Prognostic accuracy of qSOFA score, SIRS criteria, and EWSs for in-hospital mortality among adult patients presenting with suspected infection to the emergency department (PASSEM) Multicenter prospective external validation cohort study protocol.

BACKGROUND: Early identification of a patient with infection who may develop sepsis is of utmost importance. Unfortunately, this remains elusive because no single clinical measure or test can reflect complex pathophysiological changes in patients with sepsis. However, multiple clinical and laboratory parameters indicate impending sepsis and organ dysfunction. Screening tools using these parameters can help identify the condition, such as SIRS, quick SOFA (qSOFA), National Early Warning Score (NEWS), or Modified Early Warning Score (MEWS). We aim to externally validate qSOFA, SIRS, and NEWS/NEWS2/MEWS for in-hospital mortality among adult patients with suspected infection who presenting to the emergency department. METHODS AND ANALYSIS: PASSEM study is an international prospective external validation cohort study. For 9 months, each participating center will recruit consecutive adult patients who visited the emergency departments with suspected infection and are planned for hospitalization. We will collect patients' demographics, vital signs measured in the triage, initial white blood cell count, and variables required to calculate Charlson Comorbidities Index; and follow patients for 90 days since their inclusion in the study. The primary outcome will be 30-days in-hospital mortality. The secondary outcome will be intensive care unit (ICU) admission, prolonged stay in the ICU (i.e., ≥72 hours), and 30- as well as 90-days all-cause mortality. The study started in December 2021 and planned to enroll 2851 patients to reach 200 in-hospital death. The sample size is adaptive and will be adjusted based on prespecified consecutive interim analyses. DISCUSSION: PASSEM study will be the first international multicenter prospective cohort study that designated to externally validate qSOFA score, SIRS criteria, and EWSs for in-hospital mortality among adult patients with suspected infection presenting to the ED in the Middle East region. STUDY REGISTRATION: The study is registered at ClinicalTrials.gov (NCT05172479).

Effects of COVID-19 on STEMI Patients: Single-Center Experience.

Aim: The purpose of this study is to assess the effect of the COVID-19 pandemic on the volume of ST-elevation myocardial infarction (STEMI) patients and also to assess changes in patient characteristics, door-in-to-door-out (DIDO) time, door-to-balloon time (D2B) time, and STEMI outcomes during the pandemic. Methods: Patient data were retrieved retrospectively from the electronic medical record system of King Hamad University Hospital and Mohammed Bin Khalifa Cardiac Centre in the Kingdom of Bahrain. Data were compared and analyzed for the two time periods: before the pandemic (January 2019-March 2020) and during the pandemic (April 2020June 2021). Results: There was a decline of 11.1% in patients who presented with STEMI during the pandemic. There were no major differences between the patient demographics and the baseline characteristics during the two study periods. Recommended DIDO time and D2B time could be achieved only for 7.1% and 35.7% of all STEMI cases during the pandemic. However, no significant differences were noted in the 30 days of mortality, reinfarction, cardiogenic shock, hospital length of stay, and return to the hospital within 30 days for the STEMI patients in the two time periods. Conclusions: There was a decline in patients who presented with STEMI during the pandemic. This was also associated with a lower number of STEMI cases achieving the recommended DIDO time and D2B time as compared to the prepandemic period. However, there was no significant difference in the patient outcomes in the two time periods.

Women's contribution to medicine in Bahrain: leadership and workforce.

