Road Traffic Injuries in South Africa: A Complex Global Health Crisis.

1.3 million people die each year as a result of Road traffic crashes. Road Traffic Injuries are a global health crisis with 90% of global deaths affecting LMICs. Sustainable Development Goal 3.6 focuses on reducing road injury and death. The global plan is based on the Safe Systems approach. In South Africa, the burden of crashes on the health system and society is particularly high with a population death rate of 20.7 per 100 000 population. Understanding local context and culture is critical. Rurality, distorted urban planning, higher travel exposure and alcohol usage disproportionately impact racial and ethnic minorities. Pedestrian safety is a key priority. There is a critical need for the global health community to take an active role in advocacy in order to achieve SDG 3.6 by 2030.

Patterns of on-scene and healthcare system trauma deaths in the Western Cape of South Africa.

BACKGROUND: Injuries account for 8% or 4.4 million deaths annually worldwide, with 90% of injury deaths occurring in low- and middle-income countries. Inter-personal violence and road traffic injuries account for most injury deaths in South Africa, with rates among the highest globally. Understanding the location, timing, and factors of trauma deaths can identify opportunities to strengthen care. METHODS: This is a retrospective cross-sectional secondary analysis of trauma deaths from 2021 to 2022 in the Western Cape of South Africa. Healthcare system trauma deaths were identified from a multicenter study paired with a dataset for on-scene (i.e., prior to ambulance or hospital) trauma deaths in the same jurisdictions. We describe locations, timing, injury factors, and cause of death. We assess associations between those factors. RESULTS: There were 2418 deaths, predominantly young men, with most (2274, 94.0%) occurring on-scene. The most frequent mechanism of injury for all deaths was firearms (32.6%), followed by road traffic collisions (17.8%). On-scene deaths (33.2%) were significantly more likely to be injured by firearms compared to healthcare system deaths (23.6%) (p-value <0.01). Most healthcare system deaths within 4-24 h of injury occurred in a hospital emergency center. Among healthcare system decedents, half died in the emergency unit. CONCLUSIONS: We identified a large burden of deaths from interpersonal violence and road traffic collisions, mostly on-scene. In addition to primary prevention, shortening delays to care can improve mortality outcomes especially for deaths occurring within 4-24 h in emergency centers.

Cardiopulmonary resuscitation in low-resource settings: a statement by the International Liaison Committee on Resuscitation, supported by the AFEM, EUSEM, IFEM, and IFRC.

Most recommendations on cardiopulmonary resuscitation were developed from the perspective of high-resource settings with the aim of applying them in these settings. These so-called international guidelines are often not applicable in low-resource settings. Organisations including the International Liaison Committee on Resuscitation (ILCOR) have not sufficiently addressed this problem. We formed a collaborative group of experts from various settings including low-income, middle-income, and high-income countries, and conducted a prospective, multiphase consensus process to formulate this ILCOR Task Force statement. We highlight the discrepancy between current cardiopulmonary resuscitation guidelines and their applicability in low-resource settings. Successful existing initiatives such as the Helping Babies Breathe programme and the WHO Emergency Care Systems Framework are acknowledged. The concept of the chainmail of survival as an adaptive approach towards a framework of resuscitation, the potential enablers of and barriers to this framework, and gaps in the knowledge are discussed, focusing on low-resource settings. Action points are proposed, which might be expanded into future recommendations and suggestions, addressing a large diversity of addressees from caregivers to stakeholders. This statement serves as a stepping-stone to developing a truly global approach to guide resuscitation care and science, including in health-care systems worldwide.

Lessons Learned from a Global Perspective of Coronavirus Disease-2019.

Coronavirus disease-2019 has impacted the world globally. Countries and health care organizations across the globe responded to this unprecedented public health crisis in a varied manner in terms of public health and social measures, vaccination development and rollout, the conduct of research, developments of therapeutics, sharing of information, and in how they continue to deal with the widespread aftermath. This article reviews the various elements of the global response to the pandemic, focusing on the lessons learned and strategies to consider during future pandemics.

