sources were searched: Medline; Scopus; Education Research Complete, and Google Scholar to identify relevant recent primary research conducted on this topic published in 2000 onwards. The search included [MeSH] topics of; “Clinical reasoning” and “Clinical Reasoning Models”. The inclusion criteria were primary studies that described the use of clinical reasoning models in clinical and simulated settings. Two independent researchers agreed on the inclusion of the identified papers for full-text review. This review followed the review guidelines of the Joanne Briggs institute. Results: There are valid clinical reasoning models to be used for clinical and simulated settings which are; TANNER, DML, clinical Reasoning Model (CRM), Outcome-Present State Test (OPT), and Self-Regulated Learning (SRL) model (Table 1). However, the validity of these models needs to be tested considering different health care specialties, the scope of practice, complexity, and seniority levels. Conclusion: Considering the importance of clinical reasoning skills in health care practices, using structured models could enhance the clinical reasoning process, however, despite the availability of clinical reasoning models, additional validation for these models is still required.

Background: A high level of emergency medical care is now expected from paramedics dealing with the sick and injured, including pediatric patients.^1,2 Very little is known of the paramedics’ perception of competency and of pediatric prehospital education and training, which is so critical to improve a paramedics’ knowledge and performance of important skills.^2,3 The purpose of this study was to determine if pediatric training resulted in a change in knowledge among paramedics from Hamad Medical Corporation Ambulance Service (HMCAS). Methods: A mixed-methods research approach was adopted to explore diverse perspectives. A comparison of all pre and post-test results for a pediatric Continuing Professional Development (CPD) course was conducted during the study period to determine whether knowledge was gained by paramedics. A survey was also used to conduct a retrospective analysis of the paramedics’ perception of pediatric training and to review their perceived level of competency. Results: The pediatric CPD course (Table 1) was conducted 33 times between January and November 2019. The average score difference between the pre and post-test indicates a gain in knowledge post-training across the participants (n = 51). The survey results (n = 33) revealed that there was an overall positive perception of the CPD course by paramedics and the impact it had on their learning and learning styles. Active learning strategies and hands-on practice were the recommended modalities by participants. The key findings are presented in Figure 1. Conclusion: HMCAS paramedics provided positive feedback on their pediatric training opportunities. Evaluating the effectiveness of all training provides valuable insight towards the improvement of the activity. Educators should have a fair knowledge and understanding of adult learning principles and the application of effective teaching and learning strategies when developing any CPD activity. Lastly, continual advances in patient care need to be reflected in all training programs.

Background: Qatar's National Health Strategy focuses on delivering care outside institutional settings in homes and communities. To successfully accomplish this, it is crucial to shift patient populations from being passive recipients of healthcare advice to active individuals taking control of their health.¹ This work describes Qatar's initial steps to measure and enhance patient activation. Methods: A two-phased approach was adopted as follows:

• Phase 1: Assessment

The Patient Activation Measure (PAM)^©2, a 13-question behavioral survey licensed through Insignia Health, was used to assess patient activation and ability to self-manage. A cross-sectional survey approach was adopted, in which 3,255 patients receiving governmental healthcare services were surveyed for the first time in Qatar between May 2020 and April 2021. • Phase 2: Enhancement

Clinical Health Coaching^©3, an innovative approach grounded in motivational interviewing delivered by the Iowa Chronic Care Consortium, was used to transform the nature of the conversation between healthcare providers and patients. Two rounds of training were conducted with over 70 healthcare professionals successfully completing a two-month training program finishing in November 2021.

Results: Being the first of its kind to be conducted in Qatar, the study found:

• Phase 1: Assessment

The PAM^© survey revealed that 21% of the patients were categorized as “feeling overwhelmed” (Level 1). 23% were “becoming aware” but still struggling (Level 2), 44% were categorized as “taking action” (Level 3) and 22% were categorized as “maintaining behaviors” (Level 4). • Phase 2: Enhancement

Training participants, to date, reported gaining practical skills to engage with patients to affect behavior change. Other key competencies gained included patient-centric care planning and building self-care skills. Conclusion: Patient activation is a critical factor in the successful delivery of healthcare services, particularly for patients with chronic or multiple chronic conditions. Measuring and improving patient activation has significant benefits to patients, providers, and health systems.

