Emergency Medicine Around the World: Analysis of the 2019 American College of Emergency Physicians International Ambassador Country Reports.

OBJECTIVE: The specialty of emergency medicine and recognition of the need for emergency care continue to grow globally. The specialty and emergency care systems vary according to context. This study characterizes the specialty of emergency medicine around the world, trends according to region and income level, and challenges for the specialty. METHODS: We distributed a 56-question electronic survey to all members of the American College of Emergency Physicians International Ambassador Program between March 2019 and January 2020. The Ambassador Program leadership designed the survey covering specialty recognition, workforce, system components, and emergency medicine training. We analyzed results by country and in aggregate using SAS software (SAS Institute Inc). We tested the associations between World Bank income group and number of emergency medicine residency-trained physicians (RTPs) and emergency medicine specialty recognition using non-parametric Fisher's exact testing. We performed inductive coding of qualitative data for themes. RESULTS: Sixty-three out of 78 countries' teams (80%) responded to the survey. Response countries represented roughly 67% of the world's population and included countries in all World Bank income groups. Fifty-four countries (86%) recognized emergency medicine as a specialty. Ten (16%) had no emergency medicine residency programs, and 19 (30%) had only one. Eight (11%) reported having no emergency medicine RTPs and 30 (48%) had <100. Fifty-seven (90%) had an emergency medical services (EMS) system, and 52 (83%) had an emergency access number. Higher country income was associated with a higher number of emergency medicine RTPs per capita (P = 0.02). Only 6 countries (8%) had >5 emergency medicine RTPs per 100,000 population, all high income. All 5 low-income countries in the sample had <2 emergency medicine RTPs per 100,000 population. Challenges in emergency medicine development included lack of resources (38%), burnout and poor working conditions (31%), and low salaries (23%). CONCLUSIONS: Most surveyed countries recognized emergency medicine as a specialty. However, numbers of emergency medicine RTPs were small, particularly in lower income countries. Most surveyed countries reported an EMS system and emergency access number. Lack of resources, burnout, and poor pay were major threats to emergency medicine growth.

Emergency Department Characteristics and Capabilities in Quito, Ecuador.

Background: Emergency care is an essential part of a health system. Ecuador has recognized emergency medicine as a specialty and has two emergency medicine residency training programs. However, little has been published about emergency department characteristics and capabilities in Ecuador. Objective: We described the characteristics and capabilities of emergency departments (EDs) in Quito, Ecuador, in 2017, using the National Emergency Department Inventory (NEDI) survey. Methods: The 23-item survey included questions pertaining to ED characteristics, including: visit volume, physical and administrative structure, clinical capabilities, technological resources, and consult personnel availability. This study included all EDs in Quito operating 24 hours/day, 7 days/week, and serving all patients seeking care. One representative from each ED was asked to complete the survey based on calendar year 2017. Findings: Thirty EDs met the inclusion criteria, and 26 completed the survey (87% response). The median number of ED beds was 17 (range 2-61). Median annual visit volume was 22,580 (range 1,680 to 129,676). All but two EDs provided care for both children and adults. Cardiac monitors were available in 88% of EDs, CT scanners in 68%, and rooms for respiratory isolation in 31%. Most EDs could manage patients with general medicine (92%), general surgery (92%), and gynecology (88%) emergencies 24/7. Fewer were able to provide hand surgery (45%) and dental (28%) care 24/7. Typical length of stay was 1-6 hours in 65% and >6 hours in 31% of EDs. Half of EDs reported operating at full capacity and 27% reported operating over their capacity. When compared to private EDs, government EDs (public and social security) had a higher mean number of visits per year (50,090 government vs. 13,968 private, p < 0.001), higher mean number of ED beds (36 government vs. 9 private, p = 0.002), and higher length of stay (58% of patient stays > 6 hours in government EDs vs. 86% of patient stays 1-6 hours in private EDs, p = 0.009). Conclusions: EDs in Quito varied widely with respect to annual visit volume, ability to treat different pathologies 24/7, and resources. Most EDs are functioning at or over capacity, and a substantial number have long lengths of stay. Further research and investment in emergency care could help increase the capacity and efficiency of EDs in Ecuador.

Building a virtual community of practice for medical students: The Global Emergency Medicine Student Leadership Program.

Virtual communities of practice (VCoPs) facilitate distance learning and mentorship by engaging members around shared knowledge and experiences related to a central interest. The American College of Emergency Physicians and Emergency Medicine Residents' Association's Global Emergency Medicine Student Leadership Program (GEM-SLP) provides a valuable model for building a VCoP for GEM and other niche areas of interest. This VCoP facilitates opportunities for experts and mentees affiliated with these national organizations to convene regularly despite barriers attributed to physical distance. The GEM-SLP VCoP is built around multiple forms of mentorship, monthly mentee-driven didactics, academic projects, and continued engagement of program graduates in VCoP leadership. GEM-SLP fosters relationships through (1) themed mentoring calls (career paths, work/life balance, etc); (2) functional mentorship through didactics and academic projects; and (3) near-peer mentoring, provided by mentors near the mentees' stage of education and experience. Monthly mentee-driven didactics focus on introducing essential GEM principles while (1) critically analyzing literature based on a journal article; (2) building a core knowledge base from a foundational textbook; (3) applying knowledge and research to a project proposal; and (4) gaining exposure to training and career opportunities via mentor career presentations. Group academic projects provide a true GEM apprenticeship as mentees and mentors work collaboratively. GEM-SLP mentees found the VCoP beneficial in building fundamental GEM skills and knowledge and forming relationships with mentors and like-minded peers. GEM-SLP provides a framework for developing mentorship programs and VCoPs in emergency medicine, especially when niche interests or geographic distance necessitate a virtual format.

In vitro cytokine induction by TLR-activating vaccine adjuvants in human blood varies by age and adjuvant.

Most infections occur in early life, prompting development of novel adjuvanted vaccines to protect newborns and infants. Several Toll-like receptor (TLR) agonists (TLRAs) are components of licensed vaccine formulations or are in development as candidate adjuvants. However, the type and magnitude of immune responses to TLRAs may vary with the TLR activated as well as age and geographic location. Most notably, in newborns, as compared to adults, the immune response to TLRAs is polarized with lower Th1 cytokine production and robust Th2 and anti-inflammatory cytokine production. The ontogeny of TLR-mediated cytokine responses in international cohorts has been reported, but no study has compared cytokine responses to TLRAs between U.S. neonates and infants at the age of 6months. Both are critical age groups for the currently pediatric vaccine schedule. In this study, we report quantitative differences in the production of a panel of 14 cytokines and chemokines after in vitro stimulation of newborn cord blood and infant and adult peripheral blood with agonists of TLR4, including monophosphoryl lipid A (MPLA) and glucopyranosyl lipid Adjuvant aqueous formulation (GLA-AF), as well as agonists of TLR7/8 (R848) and TLR9 (CpG). Both TLR4 agonists, MPLA and GLA-AF, induced greater concentrations of Th1 cytokines CXCL10, TNF and Interleukin (IL)-12p70 in infant and adult blood compared to newborn blood. All the tested TLRAs induced greater infant IFN-α2 production compared to newborn and adult blood. In contrast, CpG induced greater IFN-γ, IL-1ß, IL-4, IL-12p40, IL-10 and CXCL8 in newborn than in infant and adult blood. Overall, to the extent that these in vitro studies mirror responses in vivo, our study demonstrates distinct age-specific effects of TLRAs that may inform their development as candidate adjuvants for early life vaccines.