Ketamine for Adults with Severe Asthma Exacerbation: A Systematic Review and Meta-analysis

BACKGROUND: Severe asthma mandates careful attention and timely management, and the benefit of ketamine in severe asthma exacerbations in adult patients require further exploration. METHODS: We conducted a systematic review and meta-analysis of the use of ketamine in cases of acute asthma exacerbation in adults. We searched PubMed, Google Scholar, Cochrane databases, and gray literature (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform); we also searched the reference lists of included articles and any systematic reviews and meta-analyses identified therein. Our search covered the period from 1963 to August 20, 2021. Search terms were “ketamine” AND “asthma”. RESULTS: Of 25 540 articles, two studies were included in the analysis. The total number of patients included in the studies was 136 (68 in the ketamine groups and 68 in the placebo group). The pooled effect size was 0.30 (95% CI: -0.04, 0.63) favouring ketamine over placebo, p=0.08, (I2=0%, p=0.39). A paired t-test revealed that ketamine improved the mean peak expiratory flow rate (PEFR) from 242.4 (SD=146.23) to 286.95 (SD=182.22), p=0.33, representing an 18.38% improvement. CONCLUSION: Ketamine can induce a 30% improvement in PEFR, representing a small positive effect in the treatment of acute severe asthma exacerbation in the emergency department (ED). The improvement was not statistically significant; nonetheless, since the improvement could be as great as 63% versus only a 4% possibility of no benefit/harm, the benefit appears to considerably outweigh any harm.

A systematic review of the systematic review of post COVID-19 syndrome

Background: The declaration of the COVID-19 pandemic triggered a global inquiry into the transmission, mortality, risk factors, and management of the disease. Recently, however, attention has shifted toward its long-term consequences. There is a need for a better understanding of the predictors and symptoms of post-COVID syndrome, to ensure appropriate care for patients recovering from COVID-19 beyond the acute phase. Methods: We searched PubMed, Google Scholar, Cochrane databases, and available data in the PROSPERO databases. We also explored the reference lists of included articles and any systematic reviews identified therein. We searched the keywords "Post Covid", "Post COVID syndrome", "Post- Covid" and "PostCOVID", until July 2021. Results: Of 8167 articles, 13 were included. The syndrome affects several systems with variable prevalence. Fatigue and sleep disturbance is the most common symptom of acute post-COVID syndrome, observed in more than two-thirds of patients, while a reduction in quality of life and general health status was noted in up to 69%. Furthermore, a reduced aerobic and diffusion capacity was seen in 38% of patients up to one month after presumed recovery from infection. Radiologically, in up to 52% of patients, a ground-glass opacity (GGO) was noted beyond three months post-infection. The incidence of new psychiatric illness increased from as early as 14 days after infection and up to three or six months. Hearing impairment or loss, whether sensorineural or conductive, was noted in up to 8.3% of patients, and tinnitus was seen in up to 4.2%. Conclusion: Overall, given the variability in the manifestation of post-COVID syndrome, a multidisciplinary team is required to better serve these patients. We therefore urge the establishment of such teams, encompassing internal medicine, pulmonology, cardiology, and neurocognitive services.

Effects of Not Intubating Non-Trauma Patients With Low Glasgow Coma Scale Scores: a Retrospective Study

Background: Endotracheal intubation (EI) is a critical life-saving procedure commonly performed on emergency department (ED) patients who present with altered mental status (AMS). Aims: We aimed to investigate the safety of observing, without EI, patients who present to the ED with decreased levels of consciousness (LOC). Methods: We reviewed the data of all adult ED patients with a Glasgow Coma Scale (GCS) score ≤ 8, during the period between 2012 and 2018, in an academic tertiary care centre. Trauma patients were excluded. The patients were divided into two groups for comparison: those who were intubated and those who were not. Data on mortality, morbidity, and baseline clinical characteristics were collected and analysed. Results: After screening 6334 electronic medical records of patients presenting to the ED with decreased LOC, only 257 patients met the inclusion criteria. 173 (67.3%) patients were intubated, while 84 (32.7%) were not. Among the intubated patients, 165 (95.4%) were intubated early (within two hours of presentation). Mortality, morbidity and length of stay for the intubated group were higher, although the baseline clinical characteristics were the same. Conclusion: It might be safe to observe non-trauma emergency patients with a GCS score ≤ 8 without intubation. However, such decision should be taken carefully, as delayed intubation can be associated with higher mortality and morbidity

The Causative Organism of Urinary Tract Infections UTI: a Cross-sectional Study from a Tertiary Hospital In Saudi Arabia

