Pocket-size point-of-care ultrasound in rural Uganda - A unique opportunity "to see", where no imaging facilities are available

Continuing professional development for primary care physicians: a pre-post analysis of a focused abdominal point-of-care ultrasound pilot training

INTRODUCTION

Abdominal pain is a leading cause of primary care visits and emergency department admissions. The recent surge in the implementation of point-of-care ultrasound into primary care underscores the necessity for specialized training to enhance the expertise of primary care physicians and foster a positive attitude toward its routine use in clinical activities.

METHODS

This prospective cohort study, conducted between March and August 2023 at Ben Gurion University, introduced an integrative abdominal ultrasound program for 48 participating primary care physicians with no prior formal experience in abdominal ultrasound. Physicians' knowledge, practical skills, and attitudes towards abdominal ultrasound integration were evaluated using a pre/post-course clips-based pathology test, a hands-on exam immediately following the course, and a survey conducted ten weeks later.

RESULTS

Post-course evaluations showed an improvement in primary care physicians' proficiency with hands-on skills, increasing from 26 to 69% (p < 0.001), with increased comfort using abdominal ultrasound (from 0 to 42%, p < 0.001) and enhanced understanding of its capabilities and limitations (from 0 to 58%, p < 0.001). Pattern recognition skills, assessed through clips, presented a notable rise from an average of 26% to 69% (p < 0.001). Ten weeks following the training, an increase in its utilization was observed; weekly usage rose from zero to 44%, and the proportion not using it declined from 94 to 19% (p < 0.001, p < 0.001, respectively).

CONCLUSIONS

An integrative two-day training program increases the application of abdominal bedside ultrasound in clinical settings, demonstrating the effectiveness of combining practical training with flexible, theoretical learning.

Is Handheld Lower-Resolution Ultrasound Evaluation Sufficient to Measure the Cross-Sectional Area of the Median Nerve?

PURPOSE

This study aimed to assess the accuracy of median nerve cross-sectional area (CSA) measurements using a handheld ultrasound (HHUS) and a cart-based high-resolution ultrasound.

METHODS

Fifteen healthy subjects were prospectively enrolled. Each subject underwent standardized ultrasound evaluations of their median nerves with HHUS and a high-resolution ultrasound by three different providers with different levels of training in musculoskeletal ultrasound. CSA calculations were performed using a standardized method. The primary outcome was the mean difference in CSA (ΔCSA) between the gold standard high-resolution ultrasound and the lower resolution handheld ultrasound, with a noninferiority margin set at ΔCSA < 2 mm2. Inter-rater reliability was calculated using Lin concordance correlation coefficient (LCCC), and the intraclass coefficient (ICC) was used to calculate intra-rater reliability.

RESULTS

The average CSA of the median nerve across all patients and reviewers using the high-resolution US was > 0.9 mm2 for the HHUS. In paired comparisons within subjects, the ΔCSA of the median nerve using the HHUS was 1.8 mm2 (95% CI, 0.8-2.7 mm2), and the LCCC was weak 0.258 (0.018-0.470). Noninferiority was not achieved. The intrarater reliability between devices was poor at 0.201. However, the inter-rater reliability among different examiners was good when using the high-resolution device, but it was poor using the HHUS.

CONCLUSIONS

The findings suggest caution for the use of handheld ultrasound in measurements of median nerve CSA because the difference between HHUS and gold standard high-resolution ultrasound was not within the noninferiority margin of 2 mm2.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Continuing professional development for primary care physicians: a pre-post study on lung point-of-care ultrasound curriculum

BACKGROUND

Point-of-care ultrasound is rapidly gaining traction in clinical practice, including primary care. Yet, logistical challenges and geographical isolation hinder skill acquisition. Concurrently, an evidentiary gap exists concerning such guidance's effectiveness and optimal implementation in these settings.

METHODS

We developed a lung point-of-care ultrasound (POCUS) curriculum for primary care physicians in a rural, medically underserved region of the south of Israel. The course included recorded lectures, pre-course assessments, hands-on training, post-workshop lectures, and individual practice. To evaluate our course, we measured learning outcomes and physicians' proficiency in different lung POCUS domains using hands-on technique assessment and gathered feedback on the course with a multi-modal perception approach: an original written pre- and post-perception and usage questionnaire.

RESULTS

Fifty primary care physicians (PCPs) showed significant improvement in hands-on skills, increasing from 6 to 76% proficiency (p < 0.001), and in identifying normal versus abnormal views, improving from 54 to 74% accuracy (p < 0.001). Ten weeks after training, primary care physicians reported greater comfort using lung ultrasound, rising from 10 to 54% (p < 0.001), and improved grasp of its potential and limits, increasing from 27.5% to 84% (p < 0.001). Weekly usage increased from none to 50%, and the number of primary care physicians not using at all decreased from 72 to 26% (p < 0.001).

CONCLUSIONS

A two-day focused in-person and remote self-learning lung-POCUS training significantly improved primary care physicians' lung ultrasound skills, comfort, and implementation.

Efficacy of Handheld Ultrasound in Medical Education: A Comprehensive Systematic Review and Narrative Analysis

Miniaturization has made ultrasound (US) technology ultraportable and, in association with their relatively low cost, made handheld devices attractive for medical education training programs. However, performing an ultrasound requires complex skills, and it is unclear whether handheld devices are suitable for the training of novices. Our study aimed to identify to what extent handheld US devices can be employed in medical undergraduates' and residents' education. We selected studies that evaluate the results obtained by students and/or residents who have participated in ultrasound training programs using handheld devices. The studies were included if they reported post-test (pre-test optional) achievements or a comparison with a control group (a group of experts or novices who underwent a different intervention). Twenty-six studies were selected, and their characteristics were summarized. Handheld ultrasound devices were used in training programs to learn echocardiography, abdominal, and/or musculoskeletal ultrasound. Statistically significant progress was noted in the ability of naïve participants to capture and interpret ultrasound images, but training duration influenced the outcomes. While ultrasound training using handheld devices has proven to be feasible for various body regions and purposes (e.g., better understanding of anatomy, clinical applications, etc.), the long-term impacts of handheld education interventions must be considered in addition to the short-term results to outline guidelines for targeted educational needs.

