Utility of Portable Ultrasound in a Community in Ghana

Objective. In many developing countries, access to medical imaging is limited by availability of resources. Portable ultrasound shows great promise to meet the needs in these countries because it is transportable and relatively inexpensive, and it has a wide range of applications. As part of the Ghana Health Mission, Sekondi‐Takoradi, Ghana, we explored the utility of ultrasound in primary care and hospital settings during March 2004. Our objective was to evaluate the clinical utility of a portable ultrasound machine in a variety of physical conditions and multiple clinical scenarios. Methods. Ultrasound examinations were performed at 2 primary care sites and 2 hospitals using a portable ultrasound machine with linear and curved linear phased array transducers. Most ultrasound examinations were musculoskeletal, with the remainder being obstetric, pelvic, breast, vascular, abdominal, and genitourinary examinations. Results. In clinic settings, musculoskeletal ultrasound represented 46% (16) of the ultrasound examinations performed, and 29% (10) of the cases were a combination of abdominal, pelvic, and genitourinary examinations. In hospital settings, abdominal, pelvic, and genitourinary ultrasound examinations combined were 56% (18), and musculoskeletal was 41% (13). Of the 67 ultrasound examinations performed, 81% (54) showed abnormal findings, 81% (54) were considered to add to the clinical diagnosis, and 40% (27) influenced medical care for the patients. Conclusions. This experience shows the usefulness of portable ultrasound examinations performed by a skilled radiologist in a clinical setting in Ghana; the challenge is to address how to best incorporate ultrasound into the current practice of medical professionals in developing countries.     

Japanese women's attitudes towards routine ultrasound screening during pregnancy

Because there are few published studies from Eastern countries concerning women's experiences of prenatal ultrasound scans, this study investigated this topic in 238 Japanese women in three different prenatal settings. A cross‐sectional questionnaire of 33 items was administered to 261 women at 14–37 weeks gestation with no known obstetrical risk, after their ultrasounds. The main reasons for the ultrasounds were evaluation of fetal growth (100%, n = 238); obstetrical conditions (n = 228, 96%); and fetal abnormalities (91%, n = 217). With increasing maternal age, participants worried more about obstetric problems or fetal abnormalities. Many were interested in fetal viability in early pregnancy, and obstetric problems or fetal abnormality in late pregnancy. While most (n = 234, 98%) looked forward to having scans, the majority (n = 235, 99%) wanted to know if their baby had an anomaly, and 72% (n = 171) worried about the detection of abnormalities. Only 50% (n = 118) had obtained information from their care provider. To assist with women's decision‐making, prenatal care providers should provide quality information and understand the factors that influence women's concerns.     

Unfractionated heparin for second trimester placental insufficiency: a pilot randomized trial

Summary. Objective: To conduct a pilot randomized controlled trial of unfractionated heparin (UFH) in women considered at high risk of placental insufficiency in the second trimester. Methods: Women with either false‐positive first trimester (pregnancy‐associated placental protein‐A [PAPP‐A] < 0.35 MoM) or second trimester (alpha‐fetoprotein [AFP] > 2.0 MoM, inhibin > 3.0 MoM, human chorionic gonadotropin > 4.0 MoM) serum screening tests or medical/obstetric risk factors were screened for placental insufficiency by sonographic evaluation of the placenta and uterine artery Doppler between 18 and 22 weeks. Thrombophilia screen‐negative women with two or three abnormal test categories were randomized by 23+6 weeks to self‐administration of subcutaneous unfractionated heparin (UFH) 7500 IU twice daily until birth or 34 weeks, or to standard care. Maternal anxiety and other maternal‐infant outcomes were determined. Results: Thirty‐two out of 41 eligible women consented, with 16 women randomized to UFH and 16 to standard care. There was no statistically significant difference identified between the two treatment groups (standard care vs. UFH) for the following: maternal anxiety score (mean [standard deviation]), 14.2 [± 1.6] vs. 14.0 [± 1.8]; birth weight (median [range]), 1795 [470–3295]g vs. 1860 [730–3050]g; perinatal death, 3 vs. 0; severe preeclampsia, 2 vs. 6; placental weight < 10th percentile, 7 vs. 4; or placental infarction, 4 vs. 3. Conclusion: Our study design identified women at high risk of adverse maternal‐infant outcomes attributable to placental insufficiency. Women with evidence of placental insufficiency were willing to undergo randomization and self‐administration of UFH without increased maternal anxiety.     

