In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.
The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.
Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987. He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.
He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE. He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery.
The International Emergency Medicine Education Project (iem-student.org) is pleased to provide Fundamentals of Research in Medicine. Our guest for this session was Prof Fikri Abu-Zidan, one of the world experts on trauma and disaster medicine research. He reviews around 60 manuscripts a year and has various roles in editorial teams of multiple journals. Prof Abu-Zidan will share his 40 years of experience and recommendations on two topics. We hope you enjoy watching this interview.
In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.
The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.
The 6th episode is “Common mistakes that researchers do”
Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987. He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.
He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE. He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery.
In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.
The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.
Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987. He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.
He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE. He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery.
In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.
The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.
Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987. He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.
He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE. He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery.
In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.
The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.
Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987. He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.
He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE. He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery.
In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.
The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.
The 2nd episode is “Practicing ethically in research.”
Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987. He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.
He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE. He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery.
Cite this article as: Arif Alper Cevik, "Practicing ethically in research," in International Emergency Medicine Education Project, October 6, 2021, https://iem-student.org/2021/10/06/research-ethics/, date accessed: June 1, 2023
In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.
The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.
The first episode is “What makes a doctor a good researcher.”
Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987. He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.
He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE. He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery.
Cite this article as: Arif Alper Cevik, "What makes a physician a good researcher," in International Emergency Medicine Education Project, September 22, 2021, https://iem-student.org/2021/09/22/good-researcher/, date accessed: June 1, 2023
“You are a research fellow working on a clinical trial for cryptococcal meningitis (CM) in Ugandan AIDS patients. If a patient is diagnosed with CM and enrolled in this trial, they receive free care for treatment duration and reimbursement for non-medical expenses. Seventy-five percent of this population lives on less than two dollars per day and cannot afford these costs otherwise. A woman presents with CM symptoms, but after testing her cerebrospinal fluid, she is instead diagnosed with deadly bacterial meningitis. She cannot be enrolled in the trial and is too poor to buy antibiotics. ”
What do you do?
I recently presented this case at a classroom discussion about global health research ethics. When this dying woman’s mother pulled on my lab coat and pleaded for help one day at the government-run Mbarara Regional Referral Hospital (MRRH), where I worked as a clinical research fellow for nearly a year, I did not know what to do, and neither did my peers.
Like many global health-oriented physicians, my career began with short-term medical mission trips as a pre-medical student. However, I found these trips to be self-serving and unsustainable; indeed, the ethical shortcomings of these trips have long been argued because often participants’ benefits outweigh those receiving of their “help.“[1] Thinking research might be a way to develop an ethical global health career, I completed a summer clinical research project in India, which I found more productive and substantial than short-term mission trips. Galvanized by the belief I could change the world through ethical research, I applied for the clinical research fellowship in Uganda.
Ultimately, I found my experience as ethically fraught as the short-term missions I swore to avoid. I am not alone in these sentiments: others have noted that AIDS in Africa has paradoxically been both a source of significant tragedy and significant academic opportunity. Unfortunately, these opportunities are distributed unevenly, producing fresh inequalities. In their efforts to reduce suffering in Africa, some global health researchers have inadvertently capitalized on the intellectual opportunities provided by those same African sufferers.[2]