Mapping access to care and identification of barriers for traumatic brain injury in a South African township.

RATIONALE: South Africa has a high traumatic injury burden resulting in a significant number of persons suffering from traumatic brain injury (TBI). TBI is a time-sensitive condition requiring a responsive and organized health system to minimize morbidity and mortality. This study outlined the barriers to accessing TBI care in a South African township. METHODS: This was a multimethod study. A facility survey was carried out on health facilities offering trauma care in Khayelitsha township, Cape Town, South Africa. Perceived barriers to accessing TBI care were explored using qualitative interviews and focus group discussions. The four-delay framework that describes delays in four phases was used: seeking, reaching, receiving, and remaining in care. We purposively recruited individuals with a history of TBI (n = 6) and 15 healthcare professionals working with persons with TBI (seven individuals representing each of the five facilities, the heads of neurosurgery and emergency medical services and eight additional healthcare providers who participated in the focus group discussions). Quantitative data were analysed descriptively while qualitative data were analysed thematically, following inductive and deductive approaches. FINDINGS: Five healthcare facilities (three community health centres, one district hospital and one tertiary hospital) were surveyed. We conducted 13 individual interviews (six with persons with TBI history, seven with healthcare providers from each of the five facilities, neurosurgery department and emergency medical service heads and two focus group discussions involving eight additional healthcare providers. Participants mentioned that alcohol abuse and high neighbourhood crime could lead to delays in seeking and reaching care. The most significant barriers reported were related to receiving definitive care, mostly due to a lack of diagnostic imaging at community health centres and the district hospital, delays in interfacility transfers due to ambulance delays and human and infrastructural limitations. A barrier to remaining in care was the lack of clear communication between persons with TBI and health facilities regarding follow-up care. CONCLUSION: Our study revealed that various individual-level, community and health system factors impacted TBI care. Efforts to improve TBI care and reduce injury-related morbidity and mortality must put in place more community-level security measures, institute alcohol regulatory policies, improve access to diagnostics and invest in hospital infrastructures.

Defining and identifying critical elements of, and lessons learned from addressing, 'operational readiness' for public health emergency events, including COVID-19: a scoping review protocol.

INTRODUCTION: Much is known around public health preparedness and response phases. However, between the two phases is operational readiness that comprises the immediate actions needed to respond to a developing risk or hazard. Currently, emergency readiness is embedded in multiple frameworks and policy documents related to the health emergency cycle. However, knowledge about operational readiness' critical readiness components and actions required by countries to respond to public health eminent threat is not well known. Therefore, we aim to define and identify the critical elements of 'operational readiness' for public health emergencies, including COVID-19, and identify lessons learnt from addressing it, to inform the WHO Operational Readiness Framework. METHODS AND ANALYSIS: This is a scoping review following the Joanna Briggs Institute guidance. Reporting will be according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist. MEDLINE, Embase and Web of Science databases and grey literature will be searched and exported into an online systematic review software (eg, Rayyan in this case) for review. The review team, which apart from scoping review methodological experts include content experts in health systems and public health and emergency medicine, prepared an a priori study protocol in consultation with WHO representatives. ATLAS.ti V.9 will be used to conduct thematic data analysis as well as store, organise and retrieve data. Data analysis and presentation will be carried out by five reviewers. ETHICS AND DISSEMINATION: This review will reveal new insights, knowledge and lessons learnt that will translate into an operational framework for readiness actions. In consultation with WHO, findings will be disseminated as appropriate (eg, through professional bodies, conferences and research papers). No ethics approvals are required as no humans will be involved in data collection. PROTOCOL REGISTRATION: This rapid scoping review has been registered on Open Science Framework (doi:10.17605/OSF.IO/6SYAH).

A living WHO guideline on drugs to prevent covid-19.

