Development of an acute medical unit to optimize patient flow and early discharges in a tertiary care hospital in the United Arab Emirates.

BACKGROUND: Hospitals worldwide are seeing an increased number of acute admissions, with resultant emergency department (ED) crowding and increased length of stay (LOS). Acute Medical Units (AMUs) have developed throughout the United Kingdom and other Western countries to reduce the burden on EDs and improve patient flow. Limited information is available on AMUs in the Middle East. The purpose of this study is to describe the development of the first AMU in the United Arab Emirates (UAE) for general medical patients and its impact on LOS, early discharges, ED boarders, and readmission rates. METHODS: We established a consultant-led AMU in a tertiary hospital in the UAE. A retrospective comparative review of all general medical admissions to the AMU between August 1, 2020 and December 31, 2020 and all admissions to the traditional medical wards between August 1, 2019 and December 31, 2019 was conducted. RESULTS: The average LOS reduced from 10 to 5 days (95% CI [4.14-6.25], p < 0.001) after the introduction of AMU. Early discharges increased by 22%. The number of outliers and number of patients boarding in ED reduced significantly (111 in 2019 vs. 60 in 2020, p < 0.05; 938 in 2019 vs. 104 in 2020, p < 0.001 respectively), with a decrease in ED waiting time from 394 min to 134 min (95% CI [229.25-290.75], p < 0.001). There was no increase in 30-day readmission rates. CONCLUSION: Restructuring the system of care can reduce LOS, overcome discharge barriers and improve patient flow. Similar units can be developed in hospitals throughout the UAE and the region to reduce LOS and improve patient flow through acute care units.

Central nervous system toxicity of mefenamic acid overdose compared with other NSAIDs: an analysis of cases reported to the United Kingdom National Poisons Information Service.

AIMS: Case reports and small case series suggest increased central nervous system (CNS) toxicity, especially convulsions, after overdose of mefenamic acid, compared with other nonsteroidal anti-inflammatory drugs (NSAIDs), although comparative epidemiological studies have not been conducted. The current study compared rates of CNS toxicity after overdose between mefenamic acid, ibuprofen, diclofenac and naproxen, as reported in telephone enquiries to the UK National Poisons Information Service (NPIS). METHODS: NPIS telephone enquiries related to the four NSAIDs, received between January 2007 and December 2013, were analysed, comparing the frequency of reported CNS toxicity (convulsions, altered conscious level, agitation or aggression, confusion or disorientation) using multivariable logistic regression. RESULTS: Of 22 937 patient-specific telephone enquiries, 10 398 did not involve co-ingestion of other substances (mefenamic acid 461, ibuprofen 8090, diclofenac 1300, naproxen 547). Patients taking mefenamic acid were younger and more commonly female than those using other NSAIDs. Those ingesting mefenamic acid were more likely to experience CNS toxicity than those ingesting the other NSAIDs combined [adjusted odds ratio (OR) 7.77, 95% confidence interval (CI) 5.68, 10.62], especially convulsions (adjusted OR 81.5, 95% CI 27.8, 238.8). Predictors of CNS toxicity included reported dose and age, but not gender. CONCLUSIONS: Mefenamic acid overdose is associated with a much larger and dose-related risk of CNS toxicity, especially convulsions, compared with overdose of other NSAIDs. The benefit-risk profile of mefenamic acid should now be re-evaluated in light of effective and less toxic alternatives.

Increasing frequency of severe clinical toxicity after use of 2,4-dinitrophenol in the UK: a report from the National Poisons Information Service.