At MRRH, where the shortages of gloves, saline, and basic medications reflect the hospital’s poverty and its patients, research-based medical care is often the only care people receive. Academic collaborations between western and sub-Saharan African institutions enable African researchers to publish in journals viewed by western audiences. As of 2017, patients presenting to MRRH with tuberculous meningitis or CM were enrolled in American-run clinical trials and treated without charge by experts with effective medications. Western-based surgical teams have improved MRRH’s surgical capacity, where sophisticated procedures are now performed with modern equipment. In 2004, after multinational research programs dedicated to tackling AIDS, tuberculosis, and malaria (ATM) worldwide were launched in the late 1990s, clinics started supplying HIV-positive Ugandans with free antiretrovirals and other services, causing a significant decline in HIV-related mortality.[3]
However, inequities in patient care are apparent in the areas of MRRH that have not yet benefitted from foreign research dollars, particularly the intensive care unit and the emergency department. The two working ventilators in the hospital are usually occupied by neurosurgical patients. Deaths due to trauma and road traffic accidents in Africa cause the loss of more life-years than AIDS and malaria combined [4], which is also true at MRRH. Like the woman in the case above, patients suffering from other non-ATM infectious diseases are sometimes victims of these inequalities at MRRH. This unequal distribution of research wealth in a resource-limited setting such as MRRH troubles me. At MRRH, often, patient care follows research dollars; when the money runs out, so does the patient care. The Declaration of Helsinki requires control groups to receive the ‘best’ current treatment, not the local one – and while in developed countries the difference between ‘best’ and ‘local’ may be small, in settings like MRRH this difference is profound and may result in severe ethical consequences.[5]
In March of 2018, I watched a presentation by researchers who conducted a CM clinical trial in eastern Uganda, similar to ours at MRRH. A conference attendee voiced concern that the trial had violated the Helsinki Declaration, since many participants in the control group had not received any treatment. The presenter responded that the standard of care treatment for CM at this hospital was often no treatment, because the hospital had nothing to treat its patients. And, in late 2017 when the CM clinical trial at MRRH ended, CM patients there no longer received free treatment.
Uganda is often cited as the success story in sub-Saharan Africa in its efforts to reduce its HIV burden, largely due to funding from large international research programs.[6] But perhaps these trials reveal that acceptance of this ethical relativism in clinical research could result in the exploitation of underserved populations abroad for research programs that could not be performed in the sponsoring country.[5] Researchers must first be aware that conducting clinical research in resource-limited settings may create as many inequalities as it alleviates, particularly where the minimal standard of care for certain conditions is lacking. Secondly, research is often the conduit for medical care for impoverished people, which in turn creates unique ethical issues.
How can we global health researchers mitigate some of these ethical quandaries? I suggest that before embarking on clinical research (particularly in underserved areas), researchers assess their site’s health care needs and risk of patient exploitation, and that teams include medical anthropologists and epidemiologists well-versed in the local population’s health care needs and their receptiveness to clinical research. At MRRH, this was not a requirement of institutional review board approval for studies, so research teams must take this responsibility onto themselves.
Billions of people worldwide have benefitted from the discoveries that clinical research provides. Unfortunately, historically in our quest for valuable intellectual resources, those benefits have sometimes come at the cost of human exploitation. To maximize the benefit of clinical research for all involved, global health researchers must ensure this exciting and evolving field grows in an ethically sound manner.
References
Roberts M. Duffle Bag Medicine. The Journal of the American Medical Association. 2006;295(13):1491-2.
Crane JT. Scrambling for Africa: AIDS, Expertise, and the Rise of American Global Health Science. Ithaca and London: Cornell University Press; 2013.
Wendler D, Krohmal B, Emanuel EJ, Grady C. Why patients continue to participate in clinical research. Arch Intern Med. 2008;168(12):1294–9.
Hulme P. Mechanisms of trauma at a rural hospital in Uganda. Pan Afr Med J. 2010;7:5.
Angell M. The Ethics of Clinical Research in the Third World. N Engl J Med. 1997;337(12):847–9.
Cite this article as: Sarah Bridge, USA, "Developing Clinical Research Ethics in the Developing World," in International Emergency Medicine Education Project, September 21, 2020, https://iem-student.org/2020/09/21/clinical-research-ethics/, date accessed: June 1, 2023
It all started as an undergraduate medical student.
I am an Assistant Professor of Emergency Medicine and Critical Care at Addis Ababa University, College of Health Sciences. As an Emergency Medicine physician, I am committed not only to develop my clinical skills in the Emergency Department but also to improving my skills in clinical research, which all started as a final year medical student during my undergraduate studies.
Emergency Medicine (EM) is a completely new specialty in Ethiopia by the time when I have started to pursue my specialty training, with not much research base exists to support our practice. Clinical research done elsewhere is rarely relevant here and many of the research questions asked elsewhere do not apply in our setting. As the practice of EM develops in Ethiopia, research to support that practice must develop also. I wanted to become an expert in the field of clinical research, so I can lead that development.