BACKGROUND: Urinary tract infections (UTIs) are a common disease with a high burden on the healthcare industry. A systematic exploration is necessary of the organisms that cause UTIs, to improve empirical management of patients with acute illness before culture results are obtained. The prevalence of these organisms, both in immunocompetent and immunocompromised patients in Saudi Arabia, needs further clarification. METHODS: This is a cross-sectional analysis reviewing the charts of patients visiting the emergency department of, and those admitted to, a tertiary hospital in Saudi Arabia during the month of July-August 2021. RESULT: The total number of participants was 199, with a mean age of 55.8 years (SD=20.02), ranging from 14 to 97 years. 61.8% of patients were immunocompromised, and one-third were from the oncology wards. 40.7% (n=81) were diabetics and 8.54% (n=17) had CKD/ESRD. Females were 25% more likely than males to acquire Candida infections, while Pseudomonas aeruginosa was 26.7% more prevalent in males. Nevertheless, mixed gram-negative bacteria caused the most UTIs, in 40.20% (n=80) of cases, followed by Candida, 16.1% (n=32), and then mixed gram-positive bacteria, in 14.57% (n=29). This was also observed among immunocompromised patients and the subsegment of oncology patients on active chemotherapy, although with variable percentages. CONCLUSION: This study demonstrates that patients’ immune status is the main determinant of the causative organism of UTIs. The treatment threshold for Candida in diabetic patients and those with CKD/ESRD should be lower, especially when they require admission.

Effectiveness of Bi-lingual Multidisciplinary Simulation-based Training in Improving Communication and Breaking Bad-News Skills

Background: Healthcare worker (HCW)-patient communication is an essential element of every patient’s journey, and evidence links good communication with favourable patient experiences and outcomes. Simulation-based training (SBT) is a promising and effective tool to improve such communication. Aim: To develop a bilingual SBT programme in communication skills for all HCWs in an academic tertiary hospital, to improve patient care, experiences and outcomes. Methods: This was a quasi-experimental design, conducted in 2018 at King Abdulaziz University (KAU). We designed and delivered a bilingual, simulation-based, full-day course for HCWs (both clinical and administrative), and measured its impact by comparing pre- and post-course test scores, participant feedback, and instructor performance satisfaction indices. Results: We trained 318 HCWs over 15 days, using 10 instructors. Post-test scores showed individual and overall improvement. The average scores were 26.6% (14-40%) for the pre-test and 55.8% (37-70%) for the post-test, with an average improvement of 29% (P<0.005). Participant feedback was 77% positive and in favour of more training. The average instructor performance satisfaction score was 96.2% (92-99%). Conclusion: We demonstrated the positive impact of SBT on communication skills for both clinical and administrative HCWs. We also demonstrated the sustainability and scalability of this course.

قياس أثر مؤشرات الأداء في تحسين جودة الخدمات الصحية " دراسة تطبيقية على مديرية الشؤون الصحية - الطائف "

مستخلص الدراسة هدفت الدراسة الحالية إلى تسليط الضوء على أثر مؤشرات الأداء في تحسين جودة الخدمات الصحية في مديرية الشؤون الصحية بمحافظة الطائف من خلال معرفة إذا ما كانت تلك المؤشرات كافية من أجل تحقيق جودة تحسين الخدمات الصحية المقدمة. واستخدم الباحث المنهج الوصفي التحليلي الذي يعتبر من أهم المناهج التي تستخدم وأكثرها استخداماً في البحوث فهو يُعتبر الأنسب لهذه الدراسة، وقد تَكَوَّن مجتمع الدراسة من منسوبي مديرية الشؤون الصحية بمحافظة الطائف والبالغ عددهم (1486)، كما تم استخدام أسلوب العينة العشوائية البسيطة ومكونة من (353) موظف وموظفة، وقد وجد الباحث أن الأداة الأكثر ملاءمة لتحقيق أهداف هذه الدراسة هي الاستبانة. وتوصلت الدراسة إلى النتائج التالية: ١- هناك موافقة بدرجة متوسطة بين أفراد الدراسة على مؤشرات الأداء وكذلك الرضا الوظيفي للعاملين، إضافة إلى تحقيق الأهداف والخطط الاستراتيجية للمديرية، وثبات مستوى الخدمات ورضا المراجعين. ٢-هناك موافقة بدرجة متوسطة بين أفراد الدراسة على أهمية مؤشرات الأداء وكذلك الاستفادة من كل القوى الكامنة للموارد البشرية فيها وتطويرها، إضافة إلى توفر البيئة التي تؤدي إلى المشاركة الكلية ببيئة العمل، وتدبير الموارد البشرية داخل المديرية بالشكل الأمثل. ٣-هناك تأثير واضح لمؤشرات الأداء على جودة الخدمات الصحية المقدمة. ٤-مستوى الأداء الوظيفي لدى العاملين جاء بمستوى متوسط. ٥-هناك علاقة طردية (إيجابية) ذات دلالة إحصائية بين التزام الإدارة العليا وقياس مؤشرات الأداء وتحسين جودة الخدمات الصحية. التوصيات: ١-ضرورة الاستفادة من التغيرات التنظيمية الخاصة بالموارد البشرية المنفذة بالاعتماد على تكنولوجيا المعلومات في تعزيز الشفافية والوضوح في المهام والواجبات المختلفة للعاملين وبما يرفع من نوعية الأداء. ٢-الإفادة من توافر المعلومات الخاصة ببرامج التدريب المختلفة في تعزيز القدرات الفردية على العمل التعاوني والتشارك في أداء المهام بصورة بسيطة دون تعقيد. ٣-الاستفادة من توافر نظم تقييم الأداء الشمولية الإلكترونية في المديرية والتي تعكس جوانب الأداء المختلفة من حيث المعاير وآليات التقييم والقرارات الاستراتيجية المرتبطة في تعزيز قدرات العاملين المختلفة والخاصة بأداء الأعمال بعيداً عن التعقيد والتداخل والقيام بالأعمال غير الضرورية.