Solar‐Powered Point‐of‐Care Sonography: Our Himalayan Experience

The benefits of sonography utilization in low‐resource communities has been thoroughly demonstrated in the literature.^1–3 As ultrasound units have become smaller and more portable, the feasibility of bringing these imaging devices into more remote areas is becoming a reality. One factor that limits ultrasound use in austere environments is battery life. Although solar power has been used for oxygen delivery^5,6 in resource‐limited settings, its use in sonography has not been previously described. This report describes the use of a Lumify (Philips; Amsterdam, Netherlands) for a month‐long trip into a remote Himalayan region of India powered exclusively with an Anker (Shenzhen, China) solar panel for the entirety of the trip. According to the Palmetto Health Institutional Review Board, this does not qualify as “research” as defined by the US Department of Health and Human Services and therefore does not meet the requirements for institutional review board review.     

Ultrasound‐Mediated Release of Hydrophilic and Lipophilic Agents From Echogenic Liposomes

Objective. To achieve ultrasound‐controlled drug delivery using echogenic liposomes (ELIPs), we assessed ultrasound‐triggered release of hydrophilic and lipophilic agents in vitro using color Doppler ultrasound delivered with a clinical 6‐MHz compact linear array transducer. Methods. Calcein, a hydrophilic agent, and papaverine, a lipophilic agent, were each separately loaded into ELIPs. Calcein‐loaded ELIP (C‐ELIP) and papaverine‐loaded ELIP (P‐ELIP) solutions were circulated in a flow model and treated with 6‐MHz color Doppler ultrasound or Triton X‐100. Treatment with Triton X‐100 was used to release the encapsulated calcein or papaverine content completely. The free calcein concentration in the solution was measured directly by spectrofluorimetry. The free papaverine in the solution was separated from liposome‐bound papaverine by spin column filtration, and the resulting papaverine concentration was measured directly by absorbance spectrophotometry. Dynamic changes in echogenicity were assessed with low‐output B‐mode ultrasound (mechanical index, 0.04) as mean digital intensity. Results. Color Doppler ultrasound caused calcein release from C‐ELIPs compared with flow alone (P < .05) but did not induce papaverine release from P‐ELIPs compared with flow alone (P > .05). Triton X‐100 completely released liposome‐associated calcein and papaverine. Initial echogenicity was higher for C‐ELIPs than P‐ELIPs. Color Doppler ultrasound and Triton X‐100 treatments reduced echogenicity for both C‐ELIPs and P‐ELIPs (P < .05). Conclusions. The differential efficiency of ultrasound‐mediated pharmaceutical release from ELIPs for water‐ and lipid‐soluble compounds suggests that water‐soluble drugs are better candidates for the design and development of ELIP‐based ultrasound‐controlled drug delivery systems.     

Variations and inconsistencies in maternal and child health indicators in Ishikawa Prefecture, Japan

As part of a community health assessment, variations in maternal and child health-related vital statistics data in Ishikawa Prefecture, Japan, from 1984 to 1993 were studied. Annual vital statistics reports published by the Prefectural government were used for the analysis. The following rates by public health district were calculated: abortion rate, early fetal mortality rate, late fetal mortality rate, perinatal mortality rate, neonatal mortality rate, and infant mortality rate. Maternal mortality rates were calculated for the Prefecture because of the small number of events. A few northern public health districts had relatively high perinatal mortality and infant mortality rates throughout the study period. Cause-specific infant mortality rates showed that the northern region had higher infant mortality rates related to the level of perinatal care, injury, and poisoning. Inconsistencies in the pattern of mortality were found in one of the 10 public health districts. No indirect maternal deaths were reported for the 10-year study period. This study identified potential problems for perinatal care in some districts. Results also suggest the potential misclassification of vital events, such as fetal deaths, induced abortions, and maternal deaths.     

