Evaluation of a Cranial Ultrasound Screening Protocol for Very Preterm Infants.

OBJECTIVES: Cranial ultrasound (cUS) screening is recommended for preterm neonates born before 32 weeks' gestational age (GA). The primary aim of this study was to determine if both a day 3 and day 8 cUS screening examination is necessary for all neonates. METHODS: A retrospective observational study was performed at a tertiary-level Australian hospital. Frequencies of cranial ultrasound abnormality (CUA) were compared between routine screening performed at postnatal days 3, 8, and 42. Univariate and multivariate analyses of risk factors for intraventricular hemorrhage (IVH) was performed using logistic regression. RESULTS: cUS examinations on 712 neonates born before 32 weeks' GA were included. Neonates were divided into 2 groups: 99 neonates in the 23-25 weeks 6 days GA (group A) and 613 neonates in the 26-31 weeks 6 days GA (group B). All CUA occurred more frequently in group A neonates and in the subset of group B neonates who had defined risk factors. Low-risk group B neonates had lower incidence of CUAs demonstrated on day 8 cUS than high-risk group B neonates, with no significant differences between day 3 and day 8. Logistic regression analysis identified a number of risk factors (vaginal delivery, small for GA, Apgar score <7 at 5 minutes, intubation, patent ductus arteriosus and infection) that were associated with increased frequency of IVH on day 8. In neonates born between 30 and 31 weeks 6 days GA, 35% had a CUA identified. CONCLUSIONS: Low-risk preterm neonates born between 26 and 31 weeks 6 days GA, without complications, could be screened with a single early cUS examination around day 8 without missing substantial abnormality.

Development of a professional competency framework for Australian sonographers-perspectives for developing competencies using a Delphi methodology.

BACKGROUND: Professional competencies are important for enhancing alignment between the needs of education, industry and health consumers, whilst describing public expectations around health professionals. The development of competency standards for the sonography profession defines the behaviours, skills and knowledge sonographers should demonstrate for each learning and experience level. OBJECTIVE: The objective of this project was to develop a set of professional competency standards for the sonography profession which described in depth the behaviours, skills and knowledge sonographers should demonstrate across multiple learning and experience levels. METHODS: Representatives of three Australian ultrasound professional associations and seven tertiary institutions involved in entry-level sonographer education in Australia formed a research team (RT). The RT recruited an expert panel that responded to six survey rounds. Using a Delphi methodology, the results and free-text comments from each previous round were fed back to participants in the subsequent survey rounds to achieve a consensus. RESULTS: The project developed a professional competency framework for sonographers, which included four major domains: detailed competency standards, sonographer knowledge, sonographer attitudes and a holistic competency matrix [https://doi.org/10.6084/m9.figshare.17148035.v2.]. CONCLUSION: The Delphi methodology is an effective way to develop professional competency standards. This paper describes the methods and challenges in developing such standards for sonographers which could be translated to other health professionals.

Early impact of moderate preterm birth on the structure, function and gene expression of conduit arteries.

NEW FINDINGS: What is the central question of this study? What is the immediate impact of moderate preterm birth on the structure and function of major conduit arteries using a pre-clinical sheep model? What is the main finding and its importance? Postnatal changes in conduit arteries, including a significant decrease in collagen within the thoracic aortic wall (predominately males), narrowed carotid arteries, reduced aortic systolic blood flow, and upregulation of the mRNA expression of cell adhesion and inflammatory markers at 2 days of age in preterm lambs compared to controls, may increase the risk of cardiovascular impairment in later life. ABSTRACT: The aim of this work was to compare the structure and function of the conduit arteries of moderately preterm and term-born lambs and to determine whether vascular injury-associated genes were upregulated. Time-mated ewes were induced to deliver either preterm (132 ± 1 days of gestation; n = 11 females and n = 10 males) or at term (147 ± 1 days of gestation; n = 10 females and n = 5 males). Two days after birth, ultrasound imaging of the proximal ascending aorta, main, right and left pulmonary arteries, and right and left common carotid arteries was conducted in anaesthetized lambs. Lambs were then killed and segments of the thoracic aorta and left common carotid artery were either snap frozen for real-time PCR analyses or immersion-fixed for histological quantification of collagen, smooth muscle and elastin within the medial layer. Overall there were few differences in vascular structure between moderately preterm and term lambs. However, there was a significant decrease in the proportion of collagen within the thoracic aortic wall (predominantly in males), narrowing of the common carotid arteries and a reduction in peak aortic systolic blood flow in preterm lambs. In addition, there was increased mRNA expression of the cell adhesion marker P-selectin in the thoracic aortic wall and the pro-inflammatory marker IL-1ß in the left common carotid artery in preterm lambs, suggestive of postnatal vascular injury. Early postnatal differences in the function and structure of conduit arteries and evidence of vascular injury in moderately preterm offspring may place them at greater risk of cardiovascular impairment later in life.

