COVID-19 Hierarchical Classification Using a Deep Learning Multi-Modal.

Coronavirus disease 2019 (COVID-19), originating in China, has rapidly spread worldwide. Physicians must examine infected patients and make timely decisions to isolate them. However, completing these processes is difficult due to limited time and availability of expert radiologists, as well as limitations of the reverse-transcription polymerase chain reaction (RT-PCR) method. Deep learning, a sophisticated machine learning technique, leverages radiological imaging modalities for disease diagnosis and image classification tasks. Previous research on COVID-19 classification has encountered several limitations, including binary classification methods, single-feature modalities, small public datasets, and reliance on CT diagnostic processes. Additionally, studies have often utilized a flat structure, disregarding the hierarchical structure of pneumonia classification. This study aims to overcome these limitations by identifying pneumonia caused by COVID-19, distinguishing it from other types of pneumonia and healthy lungs using chest X-ray (CXR) images and related tabular medical data, and demonstrate the value of incorporating tabular medical data in achieving more accurate diagnoses. Resnet-based and VGG-based pre-trained convolutional neural network (CNN) models were employed to extract features, which were then combined using early fusion for the classification of eight distinct classes. We leveraged the hierarchal structure of pneumonia classification within our approach to achieve improved classification outcomes. Since an imbalanced dataset is common in this field, a variety of versions of generative adversarial networks (GANs) were used to generate synthetic data. The proposed approach tested in our private datasets of 4523 patients achieved a macro-avg F1-score of 95.9% and an F1-score of 87.5% for COVID-19 identification using a Resnet-based structure. In conclusion, in this study, we were able to create an accurate deep learning multi-modal to diagnose COVID-19 and differentiate it from other kinds of pneumonia and normal lungs, which will enhance the radiological diagnostic process.

Cumulative pulse methylprednisolone and its relation to disease activity, damage and mortality in systemic lupus erythematosus patients: A post hoc analysis of COMOSLE-EGYPT study.

OBJECTIVE: To investigate the relation between cumulative intravenous methylprednisolone dose and disease activity, damage, and mortality among a group of Egyptian SLE patients. PATIENTS AND METHODS: This is a post hoc analysis of a retrospective multicenter COMOSLE study. Cumulative pulse methylprednisolone dose was abstracted from COMOSLE database. Patients with cumulative pulse dose of ≤ 3.0 g (median dose) were compared to those with cumulative dose of > 3.0 g regarding demographic data, Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and The Systemic Lupus International Collaborating Clinics/ACR Damage Index (SLICC) score as well as treatment received. Additionally, at 1.5, 3, 6, and 9 g of cumulative methylprednisolone, patients were compared regarding SLICC score and risk of mortality. RESULTS: Patients who received > 3 g of methylprednisolone were statistically significantly younger at disease onset, had longer disease duration, higher SLEDAI score at last visit, and higher SLICC score (p = 003, p = 0.002, p = 0.004 and p = < 0.001, respectively). Additionally, with every gram increase in the cumulative methylprednisolone, there was a significant increase in SLICC score by 0.169 (B = 0.169, CI = 0.122-0.216, p-value = < 0.001) and an increased risk of mortality by 13.5% (hazard ratio (HR) = 1.135, CI = 1.091-1.180, p-value = 0.001). The best cutoff value of methylprednisolone dose at which damage may occur, ranged between 2.75 (with sensitivity of 81.4% and specificity of 33.9%) and 3.25 g (with sensitivity of 48.3% and specificity of 71.5%). CONCLUSION: With every gram increase in the cumulative methylprednisolone, there may be increase in damage and mortality, especially in doses exceeding the range of 2.75-3.25 g. Key Points • Treatment of systemic lupus erythematosus should be with the least possible dose of steroids to decrease the risk of damage and mortality. • With every gram increase in the cumulative intravenous methylprednisolone there may be increase in damage and mortality.

High- and low-dose cyclophosphamide in Egyptian lupus nephritis patients: a multicenter retrospective analysis.

