BRAVE: A Point of Care Adaptive Leadership Approach to Providing Patient-Centric Care in the Emergency Department

The practice of emergency medicine has reached its cross roads. Emergency physicians (EPs) are managing many more time-dependent conditions, initiating complex treatments in the emergency department (ED), handling ethical and end of life care discussions upfront, and even performing procedures which used to be done only in critical care settings, in the resuscitation room. EPs manage a wide spectrum of patients, 24 h a day, which reflects the community and society they practice in. Besides the medical and “technical” issues to handle, they have to learn how to resolve confounding elements which their patients can present with. These may include social, financial, cultural, ethical, relationship, and even employment matters. EPs cannot overlook these, in order to provide holistic care. More and more emphasis is also now given to the social determinants of health. We, from the emergency medicine fraternity, are proposing a unique “BRAVE model,” as a mnemonic to assist in the provision of point of care, adaptive leadership at the bedside in the ED. This represents another useful tool for use in the current climate of the ED, where patients have higher expectations, need more patient-centric resolution and handling of their issues, looming against the background of a more complex society and world.

Opt-Out Consent at Different Levels of Attitude to Organ Donation: A Household Survey in Qatar

Purpose

Demand for an organ transplant is surpassing the number of organ donors and hence increasing waiting lists worldwide, compelling many countries to adopt an opt-out consent system for organ donation. Opt-out is used in several European countries and has increased organ registration rate. No study on this subject has been published from the gulf region to associate sociodemographic characteristics, knowledge, attitude, beliefs, and intention domains regarding an opt-out consent for organ donation.

Materials and Methods

A household survey was conducted between October and November 2016 using a validated questionnaire. Integer codes were assigned for qualitative data to interpret results at par with quantitative data for each domain to allow data for advanced statistical analysis.

Results

Of 1044 surveyed participants, 724 (69.34%) those aged 37.7±10.4 agreed to adopting an opt-out consent system of which 231 (29.4%) were Qatari citizens and 353 (48.8%) were males. Mean levels of indices such as attitude, behavioral beliefs, and intention domains to organ donation were found higher in opt out participants. After adjusting statistical significant variables, multivariate analysis showed that attitude index was associated to opt out system (OR: 16.7, 95% C.I.:10.6-26.3, p=0.001) whereas; knowledge index (OR: 0.25, 95% C.I.: 0.07-0.83, p=0.03), behavioral beliefs (OR: 0.55, 95% C.I.: 0.35-0.86, p=0.009) and intention indices (OR: 0.42, 95% C.I.: 0.20-0.87, p=0.02) were associated with opt-in system for organ donation in Qatar. Regression model was able to discriminate (AUC: 84%, 95% C.I.:81% to 87%) for opt-out consent. Future probabilities for opt-out consent were 0.80, 0.88, 0.92,0.95,0.96,0.97,0.99 and 0.993 for 0.20, 0.30, 0.40, 0.50, 0.60, 0.70, 0.80 and 0.90 attitude levels after using 200 re-samples to make traditional multivariate regression model to realistic model for the population.

Conclusion

The majority of the survey participants showed a good attitude but less knowledge, behavioral beliefs, and intention towards adopting an opt-out system for organ donation in Qatar.

Prevalence of socio-demographic and behavioral factors about organ donation in Qatar: A household survey

Background: A single organ and tissue donor can serve and save eight-fold lives, but availability of organ donors is scarce, posing a grim situation for end-stage organ failure worldwide. Knowledge, attitudes, behaviors, and beliefs toward organ donation can help policymakers develop strategies to address the challenges facing organ donation and transplantation in Qatar. Aim: To assess sociodemographic characteristics, knowledge, attitudes, beliefs and intentions regarding organ donation in the household population of Qatar. Methods: A prospective observational household survey was conducted between October and November 2016 in Qatar using a validated questionnaire. One thousand forty-four individuals aged 18 and older residing in eight municipalities in the country were enrolled in the survey. Results: Average age was 38 ± 11 years. There were 27.4% Qatari citizens and 72.6% nonQatari residents in the survey. 48.9% of the total (1044) were males. Knowledge [46% (95% C.I.: 45% − 47%)], attitude [70% (95% C.I.: 66%–74%)], behavioral beliefs [42% (95% C.I.: 39%–50%)], normative beliefs [29% (95% C.I.: 28%–30%)], control beliefs [–27% (95% C.I.: − 24% to − 30%)] and intentions towards organ donation [29% (95% C.I.: 27%–31%)] were observed in the study. Factor analyses were able to explain 70%, 72%, 70%, and 74% variations in knowledge, attitude, beliefs, and intentions domains respectively showing adequacy of construct of the domains for organ donation. Conclusion: Most of the survey participants showed good attitude but less intention towards organ donation.