Comparison of the Fat-to-Lesion Strain Ratio and the Gland-to-Lesion Strain Ratio With Controlled Precompression in Characterizing Indeterminate and Suspicious Breast Lesions on Ultrasound Imaging.

OBJECTIVES: The purpose of this study was to compare the diagnostic performance of the fat-to-lesion strain ratio (FLR) and gland-to-lesion strain ratio (GLR) for patients with indeterminate or suspicious breast lesions on ultrasound (US) imaging under a controlled precompression technique and to see whether the technique improves the reproducibility of FLR and GLR measurement. METHODS: Fifty-three lesions in 39 consecutive patients who had scheduled core biopsy or excision surgery based on US findings were examined by US elastography. Each lesion was acquired under controlled precompression by 2 sonographers independently. Both the FLR and GLR of the lesion were calculated. For diagnostic performance, the sensitivity, specificity, negative predictive value, positive predictive value, and accuracy were obtained. Interobserver reliability between different sonographers was assessed by the intraclass correlation coefficient (ICC). RESULTS: Forty lesions were benign, and 13 lesions were malignant. Both the FLR and GLR were significantly higher in malignant than benign lesions (P < .05). The FLR yielded higher accuracy and specificity compared to the GLR (accuracy, 79.2% versus 60.4%; and specificity, 87.5% versus 50.0%). With the controlled precompression applied at less than 25% during elastography, the interobserver agreement was excellent for FLR measurements (ICC, 0.853; 95% confidence interval, 0.738-0.920) and GLR measurements (ICC, 0.779; 95% confidence interval, 0.619-0.87). CONCLUSIONS: The FLR performed better than the GLR in the detection of breast malignancy; thus, fatty tissue was a better reference tissue for calculating the strain ratio on malignant breast tumor elastography. Keeping precompression to less than 25% will enable different operators to acquire similar elastograms with reproducible FLR and GLR readings.

Moderate preterm birth affects right ventricular structure and function and pulmonary artery blood flow in adult sheep.

KEY POINTS: Preterm birth occurs when the heart muscle is immature and ill-prepared for the changes in heart and lung function at birth. MRI imaging studies show differences in the growth and function of the heart of young adults born preterm, with the effects more pronounced in the right ventricle. The findings of this study, conducted in sheep, showed that following moderate preterm birth the right ventricular wall was thinner in adulthood, with a reduction in the number and size of the heart muscle cells; in addition, there was impaired blood flow in the main artery leading from the right ventricle to the lungs. The findings indicate that being born only a few weeks early adversely affects the cellular structure of the right ventricle and blood flow to the lungs in adulthood. The reduced number of heart muscle cells has the potential to deleteriously affect right ventricular growth potential and function. ABSTRACT: Preterm birth prematurely exposes the immature heart to the haemodynamic transition at birth, which has the potential to induce abnormal cardiac remodelling. Magnetic resonance imaging studies in young adults born preterm have shown abnormalities in the gross structure of the ventricles (particularly the right ventricle; RV), but the cellular basis of these alterations is unknown. The aim of this study, conducted in sheep, was to determine the effect of moderate preterm birth on RV cellular structure and function in early adulthood. Male singleton lambs were delivered moderately preterm (132 ± 1 days; n = 7) or at term (147 ± 1 days; n = 7). At 14.5 months of age, intra-arterial blood pressure and heart rate were measured. Pulmonary artery diameter and peak systolic blood flow were determined using ultrasound imaging, and RV stroke volume and output calculated. Cardiomyocyte number, size, nuclearity and levels of cardiac fibrosis were subsequently assessed in perfusion-fixed hearts using image analysis and stereological methods. Blood pressure (systolic, diastolic and mean), heart rate, levels of myocardial fibrosis and RV stroke volume and output were not different between groups. There was, however, a significant reduction in RV wall thickness in preterm sheep, and this was accompanied by a significant reduction in peak systolic blood flow in the pulmonary artery and in RV cardiomyocyte number. Cellular changes in the RV wall and reduced pulmonary artery blood flow following preterm birth have the potential to adversely affect cardiac and respiratory haemodynamics, especially when the cardiovascular system is physiologically or pathologically challenged.