Tele-Mentored Handheld Ultrasound System for General Practitioners: A Prospective, Descriptive Study in Remote and Rural Communities

BACKGROUND

Rural general practitioners (GPs) have insufficient diagnostic information to deal with complex clinical scenarios due to the inequality in medical imaging resources in rural and remote communities. The objective of this study is to explore the value of a tele-mentored handheld ultrasound (tele-HHUS) system, allowing GPs to provide ultrasound (US) services in rural and remote communities.

METHODS

Overall, 708 patients underwent tele-HHUS examination between March and October 2021 and March and April 2022 across thirteen primary hospitals and two tertiary-care general hospitals. All US examinations were guided and supervised remotely in real time by US experts more than 300 km away using the tele-HHUS system. The following details were recorded: location of tele-HHUS scanning, primary complaints, clinical diagnosis, and US findings. The recommendations (referral or follow-up) based on clinical experience alone were compared with those based on clinical experience with tele-HHUS information.

RESULTS

Tele-HHUS examinations were performed both in hospital settings (90.6%, 642/708) and out of hospital settings (9.4%, 66/708). Leaving aside routine physical examinations, flank pain (14.2%, 91/642) was the most common complaint in inpatients, while chest distress (12.1%, 8/66) and flank discomfort (12.1%, 8/66) were the most common complaints in out-of-hospital settings. Additionally, the referral rate increased from 5.9% to 8.3% (kappa = 0.202; p = 0.000).

CONCLUSIONS

The tele-HHUS system can help rural GPs perform HHUS successfully in remote and rural communities. This novel mobile telemedicine model is valuable in resource-limited areas.

A Cadaveric Study Examining the Accuracy of Wireless Hand-Held Guided Ultrasound Injections Versus Blind Injections in the Flexor Tendon Sheath

Purpose

Hand-held ultrasound (HHUS) is gaining popularity among clinicians. Although its use for procedural guidance could have several advantages in hand surgery, other surgeons may wonder about its added benefits. This cadaveric study aimed to examine the hypothesis of increased accuracy of wireless HHUS-guided injections versus that of blind injections into the flexor sheath.

Methods

Our series included 20 fresh cadaveric hands with 80 fingers randomly assigned to 2 groups. In group A, 10 hands were randomly assigned to receive a landmark injection and then received a blinded injection to the flexor tendon sheath (FTS). In group B, 10 hands were blinded in the same manner and received an ultrasound-guided injection with HHUS. Methylene blue was injected, and anatomic dissection was performed to evaluate the injection accuracy based on the dye's filling pattern in the FTS as stage I (no filling), stage II (<50% filling), and stage III (>50% filling). Statistical analysis was performed, and P <.05 indicated a significant difference.

Results

One finger was excluded because of severe Dupuytren contracture. In group A, 39 blind injections of the FTS were performed, with 82% (32/39) fingers achieving stage III filling. In group B, 40 ultrasound-guided FTS injections were performed, with 90% (36/40) of fingers achieving stage III filing. Our study did not reveal any superiority in accuracy when ultrasound guidance was used (P = .35).

Conclusions

Hand-held ultrasound-guided FTS injections were not more accurate than blind injections performed by an experienced hand surgeon. These findings suggest that blind injections can be used as routine practice when performed by experienced operators to treat trigger finger. However, the use of HHUS may offer other advantages in hand surgery practice.

Clinical relevance

Ultimately, choosing to perform HHUS-guided injection versus blind injection to treat trigger finger depends on the surgeon's experience and preference for a particular technique.

A paradigm shift in point-of-care imaging in low-income and middle-income countries

The concept of primary healthcare is now regarded as crucial for enhancing access to healthcare services in low-income and middle-income countries (LMICs). Technological advancements that have made many medical imaging devices smaller, lighter, portable and more affordable, and infrastructure advancements in power supply, Internet connectivity, and artificial intelligence, are all increasing the feasibility of POCI (point-of care imaging) in LMICs. Although providing imaging services at the same time as the clinic visit represents a paradigm shift in the way imaging care is typically provided in high-income countries where patients are typically directed to dedicated imaging centres, a POCI model is often the only way to provide timely access to imaging care for many patients in LIMCs. To address the growing burden of non-communicable diseases such as cancer and heart disease, bringing advanced imaging tools to the POCI will be necessary. Strategies tailored to the countries' specific needs, including training, safety and quality, will be of the utmost importance.

Challenges in the diagnosis and management of IBD: a sub-Saharan African perspective

With the exception of South Africa, inflammatory bowel disease (IBD) has long been considered uncommon in sub-Saharan Africa (SSA) with a dearth of peer-reviewed publications from the subcontinent. This most likely reflects underreporting as some cases may be missed due to the high burden of infectious diseases which may closely mimic IBD. In addition, many countries in SSA have limited endoscopic capacity, inadequate access to diagnostic imaging and a notable scarcity of histopathologists, radiologists and gastroenterologists. Beyond these obstacles, which significantly impact patient care, there are many other challenges in SSA, particularly the unavailability of key IBD therapies. In this review, we discuss barriers in diagnosing and managing IBD in SSA, as well as some of the initiatives currently in place to address these short comings.

