Clinical ultrasound in developing countries

An audit of Zimbabwean public sector diagnostic ultrasound services

Introduction

the provision of basic diagnostic imaging services is pivotal to achieving universal health coverage. An estimated two-thirds of the world's population have no access to basic diagnostic imaging. Accurate data on current imaging equipment resources are required to inform health delivery strategy and policy at national level. This is an audit of Zimbabwean public sector diagnostic ultrasound resources and services.

Methods

utilising the Ministry of Health and Child Care (MHCC) database, sequential interviews were conducted with provincial health authorities and local facility managers. Ultrasound equipment, personnel and services in all hospitals and clinics, nationally were recorded, collated, and analysed for the whole country, and by province.

Results

of the 1798 Zimbabwean public sector healthcare facilities, sixty-six (n=66, 3.67%) have ultrasound equipment. Ninety-nine (n=99) ultrasound units are distributed across the sonar facilities, representing a national average of 8 units per million people. More than half the equipment units (n=53, 54%) are in secondary-level healthcare facilities (district and mission hospitals), and approximately one-fifth (n=22, 22%) in the central hospitals (quaternary level). The best-resourced province has twice the resources of the least resourced. One-hundred and forty-two (n=142) healthcare workers, from six different professional groups, provide the public sector ultrasound service. Most facilities with sonar equipment (n=64/66, 97%) provide obstetrics and gynaecology services, while general abdominal scanning is available at one third (n=22, 33%). Two facilities with ultrasound equipment have no capacity to offer a sonography service.

Conclusion

in order to reach the WHO recommendation of 20 sonar units per million people, an estimated 140 additional sonar units are required nationally. The need is greatest in Masvingo, Midlands and Mashonaland East Provinces. Task-shifting plays a key role in the provision of Zimbabwean sonar services. Consideration should be given to formal training and accreditation of all healthcare workers involved in sonar service delivery.

Left ventricular mass in a patient with severe heart failure

INTRODUCTION

Cardiac masses have a wide range of etiologies with the most common being thrombi and less commonly tumors. However, in Sub-Saharan Africa other etiologies not commonly seen in developed countries such as endomyocardial fibrosis (EMF) must be considered. EMF is a disease process associated with poverty, a poor diet, and eosinophilia although its pathology is poorly understood.

CASE REPORT

We report a case of a 53-year-old male with a history of dilated cardiomyopathy who presented to a Ugandan Emergency Department in respiratory distress. Bedside echocardiography was performed which revealed a large mass in the apex of the left ventricle. The patient was subsequently given supplemental oxygen and intravenous furosemide, however he later died while in the emergency department due to limited resources and lack of definitive care.

DISCUSSION

The list of potential etiologies of cardiac masses is widely variable, and in settings such as Sub-Saharan Africa, this list must be expanded to include possible diagnoses such as EMF. EMF is a diagnosis that should be considered in patients presenting with respiratory distress and a cardiac mass present on echocardiography, such as the case presented here. The limited opportunities for medical personnel to diagnose cardiovascular disease can be made more efficient by the use of diagnostic imaging devices which are portable, yet capable of diagnosing the most common local pathologies [9-11].

Evaluating sensitivity and specificity of handheld point-of-care ultrasound testing for gynecologic pathology: a pilot study for use in low resource settings

BACKGROUND

Point-of-care ultrasound (POC-US) is a diagnostic test conducted at the site of patient care with direct interpretation by the clinician, providing immediate results. POC-US for gynecologic application is not well characterized by current literature yet has the potential to increase access in limited resource settings. We compared the diagnostics of three POC-US devices for gynecologic (GYN) pathology and then performed evaluation of sensitivity and specificity of a single best POC-US device for intended use in a low resource setting.

