Getting It Right the First Time: Defining Regionally Relevant Training Curricula and Provider Core Competencies for Point-of-Care Ultrasound Education on the African Continent.

Significant evidence identifies point-of-care ultrasound (PoCUS) as an important diagnostic and therapeutic tool in resource-limited settings. Despite this evidence, local health care providers on the African continent continue to have limited access to and use of ultrasound, even in potentially high-impact fields such as obstetrics and trauma. Dedicated postgraduate emergency medicine residency training programs now exist in 8 countries, yet no current consensus exists in regard to core PoCUS competencies. The current practice of transferring resource-rich PoCUS curricula and delivery methods to resource-limited health systems fails to acknowledge the unique challenges, needs, and disease burdens of recipient systems. As emergency medicine leaders from 8 African countries, we introduce a practical algorithmic approach, based on the local epidemiology and resource constraints, to curriculum development and implementation. We describe an organizational structure composed of nexus learning centers for PoCUS learners and champions on the continent to keep credentialing rigorous and standardized. Finally, we put forth 5 key strategic considerations: to link training programs to hospital systems, to prioritize longitudinal learning models, to share resources to promote health equity, to maximize access, and to develop a regional consensus on training standards and credentialing.

Point-of-Care Ultrasonography for the Rapid Diagnosis of Intussusception: A Case Series.

We present a case series describing an infant and a child who presented with abdominal discomfort and their conditions were diagnosed with intussusception by point-of-care ultrasound. These cases illustrate how point-of-care ultrasound led to the expeditious diagnosis of intussusception.

Ingested foreign bodies: a case series demonstrating a novel application of point-of-care ultrasonography in children.

In an era of recognizing the risks of radiation exposure, it is important to develop alternatives to radiographs. Bedside ultrasound has become an important adjunct to clinical diagnoses and procedural guidance in the emergency department. We present a case series of two patients who presented to a pediatric emergency department after witnessed coin ingestions. Point-of-care ultrasonography was able to accurately identify the location of each of the coins, at the thoracic inlet and in the stomach, as confirmed by chest radiography. To our knowledge, point-of-care ultrasonography has not been previously utilized to detect and localize esophageal foreign bodies in the emergency department.

Fake drugs: Using Baseline Spectral Fingerprinting and a sorting algorithm to infer quality of medications.

An estimated 30-70% of available medications in low-income countries and conflict states are of low quality or counterfeit. Reasons for this vary but most are rooted in regulatory agencies being poorly equipped to oversee quality of pharmaceutical stocks. This paper presents the development and validation of a method for point-of-care drug stock quality testing in these environs. The method is termed Baseline Spectral Fingerprinting and Sorting (BSF-S). BSF-S leverages the phenomena that all compounds in solution have nearly unique spectral profiles in the UV spectrum. Further, BSF-S recognizes that variations in sample concentrations are introduced when preparing samples in the field. BSF-S compensates for this variability by incorporating the ELECTRE-TRI-B sorting algorithm, which contains parameters that are trained in the laboratory using authentic, proxy low quality and counterfeit samples. The method was validated in a case study using fifty samples that include factually authentic Praziquantel and inauthentic samples prepared in solution by an independent pharmacist. Study researchers were blinded to which solution contained the authentic samples. Each sample was tested by the BSF-S method described in this paper and sorted to authentic or low quality/counterfeit categories with high levels of specificity and sensitivity. In combination with a companion device under development using ultraviolet light emitting diodes, the BSF-S method is intended to be a portable and low-cost method for testing medications for authenticity at or near the point-of-care in low income countries and conflict states.

Ultrasound assessment of optic disc edema in patients with headache.

Point-of-care ocular ultrasonography is emerging as a powerful tool to evaluate emergency department (ED) patients at risk for ophthalmologic and intracranial pathology.We present cases of 3 patients in whom optic disc swelling was identified using ocular ultrasound. Causes for optic disc swelling in our patients included idiopathic intracranial hypertension, secondary syphilis, and malignant hypertension with associated hypertensive retinopathy. Because direct visualization of the optic disc may be challenging in an ED setting, ultrasound examination of the optic disc may represent an important adjunct to fundoscopy when assessing patients with headache or visual complaints.

