Comparison of diclofenac with tramadol, tizanidine or placebo in the treatment of acute low back pain and sciatica: multi-center randomized controlled trial.

BACKGROUND: Low back pain (LBP) is a leading cause of disability worldwide and has posed numerous health and socioeconomic challenges. This study compared whether nonsteroidal anti-inflammatory drugs (NSAIDs) in combination with tramadol, tizanidine or placebo would be the best treatment regime to improve the Roland Morris Disability Questionnaire (RMDQ) scores at 1 week. METHODS: This was a multi-center, double-blind, randomized, and placebo-controlled trial including adult patients with acute LBP and sciatica in three emergency departments in Hong Kong. Patients were randomized to the receive tramadol 50 mg, tizanidine 2 mg, or placebo every 6 hours for 2 weeks in a 1:1:1 ratio. The RMDQ and other secondary outcomes were measured at baseline, Day 2, 7, 14, 21, and 28. Data were analyzed on an intention to treat basis. Crude and adjusted mean differences in the changes of RMDQ and NRS scores from baseline to Day 7 between tizanidine/tramadol and placebo were determined with 95% confidence intervals. RESULTS: Two hundred and ninety-one patients were analyzed with the mean age of 47.4 years and 57.7% were male. The primary outcome of mean difference in RMDQs on Day 7 (compared with baseline) was non-significant for tizanidine compared with placebo (adjusted mean difference - 0.56, 95% CI -2.48 to 1.37) and tramadol compared with placebo (adjusted mean difference - 0.85, 95% CI -2.80 to 1.10). Only 23.7% were fully compliant to the treatment allocated. Complier Average Causal Effect analysis also showed no difference in the primary outcome for the tizanidine and tramadol versus placebo. CONCLUSION: Among patients with acute LBP and sciatica presenting to the ED, adding tramadol or tizanidine to diclofenac did not improve functional recovery.

Mapping study for health emergency and disaster risk management competencies and curricula: literature review and cross-sectional survey.

BACKGROUND: With the increasing threat of hazardous events at local, national, and global levels, an effective workforce for health emergency and disaster risk management (Health EDRM) in local, national, and international communities is urgently needed. However, there are no universally accepted competencies and curricula for Health EDRM. This study aimed to identify Health EDRM competencies and curricula worldwide using literature reviews and a cross-sectional survey. METHODS: Literature reviews in English and Japanese languages were performed. We searched MEDLINE, EMBASE, CINAHL (English), and the ICHUSHI (Japanese) databases for journal articles published between 1990 and 2020. Subsequently, a cross-sectional survey was sent to WHO Health EDRM Research Network members and other recommended experts in October 2021 to identify competency models and curricula not specified in the literature search. RESULTS: Nineteen studies from the searches were found to be relevant to Health EDRM competencies and curricula. Most of the competency models and curricula were from the US. The domains included knowledge and skills, emergency response systems (including incident management principles), communications, critical thinking, ethical and legal aspects, and managerial and leadership skills. The cross-sectional survey received 65 responses with an estimated response rate of 25%. Twenty-one competency models and 20 curricula for managers and frontline personnel were analyzed; managers' decision-making and leadership skills were considered essential. CONCLUSION: An increased focus on decision-making and leadership skills should be included in Health EDRM competencies and curricula to strengthen the health workforce.

Health Emergency and Disaster Risk Management Workforce Development Strategies: Delphi Consensus Study.

INTRODUCTION: Health workforce development is essential for achieving the goals of an effective health system, as well as establishing national Health Emergency and Disaster Risk Management (Health EDRM). STUDY OBJECTIVE: The objective of this Delphi consensus study was to identify strategic recommendations for strengthening the workforce for Health EDRM in low- and middle-income countries (LMIC) and high-income countries (HIC). METHODS: A total of 31 international experts were asked to rate the level of importance (one being strongly unimportant to seven being strongly important) for 46 statements that contain recommendations for strengthening the workforce for Health EDRM. The experts were divided into a LMIC group and an HIC group. There were three rounds of rating, and statements that did not reach consensus (SD ≥ 1.0) proceeded to the next round for further ranking. RESULTS: In total, 44 statements from the LMIC group and 34 statements from the HIC group attained consensus and achieved high mean scores for importance (higher than five out of seven). The components of the World Health Organization (WHO) Health EDRM Framework with the highest number of recommendations were "Human Resources" (n = 15), "Planning and Coordination" (n = 7), and "Community Capacities for Health EDRM" (n = 6) in the LMIC group. "Policies, Strategies, and Legislation" (n = 7) and "Human Resources" (n = 7) were the components with the most recommendations for the HIC group. CONCLUSION: The expert panel provided a comprehensive list of important and actionable strategic recommendations on workforce development for Health EDRM.