BACKGROUND: Lupus nephritis (LN) is a common serious presentation of systemic lupus erythematosus. Cyclophosphamide (CYC) and mycophenolate mofetil (MMF) are listed as the first-line drugs in induction therapy for LN. OBJECTIVE: This study aimed to compare high- and low-dose CYC in a cohort of Egyptian LN patients. PATIENTS AND METHODS: The data of 547 patients with class III/IV active LN who received CYC as induction therapy were retrospectively analyzed. Whereas 399 patients received 6­monthly 0.5-1 g/m2 CYC doses, 148 patients received six biweekly 500 mg CYC doses. Demographic data, laboratory test results, and disease activity index were recorded and compared at presentation and at 6, 12, 18, 24, and 48 months of follow-up. RESULTS: After 48 months, the proportion of patients maintaining normal creatinine levels was higher in the group receiving induction therapy with high-dose CYC (67.9%, 60.4%, p = 0.029), and these patients also had higher proteinuria remission at 36 (26.6%, 14.8%, p = 0.014) and 48 months (24.3%, 12.8%, p = 0.006). Comparison of patient outcomes according to both induction and maintenance therapy showed the best results in patients who received high-dose CYC and continued MMF as maintenance therapy. CONCLUSION: High- and low-dose CYC are comparable in early phases of treatment. However, after a longer duration of follow-up, high-dose CYC was associated with higher remission rates in the current cohort.

Emerging Mesoporous Polyacrylamide/Gelatin-Iron Lanthanum Oxide Nanohybrids towards the Antibiotic Drugs Removal from the Wastewater.

The polyacrylamide/gelatin-iron lanthanum oxide (P-G-ILO nanohybrid) was fabricated by the free radical grafting co-polymerization technique in the presence of N,N-methylenebisacrylamide (MBA) as cross linker and ammonium persulfate (APS) as initiator. The P-G-ILO nanohybrid was characterized by the various spectroscopic and microscopic techniques that provided the information regarding the crystalline behavior, surface area, and pore size. The response surface methodology was utilized for the statistical observation of diclofenac (DF) adsorption from the wastewater. The adsorption capacity (qe, mg/g) of P-G-ILO nanohybrid was higher (254, 256, and 258 mg/g) than the ILO nanoparticle (239, 234, and 233 mg/g). The Freundlich isotherm model was the best fitted, as it gives the higher values of correlation coefficient (R2 = 0.982, 0.991 and 0.981) and lower value of standard error of estimate (SEE = 6.30, 4.42 and 6.52), which suggested the multilayered adsorption of DF over the designed P-G-ILO nanohybrid and followed the pseudo second order kinetic model (PSO kinetic model) adsorption. The thermodynamic study reveals that adsorption was spontaneous and endothermic in nature and randomness onto the P-G-ILO nanohybrids surface increases after the DF adsorption. The mechanism of adsorption of DF demonstrated that the adsorption was mainly due to the electrostatic interaction, hydrogen bonding, and dipole interaction. P-G-ILO nanohybrid was reusable for up to five adsorption/desorption cycles.

Nanograss-Assembled NiCo2S4 as an Efficient Platinum-Free Counter Electrode for Dye-Sensitized Solar Cell.

Dye-sensitized solar cells (DSSCs) are often viewed as the potential future of photovoltaic systems and have garnered significant attention in solar energy research. In this groundbreaking research, we introduced a novel solvothermal method to fabricate a unique "grass-like" pattern on fluorine-doped tin oxide glass (FTO), specifically designed for use as a counter electrode in dye-sensitized solar cell (DSSC) assemblies. Through rigorous structural and morphological evaluations, we ascertained the successful deposition of nickel cobalt sulfide (NCS) on the FTO surface, exhibiting the desired grass-like morphology. Electrocatalytic performance assessment of the developed NCS-1 showed results that intriguingly rivaled those of the acclaimed platinum catalyst, especially during the conversion of I3 to I- as observed through cyclic voltammetry. Remarkably, when integrated into a solar cell assembly, both NCS-1 and NCS-2 electrodes exhibited encouraging power conversion efficiencies of 6.60% and 6.29%, respectively. These results become particularly noteworthy when compared to the 7.19% efficiency of a conventional Pt-based electrode under similar testing conditions. Central to the performance of the NCS-1 and NCS-2 electrodes is their unique thin and sharp grass-like morphology. This structure, vividly showcased through scanning electron microscopy, provides a vast surface area and an abundance of catalytic sites, pivotal for the catalytic reactions involving the electrolytes in DSSCs. In summation, given their innovative synthesis approach, affordability, and remarkable electrocatalytic attributes, the newly developed NCS counter electrodes stand out as potent contenders in future dye-sensitized solar cell applications.