New International Guidelines and Consensus on the Use of Lung Ultrasound

Following the innovations and new discoveries of the last 10 years in the field of lung ultrasound (LUS), a multidisciplinary panel of international LUS experts from six countries and from different fields (clinical and technical) reviewed and updated the original international consensus for point-of-care LUS, dated 2012. As a result, a total of 20 statements have been produced. Each statement is complemented by guidelines and future developments proposals. The statements are furthermore classified based on their nature as technical (5), clinical (11), educational (3), and safety (1) statements.

Point-Of-Care Ultra-Sound (POCUS) for suspected surgical abdominal conditions in rural India-a mixed-method health needs assessment

INTRODUCTION

Evidence has shown a trend towards rising mortality from surgical abdominal conditions with increasing distance from hospitals in Eastern India. It has been claimed that imaging modalities such as portable ultrasound are ideal for use in rural areas of developing countries for diagnosis and management of a variety of acute abdominal conditions. This mixed-methods study aimed to explore the need for increased access to POCUS in rural, hard-to-reach populations within India, and to identify barriers that may exist to increasing this access.

METHODS

This mixed-methods study utilized a health needs assessment framework. Quantitative data was extracted from medical records within two outreach camp organisations supporting hard-to-reach populations in Uttarakhand and Jharkhand to provide contextual background statistics. Qualitative data was collected using semi-structured interviews taken from employees of each outreach camp. A framework analysis was employed to analyse the qualitative data. Both datasets were analysed in parallel.

RESULTS

Twelve semi-structured interviews were undertaken, and 3 months of medical records were reviewed. Themes that presented themselves from the data included the use of camps for case-finding of conditions amenable to routine surgery, a need for POCUS to help with this diagnostic process, a perceived high disease burden from renal calculi, and complex cultural and legislative barriers to POCUS specific to this setting.

DISCUSSION

POCUS was considered a useful tool in expanding access to surgery for these settings and finding ways of overcoming cultural and legislative barriers to its use should be of high priority. POCUS should be highly portable, robust, easily repairable, and battery operated. For telemedicine to be fully utilised, signal quality will have to be proven to be reliable.

Point-of-care ultrasound needs assessment in a paediatric acute care setting in Malawi

OBJECTIVE

To describe the use of point-of-care ultrasound (POCUS) in an acute-care paediatric setting in Malawi, including clinical indications, types of examinations and frequency of positive findings.

METHODS

Retrospective, cross-sectional study of a convenience sample of POCUS examinations performed in one tertiary referral hospital in Lilongwe, Malawi over 1 year. POCUS examinations were performed by Paediatric Emergency Medicine physician consultants as part of routine clinical practice and at the request of local clinicians. Images were saved along with the clinical indication and physician interpretation for quality review. Ultrasounds performed by the radiology department and those examinations that were technically faulty, missing clinical application or interpretation were excluded.

RESULTS

In total, 225 ultrasounds of 142 patients were analysed. The most common clinical indications for which examinations were completed were respiratory distress (23%), oedema (11.7%) and shock/arrest (6.2%). The most common examinations performed were cardiac (41.8%) and lung (15.1%), focused assessment with sonography in trauma (FAST; 12.9%) and ultrasound-guided procedural examinations (9.8%). Pathology was identified in 68% of non-procedural examinations. Cardiac examinations demonstrated significant pathology, including reduced cardiac function (12.8%), gross cardiac structural abnormality (11.8%) and pericardial effusion (10.3%).

CONCLUSIONS

POCUS was used for both clinical decision-making and procedural guidance, and a significant number of POCUS examinations yielded positive findings. Thus, we propose that cardiopulmonary, FAST and procedural examinations should be considered in future for the POCUS curriculum in this setting.

mHealth in sub-Saharan Africa and Europe: A systematic review comparing the use and availability of mHealth approaches in sub-Saharan Africa and Europe

Background

mHealth can help with healthcare service delivery for various health issues, but there's a significant gap in the availability and use of mHealth systems between sub-Saharan Africa and Europe, despite the ongoing digitalization of the global healthcare system.

Objective

This work aims to compare and investigate the use and availability of mHealth systems in sub-Saharan Africa and Europe, and identify gaps in current mHealth development and implementation in both regions.

Methods

The study adhered to the PRISMA 2020 guidelines for article search and selection to ensure an unbiased comparison between sub-Saharan Africa and Europe. Four databases (Scopus, Web of Science, IEEE Xplore, and PubMed) were used, and articles were evaluated based on predetermined criteria. Details on the mHealth system type, goal, patient type, health concern, and development stage were collected and recorded in a Microsoft Excel worksheet.

Results

The search query produced 1020 articles for sub-Saharan Africa and 2477 articles for Europe. After screening for eligibility, 86 articles for sub-Saharan Africa and 297 articles for Europe were included. To minimize bias, two reviewers conducted the article screening and data retrieval. Sub-Saharan Africa used SMS and call-based mHealth methods for consultation and diagnosis, mainly for young patients such as children and mothers, and for issues such as HIV, pregnancy, childbirth, and child care. Europe relied more on apps, sensors, and wearables for monitoring, with the elderly as the most common patient group, and the most common health issues being cardiovascular disease and heart failure.

Conclusion

Wearable technology and external sensors are heavily used in Europe, whereas they are seldom used in sub-Saharan Africa. More efforts should be made to use the mHealth system to improve health outcomes in both regions, incorporating more cutting-edge technologies like wearables internal and external sensors. Undertaking context-based studies, identifying determinants of mHealth systems use, and considering these determinants during mHealth system design could enhance mHealth availability and utilization.

Ambulatory Use of Handheld Point-of-Care Ultrasound (HH-POCUS) in Rural Brandenburg - A Pilot Study

PURPOSE

 This study aims to evaluate the use of handheld ultrasound devices (HHUS) for point-of-care ultrasound (POCUS) to improve outpatient care in rural Brandenburg.

