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Seroprevalence of the General Lebanese Population to COVID-19 Between 2023 and 2024
Background Understanding population immunity to SARS-CoV-2 is crucial for public health planning, especially Lebanon where unique healthcare challenges exist. This study aimed to assess the seroprevalence of SARS-CoV-2 antibodies and identify predictors of serostatus in a sample of the Lebanese population in 2023. Methods We conducted an observational study of 350 adult patients presenting to two emergency departments in Lebanon. Participants were tested using a ZEKMED COVID-19 IgG/IgM rapid test, a qualitative rapid SARS-CoV-2 anti-E antibody kit. A comprehensive statistical analysis including logistic regression, Bayesian modeling, and a Random Forest classifier was performed to identify predictors of IgG seropositivity. Results Our results showed high IgG seroprevalence of 95.1% (n=333), suggesting prevalent natural infection. While vaccination status and self-reported prior infection were not significant predictors of serostatus in standard analyses, both Bayesian and Random Forest models identified increased age as a potential predictor associated with a negative IgG antibody response (94% HDI: [-1.531, -0.000]; importance score: 0.61). Conclusion Our findings indicate high exposure to natural SARS-CoV-2 infection in this Lebanese cohort. However, the association of advanced age with a negative antibody response suggests that older populations may remain more vulnerable. This highlights the need for continued targeted public health surveillance and strategies despite high overall seroprevalence from past infections. Introduction Covid-19 infection is a recent pandemic, known to cause severe respiratory illness. Since the Coronavirus Infectious Disease 19 (COVID-19) pandemic hit, vaccination, infection control and immunity became a major interest for healthcare [1]. People were infected in groups, sometimes whole communities, which while overwhelming, contributed to population-level seroprevalence after resolution [2]. However, not everyone had the same COVID-19 presentation, as a large number of individuals had asymptomatic infection, detected by contact tracing or random antibody testing. Others acquired passive immunity through vaccination [3]. Historically speaking, as was the case with poliomyelitis and measles, a detectable immunity in up to 80 to 95% of the population is needed for effective herd immunity [3]. In the case of COVID-19, the data shows a similar story. In the Unites States of America (USA), 60% adult vaccination rates did not provide enough population immunity to impede the virus spread [4, 5]. A similar trend was seen in Wales [6]. However, the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is a ribonucleic acid (RNA) virus that mutates and creates new variants and strains [7]. In addition, the gained immunity wanes over time, which is why we sometimes over-estimate the immunity we have, ending up with a more vulnerable population with the coming variant waves, as in the case of New England in August 2021 [8]. Population level antibody responses for COVID-19 shows consistent international trends. However, they can be influenced by a variety of local factors unique to each region. For instance, the attitude of people in the Middle East towards lockdowns and vaccination would create unique conditions that influence seroprevalence in the region. In Lebanon, several studies emerged assessing the population immunity to COVID-19. A nationwide study published in January 2022 by Hoballah et al assessing over 2000 participants showed that despite all efforts to vaccinate the public, the population remained vulnerable to a new COVID-19 outbreak [9]. According to the World Health Organization (WHO), a total of 5,814,699 vaccine doses have been administered in Lebanon as of December 2022 [10]. Nevertheless, according to the Lebanese Ministry of Public Health (MoPH), we still have new infections and deaths related to COVID-19 as of May 2023 [11]. The vaccination rates are not likely to increase further, especially that a lot of the Lebanese people have concerns regarding vaccine safety and efficacy, rendering them unlikely to get vaccinated [12]. This is alarming in the setting of a country that suffers a suffering healthcare system due to massive challenges and a major economic collapse, making the country less likely to be able to deal adequately with a new wave [13]. There is no new update regarding the Lebanese population preparedness and immune status regarding COVID-19. It is of importance to assess the population-level immunity in Lebanon against COVID-19, as it would provide updated insight on the magnitude of a possible new wave in the country, especially as social distancing and mask wearing measure have stopped. In addition, it would provide an idea of the how the Lebanese population reacts to new outbreaks. Methods Study Design and population Our study is an observational study conducted on a sample of patients presenting to the Emergency Departments (ED) at the Lebanese American University Medical Center – Rizk Hospital (LAUMC-RH) and Kesrwan Medical Center (KMC) between July 2023 and January2024. All adult patients above 18 years of age presenting to the ED were offered to perform a rapid fingerstick antibody test for COVID-19. This was done for any visit at any time in the ED, offered to all adult patients. People who cannot give an informed consent with waiver of documentation, and patients on chemotherapy and immunomodulators were excluded. Data collection included the number of COVID-19 vaccination doses and whether they had a prior COVID-19 infection in the past. Kits Detection of SARS-CoV-2 antibodies was performed using the ZEKMED COVID-19 IgG/IgM Rapid Test Cassette (ZENUM Sarl, Marly, Switzerland), which is a qualitative lateral flow immunoassay that was used with whole blood.14 It uses a colloidal gold-conjugated recombinant Coronavirus envelope antigen to detect IgG and IgM antibodies against the COVID-19 envelope protein (anti-E), with results interpreted at 15 minutes per the manufacturer’s instructions.15The kit’s performance has been independently validated, demonstrating a sensitivity of 97% and specificity approaching 100% in clinical trials [14]. Sample size calculation Based on the standard for prevalence studies, a 95% confidence level (Z=1.96) and a 5% margin of error (d=0.05) were selected for reliability and precision. The expected prevalence (P) of IgG seropositivity was estimated at 85% (0.85). This estimation was informed by the high reported rates of prior SARS-CoV-2 infection and widespread vaccination coverage in the Lebanese population,16,17 while also accounting for antibody waning over time and detection capabilities of rapid IgG kits, which can miss very low titers. Using the formula for estimating a population proportion, n=(Z^2∙P(1-P))/d^2 , the initial calculation yielded approximately 196 participants. To increase the study power and account for non-response rates, incomplete data, or invalid test, a target sample size of 230 participants as a buffer was used. The study successfully recruited 350 participants, exceeding the calculated sample size, which increased the statistical power of the derived estimates of COVID-19 IgG immunity within this patient population. Statistics Descriptive statistics were used to summarize the demographic, clinical, and serological characteristics of the 350 participants. Bivariate analyses were performed to check associations with IgG antibody status. Chi-Square (χ²) test was used to test associations between categorical variables, and the Mann-Whitney U test was used for continuous variables. To assess the combined and independent effects of all factors, two multivariate approaches were used. A multivariate logistic regression was performed first, but due to perfect separation in the data, it was adjusted by combining the vaccination status into a yes/no variable. Then, a Bayesian logistic regression was employed as an alternative to handle these challenges. It used weakly informative priors (Normal (0, sigma=5)) to estimate the full posterior probability distribution for the effect of each predictor, with results assessed via the 94% Highest Density Interval (HDI). To explore non-linear relationships and predictive power, a Random Forest Classifier was used. Random Forests are a powerful machine learning method that creates many simple decision-making flowcharts and then combines all their outcomes to a single comprehensive prediction. This model identified the most important features for predicting the rare IgG-negative outcome. To address the class imbalance in the data, the SMOTE (Synthetic Minority Over-sampling Technique) was applied to the training dataset, which is a method that creates new, synthetic data points for the minority class to create a more balanced dataset for model training. Ethical considerations This study was approved by the LAU Institutional Review Board. Patient names and personal identifiers were not stored. Results A total of 350 patients visiting the emergency department consented to participate in the study. The cohort had a mean age of 48.5 (+/- 15.2) years, with participants distributed across multiple age groups. The 31-40 age group was the largest, comprising 18% (n=63) of the sample. Regarding vaccination status, 77.4% (n=271) of participants reported receiving two doses of a COVID-19 vaccine, 20.6% (n=72) reported receiving three doses, and 2.0% (n=7) reported being unvaccinated. A history of prior SARS-CoV-2 infection was reported by 15.7% (n=55) of participants, while 84.3% (n=295) reported no known prior infection. Rapid antibody testing using the mentioned kits revealed that 95.1% (n=333) of participants were positive for SARS-CoV-2 IgG antibodies, while only 1.1% (n=4) were positive for IgM antibodies. Statistical associations The bivariate and multivariate analyses did not find any statistically significant predictors of IgG status. No significant association was found between IgG status and prior infection (p=0.21), the number of vaccine doses (p=0.46), or participant age (p=0.051). The adjusted logistic regression model confirmed that none of these factors were significant independent predictors. After that, the Bayesian logistic regression showed a credible small, negative association between age and the likelihood of IgG positivity (94% HDI: [-1.531, -0.000]), which was not seen with prior infection and vaccination. As for predictive power, the Random Forest model identified age as the most important predictive feature for IgG positivity (importance score: 0.61), followed by the number of vaccine Doses (0.30) and prior infection (0.09). Discussion Our study findings show that the majority of the people presenting to the emergency department in our sample had a previous exposure to COVID-19, demonstrated by the 95% IgG seroprevalence. This antibody response mirrors what is seen in other countries such as the Unites States,18 but is higher than what is observed in the United Kingdom [19]. However, the COVID-19 antibody response comes from infection and vaccination. Since all mRNA based vaccines target the S protein, they will induce an anti-S response not detected by our kits. Thus, anti-E antibodies are detected in prior infection or by vaccination using the conventional inactivated, non-mRNA based vaccines [20]. Since most COVID-19 vaccines used in Lebanon were mRNA based, our detected seropositivity most likely comes from natural immunity [21]. To understand this antibody response better, it is important to differentiate between different anti-SARS-CoV-2 antibodies. They are of 3 types, anti-nucleocapsid (N), anti-spike (S) and anti-envelope (E) (Table 1) [20]. In clinical applications, these antibodies have different functional roles. Anti-N antibodies serve as the most reliable diagnostic markers for confirming previous SARS-CoV-2 infection due to their elevation in infected patients [20]. Anti-S antibodies are considered essential for immune protection, as they have the ability to neutralize the. Anti-E increase in levels following infection, but sera with elevated anti-E IgG levels have no virus-neutralizing activity. Therefore, both N and E antibodies can function as markers of viral exposure, but only S-specific antibodies are associated with immunity [20]. The majority of the Lebanese population was vaccinated using the mRNA vaccines, and most of the detected antibodies would have come from natural exposure to the SARS-CoV-2 virus [21]. In addition, COVID-19 vaccine-induced antibodies wane after several months and are not long-lasting, making them shorter-lived than natural or hybrid immunity [22]. The lack of association between vaccination history and our anti-E test results is an expected finding, as the mRNA vaccines prevalent in Lebanon do not generate an anti-E antibody response. This further supports the conclusion that the detected seropositivity reflects natural immunity. Since up to 45% of people infected with COVID-19 remain asymptomatic, the number of people reporting a previous infection is an underestimation of the actual estimate of people who got exposed to SARS-CoV-2. This would explain why a reported history of COVID-19 infection did not have a significant association with IgG positivity in our sample. However, for almost all infections, age is an important predictor of mounting a robust immune response. With increased age, immunity wanes, and so does the antibody response to COVID-19 [23, 24]. This goes with our Bayesian logistic regression findings, that showed advanced age predicting weaker antibody responses and the random forest showing age as a stronger predictor for an IgG response as compared to prior vaccination or reported past infection. However, this might also be explained by the more cautious approach of the older populations towards the pandemic compared to younger populations. Currently, we are not aware of any on-going surveillance for COVID-19 in Lebanon. The last ministry of public health update was on October 10, 2024 [11]. However, we believe there is a need for more monitoring in the country to assess the population status, number of new cases and the potential of a new impending outbreak and its possible impact. Our study has its limitations. First, anti-E rapid testing kits were used. These kits only test for exposure to the whole virus, and do not provide information about mRNA vaccination-induced responses or immunity status. Coupling the results to anti-S or anti-N antibody testing kits would provide a more holistic understanding on the immunologic status of these participants against COVID-19. Besides, data on demographics such as sex as well as other comorbidities was not collected, which might have introduced confounders or other factors to the discussion. Finally, there is the potential selection bias due to having 2 participating hospital emergency departments, which might not be reflective of the actual community numbers. These weaknesses were addressed by using multivariate analysis as well as Bayesian regression and random forest models to suggest associations that would account for known and unknown confounders. Demographic data such as sex and comorbidities were not collected in this study, to ensure compliance to the approved project by the IRB. Further studies exploring COVID-19 seropositivity would need to aim to collect such data, as these factors are known to influence the COVID 19 immunity status. Conclusion Our findings show that a large proportion (95.1%) of the Lebanese population presenting to our emergency departments has been exposed to COVID-19, developing anti-E antibodies that indicate of natural infection. While vaccination status and reported infection history were not significant predictors of seropositivity, our results consistently identified increased age as a potential predictorassociated with a negative antibody response. This suggests that while anti-E seroprevalence from past infection exists, older populations may remain vulnerable, highlighting the need for continued targeted public health strategies and surveillance. This calls for the need of booster vaccine campaigns, especially for the older populations. In addition, More focused research would be needed to identify the effectiveness of the immunity associated with this anti-E COVID-19 response and its longevity. Author contributions All authors contributed equally and validated the final version of record. Declarations Conflicts Of Interest Zekmed COVID-19 cassettes were provided by Zekmed. However, the study methodology was independently performed, and the results were analyzed exclusively by the authors, without any influence and/or interference from anyone not listed in the author list. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval This study was approved by the LAU Institutional Review Board. Patient names and personal identifiers were not stored. 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Copyright (c) 2026 Hilal Abdessamad, Elsy Jabbour, Danielle Abou Khater, Mariana Helou (Author) https://creativecommons.org/licenses/by/4.0
Factors Associated With Prolonged Ambulance TurnaroundTime in a Large Quebec Health Network:A Two-Year Retrospective Study
Background Ambulance turnaround time (TAT), defined as the interval from ambulance arrival at the emergency department (ED) to vehicle readiness for a new call, is a key performance indicator for emergency medical services (EMS). Prolonged TAT reduces ambulance availability, compromises system efficiency, and may adversely affect patient outcomes. In Quebec, performance targets require that 80% of TATs be under 35 minutes and 98% under 45 minutes. Objective This study aimed to identify factors associated with ambulance TAT exceeding 45 minutes across hospitals within the Mauricie-Centre du Quebec Integrated Health and Social Services Centre (CIUSSS MCQ) over two consecutive fiscal years. Methods A retrospective observational study was conducted using anonymized EMS operational data from the PACQSPU database. All ambulance calls recorded between April 2023 to March 2024 and April 2024 to March 2025 were analyzed. Calls with TAT >45 minutes were examined according to month, time of day, call priority, receiving hospital, and day of the week. Results Of 118 953 ambulance calls, approximately 23 to 25% exceeded the 45-minute TAT threshold in both years. Delays occurred predominantly during daytime shifts and weekdays. Priority levels P1 and P3 accounted for most delayed calls, while P0 calls showed the highest proportion of prolonged TAT. Urban hospitals, particularly the regional referral center, exhibited higher delay rates.
Copyright (c) 2026 Laurence Larouche, Christian Shooner, Chady El Tawil (Author) https://creativecommons.org/licenses/by/4.0
Comparative Study of Medical Error Legislation in the League of Arab States (LAS). A proposal to Unify Medical error definition and its liability Legislations
Background The concept of unifying medical error legislation offers multiple potential benefits to the League of Arab States (LAS). Methods This descriptive study examined LAS medical error legislation to highlight the current state of medical error legislation principles and proposes an approach that member states of the LAS could leverage to unify their regulations governing medical error. Result Among LAS countries, only 15 out of 22 (68%) had a specific medical liability law and only 12 of them (54%) defined medical error. The Civil and Penal Code was applied in 4 countries (18%) while information could not be found for 3 countries (13.6%). Conclusion The study recommends that LAS countries undertake medical error legislation reform to unify the definition, restrict criminal liability for actions prohibited by law, and limit medical error liability to corrective disciplinary and civil penalties (award), which will reflect positively in the healthcare system and practice of medicine. Background The League of Arab States (LAS) was established in 1945 to enhance mutual collaboration in economics, communication, peace, culture, social welfare, and health [1]. The organization includes 22 countries as member states from the Middle East and North Africa with similar legislative backgrounds. They applied the Ottoman Empire's “Kanun,” which stems from Sharia (Hanafi school of Islam - Madhhab Ḥanīfah), mandated by the Ottoman Empire when it was under its jurisdiction. The codes were compiled into 16 books and published as one journal, known as MAJALLA AL AHKAM AL ADALIYYAH - The Ottoman Courts Manual [2]. However, during the twentieth century and in the aftermath of World War I, Egypt took the lead in developing its system of codified law. Subsequently, numerous other countries in the Arab region followed suit and embarked on the path of legal development. Many of these nations drew inspiration from Egypt’s legal framework, which was initially derived from the French legal system, while also incorporating the principles of Sharia [2]. Medical Liability Law is a specific subset of civil law that outlines standards for medical practice and addresses professional negligence or deviation from the standard of care, resulting in injury or damage to the patient. It also outlines penalties for failing to comply with the law [3]. Healthcare services vary among LAS countries; however, they are evolving and developing in most jurisdictions [4]. The Council of Arab Health Ministers was established in Cairo in 1975, with the primary objective of coordinating efforts to enhance healthcare services throughout the Arab world. The council aimed to foster collaboration in research, seeking unified solutions that would benefit the entire Arab region. Medical malpractice is defined as any commission or omission by a healthcare provider during management of a patient that deviates from accepted norms of practice and causes an injury to the patient, and internationally, it is addressed under the tort principle [3]. However, it is essential to note that medical error is the term used in all LAS countries to reflect medical malpractice. The definition of medical error, procedures for filing complaints, and penalties stipulated for committing medical errors that result in patient injury (medical malpractice) vary among countries within the Arab world. While all these countries uphold Sharia principles when formulating their laws, disparities arise when doctors from different Arab nations discuss medical liability of medical error and express concerns regarding the application of best practices, particularly fearing litigation when caring for high-risk patients where decisions are taken rapidly and under uncertainty, such as acute and emergency care. In these settings, the legal definition of medical error and liability may directly influence physicians’ willingness to act, assume risk, or initiate invasive but potentially life-saving interventions. Therefore; taking decisions urgency and time of contact with patients in consideration when assessing medical error is of important value which align with reasonable person standard theory rather than best care standard which is used for clinical trials, research and quality improvement purposes [5]. Overall, there is a prevalent fear of legal repercussions if patient outcomes are unfavorable. This descriptive study aims to compare the existing medical liability legislation for medical error across all LAS countries, outline the current state, and propose a set of unified medical liability of medical error principles that can be universally applied throughout the LAS countries. Methods A descriptive comparative legal analysis to compare the medical liability of medical error legislation across the LAS countries. The study aims to examine the legislation of LAS countries regarding the following criteria: the existence of specific medical liability laws, the definition of medical error, the legal responsibility applied to medical errors, the process of medical error litigation, penalties stipulated for medical errors, and the presence of a statute of limitations. A comprehensive web search was conducted to identify the medical liability legislation of each LAS country. The study authors conducted web searches in April-June 2023 for medical liability legislation in English and Arabic. A second search was conducted in March 2025 to identify any new legislation enacted since the initial search. The following keywords were used: medical liability Law, Health Law, medical error definition, medical malpractice, and medical negligence. To ensure a thorough understanding of the subject, the study authors reviewed published research papers and law school theses that delved into medical liability within each country. When the information was unclear, the study authors consulted practicing physicians in specific countries for legislative insights; their expertise and firsthand experience helped verify and supplement our search findings. The study primary data sources (official legislative and regulatory texts) and secondary sources (interpretative legal papers) analysis followed a functional comparative legal approach, focusing on how different legal systems regulate similar issues related to medical error and professional liability. Results Among LAS countries, only 15 out of 22 (68%) had a specific medical liability law and only 12 of them (54%) defined medical error. The Civil and Penal Code was applied in 4 out of 22 (18%) countries when medical error occur. Information was not available on 3 out of 22 (13.6%) countries. Data was extracted and summarized in five tables in an intention to provide a comparative analytical overview of legislative approaches rather than an exhaustive codification of national legal systems. [Table 1] provides an overview of the medical liability legislation across all 22 LAS countries. It indicates whether each country has a specific Medical Liability Law, along with the dates of issuance and the presence or absence of a specific definition of medical error. Additionally, it indicates whether the Civil or Penal Code is used to address medical errors in countries that lack specialized legislation. This was extracted from published literature about medical error litigation in these countries. Regarding the definition of medical error, some countries briefly mentioned it, while others explicitly outlined it. However, across all countries, the concept of negligence formed the basis for defining medical errors. A few countries provided further details by specifying the actions considered negligent. [Table 2] lists the definitions of medical errors, and the penalties stipulated for medical errors in countries with specific medical liability laws. In nearly all countries, criminal and civil penalties were mandated for medical errors. Disciplinary penalties were stipulated in some of the medical liability laws examined however not in details as likely it is addressed in regulations governing practicing medicine and licensing in each country [Table 2]. Regarding the medical error litigation process, only 9 out of 22 (40%) countries prohibit the arrest of the healthcare provider or interrogation by the prosecutor for a claim regarding a medical error or professional misconduct before a professional committee examines the allegation and confirms the occurrence of the medical error, [Table 3] list the Arab countries that have these specific legislations in this regard as well as the specific article from the medical liability Law. Only 3 out of 22 countries (13.6%) have a statute of limitation for medical error litigation mentioned and specified; the rest did not mention it and, hence, applied the general civil law principles which is 3 years since knowing the medical error or 15-years from the event occurrence, [Table 4], lists the countries that have specific statutes of limitation for medical error litigation, wirth noting Kingdome of Saudi Arabia stipulated statute of limitation on the public criminal action 1 year from the knowledge of the medical error however the civil liability will be following the general civil Law principles. Finally, 3 out of 22 countries (13.6%) mandate the establishment of a registry for medical error claims, including final judicial rulings to facilitate research and inform legislation improvement [Table 5]. Discussion The study discussion focused on the elements of the comparative study conducted, which are the existence of specific medical liability law, the definition of medical error, the legal responsibility applied to medical error, the process of medical error litigation, and the penalty stipulated on medical error, in addition to the presence of a statute of limitations and presence of medical error registry. Existence of specific medical liability law Upon reviewing the medical liability legislation in the LAS countries, it was observed that many countries still lack specific laws to address medical liability, instead relying on civil and penal codes to handle allegations of medical error. There are two internationally recognized legal systems: the Civil Law and the Common Law. Traditionally, the literature describes customary and religious legal systems; however, these are rarely standalone and are usually integrated within the civil law system, which can then be referred to as a hybrid legal system. The LAS countries can be described as hybrid, as they adopt the Civil Law system in addition to applying Sharia principles to both civil and criminal legal frameworks [14]. The Civil Law system stems back to the Roman Empire and developed in Europe, the Ottoman Empire, and most of the world except North America and Britain. It is based on several theories and principles, one of which is legal positivism, which states that Law is a set of rules and norms set by the legislator [15, 16]. Then, the systematization of legislation theory, where similar law rules are consolidated in a specific code, becomes the primary source of legislation and paves the way for its implementation, guiding legal policies in that field [17]. The third principle of the civil legal system is that it is an inquisitorial system based on extensive pre-trial investigations to ascertain the truth where the judge is empowered to oversee the investigation and interrogation process. Such principles ensure that innocent people are not brought to trial [18]. In the civil legal system, the Civil Code is considered the primary source of legislation where general principles are laid out and referred to whether the case is civil or criminal. The civil code can be supplemented by specialized statutes such as consumer protection law, labor law, and medical liability law [19]. Having special statutes provides clear and specific definitions of terminology, which enhances legal certainty when adapting legal principles to the subject. In addition, specialized statutes offer a deeper understanding of the legal principles pertinent to the field, as penalties are tailored to enhance the field and address its challenges. Lastly, it may lead to increased efficiency in the judicial process, as all sets of rules are consolidated into a single statute [20]. The definition of medical error Few LAS countries that had medical liability laws did not define medical error. LAS countries that had definitions of medical error, it was noted that all of them were based on the concept of negligence; some countries provided detailed descriptions of acts or omissions that constitute negligence, while others offered a more general definition. In addition, in Law a person is liable for negligent act only if it results in damages (Tort) and a causation relationship between the act and the damage can be established. When examining medical error definitions in LAS countries, some included damages in the definition while others focused on describing negligence and did not mention that it must cause damage to the patient which can be confusing to medical liability experts when assessing presence or absence of medical error from legal point of view [21]. Overall, medical liability in LAS countries is viewed under ‘Tort’ rather than contract liability principles. In Legal literature “Tort” is defined as an act of civil wrong done to another violating a protected right and resulting in damage or harm [22]. Adhering to Tort principle when addressing medical errors is consistent with most of the international legislation except for France, which shifted from tort principle to contractual liability in 1936. However, in 2002 patient rights law changed from contractually based liability to a specific independent legal regime structured as a combination of both Tort principle and contract [23]. The LAS countries share similar religious and cultural backgrounds, which effectively unify their understanding of errors in general, as well as the consequent legal liability and penalties for individuals who commit an error. Therefore, having a unified definition of medical error is possible and helpful in easing communication among healthcare professionals and policymakers, as no internationally agreed-upon definition currently exists [3, 24]. The United States Institute of Medicine defined medical error as “the failure of a planned action to be completed as intended or the use of an incorrect plan to achieve an aim”. Therefore, it is a failure, not necessarily due to negligence. However, realizing that despite being diligent, humans are error-prone and, hence, may still fail to enact a concise plan or that the plan itself may not be the most optimal for that patient [25, 26]. Not all medical errors in the United States warrant legal litigation, only medical malpractice, in another word, all medical malpractice involve medical error, but not all medical error are medical malpractice [3]. The definition of medical error in the United States aligns with the Islamic Fiqh of fault, which is “an act that, through ignorance, deficiency, or accident, departs from or fails to achieve what should be done”, referred to as “Galat, or Gala غلط" and scholar Ibn Manthoor called it “Mistake” [27, 28, 29]. On the other hand, Neglicance based error or fault (medical malpractice in USA) -referred to as “Khatt’a” in Arabic- is defined as “an error or defect in judgment or conduct that deviates from prudence or duty due to inattention, incapacity, perversity, bad faith, or mismanagement and may result in harm to another person and may be intentional or negligent.” [26]. Therefore, LAS countries need to establish two definitions one of “Galat, or Gala غلط , 6 ” which is errors that occurs even when utmost care and diligence are exercised yet harm may occur despite taking all necessary precautions to prevent it which must be investigated at hospital or system level to improve quality of medical care provided and hold no legal liability. The second definition is of “Khatt’a” , خطأ which is a fault that is the result of negligence and a breach of the duty of care, and result in hard and necessitate legal liability. Hence, the use of “medical fault” as Englis term ( خطأ طبي )is more accurate to reflect negligence-based medical malpractice than “medical error” - غلط طبي. It is essential to accurately define these two definitions as one implies legal liability while the other does not, as not doing so can hinder the provision of necessary care due to fears of litigation. For instance, in emergency medicine, physicians frequently make rapid decisions under conditions of incomplete information. In such contexts, overlooking a diagnosis when clinical picture is unclear or previous patient data (history) may not be available or decisions are made under service and time pressure may be miss interpreted as medical error where in reality its explained by “reasonable person standard” for any physician working under similar circumstances that day, therefore emphasis on reasonable person standard which account for time pressure or clinical uncertainty of decision making in the Emergency Department or the Operating Room need to be clarified in the medical error definition or the medical liability Law illustrative document that follows . This illustrates how legal frameworks governing medical error may have unintentional practical consequences on clinical behavior, risk-taking, and ultimately patient safety if not detailed and clarified. Perhaps another approach might be to drop the medical error terminology and use the Kuwait approach of defining when physician is legally liable which include deviation from standard of care and neglecant which is like the United State approach where they use (medical malpractice) as a term rather than medical error. The legal responsibility applied to medical error Regarding legal responsibilities and penalties for medical error, all LAS countries impose civil, criminal, and administrative penalties on healthcare providers found to be negligent. The criminal liability of medical professionals for medical errors dates to ancient times, when the medical profession was not yet fully established. Doctors were often viewed with suspicion, likened to witches or individuals with malevolent intentions rather than being regarded as healers [30]. Punishment in the penal code is based on two philosophical theories, utilitarian and retributive theories. According to utilitarian theories, punishment is justified by its deterrence of criminal behavior and by its other beneficial consequences for both individuals and society. According to the utilitarian theory, criminal acts are penalized and punished to deter individuals and the community from committing crimes, thereby protecting society [31]. This does not apply to medical errors, as penalizing professionals who commit medical errors while caring for and serving patients holds no benefit to the patient, the community, or the healthcare practice. Indeed, it may be harmful to the community, as healthcare providers may be deterred from taking calculated risks in managing patients [32, 33]. The retributive theory involves three criteria, all of which must be met; first, a person may be punished only if the wrong act is voluntary. Second, the punishment must be equal to the damage caused, and third, the punishment must be justified on moral and just grounds [34]. Therefore, retributive theory also cannot justify punishment for medical error, given that it is not voluntary, nor is it moral or justifiable. In addition, two basic principles in criminal law do not apply to criminalizing medical errors, which are the “benefit of doubt” rule and the “acquittance is the rule.” The “benefit of the doubt” is a cornerstone of criminal law and necessitates that if reasonable doubt exists regarding the guilt of the accused (the healthcare professional), they should be accorded the benefit of that doubt and not deemed guilty as it must be proven that the accused is guilty “beyond all reasonable doubts”, in addition, the burden of proof is on the prosecution and the plaintiff not on the accused [35]. This, coupled with the legal principle that states “acquittance is the rule,” makes it challenging to criminalize medical errors. First, determining negligence is often subjective; thus, medical experts and professional committees cannot confirm whether negligence occurred solely based on objective evidence but rather through indirect signs. In addition, negligence is not exclusively the responsibility of the individual; there are indeed many confounding factors that may contribute to healthcare provider negligence, such as long working hours, working during non-social hours, inadequate administrative support processes, and a lack of social or collegial support. Therefore, imposing criminal liability on medical errors requires examination by LAS countries considering addressing medical errors under tort principle and sparing criminal penalties for healthcare professionals on actions that they are explicitly prohibited from undertaking, such as practicing without a license, performing illegal abortions, assisting patients to die, or facilitating the misuse of controlled drugs and other similar prohibited actions [36]. On the other hand focusing on compensating patients for the damage they suffer via valuable Civil Award to help them recover the damage if possible or mange it, is more beneficial for the patient and their families than punishing the healthcare professional criminally [25]. Additionally, the imposition of appropriate corrective disciplinary penalties will ensure that healthcare professionals are deterred from negligence [37]. By focusing on system-level and individual-level improvements rather than punitive measures against healthcare providers, the system can avoid negative consequences that may discourage doctors from managing high-risk patients or offering alternative treatment options that may have benefits not commonly recognized [27]. Conclusively, whether we consider the utilitarian or retributive theory or consider basic criminal law principles, “the benefit of doubt” rule and the “acquittance is the rule,” it is found that criminally charging a healthcare professional neither serves the public nor the patient nor the healthcare provider [28]. The process of medical error litigation The process of medical error litigation across LAS countries is diverse. Only 9 of the 22 countries with medical liability-specific legislation state that physicians can't be brought to court except after a medical error is proven by the medical committee's final report (Table 3). The UAE Medical Liability Law explicitly describes the process where the claim investigation is purely administrative, with a professional medical liability committee investigating the claim to determine if a medical error occurred. Both parties, the claimant and the defendant, have 30 days to appeal, and afterward, another independent committee (the higher committee of medical liability) re-investigates the case and issues their decision administratively; their decision counts as final where if no medical error is found, claimant can’t file a case in court. In many LAS countries, where the medical malpractice litigation process is not outlined in law, patients can approach a prosecutor to file a claim, and the prosecution initiates an investigation involving healthcare workers before the medical error is proven. The role of the professional committee only comes into play once the case is referred to the court. During the process of prosecution investigations, healthcare professionals may be detained for days or weeks, which can be demoralizing to both the healthcare worker under investigation and their colleagues, as well as to the healthcare community in the perspective country, especially if the care provided meets the standards of care. Such harsh criminal investigation processes may harm medical practice, as doctors may be deterred from taking risks in managing high-risk patients, fearing criminal charges if complications arise [38]. Here is another area of medical liability reform for LAS countries which is preventing any prosecution or judicial litigation or investigation prior to confirming medical errors that necessitate legal liability. The presence of a statute of limitations Out of all the LAS countries' legislations reviewed, only Saudi Arabia, Tunisia and Palestine have explicitly stipulated a statute of limitations for medical error litigation. The absence of such a provision leaves the timeframe open for up to 15 years, according to standard rules of civil law. However, this extended timeframe becomes increasingly unrealistic over time due to the rapid advancement and changing standards of care, diagnostic methods, and treatment modalities. Implementing a statute of limitations would ensure a more realistic and fair approach to addressing medical error claims within a reasonable timeframe [3, 39]. In addition, the longer the time frame, the more difficult it is to perform robust investigations as most hospitals keep records for up to 5 years only; hence, evidence might be lacking if investigations are conducted on incidents that occurred longer than 3-5 years [40, 41]. Recommendations Based on the comparison conducted, the review and analysis of current legislation regarding LAS Medical Liability of medical errors, the study suggests the following six legislative reform initiatives: 1- To Consider adopting two definitions of medical error, one that is negligence based and imply legal liability, and another that is not negligent based and does not imply legal liability. They can consider using the term “fault” instead of error for negligence based medical error and call it (medical fault) “Khatt’a” (a medical error that infers legal liability, ie; medical malpractice) and use the term “Galat” medical errors which is ignorance-based and can occur despite exercising due diligence and does not imply legal liability. 2- To provide an objective description of actions that will be considered negligence. 3- To establish a unified framework for non-criminal liability of negligence-based medical error, reserving criminal liability for acts explicitly prohibited by law such as non-medical abortion, euthanasia, refusal to treat a patient in case of emergency and other similar actions. 4- To adopt a unified statute of limitations to ensure a reasonable timeframe for medical error litigation. 5- To create a centralized database within the LAS that records all medical error litigations, which can be utilized for research and educational purposes, promoting knowledge sharing and improving the healthcare system collectively. Strengths and limitations The research methodology stands out as the first comprehensive examination of medical liability legislation in the LAS countries. The proposal put forward, encompassing a unified definition of medical error, consistent principles for penalties, and other essential considerations, is poised to foster collaboration and improve healthcare provision among these nations. It is crucial to acknowledge the study's limitations. This research did not address administrative, disciplinary, and restorative aspects of medical error in detail, and we suggest these as areas for future research. This research heavily relied on online searches and the insights gathered from the authors' network of colleagues practicing in different Arab countries. Consequently, the most up-to-date medical liability legislation, as well as any updates that may not have been published online, may have been missed and not included. While formal communication with each country’s Ministry of Health could have provided more accurate information, the time constraints and logistical complexities led the authors to opt for an initial online review. Future studies are needed to build upon this groundwork, potentially led or facilitated by the Arab Health Council, to ensure a more robust and comprehensive exploration of medical liability in the LAS countries. Conclusion The League of Arab States shares a common cultural and legal background, presenting an opportunity for harmonizing medical liability legislation related to medical errors. By adopting a unified definition of medical error, applying civil and disciplinary non-criminal penalties, and establishing a unified statute of limitations in addition to other reform initiatives, these countries can positively impact their healthcare systems. Lastly, the study proposes that this review be conducted with the support of the Arab Healthcare Council to ensure the participation of all countries and achieve a comprehensive and accurate understanding of medical liability related to medical errors across the League of Arab States. Authors' contributions Both authors contributed equally to the manuscript and study. Both authors have a Bachelor of Laws and are interested in medical liability in addition to legislation related to healthcare. Both authors serve as medical examiners for medical malpractice cases in their respective jurisdictions of practice. Declarations Use of Artificial Intelligence declaration Authors would like to declare that Chat GPT was used to translate Law articles and Law titles from Arabic to English as many of the Legislations reviewed are available in Arabic and not available in English. Ethics approval and consent to participate This is a descriptive comparative study that compares published legislation; therefore, no ethics approval or consent was required. Consent for publication Not applicable Availability of data and materials All legislation and literature reviewed are referenced and available upon request. Competing interests Both authors declare no competing interests. Funding No funding was received for this study. References 1. “The Arab League,” Council on Foreign Relations. Accessed: Jun. 30, 2023. [Online]. Available: https://www.cfr.org/backgrounder/arab-league 2. “Application Of Islamic Law In The Middle East - International Trade & Investment - Worldwide.” Accessed: Jun. 30, 2023. [Online]. Available: https://www.mondaq.com/international-trade-amp-investment/52976/application-of-islamic-law-in-the-middle-east 3. Bal, S. B. (2009). An introduction to medical malpractice in the united states. 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Copyright (c) 2026 Ayesha Almemari, Abdussalam Alshehri (Author) https://creativecommons.org/licenses/by/4.0
Can a 2-Week Lockdown Control a COVID-19 Outbreak? A Cross-Sectional Analysis of the Lebanese COVID-19 Response
Introduction With the rise of the novel coronavirus cases and fatalities around the world, researchers were invested in studying not only the therapeutic measures, but also, the preventive ones. As observed in other countries, many governments resorted to the shutdown of all services and closure of all facilities thus isolating people in their homes. Due to the rapidly collapsing local currency and deteriorating Lebanese economy, the local government implemented a two-week lockdown hoping it will reduce the surge in newly diagnosed Corona Virus Disease - 19 (COVID-19) cases without worsening the economic situation. Method In this study, we aim to understand the effectiveness of such plans in Lebanon and the contribution of the Lebanese people in its accomplishment. We looked at the numbers in all Lebanese territories over 2 weeks before the lockdown, during the 2-week lockdown (from 16 till 28thNovember 2020) and 2 weeks post lockdown. After collecting the data, we analyzed the mean number of cases and death before, during and after lockdown and by followed the growth factor of cases during this period. Result It was shown that for all studied districts, there was a trend in decline of the total number of cases, but the results were not statistically significant to prove that a 2-week lockdown can impact the epidemic. Conclusion A short, partial lockdown has no benefit over the growth or reduction in the virus impact or transmission, however, it might have some positive outcomes if implemented for longer periods.