CLINICAL QUESTION: What is the role of drugs in preventing covid-19? WHY DOES THIS MATTER?: There is widespread interest in whether drug interventions can be used for the prevention of covid-19, but there is uncertainty about which drugs, if any, are effective. The first version of this living guideline focuses on the evidence for hydroxychloroquine. Subsequent updates will cover other drugs being investigated for their role in the prevention of covid-19. RECOMMENDATION: The guideline development panel made a strong recommendation against the use of hydroxychloroquine for individuals who do not have covid-19 (high certainty). HOW THIS GUIDELINE WAS CREATED: This living guideline is from the World Health Organization (WHO) and provides up to date covid-19 guidance to inform policy and practice worldwide. Magic Evidence Ecosystem Foundation (MAGIC) provided methodological support. A living systematic review with network analysis informed the recommendations. An international guideline development panel of content experts, clinicians, patients, an ethicist and methodologists produced recommendations following standards for trustworthy guideline development using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. UNDERSTANDING THE NEW RECOMMENDATION: The linked systematic review and network meta-analysis (6 trials and 6059 participants) found that hydroxychloroquine had a small or no effect on mortality and admission to hospital (high certainty evidence). There was a small or no effect on laboratory confirmed SARS-CoV-2 infection (moderate certainty evidence) but probably increased adverse events leading to discontinuation (moderate certainty evidence). The panel judged that almost all people would not consider this drug worthwhile. In addition, the panel decided that contextual factors such as resources, feasibility, acceptability, and equity for countries and healthcare systems were unlikely to alter the recommendation. The panel considers that this drug is no longer a research priority and that resources should rather be oriented to evaluate other more promising drugs to prevent covid-19. UPDATES: This is a living guideline. New recommendations will be published in this article and signposted by update notices to this guideline. READERS NOTE: This is the first version of the living guideline for drugs to prevent covid-19. It complements the WHO living guideline on drugs to treat covid-19. When citing this article, please consider adding the update number and date of access for clarity.

A living WHO guideline on drugs to prevent COVID-19

Clinical question What is the role of drugs in preventing covid-19? Why does this matter?There is widespread interest in whether drug interventions can be used for the prevention of covid-19, but there is uncertainty about which drugs, if any, are effective. The first version of this living guideline focuses on the evidence for hydroxychloroquine. Subsequent updates will cover other drugs being investigated for their role in the prevention of covid-19. The guideline development panel made a strong recommendation against the use of hydroxychloroquine for individuals who do not have covid-19 (high certainty). How this guideline was created This living guideline is from the World Health Organization (WHO) and provides up to date covid-19 guidance to inform policy and practice worldwide. Magic Evidence Ecosystem Foundation (MAGIC) provided methodological support. A living systematic review with network analysis informed the recommendations. An international guideline development panel of content experts, clinicians, patients, an ethicist and methodologists produced recommendations following standards for trustworthy guideline development using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Understanding the new recommendation The linked systematic review and network meta-analysis (6 trials and 6059 participants) found that hydroxychloroquine had a small or no effect on mortality and admission to hospital (high certainty evidence). There was a small or no effect on laboratory confirmed SARS-CoV-2 infection (moderate certainty evidence) but probably increased adverse events leading to discontinuation (moderate certainty evidence). The panel judged that almost all people would not consider this drug worthwhile. In addition, the panel decided that contextual factors such as resources, feasibility, acceptability, and equity for countries and healthcare systems were unlikely to alter the recommendation. The panel considers that this drug is no longer a research priority and that resources should rather be oriented to evaluate other more promising drugs to prevent covid-19. Updates This is a living guideline. New recommendations will be published in this article and signposted by update notices to this guideline.

A successful hybrid emergency medicine postgraduate partnership in Southern Africa.

Emergency Medicine (EM) development is established worldwide and fast developing in Sub-Saharan Africa. Medical specialty development requires multiple human resources and logistics which are frequently not available in LMICs. This article describes an innovative hybrid EM specialization program in Botswana that involved partnership with a neighbouring country in Sub-Saharan Africa. Many initial problems challenged its development, but significant local and regional support led to success. Botswana graduated its first three EM specialists in 2018 and now has an ongoing and sustainable EM program. This regional partnership resulted in numerous academic, research and clinical EM developments for Botswana and SA. UB-UCT EM training Partnership Model is a novel and sustainable cross- African collaboration with significant benefits for both health systems as well as for the individual trainees. This hybrid arrangement should be considered by other LMICs looking for EM specialty training and development.