METHODS

This is prospective, pilot descriptive study of 60 subjects. In part 1, comparison of three POC-US devices was performed. Twenty subjects underwent POC-US with three test units [GE Vscan (Vscan), Sonosite Iviz (Iviz), Philips Lumify (Lumify)] followed by diagnostic ultrasound (Dx-US) for reference imaging. Image quality and correlation for devices was scored by blinded reviewers and quantitative measurements of GYN pathology were compared. In part 2, forty subjects underwent POC-US validation with the highest scoring device (Lumify) and Dx-US for reference imaging. Concordance of POC-US operator-interpreted diagnosis with reference imaging interpretation were assessed by Cohen's unweighted kappa coefficient. Accuracy and agreement of POC-US were assessed by linear regression and Bland-Altman plot analysis. Sensitivity and specificity of POC-US for gynecologic pathologies were calculated.

RESULTS

In aggregate qualitative measurements, Lumify and Iviz units performed superiorly to Vscan. There was no statistically significant difference in quantitative measurements between devices, but a trend towards lower mean error was seen for Lumify and Iviz as compared to Vscan. Lumify device had highest overall scoring and was selected for further testing. In validation comparison of Lumify to Dx-US, no statistically significant differences were found for measurements of endometrium, uterus, ovaries, adnexal pathology, or leiomyomata, (P < 0.02) with excellent agreement in operator-interpreted diagnosis (Kappa > 0.7). Sensitivity and specificity of detecting pathology was 80-100% with PPV and NPV 76-100%.

CONCLUSION

Among three POC-US devices, Lumify and Iviz devices show highest potential for successful application to clinical gynecologic ultrasound. Clinician-performed POC-US has high diagnostic accuracy, sensitivity, and specificity for basic GYN anatomy and pathology. POC-US is an acceptable and feasible diagnostic tool with potential for future application in a low resource setting to increase access to ultrasound.

Impact of point-of-care ultrasound on clinical decision-making at an urban emergency department in Tanzania

BACKGROUND

Point of care ultrasound (PoCUS) is an efficient, inexpensive, safe, and portable imaging modality that can be particularly useful in resource-limited settings. However, its impact on clinical decision making in such settings has not been well studied. The objective of this study is to describe the utilization and impact of PoCUS on clinical decision making at an urban emergency department in Dar es Salaam, Tanzania.

METHODS

This was a prospective descriptive cross-sectional study of patients receiving PoCUS at Muhimbili National Hospital's Emergency Medical Department (MNH EMD). Data on PoCUS studies during a period of 10 months at MNH EMD was collected on consecutive patients during periods when research assistants were available. Data collected included patient age and sex, indications for ultrasound, findings, interpretations, and provider-reported diagnostic impression and disposition plan before and after PoCUS. Descriptive statistics, including medians and interquartile ranges, and counts and percentages, are reported. Pearson chi squared tests and p-values were used to evaluate categorical data for significant differences.

RESULTS

PoCUS data was collected for 986 studies performed on 784 patients. Median patient age was 32 years; 56% of patients were male. Top indications for PoCUS included trauma, respiratory presentations, and abdomino-pelvic pain. The most frequent study types performed were eFAST, cardiac, and obstetric or gynaecologic studies. Overall, clinicians reported that the use of PoCUS changed either diagnostic impression or disposition plan in 29% of all cases. Rates of change in diagnostic impression or disposition plan increased to 45% in patients for whom more than one PoCUS study type was performed.

CONCLUSIONS

In resource-limited emergency care settings, PoCUS can be utilized for a wide range of indications and has substantial impact on clinical decision making, especially when more than one study type is performed.

Evaluation of a point of care ultrasound curriculum for Indonesian physicians taught by first-year medical students

BACKGROUND

The purpose of this study was to assess the short-term efficacy of a 4-week ultrasound curriculum taught by American first-year medical students to general practitioners working in public health care clinics, or puskesmas, in Bandung, Indonesia.

METHODS

We performed a prospective, observational study of Indonesian health care practitioners from public clinics in Bandung, Indonesia. These practitioners were enrolled in a 4-week ultrasound training course taught by first-year American medical students. A total of six sessions were held comprising of 38 ultrasound milestones. A pre-course and post-course written exam and practical exam was taken by each participant.