PHEOC - Public Health Emergency Operational Centers
Copyright (c) 2026 Mahmoud El-Hussein, Malika Ait Haddou Mouloud, Rachid Moudoud, Faouzi Abdellaoui, Brahim Houmadi, Cima Hamieh (Author) https://creativecommons.org/licenses/by/4.0
Rethinking Anticoagulation in Kidney Disease and Kidney Transplantation
Background A clinical dilemma exists in patients with CKD, ESKD, and after kidney transplantation, as they face concurrent risks of both thromboembolic and hemorrhagic complications. Objective To review the literature on anticoagulant treatments in CKD, hemodialysis, and transplantation, with particular emphasis on pharmacology, safety, and clinical implementation. Methods Narrative review of scientific articles from PubMed, EMBASE, and Cochrane databases up to July 2025 inclusive using predefined search strategy. Observational studies, randomized trials, and major guidelines (KDIGO, AHA/ACC, ESC) were included. Results Despite its widespread use, warfarin has the disadvantage of bleeding and vascular calcification. Apixaban has the best data available among DOACs for use in CKD stage 5. The use of UFH is preferred in dialysis patients due to its reversibility properties. Other new drugs like factor XI inhibitors and LAAO are also very promising. Conclusion Anticoagulant therapy in patients with renal diseases needs personal risk assessment, proper selection of medications, and good management, especially during emergencies. Introduction An intriguing hemostatic paradox exists in patients with CKD: both thrombotic and hemorrhagic complications arise from uremic changes affecting platelet function, coagulation pathways, endothelial cells, and vascular calcification [1–3]. This challenge is further magnified among ESKD patients on dialysis and in those receiving kidney transplantations, where additional variables — including extracorporeal circuits, perioperative stress, altered pharmacokinetics, and extensive drug-drug interactions attributable to immunosuppressant medications — complicate anticoagulation management [2, 3]. Within this context, this review critically analyzes the current literature on anticoagulation therapy in patients with CKD, on dialysis, and after kidney transplantation. This topic is clinically significant due to the increasing incidence of chronic kidney disease throughout the world and the increased use of DOACs, making an evidence-based strategy critical for efficacy and reduced bleeding complications [4]. Epidemiology Patients with CKD face an established, progressively increased susceptibility to both thromboembolic and hemorrhagic events, including venous thromboembolism (VTE) and atrial fibrillation (AF). The degree of this susceptibility is proportionate to the severity of kidney function impairment and the impact of coexisting conditions like diabetes and high blood pressure [2–4]. The prothrombotic state is accompanied by a concurrent propensity for bleeding complications, arising from hemostatic abnormalities intrinsic to CKD. Patients with end-stage renal disease (ESKD) on dialysis face additional thrombotic and hemorrhagic risks related to frequent vascular access, extracorporeal circulation, dialysis-related anticoagulation, and uremia-induced platelet dysfunction [3–6]. Kidney transplant recipients constitute a further high-risk subgroup, in whom surgical trauma and ongoing immunosuppressive therapy contribute to an elevated early post-transplant risk of VTE [2, 7]. Methods This is a narrative review. It does not aim to conduct a systematic review; rather, it synthesizes available scientific evidence on anticoagulant therapy in patients with CKD, ESKD, dialysis, and kidney transplantation. The literature search was conducted across PubMed, EMBASE, and the Cochrane Library from database inception through July 2025. Search terms were combined using Boolean operators (AND/OR) and included: "chronic kidney disease," "end-stage renal disease," "dialysis," "kidney transplant," "anticoagulation," "warfarin," "direct oral anticoagulants (DOACs)," "bleeding," "thrombosis," and "stroke." Studies considered eligible comprised randomized controlled trials (RCTs) as well as observational, cohort studies, meta-analyses, and major international clinical practice guidelines (KDIGO, AHA/ACC, and ESC). Case reports, narrative commentaries without original data, and non-English publications were excluded. Study selection was carried out in two phases: a preliminary review of titles and abstracts, followed by full-text assessment for relevance to the pharmacokinetics and clinical use of anticoagulants in CKD, dialysis, and transplantation populations. Given the known exclusion of patients with an estimated glomerular filtration rate (eGFR) <30 mL/min from most RCTs, the evidence base was anticipated to rely predominantly on observational studies and post-hoc subgroup analyses — a finding that was confirmed. Qualitative data synthesis was performed through comparison of efficacy, bleeding risk, pharmacokinetics, and clinical applicability in both chronic and emergency settings. Pharmacokinetic considerations Renal dysfunction significantly impacts drug distribution, protein binding, and metabolism; hence, thereby influencing anticoagulant pharmacodynamics. DOACs vary widely in their reliance on renal elimination; dabigatran is highly dependent, being primarily eliminated by the kidneys [4, 11]. For ESKD patients, available treatment options are restricted, as only a few anticoagulants — including warfarin and apixaban — have received FDA approval in this population [10–13]. Significant drug-drug interactions are also common in kidney transplant patients owing to concomitant use of immunosuppressants [7]. Results: Evidence Synthesis by Anticoagulant Class Vitamin K Antagonists Warfarin remains the most widely used anticoagulant in CKD and ESKD (Table 1) owing to its long clinical track record and reversibility. However, its use is limited by a narrow therapeutic index, frequent drug and food interactions, and increased risks of bleeding and vascular calcification, including calciphylaxis [8, 9]. Observational studies suggest no consistent reduction in stroke risk in dialysis populations, with a concurrent increase in major bleeding compared with non-CKD cohorts. Direct Oral Anticoagulants (DOACs) DOACs offer more predictable pharmacokinetics and do not require routine monitoring compared with warfarin, although pharmacokinetic variation among agents is notable (Table 2). Among DOACs, apixaban has the largest body of clinical evidence in patients with severe CKD and those on dialysis [10–14]. Observational studies consistently indicate that apixaban reduces the incidence of major bleeding and provides similar or superior antithrombotic efficacy compared with warfarin. By contrast, dabigatran is primarily excreted renally, leading to drug accumulation in CKD; its use is therefore generally not recommended in severe CKD in this population. In addition, rivaroxaban and edoxaban have moderate renal clearance, and data on their use in ESKD patients remain limited. Heparins and LMWH Nevertheless, UFH remains the gold standard for anticoagulation during hemodialysis because of its short half-life and completely reversible action. While LMWHs exhibit superior pharmacokinetic behavior, their use should be strictly controlled since there is a possibility of their accumulation in patients with renal insufficiency [5, 6]. The pharmacology of these medications is described in Table 3. Emerging Therapies Novel anticoagulant strategies are summarized in Table 4. Antiplatelets may be used adjunctively in select transplant patients but increase bleeding risk [16]. Novel strategies such as Factor XI inhibitors and left atrial appendage closure are promising [25, 26]. Population-specific considerations For patients undergoing hemodialysis, there is a need for achieving a balance between the timing of doses and the risk of vascular access complications as well as clot formation within the dialysis machine circuit. Peritoneal dialysis is relatively safe regarding the pharmacokinetic stability and decreased bleeding tendency. However, evidence supporting this remains limited. For patients receiving a kidney transplant, there are notable adverse drug interactions that may affect the pharmacologic efficacy of the drug, especially with regards to CYP3A4 and P-glycoprotein mechanisms [7, 16]. Discussion The management of anticoagulation therapy for those with CKD, dialysis, and kidney transplantation represents one of the most complex tasks owing to the risks of developing both thrombosis and bleeding. Research concerning this issue shows that there is a high degree of heterogeneity, while the majority of studies conducted are observational. Few randomized controlled trials have been conducted for advanced renal dysfunction. As far as warfarin is concerned, it is one of the most researched anticoagulants in CKD patients, although its application poses risks including increased chances of bleeding, need for regular monitoring, and vascular calcification. Among the DOACs, apixaban appears to be quite promising. Evidence grading across therapies highlights that high‑quality RCT data are restricted to general atrial fibrillation populations with minimal inclusion of advanced CKD patients, moderate evidence stems from post‑hoc or subgroup analyses of DOAC trials that remain underpowered for renal endpoints, and low to moderate evidence is dominated by observational studies, especially for apixaban, which consistently signals reduced bleeding compared with warfarin. Expert opinion and guideline‑based recommendations reflect this uncertainty: KDIGO emphasizes insufficient evidence, whereas AHA/ACC and ESC guidelines cautiously support DOAC use in selected CKD patients [15–17]. With regards to the field of emergency medicine, the proper identification of the anticoagulant in question along with its reversal become particularly crucial in the situation of either bleeding or urgent procedures, which might involve the utilization of vitamin K and PCC as treatment strategies in managing bleeding due to warfarin, idarucizumab as a treatment strategy aimed at reversing the effects of dabigatran, and andexanet alfa as a treatment strategy used to reverse the action of factor Xa inhibitors, although, only with the modest efficiency of hemodialysis in the latter case and without having any impact on most of the factor Xa inhibitors. There is no applicability of the findings obtained from the existing research studies due to several factors: the lack of data obtained within the framework of randomized trials, the involvement of individuals who have an estimated GFR below 30 mL/min, heterogeneous study designs, the insufficient representation of patients with transplants, and lack of consistency in defining the endpoint. In summary, although apixaban has been shown to be the safest of all anticoagulants through observational studies and heparin unfractionated still plays an important role in dialysis, there is still no certainty about which approach is superior in patients with advanced stages of CKD. Some of the areas that remain challenging and require further research include adequately powered RCTs among dialysis and transplanted patients [6, 17], improvement of risk stratification models accounting for specific uremia-related factors [17], and development of more tolerable medications including factor XI inhibitors [17]. Possible strategies to improve anticoagulation therapy among this population include increasing the availability of reversal agents for DOACs [13] and validation of other non-pharmacologic methods like left atrial appendage closure (LAAC) [18]. Recent Developments in Anticoagulation in CKD (2022–2025) Recent developments (2022–2025) have contributed substantially to the scientific basis of anticoagulation in patients with chronic kidney disease (CKD), especially in dialysis, transplantation, and non-pharmacologic approaches. Use of DOACs in Dialysis Populations New insights gained from current meta-analyses and cohort studies show that DOACs, specifically apixaban, might offer a better safety profile when compared with VKAs in dialysis patients, mainly based on a reduced bleeding risk without compromising thromboembolism prevention [6, 13]. New systematic reviews from clinical trials and observational studies demonstrate that DOACs can decrease bleeding risk in dialysis patients, despite the limited number of participants and study heterogeneity [6]. Nonetheless, guidelines still recommend caution in view of the lack of large-scale randomized clinical trials in ESKD populations [17]. Factor XI Inhibitors (Newer Anticoagulants) Newer factor XI inhibitors, among which there is abelacimab and milvexian, represent a novel anticoagulant class aiming to improve thromboprotection without increasing bleeding risks. Phase II and ongoing Phase III clinical studies indicate that the selective targeting of factor XI may be more beneficial for high-bleeding-risk individuals, such as CKD patients, owing to the minimal dependence on renal elimination [25]. However, at present, there is not enough randomized trial data about the use of factor XI inhibitors among dialysis patients. Left Atrial Appendage OccCClusion (LAAO) The latest literature (2022–2025) highlights new evidence regarding the potential benefits of using left atrial appendage occlusion (LAAO) as a non-medication therapy modality for stroke prevention among atrial fibrillation patients who suffer from CKD and ESKD. According to modern findings, LAAO has been proven to have some advantages over long-term oral anticoagulation therapy concerning both decreased mortality rate and lower major bleeding rates [18, 26]. Moreover, observational registries in dialysis patients confirm satisfactory procedural safety, with no increased hemorrhagic events despite limited randomized comparison with DOACs [6, 26]. Anticoagulation in Kidney Transplant Recipients In recent years, new research has shown the difficulty of anticoagulation among kidney transplant recipients, where interactions between drugs such as calcineurin inhibitors and mTOR inhibitors play a role in the pharmacokinetics of anticoagulants. According to recently updated cohort studies (2023–2025), apixaban and rivaroxaban can be safely administered among specific transplant patients, despite possible interactions with cytochrome P450 3A4 and P-glycoprotein [8]. While observational studies show the relative safety of DOACs among transplant recipients, more evidence is still needed from randomized controlled trials. Warfarin is thus a common choice for such patients [7]. Integrated Interpretation of Recent Evidence As a whole, findings reported over the years 2022–2025 have supported the notion that there has been a relatively slow move toward increasing yet prudent administration of apixaban in dialysis patients, emergence of factor XI inhibitors as future safe anticoagulants, and further confirmation of LAAO as an effective approach in high-risk CKD patients. Simultaneously, the use of DOACs in renal transplant patients has become more prevalent but still highly restricted owing to various safety issues. Nevertheless, even with such advancements, it should be noted that most of the available evidence continues to come from observational studies, calling for randomized controlled trials involving advanced CKD, dialysis, and transplant patients. Limitations The current review is limited by its narrative approach and heterogeneous sources of information. The high number of observational studies and subgroup analyses increases the risk of bias and decreases the generalizability of findings. Moreover, the majority of randomized clinical trials do not include patients with advanced kidney failure, which limits the level of the obtained evidence. The lack of information among kidney transplant recipients is another limitation. Future directions Further studies should focus on RCTs involving dialysis and transplantation patients [6, 17]. The creation of new CKD-risk stratification models will be essential in achieving an optimal balance between thromboembolism and hemorrhagic complications [17]. New anticoagulants, especially that inhibiting factor XI, can be promising for future clinical practice [17]. Finally, the development of DOAC reversal agents and novel treatment modalities, such as LAA occlusion, needs to be considered [13, 18]. Future AI-based methods might become indispensable for personalized anticoagulation. Conclusion Despite the concurrent presence of a heightened risk for thrombosis and bleeding, anticoagulation therapy in CKD patients, dialysis, and kidney transplantation remains challenging. In clinical practice, warfarin is still largely used, while UFH is the preferred choice of anticoagulant in dialysis patients. When considering the DOACs, apixaban appears to have a favorable safety profile based on observational data as long as dosage modification is considered. In conclusion, for an ideal anticoagulation therapy, risk-benefit analysis, monitoring, and choosing the appropriate medication are all essential. More research studies using randomized controlled trials are recommended for the future. Author Contributions AJZ conceived, drafted, critically reviewed and edited the manuscript. The author approved the final version. Declarations Ethical Approval This review is based entirely on previously published studies and publicly available data. No individual patient data were collected or analyzed. Institutional review board approval was not required. Informed Consent No new human participants were involved in this review article; informed consent was not required. Animal Research This article does not contain any studies with animals performed by the author. Conflict of Interest The author declare that he has no conflicts of interest related to this work. Funding This research received no external funding. Data Availability All data underlying this article are derived from the published literature cited herein. No new datasets were generated or analyzed by the author. References 1. Kovesdy CP. Epidemiology of chronic kidney disease: an update 2022. Kidney Int Suppl (2011). 2022 Apr;12(1):7–11. https://doi.org/10.1016/j.kisu.2021.11.003 2. Waddy SP, Solomon AJ, Becerra AZ, Ward JB, Chan KE, Fwu CW, et al. Racial/Ethnic Disparities in Atrial Fibrillation Treatment and Outcomes among Dialysis Patients in the United States. 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Anticoagulants, Warfarin, Chronic Renal Insufficiency, Renal Dialysis, Kidney Transplantation
Copyright (c) 2026 Dr. Antoine J. Zgheib (Author) https://creativecommons.org/licenses/by/4.0
Beyond the Checklist: A Scaffolded, Experiential Learning Framework for Medical Rescue Simulation (Part 1 of 2)
The effective training of Technical Rescue Specialists (TRS) for high-stakes dynamic environments requires a sophisticated pedagogical approach. This article introduces a comprehensive framework for Simulation-based Education (SBE) designed to elevate Medical Rescue Simulation (MRS). The framework is built upon four interconnected pillars: Foundational Learning Theory, Systematic Skill Scaffolding, Integrated Physical Preparedness, and Stringent Safety Protocols. This article will concentrate specifically on Kolb's learning cycles and the principles of scaffolding. Grounded in Kolb's Experiential Learning Cycle, the framework ensures that learning moves beyond rote memorisation to foster deep understanding and adaptive expertise. The core pedagogical strategy involves scaffolding complex medical rescue procedures, by deconstructing them into isolated, manageable skills. Students’ progress through scenarios of increasing fidelity and complexity, from low-fidelity drills and Visually Enhanced Mental Rescue Simulations (VEMRS) to immersive, high-fidelity exercises, that mirror real-world pressures. This structured progression manages cognitive load, and is designed to cultivate the "emergence" of proficient practice by ensuring foundational competencies are robustly established, thereby preventing the "absence" of critical skills in high-stakes situations. Introduction The effective training of Technical Rescue Specialists (TRS) within higher education institutions, particularly in the demanding and high-stakes context of medical rescue operations, requires a pedagogically sound and integrated approach. These environments are characterised by dynamic, unpredictable scenarios that demand not only technical proficiency but also rapid decision-making, physical endurance, and cohesive teamwork [1]. In response to these challenges, Simulation-based Education (SBE) has emerged as a cornerstone methodology, offering a controlled yet realistic platform for the development of critical competencies, reflective practice, and performance assessment [2]. Central to the success of SBE in medical rescue training is a framework built upon four interconnected pedagogical pillars: Foundational Learning Theory, Systematic Skill Scaffolding, Integrated Physical Preparedness, and Stringent Safety Protocols. These pillars collectively support the development of resilient, competent TRS capable of navigating the complexities of real-world emergencies. However, this article focuses specifically on the first two pillars, foundational learning theory and systematic skill scaffolding, as the primary mechanisms for effective learning within Medical Rescue Simulation (MRS). While the importance of physical conditioning and safety protocols is acknowledged, their detailed exploration falls outside the scope of this article. The theoretical foundation of this framework draws on Kolb’s Experiential Learning Cycle (ELC), which conceptualises learning as a cyclical process involving concrete experience, reflective observation, abstract conceptualisation, and active experimentation [3,4]. This model ensures that learners engage deeply with simulation scenarios, moving beyond passive participation to develop adaptive expertise through structured reflection and iterative practice. Complementing this, is the principle of scaffolding, informed by Vygotsky’s Zone of Proximal Development (ZPD), which provides a systematic approach to managing cognitive load. By deconstructing complex procedures into isolated skills and gradually increasing scenario fidelity and complexity, scaffolding enables learners to acquire competence incrementally, and with appropriate support [12,15]. This article aims to articulate a theoretically grounded and practically applicable framework for SBE in MRS. By focusing on the foundational mechanisms that underpin effective learning, it offers educators and programme developers a structured guide to optimise simulation design and delivery. Ultimately, this approach seeks to foster the emergence of competent practice while mitigating the risk of absence in critical skills, ensuring that TRS are not only prepared to perform effectively but also to adapt and thrive in the unpredictable realities of emergency medical operations. Guiding Educational Philosophies for Medical Rescue Simulation (MRS) The effective training of TRS, particularly within the demanding context of South Africa, necessitates a robust pedagogical foundation. Medical rescue operations are characterised by high stakes, dynamic environments, and the critical need for skilled individuals to work within teams [1]. Simulation-based training has emerged as a cornerstone for developing the requisite competencies, offering a safe and controlled environment for practice and assessment [2]. Central to effective MRS is the principle of experiential learning, best exemplified by David Kolb's ELC [3]. This model posits that learning is a cyclical process involving four distinct stages: Concrete Experience (CE), Reflective Observation (RO), Abstract Conceptualisation (AC), and Active Experimentation (AE). This cycle provides a comprehensive framework for designing MRS sequences, that move beyond rote memorisation to foster deep understanding, critical reflection, and adaptive expertise [4]. The integration of Kolb's ELC into a structured MRS curriculum is illustrated below (Figure 2). ● AC - Theory Lectures: The learning journey commences with the introduction of foundational knowledge. During theory lectures, students are exposed to the core concepts, principles, operational protocols, and theoretical underpinnings essential for medical rescue operations. This stage is vital as it establishes the cognitive architecture upon which practical skills and experiential understanding will be built. Without this initial framework, subsequent hands-on activities may lack the necessary context and depth, hindering the development of true comprehension. This aligns with the broader imperative for evidence-based practice in medical rescue, where actions are informed by established knowledge [5]. ● CE & AC - Equipment Orientation: This phase serves as a crucial bridge between theoretical knowledge and its tangible application. Students engage in an initial Concrete Experience by physically handling and familiarising themselves with medical rescue equipment. Simultaneously, this interaction reinforces Abstract Conceptualisation, by allowing students to connect the theoretical functions and principles of the equipment (learned in lectures) to its actual features, operation, and limitations. This transitional stage is significant because it embodies the understanding that knowledge must not only be intellectually grasped but also practically engaged with to become meaningful [6]. ● CE & RO - Isolated Skills Practice and Sign-off: This stage places a strong emphasis on Concrete Experience through the active practice of specific, discrete medical rescue skills. Students repeatedly perform these skills in a controlled setting. The "sign-off" component, which involves assessment and feedback from instructors, directly facilitates Reflective Observation. Students are prompted to reflect on their performance of each skill, identify areas requiring improvement, and consider the effectiveness of their techniques. This reflection can lead to a refined understanding (AC) of how to execute the skill proficiently. This stage underscores the value of deliberate practice and the indispensable role of structured reflection and feedback in skill acquisition and refinement, linking directly to professional accountability and standards of competence [6]. ● CE - Team MRS Practice: Following the mastery of isolated skills, students progress to a more complex and richer experience. Here, they must apply their theoretical knowledge, equipment handling abilities, and individual procedural skills, within a dynamic, interactive, and often immersive team environment. These MRS are designed to mirror the complexities and pressures of real-world medical rescue scenarios. This stage represents the core of experiential learning for professions that rely heavily on teamwork. It shifts the focus from individual skill execution to integrated team performance, fostering an understanding of team dynamics, communication, and coordinated action elements, crucial for successful medical rescue outcomes [7]. The immersive nature of these MRS promotes situated cognition, where learning is deeply embedded in the context of practice [8]. ● RO & AC - Team Assessment: This critical stage is heavily weighted towards Reflective Observation and the subsequent development of new Abstract Conceptualisations. Through comprehensive debriefing sessions, performance reviews, and multi-source feedback (including self-assessment, peer feedback, and instructor evaluations), students and teams meticulously analyse what occurred during the MRS. They explore the rationale behind actions taken, the consequences of those actions, and how their collective performance aligned with established principles, protocols, and objectives. This structured reflection is not merely a feedback mechanism; it is a profound learning process that facilitates the deconstruction of the experience, an understanding of cause-and-effect relationships, and the re-conceptualisation of their mental models and approaches [9]. This leads to new insights, modified strategies, and a deeper, more nuanced understanding (AC) of medical rescue operations. ● AE - Application and Iteration: The cycle culminates in Active Experimentation. Based on the rich RO and refined AC generated during the team assessment and debriefing, students plan how to apply their revised understandings and newly acquired insights in future contexts. This could involve subsequent, more challenging MRS, further targeted practice, or, ultimately, application in real-world medical rescue situations, which becomes a new Concrete Experience, restarting the cycle, ideally at a progressively higher level of competence. This stage emphasises that learning is not a terminal event but a continuous, recurring process of action, reflection, and adaptation. This iterative nature is fundamental for professions like medical rescue that demand lifelong learning, continuous quality improvement, and the constant pursuit of enhanced performance [10]. The consistent application of Kolb's ELC in MRS naturally fosters a pedagogical shift from a predominantly didactic, teacher-centred approach, to a more facilitative, student-centred philosophy. The emphasis on students actively engaging in experiences (CE) and critically reflecting on those experiences (RO) empowers them to construct their own understanding and meaning. Scaffolding the Complex Medical Rescue Procedures Through MRS The development of proficient and adaptable TRS necessitates pedagogical approaches, that can effectively bridge the gap between theoretical knowledge and the complex, often chaotic, realities of emergency situations [11]. SBE has emerged as a cornerstone in this endeavour, providing a safe yet realistic environment for students to practice and refine critical skills. Within SBE, the principle of scaffolding offers a robust framework for structuring learning experiences, enabling the incremental acquisition of complex medical rescue competencies [15]. The Principle of Scaffolding in SBE Scaffolding, in an educational context, refers to a process whereby students are provided with temporary, tailored support to achieve learning outcomes that would otherwise be beyond their unassisted reach. This support is gradually withdrawn as the student's proficiency and independence increase [15]. The concept, most famously associated with Vygotsky's (1978) notion of the Zone of Proximal Development (ZPD), posits that learning is most effective when it occurs in the space between what a student can do independently and what they can achieve with guidance [12, 13]. In SBE for complex medical rescue procedures, scaffolding is not merely about simplifying tasks, but about structuring the learning environment to make complex cognitive and psychomotor processes accessible. Medical rescue operations are characterised by high stakes, significant time pressures, dynamic environments, and the need for sophisticated team coordination. These elements can generate considerable cognitive load, potentially overwhelming novice students, and hindering the development of robust skills [14]. A scaffolded approach systematically manages this load, allowing students to focus on specific aspects of performance at different stages of their development [15]. Effective scaffolding aims to reveal the underlying causal mechanisms that constitute competent performance [16]. By providing structured support, instructors can help students identify, understand, and internalise these mechanisms, such as critical decision-making heuristics, effective communication strategies, or precise motor skills, rather than merely mimicking superficial actions [17]. The "emergence" of expert performance is thus cultivated through a carefully modulated process that respects the student's current capacities while strategically expanding them [18]. Breaking Down Procedures: Practising Isolated Skills Many complex medical rescue procedures are, in reality, a concatenation of several discrete skills and decision points. Attempting to teach or practice such multifaceted procedures, holistically from the outset, can be counterproductive. The principle of "part-task training," a core element of scaffolding, involves deconstructing a complex skill into its constituent components, allowing students to practice and achieve mastery of these isolated elements before integrating them into a more fluid and comprehensive performance [6]. Figure 3. offers a broad perspective of a high-angle rescue scenario, highlighting the diverse competencies, that rescue students are expected to develop. These constructs, when merged, will showcase, although simplistic and generalised, the activities that will take place during such a medical rescue operation. Fidelity Progression Low-fidelity Environment: These may involve basic rope work, like knot making or tabletop exercises. The focus is on fundamental concepts, decision-making processes, and basic procedural steps, without the distraction of highly realistic but potentially overwhelming environmental cues. For example, practising communication protocols or anchor point identification, knot making, etc. To address the multifaceted demands of modern medical rescue incidents, we developed the Visually Enhanced Mental Rescue Simulation (VEMRS) as demonstrated in Figure 4. This low-cost, highly interactive modality is an adaptation of the Visual Enhanced Mental Simulation (VEMS) methodology created for training in resource-constrained environments [19]. VEMRS deliberately shifts the focus from singular patient care to the wider operational landscape, challenging students with issues of incident command, inter-agency communication, and strategic decision-making under pressure [20]. Adopting VEMRS functions as more than a training tool; it is a research platform for identifying the deep-seated causal mechanisms, like team dynamics and communication habits, that are pivotal in determining medical rescue outcomes [21]. Medium-fidelity Environment: These might incorporate controlled outdoor training sites capable of exhibiting physiological responses, more realistic equipment, and some environmental distractors. Students begin to integrate skills in a more contextualised manner. High-fidelity Environment: These are designed to closely mirror the complex and unpredictable nature of real-world situations. By incorporating authentic locations, such as mountainous terrain, these environments introduce genuine uncertainty and time pressures, requiring participants to quickly adapt. The involvement of live actor patients further increases the realism, compelling participants to integrate all necessary skills while under significant stress. The pursuit of authenticity, however, increases the risk of physical injury. The dynamic and uncontrolled elements present in such environments, require strong safety measures. To mitigate these risks, it is essential to conduct comprehensive risk assessments, hold mandatory safety briefings, ensure the presence of dedicated safety officers with clear authority to intervene, and establish emergency protocols. These measures are vital to guarantee that the valuable and immersive learning experience does not compromise students' well-being, balancing realism with strict safety oversight. Complexity Progression Complexity can be increased by manipulating variables such as: Number of Tasks: Starting with single-focus scenarios, and moving towards multi-tasking requirements. Information Load: Initially providing clear and unambiguous information, then introducing incomplete or conflicting data. Environmental Stressors: Adding background noise, weather, or challenging physical spaces. Team Dynamics: Progressing from individual tasks to scenarios requiring intricate interprofessional collaboration and communication. Patient Condition: Starting with stable patients or single pathologies and advancing to deteriorating patients with multiple co-morbidities. This progressive approach ensures that students are continually challenged but not excessively overwhelmed. Each stage builds upon the last, allowing for the consolidation of learning and the gradual development of resilience and adaptability. From a critical realist standpoint, the increasing complexity and fidelity seen in Figure 5. allow for the interaction of more numerous and varied causal mechanisms, providing students with insight into how these mechanisms interplay in real-world settings to produce outcomes [22]. The "geo-history" of the student, their prior experiences and learning trajectories, also informs their engagement with these progressively complex scenarios, highlighting the individualised nature of skill emergence [23]. Principles of Scaffolding in High-Angle Medical Rescue Training In SBE, the concepts of fidelity and complexity progression are closely intertwined. For example, when applying scaffolding principles in high-angle rescue training, students progress from scenarios with low complexity and high levels of support to those with greater complexity and reduced support. Throughout this progression, the level of instruction, hands-on practice, and feedback is gradually adjusted to match the student’s development and needs [24]. Basic Knot Tying and Equipment Familiarisation Low Complexity, High Support: ● Instruction: Direct, step-by-step demonstration of each knot (e.g., figure-eight, double fisherman's) and explanation of each equipment piece (e.g., carabiners, belay devices, ascenders). ● Practice: Repetitive, isolated practice of individual knots on a rope segment or familiarisation with equipment function in a low-pressure setting. ● Feedback: Immediate, prescriptive correction and verification of accuracy by the instructor. Set Up of a Single Person Ascend and Descend Line Medium Complexity, Medium Support: ● Instruction: Guided demonstration of how to integrate known knots and equipment (harness, descender/ascender, belay device, anchor) for personal ascent/descent. ● Practice: Supervised students practice on a low, stable structure (e.g., a training tower or short wall) with redundant safety systems in place. ● Feedback: Real-time coaching on body mechanics, safety checks, and procedural flow; interventions for significant errors. Set Up of a Basic Mechanical Advantage System Medium Complexity, Medium Support: ● Instruction: Explanation of principles of mechanical advantage (e.g., 3:1, 5:1 systems) and demonstration of combining rope, pulleys/carabiners, and anchors to build a simple system. ● Practice: Team-based exercises to assemble and operate the system with a non-critical load (e.g., a rescue dummy) on flat ground or a gentle slope. ● Feedback: Focus on correct rigging, load management, and team communication; troubleshooting common issues as they arise. Apply Medical Rescue Techniques to Different and Novel Environments High Complexity, Low Support: ● Instruction: Scenario-based briefings with minimal direct instruction on specific techniques; emphasis on problem-solving and adaptation. ● Practice: Full-scale exercises in varied, less predictable environments (e.g., multi-story structures, natural rock faces, confined spaces) with complex scenarios and potential stressors (e.g., noise, limited visibility). ● Feedback: Instructor primarily observes, intervenes only for critical safety concerns, and facilitates comprehensive debriefings focused on decision-making, risk assessment, team coordination, and adaptive problem-solving under pressure. Students are encouraged to self-assess and provide peer feedback. This allows students to develop the specific motor skills and cognitive understanding required for each step without the immediate pressure of managing the entire scenario. Once proficiency in these isolated skills is demonstrated, they can be progressively chained together. This methodical approach ensures that foundational competencies are robustly established, which is critical for the successful "emergence" of the more complex, integrated skill. The "absence" of a specific foundational skill can lead to cascading failures in a real-world medical rescue operation; isolated practice helps identify and remediate such potential absences early in the MRS process. This aligns with a critical realist emphasis on understanding how component parts (mechanisms) contribute to the functioning (or dysfunctioning) of the whole system [25]. Progressive Scenario Design: From Low to High Fidelity and Complexity Effective scaffolding in SBE extends beyond individual skills to the overall design of MRS scenarios. Progressive scenario design involves a deliberate and incremental increase in both the fidelity and complexity of MRS as students advance [26]. Techniques for Effective Scaffolding (Micro-level) Beyond the macro-level design of curricula and scenarios, effective scaffolding relies on specific techniques employed by instructors during the MRS and debriefing phases. These micro-level interactions provide crucial real-time support and guidance [27]. Clear Pre-briefing: Before a scenario begins, instructors must clearly articulate the learning objectives, the expected level of performance, the available resources, and the degree of support that will be offered. This manages student expectations and focuses their attention [28]. Thinking Aloud: Encouraging students to verbalise their thought processes during a scenario can provide instructors with insights into their decision-making and allow for timely, targeted guidance. It also helps students to self-monitor and reflect-in-action [29]. Prompting and Cueing: When students encounter difficulties, instructors can provide subtle hints, questions, or direct cues to guide them towards appropriate actions or considerations. This might involve drawing attention to a critical piece of data or suggesting a potential intervention. The level of prompting should be inversely proportional to the student's developing expertise [30]. Structured Feedback: Providing specific, objective, and constructive feedback, both during (if appropriate and aligned with the scaffolding strategy) and after the scenario, is essential. This feedback should focus on observed behaviours and their consequences, linking them to the underlying principles and mechanisms of effective care [31, 32]. Pause and Discuss: In some instances, particularly during formative learning, it can be beneficial to temporarily pause the MRS to discuss a critical decision point, clarify a misunderstanding, or reinforce a teaching point before resuming the scenario [33]. Gradual Withdrawal of Support (Fading): As students demonstrate increased competence and confidence, the instructor systematically reduces the level of prompting, cueing, and direct intervention. This encourages greater autonomy and allows students to take fuller ownership of the problem-solving process [30]. Effective Debriefing: The post-scenario debriefing is a cornerstone of SBE and a critical component of scaffolding. Instructors should guide a reflective discussion that encourages students to explore not only what happened, but why it happened and how it could be improved. This involves examining the causal chains of events, the decisions made (and their rationales), and the impact of team interactions [34]. An informed debriefing might explicitly probe the interplay of contextual factors, individual actions, and underlying mechanisms that shaped the scenario's outcomes [35]. These micro-level techniques, when skilfully applied, create a dynamic and responsive learning environment that supports students in navigating complex challenges and internalising the deep structures of proficient medical rescue practice [27]. Scaffolding complex medical rescue procedures through SBE is a powerful pedagogical strategy that aligns with the demands of preparing TRS for high-stakes environments. By systematically breaking down procedures, progressively designing scenarios from low to high fidelity and complexity, and employing effective micro-level support techniques, instructors can create pathways for students to develop the robust, adaptable competencies required in medical rescue. This approach not only fosters the emergence of proficient performance but also cultivates a deeper understanding of the causal mechanisms that underpin successful outcomes in medical rescue situations. Such a structured, yet adaptable, pedagogical framework is indispensable for programmes aiming to produce critically thinking and highly capable TRS. Conclusion The systematic scaffolding of complex medical rescue procedures, through deliberate progression in simulation fidelity and task complexity, alongside the decomposition of procedures into discrete, manageable skills, effectively mitigates cognitive and psychomotor overload. This structured approach facilitates the incremental development of proficiency, enabling learners to build upon foundational competencies in a manner that supports the emergence of expert performance. While the broader framework of MRS encompasses four interconnected pillars, this article has primarily focused on the pedagogical dimensions of foundational learning theory, and systematic skill scaffolding as critical drivers of effective SBE. The remaining pillars, which are integrated physical preparedness and stringent safety protocols, although acknowledged as essential to the holistic development of TRS, were not the central focus of this article. Their roles in ensuring physical readiness and safeguarding psychological and physical well-being warrant dedicated exploration in future work. By emphasising the theoretical and instructional foundations of simulation, this article contributes to the advancement of evidence-informed practices in medical rescue training. Institutions committed to producing competent, resilient, and critically thinking TRS must adopt such structured and theory-driven approaches to SBE, ensuring that learners are equipped not only with technical expertise, but also with the cognitive agility required to navigate the complexities of real-world emergencies. Author contributions All authors contributed equally and validated the final version of record. Declarations Conflicts Of Interests The Authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval Ethical approval for this study was not required. References 1. Hooshangi N, Mahdizadeh Gharakhanlou N, Ghaffari-Razin SR. Urban search and rescue (USAR) simulation in earthquake environments using queuing theory: estimating the appropriate number of rescue teams. Int J Disaster Resil Built Environ. 2024;15(1):1‒18. https://doi.org/10.1108/IJDRBE-09-2021-0122 2. Elendu C, Amaechi DC, Okatta AU, Amaechi EC, Elendu TC, Ezeh CP, et al. The impact of simulation-based training in medical education: a review. 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Visually Enhanced Mental Rescue Simulation
Copyright (c) 2026 Athenkosi Sobada, John Meyer, Elroy Cameron, Glenhael Carolus (Author) https://creativecommons.org/licenses/by/4.0
Emergency Staff Perceptions of Mass Casualty Management Effectiveness in Lebanese Hospitals: A Cross-Sectional Study
Introduction Mass Casualty Incidents (MCIs) present significant challenges to hospitals, often overwhelming available resources and requiring rapid, coordinated responses. Effective casualty management plans are essential to ensure optimal patient care during such crises. Key components include staff training, interdepartmental communication, resource allocation, psychological support, and post-disaster evaluation. Objective This study aimed to evaluate the perceived effectiveness of disaster management plans in Lebanese hospitals from the perspective of emergency staff responsible for implementing Mass Casualty Management (MCM) plans. Materials and Methods A cross-sectional quantitative study was conducted with 71 emergency staff members, including chiefs and personnel directly involved in MCM, from 12 public and private hospitals across Lebanon. Data were collected via a structured questionnaire covering demographics, overall plan effectiveness, specific plan components (triage, communication, coordination, resource allocation), and open-ended suggestions. Results Significant positive correlations were observed between staff training and perceived plan effectiveness (r = 0.528, p < 0.01), perceived triage efficiency and the staff’s perception of reduced mortality and morbidity (r = 0.505, p < 0.01), resource allocation and perceived plan effectiveness (r = 0.572, p < 0.01), communication and team coordination (r = 0.481, p < 0.01), and psychological support and staff satisfaction (r = 0.541, p < 0.01). Conclusion Emergency staff perceive continuous training, effective communication, optimized resource allocation, and psychological support as critical to improving the effectiveness of MCM plans. Hospitals should adopt an integrated approach that combines these elements with systematic post-disaster evaluation to strengthen preparedness, staff resilience, and patient care during mass casualty incidents. Introduction Context Lebanon has faced repeated crises in recent years, including the Beirut port explosion of 2020, ongoing political instability, and strained healthcare resources, that have exposed critical vulnerabilities in hospital preparedness for Mass Casualty Incidents (MCIs). MCIs are large-scale emergencies that generate a sudden influx of patients with diverse and severe injuries, often exceeding the capacity of local healthcare systems [1]. These events place hospitals under extreme pressure, especially in resource-limited settings, and highlight the need for structured preparedness and response strategies [2]. Without adequate planning, the continuous arrival of casualties can quickly destabilize hospital systems, increasing morbidity and mortality [3]. Mass Casualty Management (MCM) provides an essential framework for mitigating these challenges. It encompasses measures to optimize resource allocation, organize patient care, and coordinate inter-institutional efforts to ensure equitable distribution of patients and continuity of hospital services [4].Within this framework, the crisis management cycle outlines key phases: immediate response, relief, rehabilitation, prevention, mitigation, and preparedness. Each phase requires coordinated actions among hospitals, government agencies, and community stakeholders to strengthen resilience and reduce disaster impact [5]. Effective crisis response depends on three fundamental principles: triage, communication, and adaptability. Triage enables prioritization of care, maximizes survival outcomes, and ensures efficient use of limited resources [6]. Clear communication among hospitals, emergency services, public authorities, and international organizations reduces delays and errors, while centralized information systems support timely decision-making [7]. Flexibility and adaptability are equally critical, as crises often create unpredictable demands that require rapid redistribution of resources and decentralized decision-making at the frontline level [8]. Hospital preparedness is further enhanced through MCM training programs, which strengthen the capacity of health systems to respond effectively to crises. Evidence demonstrates that such training improves staff performance in three key areas. First, it enables faster and more coordinated responses by standardizing protocols, thus reducing delays in patient care [8]. Second, it improves patient flow management through more accurate triage and better allocation of medical units, preventing service blocks [9]. Third, it enhances communication across stakeholders, ensuring real-time coordination and optimal use of available resources [1]. By improving efficiency, patient management, and interprofessional collaboration, MCM training may contribute to a perceived reduction of preventable mortality and morbidity during disaster events [10]. However, despite growing international literature on hospital disaster preparedness, there is limited evidence from Lebanon examining how frontline emergency staff perceive the effectiveness of mass casualty management plans and their key operational components in real-world crisis settings. Objective This study aimed to assess emergency staff perceptions of the effectiveness of mass casualty management plans in Lebanese hospitals and to examine perceived associations between key plan components and perceived management effectiveness. Materials and methods This quantitative cross-sectional study was conducted to evaluate the effectiveness of disaster management plans in Lebanese hospitals. Data were gathered from a purposive sample of 71 nursing leadership and supervisory staff members directly involved in the operational implementation of Mass Casualty Management (MCM) protocols. Participants were recruited using a non-probability convenience sampling approach. In each participating hospital, a local contact person facilitated questionnaire distribution to eligible emergency staff directly involved in mass casualty management. Because participation depended on availability and willingness to respond, the sample may not be fully representative of all emergency personnel within each institution. While this method ensured high-level perspectives on departmental coordination, we acknowledge that reliance on availability and the specific targeting of management may introduce selection bias by excluding broader frontline staff. Consequently, these findings reflect the insights of nursing leadership and should be interpreted with caution regarding their generalizability to the wider Lebanese healthcare workforce. Data collection was performed using a structured questionnaire divided into four sections: - Section A: Demographic information collected participants’ personal and professional characteristics, including gender, age, years of experience, and hospital type. - Section B: Evaluation of the disaster management plan measured participants’ perceptions of their hospital’s disaster management plan using a Likert scale ranging from “strongly disagree” to “strongly agree.” - Section C: Specific components of the plan assessed critical elements of the disaster management plan, including triage systems, communication protocols, and collaboration with external agencies. - Section D: Results and recommendations comprised open-ended questions allowing participants to suggest improvements and recommend training initiatives. The data collection process included the following steps: 1. Authorization: Obtaining approval from relevant ethics committees and hospital authorities. 2. Coordination: Designating a contact person at each hospital to facilitate questionnaire distribution and collection. 3. Distribution: Providing questionnaires in either paper or electronic format, according to hospital preference. 4. Collection: Gathering completed questionnaires over a one-month period, with regular reminders to maximize response rates. 5. Validation: Reviewing completed questionnaires to ensure completeness and alignment with study objectives. To ensure validity, a pilot test was conducted with 10 nurses prior to full-scale distribution. Reliability was assessed using Cronbach’s alpha, demonstrating excellent internal consistency of the survey items (⍺= 0.933). Data Analysis Collected data were entered into SPSS version 26 (IBM Corp., Armonk, NY, USA) for statistical analysis. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize participants’ demographic characteristics and responses regarding disaster management plans. Inferential statistics were applied to assess relationships between variables. Pearson correlation coefficients were calculated to examine the association between staff training, resource allocation, communication, psychological support, and the perceived effectiveness of hospital disaster management plans. Significance was set at p < 0.05 for all analyses. Open-ended responses from Section D of the questionnaire were analyzed qualitatively using thematic content analysis. Responses were coded to identify recurring themes and recommendations for improving disaster management plans and training programs. The combination of quantitative and qualitative analyses allowed for a comprehensive evaluation of hospital disaster management strategies, providing both numerical associations and practical insights from frontline staff. Results Participant Demographics The study included 71 healthcare staff members from 12 public and private hospitals across Lebanon. Participants’ demographic characteristics are summarized in Table 1. The sample included both genders, with a slight predominance of females (55%). Age distribution ranged from 24 to 58 years, with a mean age of 36.4 ± 7.8 years. The majority of participants had between 5 and 15 years of professional experience (61%), while 20% had less than 5 years and 19% had more than 15 years. Participants were drawn from various hospital types, including 8 public hospitals (45%) and 4 private hospitals (55%). This diversity ensured a representative sample across hospital settings. Descriptive Analysis Table 2 presents descriptive statistics on participants’ perceptions of the effectiveness of the disaster management plan. Overall, the disaster management plan received a mean score of 3.75 out of 5, indicating a generally positive perception among hospital staff. Pre-crisis training in disaster management protocols was rated 3.62, suggesting moderate preparedness but highlighting area for improvement. Coordination between medical teams (mean = 3.68 ± 0.858) and resource allocation (mean = 3.70 ± 0.901) were perceived as relatively effective. In contrast, the consideration of staff psychological needs received a lower mean score (3.18 ± 1.004), identifying a key area requiring further attention. Integration of external agencies (mean = 3.65 ± 0.987) and interdepartmental communication (mean = 3.59 ± 0.748) were rated moderately positive. The perceived impact of the plan on reducing mortality and morbidity was favorable (mean = 3.66 ± 0.877). These findings highlight the need for targeted improvements in pre-crisis training and psychological support (Table 2). Inferential Analysis Training and perceived effectiveness Pearson correlation analysis revealed a significant positive relationship between disaster management training and the perceived effectiveness of the plan (r = 0.528, p < 0.01; Table 3). This finding suggests that greater perceived adequacy of training is associated with higher perceived effectiveness of the disaster management plan. Triage efficiency and perceived reduction in mortality and morbidity A significant correlation was observed between triage efficiency and perceived reduction in mortality rates (r = 0.505, p < 0.01; Table 4). Structured triage systems and training could lead to improved patient survival during mass casualty events. Resource allocation and plan effectiveness Efficient allocation of hospital resources was strongly correlated with the perceived effectiveness of the disaster management plan (r = 0.572, p < 0.01; Table 5). Hospitals with better management of staff, equipment, and supplies demonstrated increased capacity to handle mass influxes of patients. Communication and coordination Clear communication between medical teams was significantly associated with improved coordination during crisis management (r = 0.481, p < 0.01; Table 6). This underscores the importance of standardized communication protocols and technologies, such as briefing meetings and instant messaging systems, to enhance hospital response. Psychological care and staff satisfaction Psychological support for staff was positively correlated with overall staff satisfaction regarding the disaster management plan (r = 0.541, p < 0.01; Table 7). These findings highlight the value of post-crisis consultations, debriefing sessions, and stress management training in promoting staff well-being and sustaining effective disaster response. Thematic Analysis of Open-Ended Responses Analysis of open-ended responses identified five key themes highlighting staff concerns and recommendations (Table 8): 1. Continuous training and simulation: Staff emphasized the need for regular disaster drills and updated training programs to maintain preparedness. 2. Improved coordination: Enhancing coordination within departments and with external partners, such as the Red Cross and Civil Defense, was recommended. 3. Resource optimization: Respondents highlighted the importance of effective allocation and management of human and material resources during crises. 4. Psychological support: Providing structured psychological care for medical staff was consistently identified as a critical gap. 5. Post-Crisis evaluation: Establishing systematic post-crisis assessments was suggested to refine disaster management plans and incorporate lessons learned. Overall, the combination of quantitative and qualitative findings indicates that Lebanese hospitals generally implement effective disaster management plans but require targeted improvements in staff training, psychological support, resource management, and post-crisis evaluation. Discussion The results of this study provide clear insights into the effectiveness of disaster management plans in Lebanese hospitals and the factors influencing their success. By combining quantitative and qualitative analyses, this research demonstrates that staff training, interdepartmental coordination, resource allocation, and psychological support are all critical components of effective Mass Casualty Management (MCM). The observed positive correlation between staff training and perceived plan effectiveness (r = 0.528, p < 0.01) confirms that well-trained personnel significantly enhance the hospital’s emergency response capabilities. These findings align with Yao & Kuago (2022), who reported that regular simulation exercises and practical training improve caregivers’ preparedness, reduce errors, and facilitate rapid, coordinated action in crises [11]. Similarly, Bodina et al. (2017) highlighted those hospitals investing in comprehensive theoretical and practical training experience better interdepartmental coordination and overall plan efficiency [12]. Effective communication and coordination among hospital teams were significantly correlated (r = 0.481, p < 0.01), emphasizing that clear communication channels are essential to ensure smooth patient flow and minimize errors during emergencies. These results corroborate the work of Xue et al. (2020), who demonstrated that structured protocols and regular inter-agency meetings enhance operational efficiency [13]. Furthermore, Soltani-Sobh et al (2016) highlighted that communication training and pre-established collaboration agreements with external organizations, such as the Red Cross, improve response quality during disasters [7]. Resource allocation emerged as a key determinant of plan effectiveness, with a strong positive correlation (r = 0.572, p < 0.01). Hospitals with better management of staff, medical supplies, beds, and equipment were more capable of handling patient surges. This aligns with Yao et al. (2022), who emphasized that efficient resource management, supported by inventory systems and digital monitoring technologies, improves emergency care outcomes and overall hospital preparedness [14]. The study confirms that psychological care for hospital staff significantly impacts their satisfaction and performance during crises (r = 0.541, p < 0.01). These results support findings by Hussaini et al 2023, who advocate for structured post-crisis debriefings, stress management training, and continuous psychological support to prevent burnout and maintain quality care. Integrating psychological support into MCM plans not only improves staff well-being but also indirectly enhances patient care and institutional resilience [5]. An important finding of this study is that psychological support for staff received the lowest mean score among all assessed components (3.18 ± 1.004). In the Lebanese context, this result may reflect the cumulative burden of repeated crises, including the Beirut port explosion, prolonged economic instability, workforce shortages, and sustained occupational stress. These contextual pressures may contribute to emotional exhaustion and burnout among healthcare professionals, thereby limiting the perceived adequacy of institutional psychological support mechanisms. This finding suggests that psychological preparedness should be integrated more explicitly into hospital disaster plans through debriefing protocols, peer-support systems, referral pathways, and post-incident mental health follow-up. Responses to open-ended questions highlighted the importance of systematic post-crisis evaluation. Regular assessment of disaster management plans, as recommended by Tegegne et al. (2023), allows hospitals to identify weaknesses, implement corrective measures, and improve overall preparedness [15]. This iterative process, combined with nursing leadership/supervisors’ feedback, ensures continuous improvement, better resource allocation, and enhanced team coordination for future incidents. Overall, this study demonstrates that effective disaster management in hospitals is multifactorial. Staff training, communication, resource management, psychological support, and post-crisis evaluation are interdependent components that together enhance hospital preparedness, improve patient outcomes, and increase institutional resilience during mass casualty incidents. Strengths and limitations Strengths - The mixed-methods approach allowed for a comprehensive evaluation of disaster management plans by combining quantitative and qualitative analyses. - The quantitative instrument demonstrated high reliability, with an excellent internal consistency (Cronbach’s alpha = 0.933). - The research successfully identified and confirmed critical pillars of effective Mass Casualty Management (MCM), specifically staff training, communication, resource allocation, and psychological support, providing a robust framework for institutional assessment. Limitations Despite these strengths, several limitations must be considered: - The study utilized a non-probability convenience sampling approach with a relatively small sample size (N=71), which may limit the generalizability of the findings to all hospitals in Lebanon. Furthermore, by targeting nursing leadership and supervisors as key informants, the study captures high-level perspectives on departmental oversight but may introduce selection bias. Consequently, the findings primarily reflect the insights of nursing management and may not fully capture the frontline experiences of bedside emergency staff. - The reliance on self-reported data may introduce participant perception bias. Additionally, the possibility of common method bias exists, as both predictor and outcome variables were collected from the same respondents simultaneously. This suggests that some observed associations may partly reflect general response tendencies rather than distinct underlying constructs. - The cross-sectional design restricts the ability to evaluate the long-term evolution of hospital practices over time. More over, the focus on specific institutional contexts means the results may not be directly comparable to facilities with different infrastructures or policies. - While the study distinguished between leadership and staff involved in MCM, detailed professional sub-categories were not systematically captured. Incorporating objective metrics, such as response times or mortality rates, in future research would provide a more granular assessment of MCM effectiveness. Ethical considerations Ethical approval was obtained from the Ethical Committee-Holy Family University, approval number [004/2026]. Administrative authorization was also obtained from the participating hospitals. Conclusion This study highlights that, from the perspective of emergency staff, disaster preparedness in Lebanese hospitals depends on several interrelated dimensions, particularly training, communication, resource allocation, and psychological support. The findings should be interpreted as staff perceptions rather than objective measures of clinical effectiveness. Nevertheless, they identify priority areas for strengthening hospital disaster readiness. Practical implications include regular simulation-based training, clearer interdepartmental communication pathways, formal staff support mechanisms after crisis events, and structured post-incident audits to guide continuous quality improvement. Future studies should combine staff perceptions with objective institutional indicators and clinical outcomes to provide a more comprehensive assessment of mass casualty management effectiveness. Author contributions Eliana GHAZAL: Conceived the study, wrote the introduction, and participated in the discussion. Dunya NOHRA: Developed the methodology and contributed to data interpretation. Maha NEHME: Conducted data analysis and participated in the discussion and conclusion. Hilda CHELALA: Provided critical feedback on the manuscript. All authors validated the final version of record. Declarations Conflicts Of Interests The Author declares that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval Ethical approval for this study was not required. References 1. Alpert EA, Kohn MD. EMS Mass Casualty Response. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025. Available from: http://www.ncbi.nlm.nih.gov/books/NBK536972/ 2. Staribacher D, Rauner MS, Niessner H. Hospital Resource Planning for Mass Casualty Incidents: Limitations for Coping with Multiple Injured Patients. Healthcare. 2023;11(20):2713. https://doi.org/10.3390/healthcare11202713 3. Aqtam I, Shouli M, Al-qoroum S, Shouli K, Ayed A. Evaluating Disaster Management Preparedness among Healthcare Professionals During Pandemics: Palestinian Context. Sage Open Nurs. 2024 Sep 19;10:23779608241283698. https://doi.org/10.1177/23779608241283698 4. Tong J. Mass casualty management. Int Anesthesiol Clin. 2021 Feb 9;Publish Ahead of Print. https://doi.org/10.1097/AIA.0000000000000315 5. Husaini BA, Sugiarto S, Rahmanand S, Oktari RS. Assessing hospital disaster preparedness: A scoping review of available tools. Narra J. 2023 Aug;3(2):e210. https://doi.org/10.52225/narra.v3i2.210 6. 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The epidemiology of emergency presentations for falls from height across Western Victoria, Australia. Australas Emerg Care. 2020 Jun;23(2):119–25. https://doi.org/10.1016/j.auec.2019.09.002 11. Yao G. Flexible and adaptable : a strategy for future healthcare facility toward disaster and emergency [Internet] [Master’s thesis]. [Milan, Italy]: Politecnico Milano; 2022 [cited 2025 Sep 2]. Available from: https://www.politesi.polimi.it/handle/10589/188942 12. Bodina A, Pavan A, Castaldi S. Resource allocation criteria in a hospital. J Prev Med Hyg. 2017 Jun;58(2):E184–9. 13. Xue CL, Shu YS, Hayter M, Lee A. Experiences of nurses involved in natural disaster relief: A meta-synthesis of qualitative literature. J Clin Nurs. 2020 Dec;29(23–24):4514–31. https://doi.org/10.1111/jocn.15476 14. Tegegne SG, Mengestu TK, Francisco K, Bollars C, Kapanga H, Galbert FT, et al. Process of developing Country Cooperation Strategy in Tanzania, as an effective tool for aligning WHO’s support to the member state in achieving health and health-related sustainable development goal. Pan Afr Med J. 2023;45(Suppl 1):2. https://doi.org/10.11604/pamj.supp.2023.45.1.39584 15. Higginbotham EJ, Church KC. Strategic planning as a tool for achieving alignment in academic health centers. Trans Am Clin Climatol Assoc. 2012;123:292–303
Copyright (c) 2026 Eliana Ghazal, Dunya Nohra, Hilda Chelala, Maha Nehme (Author) https://creativecommons.org/licenses/by/4.0
The Burden of Road Traffic Injuries: A Global Perspective
Introduction Road Traffic Injury (RTI) pose a significant health challenge. It represents the eighth leading cause of death globally, prompting the UN to designate 2011-2020 as the “Decade of Action for Road Safety”. This study aims to determine the global and regional burden of RTIs, and the impact of drink-driving and seatbelt-wearing on RTIs in 2017, while also assessing the UN Action Plan outcomes and forecasting the RTI rate for 2029. Methods Data on the global and regional RTI rates (2000-2019), regional seatbelt use (2017), and regional drink-driving (2017) were compiled from the Global Health Observatory Estimates. The investigated key metrics are global and regional RTI rate per 100,000 population in 2000-2019, percentage of regional seatbelt-wearing, drink-driving RTIs, and enforced seatbelt and drink-driving laws in 2017. Results This study reveals a heterogenous regional distribution of road traffic injuries in 2017. Africa sustained the highest RTI rate (27.6/100,000 population), while Europe reported the lowest rate (10.98/100,000 population). Regional variation in seatbelt laws exists, with the highest legalization in Europe (100%), and the lowest in Western Pacific (80.95%). Eastern Mediterranean (87.43%) and South-East Asia (46.8%) reported the highest and lowest driver seatbelt-wearing rates, respectively. All countries, except the Maldives, legislated drink-driving laws. Western Pacific (29.98%) and Eastern Mediterranean (1.65%) suffer from the highest and lowest burden of drink-driving RTI, respectively. Conclusion Despite a relatively stable global RTI rate from 2011-2020 and a steady decline till 2029, the future trajectory remains uncertain in developing countries bearing the highest burden, due to slow national law enforcement, rendering the UN Action Plan insufficient in curbing the burden of RTIs. INTRODUCTION Road traffic injury (RTI) is a major global health challenge, impacting millions of individuals worldwide [1]. With approximately 20-50 million non-fatal injuries, 70 million disability-adjusted life years (DALYs), and 1.3 million deaths annually, RTI remains a neglected yet major health problem globally [1, 2]. According to the World Health Organization (WHO), RTI is ranked the 6th and 8th leading cause of DALYs and mortality globally, respectively [1, 3, 4]. The current steady RTI trends suggest that traffic fatalities are expected to become the 7th leading cause of death worldwide by 2030 [4]. RTI imposes a real threat to the health and well-being of all populations across all age groups, with a particularly heightened burden on the youth population [5]. In fact, RTI constitutes the primary cause of death for people aged 5 to 29 years; the majority of victims were among the male populations compared to their female counterparts [1, 2, 6]. Existing literature identifies multiple factors that contribute to the increased rate in RTI mortality and morbidity among the youth and the males’ population, including the tendency to violate traffic laws such as traffic signals, and the lack of seatbelts/helmets use, in addition to the potential engagement in high-risk driving behavior, including car racing and drink-driving [7-10]. Females are relatively safer drivers at all times (day/night), and in all road conditions (i.e. weather, road layout, etc.), which decreases their risk of sustaining road fatalities, with nearly 3 times less likelihood of females being killed in road traffic crashes [1, 11, 12]. Besides the health impact, RTIs inflict a serious economic and societal toll on individuals, families, and communities, incurring large direct and indirect costing reaching up to 3% of most countries’ gross domestic product (GDP) [1]. The human and economic loss associated with RTI is disproportionately more prominent in low- and middle-income countries (LMICs), where 93% of road traffic deaths (RTI) occur [1]. The latter is explained by several factors, including the high proportion of vulnerable road users, such as pedestrians and cyclists, the absence of road safety regulations, and the extensive illiteracy and defiance of laws in LMICs [8]. RTIs are expected to further rise in LMICs with the increasing motorization and urbanization [10]. In addition to environmental factors, human behavior is responsible for the majority of road crashes [13, 14]. Human observation, interpretation, and planning errors further predispose individuals to traffic crashes and impact injury severity and outcome [14]. Various factors are associated with RTIs including speeding, fatigue, poor driving skills, alcohol and substance consumption, poor vehicle conditions, violation of traffic laws (i.e. improper seatbelt/helmet/child seat use, use of mobile phone while driving, disregarding traffic signs, etc.), unsafe road environments (i.e. bad weather, poor infrastructure, poor lighting, lack of pedestrian facilities, etc.), and inadequate post-crash care (i.e. first aid care, fast access to medical personnel, rehabilitation services, etc.), amongst others, contribute to increased traffic mortalities and morbidities [2, 13]. Enforcing the required measures of road safety and adopting safer road behavior substantially reduce road traffic crashes and subsequently prevents RTIs [1]. Alcohol use, even in insignificant amounts, impairs the cognition, vision, and reaction time of all consumers [4, 10, 15]. Accordingly, blood alcohol concentration (BAC) above zero has been identified as a primary risk factor in the causation and severity of traffic crashes for all road users, including motorists and pedestrians [15]. Notably, drink-driving with a BAC greater than 0.04 g/dl results in severe behavior impairments associated with reckless driving, speeding, unfastening seatbelt/helmet, and disobeying traffic laws, and in turn dire traffic crashes and injuries [1, 15]. Alarmingly, approximately 20% of traffic fatalities in high-income countries and 33-69% of traffic deaths in LMICs are attributed to alcohol consumption, predominantly affecting young and novice drivers [10, 16]. Several countries including Canada, Australia, and Italy have adopted strategies to reduce RTI injuries and deaths among this high-risk group including the decrease of the BAC limit to ≤0.02 g/dl for young and/or novice drivers. This policy lead to a substantial reduction in traffic crashes by up to 24% [2, 4]. Other RTI reduction successful measures were implemented by over one hundred countries to reduce drink-driving include public awareness, random breath testing, and police sobriety checkpoints [4, 17]. Yet, given that LMICs are currently exposed to the growing use of alcohol, hardly any developing countries have enforced measures to control drink-driving [18]. Assessing the contribution of drink-driving on RTIs is crucial to develop prevention strategies, though data on drink-driving remains limited in the majority of LMICs and some high-income countries (HIC) [2, 4]. While functional seatbelt laws and increasing compliance are enacted in more countries compared to drink-driving laws, many LMICs lack mandatory safety requirements with limited law enforcement and compliance [2, 4, 19, 20]. The WHO, the FIA Foundation, and partners, have highlighted the urgent need to increase seatbelt and child restraint use, particularly in LMICs experiencing rapid motorization. Seat-belts can reduce vehicle occupant deaths by up to 50%, while child restraints can prevent up to 71% of fatalities among infants. Despite high compliance in regions such as Europe, usage remains low in other regions. Updated WHO guidelines, as noted by Dr. Khayesi, emphasize comprehensive programs combining legislation, enforcement, and public education to promote seatbelt use and convince governments and citizens of such need [23, 24]. Since the vast majority of RTIs are both predictable and preventable, global efforts have been concerted for decades to address the burden of traffic fatalities and injuries [2, 4]. Almost 123 countries, representing around six billion people, amended laws on at least one of the five key risk factors of road injuries, such as speeding, seatbelt and helmet use, child restraint use, and drink-driving [2]. HICs succeeded in reducing the toll of RTIs by relying on data-driven evidence and resources to inform strategic safety rules and regulations [2]. With the lack of adequate data on any traffic crash-related risk factor, such as alcohol consumption and seatbelt use, LMICs continued to mismanage RTIs and traffic deaths [2, 4]. Accordingly, the United Nations (UN) General Assembly launched the Decade of Action for Road Safety 2011–2020, with a target to save 5 million lives by the year 2020 [25]. This approach focused on five main pillars: road safety management, safer roads, safer vehicles, safer road user behavior, and post-crash care [25]. Evaluating the success of this plan is key to developing successful future strategies regarding traffic injuries and deaths worldwide. This study aims to describe the current burden of road injuries worldwide, for the period from 2000 to 2019, to highlight the impact of two major risk factors including alcohol consumption and seatbelt usage in 2017, and to forecast the future trends in road traffic deaths. It further assesses whether the period ranging between the years 2011 and 2020 was indeed the “Decade of Action for Road Safety” as proclaimed by the UN General Assembly. Findings from this study help to suggest reliable measurements that can be implemented globally and nationally to reduce and mitigate injuries and deaths on the roads. METHODS Data Sources Data were retrieved from the Global Health Observatory Estimates generated by the WHO for Information, Evidence, and Research. Data on six regions (Americas, Africa, Europe, Eastern Mediterranean, South-East Asia, and Western Pacific) were extracted and analyzed [26]. Data posted by WHO on seatbelt wearing rate and attribution of RTIs to alcohol were only available for the year 2017. Road traffic mortality rates and the estimated number of deaths worldwide are reported for the time falling between the years 2000 and 2019. Data Processing The collected data were processed using Power BI (Microsoft, Redmond, USA). Power BI is an interactive data visualization software product developed by Microsoft and focuses on business intelligence [27]. To build the dashboard, the following datasets were uploaded and used: estimated number of RTIs per gender, estimated RTI rate per gender (per 100,000 population), seatbelt use rate (%), the impact of RTIs on alcohol (%), and drink-driving existing national law (Binary yes/no), road safety strategy (Binary yes/no), and seatbelt law (Binary yes/no). All data attributes had a categorical parent location (i.e., region), location (i.e., country), and numerical period (i.e., year). Before data visualization using Power BI, data were compiled, uploaded, and preprocessed. A unique identifier (composite key) was created for the first four tables on the dashboard. The key encompasses the location and period (e.g. Afghanistan2000). The created identifiers were used to link the tables, and ultimately create the dynamic dashboard. For data visualization, parent location, location, and period, were then referred to as region, country, and year, respectively. The key metrics that were investigated in this study are as follows: RTIs rate (per 100 000 population) during the period 2000-2019, average regional RTI rate (per 100 000 population) and percentage in 2000-2019, percentage of driver seatbelt wearing rate (%) in 2017 per region, percentage of drink-driving RTIs (%) in 2017 per region, and the percentage of legalization of seatbelt use and drink-driving laws per region. As for the projection, it was generated using a linear regression model based on historical data of road traffic fatalities. The model assumes a consistent trend over time and extrapolates future values accordingly. This approach was chosen to provide a basic forecast of the potential trajectory if current patterns persist, recognizing that more complex models were beyond the scope of this study. RESULTS Of the six regions examined, Africa sustained the highest burden of RTIs with 27.6 RTIs per 100,000 population between 2000 and 2019, followed by the Eastern Mediterranean region (EMR) with 21.05 RTIs per 100,000 population. South-East Asia (16.95 RTI per 100,000) and the Americas (16.5 RTI per 100,000) suffered from a comparable rate of road traffic injuries, while Western Pacific and Europe sustained only 13.51 RTI per 100,000 and 10.98 RTI per 100,000 of RTIs during the same period, respectively (Table 1). Inversely, Europe reports 82.1% driver’s seatbelt compliance in 2017 (62.72% of European countries reporting this rate). With 53.33% of American countries reporting this measure, the driver’s seatbelt-use rate was 67.23% in 2017. Although the seatbelt-use rate of drivers in the EMR was high in 2017 (87.43%), only 4 out of 19 EMR countries (21.05%) disclose relevant statistics. Africa has the lowest reporting rate (18.18% of African countries reporting) and average driver seatbelt-use rate (47.78%) compared to other regions. With relatively moderate reporting, South-East Asia, and the Western Pacific regions (30 and 38.1% countries reporting, respectively) disclose a 46.8% and 77.66% seatbelt compliance rate in 2017, respectively (Table 2). Assessing the contribution of alcohol consumption to RTIs in 2017 across different regions revealed that Western Pacific (29.98% attribution with around 71.42% countries in the Western Pacific reporting their numbers) suffers from a relatively large burden of drink-driving RTIs compared to other regions, particularly EMR (1.65% attribution with 42.1% countries in EMR reporting their numbers). With an average reporting of 43.33% of the countries in the Americas, alcohol consumption was linked to 16.91% of their RTIs in 2017. Africa (14.35% attribution with only 25% of countries in Africa reporting their numbers), followed by South-East Asia (13.2% attribution with 30% of countries in South-East Asia reporting their numbers) and Europe (12.97% attribution with 76.47% countries in Europe reporting their numbers), suffered from relatively moderate drink-driving RTIs in 2017 (Table 2). In 2017, all European, African, American, EMR, South-East Asian, and Western-Pacific countries have existing national drink-driving laws, except the Maldives in South-East Asia (Figure 1). A clear discrepancy exists between regions when assessing the presence of national seatbelt laws across all countries in 2017. All European countries have established seatbelt safety laws. Americas (93.33%), followed by South-East Asia (90%), EMR (89.47%), and Africa (88.64%), further established seatbelt safety policies. Yet, only 80.95% of the Western Pacific region countries successfully adopted such laws to increase seatbelt wearing in 2017 (Figure 2). Although the overall RTI burden declined from 19.2 RTIs per 100,000 population in the year 2000 to 17.1 RTIs per 100,000 population in the year 2019, this rate insignificantly fluctuated (≈ 17.1 RTIs per 100,000 population) during the period between 2011 and 2020. Forecasting the overall global burden of RTIs from the year 2020 till the year 2029 revealed that the RTI rate is expected to steadily decrease (Figure 3). DISCUSSION This study explored the global distribution of RTIs across different regions. It further examined the impact of various risk factors on RTIs including driver seatbelt use and drink-driving. Evidence from this study will be key to assessing the degree of success of the “UN Decade of Action for Road Safety Plan” from 2011 to 2020, and further facilitates the prediction of the upcoming pattern of global rates of traffic injuries and fatalities. Consistent with previous studies, a substantial discrepancy in the burden of RTI existed between different regions [22, 28, 29]. Despite the global increase in traffic jams and the use of motor vehicles, Africa sustains a three-time higher risk of RTIs compared to Europe. This can be attributed to the strong link between traffic injuries and fatalities, and the country’s income level [28], as well as the diverse terrain in Africa which was associated with increased risk of RTIs [30-32]. Interestingly, RTI depicted an increasing trajectory with increasing GDP in LMICs, and decreasing patterns with an increased GDP in HICs [28]. One study suggests that besides the growing mobilization in developing countries, the common hazardous driving, unsafe roads, and the high proportion of vulnerable road users, collectively increase the prevalence of local RTIs [8, 28]. Developed countries can mitigate this burden with the establishment of safer roads, efficient road safety policies, and enhanced emergency transport and medical treatment [28]. Accordingly, the classification of the majority of the African and EMR countries as low and lower-middle-income countries explains the high RTI rate, compared to upper-middle and high-income countries in Europe, the Americas, Western Pacific, and South-East Asia [33]. The varying RTI toll across regions is found to be further associated with informing and enforcing regional and national road safety policies. While a portion of the burden lies on the government’s inefficient and limited resources to invest in road safety, human behavior predominantly contributes to RTIs [34]. Among the leading risk factors of RTIs are drink-driving and failing to use seatbelts among vehicle occupants and child restraint systems [35]. Findings from this study reveal that although all countries, except the Maldives, had established drink-driving laws in 2017, alcohol consumption still majorly contributes to RTIs globally. Aligned with existing studies, the Eastern Mediterranean Region sustains the lowest burden of drink-driving injuries and mortalities [36, 37]. In addition to the national laws, the strict cultural and Muslim religious practices in most EMR countries prohibit drinking and restrict alcohol consumption [36]. On the contrary, drink-driving remains an increasingly major concern in other regions, particularly the Western Pacific, followed by the Americas and Africa. The elevated alcohol-attributable burden of RTI in the Western Pacific region is associated with the uppermost alcohol consumption rates in many countries like Tongo, Cooks Island, Australia, Papua New Guinea, and New Zealand [36, 37]. An existing study suggests that more than half of the RTIs in Papua New Guinea and Tongo, and one-third of the RTIs in Australia and New Zealand in 2017 are attributed to alcohol consumption above the legal limit [36]. A similar trend is seen in the Americas and Africa where alcohol use massively increased during the past decade, thus chiefly contributing to the toll of RTIs in countries like Canada, the USA, and South Africa [35, 36]. According to the WHO, 45 countries including Brazil, Canada, New Zealand, and Australia, in addition to the majority of European countries like France, established drink-driving laws meeting the best practices (BAC ≤ 0.05 g/dl and BAC for young/novice drivers ≤ 0.02 g/dl) [2]. By monitoring the patterns of traffic injuries and fatalities via injury registries, such countries were capable of further legislating and amending country-specific policies [38]. Not only did Brazil restrict the BAC limit (0 g/l), it further mandated random breath testing, doubled the fines for drink-driving, and enhanced police power, to reduce the burden of RTIs [2, 39]. In France, driving under the influence of alcohol remains the second leading cause of traffic fatalities [40]. One French-based study showed that 90.7% of alcohol-positive subjects had an alarmingly high BAC (>0.08 g/dl) while driving [41]. Accordingly, without effective law enforcement and safer road user behavior, notably through compulsory random breath testing, efforts to address drink-driving remain inefficient [22, 28, 38]. Evidence from this study reveals that legislation and implementation of seatbelt use are critical to reducing the global burden of RTIs. A previous study assessing the impact of human behavior on seatbelt use found that seatbelt non-use is positively associated with severe traffic injuries and deaths [42]. Improper driver seatbelt use has been found to increase traffic fatalities by 45-50% [2]. The relatively low toll of RTIs in Europe can be associated with the full establishment of mandatory seatbelt-use laws, and with the high driver’s seatbelt-use rate. The latter reflects mature road user behavior, where the level of literacy and awareness, among other factors such as the law penalty and residing in urban areas, were found to be positively associated with seatbelt use [34, 43]. The interventions to increase the use of seatbelts in HICs, including enhanced police training and enforcement, public awareness, and health education, further improved seatbelt-use compliance [44]. Europe further adopted mandatory installation of seatbelt reminder systems, as studies showed that this method is highly effective in enforcing seatbelt use [45]. Collectively, with the recent increasing motorization, high illiteracy, inadequate seatbelt-use laws, and the absence of intervention strategies in many LMICs, the toll of RTIs in developing regions, like Africa and South-East Asia, continues to rise [44, 46]. The assessment of intervention strategies in LMICs must account for country-specific factors, such as barriers, cost, and sustainability, making HICs’ intervention strategies untransferable [34]. In this regard, culture and religion are two significant factors to investigate. Existing studies report that the strong belief in fate and destiny in Africa, South-East Asia, and EMR has been linked to riskier driving and seatbelt non-use [47-52]. Other studies found that religiosity is positively associated with better self-protection practices such as seatbelt use and no alcohol consumption [53, 54]. Implementing national research-based customized awareness campaigns and policies must address such research gaps. However, the presence of limited data in LMICs represents another major barrier to the understanding and assessment of RTIs [2]. Although our analysis covers data only up to 2019, the Global Status Report on Road Safety 2023 confirms that recent global trends continue to show growing disparities [55]. While the global target of halving road traffic deaths between 2011 and 2020 was not achieved worldwide, 10 countries, including Belarus, Brunei Darussalam, Denmark, Japan, Lithuania, Norway, the Russian Federation, Trinidad and Tobago, the United Arab Emirates and Venezuela, did achieve reductions of at least 50% in fatalities. A further 15 countries saw decreases of 40–49%, 20 countries had decreases of 30–39%, and 33 countries reduced deaths by 20–29%. The European Region experienced the largest overall decline, with a 36% decrease in road traffic deaths, and the Western Pacific Region reported a 16% reduction. These successes coincide with countries that have broadly implemented “safe system” approaches, combining comprehensive legislation, enforcement and infrastructure improvements. When adjusted for population growth, the global fatality rate also declined from nearly 18 per 100 000 people in 2010, to about 15 per 100 000 in 2021, a 16% reduction. By contrast, many LMICs, especially those in the African Region, have not seen comparable progress. During the same period, 66 countries reported increases in road traffic deaths, including 28 in Africa, where fatalities rose by 17% overall. The African Region continues to have the highest death rates globally, and more than 90% of all road traffic fatalities still occur in LMICs, with pedestrians, cyclists and motorcyclists making up more than half of the victims. These figures highlight a persistent imbalance: the policies and investments that have successfully reduced deaths in high-income settings have not been implemented, or have been far less effective, in resource-constrained contexts. Without targeted support, stronger enforcement, and scaled-up investment in road safety for LMICs, particularly in Africa, the global goal of halving road traffic deaths and injuries by 2030 is unlikely to be equitably achieved. According to the WHO, global progress was slow to allow the anticipated reduction in RTIs as on-ground implementation was limited, especially in LMICs. This heterogeneity can be attributed to the funding gap, poor civic engagement, and governmental support in many LMICs [56, 57]. Besides setting an action plan, political commitment and public support are key to the successful enforcement of good practices and intervention strategies [57]. The lack of global and national data regarding RTI and its relative risk factors, like seatbelt use and drink-driving, especially in LMICs, further misled the progress of the “UN Decade of Action for Road Safety (2011–2020)” [2]. Investing in health policy research is important to reduce the burden of road traffic injuries. Relevant and representative data should be collected especially from countries where RTIs continue to increase, like Paraguay, Chad, and Pakistan [22]. The European Transport Safety Council has adopted evidence-based research to improve transport safety in Europe [22]. In the USA, the Insurance Institute for Highway Safety conducted extensive science-based multidisciplinary research to employ low-cost road safety programs to enhance traffic safety [22]. Building on these examples, increasing the routine use of proven child safety measures, such as booster seats, bicycle helmets, and graduated driver licensing, can save governments and payers substantial medical and productivity costs. However, these interventions remain underutilized due to barriers such as split savings across payers, long payback periods, and political or practical challenges [58]. Based on the marginal global improvement of traffic safety during the past decade and the continuous international and national efforts to reduce RTIs, this study forecasted a steady decrease in the global rate of RTIs in the upcoming years until 2029. A comparable pattern was obtained in a previous study, where the rate of RTIs was estimated between the years 2017 and 2030. Specifically, the rate of RTI was forecasted to decline by 12%, from 16.3 RTIs per 100,000 population in 2017 to 14.3 per 100,000 population in 2030 [59]. An existing study further predicted a steady decrease in the global rate of pedestrian road-traffic injuries between 2020 and 2030, indirectly imposing a similar reduction pattern of RTIs [60]. Regardless, this estimation might not apply if drastic measures and technologies were implemented during this period, or if global and national efforts were halted. This study has some limitations and strengths. A key limitation is that data in many countries are underreported. The missing data from all regions, particularly from LMICs in Africa and EMR, further limited this study. This might underestimate the burden of traffic injuries in many countries, thus altering the design of efficient intervention strategies to reduce RTIs. Another limitation of this study is that it disregards the political and socio-economic discrepancies between countries in the same region. Thus, even if the regional RTI rate declined, some countries might report an increasing burden due to country-specific factors. Also, the collective association and effect of other risk factors have not been studied. This study did not assess the cost-effectiveness of the proposed interventions, which limits the ability to determine their practicality across different economic settings. The use of a linear regression model assumes a consistent trend, which may not capture sudden policy changes, technological advancements, or other external shocks that could influence road safety outcomes. On the other hand, this study's strengths reside in using advanced data visualization software to process, manage, analyze, and visualize the data. Power BI helped create data models and relationships between the imported datasets. Moreover, its predictive analytics feature provided estimates of RTIs in the coming years, thus encouraging proactive measures to be taken to help curb the RTI phenomenon. This study further provides a global as well as a regional view of the RTI phenomenon in terms of seatbelt-use wearing rate and alcohol consumption rate, two of the major risk factors of RTIs. This study’s overview of the current global and regional distribution of RTIs shows an alarming heterogonous burden. Findings from this study urge policymakers and stakeholders to adopt and enforce safer and more efficient road policies and intervention strategies, and citizens to practice safer and more responsible road traffic behavior. Recommendations Based on these findings, actionable strategies should be prioritized, especially in LMICs. First, establishing a standardized and sustainable national road injury surveillance system is crucial to overcome data gaps and accurately guide interventions. Second, governments should consider implementing low-cost, research-informed campaigns tailored to local culture and beliefs to address key risk factors. For example, partnerships with community leaders may help reinforce positive behaviors. In addition, we recommend investing in capacity-building for local law enforcement and emergency services to reduce the burden of RTIs globally. CONCLUSION The future of road safety is expected to show a steady decrease in RTI rates globally, but this trajectory will remain heterogeneous across regions and countries. With the lack of strong enforcement of evidence-based intervention strategies, the burden of road traffic injuries and fatalities will remain high in developing countries. Minor changes in road safety behavior, such as seatbelt use, will significantly accelerate the reduction of the RTI rate, particularly in LMICs. The high rates of drink-driving and low rates of seatbelt use globally should be addressed via collective global, governmental, and societal efforts. The socioeconomic discrepancies should be considered during legislation to secure large-scale adoption of safety measures and enforcement of road safety laws at a national level. The alarmingly high missing data reported in this study call for reliable national data registries to ensure the success of the current “UN Decade of Action for Road Safety (2020-2030)” via country-specific intervention strategies. Author contributions All authors contributed equally and validated the final version of record. Declarations Conflicts Of Interests The Authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval Ethical approval for this study was not required. References 1. 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Copyright (c) 2026 Johny El-Achkar, Maya El-Gharib, Nesrine Ahmad, Samar Al-Hajj (Author) https://creativecommons.org/licenses/by/4.0
Knowledge and Stigma Regarding HIV and Homosexuality: An Exploratory Survey of Responding Physicians in Lebanon
Background HIV remains a major public health challenge in the Middle East and North Africa (MENA), where stigma against people with HIV (PWH) and men who have sex with men (MSM) hinders access to care. In Lebanon, little is known about physicians’ current knowledge, attitudes, and willingness to provide care for PWH. Methods We conducted an exploratory online survey of all Lebanese physicians registered with the Ministry of Public Health, distributed in four waves between 2023 and 2025. The 58-item questionnaire assessed HIV knowledge, attitudes toward PWH and homosexual colleagues, willingness to provide medical care, and practices related to sexual history and pre-exposure prophylaxis (PrEP). Out of 4,331 emails, 760 were invalid and 127 physicians responded (3.2%). Results Interpretation is limited by a low response rate, and findings should be considered for hypothesis generation rather than prevalence estimates. Respondents were mostly male (63%), with varied specialties and practice settings. Knowledge of HIV transmission was generally high, though gaps were identified: 54% did not recognize breastmilk as a transmission route, 20% were unaware of confidential testing facilities, and only 64% knew that PrEP prevents transmission. While 86% were willing to medically examine PWH and over 90% would perform minor or major procedures, 29% believed physicians have the right to refuse care due to fear of infection. Stigmatizing attitudes were also noted, where 13% would not buy food from PWH, 33% would not allow their child to play with PWH, and 39% would not accept surgery from a surgeon living with HIV. Regarding homosexuality, 10–12% opposed accepting homosexual applicants to medical training or granting them practicing privileges. Most respondents (61%) did not routinely take sexual histories, and 84% had never prescribed PrEP, while 96% agreed on the need for further education. Conclusion In this exploratory sample, respondents had adequate HIV knowledge, but signs of stigma and prevention gaps (PrEP/sexual history) were identified toward PWH and homosexual colleagues, coupled with significant gaps in awareness of PrEP and HIV testing. Physician-targeted educational campaigns focusing on transmission, PrEP, and non-discrimination may help reduce barriers to HIV care and align Lebanon with WHO’s goal of ending the epidemic. INTRODUCTION As of 2025, HIV remains one of the longest on-going pandemics [1]. Affecting diverse populations, different areas of the world deal with it differently [2]. Thus, the barriers to HIV care tend to be unique to certain areas of the world, dictated by the prevalence of certain modes of transmission, access to care, availability and cost of medication, ease of diagnosis, lack of awareness and stigma and social barriers [3]. As of 2019, the United Nations Programme on HIV/AIDS (UNAIDS) reported a 95% surge in HIV incidence in the Middle East and North Africa (MENA) region [4]. With a high proportion of new infections occurring in the population of men who have sex with men (MSM) [5], these populations face a lot of stigma and stereotype that challenges their access to HIV-related care. In addition, insurances are able to legally refuse and deny coverage for a person living with HIV (PWH) [6]. Moreover, not all Lebanese physicians are willing to assess PWH or people belonging to the Lesbian/Gay/Bisexual/Transsexual+ (LGBT+) community [7]. These people often face discrimination when seeking medical care, which can root from discrimination or lack of proper training due to excessive stigma [8]. With the Lebanese Ministry of Public Health (MoPH), the National AIDS Control Program and the local NGOs, awareness was improved and medication was provided for free, in an attempt to improve sexual health, prevention and HIV care [9]. There was a decrease of 52% in HIV incidence in 2020 [10]. However, despite evidence of continued transmission during coronavirus lockdown years [11], little data exists about the progress related to stigma and awareness, especially with a big outflow of physicians and an economic crisis [12]. Among the tools available to assess physicians’ perspective on this matter, surveys provide valuable data, but they are challenged by low response rates, leading to selection bias [13, 14]. Despite these challenges, nationwide surveys provide very meaningful exploratory information in such settings in the most cost-effective way [15]. To assess the current situation, we conducted an exploratory survey sent to all registered Lebanese physicians to assess their attitudes towards HIV and homosexuality as well as their knowledge about HIV. This would provide a descriptive assessment of the current situation amongst Lebanese providers and their current willingness to engage, treat and assist in the care of PWH in Lebanon. As we have little data regarding this area in Lebanon, recording such responses would provide valuable information about the nature of the situation and help identify areas to focus efforts for future intervention for a more effective approach towards the World Health Organization (WHO) goals to ending the HIV epidemic. Emergency and acute care settings are usually the first point of contact for people with undiagnosed HIV, patients presenting after occupational exposure or sexual assault, and those requiring urgent interventions. Physician knowledge of HIV transmission risk, comfort with procedural care, and familiarity with HIV prevention strategies affect patient safety, occupational safety, and equity of care. METHODS Analyses were planned as primarily descriptive given the exploratory study design and anticipated low response rate. To assess the current attitudes of Lebanese physicians towards PWH and homosexual patients, we conducted an online survey that was sent to all registered Lebanese physicians via email, in 4 waves between 2023 and 2025. The survey consisted of 58 multiple-choice questions regarding HIV transmission awareness, attitude towards PWH, experience and willingness to provide medical care to PWH, healthcare professionals living with HIV and colleagues who are homosexual and sexual history and pre-exposure prophylaxis (PrEP). The 58-item instrument was developed for exploratory use based on domains relevant to HIV care and stigma (transmission knowledge, willingness to provide care/procedures, occupational exposure/PEP/PrEP awareness, sexual history practices, and attitudes toward colleagues). Items were reviewed by the study team for clarity and validity prior to distribution. The questionnaire was not normally psychometrically validated. We used a registry of emails provided by the Lebanese AIDS Society which contains emails of all registered Lebanese physicians in the MoPH as of 2019. This yielded 4331 email addresses. A special email address was used to send the IRB-approved email template containing the google docs link to the survey. Out of the email addressed contacted, 760 addressed were unreachable due to a wrong, inactive or outdated address. The remaining 3571 addresses received all 4 email invitations, which yielded 127 (3.2%) responses. Given the low response rate, results are subject to nonresponse and selection bias, and are presented as exploratory findings rather than population estimates. STATISTICAL ANALYSIS Responses were summarized using counts and percentages. Given the exploratory design and limited sample size, we restricted analyses to descriptive statistics and bivariate comparisons. Associations between physician characteristics and outcomes related to HIV stigma and prevention were explored by chi-square or Fisher’s exact tests, as appropriate. Univariable logistic regression was performed to estimate odds ratios (ORs) with 95% confidence intervals when possible. No multivariable modeling was planned. All analyses were considered hypothesis-generating, and p-values were interpreted descriptively without adjustment for multiple comparisons. ETHICS This project was reviewed and granted approval by the Lebanese American University Institutional Review Board. All survey answers were kept anonymous. RESULTS Out of the 127 responses, 81 (63%) were male, 12 (9.4%) graduated before 1989, 19 (15%) between 1990 and 1999, 44 (35%) between 2000 and 2009 and 52 (41%) after 2010. Among respondents, 81 (64%) graduated from Lebanese private universities, 25 (19.6%) graduated from the Lebanese University and 20 (15.7%) graduated from outside Lebanon. They practiced in different specialties, with family medicine, pediatrics, anesthesiology, obstetrics and gynecology and infectious diseases being the most reported specialties reported. Regarding studies, 94 (74%) of respondents reported to have studied abroad at some point in their careers, and 75 (59%) of them reported practicing medicine at some point outside Lebanon. As for practice, 77 (60.6%) reported practicing in a university medical center and 64 (50.3%) reported engaging in teaching activities at least 2 times weekly. 