Emergency Care and Health Systems: Consensus‐based Recommendations and Future Research Priorities

The theme of the 14th annual Academic Emergency Medicine consensus conference was “Global Health and Emergency Care: A Research Agenda.” The goal of the conference was to create a robust and measurable research agenda for evaluating emergency health care delivery systems. The concept of health systems includes the organizations, institutions, and resources whose primary purpose is to promote, restore, and/or maintain health. This article further conceptualizes the vertical and horizontal delivery of acute and emergency care in low‐resource settings by defining specific terminology for emergency care platforms and discussing how they fit into broader health systems models. This was accomplished through discussion surrounding four principal questions touching upon the interplay between health systems and acute and emergency care. This research agenda is intended to assist countries that are in the early stages of integrating emergency services into their health systems and are looking for guidance to maximize their development and health systems planning efforts.     

上海闵行区部分流动人口产前检查现状的调查分析

目的调查闵行区流动人口产前检查状况,提出改进措施,以降低围产儿和孕产妇的死亡率,保障母婴安全。方法采用方便抽样,自行设计问卷,了解孕产妇的一般资料,对产前检查的认知度及对相关政策的了解情况。将数据结果应用SPSS13．0统计软件进行分析。结果调查显示,闵行区流动人口孕产妇对于正规产检重要性的认知程度低,社区保健获得较少,平价分娩医院的获得信息少。结论闵行区妇幼保健人员应有计划、有组织地加强宣传力度,充分利用各种信息平台介绍平价分娩医院,以提高流动人口孕妇的产前检查率。     

Obstetric admissions to the intensive care unit in a tertiary referral hospital

PurposeThe present study was conducted to evaluate the obstetric admissions to the intensive care unit (ICU) in the setting of a tertiary referral hospital in an attempt to identify the risk factors influencing maternal outcome.Materials and MethodsAll of the obstetric patients who seeked care for delivery at the emergency department and who were admitted to the ICU between January 2006 to July 2009 were retrospectively identified. The Simplified Acute Physiology Score (SAPS II) was calculated and the maternal mortality rate was estimated for each patient. The mean SAPS II scores and the mean estimated maternal mortality rates for the surviving patients and the nonsurviving patients were compared.ResultsSeventy-three obstetric patients were admitted to the ICU. There were 9 maternal deaths and 24 fetal deaths. For the surviving group of patients, the mean SAPS II score was 34 and estimated maternal mortality rate was 20%, whereas for the nonsurviving group of patients, the SAPS II score was 64 and estimated maternal mortality rate was 73%. The difference between the surviving group of patients and the nonsurviving group of patients was statistically significant regarding both the mean SAPS II scores and the mean estimated maternal mortality rates.ConclusionsPregnancy-induced hypertensive disorders and hemorrhage appear as the major risk factors influencing maternal outcome in obstetric patients. Considering that the use of the SAPS II scores have enabled the reliable estimation of the mortality rates in the present study, the attempts at defining the focus of care for the obstetric patients who bear the major risk factors and who are admitted to the ICU should be carried out under the guidance of the ICU scoring systems such as the SAPS II.     

Making Recording and Analysis of Chief Complaint a Priority for Global Emergency Care Research in Low‐income Countries

The chief complaint is a patient's self‐reported primary reason for presenting for medical care. The clinical utility and analytical importance of recording chief complaints have been widely accepted in highly developed emergency care systems, but this practice is far from universal in global emergency care, especially in limited‐resource areas. It is precisely in these settings, however, that the use of chief complaints may have particular benefit. Chief complaints may be used to quantify, analyze, and plan for emergency care and provide valuable information on acute care needs where there are crucial data gaps. Globally, much work has been done to establish local practices around chief complaint collection and use, but no standards have been established and little work has been done to identify minimum effective sets of chief complaints that may be used in limited‐resource settings. As part of the Academic Emergency Medicine consensus conference, “Global Health and Emergency Care: A Research Agenda,” the breakout group on data management identified the lack of research on emergency chief complaints globally—especially in low‐income countries where the highest proportion of the world's population resides—as a major gap in global emergency care research. This article reviews global research on emergency chief complaints in high‐income countries with developed emergency care systems and sets forth an agenda for future research on chief complaints in limited‐resource settings.     