Analysis of pediatric trauma data from a hospital based trauma registry in Qatar

BACKGROUND

Trauma is the leading killer in the young age children, but data about the injury burden on pediatric population are lacking. The aim of this study is to describe the epidemiology and outcome of the traumatic injuries among children in Qatar.

MATERIALS AND METHODS

This is a retrospective analysis of a trauma registry database, which reviewed all cases of serious traumatic injury (ISS ≥ 9) to children aged 0-18 years who were admitted to the national pediatric Level I trauma center at the Hamad General Hospital (HGH), over a period of one year. Data included demographics, day of injuries, location, time, type and mechanism of injuries, co-morbidity, safety equipment use, pre-hospital intubation, mode of pre-hospital transport, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), emergency department (ED) intervention, hospital length of stay and mortality outcome.

RESULTS

The incidence of severe pediatric trauma was 163 per 280,000 children who visited the ED of HGH in 2011. Out of them, 83% were male, mean age was 9.6 ± 5.9 years and mortality rate was 1.8%. On presentation to the ED, the mean ISS was 13.9 ± 6.6 and GCS was 13.4 ± 3.8. Over half of the patients needed ICU admission. For the ages 0-4 years, injuries most frequently occurred at home; for 5-9 years (59%) and 15-18 years (68%), the street; and for 10-14 years (50%), sports and recreational sites. The most common mechanisms of injury for the age groups were falls for 0-4 years, motor vehicle collision (MVC) or pedestrian injury for 5-9 years, all-terrain vehicle (ATV)/bicycle injuries for 10-14 years, and MVC injuries for 15-18 years. Head (34%) and long bone (18%) injuries were the most common, with 18% suffering from polytrauma. None of the patients were using safety equipment when injured.

CONCLUSION

Traumatic injuries to children have an age- and mechanism-specific pattern in Qatar. This has important implications for the formulation of focused injury prevention programs for the children of Qatar.

Cardiovascular benefits of black cumin (Nigella sativa)

Black Cumin (Nigella sativa), which belongs to the botanical family of Ranunculaceae, commonly grows in Eastern Europe, the Middle East, and Western Asia. Its ripe fruit contains tiny black seeds, known as "Al-Habba Al-Sauda" and "Al-Habba Al-Barakah" in Arabic and black seed or black cumin in English. Seeds of Nigella sativa are frequently used in folk medicine in the Middle East and some Asian countries for the promotion of good health and the treatment of many ailments. However, data for the cardiovascular benefits of black cumin are not well-established. We reviewed the literature from 1960 to March 2012 by using the following key words: "Nigella sativa," "black seeds," and "thymoquinone." Herein, we discussed the most relevant articles to find out the role of Nigella sativa in the cardiovascular diseases spectrum especially when there is a paucity of information and need of further studies in human to establish the utility of Nigella sativa in cardiovascular system protection.

Pedestrians: the daily underestimated victims on the road

Traffic-related pedestrian injuries (TRPI) are vulnerable to road users. In this study, we aimed to evaluate the demographic pattern of injury and outcome of TRPI. Patients with TRPI admitted between November 2007 and March 2010 to the only level 1 trauma centre in Qatar were included. A retrospective analysis was based on medical records and Emergency Medical Services run sheets. The spreadsheet included demographic data and pre-hospital transport, service admissions and injuries by system and mortality. Of 4077 patients who were admitted, 420 (10.3%) had TRPI. The mode of transportation included ambulances (91%), private vehicles (6%) and helicopters (3%). The direct dispositions were trauma intensive care units (38%), surgical wards (42%) and operating rooms (17%). Patients were classified according to Injury Severity Score (1-8 in 28%, 9-15 in 25%, 16-24 in 20% and 25-75 in 17% cases). Multisystem injuries were most characteristic. Of 804 injures, injury of extremities was predominant followed by head, thorax and abdomen. The overall mortality was 8%. Pedestrian injuries are a significant cause of serious trauma in Qatar. Motor vehicle/pedestrian interface contributes to this ongoing public health problem. Reducing pedestrian trauma requires recognition of the problem and implementing programmes to mitigate these largely preventable injuries.

Diabetic retinopathy: a new predictor in patients on regular hemodialysis

BACKGROUND

Data evaluating the presence and impact of diabetic retinopathy (DR) in patients on regular hemodialysis (HD) are scarce.

OBJECTIVE

To assess prevalence and outcomes of DR in HD patients.