From in vivo to in vitro: How the Guatemala STD Experiments Transformed Bodies Into Biospecimens.

Policy Points: While most scholarship regarding the US Public Health Service's STD experiments in Guatemala during the 1940s has focused on the intentional exposure experiments, secondary research was also conducted on biospecimens collected from these subjects. These biospecimen experiments continued after the Guatemala grant ended, and the specimens were used in conjunction with those from the Tuskegee syphilis experiments for ongoing research. We argue there should be a public accounting of whether there are still biospecimens from the Guatemala and Tuskegee experiments held in US government biorepositories today. If such specimens exist, they should be retired from US government research archives because they were collected unethically as understood at the time. CONTEXT: The US Public Health Service's Guatemala STD experiments (1946-1948) included intentional exposure to pathogens and testing of postexposure prophylaxis methods for syphilis, gonorrhea, and chancroid in over 1,300 soldiers, commercial sex workers, prison inmates, and psychiatric patients. Though the experiments had officially ended, the biospecimens collected from these subjects continued to be used for research at least into the 1950s. METHODS: We analyzed historical documents-including clinical and laboratory records, correspondence, final reports, and medical records-for information relevant to these biospecimen experiments from the US National Archives. In addition, we researched material from past governmental investigations into the Guatemala STD experiments, including those of the US Presidential Commission for the Study of Bioethical Issues and the Guatemalan Comisión Presidencial para el Esclarecimiento de los Experimentos Practicados con Humanos en Guatemala. FINDINGS: Identified spinal fluid, blood specimens, and tissue collected during the Guatemala diagnostic methodology and intentional exposure experiments were subsequently distributed to laboratories throughout the United States for use in ongoing research until at least 1957. Five psychiatric patient subjects involved in these biospecimen experiments died soon after experimental exposure to STDs. The same US government researchers working with the Guatemala biospecimens after the exposure experiments ended were also working with specimens taken from the Tuskegee syphilis study. CONCLUSIONS: There should be a complete public accounting of whether biospecimens from the Guatemala and Tuskegee experiments are held in US government biorepositories today. If they still exist, these specimens should be retired from such biorepositories and their future disposition determined by stakeholders, including representatives from the communities from which they were derived.

A Child's Right to Be Well Born: Venereal Disease and the Eugenic Marriage Laws, 1913-1935.

An extensive literature describes the legal impact of America's eugenics movement, and the laws mandating sterilization, restriction of marriage by race, and ethnic bans on immigration. But little scholarship focuses on the laws adopted in more than 40 states that were commonly referred to as "eugenic marriage laws." Those laws conditioned marriage licenses on medical examinations and were designed to save innocent women from lives of misery, prevent stillbirth or premature death in children, and save future generations from the myriad afflictions that accompanied "venereal infection." Medical journals, legal journals, and every kind of public press outlet explained the "eugenic marriage laws" and the controversies they spawned. They were inextricably bound up in reform movements that attempted to eradicate prostitution, stamp out STIs, and reform America's sexual mores in the first third of the 20th century. This article will explain the pedigree of the eugenic marriage laws, highlight the trajectory of Wisconsin's 1913 eugenic enactment, and explore how the Wisconsin Supreme Court case upholding the law paved the way for the majority of states to regulate marriage on eugenic grounds.

When early life growth restriction in rats is followed by attenuated postnatal growth: effects on cardiac function in adulthood.