93 (73.2%) of them reported seeing on average more than 10 patients per day. Questions regarding HIV and transmission awareness The vast majority (125; 98.4%) of respondents knew HIV cannot be transmitted by sharing eating and drinking utensils or by sharing towels and toilets with PWH. Regarding other sexually transmitted infections (STIs) like gonorrhea and genital herpes, 88 (69.2%) of respondents knew they increase the likelihood of HIV transmission if untreated. For vertical transmission, 111 (87.4%) knew a mother with HIV can have an uninfected baby. However, 69 (54.3%) respondents did not know that HIV can be transmitted to the baby by breastmilk. As for routine antibody-based testing, 114 respondents (89.7%) were certain these tests are not able to detect HIV antibodies within a few days of infection, and 25 (19.7%) of respondents did not know there are facilities in Lebanon that provide confidential testing. Furthermore, 3 (2.3%) physicians responded that they can tell if someone is a PWH by their appearance. 108 (85%) responded that antiretroviral therapy (ART) prolongs the life of PWH, and 81 (64%) knew that oral PrEP is effective in HIV prevention. Questions regarding general attitude towards PWH When asked about interactions with PWH, 9 (7%) respondents did not agree to go to a store owned by a PWH, 17 (13.3%) did not agree to buy food from a PWH, 42 (33.1%) did not agree to let their child play with a PWH, 19 (15%) did not agree to play sports with someone with HIV, 16 (12.6%) were reluctant to accept a dinner invitation from a friend living with HIV and 2 (1.6%) thought that PWH should be isolated. Questions regarding experience and willingness to provide medical care to PWH When it came to experience with PWH, 89 (70.1%) of respondents have treated a PWH at some point in their careers, and 122 (86.1%) of them expressed willingness to medically examine a PWH. If that person is a relative, 117 (92.1%) were willing to medically care for them. When asked if they were willing to perform minor procedures on PWH, such as venipuncture, abscess drainage, mole excision, chest tube placement, 81 of the 87 (93.1%) eligible respondents expressed willingness to do so, and with open surgery, 56 of the 60 (93.33%) eligible respondents were willing to do so. A third of respondents (37, 29.1%) agreed that physicians have the right to refuse medical care to PWH for fear of contamination. Questions regarding healthcare professionals living with HIV and colleagues who are homosexual Among the physicians who responded to the survey, 12 (9.4%) reported they would not accept to be treated by a doctor who lives with HIV, and 50 (39.4%) reported not accepting to be operated on by a surgeon living with HIV. While 124 (97.6%) expressed willingness to get tested for HIV if exposed, 22 (17.3%) have never been tested before. Regarding colleagues with HIV, 15 respondents (11.8%) were unwilling to refer patients to a colleague with HIV, 9 (7.%) think a colleague who gets infected with HIV should not be allowed to continue working and 15 (11.8%) think a qualified applicant with HIV should not be admitted to medical school or residency programs. Regarding homosexuality, 15 (11.8%) would not refer a patient to a colleague who is homosexual, 13 (10.2%) think such a colleague should be denied practicing privileges and 12 (9.4%) think a qualified applicant who is homosexual should not be admitted to medical school or residency programs. Questions regarding sexual history and PrEP Most respondents (78, 61.4%) did not take sexual history in their routine history taking, and 107 (84.2%) had never prescribed PreP. Furthermore, 61 (48%) expressed unwillingness to prescribe it for someone with high risk of HIV infection, and 62 (49%) believed it will decrease safe sex practices and increase the incidence of STIs. Similarly, 23 (18.1%) would not advise an exposed colleague to start PrEP, and 44 (34.6%) believed PreP will cause ART resistance. The majority of respondents (122, 96.1%) believed more education around PrEP should be implemented before prescribing it routinely. Exploratory Association Analyses We performed exploratory bivariate analyses to assess if certain physician characteristics were associated with stigma and prevention outcomes. No statistically significant associations were observed for routine sexual history taking, PrEP prescribing, belief in the right to refuse care, or willingness to accept surgery from a surgeon/dentist living with HIV (all p>0.05). Univariable logistic regression similarly did not identify significant predictors; however, there was a trend toward lower refusal of surgery among physicians who had studied abroad (OR 0.51, 95% CI 0.23–1.14; p=0.10). DISCUSSION While we had different demographic profiles of respondents, most younger graduates, who work in educational institutions and had some international experience with a big patient load. This coincides with the known profile of physicians who are more likely to respond to survey invitations, are they are more familiar with such an approach [16]. Furthermore, such profiles are generally more accepting and less stigmatizing of patient populations, due to general and educational trends, making them more inclined to answer surveys related to stigma around HIV and homosexuality [17, 18]. In general, our exploratory survey showed a high awareness of the general knowledge about HIV transmission and the safety of sharing utensils and toilets with PWH, which is a good baseline. This situation is better than the 1990s, where PWH were discriminated against because of misinformation around this topic. Back then even nurses would not enter the rooms of PWH and they would be left alone, stigmatized, and quarantined [19]. However, our results show significant gaps in knowledge around HIV transmission and its interaction with other STIs. Only 69% of respondents knew that untreated gonorrhea and herpes increase HIV transmission risk, and around 46% not being sure or not knowing that HIV can be transmitted via breastmilk might be indicators of an awareness gap, worthy of a focused intervention in future campaigns. Furthermore, around 10% of respondents were not certain about antibody testing windows and 20% were not aware of confidential testing facilities. These can be barriers to effective testing, where some PWH might not know their status. In addition, while 85% of provider respondents knew that ART prolongs life or PWH, only 65% of them knew PrEP is effective in prevention, which can be an awareness gap to target for future campaigns. While a small number, still having some providers think they can tell PWH by appearance and that they should be quarantined, is a significant indicator that stigma and misinformation are not fully eradicated, even among physicians. This is especially evident in a quantifiable stigma attitude towards PWH, which ranges from somewhere around 7% with minimal interaction (buying groceries from shopper) to around 33% when a respondent’s child is playing with a PWH. The 1996-2004 Lebanese study showed a gap between HIV awareness and declining knowledge in prevention and safe practices. When this stigma is not eradicated, even among physicians, this can impede public health interventions. This shows there is a multi-layered problem where misinformation not only affects the general public, but also some healthcare providers [20]. However, when it comes to providing care, the general trend was positive, with more than 85% of respondents willing to examine PWH or caring for relatives with HIV and performing minor procedures or surgeries on them. This can represent an improvement from the 50-50 willingness of physician care for PWH in 2014(7). Nevertheless, 29% of them agreeing that physicians have the right to refuse care for PWH because of fear of contamination might be a point to target in future campaigns to stress on non-transmissibility of the virus in treated PWH with controlled viral loads [21]. This hesitation is concerning in emergency departments, where delays in triage or refusal of urgent procedures due to fear of transmission can impact patient morbidity [22]. Therefore, more education about basic infection control barriers and their effectiveness in prevention of any blood-borne illness prevention should always be implemented, especially that most patients are not routinely tested for HIV. If all barriers fail and a needlestick injury happens, post-exposure prophylaxis, or PEP, is available and effective [23]. This remains better than the situation in the 1990s, where physicians and dentists in the west would deny PWH care due to fear of the infection and of stigma, despite effective treatment emergence [24]. Furthermore, the percentages of respondents who discriminate against medical (9.4%) or surgical (39.4%) colleagues with HIV was alarming. Their unwillingness to refer patients to colleagues who live with HIV (11.8%), and similar percentages of respondents thinking colleagues with HIV or who are homosexual should be denied practicing privileges or prevented from admission to medical school or residency programs shows some clear discriminatory points in the medical community against PWH and LGBT+ people. Regarding sexual history taking and PrEP, having 61% of respondents admitting to not routinely taking sexual history shows possible missed opportunity for detecting new exposure and preventing new infection. However, 84% of respondents have never prescribed PrEP and 48% are not willing to do so with one-third of them lack up-to-date knowledge about its use or safety. Surveys responses can be low, sometimes less than 5%, especially in uncompensated surveys as in our case. 13 Physician surveys are especially known to have low response rates [25]. Furthermore, the coronavirus pandemic induced a “survey fatigue”, further decreasing response rates [26]. Some invitations would have been lost in the high volume of emails received daily by physicians. Furthermore, since there is no perceived benefit from filling the surveys, many would have just ignored the invitation [13, 27, 28]. The financial crisis and general stress and burnout would be demotivating to fill a survey, and the outflow of physicians to outside the country means that many of them might have abandoned the previously registered email accounts. Moreover, it is impossible for us to know with certainty the number of active email addresses in the registry, so our calculated 3.2% response rate might be an underestimation of the actual rate of response from physicians who received the invitation and filled the survey. Therefore, percentages in this study should be interpreted as signals among respondents, not as estimates of stigma prevalence among Lebanese physicians overall. This low response rate would lead to a selection and a nonresponse bias, which affects data representativeness and accuracy. However, the exploratory nature of this study in a topic that is stigmatized and faced with the obstacles mentioned makes our findings important. While our study was not made to draw generalizable conclusions, it aims to gain insight into the current situation among physicians, providing us with potential areas of focus for future interventions in the country to mitigate challenges PWH face while seeking healthcare. These results would help us make some recommendations for prevention efforts against HIV in Lebanon in the coming years based on the possible gaps identified in our exploratory survey. These recommendations would be for awareness campaigns targeted for physicians practicing medicine in Lebanon. Based on these findings, we recommend that future educational campaigns for Lebanese physicians prioritize three areas. First, interventions must correct persistent misconceptions regarding horizontal transmission and teach the concept that Undetectable = Untransmissible (U=U) to reduce refusal of care. Second, training should focus on practical protocols regarding indications for PrEP, the window periods for different HIV tests, and the availability of confidential testing sites. Finally, to ensure occupational safety and reduce delays in procedures, education should include efficacy of PEP following needle-stick injuries, ensuring that fear of contamination does not compromise urgent surgical or emergency interventions. LIMITATIONS Our study has some limitations, especially its low response rate. This is mitigated by the exploratory nature of the study. The questionnaire was not pilot-tested or psychometrically validated, which may affect reliability and comparability across studies. In addition, the list of emails used was from 2019, which was largely due to the unavailability of a more updated list after the COVID-19 pandemic. As a lot of physicians left Lebanon after the pandemic, this can be a contributing factor to the low response rate. CONCLUSION With stigma and misinformation affecting the public and healthcare professionals regarding HIV and homosexuality in Lebanon, it is important to identify areas of actionable concern. This exploratory survey revealed knowledge gaps, especially in PrEP use, HIV testing and transmission. In general, physician-targeted campaigns on HIV awareness regarding transmission, screening, testing, availability of confidential testing sites, PrEP and PEP might play a role in promoting acceptance, especially in the emergency department. These targeted campaigns, identified by our survey, might be very promising in changing Lebanese physicians’ attitudes towards HIV in Lebanon, and subsequently their attitude towards homosexuality. This would lead to more testing, more treatment and more viral control, contributing eventually to the WHO goals to end HIV. Author contributions All authors contributed equally and validated the final version of record. Declarations Conflicts Of Interests The Author declares that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval This project was reviewed and granted approval by the Lebanese American University Institutional Review Board. All survey answers were kept anonymous. References <!-- [if supportFields]> ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY <![endif]-->1. A Timeline of HIV and AIDS. HIV.gov. Accessed May 12, 2025. https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline 2. Global Statistics. HIV.gov. Accessed May 12, 2025. https://www.hiv.gov/hiv-basics/overview/data-and-trends/global-statistics 3. Sambayi GL, Bwire GM, Kilapilo MS, Myemba D, Mosha IH, Kilonzi M, et al. Barriers and Enablers to Retention in HIV Care and Adherence to Antiretroviral Therapy: Evidence from Dar es Salaam, Tanzania. HIV AIDS (Auckl). 2024 Jul 26;16:301–311. https://doi.org/10.2147/HIV.S458545 4. Assi A, Abu Zaki S, Ghosn J, Kinge N, Naous J, Ghanem A, et al. Prevalence of HIV and other sexually transmitted infections and their association with sexual practices and substance use among 2238 MSM in Lebanon. Sci Rep. 2019 Oct 22;9(1):15142. https://doi.org/10.1038/s41598-019-51688-7 5. Country progress report - Lebanon [Internet]. Global AIDS Monitoring 2020; Accessed May 12, 2025. https://www.unaids.org/sites/default/files/country/documents/LBN_2020_countryreport.pdf 6. Berk E. Viral Subjects: Stigma, Civil Society Activism, and the Making of HIV/AIDS in Lebanon [Internet] [PhD dissertation]. Yale Graduate School of Arts and Sciences; 2021. Available from: https://elischolar.library.yale.edu/gsas_dissertations/303 7. Abdessamad HM, Fattal O. Lebanese Medical Association for Sexual Health: Advancing Lesbian, Gay, Bisexual, and Transgender Health in Lebanon. LGBT Health. 2014;1(2):79–81. https://doi.org/10.1089/lgbt.2013.0039 8. Daoud Khatoun W, Slim A, Makhlouf J, Lau SSS, Cheng MCH, Chebat A, et al. Health conditions, health literacy, access to care, and health care experiences among lesbian, gay, bisexual, transgender and queer adults in Lebanon. International Journal for Equity in Health. 2025 Apr 7;24(1):95. https://doi.org/10.1186/s12939-025-02417-2 9. National AIDS Control Program. National HIV Strategic Plan 2023-2028 [Internet]. Ministry of Public Health of Lebanese Republic; 2025. Available from: https://www.moph.gov.lb/userfiles/files/Prevention/NationalAIDSControlProgram/National%20HIV%20Strategic%20Plan%202023-2028_Final.pdf 10. WHO - Regional Office for the Eastern Mediterranean. World Health Organization. [cited 2025 May 12]. Lebanon HIV/AIDS country profile 2020. Available from: http://www.emro.who.int/asd/country-activities/lebanon.html 11. STI & HIV 2023 World Congress [Internet]. American Sexually Transmitted Diseases Association; [cited 2025 May 12]. Available from: https://stihiv2023.org/ 12. Bou Sanayeh E, El Chamieh C. The fragile healthcare system in Lebanon: sounding the alarm about its possible collapse. Health Econ Rev. 2023;13(1):21. https://doi.org/10.1186/s13561-023-00435-w 13. Ellis LA, Pomare C, Churruca K, Carrigan A, Meulenbroeks I, Saba M, et al. Predictors of response rates of safety culture questionnaires in healthcare: a systematic review and analysis. BMJ Open. 2022 Sep 1;12(9):e065320. https://doi.org/10.1136/bmjopen-2022-065320 14. American Medical Association [Internet]. 2018 [cited 2025 May 13]. 3 legitimate concerns about patient-experience surveys. Available from: https://www.ama-assn.org/delivering-care/ethics/3-legitimate-concerns-about-patient-experience-surveys 15. American Medical Association [Internet]. 2017 [cited 2025 May 13]. How physician surveys impact major issues. Available from: https://www.ama-assn.org/delivering-care/public-health/how-physician-surveys-impact-major-issues 16. Larson N, Neumark-Sztainer D, Harwood EM, Eisenberg ME, Wall MM, Hannan PJ. Do young adults participate in surveys that ‘go green’? Response rates to a web and mailed survey of weight-related health behaviors. Int J Child Health Hum Dev. 2011;4(2):225-231. 17. GLAAD [Internet]. New York; 2023 [cited 2025 May 14]. GLAAD releases fourth annual HIV stigma study. Available from: https://glaad.org/releases/glaad-releases-fourth-annual-hiv-stigma-study/ 18. Ghanem CA, El Khoury C, Mutchler MG, Ghosh-Dastidar B, Kegeles S, Balan E, et al. Gay Community Integration as Both a Source of Risk and Resilience for HIV Prevention in Beirut. 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Perioperative Care in Adults With HIV. Johns Hopkins University; 2024. Accessed December 22, 2025. http://www.ncbi.nlm.nih.gov/books/NBK576018/ 23. Post-Exposure Prophylaxis (PEP) | NIH. Accessed May 14, 2025. https://hivinfo.nih.gov/understanding-hiv/fact-sheets/post-exposure-prophylaxis-pep 24. Lambert B. AIDS WAR SHUNNED BY MANY DOCTORS. The New York Times. https://www.nytimes.com/1990/04/23/nyregion/aids-war-shunned-by-many-doctors.html. April 23, 1990. Accessed May 14, 2025. 25. Cunningham CT, Quan H, Hemmelgarn B, Noseworthy T, Beck CA, Dixon E, et al. Exploring physician specialist response rates to web-based surveys. BMC Med Res Methodol. 2015 Apr 9;15(1):32. https://doi.org/10.1186/s12874-015-0016-z 26. de Koning R, Egiz A, Kotecha J, Ciuculete AC, Ooi SZY, Bankole NDA, et al. Survey Fatigue During the COVID-19 Pandemic: An Analysis of Neurosurgery Survey Response Rates. Front Surg. 2021;8:690680. https://doi.org/10.3389/fsurg.2021.690680 27. Peabody JW, Taguiwalo MM, Robalino DA, Frenk J. Improving the quality of care in developing countries. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al., editors. Disease Control Priorities in Developing Countries [Internet]. New York: Oxford University Press; 2006. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21250362 28. Booker QS, Austin JD, Balasubramanian BA. Survey strategies to increase participant response rates in primary care research studies. Family Practice. 2021;38(5):699–702. https://doi.org/10.1093/fampra/cmab070
Copyright (c) 2026 The Authors https://creativecommons.org/licenses/by/4.0
A Near-Fatal Anaphylactic Reaction to Biliary Contrast: A Cautionary Case During Laparoscopic Cholecystectomy
Anaphylactic reactions to iodinated contrast agents during intraoperative cholangiography (IOC) are extremely rare, although such reactions are well documented with intravenous (IV) administration. We present the case of a 71-year-old female with a known allergy to iodinated contrast, who experienced a life threatening anaphylactic reaction immediately after intraoperative cholangiography (IOC) during laparoscopic cholecystectomy. Shortly after the administration of iodinated contrast into the biliary duct, the patient developed supraventricular tachycardia and profound hypotension. This case underscores the risk of systemic absorption and hypersensitivity reactions from biliary-administered contrast agents, even in the absence of intravenous exposure. It highlights the need for a comprehensive preoperative allergy evaluation in high-risk patients undergoing biliary procedures and the importance of considering alternative imaging methods to avoid serious complications. Introduction Cholecystitis, inflammation of the gallbladder mostly due to obstruction of the cystic duct by a gallstone, is considered one of the most frequent indications for laparoscopic cholecystectomy [1]. Intraoperative cholangiography (IOC) is performed during cholecystectomy to visualize the biliary anatomy and identify any residual obstruction [2]. The technique involves inserting a catheter into the cystic duct and injecting an iodinated contrast agent to highlight the biliary tree under fluoroscopy. While this contrast agent is generally safe and plays a crucial role in optimizing surgical outcomes, its use carries a very low risk of hypersensitivity reactions [3]. Although contrast is administered directly into the biliary tree rather than intravenously, iodinated agents can still be absorbed into the systemic circulation, potentially triggering hypersensitivity reactions, including anaphylaxis [4]. While such events are rare during intraoperative cholangiography (IOC), they are clinically significant due to their rapid onset and the potential for general anesthesia to obscure early warning signs like respiratory distress [5]. In this report, we present a critical case involving a 71-year-old female who experienced intraoperative anaphylactic shock following the administration of iodinated contrast dye during IOC in the course of a laparoscopic cholecystectomy for acute cholecystitis. This case highlights the importance of heightened awareness and preparedness for anaphylaxis during interventional oncology procedures. Case Presentation A 71-year-old woman with a medical history of coronary artery disease (status post placement of two coronary stents), hypothyroidism, diabetes mellitus, and hepatocellular carcinoma (was on tyrosine kinase inhibitor-lenvatinib) presented for one week history of epigastric and right upper quadrant pain, along with postprandial nausea and vomiting. The patient also reported being allergic to intravenous iodinated contrast, characterized by a self-resolving mild skin rash after previous exposure. Abdominal ultrasound (Figure 1) revealed acute cholecystitis, and the patient was planned for cholecystectomy. Preoperative transthoracic echocardiography (TTE) (Figure 2) showed a good left ventricular ejection fraction (60%-65%) with mild septal hypokinesia. The patient underwent a laparoscopic cholecystectomy under general anesthesia. During the procedure, the surgeons began by dissecting Calot’s triangle, followed by the introduction of iodinated contrast for intraoperative cholangiography (IOC) (Figure 3) to assess for any residual stones in the bile duct. Within minutes, the patient developed tachycardia at a rate of 188 bpm, hypotension with a nadir of 80/56 mm Hg, mydriasis, and absence of brainstem reflexes. The ECG (Figure 4) revealed supraventricular tachycardia (SVT). The operating room team promptly performed synchronized cardioversion to restore sinus rhythm and administered 300 mg of intravenous Amiodarone. Following this intervention, the SVT converted to atrial fibrillation, as shown in ECG 2. The differential diagnoses considered included anaphylactic shock, septic shock, acute coronary syndrome, cerebrovascular accident, and pulmonary embolism. A postoperative TTE (Figure 5) showed a normal ejection fraction with no signs of myocardial ischemia. Additionally, echocardiography revealed no evidence of right ventricular strain, effectively ruling out pulmonary embolism. Moreover, CT brain was normal (Figure 6) and Echo Doppler venous lower limbs ruled out deep venous thrombosis. Further investigations, including a non-contrast abdominal computed tomography, excluded other potential causes such as biliary tract perforation and postoperative bleeding. Considering the timing of IOC administration and the lack of alternative explanations, an anaphylactic reaction to the biliary iodinated contrast was deemed the most likely diagnosis, complicated by disseminated intravascular coagulation (DIC) at day 3 post-op. The patient was transferred to the intensive care unit (ICU) for close monitoring. Upon admission, the patient received 0.3 mg of Adrenaline intramuscularly and 100 mg of Hydrocortisone intravenously, followed by 50 mg IV of Hydrocortisone every 6 hours. Intravenous antibiotics were initiated, including Amikacin 1 g, Vancomycin 2 g, and continued Meropenem at 1 g IV every 8 hours. Norepinephrine was also infused to maintain MAP > 65 mm Hg. On the third postoperative day, Magnetic resonance cholangiopancreatography (MRCP) (Figure 7) was performed to investigate the persistently elevated cholestatic liver enzymes; however, the results were normal. Over the following days, the patient's clinical condition improved significantly. She was successfully extubated and weaned off vasopressors. Esophagogastroduodenoscopy was performed on day 6 post-op for persistent nausea, revealing candidal esophagitis and multiple gastric polyps. The patient was treated with antifungal agents and subsequently tolerated enteral feeding. The pathology of the resected gallbladder confirmed chronic cholecystitis with multiple yellow stones and wall thickening. Discussion This case represents only the third reported instance in the literature of anaphylactic shock following the administration of iodinated contrast into the biliary tree during intraoperative cholangiography (IOC), highlighting its rarity and potential lethality [4, 6]. While anaphylaxis is a recognized risk associated with intravenous iodinated contrast, its occurrence via non-vascular routes, such as the biliary system, is exceptionally rare. However, systemic absorption of contrast through the biliary tree can occur, particularly in the presence of inflammation, which may enhance vascular permeability and facilitate entry into the systemic circulation [7]. To date, only two prior cases have documented similar reactions. Moskovitz et al. described a case of anaphylactic shock following IOC during laparoscopic cholecystectomy in a patient with no prior intravenous contrast exposure, suggesting that biliary administration alone can trigger severe hypersensitivity reactions [4]. Although only available as an abstract, the report highlights the rapid onset of symptoms, including hypotension and respiratory distress, consistent with our patient's presentation [4]. Similarly, Ishiyama et al. reported an intraoperative allergic reaction to biliary contrast that progressed to disseminated intravascular coagulation (DIC), emphasizing the potential for severe systemic complications [6]. The abstract details a case where the reaction led to significant coagulopathy, mirroring the DIC observed in our patient on postoperative day 3 [6]. These cases, despite being limited to abstracts, underscore the clinical relevance and severity of anaphylactic reactions to biliary contrast, particularly in sensitized individuals. The pathophysiology of anaphylactoid reactions to iodinated contrast media (ICM) involves non-IgE-mediated mechanisms, primarily through direct activation of mast cells and release of mediators such as histamine, prostaglandins, and bradykinins [8]. Inflammation in the biliary tree, as seen in acute or chronic cholecystitis, may exacerbate systemic absorption, increasing the risk of such reactions [7]. Recent studies suggest that some immediate reactions may involve IgE-mediated pathways, supported by elevated histamine and tryptase levels in affected patients [8]. In our case, the patient’s history of a mild iodinated contrast allergy, combined with rapid cardiovascular collapse and laboratory evidence of DIC (e.g., elevated D-dimer, decreased platelets, and prolonged INR on day 3), strongly supports an anaphylactoid reaction complicated by coagulopathy. The occurrence of DIC in this context is exceptionally rare. A review by Andreucci M et al. notes that iodinated contrast can trigger DIC through endothelial injury and activation of the coagulation cascade, particularly in patients with underlying inflammatory conditions [9]. The elevated D-dimer (8068 on day 2, 3755 on day 3) and decreased fibrinogen (177 mg/dl on day 3) in our patient align with this mechanism, suggesting that the anaphylactoid reaction may have initiated a systemic inflammatory response leading to DIC. The absence of other causes, such as sepsis or massive hemorrhage, further supports this association. Management of anaphylactoid reactions requires immediate intervention. Epinephrine, administered intramuscularly, remains the cornerstone of treatment for systemic symptoms like hypotension and bronchospasm [5]. Our patient received 0.3 mg of adrenaline and hydrocortisone, with norepinephrine to support blood pressure, consistent with guideline-directed therapy. The subsequent development of DIC necessitated close monitoring and supportive care, including blood products if bleeding had occurred, though this was not required in our case. To prevent such reactions, preoperative strategies are critical. Patients with a history of contrast allergy, even if mild, should be evaluated thoroughly. Premedication with corticosteroids and antihistamines is commonly used, but its efficacy is debated, as it does not eliminate the risk of severe reactions [5]. Alternative imaging modalities, such as intraoperative ultrasound, indocyanine green (ICG) fluorescence cholangiography, or preoperative magnetic resonance cholangiopancreatography (MRCP), offer safer options for visualizing the biliary tree [10]. ICG fluorescence, in particular, has gained attention for its safety profile and effectiveness in delineating biliary anatomy without the risks associated with iodinated contrast [10]. Gadolinium-based agents, while used in some cases, carry their own risks and are not universally recommended for biliary imaging [11]. This case also highlights the need for surgical teams to maintain vigilance for rare complications like DIC. Monitoring for coagulopathy, including serial measurements of INR, fibrinogen, and D-dimer, is essential in patients with suspected anaphylactoid reactions to contrast. Future research should focus on identifying risk factors for such reactions and optimizing alternative imaging techniques to enhance patient safety during laparoscopic cholecystectomy. Conclusion Anaphylactic shock resulting from intra-biliary contrast administration is a rare but potentially fatal complication during IOC, particularly in patients with a known allergy to iodinated contrast, even those with only mild previous reactions. This case highlights the importance of thorough preoperative allergy evaluations, especially for high-risk individuals. It also underscores the need to consider alternative imaging techniques such as MRCP, intraoperative ultrasound, indocyanine green fluorescence cholangiography, or gadolinium-based agents to mitigate risk. Given the critical role of IOC in laparoscopic cholecystectomy, further research is warranted to develop strategies that minimize contrast-related risks and identify safer imaging options for vulnerable patients. Conversely, our case underscores another exceptionally rare adverse event linked to IOC: disseminated intravascular coagulation (DIC). While DIC is a recognized complication of iodinated contrast media, its occurrence following biliary administration is extremely rare and not well-documented in the literature. Clinicians should remain vigilant for signs of coagulopathy following contrast administration. Author contributions All authors contributed equally and validated the final version of record. Declarations Conflicts Of Interests The Author declares that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval Ethical approval for this study was not required. Patient consent Authors confirmed that they have received patient consent to publish this case. References 1. Strasberg SM. Acute calculous cholecystitis. N Engl J Med. 2008;358(26):2804–2811. https://doi.org/10.1056/NEJMcp0800929 2. Flum DR, Cheadle A, Prela C, Dellinger EP, Chan L. Bile duct injury during cholecystectomy and survival in medicare beneficiaries. JAMA. 2003;290(16):2168–2173. https://doi.org/10.1001/jama.290.16.2168 3. Bettmann MA. Frequently asked questions: iodinated contrast agents. Radiographics. 2004;24 suppl 1:S3–S10. https://doi.org/10.1148/rg.24si045519 4. Moskovitz AH, Bush WH, Horvath KD. Anaphylactoid reaction to intraoperative cholangiogram. Report of a case, review of literature, and guidelines for prevention. Surg Endosc 2001;15(10):1227. https://doi.org/10.1007/s004640041033 5. Brockow K, Christiansen C, Kanny G, Clément O, Barbaud A, Bircher A et al. Management of hypersensitivity reactions to iodinated contrast media. Allergy. 2005;60(2):150–158. https://doi.org/10.1111/j.1398-9995.2005.00745.x 6. Ishiyama T, Murakami N, Takeda T, Shimonaka H, Dohi S. [Anaphylactoid reactions to contrast media which occurred during cholecystectomy and subsequent disseminated intravascular coagulation–a case report]. Masui. 1992;41 8:1314–8. 7. Muñoz-Cano R, Pascal M, Araujo G, Goikoetxea MJ, Valero AL, Picado C et al. Mechanisms, Cofactors, and Augmenting Factors Involved in Anaphylaxis. Front Immunol. 2017;8:1193. https://doi.org/10.3389/fimmu.2017.01193 8. Bottinor W, Polkampally P, Jovin I. Adverse reactions to iodinated contrast media. Int J Angiol. 2013;22(3):149–154. https://doi.org/10.1055/s-0033-1348885 9. Andreucci M, Solomon R, Tasanarong A. Side effects of radiographic contrast media: pathogenesis, risk factors, and prevention. Biomed Res Int. 2014;2014:741018. https://doi.org/10.1155/2014/741018 10. Boni L, David G, Mangano A, et al. Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery. Surg Endosc. 2015;29(7):2046–2055. https://doi.org/10.1007/s00464-014-3895-x 11. Ose K, Doue T, Zen K, Hadase M, Sawada T, Azuma A et al. 'Gadolinium' as an alternative to iodinated contrast media for X-ray angiography in patients with severe allergy. Circ J. 2005;69(4):507–509. https://doi.org/10.1253/circj.69.507
Copyright (c) 2026 Hiba Hamdar, Aktham Abdelhadi, Dareen Al Ayash, Yaser Harb, Nadim Chaarani, Abbas Al Bazzal, Nazim Matta, Mirna Fares (Author) https://creativecommons.org/licenses/by/4.0
Suggestions for the Study of Ethics of Simulation in Healthcare
Simulation can be used in healthcare education to provide learners with the opportunity to develop the knowledge and skills needed to manage complex situations and provide patient care, however one aspect easily overlooked and which has many ramifications, is that of ethical practice. Simulation-based education is a moral and ethical imperative. “Never the first time on the patient!” is displayed at the entrance of some clinical simulation centres, but the rest of the ethical obligations, besides the professional code of ethics, are either not mentioned or only sporadically. By using an interpretive framework based upon the 4 bioethics principles used for patients (autonomy, beneficence, nonmaleficence, and distributive justice), we propose, as a conceptual framework, an analysis on the stakeholders of simulation-based education (SBE) - educators, learners, and simulated participants - to broaden and explore in depth the conventional views of ethics in simulation. This article also discusses specific features in simulation which sometimes pose an ethical dilemma such as facing simulated death, breaking bad news, research, the use of biological tissue, teaching ethics, and computer simulation. This proposal to explore ethics in healthcare simulation is intended to stimulate reflection rather than serve as a model seeking external validation. Foreword Before embarking on exploring ethics in healthcare simulation as a conceptual framework, we believe it is important to clarify the relationship between a practice, its ethical aspects, and its legal aspects. The relationship between biomedical practice, ethics, and legislation is closely tied to a society’s historical, cultural, political, and religious context [1, 2]. More specifically, the relationship between ethics and the law regarding a given action evolves according to dynamics shaped by this context. Two examples related to simulation illustrate this point: 1. In France, donating a body to science has been legal since 1953, provided there is prior consent from the donor and that it is done with due respect for the body [3]. In 2019, a scandal was revealed by the press at an anatomy laboratory at Paris-Descartes University involving the discovery of inappropriately managed dismembered bodies and scattered anatomical parts [4]. Yet it was legal and must have been practiced in other laboratories for years. The fact that there were also illegal practices (poor hygiene, removal of jewelry from corpses) triggered an investigation and revealed a set of practices that had become unethical. This, in addition to disciplinary action against an individual, was deemed unethical (in light of the evolving concept of due respect for the body since 1953) and prompted the government to put a new law in place to better regulate this practice [5]. Thus, French law is the product of what occurs within the context of French society and may or may not correspond to practices in other countries. It is neither transferable nor generalizable. It may inspire other communities to amend their legislation in accordance with their historical, cultural, political, and religious contexts. In this case, the practice of donating one’s body to science was originally legal and ethical; however, due to illegal abuses, it aroused appropriately founded concerns and came to be viewed as unethical in its current form, prompting lawmakers to strengthen the law to align with bioethical principles as perceived by the French public in 2022 [6]. 2. As of today, in France as elsewhere, the use of Artificial Intelligence (AI) is legal (or rather, not illegal) and ethical in simulation. However, certain developments in AI may be viewed as risks that challenge bioethical principles. In such situations, a country’s legislation might need to change to legally regulate the use of AI, for example, if there is a potential harm to individuals. In other countries, this use could continue unhindered. Finally, for certain communities, although legal, the use of AI should comply with a code of ethics established by one or more medical societies. We thus see the importance of the sociological context regarding the tensions between legislation and ethics that may arise over time, and the dynamics that enable their resolution. For example, would it be ethical to have an AI entity conduct a debriefing of a healthcare professional following a simulation-based activity in order to determine whether they can return to work after an extended sick leave? For now, this is neither mandatory nor illegal, but is it ethical? [7]. Consequently, the approach we present here is closely tied to the sociological context of our country of origin and, therefore, to the evolution of its legislation. This is inevitable in any human community. Introduction The rapid and universal deployment of simulation in healthcare for educational or system testing or redesign purposes raises the question of its limits. Technological limits seem ephemeral, falling one after the other as years go by. However, simulation in healthcare, like any human activity, has ethical limits that codify and modulate the use of these technological advances. Here we propose a conceptual framework that allows us to broaden and explore in depth the conventional view of ethics in simulation, which is tied to the principle of beneficence toward the patient (“never the first time on the patient”). In fact, the rest of the ethical obligations besides the professional code of ethics, are either not mentioned or are mentioned only sporadically. Because simulation in healthcare education is an activity aiming to improve patient care, we have chosen to use the “bioethical principles” tool – usually reserved to patients or research participants – to describe these limits and apply them to activities concerning people who are upstream or downstream of the use of simulation as an educational approach, taking into account the different people who may use it, and highlighting the conflicts that may exist between certain bioethical principles in particular situations. Therefore, the objective of this article is to provide a broader and more detailed perspective on ethics in simulation using the framework provided by bioethical principles. It includes not only patients but also all stakeholders (educators, learners, and simulated participants) and to examine several specific simulation situations. This proposal to explore ethics through healthcare simulation is intended to stimulate reflection rather than serve as a model seeking external validation outside of its sociological context. This article is based on the simulation in healthcare good practice guide published in March 2024 by the French National Healthcare Authority [8]. Simulation-based education is an ethical and moral imperative The benefits of simulation-based learning in healthcare have been demonstrated [9, 10], and like any human activity, it has both ethical and professional requirements and limits. The four principles of bioethics are autonomy, beneficence, non-maleficence, and distributive justice [11]. Simulation in healthcare education is an ethical and moral imperative for healthcare professionals and trainees with respects to their patients, as Ziv et al. put it over twenty years ago [12]. Simulation therefore begins with an important moral commitment: ‘’We must do the best we can to keep patients safe while training the next generation of clinicians and retraining current clinicians so that they are kept up to date. If we can introduce clinicians to patients when these clinicians have more “experience” with quasi-patients of a wide variety, we lessen the chances that vulnerable patients will be harmed. Ethics is not an add-on to simulation; an ethical claim drives the practices of simulation themselves’’ [13]. Furthermore, simulation has an epistemic role in that it can transform theoretical knowledge into practical know-how, enabling the universal application of international recommendations for patient wellbeing [14, 15]. Simulation users as educators must therefore endorse a professional ethics and have the responsibility of training all healthcare professionals at the highest level of performance possible. Ethics and simulation-based education The principles of bioethics can also be extended to everything patient related. If the care provided to patients appears to be the primary concern - the ethics of simulation-based education (SBE) for the patient - so too is the learning of the healthcare professionals who will deliver this care. Indeed, better learning is the key to better care [16]. This objective can also include the ethics of those involved in the educational process. In this way, we can define the ethical aim and content of the various bioethical principles applied to these people and which we have summarised in Table 1. For patients The ethical aim for patients is that simulation should help them receive the best possible care according to current evidenced-based practice. Autonomy, the ability to decide for oneself, was reinforced by the French Law of March 4, 2002 [17]. It is essentially based on the principle of information and consent. In the domain of healthcare education, it can refer to informing patients that the training of healthcare professionals involves the use of simulation. This can be done through disclosure in the patients’ welcome booklet or on information boards, but also orally before a procedure is performed, for example. It has been reported that patients preferred to have a procedure performed by a simulation-trained professional rather than by a professional who has not been trained using simulation [18]. This also includes information on the fact that procedures performed by a junior simulation-trained clinician will be supervised by a more senior clinician, with the inevitable patient right of refusal without prejudice. Another aspect relates to the commercial independence of prescriptions (medical devices and drugs) made for the patient. In the case of in-situ simulation in a real clinical setting, it is imperative to inform patients on the unit that there are two teams: a care team and a simulation training team. The latter may cause some noise and temporary inconvenience, but it should never to the detriment of patient care. Once the patient has been given clear, fair information in a language they can understand, written consent for the treatment should be obtained. The principle of beneficence means looking for elements of the simulation that are intended to benefit the patient. The Kirkpatrick pyramid [19] can be used to classify them into levels. Simulation-based training aims to benefit the patient by improving the performance level of healthcare professionals (Kirkpatrick level 2 = K2), changing professional practices and increasing compliance with recommendations (K3). Simulation benefits patients by reducing morbidity (complications, worsening, etc.) and mortality in the rare studies that have reached K4 [20, 21]. Simulation has also been shown to reduce healthcare costs [20, 22], which can be considered as level 5 of the Kirkpatrick's pyramid (K5). The arguments are so numerous that this led to the saying “Never the first time on the patient” being displayed at the entrance of some clinical simulation centres [23]. The principle of non-maleficence corresponds to tracking down conflicts of interest that would lead to harm for the patient. For example, excessive development of in-situ simulation at the expense of clinical timetables or human resources for patient care would be a case of maleficence. Similarly, the risk of mixing of simulated drugs and medical devices with those dedicated to real patients in a clinical unit where in-situ simulation is taking place, would also be a case of maleficence [24]. The same would apply if a patient room used for in-situ simulation was not cleaned before a patient was admitted. There could be unfortunate consequences in terms of iatrogenic and nosocomial infections. Applying the principle of distributive justice means, on the one hand, ensuring that all patients can benefit from healthcare professionals trained using SBE, and, on the other hand, that the care delivered by trained staff is provided to all patients, regardless of resources, religion, opinion, ethnicity, age or gender... irrespective of the type of service, the status of the staff and their working hours (day or night shift), 24 hours a day, 7 days per week. For educators Immersive scenario-based simulation probably provides the best possible learning experience in the field of health to learners so that they develop better skills, provide more humanistic care, avoid errors and adverse events, and minimize their consequences, and thus make medical practice safer [25]. As such, educators should have for ethical aim to foster the use of SBE at every opportunity. Autonomy. A first obstacle to this freedom would be resistance to the ''simulation'' concept by decision-maker (hospitals, universities, professional and accreditation bodies...). In this respect, it is interesting to go back to the beginnings of simulation in aeronautics, which encountered this same obstacle. As McLoed said in the late 1960s: ‘’I expressed my growing concern for the future of mankind and my intention of applying the technology of simulation to help alleviate the problems of society. It hasn't been easy. Among other things I have felt grave concern over the lack of acceptance of the results of modelling and simulation. In a time of increasing complexity of life, when decision-makers need all the help they can get, the very powerful tool of modelling is sometimes not used, or is misused, or the results of modelling, once obtained, are not acted upon’’ [26]. These words are still relevant today in the world of healthcare. This ethical obstacle has largely been overcome by the inclusion of SBE in initial and continuing training programmes, and other governmental or professional initiatives [27]. Secondly, autonomy could correspond to the freedom to initiate SBE programmes without being dependent on commercial companies. However, freedom of choice in the acquisition of simulation equipment depends on sources of funding, and therefore on institutional, regional, and national political powers to supply these resources. Otherwise, these same institutions must guarantee and enforce ethical rules with regards to companies. These rules are now well established and guarantee the educators’ autonomy in the practice of healthcare simulation. Another problem that can hamper the freedom of the simulation educator is the growing competition between multiple companies, making this choice inevitably subject to commercial pressures (discounts on the purchase of several models, addition of complimentary devices in the event of an expensive purchase...). Paradoxically, the absence of freedom of choice linked to a governmental decision can make it possible to free oneself from financial influence struggles. An example is the recent purchase by each medical school in France of the simulation models required for Objective Structured Clinical Examinations according to a list prescribed by a national steering committee. This underscores the importance of drafting and disseminating recommendations on pedagogical efficiency, which should prevail over any costly investments in the field of healthcare SBE. One might think that the beneficence for the educator would be the ease with which they could deliver courses without institutional or financial obstacles, and that these courses could clearly benefit learners. This largely depends on the “simulation culture” of a country or region, and on the way in which legislative texts related to the use of SBE for healthcare professionals are applied, as well as on the acceptance and integration of simulation education concepts and tools by those involved. Non-maleficence. All too often, the use of simulation as a learning approach in the healthcare professions involves resolving professional practice conflicts. The primary conflict in many countries, is the educator's personal time dedicated to SBE when they have a full-time clinical role. This time is still often the educator's personal time, not identified or accounted for by the employer. Such personal time commitment initially made it possible, and is still an enabler to launch SBE activities in many institutions, but under no circumstances can it be made permanent, at the risk of undermining motivation. The second conflict concerns in-situ simulation. This often takes place in emergency care units and must be balanced against the care of real patients [24]. Limited staff resources hamper the development of in-situ simulation, which can only take place when the patient flow remains reasonable. Applying the principle of distributive justice to simulation educators means talking about access to SBE for educators in relation to their own training. This is largely dependent on country, culture, and mentality. Two examples illustrate this point. The first is the assistance in equipment and training provided by volunteer international educators in 2013 from the International Paediatric Simulation Society to the only paediatrician in Malawi to improve infant care in the country [28]. The second example is the beneficial action of the programme “Helping Babies Breathe” carried out in 2016 by the American Academy of Paediatrics, supported by the United Nations High Commissioner for Refugees, and sponsored by the Laerdal Foundation in Ghana, Rwanda, Indonesia, and Nepal. This involved the supply of low-cost newborn manikins with a training programme, teaching material, training of trainers, evaluators for initial and remote monitoring over several years, resulting in a significant reduction in neonatal mortality [29]. Another issue in some countries is the impossibility for healthcare professionals to have access to anatomical subjects for SBE purposes due to religious barriers. For example, Libyan surgeons have twice come to France to train on the SimLife model [30]. An alternative approach is the use of synthetic or digital simulation tools as they allow for the rapid dissemination of SBE, requiring only a power outlet and internet access. Other principles For educators, it is important to add two other aspects of ethics that cannot be included in bioethics principles: professional ethics and the ethics of responsibility. Professional ethics refers to procedural ethics including all the rules of good SBE practice [31], while keeping learners safe, preventing errors and facilitating learning, as described as imperatives in the Society of Simulation in Healthcare's Code of Ethics [13, 32]. Furthermore, SBE also involves training in the practice of debriefing so that it is relevant and non-offensive [33]. This benevolence towards learners is part of the rules of healthcare simulation and attempts to mirror the principle of beneficence that should guide healthcare professionals towards doing their best for their patients. It is an essential professional ethics principle, and this notion comes close to the ethics of virtue by “doing good” for the patient and for the learner [34], but also anchoring this ability in the absolute necessity of evaluating the performance of learners' actions and behaviours. The idea of an ethic of responsibility for the educator is that they must do everything possible to obtain results corresponding to the K2, K3, and even K4 levels of Kirkpatrick's pyramid [35, 36]. The ethical importance of evaluation in SBE can be seen here, as it is the only way to demonstrate progress in learning and performance. For learners The ethical aim for learners in a simulation programme is to benefit from the best possible education to develop their knowledge and competence to improve patient care. Autonomy. In initial training, like in continuing professional development, the validation of SBE has almost become an obligation [37]. Learners must be briefed concerning any SBE activity they get involved in and give their consent [38, 39]. Inappropriate briefing or consent increases the risk of a difficult debriefing which could impact the learning process [40, 41]. Information within the briefing must include various elements: - Educators’ compliance with the Simulation Code of Ethics [32]. - Context of the activity (pre-briefing and orientation): Review of prerequisite learning, presenting ground rules (confidentiality, benevolence, respect, neutrality, mutual trust), and type of activity (scheduled/unannounced, summative/formative) [36]. It is also important to help learners familiarise with the environment (centre or in-situ, peri-situ) and the medical and simulation equipment [42]. If there is a formative assessment of performance during the scenario, it is only for guiding the debriefing and it will not be transmitted to anyone in the clinical setting. - Briefing: Providing an introduction to the scenario; explaining that it may include specific critical procedures with a causal link to the survival of the “patient” [42]. - Limitations of the simulation experience: Possible differences from practice in a clinical unit and potential technological issues with the manikin [43], up to the point where a scenario may have to continue in a verbal form. - Need for engagement – with the ‘’as if’’ concept so learners suspend disbelief about aspects that lack realism [43-45]. Suspension of disbelief becomes the core of the efficiency of SBE and is agreed upon as part of a fiction contract established with the learners [46]. - Awakening to the knowledge of possible “intruders”. Unexpected external events may be planned in the scenario to approximate reality such as the visit of angry relatives, voluntary malfunction of a device, unavoidable death of the manikin, etc. In this case, the information is limited to: “You are required to deal with the present case as you would in real life”. Other elements independent of the scenario's story must also be given to learners, so that they can freely accept the simulation without feeling prejudiced [47]. - Use of personal data: give full details of how any video recording of the activity or learners' computerized performance data collected by any type of sensors will be used. - Independence from any commercial interest: There should be no passive commercial seeding of learners, fraudulent reuse of digital data (mailing lists...), devices, healthcare services in all their forms, direct or indirect <!