Advanced life support courses in Africa: Certification, availability and perceptions.

BACKGROUND: Advanced life support (ALS) short training courses are in demand across Africa, though overwhelmingly designed and priced for non-African contexts. The continental expansion of emergency care is driving wider penetration of these courses, but their relevance and accessibility is not known. We surveyed clinicians within emergency settings to describe ALS courses' prevalence and perceived value in Africa. METHODS: We conducted a cross-sectional quantitative analysis of 235 clinicians' responses to the African Federation for Emergency Medicine's online needs assessment for an open-access ALS course in Africa. Participants responded to multiple-choice and open answer questions assessing demographics, ALS course certification and availability, perceptions of ALS courses, and barriers and facilitators to undertaking such courses. RESULTS: 235 clinicians working in 23 African nations responded. Most clinicians reported ALS course completion within the past three years (73%) and in-country access to ALS courses (76%). Most believed the content adequately met their region's needs (60%). Price and course availability were the most common barriers to taking an ALS course. The most common courses were cardiac and paediatric-focused, and the most common reasons to take a course included general career development, personal interest, and departmental requirements. CONCLUSION: One-quarter of emergency care clinicians lack access to ALS courses in twenty-three African nations. Most clinicians believe that ALS courses have value in their clinical settings and meet the needs of their region. Our findings illustrate the need for an affordable, widely available ALS course tailored to lower-resource African settings that could reach rural and peri-urban clinicians.

Cross-Sectional Survey of Former International Emergency Medicine Fellows 2010-19.

INTRODUCTION: International emergency medicine is a new subspecialty within emergency medicine. International emergency medicine (EM) fellowships have been in existence for more than 10 years, but data is limited on the experiences of the fellows. Our goal in this study was to understand the fellowship experience. METHODS: The study employed a cross-sectional survey in which participants were asked about their demographics, fellowship program, and advanced degree. Participants consisted of former fellows who completed the fellowship between 2010-19. The survey consisted of both closed and open-ended questions to allow for further explanation of former fellows' experience. Descriptive analysis was conducted on the quantitative survey data while content analysis was conducted to ascertain salient themes from the open-ended questions. RESULTS: We contacted 71 former fellows, of whom 40 started and 36 completed surveys, for a 51% response rate (55.6% women). Two-year fellowships predominated, with 69.4% of respondents. Prior to fellowship, a subset of fellows spoke the native languages of their service sites: French, Spanish, Haitian Creole, Mandarin, or Kiswahili. Half the respondents spent 26-50% of their fellowship in field work, with 83.3% of institutions providing direct funding for this component. Many respondents stated a need for further institutional support (money or infrastructure) for fieldwork and mentoring. Non-governmental organizations comprised 29.7% of respondents' work partners, while 28.6% were with academic institutions in country, focused mostly on education, health systems development, and research. The vast majority (92%) of respondents continued working in global EM, with the majority based in American academic institutions. Those who did not cited finances and lack of institutional support as main reasons. CONCLUSION: This study describes the fellow experience in international EM. The majority of fellows completed a two-year fellowship with 26-50% of their time spent in fieldwork with 83.3% of institutions providing funding. The challenges in pursuing a long-term career in global EM included the cost of international work, inadequate mentorship, and departmental funding.

South African paramedic perspectives on prehospital palliative care.

