Focused cardiac ultrasound: Competency among pre-internship medical officers in diagnosing cardiac causes of dyspnea.

BACKGROUND: Differentiating cardiovascular causes of dyspnea in resource-limited healthcare settings can be challenging. The use of easy-to-train, point-of-care, focused cardiac ultrasound (FoCUS) protocols may potentially alleviate this challenge. RESEARCH QUESTION: Can novices attain competency in FoCUS use after training using the cardiac ultrasound for resource-limited settings (CURLS) protocol? METHODS: A quasi-experimental study was conducted at the Kenyatta National Hospital in Nairobi, Kenya. Forty-five graduate medical pre-interns, novices in cardiac ultrasound, received simulated didactic and hands-on FoCUS skills training using the CURLS protocol and 2018 European Association of Cardiovascular Imaging (EACVI) FoCUS training and competence assessment recommendations. Competency was assessed in image interpretation, image acquisition, and image quality. RESULTS: Aggregate image interpretation competency was attained by n = 38 (84%) of trainees with a median score of 80%. The proportion of trainees attaining category-specific image interpretation competency was as follows: pericardial effusion n = 44 (98%), left atrial enlargement n = 40 (89%), cardiomyopathy n = 38 (84%), left ventricular hypertrophy n = 37 (82%), and right ventricular enlargement n = 29 (64%). Image acquisition skills competency was attained by n = 36 (80%) of trainees. Three-quarters of trainee-obtained images were of good quality. CONCLUSION: Majority of the trainees attained competency. Training constraints limit the generalizability of our findings.

Diagnostic accuracy of combined thoracic and cardiac sonography for the diagnosis of pulmonary embolism: A systematic review and meta-analysis.

OBJECTIVES: Computed tomography pulmonary angiography (CTPA) is the diagnostic standard for pulmonary embolism (PE), but is unavailable in many low resource settings. We evaluated the evidence for point of care ultrasound as an alternative diagnostic. METHODS: Using a PROSPERO-registered, protocol-driven strategy (https://www.crd.york.ac.uk/PROSPERO, ID = CRD42018099925), we searched MEDLINE, EMBASE, and CINHAL for observational and clinical trials of cardiopulmonary ultrasound (CPUS) for PE. We included English-language studies of adult patients with acute breathlessness, reported according to PRISMA guidelines published in the last two decades (January 2000 to February 2020). The primary outcome was diagnostic accuracy of CPUS compared to reference standard CTPA for detection of PE in acutely breathless adults. RESULTS: We identified 260 unique publications of which twelve met all inclusion criteria. Of these, seven studies (N = 3872) were suitable for inclusion in our meta-analysis for diagnostic accuracy (two using CTPA and five using clinically derived diagnosis criterion). Meta-analysis of data demonstrated that using cardiopulmonary ultrasound (CPUS) was 91% sensitive and 81% specific for pulmonary embolism diagnosis compared to diagnostic standard CTPA. When compared to clinically derived diagnosis criterion, CPUS was 52% sensitive and 92% specific for PE diagnosis. We observed substantial heterogeneity across studies meeting inclusion criteria (I2 = 73.5%). CONCLUSIONS: Cardiopulmonary ultrasound may be useful in areas where CTPA is unavailable or unsuitable. Interpretation is limited by study heterogeneity. Further methodologically rigorous studies comparing CPUS and CTPA are important to inform clinical practice.

Obstructive Sleep Apnea Awareness among Primary Care Physicians in Africa.