MATERIALS AND METHODS

 A group of general practitioners (n = 9), palliative care physicians (n = 6), emergency physicians (n = 4), and nurses from palliative care services (n = 5) participated in this study. Following a 3-hour workshop and 2 weeks of individual training, participants performed POCUS using HHUS (HH-POCUS). Indications, examination results, and resulting treatment changes (e. g., acute interventions, new medication) were documented in a standardized data entry form.

RESULTS

 19 physicians with different ultrasound experience and 5 palliative care nurses attended the workshop program and took part in the study. Three of the participating physicians were out of training in ultrasound and received prolonged supervision. Among 427 HH-POCUS examinations, the FAST scan and kidney scan were performed most often. Pain and dyspnea were the most common indications for HH-POCUS. Among the examinations performed by physicians (n = 311), ascites was the most common pathology (27 % of cases). Using a simplified examination protocol, palliative care nurses diagnosed fluid collections, hydronephrosis and transurethral catheter position or urinary retention. In 80.4 % of physician-performed cases, HH-POCUS made a valuable impact on patient management. HH-POCUS contributed to treatment decisions in 49.5 % of cases, including a change of medication in 29.6 % and performance of therapeutic interventions in 19.9 %. Hospital admission or referral to an ambulatory specialist was initiated due to HH-POCUS findings in 17.7 % of patients.

CONCLUSION

 HH-POCUS helped doctors in rural areas to optimize patient care through rapid on-site collection of therapeutically relevant findings. In addition, it was shown that specialized and motivated nurses can independently detect simple ultrasound findings and thus provide clinically relevant information to doctors.

Medial Meniscal Extrusion Evaluation With Weight-Bearing Ultrasound: Correlation With MR Imaging Findings and Reported Symptoms: Correlation With MR Imaging Findings and Reported Symptoms

OBJECTIVES

To compare medial meniscal extrusion on weight-bearing ultrasound (US) with supine US and magnetic resonance (MR) imaging correlating with meniscal pathology and reported symptoms.

METHODS

IRB approved study with informed consent. Patients obtaining routine knee MR imaging for suspected knee pathology were prospectively evaluated with supine and weight-bearing US of the medial meniscus. Meniscal extrusion was measured independently by two fellowship-trained musculoskeletal radiologists. Correlation was made to presence or absence of meniscal degeneration or tear on MR imaging, as well as reported symptoms. Statistical significance was calculated via intraclass correlation coefficient (ICC) and analysis of variance (ANOVA).

RESULTS

Ninety-nine knees from 95 subjects (50 males, 45 females; mean age 45 ± 15 years) were included. Mean medial meniscal extrusion measured at US for a normal meniscus (n = 36) was 0.8 mm when supine, increasing to 1.6 mm on weight-bearing. Mean meniscal extrusion in subjects with mucoid degeneration (n = 20) and those with meniscal tears (n = 43) was 1.6 mm, increasing to 2.3 mm with weight bearing. Inter-reader reliability showed ICC values of 0.853 to 0.940. There was a significant difference in medial meniscal extrusion comparing subjects with a normal medial meniscus at magnetic resonance imaging (MRI) and subjects with either meniscal degeneration or tear. There was no significant difference in degree of meniscal extrusion between subjects with meniscal degeneration or tear. There was trend of worsening symptoms and increasing functional limitations moving from normal meniscus to meniscal degeneration to meniscal tear.

CONCLUSIONS

A normal meniscus shows lesser mobility between supine and upright position, than a pathologic meniscus. Both mucoid degeneration and meniscal tear demonstrate extrusion in the supine position, which increases with weight-bearing position.

Effect of Point-of-Care Ultrasound on Clinical Outcomes in Low-Resource Settings: A Systematic Review

Despite the potential for improved patient care, little is known of the true effect of point-of-care ultrasound (POCUS) on patient outcomes in resource-limited settings. Electronic databases were searched using medical subject heading and free text terms related to POCUS and resource-limited settings through August 2020. Two authors independently selected studies, assessed methodological quality using the Downs and Black scale and extracted data. Twenty observational studies were included in the final review. All studies had moderate to high risk of bias. No studies exhibited an effect on the pre-specified primary outcome of mortality. Varying degrees of change in differential diagnosis and management were reported, but definitions varied widely among studies. Estimates for change in diagnosis as a result of POCUS ranged from 15% to 52%, and those for change in management, from 17% to 87%. Articles on POCUS clinical utility represent a small part (4.6%) of the scholastic literature dedicated to POCUS in low-resource settings. POCUS is a valuable intervention to consider in resource-limited settings, with the potential to change diagnosis and patient management. The exact magnitude of effect remains unknown. There is a continued need for large-scale experimental studies to investigate the effect of POCUS on patient diagnosis, management and mortality.

Pocket-Sized Ultrasound Versus Traditional Ultrasound Images in Equine Imaging: A Pictorial Essay

This pictorial essay aims to display the image quality of pocket-sized ultrasound devices and hospital-based equipment to provide clinicians visual information about the potential uses of point-of-care ultrasonography (POCUS) in equine practice. Twenty-two paired images were obtained using traditional ultrasound equipment and pocket-sized ultrasound devices from patients evaluated at veterinary teaching hospitals. Images of many common ultrasound windows and miscellaneous sonographic abnormalities were obtained using pocket-sized ultrasound equipment.