-- [if supportFields]> ADDIN EN.CITE ADDIN EN.CITE.DATA <![if gte mso 9]> 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<![endif]--><!-- [if supportFields]><![endif]-->. - Assurance of the ethical aspect of the simulation model: for a simulated patient: acceptance of the role, irrespective of their age <!-- [if supportFields]> ADDIN EN.CITE Curry 2015 2155 (51) 2155 2155 17 Curry, Allison E Peek-Asa, Corinne Hamann, Cara J Mirman, Jessica H Effectiveness of parent-focused interventions to increase teen driver safety: A critical review Journal of Adolescent Health Journal of Adolescent Health S6-S14 57 1 2015 1054-139X <![endif]-->(51)<!-- [if supportFields]><![endif]-->; for the use of cadavers: compliance with the rules governing the donation of the body to science <!-- [if supportFields]> ADDIN EN.CITE 2022 2666 (5) 2666 2666 50 Décret n° 2022-719 of 27th April 2022 in relation to "don de corps à des fins d’enseignement médical et de recherche". Journal Officiel 99 28 April 2022 2022 France <![endif]-->(5)<!-- [if supportFields]><![endif]-->; for an animal anatomical part: compliance with ethical rules related to animals <!-- [if supportFields]> ADDIN EN.CITE Autissier 2008 2640 (52, 53) 2640 2640 17 Autissier, Chantal Réglementation éthique de l’expérimentation animale en recherche biomédicale Médecine/Sciences médecine/sciences 437-442 24 4 2008 0767-0974 Rubeis 2018 2651 2651 2651 17 Rubeis, Giovanni Steger, Florian Is Live-Tissue Training Ethically Justified? An Evidence-based Ethical Analysis Alternatives to Laboratory Animals Alternatives to Laboratory Animals 65-71 46 2 animal ethics, bioethics, human patient simulators, live-tissue training, military medicine, trauma training 2018 29856644 https://journals.sagepub.com/doi/abs/10.1177/026119291804600206 <electronic-resource-num>10.1177/026119291804600206</electronic-resource-num> <![endif]-->(52, 53)<!-- [if supportFields]><![endif]-->. For learners, the principle of beneficence amounts to asserting that SBE provides a benefit, and in the case of normative evaluation, training validation or recertification <!-- [if supportFields]> ADDIN EN.CITE SoFraSimS 2022 2671 (54) 2671 2671 46 SoFraSimS Évaluation Sommative et Simulation en Santé 2022 18/02/2022 Available at: https://www.sofrasims.org/articles/117715-evaluation-sommative [accessed 22 May 2025] <![endif]-->(54)<!-- [if supportFields]><![endif]-->. This benefit is based on the rules of SBE, especially benevolence. - The scenario should be adapted to the learners' level so as not to set them up for failure but just to challenge them enough so they operate at the edge of their comfort zone whereby they may be expected to make mistakes without being completely overwhelmed (14, 55). - The realism, which corresponds to the fidelity of the “simulation” experience as perceived by the learners (environment, model, and scenario), should match the clinical reality required to achieve the activity’s learning objectives whilst also providing learner satisfaction (K1) <!-- [if supportFields]> ADDIN EN.CITE Der Sahakian 2019 1974 (36, 43) 1974 1974 5 Der Sahakian, Guillaume Buléon, Clément Alinier, Guillaume Chiniara, G Educational Foundations of Instructional Design Applied to Simulation-Based Education Clinical Simulation: Education, Operations, and Engineering 185-206 2nd 2019 Elsevier Alinier 2022 2236 2236 2236 17 Alinier, Guillaume Oriot, Denis Simulation-based education: deceiving learners with good intent Advances in Simulation Advances in Simulation 8 7 1 2022 2022/03/18 2059-0628 https://doi.org/10.1186/s41077-022-00206-3 <electronic-resource-num>10.1186/s41077-022-00206-3</electronic-resource-num> <![endif]-->(36, 43)<!-- [if supportFields]><![endif]-->. This may also be linked to the possibility of interacting with the model: simulated patient, manikin, Virtual Reality simulator, cadaver, etc. <!-- [if supportFields]> ADDIN EN.CITE ADDIN EN.CITE.DATA <![if gte mso 9]> 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<![endif]--><!-- [if supportFields]><![endif]-->. These elements (environment, model, scenario) combined with psychological fidelity (contextualization of the scenario and realistic and immersive engagement of the learners in the activity), constitute the 4 elements of simulation fidelity, which corresponds to the highest level of realism <!-- [if supportFields]> ADDIN EN.CITE Alinier 2022 2236 (43) 2236 2236 17 Alinier, Guillaume Oriot, Denis Simulation-based education: deceiving learners with good intent Advances in Simulation Advances in Simulation 8 7 1 2022 2022/03/18 2059-0628 https://doi.org/10.1186/s41077-022-00206-3 <electronic-resource-num>10.1186/s41077-022-00206-3</electronic-resource-num> <![endif]-->(43)<!-- [if supportFields]><![endif]-->. This guarantees that learners are exposed to a valid SBE experience. - The increase in knowledge, know-how, interpersonal skills, as well as self-confidence and a sense of personal efficacy, corresponding to level K2 <!-- [if supportFields]> ADDIN EN.CITE Der Sahakian 2019 1974 (36) 1974 1974 5 Der Sahakian, Guillaume Buléon, Clément Alinier, Guillaume Chiniara, G Educational Foundations of Instructional Design Applied to Simulation-Based Education Clinical Simulation: Education, Operations, and Engineering 185-206 2nd 2019 Elsevier <![endif]-->(36)<!-- [if supportFields]><![endif]-->. - The debriefing should be of quality, respectful, non-offensive, and relevant. This is dependent on the training of the educators so they develop optimal debriefing skills (59). Respecting the principle of non-maleficence means avoiding any harm to learners or ensuring that any potential harm is associated with a positive benefit/risk ratio. This is about not “tricking” learners with bad intentions, nor purposefully provoking negative emotions. The feeling of being deceived can come from the scenario itself, from simulated participants, or from an intentional equipment malfunction [43, 47]. Negative emotions can also be generated by the provoked and unavoidable death of the “patient” [60]. It is important to realise that deception is often purposefully incorporated into scenarios to enhance their authenticity, and hence it is no related to non-maleficence but benevolence [43]. If the simulation is multi-professional, and even more so in-situ, then a tension arises between the “good for the team, the unit, the institution” (imagining all possible cases, even the most difficult) and the “good for the learner” (avoiding the feeling of deception). It also raises a dilemma between the scenario's loss of authenticity, which threatens the principle of beneficence, and the learners’ loss of psychological safety, which threatens the principle of non-maleficence [61]. It is on this basis that a controversy has arisen in the world of SBE about whether or not it is possible to deceive learners for their own good. The key lies in the quality of upstream information, which is the learners’ preparation in the form the pre-briefing and associated learning contract [43]. The principle of distributive justice applied to the learner is that all learners should benefit from SBE. This requires well trained simulation educators, sufficient training space, and good administrative and technical support and processes. All these elements ensure the reproducibility and accessibility of SBE to all learners. For simulated participants The ethical aim for a simulated (or standardized) participant or patient (SP) is to increase the realism of a scenario. Learners are still immersed in a controlled environment within which they can make mistakes and develop technical and communication skills without this being harmful to the patient [43]. The principle of autonomy for the SP corresponds to the freedom to choose to be involved in a scenario depending on the level of physical exposure required, the type of physical assessment or procedures to be performed on them, and the type and tone scenario script language [62]. This is similar to an actor’s right to accept or not a role and its associated script for a movie. Prior information must be as exhaustive as possible, specifying the number of scenarios enacted over a set duration, the break times, and so on. It is also important to provide a framework that includes role portrayal training, image rights, and training to evaluate learners’ performance or providing feedback. Two examples illustrate the possible limits of the role of SPs: Their use to teach pelvic examination [63] or to receive repeatedly a diagnosis with a poor prognosis [64]. Beneficence. Simulated patients need to work in good conditions, including a space where they can get changed, “get in” and “get out” of character, and wait between scenarios [62, 65]. The benefits of participating in SBE for SPs can be of various kinds: 1/ Participation in improving the skills of healthcare professionals, particularly for expert patients; 2/ Personal development in another field of theatrical art for actors; 3/ Financial benefits through remuneration for preparation time, simulation-based activity with learners, and travel expenses [65, 66]. Respecting the principle of non-maleficence corresponds to avoiding the simulated patient's insecurity. This is essentially psychological but also physical insecurity in relation to body parts exposure. This means ensuring the psychological safety and mental wellbeing of the SPs by taking care of not awakening negative prior experiences, evaluating the impact of the frequency of training situations on the SPs’ psyche (e.g., the consequences of being diagnosed with cancer several times a day/week), and debriefing the SPs regularly about their role and experience and offering the support of a psychologist if needed [65, 67]. Distributive justice would correspond to the national and international availability and use of SPs for the training of healthcare professionals in SBE programmes. Other principles: There is a professional ethical principle whereby the SPs must accept to take part in training sessions to learn how to act as per the patient they need to impersonate and how to provide feedback to learners or complete evaluation forms about their performance. They need to accept receiving feedback on their own acting performance. They must respect a certain number of points linked to SBE [62]. These include adhering to the principles of simulation including confidentiality (especially for in-situ simulation) and benevolence. Special features Ethics and disclosure of bad news When it comes to breaking bad news in simulation, the psychological safety of learners and SPs cannot be ignored. It is part of professional ethics, without which learning becomes random or dangerous. Indeed, the disclosure of bad news refers to the emotions expressed by SPs that can provoke a psychological distress in relation to an event already experienced by learners [68]. This can raise ethical issues and cause trauma for learners [69]. For this reason, making sure at an earlier stage that this type of simulation does not disturb the learner and that the verbal and behavioural expressions of the SPs are not too destabilizing for a beginner learner helps to ensure their psychological safety. Such assessment can be based on the SPIKES method (Setting, Perception, Invitation, Knowledge, Empathy, Strategy, and Summary) [70] or its French translations – EPICES (Environnement, Perception, Invitation, Connaissances, Empathie, Stratégie et Synthèse) [71]. Ethics and death in simulation After several decades of simulation during which educators advocated against allowing the simulator to die unless death was part of the learning objectives [72], this practice has been called into question. There is a profound discrepancy between cardiopulmonary resuscitation (CPR) management in simulation compared to real life: it is shorter and a lot less sad [73]. The risk is therefore a loss of “fidelity” of the scenario and thus a threat to the principle of beneficence as the learning experience no longer fully exposes learners to the reality of clinical practice. It has also been reported that presenting scenarios with a systematic death of the manikin leads to an increase in anxiety-depression with increased State-Trait Anxiety Inventory (STAI) scores [60]. This consequence was not reported in another randomized study [74]. But a recent meta-analysis has shown an association between an increased STAI score and anxiety or depression [75]. A randomized trial reported that students exposed to unexpected simulated patient death had more negative emotions, higher cognitive load, and were less competent to diagnose and manage a case [76]. This risk of negative impact is important to note as an element that could threaten the principle of non-maleficence. There is therefore a dilemma between the principle of beneficence and that of non-maleficence. In the context of death during SBE, the principle of autonomy involves fully informing learners about the possibility of death and obtaining learners' consent [42]. In one study learners had the same sense of self-efficacy having been informed or not of the possible manikin's death beforehand [77]. The unexpected death of the manikin in simulation is only conceivable and ethical if learners are informed during the pre-briefing and that they give their consent [43, 78]. Thus, the possibility of the manikin's death in simulation appears ethical if: 1/ it is appropriate to the scenario; 2/ the learner is experienced and has already seen deteriorating patients; in another words, it should not be with novice learners, given the potentially deleterious effect of the emotional shock of being confronted with death early on in vocational training. [79]; 3/ the principle of autonomy is respected (learners are fully informed beforehand that the manikin may sometimes die) and learners give their consent. Prior to a particularly difficult scenario, it is important to inform learners that it involves 'critical' actions with a strong correlation with whether or not the manikin will survive (Table 2, Type 5). Table 2 presents different speculative possibilities in relation to the patient’s death during SBE activities. The first possibility is to mimic clinical reality with less than 10% of survival (and increase learning gains and therefore beneficence), but at the risk of learner dissatisfaction and therefore less non-maleficence. Conversely, the second option provides over 90% survival after simulated cardiac arrest, which increases learner satisfaction, but at the risk of being less realistic. The same applies to option 3 with the manikin surviving all the deleterious learners’ actions that could lead to death. On the other hand, the fourth possibility, which links each deleterious action to the manikin's death, although realistic, seems excessive and will greatly diminish learners' sense of satisfaction. The fifth possibility of presenting death in simulation seems ethically the least unfavourable. It allows the manikin to sometimes die in very specific cases where the action/inaction of the learners has a strong causal link with the outcome. It is therefore directed by the learners' performance and leads us to consider that a simulation educator may sometimes intentionally deceive learners for their own good (by authorizing the manikin's death if the action with a strong correlation with survival has not been carried out or if inaction is automatically linked to death). This way of representing death in simulation may, in some cases, reduce learner satisfaction and create a degree of frustration, but it also increases learning [43]. Interestingly, this ethical resolution of the problem of death in simulation upsets Kirkpatrick's pyramid at its base, as far as it is not necessary to have learner satisfaction to improve their knowledge or skills. Further research is needed to fully explore this theme, and in particular, the psychological effects of manikin death. Ethics and research For the researcher, professional ethics include compliance with the Simulationist Code of Ethics [32, 37], the use of simulation according to one of the 4 modalities described (intervention, evaluation, context, pretext), and full information for the research participant on the same elements as the learner during a simulation session (Pre-briefing and briefing) [80]. When a participant is included in a simulation-based research study, written consent is mandatory [81]. Often there are inconveniences associated with research evaluation studies such as biological sample testing (e.g. blood, urine, saliva), wearing sensors, completing numerous questionnaires, not smoking for 24 hours, etc [82]. To respect the principle of beneficence for all, researchers must provide an equal training opportunity to the “non-simulation” group (control group) participants after the research has been conducted [83]. Ethics and the use of biological tissue The ethical aim here is not the professional protection of the learner (guaranteed by the educator), but rather the respect and protection of the biological tissue(s) used in the course of a mostly procedural simulation-based activity. For the educator, it is in all cases a professional ethics of respect for regulations concerning the use of animals or parts of animals [52, 53], and cadavers donated to science [5, 53] as presented in the first example of the foreword. The ethical guarantor with regards to biological tissues is the anatomy laboratory’s ethics committee acting as a protector of the ethics linked to the management of biological tissues [5]. However, the guarantor of ethics with regards to learners remains the educator, responsible for the application of learning regulations (see “Ethics for the learner” above). This dual ethical protection is specific to procedural simulation and must be precisely organized and validated in every SBE activity of this type. As far as the whole animal is concerned, the essential ethical aspect is to provide sufficient analgesia or anaesthesia so as not to cause suffering [52, 53]. The French National Committee for Ethical Reflection on Animal Experimentation is tasked with ethical issues related to animal experimentation [84]. Concerning the use of cadavers in simulation (complete subjects or anatomical parts), the framework has been precisely defined by a recent French Decree [5], which sets out the principles and procedures (ethics, scientific, and educational committee). In addition to the guarantees provided by the various committees of the body donation centres (ethical, scientific, and pedagogical) of the Law [5], one must adhere to the respect due to the deceased human body [85], and provide a prevention of viral infections by searching for any viral infectious agents on bodies donated to science before they are used [86]. Teaching ethics through simulation Learning ethics through simulation plays an important professional role. It contributes to the preservation of values and cultural heritage of societies and healthcare systems, which is a major concern of educational systems [87]. Although not frequently used, simulation enables learners to acquire bioethical principles for the patient [88]. Ethics in medicine and nursing takes place in situations that are inherently uncertain and open-ended [89]. Simulation can be designed to reflect the choices faced by patients and clinicians, and the factors that influence the dynamics between them, and present them in a context that emphasizes the need for a nuanced approach to ethics education and practice [89]. Simulation then provides learners with the opportunity to develop the knowledge and skills needed to manage complex situations and ethical dilemmas [90]. Nevertheless, the complex nature of the scenarios means that they are aimed at end-of-course learners who have already a wide experience of medico-technical situations. The teaching of bioethics in simulation has been reported in medical [91], nursing [92] and midwifery studies [90]. It is fundamental to teach about ethics in nursing education as nurses are considered the biggest human capital in the health care system [93]. In addition, simulation has been used to determine, on an assessment scale, the threshold value of skills needed in ethical decision-making [94]. Finally, SBE provides insights into the application of bioethics in other countries and cultures [95]. Ethics and computer simulation According to Moor's Law, there is a correlation between technological advances and social and ethical impacts [96]. VR, and more broadly the sensory virtualization of all or part of the simulation environment, opens up a new dimension of ethical concerns. This development threatens virtue ethics like any new development in human activity [34]. While the potential benefits of VR are heralded by some as limitless possibilities (Metaverse), there is in fact a necessary debate on its real educational efficiency and on the ethical implications that this technology represents in relation to its physiological, cognitive, and behavioural impacts. There may be visual or even pluri-sensory isolation of the educator/learner pair, as well as isolation regarding social dynamics and inter-individual relations [97]. The beneficence of this approach was the first to be raised as potentially threatened or modified by VR for clinicians and patients [98], as well as lay people [99]. The second concern has been distributive justice as simulation using VR is not financially accessible to all training programmes, even though it promises to be an important teaching tool [100]. It seems that currently the crucial problem is that of “virtual ownership” of both the educational content and the information gathered and processed through machine learning. This is a threat to the principle of learner autonomy. For example, a user may be considered the owner of an island in a virtual world, but the entire world, including the island, may be the property of the company that created it and allows users to ”live” in it [101]. For example, the development of many surgical training software is in fact financed by industry, such as implant manufacturers, with the aim not only of promoting the implantation technique for the trained professional, but also of commercially seeding their product to inexperienced learners. A whole virtual economy can develop here, as in Second Life [102]. VR presents a major potential ethical problem, as the technology and financing it imposes can generate a deleterious relationship of dependency between the financial world and the world of healthcare training, particularly through the exploitation of personal physical and psychological data, which may be collected without the knowledge of their authors and for unknown purposes. There is therefore a great vulnerability to this technique, which can be a source of abuse for malicious or financial purposes [103]. The same applies to augmented reality (AR), which can fall victim to misuse and whose data can also be the source of abuse [104]. In order to respect the integrity of human beings and their ability to decide for themselves what is done with their own data, it is essential to lay down precise operating rules for the collection and use of such data [105]. As technology and SBE practices evolve, it is necessary to ensure that ethical principles are always followed, especially as AI may easily ignore related core principles without us realising it. There lay further important ethical questions. Conclusion Bioethics was mainly developed for healthcare research and has been extended to patient care. We think it is mandatory to spread its principles to SBE activities with respects to all stakeholders, including the learners, educators, simulated participants, and the patients themselves. Healthcare SBE retains its core ethical foundation of beneficence: “Never the first time on the patient”. However, in its many developments and modalities, simulation must respect bioethical principles. This ethical perspective enables SBE to be seen in a different light and to meet requirements other than those hitherto accepted. This allows us to explore the ethical dimensions of each stakeholder’s practices in SBE and to see how changes over time can alter ethical tensions, prompting us to exercise greater caution. It also enables the development in each centre, of an SBE network built in accordance with bioethical principles, with the ultimate goal of improving patient care. Research is needed to develop a differentiated perspective based on cultures and practices, in order to better understand the specific characteristics of each. Author contributions All authors contributed equally and validated the final version of record. Declarations Conflicts Of Interests The Author declares that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval Ethical approval for this study was not required. References <!-- [if supportFields]> ADDIN EN.REFLIST <![endif]-->1. Smith WR, Audi R. Religious Accommodation in Bioethics and the Practice of Medicine. The J Med Philo. 2021;46(2):188–218. https://doi.org/10.1093/jmp/jhaa038 2. Gray B. (Bio)Ethics in a Pluralistic Society. Challenges. 2019;10(1):12. https://doi.org/10.3390/challe10010012 3. French National Assembly and Senate. Loi 94-654 du 29 juillet 1994 relative au don et à l’utilisation des éléments et produits du corps humain, à l’assistance médicale à la procréation et au diagnostic prénatal [Internet]. Jul 29, 1994. 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Copyright (c) 2026 Denis Oriot, Guillaume Alinier, Zineb Messarat-Haddouche, Hervé Thomazeau, Laetitia May-Michelangeli, Marie-Christine Moll, Jean-Claude Granry (Author) https://creativecommons.org/licenses/by/4.0
The Assessment of Lebanese Hospital Nurses’ Qualifications in The Fight Against COVID-19: Are They Well Prepared?
Background On December 31, 2019 China reported multiple cases of a novel coronavirus, This rapid and unexpected increase in cases caused a shortage of testing kits, personal protective equipment (PPE), medical treatments, ventilators, and other medical supplies. Therefore, nurses and physicians needed to feel safe, protected and confident while treating ill patients. It is the responsibility of the healthcare system's to wisely use the skills and available resources for an effective response and ensure the safety of the personnel. Our primary objective is to assess the preparedness of nurses against the coronavirus and then to evaluate the impact of the outbreak on the nurses and their attitude towards the pandemic. Methods An anonymous online survey was conducted among nurses across Lebanon. It consisted of 24 multiple-choice, closed-ended questions related to knowledge, attitude and practice. Results A total of 370 registered nurses completed the survey. Analysis showed that age had no effect on knowledge; males were more trained than females for triage, hand hygiene and working in isolation units, while females were more trained for handling PPE. Additionally, females attended national lectures more than males, while males received information from media and brochures. The training for PPE use and working in isolation unit was better conducted in university hospitals as compared to non-university ones. 50% of nurses in both hospital types did not attend any lectures. The nurses in all Lebanese districts had training about hand hygiene and working in isolation unit before the pandemic while they had the triage training mostly after the pandemic started. Analysis also showed that the nurse-to-patient ratio was higher for older nurses and in peripheral areas. For both genders, 66.3% had never undergone an N95 fit test. Lastly, almost half of the nurses thought about quitting their job. Conclusion The study showed that there is some lack of nurses’ knowledge towards COVID-19. Variations were observed in nurses’ practice regarding age, gender, hospital type, district and nurses’ position. Introduction On December 31, 2019 China reported multiple cases of acute respiratory illnesses that were later found to be caused by a novel coronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1]. This virus is a member of the subfamily Coronavirinae and belongs to the same genus as coronaviruses that caused the severe acute respiratory syndrome (SARSCoV) reported in China in 2003, and Middle East respiratory syndrome (MERS-CoV) reported in Saudi Arabia in 2012 [2]. Unfortunately, the new coronavirus had spread very rapidly around the globe, so on March 11, 2020 the World Health Organization (WHO) declared SARS-CoV-2 a pandemic [3]. This rapid and unexpected increase in cases caused a shortage of testing kits, personal protective equipment (PPE), medical treatments, ventilators, and other medical supplies. In addition, the insufficiency was not only observed in material resources but in human resources as well, number of staff and preparedness of personnel [4]. Despite the elapse of more than a year after the declaration of the pandemic, there is still no curative treatment for SARS-CoV-2 and numbers continue to rise with nearly one million new cases in the last week of March 2021 and the emergence of new strains, more virulent, like the latest one in India [5-6]. According to Guest et al, the major steps in overcoming this pandemic are an effective lockdown, an increase in testing and most importantly an improvement of the healthcare system’s capacity to respond, which is the aim of this study [7]. In turn, ensuring the safety of health care workers (HCWs) should be a priority by vaccinating them, providing them with the appropriate PPEs, giving them the adequate training and updating their knowledge of the pandemic. Researchers in Taiwan found that the number of HCW decreased as the sense of security among them decreased; they felt unsafe treating coronavirus disease (COVID-19) patients, and avoided working in COVID-19 units [3]. Therefore, nurses and physicians needed to feel safe, protected and confident while treating ill patients; for this purpose, infectious disease specialists in Taiwan developed a “Traffic control bundling” map that ensures a passage for patients from triage to treatment zone where HCW are not exposed to the patient and those who are directly taking care of them are in full PPE. This map aims at preventing shortage in medical staff secondary to anxiety, thereby improving the workflow [3]. It is also very important for the workflow that the medical staff in a pandemic is not subject to any anxiety or stress. while it is difficult to determine the number of lives saved by epidemiological research, yet it is certain that good intervention and prevention strategies save millions of lives. It is our responsibility to wisely use the skills and available resources for an effective response. For this reason, the WHO published a checklist to help hospitals assess their preparedness in order to ensure a rapid response to the outbreak [8]. This study aims to assess how well the Lebanese nurses are prepared for this new pandemic. Our primary objective is to assess the preparedness of nurses against the SARS-CoV-2 outbreak based on the level of knowledge, training and practice. The secondary objective is to evaluate the impact of the outbreak on the nurses and their attitude towards the pandemic. Materials and methods Study design and data collection procedure This is a descriptive, observational cross-sectional study, for which the approval of the Institutional Review Boards of the Lebanese American University was obtained in May 2020 IRB #: LAU.SOM.RS2.11/ May/2020. It was based on an anonymous self-administered online survey. The questionnaire was created using Google Forms, saved as a link, and reviewed by the Lebanese Order of Nurses who distributed it via email to all registered nurses. Data collection took place between July 2020 and February 2021 (The Beirut Blast that occurred on the 4th of August 2020, caused a halt in data collection for approximately two months.) Only answers of currently practicing nurses, whether in the private or public sector, working in any of the Lebanese governorates, were included. Nurses who were not registered, did not hold a license to practice, or were not currently practicing were excluded from the study. Sample size The sample size was calculated using Epi Info 7 StatCalc functions for a population survey. Given that the number of registered nurses in 2020 was 16927 and, with an expected confidence level of 95% along with a margin of error of 5%, the minimum sample size required to obtain statistically significant results was determined to be 370 nurses. Survey development The questionnaire was designed after reviewing multiple studies discussing COVID-19 preparedness among HCW, as well as preparedness for other epidemics and pandemics. It was initially written in English then translated to Arabic by a translator and cross-checked with the team of the study. It was then back-translated to ensure accuracy to English. Both the English and Arabic versions were piloted by two nurses, one day apart, to make sure they were equally understood. This way we were able to check for the comprehension of the questionnaire in both languages and agreement (reliability of the questionnaire) in their answers before conducting the study. The questionnaire was composed of 24 multiple choice questions that mainly look into the sociodemographic characteristics of the nurses, their training and educational backgrounds. This allowed us to assess nurses’ knowledge, the load they were dealing with and to analyze their practice. In addition, there were few questions that look into nurses’ attitude towards this crisis. To note that the survey was sent in both languages, Arabic and English, and the answers provided were collected on an online sheet. Data management and statistical analysis Statistical analysis was conducted using the Statistical Package for the Social Sciences (SPSS) for Windows, Version 23.0. Means and standard deviations were reported for continuous variables. Categorical variables were assessed and described as frequency and percentage. Bivariate analysis was performed using Chi square test and Fisher test to examine associations between knowledge, practice and attitude and the different sociodemographic variables (gender, age, experience, job position, years of experience, type of hospital and hospital location). A p-value of <0.05 was considered statistically significant. Results General Characteristics A total of 370 nurses responded to the questionnaire; however, only 359 were currently practicing and thus included in the study. Among them, 155 were male (41.8%) and 215 were female (58.2%).Respondents’ ages ranged from 21 to 63 with a mean age of 32 years. Additionally, 223 (62.1%) worked in private hospitals, 89 (24.8%) worked in public hospitals and 47 (13.1%) worked in both sectors simultaneously. When considering the type of hospital, 204 (56.8 %) participants were practicing in university hospitals while the rest were working in non-university hospitals. Moreover, when considering the geographical distribution, the majority 167 (46.5 %) of nurses were practicing in the capital Beirut, and the rest were distributed across the North, South, Bekaa and Mount Lebanon. After reviewing the numbers and the descriptions of the sample obtained, we tried to observe the correlation between the above-mentioned demographics and other characteristics such as experience, job position…with the knowledge, practice and attitude of the nurses towards the pandemic; result of our observations is described in the following section. Nurses’ Knowledge To assess nurses’ knowledge, the questionnaire included questions regarding training (triage of COVID-19 patients, use of PPEs, hand hygiene and different types of isolation) and educational activities (such as conferences’ and lectures’ attendance), were included in the questionnaire. Regarding training, we looked into possible associations with participants’ age and gender, also with the type and location of hospital. Association with age Data analysis showed no association between age and any of the previously cited variables. Therefore, age had no effect on nurses’ knowledge of SARS-CoV-2. Association with gender Data analysis showed an association between gender and studied variables, as summarized in Table 1. Male nurses had more training sessions than females, in triage, hand hygiene and working in isolation units. In contrast, female nurses received more training in the proper use of PPE. Our observations found that nurses were trained for triage and PPE handling after the emergence of the SARS-COV-2 in Lebanon, while trainings concerning hand hygiene and different isolation types, were acquired before the start of the pandemic. To note that a small percentage of nurses never had any type of training (around 16 % for triage training and 8% for each of the rest). Concerning the information platforms, 27% of respondents reported access to international resources such as those from UNICEF or WHO and 79% noted receiving information from infection control committee of their hospital. However, no statistically significant difference was observed between genders for the abovementioned sources. 30.9% of the nurses received information from the national health authorities (Ministry of Public Health), with a predominance among female respondents. 70.8% of nurses received their information from media, 49% from brochures and 42.3% from occupational health and safety committees; with a significant male predominance across all three sources. Association with type of hospital (University vs. Non-University hospital) The data is summarized in Table 2. For triage training, data analysis showed no significant difference between university and non-university hospitals. As for the rest, before and after the pandemic there was a statistical difference concerning training for PPE use (p value 0.042), hand hygiene (p < 0.001) and working in isolation units (p< 0.001) was significantly more common in university hospitals. It is important to note that not all hospitals provided training sessions. In fact, 8% of hospitals in both categories offered no training at all. As for taking lectures, data was significant for the following observation: 35% of nurses working in university hospitals attended lectures from International Organizations as compared to 16% of nurses working in non -university hospitals. 37 % of nurses working in university hospital attended lectures given by the Ministry of Public Health while only 23% of those working in non-university hospitals did. Almost 50% of nurses from both hospital types did not attend any lectures. On the other hand, 62 % of nurses working in non-university hospitals relied more on self-education through random brochures compared to 32% of those in university hospitals. Association with hospital location in Lebanese governorates Training for hand hygiene and working in isolation units, were already implemented in hospitals across all Lebanese governorates. For triage, triage training was introduced after the pandemic began. As for the PPE, For PPE training, it was observed that hospitals in Beirut and Mount Lebanon enforced training mainly after the emergence of the first confirmed case in Lebanon. Regarding lectures, nurses working in Beirut and Mount Lebanon area attended more international and national lectures, as compared to nurses working in Bekaa, North and South districts. Nurses in the latter regions were mainly getting their information from media and brochures. In all the districts, the hospital infection control and the occupational health and safety committees played an equally active role in educating nurses. Association with nurses’ position and years of experience Nurses' roles were categorized into three groups, head nurses, critical care nurses (Emergency Room and Intensive Care Unit) and non-critical nurses (Pediatrics and regular ward). All lectures and trainings were not significantly affected by position. However, 22% of non-critical care nurses, 5% of head nurses and 14% of critical care unit nurses never had triage training. Neither getting any training nor attending lectures showed a statistically significant difference when comparing years of experience. Nurses’ Practice Using the same variables (gender, age, hospital type, hospital location, and job position), the practice of nurses was evaluated. The key indicators assessed were whether nurses underwent N95 fit testing, their experience working in negative pressure units, and the patient load assigned to them. Association with age Data analysis showed that no significant difference was observed in N95 fit testing when comparing different age groups, nor in working in negative pressure units. However, the assigned number of patients increased as nurses’ age increased. Actually, nurses who were 30 years and older had 10 to 20 patients to take care of whereas nurses who were 30 years and younger had 5 to 10 patients to take care of. Association with gender For both genders, the overall rate for N95 fit testing was very low: in total 66.3% of nurses reported never having undergone an N95 fit test. Within those who had the test, 30.1% of the females and 18% of males had the fit test after the pandemic while 8.1% of females and 9% of males had it before. Regarding working in negative pressure unit, male nurses significantly had previous experience, 39.3% of males as compared to 28.7% of females (p=0.035). As for the load of patients during their practice there was no significant difference between genders. Association with type of hospital (University vs non-university) Hospital type (university vs. non-university) did not seem to affect the practice of the nurses. Association with hospital location in Lebanese governorates Beirut was the area where nurses had N95 fit test done the most, and mainly after the start of the pandemic (31.7%, or n=53 with p-value =0.002). The load of the patients assigned to each nurse during the pandemic was higher in peripheral areas (North, South and Bekaa) as compared to the Capital, however, no statistical difference existed before the pandemic between the different districts. Association with nurses’ position 66% (n=238) of the of nurses did not have the N95 fit test done at all, 8% (n=31) did it before the pandemic and 26% (n=90) after. 42% (n=51) of critical care nurses were familiar with working in negative pressure unit compared to non-critical care and head nurses (28.6 % or n=68). Nurses’ Attitude To understand the emotional and psychological burden experienced by Lebanese nurses during the COVID-19 pandemic, the last section of the survey contained two questions that address the nurses’ will to take an unpaid leave or even quit their job. A bivariate analysis of the different studied characteristics (age, gender, hospital type and location, and job position) showed that none of them was significantly associated with the nurses’ will to take a break or quit. In all categories, almost 50% of the respondent nurses thought of taking an unpaid leave, the percentage decreases to 33% of the total responses when asked about quitting their jobs. Discussion HCW and in particular nurses are at the frontline of SARS-CoV-2 pandemic response. In this study we assess the knowledge, practice and attitude of the Lebanese nurses towards the pandemic all over Lebanon. Knowledge is a key factor in the fight against any pandemic, since a poor understanding of the disease can result in delayed identification of positive cases and therefore lead to rapid spread of the infection. Guidelines for HCW along with online courses have been developed by several national and international organizations such as the Lebanese Ministry of Public Health, infectious disease societies, the WHO, the Centers for Disease Control and Prevention, and the National Institutes of Health [9]. This is not the first study to explore the awareness and attitude of Lebanese HCW in Lebanon regarding the pandemic. Other studies done earlier, only described the knowledge and attitude of nurses and pharmacists in Lebanon but without trying to identify the reasons behind the deficiency and consequently failed to provide a space for improvement [10]. In a similar study, Saade et al. analyzed the knowledge and attitude of Lebanese nurses and reported that they were well informed, based on their understanding of the disease transmission, clinical presentation and effective protective measures [10]. However, our study focused more specifically on the source of this knowledge and we found that the majority of nurses (almost 2/3) did not receive any lectures or trainings from international organizations while the study of Saade et al showed that ¾ (74.6%) attended an awareness session on COVID-19. The information gathered by the nurses was from personal effort in looking at various accredited and non-accredited resources online, from media and brochures, especially in non-university hospitals and outside the capital [10]. This means that a big number of Lebanese nurses are getting their information from non-evidence-based sources, which raises concerns about the precision of this knowledge. A study conducted in Lebanon by Domiati et al. found that 61% of the Lebanese population obtained their COVID-19 knowledge from HCWs, positioning nurses as a key source of public information [11]. The Lebanese Order of Nurses could play an important role in solving this issue, by helping the registered nurses in attending virtual international and national conferences, based on evidence- based, updated guidelines and on experts’ opinion. Hospitals also have a responsibility to promote the role of infection control and occupational health and safety committees in educating their nurses and improving their trainings. Although the Lebanese authorities including the Ministry of Public Health launched a dedicated website for all information regarding COVID-19 and started broadcasting preventive methods on local television channels. These efforts primarily target the general population, and not HCWs [12]. The Ministry of Public Health has an important part to play through updating daily news, about the cases in Lebanon, and awareness campaigns. Finally, the nurses themselves should also be encouraged to read articles from trusted and evidence-based literature. In most similar studies, males demonstrated low levels of knowledge, attitude and preventive practices compared to females [13-16]. However, in our study male nurses received more training and lectures. This may be due to some hospitals assigning male nurses to SARS-CoV-2 wards more frequently and investing more in their training. It could also be secondary to some societal norms favoring educational opportunities for men over women. Similar to finding of a study looking at Lebanese pharmacists’ practice towards the pandemic [17]. Our results showed that nurse’s practice was also affected by not having enough PPE, and also by not having N95 Fit test, which can render the nurses hesitant in their jobs. The delivery of PPE is a must to provide adequate protection of healthcare workers and other non-infected patients. Compared to Saade et al, our questionaries’ regarding practice was complementary to theirs [10]. They asked about getting the infection, being tested for COVID 19, having infected co-workers, treating COVID 19 patients, having sufficient PPEs and correctly using it, evaluating hospital preparedness, educating patients and testing the n95 masks themselves (46% vs 34% in our study) [10]. Our study addressed, on top of the fit test, the load of patients per nurse and working in negative pressure units. The load per nurses was observed in older nurses, probably because they are more experienced and have greater resilience. Moreover, the nurse-to-patient ratio was greater for those working in peripheral areas most probably because of the lack of staff working in rural areas, and the lower number of hospitals as compared to the capital. This finding is comparable to a similar study done in China where the nurses in urban areas had more knowledge especially the ones with more than 20 years of experience and therefore were assigned a higher patient load [18]. Finally, when assessing the attitude of nurses, Saade et al. described Lebanese nurses as being afraid of getting the infection, or transmitting it to their loved ones [10]. Although a study done in the Philippines showed that the fear of getting infected with COVID-19 is associated with higher knowledge and that is the case with nurses since they have more knowledge of the disease than the general population [19]. Saade et al. also documented the nurses’ psychological burden by looking at their levels of anxiety, stress and depression, and the negative consequences of these burdens on their duties, relationship with their families and co-workers [10]. Saade et al. focused on the psychological impact on the nurses’ attitude; one common question between the two studies, regarding leaving work due to COVID, showed similar results: 64% of their respondents’ vs 67% of ours declared not wanting to quit. This actually shows a positive attitude toward COVID-19 and the result is comparable to the study done in the general population in Lebanon [11]. This reasoning can also be explained by the economic crisis affecting the country and further studies about nurses’ burnout should be addressed. Limitations The study was conducted through an online survey therefore only nurses who had access to it were able to complete it. Also, since the data are based on self-reported responses, there might be information and recall bias. Since the study is cross-sectional, we cannot conclude any direct causality between dependent and independent variables. More specifically, our survey only addressed some aspects of knowledge, practice and attitudes; we therefore didn’t assess the reasons behind nurses’ will to quit or take unpaid leaves. Conclusions This study showed gaps in knowledge regarding SARS-CoV-2 among Lebanese nurses, mainly due to the absence of a proper educational program and training. This gap persisted despite the fact that the COVID-19 pandemic had been ongoing for over 6 months during the study period. However, variations existed in nurses’ practice regarding age, gender, hospital type, district and nurses’ position. The nurses, despite the pandemic, did not report a high willingness to quit or take unpaid leaves. In conclusion, greater efforts must be invested in educating and training nurses, who represent the backbone of the healthcare system. These efforts should be coordinated by multiple stakeholders, including scientific societies, the Lebanese Order of Nurses, and the Ministry of Public Health. Moreover, hospitals should be adequately equipped with essential resources to face a pandemic. This moment offers a valuable opportunity to reassess outbreak management challenges and develop sustainable strategies for future health crises. Additional studies are also recommended to evaluate nurses' burnout and the current level of institutional preparedness. Author contributions All authors contributed equally and validated the final version of record. Declarations Conflicts Of Interests The Authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval Ethical approval for this study was not required. References 1. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia. N Engl J Med. 2020 Mar 26;382(13):1199–207. https://doi.org/10.1056/NEJMoa2001316 2. Al-Mandhari A, Samhouri D, Abubakar A, Brennan R. Coronavirus Disease 2019 outbreak: preparedness and readiness of countries in the Eastern Mediterranean Region. East Mediterr Health J. 2020 Feb 24;26(2):136–7. https://doi.org/10.26719/emhj.23.051 3. Novel Coronavirus (2019-nCoV): Situation Report 1 [Internet]. World Health Organization; 2020 Jan. Available from: https://apps.who.int/iris/bitstream/handle/10665/330776/nCoVsitrep31Jan2020-eng.pdf 4. Médecins Sans Frontières (MSF) [Internet]. 2021. Overlapping crises in Lebanon increase needs and worsen access to care. Available from: https://www.msf.org/lebanon-overlapping-crises-increase-needs-and-worsen-access-care 5. World Health Organization [Internet]. 2021. Weekly epidemiological update on COVID-19 – 23 March 2021. Available from: https://www.who.int/publications/m/item/weekly-epidemiological-update-on-covid-19---23-march-2021 6. Hackethal V. MedPage Today. 2021. India’s COVID-19 Variant: What We Know So Far. Available from: https://www.medpagetoday.com/special-reports/exclusives/92345 7. Guest JL, Del Rio C, Sanchez T. The three steps needed to end the COVID-19 pandemic: bold public health leadership, rapid innovations, and courageous political will. JMIR Public Health Surveill. 2020 Apr 6;6(2):e19043. https://doi.org/10.2196/19043 8. World Health Organization. Hospital Readiness Checklist for COVID-19 [Internet]. Copenhagen: WHO Regional Office for Europe; 2020. Available from: https://iris.who.int/bitstream/handle/10665/333972/WHO-EURO-2020-1012-40758-54954-eng.pdf 9. World Health Organization. Introduction to COVID-19: Methods for Detection, Prevention, Response and Control [Internet]. OpenWHO; 2021. Available from: https://openwho.org/courses/introduction-to-ncov 10. Saadeh D, Sacre H, Hallit S, Farah R, Salameh P. Knowledge, attitudes, and practices toward the coronavirus disease 2019 (COVID-19) among nurses in Lebanon. Perspect Psychiatr Care. 2021;57(3):1212–1221. https://doi.org/10.1111/ppc.12676 11. Domiati S, Itani M, Itani G. Knowledge, Attitude, and Practice of the Lebanese Community Toward COVID-19. Front Med. 2020, 7:542. https://doi.org/10.3389/fmed.2020.00542 12. Republic of Lebanon Ministry of Public Health (MoPH) [Internet]. 2020. New Website Launched by the Ministry of Information Regarding Coronavirus Latest News in Lebanon. Available from: https://www.moph.gov.lb/en/ 13. Zhong BL, Luo W, Li HM, Zhang QQ, Liu ZG, Li WT et al. Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: a quick online cross-sectional survey. Int J Biol Sci. 2020;16(10):1745–1752. https://doi.org/10.7150/ijbs.45221 14. Al-Hanawi MK, Angawi K, Alshareef N, Qattan AMN, Helmy HZ, Abudawood Y et al. Knowledge, Attitude and Practice Toward COVID-19 Among the Public in the Kingdom of Saudi Arabia: A Cross-Sectional Study. Front Public Health. 2020;8:217. https://doi.org/10.3389/fpubh.2020.00217 15. Haque T, Hossain K, Bhuiyan M, Ananna S, Mian M, Islam M, et al. Knowledge, attitude and practices (KAP) towards COVID-19 and assessment of risks of infection by SARS-CoV-2 among the Bangladeshi population: An online cross sectional survey [Internet]. medRxiv; 2020. Available from: https://www.medrxiv.org/content/10.1101/2020.05.26.20104497v1.full.pdf 16. Maheshwari S, Gupta PK, Sinha R, Rawat P. Knowledge, attitude, and practice towards coronavirus disease 2019 (COVID-19) among medical students: a cross-sectional study. J Acute Dis. 2020;9(3):100–104. https://doi.org/10.4103/2221-6189.283886 17. Zeenny RM, Ramia E, Akiki Y, Hallit S, Salameh P. Assessing knowledge, attitude, practice, and preparedness of hospital pharmacists in Lebanon towards COVID-19 pandemic: a cross-sectional study. J of Pharm Policy and Pract. 2020;13:54. https://doi.org/10.1186/s40545-020-00266-8 18. Wen X, Wang F, Li X, Gu H. Study on the Knowledge, Attitude, and Practice (KAP) of Nursing Staff and Influencing Factors on COVID-19. Front Public Health. 2021, 8:560606. https://doi.org/10.3389/fpubh.2020.560952 19. Lau LL, Hung N, Go DJ, Ferma J, Choi M, Dodd W et al. Knowledge, attitudes and practices of COVID-19 among income-poor households in the Philippines: a cross-sectional study. J Glob Health. 2020;10(1):011007. https://doi.org/10.7189/jogh.10.011007 20. Chaiban C, Maamari O, Issa ST, Kosremelli Asmar M: The experience of ER nurses in Lebanese hospitals during the COVID-19 outbreak: a qualitative study. Disaster Med Public Health Prep. 2023;17:e334. https://doi.org/10.1017/dmp.2022.304 21. Clinton M, Bou-Karroum K, Doumit MA, Richa N, Alameddine M. Determining levels of nurse burnout during the COVID-19 pandemic and Lebanon's political and financial collapse. BMC Nurs. 2022;21(1):11. https://doi.org/10.1186/s12912-021-00789-8 22. Youssef D, Abboud E, Abou-Abbas L, Hassan H, Youssef J. Prevalence and correlates of burnout among Lebanese health care workers during the COVID-19 pandemic: a national cross-sectional survey. J of Pharm Policy and Prac. 2022;15:102. https://doi.org/10.1186/s40545-022-00503-2 23. Bizri M, Kassir G, Tamim H, Kobeissy F, El Hayek S. Psychological distress experienced by physicians and nurses at a tertiary care center in Lebanon during the COVID-19 outbreak. J Health Psychol. 2022 May 1;27(6):1288–1300. https://doi.org/10.1177/1359105321991630