BACKGROUND: Palliative care is typically performed in-hospital. However, Emergency Medical Service (EMS) providers are uniquely positioned to deliver early palliative care as they are often the first point of medical contact. The aim of this study was to gather the perspectives of advanced life support (ALS) providers within the South African private EMS sector regarding pre-hospital palliative care in terms of its importance, feasibility and barriers to its practice. METHODS: A qualitative study design employing semi-structured one-on-one interviews was used. Six interviews with experienced, higher education qualified, South African ALS providers were conducted. Content analysis, with an inductive-dominant approach, was performed to identify categories within verbatim transcripts of the interview audio-recordings. RESULTS: Four categories arose from analysis of six interviews: 1) need for pre-hospital palliative care, 2) function of pre-hospital healthcare providers concerning palliative care, 3) challenges to pre-hospital palliative care and 4) ideas for implementing pre-hospital palliative care. According to the interviewees of this study, pre-hospital palliative care in South Africa is needed and EMS providers can play a valuable role, however, many challenges such as a lack of education and EMS system and mindset barriers exist. CONCLUSION: Challenges to pre-hospital palliative care may be overcome by development of guidelines, training, and a multi-disciplinary approach to pre-hospital palliative care.

Paediatric Emergency Department preparedness in Nigeria: A prospective cross-sectional study.

INTRODUCTION: Paediatric emergency medicine (PEM) is poorly developed in low and middle-income countries. The magnitude of challenges facing Paediatric Emergency Departments (PEDs) in Nigeria has not been well described. This study aimed to assess paediatric emergency care preparedness across PEDs in Nigeria. METHODS: This was a prospective cross-sectional study that utilized a self-administered questionnaire and a check list to assess three key domains (managerial, medication and equipment) in tertiary care PED facilities that were recruited across Nigeria. Preparedness scores and other institutional attributes were compared between zones and regions. RESULTS: Thirty-four tertiary-level PEDs across Nigeria were included. The mean number of patient visits over the 30-day period prior to data collection was 253.2 (±261.2). The mean (SD) managerial, medication and equipment performance scores of the included PEDs were 42.9% (±14.3%), 50.7% (±22.3%) and 43.9% (±11.8%) respectively. The mean (SD) total performance score was 46.9% (±15.3%). Only 13 PEDs had a total performance score of >50%. There was a statistically significant higher mean equipment score (p = 0.029) in the Southern region (47.6 ± 3.1) compared to the Northern region (38.9 ± 2.3) of the country. CONCLUSIONS: This study reports a global but remediable deficiency in emergency care preparedness amongst PEDs in tertiary care facilities in Nigeria. This study highlights the need for training of PED managers in basic and advanced life support and for the improvement in medication and equipment procurement across Nigeria.

A living WHO guideline on drugs for covid-19

Updates: This is the fourteenth version (thirteenth update) of the living guideline, replacing earlier versions (available as data supplements). New recommendations will be published as updates to this guideline. Clinical question: What is the role of drugs in the treatment of patients with covid-19? Context: The evidence base for therapeutics for covid-19 is evolving with numerous randomised controlled trials (RCTs) recently completed and underway. Emerging SARS-CoV-2 variants and subvariants are changing the role of therapeutics. What is new?: The guideline development group (GDG) defined 1.5% as a new threshold for an important reduction in risk of hospitalisation in patients with non-severe covid-19. Combined with updated baseline risk estimates, this resulted in stratification into patients at low, moderate, and high risk for hospitalisation. New recommendations were added for moderate risk of hospitalisation for nirmatrelvir/ritonavir, and for moderate and low risk of hospitalisation for molnupiravir and remdesivir. New pharmacokinetic evidence was included for nirmatrelvir/ritonavir and molnupiravir, supporting existing recommendations for patients at high risk of hospitalisation. The recommendation for ivermectin in patients with non-severe illness was updated in light of additional trial evidence which reduced the high degree of uncertainty informing previous guidance. A new recommendation was made against the antiviral agent VV116 for patients with non-severe and with severe or critical illness outside of randomised clinical trials based on one RCT comparing the drug with nirmatrelvir/ritonavir. The structure of the guideline publication has also been changed; recommendations are now ordered by severity of covid-19. About this guideline: This living guideline from the World Health Organization (WHO) incorporates new evidence to dynamically update recommendations for covid-19 therapeutics. The GDG typically evaluates a therapy when the WHO judges sufficient evidence is available to make a recommendation. While the GDG takes an individual patient perspective in making recommendations, it also considers resource implications, acceptability, feasibility, equity, and human rights. This guideline was developed according to standards and methods for trustworthy guidelines, making use of an innovative process to achieve efficiency in dynamic updating of recommendations. The methods are aligned with the WHO Handbook for Guideline Development and according to a pre-approved protocol (planning proposal) by the Guideline Review Committee (GRC). A box at the end of the article outlines key methodological aspects of the guideline process. MAGIC Evidence Ecosystem Foundation provides methodological support, including the coordination of living systematic reviews with network meta-analyses to inform the recommendations. The full version of the guideline is available online in MAGICapp and in PDF on the WHO website, with a summary version here in The BMJ. These formats should facilitate adaptation, which is strongly encouraged by WHO to contextualise recommendations in a healthcare system to maximise impact. Future recommendations: Recommendations on anticoagulation are planned for the next update to this guideline. Updated data regarding systemic corticosteroids, azithromycin, favipiravir and umefenovir for non-severe illness, and convalescent plasma and statin therapy for severe or critical illness, are planned for review in upcoming guideline iterations.