While I was having my three poster presentations at the International Conference on Emergency Medicine (ICEM 2016) in Cape Town South Africa and also participating in a two-day pre-conference workshop in Research Methodology, I heard news of my acceptance for a one year Harvard Medical School Global Clinical Scholars Research Training Program 2016/17.
This was after my own web-based search and application for clinical research training in addition to my residency training.
Global Clinical Scholars Research Training Program (GCSRTP) offered by Harvard University Medical School Office of Global Education is highly competitive clinical research training for clinical research scientists from all over the country. I am one of 113 advanced trainees from around the world selected for their ability and interest in pursuing clinical or epidemiological research. Students are drawn from hospitals, clinics, and academic communities globally and bring the unique perspective of their home country and institution to address research issues in a clinical or population-based setting.
This is a year-long intensive program is designed for clinicians and clinician-scientists aimed to achieve three goals:
To build skills in clinical research,
To provide knowledge to address issues critical for success in contemporary clinical research, and
To develop a global network.
The GCSRTP consists of three on-site workshops (two in London, UK, and one in Boston) as well as 85 online lectures, 5 team assignments, 20 quizzes covering lecture content, a midterm and a final exam, as well as 2 or 3 interactive webinars per month in biostatistics, epidemiology, biostatistical computing, ethics and regulatory approaches, leadership, applied regression, longitudinal analysis and correlated outcomes, survey design, causal diagrams, and advanced quantitative methods. Additionally, I have selected an elective and a concentration and completed my own course work related to those tracks. The program requires an original research proposal as a Capstone Project. Graduation from the program relies on successful completion of this project. And thus, I had successfully completed my capstone project titled Diuretics Options in Acute Coronary Syndrome as a requirement for my successful graduation.
Through the Harvard Medical School Tuition Reduction Program, I was able to negotiate a 50% reduction in the usual tuition of $11,900 for the program. Additional expenses for travel and accommodation and supplies were my responsibility.
How all of the above came into fruition as a start base from my undergraduate study in Medicine?
There was a medical student mentorship research program of the Medical Education Partnership Initiative as a part of the NIH funded grant in 2013. For the same, I have assessed an undergraduate medical student’s clerkship rotation in Emergency Medicine as an Ethiopian experience. This paper, which was also published in the African Journal of Emergency Medicine, was a gateway for all of my clinical research experiences to date. There is a blog post about my clinical research experience in the same journal as well as I was a speaker on the most recent African Conference on Emergency Medicine in Kigali Rwanda, 2018.
My subsequent future as a clinical researcher:
I completed my residency in January 2018. With the skills developed in the GCSRT and my clinical qualification, I was well-positioned to apply for further clinical research fellowship at Addis Ababa University and got accepted for a Junior Faculty Research Fellowship under an NIH funded grant of Medical Education Partnership Initiative 2019-2020. I hope to begin developing research projects, possibly multi-site within Ethiopia that will address the many questions that are relevant to Emergency Medicine as it is practiced in our low-resource setting.
It’s 2 AM, and the Pediatric Emergency Department (ED) at a community hospital in New York is overflowing with children and caregivers. A young Nigerian boy is being transported down the center of a hallway, past a long line of doors to patient rooms. The porter is calm and walks briskly, determined to bring this boy to get immediate care. The boy winces, his hands outstretched next to him, rigid, and frozen in space, and while he is seated in the wheelchair, his legs bent at the knees are thin frames, held in place with his feet planted on the wheelchair pedestals. He is afraid to move any of his extremities; tears are rolling down his face; he is fighting the urge to grimace and furrow his brow. He cries how much it hurts to move. He knows he needs help. Behind him, his mother follows close holding a one-year-old baby in her arms, and behind her, five other young children aged 3 through to thirteen stream in. There is quiet concern on all of their faces. The older siblings have seen this before. We learn that he has Sickle Cell Disease (SCD). He has been in excruciating pain for the past 4 hours and is now presenting with dactylitis. This case has not been the first in this ED, and like other EDs across the United States and in the world, the number of cases presenting with SCD will increase.