Copyright (c) 2026 Cima Hamieh, Mahmoud El-Hussein, Alicia Djoundourian, Rachelle Riachy, Ghinwa Hayek, Rania Sakr (Author) https://creativecommons.org/licenses/by/4.0
The Digital Stethoscope: Harnessing Artificial Intelligence in Pediatric Emergency Medicine
Dear Editor, Artificial Intelligence (AI) is increasingly recognized as a transformative force in healthcare, with Pediatric Emergency Medicine (PEM) standing to benefit significantly from its adoption. Children often present with subtle, atypical signs, making timely recognition of critical illness challenging. AI-driven tools are being applied in triage, predictive monitoring, diagnostic imaging, and resuscitation support, while also enhancing education through simulation and personalized learning. For global health, AI offers opportunities to reduce disparities by extending decision support to resource-limited settings. However, challenges such as data bias, ethical oversight, and the need for clinician training remain critical considerations. AI should be viewed not as a replacement for pediatric emergency physicians but as an augmentation of human expertise, amplifying decision-making, enhancing safety, and expanding access to quality care. This letter to the editor reflects on the promise, pitfalls, and potential of AI in PEM, advocating for its thoughtful and equitable integration into practice and education. Why AI matters in pediatrics emergencies Children are unique individuals with dynamic physiology. Their developmental stages influence clinical presentations, and emergencies can quickly become critical. Traditional triage and diagnostic tools, primarily designed for adults, often fail to meet the specific needs of pediatric care [1]. AI offers a transformative solution by providing rapid risk stratification and pattern recognition that surpasses human intuition, all while maintaining clinician oversight. Just as pulse oximetry revolutionized patient monitoring decades ago, AI is poised to become an indispensable tool in pediatric triage. Diagnostics and resuscitation : AI as an ally Machine learning systems are already making strides in predicting sepsis, respiratory failure, and unrecognized deterioration [2, 3]. In the realm of cardiac arrest, AI-driven rhythm interpretation and chest compression feedback are being tested as digital "coaches" [4]. This evolution mirrors the transformation brought about by Automated External Defibrillators (AEDs), which were once met with skepticism but are now indispensable worldwide. Similarly, AI can enhance the role of the CPR coach or even act as a resuscitation co-lead by providing evidence-based prompts, allowing leaders to maintain their focus on team dynamics. Education and simulation : Extending the classroom Rare pediatric emergencies, like congenital heart lesions or toxin ingestions, are infrequent in training but essential to master. While simulation addresses this gap, it is often resource-intensive and reliant on faculty. AI-enhanced virtual patients and adaptive case generators offer scalable solutions [5]. Just as flight simulators revolutionized aviation training, AI-enabled simulation could democratize access to high-quality pediatric emergency training worldwide. Additionally, natural language processing tools that analyze debriefings can help novice faculty provide structured, personalized feedback [6]. Global equity : Narrowing the gap or widening it? In low- and middle-income countries, where pediatric emergency subspecialists are scarce, AI-assisted decision-support tools embedded in mobile platforms have the potential to dramatically improve outcomes. These tools can provide rapid, evidence-based guidance to healthcare providers, helping them make critical decisions in real-time. However, there is a significant risk that algorithms trained on data from high-income populations may not perform accurately in different contexts, potentially leading to misclassification and inappropriate treatment decisions. This could exacerbate existing health inequities rather than alleviate them [7, 8]. The lesson from global vaccination campaigns is instructive: technology alone is insufficient to address complex health challenges. Successful implementation requires deliberate inclusion of diverse populations in the development and testing of AI tools, local adaptation to ensure relevance and effectiveness, and equitable distribution to ensure that all communities benefit. Without these measures, the promise of AI in improving pediatric emergency care may remain unfulfilled, and the gap between high- and low-income countries could widen further [9,10]. Challenges: Navigating bias, trust and integration AI, like any new diagnostic tool, faces significant barriers. Data bias is particularly problematic when pediatric datasets are small and heterogeneous. Blackbox algorithms that clinicians cannot interrogate risk eroding trust. Integration into workflows must be seamless; otherwise, clinicians may abandon tools that slow rather than support their practice. Lessons from electronic health record implementation highlight how poorly integrated systems can frustrate providers and compromise safety. The way forward AI in Pediatric Emergency Medicine should be viewed not as "artificial" intelligence but as “an augmented intelligence partner” that enhances human expertise without replacing it. The analogy to the stethoscope is fitting: a tool once controversial, now indispensable, but only effective in the hands of a trained clinician. The same will hold for AI. Preparing the workforce through faculty development, establishing ethical oversight, and ensuring equitable design are essential next steps. Author contributions All authors contributed equally and validated the final version of record. Declarations Conflicts Of Interests The Author declares that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval Ethical approval for this study was not required. References 1. Kauppi W, Imberg H, Herlitz J, Molin O, Axelsson C, Magnusson C. Advancing a machine learning-based decision support tool for pre-hospital assessment of dyspnoea by emergency medical service clinicians: a retrospective observational study. BMC Emerg Med. 2025 Jan 5;25(1):2. https://doi.org/10.1186/s12873-024-01166-9 2. Muralitharan S, Nelson W, Di S, McGillion M, Devereaux P, Barr NG, et al. Machine Learning–Based Early Warning Systems for Clinical Deterioration: Systematic Scoping Review. J Med Internet Res. 2021 Feb 4;23(2):e25187. https://doi.org/10.2196/25187 3. Jahandideh S, Ozavci G, Sahle BW, Kouzani AZ, Magrabi F, Bucknall T. Evaluation of machine learning-based models for prediction of clinical deterioration: a systematic literature review. Int J Med Inform. 2023 Jul 1;175:105084. https://doi.org/10.1016/j.ijmedinf.2023.105084 4. Chikatimalla R, Trivedi YV, Chigurupati HD, Faheem MSB, Naveed MA, Sattar Y, et al. From prediction to precision: Artificial intelligence and emerging technologies in cardiopulmonary resuscitation. Prog Cardiovasc Dis. 2025 Sep 1;92:97–107. https://doi.org/10.1016/j.pcad.2025.09.004 5. Díaz-Guio DA, Henao J, Pantoja A, Arango MA, Díaz-Gómez AS, Gómez AC. Artificial intelligence, applications and challenges in simulation-based education. Colomb J Anesthesiol. 2024;52(1). 6. Shaik T, Tao X, Li Y, Dann C, McDonald J, Redmond P, et al. A Review of the Trends and Challenges in Adopting Natural Language Processing Methods for Education Feedback Analysis. IEEE Access. 2022;10:56720–39. https://doi.org/10.1109/ACCESS.2022.3177752 7. Mir MM, Mir GM, Raina NT, Mir SM, Mir SM, Miskeen E, et al. Application of artificial intelligence in medical education: current scenario and future perspectives. J Adv Med Educ Prof. 2023 Jul;11(3):133. https://doi.org/10.30476/jamp.2023.98655.1803 8. Ejaz H, McGrath H, Wong BL, Guise A, Vercauteren T, Shapey J. Artificial intelligence and medical education: a global mixedmethods study of medical students’ perspectives. Digit Health. 2022 May;8:20552076221089099. https://doi.org/10.1177/20552076221089099 9. Chin MH, Afsar-Manesh N, Bierman AS, Chang C, Colón-Rodríguez CJ, Dullabh P, et al. Guiding principles to address the impact of algorithm bias on racial and ethnic disparities in health and health care. JAMA Netw Open. 2023 Dec 1;6(12):e2345050. https://doi.org/10.1001/jamanetworkopen.2023.45050 10. Nazer LH, Zatarah R, Waldrip S, Ke JX, Moukheiber M, Khanna AK, et al. Bias in artificial intelligence algorithms and recommendations for mitigation. PLOS Digit Health. 2023 Jun 22;2(6):e0000278. https://doi.org/10.1371/journal.pdig.0000278
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Proceedings of the Qatar Paediatric Emergency Medicine 2026 Conference - Selected Abstracts
Welcome to this issue of Panorama of Emergency Medicine (POEM) dedicated to the 10th Qatar Paediatric Emergency Medicine (Q-PEM) International Conference which was organised and hosted by Sidra Medicine (Doha, Qatar) and held online from January 16 to 18, 2026. Since its first iteration in 2017, Q-PEM has steadily evolved into an international forum for clinicians, educators, and researchers involved in the acute care of children to exchange knowledge, reflect on clinical practice, and share emerging research in paediatric emergency medicine. In 2025, the conference welcomed 2,000 online delegates from 22 countries and the programme included over 55 speakers [1]. Adopting a similar format, with 3 parallel sessions covering different important and contemporary topics, the event proved as popular in its 2026 edition with nearly identical numbers, yet we marked an important milestone for the Q-PEM community. Building on the success of previous years, the meeting again attracted a large international audience with multidisciplinary participation from physicians, nurses, pharmacists, allied health professionals, and trainees involved in paediatric emergency care. Similar to previous editions, the scientific programme combined plenary sessions, focused tracks, and research presentations to provide practical, evidence-based updates relevant to frontline emergency care. The conference was designed to enhance recognition and management of serious illness and injury in children, promote patient safety, and facilitate the translation of evidence into everyday clinical practice. Emergency Medicine is still a relatively young specialty, yet it is important to recognise that it includes a number of subspecialisations with clinicians of different professions each with their specific skill sets and knowledge to match the needs of the distinctive patient groups they care for [2]. Emergency Medicine continues to expand into highly specialized domains requiring multidisciplinary expertise. Paediatric Emergency Medicine represents one of the most demanding of these areas, where clinicians must rapidly recognize critical illness, manage complex physiological responses in children, and coordinate care within dynamic team environments. Q-PEM was established to support this evolving field by providing a platform for clinicians to share experiences, explore best practices and discuss emerging challenges in paediatric emergency care. A new and welcome development in the 2026 conference was the introduction of a call for abstracts, allowing delegates to contribute directly to the scientific programme. A total of 23 abstracts were received, all of which were reviewed by a panel of experienced clinicians from various countries. It resulted in 19 abstracts being presented during the conference in the form of e-posters. The abstracts presented reflect several important themes within contemporary paediatric emergency practice. We are now pleased to publish Open Access a selection of the accepted poster abstracts in collaboration with the journal POEM. Topics ranged from a systematic review exploring the use of simulation in training paramedics caring for paediatric patients [3] to the development of a prehospital paediatric sepsis screening tool designed to improve early recognition and referral pathways [4]. These contributions highlighted the diversity of ongoing work within paediatric emergency medicine, spanning clinical research, quality improvement initiatives, and educational innovation. They also illustrate the growing emphasis on early detection of critical illness, multidisciplinary education, and system level approaches to improving outcomes for children in emergency settings. The presenters of the top 3 abstracts [5-7] as ranked by the review panel were invited to deliver short oral presentations during the conference. Plenary Sessions The plenary sessions provided a broader perspective on the evolving challenges facing paediatric emergency medicine globally. International experts explored topics such as advances in resuscitation science, systems-based approaches to emergency care, and the integration of evidence-based protocols into busy emergency departments. Several plenary discussions emphasized the realities of decision-making under pressure—particularly in overcrowded departments where clinicians must balance speed, accuracy, and team coordination. Themes such as cognitive load, team leadership during resuscitation, and the importance of structured decision frameworks were recurrent throughout these sessions. Speakers also highlighted emerging tools that support clinical decision-making, including cognitive aids, simulation-based training, and digital health innovations. Collectively, the plenary sessions reinforced the importance of structured resuscitation approaches, effective team communication, and continuous professional development in improving outcomes for critically ill children presenting to emergency departments. Conference Tracks To allow deeper exploration of specific domains within paediatric emergency medicine, the Q-PEM 2026 scientific programme was structured around several parallel thematic tracks, each addressing key clinical and professional areas relevant to modern paediatric emergency practice. Paediatric emergency medicine core track The PEM core track focused on the fundamental clinical presentations encountered in paediatric emergency departments, including acute respiratory illness, shock states, neurological emergencies, and metabolic crises. Sessions emphasized structured clinical reasoning and the application of evidence based management pathways for common but potentially life-threatening conditions. Participants gained updated perspectives on recognizing early clinical deterioration in children and applying standardized approaches to diagnosis and stabilization. The track reinforced the importance of maintaining strong clinical fundamentals while adapting to evolving evidence and guidelines. Learning outcomes included: • Improved recognition of early warning signs of serious illness in children. • Application of evidence-based pathways in common paediatric emergencies. • Strengthening clinical reasoning in time-critical decision-making. Critical care and resuscitation track The Critical Care and Resuscitation track addressed the management of high-acuity paediatric emergencies, including septic shock, traumatic injury, cardiac arrest, and respiratory failure. Sessions highlighted advances in resuscitation science, high performance team dynamics, and post-resuscitation care. Speakers emphasized the role of structured resuscitation algorithms, coordinated multidisciplinary teamwork, and rapid escalation pathways. Discussions also explored the challenges of maintaining clinical clarity during high-stress scenarios and the strategies that support effective leadership during resuscitation events. Learning outcomes included: • Updated approaches to paediatric resuscitation and shock management. • Improved understanding of high-performance team communication during resuscitation. • Recognition of the importance of early stabilization and escalation of care. Toxicology track The Toxicology track explored acute poisoning and toxic exposures in children, a frequent yet often complex presentation in paediatric emergency departments. Sessions addressed the identification of high-risk ingestions, emerging toxicological threats, and evidence-based management strategies. Presenters discussed practical approaches to risk assessment, antidote use, and supportive care, while also highlighting the role of poison control systems and multidisciplinary collaboration in managing toxicological emergencies. Learning outcomes included: • Recognition of red-flag features in paediatric toxicology presentations. • Evidence-based approaches to managing common and high-risk ingestions. • Improved coordination with toxicology specialists and poison centres. Academic and research track The Academic and Research track focused on advancing scholarship within paediatric emergency medicine, including clinical research methodologies, quality improvement initiatives, and innovations in medical education. Sessions encouraged participants to critically evaluate evidence, translate research findings into practice, and contribute to the growing academic foundation of the specialty. The introduction of abstract presentations during Q-PEM 2026 further strengthened this academic component by providing a platform for clinicians and trainees to share original work with an international audience. Learning outcomes included: • Strengthening research literacy among clinicians. • Encouraging participation in quality improvement and scholarly work. • Promoting evidence-based practice in paediatric emergency medicine. Communication and patient-safety track Recognizing that safe paediatric emergency care extends beyond clinical decision-making, this track focused on communication, teamwork, and patient safety within emergency systems. Topics included medication safety, safeguarding pathways, digital safety tools, and strategies for reducing system errors. Speakers emphasized that improving outcomes for children often requires not only clinical expertise but also well-designed systems, effective interprofessional communication, and a culture of safety within healthcare teams. Learning outcomes included: • Improved communication strategies in high-stress clinical environments. • Identification of common patient safety risks in paediatric emergency care. • Integration of safety frameworks into daily clinical practice. Nursing track The Nursing track highlighted the critical role of paediatric emergency nurses in frontline resuscitation, patient monitoring, and family communication. Sessions addressed practical clinical care, nursing leadership during emergencies, and strategies for improving multidisciplinary collaboration. By focusing on the perspectives and expertise of nursing professionals, this track reinforced the importance of a truly team-based approach to paediatric emergency care. Learning outcomes included: • Strengthening nursing leadership during emergencies. • Enhancing collaboration between physicians and nursing teams. • Improving patient-centred care in the paediatric emergency environment. Looking ahead Across the programme, a consistent message emerged: clinicians value practical, evidence-informed education that directly supports bedside decision-making. Delegates particularly appreciated sessions that combined clinical evidence with real-world experience, interactive discussion, and multidisciplinary perspectives. The introduction of the abstract programme further strengthened the academic dimension of the conference and provided an opportunity for clinicians to share their work with the wider paediatric emergency medicine community. We are very thankful for everyone’s contribution to the success of Q-PEM 2026. As interest in the conference continues to grow, future editions of Q-PEM will aim to expand opportunities for research dissemination, skills-based learning, and global collaboration, notably through the likely reiteration of a call for abstracts in 2027. Author contributions All authors contributed equally and validated the final version of record. Acknowledgements Special thanks to the abstract submitters and reviewers for their input to the conference programme and to Panorama of Emergency Medicine for supporting the Open Access publication of a selection of the accepted Q-PEM 2026 abstracts. For more information about Q-PEM, please visit: https://q-pem.com/ Declarations Conflicts Of Interests The Authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval Ethical approval for this study was not required. References 1. Blackie B, Al Ansari K, Alinier G, Haidar N, Huda S, Adeola R, Akram S, Reid L, Sendad N. (2024). The Qatar Pediatric Emergency Medicine International Conference – Knowledge Translation Successes and Challenges. Proceedings of the Qatar Health Congress 2023 and 3rd Public Health Conference. Manara - Qatar Research Repository. Conference contribution. https://doi.org/10.57945/manara.25709457 2. Heymann EP, Lim R, Maskalyk J, Pulfrey S, Chun S, Osei-Ampofo M, Desouza K, Landes M, Lang E. Emergency medicine: a global perspective on its past, evolution, and future. Internal and Emergency Medicine. 2025,20(6):1917-21. https://doi.org/10.1007/s11739-024-03812-3 3. Al Badawi AK, Tomeh B, Alinier N, Alinier G. Literature review of the use of simulation for the training of paramedics in relation to caring for pediatric patients. Panorama of Emergency Medicine. 2026,4(2) https://doi.org/ 10.26738/poem.v4i2.6 4. Naidoo V, Ashou R, Gueddes A. Development and Implementation of a Prehospital Paediatric Sepsis Screening Tool: Enhancing Early Recognition, Resuscitation, and Referral. Panorama of Emergency Medicine. 2026,4(2) https://doi.org/ 10.26738/poem.v4i2.7 5. Ali N, Shakeel E, Raheem A, Ather H, Bano S. Risk Factors of Peri-intubation Cardiac Arrest in Critically Ill Pediatric Patients Presenting to the Emergency Department of a Low-Middle-Income Country: A Case-Control Study. Panorama of Emergency Medicine. 2026,4(2) https://doi.org/ 10.26738/poem.v4i2.3 6. Fatahi M, Shahidi R. Diagnostic accuracy of ultrasound findings for distinguishing complicated appendicitis from simple appendicitis in pediatric patients: A systematic review and meta-analysis. Panorama of Emergency Medicine. 2026,4(2) https://doi.org/ 10.26738/poem.v4i2.8 7. Fahmi A, Al-Kuwari S, Al-Ansari A, Hashem S, Kamal M. Reversal of Bradycardia through Nutritional Rehabilitation in Paediatric Anorexia Nervosa: A Retrospective Study from Qatar. Panorama of Emergency Medicine. 2026,4(2) https://doi.org/10.26738/poem.v4i2.1
Literature review of the use of simulation for the training of paramedics in relation to caring for pediatric patients
Background Paramedics face unique challenges when managing paediatric emergencies due to limited clinical exposure, insufficient training, the unpredictable prehospital environment, and scarce resources [1]. These factors increase anxiety and medical error risk, especially during rare, high-stakes events [2]. Simulation-based education (SBE) provides a safe, controlled environment that bridges the gap between knowledge and practice by allowing learners to rehearse decision-making and technical skills. Aim This review assesses the current state of paediatric simulation literature, evaluates the effectiveness of SBE in paramedic training using the Kirkpatrick evaluation framework, and identifies directions for future research. Methods A comprehensive search was conducted across PubMed, PsycINFO, CINAHL, ERIC, and Scopus for studies published between 2003 and 2023, using keywords and MeSH terms related to paramedics, prehospital care, paediatrics, and simulation. The review followed PRISMA 2020 guidelines, and methodological quality was appraised using the Joanna Briggs Institute checklists. Studies were categorised according to the four Kirkpatrick levels. Findings A total of 227 articles were identified, and upon removing duplicates, 184 were screened, and 60 were assessed for eligibility, following which 46 were excluded. In the remaining 14 studies, the use of SBE was generally reported to have had a positive impact on paramedics’ confidence and competence in performing several procedures (Table 1). Several studies reported that paramedics often felt uncomfortable providing care to children, made fewer errors, and wished they had more such training opportunities. No studies reported on how the training interventions contributed to improving actual patient care to fulfil the criteria of Kirkpatrick level 4. The full details of the findings have recently been reported [3]. Conclusion Simulation shows promise in improving paramedics' readiness for paediatric emergencies, especially knowledge, skills, and confidence. Future studies should use longitudinal designs to determine whether simulation training improves patient safety and clinical outcomes. Author contributions All authors contributed equally and validated the final version of record. Acknowledgements This work was primarily conducted by the first author as part of his Master in Medical Education with Dundee University, Scotland Declarations Conflicts Of Interest The Authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval Ethical approval for this study was not required. References 1. Yuknis ML, Weinstein E, Maxey H, Price L, Vaughn SX, Arkins T, et al. Frequency of pediatric emergencies in ambulatory practices. Pediatrics. 2018;142(2). https://doi.org/10.1542/peds.2017-3082 2. Der Sahakian G, Buléon C, Alinier G. Chapter 14 – Educational Foundations of Instructional Design Applied to Simulation-Based Education. In: Chiniara G, editor. Clinical Simulation (Second Edition). Academic Press. 2019:185–206. https://doi.org/10.1016/B978-0-12-815657-5.00014-0 3. Al Badawi AK, Alinier G, Nashwan AJ, Kunjavara J, Tomeh B. Effectiveness of paediatric simulation in paramedic education: a literature review. International Paramedic Practice. 2025 Aug 2;15(2):43–51. https://doi.org/10.12968/ippr.2025.0001
Diagnostic accuracy of ultrasound findings for distinguishing complicated appendicitis from simple appendicitis in pediatric patients: A systematic review and meta-analysis
Background Acute appendicitis is the most common surgical emergency in children. While up to 85% of pediatric appendicitis cases are uncomplicated, the rate of complicated appendicitis can be significant, ranging from approximately 30% overall to as high as 50–75% in certain cohorts [1]. Ultrasound (US) is a first-line imaging modality, yet its diagnostic performance in accurately identifying these complications remains uncertain [2]. Methods Following PRISMA [3], we searched PubMed, Embase, Web of Science, and Scopus from inception. Risk of bias was assessed with QUADAS-2. Bivariate random effect model pooled sensitivity and specificity; heterogeneity was summarized using I² and Q; small-study effects were evaluated using Deeks’ test. Clinical utility was illustrated using a Fagan nomogram, and overall accuracy was assessed using a summary receiver-operating characteristic (SROC) curve. Results Twenty-one studies met the inclusion criteria. Nearly all procedures were conducted by specialists or residents in radiology. The age range for the pediatric population was between 0 to 18 years old. Pooled US sensitivity for identifying complicated appendicitis was 0.52 (95% CI 0.41–0.62), and specificity was 0.90 (0.84–0.94) (Figure 1). The area under the curve was 0.80 (0.76–0.83) (Figure 2), and the summary operating point mirrored the pooled estimates. Deeks’ test suggested no significant asymmetry (p=0.08). Assuming a pre-test probability of 25%, a positive US result (LR+ = 5) increased the post-test probability to ~64%, whereas a negative result (LR–=0.54) reduced it to ~15%. Conclusion In pediatric appendicitis, US demonstrates high specificity but moderate sensitivity for discriminating complicated from simple disease. A positive scan can “rule in” complication and support expedited, targeted management; a negative scan cannot exclude complication and should be interpreted alongside clinical findings, laboratory data, and, when indicated, adjunct imaging. Future studies should standardize sonographic criteria and report per feature performance to refine thresholds and reduce heterogeneity. Author contributions All authors contributed equally and validated the final version of record. Declarations Conflicts Of Interest The Authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval Ethical approval for this study was not required. References 1. Benabbas R, Hanna M, Shah J, Sinert R. Diagnostic accuracy of history, physical examination, laboratory tests, and point‐of‐care ultrasound for pediatric acute appendicitis in the emergency department: a systematic review and meta‐analysis. Acad Emerg Med. 2017 May;24(5):523–51. https://doi.org/10.1111/acem.13181 2. Badlis M, Amari K, Alkheshi M, Alolaby K, Alsaid B. Ultrasound and computed tomography in differentiating between simple and complicated appendicitis in pediatric patients. Pediatr Surg Int. 2024 Nov 9;40(1):299. https://doi.org/10.1007/s00383-024-05880-0 3. Sarkis-Onofre R, Catalá-López F, Aromataris E, Lockwood C. How to properly use the PRISMA Statement. Syst Rev. 2021 Apr 19;10(1):117. https://doi.org/10.1186/s13643-021-01671-z
Development and Implementation of a Prehospital Paediatric Sepsis Screening Tool: Enhancing Early Recognition, Resuscitation, and Referral
Background Paediatric sepsis remains a leading cause of preventable morbidity and mortality, contributing to 11 million deaths annually, including 1.2 million children [1, 2]. Early recognition is critical, yet prehospital identification is hindered by subtle presentations, age-related physiological variability, and limited diagnostic capability [1, 3]. Currently, no validated prehospital paediatric sepsis screening tool exists. The aim of this project was to develop and implement an evidence-based prehospital paediatric sepsis screening tool for paramedics. Methods The development process included a targeted literature review and formal stakeholder engagement with Hamad Medical Corporation Ambulance Service (HMCAS) and Sidra Medicine. The iterative tool refinement was informed by international guidelines, aligned with Sidra Medicine pathways, and adapted to support HMCAS clinical practice guidelines. Age-specific physiological thresholds were calibrated using Advanced Paediatrc Life Support vital-sign parameters within the sepsis context. Implementation was supported by a blended educational model comprising 4 hours of online preparatory modules, 7 hours of face-to-face workshops, and simulation-enhanced active learning sessions. Results The final screening tool integrated infection-risk assessment, high-risk clinical criteria, age-specific vital-sign thresholds, and key physiological indicators, supported by an algorithm (Figure 1). A corresponding prehospital sepsis care bundle (Figure 2) was incorporated to standardise timely recognition, intervention, and escalation, aligned with the “Sepsis Golden Hour” and “Sepsis 6” principles [1, 3]. Clinical validation and alignment were provided through expert review by paediatric sepsis specialists from Sidra Medicine. Case-based learning, deliberate practice, and simulations supported the application of the tool for operational practice. Conclusion The Prehospital Paediatric Sepsis Screening Tool was successfully developed and implemented, supported by structured educational preparation to strengthen early recognition and clinical decision-making. By the end of Quarter 1, 2025, 1,513 HMCAS staff (89%) had completed the training. Future study with ongoing evaluation should examine the tool’s impact on recognition accuracy, timeliness of intervention, and patient outcomes across the prehospital paediatric sepsis pathway. Author contributions All authors contributed equally and validated the final version of record. Declarations Conflicts Of Interests The Authors declare that there is no conflict of interest. Funding No financial support or sponsorship was received for the development or implementation of the Prehospital Paediatric Sepsis Screening Tool. Registration No registration applicable. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval Ethical approval for this study was not required. References 1. World Sepsis Day [Internet]. [cited 2025 Nov 18]. Sepsis facts. Available from: https://www.worldsepsisday.org/sepsisfacts 2. Zick, Marvin. Global Sepsis Alliance Joins WHO’s Acute Care Action Network (ACAN) [Internet]. Global Sepsis Alliance; 2024 [cited 2024 Dec 12]. Available from: https://globalsepsisalliance.org/news/2024/10/21/global-sepsis-alliance-joins-whos-acute-care-action-network-acan 3. Labib A, Ashour R. Qatar National Paediatric Sepsis Program: Where are we? Qatar Med J. 2019 Nov 7;2019(2):65. https://doi.org/10.5339/qmj.2019.qccc.65
Impact of Interprofessional Simulation-Based Training on Enhancing Non-Technical Skills and Team Readiness in Pediatric Resuscitation
Background Effective pediatric resuscitation relies on both technical proficiency and non-technical skills, including leadership, communication, and teamwork [1]. These skills enhance role clarity, situational awareness, and coordinated interprofessional responses under pressure [2]. Combined with technical performance, they improve outcomes, build confidence, and foster collaboration. Simulation-based training provides a structured environment to strengthen decision-making, task delegation, and closed-loop communication [3]. This study assessed the impact of interprofessional simulation-based pediatric resuscitation training on non-technical skills and team readiness. Methods A pre/post interventional study was conducted at Al Wakra Hospital over 10 months starting December 2024, included 75 participants, comprising physicians and pediatric nurses, who were randomized into 12 teams with a designated leader for each team. 2.5-3 hours program following Advanced Life Support Group (ALSG) Guidelines, included a 1-hour interactive presentation and 1.5-2 hours of simulation scenarios, with 2–3 leaders trained per session with their teams. Each leader led a 10-15-minute pediatric resuscitation scenario with structured debriefing and faculty feedback. Pre-training scores were collected immediately before, and post-training scores after completion of entire mass training. Outcomes were measured using a validated 30-item non-technical skills checklist scored by independent observers with each item rated as 1 if demonstrated and 0 if not demonstrated (maximum possible score = 30), covering leadership, teamwork, and communication. Team readiness was assessed by post-training self-reported survey. Pre–post differences were analyzed with Wilcoxon signed-rank test. Results Descriptive and inferential data analysis of normalized mean scores (0–1 scale, with 1 representing the maximum possible score: leadership = 10, teamwork = 14, communication = 6) demonstrated significant improvements in leadership (0.32 → 0.90, p<0.01), teamwork (0.71 → 0.92, p=0.02), and communication (0.20 → 0.88, p<0.01) (Table 1). Participants likewise reported enhanced team readiness (Figure 1). Conclusion Interprofessional simulation-based training markedly improved non-technical skills and team readiness in pediatric resuscitation. Author contributions All authors contributed equally and validated the final version of record. Acknowledgements We would like to express our sincere appreciation to the administration of the Hamad International Training Center (HITC) for their continuous guidance and support, Ms. Khulud Maghraby for her input and to the administration of Al Wakra Hospital, along with the Nursing Education Team and the Pediatric Division, for their invaluable cooperation and contributions throughout this project. Declarations Conflicts Of Interests The Authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval The study was approved as Quality improvement project by Director of HITC and was exempted from ethical approval. References 1. Friedlaender RF, Gubert EM, Fernandes CMB, Mello RG, Coelho ICMM. Evaluation of acquisition and retention of non-technical skills of residents submitted to interprofessional simulation-based training in pediatric cardiopulmonary resuscitation. J Pediatr (Rio J). 2025 Feb 26;101(3):394–9. https://doi.org/10.1016/j.jped.2024.12.003 2. Matlhaba K. Managing Complex Situations. In: Enhancing Clinical Competence of Graduate Nurses. 1st ed. Springer Cham; 2025. p. 161–72. https://doi.org/10.1007/978-3-031-81407-5 3. Rehman U, Sarwar MS, Jarvis S, Oeppen RS, Brennan PA. The critical importance of non-technical skills in developing surgical teams in the digital era. Surgery (Oxford). 2025 Mar 1;43(3):171–7. https://doi.org/10.1016/j.mpsur.2025.01.005
Enhancing Paediatric & Adult Resuscitation Performance Through Flowchart Driven Targeted Training in the Critical First Five Minutes
Background Early recognition of cardiac arrest and delivery of high-quality early resuscitation are critical for survival [1]. Performance during this phase remains inconsistent in healthcare settings [2]. Simulation-based multidisciplinary team (MDT) training has shown superior outcomes compared to traditional lecturing, especially when monitored by measurable key performance indicators (KPIs) [3]. Data collected by Resuscitation Officers from the Hamad International Training Centre revealed KPIs not being met (Table 1), prompting a revised training method at Hamad Medical Corporation’s (HMC) hospitals, in Qatar. This study aimed to evaluate the introduction of a MDT training program integrating response algorithms emphasizing the first five minutes on resuscitation KPIs in simulated clinical settings. Methods A pre-/post-intervention study was conducted with 80 participants randomly allocated from newly formed MDT as per the shift roster at a newly opened HMC hospital providing diverse services. Each MDT consisted of two physicians and six nurses with defined roles, all with over 5 years of post-registration experience and qualified in Immediate Life Support or Paediatric Life Support. (European Resuscitation Committee 2021 guidelines). Performance was evaluated before and after the introduction of the revised training model. The initial sessions were skills-based (90 minutes of Basic Life Support airway and defibrillation) followed by a cardiac arrest simulation (30 minutes), latter sessions of the same duration were entirely simulation-based with coaching and emphasis on rapid assessment, timely recognition, and prompt initiation of interventions within the first five minutes of collapse, reinforced by the implementation of response algorithms (Figure 1). Data collection focused on six KPIs (Table 1). Results Implementation of the MDT training program and response pathway algorithms replacing solely skills training, resulted in improvements across all KPIs (Table 1). Conclusion This training with algorithms improved performance across KPIs highlighting the significance of integrating clear response pathways and defined roles. Author contributions All authors contributed equally and validated the final version of record. Acknowledgements We would like to express our sincere appreciation to, Dr. M HA Nasser ALamri Snr. Con. Paeds for their continuous guidance and support. We also extend our gratitude to the leadership team and staff of Aisha Bint Hamad al Attiyah Hospital for their invaluable cooperation throughout this project. Declarations Conflicts Of Interests The Authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval The study was approved as Quality improvement project by Director of Hamad International Training Centre. References 1. Advanced Life Support Group (ALSG). Advanced Paediatric Life Support: A Practical Approach to Emergencies, 7th Edition. Smith S, editor. Wiley-Blackwell; 2023. 528 p 2. Chapman SM. Recognition of Clinical Deterioration in Children. In: DeVita MA, editor. Textbook of Rapid Response Systems: Concept and Implementation [Internet]. Cham: Springer Nature Switzerland; 2024. p. 489–97. Available from: https://doi.org/10.1007/978-3-031-67951-3_42 3. Aboudonya ME, Tobin J, Peter VL, Mahadiva A, Almomani EA, Karic E, et al. Enhancing preparedness and competence of front-line healthcare providers to manage maternal cardiac arrest: a quantitative observational study. BMJ Open Quality. 2025;14(Suppl 2):A1. https://doi.org/10.1136/bmjoq-2025-IHI.1
Risk Factors of Peri-intubation Cardiac Arrest in Critically Ill Pediatric Patients Presenting to the Emergency Department of a Low-Middle-Income Country: A Case-Control Study
Background Peri-intubation cardiac arrest is defined as cardiac arrest that occurs within 20 minutes of airway management [1]. Incidence in the pediatric population ranges from 0.7% to 1.7% [2, 3]. Identifying pre-intubation risk factors may improve preparedness and outcomes during emergency intubations. This study aims to identify clinical and physiological predictors associated with peri-intubation cardiac arrest in pediatric patients undergoing emergency airway management in a tertiary care emergency department. Methods A retrospective case-control study was conducted at the emergency department of a tertiary care hospital in Karachi, Pakistan, from January 2019 to June 2023. Pediatric patients (<18years) who experienced cardiac arrest within 20 minutes of intubation were included as cases. For each case, four controls were randomly selected from the same cohort who were intubated without arrest. Pre-intubation clinical data, laboratory parameters, and vital signs were analyzed. Multivariable logistic regression was used to identify independent predictors of peri-intubation cardiac arrest. Results A total of 125 pediatric patients were included, 25 cases and 100 controls. Multivariate analysis identified several independent predictors of peri-intubation cardiac arrest. Age less than one year (aOR:10.97; p=0.028), hypoxemia (SpO₂<92%) (aOR:5.48; p=0.047), elevated heart rate (aOR:2.88; p=0.029), low systolic blood pressure (aOR:6.16; p=0.043), elevated shock index (≥1.2) (aOR:5.52; p=0.046), modified shock index ≥1.3 (aOR:11.11; p=0.048), lactate ≥2 mmol/L (aOR:15.64; p=0.023), and capillary refill time >3 seconds (aOR:7.55; p=0.042), were found to be independent predictors of peri-intubation cardiac arrest (Table 1). Conclusion Pre-intubation physiological instability is strongly associated with peri-intubation cardiac arrest in pediatric patients. Early recognition of high-risk features such as hypoxemia, tachycardia, hypotension, elevated lactate levels, delayed capillary refill time, and elevated shock indices may allow for better preparation and resuscitation planning. These findings support the need for structured pre-intubation assessment protocols in emergency settings. Declarations Conflicts Of Interests The Authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval The research has been approved by the Ethical Review Committee of the Aga Khan University Hospital, Karachi, Pakistan (2023-8659-24735). References 1. Esangbedo ID, Byrnes J, Brandewie K, Ebraheem M, Yu P, Zhang S, et al. Risk factors for peri-intubation cardiac arrest in pediatric cardiac intensive care patients: a multicenter study. Pediatr Crit Care Med. 2020 Dec 4;21(12):e1126–33. https://doi.org/10.1097/pcc.0000000000002472 2. Pek JH, Ong GY. Emergency intubations in a high-volume pediatric emergency department. Pediatr Emerg Care. 2018 Dec 1;34(12):852–6. https://doi.org/10.1097/pec.0000000000001355 3. Long E, Sabato S, Babl FE. Endotracheal intubation in the pediatric emergency department. Paediatr Anaesth. 2014 Dec;24(12):1204–11. https://doi.org/10.1111/pan.12490
The Emergence of Excellence: Proposing the Paediatric Transport Reflective Improvement and Simulation-based Education (PaeTRISE) Framework for the Western Cape, South Africa
Background: Inter-facility transport of critically ill children in the Western Cape, in South Africa, poses significant risks, often contributing to preventable morbidity.1 While specialised teams exist, many transfers are undertaken by non-specialist personnel. South African literature confirms this gap, noting that paediatric critical care retrieval is often absent as a formal, stand-alone course in tertiary curricula and that transfers are handled by personnel with variable baseline training.2 This lack of standardised, continuous professional development creates a gap between theoretical knowledge and clinical application. Methods: We developed the Paediatric Transport Reflective Improvement and Simulation-based Education (PaeTRISE) framework, informed by literature on simulation, reflective practice, and transport medicine. PaeTRISE is founded on two pillars: Reflective Improvement (structured debriefing to critically analyse clinical experiences) and Simulation-based Education (safe practice of high-acuity, low-occurrence events.3 The framework integrates these pillars into a continuous cycle of learning, reflection, and adaptation, tailored to the geo-historical and socio-cultural realities of the Western Cape healthcare system. Results: PaeTRISE has the potential to cultivate emergent excellence. By coupling simulation with reflective practice, it transcends procedural training to enhance adaptive decision-making, teamwork, and resilience. From a critical realist perspective, PaeTRISE functions as a causal mechanism to activate practitioners’ latent capacity. Crucially, it directly addresses the documented absence of a formalised, standardised learning structure for this high-risk activity, proposing a scalable, contextually relevant model for continuous professional development. The explicit integration of reflection and simulation represents a novel contribution to standardising paediatric transport education in South Africa. Conclusion: PaeTRISE offers a theoretically grounded, practical framework to strengthen the quality and safety of paediatric transport. Adoption of this model may empower healthcare providers, improve patient outcomes, and foster a culture of reflective excellence Author contributions All authors contributed equally and validated the final version of record. Declarations Conflicts Of Interests The Authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval Ethical approval for this study was not required. References 1. Abdullah N, Majiet N, Sobuwa S. The prehospital paediatric emergency care burden managed by a public ambulance service in the Western Cape, South Africa. BMC Emerg Med. 2024 Dec 18;24(1):234. https://doi.org/10.1186/s12873-024-01146-z 2. Williams W, Theron E, Khan W, Stassen W. Developing a South African curriculum for education in neonatal critical care retrieval: An initial exploration. PLoS One. 2023 Aug 31;18(8):e0290972. https://doi.org/10.1371/journal.pone.0290972 3. Alinier G, Al Shaikh L, Campbell C, Fawzy I, Meyer J. Board# 200-Program Innovation Development of a Multi-disciplinary Simulation-based Training Course for the Safe High Acuity Adult Retrieval Programme (SHAARP) (Submission# 9978). Simulation in Healthcare. 2014 Dec 1;9(6):439. https://doi.org/10.1097/01.SIH.0000459339.11544.33
Reversal of Bradycardia through Nutritional Rehabilitation in Paediatric Anorexia Nervosa: A Retrospective Study from Qatar
Background Anorexia nervosa (AN) is a severe mental health disorder characterized by persistent energy intake restriction, intense fear of weight gain, and a distorted body image. AN affects nearly every organ system, with the cardiovascular system being affected in up to 80% of cases [1]. AN carries the highest mortality among psychiatric disorders, with sudden cardiac death as a major cause [2]. Bradycardia is the most common cardiovascular manifestation in AN.1 Nutritional rehabilitation reverses these abnormalities, but rapid weight gain can pose risks such as electrolyte imbalance and arrhythmias. Early detection and monitoring of bradycardia are therefore crucial [3]. Methods We conducted a retrospective cohort study using data from Sidra Medicine and Hamad General Hospital in Qatar. Patients admitted between December 2016 and June 2024 with AN and bradycardia (Heart Rate (HR) <60 beats per minute (bpm)) were included. Patientswith incomplete records were excluded. Ethical approval was obtained from the institutional review board of Sidra Medicine (IRB 1929504). Data were extracted and analyzed by independent reviewers. Results Of 222 screened patients (aged 10–18 years), 46 met the inclusion criteria. The majority were female (91.3%), with a mean age of onset at 14 years and a percentile of median BMI for age (%mBMI) of 9.1% (z-score -2.36) (Table 1). The average admission HR was 49.96bpm, confirming bradycardia as a frequent complication. All patients underwent nutritional rehabilitation with caloric intake starting from around 1200kCal/day and increasing by 200kCal/day/day. At 1–2 weeks follow-up, the mean HR improved significantly to 78.63bpm (Table 1). Figure 1 shows the correlation between %mBMI and the change in HR (R2=0.07, p=0.133). Conclusion This study highlights the burden of bradycardia among adolescents with AN in Qatar. Nutritional rehabilitation was effective in restoring HR, emphasizing the need for early recognition and careful monitoring. Future studies with larger sample size are needed to validate these findings and improve generalizability. Declarations Conflicts Of Interests The Authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval This study was approved by the Institutional Review Board of Sidra Medicine (1929504). References 1. Casiero D, Frishman WH. Cardiovascular complications of eating disorders. Cardiol Rev. 2006 Sep 1;14(5):227–31. https://doi.org/10.1097/01.crd.0000216745.96062.7c 2. Yahalom M, Spitz M, Sandler L, Heno N, Roguin N, Turgeman Y. The significance of bradycardia in anorexia nervosa. Int J Angiol. 2013 June;22(2):83–94. https://doi.org/10.1055/s-0033-1334138 3. Proulx-Cabana S, Metras ME, Taddeo D, Jamoulle O, Frappier JY, Stheneur C. To Improve the Initial Inpatient Management of Adolescents Admitted with Severe Anorexia Nervosa: A Narrative Review and a Convenient Protocol. Nutrients. 2022 Jan;14(1):229. https://doi.org/10.3390/nu14010229
Non-invasive positive pressure ventilation for acute asthma in children: Very uncertain results
Source: Korang SK, Baker M, Feinberg J et al. (2024) Non-invasive positive pressure ventilation for acute asthma in children. Cochrane Database Syst Rev. 2024 Oct 2;10(10):CD012067 http://doi.org/10.1002/14651858.CD012067.pub3 Clinical Question Asthma is the most common chronic disease in children and accounts for 2.3% of pediatric hospitalizations. This condition has a major medico-economic impact, affecting both children’s quality of life and healthcare costs. In 10–12% of cases, intensive conventional treatment based on bronchodilators and corticosteroids is insufficient, and management must be escalated to endotracheal intubation and invasive mechanical ventilation. Some observational studies suggest that non-invasive positive pressure ventilation (NPPV) could reduce the need for intubation. Bottom Line To assess the effects of NPPV combined with conventional treatments compared with conventional treatments alone in children with moderate to severe acute asthma, in terms of mortality, occurrence of serious adverse events (SAEs), length of stay in intensive care, and asthma symptom scores during the acute phase. Main Results No all-cause mortality was reported in either group. Only one randomized study assessed SAEs, namely the intubation rate. Bilevel positive airway pressure (BiPAP) may substantially reduce the intubation rate and appears to shorten the length of stay in intensive care, but these results are very uncertain (very low level of evidence). Acute asthma symptoms score was evaluated in only two studies using different outcome measures, which did not allow meta-analysis. BiPAP may have a beneficial effect on the score, but this result is also very uncertain (very low level of evidence). Caveats Current data are limited, with small sample sizes, resulting in very uncertain evidence and preventing a comprehensive evaluation of the benefits and risks of NPPV in children with acute asthma. Large, well-designed randomized controlled trials with low risk of bias are therefore needed. In the trials included in the review, the positive end-expiratory pressure (PEEP) was relatively low (4–5 cmH₂O), whereas pressures of 8 to 12 cmH₂O may be necessary to compensate for intrinsic PEEP. Author contributions All authors contributed equally and validated the final version of record. Acknowledgments This editorial is a summary of a systematic review previously published in the Cochrane Database of Systematic Reviews (see https://www.cochranelibrary.com/ for more information). This summary is prepared in coordination with Patricia Jabre, Daniel Meyran, Julie Dumouchel, Yannick Auffret, Nordine Nekhili, Nicolas Cazes, Aurélien Renard et Tania Marx from the Cochrane Pre-hospital and Emergency Care Group. Declarations Conflicts Of Interests The Authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement No new data were created or analyzed in this study. Data sharing is not applicable to this article. Ethical approval Ethical approval for this study was not required.