Harnessing inter-disciplinary collaboration to improve emergency care in low- and middle-income countries (LMICs): results of research prioritisation setting exercise.

BACKGROUND: More than half of deaths in low- and middle-income countries (LMICs) result from conditions that could be treated with emergency care - an integral component of universal health coverage (UHC) - through timely access to lifesaving interventions. METHODS: The World Health Organization (WHO) aims to extend UHC to a further 1 billion people by 2023, yet evidence supporting improved emergency care coverage is lacking. In this article, we explore four phases of a research prioritisation setting (RPS) exercise conducted by researchers and stakeholders from South Africa, Egypt, Nepal, Jamaica, Tanzania, Trinidad and Tobago, Tunisia, Colombia, Ethiopia, Iran, Jordan, Malaysia, South Korea and Phillipines, USA and UK as a key step in gathering evidence required by policy makers and practitioners for the strengthening of emergency care systems in limited-resource settings. RESULTS: The RPS proposed seven priority research questions addressing: identification of context-relevant emergency care indicators, barriers to effective emergency care; accuracy and impact of triage tools; potential quality improvement via registries; characteristics of people seeking emergency care; best practices for staff training and retention; and cost effectiveness of critical care - all within LMICs. CONCLUSIONS: Convened by WHO and facilitated by the University of Sheffield, the Global Emergency Care Research Network project (GEM-CARN) brought together a coalition of 16 countries to identify research priorities for strengthening emergency care in LMICs. Our article further assesses the quality of the RPS exercise and reviews the current evidence supporting the identified priorities.

A living WHO guideline on drugs for COVID-19

What is the role of drug interventions in the treatment of patients with covid-19? The latest version of this WHO living guidance focuses on remdesivir, following the 15 October 2020 preprint publication of results from the WHO SOLIDARITY trial. It contains a weak or conditional recommendation against the use of remdesivir in hospitalised patients with covid-19 The first version on this living guidance focused on corticosteroids. The strong recommendation for systemic corticosteroids in patients with severe and critical covid-19, and a weak or conditional recommendation against systemic corticosteroids in patients with non-severe covid-19 are unchanged.

Remdesivir for severe COVID-19: a clinical practice guideline

Clinical question: What is the role of remdesivir in the treatment of severe covid-19? This guideline was triggered by the ACTT-1 trial published in the New England Journal of Medicine on 22 May 2020.Remdesivir has received worldwide attention as a potentially effective treatment for severe covid-19. After rapid market approval in the US, remdesivir is already being used in clinical practice. The guideline panel makes a weak recommendation for the use of remdesivir in severe covid-19 while recommending continuation of active enrolment of patients into ongoing randomised controlled trials examining remdesivir.How this guideline was created: An international panel of patients, clinicians, and methodologists produced these recommendations in adherence with standards for trustworthy guidelines using the GRADE approach. The recommendations are based on a linked systematic review and network meta-analysis. The panel considered an individual patient perspective and allowed contextual factors (such as resources) to be taken into account for countries and healthcare systems.The evidence: The linked systematic review (published 31 Jul 2020) identified two randomised trials with 1300 participants, showing low certainty evidence that remdesivir may be effective in reducing time to clinical improvement and may decrease mortality in patients with severe covid-19. Remdesivir probably has no important effect on need for invasive mechanical ventilation. Remdesivir may have little or no effect on hospital length of stay.Understanding the recommendation: Most patients with severe covid-19 would likely choose treatment with remdesivir given the potential reduction in time to clinical improvement. However, given the low certainty evidence for critical outcomes and the fact that different perspectives, values, and preferences may alter decisions regarding remdesivir, the panel issued a weak recommendation with strong support for continued recruitment in randomised trials.