Background: The Coronavirus Disease 2019 (COVID-19) pandemic has triggered a global emergency in all social realms, including but not restricted to the economy, health, and education. The health sector requires all healthcare professionals to be well-equipped with the latest advances in knowledge and research through Continuing Professional Development (CPD) and postgraduate training programs such as residencies and fellowships.¹ These educational endeavors have been severely affected and potentially compromised since they heavily rely on learning through face-to-face interactive activities.²Methods: This is a narrative review that discusses the utilization of distance learning in CPD and postgraduate training programs, and the potential for a more active utilization in the post- COVID-19 era as one of the effective tools to meet healthcare practitioners’ education, training, and professional development needs. Results: Through this review, we propose a shift towards a more active utilization of online tools for on-site and distance healthcare training and CPD activities, via online platforms that offer video and audio facilities. The advantages of this approach include the flexibility of using such methods, being more convenient, cost-effective, as well as promising continuity even in challenging situations like the current pandemic, aiming at equipping healthcare personnel with the necessary skills and knowledge to ensure safe and effective care for their patients. This is in consideration to several key features for effective distance learning platforms.³Figure 1 is a conceptual framework that summarizes this approach and addresses the problem, solutions, and challenges to overcome. Conclusion: The current traditional educational model of healthcare training, education, and CPD have been challenged in terms of its effectiveness and continuity, especially during complicated situations like the COVID-19 pandemic. Therefore, this model needs to evolve and utilize distance learning solutions in the era post-COVID-19, in order to guarantee its continuity to equip healthcare workers with the needful skills for safe and effective patient care.

Background: Failed intubation is the single most important cause of patient morbidity and mortality during anesthesia for surgery. The incidence of difficult intubation could be as high as 12% while failed intubation is around 0.5%.¹ Disaster and mass casualty management may increase this risk multi-fold due to the paucity of airway-trained medical personnel.² Automation of the entire procedure could potentially save lives particularly in situations where mass casualties could happen without the immediate availability of skilled airway specialists. Thanks to the combination of existing technology involving 3-D image capture, artificial intelligence (AI), machine learning (ML) for image analysis, and robotics, airway management could be revolutionized. Work is already underway in this domain, but many challenges still need to be overcome to make the technology more practical and user-friendly.³Methods: Experts in the above fields from Hamad Medical Corporation (Qatar), Qatar University (Qatar), and Teesside University (UK) were brought together to collaborate on this potentially game-changing technological solution. The team includes clinicians specialized in airway management, engineers with a very strong track record of accomplishments in artificial intelligence and computer algorithm-based software development. The team is regularly meeting online to discuss the integration of the various technologies to develop a prototype automated device. Recommendations: A concept model based on Clinical-Technology-Research integration was arrived at as illustrated in Figure 1. The team is presently seeking funding to start the development of a working prototype combining AI, ML, and robotics. The planned work packages are briefly presented in Table 1. Conclusion: This work has shown that an automated device to disrupt the practice in airway management is feasible and could save lives particularly in disaster management and in geographical areas with a lack of clinicians with expertise in airway management.

Background: Cardiovascular disease (CVD) is the leading cause of death worldwide.¹ Unfortunately, CVD risk assessment and management (RAM) services face many challenges and barriers in the community. Mobile technology offers the opportunity to empower patients and improve access to health prevention strategies to overcome these barriers.² The purpose of this study was to pilot test the Arabic and English versions of the EPIRxISK™ CVD risk calculator in the public sector. Methods: Pilot testing of an Arabic and English version of the online application EPIRxISK™ for CVDRAM (Figure 1) was done by potential users from a sample consisting of the general population and pharmacists attending community pharmacies. Participants’ feedback was gathered in a qualitative interview which was recorded and transcribed for quality assurance and review by the research team. Responses from all interviews were analyzed and recommendations were made to finalize the application before phase II of the study. In phase II, quantitative and qualitative methods will be utilized to assess the feasibility of implementing a community pharmacy-based CVD risk assessment program using the English and Arabic versions of the EPIRxISK™ online application. Results: In phase I, a total of 9 pharmacists from community pharmacies and 5 general participants from the general population were interviewed. As shown in Table 1, the analysis of the interviews resulted in themes related to five frameworks: engagement, functionality, aesthetics, information, and subjective quality. Overall, the themes demonstrated acceptance and satisfaction with the features of the application. Phase II is currently in progress. Conclusion: The overall results of this study are indicative that the use of the EPIRxISK™ application for CVDRAM may be of benefit in Qatar, considering it is the first available in the Arabic language. The tool is likely well equipped to support continuous and standardized CVDRAM in Qatar's primary care sector.³