Outcomes of Invasive and Noninvasive Ventilation in a Haitian Emergency Department.

Background: Limited data exist on the outcomes of patients requiring invasive ventilation or noninvasive positive pressure ventilation (NIPPV) in low-income countries. To our knowledge, no study has investigated this topic in Haiti. Objectives: We describe the clinical epidemiology, treatment, and outcomes of patients requiring NIPPV or intubation in an emergency department (ED) in rural Haiti. Methods: This is an observational study utilizing a convenience sample of adult and pediatric patients requiring NIPPV or intubation in the ED at an academic hospital in central Haiti from January 2019-February 2021. Patients were prospectively identified at the time of clinical care. Data on demographics, clinical presentation, management, and ED disposition were extracted from patient charts using a standardized form and analyzed in SAS v9.4. The primary outcome was survival to discharge. Findings: Of 46 patients, 27 (58.7%) were female, mean age was 31 years, and 14 (30.4%) were pediatric (age <18 years). Common diagnoses were cardiogenic pulmonary edema, pneumonia/pulmonary sepsis, and severe asthma. Twenty-three (50.0%) patients were initially treated with NIPPV, with 4 requiring intubation; a total of 27 (58.7%) patients were intubated. Among those for whom intubation success was documented, first-pass success was 57.7% and overall success was 100% (one record missing data); intubation was associated with few immediate complications. Twenty-two (47.8%) patients died in the ED. Of the 24 patients who survived, 4 were discharged, 19 (intubation: 12; NIPPV: 9) were admitted to the intensive care unit or general ward, and 1 was transferred. Survival to discharge was 34.8% (intubation: 22.2%; NIPPV: 52.2%); 1 patient left against medical advice following admission. Conclusions: Patients with acute respiratory failure in this Haitian ED were successfully treated with both NIPPV and intubation. While overall survival to discharge remains relatively low, this study supports developing capacity for advanced respiratory interventions in low-resource settings.

Critical care capacity and care bundles on medical wards in Malawi: a cross-sectional study.

INTRODUCTION: As low-income countries (LICs) shoulder a disproportionate share of the world's burden of critical illnesses, they must continue to build critical care capacity outside conventional intensive care units (ICUs) to address mortality and morbidity, including on general medical wards. A lack of data on the ability to treat critical illness, especially in non-ICU settings in LICs, hinders efforts to improve outcomes. METHODS: This was a secondary analysis of the cross-sectional Malawi Emergency and Critical Care (MECC) survey, administered from January to February 2020, to a random sample of nine public sector district hospitals and all four central hospitals in Malawi. This analysis describes inputs, systems, and barriers to care in district hospitals compared to central hospital medical wards, including if any medical wards fit the World Federation of Intensive and Critical Care Medicine (WFSICCM) definition of a level 1 ICU. We grouped items into essential care bundles for service readiness compared using Fisher's exact test. RESULTS: From the 13 hospitals, we analysed data from 39 medical ward staff members through staffing, infrastructure, equipment, and systems domains. No medical wards met the WFSICCM definition of level 1 ICU. The most common barriers in district hospital medical wards compared to central hospital wards were stock-outs (29%, Cl: 21% to 44% vs 6%, Cl: 0% to 13%) and personnel shortages (40%, Cl: 24% to 67% vs 29%, Cl: 16% to 52%) but central hospital wards reported a higher proportion of training barriers (68%, Cl: 52% to 73% vs 45%, Cl: 29% to 60%). No differences were statistically significant. CONCLUSION: Despite current gaps in resources to consistently care for critically ill patients in medical wards, this study shows that with modest inputs, the provision of simple life-saving critical care is within reach. Required inputs for care provision can be informed from this study.

