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Climate-sensitive extreme weather events are increasingly impacting frontline clinic operations. We conducted a national, cross-sectional survey of 284 self-identified administrators and other staff at frontline clinics determining their attitudes toward climate change and the impacts, resilience, and preparedness of clinics for extreme weather events. Most respondents (80.2%) reported that humans are causing climate change, and nearly half (45.9%) reported concerns about extreme weather impacting their job, with barriers to preparedness including financing and knowledge and resources. Over a third (41.8%) of respondents reported taking steps to protect their clinic infrastructure from extreme weather, including by addressing power and improving ventilation., Competing Interests: This research was supported by a grant from Biogen. None of the authors declare any conflicts of interest., (Copyright © 2025 The Authors. Published by Wolters Kluwer Health, Inc.)

Background Climate change is affecting health and health care, but most physicians lack formal training on climate change. There is a need for graduate medical education (GME) programs that prepare physician leaders to address its health impacts. Objective To describe the development and iterative piloting of a GME fellowship in climate change and health and to assess fellows' academic output and public engagement before and after fellowship matriculation. Methods A GME training program was developed and implemented at an emergency medicine department in a US teaching hospital in collaboration with affiliated academic centers. Participants consisted of emergency physicians from the United States and abroad. Program duration and format were adjusted to meet individual career goals. Outcomes assessed include program completion, postgraduation professional roles, and academic outputs and public engagement before and after fellowship matriculation (2019-2023), compared via paired t tests. Results Five fellows have matriculated; 2 have graduated, while 3 remain in training. Costs and in-kind support include salaries, faculty time, research support, travel to conferences, and tuition for a public health degree. Fellows averaged 0.26 outputs per month before matriculation (95% CI 0.01-0.51) and 2.13 outputs per month following matriculation (95% CI 0.77-3.50); this difference was significant via 2-tailed t test (alpha=.05, P =.01). Subanalyses of academic output and public engagement reveal similar increases. Following matriculation, 186 of 191 (97.4%) of outputs were related to climate change. Conclusions For the 5 fellows that have enrolled in this GME climate change fellowship, academic and public engagement output rates increased following fellowship matriculation.

Background: Frontline clinics - primary care clinics that predominantly serve low-income and socially disadvantaged communities - are facing increasing impacts from climate-related extreme events. This study evaluated staff perspectives at frontline clinics on the health risks of climate change, the impacts of extreme events on their clinics and patients, and their motivators to improve climate resiliency., Methods: A national, cross-sectional survey was conducted of staff working at frontline clinics including administrators, case workers, and providers across the United States. Survey questions assessed clinic and respondent attributes, knowledge of health risks of climate change, preferences for climate change educational and operational resources, and clinic and patient climate impacts and resilience. The survey was distributed electronically to a convenience sample of primary care clinics and to the National Association of Community Health Centers (NACHC) and National Association of Free and Charitable Clinics (NAFC) listservs. Data was collected from September to November of 2021. Respondents were current staff who consented to the survey. Responses were collected via Qualtrics, and the statistical analysis was completed using Stata., Results: A total of 430 surveys were completed representing clinics in 43 states. Most (82.0%) respondents reported human activities were causing climate change. Over half (52.8%) of respondents reported an operational disruption to their clinic from extreme events in the past 3 years, and another 54.4% had plans in place to address risks from extreme events. The most useful resources identified to improve operational resilience were checklists and planning guidance. Over half (52.0%) of respondents reported they were motivated to use these resources to improve clinic preparedness. Most (84.4%) providers and case workers reported that climate change impacted patient health, however only 36.2% discussed health risks with patients, with barriers including more pressing topics and time available. Another 55.7% of respondents reported they were motivated to learn ways to help patients prepare for extreme events., Conclusions: Climate-related extreme events were reported to impact patient health and disrupt frontline clinic operations. Overcoming gaps in knowledge about climate change impacts on health and providing climate educational resources can engender motivation to improve clinic and patient resilience to climate change., Competing Interests: Declarations. Ethics approval and consent to participate: This study that involves human subjects was approved by the Harvard T.H. Chan School of Public Health Institutional Review Board Protocol # IRB21-0726. Informed consent was obtained from all subjects prior to completing the electronic survey. A brief introduction to the survey detailing the purpose of the survey, the voluntary nature, confidentiality, and potential risks and benefits per guidelines of informed consent was provided electronically and participants consented electronically prior to completing the survey. The introduction process for electronic informed consent was approved by the above Institutional Review Board. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

With the ultimate goal of developing an accident and emergency (A&E) department HIV testing program in Belize City, Belize, we sought input from key stakeholders on program components and potential facilitators and barriers to HIV testing in emergency care. We conducted semistructured interviews among 4 key stakeholder groups at Karl Heusner Memorial Hospital Authority (KHMHA) in Belize City: (1) 20 A&E patients, (2) 5 A&E physicians, (3) 5 A&E nurses, and (4) 5 KHMHA administrators. We performed a qualitative content analysis of the interview transcripts and isolated important themes. Major themes included: (1) Patient selection: patients preferred to test all A&E patients. All other stakeholder groups preferred testing specific patient groups. (2) Training: Specific training should be completed for staff. (3) Confidentiality: integral for testing. (4) Facilitators and barriers: facilitators included respectful relationships, privacy, resources, coordination, and education. Barriers included stigmatization, patient willingness, inadequate resources, privacy, and testing biases.