RESULTS

We enrolled 41 clinicians in the course. The average pre-course exam score was 35.2% with a 2.4% pass rate, whereas the average post-course exam score was 82.0% with a 92.7% pass rate. The average practical score at the completion of the course was 83.2% (SD=0.145) with 82.9% of the class passing (score above 75.0%).

CONCLUSION

Our data suggests that first-year medical students can effectively teach ultrasound to physicians in Indonesia using a 4-week intensive ultrasound training course. Future studies are needed to determine the amount of training required for proficiency and to evaluate the physicians' perceptions of the student-instructors' depth of knowledge and skill in point of care ultrasound.

Bedside ultrasound training at Muhimbili National Hospital in Dar es Salaam, Tanzania and Hospital San Carlos in Chiapas, Mexico

INTRODUCTION

In resource-rich settings, bedside ultrasound has rapidly evolved to be a crucial part of emergency centre practice and a growing part of critical care practice. This portable and affordable technology may be even more valuable in resource-limited environments where other imaging modalities are inaccessible, but the optimal amount of training required to achieve competency in bedside ultrasound is largely unknown. We sought to evaluate the feasibility of implementation of a mixed-modality bedside ultrasound training course for emergency and generalist acute care physicians in limited resource settings, and to provide a description of our core course components, including specific performance goals, to facilitate implementation of similar initiatives.

METHODS

We conducted a standardised training course at two distinct sites-one large, urban tertiary hospital in Tanzania with a dedicated Emergency Centre, and one small, rural, hospital in southern Mexico with a general, acute intake area. We report on pre-training ultrasound use at both sites, as well as pre- and post-training views on most useful indications.

RESULTS

Overall, participants were very satisfied with the course, although approximately one-third of the providers at both sites would have preferred more hands-on training. All participants passed a standardised exam requiring image acquisition and interpretation.

DISCUSSION

Introducing bedside ultrasound training in two distinct resource-limited settings was feasible and well-received. After a brief intensive period of training, participants successfully passed a comprehensive examination, including demonstration of standardised image acquisition and accurate interpretation of normal and abnormal studies.

A comparison of telemedicine teaching to in-person teaching for the acquisition of an ultrasound skill - a pilot project

Telemedicine is widely used for medical education but few studies directly investigate how telemedicine teaching compares to conventional in-person teaching. Here we determine whether telemedicine teaching is as effective as in-person teaching for the acquisition of an ultrasound skill important in trauma care. Nurses with no prior ultrasound experience (n = 10) received study material and a teaching session on how to locate and image the hepatorenal space (Morison's pouch). One group of nurses was taught in-person (In-person Group) and the other group was taught via telemedicine (Telemedicine Group). Telemedicine allowed two-way audio and visual communication between the instructor and the nurses. A comparison of the teaching techniques showed that telemedicine teaching was equivalent to in-person teaching for the acquisition of practical and theoretical skills required to locate Morison's pouch. The average time required to locate Morison's pouch after teaching was similar between both groups. The results demonstrate that telemedicine teaching is as effective as in-person teaching for the acquisition of bedside ultrasound skills necessary to identify Morison's pouch. Remote teaching of these bedside ultrasound skills may help in the diagnosis of intra-abdominal bleeding in rural healthcare centers.

Characterizing the limited use of point-of-care ultrasound in Colombian emergency medicine residencies

Background

Emergency medicine (EM) is a growing specialty in Colombia with five residency programs in the country. EM leadership is interested in incorporating point-of-care (POC) ultrasound into a standardized national EM residency curriculum. This study is a nationwide survey of Colombian EM residents designed to explore the current state of POC ultrasound use within EM residencies and examine specific barriers preventing its expansion.

Methods

We conducted a mix-methodology study of all available current EM residents in the five EM residencies in Colombia. The quantitative survey assessed previous ultrasound experience, current use of various applications, desire for further training, and perceived barriers to expanded use. Focus group discussions (FGDs) were conducted with current EM residents to gather additional qualitative insight into their practice patterns and perceived barriers to clinician-performed ultrasound.