BACKGROUND: Women make up a significant proportion of workforce in healthcare. However, they remain underrepresented in leadership positions relating to healthcare for a multitude of reasons: balancing personal and work duties, favoritism toward men, lack of support from colleagues and mentors, as well as other factors. This study aims to recognize the contribution made by women in the Bahraini healthcare sector by determining the gender distribution in Bahrain's medical schools, government hospitals, Ministry of Health, and National Health Regulatory Authority. METHODS: Data were collected from the Bahraini Ministry of Health, National Health Regulatory Authority, Salmaniya Medical Complex, King Hamad University Hospital, Bahrain Defence Force Royal Medical Services, the College of Medicine and Medical Sciences in the Arabian Gulf University, and the Royal College of Surgeons in Ireland-Bahrain. Only physicians who held a Bachelor of Medicine and Surgery and a valid license to practice from NHRA were eligible to participate. Descriptive statistics were used to derive the frequencies and percentages of physicians with the following leadership positions: (1) top administrative positions (e.g., Chief executive officer); (2) heads of departments; (3) heads of committees; and (4) academic positions (e.g., Professor). Data were also collected from the two medical schools in Bahrain to see the trend in female enrollment into medical schools since 2004. RESULTS: The results of the study indicated that leadership positions were mostly held by males in Bahrain (59.4% vs. 40.6%). However, Bahraini males and females equally dominated academic positions. Male physicians also dominated surgical specialties; however, female Bahraini physicians slightly surpassed male Bahraini physicians at the specialist and consultant levels (female to male: 11.9% vs. 10.4% and 33.2% vs. 30.4%, respectively). Furthermore, more females were reported to have general licenses. A trend analysis since 2004 showed that female medical students' representation was higher than males over the years. CONCLUSIONS: This study highlights the increasing trend of women's participation and contribution to medicine in Bahrain. The data indicated continued growth in the number of female medical students and physicians. As such, it is likely that females will have a bigger impact on healthcare in the future with potential to hold more leadership positions in Bahrain.

Bird's-Eye View of COVID-19 Knowledge, Attitude and Practice Among Emergency Physicians in the Kingdom of Bahrain: A Cross-Sectional Study.

BACKGROUND: Coronavirus 2019 (COVID-19) has exemplified the crucial role played by emergency physicians on the frontlines, by triaging, quarantining and treating myriad patients in time. Despite this, there exists a dearth of literature comprehensively assessing the knowledge and awareness of these health-care workers on the disease in the Kingdom of Bahrain. This study was designed to evaluate the knowledge, attitude, and practice (KAP) of emergency physicians in the Kingdom of Bahrain towards COVID-19. METHODS: This cross-sectional descriptive study included 142 emergency physicians from three major hospitals in Bahrain. A self-designed questionnaire divided into 4 parts, which consists of demographics, knowledge, attitude and practices towards COVID-19, was completed by the emergency physicians working in these hospitals. Analysis of variance (ANOVA), t-test, chi-square test, and multiple linear regression were employed to evaluate KAP scores. RESULTS: The mean COVID-19 knowledge and practice score was 26.29 for a maximum score of 32 suggesting an overall 82.15% correct rate on the knowledge and practice test. Multiple linear regression analysis highlighted age (p=0.038), genders (p=0.033), marital status (p=0.021), organization (p=0.032), having children (p=0.008), and continuing professional development (CPD) activity (p=0.0001) as significant predictors for knowledge and practice scores. The attitude towards the final success in controlling COVID-19 significantly differed across marital status (p=0.021), organization of participants (p=0.020) and position of participants (p=0.012), respectively. CONCLUSION: Adequate knowledge, positive attitude and sufficient safe practice towards COVID-19 were observed in majority of the participants. These findings can foster development of nuanced and salient health management strategies that augment KAP so that proper control and elimination of the disease can be achieved, while prioritizing patient health and satisfaction.

Epidemiology of pediatric trauma in the Kingdom of Bahrain: a national pediatric trauma registry pilot study.