OBJECTIVE: 2,4-Dinitrophenol (DNP) increases energy consumption by uncoupling oxidative phosphorylation. Although not licensed as a medicine, it is sometimes used by 'body sculptors' and for weight loss as a 'fat burning' agent. This research was performed to characterise patterns of presentation, clinical features and outcomes of patients reported to the National Poisons Information Service (NPIS) in the UK after exposure to DNP. METHODS: NPIS telephone enquiry records and user sessions for TOXBASE, the NPIS online information database, related to DNP, were reviewed from 1 January 2007 to 31 December 2013. RESULTS: Of the 30 separate systemic exposures to DNP reported by telephone to NPIS during the study period (27 males, 3 females, with a median age of 23.5 years), there were 3 during 2007-2011 (inclusive), 5 during 2012 and 22 during 2013. TOXBASE user sessions also increased sharply from 6 in 2011 to 35 in 2012 and 331 in 2013. The modes of exposure reported in telephone enquiries were chronic (n=2), acute (n=12) and subacute (n=16). Commonly reported clinical features were fever (47%), tachycardia (43%), sweating (37%), nausea or vomiting (27%), skin discolouration or rash (23%), breathing difficulties (23%), abdominal pain (23%), agitation (13%) and headache (13%). There were five (17%, 95% CI 6.9% to 34%) fatalities, four involving acute overdose. CONCLUSIONS: The study indicates a substantial recent increase in clinical presentations with toxicity caused by exposure to DNP in the UK with an associated high mortality. Further steps are needed to warn potential users of the severe and sometimes fatal toxicity that may occur after exposure to this compound.

Clinical characteristics of patients with mpox infection in the United Arab Emirates: a prospective cohort study.

OBJECTIVES: The study aims to explore the risk factors, clinical characteristics, and outcomes of mpox infection in Abu Dhabi, United Arab Emirates (UAE). METHODS: A prospective cohort study was conducted at two communicable disease centers in Abu Dhabi, UAE and patients admitted with confirmed mpox infections between May 01, 2022 and December 31, 2022 were included in our study. RESULTS: A total of 176 mpox patients were admitted, of which 93% (n = 164) were men and mean age was 30.4 ± 7 years. Individuals presented with mucocutaneous lesions, most commonly on the genital and anal regions (n = 157; 89%). Only 70 (39.8%) gave a history of sexual exposure. The most common systemic symptoms reported were fever (n = 91; 52%), exanthema (n = 92; 52%), and inguinal lymphadenopathy (n = 60; 34%). Median timeframe from systemic symptoms to appearance of lesions was 4 days (interquartile range 4-6 days). Complications were observed in seven (4%) participants; two (1.1%) individuals developed conjunctivitis, four (2.3%) patients developed penile edema, and one (0.6%) case of myocarditis was reported. In 60% (n = 106) of patients, a potential source of sexual exposure was not identified. CONCLUSION: The clinical characteristics of mpox cases in the UAE are similar to those in other countries. However, cultural and religious factors likely prevent patient disclosure of sexual exposure and symptoms, contributing to the limited information about the disease in the Middle East.

The Impact of an Acute Medical Unit in Internal Medicine on Resident Education.

Background: Medical trainees are expected to provide care for increasingly sick and treatment intensive patients. To improve patient care, hospitals worldwide have developed acute medical units (AMUs), dedicated medical wards that provide care for patients during the first 24 to 72 hours of an emergency medical hospital admission. A distinguishing feature of these units is that they are supervised by senior clinicians and offer multidisciplinary patient-centered care. Little is known about the impact of AMUs on trainee supervision and education. Methods: In this educational case study, we describe the evolution, process and structure of our AMU service. We also provide resident and teaching faculty perceptions of the impact of this intervention on education and supervision. Results: Questionnaire results showed that residents and teaching attendings believed that supervision and education were improved on the AMU, as compared to the traditional medical ward model. Residents also felt that their knowledge and clinical skills in managing acute patients improved. Procedure skills were less impacted by the intervention. A small number of residents believed that the AMU model worsened supervision and education. Conclusion: Integrating medical trainees into an AMU allowed for early evaluation and input from senior clinicians and increased opportunities to work in and learn from multidisciplinary teams, contributing to improved resident supervision and education. Future studies are needed to assess the long-term impact of the AMU on educational outcomes.

Effectiveness of BBIBP-CorV vaccine against severe outcomes of COVID-19 in Abu Dhabi, United Arab Emirates.

The effectiveness of the inactivated BBIBP-CorV vaccine against severe COVID-19 outcomes (hospitalization, critical care admission and death due to COVID-19) and its long-term effectiveness have not been well characterized among the general population. We conducted a retrospective cohort study using electronic health records of 3,147,869 adults, of which 1,099,886 vaccinated individuals were matched, in a 1:1 ratio to 1,099,886 unvaccinated persons. A Cox-proportional hazard model with time varying coefficients was used to assess the vaccine effectiveness adjusting for age, sex, comorbidity, ethnicity, and the calendar month of entry into the study. Our analysis showed that the effectiveness was 79.6% (95% CI, 77.7 to 81.3) against hospitalization, 86% (95% CI, 82.2 to 89.0) against critical care admission, and 84.1% (95% CI, 70.8 to 91.3) against death due to COVID-19. The effectiveness against these severe outcomes declined over time indicating the need for booster doses to increase protection against severe COVID-19 outcomes.