METHODS

Data were collected from 252 consecutive HD-dependent patients who underwent eye examination for detection of DR in 2007. Patients were divided into two groups (DR vs. no-DR) and followed up for 3 years. Demographic and clinical profiles were analyzed and compared. Multivariate logistic regression was used to find out the predictors of DR, morbidity and mortality.

RESULTS

DR was diagnosed in 113 patients (45%). In comparison to no-DR, DR patients were older and more likely to have high prevalence of dyslipidemia, coronary artery disease and cerebrovascular accidents. Duration of DM was longer in DR patients (p = 0.02). There was significant correlation between DR and nephropathy (r = 0.38; p = 0.001) and PAD (r = 0.27; p = 0.001). Hemoglobin A1c, serum calcium and total cholesterol were higher while serum albumin and phosphorus were lower in DR in comparison to no-DR group. The rates of renal transplant, coronary artery disease and cerebrovascular accidents were comparable in the two groups. Peripheral arterial disease (PAD) was associated with 4-fold increase in the presence of DR (Adjusted OR 3.9; p = 0.009). DR was independent predictor for PAD (adjusted OR 2.2; p = 0.01). Age-sex adjusted DR was independent predictor of 3-year mortality (OR 2.04; p = 0.03).

LIMITATIONS

The main issue with a cross-sectional study such as this, is differentiating cause and effect from simple association. Also, the current study did not specify the severity of DR.

CONCLUSION

Prevalence of DR is high among HD patients and associated with high mortality. DR is an independent predictor for PAD and not for transplantation. Early detection of DR is highly recommended among HD population for risk-stratification and counseling. Further randomized controlled studies are needed to support our finding.

Polyvascular disease in patients presenting with acute coronary syndrome: its predictors and outcomes

We evaluated prevalence and clinical outcome of polyvascular disease (PolyVD) in patients presenting with acute coronary syndrome (ACS). Data for 7689 consecutive ACS patients were collected from the 2nd Gulf Registry of Acute Coronary Events between October 2008 and June 2009. Patients were divided into 2 groups (ACS with versus without PolyVD). All-cause mortality was assessed at 1 and 12 months. Patients with PolyVD were older and more likely to have cardiovascular risk factors. On presentation, those patients were more likely to have atypical angina, high resting heart rate, high Killip class, and GRACE risk scoring. They were less likely to receive evidence-based therapies. Diabetes mellitus, renal failure, and hypertension were independent predictors for presence of PolyVD. PolyVD was associated with worse in-hospital outcomes (except for major bleedings) and all-cause mortality even after adjusting for baseline covariates. Great efforts should be directed toward primary and secondary preventive measures.

In-hospital major clinical outcomes in patients with chronic renal insufficiency presenting with acute coronary syndrome: data from a Registry of 8176 patients

OBJECTIVE

To assess the impact of chronic renal insufficiency (CRI) on in-hospital major adverse cardiac events across the acute coronary syndrome (ACS) spectrum.

PATIENTS AND METHODS

From January 29, 2007, through July 29, 2007, 6 adjacent Middle Eastern countries participated in the Gulf Registry of Acute Coronary Events, a prospective, observational registry of 8176 patients. Patients were categorized according to estimated glomerular filtration rate into 4 groups: normal (>or=90 mL/min), mild (60-89 mL/min), moderate (30-59 mL/min), and severe CRI (<30 mL/min). Patients' characteristics and in-hospital major adverse cardiac events in the 4 groups were analyzed.

RESULTS

Of 6518 consecutive patients with ACS, 2828 (43%) had mild CRI, 1304 (20%) had moderate CRI, and 345 (5%) had severe CRI. In CRI groups, patients were older and had a higher prevalence of hypertension, diabetes mellitus, and dyslipidemia. On admission, these patients had a higher resting heart rate and frequently had atypical and delayed presentations. Compared with the normal estimated glomerular filtration group, CRI groups were less likely to receive antiplatelet drugs, beta-blockers, angiotensin-converting enzyme inhibitors, and statins and were less likely to undergo coronary angiography. In-hospital heart failure, cardiogenic shock, and major bleeding episodes were significantly higher in all CRI groups. In multivariate analysis, mild, moderate, and severe CRI were associated with a higher adjusted odds ratio (OR) of death (mild: OR, 2.1; 95% confidence interval [CI], 1.2-3.7; moderate: OR, 6.7; 95% CI, 3.9-11.5; and severe: OR, 12.0; 95% CI, 6.6-21.7).

CONCLUSION

Across the ACS spectrum, patients with CRI had a worse risk profile, had more atypical and delayed presentations, and were less likely to receive evidence-based therapy. Chronic renal insufficiency of varying stages is an independent predictor of in-hospital morbidity and mortality.