Ultrasound-guided regional anesthesia: feasibility and effectiveness of teaching via telesimulation in Ethiopia.

BACKGROUND: Acute pain management in resource-poor countries remains a challenge. Ultrasound-guided regional anesthesia is a cost-effective way of delivering analgesia in these settings. However, for financial and logistical reasons, educational workshops are inaccessible to many physicians in these environments. Telesimulation provides a way of teaching across distance by using simulators and video-conferencing software to connect instructors and students worldwide. We conducted a prospective study to determine the feasibility of ultrasound-guided regional anesthesia teaching via telesimulation in Ethiopia. METHODS: Eighteen Ethiopian orthopedic and emergency medicine house staff participated in telesimulation teaching of ultrasound-guided femoral nerve block. This consisted of four 90-min sessions, once per week. Week 1 consisted of a precourse test and a presentation on aspects of performing a femoral nerve block, weeks 2 and 3 were live teaching sessions on scanning and needling techniques, and in week 4, the house staff undertook a postcourse test. All participants were assessed using a validated Global Rating Scale and Checklist. RESULTS: Participants were provided with a validated checklist and global rating scale as a pretest and post-test. The participants showed significant improvement in their test scores, from a total mean of 51% in the pretest to 84% in their post-test. CONCLUSIONS: Teaching ultrasound-guided regional anesthesia of the femoral nerve remotely via telesimulation is feasible. Telesimulation can greatly improve the accessibility of ultrasound-guided regional anesthesia teaching to physicians in remote areas.

A review of the information and support needs of family carers of patients with chronic obstructive pulmonary disease.

AIMS AND OBJECTIVES: The objectives of this narrative review were to identify: (1) The information and support needs of carers of family members with chronic obstructive pulmonary disease; (2) appropriate interventions to support carers in their caregiving role; (3) information on carers' needs as reported in studies of patients living with COPD in the community. BACKGROUND: Chronic obstructive pulmonary disease is a major health problem in the UK resulting in significant burden for patients, families and the health service. Current National Health Service policies emphasise, where medically appropriate, early discharge for acute exacerbations, hospital-at-home care and other models of community care to prevent or reduce re-hospitalisations of people with chronic conditions. Understanding carers' needs is important if health care professionals are to support carers in their caregiving role. DESIGN: A narrative literature review. METHODS: Thirty five papers were reviewed after searching electronic databases. RESULTS: Few studies were identified which addressed, even peripherally, carers' needs for information and support, and no studies were found which described and evaluated interventions designed to enhance caregiving capacity. Several studies of hospital-at-home/early discharge, self care and home management programmes were identified which included some information on patients' living arrangements or marital status. However, there was little or no detail reported on the needs of, and in many cases, even the presence of a family carer. CONCLUSIONS: This review highlights the dearth of information on the needs of carers of chronic obstructive pulmonary disease patients and the need for future research. RELEVANCE TO CLINICAL PRACTICE: There is little research based knowledge of the needs of carers of chronic obstructive pulmonary disease patients and interventions to assist them in providing care. This knowledge is critical to ensure that carers receive the information they need to carry out this role while maintaining their own physical and emotional health.

Content and style of speech from mothers with schizophrenia towards their infants.

Schizophrenia can affect verbal communication and relational processes, but how it might disrupt maternal infant-directed (ID) speech is unknown. Maternal speech characteristics were coded, blind to clinical information, from brief videotaped mother-infant interactions of 14 mothers with schizophrenia and 36 mothers with similar hospitalisation but with other clinical diagnoses. Compared with the non-schizophrenia group, the speech of mothers with schizophrenia was less infant-focused. Infant-focused content was also predicted by maternal age, but not by duration of hospitalisation or infant gender. Mothers with schizophrenia also used significantly fewer songs or rhymes than the comparison group, and showed a trend towards fewer negative comments. Speech prosody/content deviations were rarely observed in either group, and no differences were found in speech rate or structure. The marked lack of ID speech content of mothers with schizophrenia reflects low maternal sensitivity, perhaps due to 'theory of mind' impairment and blunted affect, and may contribute to the early developmental vulnerability of their children.