An eight country cross-sectional study of the psychosocial effects of COVID-19 induced quarantine and/or isolation during the pandemic.

Forced quarantine and nationwide lockdowns have been a primary response by many jurisdictions in their attempt at COVID-19 elimination or containment, yet the associated mental health burden is not fully understood. Using an eight country cross-sectional design, this study investigates the association between COVID-19 induced quarantine and/or isolation on probable generalized anxiety disorder (GAD) and major depressive episode (MDE) psychological outcomes approximately eight months after the pandemic was declared. Overall, 9027 adults participated, and 2937 (32.5%) were indicated with GAD and/or MDE. Reported quarantine and/or isolation was common, with 1199 (13.8%) confined for travel or health requirements, 566 (6.5%) for being close contact, 720 (8.3%) for having COVID-19 symptoms, and 457 (5.3%) for being COVID-19 positive. Compared to those not quarantining or isolating, the adjusted estimated relative risks of GAD and/or MDE associated with quarantine and/or isolation was significant (p < 0.001), ranging from 1.24 (95% confidence interval [CI]: 1.07, 1.43) for travel/health to 1.37 (95% CI 1.19, 1.59) for COVID-19 symptom isolation reasons. While almost universally employed, quarantine and/or isolation is associated with a heavy mental health toll. Preventive strategies are needed, such as minimizing time-limits imposed and providing clear rationale and information, together with additional treatment and rehabilitation resources.

Psychological Distress, Pain and Insurance Claims Negatively Affect Long-Term Health-Related Quality of Life After Road Traffic Injuries.

OBJECTIVE: A prospective cohort study to investigate how injury and early post-injury psychosocial factors influence health outcomes 12 months after road traffic injury. METHODS: Residents of New South Wales, Australia, with road traffic injury in the period 2013-16 were recruited. Explanatory factors were evaluated for outcomes over 12 months using 12-Item Short Form Survey (SF-12) Physical and Mental Component Scores (PCS and MCS). Path models and mediation analysis were used to examine the effect of injury severity and explanatory factors. RESULTS: SF-12 PCS and MCS outcomes were poorer among participants with baseline psychological distress, for all injury severities (ß coefficients -3.3 to -9.3, p < 0.0001). Baseline pain and psychological distress, and baseline PCS and MCS were each involved in indirect effects of injury severity on 12-month PCS and MCS. Injury severity, baseline PCS and MCS, and baseline psychological distress were also associated with the likelihood of a compulsory third-party insurance claim, and claiming was negatively associated with 12-month PCS and MCS outcomes (beta coefficients -0.22 and -0.14, respectively, for both, p < 0.01). CONCLUSION: Baseline factors, including pain, psychological distress and lodging a compulsory third-party insurance claim, negatively impact long-term physical and mental health status following road traffic injury, emphasizing the importance of early screening and intervention. TRIAL REGISTRATION: Australia New Zealand Clinical trial registry identification number: AC- TRN12613000889752.

Filling the Gaps in the Pharmacy Workforce in Post-Conflict Areas: Experience from Four Countries in Sub-Saharan Africa.