Hydrothermal extraction and physicochemical characterization of biogenic hydroxyapatite nanoparticles from buffalo waste bones for in vivo xenograft in experimental rats.

Hydroxyapatite (HA) can be used in odontology and orthopedic grafts to restore damaged bone due to its stable chemical characteristics, composition, and crystal structural affinity for human bone. A three-step hydrothermal method was used for the extraction of biogenic calcined HA from the buffalo waste bones at 700 °C (HA-700) and 1000 °C (HA-1000). Extracts were analyzed by thermogravimetric analysis, differential scanning calorimetry, X-ray fluorescence, X-ray diffraction, Fourier transform infrared spectroscopy, scanning electron microscopy, and in vivo examination of HA xenografts for femoral lesions in experimental rats. Crystallinity, purity, and morphology patterns showed that the HA main phase purity was 84.68% for HA-700 and 88.99% for HA-1000. Spherical HA nanoparticles were present for calcined HA-700 samples in the range 57-423 nm. Rats with critical bone lesions of 3 mm in diameter in the left femur treated with calcined HA-700 nanoparticles healed significantly (p < 0.001) faster than rats treated with HA-1000 or negative controls. These findings showed that spherical biogenic HA-700 NPs with a bud-like structure have the potential to stimulate both osteoconduction and bone remodeling, leading to greater bone formation potential in vivo. Thus, the calcined biogenic HA generated from buffalo waste bones may be a practical tool for biomedical applications.

Critical Care Units in Malawi: A Cross-Sectional Study.

Background: The global burden of critical illness falls disproportionately outside high-income countries. Despite younger patient populations with similar or lower disease severity, critical illness outcomes are poor outside high-income countries. A lack of data limits attempts to understand and address the drivers of critical care outcomes outside high-income countries. Objectives: We aim to characterize the organization, available resources, and service capacity of public sector critical care units in Malawi and identify barriers to improving care. Methods: We conducted a secondary analysis of the Malawi Emergency and Critical Care Survey, a cross-sectional study performed from January to February 2020 at all four central hospitals and a simple random sample of nine out of 24 public sector district hospitals in Malawi, a predominantly rural, low-income country of 19.6 million in southern Africa. Data from critical care units were used to characterize resources, processes, and barriers to care. Findings: There were four HDUs and four ICUs across the 13 hospitals in the Malawi Emergency and Critical Care Survey sample. The median critical care beds per 1,000,000 catchment was 1.4 (IQR: 0.9 to 6.7). Absent equipment was the most common barrier in HDUs (46% [95% CI: 32% to 60%]). Stockouts was the most common barriers in ICUs (48% [CI: 38% to 58%]). ICUs had a median 3.0 (range: 2 to 8) functional ventilators per unit and reported an ability to perform several quality mechanical ventilation interventions. Conclusions: Although significant gaps exist, Malawian critical care units report the ability to perform several complex clinical processes. Our results highlight regional inequalities in access to care and support the use of process-oriented questions to assess critical care capacity. Future efforts should focus on basic critical care capacity outside of urban areas and quantify the impact of context-specific variables on critical care mortality.

Evaluation of emergency care education and triage implementation: an observational study at a hospital in rural Liberia.

INTRODUCTION: In Liberia, emergency care is still in its early development. In 2019, two emergency care and triage education sessions were done at J. J. Dossen Hospital in Southeastern Liberia. The observational study objectives evaluated key process outcomes before and after the educational interventions. METHODS: Emergency department paper records from 1 February 2019 to 31 December 2019 were retrospectively reviewed. Simple descriptive statistics were used to describe patient demographics and χ2 analyses were used to test for significance. ORs were calculated for key predetermined process measures. RESULTS: There were 8222 patient visits recorded that were included in our analysis. Patients in the post-intervention 1 group had higher odds of having a documented full set of vital signs compared with the baseline group (16% vs 3.5%, OR: 5.4 (95% CI: 4.3 to 6.7)). After triage implementation, patients who were triaged were 16 times more likely to have a full set of vitals compared with those who were not triaged. Similarly, compared with the baseline group, patients in the post-intervention 1 group had higher odds of having a glucose documented if they presented with altered mental status or a neurologic complaint (37% vs 30%, OR: 1.7 (95% CI: 1.3 to 2.2)), documented antibiotic administration if they had a presumed bacterial infection (87% vs 35%, OR: 12.8 (95% CI: 8.8 to 17.1)), documented malaria test if presenting with fever (76% vs 61%, OR: 2.05 (95% CI: 1.37 to 3.08)) or documented repeat set of vitals if presenting with shock (25% vs 6.6%, OR: 8.85 (95% CI: 1.67 to 14.06)). There was no significant difference in the above process outcomes between the education interventions. CONCLUSION: This study showed improvement in most process measures between the baseline and post-intervention 1 groups, benefits that persisted post-intervention 2, thus supporting the importance of short-course education interventions to durably improve facility-based care.