Post-infectious and post-acute sequelae of critically ill adults with COVID-19.

BACKGROUND: Data on the post-acute and post-infectious complications of patients who have recovered from severe coronavirus disease 2019 (COVID-19) are limited. While studies report that approximately 5-15% of COVID-19 hospitalized patients require intensive care and mechanical ventilation, a substantially higher number need non-invasive ventilation and are subject to prolonged hospitalizations, with long periods of immobility and isolation. The purpose of this study is to describe the post-infectious sequelae of severe viral illness and the post-acute complications of intensive care treatments in critically ill patients who have recovered from severe COVID-19 infection. METHODS: We performed a retrospective chart review of adult patients initially hospitalized with confirmed COVID-19 infection, who recovered and were transferred to a general medical ward or discharged home between March 15, 2020 and May 15, 2020, dates inclusive, after an intensive care unit (ICU) or high dependency unit (HDU) admission in a designated COVID-19 hospital in the United Arab Emirates. Demographic data, underlying comorbidities, treatment, complications, and outcomes were collected. Descriptive statistical analyses were performed. RESULTS: Of 71 patients transferred out of ICU (n = 38, 54%) and HDU (n = 33, 46%), mean age was 48 years (SD, 9.95); 96% men; 54% under age 50. Mean ICU stay was 12.4 days (SD, 5.29), HDU stay was 13.4 days (SD, 4.53). Pre-existing conditions were not significantly associated with developing post-acute complications (Odds Ratio [OR] 1.1, 95% confidence interval [CI] 0.41, 2.93, p = 1.00). Fifty nine percent of patients had complications; myopathy, swallowing impairments, and pressure ulcers were most common. Delirium and confusion were diagnosed in 18% (n = 13); all were admitted to the ICU and required mechanical ventilation. Of note, of all patients studied, 59.2% (n = 42/71) had at least 1 complication, 32.4% (n = 23) had at least 2 complications, and 19.7% (n = 14) suffered 3 or more sequelae. Complications were significantly more common in ICU patients (n = 33/38, 87%), compared to HDU patients (n = 9/33, 27%) (OR 17.6, 95% CI 5.23, 59.21, p <0.05). CONCLUSION: In a subset of critically ill patients who recovered from severe COVID-19 infection, there was considerable short-term post-infectious and post-acute disability. Long-term follow-up of COVID-19 survivors is warranted.

Covid-19 pandemic research opportunity: Is the Middle East & North Africa (MENA) missing out?

BACKGROUND: The Covid-19 pandemic has caused fear and panic worldwide, forcing healthcare systems to disregard conventional practices and adopt innovation to contain the infection and death. Globally, there has been a rapid proliferation of research studies and clinical trials assessing risks, infectivity and treatment. METHODS: This review assesses the opportunities and challenges in the Middle East North Africa (MENA) region to engage in the conduct of high quality clinical trials during the Covid-19 pandemic. RESULTS: Opportunities are abundant for conducting clinical trials in MENA countries, including substantial cost savings, academic health centers, integrated health information systems, international accreditation, and international collaborations. Yet, the MENA region has missed out on opportunities to advance patient research during prior infectious disease outbreaks caused by the Severe Acute Respiratory Syndrome, Ebola, and the Middle East Respiratory Syndrome, as evidenced by the lack of concerted research and clinical trials from the region. A large vulnerable population, especially the poor expatriate work force, the current isolation of the health centers, and the lack of an expert network or field trained task force, all contribute to challenges preventing the formation of a pan Arab research enterprise for epidemics. CONCLUSION: Quality clinical research is critical during public health emergencies to identify treatments and solutions. The efficient conduct of clinical trials requires innovative strategies in research design, approval, and dissemination. Many countries in the MENA region have an opportunity to quickly ramp up research capacity and contribute significantly to the fight against the Covid-19 global threat.