Rationale: Obstructive sleep apnea (OSA) is a significant health problem among adults and children globally, resulting in decreased quality of life and increased costs of healthcare. For optimal clinical care, primary care physicians should be familiar with OSA and confident in their ability to screen, diagnose, and manage this condition.Objectives: To assess the knowledge, attitudes, and practices of primary care physicians in Kenya, Nigeria, and South Africa regarding OSA in adults and children.Methods: We conducted a multicenter cross-sectional survey in Kenya (Nairobi), Nigeria (Edo State), and South Africa (Cape Town) between April 2016 and July 2017. At least 40 participants were randomly selected from a register of primary care physicians at each site. Potential participants were contacted to receive online/paper-based, validated OSA Knowledge and Attitudes (OSAKA) and OSAKA in Children (OSAKA-KIDS) questionnaires related to adults and children, respectively. The median percentage knowledge scores and proportions of favorable attitude were computed and current diagnostic and referral practices were documented.Results: The median OSAKA knowledge scores were 83.3% (interquartile range [IQR], 77.8-88.9), 66.7% (IQR, 55.6-77.8), and 61.1% (IQR, 55.6-77.8) among South African, Kenyan, and Nigerian physicians, respectively. For OSAKA-KIDS, the median knowledge scores were 61.1% (IQR, 50.0-72.2), 64.2% (IQR, 35.3-93.2), and 58.3% (IQR, 44.4-66.7) among South African, Kenyan, and Nigerian physicians, respectively. Most physicians (90-94%) considered adult and pediatric OSA very/extremely important. Fewer physicians agreed/strongly agreed that they were confident about OSA diagnosis (55%), management (25%), and continuous positive airway pressure (18%) use in adults. Even fewer physicians agreed/strongly agreed that they were confident about pediatric OSA diagnosis (35%), management (21%), and continuous positive airway pressure use (18%). South African physicians mainly prescribed polysomnography (51%) and overnight oximetry (22%), whereas 49% of Nigerian physicians and 65% of Kenyan physicians commonly requested lateral cervical radiography.Conclusions: Primary care physicians in South Africa, Nigeria, and Kenya considered OSA to be important but had modest knowledge about OSA in adults and children, and had a low perceived confidence in adult and pediatric management. Focused educational interventions during undergraduate training and continuing professional development programs may improve primary physicians' knowledge about OSA and its diagnosis and management.

Health Risks Associated with Occupational Exposure to Ambient Air Pollution in Commercial Drivers: A Systematic Review.

Ambient air pollution is a major global health problem and commercial drivers are particularly exposed to it. As no systematic assessment of the health risks associated with occupational exposure to ambient air pollution in this population had yet been carried out, we conducted a systematic review using a protocol-driven strategy. Papers published from inception to April 20, 2018 in MEDLINE, EMBASE, CINAHL, African journals online, the Cochrane library, ISRCTN WHO ICTRP, and the Web of Science and Scopus databases were screened for inclusion by two independent reviewers. Original articles with at least an available abstract in English or French were included. The initial search retrieved 1454 published articles of which 20 articles were included. Three studies reported a significant difference in white blood cells (106/L) among commercial motorcyclists compared to rural inhabitants (5.041 ± 1.209 vs. 5.900 ± 1.213, p = 0.001), an increased risk of lung cancer (RR = 1.6, 95%CI 1.5⁻1.8) in bus drivers and an increased standardized mortality ratio (SMR) in bus drivers from Hodgkin's lymphoma (SMR 2.17, 95%CI 1.19⁻3.87) compared to white-collar workers. Other studies also found that drivers had more oxidative DNA damage and chromosome breaks. Four papers failed to demonstrate that the drivers were more exposed to air pollution than the controls. Three other studies also reported no significant difference in lung function parameters and respiratory symptoms. The genetic polymorphisms of detoxifying enzymes were also not homogeneously distributed compared to the controls. There is some evidence that occupational exposure to ambient air pollution among commercial drivers is associated with adverse health outcomes, but the existing literature is limited, with few studies on small sample size, methodological weaknesses, and contradictory findings-thus, further research is recommended.

A cross-sectional study with an improved methodology to assess occupational air pollution exposure and respiratory health in motorcycle taxi driving.

INTRODUCTION: Motorcycle taxi driving is common in many African cities. This study tested whether this occupation is associated with more respiratory disorders in a context of widespread urban air pollution with an improved methodology. METHODS: In a cross sectional study we compared 85 male motorcycle taxi drivers in the capital city of the Republic of Benin (Cotonou) with an age and neighborhood matched control group. All participants carried a portable carbon monoxide data logger for 8 hours per day to assess exposure to air pollution. Respiratory symptoms were obtained using a standardized questionnaire and pulmonary function was assessed by spirometry. RESULTS: The two groups did not differ significantly (p>0.10) in their age, height, educational level, and exposures to smoke from biomass fuels and tobacco products. The taxi drivers were exposed to higher mean (SD) levels of carbon monoxide (7.6±4.9ppmvs. 5.4±3.8ppm p=0.001). They reported more phlegm and tended to have slightly lower levels of lung function, although these differences were not statistically significant. CONCLUSION: In this cross sectional study of young motorcycle taxi drivers with substantial exposure to urban traffic and a matched control group, we found no evidence for respiratory impairment. A follow-up of such study population with other pollution exposure surrogate and other clinical endpoint may provide a more robust conclusion regarding the exposure response in this professional group.