"Underneath the visible" - COVID-19 Risk prediction tools in a high-volume, low-resource Emergency Department

Objectives

Patient risk stratification is the cornerstone of COVID-19 disease management; that has impacted health systems globally. We evaluated the performance of the Brescia-COVID Respiratory Severity Scale (BCRSS), CALL (Co-morbid, age, Lymphocyte and Lactate dehydrogenase) Score, and World Health Organization (WHO) guidelines in Emergency department (ED) on arrival, as predictors of outcomes; Intensive care unit (ICU) admission and in-hospital mortality.

Methods

A two-month retrospective chart review of 88 adult patients with confirmed COVID-19 pneumonia; requiring emergency management was conducted at ED, Indus Hospital and Health Network (IHHN), Karachi, Pakistan, (April 1 to May 31, 2020). The sensitivity, specificity, receiver operator characteristic curve (ROC) and area under the curve (AUC) for the scores were obtained to assess their predictive capability for outcomes.

Results

The in-hospital mortality rate was 48.9 % with 59.1 % ICU admissions and with a mean age at presentation of 56 ± 13 years. Receiver operator curve for BCRSS depicted good predicting capability for in hospital mortality [AUC 0.81(95% CI 0.71-0.91)] and ICU admission [AUC 0.73(95%CI 0.62-0.83)] amongst all models of risk assessment.

Conclusion

BCRSS depicted better prediction of in-hospital mortality and ICU admission. Prospective studies using this tool are needed to assess its utility in predicting high-risk patients and guide treatment escalation in LMIC's.

Patient perception regarding privacy and confidentiality: A study from the emergency department of a tertiary care hospital in Karachi, Pakistan

Background and Objective:

Maintaining privacy and ensuring confidentiality with patients is paramount to developing an effective patient-provider relationship. This is often challenging in over-crowded Emergency Departments (EDs). This survey was designed to explore patients’ perceptions on maintenance of privacy and confidentiality and their subsequent interactions with providers in a busy tertiary care hospital in Karachi.

Methods:

Trained nursing staff conducted structured interviews with 571 patients who presented to The Indus Hospital (TIH) ED from January to December 2020. All patients were 14 years of age or older, could speak and understand Urdu, and provide informed consent. Patients were asked about their perceptions of privacy and confidentiality in the ED and whether this affected their interactions with providers.

Results:

Respondents were primarily men (64%) under the age of 45 (62%) presenting for the first time (49%). The majority of patients felt that privacy and confidentiality were maintained, however 10% of patients reported that they had rejected examination due to privacy concerns and 15% of patients reported that they had changed or omitted information provided to a provider due to confidentiality concerns. There was correlation between privacy and confidentiality concerns and patient-provider interactions (p<0.0001).

Conclusions:

Despite the often over-crowded and busy environment of the ED, patients generally felt that privacy and confidentiality were maintained. Given the correlation between perception and behavior and the importance of an effective patient-provider relationship, particularly in the acute setting when morbidity and mortality is high, initiatives that focus on maintaining privacy and confidentiality should be pursued.

Global Emergency Medicine: A Review of the Literature From 2017

OBJECTIVES

The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer-reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a global audience of academics and clinical practitioners.

METHODS

This year, 17,722 articles written in three languages were identified by our electronic search. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. Another two reviewers searched the gray literature, yielding an additional 11 articles. All articles that were deemed appropriate by at least one reviewer and approved by their editor underwent formal scoring of overall quality and importance. Two independent reviewers scored all articles.

RESULTS

A total of 848 articles met our inclusion criteria and underwent full review. Sixty-three percent were categorized as emergency care in resource-limited settings, 23% as disaster and humanitarian response, and 14% as EM development. Twenty-one articles received scores of 18.5 or higher out of a maximum score 20 and were selected for formal summary and critique. Inter-rater reliability testing between reviewers revealed a Cohen's kappa of 0.344.

CONCLUSIONS

In 2017, the total number of articles identified by our search continued to increase. Studies and reviews with a focus on infectious diseases, pediatrics, and trauma represented the majority of top-scoring articles.

Global Emergency Medicine: A Review of the Literature From 2015

OBJECTIVES

The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer-reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a global audience of academics and clinical practitioners.

METHODS

This year 12,435 articles written in six languages were identified by our search. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. An additional two reviewers searched the gray literature. A total of 723 articles were deemed appropriate by at least one reviewer and approved by their editor for formal scoring of overall quality and importance. Two independent reviewers scored all articles.

RESULTS

A total of 723 articles met our predetermined inclusion criteria and underwent full review. Sixty percent were categorized as emergency care in resource-limited settings (ECRLS), 17% as EM development (EMD), and 23% as disaster and humanitarian response (DHR). Twenty-four articles received scores of 18.5 or higher out of a maximum score 20 and were selected for formal summary and critique. Inter-rater reliability between reviewers gave an intraclass correlation coefficient of 0.71 (95% confidence interval = 0.66 to 0.75). Studies and reviews with a focus on infectious diseases, trauma, and the diagnosis and treatment of diseases common in resource-limited settings represented the majority of articles selected for final review.