Results

Sixty-nine EM residents completed the quantitative survey, a response rate of 85% of all current EM residents in Colombia; 52% of resident respondents had previously used ultrasound during their training. Of these, 58% indicated that they had performed <10 scans and 17% reported >40 scans. The most frequently used applications indicated by respondents were trauma, obstetrics, and procedures including vascular access. A quarter indicated they had previously received some ultrasound training, but almost all expressed an interest in learning more. Significant barriers included lack of trained teachers (indicated by 78% of respondents), absence of machines (57%), and limited time (41%). In FGDs, the barriers identified were inter-specialty conflicts over the control of ultrasonography, both institutionally and nationally, and program-specific curriculum decisions to include POC ultrasound.

Conclusion

While currently limited in their access, EM residents in Colombia have a strong interest in integrating POC ultrasound into their training. Current barriers to expanded use include traditional barriers such as a lack of equipment seen in many developing countries, as well as inter-specialty conflicts typical of developed countries. Further collaboration is underway to help overcome these obstacles and integrate POC ultrasound into Colombian EM residency training.

Implementing an obstetric ultrasound training program in rural Africa

OBJECTIVE

To evaluate the feasibility and sustainability of basic obstetric ultrasound training in rural Africa.

METHODS

An 8-week training course, led by UK-based sonographers, was supported by training videos and followed by 10 months of remotely supported scanning in Mandimba, Mozambique. Data were collected prospectively using an Android tablet and the EpiCollect web application.

RESULTS

The study group included 1744 pregnant women: 804 scanned by trainees under direct supervision and 940 scanned by trainees alone. Ultrasound identified 36 (2.1%) twin pregnancies, 230 (13.2%) breech presentations, 83 (4.8%) transverse presentations, and 22 (1.3%) cases of placenta previa. The detection rates for the above features were similar in the 2 groups. A subgroup of 230 (13.2%) women had a follow-up scan and 62 (3.6%) were referred to a doctor; 21 of these women required cesarean delivery.

CONCLUSION

Ultrasound training in a rural setting supported remotely is feasible, efficient, and sustainable. It can help local healthcare workers to screen their prenatal populations for obstetric and neonatal risks, and therefore has the potential to improve outcomes at delivery and provide site-specific epidemiologic data that can be used to develop new healthcare provision strategies.

Teaching ultrasound in tropical countries

INTRODUCTION

This paper reports my experience as a teacher of clinical ultrasound (US) in an African hospital. While US in tropical countries has received some attention and a few papers - though possibly fewer than deserved by this issue-are available in the medical literature on this subject, very little has been done in terms of assessment of teaching.

MATERIALS AND METHODS

Given the increasing number of groups, NGOs and volunteers that go to Africa and other resource limited settings to do this, I thought that sharing my experience with those who have walked or are thinking of walking the same path could be mutually beneficial.

RESULTS

The first section of the article presents the situation where I've been working in the past 13 years, the second section details our teaching programme.

DISCUSSION

This report describes the rationale for the implementation of ultrasound training programmes in rural areas of Africa and lessons learnt with 13 years experience from the UK with recommendations for the way forward.

Review: indications for ultrasound use in low- and middle-income countries

OBJECTIVE

To determine the indications for using ultrasound, in low- and middle-income countries (LMICs) and to assess whether its use alters clinical management.

METHODS

Literature review. We conducted a Pubmed search on the clinical use of ultrasound in LMIC for articles published between January 2000 and December 2010, recording country of origin, speciality and whether ultrasound use led to a change in management.

RESULTS

Fifty-eight articles were identified from 32 countries and represented nine specialties. Ultrasound was most commonly used for assisting with the diagnosis of obstetrical conditions, followed by intra-abdominal conditions such as liver abscesses and intussusceptions. Clinical management was altered in >30% of cases.