Applying the WHO-ICRC BEC course to train emergency and inpatient healthcare workers in Sierra Leone early in the COVID-19 outbreak.

BACKGROUND: Treating critical illness in resource-limited settings during disease outbreaks is feasible and can save lives. Lack of trained healthcare workers is a major barrier to COVID-19 response. There is an urgent need to train healthcare workers to manage COVID-19. The World Health Organization and International Committee of the Red Cross's Basic Emergency Care course could provide a framework to cross-train personnel for COVID-19 care while strengthening essential health services. METHODS: We conducted a prospective cohort study evaluating the Basic Emergency Care course for healthcare workers from emergency and inpatient units at two hospitals in Sierra Leone, a low-income country in West Africa. Baseline, post-course, and six month assessments of knowledge and confidence were completed. Questions on COVID-19 were added at six months. We compared change from baseline in knowledge scores and proportions of participants "very comfortable" with course skills using paired Student's t-tests and McNemar's exact tests, respectively. RESULTS: We enrolled 32 participants of whom 31 completed pre- and post-course assessments. Six month knowledge and confidence assessments were completed by 15 and 20 participants, respectively. Mean knowledge score post-course was 85% (95% CI: 82% to 88%), which was increased from baseline (53%, 48% to 57%, p-value < 0.001). There was sustained improvement from baseline at six months (73%, 67% to 80%, p-value 0.001). The percentage of participants who were "very comfortable" performing skills increased from baseline for 27 of 34 skills post-training and 13 skills at six months. Half of respondents strongly agreed the course improved ability to manage COVID-19. CONCLUSIONS: This study demonstrates the feasibility of the Basic Emergency Care course to train emergency and inpatient healthcare workers with lasting impact. The timing of the study, at the beginning of the COVID-19 pandemic, provided an opportunity to illustrate the strategic overlap between building human resource capacity for long-term health systems strengthening and COVID-19. Future efforts should focus on integration with national training curricula and training of the trainers for broader dissemination and implementation at scale.

The Malawi emergency and critical care survey: A cross-sectional national facility assessment.

BACKGROUND: Data on emergency and critical care (ECC) capacity in low-income countries (LICs) are needed to improve outcomes and make progress towards realizing the goal of Universal Health Coverage. METHODS: We developed a novel research instrument to assess public sector ECC capacity and service readiness in LICs. From January 20th to February 18th, 2020 we administered the instrument at all four central hospitals and a simple random sample of nine of 24 district hospitals in Malawi, a landlocked and predominantly rural LIC of 19·1 million people in Southern Africa. The instrument contained questions on the availability of key resources across three domains and was administered to hospital administrators and clinicians from outpatient departments, emergency departments, and inpatient units. Results were used to generate an ECC Readiness Score, with a possible range of 0 to 1, for each facility. FINDINGS: A total of 114 staff members across 13 hospitals completed interviews for this study. Three (33%) district hospitals and all four central hospitals had ECC Readiness Scores above 0·5 (p-value 0·070). Absent equipment was identified as the most common barrier to ECC Readiness. Central hospitals had higher median ECC Readiness Scores with less variability 0·82 (interquartile range: 0·80-0·89) than district hospitals (0·33, 0·23 to 0·50, p-value 0·021). INTERPRETATION: This is the first study to employ a systematic approach to assessing ECC capacity and service readiness at both district and central hospitals in Malawi and provides a framework for measuring ECC capacity in other LICs. Prior ECC assessments potentially overestimated equipment availability and our methodology may provide a more accurate approach. There is an urgent need for investments in ECC services, particularly at district hospitals which are more accessible to Malawi's predominantly rural population. These findings highlight the need for long-term investments in health systems strengthening and underscore the importance of understanding capacity in LIC settings to inform these efforts. FUNDING: Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Department of Emergency Medicine, Brigham and Women's Hospital.