BACKGROUND: While the pharmacy workforce is the third largest professional healthcare group worldwide, the pharmacy workforce landscape remains unclear in post-conflict areas in sub-Saharan Africa. METHOD: Key informants were selected for semi-structured interviews due to their role in providing pharmacy services in the selected country: the Central African Republic (CAR), the Democratic Republic of Congo (DRC), Ethiopia, and South Sudan. Transcripts from the interviews were anonymized, coded, and analyzed. RESULTS: Nine participants were recruited (CAR: 2; DRC: 2; Ethiopia: 2; South Sudan: 3), and all except two were pharmacists. Conflict-specific challenges in pharmacy service delivery were identified as the following: unpredictable health needs and/or mismatched pharmaceutical supply, transport difficulties due to insecure roads, and shortage of pharmacy workforce due to brain drain or interrupted schooling. Barriers to health workforce retention and growth were identified to be brain drain as a result of suboptimal living and working conditions or remuneration, the perception of an unsafe work environment, and a career pathway or commitment duration that does not fit the diaspora or expatriate staff. CONCLUSION: To tackle the barriers of pharmacy health workforce retention and growth, policy solutions will be required and efforts that can bring about long-term improvement should be prioritized. This is essential to achieve universal health coverage and the targets of the sustainable development goals for conflict affected areas, as well as to "leave no one behind".

CCOUC Ethnic Minority Health Project: A Case Study for Health EDRM Initiatives to Improve Disaster Preparedness in a Rural Chinese Population.

Disasters disproportionately impact poor and marginalised populations due to greater vulnerability induced by various risk determinants, such as compromised living conditions, language barriers, and limited resources for disaster risk management. Health Emergency and Disaster Risk Management (Health EDRM) emphasises a people- and community-centred approach for building stronger capacities in communities and countries since community members are often the first responders to health emergencies and should be central to effective risk management. A key action for promoting community disaster preparedness is the provision of Health EDRM education interventions. The Ethnic Minority Health Project (EHMP) has provided community-based Health EDRM education interventions in 16 ethnic minority-based villages in remote areas of China since 2009. It aims to enhance community disaster preparedness and resilience by improving health-risk literacy and self-help capacity at the individual and household levels. This case study outlines the first EHMP project in an ethnic minority-based community (Ma'an Qiao Village) in Sichuan Province, China. It highlights the key elements for planning and managing such a project and is a good demonstration of an effective Health EDRM workforce development project in rural communities. This report concludes with five recommendations for setting up a sustainable and effective Health EDRM education intervention in similar contexts.

Health Workforce Development in Health Emergency and Disaster Risk Management: The Need for Evidence-Based Recommendations.

The Sendai Framework for Disaster Risk Reduction 2015-2030 placed human health at the centre of disaster risk reduction, calling for the global community to enhance local and national health emergency and disaster risk management (Health EDRM). The Health EDRM Framework, published in 2019, describes the functions required for comprehensive disaster risk management across prevention, preparedness, readiness, response, and recovery to improve the resilience and health security of communities, countries, and health systems. Evidence-based Health EDRM workforce development is vital. However, there are still significant gaps in the evidence identifying common competencies for training and education programmes, and the clarification of strategies for workforce retention, motivation, deployment, and coordination. Initiated in June 2020, this project includes literature reviews, case studies, and an expert consensus (modified Delphi) study. Literature reviews in English, Japanese, and Chinese aim to identify research gaps and explore core competencies for Health EDRM workforce training. Thirteen Health EDRM related case studies from six WHO regions will illustrate best practices (and pitfalls) and inform the consensus study. Consensus will be sought from global experts in emergency and disaster medicine, nursing, public health and related disciplines. Recommendations for developing effective health workforce strategies for low- and middle-income countries and high-income countries will then be disseminated.

Impacts of injury severity on long-term outcomes following motor vehicle crashes.