Validity and reliability of an ultrasound system for estimating adipose tissue

When health professionals measure the fitness levels of clients, body composition is usually estimated. In field settings, body composition is commonly estimated with skinfolds or bioelectrical impedance analysis. Recently, a portable ultrasound device has been manufactured to estimate what percentage of body mass is composed of adipose tissue (AT%). A reported advantage of using ultrasound is that inter‐ and intrarater variations may be minimized when compared with the skinfold technique. Therefore, the purpose of this pilot study was twofold; 1) to determine the validity of a portable ultrasound device compared with skinfolds and 2) determine the reliability of the portable ultrasound device. Participants had their measurements taken in the following order: urine specific gravity, body mass, height, skinfolds and ultrasound determined. Participants had their urine specific gravity and ultrasound determined AT% estimates measured again 48 h later. The current pilot study found that the ultrasound was not a valid estimate of AT% when compared with the skinfold estimate (TE > 4%). In addition, the 1‐site estimate from the ultrasound was more reliable than the 3‐site estimate of AT%. These data are of importance to practitioners because it demonstrates that while the ultrasound is not a valid estimate compared with skinfolds, the 1‐site estimate may be able to track changes in AT% over time, making the ultrasound an option for assessing changes in body composition.     

Clinical and Translational Research in Global Health and Emergency Care: A Research Agenda

As policy‐makers increasingly recognize emergency care to be a global health priority, the need for high‐quality clinical and translational research in this area continues to grow. As part of the proceedings of the 2013 Academic Emergency Medicine consensus conference, this article discusses the importance of: 1) including clinical and translational research in the initial emergency care development plan, 2) defining the burden of acute disease and the barriers to conducting research in resource‐limited settings, 3) assessing the appropriateness and effectiveness of local and global acute care guidelines within the local context, 4) studying the local research infrastructure needs to understand the best methods to build a sustainable research infrastructure, and 5) studying the long‐term effects of clinical research programs on health care systems.     

Modern results and old-established methods in obstetrics (author's transl)]

More than 20.000 obstetric cases were attended to during the years 1965 to 1974 at the Semmelweis-Klinik in Vienna. The perinatal maternal mortality rate was 0.1% and the perinatal infant mortality rate was finally 15%. The cases were treated according to oldfashioned obstetric principles. Hence, although the more modern obstetric methods might be of some scientific value, their importance appears to have been overestimated from a practical point of view. A return to the conscientious implementation of simple, long-established methods of pernatal care appears to be called for, even with the most modern monitoring machines at hand.     

Rapid Assessment of the Neonate With Sonography (RANS) Scan

The use of point‐of‐care sonography in clinical settings such as emergency medicine and intensive care units has increased, but adoption in neonatology has been slow. Unlike the focused assessment with sonography for trauma scan used in adults, a quick bedside scan to rapidly evaluate an acutely deteriorating neonate does not exist. The objective of our article is to introduce a focused bedside ultrasound scan that is easy to learn, rapidly performed, and relatively inexpensive.© 2018 by the American Institute of Ultrasound in Medicine     

Charlson Index Is Associated with One-year Mortality in Emergency Department Patients with Suspected Infection

Objectives: A patient's baseline health status may affect the ability to survive an acute illness. Emergency medicine research requires tools to adjust for confounders such as comorbid illnesses. The Charlson Comorbidity Index has been validated in many settings but not extensively in the emergency department (ED). The purpose of this study was to examine the utility of the Charlson Index as a predictor of one‐year mortality in a population of ED patients with suspected infection. Methods: The comorbid illness components of the Charlson Index were prospectively abstracted from the medical records of adult (age older than 18 years) ED patients at risk for infection (indicated by the clinical decision to obtain a blood culture) and weighted. Charlson scores were grouped into four previously established indices: 0 points (none), 1–2 points (low), 3–4 points (moderate), and ≥5 points (high). The primary outcome was one‐year mortality assessed using the National Death Index and medical records. Cox proportional‐hazards ratios were calculated, adjusting for age, gender, and markers of 28‐day in‐hospital mortality. Results: Between February 1, 2000, and February 1, 2001, 3,102 unique patients (96% of eligible patients) were enrolled at an urban teaching hospital. Overall one‐year mortality was 22% (667/3,102). Mortality rates increased with increasing Charlson scores: none, 7% (95% confidence interval [CI] = 5.4% to 8.5%); low, 22% (95% CI = 19% to 24%); moderate, 31% (95% CI = 27% to 35%); and high, 40% (95% CI = 36% to 44%). Controlling for age, gender, and factors associated with 28‐day mortality, and using the “none” group as a reference group, the Charlson Index predicted mortality as follows: low, odds ratio of 2.0; moderate, odds ratio of 2.5; and high, odds ratio of 4.7. Conclusions: This study suggests that the Charlson Index predicts one‐year mortality among ED patients with suspected infection.     