Background: Internet of Medical Things (IOMT) has the potential to monitor health continuously and in real-time. One of the main issues that arise in IOMT is how securely the data can be transmitted to the clinical team. In this project, biometric Identity-based encryption was utilized using the Fuzzy-IBE (Identity-based encryption) scheme that uses face features of the clinicians to create the public key. Figure 1 shows the testbed setup designed to improve the privacy and security of the patients’ healthcare data. Methods: The testbed comprises an ESP32 platform sensing and encrypting data, the Nvidia Jetson Nano for data collection and decryption, and the Thingsboard online platform for vital information visualization. Fuzzy Identity-Based Encryption (FIBE)^1–3 uses legitimate users’ facial features. The encrypted vital information is transmitted to the Edge-device (Jetson Nano) through BLE/Wi-Fi. On the edge-device of the healthcare system, the face authentication mechanism verifies the user's (clinician) legitimacy to assess the data. Upon user authentication, their facial features will be used to generate a private decryption key that can decrypt the received encrypted data. The data is further sent to the core cloud (Thingsboard) for storage and visualization. To secure the data on the cloud, we deployed an Intrusion Detection System (IDS) model using deep learning to identify the inter-domain stream of malicious traffic. Results: The face authentication testing using Fuzzy Identity-based Cryptography relied on a public data set. The execution time was calculated for Encryption (time to encrypt the patient's vital data using a public key of health physician's facial features) and decryption (time to match at least d components of the ciphertext and perform message decryption). The experimental results are reported in Table 1. Conclusion: In today's age of advanced telecommunication technology, cyber security is a very important factor. The designed testbed setup in this work showcases how healthcare data can be secured against malicious attacks.

Background: Effective communication among physicians and nurses in in-patient settings is associated with better patient care¹, increased teamwork, and job satisfaction², however, no literature has addressed the concern of the gap in perception of communication between physicians and nurses.³ this study aims to explore the perceptions of physicians and nurses toward proper communication and collaboration before and after an intervention. The study period encompassed before and during the COVID-19 pandemic. Methods: A cross-sectional pilot survey was administered in September-November 2015 in pediatrics in-patient wards at Hamad Medical Corporation (Doha, Qatar) followed by a post-intervention program survey in November-December 2020. The interventions included establishing a multidisciplinary unit-based council involving physicians and nurses, and a communication skills course for physicians. The questionnaire included details of demographics, perceptions towards proper communication, and collaboration in daily clinical practice. Questions used a 3-point Likert scale. Result: 124 responses (66% physician/44% nurses) were obtained in 2015 and 83 responses (51% physician/49% nurses) in 2020. The physicians’ reported perceptions improved for nearly all survey questions, often in a statistically significant way, but it was not the case for their enjoyment of collaboration which was reduced by 10% points (p = 0.01) (Table 1). The enjoyment of collaborating with the other professions declined for the physicians (p = 0.01) whereas it improved for the nurses, but it was not statistically significant (p = 0.06). For the nurses, their perception improved across all items, but less often in a statistically significant manner. In general, nurses had higher levels of satisfaction regarding communication and team collaboration (Figure 1). Conclusions: Our study showed that physicians and nurses’ perceptions improved post-interventions. Nurses seemed to be more affected by the interventions. The biggest effect was in decision sharing as both had almost a similar improvement. Promoting communication and collaboration in a complex clinical environment is paramount. Interventions such as multidisciplinary rounds and adapting structured communication tools improve organizational culture.

Background: Methanol, ethylene glycol, diethylene glycol, propylene glycol, and isopropanol are common alcohols, whose consumption can lead to toxicity and significant morbidity and mortality^1,2. Clinicians must often rely on clinical features and laboratory values to determine the possible causative agent. Annually, almost 95,000 people die due to alcohol and it is the third leading cause of preventable deaths in the United States of America³. Case presentation: A 53-year-old male patient reported to the Emergency Department with vomiting, severe chest, and abdominal pain for one day. He looked unwell and was unstable. The blood gases showed metabolic acidosis with lactate of 10-mmol/L. Investigations on the line of Acute Mesenteric Ischemia, Pulmonary Embolism, and Aortic Dissection were negative. With time, the patient deteriorated with severe metabolic acidosis requiring rapid sequence intubation. Blood investigations showed multi-organ failure, high serum osmolarity, and high osmolar gap. Later, he was admitted to the intensive care unit and underwent hemodialysis. His laboratory test results improved, and he was extubated. Eventually, he revealed having taken homemade alcohol. Recommendations: High Anion Gap is a hallmark of toxic alcohol poisoning. A potential toxic alcohol ingestion surrogate marker is an elevated osmol gap. Abnormal presentation and a patient hiding key information can delay the diagnosis. The key to successful early diagnosis is good history taking, patient collaboration, complete examination, and interpretation of laboratory results. Isopropyl alcohol is associated with nausea, vomiting, and abdominal pain since it is a gastrointestinal irritant. Magnetic Resonance Imaging of the brain can play a role in diagnosing toxic alcohol ingestion especially methanol, due to its characteristics findings like hemorrhagic putamen necrosis (Figure 1), however, clinical suspicion should not delay a patient's treatment. Conclusion: Abnormal presentations are quite common, and one should always keep a wide differential diagnosis in mind. Uncommon causes of severe metabolic acidosis could be easily missed. The main success factor in the management of toxic alcohol ingestion is to recognize it, do the calculations, and provide treatment.