BACKGROUND: There is growing evidence that a range of pre-injury, injury related and post-injury factors influence social and health outcomes across the injury severity spectrum. This paper documents health related outcomes for people with mild, moderate and severe injury after motor vehicle crash (MVC) injuries in New South Wales, Australia. METHODS: This inception cohort study followed 2019 people injured in MVCs, for 6 and 12 months post-injury. We categorised moderate injury as hospital length-of-stay (LOS) of 2-6 days and Injury Severity Score (ISS) of 4-11, while severe injury as LOS ≥7 days or ISS ≥ 12. We examined differences in paid work status, 12-Item Short Form Survey (SF12), EQ-5D and World Health Organisation Disability Assessment Schedule II (WHODAS) outcomes longitudinally from baseline to 12 months between levels of injury severity using linear mixed models for repeated measures. We first considered minimally sufficient adjustment factors (age, sex, crash role, perceived danger in crash, pre-injury health, pre-injury EQ-5D, recruitment source), and then more extensive adjustments including post-injury factors. The presence of mediating pathways for SF-12 Physical Component Summary (PCS) and Mental Component Summary (MCS) via post-injury factors was evaluated. RESULTS: Based on hospital length of stay (LOS), 25 and 10% of participants sustained moderate and severe injuries, respectively, while 43 and 4% had these injuries based on ISS. Twelve months post-injury LOS ≥7 days versus ≤1 day was associated with an estimated 9 units lower mean SF12 PCS using a minimally sufficient adjustment model, and LOS ≥ 7 days was associated with a 3 units lower mean SF12 MCS score. Mediation analyses (LOS ≥ 7 days vs ≤1 day) found for SF12 MCS outcomes, effects of injury severity were small and mostly indirect (direct effect - 0.03, indirect effect - 0.22). Whereas for SF12 PCS outcomes the effect of having a more severe injury rather than mild were both direct and indirect (direct effect - 0.50, indirect effect - 0.38). CONCLUSIONS: Individuals with severe injuries (those with LOS ≥ 7 days and ISS 12+) had poorer recovery 12 months after the injury. In addition, post-injury mediators have an important role in influencing long-term health outcomes. TRIAL REGISTRATION: Australia New Zealand Clinical trial registry identification number - ACTRN12613000889752 .

Adult Basic Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

This 2020 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care Science With Treatment Recommendations on basic life support summarizes evidence evaluations performed for 22 topics that were prioritized by the Basic Life Support Task Force of the International Liaison Committee on Resuscitation. The evidence reviews include 16 systematic reviews, 5 scoping reviews, and 1 evidence update. Per agreement within the International Liaison Committee on Resuscitation, new or revised treatment recommendations were only made after a systematic review. Systematic reviews were performed for the following topics: dispatch diagnosis of cardiac arrest, use of a firm surface for CPR, sequence for starting CPR (compressions-airway-breaths versus airway-breaths-compressions), CPR before calling for help, duration of CPR cycles, hand position during compressions, rhythm check timing, feedback for CPR quality, alternative techniques, public access automated external defibrillator programs, analysis of rhythm during chest compressions, CPR before defibrillation, removal of foreign-body airway obstruction, resuscitation care for suspected opioid-associated emergencies, drowning, and harm from CPR to victims not in cardiac arrest. The topics that resulted in the most extensive task force discussions included CPR during transport, CPR before calling for help, resuscitation care for suspected opioid-associated emergencies, feedback for CPR quality, and analysis of rhythm during chest compressions. After discussion of the scoping reviews and the evidence update, the task force prioritized several topics for new systematic reviews.

Adult Basic Life Support: International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

This 2020 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care Science With Treatment Recommendations on basic life support summarizes evidence evaluations performed for 20 topics that were prioritized by the Basic Life Support Task Force of the International Liaison Committee on Resuscitation. The evidence reviews include 16 systematic reviews, 3 scoping reviews, and 1 evidence update. Per agreement within the International Liaison Committee on Resuscitation, new or revised treatment recommendations were only made after a systematic review. Systematic reviews were performed for the following topics: dispatch diagnosis of cardiac arrest, use of a firm surface for CPR, sequence for starting CPR (compressions-airway-breaths versus airway-breaths-compressions), CPR before calling for help, duration of CPR cycles, hand position during compressions, rhythm check timing, feedback for CPR quality, alternative techniques, public access automated external defibrillator programs, analysis of rhythm during chest compressions, CPR before defibrillation, removal of foreign-body airway obstruction, resuscitation care for suspected opioid-associated emergencies, drowning, and harm from CPR to victims not in cardiac arrest. The topics that resulted in the most extensive task force discussions included CPR during transport, CPR before calling for help, resuscitation care for suspected opioid-associated emergencies, feedback for CPR quality, and analysis of rhythm during chest compressions. After discussion of the scoping reviews and the evidence update, the task force prioritized several topics for new systematic reviews.

Narrative review of non-pharmaceutical behavioural measures for the prevention of COVID-19 (SARS-CoV-2) based on the Health-EDRM framework.