PURPOSE: Epidemiological and experimental studies demonstrate that intrauterine growth restriction (IUGR) followed by accelerated postnatal growth leads to increased risk of developing cardiac disease in adulthood. The aim of this study was to examine the effect of early life growth restriction on cardiac structure and function in young adult rats. METHODS: IUGR was induced in Wistar Kyoto dams through administration of a low protein diet (LPD; 8.7% casein) during pregnancy and lactation; controls received a normal protein diet (NPD; 20% casein). Cardiac function and structure were assessed in female NPD (n = 7) and LPD (n = 7) offspring at 18 weeks of age by echocardiography and pressure-volume techniques, and systolic blood pressure by tail-cuff sphygmomanometry. RESULTS: LPD offspring remained significantly smaller throughout life compared to controls. There were no differences in the levels of systolic blood pressure, left ventricular cardiac dimensions, heart rate, ejection fraction and fractional shortening of the cardiac muscle between the investigated groups. Aortic peak systolic velocity was significantly reduced in the LPD group (P = 0.02). CONCLUSION: Our findings support the idea that the programming of adult cardiovascular disease can be prevented or delayed in IUGR offspring when postnatal growth trajectory resembles that of in utero.

When Harvard said no to eugenics: the J. Ewing Mears Bequest, 1927.

James Ewing Mears (1838-1919) was a founding member of the Philadelphia Academy of Surgery. His 1910 book, The Problem of Race Betterment, laid the groundwork for later authors to explore the uses of surgical sterilization as a eugenic measure. Mears left $60,000 in his will to Harvard University to support the teaching of eugenics. Although numerous eugenic activists were on the Harvard faculty, and two of its Presidents were also associated with the eugenics movement, Harvard refused the Mears gift. The bequest was eventually awarded to Jefferson Medical College in Philadelphia. This article explains why Harvard turned its back on a donation that would have supported instruction in a popular subject. Harvard's decision illustrates the range of opinion that existed on the efficacy of eugenic sterilization at the time. The Mears case also highlights a powerful irony: the same week Harvard turned down the Mears legacy, the U.S. Supreme Court endorsed eugenic sterilization in the landmark case of Buck v. Bell. Justice Oliver Wendell Holmes, Jr., graduate of Harvard and former member of its law faculty wrote the opinion in that case, including the famous conclusion: "Three generations of imbeciles are enough."

Routine sonographic measurement of the near-field lateral ventricle during second-trimester morphologic scans.

OBJECTIVES: The purpose of this study was to determine whether measurement of the near-field lateral ventricular diameter can be reliably obtained within a practical time frame during second-trimester obstetric scans by angling the fetal head approximately 30° away from the horizontal image axis such that the posterior aspect of the fetal head lies closer to the transducer. METHODS: Fifty consecutive singleton pregnancies presenting for a routine-second trimester scan were recruited for this study. The far-field lateral ventricular diameter was measured, followed by the near-field lateral ventricular diameter using the proposed technique. The measurements were repeated by a second operator who was blinded to the first measurement. Both operators recorded the measurements taken and scored the level of visibility of the near-field lateral ventricle. The difference between the two operators' measurements was compared by a κ analysis. RESULTS: The near-field lateral ventricle was visualized in 49 of 50 cases (98%). There was no statistically significant difference in the measurement of the near-field lateral ventricular diameter by the two operators (P = .34). There was, however, a statistically significant difference in the time it took each operator to obtain the near-field measurement after the far-field measurement (P = .01). CONCLUSIONS: Manipulating the transducer to position the falx of the fetal head approximately 30° away from the horizontal image axis allows the near-field lateral ventricle to be routinely visualized and measured with a high degree of interoperator agreement and within a practical time frame once the operator is experienced in performing the technique.

Effectiveness of mastoid process percussion for identification of the vertebral artery ostium on Doppler studies.