Objective: To evaluate the utility of the quick Sepsis-related Organ Failure Assessment (qSOFA) score to predict risks for emergency department (ED) and hospital mortality among patients in a sub-Saharan Africa (SSA) setting., Methods: This retrospective cohort study was carried out at a tertiary-care hospital, in Kigali, Rwanda and included patients ≥15years, presenting for ED care during 2013 with an infectious disease (ID). ED and overall hospital mortality were evaluated using multivariable regression, with qSOFA scores as the primary predictor (reference: qSOFA=0), to yield adjusted relative risks (aRR) with 95% confidence intervals (CI). Analyses were performed for the overall population and stratified by HIV status., Results: Among 15,748 cases, 760 met inclusion (HIV infected 197). The most common diagnoses were malaria and intra-abdominal infections. Prevalence of ED and hospital mortality were 12.5% and 25.4% respectively. In the overall population, ED mortality aRR was 4.8 (95% CI 1.9-12.0) for qSOFA scores equal to 1 and 7.8 (95% CI 3.1-19.7) for qSOFA scores ≥2. The aRR for hospital mortality in the overall cohort was 2.6 (95% 1.6-4.1) for qSOFA scores equal to 1 and 3.8 (95% 2.4-6.0) for qSOFA scores ≥2. For HIV infected cases, although proportional mortality increased with greater qSOFA score, statistically significant risk differences were not identified., Conclusion: The qSOFA score provided risk stratification for both ED and hospital mortality outcomes in the setting studied, indicating utility in sepsis care in SSA, however, further prospective study in high-burden HIV populations is needed., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Competing Interests: Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.

Background: Lower extremity trauma during earthquakes accounts for the largest burden of geophysical disaster-related injuries. Insufficient pain management is common in disaster settings, and regional anesthesia (RA) has the potential to reduce pain in injured patients beyond current standards. To date, no prospective research has evaluated the use of RA in a disaster setting. This cross-sectional study assesses knowledge translation and skill acquisition outcomes for lower extremity RA performed with and without ultrasound guidance among a cohort of Médecins Sans Frontières (MSF) volunteers who will function as proceduralists in a planned randomized controlled trial evaluating the efficacy of RA for pain management in an earthquake setting., Methods: Generalist humanitarian healthcare responders, including both physicians and nurses, were trained in ultrasound guided femoral nerve block (USGFNB) and landmark guided fascia iliaca compartment block (LGFICB) techniques using didactic sessions and interactive simulations during a one-day focused course. Outcome measures evaluated interval knowledge attainment and technical proficiency in performing the RA procedures. Knowledge attainment was assessed via pre- and post-test evaluations and procedural proficiency was evaluated through monitored simulations, with performance of critical actions graded by two independent observers., Results: Twelve humanitarian response providers were enrolled and completed the trainings and assessments. Knowledge scores significantly increased from a mean pre-test score of 79% to post-test score of 88% (p<0.001). In practical evaluation of the LGFICB, participants correctly performed a median of 15.0 (Interquartile Range (IQR) 14.0-16.0) out of 16 critical actions. For the USGFNB, the median score was also 15.0 (IQR 14.0-16.0) out of 16 critical actions. Inter-rater reliability for completion of critical actions was excellent, with inter-rater agreement of 83.3% and 91.7% for the LGFICB and USGFNB evaluations, respectively., Discussion: Prior to conducting a trial of RA in a disaster setting, providers need to gain understanding and skills necessary to perform the interventions. This evaluation demonstrated attainment of high knowledge and technical skill scores in both physicians and nurses after a brief training in regional anesthesia techniques. This study demonstrates the feasibility of rapidly training generalist humanitarian responders to provide both LGFICB and USGFNB during humanitarian emergencies.