Albendazole Treatment Improves Work Capacity in Women Smallholder Farmers Infected with Hookworm: A Double-Blind Randomized Control Trial.

An estimated 4.7 billion people live in regions exposed to soil-transmitted helminths, intestinal parasites that have significant impacts on the health of women smallholder farmers. The goal of this trial was to determine whether treatment with albendazole impacts the work capacity of these farmers. This is a prospective double-blind, randomized effectiveness trial. Participants (N = 250) were randomly selected from safe motherhood groups in the Democratic Republic of Congo. Prevalence/intensity of hookworm infection, hemoglobin, and demographics was obtained. At study (Time = 0), participants were randomized into treatment (albendazole 400 mg) and placebo (similar placebo tablet) groups. A step test was administered as a proxy metric for work capacity. Work capacity was defined as ∆heart rate before and after 3 minutes of step testing, in beats per minute. At study (time = 7 months), the step test was repeated and work capacity remeasured. The ∆work capacity (time = 0 minus time = 7 months) was the primary outcome. Investigators/field assistants were blinded to who was enrolled in groups, hookworm status, and step test results. Regression showed highly significant interactive effects of hookworm status and treatment group relative to ∆work capacity after controlling for resting pulse rate and age (P < 0.002). Estimated marginal means for work capacity (WC) for each of four groups (hookworm positive plus placebo, hookworm positive plus treatment, hookworm negative plus placebo, and hookworm negative plus treatment) showed women who were hookworm positive and received treatment decreased heart rate by 9.744 (95% confidence interval [CI]: 6.42, 13.07) beats per minute (increased WC), whereas women who were hookworm positive and received placebo saw a nonsignificant decrease of 0.034 (95% CI: -3.16, 3.84) beats per minute. Treatment with albendazole was associated with improved aerobic work capacity posttreatment. Given modest costs of drug distributions, risk benefits of periodic deworming warrants further study in larger controlled trials.

A survey of emergency medicine and orthopaedic physicians' knowledge, attitude, and practice towards the use of peripheral nerve blocks.

INTRODUCTION: Peripheral nerve blocks (also known as regional anaesthesia) are currently used by many anaesthesiologists and emergency physicians for perioperative and procedural pain management. METHODS: This is a cross sectional descriptive study conducted to evaluate knowledge, attitudes, and current practice towards use of peripheral nerve blocks for lower extremity injuries at Black Lion Hospital, a tertiary trauma centre in Addis Ababa. RESULTS: A standardised survey was conducted with 64 participants working in emergency medicine [30/64 (46.9%)] and orthopaedics [34/64 (53.1%)]. Twenty-three of 64 (35.9%) respondents had received formal training. Knowledge was acquired from didactic/workshop format for 15/23 (65.2%), followed by peer training 6/23 (39.1%). The majority, 62/64 (96.9%), believed that knowledge of general anatomy and nerve blocks are very important. Thirty-one of 64 (48%) of the respondents did not routinely perform peripheral nerve blocks. A majority, 27/31 (87.1%) stated they lacked the required skills. Ultrasound guidance of the femoral nerve 16/33 (48.5%) was the most commonly performed peripheral nerve block, followed by ankle block using anatomic landmarks 15/33 (45.5%). Almost all (15/16) ultrasound-guided nerve blocks were done by emergency medicine providers, while all anatomic land mark guided blocks were done by orthopaedic teams. A majority of the respondents (93.8%) (n = 60) were optimistic that their practice on peripheral nerve blocks would increase in future. A highly significant association was found between previous training on peripheral nerve blocks and the number of peripheral nerve blocks performed in a month; p value - 0.006. DISCUSSION: This study indicates peripheral nerve blocks are likely underutilised due to lack of training. There was a positive attitude towards peripheral nerve blocks but gaps on knowledge and practice.