OBJECTIVES: The pretransverse or first segment of the vertebral artery may be confused with adjacent branches of the proximal subclavian artery during Doppler assessment. This study investigated the effectiveness of mastoid process percussion, the "mastoid tap" maneuver, for identification of the vertebral artery ostium. METHODS: Fifty patients presenting consecutively for carotid sonography were recruited. Doppler waveforms were collected at the vertebral artery ostia, thyrocervical trunks, and proximal subclavian arteries while the mastoid tap maneuver was performed. The outcome indicator was serrate distortion of the Doppler waveform. Two raters graded the waveforms according to a 3-grade system: grade 0, no distortion; grade 1, mild distortion; and grade 3, marked distortion. The difference between the proportions of the vertebral artery ostia and thyrocervical trunks showing waveform distortion was evaluated with the χ(2) test. The differences in the extents of waveform distortion in the ipsilateral vertebral artery ostia, thyrocervical trunks, and subclavian arteries were evaluated with Friedman and Wilcoxon signed rank tests. RESULTS: Ninety-five vertebral artery ostia in 50 patients were successfully assessed. There was a significant difference between the proportions of vertebral artery ostia (95 of 95 [100%]) and thyrocervical trunks (9 of 95 [9.5%]) that showed waveform distortion (P < .001). There were significant differences in the extents of distortion between the ipsilateral vertebral artery ostia and thyrocervical trunks and between the ipsilateral vertebral artery ostia and subclavian arteries, with the vertebral artery ostia showing a higher degree of distortion in both cases (P < .001). CONCLUSIONS: The mastoid tap maneuver is useful for distinguishing between the vertebral arteries and thyrocervical trunks on Doppler studies.

Recent developments in health care law: culture and controversy.

This article reviews recent developments in health care law, focusing on controversy at the intersection of health care law and culture. The article addresses: emerging issues in federal regulatory oversight of the rapidly developing market in direct-to-consumer genetic testing, including questions about the role of government oversight and professional mediation of consumer choice; continuing controversies surrounding stem cell research and therapies and the implications of these controversies for healthcare institutions; a controversy in India arising at the intersection of abortion law and the rights of the disabled but implicating a broader set of cross-cultural issues; and the education of U.S. health care providers and lawyers in the theory and practice of cultural competency.

Republicans, Democrats, & Doctors: The Lawmakers Who Wrote Sterilization Laws.

During the 20th Century, thirty-two state legislatures passed laws that sanctioned coercive sexual sterilization as a solution to the purported detrimental increases in the population of "unfit" or "defective" citizens. While both scholarly and popular commentary has attempted to attribute these laws to political parties, or to broad or poorly defined ideological groups such as "progressives," no one has identified the political allegiance of each legislator who introduced a successfully adopted sterilization law, and the governor who signed it. This article remedies that omission.

"A Vigorous Campaign against Abortion": Views of American Leaders of Eugenics v. Supreme Court Distortions.

The Supreme Court decided Box v. Planned Parenthood of Indiana and Kentucky in 2019. Justice Clarence Thomas's opinion in the case claimed there was a direct connection between the legalization of abortion, in the late 20th Century, and the beginnings of the birth control movement a full three quarters of a century earlier. "Many eugenicists," Thomas argued, "supported legalizing abortion."Justice Samuel Alito highlighted similar claims in Dobbs v. Jackson Women's Health, citing a brief entitled "The Eugenic Era Lives on through the Abortion Movement." That brief was an echo of Justice Thomas' misguided attempt at history in the Box opinion. Similar claims reoccur in Judge Matthew Kacsmaryk's opinion in the Texas mifepristone case, Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration.These false claims are the focus of this article. There is no evidence that early leaders of the eugenics movement supported abortion as part of the movement for birth control. It is accurate to describe those leaders as anti-abortion, and their followers as people who condemned abortion for moral, legal, and medical reasons.

Australian sonographers' perceptions of patient safety in ultrasound imaging: Part two - translation into practice.

