Comparison of Commonly Carried Liquids Against Commercial Ultrasound Gel for Use in the Backcountry Setting.

INTRODUCTION: Point-of-care ultrasound (POCUS) is utilized in austere environments because it is lightweight, durable, battery powered, and portable. In austere settings, weight and space constraints are limitations to carrying dedicated ultrasound gel. Few studies have assessed commonly carried liquids as gel alternatives. The study objective was to assess the suitability of common food and personal care products as ultrasound coupling agents compared with that of commercial gel. METHODS: A noninferiority study compared 9 products to commercial gel. Each substance was independently tested on 2 subjects by 2 sonographers covering 8 standardized ultrasound windows. Clips were recorded, blinded, and independently graded by 2 ultrasound fellowship-trained physicians on the ability to make clinical decisions and technical details, including contrast, resolution, and artifact. A 20% noninferiority margin was set, which correlates to levels considered to be of reliably sufficient quality by American College of Emergency Physicians' guidelines. The substances included water, soap, shampoo, olive oil, energy gel, maple syrup, hand sanitizer, sunscreen, and lotion. RESULTS: A total of 300 of 318 (94%) clips met the primary endpoint of adequacy to make a clinical decision. All media, except sunscreen, were noninferior to commercial gel in the ability to make a clinical decision (α=0.05). In terms of secondary outcomes, resolution, artifact, and contrast, all substances were noninferior to commercial gel (α=0.05). The sonographers concluded that all gel alternatives' usability performed similarly to commercial gel, with the exception of energy gel. CONCLUSIONS: Of the 9 substances tested, 8 were noninferior to commercial gels for clinical decisions. Our study indicates that several POCUS gel substitutes are serviceable to produce clinically adequate images.

Surgical Care and Health Systems.

BACKGROUND: While surgical care impacts a wide variety of diseases and conditions with non-operative and operative services, both preventive and curative, there has been little discussion concerning how surgery might be integrated within the health system of a low and middle-income country (LMIC), nor how strengthening surgical services may improve health systems and population health. METHODS: We reviewed reports from several meetings of the working group on health systems strengthening of the Global Initiative for Emergency and Essential Surgical Care, and also performed a review of the literature including the search terms "surgery," "health system," "developing country," "health systems strengthening," "health information system," "financing," "governance," and "integration." RESULTS: The literature search revealed no reports which focused on the integration of surgical services within a health system or as a component of health system strengthening. A conceptual model of how surgical care might be integrated within a health system is proposed, based on the discussions of our working group, combined with sources from the medical literature, and utilizing the World Health Organization's conceptual model of a health system. CONCLUSIONS: Strengthening the delivery of surgical services in LMICs will require inputs at multiple levels within a health system, and this effort will require the coalescence of committed individuals and organizations, supported by civil society.

Demographic and Clinical Factors Affecting Pediatric Survival in South Kivu, the Democratic Republic of the Congo.

Promoting children's health is challenging in underresourced regions, with worse outcomes in areas of sociopolitical instabilities. This encapsulates the difficulties faced by the Panzi General Referral Hospital (PGRH) in South Kivu, the Democratic Republic of the Congo. In this retrospective, cross-sectional study of 456 children ≤ 18 years who presented to the pediatric emergency department of PGRH between December 2018 and May 2019, we present demographic and clinical predictors that affect pediatric survival. We note that referrals from external clinics (odds ratio [OR], 0.37; 95% CI, 0.18-0.75), poor maternal education (OR, 0.21; 95% CI, 0.07-0.67), diagnoses of meningitis (OR, 0.37; 95% CI, 0.18-0.75) or malnutrition (OR, 0.21; 95% CI, 0.07-0.67) are risk factors hindering pediatric survival. Paternal unemployment or longer durations of hospital stay, on the other hand, are protective toward survival. These predictors confirm the importance of accessibility and availability of medical resources and knowledge as levers to establish an effective, robust network of pediatric care delivery capable of withstanding South Kivu's unresolved political tumult.

Serotonin syndrome following a single 50 mg dose of sertraline in a child.

OBJECTIVE: To report a case of serotonin syndrome associated with a single, 50 mg dose of sertraline in a child and discuss the findings in context with previous relevant literature involving other selective serotonin reuptake inhibitors used in children. CASE SUMMARY: A nine-year old male with chronic behavioral problems was prescribed oral sertraline 50 mg daily. After the first dose, the patient presented with abdominal pain, seizure-like activity, and change in mental status. He was admitted to a tertiary-care pediatric hospital and was treated for serotonin syndrome. Laboratory findings of elevated creatine kinase and serum creatinine were consistent with rhabdomyolysis as result of continued hypertonicity. Sertraline was discontinued and treatment with lorazepam and cyproheptadine was initiated. Clinical status, creatine kinase, and serum creatinine improved over 5 days of hospitalization. The Adverse Drug Reaction Probability Scale by Naranjo et al was applied to assess causality. The scale indicated the association of a single dose of sertraline and serotonin syndrome as "probable." CONCLUSION: To our knowledge this is the first reported case of serotonin syndrome associated with a single dose of sertraline in a child using a validated causality scale. The sertraline 50 mg dose given to the child was higher than usual recommended initial doses (25 mg). This potential adverse reaction should be considered when selecting antidepressant therapy for children.