An exploratory analysis of factors contributing to resident pass rates on a national licensure OSCE in the United Arab Emirates.

PURPOSE: To explore resident perceptions of factors contributing to pass rates on a high-stake licensing objective structured clinical exam (OSCE). MATERIALS AND METHODS: A cross-sectional survey was administered to all 51 applicants of the April 2019 internal medicine Arab Board OSCE examination in Abu Dhabi, United Arab Emirates (UAE), and included questions on preparedness, stress level, and prior educational experiences. Exposures were evaluated for correlation against Arab Board pass rates using Pearson correlation and the two-tailed significance was recorded. RESULTS: All 51 examinees completed the survey (100% response rate). Participants were primarily female n = 35 (67%) and all completed residency training in the UAE. Gender differences were noted, with higher pass rates for the male residents (13/35, 37% females vs. 8/16, 50% males, P < 0.05). Further, 65% (P < 0.001) of female examinees reported higher levels of anxiety than male residents. Examinees reported regular exposure during residency to clinical skills training (74%), standardized patients (71%), simulation (66%), and OSCEs (72%) but none of these educational modalities correlated with higher pass rates. Of multiple exam preparation modalities, only self-directed learning with deliberate practice, the intentional repetition of a task with feedback, was associated with higher pass rates. CONCLUSION: Clinical exam skills are vital for trainees to deliver high-quality primary healthcare services. National licensure OSCEs have become the norm in the Arab world for assessing resident clinical exam skills. Our results suggest that residency programs should encourage residents' intentional deliberate practice and mastery learning in the acquisition and retention of physical examination techniques.

Optimizing Supportive Care in COVID-19 Patients: A Multidisciplinary Approach.

Within just a few months, SARS-CoV-2 has evolved from a virtually unknown pathogen to a leading cause of morbidity and mortality worldwide. As COVID-19 infection can affect multiple organ systems, treating many manifestations and complications requires clinical expertise across the healthcare professional spectrum. Therefore, interprofessional and multidisciplinary collaboration should form the cornerstone of every hospital's COVID-19 management approach. In this manuscript, we discuss the non-microbial management strategies for our COVID-19 inpatient population. Specifically, through an inter-professional and collaborative approach to care delivery, we provide rationale and guidance on prone positioning, oxygen strategies, early mobilization, identifying and treating co-infections, anticoagulation and ensuring appropriate psychological support for patients and their families. It is our hope that these recommendations help supporting clinician management decisions to best care for hospitalized COVID-19 patients in the region and worldwide.

Rapid Development and Utilization of a Clinical Intelligence Dashboard for Frontline Clinicians to Optimize Critical Resources During Covid-19.

INTRODUCTION: The COVID-19 pandemic has created an unprecedented situation where sudden and prolonged surges of critically ill patients have disrupted healthcare systems worldwide A major concern for hospitals worldwide is how to best manage large numbers of COVID-19 infected and non-infected patients, while still maintaining high-quality clinical care. AIM: This manuscript describes the system development, collaborative efforts and the challenges encountered in developing an in-house clinical intelligence dashboard. METHODS: Through a longitudinal, interdepartmental collaboration, a COVID-19 clinical intelligence dashboard was created using Microsoft Power BI and Cerner Computer Language (CCL) to demonstrate clinical severity of patients and patient location in a single screen. A color-coding schema was applied to produce a red highlight for patients whose condition is deteriorating, whether due to increasing oxygen demand or worsening laboratory values. An additional function enabled users to drill down into the patient's clinical and laboratory parameters for the past 5 days, and ultimately to the respective patient chart for further assessment. RESULTS: The development of an in-house clinical intelligence dashboard is a feasible, effective tool to allow frontline clinicians to monitor patient status in multiple wards and proactively intervene as clinically necessary and transfer patients to the appropriate level of care. Comparing the 30 days before and 30 days after the implementation of the dashboard, the percentage of patients who required urgent intubation or cardiac resuscitation on the general medical ward, rather than a critical care setting, declined by over 50% (8 out of 34, 33% vs. 7 out of 55, 13%; two-tailed p < 0.05 by Fisher's exact test; OR 3.43; CI 1.07 to 10.95). CONCLUSION: The dashboard has enabled physicians to efficiently assess patient volumes and case severity to prioritize clinical care and appropriately allocate scarce resources. The dashboard can be replicated by developing healthcare systems that are continuing to grapple with the pandemic.