Cardiovascular examination using hand-held cardiac ultrasound

Echocardiography is the first-line imaging modality for assessing cardiac function and morphology. The miniaturisation of ultrasound technology has led to the development of hand-held cardiac ultrasound (HCU) devices. The increasing sophistication of available HCU devices enables clinicians to more comprehensively examine patients at the bedside. HCU can augment clinical exam findings by offering a rapid screening assessment of cardiac dysfunction in both the Emergency Department and in cardiology clinics. Possible implications of implementing HCU into clinical practice are discussed in this review paper.

Ultrasound-guided internal jugular venipuncture using pocket-sized versus standard ultrasound devices: a prospective non-inferiority trial

PURPOSE

Pocket-sized ultrasound devices (PUDs) are commonly adopted for bedside use despite their inferior performance compared with standard ultrasound devices (SUDs). We investigated the non-inferiority of PUDs versus SUDs for ultrasound-guided internal jugular venipuncture.

METHODS

All patients undergoing scheduled surgery with general anesthesia and internal jugular vein catheter placement were prospectively included in this randomized non-inferiority trial to compare the qualities of the internal jugular venipuncture between the PUD group (Group P) and SUD group (Group S). The primary endpoint was puncture time, and the secondary endpoints included number of punctures, needle and guidewire visibility, and anatomic visibility.

RESULTS

Fifty-two patients were randomized to one of the two groups (26 per group). The mean (SEM) puncture time was 56.4 (10.9) s in Group P and 45.5 (4.0) s in Group S. The mean difference of 10.9 s was within the prespecified non-inferiority margin of 100% (two-sided 95% CI: - 12.9-34.6, upper limit of the 95% CI: 45.5) for puncture time. The mean (SEM) number of punctures was 1.15 (0.12) times in Group P and 1.12 (0.06) times in Group S. The difference of 0.04 punctures was within the prespecified non-inferiority margin of 100% (two-sided 95% CI: - 0.24-0.31, upper limit of the 95% CI: 1.12) for number of punctures. Non-inferiority was not shown for needle and guidewire visibility and anatomic visibility.

CONCLUSION

PUDs for internal jugular venipuncture are not inferior to SUDs with regard to puncture time and number of punctures, despite differences in visibility and device performance.

Performance of a Handheld Ultrasound Device to Assess Articular and Periarticular Pathologies in Patients with Inflammatory Arthritis

The purpose of this study was to assess the accuracy and performance of a new handheld ultrasound (HHUS) machine in comparison to a conventional cart-based sonographic machine in patients with inflammatory arthritis (IA). IA patients with at least one tender and swollen joint count were enrolled. US was performed on the clinically affected joints using a cart-based sonographic device (Samsung HS40) and a HHUS device (Butterfly iQ). One blinded reader scored all images for the presence of erosions, bony enlargement, synovial hypertrophy, joint effusion, bursitis, tenosynovitis, and enthesitis. Synovitis was graded (B mode and power Doppler (PD)) by the 4-level EULAR-OMERACT scale. To avoid bias by the blinded reader, we included 67 joints of two healthy volunteers in the evaluation. We calculated the overall concordance and the concordance by type of joint and pathological finding. We also measured the time required for the US examination per joint with both devices. Thirty-two patients (20 with RA, 10 with PsA, and one each with gout and SLE-associated arthritis) were included, and 186 joints were examined. The overall raw concordance in B mode was 97% (κappa 0.90, 95% CI (0.89, 0.94)). In B mode, no significant differences were found in relation to type of joint or pathological finding examined. The PD mode of the HHUS device did not detect any PD signal, whereas the cart-based device detected a PD signal in 61 joints (33%). The portable device did not offer any time savings compared to the cart-based device (47.0 versus 46.3 s). The HHUS device was accurate in the assessment of structural damage and inflammation in patients with IA, but only in the B mode. Significant improvements are still needed for HHUS to reliably demonstrate blood flow detection in PD mode.

Utility of Point of Care Ultrasound in Humanitarian Assistance Missions

INTRODUCTION

Point of care ultrasound (POCUS) is increasingly used in primary care in the USA and has been shown to provide significant benefit to care in deployed military settings and during disaster relief efforts. It is less studied as a tool during humanitarian assistance missions. We sought to determine the utility of POCUS in a humanitarian assistance setting during the February 2019 joint U.S.-Brazilian hospital assistance mission aboard the Hospitalar Assistance Ship Carlos Chagas along the Madeira River in the Brazilian Amazon.

MATERIALS AND METHODS

Point of care ultrasound was offered as a diagnostic modality to primary care physicians during the course of a month-long mission. A handheld IVIZ ultrasound machine was loaned for use during this mission by Sonosite. A P21v phased array (5-1 MHz) or an L38v linear (10-5 MHz) transducer was used for scanning. Requests for POCUS examinations, their findings, and changes in patient management were recorded.

RESULTS

Point of care ultrasound examinations were requested and performed in 24 of 814 (3%) outpatient primary care visits. Ten of these studies (42% of POCUS examinations, 1.2% of all patient visits) directed patient management decisions, in each case preventing unnecessary referral.

CONCLUSIONS

In this austere setting, POCUS proved to be an inexpensive, effective tool at preventing unnecessary referrals. Future medical humanitarian assistance missions may likewise find POCUS to be a primary care force-multiplier.

Emerging applications of clinical ultrasonography

In this work, we introduce the numerous emerging areas and frontiers in the use of point-of-care ultrasonography. Of these, we review the following three: 1) the use of clinical ultrasonography in infectious and tropical diseases (we address its usefulness in the diagnosis and follow-up of the main syndromes, in tropical diseases, and in areas with scarce resources); 2) the usefulness of clinical ultrasonography in the assessment of response to volume infusion in severely ill patients (we review basic concepts and the main static and dynamic variables used for this evaluation); and 3) the use of clinical ultrasonography in the assessment of muscle mass in elderly patients with primary sarcopenia (we review the main muscles and measurements used for it).