INTRODUCTION: Non-pharmaceutical measures to facilitate a response to the COVID-19 pandemic, a disease caused by novel coronavirus SARS-CoV-2, are urgently needed. Using the World Health Organization (WHO) health emergency and disaster risk management (health-EDRM) framework, behavioural measures for droplet-borne communicable diseases and their enabling and limiting factors at various implementation levels were evaluated. SOURCES OF DATA: Keyword search was conducted in PubMed, Google Scholar, Embase, Medline, Science Direct, WHO and CDC online publication databases. Using the Oxford Centre for Evidence-Based Medicine review criteria, 10 bottom-up, non-pharmaceutical prevention measures from 104 English-language articles, which published between January 2000 and May 2020, were identified and examined. AREAS OF AGREEMENT: Evidence-guided behavioural measures against transmission of COVID-19 in global at-risk communities were identified, including regular handwashing, wearing face masks and avoiding crowds and gatherings. AREAS OF CONCERN: Strong evidence-based systematic behavioural studies for COVID-19 prevention are lacking. GROWING POINTS: Very limited research publications are available for non-pharmaceutical measures to facilitate pandemic response. AREAS TIMELY FOR RESEARCH: Research with strong implementation feasibility that targets resource-poor settings with low baseline health-EDRM capacity is urgently needed.

Narrative Review on Health-EDRM Primary Prevention Measures for Vector-Borne Diseases.

Climate change is expanding the global at-risk population for vector-borne diseases (VBDs). The World Health Organization (WHO) health emergency and disaster risk management (health-EDRM) framework emphasises the importance of primary prevention of biological hazards and its value in protecting against VBDs. The framework encourages stakeholder coordination and information sharing, though there is still a need to reinforce prevention and recovery within disaster management. This keyword-search based narrative literature review searched databases PubMed, Google Scholar, Embase and Medline between January 2000 and May 2020, and identified 134 publications. In total, 10 health-EDRM primary prevention measures are summarised at three levels (personal, environmental and household). Enabling factor, limiting factors, co-benefits and strength of evidence were identified. Current studies on primary prevention measures for VBDs focus on health risk-reduction, with minimal evaluation of actual disease reduction. Although prevention against mosquito-borne diseases, notably malaria, has been well-studied, research on other vectors and VBDs remains limited. Other gaps included the limited evidence pertaining to prevention in resource-poor settings and the efficacy of alternatives, discrepancies amongst agencies' recommendations, and limited studies on the impact of technological advancements and habitat change on VBD prevalence. Health-EDRM primary prevention measures for VBDs require high-priority research to facilitate multifaceted, multi-sectoral, coordinated responses that will enable effective risk mitigation.

qSOFA is a Poor Predictor of Short-Term Mortality in All Patients: A Systematic Review of 410,000 Patients.

BACKGROUND: To determine the validity of the Quick Sepsis-Related Organ Failure Assessment (qSOFA) in the prediction of outcome (in-hospital and 1-month mortality, intensive care unit (ICU) admission, and hospital and ICU length of stay) in adult patients with or without suspected infections where qSOFA was calculated and reported; Methods: Cochrane Central of Controlled trials, EMBASE, BIOSIS, OVID MEDLINE, OVID Nursing Database, and the Joanna Briggs Institute EBP Database were the main databases searched. All studies published until 12 April 2018 were considered. All studies except case series, case reports, and conference abstracts were considered. Studies that included patients with neutropenic fever exclusively were excluded. RESULTS: The median AUROC for in-hospital mortality (27 studies with 380,920 patients) was 0.68 (a range of 0.55 to 0.82). A meta-analysis of 377,623 subjects showed a polled AUROC of 0.68 (0.65 to 0.71); however, it also confirmed high heterogeneity among studies (I² = 98.8%, 95%CI 98.6 to 99.0). The median sensitivity and specificity for in-hospital mortality (24 studies with 118,051 patients) was 0.52 (range 0.16 to 0.98) and 0.81 (0.19 to 0.97), respectively. Median positive and negative predictive values were 0.2 (range 0.07 to 0.38) and 0.94 (0.85 to 0.99), respectively.

The role of the hotel industry in the response to emerging epidemics: a case study of SARS in 2003 and H1N1 swine flu in 2009 in Hong Kong.