BACKGROUND: A pediatric trauma registry for the Kingdom of Bahrain would be a novel public health tool for the Bahraini health system. The aim of this study was to explore the epidemiology of pediatric trauma at the national level by describing the distribution of pediatric injury in the Kingdom, and quantifying the burden of injury shouldered by the study population. METHODS: This multicenter observational cross-sectional study was conducted in Bahrain using data from the Pediatric Trauma Registry (PTR), which was a short-term paper-based prospective trauma registry that collected data over a three-month period in 2018. PTR was based in the pediatric emergency departments (ED) of the three national referral hospitals in the Kingdom. By simultaneously collecting data from all three trauma hospitals in the country, it was assumed that during the data collection period all major pediatric trauma patients in the country would be captured by the study, and that the data collected would provide national estimates of trauma. Inclusion criteria for the study was any individual under the age of 14, that arrived at the ED seeking care for intentional and unintentional injuries. RESULTS: A total of 1328 patients were included in the study. Sixty-nine percent of patients were treated and discharged from the ED, 30.5% were admitted to the hospital, admitted for surgery, or seen by a specialist, and 0.5% were declared deceased. The percentage of patients documented as unrestrained during Motor Vehicle Collisions (MVC) was 92.3%, and amongst those involved in MVC, 12% were ejected from the cabin of the vehicle. CONCLUSIONS: There are significant implications that this study holds for policy implementation and practice surrounding injury prevention in the Kingdom of Bahrain. Low seatbelt utilization and the high proportion of ejection amongst MVC victims warrant immediate public health policy implementation, including enforcement of seat belt laws, strengthening of the traffic court system, and awareness campaigns for MVC prevention. Additionally, pediatric drowning prevention programs centered on constant adult supervision, pool isolation fencing, personal flotation devices, and swimming education should be created to address the mortality attributable to drowning in this study.

Discharge against medical advice from the emergency department in a university hospital.

BACKGROUND: Patients discharged against medical advice (DAMA) act as a high-risk population for the Emergency Department (ED), regardless of their presentations, and can pose a serious burden for the hospital. This study examines the prevalence, demographic and clinical characteristics, reasons, and clinical outcomes of a small sample of DAMA patients in a teaching university hospital, including readmission, morbidity, and mortality. METHODS: A prospective, descriptive cross-sectional study was conducted in the ED of King Hamad University Hospital (KHUH) with 98,992 patient visits during a 1-year period from June 2018 to June 2019. Consenting DAMA patients were asked to complete a data collection form. RESULTS: Patients (n = 413) had a mean age of 44.1 years with a female majority (57.1%). The majority were categorized as triage level-3 (87.7%). The main reasons for DAMA included refusal of the procedure/operation (23.2%), long ED waiting time (22.2%), subjective improvement with treatment (17.7%), and children at home (14.8%), whereas the least selected reason was dissatisfaction with medical care (1.2%). Follow-up of DAMA patients revealed that 86 cases (20.8%) were readmitted to the ED within 72 h of which 41 (47.7%) cases were morbidity and 2 (2.3%) were mortality. Marital status was a predictor of DAMA patients who revisit the ED within 72 h. CONCLUSION: The results act as a pilot study to examine a small sample of DAMA patients' characteristics, diagnosis, and ED revisits. Hospitals should investigate further the DAMA population on a larger scale, reasons for refusing procedures, and utilize this knowledge to improve the healthcare process.

Propafenone and propranolol dual toxicity.

Propranolol is a highly lipid-soluble beta-receptor antagonist and propafenone is a potent class 1c anti-arrhythmic agent with strong Na-channel blockade effect. We describe a novel case of dual overdose of propafenone and propranolol resulting in hypotension, generalized seizures, and reduced level of consciousness that was successfully treated. A 52-year-old female ingested 500 mg of propranolol and 1.5 g of propafenone. The patient was brought to the emergency department (ED) and exhibited signs of systemic toxicity and reduced level of consciousness. The patient was treated as a case of combined ß-blocker and propafenone toxicity using high dose insulin, NaHCO3, glucagon, atropine, and dopamine. She started improving and becoming more alert, with subsequent ECGs revealing normal sinus rhythm. The patient was discharged 4 days later. We believe that early administration of NaHCO3 should be administered in patients exhibiting signs of Na-channel blockade.

Correction to: Evolution of emergency medical services in the Kingdom of Bahrain.

An amendment to this paper has been published and can be accessed via the original article.

Healthcare providers' perspectives on family presence during resuscitation in the emergency departments of the Kingdom of Bahrain.