Introduction: A lack of patient safety research hampers capacity to improve safety in healthcare.Ultrasound is often considered 'safe' as it does not use ionising radiation, a simplistic view of patient safety. Understanding sonographers' actions towards patient safety is crucial; however, self-reported measures cannot always predict behaviour. This study is part of a PhD exploring patient safety in medical diagnostic ultrasound. The aim of this paper is to explore sonographers' responses to the patient safety concerns identified in Part one of this study. The ultimate aim of the study is to inform the final phase of the doctoral study which will consider the next steps in improving the quality and safety of healthcare experienced by patients. Methods: A qualitative study using semi-structured, one-on-one interviews. The Theory of Planned Behaviour (TPB) explained how sonographers respond to perceived patient safety risks in practice. Results: Thirty-one sonographers were interviewed. Based on the seven themes identified in Part one of the study, results showed that incongruences exist between identifying patient safety risks and the actions taken in practice to manage these risks. Conclusion: The TPB showed that behavioural, normative and control beliefs impact sonographers' responses to perceived patient safety risks in practice and can lead to risk avoidance. Lack of regulation in ultrasound creates a challenge in dealing with Fitness to Practice issues. Collective actions are required to support sonographers in taking appropriate actions to enhance patient safety from multiple stakeholders including accreditation bodies, regulatory authorities, educational institutions and employers.

Australian sonographers' perceptions of patient safety in ultrasound imaging: Part 1 - identifying the main safety concerns, a qualitative study.

Introduction: Patient safety has been an undervalued component of quality healthcare but is a challenging area of research.Ultrasound is the most common imaging modality in the world. Research on patient safety in ultrasound is generally focused on bioeffects and safe operation of ultrasound equipment. However, other safety issues exist in practice that warrant consideration.This paper forms the first part of a PhD study exploring patient safety in medical diagnostic ultrasound, beyond the notion of bioeffects.The ultimate aim of the study is to inform the final phase of the research study which will consider the next steps in improving the quality and safety of healthcare experienced by patients. Methods: A qualitative study using semi-structured, one-on-one interviews. A thematic analysis categorised data into codes and generated final themes. Results: A heterogeneous mix of 31 sonographers, who reflected the profile of the profession in Australia, were interviewed between September 2019 and January 2020. Seven themes emerged from the analysis. These were bioeffects, physical safety, workload, reporting, professionalism, intimate examinations and infection control. Conclusion: This study presents a comprehensive analysis of sonographers' perceptions of patient safety in ultrasound imaging, not previously available in the literature. Consistent with the literature, patient safety in ultrasound tends to be viewed in technical terms through the potential for bioeffects of tissue damage or physical harm to the patient. However, other patient safety issues have emerged, and while not as well recognised, have the potential to negatively impact on patient safety.

Medullary pyramid thickness: The optimal cut-off value associated with the need for pyeloplasty in infants.

INTRODUCTION: The medullary pyramid compresses during the early phases of severe hydronephrosis and represents a promising ultrasound metric for the diagnosis and surveillance of PUJ obstruction. The aim of this study was to define the optimal cut-off value and utility of medullary pyramid thickness (MPT) associated with the need for pyeloplasty in infants being followed up for hydronephrosis. METHODS: A retrospective review was performed over a five-year period to identify patients that were under surveillance for hydronephrosis during infancy and underwent a MAG3 to monitor the possible need for pyeloplasty. Ultrasound images were retrospectively reviewed to measure the MPT of the affected kidney in a blinded fashion. The primary outcome measure was subsequent requirement for pyeloplasty before three years of age. The Mann-Whitney U Test was used to determine statistically significant differences in the minimum MPT between the infant group requiring pyeloplasty and the non-operative group. Receiver operating characteristic analysis was performed to determine the optimal cut-off value associated with the requirement for pyeloplasty. RESULTS: A total of 63 patient cases were included, of which 45 underwent pyeloplasty (70%). A significant difference was found in the median MPT measurement between the pyeloplasty and non-operative groups (1.7 mm vs. 3.8 mm, p < 0.001). The optimal cut-off value of MPT associated with pyeloplasty was 3.4 mm. An MPT threshold of ≤3.4 mm conferred a sensitivity of 98%, specificity of 63%, positive predictive value of 86%, and negative predictive value of 92%. CONCLUSION: Thinning of the medullary pyramid is an important ultrasound sign of parenchymal deterioration in high-grade hydronephrosis. An optimal MPT cut-off value of ≤3.4 mm is associated with subsequent pyeloplasty in infants. MPT should be considered in future studies addressing the diagnosis and surveillance of PUJ obstruction.