Clinical toxicity following analytically confirmed use of the synthetic cannabinoid receptor agonist MDMB-CHMICA. A report from the Identification Of Novel psychoActive substances (IONA) study.

CONTEXT: Recreational use of Synthetic Cannabinoid Receptors Agonists (SCRAs) has become increasingly common in many countries and may cause severe toxic effects. OBJECTIVE: To describe the clinical features of toxicity in seven men after analytically confirmed exposure to MDMB-CHMICA, a recently described indole-based SCRA. MATERIALS AND METHODS: Clinical information and biological samples (blood, urine) were collected from patients with severe toxicity after suspected use of novel psychoactive substances. Samples were analyzed by data-independent liquid chromatography-tandem mass spectrometry (LC-MS/MS). CASE REPORTS: All seven cases were men who presented to hospitals in England between July and October 2015; six reported smoking "legal high" products. In all cases, MDMB-CHMICA was identified in blood samples taken on admission to hospital. Other substances were identified in four cases (methadone 1, methiopropamine 1, other SCRAs 2). Clinical features in all seven cases and in the three exposed to MDMB-CHIMICA alone included acidosis (7/7 and 3/3) which was respiratory (3/7 and 3/3), metabolic (3/7 and 0/3) or mixed (1/7, 0/3), reduced level of consciousness (6/7 and 3/3), mydriasis (5/7 and 3/3), tachycardia (5/7 and 2/3), bradycardia (2/7 and 1/3), tonic-clonic convulsions (2/7 and 1/3) and agitation (3/7 and 1/3). Recovery occurred within 24 h in all cases except one male also exposed to methiopropamine. CONCLUSIONS: Analytically confirmed exposure to MDMB-CHMICA was associated with acidosis (often of respiratory origin), reduced level of consciousness, mydriasis, heart rate disturbances and convulsions.

Patterns of presentation and clinical features of toxicity after reported use of ([2-aminopropyl]-2,3-dihydrobenzofurans), the 'benzofuran' compounds. A report from the United Kingdom National Poisons Information Service.

OBJECTIVE: To characterise the patterns of presentation and clinical features of toxicity following reported recreational use of benzofuran compounds ((2-aminopropyl)-2,3-dihydrobenzofurans) in the UK, as reported to the National Poisons Information Service (NPIS), and to compare clinical features of toxicity with those after reported mephedrone use. METHODS: NPIS patient-specific telephone enquiries and user sessions for TOXBASE(®), the NPIS online information database, related to (2-aminopropyl)-2,3-dihydrobenzofurans and associated synonyms were reviewed from March 2009 to August 2013. These data were compared with those of mephedrone, the recreational substance most frequently reported to NPIS, collected over the same period. RESULTS: There were 63 telephone enquiries concerning 66 patients and 806 TOXBASE(®) user sessions regarding benzofuran compounds during the period of study. The first telephone enquiry was made in July 2010 and the highest numbers of enquiries were received in August 2010 (33 calls, 112 TOXBASE(®) sessions). Patients were predominantly male (82%) with a median age of 29 years; 9 reported co-ingestion of other substances. Comparing the 57 patients who reported ingesting benzofuran compounds alone with 315 patients ingesting mephedrone alone, benzofurans were more often associated with stimulant features, including tachycardia, hypertension, mydriasis, palpitation, fever, increased sweating, and tremor, (72% vs. 38%, odds ratio [OR] 4.2, 95% confidence interval [CI] 2.27-7.85, P < 0.0001) and mental health disturbances (58% vs. 38%, OR 2.3, 95% CI 1.29-4.07, P = 0.006). Other features reported after benzofuran compound ingestion included gastrointestinal symptoms (16%), reduced level of consciousness (9%), chest pain (7%), and creatinine kinase elevation (5%). CONCLUSIONS: Reported ingestion of benzofuran compounds is associated with similar toxic effects to those of amphetamines and cathinones. Mental health disturbances and stimulant features were reported more frequently following reported ingestion of benzofuran compounds than after ingestion of mephedrone.