BACKGROUND: Worldwide, policies exist on family presence during resuscitation (FPDR), however, this is still lacking in the Gulf Corporation Countries (GCC) in general and in the Kingdom of Bahrain in particular. The aim of this study is to assess the perspectives of healthcare providers (HP) on FPDR among those working in the emergency departments (EDs) in the Kingdom. METHODS: A self-administered anonymous electronic survey was collected from 146 HPs (emergency physicians and nurses) working in the three major EDs in the Kingdom of Bahrain. Besides demographic data, 18 items measuring HPs' perceptions of FPDR were generated using the 5-point Likert scale. RESULTS: Surveys (n = 146) from physicians and nurses were analysed (45.9% vs. 54.1%, respectively). There were significant differences between physicians and nurses in terms of personal beliefs, FPDR enhancing professional satisfaction and behaviour, and the importance of a support person and saying goodbye (p < 0.001). However, general responses demonstrated that the majority of HPs encouraged and supported FPDR, but with greater support from physicians than nurses. CONCLUSION: The study reflects that many HPs in EDs participated in and are familiar with FPDR, with the majority of ED physicians supporting it. Further studies should investigate the reasons for the lack of support from nurses. Results may contribute to the development of hospital ED policies that allow FPDR in the region.

Evolution of emergency medical services in the Kingdom of Bahrain.

Emergency medical services (EMS) is crucial to any healthcare system, especially in urban countries. The Kingdom of Bahrain has always strived to develop healthcare services throughout the Kingdom including EMS. Like any other country, the Kingdom has gone through several stages in the provision of EMS. This article will focus on the development of EMS in the Kingdom and its evolution from a scattered hospital-based system to a unified system, which ensures ease of access for the population and speed of delivery to the healthcare facilities. The major focus will be the most recent national project which is the National Ambulance.

Correction to: Emergency Medicine in the Kingdom of Bahrain.

Following the publication of the original article [1], it was brought to our attention that author Leena Alqasem was erroneously included as Leena Alqusem.

Emergency Medicine in the Kingdom of Bahrain.

It has been more than a decade since emergency medicine became recognized as a specialty in the Kingdom of Bahrain. In the last fifteen years emergency medicine has widely established itself and developed rapidly in the Kingdom. The three main emergency departments are: Salmanyia Medical Complex (SMC), Royal Medical Services of Bahrain Defence Force (RMS-BDF) and King Hamad University Hospital (KHUH) are now fully equipped and operated by a majority of board certified emergency physicians.Standardized protocols, and the Central National Ambulance will be established in the near future, and the ambulances will offer both basic and advanced life support by trained nurses and paramedics.Emergency Medicine residency training programs were established in the main three hospitals in Bahrain for the Arab Board Certification initially, while currently only two hospitals, BDF hospital and KHUH are recognized as training centers for the Saudi Board Residency Program.This article will focus on many aspects related to emergency medicine in the Kingdom of Bahrain including: history of health care systems in Bahrain, hospitals and primary care, disaster management, Emergency medical services (EMS), hospital-based emergency care, training in emergency medicine and universities. We aim to present Bahrain's past and existing emergency medicine experience, our perspective about the existing challenges faced by the specialty, and the future plans for the advancement of emergency medicine in the Kingdom.

Clomiphene Associated Inferior STEMI in a Young Female due to Right Coronary Artery Dissection.

Nonatherosclerotic spontaneous coronary artery dissection (NA-SCAD) is an uncommon cause of myocardial infarction. It most commonly affects females in the perimenopausal age. NA-SCAD has been associated with many predisposing factors including pregnancy and hormonal therapy for both contraception and ovulation induction. The presented case is a previously healthy 41-year-old woman diagnosed with inferior ST-elevation myocardial infarction due to right descending coronary artery dissection associated with recent use of clomiphene monotherapy for ovulation induction (a previously fertile woman), which was not previously reported. Learning Objectives. Emergency physicians (EPs) should be aware about NA-SCAD as a cause of acute coronary syndrome (ACS) especially in perimenopausal women even with no risk factors. NA-SCAD occurs more commonly in the postpartum period and in females following hormonal therapy. Here, clomiphene monotherapy was reported as a possible contributing factor to NA-SCAD. Guidelines for NA-SCAD management are not up to date, and EPs should avoid some interference before the final diagnosis of the cause of myocardial infarction.