INTRODUCTION: Les blocs nerveux périphériques (également connus sous le nom d'anesthésies locorégionales) sont actuellement utilisées par de nombreux anesthésistes et urgentistes à des fins de gestion de la douleur. MÉTHODES: Cette étude est une étude descriptive cross sectional menée afin d'évaluer les connaissances, attitudes et pratiques actuelles en matière d'utilisation des blocs nerveux périphériques pour les blessures aux extrémités inférieures au Black Lion Hospital, un centre de traumatologie tertiaire à Addis-Abeba. RÉSULTATS: Une étude standardisée a été menée auprès de 64 participants travaillant en médecine d'urgence [30/64 (46,9%)] et en orthopédie [34/64 (53,1%)]. Vingt-trois sur les 64 (35.9%) personnes interrogées ot bénéficié d'une formation formelle. Les connaissances ont été acquises sous forme didactique/d'atelier pour 15/23 (65,2%) d'entre eux, suivies d'une formation par les pairs pour 6/23 (39,1%) d'entre eux. La majorité, 62/64 (96,9 %) d'entre eux, considérait que les connaissances en anatomie générale et les blocs nerveux comme très importantes. Trente et un sur 64 (48%) personnes interrogées ne réalisaient pas régulièrement des blocs nerveux périphériques. Une majorité 27/31 (87,1%) de participants a indiqué ne pas disposer des compétences requises. Ultrasound guidance of the femoral nerve 16/33 (48,5%) était le bloc nerveux périphérique réalisé le plus fréquemment, suivi du ankle block using anatomic landmarks 15/33 (45,5%). La quasi-totalité (15/16) des blocs nerveux ultrasound-guided étaient réalisés par des emergency medicine providers, while all anatomic land mark guided blocks étaient réalisés par des équipes d'orthopédistes. Une majorité de personnes interrogées (93,8%) (n = 60) indiquaient être optimistes quant au fait que leur pratique sur les blocs nerveux périphériques augmenterait à l'avenir. Une association hautement significative a été trouvée entre la formation antérieure sur les blocs nerveux périphériques et le nombre de blocs nerveux périphériques réalisés au cours d'un mois; p value ­ 0,006. DISCUSSION: Cette étude indique que les blocs nerveux périphériques sont probablement sous-utilisés en raison d'un manque de formation. On a pu observer une attitude positive à l'égard des blocs nerveux périphériques, mais des lacunes en matière de connaissances et de pratique.

Prevalence and predictors of parenting outcomes in a cohort of mothers with schizophrenia admitted for joint mother and baby psychiatric care in England.

OBJECTIVES: Most women with schizophrenia have children. Schizophrenia has been identified as an independent predictor of poor parenting outcome following joint mother and baby psychiatric admission. We aimed to describe the characteristics of these women postnatally and to estimate the prevalence of, and identify independent predictors of, parenting outcomes. METHOD: Clinical and psychosocial data from consecutive joint psychiatric admissions of mothers and infants between September 1996 and September 2002 were collected. Diagnoses were based on ICD-10 criteria (N = 239 schizophrenia; N = 693 affective disorders). The prevalence of each parenting outcome at discharge, assessed according to social services intervention and staff-rated measures of parenting ability, was estimated. Factors associated with poor parenting outcomes and independent predictors were identified using "modified" Poisson regression, and prevalence of these parenting outcomes was estimated in subgroups of mothers stratified by combinations of protective/risk factors. RESULTS: Mothers with schizophrenia were characterized as having more complex clinical and psychosocial problems and were considerably more likely to experience all types of poor parenting outcomes, compared to mothers with affective disorders. Mothers with schizophrenia reporting supportive marital and other relationships, those whose partners were well, and those of higher social class showed the best parenting outcomes. CONCLUSIONS: Mothers with schizophrenia who experience better parenting outcomes may be protected by certain factors. Successful parenting is related, partly, to stability within the family and access to financial and social resources. The nature of the relationship between identified predictors and parenting outcomes in this group is unclear but may suggest that parenting outcome varies with clinical outcome in schizophrenia. Future research and service development should focus on potential protective factors that may encourage successful parenting outcomes in this vulnerable group.