Cochrane Pre-hospital and Emergency Care Group
Copyright (c) 2026 Yannick Auffret, Tania Marx, Patricia Jabre, Cochrane Pre-hospital and Emergency Care Group (Author) https://creativecommons.org/licenses/by/4.0
Therapeutic hypothermia may improve neurological outcome of cardiac arrest in adults
Source: Arrich J, Schütz N, Oppenauer J et al. (2023) Hypothermia for neuroprotection in adults after cardiac arrest. Cochrane Database Syst Rev. 2023 May 22;5(5):CD004128. http://doi.org/10.1002/14651858.CD004128.pub5 Context Neurological prognosis after resuscitated cardiac arrest is challenging to determine. Early resuscitation is essential for a favorable outcome. Experimental studies suggest that therapeutic hypothermia (TH) may have beneficial effects, and several clinical trials have investigated this intervention. Clinical question What are the benefits and harms of TH (target temperature 32–34 °C) in adults after resuscitated cardiac arrest, compared with standard treatment? Bottom Line TH may be associated with better neurological outcome than standard treatment, even at a maintained temperature of 36 °C (low level of evidence). Subgroup analyses indicate that TH offers better chances of neurological recovery than no cooling or fever prevention (temperature >36 °C) (low level of evidence). In contrast, data do not suggest a difference between TH and fever control or temperature management at 36 °C (low level of evidence). Regarding survival at short, medium, and long-term follow-up, TH shows little or no difference compared with standard treatment, with or without active cooling to 36 °C (low level of evidence). Concerning adverse effects, TH may lead to a slight increase in the incidence of pneumonia and severe arrhythmia (low level of evidence). Evidence is very uncertain regarding the effect of TH on the risk of hypokalaemia (very low level of evidence). Two studies assessed quality of life at six months, but the evidence was insufficient to draw conclusions. Caveats Several sources of bias were identified in the included studies; two studies were considered at high risk of bias. Standard cooling methods were employed in all studies, such as ice packs or cooling pads. Only one study used hemofiltration, but its data could not be pooled with the others. Further research is needed to develop optimal cooling protocols, clarify the timing of TH initiation, and determine the target temperature and dose response effects. Author contributions All authors contributed equally and validated the final version of record. Acknowledgments This editorial is a summary of a systematic review previously published in the Cochrane Database of Systematic Reviews (see https://www.cochranelibrary.com/ for more information). This summary is prepared in coordination with Patricia Jabre, Daniel Meyran, Julie Dumouchel, Yannick Auffret, Nordine Nekhili, Nicolas Cazes, Aurélien Renard et Tania Marx from the Cochrane Pre-hospital and Emergency Care Group. Declarations Conflicts Of Interests The Authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable. Data availability statement No new data were created or analyzed in this study. Data sharing is not applicable to this article. Ethical approval Ethical approval for this study was not required.
Copyright (c) 2026 Nordine Nekhili, Daniel Meyran, Patricia Jabre, Cochrane Pre-hospital and Emergency Care Group (Author) https://creativecommons.org/licenses/by/4.0
All for one and one for all: Scaling mountains for a good cause. SDG 4: quality education awareness campaign
How it all started? In the mountains, I discover a profound inner tranquility, revitalizing my mind and fortifying myself to confront life’s obstacles. Hiking has deeply transformed my life, igniting a passion to push the boundaries of my physical capabilities, enabling me to venture further and ascend higher. In 2017, during my inaugural hiking expedition, I seized the opportunity to spotlight the issue of burnout, a struggle I was personally overcoming. Amidst inquiries about how I managed time for training and hiking, I found a platform to raise awareness and advocate for self-care amidst life’s demands.In July 2023, fueled by a Law school course on the significance of international organizations and inspired by the UAE’s designation of 2023 as the year of sustainability, I resolved to amplify awareness around Sustainable Development Goal (SDG) 3: Health. In the four days leading up to my departure, I delved into research, crafted social media campaigns, and hand-painted banners bearing meaningful messages, each destined to be showcasing varying altitudes throughout my journey. Remarkably, this preparatory work alleviated the stress that typically accompanies summit preparations. It transformed the purpose of my expedition from a solitary pursuit of reaching the peak to a collective endeavor of championing a noble cause. This shift not only mitigated stress but also infused each hiking day with embedded purpose, as I ascended to new altitudes, unveiling campaign banners—a tangible representation of progress and a triumph in itself. Why SDG 4: Quality Education? In January 2024, I proudly attained my Law degree, a decision not taken lightly, especially after completing medical school, obtaining board certification in two demanding specialties, and earning three master’s degrees, all while juggling numerous professional commitments such as speaking engagements, research endeavors, and educational pursuits. The four years spent as a Law student profoundly transformed me, deepening my gratitude for the educational system that afforded me the opportunity for such high-quality learning experiences. As a celebration of my Law school graduation, I embarked on a journey to conquer Aconcagua, standing at a staggering 6,992 meters above sea level, the tallest peak in South America renowned for its unforgiving weather conditions. This expedition served as a well-deserved respite following the rigorous four-year commitment of being a full-time student while simultaneously managing roles as a clinician, researcher, educator, avid mountain hiker, and long-distance runner. As John Dewey rightly said, “Education is not preparation for life; education is life itself,” and, therefore, in recognition of the educational opportunities afforded to me, I dedicated the Aconcagua expedition to raising awareness for Sustainable Development Goal #4: Quality Education. SDG 4. Definition and the role of technology in achieving it The primary objective of the initial message was to introduce the United Nations Sustainable Development Goal 4, which aims to guarantee inclusive and equitable access to quality education while fostering lifelong learning opportunities for all individuals (Figure 1) [1]. SDG 4 is only achievable by international, national, induvial efforts and collaborations. On the second day the message brought attention to the role of artificial Intelligence (AI) to address SDG 4. Artificial Intelligence (AI) can contribute significantly by leveraging personalized learning platforms, virtual tutoring, and data-driven insights to improve educational outcomes and accessibility. Moreover, AI-driven tools can play a pivotal role in tracking progress, pinpointing learning deficiencies, and tailoring content to individual needs, thereby nurturing inclusivity within the realm of education<!-- [if supportFields]> ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"WRt04oa4","properties":{"formattedCitation":"[2]","plainCitation":"[2]","noteIndex":0},"citationItems":[{"id":4260,"uris":["http://zotero.org/users/1172831/items/PESNQXGB"],"itemData":{"id":4260,"type":"webpage","title":"Exploring the potential of artificial intelligence to accelerate the progress towards SDG 4 -Education 2030 - UNESCO Digital Library","URL":"https://unesdoc.unesco.org/ark:/48223/pf0000367373","accessed":{"date-parts":[["2024",3,17]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} <![endif]-->[2]<!-- [if supportFields]><![endif]-->. Importance of Role models as source of inspiration Role models serve as beacons of inspiration, lighting the way with the trails they blaze for us. In the rich tapestry of the United Arab Emirates' history, Sheikh Muhammad bin Saeed bin Ghubash Al Marri (1899-1968) emerges as a luminous figure (Figure 2). As the first Emirati university graduate, he defied the constraints of limited educational opportunities in the Emirates during his time, embarking on a journey of learning that spanned continents. His educational journey commenced in local Quranic schools, where he immersed himself in the study of the Quran, Hadith, and religious sciences. Despite the challenges, he persevered, spending five formative years at the Rajbani School in Ras Al Khaimah. Undeterred by barriers, he ventured further, seeking knowledge at the Taimiyyah Al Mahmoudiya School in Sharjah in 1907, before pursuing his studies at the Athariyah School in Qatar in 1917. In 1926, his quest for enlightenment led him to Egypt, where he delved into Islamic sciences at the prestigious Al-Azhar University. Upon his return, armed with wisdom and experience, he dedicated himself to service. Initially serving in the judiciary, he adorned the robe of justice as a judge in Ras Al Khaimah, adjudicating disputes with fairness and integrity until 1951. Sheikh Muhammad bin Saeed bin Ghubash Al Marri's legacy illuminates the power of resilience, determination, and unwavering pursuit of knowledge. His remarkable journey not only symbolizes personal triumph but also serves as a testament to the transformative potential of education, inspiring generations to strive for excellence and chart their own paths toward enlightenment and progress. Later in his career, he expanded his horizons, lending his expertise to Saudi Arabia and Qatar. Tragically, in 1969, his journey was cut short by a fatal traffic accident. Among his notable works, Sheikh Muhammad bin Saeed bin Ghubash Al Marri left behind a legacy of written treasures. One such manuscript, "Benefits in the History of the Emirates," meticulously chronicles the rich history and genealogy of several Emirati tribes and families, offering invaluable insights into their origins and lineage. <!-- [if supportFields]> ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"uvRDvx0P","properties":{"formattedCitation":"[3]","plainCitation":"[3]","noteIndex":0},"citationItems":[{"id":4262,"uris":["http://zotero.org/users/1172831/items/YXM52SZZ"],"itemData":{"id":4262,"type":"webpage","abstract":"في الأول من ديسمبر 2014 كرّم صاحب السمو الشيخ محمد بن راشد آل مكتوم نائب رئيس دولة الإمارات العربية المتحدة، رئيس مجلس الوزراء، حاكم دبي في احتفال كبير ب","language":"en","title":"محمد بن سعيد بن غباش.. أول خريج جامعي من مواطني الإمارات","URL":"https://alay.am/p/5zjj","accessed":{"date-parts":[["2024",3,17]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} <![endif]-->[3]<!-- [if supportFields]><![endif]-->. Among the esteemed figures from the distant annals of UAE history stands Ahmad bin Majid bin Muhammad (1418-1501 CE), an illustrious navigator and geographer hailing from Julphar, now known as Ras Al Khaimah. Revered for his mastery of astronomy, navigation, and geography, he was bestowed with the epithet "Asad al-Bahr" (Lion of the Sea), a testament to his unparalleled prowess on the waters. Ahmad bin Majid emerged as one of the foremost Arab navigators of the latter half of the 15th century, leaving an impactful mark on maritime exploration. Under the tutelage of his father, Majid bin Muhammad Al Saadi, and other seasoned sailors, Ahmad bin Majid received his early education. Immersing himself in their gatherings and debates, he developed his skills, surpassing the knowledge of his predecessors. Through relentless self-study, he mastered celestial navigation, meticulously measuring and observing stars, understanding their celestial movements, and deciphering their influence on maritime seasons. Ahmad bin Majid's drive for knowledge transcended conventional boundaries. He meticulously scrutinized and rectified numerous inaccuracies in existing navigational data, enriching it with his own practical insights and experiences. Documenting his profound wisdom in poetic compositions, he not only disseminated his expertise but also safeguarded it from the ravages of time. Ahmad bin Majid's legacy endures as a beacon of enlightenment, illuminating the path for future generations of navigators and scholars, and immortalizing his contributions to the advancement of maritime exploration and knowledge dissemination. Ahmad bin Majid's ingenuity extended to the invention of the magnetic needle, famously referred to as the "qibla," which revolutionized maritime navigation by providing a reliable means to ascertain directions during sea voyages. This compass, a testament to his innovative spirit, played a pivotal role in simplifying and enhancing navigation techniques for sailors of his time. Beyond his groundbreaking contributions to maritime exploration, Ahmad bin Majid distinguished himself as a prolific writer and poet. His literary legacy comprises approximately forty works, predominantly in poetic form. Among his notable literary achievements is the prose work titled "Kitab al-Fawaid fi Usul Ilm al-Bahr wa al-Qawa'id” (“The Book of Benefits in the Principles of the Science of the Sea and the Rules”), a comprehensive treatise shedding light on the fundamental principles of maritime science and navigational rules. Through his array of talents as a navigator, writer, and poet, Ahmad bin Majid left an indelible mark on both the realms of exploration and literature, solidifying his legacy as a Renaissance figure of his era. Ahmad bin Majid's legacy resonates through his array of contributions, notably his invention of the magnetic needle, dubbed the “qibla,” a pivotal tool in maritime navigation. This ingenious compass revolutionized sea journeys by offering a reliable means to determine directions, thereby streamlining navigation processes. Utilizing poetry as a vessel for documenting his ideas, culture, knowledge, and practical experiences during sea voyages, Ahmad bin Majid ensured accessibility of his insights to fellow navigators and sailors. His literary level served as an invaluable resource for maritime enthusiasts and scholars alike. Ahmad bin Majid's enduring legacy as a navigator, geographer, and writer is truly etched into maritime and UAE history, a testament to his profound impact on the exploration of the seas and the preservation of invaluable maritime knowledge for generations to come <!-- [if supportFields]> ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ZGcUv569","properties":{"formattedCitation":"[4], [5]","plainCitation":"[4], [5]","noteIndex":0},"citationItems":[{"id":4264,"uris":["http://zotero.org/users/1172831/items/JQ6478NK"],"itemData":{"id":4264,"type":"webpage","abstract":"Away and close to the political news, at the same time, I followed a while ago an input posted by the Ruler of the Emirate of Sharjah, in the UAE, Sheikh Dr. Sultan Al Qasimi, requesting reconsideration and review of some of the topics educated within the educational curricula in the UAE.","container-title":"The Personal Website of H.H. Sheikh Dr. Sultan bin Muhammad Al Qasimi","language":"en-GB","title":"Was Seaman Ibn Majid A Traitor?","URL":"https://sheikhdrsultan.ae/Portal/en/media-center/ruler-in-their-pens/15/3/2014/هل-خان-البحار-ابن-ماجد.aspx","accessed":{"date-parts":[["2024",3,17]]},"issued":{"date-parts":[["2014",3,15]]}}},{"id":4266,"uris":["http://zotero.org/users/1172831/items/SDM9S87A"],"itemData":{"id":4266,"type":"webpage","abstract":"Ahmad ibn Majid was one of the greatest and most illustrious Arab navigators and cartographers of all times. He gained fame in the West as the man who guided Vasco da Gama to find his way from the east coast of Africa to India around the Cape of Good Hope. His wide knowledge of the seas greatly impressed the Portuguese and, in their writings, they referred to him as the \"Master of Astrological Navigation.\"","language":"en-EN","title":"Ahmad ibn Majid","URL":"https://prabook.com/web/ahmad.ibn_majid/3720561","accessed":{"date-parts":[["2024",3,17]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} <![endif]-->[4], [5]<!-- [if supportFields]><![endif]-->. Undoubtedly, both role models showcase an exceptional talent for making the most of the educational resources within reach. Their successes highlight the significance of determination and resilience, qualities that hold profound importance for the advancement and well-being of a nation. Defining interdisciplinary education and its importance On Day four, the message centered on promoting interdisciplinary education, which involves the integration of two or more academic, scientific, or artistic disciplines. Interdisciplinary learning or training empowers individuals to blend diverse subjects, fostering innovative thinking and addressing intricate challenges. Throughout history, scientists have embraced interdisciplinary approaches, transcending narrow specializations to yield groundbreaking inventions and advancements that have reshaped human civilization. Three exemplary interdisciplinary scientists are Jabir ibn Hayyan, Ibn Sina, and Marie Curie. Jabir ibn Hayyan, an Arab Muslim scientist, demonstrated exceptional proficiency in a wide array of fields including chemistry, astronomy, engineering, metallurgy, philosophy, medicine, and pharmacy. Revered as the pioneer of practical chemistry, his contributions laid the foundation for modern chemical science. Ibn Sina, also known as Avicenna, was a distinguished Muslim scholar and physician. Renowned for his profound insights into medicine and philosophy, he made significant strides in advancing both fields, leaving an indelible mark on intellectual history. Finally, Marie Curie, a renowned physicist and chemist, epitomized interdisciplinary excellence with her groundbreaking work in radioactivity. Her interdisciplinary approach bridged the realms of physics and chemistry, leading to transformative discoveries that earned her two Nobel Prizes and revolutionized our understanding of the natural world. These exemplary figures exemplify the transformative potential of interdisciplinary collaboration, inspiring future generations to embrace diverse perspectives and forge new pathways of knowledge and innovation<!-- [if supportFields]> ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"OnxCMB77","properties":{"formattedCitation":"[6]","plainCitation":"[6]","noteIndex":0},"citationItems":[{"id":4268,"uris":["http://zotero.org/users/1172831/items/8QFK5GMW"],"itemData":{"id":4268,"type":"article-journal","container-title":"Annals of Saudi Medicine","DOI":"10.5144/0256-4947.2007.53","ISSN":"0256-4947","issue":"1","journalAbbreviation":"Ann Saudi Med","note":"PMID: null\nPMCID: PMC6077026","page":"52-53","source":"PubMed Central","title":"Jabir ibn Hayyan","volume":"27","author":[{"family":"Amr","given":"Samir S."},{"family":"Tbakhi","given":"Abdelghani"}],"issued":{"date-parts":[["2007"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} <![endif]-->[6]<!-- [if supportFields]><![endif]-->. Ibn Sina, widely known as the "Prince of Physicians" in the Western world, wrote over 200 books covering a diverse range of subjects, with a significant focus on philosophy and medicine. His magnum opus, "The Canon of Medicine," stood as the definitive reference in the medical field for an astounding seven consecutive centuries. Notably, Ibn Sina's pioneering contributions include the precise description of meningitis, the identification of jaundice causes, the delineation of bladder stones symptoms, and the acknowledgment of psychological treatment's therapeutic efficacy in healing processes <!-- [if supportFields]> ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"SeJs8DxW","properties":{"formattedCitation":"[7]","plainCitation":"[7]","noteIndex":0},"citationItems":[{"id":4271,"uris":["http://zotero.org/users/1172831/items/8IIG8YPU"],"itemData":{"id":4271,"type":"webpage","title":"Ibn Sina (Avicenna): The Prince Of Physicians - PMC","URL":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6077049/","accessed":{"date-parts":[["2024",3,17]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} <![endif]-->[7]<!-- [if supportFields]><![endif]-->. Marie Curie (1867–1934) was a pioneering scientist in the fields of physics and chemistry. Her groundbreaking research on radioactivity led to the discovery of the element’s polonium and radium, significantly advancing our understanding of radiation's properties <!-- [if supportFields]> ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"qejZzOnN","properties":{"formattedCitation":"[8]","plainCitation":"[8]","noteIndex":0},"citationItems":[{"id":4273,"uris":["http://zotero.org/users/1172831/items/KJNYMWEH"],"itemData":{"id":4273,"type":"webpage","abstract":"The Nobel Prize in Physics 1903 was divided, one half awarded to Antoine Henri Becquerel \"in recognition of the extraordinary services he has rendered by his discovery of spontaneous radioactivity\", the other half jointly to Pierre Curie and Marie Curie, née Skłodowska \"in recognition of the extraordinary services they have rendered by their joint researches on the radiation phenomena discovered by Professor Henri Becquerel\"","container-title":"NobelPrize.org","language":"en-US","title":"The Nobel Prize in Physics 1903","URL":"https://www.nobelprize.org/prizes/physics/1903/marie-curie/biographical/","accessed":{"date-parts":[["2024",3,17]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} <![endif]-->[8]<!-- [if supportFields]><![endif]-->. Indeed, interdisciplinary education and active learning opened the door for innovation. As Gyan Nagpal said “Breakthrough innovation occurs when we bring down boundaries and encourage disciplines to learn from each other.” UAE as a role modeling in achieving SDG 4 Day five of the campaign was dedicated to expressing gratitude to the UAE and the educational institutions that played a crucial role in shaping my life journey (Figure 3). The UAE provided me with invaluable opportunities for quality education, including two scholarships that allowed me to pursue medicine at Arabian Gulf University in Bahrain from 1996 to 2002, followed by specialization in Emergency Medicine and Critical Care at McGill University in Montreal, Canada, from 2005 to 2011. These experiences not only nurtured my growth as a medical professional but also enriched my personal development, enforcing in me a commitment to continuous learning and exploration of diverse disciplines to tackle current and future healthcare challenges. In my quest for knowledge and skills enhancement, I pursued further academic endeavors, including a Master's in Quality and Safety in Healthcare from RCSI-Dubai in 2014, followed by a Master's in Organ Donation and Transplantation from the University of Barcelona in 2017. Subsequently, I completed an Executive MBA at Hult University in Dubai in 2019, and culminated my educational journey with a Bachelor of Law from Al Ain University in 2023. Reflecting on the vision of H.H. Shaikh Zayed Bin Sultan Al Nahyan, the founding Father of the UAE, who emphasized the role of education in advancing a nation, I was inspired by his belief that the progress of societies is intricately tied to the level and accessibility of education. His unwavering support for education, regardless of gender, has contributed significantly to the UAE's remarkable literacy rate, which soared from 58% in 1975 to a record breaking 98% in 2021! (Figure 4). The UAE has implemented various literacy initiatives, catering to diverse demographics. For instance, the Elderly education program, with its flexible design, allows seniors to attend literacy sessions. Additionally, government entities offer incentives to employees pursuing education. Furthermore, legislative measures, such as Law No. 11 of 1972 on Compulsory Education, mandate parents or legal guardians to ensure their children attend school. Under the leadership's commitment to education accessibility, schooling is provided free of charge to the entire population. In 2012, the UAE Cabinet introduced a new federal law on compulsory education, updating the previous legislation and refining the stages of compulsory education. This law mandates that all children aged between six and 18 years must be enrolled in school, reaffirming the nation's dedication to universal education. <!-- [if supportFields]> ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Zc00m0TC","properties":{"formattedCitation":"[9]","plainCitation":"[9]","noteIndex":0},"citationItems":[{"id":4275,"uris":["http://zotero.org/users/1172831/items/AKY9D3TX"],"itemData":{"id":4275,"type":"webpage","title":"4. Quality education | The Official Portal of the UAE Government","URL":"https://u.ae/en/about-the-uae/leaving-no-one-behind/4qualityeducation","accessed":{"date-parts":[["2024",3,17]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} <![endif]-->[9]<!-- [if supportFields]><![endif]-->. In 2016, the UAE introduced the National Reading Law, establishing a comprehensive legislative framework and specific government responsibilities aimed at fostering lifelong learning for the UAE population<!-- [if supportFields]> ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"7GKhet05","properties":{"formattedCitation":"[10]","plainCitation":"[10]","noteIndex":0},"citationItems":[{"id":4278,"uris":["http://zotero.org/users/1172831/items/TKHWQIDQ"],"itemData":{"id":4278,"type":"webpage","title":"National Literacy Strategy | The Official Portal of the UAE Government","URL":"https://u.ae/en/about-the-uae/strategies-initiatives-and-awards/strategies-plans-and-visions/human-resources-development-and-education/national-literacy-strategy","accessed":{"date-parts":[["2024",3,17]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} <![endif]-->[10]<!-- [if supportFields]><![endif]-->. What can individuals do to support SDG 4? In its final message, the campaign highlights the power of individual actions in collectively advancing the global goals outlined in SDG 4 (Figure 5). Whether through advocacy, volunteering, or supporting educational initiatives, individuals play a crucial role in promoting quality education for all. By volunteering with organizations that provide educational resources to underserved communities, individuals can help improve access to education. Similarly, empowering others through teaching, by volunteering as tutors or mentors, can make a significant difference. Embracing a culture of lifelong learning for oneself and encouraging others to do the same fosters continuous personal and societal growth. Active engagement with educational institutions, such as participating in parent-teacher associations or supporting local school initiatives, is another effective way to contribute. Additionally, advocating for education, especially for girls and women, and leveraging social media platforms to share information about the importance of education and ongoing initiatives can amplify impact. In conclusion, education is a fundamental human right, and it is imperative that we collectively strive to make quality education accessible to everyone, everywhere. Although SDG 4 presents a formidable challenge, it is achievable through united efforts by all and for all. Conclusion In summary, combining my passion for public education, humanitarian work and mountain hiking works well for all three purposes as well as taking the summit stress out completely out of the equation. As I share the messages day by day and feel the interaction with the public, my attention shifts to the public oriented goal more than my personal mountain Goal and the summit becomes secondary rather than the primary goal of the trip. Declarations Author contributions All authors contributed equally and validated the final version of record. Conflicts Of Interest The Author(s) declare(s) that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval Ethical approval for this study was not required. References 1. Project Everyone. The Global Goals. [cited 2024 Mar 17]. Goal 4: Quality education. Available from: https://globalgoals.org/goals/4-quality-education/ 2. UNESCO Executive Board. Exploring the potential of artificial intelligence to accelerate the progress towards SDG 4 -Education 2030 [Internet]. Paris: UNESCO; 2019 Mar [cited 2024 Mar 17] p. 4. Report No.: 206 EX/44 REV. + CORR. Available from: https://unesdoc.unesco.org/ark:/48223/pf0000367373 3. عبدالله المدني. Alayam. 2022 [cited 2024 Mar 17]. محمد بن سعيد بن غباش.. أول خريج جامعي من مواطني الإمارات. Available from: https://alay.am/p/5zjj 4. The Personal Website of H.H. Sheikh Dr. Sultan bin Muhammad Al Qasimi [Internet]. 2014 [cited 2024 Mar 17]. Was Seaman Ibn Majid A Traitor? Available from: https://sheikhdrsultan.ae/Portal/en/media-center/ruler-in-their-pens/15/3/2014/%D9%87%D9%84-%D8%AE%D8%A7%D9%86-%D8%A7%D9%84%D8%A8%D8%AD%D8%A7%D8%B1-%D8%A7%D8%A8%D9%86-%D9%85%D8%A7%D8%AC%D8%AF.aspx 5. Prabook [Internet]. [cited 2024 Mar 17]. Ahmad ibn Majid. Available from: https://prabook.com/web/ahmad. ibn_majid/3720561 6. Amr SS, Tbakhi A. Jabir ibn Hayyan. Ann Saudi Med. 2007 Jan 1;27(1):52–3. https://doi.org/10.5144/0256-4947.2007.53. 7. Amr SS, Tbakhi A. Ibn Sina (Avicenna): the prince of physicians. Ann Saudi Med. 2007 Mar;27(2):134–5. https://doi.org/10.5144/0256-4947.2007.134. 8. The Nobel Prize [Internet]. [cited 2024 Mar 17]. The Nobel Prize in Physics 1903. Available from: https://www.nobelprize.org/prizes/physics/1903/marie-curie/biographical/ 9. The Official Portal of the UAE Government [Internet]. [cited 2024 Mar 17]. 4. Quality education | The UN’s 2030 Agenda. Available from: https://u.ae/en/about-the-uae/leaving-no-one-behind/4qualityeducation 10. The Official Portal of the UAE Government [Internet]. [cited 2024 Mar 17]. National Literacy Strategy. Available from: https://u.ae/en/about-the-uae/strategies-initiatives-and-awards/strategies-plans-and-visions/human-resources-development-and-education/national-literacy-strategy
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Unilateral optic disc swelling: an atypical presentation for a large frontal meningioma
Intracranial masses pose frequent diagnostic dilemmas for community facing physicians especially in patients presenting with neurological or ophthalmological signs. We describe a case of a large meningioma in a 47-year-old man presenting with left sided optic disc swelling and right visual field disturbance alongside atypical headaches, and mild behavioural disturbance. Neuroimaging demonstrated a large mass with signs of raised intracranial pressure (ICP) and parenchymal herniation. He underwent surgical debulking and biopsy, confirming the suspected diagnosis. Post-operative course was complicated by day one hemiparesis due to venous strokes, with full subsequent motor recovery. Whilst raised ICP is classically thought to cause bilateral optic disc swelling, unilaterality does not exclude this. Careful assessment and use of red flag indicators are therefore needed in determining need for neuroimaging. Declining utility of fundoscopy in non-specialists creates an additional barrier to diagnosis in these presentations and warrants increased research or training to bridge this gap. Introduction Primary brain tumours (BT) are common cancers in those under 65 but are uncommon when pooled across cancers in all ages. Despite this, they demonstrate disproportionately higher morbidity and mortality rates, even among non-malignant cases. Meningiomas represent the commonest non-malignant primary BT, with data from the United States demonstrating that they account for 53% of cases 1. Symptoms associated with intracranial masses include headaches, new focal neurology, visual acuity (VA) changes, persistent vomiting, new onset seizures or behavioural changes (including reduced energy, apathy, executive dysfunction and disinhibition) (2– 4). Symptoms such as these are commonplace, but as BT remain a rare cause each symptom, correctly diagnosing a brain tumour from such symptoms can be troublesome 3. For instance, at least 50% of headaches are attributed to primary causes: tensiontype, migraine and trigeminal neuralgia 5. Intracranial masses represent an important differential in these presentations. The challenge to community facing physicians is stratifying which patients require more investigation. Studies advocate for the utilisation of ‘red flag’ indicators in headache presentations. These include changes in severity from orthostatic/Valsalva manoeuvres, acute change in existing headaches, new headache in those >50 years, progressive change in headache over days/weeks, focal neurology or prior malignancy history 4. Fundoscopic assessment for raised optic discs should form a part of this diagnostic workup but, through multiple factors regarding training and healthcare professionals’ perceptions of this component, it’s utility by non-specialists, has been declining 6. Case report In September 2024, a 47-year-old man with a history of hypercholesterolaemia and hypertension was referred to the emergency department (ED) by his optician, having noted new left sided optic disc swelling compared to two months prior. This review was due to patient concerns of new progressive right eye visual disturbance despite a recent new glasses prescription. He denied loss of vision, diplopia or photophobia. The patient also reported intermittent, severe headaches with bilateral cervical to frontal radiation. He denied diurnal, orthostatic or Valsalva exacerbations and reported only a single, isolated episode of vomiting. He had achieved moderate control of these headaches with the use of simple analgesia, physiotherapy exercises and heat packs. He denied weight loss, fevers, change in energy levels or seizure activity during this time. The patient’s family raised concerns of cognitive changes including mild intermittent delays in responses to questions. Ophthalmological assessment demonstrated no diplopia, no visual field loss, normal conjugate gaze, normal pupillary light reflexes, no change in colour vision and no periorbital, cranial or cervical skin changes or tenderness. He was orientated to time, place and person with preserved attention and memory with his wife corroborating the history. With his new glasses prescription, right eye VA was 6/30 and left eye VA was 6/6. Following pupillary dilation using topical tropicamide drops, left sided optic disc swelling was visualised on fundoscopy with a normal appearing right optic disc. Further examination demonstrated preserved power (MRC grade 5/5) in all limbs, preserved reflexes, no loss to light touch sensation and no signs of cerebellar dysfunction. The ophthalmology team suggested computerised tomography (CT) imaging of the brain was indicated and, if negative for acute pathology, the patient could be reviewed as an outpatient. The neurology team also suggested a CT brain and, if this were negative, no further neurology input would be needed at this time. A CT angiogram demonstrated a large (52mm TR x 50mm AP x 49mm CC) right, homogenously hyperdense paraclinoid frontal lobe mass (Figure 1). Involvement of multiple intracranial arterial vessels was noted including narrowing and medial displacement of the right supraclinoid internal carotid artery (ICA), posteromedial displacement of the right M1 middle cerebral artery (MCA), non-enhancement of right M2 MCA (with surrounding collateral vessel enhancement) and displacement of the anterior cerebral arteries (ACA). This scan also demonstrated compression of the right optic nerve, global sulcal effacement, right lateral ventricle effacement, anterior and posterior clinoid process erosions and 14mm left midline shift. Given the appearance and location, a sphenoid wing meningioma was suspected. Given these findings, this patient was discussed with the neurosurgical on call team. He was commenced on oral dexamethasone and transferred urgently to the tertiary neurosurgical centre for urgent review. Magnetic Resonance Imaging (MRI) (Figure 2) of his brain and orbits detailed further significant vascular involvement, including invasion of the right cavernous sinus, encasement of the right supraclinoid ICA, proximal right M1 MCA and foetal posterior cerebral artery (PCA). The A1 ACA segment was absent or occluded and the right M1 MCA was severely stenosed. The mass directly abutted the lateral surface of the right optic nerve but without evidence of involvement or chronic nerve atrophy (Figure 3). Formal ophthalmology assessment noted improvement in his VA to 6/6 bilaterally with grade 1-2 optic disc swelling in the left eye without evidence of vascular changes and normal appearance of the right optic disc. Operative management involved craniotomy with dissection of the tumour, retrograde to the direction of the MCA. Gradual tumour bulk removal allowed for visualisation of the optic nerve, ICA, ACA, MCA, posterior communicating artery (PCOM) and anterior communicating artery. Despite the operation’s success in removing the majority of the tumour bulk, the mass was closely adherent to the MCA (and associated perforators), avernous sinus and right posterior communicating artery. These sections were unable to be completely excised. Biopsies were taken, demonstrating tissue consistent with World Health Organisation (WHO) grade 1 meningioma without invasion into brain parenchyma. Post-operative recovery was complicated with day one dense left hemiparesis. A CT stroke code identified an acute right MCA territory infarct with a subsequent MRI identifying acute infarcts of the right basal ganglia and caudate head. As perforator arteries were thought to be culprit, the patient was managed conservatively, where, over the following week, he made a full neurological recovery. This rapid symptomatic improvement suggested that the observed infarcts were likely related to venous strokes. On discharge, the patient had regained power, was mobilising independently and remained fully cognisant. He was planned for reviews from neurosurgical, endocrinology, ophthalmology and physiotherapy perspectives. Discussion This case demonstrates a rare and important presentation for community facing clinicians when assessing individuals for raised ICP, both regarding the discordance in findings between eyes and the atypical secondary symptoms. Presentation with unilateral optic disc swelling was the main diagnostic dilemma, especially given the contralateral changes in reported vision. Classically, an intracranial mass large enough to precipitate raised ICP and therefore optic disc swelling is thought to do so bilaterally7. Unilateral optic disc swelling usually suggests local pathologies (AION, ON and, by extension, multiple sclerosis) or with concomitant contralateral optic nerve atrophy (Foster-Kennedy syndrome (FKS)) 8. FKS may have offered an explanation in the mismatch between optic disc appearance and VA changes. Though, without direct evidence of optic nerve involvement or atrophy, this case would not match this conditions usual phenotype 8. Pathophysiological studies demonstrated that development of raised optic discs is not directly due to raised ICP, rather consequential disruptions in axoplasmic flow within the optic nerve sheath causing cellular oedema and extracellular fluids accumulation. These studies also demonstrated that supratentorial masses would initially lead to a unilateral or asymmetrical raised optic disc but, importantly, affecting the optic nerve ipsilateral to the mass – contrary to this case 7. Case reports detailing individuals presenting with unilateral optic disc swelling are sparse with the majority of these attributed to idiopathic intracranial hypertension (IIH) 9. Knowledge of this atypical presentation is therefore crucial to avoid premature exclusion of raised ICP. The additional symptoms in this patient’s presentation were also not stereotypical for an intracranial mass. His headache lacked the orthostatic variation and persistent vomiting consistent with raised ICP. Secondly, the behavioural changes reported by his family were not fully consistent with those usually found in frontal brain tumours (apathy, disinhibition, executive dysfunction or anergy) 2. Bedside fundoscopy remains an important component of these assessments 7. Despite this, clinical utilisation by non-specialists has been declining. Contributory factors to this include lack of equipment or knowledge to perform the examination, perceived disapproval from seniors and low perceived clinical utility 6.Bedside ocular ultrasound (BOUS) has been shown to be a useful non-invasive clinical adjunct to assess for the presence of optic disc swelling, demonstrating sensitivities between 90-100% and may offer an alternative approach to this part of the assessment 10. Conclusion Intracranial masses remain an important differential for those presenting with visual changes, headaches and changes in behaviour. With the ever-increasing utilisation of CT imaging in the ED, investigating such pathologies is becoming more straightforward. This case demonstrates the importance of a comprehensive assessment in those with symptoms consistent with raised ICP, with specific focus on lesser assessed and atypical features. This, combined with screening for red flag symptoms, are key to stratifying these patients, allowing for early identification of potentially life threatening diagnoses. The linchpin in this case was the ophthalmoscopy findings, as without this, he may have presented later in his disease course. Given the noted decline in fundoscopy in non-specialists, without work into increasing its utility or incorporating alternative tools, patients such as this, may be missed. Declarations Author contributions All authors contributed equally and validated the final version of record. Conflicts Of Interest The Author(s) declare(s) that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval Written informed consent was given by the patient about which this case was written. Details of the history have been anonymised and any imaging for this report have been deidentified. Ethics approval for this case report has been granted by the local hospital ethics committee. ERM: 114100. References 1. Miller KD, Ostrom QT, Kruchko C, Patil N, Tihan T, Cioffi G, et al. Brain and other central nervous system tumor statistics, 2021. CA Cancer J Clin. 2021 Sep 24;71(5):381–406. https://doi.org/10.3322/caac.21693 2. Cabrera S, Edelstein K, Mason WP, Tartaglia MC. Assessing behavioral syndromes in patients with brain tumors using the frontal systems behavior scale (FrSBe). Neurooncol Pract. 2016 Jun 1;3(2):113–9. https://doi.org/10.1093/nop/npv055 3. Comelli I, Lippi G, Campana V, Servadei F, Cervellin G. Clinical presentation and epidemiology of brain tumors firstly diagnosed in adults in the Emergency Department: a 10-year, single center retrospective study. Ann Transl Med. 2017 Jul;5(13):269. https://doi.org/10.21037/atm.2017.06.12 4. Palmieri A, Valentinis L, Zanchin G. Update on headache and brain tumors. Cephalalgia. 2021 Apr 28;41(4):431–7. https://doi.org/10.1177/0333102420974351 5. Viera AJ, Antono B. Acute Headache in Adults: A Diagnostic Approach. Am Fam Physician. 2022 Sep;106(3):260–8. 6. Dunn HP, Kang CJ, Marks S, Dunn SM, Healey PR, White AJ. Optimising fundoscopy practices across the medical spectrum: A focus group study. PLoS One. 2023;18(1):e0280937. https://doi.org/10.1371/journal.pone.0280937 7. Hayreh SS. Pathogenesis of optic disc edema in raised intracranial pressure. Prog Retin Eye Res. 2016 Jan;50:108–44. https://doi.org/10.1016/j.preteyeres.2015.10.001 8. Hata M, Miyamoto K. Causes and Prognosis of Unilateral and Bilateral Optic Disc Swelling. Neuroophthalmology. 2017 Apr 10;41(4):187–191. https://doi.org/10.1080/01658107.2017.1299766 9. Huna–Baron R, Landau K, Rosenberg M, Warren FA, Kupersmith MJ. Unilateral swollen disc due to increased intracranial pressure. Neurology. 2001 Jun 12;56(11):1588–90. https://doi.org/10.1212/wnl.56.11.1588 10. Carter SB, Pistilli M, Livingston KG, Gold DR, Volpe NJ, Shindler KS, et al. The role of orbital ultrasonography in distinguishing papilledema from pseudopapilledema. Eye (Lond). 2014 Dec 5;28(12):1425–30. https://doi.org/10.1038/eye.2014.210
Peritoneal carcinomatosis presenting as a mimic for DVT
Unilateral leg swelling poses a diagnostic challenge with a myriad of potential differential diagnosis, including deep vein thrombosis (DVT), Baker's cyst, and cellulitis. As some of these causes can be benign and easily treatable, other causes may be more severe and even life threatening. This article highlights the critical need for healthcare professionals to expand their differential diagnosis when common causes have been excluded, recognizing that some rare etiologies may signify severe underlying conditions. We present the case of a 55-year-old female with a two-month history of right leg swelling, initially attributed to erysipelas due to negative DVT findings. Upon closer examination, an abdomino-pelvic CT scan revealed diffuse peritoneal carcinomatosis, obstructing the right external iliac vein and elucidating the unilateral lower limb edema. This case focuses the importance of considering atypical causes, especially in patients with a history of cancer, and the potential life-threatening nature of rare etiologies. The article emphasizes the significance of a multidisciplinary approach, comprehensive laboratory assessments, and advanced imaging techniques in achieving accurate and timely diagnoses, ultimately guiding effective patient management. Introduction Unilateral leg swelling can be attributed to various factors, with deep vein thrombosis (DVT), Baker's cyst, and cellulitis being the most prevalent causes. It is particularly crucial for healthcare professionals to promptly diagnose DVT, due to its potential life-threatening complication of pulmonary embolism (1). When ruling out these more common etiologies, it is important to recognize that numerous less common causes of unilateral leg swelling exist, spanning a spectrum from benign to potentially serious conditions. Therefore, clinicians should be mindful of rare etiologies, such as arterial insufficiency, lymphatic or venous obstruction, or systemic diseases like vasculitis (2). Conditions like popliteal artery entrapment syndrome, lymphangioleiomyomatosis, or Behçet's disease may present with unilateral leg swelling, posing diagnostic challenges due to their infrequent occurrence (3). Furthermore, certain rare genetic disorders, such as hereditary angioedema or Milroy's disease, can manifest as unilateral leg swelling (4). These conditions, though infrequent, underscore the importance of considering a broad differential diagnosis. In fact, any lesion or disease process that mechanically obstruct major abdominal veins, can potentially present as unilateral or bilateral leg swelling, mimicking DVT, ranging from cysts, malignancies, even abscesses (5). This article presents a never yet reported case of upstream venous obstruction, due to diffuse peritoneal carcinomatosis obstructing at the level of the right external vein, in a patient with 2-month history of unilateral leg swelling, with negative workup for DVT and no improvement with antibiotics. Case presentation This is the case of a 55-year-old female patient, known to have breast carcinoma in 2010 status post remission after chemotherapy and radiotherapy, and endometrial cancer in 2019 status post hysterectomy and bilateral oophorectomy, presented to the emergency room for unilateral right leg pain and swelling of two months duration. The history goes back to multiple visits to her primary care physician for the same complaint; ultrasound was conducted at that time and eliminated a DVT of the lower extremity, or the presence of a cyst. The patient was then prescribed antibiotics, assuming erysipelas was the etiology of the clinical presentation. After a 7 days course of treatment, the patient noticed no amelioration, therefore she presented to the emergency department. Upon presentation, the patient was tachycardic, afebrile and in pain. Physical exam was unremarkable, except for non-pitting right lower limb edema extending to the mid-thigh, with minimal erythema and positive pedal pulses (Figure 1). Review of personal history was non-significant except for the previously mentioned oncologic disorder, and recent ablation of a cutaneous lesion on right leg that was found benign on histology; review of family history and review of systems were insignificant. Laboratory workup were ordered and showed an elevated D-Dimer (3120 ng/ml with a reference value of <500 ng/ml) and CRP (22 mg/L), with a negative white blood cells count, normal creatinine and normal liver enzymes. In light of a negative DVT workup, and elevated D-Dimer, malignancy was suspected, and therefore an abdominal-pelvic CT with injection was ordered. Surprisingly, the report showed diffuse peritoneal carcinomatosis, with an intra-peritoneal speculated lesion, lateral to the bladder on the right, compressing the right external iliac vein that could explain the unilateral lower limb swelling. After seeking surgical, gynecologic and oncologic consults, the plan was to admit the patient and put her on prophylactic anticoagulation, waiting for further investigations and management, including chest CT scan, MRI of the pelvis, biopsies. Verbal consent was taken from the patient to publish these data anonymously. Discussion This case highlights the imperative need for healthcare professionals to maintain a broad and comprehensive approach when confronted with unilateral leg swelling, particularly when common etiologies like deep vein thrombosis (DVT), Baker's cyst, and cellulitis have been ruled out. Although rare etiologies can be benign and non-life threatening, others can be more serious, and can be the superficial, visible tip of an iceberg, hiding underneath the surface a very serious condition, that needs prompt investigations and management. For instance, the case of unilateral lower limb edema, depicted in this report, unveiled a hidden malignancy and introduces a rare etiology of venous obstruction, although mechanical obstruction due to compression by a mass is relatively a common cause of edema and swelling (6), having peritoneal carcinomatosis as the cause of the presentation is not documented in the literature yet. In fact, obstruction related to peritoneal carcinomatosis have been reported mainly as small bowel occlusion (highlighting the distinctiveness of this case report (7-8). Furthermore, this patient had strong risk factors and signs for DVT: unilateral leg swelling, 2 months duration, elevated D-Dimer, history of breast and endometrial cancer, no improvement on antibiotics, and was tachycardic upon presentation (which could be a sign of consequences of DVT such as pulmonary embolism), which could easily lead to a bias in diagnosis; but the negative Doppler Ultrasound mead the physicians in the emergency department into further investigation. Given her past medical history, other diagnosis could be thought of such as idiopathic lymphedema, heart failure, kidney failure, pulmonary hypertension … all of which were eliminated by the physical exam, laboratory workup and imaging done in the ER. The delayed diagnosis in this case demonstrates the potential life-threatening nature of rare etiologies and the importance of promptly identifying and addressing them, even though Peritoneal Carcinomatosis (PC) is a late-stage manifestation of several gastrointestinal and gynecological malignancies, and is usually a sign of metastatic disease and has a poor prognosis (9). Finally, it is important to note that, in low-resource settings, the practical challenges of investigating lower limb edema can be significant. Relying on expensive imaging techniques like CT scans may not be realistic due to the high costs involved and limited access to such technology. This can make it difficult for healthcare providers to accurately diagnose the underlying cause of a similar presentation and develop an appropriate treatment plan. In these settings, healthcare providers may need to rely on less expensive and more readily available diagnostic tools, such as physical exams and basic laboratory tests, which can lead to misdiagnosis. The multidisciplinary approach taken, involving surgical, gynecologic, and oncologic consultations, exemplifies the complexity of managing such cases. The decision to initiate anticoagulation while awaiting additional investigations reflects a cautious approach given the potential complications associated with venous obstruction, including a chest CT to rule out any potential pulmonary embolisms. Further investigations are in order, including MRI, biopsies with histological and pathological studies to assess the extent of the disease and potentially the source of PC. Conclusion This case underscores the significance of broadening the differential diagnosis for unilateral leg swelling beyond common causes. Clinicians should remain vigilant for rare etiologies, recognizing their potential to be life threatening or indicative of more extensive and serious underlying conditions. A multidisciplinary approach, comprehensive laboratory assessments, and advanced imaging techniques are essential in ensuring timely and accurate diagnoses, thereby facilitating appropriate and effective patient management. References 1. Brice G, Mansour S, Ostergaard P, Connell F, Jeffery S, Mortimer P. Milroy disease. In: Adam M, Ardinger H, Pagon R, Wallace S, Bean L, Stephens K, et al., editors. GeneReviews(®) [Internet]. Seattle (WA): University of Washington, Seattle; 1993. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1239/ 2. Davis DD, Shaw PM. Popliteal artery entrapment syndrome. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441965/ 3. Demarest K, Lavu H, Collins E, Batra V. Comprehensive Diagnosis and Management of Malignant Bowel Obstruction: A Review. J Pain Palliat Care Pharmacother. 2023 Jan 2;37(1):91–105. https://doi.org/10.1080/15360288.2022.2106012 4. Elgendy IY, Lo MC. Unilateral lower extremity swelling as a rare presentation of non-Hodgkin’s lymphoma. BMJ Case Rep. 2014 Jan 13;2014:bcr2013202424. https://doi.org/10.1136/bcr-2013-202424 5. Gasparis AP, Kim PS, Dean SM, Khilnani NM, Labropoulos N. Diagnostic approach to lower limb edema. Phlebology. 2020 Oct 1;35(9):650–5. https://doi.org/10.1177/0268355520938283 6. Ijaz M, Sakam S, Ashraf U, Marquez JG. Unusual Presentation of Recurrent Pyogenic Bilateral Psoas Abscess Causing Bilateral Pulmonary Embolism by Iliac Vein Compression. Am J Case Rep. 2015;16:606–610. https://doi.org/10.12659/ajcr.894206 7. Santangelo ML, Grifasi C, Criscitiello C, Giuliano M, Calogero A, Dodaro C, et al. Bowel obstruction and peritoneal carcinomatosis in the elderly. A systematic review. Aging Clin Exp Res. 2017 Feb 1;29(1):73–8. https://doi.org/10.1007/s40520-016-0656-9 8. Stone J, Hangge P, Albadawi H, Wallace A, Shamoun F, Knuttien MG, et al. Deep vein thrombosis: pathogenesis, diagnosis, and medical management. Cardiovasc Diagn Ther. 2017 Dec 21;7(Suppl_3):S276–84. https://doi.org/10.21037/cdt.2017.09.01 9. Szadkowska MA, Pałucki J, Cieszanowski A. Diagnosis and treatment of peritoneal carcinomatosis – a comprehensive overview. Pol J Radiol. 2023;88:89–97. https://doi.org/10.5114/pjr.2023.125027