BACKGROUND: The global travel and tourism industry has been rapidly expanding in the past decades. The traditional focus on border screening, and by airline and cruise industries may be inadequate due to the incubation period of an infectious disease. This case study highlights the potential role of the hotel industry in epidemic preparedness and response. METHODS: This case study focuses on the epidemic outbreaks of SARS in 2003 and H1N1 swine flu in 2009 in Hong Kong, and the subsequent guidelines published by the health authority in relation to the hotel industry in Hong Kong which provide the backbone for discussion. RESULTS: The Metropole Hotel hastened the international spread of the 2003 SARS outbreak by the index case infecting visitors from Singapore, Vietnam, Canada as well as local people via close contact with the index case and the environmental contamination. The one-week quarantine of more than 300 guests and staff at the Metropark Hotel during the 2009 H1N1 swine flu exposed gaps in the partnership with the hotel industry. The subsequent guidelines for the hotel industry from the Centre of Health Protection focused largely on the maintenance of hygiene within the hotel premises. CONCLUSION: Positive collaborations may bring about effective preparedness across the health and the tourism sectors for future epidemics. Regular hygiene surveillance at hotel facilities, and developing coordination mechanism for impending epidemics on the use of screening, swift reporting and isolation of infected persons may help mitigate the impact of future events. Preparedness and contingency plans for infectious disease control for the hotel industry requires continuous engagement and dialogue.

Performance of automated external defibrillators under conditions of in-flight turbulence.

INTRODUCTION: Modern automated external defibrillators (AEDs) are designed to prevent shock delivery when excessive motion produces rhythm disturbances mimicking ventricular fibrillation (VF). This has been reported as a safety issue in airline operations, where turbulent motion is commonplace. We aimed to evaluate whether all seven AEDs can deliver shock appropriately in a flight simulator under turbulent conditions. METHODS: The study was performed in a Boeing 747-400 full motion flight simulator in Hong Kong. An advanced life support manikin and arrhythmia generator were used to produce sinus rhythm (SR), asystole, and five amplitudes of VF, with a programmed change to SR in the event of an effective shock being delivered. All rhythms were tested at rest (no turbulence) and at four levels of motion (ground taxi vibration, and mild, moderate and severe in-flight turbulence). Success was defined as: 1. effective shock being delivered where the rhythm was VF successfully converted to SR; 2. no inappropriate shock being delivered for asystole or SR. RESULTS: Five AEDs produced acceptable results at all levels of turbulence. Another was satisfactory for VF except at very fine amplitudes. One model was deemed unsatisfactory for in-flight use as its motion detector inhibited shocks at all levels of turbulence. CONCLUSION: Some AEDs designed primarily for ground use may not perform well under turbulent in-flight conditions. AEDs for possible in-flight or other non-terrestrial use should be fully evaluated by manufacturers or end-users before introduction to service.

Comparison of outcomes in emergency department patients with suspected cardiac chest pain: two-centre prospective observational study in Southern China.

BACKGROUND: Hong Kong (HK) and Guangzhou (GZ) are cities in China with different healthcare systems. This study aimed to compare 30-day and 6-month mortality and characteristics of patients with suspected cardiac chest pain admitted to two emergency departments (ED) in HK and GZ. METHODS: A prospective observational study enrolled patients with suspected cardiac chest pain presenting to EDs in the Prince of Wales Hospital (PWH), HK and the Second Affiliated Hospital of Guangzhou Medical University (AHGZMU),GZ. The primary outcome was 30-day and 6-month mortality. RESULTS: In total, 996 patients were recruited, 407 cases from GZ and 589 cases from HK.The 30-day and 6-month mortality of chest patients were 3.7% and 4.7% in GZand 0.3% and 1.9% in HK, respectively. Serum creatinine level (Cr) was an independent factor for 30-day mortality whilst Cr and systolic blood pressure (SBP) were independent factors for 6-month mortality. In Cox regression analysis, unadjusted and adjusted hazard ratios for 30-day and 6-month mortality in GZ were significantly increased. CONCLUSION: The 30-day and 6-month mortality of patients with suspected cardiac chest pain in Guangzhou were higher than in Hong Kong due to due to different baseline clinical characteristics of patients and different distributions of diagnoses, which were associated with different healthcare systems. Serum creatinine and SBP were independent factors for 30-day and 6-month mortality.