CONCLUSIONS

In 2015, there were almost twice as many articles found by our search compared to the 2014 review. The number of EMD articles increased, while the number ECRLS articles decreased. The number of DHR articles remained stable. As in prior years, the majority of articles focused on infectious diseases.

The intersecting roles of violence, gender, and substance use in the emergency department: a research agenda

The relationship between gender, violence, and substance use in the emergency department (ED) is complex. This article examines the role of gender in the intersection of substance use and three types of violence: peer violence, intimate partner violence, and firearm violence. Current approaches to treatment of substance abuse and violence are similar across both genders; however, as patterns of violence and substance abuse differ by gender, interventions may be more effective if they are designed with a specific gender focus.

Evaluation of medical supplies essential for the care of survivors of sex- and gender-based violence in post-conflict Eastern Democratic Republic of Congo

The fundamental concepts set forth in the formal Post-Conflict Needs Assessment (PCNA) initiative created by the United Nations Development Group have the potential to be adapted to assist local groups in documenting the needs of and the provision of health care to survivors of sex- and gender-based violence (SGBV) in Eastern Democratic Republic of Congo (DRC). In partnership with Congolese health care providers, we took the first step in advocating for a locally-adapted and focused needs assessment through the development and administration of surveys to providers in the South Kivu Province, DRC. The content of the surveys was largely based on lists of medical supplies deemed essential for reproductive health and for the care of survivors by the Reproductive Health Response in Crises Consortium. The providers in both urban and rural settings considered many of the supplies identified on the surveys necessary for the care of survivors (84%; p < 0.05) but considered few accessible (26%; p < 0.05) in their particular clinical settings. Providers also felt that the existing list of supplies was inadequate to meet the needs of survivors, and also that providers needed ongoing training to improve supply procurement and management, more knowledge of the needs of male survivors of SGBV, and more educational opportunities to improve the quality of care to survivors. Given the deficiencies expressed by providers in the surveys, this study demonstrated a critical need for a locally-adapted and focused needs assessment to improve health services to survivors.

P190B RhoGAP has pro-tumorigenic functions during MMTV-Neu mammary tumorigenesis and metastasis

Introduction

Rho GTPases are overexpressed and hyperactivated in human breast cancers. Deficiency of p190B RhoGAP, a major inhibitor of the Rho GTPases, inhibits mouse mammary tumor virus long terminal repeat (MMTV)-Neu/ErbB2 mammary tumor formation and progression in part through effects within the stromal environment, suggesting that p190B function is pro-tumorigenic. To further investigate the potential pro-tumorigenic actions of p190B, we examined the effects of exogenous p190B expression within the mammary epithelium on MMTV-Neu tumor formation and progression.

Methods

Tetracycline (tet)-regulatable p190B transgenic mice were bred to MMTV-Neu mice, and the effects of exogenous p190B expression on tumor latency, multiplicity, growth rates, angiogenesis, and metastasis were examined. The effects of exogenous p190B expression on cell-matrix adhesion and invasion were tested using non-transformed primary mammary epithelial cells (MECs). Rho GTPase activity, oxidative stress as an indicator of reactive oxygen species (ROS) production, and downstream signaling pathways were analyzed.

Results

Altered p190B expression resulted in a two-fold increase in tumor multiplicity and a three-fold increase in metastases compared to control mice indicating that exogenous p190B expression in the mammary epithelium promotes MMTV-Neu mammary tumor formation and progression. Interestingly, non-transformed primary MECs expressing exogenous p190B displayed increased adhesion to laminin and type IV collagen and formed invasive structures in a three-dimensional culture assay. Ras related C3 botulinum toxin 1 (Rac1)-GTP levels were elevated in p190B transgenic tumors whereas Ras homologous A (RhoA) and cell division cycle 42 (Cdc42)-GTP levels were not significantly altered. Rac1 activity affects production of ROS, which regulate transformation, metastasis, and oxidative stress. Protein carbonylation, which is indicative of oxidative stress, was elevated 1.75-fold in p190B transgenic tumors as compared to control tumors suggesting that exogenous p190B expression may affect Rac1-dependent ROS production.

Conclusions

These studies indicate that paradoxically, p190B RhoGAP, a major inhibitor of the Rho GTPases in vitro, has pro-tumorigenic functions that enhance MMTV-Neu induced mammary tumor formation and metastasis. Furthermore, exogenous p190B expression enhances cell adhesion and invasion, which may facilitate metastasis. Rac1 activity and oxidative stress are elevated in tumors expressing exogenous p190B suggesting that p190B may promote tumorigenesis through a Rac1/ROS dependent mechanism.