Mass Casualty Incident Management for Resource-Limited Settings: Lessons From Central Haiti.

OBJECTIVE: Mass casualty incidents (MCIs) have gained increasing attention in recent years due multiple high-profile events. MCI preparedness improves the outcomes of trauma victims, both in the hospital and prehospital settings. Yet most MCI protocols are designed for high-income countries, even though the burden of mass casualty incidents is greater in low-resource settings. RESULTS: Hôpital Universitaire de Mirebalais (HUM), a 300-bed academic teaching hospital in central Haiti, developed MCI protocols in an iterative process after a large MCI in 2014. Frequent MCIs from road traffic collisions allowed protocol refinement over time. HUM's protocols outline communication plans, triage, schematics for reorganization of the emergency department, clear delineation of human resources, patient identification systems, supply chain solutions, and security measures for MCIs. Given limited resources, protocol components are all low-cost or cost-neutral. Unique adaptations include the use of 1) social messaging for communication, 2) mass casualty carts for rapid deployment of supplies, and 3) stickers for patient identification, templated orders, and communication between providers. CONCLUSION: These low-cost solutions facilitate a systematic response to MCIs in a resource-limited environment and help providers focus on patient care. These interventions were well received by staff and are a potential model for other hospitals in similar settings.

White Paper on Early Critical Care Services in Low Resource Settings.

This White Paper has been formally accepted for support by the International Federation for Emergency Medicine (IFEM) and by the World Federation of Intensive and Critical Care (WFICC), put forth by a multi-specialty group of intensivists and emergency medicine providers from low- and low-middle-income countries (LMICs) and high-income countries (HiCs) with the aim of 1) defining the current state of caring for the critically ill in low-resource settings (LRS) within LMICs and 2) highlighting policy options and recommendations for improving the system-level delivery of early critical care services in LRS. LMICs have a high burden of critical illness and worse patient outcomes than HICs, hence, the focus of this White Paper is on the care of critically ill patients in the early stages of presentation in LMIC settings. In such settings, the provision of early critical care is challenged by a fragmented health system, costs, a health care workforce with limited training, and competing healthcare priorities. Early critical care services are defined as the early interventions that support vital organ function during the initial care provided to the critically ill patient-these interventions can be performed at any point of patient contact and can be delivered across diverse settings in the healthcare system and do not necessitate specialty personnel. Currently, a single "best" care delivery model likely does not exist in LMICs given the heterogeneity in local context; therefore, objective comparisons of quality, efficiency, and cost-effectiveness between varying models are difficult to establish. While limited, there is data to suggest that caring for the critically ill may be cost effective in LMICs, contrary to a widely held belief. Drawing from locally available resources and context, strengthening early critical care services in LRS will require a multi-faceted approach, including three core pillars: education, research, and policy. Education initiatives for physicians, nurses, and allied health staff that focus on protocolized emergency response training can bridge the workforce gap in the short-term; however, each country's current human resources must be evaluated to decide on the duration of training, who should be trained, and using what curriculum. Understanding the burden of critical Illness, best practices for resuscitation, and appropriate quality metrics for different early critical care services implementation models in LMICs are reliant upon strengthening the regional research capacity, therefore, standard documentation systems should be implemented to allow for registry use and quality improvement. Policy efforts at a local, national and international level to strengthen early critical care services should focus on funding the building blocks of early critical care services systems and promoting the right to access early critical care regardless of the patient's geographic or financial barriers. Additionally, national and local policies describing ethical dilemmas involving the withdrawal of life-sustaining care should be developed with broad stakeholder representation based on local cultural beliefs as well as the optimization of limited resources.

Q-DEPICT: Qatar Determining Emergency Physician Incidence of COVID-Positive Testing.