Real-Time Remote Tele-Mentored Echocardiography: A Systematic Review

Background and Objectives: Real-time remote tele-mentored echocardiography (RTMUS echo) involves the transmission of clinical ultrasound (CU) cardiac images with direct feedback from a CU expert at a different location. In this review, we summarize the current uses of RTMUS to diagnose and manage cardiovascular dysfunction and discuss expanded and future uses. Materials and Methods: We performed a literature search (PubMed and EMBase) to access articles related to RTMUS echo. We reviewed articles for selection using Covidence, a web-based tool for managing systematic reviews and data were extracted using a separate standardized collection form. Results: Our search yielded 15 articles. Twelve of these articles demonstrated the feasibility of having a novice sonographer mentored by a tele-expert in obtaining a variety of cardiac ultrasound views. The articles discussed different technological specifications for the RTMUS system, but all showed that adequate images were able to be obtained. Overall, RTMUS echo was found to be a positive intervention that contributed to patient care. Conclusion: RTMUS echo allows for rapid access to diagnostic imaging in various clinical settings. RTMUS echo can help in assessing patients that may require a higher level of isolation precautions or in other resource-constrained environments. In the future, identifying the least expensive way to utilize RTMUS echo will be important.

Emerging applications of clinical ultrasonography

In this work, we introduce the numerous emerging areas and frontiers in the use of point-of-care ultrasonography. Of these, we review the following three: 1) the use of clinical ultrasonography in infectious and tropical diseases (we address its usefulness in the diagnosis and follow-up of the main syndromes, in tropical diseases, and in areas with scarce resources); 2) the usefulness of clinical ultrasonography in the assessment of response to volume infusion in severely ill patients (we review basic concepts and the main static and dynamic variables used for this evaluation); and 3) the use of clinical ultrasonography in the assessment of muscle mass in elderly patients with primary sarcopenia (we review the main muscles and measurements used for it).

Sonographic findings in visceral leishmaniasis - A narrative review

BACKGROUND

Visceral leishmaniasis (VL) is predominantly a neglected tropical parasitic disease but may also be acquired by travellers. We aimed at summarizing knowledge on sonographic presentation of VL to better understand sonographic features of VL.

METHODS

PubMed was searched for studies and case reports presenting original data on sonographic findings of VL, published before August 13th, 2019. Demographic, clinical, and sonographic data were extracted and summarized in a qualitative approach.

RESULTS

A total of 36 publications were included in this review; 27 of these were case reports and the remainder were prospective or retrospective studies. No study reported systematic cross-sectional comparative imaging. Overall, publications reported on 512 patients with VL of whom 12 were reported HIV-infected. Spleno- and hepatomegaly were the most frequently reported findings. Further relevant and repeatedly reported findings were splenic and hepatic lesions, abdominal lymphadenopathy, pleural and pericardial effusion and ascites. Reported focal splenic lesions were heterogeneous in size, shape, and echogenicity. Several publications reported gradual diminution and resolution of sonographic findings with VL treatment.

CONCLUSION

Available literature on sonographic findings of VL is limited. Available reports indicate that spleno- and hepatomegaly, free fluid, abdominal lymphadenopathy, and focal splenic lesions may be common sonographic features in patients with VL. Because of the apparent overlap of sonographic features of VL, extrapulmonary tuberculosis and other conditions, interpretation of sonographic findings needs to be made with particular caution.

Hand-Held Portable Versus Conventional Cart-Based Ultrasound in Musculoskeletal Imaging

Background:

Portable ultrasound machines are now common, used for point-of-care applications and needle guidance for percutaneous procedures; however, the effectiveness of portable ultrasound in evaluation of the musculoskeletal system has not been fully assessed.

Purpose:

To prospectively evaluate the use of portable hand-held ultrasound in comparison with conventional cart-based ultrasound in evaluation of the musculoskeletal system.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

In this institutional review board–approved, prospective study, 100 consecutive patients with informed consent were imaged through use of both portable and cart-based ultrasound equipment using 12-5 MHz linear transducers. Agreement in ultrasound diagnosis was documented along with expected clinical changes in management if there was disagreement (definitely no, probably no, uncertain, probably yes, definitely yes). Imaging details of disagreement cases were recorded, and descriptive statistics were calculated.

Results:

There were 42 male and 58 female patients (mean ± SD age, 53 ± 13 years) imaged over a time period of 20 months. Anatomic areas scanned were the shoulder (n = 30), elbow (n = 11), hand and wrist (n = 15), hip (n = 10), knee (n = 11), foot and ankle (n = 12), and others (n = 11). Scanning with conventional ultrasound revealed abnormality in 92% of patients. Agreement in diagnosis made between portable versus cart-based ultrasound was found in 65% of patients. In the 35% of patients with discordant results, the change in diagnosis resulted in no change in clinical management in 46%, probably no change in 29%, uncertain change in 14%, probable change in 11%, and definite change in 0%. The diagnoses changing management (4%; 4/100) included nondetection of a satellite nodule (n = 1), ganglion cyst (n = 1), hernia (n = 1), and underestimated tendon tear (n = 1).

Conclusion:

When compared with conventional cart-based ultrasound, a musculoskeletal diagnosis using portable hand-held ultrasound was concordant or was discordant without clinical relevance in 96% (96/100) of patients. Knowledge of benefits and limitations of portable hand-held ultrasound will help determine areas where specific types of ultrasound equipment can be used.

Trends in Ultrasound Use in Low and Middle Income Countries: A Systematic Review

BACKGROUND

Evidence on recent trends regarding the impact and cost-benefits of ultrasound in resource-constrained settings is limited. This study presents a systematic review to determine recent trends in the utility and applicability of ultrasound use in low and middle income countries (LMIC). The review includes characterizing and evaluating trends in (1) the geographic and specialty specific use of ultrasound in LMICs, (2) the innovative applications and the accompanying research findings, and (3) the development of associated educational and training programs.