Alternative Ultrasound Gel for a Sustainable Ultrasound Program: Application of Human Centered Design.

This paper describes design of a low cost, ultrasound gel from local products applying aspects of Human Centered Design methodology. A multidisciplinary team worked with clinicians who use ultrasound where commercial gel is cost prohibitive and scarce. The team followed the format outlined in the Ideo Took Kit. Research began by defining the challenge "how to create locally available alternative ultrasound gel for a low-resourced environment? The "End-Users," were identified as clinicians who use ultrasound in Democratic Republic of the Congo and Ethiopia. An expert group was identified and queried for possible alternatives to commercial gel. Responses included shampoo, oils, water and cornstarch. Cornstarch, while a reasonable solution, was either not available or too expensive. We then sought deeper knowledge of locally sources materials from local experts, market vendors, to develop a similar product. Suggested solutions gleaned from these interviews were collected and used to create ultrasound gel accounting for cost, image quality, manufacturing capability. Initial prototypes used cassava root flour from Great Lakes Region (DRC, Rwanda, Uganda, Tanzania) and West Africa, and bula from Ethiopia. Prototypes were tested in the field and resulting images evaluated by our user group. A final prototype was then selected. Cassava and bula at a 32 part water, 8 part flour and 4 part salt, heated, mixed then cooled was the product design of choice.

Patterns of maternal responding in postpartum mothers with schizophrenia.

Little is known about how schizophrenia might affect how a mother responds to her infant, such as whether responding is reduced or impaired. The aim was to identify, from brief videotaped interactions, whether the responses of mothers with schizophrenia were fewer, less positive, more negative, and more 'abnormal' than mothers with affective disorder, and whether their infants (mean age: 15 weeks) lacked activity or initiation to which mothers could respond. Mothers with schizophrenia (N=14) were as responsive as mothers with affective disorder (N=31), but they showed markedly low positive responsiveness. Only the schizophrenia group exhibited non-responses as a result of being psychologically withdrawn from the interaction, and abnormal behaviors. Inconsistent to our hypothesis, infants in both groups showed similar levels of activity, initiative and negativity. The findings highlight the need for further research to examine the contribution of maternal response impairments to the developmental vulnerability of this genetically high-risk group.

Smoking cessation interventions in chronic obstructive pulmonary disease and the role of the family: a systematic literature review.

AIM: This paper is a report of a systematic review to assess the effectiveness of family-focused smoking cessation interventions for people with chronic obstructive pulmonary disease and to determine what data on families are documented in studies of smoking cessation interventions. BACKGROUND: Chronic obstructive pulmonary disease is a major public health problem and cigarette smoking is the most important factor contributing to its development and progression. However, smoking cessation rates are low and relapse is common. The role of families in smoking cessation efforts has received little attention. METHODS: All studies were included in the review that (i) addressed an evaluation of a psycho-social/educational smoking cessation intervention for people with chronic obstructive pulmonary disease, (ii) addressed some information on the family (i.e. living arrangements, marital status, smoking history of family members, support for quitting) and/or included the family as part of the intervention and (iii) were published between 1990 and 2006. Electronic data sources, existing systematic reviews of smoking cessation interventions and the grey literature were reviewed. RESULTS: Seven studies were included. Six studies (11 papers) included data on marital status, smoking status of household members, support for quitting smoking and related variables. In two of the studies, the variable on the family was used to analyse smoking cessation outcomes. One additional study met the inclusion criterion of an evaluation of a smoking cessation intervention, which also included a family focus in the intervention. CONCLUSION: No conclusions about the effectiveness of a family-focused smoking cessation intervention could be drawn from this review. Further research is needed to determine if a more family-focused intervention, in conjunction with pharmacological and counselling approaches, would lead to improved smoking cessation outcomes.

What predicts poor mother-infant interaction in schizophrenia?