Despite protective measures such as personal protective equipment (PPE) and a COVID airway management program (CAMP), some emergency physicians will inevitably test positive for COVID. We aim to develop a model predicting weekly numbers of emergency physician COVID converters to aid operations planning. The data were obtained from the electronic medical record (EMR) used throughout the national healthcare system. Hamad Medical Corporation's internal emergency medicine workforce data were used as a source of information on emergency physician COVID conversion and numbers of emergency physicians completing CAMP training. The study period included the spring and summer months of 2020 and started on March 7 and ran for 21 whole weeks through July 31. Data were extracted from the system's EMR database into a spreadsheet (Excel, Microsoft, Redmond, USA). The statistical software used for all analyses and plots was Stata (version 16.1 MP, StataCorp, College Station, USA). All data definitions were made a priori. A total of 35 of 250 emergency physicians (14.0%, 95% CI 9.9%-19.9%) converted to a positive real-time reverse transcriptase-polymerase chain reaction (PCR) during the study's 21-week period. Of these. only two were hospitalized for having respiratory-only disease, and none required respiratory support. Both were discharged within a week of admission. The weekly number of newly COVID-positive emergency physicians was zero and was seen in eight of 21 (38.1%) weeks. The peak weekly counts of six emergency physicians with new COVID-positive were seen in week 14. The mean weekly number of newly COVID-positive emergency physicians was 1.7 ± 1.9, and the median was 1 (IQR, 0 to 3). This study demonstrates that in the State of Qatar's Emergency Department (ED) system, knowing only four parameters allows the reliable prediction of the number of emergency physicians likely to convert COVID PCR tests within the next week. The results also suggest that attention to the details of minimizing endotracheal intubation (ETI) risk can eliminate the expected finding of the association between ETI numbers and emergency physician COVID numbers.

Combating information chaos: a case for collaborative clinical guidelines in a pandemic.

The speed and scale of new information during the COVID-19 pandemic required a new approach toward developing best practices and evidence-based clinical guidance. To address this need, we produced COVIDProtocols.org, a collaborative, evidence-based, digital platform for the development and dissemination of COVID-19 clinical guidelines that has been used by over 500,000 people from 196 countries. We use a Collaborative Writing Application (CWA) to facilitate an expedited expert review process and a web platform that deploys content directly from the CWA to minimize any delays. Over 200 contributors have volunteered to create open creative-commons content that spans over 30 specialties and medical disciplines. Multiple local and national governments, hospitals, and clinics have used the site as a key resource for their own clinical guideline development. COVIDprotocols.org represents a model for efficiently launching open-access clinical guidelines during crisis situations to share expertise and combat misinformation.

Development of a Prehospital Care Rotation for Emergency Medicine Residents in Haiti.

BACKGROUND: Prehospital care is a key component of an emergency care system. Prehospital providers initiate patient care in the field and transition it to the emergency department. Emergency Medicine (EM) specialist training programs are growing rapidly in low- and middle-income countries (LMICs), and future emergency physicians will oversee emergency care systems. Despite this, no standardized prehospital care curriculum exists for physicians in these settings. This report describes the development of a prehospital rotation for an EM residency program in Central Haiti. METHODS: Using a conceptual framework, existing prehospital curricula from high-income countries (HICs) were reviewed and adapted to the Haitian context. Didactics covering prehospital care from LMICs were also reviewed and adapted. Regional stakeholders were identified and engaged in the curriculum development. RESULTS: A one-week long, 40-hour curriculum was developed which included didactic, clinical, evaluation, and assessment components. All senior residents completed the rotation in the first year. Feedback was positive from residents, field sites, and students. CONCLUSIONS: A standardized prehospital rotation for EM residents in Haiti was successfully implemented and well-received. This model of adaptation and local engagement can be applied to other residency programs in low-income countries to increase physician engagement in prehospital care.

Current practice patterns for initial umbilical hernia repair in the United States.