METHODS

The electronic databases Medline OVID, EMBASE, and Cochrane were searched from 2010 to 2018 for studies available in English, French, and Spanish. Commentaries, opinion articles, reviews and book chapters were excluded. Two categories were created, one for reported applications of ultrasound use in LMICs and another for novel ultrasound studies.

RESULTS

A total of 6,276 articles were identified and screened, 4,563 studies were included for final review. 287 studies contained original or novel applications of ultrasound use in LMICs. Nearly 70% of studies involved ultrasound usage originating from Southeast Asia and sub-Saharan Africa, the latter being the region with the highest number of innovative ultrasound use. Educational studies, global collaborations, and funded studies were a substantial subset of overall ultrasound research. Our findings are limited by the lack of higher quality evidence and limited number of randomized clinical trials reported.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Our systematic literature review of ultrasound use in LMICs demonstrates the growing utilization of this relatively low-cost, portable imaging technology in low resource settings.

[Epidemic and emerging prone-infectious diseases: Lessons learned and ways forward]

Africa along side with south-east Asia are the epicentres of emerging and epidemic prone-infectious diseases and megacity biosecurity threat scenarios. Massive mobility and reluctance in the populations exposed to epidemic and emerging prone-infectious diseases coupled by a weak health system made disease alert and control measures difficult to implement. The investigation of virus detection and persistence in semen across a range of emerging viruses is useful for clinical and public health reasons, in particular for viruses that lead to high mortality or morbidity rates or to epidemics. Innovating built facility to safely treat patients with highly pathogenic infectious diseases is urgently need, not only to prevent the spread of infection from patients to healthcare workers but also to offer provision of relatively invasive organ support, whenever considered appropriate, without posing additional risk to staff. Despite multiple challenges, the need to conduct research during epidemics is inevitable, and candidate products must continue undergoing rigorous trials. Preparedness including management of complex humanitarian crises with community distrust is a cornerstone in response to high consequence emerging infectious disease outbreaks and imposes strengthening of the public health response infrastructure and emergency outbreak systems in high-risk regions.

Congenital Heart Disease in Low- and Lower-Middle-Income Countries: Current Status and New Opportunities

PURPOSE OF REVIEW

The paper summarises the most recent data on congenital heart disease (CHD) in low- and lower-middle-income countries (LLMICs). In addition, we present an approach to diagnosis, management and interventions in these regions and present innovations, research priorities and opportunities to improve outcomes and develop new programs.

RECENT FINDINGS

The reported birth prevalence of CHD in LLMICs is increasing, with clear evidence of the impact of surgical intervention on the burden of disease. New methods of teaching and training are demonstrating improved outcomes. Local capacity building remains the key. There is a significant gap in epidemiological and outcomes data in CHD in LLMICs. Although the global agenda still does not address the needs of children with CHD adequately, regional initiatives are focusing on quality improvement and context-specific interventions. Future research should focus on epidemiology and the use of innovative thinking and partnerships to provide low-cost, high-impact solutions.

Tele-Ultrasound in Resource-Limited Settings: A Systematic Review

Background: Telemedicine, or healthcare delivery from a distance, has evolved over the past 50 years and helped alter health care delivery to patients around the globe. Its integration into numerous domains has permitted high quality care that transcends obstacles of geographic distance, lack of access to health care providers, and cost. Ultrasound is an effective diagnostic tool and its application within telemedicine (“tele-ultrasound”) has advanced substantially in recent years, particularly in high-income settings. However, the utility of tele-ultrasound in resource-limited settings is less firmly established.

Objective: To determine whether remote tele-ultrasound is a feasible, accurate, and care-altering imaging tool in resource-limited settings.

Data Sources: PubMed, MEDLINE, and Embase.

Study Eligibility Criteria: Twelve original articles met the following eligibility criteria: full manuscript available, written in English, including a direct patient-care intervention, performed in a resource-limited setting, images sent to a remote expert reader for interpretation and feedback, contained objective data on the impact of tele-ultrasound.

Study Appraisal and Synthesis Methods: Abstracts were independently screened by two authors against inclusion criteria for full-text review. Any discrepancies were settled by a senior author. Data was extracted from each study using a modified Cochrane Consumers and Communication Review Group's data extraction template. Study bias was evaluated using the ROBINS-I tool.

Results: The study results reflect the diverse applications of tele-ultrasound in low-resource settings. Africa was the most common study location. The specialties of cardiology and obstetrics comprised most studies. Two studies primarily relied on smartphones for image recording and transmission. Real-time, rather than asynchronous, tele-ultrasound image interpretation occurred in five of the 12 studies. The most common outcome measures were image quality, telemedicine system requirements, diagnostic accuracy, and changes in clinical management.

Limitations: The studies included were of poor quality with a dearth of randomized control trials and with significant between study heterogeneity which resulted in incomplete data and made cross study comparison difficult.

Conclusions and Implications of Key Findings: Low-quality evidence suggests that ultrasound images acquired in resource-limited settings and transmitted using a telemedical platform to an expert interpreter are of satisfactory quality and value for clinical diagnosis and management.

Diagnosis and Management of Acute Heart Failure in Sub-Saharan Africa

PURPOSE OF REVIEW

Acute heart failure (AHF) is a common emergency presentation in Sub-Saharan Africa (SSA). In the current review, we present the most recent data on the epidemiology of AHF in SSA and discuss recommended approaches to management in resource-limited settings, with a particular focus on primary and secondary facilities (e.g., health centers and district hospitals), where these patients often present.