Elderly patient with late diagnosed metastatic bone lytic lesions
Low back pain is a frequent reason for emergency department visits, pain management and screening for red flags should be considered for every patient, especially in elderly even with reassuring physical exam. In this case report, we discuss a case of an elderly patient who visited the emergency department many times with low back pain. His physical exam was reassuring. A low suspicion threshold, and a prompt history taking were the keys for diagnosis of bone-destroying lesions with multiple fractures and metastases. The patient had history of liver cirrhosis post hepatitis B, Alpha foetoprotein was high and he was diagnosed with metastatic hepatocarcinoma with extensive bone metastasis. Persistent pain, especially in older adults with progressive back pain, should be thoroughly investigated for serious conditions like bone metastases. Remember the "red flags" for lower back pain and note that physical exams may appear normal even with advanced bone issues. Introduction Acute back pain is one of the main reasons for emergency department (ED) presentations, and constitutes 4.4% of emergency department applications worldwide [1]. Advanced age places the patient at higher risk and requires further investigation [4]. Malignancies and related metastatic bone lesions form a small part of people who present to the emergency department with low back pain [4]. However, it should not be forgotten in elderly people with low back pain [3]. Emergency physicians should utilize red flag screening methods to detect those with serious diseases and, thus, patients who need to be investigated [2,3]. History of malignancy and cancer risk factors are considered among the serious red flags, since bone tissue appears as a frequent region in terms of metastasis. The presence of bone metastases is an indicator of poor prognosis in cancer patients. Prostate and breast cancers frequently metastasize to the skeletal system. Bone metastases occur much more often than primary bone cancers, especially in adults. The overall incidence of bone metastasis is unknown. The presence of bone metastases may cause severe pain as well as pathological fractures, limitation of mobility, bone marrow aplasia, compression of the spinal cord, and hypercalcemia [5]. In this case report, we present a patient with extensive bony lytic lesions who were mobile despite having many pathological fractures and metastatic lesions that caused almost complete disappearance of one-half of the pelvis. The institution's approval was obtained from Medical Research Center (CIRC-RDB-43-12-2022), and written informed consent was obtained from the patient. The paper was presented at the World Academic Congress of Emergency Medicine in Antalya, Türkiye, from October 28 to 31, 2023. Case Presentation A sixty-seven-year-old male presented to the emergency department with a complaint of lower back pain for 4 months. There was no history of trauma. The pain was on and off, radiating to his right hip and gluteal region, worsening for the last two weeks, and associated with walking difficulty for the last ten days. Within this period, the patient was seen multiple times in primary health care services and at the ED. Detailed neurological examination was reported as normal. Non-steroidal anti-inflammatory drugs were prescribed at various times at the health center and ED, but the patient's complaints gradually increased, although there was no reduction in his pain during these four months. He had a past medical history of hypertension, chronic gastritis, and liver cirrhosis post hepatitis B, with no regular follow-up for the last three years. During the last ED visit, the patient’s vitals were stable. On physical assessment, motor and sensory examination results were normal. There was tenderness in the right gluteal region and the lower back. At the same time, it was seen that the anal sphincter tone was normal. There was no saddle anesthesia or signs of dropping foot. The X-ray of the pelvis and thoracic spine showed a compression fracture of thoracic (T) 9 vertebra, absence of right pedicle of lumbar (L) 4 vertebra, destruction of bilateral pubic rami and ischial tuberosity, a large pelvic bone lytic lesion accompanied by a secondary pathological fracture, as well as a large soft tissue component eroding the adjacent part of the sacrum (Figure 1). Thoracolumbar spine and pelvis computed tomography (CT) performed and showed multiple lytic lesions in the thoracic and lumbar spine involving both vertebral bodies and posterior elements of the spine. Bilateral pelvic bones multifocal lytic lesions with pathological fractures are seen (Figure 2). Magnetic resonance imaging (MRI) of the spine showed multiple expansile osteolytic lesions along the axial skeleton, including the thoracic and lumbar vertebrae, ribs, and pelvic bones. A large expansile lesion involving the posterior neural element of the (T3) vertebra with intraspinal epidural soft tissue component compressing the posterior aspect of the upper thoracic cord was noted. Another expansile lesion, as seen in the (T6) and (T7) vertebra with a large soft tissue component totally occluding the neural canal, was noted (Figure 3). The patient was admitted to the neurosurgery department for pain management and further workup. Alpha fetal protein (AFP) level was 12,244 IU/ml (AFP normal level 0-6 IU/ml). Pan CT showed extensive bony lesions with soft tissue components through the cervical spine, cirrhotic liver with portal hypertension, and extensive portosystemic collateral formation, metastases involving the liver and the lung parenchyma. The most likely diagnosis was hepatocellular carcinoma with metastases. The case was discussed in the oncology team meeting, and a decision for palliative radiotherapy was made considering the patient’s status and the cancer stage. The patient was discharged after one week, and a rapid appointment with the radiotherapy clinic was arranged. Discussion In this case report, we presented a patient who came to the emergency department with back pain and had metastatic bone lesions with failure to diagnose early, even after multiple visits to the hospital. It was quite surprising that the patient had osteolytic lesions, causing severe destruction, and yet, was mobile. We have not encountered a patient presentation with such advanced lesions and are still mobile in the literature. We tried to emphasize that advanced age is a red flag for low back pain. In addition, it should be kept in mind that the neurologic examination may be normal despite advanced vertebral lesions. Back pain is one of the common reasons for emergency presentation; it is a condition that seriously affects people's daily activities and comfort [1]. Our patient visited health care facilities frequently despite taking his analgesics properly. During the last days preceding the last visit, he had walking difficulties affecting his daily routine. Low back pain is often defined as nonspecific or mechanical low back pain and constitutes 90% of the cases. Usually, the condition is self-limited and resolves within 4 to 6 weeks [3]. Rarely, patients may have serious pathologies, and critical diagnoses are often missed at the first presentation because of cognitive errors, lack of knowledge, and overlooked signs and symptoms [3]. Considering the frequency of patients presenting with back pain, it is necessary to comprehensively evaluate patients with lumbar complaints to keep patients with overlooked serious pathology to a minimum. The alarming signs should be figured out, and a detailed systemic investigation and examination should be carried out. Failure to notice these symptoms promptly can lead to a poor patient outcome. Getting a comprehensive history is particularly important in this stage. Our patient had history of liver cirrhosis post hepatitis B with no follow up for three years. This detail in history should alert the treating physician to consider further investigation considering the well-known risk of hepatocarcinoma in cirrhotic patients [6]. A complete physical examination following this will guide clinicians in recognizing the danger signs [7]. For this purpose, red flag scanning methods have been developed. While taking the history, age, history of surgery, trauma, immunosuppression, intravenous drug use, and sexual dysfunction should be questioned. In addition, the patient should be asked about any history of fever, anticoagulant use, urinary retention, epidural injection, decrease in anal sphincter tone, lower extremity motor weakness, and saddle anesthesia [8]. Serious pathologies can be revealed from the patient's history or by identifying abnormal musculoskeletal systems and abnormal neurological examination findings. In general, progression, change in character, or persistence of symptoms are alarming and may indicate serious pathology [8]. The presence of acute back pain in patients under the age of 18 or over the age of 50 should be a cause of concern. In young patients, congenital defects, spondylolysis, or vertebral fractures may be the cause of low back pain [9]. In patients over 50 years of age, new-onset back pain may be associated with intra-abdominal processes such as tumor, infection, abdominal aortic aneurysm, pancreatitis, or kidney stone. Osteoporosis accelerates with age progression. The decrease in the strength of bone tissue with osteoporosis may cause fractures in the bone tissue without trauma or with minor traumas. These fractures can be in the whole bone tissue as well as in the vertebrae. Therefore, vertebral fractures should be investigated in elderly patients presenting with acute onset low back pain. In addition, malignancy and metastatic bone lesions can be seen in both adolescents and the elderly, the presence of night pain and weight loss together with back pain requires investigation for malignancy [10]. Bone metastases are much more common than primary bone cancers, especially in adults [5]. Once cancer has spread to the bones, it is rarely curable, but treatments are used to slow the progression of the disease. Bone metastases may be osteolytic, osteoblastic, or mixed [5]. Our patient had extensive osteolytic lesions, interestingly, his physical exam was reassuring and did not identify any neurological compromise. However, he had walking difficulties but was still ambulating with walking aid despite the extensive pelvic lesions with pathological fracture. This could be explained by the fact that body movement is multifactorial and does not depend only on bone integrity. Interactions between bones, muscles and joints play a major role in maintaining movements including the capacity of walking [11]. Osteolytic metastases are characterized by osteoclast-mediated destruction of normal bones. The main malignancies in which osteolytic metastases are seen are multiple myeloma, renal cell carcinoma, melanoma, non-small cell lung cancer, non-Hodgkin lymphoma, thyroid cancer, and Langerhans cell histiocytosis [12]. Osteoblastic metastases are characterized by new bone deposition. The main malignancies are prostate cancer, carcinoid, small cell lung cancer, Hodgkin lymphoma, or medulloblastoma [13]. Mixed metastases are malignancies in which both osteolytic and osteoblastic lesions are seen. The main causes are breast cancer, gastrointestinal cancer, and squamous cancers [14]. Bone metastasis in hepatocarcinoma are predominately osteolytic like in our case report, however osteoblastic or mixed lesions are possible [15]. Uncomplicated acute lower back pain and/or radiculopathy of less than six weeks is considered a self-limiting and benign low back pain and does not require any imaging studies. However, further investigation should be carried out to determine if malignancy or infection is suspected clinically by red flags or pathological markers. In the presence of severe, progressive neurological deficits, diagnostic imaging, and laboratory tests are recommended to guide treatment. Although the systemic examination is completely normal, initial investigation efforts should begin with X-ray, metastases and malignant tumors come to mind, especially if bone lesions are seen in advanced ages. For this reason, the age of patients with suspected bone tumors or metastasis at the time of presentation is of great importance [16]. For elderly patients with persistent back pain and advanced bone lesions, a comprehensive treatment plan is essential. Medications such as bone-building drugs (e.g., bisphosphonates), pain medications, steroids, hormone therapy, and chemotherapy play a crucial role in managing symptoms and reducing pain [6]. Radiation therapy, including intravenous radiation for multiple bone metastases and external beam radiation for localized pain relief, is also recommended [14]. Surgical interventions, such as curettage and bone grafting for benign lesions, marginal resection or wide resection for aggressive lesions, and minimally invasive spine stabilization for spinal involvement, are important treatment options [8]. Palliative care techniques, like percutaneous cryoablation and embolization, help manage pain and improve quality of life [14]. Early diagnosis through imaging techniques like X-rays, CT scans, and MRIs, along with a multidisciplinary approach and patient education, is vital for effective management and improved prognosis [16]. Conclusion This case highlights the need for thorough evaluation in elderly patients with persistent back pain, especially when standard treatments fail. Despite extensive bone lesions and fractures, the patient's mobility was preserved, stressing the importance of considering malignancy, even with a reassuring physical exam. Physical exams can appear normal despite advanced lesions, hence a low threshold of suspicion for serious conditions like bone metastases should be maintained especially in elderly patients. Comprehensive diagnostic workups, starting with X-rays and progressing to CT scans, MRIs, and lab tests, are crucial for early detection and management, enhancing symptom control and overall prognosis. Declarations Author contributions All authors contributed equally and validated the final version of record. Conflicts Of Interest The Author(s) declare(s) that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Registration No registration applicable Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Ethical approval The institution’s approval was obtained from Medical Research Center (CIRC-RDB-43-12-2022), and written informed consent was obtained from the patient. References 1. Coombs DM, Machado GC, Richards B, Wilson R, Chan J, Storey H, et al. Healthcare costs due to low back pain in the emergency department and inpatient setting in Sydney, Australia. Lancet Reg Health West Pac. 2021 Jan 29;7:100089. https://doi.org/10.1016/j.lanwpc.2020.100089 2. Traeger A, Buchbinder R, Harris I, Maher C. Diagnosis and management of low-back pain in primary care. CMAJ. 2017 Nov 13;189(45):E1386–E1395. https://doi.org/10.1503/cmaj.170527 3. DePalma MG. Red flags of low back pain. JAAPA. 2020 Aug;33(8):8–11. https://doi.org/10.1097/01.jaa.0000684112.91641.4c 4. Saes-Silva E, Vieira YP, Saes MO, Meucci RD, Aikawa P, Cousin E, et al. Epidemiology of chronic back pain among adults and elderly from Southern Brazil: a cross-sectional study. Braz J Phys Ther. 2021 May-Jun;25(3):344–351. https://doi.org/10.1016/j.bjpt.2020.12.005 5. Macedo F, Ladeira K, Pinho F, Saraiva N, Bonito N, Pinto L, et al. Bone Metastases: An Overview. Oncol Rev. 2017 May 9;11(1):321. https://doi.org/10.4081/oncol.2017.321 6. Shiffman ML. Approach to the patient with chronic hepatitis B and decompensated cirrhosis. Liver Int. 2020;40(Suppl. 1):22–26. https://doi.org/10.1111/liv.14359 7. Oliveira CB, Maher CG, Pinto RZ, Traeger AC, Lin CC, Chenot JF, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018 Nov;27(11):2791–2803. https://doi.org/10.1007/s00586-018-5673-2 8. Verhagen AP, Downie A, Popal N, Maher C, Koes BW. Red flags presented in current low back pain guidelines: a review. Eur Spine J. 2016 Sep;25(9):2788–802. https://doi.org/10.1007/s00586-016-4684-0 9. Casazza BA. Diagnosis and treatment of acute low back pain. Am Fam Physician. 2012 Feb 15;85(4):343–50. 10. O'Sullivan P, Smith A, Beales D, Straker L. Understanding Adolescent Low Back Pain from a Multidimensional Perspective: Implications for Management. J Orthop Sports Phys Ther. 2017 Oct;47(10):741–751. https://doi.org/10.2519/jospt.2017.7376 11. Lu TW, Chang CF. Biomechanics of human movement and its clinical applications. Kaohsiung J Med Sci. 2012 Feb 1;28(2S):S13–25. https://doi.org/10.1016/j.kjms.2011.08.004 12. Della-Giustina D. Evaluation and treatment of acute back pain in the emergency department. Emerg Med Clin North Am. 2015 May;33(2):311–26. https://doi.org/10.1016/j.emc.2014.12.005 13. Taube T, Elomaa I, Blomqvist C, Beneton MNC, Kanis JA. Histomorphometric evidence for osteoclast-mediated bone resorption in metastatic breast cancer. Bone. 1994 Mar 1;15(2):161–6. https://doi.org/10.1016/8756-3282(94)90703-X 14. Coleman RE. Metastatic bone disease: clinical features, pathophysiology, and treatment strategies. Cancer Treat Rev. 2001 Jun;27(3):165–76. https://doi.org/10.1053/ctrv.2000.0210 15. Yuan X, Zhuang M, Zhu X, Cheng D, Liu J, Sun D, et al. Emerging Perspectives of Bone Metastasis in Hepatocellular Carcinoma. Front Oncol. 2022 Jun 29;12:943866. https://doi.org/10.3389/fonc.2022.943866 16. Coleman RE, Seaman JJ. The role of zoledronic acid in cancer: Clinical studies in the treatment and prevention of bone metastases. Semin Oncol. 2001 Apr 1;28:11–6. https://doi.org/10.1016/S0093-7754(01)90260-X
The Killer Wound; Early Diagnosis and Management of Necrotizing Fasciitis Utilizing Point-of-Care Ultrasound: A Case Repor
Background: Necrotizing fasciitis (NF) is a rapidly progressive and life-threatening infection of the fascia and subcutaneous tissues. Early diagnosis and prompt surgical intervention are critical to reducing morbidity and mortality. This case report highlights the importance of point-of-care ultrasound (PoCUS) in the rapid diagnosis of NF. Case Presentation: A 34-year-old male carpenter presented to the Emergency Department of Casey Hospital, with a 48-hour history of increasing swelling and pain in his right arm and chest. Two weeks prior, he sustained an open wound to his right wrist from a rusty nail. Initial management by his family doctor focused on musculoskeletal injury without antibiotics. On ED presentation, the patient exhibited signs of systemic infection and gross swelling of the right upper limb and chest. PoCUS demonstrated characteristic findings of NF, including cobble stoning and subcutaneous air with dirty shadowing, leading to an expedited surgical consultation and immediate intervention. Management and Outcome: The patient underwent multiple debridements, antibiotic therapy, and hyperbaric oxygen therapy. Post-surgical rehabilitation showed substantial gains in function and mobility. Discussion: This case underscores the crucial role of PoCUS in the early diagnosis and management of NF. PoCUS allows for rapid bedside imaging, enabling timely surgical consultation and intervention, thereby improving patient outcomes. The multidisciplinary approach, involving emergency physicians, surgeons, and intensivists, is essential for optimal management of NF. Conclusion: Early recognition and treatment, facilitated by PoCUS, are key to reducing the high morbidity and mortality. Key Messages * Early surgical intervention and antibiotic therapy are crucial in reducing morbidity and mortality in Necrotizing Fasciitis. * Multidisciplinary coordination is required for patient stabilization and rapid transfer from the Emergency Department to the operating theatre, as surgical debridement is the definitive treatment. * Utilization of Point-of-Care Ultrasound (PoCUS) is essential for the early diagnosis and management of Necrotizing Fasciitis and associated complications, significantly impacting patient outcomes. Presentation In November 2022, a 34-year-old male carpenter presented to the Emergency Department (ED) of Casey Hospital, Monash Health, a 229-bed facility providing comprehensive health services, including ICU, to Melbourne’s outer-east communities. The patient reported increased swelling and pain in his right arm and chest over the past 48 hours. Two weeks prior, he sustained an open wound to the dorsum of his right wrist from a rusty nail at work. He did not seek medical treatment and only cleaned the wound with a Betadine wash. Three days before presenting to the ED, he visited his family doctor due to feeling unwell with right arm swelling and right-sided chest pain. He was managed as a musculoskeletal (MSK) injury with analgesia, including non-steroidal anti-inflammatory drugs (NSAID), and rest. The day before his ED presentation, he revisited his family doctor with worsening pain and lethargy. An X-ray and MSK ultrasound were planned, and the NSAID was discontinued. No antibiotics were considered at that time. Initial ED Assessment and Management Upon ED presentation, he was tachycardic at 139/min, borderline tachypneic at 28 breaths per minute, apyrexial at 36.7°C, with an initial blood pressure of 115/78 mmHg. Examination revealed gross swelling of the right upper limb and chest, a 2 cm sloughy, partially healed open wound on the posterior aspect of the right forearm with surrounding erythema, and no purulent discharge (Figure 1). No palpable subcutaneous emphysema was noted. A C6 dermatomal sensation deficit was observed, likely secondary to inflammation and swelling. Capillary refill time (CRT) was greater than 5 seconds with a palpable radial pulse. The patient reported increasing pain, intermittent fevers, anorexia, and anuria for the past two days1. His social history revealed he was a non-smoker, social drinker, and did not use illicit drugs. ED Investigations and Initial Management He was triaged as category 2 (ATS; to be seen within 10 minutes) and self-mobilized to a resuscitation cubicle after identification of his critical condition. Observations and monitoring were applied, and two large-bore 18G IV cannulas were inserted into his left arm. An ECG (Figure 2) showed sinus tachycardia. Pathology tests, including a venous blood gas, inflammatory markers, UECs, LFTs, coagulation screen, and troponin, were taken2. His VBG indicated respiratory acidosis (pH 7.09, pCO2 65) and profound hyperlactatemia of 10.5. It also noted a haemoglobin of 166, potentially being indicative of dehydration/sepsis. His electrolytes were noted to be mildly deranged (Na 133, K 5.1, Cl 97). With a provisional diagnosis of sepsis, resuscitation with crystalloid intravenous fluids (NaCl) was initiated. Point-of-Care Ultrasound (PoCUS) demonstrated cobblestoning and subcutaneous air with dirty shadowing of the entire upper limb and right-side chest wall3 (Figure 3), suspicious for Necrotizing Fasciitis, as well as a non-compressible proximal part of the axillary vein suspicious for concurrent thrombus (Figure 4), likely secondary to swelling and immobility. Extended PoCUS showed a hyperdynamic heart without effusion, LV dysfunction, or significant right heart strain. Triple antibiotics, including clindamycin, piperacillin/tazobactam, and vancomycin, were commenced according to therapeutic guidelines4, followed by surgical and plastics consultation for urgent debridement5 in the operating theatre (OT) and post-op ICU admission. During transport to OT, he became hypotensive with septic shock and was managed with peripheral metaraminol with a good temporary response. Operative and Post-ED Management Upon arrival to the theatre, he was intubated, and invasive access for monitoring and management, including arterial and central venous lines, was established. Initial debridement found a large collection of pus under the pectoral, with pustular tracts noted between the pectoral major and minor towards the axilla. The fascia was healthy. Further exploration later that night revealed pus collections in the acromioclavicular and sternoclavicular joints, requiring washouts. Tissue samples were sent for microscopy and culture. Triple antibiotic therapy continued, and he was transferred to the ICU at Casey Hospital. With a confirmed diagnosis of Necrotizing Fasciitis intraoperatively, he was transferred to the Alfred Hospital, a metropolitan tertiary centre, for hyperbaric oxygen therapy and ongoing care. At the Alfred Hospital, he underwent two further debridements. His antibiotics were changed to cefepime, benzylpenicillin, and clindamycin, aligned with intraoperative tissue sample antibiogram sensitivities. Nasogastric feeds commenced, and he weaned off vasopressor support. Bilateral pleural effusions secondary to sepsis were found, and intercostal catheters were placed after bronchoscopy. He was transferred back to Monash Health (Dandenong Hospital) for ongoing management under plastics surgery care. Due to ongoing fevers and concerns for an empyema, his antibiotic therapy was escalated to include ciprofloxacin, linezolid, metronidazole, and micafungin4. Surgical Timeline D0: Initial debridement of the right upper limb/chest wall with biopsies concerning for Necrotizing Fasciitis. D2: Secondary debridement of the right arm/axilla/chest wall. D4: Third debridement with change of VAC dressing right upper limb and chest wall. D7: Fourth debridement and VAC change right arm, axilla, and chest. D14: VAC change and re-washout (assisted by Cardiothoracic Surgical team). D16: VAC change right chest wall. D21: Right axilla debridement and VAC change. Discussion Diagnosis of Necrotizing Fasciitis Necrotizing Fasciitis is a rapidly progressive, life-threatening infection of the fascia and subcutaneous tissues that requires immediate medical and surgical intervention. Early diagnosis is crucial to prevent significant morbidity and mortality. Clinical diagnosis can be challenging due to its variable presentation and overlap with other less severe soft tissue infections. Typical symptoms include severe pain, swelling, erythema, and systemic signs of sepsis such as fever, tachycardia, and hypotension. However, these symptoms can be nonspecific and may lead to initial misdiagnosis, as seen in this case, where the patient was initially treated for a musculoskeletal injury6. Diagnostic imaging plays a pivotal role in the early detection and management of Necrotizing Fasciitis. Radiographic imaging such as X-rays may show soft tissue gas, while computed tomography (CT) and magnetic resonance imaging (MRI) can provide more detailed information regarding the extent of infection. However, these modalities can be time-consuming, and may delay critical treatment. Utility of Point-of-Care Ultrasound (PoCUS) in Diagnosis Point-of-Care Ultrasound (PoCUS) has emerged as a valuable tool in the rapid diagnosis of Necrotizing Fasciitis, especially in the emergency department setting. PoCUS allows for bedside imaging, which can significantly reduce the time to diagnosis and subsequent treatment. In this case, PoCUS was instrumental in identifying the hallmark features of Necrotizing Fasciitis, including cobblestoning, subcutaneous air with dirty shadowing, and non-compressible veins suggesting thrombus formation7. These findings prompted immediate surgical consultation and expedited surgical intervention. The utility of PoCUS extends beyond diagnosis to include ongoing management and monitoring of disease progression. It provides real-time information about the extent of infection and can be used to guide fluid resuscitation, identify complications, such as abscess formation, and monitor the effectiveness of therapeutic interventions. Additionally, PoCUS can be used to evaluate cardiac function and detect hemodynamic instability, as was done in this case6. Antibiotic Stewardship The Australian Therapeutic Guidelines (ETG) is a leading source of independent, evidence based, practical treatment advice to assist practitioners with decision making at the point-of care. The content is regularly updated, based on the latest international literature, interpreted by Australia’s most respected experts, with input from an extensive network of general practitioners, pharmacists and other users. Thus, becoming the standard of practice in Australasia and most other countries like the United Kingdom and the United States of America. As per ETG, three antibiotics are required for empirical therapy for necrotizing skin Infections; Either meropenem or piperacillin/tazobactam, plus vancomycin, plus either clindamycin or lincomycin can be commenced4. This regime provides appropriate gram-positive and gram-negative aerobic cover, as well as coverage for anaerobes and MRSA. Decision for Limb Sparing Surgery In many instances there is a preference to preserve limbs whilst performing surgical intervention if possible. This coincides with the desire to avoid amputation in order to best return the patient to as close to return of function as possible8. Even though there is a deficit in published studies to support this claim, it was the preferred choice of the patient and the surgical team. Role of Multi-Disciplinary Intervention The initial suspicion and subsequent diagnosis of Necrotizing Fasciitis was completed by the Emergency Department team. Prompt inclusion of the intensive care, surgical/plastics team was required for definitive and post operative supportive treatment9. Post operative care included allied health involvement (physiotherapy, hand therapy, occupational therapy and social work). A multi-disciplinary approach provided the best outcome for this patient, giving him the greatest chance for return to function. Conclusion This case highlights the critical importance of early diagnosis and multidisciplinary management in patients with Necrotizing Fasciitis. Point-of-Care Ultrasound (PoCUS) proved to be a rapid, effective diagnostic tool that facilitated prompt surgical intervention and appropriate medical management, ultimately improving patient outcomes10. Early recognition and aggressive treatment, including the use of PoCUS for rapid bedside assessment, are key to reducing the high morbidity and mortality associated with Necrotizing Fasciitis. Patient Outcome Following surgical interventions, antibiotic therapy, and rehabilitation, the patient has made significant gains in function and mobility. Almost two years post-initial presentation, he has not fully returned to baseline but continues to make progress (Figure 5). References 1. Stevens DL, Bryant AE, Goldstein EJ. Necrotizing soft tissue infections. Infect Dis Clin North Am. 2021;35(1):135–155. https://doi.org/10.1016/j.idc.2020.10.004 2. Fernando SM, Tran A, Cheng W, Rochwerg B, Kyeremanteng K, Seely AJE, et al. Necrotizing Soft Tissue Infection: Diagnostic Accuracy of Physical Examination, Imaging, and LRINEC Score: A Systematic Review and Meta-Analysis. Ann Surg. 2019;269(1):58–65 https://doi.org/10.1097/SLA.0000000000002774 3. Marks A, Patel D, Sundaram T, Johnson J, Gottlieb M. Ultrasound for the diagnosis of necrotizing fasciitis: a systematic review of the literature. Am J Emerg Med. 2023;65:31–35. https://doi.org/10.1016/j.ajem.2022.12.037 4. Therapeutic Guidelines [Internet]. 2024 [cited 2024 Dec 9]. Therapeutic Guidelines | Independent, reliable, relevant and respected. Available from: https://www.tg.org.au/ 5. Wong CH, Yam AK, Tan AB, Song C. Approach to debridement in necrotizing fasciitis. Am J Surg. 2008;196(3):e19–e24. https://doi.org/10.1016/j.amjsurg.2007.08.076 6. Goh T, Goh LG, Ang CH, Wong CH. Early diagnosis of necrotizing fasciitis. Br J Surg. 2014;101(1):e119–e125. https://doi.org/10.1002/bjs.9371 7. Kohen B, Halperin M, Felix G, Dixon T, Montenegro M, Patel F. Sonographic crepitus, a point-of-care ultrasound finding. POCUS J. 2022;7(1):129–130 https://doi.org/10.24908/pocus.v7i1.15406 8. Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Front Surg. 2014;1:36. https://doi.org/10.3389/fsurg.2014.00036 9. Marchesi A, Marcelli S, Parodi PC, Perrotta RE, Riccio M, Vaienti L. Necrotizing fasciitis in aesthetic surgery: a review of the literature. Aesthetic Plast Surg. 2017;41(2):352–358. https://doi.org/10.1007/s00266-016-0754-2 10. Raj S, Williams EM, Davis MJ, Abu-Ghname A, Luu BC, Buchanan EP. Cost-effectiveness of multidisciplinary care in plastic surgery: a systematic review. Ann Plast Surg. 2021;87(2):206–210. https://doi.org/10.1097/SAP.0000000000002931
Assessment of Relatives’ Satisfaction in the Emergency Department
Introduction: Emergency departments (EDs) are high-pressure environments where both patients and their relatives face numerous challenges. While patient satisfaction has been widely studied, the satisfaction of relatives remains underexplored, despite their crucial role in supporting patient care and decision-making. Recognizing relatives as key actors in the care process helps improve communication and reduce stress. This study aimed to assess the satisfaction of relatives of patients treated in the ED. Methods: A prospective, descriptive study was conducted at the ED of the Mahmoud Yaacoub Center for Urgent Medical Assistance in Tunis from October 2023 to January 2024. Satisfaction was assessed using a 25-item structured questionnaire. Included participants were adult relatives directly involved in patient care who gave informed consent. Assessed dimensions included reception and management, information provided and overall satisfaction. Results: The study included 165 relatives (mean age 41 ± 13 years, 52.1% female). Relationships included parents (26%), offspring (18.9%), and siblings (14.8%). Overall satisfaction was high: 78% were satisfied with the overall care, 82% with the initial reception, 74% with waiting times, 80% with accessibility, and 77% with information clarity. No significant associations were found between age or education and overall satisfaction. However, relatives from healthcare or paramedical backgrounds showed significantly higher satisfaction (85%) with the registration process compared to non-healthcare relatives (62%) (p = 0.043). Conclusion: The study supports strengthening the involvement of relatives in strategies aimed at improving ED care quality Introduction Emergency Departments (EDs) are high-pressure, overcrowded environments where skilled professionals provide care for critically ill patients [1,2]. The fast-paced, overcrowded, and unfamiliar ED environment can cause stress and frustration for patients and families, often leading to feelings of alienation and reduced involvement in care. Recognizing relatives’ as integral to the critical care process, and striving to support both patients and their loved ones has been proven to be a crucial aspect of comprehensive patient care [3–6]. Understanding and addressing the needs, emotions, and expectations of relatives of critically ill patients, along with gathering their feedback, helps ED professionals improve communication, enhance care quality, build trust, and reduce distress or aggressive behavior [7,8]. Factors influencing family satisfaction in the ED include the clarity and frequency of communication with healthcare professionals, the perceived empathy and responsiveness of the care team, and logistical considerations, such as waiting times and access to information. Negative experiences in these areas can lead to significant dissatisfaction, potentially undermining trust in the healthcare system and discouraging future engagement with healthcare services. Conversely, positive interactions characterized by clear communication, empathy, and a supportive care environment can enhance the family’s understanding of the patient’s condition, foster greater cooperation with healthcare providers, and contribute to a more favorable overall experience. However, there is a notable gap in research focusing on ED, where the unique dynamics of acute care can significantly impact patient and relatives’ experience. Moreover, the satisfaction of relatives of patients in the ED has been even less frequently assessed, despite their crucial role in supporting patient care and decision-making. While patient satisfaction has been extensively studied, the satisfaction of patients' relatives, particularly within the high-pressure environment of the ED, remains under-explored [9]. In the ED, where patients frequently present with acute, often life-threatening conditions, the patient may be unable to actively participate in their care, placing greater importance on the involvement and perspectives of their relatives [10]. This study aimed to assess the satisfaction of patients' relatives in a Tunisian ED and to identify the factors influencing their satisfaction. Methods Study design This study was a monocentric, prospective, observational, descriptive study conducted at the ED of Mahmoud Yaacoub Center for Urgent Medical Assistance in Tunis. The study was conducted over a four-month period, from October 2023 to January 2024. The study targeted adult relatives, aged 18 years or older, who were directly involved in the care of a patient during their visit to the ED. Eligible participants included parents, offspring, spouses, siblings, other family members, friends, or neighbors accompanying the patient. Relatives were not included if they were under 18, declined to participate, were accompanying incarcerated patients, or were related to patients who passed away during their ED stay. Surveys were excluded if they had a non-response rate exceeding 20%, defined as more than five unanswered items out of the 25-question survey. Additionally, responses related to patients who left the ED before completing their care were excluded from the final analysis. Informed consent was obtained from all participating relatives after explaining the study's purpose. Explicit verbal consent was also obtained from patients to allow accompanying relatives to receive medical information during the ED visit. Study Protocol A comprehensive family satisfaction survey was specifically developed for this study to assess the experience of relatives in the ED. The survey was inspired from existing surveys in other departments and was designed for a local context. It was validated by a committee of practitioners [11–14] . The survey consisted of 25 items grouped into four main domains: relative’s background information, reception and management by the healthcare team, information provided to the relative and overall satisfaction (appendix 1). The first domain collected demographic and contextual data such as age, sex, relationship to the patient, educational level, frequency of ED visits, healthcare employment status, distance to the hospital, and reason for the visit. The second domain assessed aspects of care delivery including reception and consultation delays, registration procedures, length of stay, staff accessibility, interaction quality, and understanding of healthcare roles. The third domain focused on the information provided to relatives, evaluating clarity, honesty, satisfaction with communication from doctors and paramedics, and consistency of information. The final domain addressed overall satisfaction with the reception, management, and care provided to the patient. Most items were rated on a 4-point Likert scale ranging from "V ery D issatisfied" to "V ery S atisfied," while four items were structured as yes/no questions. The survey was developed in formal Arabic and French to enhance accessibility and administered at the end of the patient's ED care, with only one relative per patient invited to participate. On-call physicians or paramedical staff explained the study, obtained informed consent, guided respondents through the process, and ensured confidentiality and anonymity. The survey was administered after the patient's condition was stabilized and before the patient’s discharge from the ED. In this study, relatives were defined as individuals accompanying the patient to the ED, including immediate or extended family members, friends, neighbors, or any primary caregiver involved in the patient's support. Age groups were categorized based on the World Health Organization (WHO) classification: Adolescents and Young Adults (15–24 years), Adults (25–64 years), and Older Adults or Seniors (65 years and older) [15]. The study received approval from the institutional ethics committee prior to initiation. Statistical analysis Statistical analysis was conducted using SPSS software, version 25.0, with a significance level set at p < 0.05. Descriptive statistics included frequencies, percentages, means, standard deviations, medians, interquartile ranges, and overall range. Analytical methods involved correlation and regression analyses to explore potential associations between various factors and levels of satisfaction among relatives. Results Descriptive study A total of 169 relatives were included in our study (Figure 1). The participants' ages ranged from 18 to 73 years, with a mean age of 41 ± 13 years (52.1% female). Table 1 summarized the demographic characteristics of the population. Reception and Management by the Healthcare Team The average reception delay reported by participants was 4.82 ± 4.18 minutes, with the majority 142 respondents (84.%) reportedly being attended to in less than 10 minutes. When asked about their familiarity with the role of each healthcare provider involved in the patient's care, 95 participants (56.2%) responded affirmatively (Figure 2). Information Provided to the Patient's Relative Most of the participants (94.7%) stated they had received information regarding the patient’s care. However, 12 participants (7.1%) reported inconsistencies or contradictions in the information provided (Figure 3). Overall Satisfaction Satisfaction in the domain of reception and management was high, with 89.7% of participants expressing full satisfaction. Similarly, 87.4% were satisfied with the information received. The overall satisfaction domain recorded the highest satisfaction, with 93.9% of respondents expressing a positive evaluation (Table 2). Factors Associated with Satisfaction of Patients’ Relatives in the ED Multivariate analysis showed significantly higher registration satisfaction among healthcare workers compared to non-healthcare participants (p = 0.043; OR = 2.64; 95% CI: 1.03–6.77) No significant associations were found between age, sex, or educational background and satisfaction in reception and management, information provided, or overall satisfaction (Table 3). Discussion This prospective study aimed to assess the satisfaction of patients’ relatives in the ED of Mahmoud Yaacoub Center for Urgent Medical Assistance. The study found high satisfaction levels across most domains, including overall care (96.4%), reception (89.3%), and belief that the best care was provided (95.9%). In the Tunisian context, medical confidentiality is protected by the Penal Code and the Medical Code of Ethics [16] [17]. Disclosure of information to relatives requires the patient’s explicit consent, which must be distinguished from mere accompaniment. However, recent legal provisions permit the medical team to inform relatives in life-threatening emergencies requiring immediate medical intervention. Our finding that 94.7% of relatives received information suggests that ED staff are effectively navigating these ethical and legal requirements, likely by obtaining consent when possible, or acting under these emergency provisions. The demographic characteristics of the study population, with a mean age of 41 ± 13 years and slight female predominance, aligned with previous studies on relatives in ED/ICU settings [10,18,19]. The distribution of relationships to the patient, showing high involvement of parents, offspring, and siblings, also corresponds with other research findings [18,20,21]. The high proportion of participants with secondary or university education was consistent with observations regarding family involvement in care decisions [20–22]. Our analytical study revealed a significant difference in satisfaction with the registration procedure between healthcare and non-healthcare employees, with the former expressing higher satisfaction (85% vs 62%, p=0.043). This may be attributed to their greater familiarity with hospital administrative processes, supporting prior research [23]. Unlike evaluation of relatives’ satisfaction with healthcare, the evaluation of patient satisfaction has been extensively studied in healthcare settings [24] , particularly in I ntensive C are U nits (ICUs) and P ediatric D epartments [25–27]. It is a well-established indicator of healthcare quality, routinely measured through surveys designed to identify areas for improvement and enhance service delivery [11,28] . These surveys have become integral to the patient-centered approach that dominates modern healthcare, allowing providers to align their services more closely with patient needs and expectations [12]. Studies on relatives' satisfaction in ICUs have emphasized the importance of fostering understanding, as relatives often navigate complex emotions and interactions with healthcare providers during critical moments of care [29,30]. Similarly, in pediatric settings, research has emphasized the impact of communication and empathy on parental satisfaction. However, in the ED, where rapid decision-making and high patient turnover are common, the satisfaction of relatives has not been sufficiently assessed. This gap in literature suggests a need for targeted research to better understand and improve the experiences of both patients and their families in the emergency care environment. In our study, the high satisfaction with reception and management by healthcare providers [6,26], including short reception delays for the majority, and high satisfaction with consultation delay [22,23,31] , registration [9], availability, and relationships [22,23,31] , aligned with the importance of timely reception in emergency settings. However, the observed dissatisfaction regarding the honesty of information provided (39.6% unsatisfied) suggests potential gaps in transparency, corroborating studies where families felt information was withheld, particularly in critical cases [25,27]. We also found that 7.1% of respondents reported receiving conflicting information, which aligned with findings from other studies that emphasize the impact of inconsistent messaging [25,32]. Interestingly, unlike some other studies, our study found no significant association between age, sex, or educational background and overall satisfaction, which is consistent with literature reporting inconsistent associations between demographic factors and parent satisfaction [33]. This could suggest that the ED's practices are effective across diverse demographics or may be influenced by the homogeneity of the specific study population [10,25,34,35]. Our findings, particularly the high overall satisfaction rates, can be interpreted in light of specific cultural norms in Tunisia, where strong family involvement in patient care is deeply ingrained and expected. The significant proportions of relatives accompanying patients for 'transport' (40.2%) and fulfilling 'cultural/family/social obligations' (45.6%) underscore this active family presence. This societal expectation might contribute to higher satisfaction when families feel included and informed. Additionally, cultural perceptions of medical authority and the public's trust in healthcare providers could play a role in the generally positive satisfaction levels observed. Strengths and Limitations To the best of our knowledge, this is the first study in Tunisia to assess the satisfaction of relatives in the ED, specifically focusing on adult family members, an often-overlooked perspective in patient-centered care. Using a structured scoring system, we evaluated key factors influencing satisfaction, including reception, clarity of communication, and overall experience. The prospective design further strengthens the reliability of the data collected in real-time clinical settings. We acknowledge several limitations: the small, single-center sample may limit generalizability, and findings may not reflect other regions or settings. Larger, multicenter, and longitudinal studies are needed to enhance validity and assess changes in satisfaction over time. Recommendations Based on the findings of our study, several strategies are recommended to improve the satisfaction of relatives in EDs. First, administrative procedures should be simplified and streamlined, especially for non-healthcare users, with consideration given to digital solutions such as pre-registration platforms. Second, providing real-time updates on waiting times and offering comfort measures in waiting areas could help reduce stress and improve the overall experience. Third, ED staff should be trained and encouraged to communicate clearly, compassionately, and consistently with patients' relatives. This research highlights the importance of improving communication with patients' relatives to reduce frustration that may lead to aggression, and to strengthen their support for the patient, ultimately enhancing the quality of care in the ED. Conclusion Our findings highlight that while overall satisfaction of patients’ relatives was high in the ED, areas like the registration process require targeted improvement, especially for those unfamiliar with healthcare systems. Our study underscores the importance of clear communication, streamlined administrative processes, and a supportive environment. These insights contribute valuable information for developing family-centered care strategies that could lead to enhanced patient outcomes and a more supportive emergency care environment. Declarations Author contributions All authors contributed equally and validated the final version of record. Conflicts Of Interest The Author(s) declare(s) that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. 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