Sickle Cell Disease (SCD)
SCD is a condition that causes red blood cells to morph from a biconcave dumbbell-shaped disc, into a rigid semi-circular shape. This disease is inherited genetically by receiving two sickle genes, one from each parent and risk for complications are attributed to a variety of factors, including deoxygenation, dehydration. It is most common in African Americans as well as Latinos and people of Middle Eastern, Indian, Asian and Mediterranean backgrounds. In the United States, SCD is the most common genetic blood disorder and affects approximately 100,000 Americans(1) and although babies are screened at birth, management plans vary with the degree of disease progression and exacerbation severity, as well as with the availability of resources and education.
Image: Sickle cells and normal red blood cells from Sickle Cell Disease, Genome. Gov
Why Emergency Physicians need to be Familiar with SCD
SCD affects both pediatric and adult patients, and it has been reported that patients between the ages of 18 to 30 years old have increased emergency department utilization. A major reason for this is due to the transition by young adults from pediatric to adult care in the management of SCD, and this population is simultaneously also learning to navigate the health care system and community resources (pediatric to adult care, insurance, independent decision making, housing, education, workforce) as discussed further below(2). In addition, the use of community health workers is important as they can act as liaisons between the health care systems and patients to disseminate information and resources. However, despite the awareness of the disproportionate use of the ED among patients with SCD, the social factors that impact care remain unknown(3) and more research and investigation is needed to understand this patient population.
Often when a complication or crisis occurs in patients with SCD, patients seek immediate care in the Emergency Department. Included in the potential list of complications include infections, such as those with encapsulated bacteria; sepsis; stroke; splenic sequestration, and early treatment is essential in managing patients. Of these complaints, the emergent cases to be aware of in the ED include vaso-occlusive crisis and pain, sickle cell anemia (SCA)(4) central nervous system such as stroke, and acute chest syndrome (ACS), where ACS due to blocked capillaries in the lungs, may be caused by infections, asthma exacerbations and/or pulmonary embolisms, and is the leading cause of morbidity in patients with SCD. Further, the Emergency Severity Index (ESI) Version 4 triage system, commonly used in the majority of EDs in the United States, suggest that patients with SCD be triaged as ESI level 2, indicating a very high priority, and that rapid placement be facilitated(5).
Although the discussion of complications of SCD including the presentation and management is a complex topic, and will be covered in detail in future posts, information and algorithms for clinicians are available online for reference. One such resource is a treatment algorithm that acts as a how-to guide for SCD and is available online in the Annals of Emergency Medicine(6). This approach is based on the point-of-care hemoglobin level, and discusses issues such as myonecrosis, aplastic crisis, ACS.
Pain in SCD
When tissues and organs are not adequately perfused with oxygen, in part due to the sickled shape of RBCs, tissue damage and death can occur. Patient management of vaso-occulusive crisis and pain varies by practices and the medications available for use around the world, however it is important to note that pain in patients with SCD is often extreme and may require treatment with opioids. In a response to the American Society of Hematology (ASH) draft recommendations to Sickle Cell Disease-Related Pain in May 2019(7), emDOCs.net published a response to the drafted recommendations and offered insight to pain management and includes an algorithm(8). The insight provided is essential in decreasing the suffering experienced by patients during an SCD crisis, and notes the use of Dilaudid, Ketamine, Dexmedetomidine, and Lidocaine. Further, the understanding of limiting the use of NSAIDS due to impaired renal function caused by the disease is also outlined in the response.
Management of pain in pediatric patients with SCA and vaso-occulsive pain also varies according to hospital and individual provider practices, and scientific investigation and patient research is needed to provide proper care to this population. An example includes a study by PECARN addressing the use of a normal saline bolus in pediatric emergency departments found an association with poorer pain control(9). Identifying and implementing results from research studies is important in understanding and managing SCD in both adult and pediatric patients.