CONCLUSION

Ultrasound is a highly valuable diagnostic tool in LMICs and its use should be considered essential for all district medical facilities. The use could be applied more widely, eg., for tropical and non-communicable diseases. Additional research is needed to further characterize the impact of task shifting on ultrasound use in LMICs.

Assessing the utility of ultrasound in Liberia

Sub-Saharan Africa has sparse imaging capacity, and data on ultrasound (US) use is limited. We collected prospective data on consecutive patients undergoing US to assess disease spectrum and US utility in Liberia. A total of 102 patients were prospectively enrolled. Average age was 33 years (0-84), 80% were female. US indications were: 53% Obstetrics/Gynecology (OB/GYN) (24% gynecologic, 17% second/third trimester, 12% first trimester), 14% hepatobiliary, 10% intraperitoneal/intrathoracic fluid, 8% cardiac, 5% focused assessment of sonography in trauma, and 4% renal. US changed management in 62% of cases. Greatest impact was in first trimester OB (86%), FAST (83%), ECHO (80%), and second/third trimester OB (77%). US changed management in 47% of right upper quadrant and 33% of gynecologic studies. Curvilinear probe addressed over 80% of need. The primary role for US in developing countries is in management of obstetrics, with a secondary role for traumatic and a-traumatic abdominal processes. Most needs can be met with the curvilinear probe. Training should begin with obstetrics and should be a primary focus for curriculum.

Impact of the introduction of ultrasound services in a limited resource setting: rural Rwanda 2008

BACKGROUND

Over the last decade, utilization of ultrasound technology by non-radiologist physicians has grown. Recent advances in affordability, durability, and portability have brought ultrasound to the forefront as a sustainable and high impact technology for use in developing world clinical settings as well. However, ultrasound's impact on patient management plans, program sustainability, and which ultrasound applications are useful in this setting has not been well studied.

METHODS

Ultrasound services were introduced at two rural Rwandan district hospitals affiliated with Partners in Health, a US nongovernmental organization. Data sheets for each ultrasound scan performed during routine clinical care were collected and analyzed to determine patient demographics, which ultrasound applications were most frequently used, and whether the use of the ultrasound changed patient management plans. Ultrasound scans performed by the local physicians during the post-training period were reviewed for accuracy of interpretation and image quality by an ultrasound fellowship trained emergency medicine physician from the United States who was blinded to the original interpretation.

RESULTS

Adult women appeared to benefit most from the presence of ultrasound services. Of the 345 scans performed during the study period, obstetrical scanning was the most frequently used application. Evaluation of gestational age, fetal head position, and placental positioning were the most common findings. However, other applications used included abdominal, cardiac, renal, pleural, procedural guidance, and vascular ultrasounds.Ultrasound changed patient management plans in 43% of total patients scanned. The most common change was to plan a surgical procedure. The ultrasound program appears sustainable; local staff performed 245 ultrasound scans in the 11 weeks after the departure of the ultrasound instructor. Post-training scan review showed the concordance rate of interpretation between the Rwandese physicians and the ultrasound-trained quality review physicians was 96%.

CONCLUSION

We suggest ultrasound is a useful modality that particularly benefits women's health and obstetrical care in the developing world. Ultrasound services significantly impact patient management plans especially with regards to potential surgical interventions. After an initial training period, it appears that an ultrasound program led by local health care providers is sustainable and lead to accurate diagnoses in a rural international setting.

Introduction of a portable ultrasound unit into the health services of the Lugufu refugee camp, Kigoma District, Tanzania

BACKGROUND

Diagnostic imaging services are scarce in much of the developing world. Ultrasound is a low-cost, safe, and widely applicable imaging modality.

AIMS

We delivered a portable ultrasound machine to the Lugufu refugee camp in Tanzania and conducted a course on its use in order to assess the feasibility of introducing this technology into a very low-resource setting.

METHODS

We conducted an intensive 4-day ultrasound training course for health care providers at Lugufu and established an exam logbook to track the frequency of use, distribution of ultrasound applications, and gender and age distribution of patients.