BACKGROUND: Poor clinician-rated parenting outcome and observed interactive deficits in mothers with schizophrenia admitted to a psychiatric mother and baby unit (MBU) reflect continuing concerns over the parenting capacity of this group. However, little is known about whether interaction deficits are accounted for by severity of illness or adverse social circumstances typically experienced by these mothers. METHOD: Thirty-eight women with severe perinatal illness (schizophrenia n=13; affective disorders n=25) and their infants were observed in play interaction a week prior to MBU discharge. Clinical and sociodemographic data were also obtained. RESULTS: Mothers with schizophrenia and their infants were rated to have poorer interactive behaviour than the affective disorders group. Infant avoidance of the mother was associated with a lack of maternal sensitivity and responsiveness. The deficits in mother-infant interaction found in the schizophrenia group could not be accounted for by our measures of illness severity or factors relating to adverse social circumstances. CONCLUSIONS: The results replicate and extend previous findings showing poor interactive behaviours in mothers with schizophrenia, their infants, and in the dyad, in a range of areas following clinical recovery. The findings suggest that factors other than illness duration, dose of medication, marital status and occupational status are explanatory for the interactive deficits associated with maternal schizophrenia. Parenting interventions that aim to improve maternal sensitivity need to be developed specifically for this group.

Predictors of social services supervision of babies of mothers with mental illness after admission to a psychiatric mother and baby unit.

BACKGROUND: There is insufficient information on the predictors of parenting difficulties in mothers with severe mental illness. Using data from mother and baby units in the UK we aimed to examine the social and clinical characteristics of mothers whose babies were supervised by social services on discharge. METHOD: A case-control study was carried out using data from mother and baby units and facilities entered onto the Marce database. RESULTS: Of 1197 mothers, 23% were discharged with their babies under some form of social services supervision. Factors independently associated with an increased risk of supervision included social class (OR 3.16, 95% CI 1.99-5.03), single marital status (OR 2.10, 95% CI 1.38-3.20), behavioural disturbance (OR 1.69, 95% CI 1.08-2.65) and psychiatric illness in the partner (OR 2.67, 95% CI 1.59-4.49). The diagnostic groups independently associated with the highest risk of having a supervised baby were schizophrenia (OR 5.16, 95% CI 2.61-10.21) and personality disorder (OR 9.29, 95% CI 3.46-24.91). CONCLUSIONS: Mothers with schizophrenia are at particularly high risk of having their baby supervised by social services. Preventative interventions should be targeted at socio-economic difficulties, early detection of psychiatric disorders postpartum and treatment of perinatal mental illness in the context of the whole family.

Clinical and parenting skills outcomes following joint mother-baby psychiatric admission.

OBJECTIVE: To examine maternal clinical and parenting outcomes as a function of diagnosis following joint mother-baby admission; to identify the associations of poor outcome. METHOD: Demographic and clinical information was collected on 1081 joint mother-baby admissions, including 224 women with schizophrenia, 155 with bipolar disorder and 409 with non-psychotic depression. Information was based on clinical judgements of senior staff in participating units using the Marcé checklist. Predictors of poor maternal clinical outcome, practical problems in baby care, poor emotional responsiveness to infant and perceived risk of harm to baby were identified by logistic regression. RESULTS: Good clinical outcome was reported in 848 (78%) cases. On each parenting outcome, good outcome was reported in at least 80%. The predictors of poor outcome were similar for all four outcomes. These were a diagnosis of schizophrenia, behavioural disturbance, low social class and either psychiatric illness in the woman's partner or a poor relationship with the partner. Of those with poor outcome on all four variables, 66% suffered with schizophrenia. Women with schizophrenia showed more behavioural disturbance, were more likely to experience hallucinations and delusions, and were more likely to be of low social class. They were also less likely to have a partner and more likely to have a partner with a psychiatric illness. CONCLUSIONS: Clinical and parenting outcomes, as reported by clinical staff, are usually good following joint mother-baby admission. Women with schizophrenia may need particular measures to improve their parenting. A marital approach to treatment, directed at the woman's relationship with her partner or the latter's own mental health may improve outcome.