Clinical Research in Saudi Arabia: Trainee Knowledge and Attitude

Background Clinical research is an integral part of medical and surgical residency programmes, as well as medical school. Aim This study aimed to investigate attitudes toward, the experience of, and perceived barriers to, conducting clinical research in the medical and surgical fields in Saudi Arabia. We also aimed to explore attitudes toward article processing charges and submission fees. Methods A cross-sectional study conducted in Saudi Arabia during the months of May-June 2021. The inclusion criteria were trainees in various medical and surgical specialities. Results The majority of participants conducted at least one research project, representing 92.5% (n=185); of those, 77.3% (n=143) had already published their research. While 33.5% (n=67) of participants felt comfortable designing, leading and critically appraising articles, only 17.3% (n=34) were comfortable using statistical software. Barriers to clinical research include lack of personal interest, lack of interest on the part of programme directors/mentors, inadequate support from mentors/assistants, being overwhelmed with educational activities and examinations, lack of reward and/or motivation, and difficulties obtaining an appropriate sample. Conclusion This article provides new insight into the knowledge of, and attitude toward, clinical research among Saudi Arabian trainees, and discusses the implications thereof and the future direction of clinical research in Saudi Arabia.

Challenges Facing Emergency Medicine Residents in Saudi Arabia: A Cross-Sectional Study

ABSTRACT Background: Challenges related to the residency programme differ according to residents’ roles, interactions, culture, responsibilities and expectations. Aim: This study aims to explore the challenges faced by emergency medicine physicians during their residency programme. We also aim to investigate the influence of several demographic variables on their training experience. Method: This is a cross-sectional study, conducted in Saudi Arabia from June, 2021 to July 2021, using a survey designed by the author. Results: The total number of participants was 37. Of these, 24.3% (n=9) were R1 residents, 10.8% (n=4) were R2, 35.1% (n=13) were R3, and 29.7% (n=11) were R4. While most of the participants (89%) clearly understood which reference to use for studying, only 56.7% had a clear understanding of how to study for the exams. Reading club was advocated by 72% of participants, and only half the participants had a positive perception of leading, preparing, and discussing topics during academic activity. Of all the residency levels, R3 residents were the most supportive of having expert physician guidance during ED procedures, p=0.04. Other factors given more importance by R3 residents than by other levels were mentorship, p=0.051, and having a course review for the exam, p=0.001. Conclusion: This study uncovers several challenges reported by participants from different residency levels. We noted that the R3 training level, being a period of transition from junior to senior level, is a significant period requiring more attention; more emphasis on mentorship and reading club is advocated.

Lactation Ketoacidosis in a COVID- 19 patient: A Case Report

Lactation ketoacidosis is an uncommon cause of high anion gap metabolic acidosis affecting breastfeeding women due to increased metabolic demands, reduction in carbohydrate intake, and acute illness. Meanwhile, recent literature showed that COVID-19 might cause ketosis, ketoacidosis, and diabetic ketoacidosis. We report a case of a 22-year-old lady, four weeks postpartum, with a confirmed diagnosis of COVID-19. She presented with severe symptomatic ketoacidosis with a high anion gap, ketonuria and hypoglycemia that was due to lactation ketoacidosis. She was not tolerating orally for days because of abdominal pain, vomiting, and viral infection. After proper treatment in the ward for the presenting symptoms of lactation ketoacidosis and refeeding, she rapidly improved and discharged five days later. While ketoacidosis may be induced by starvation and/or lactation, it is our conclusion that the condition may be aggravated by COVID-19 infection. Emergency services should consider the risk of lactation ketoacidosis exacerbated by COVID- 19 in postpartum women.

Scenario Planning in Disaster Management: A Call to Change the Current Practice

The current pandemic uncovered how disastrous our disaster plans. The disaster doctrine in its current state is far from ideal, and another model of thinking is warranted. Scenario planning provides a standardised way of thinking on how to plan for the future. We believe disaster doctrine is probably the most doctrine that will benefit from this thinking model. Using scenario planning will uncover our assumptions, deficiencies and will inform a disaster best practice.