Emergency Physicians around the world should be aware of strategies for identifying SCD, and management, specifically in areas around the world where refugees from countries with SCD prevalence is common. Countries where refugees and migrants are commonly are known to disembark, such as those in southern Europe(10) and certain areas in the United States and Canada would benefit from in-depth analysis of the issue and could allow for appropriate and accessible health care to vulnerable populations, as well as educate providers who are unexposed to managing emergencies in SCD patients while setting in place integrated and individual health plans away from emergency room dependence(11). In developing countries with SCD populations, such as Nigeria, there is a high prevalence of pediatric emergency cases, and the proper management of the disease as well as policy and hospital organization for high volume and off-hour admissions, may reduce hospital stays(12). Further, the self-efficacy of adult patients with SCD, from education, pro-active efforts, understanding of disease management, also can allow for decreased ED visits and hospitalizations for pain(13).
Investigations, Resources, Education
A number of investigative studies, clinical trials and research is being conducted around the world for a better understanding of SCD, including patient care in adult and pediatric patients, genetic factors, supportive services, associated co-morbidities, and search for cures. Investigations around the world include collaborations and information sharing between academic researchers, patients, clinical providers, and health care providers and officials around the world.
The National Heart, Lung, and Blood Institute hosted a series of Webinars in September 2018, during Sickle Cell awareness month from experts in blood science and sickle science research and are available to watch for free online(14). Some of the key highlights from two of the webinars: Serving the Sickle Cell Disease Community Here and Abroad; Sickle Cell Transitional Care from Childhood to Adulthood, are discussed here.
Webinar Overview Serving the Sickle Cell Disease Community Here and Abroad Presented by Dr. Keith Hoots, Director of Division of Blood Diseases and Resources, NHLBI
Prevalence of the disease is so much larger in Africa than most places in the world. There are as many babies born with SCD born in Nigeria there are babies born with SCD, by estimate, as there almost are total people with SCD in the United States.
There is a need to share research and practices in the developed world with the developing world.
Three New Research Initiatives in Africa:
The Sickle Pan-African Research Consortium (SPARCO) Overview: The study sites for this research include East Africa (Tanzania), West Africa (Ghana, Nigeria) and central Africa (Cameroon, Democratic Republic of Congo) with the goal to later include 20 sites in 15 countries. SPARCO’s aim is to develop an SCD database, standards of care, and strengthen research investigation.
Sickle Cell Disease Genomics of Africa (SickleGenAfrica) Overview: The purpose is to develop strategies to predict, prevent and treat organ damage in SCD and to investigate biomarkers associated with the development of organ damage, including molecules released during red blood cell damage in sub-Saharan African populations.
Webinar Overview: Sickle Cell Transitional Care from Childhood to Adulthood Part 1 Presented by Dr. David Wong, MD, FAAP, Medical Officer, Office of Minority Health
SCD is no longer a childhood disease. Young adults are at a higher risk for hospitalization due to illness and pain.
Treatment and management examples in childhood include annual transcranial dopplers to assess for risk of stroke; vaccinations; hydroxyurea; L-glutamine; opioids for pain management; penicillin prophylaxis; RBC transfusions; water intake to avoid exacerbations due to dehydration; splenectomy. The cure available is bone marrow transplant.
Prior to July 2017, Hydroxyurea was the only FDA approved therapy for 20 It is used in adults and children. It has been shown to reduces hospital admissions, pain crisis, and ACS however barriers to hydroxyurea use exist. These include difficulty with communicating the use to patients and caregivers, issues with frequent monitoring, lack of adherence, lack of provider knowledge and comfort with its use.
Community Health Workers (CHWs) are key players in effective patient care. CHW can provide information affected by social and health determinants from local economic and environmental (housing, employment), local communities (families, safety, support), activities (learn, work, play, move, shop), lifestyles (alcohol, drugs, smoking, sexual health, physical activity, and individual needs (age, genetics). CHW are experts in condition-specific information and navigating complex health systems, including accessing care in a medical home (the approach to providing comprehensive care). This is particularly important when care is not always contained or organized by one organization, where care should be accessible, continuous, comprehensive, family-oriented, coordinated, compassionate and culturally competent. Pediatric medical home principles include family-centered partnerships, community-based systems, transition care, value. Interventions for education such as warning signs and treatment options and links to care are important.