PURPOSE: The approach to repairing an initial umbilical hernia (IUH) varies substantially, and this likely depends on hernia size, patient age, sex, BMI, comorbidities including diabetes mellitus, and surgeon preference. Of these, only hernia size has been widely studied. This cross-sectional study aims to look at the practice pattern of umbilical hernia repair in the United States. METHODS: A retrospective study was performed using data from the America Hernia Society Quality Collaborative. Patient characteristics included age, sex, hernia width, BMI, smoking status, and diabetes. Outcomes were use of mesh for repair, as well as surgical approach (open vs minimally invasive). Multivariate logistic regression was performed to assess the independent effect of age, sex, hernia width, BMI, smoking status, and diabetes on use of mesh and approach to repair. RESULTS: 3475 patients were included. 74% were men. Mesh use was more common in men (67% vs 60%, P < 0.001). Mesh was used in 33% of repairs ≤ 1 cm, and 82% of repairs > 1 cm (P < 0.001). Younger patients were less likely to receive a mesh repair (54% if age ≤ 35 vs 67% for age > 35, P < 0.001). However, on multivariate analysis, mesh use was associated with increasing hernia width (OR 5.474, 95% CI 4.7-6.3) as well as BMI (OR 1.8, 95% CI 1.5-2.1) but not with age or sex. CONCLUSION: The majority of IUH are performed open. Patient BMI and hernia defect size contribute to choice of surgical technique including use of mesh. The use of mesh in 33% of hernias below 1 cm demonstrates a gap between evidence and practice. Patient factors including patient age and sex had no impact on operative approach or use of mesh.

In Silico Prediction of Protein Adsorption Energy on Titanium Dioxide and Gold Nanoparticles.

The free energy of adsorption of proteins onto nanoparticles offers an insight into the biological activity of these particles in the body, but calculating these energies is challenging at the atomistic resolution. In addition, structural information of the proteins may not be readily available. In this work, we demonstrate how information about adsorption affinity of proteins onto nanoparticles can be obtained from first principles with minimum experimental input. We use a multiscale model of protein-nanoparticle interaction to evaluate adsorption energies for a set of 59 human blood serum proteins on gold and titanium dioxide (anatase) nanoparticles of various sizes. For each protein, we compare the results for 3D structures derived from experiments to those predicted computationally from amino acid sequences using the I-TASSER methodology and software. Based on these calculations and 2D and 3D protein descriptors, we develop statistical models for predicting the binding energy of proteins, enabling the rapid characterization of the affinity of nanoparticles to a wide range of proteins.

Protocolized emergency department observation care improves quality of ischemic stroke care in Haiti.

INTRODUCTION: In many low-income countries, Emergency Medicine is underdeveloped and faces many operational challenges including emergency department (ED) overcrowding and prolonged patient length of stays (LOS). In high-resource settings, protocolized ED observation unit (EDOU) care reduces LOS while preserving care quality. EDOUs are untested in low-income countries. We evaluate the effect protocolized EDOU care for ischemic stroke on the quality and efficiency of care in Haiti. METHODS: We performed a prospective cohort study of protocolized observation care for ischemic stroke at a Haitian academic hospital between January 2014 and September 2015. We compared patients cared for in the EDOU using the ischemic stroke protocol (study group) to eligible patients cared for before protocol implementation (baseline group), as well as to eligible patients treated after protocol introduction but managed without the EDOU protocol (contemporary reference group). We analysed three quality of care measures: aspirin administration, physical therapy consultation, and swallow evaluation. We also analysed ED and hospital LOS as measures of efficiency. RESULTS: Patients receiving protocolized EDOU care achieved higher care quality compared to the baseline group, with higher rates of aspirin administration (91% v. 17%, p < 0.001), physical therapy consultation (50% v. 9.6%, p < 0.001), and swallow evaluation (36% v. 3.7%, p < 0.001). We observed similar improvements in the study group compared to the contemporary reference group. Most patients (92%) were managed entirely in the ED or EDOU. LOS for non-admitted patients was longer in the study group than the baseline group (28 v. 19 h, p = 0.023). CONCLUSION: Protocolized EDOU care for patients with ischemic stroke in Haiti improved performance on key quality measures but increased LOS, likely due to more interventions. Future studies should examine the aspects of EDOU care are most effective at promoting higher care quality, and if similar results are achievable in patients with other conditions.