Comparing Image Processing Techniques for Improved 3‐Dimensional Ultrasound Imaging

Objective. The purpose of this study was to compare volumetric image processing techniques for reducing noise and speckle while retaining tissue structures in 3‐dimensional (3D) gray scale ultrasound imaging. Methods. Eighty subjects underwent a clinically indicated abdominal or obstetric 3D ultrasound examination (20 hepatic, 20 renal, and 40 obstetric cases). Volume data were processed on a pixel (“2‐dimensional [2D] processing”) or a voxel (“3D processing”) basis using commercially available image enhancement software (ContextVision AB, Linköping, Sweden). Randomized, side‐by‐side comparisons of the image processing techniques were performed for each subject. An independent and blinded reader scored the volumes for image quality on a 3‐point scale from 1 (worst) to 3 (best) and compared the results using a nonparametric Wilcoxson signed rank test. Results. The 40 subjects with abdominal 3D imaging received a mean score (± 1 SD) of 1.52 ± 0.51, 2.45 ± 0.60, and 2.75 ± 0.44 for the original, the 2D processed, and the 3D processed volumes, respectively. The differences between the unprocessed and the processed volumes were highly statistically significant (P < .0001), as was the difference between the 2D and 3D processing methods (P = .002). Similar results were obtained for the obstetric data sets (n = 39 due to an acquisition problem) with a mean score of 1.03 ± 0.16 for the original, 2.33 ± 0.48 for the 2D processed, and 2.79 ± 0.47 for the 3D processed volumes (P < .003). Conclusions. A new volumetric ultrasound image enhancement technique has been assessed in abdominal and obstetric applications. Compared to unprocessed volumes and volumes processed with 2D image enhancement software, the new 3D processing technique performed best.     

Second‐Trimester Uterine Model for Teaching Ultrasound‐Guided Obstetric Procedures

The declining number of ultrasound‐guided obstetric procedures in clinical practice mandates a shift toward simulation‐based teaching. Current uterine simulation aids are animal tissue–sourced or expensive, and improvement is needed. We describe a low‐cost reusable uterine model with “fetus,” cord and skin, constructed from synthetic gel and silicone rubber. Ultrasound appearance and tactile feedback approximate clinical use, and all parts of the model are portable, durable, and shelf‐stable. Those made of ballistics gel can be recycled numerous times without noticeable effect. This appears to be ideal for proctored learning and independent practice within an ultrasound procedural curriculum.     

Focused Maternal Ultrasound by Midwives in Rural Zambia

Point-of-care ultrasound is being increasingly implemented in resource-poor settings in an ad hoc fashion. We developed a focused maternal ultrasound-training program for midwives in a rural health district in Zambia. Four hundred forty-one scans were recorded by 21 midwives during the 6-month study period. In 74 scans (17%), the ultrasound findings prompted a change in clinical decision-making. Eight of the midwives were evaluated with a 14-question observed structured clinical examination (OSCE) and demonstrated a slight overall improvement with mean scores at 2 and 6 months of 10.0/14 (71%) and 11.6/14 (83%), respectively. Our pilot project demonstrates that midwives in rural Zambia can be trained to perform basic obstetric ultrasound and that it impacts clinical decision-making. Ultrasound skills were retained over the study period. More data is necessary to determine whether the introduction of ultrasound ultimately improves outcomes of pregnant women in rural Zambia. (E-mail: hkimberly@partners.org)