Remdesivir for severe covid-19: a clinical practice guideline.

CLINICAL QUESTION: What is the role of remdesivir in the treatment of severe covid-19? This guideline was triggered by the ACTT-1 trial published in the New England Journal of Medicine on 22 May 2020. CURRENT PRACTICE: Remdesivir has received worldwide attention as a potentially effective treatment for severe covid-19. After rapid market approval in the US, remdesivir is already being used in clinical practice. RECOMMENDATIONS: The guideline panel makes a weak recommendation for the use of remdesivir in severe covid-19 while recommending continuation of active enrolment of patients into ongoing randomised controlled trials examining remdesivir. HOW THIS GUIDELINE WAS CREATED: An international panel of patients, clinicians, and methodologists produced these recommendations in adherence with standards for trustworthy guidelines using the GRADE approach. The recommendations are based on a linked systematic review and network meta-analysis. The panel considered an individual patient perspective and allowed contextual factors (such as resources) to be taken into account for countries and healthcare systems. THE EVIDENCE: The linked systematic review (published 31 Jul 2020) identified two randomised trials with 1300 participants, showing low certainty evidence that remdesivir may be effective in reducing time to clinical improvement and may decrease mortality in patients with severe covid-19. Remdesivir probably has no important effect on need for invasive mechanical ventilation. Remdesivir may have little or no effect on hospital length of stay. UNDERSTANDING THE RECOMMENDATION: Most patients with severe covid-19 would likely choose treatment with remdesivir given the potential reduction in time to clinical improvement. However, given the low certainty evidence for critical outcomes and the fact that different perspectives, values, and preferences may alter decisions regarding remdesivir, the panel issued a weak recommendation with strong support for continued recruitment in randomised trials.

Emergency Medicine Training Programs in Low- and Middle-Income Countries: A Systematic Review.

Background: Despite the growing interest in the development of emergency care systems and emergency medicine (EM) as a specialty globally, there still exists a significant gap between the need for and the provision of emergency care by specialty trained providers. Many efforts to date to expand the practice of EM have focused on programs developed through partnerships between higher- and lower-resource settings. Objective: To systematically review the literature to evaluate the composition of EM training programs in low- and middle-income countries (LMICs) developed through partnerships. Methods: An electronic search was conducted using four databases for manuscripts on EM training programs - defined as structured education and/or training in the methods, procedures, and techniques of acute or emergency care - developed through partnerships. The search produced 7702 results. Using a priori inclusion and exclusion criteria, 94 manuscripts were included. After scoring these manuscripts, a more in-depth examination of 26 of the high-scoring manuscripts was conducted. Findings: Fifteen highlight programs with a focus on specific EM content (i.e. ultrasound) and 11 cover EM programs with broader scopes. All outline programs with diverse curricula and varied educational and evaluative methods spanning from short courses to full residency programs, and they target learners from medical students and nurses to mid-level providers and physicians. Challenges of EM program development through partnerships include local adaptation of international materials; addressing the local culture(s) of learning, assessment, and practice; evaluation of impact; sustainability; and funding. Conclusions: Overall, this review describes a diverse group of programs that have been or are currently being implemented through partnerships. Additionally, it highlights several areas for program development, including addressing other topic areas within EM beyond trauma and ultrasound and evaluating outcomes beyond the level of the learner. These steps to develop effective programs will further the advancement of EM as a specialty and enhance the development of effective emergency care systems globally.