The SCD Newborn screening program, and the Sickle Cell Disease Treatment Demonstration Program for patients who solely rely on the ED for SCD care, aid the care options for patients with SCD.
Follow this iEM story for part two which will include information on adult and pediatric management of SCD in the ED, as well as an overview of four NHLBI webinars: Holistic Health and Sickle Cell Disease A Focus on Mental and Behavioral Health; Genetic Therapies in Sickle Cell Disease; Bone Marrow Transplants, Other Therapies, and Sickle Cell; Improvement Initiatives and Ongoing Research.
The Global Emergency Medicine Literature Review Group
The Global Emergency Medicine Literature Review Group (https://gemlrgroup.wixsite.com/mysite) is a team of students and physicians from around the world that work together each year to review and highlight the published literature related the practice of emergency medicine in resource-constrained settings. The Global Emergency Medicine Literature Review (GEMLR) started in 2005 and has been published annually (you can review past editions of the GEMLR: here, https://www.ncbi.nlm.nih.gov/pubmed/?term=gemlr).
Annual Systematic Review
The review group completes their annual systematic review of scholarly work around international emergency medicine, which screens for and then reviews relevant peer-reviewed and gray literature. The authors of this years review note that the term international emergency medicine is quite subjective, but the research of interest is generally related to “the practice and development of emergency medicine in settings without the robust or mature systems commonly seen in resource-rich western countries.”
The 2018 Review
The 2018 review was just recently published online in Academic Emergency Medicine (https://www.ncbi.nlm.nih.gov/pubmed/31313411), and this edition was put together by a team of 7 editors, 5 editorial board members, and 27 reviewers (of note, I was one of the reviewers for 2018). Interestingly, a number of reviewers are tasked with reviewing literature in other languages with which that reviewer is fluent in order to include any relevant studies from around the world. Articles are screened for appropriateness and then grouped into three main categories: the development of emergency medicine, disaster and humanitarian response, and emergency care in resource-limited settings.
The GEMLR group screened over 19,000 articles for the 2018 review, and of these 517 were found to be of appropriate quality and content for a full review. Each screened article is then obtained in full-text format and both categorized and scored by two independent reviewers. This edition of the GEMLR found the screened articles fell into each category as follows: 15% in the development of emergency medicine, 25% in disaster and humanitarian response, and 60% in emergency care in resource-limited settings. After scoring, a total of 25 articles (approximately 5% of all of the scored literature is selected for a full summary and critique. This year’s publication included the full summary and the critical appraisal of each of the highest-scoring articles in Supplement 7.
The 2018 GEMLR authors found that this year’s edition included “studies and reviews focusing on pediatric infections, several new and traditionally under-represented topics, and landscape reviews that may help guide clinical care in new settings represented the majority of top-scoring articles. A shortage of articles related to the development of EM as a specialty was identified.”
The body of published work around international emergency medicine continues to grow; 7.3% more studies were identified as compared to 2017. I would encourage you to looking through the most recently published GEMLR reviews to find content areas that are currently gaps in the peer-reviewed literature and consider finding ways to help prepare and publish relevant work. The great news is that the body of work in international emergency medicine is expanding.
Ongoing Scholar Work Around International Emergency Medicine
This and other recent GEMLR publications are a great resource and can be a really helpful starting point in looking at ongoing scholarly work around international EM. This is also a great resource to consider as content to be used in your next journal club. I strongly recommend you take a look at this year’s publication and then go look at a few of the articles; there is a lot of great work being done and published!
Although applications to be a reviewer for the 2019 review have just recently closed, keep your eyes on the GEMLR team (@gemlrgroup) for the latest in IEM research, and for the opportunity to join the GEMLR team for next year.
Applications open: become a Global Emergency Medicine Literature Group reviewer! Seeking diverse applicants from around the world with talent for writing\editing & global health research or practical experience. Applications due August 1 – please share. https://t.co/NgKp2AhTLg