Background: Lower extremity trauma during earthquakes accounts for the largest burden of disaster-related injuries. Insufficient pain management is common in resource-limited disaster settings, and regional anesthesia (RA) may reduce pain in injured patients beyond current standards of care. To date, no controlled trials have been conducted to evaluate the use of RA for pain management in a disaster setting., Methods/design: The Regional Anesthesia for Painful Injuries after Disasters (RAPID) study aims to evaluate whether regional anesthesia (RA), either with or without ultrasound (US) guidance, can reduce pain from earthquake-related lower limb injuries in a disaster setting. The proposed study is a blinded, randomized controlled equivalence trial among earthquake victims with serious lower extremity injuries in a resource-limited setting. After obtaining informed consent, study participants will be randomized in a 1:1:1 allocation to either: standard care (parenteral morphine at 0.1 mg/kg); standard care plus a landmark-guided fascia iliaca compartment block (FICB); or standard care plus an US-guided femoral nerve block. General practice humanitarian response providers who have undergone a focused training in RA will perform nerve blocks with 20 ml 0.5 % levobupivacaine. US sham activities will be used in the standard care and FICB arms and a normal saline injection will be given to the control group to blind both participants and nonresearch team providers. The primary outcome measure will be the summed pain intensity difference calculated using a standard 11-point Numerical Rating Scale reported by patients over 24 h of follow-up. Secondary outcome measures will include overall analgesic requirements, adverse events, and participant satisfaction., Discussion: Given the high burden of lower extremity injuries in the aftermath of earthquakes and the currently limited treatment options, research into adjuvant interventions for pain management of these injuries is necessary. While anecdotal reports on the use of RA for patients injured during earthquakes exist, no controlled studies have been undertaken. If demonstrated to be effective in a disaster setting, RA has the potential to significantly assist in reducing both acute suffering and long-term complications for survivors of earthquake trauma., Trial Registration: ClinicalTrials.gov ( NCT02698228 ), registered on 16 February 2016.

Study Objective: The current outbreak of Ebola virus disease in West Africa is the largest on record and has overwhelmed the capacity of local health systems and the international community to provide sufficient isolation and treatment of all suspected cases. The goal of this study is to develop a clinical prediction model that can help clinicians risk-stratify patients with suspected Ebola virus disease in the context of such an epidemic., Methods: A retrospective analysis was performed of patient data collected during routine clinical care at the Bong County Ebola Treatment Unit in Liberia during its first 16 weeks of operation. The predictive power of 14 clinical and epidemiologic variables was measured against the primary outcome of laboratory-confirmed Ebola virus disease, using logistic regression to develop a final prediction model. Bootstrap sampling was used to assess the internal validity of the model and estimate its performance in a simulated validation cohort., Results: Ebola virus disease testing results were available for 382 (97%) of 395 patients admitted to the Ebola treatment unit during the study period. A total of 160 patients (42%) tested positive for Ebola virus disease. Logistic regression analysis identified 6 variables independently predictive of laboratory-confirmed Ebola virus disease, including sick contact, diarrhea, loss of appetite, muscle pains, difficulty swallowing, and absence of abdominal pain. The Ebola Prediction Score, constructed with these 6 variables, had an area under the receiver operator characteristic curve of 0.75 (95% confidence interval 0.70 to 0.80) for the prediction of laboratory-confirmed Ebola virus disease. Patients with higher Ebola Prediction Scores had higher likelihoods of laboratory-confirmed Ebola virus disease., Conclusion: The Ebola Prediction Score can be used by clinicians as an adjunct to current Ebola virus disease case definitions to risk-stratify patients with suspected Ebola virus disease. Clinicians can use this new tool for the purpose of cohorting patients within the suspected-disease ward of an Ebola treatment unit or community-based isolation center to prevent nosocomial infection or as a triage tool when patient numbers overwhelm available capacity. Given the inherent limitations of clinical prediction models, however, a low-cost, point-of-care test that can rapidly and definitively exclude Ebola virus disease in patients should be a research priority., (Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Exposure to particulate matter from burning biomass fuels is believed to affect oxidant-antioxidant balance and to induce oxidative stress., Methods: Fifty-nine mother-child pairs from 59 households that used firewood exclusively for cooking in three rural communities in southwest Nigeria underwent blood test for albumin, pre-albumin, retinol-binding protein (RBP), superoxide dismutase (SOD), vitamins C, vitamin E, malondialdehyde (MDA) and C-reactive protein (CRP). Spirometry was performed and indoor levels of PM2.5 were determined., Results: Mean age (± SD; years) of mothers and children was 43.0±11.7 and 13.6±3.2, respectively. The median indoor PM2.5 level was 1575.1 µg/m3 (IQR 943.6--2847.0, p<0.001), which is substantially higher than the World Health Organization (WHO) standard of 25 µg/m3. The mean levels of pre-albumin (0.21±0.14 g/dL) and RBP (0.03±0.03 g/dL) in women were significantly lower than their respective normal ranges (1-3 g/dL and 0.2-0.6 g/dL, respectively, p<0.05). Similarly, the mean levels of pre-albumin (0.19±0.13 g/dL) and RBP (0.01±0.01 g/dL) in children were significantly lower than the respective normal ranges (1-3 g/dL and 0.2-0.6 g/dL, respectively, p<0.05). Mean serum concentrations of MDA in children (5.44±1.88 µmol/L) was positively correlated to serum concentrations of CRP (r=0.3, p=0.04) and negatively correlated to lung function (FEV1/FVC) in both mothers and children (both r=-0.3, p<0.05). Also, regression analysis indicates that CRP and SOD are associated with lung function impairment in mothers (-2.55±1.08, p<0.05) and children (-5.96±3.05, p=0.05) respectively., Conclusion: Exposure to HAP from biomass fuel is associated with pulmonary dysfunction, reduced antioxidant defense and inflammation of the airways. Further studies are needed to better define causal relationships and the mechanisms involved.