RESULTS

Between 4 October 2005 and 1 November 2007 547 separate ultrasound exams on 460 patients were recorded at Lugufu. Overall, 86% of patients studied were female. Pregnancy-related exams accounted for 24.1% of total usage. The 20- to 29-year-old age group accounted for over one third of total exams performed.

CONCLUSION

Ultrasound is a feasible and sustainable imaging modality in a very low-resource setting such as the Lugufu refugee camp in Tanzania.

Development of an ultrasound training curriculum in a limited resource international setting: successes and challenges of ultrasound training in rural Rwanda

Background

Over the last decade, the diffusion of ultrasound technology to nontraditional users has been rapid and far-reaching. Much research and effort has been focused on developing an ultrasound curriculum and training and practice guidelines for these users. The potential for this diagnostic tool is not limited to the developed world and in many respects ultrasound is adaptable to limited resource international settings. However, needs-based curriculum development, training guidelines, impact on resource utilization, and sustainability are not well studied in the developing world setting.

Aims

We review one method of introducing applicable curriculum, training local providers, and sustaining a comprehensive ultrasound program.

Methods

Two rural Rwandan hospitals affiliated with a US nongovernmental organization participated in a pilot ultrasound training program. Prior to introduction of ultrasound, local physicians completed a survey to determine the perceived importance of various ultrasound scan types. Hospital records were also reviewed to determine disease and presenting complaint prevalence as part of an initial needs assessment and to define our curriculum. We hypothesized certain studies would be more utilized and have a greater impact given available treatment resources.

Results

We review here the choice of curriculum, the training plan, helpful equipment specifications, and implementation of ongoing measures of quality assessment and sustainability. Our 9-week lecture and practice-based ultrasound curriculum included obstetrics, abdominal, renal, hepatobiliary, cardiac, pleural, vascular, and procedural ultrasound.

Conclusions

While ultrasound as a diagnostic modality for resource-poor parts of the world has generated interest for years, recent advances in technology have brought ultrasound again to the forefront as a sustainable and high impact technology for resource-poor developing world nations. From our experience in rural Rwanda, we conclude that ultrasound remains helpful in patient care and the diagnostic impact is enhanced by choosing the correct applications to implement. We also conclude that ultrasound is a teachable skill, with a several week intensive training period involving hands-on practice skills and plans for long-term learning and have begun a second phase of evaluating knowledge retention for this introductory program.

Hand-carried cardiac ultrasound enhances healthcare delivery in developing countries

The availability of cardiac ultrasound is limited in developing countries. We evaluated the feasibility and diagnostic capability of a hand-carried cardiac ultrasound device in 126 patients (age 44 +/- 24 years) referred for consultation to a cardiology clinic in rural Mexico. The hand-carried cardiac ultrasound device identified 86 cardiac findings and obviated the need for further comprehensive echocardiographic evaluation in 90% of patients (113 of 126).

Feasibility of an ultrasound service on district health care level in Botswana

OBJECTIVE

To assess the clinical benefit and financial feasibility of an ultrasound service in a district hospital in Botswana.

METHOD

An ultrasound service was established in the study hospital. Clinical and ultrasound-aided diagnoses were compared in patients who met eligibility criteria laid down in an indication list.

RESULTS

We enrolled 2309 patients over 18 months. The most frequent indications for ultrasound were pregnancy-related diagnoses followed by gynaecological and hepato-biliary disorders. Ultrasound assistance improved case management in 696 cases (30%) and led to an immediate change in management in 151 patients. Ultrasound diagnosis was used as gold standard to assess the accuracy of the clinical diagnosis of incomplete abortion (sensitivity 24%; positive predictive value, PPV 66%), pelvic mass (sensitivity 53%; PPV 69%), ectopic pregnancy (sensitivity 75%; PPV 28%), and gall bladder stones (sensitivity 30%; PPV 32%).

CONCLUSIONS

Ultrasound improved case management for a wide diversity of clinical problems encountered on district health care level. The service proved to be affordable for the Botswana health care system.