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

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.