RECENT FINDINGS

AHF in SSA is most often due to hypertension, cardiomyopathies, and rheumatic heart disease. The etiology of AHF may be different in rural as compared with urban settings. Diagnostic tools for AHF are often lacking in SSA, especially at the first-level facilities. Point-of-care ultrasound (POCUS) and biomarker tests, such as brain natriuretic peptide (BNP), offer promise in helping to mitigate diagnostic challenges. POCUS can also help distinguish among types of heart failure and prompt the correct treatment strategy. Many of the drugs and equipment commonly used to treat AHF in resource-rich settings are lacking in SSA. However, some adaptations of commonly available materials may provide temporary alternatives. The epidemiology of AHF in SSA differs from that of high-income settings. Management of AHF at the first-level facility in SSA is an important and understudied problem. Simplified diagnostic and treatment algorithms rooted in knowledge of the local epidemiology should be developed and tested as part of broader efforts to combat cardiovascular disease in SSA.

Seeing with Sound: How Ultrasound Is Changing the Way We Look at Anatomy

Ultrasound uses high frequency sound waves and their rebounding echoes to capture live images of the structures beneath the skin. Thanks to recent technological advances, contemporary ultrasound machines offer excellent image resolution packaged in smaller, highly portable devices, which has allowed ultrasound to expand into new areas, both within the hospital as well as across non-traditional settings. Ultrasound is an incredibly powerful visualization tool in medicine, allowing physicians to safely see and interrogate the most relevant parts of their patient's internal anatomy instantly. Point-of-care ultrasound, a focused ultrasound evaluation performed at the patient's bedside, is now common across medical specialties, encompassing a vast array of diagnostic, procedural and screening applications. The impressive expansion of point-of-care ultrasound has resulted in an increased demand for ultrasound training earlier during medical school. As a non-invasive and non-destructive way to see inside the living body, ultrasound is an ideal tool to teach anatomy. It allows both medical and non-medical students the ability to improve their understanding and retention of anatomical form and function. The widespread and still expanding use of ultrasound in healthcare today, as well as its adoption into the anatomy classroom, is a testament to the power of ultrasound for achieving real-time visualization of the hidden aspects of our bodies.

Assessment of Point-of-Care Ultrasound Training for Clinical Educators in Malawi, Tanzania and Uganda

Integrating point-of-care ultrasound (POCUS) to enhance diagnostic availability in resource-limited regions in Africa has become a main initiative for global health services in recent years. In this article, we present lessons learned from introducing POCUS as part of the Global Health Service Partnership (GHSP), a collaboration started in 2012 between the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Peace Corps and Seed Global Health to provide health care work force education and training in resource-limited countries. A cross-sectional survey of GHSP clinical educators trained to use POCUS and provided with hand-held ultrasound during their 1-y deployment during the period 2013-2017. The survey consisted of 35 questions on the adequacy of the training program and how useful POCUS was to their overall clinical and educational mission. Clinical educators engaged in a series of ultrasound educational initiatives including pre-departure training, bedside training in the host institutions, online educational modules, educational feedback on transmitted images and training of local counterparts. In this study 63 GHSP clinical educators who participated in the POCUS trainings were identified, and 49 were included at the study (78% response rate). They were assigned to academic institutions in Tanzania (n = 24), Malawi (n = 21) and Uganda (n = 18). More than 75% reported use of POCUS in clinical diagnoses and 50% in determining treatment, and 18% reported procedural application of ultrasound in their practice. The top indications for POCUS were cardiac exams, second- and third-trimester obstetric exams, lung and pleura, liver and spleen and gynecology/first-trimester obstetrics. The largest perceived barriers were lack of ultrasound knowledge by the clinical educators, lack of time, equipment security, difficulty accessing the Internet and equipment problems. We concluded that our multiphase POCUS training program has increased the utility, acceptability and usage of POCUS in resource-limited settings.

Implementation science in resource-poor countries and communities

Background

Implementation science in resource-poor countries and communities is arguably more important than implementation science in resource-rich settings, because resource poverty requires novel solutions to ensure that research results are translated into routine practice and benefit the largest possible number of people.

Methods

We reviewed the role of resources in the extant implementation science frameworks and literature. We analyzed opportunities for implementation science in resource-poor countries and communities, as well as threats to the realization of these opportunities.

Results

Many of the frameworks that provide theoretical guidance for implementation science view resources as contextual factors that are important to (i) predict the feasibility of implementation of research results in routine practice, (ii) explain implementation success and failure, (iii) adapt novel evidence-based practices to local constraints, and (iv) design the implementation process to account for local constraints. Implementation science for resource-poor settings shifts this view from “resources as context” to “resources as primary research object.” We find a growing body of implementation research aiming to discover and test novel approaches to generate resources for the delivery of evidence-based practice in routine care, including approaches to create higher-skilled health workers—through tele-education and telemedicine, freeing up higher-skilled health workers—through task-shifting and new technologies and models of care, and increasing laboratory capacity through new technologies and the availability of medicines through supply chain innovations. In contrast, only few studies have investigated approaches to change the behavior and utilization of healthcare resources in resource-poor settings. We identify three specific opportunities for implementation science in resource-poor settings. First, intervention and methods innovations thrive under constraints. Second, reverse innovation transferring novel approaches from resource-poor to research-rich settings will gain in importance. Third, policy makers in resource-poor countries tend to be open for close collaboration with scientists in implementation research projects aimed at informing national and local policy.

Conclusions

Implementation science in resource-poor countries and communities offers important opportunities for future discoveries and reverse innovation. To harness this potential, funders need to strongly support research projects in resource-poor settings, as well as the training of the next generation of implementation scientists working on new ways to create healthcare resources where they lack most and to ensure that those resources are utilized to deliver care that is based on the latest research results.