Robert Nathan

First look: a cluster-randomized trial of ultrasound to improve pregnancy outcomes in low income country settings

BackgroundIn high-resource settings, obstetric ultrasound is a standard component of prenatal care used to identify pregnancy complications and to establish an accurate gestational age in order to improve obstetric care. Whether or not ultrasound use will improve care and ultimately pregnancy outcomes in low-resource settings is unknown.Methods/DesignThis multi-country cluster randomized trial will assess the impact of antenatal ultrasound screening performed by health care staff on a composite outcome consisting of maternal mortality and maternal near-miss, stillbirth and neonatal mortality in low-resource community settings. The trial will utilize an existing research infrastructure, the Global Network for Women’s and Children’s Health Research with sites in Pakistan, Kenya, Zambia, Democratic Republic of Congo and Guatemala. A maternal and newborn health registry in defined geographic areas which documents all pregnancies and their outcomes to 6 weeks post-delivery will provide population-based rates of maternal mortality and morbidity, stillbirth, neonatal mortality and morbidity, and health care utilization for study clusters. A total of 58 study clusters each with a health center and about 500 births per year will be randomized (29 intervention and 29 control). The intervention includes training of health workers (e.g., nurses, midwives, clinical officers) to perform ultrasound examinations during antenatal care, generally at 18–22 and at 32–36 weeks for each subject. Women who are identified as having a complication of pregnancy will be referred to a hospital for appropriate care. Finally, the intervention includes community sensitization activities to inform women and their families of the availability of ultrasound at the antenatal care clinic and training in emergency obstetric and neonatal care at referral facilities.DiscussionIn summary, our trial will evaluate whether introduction of ultrasound during antenatal care improves pregnancy outcomes in rural, low-resource settings. The intervention includes training for ultrasound-naïve providers in basic obstetric ultrasonography and then enabling these trainees to use ultrasound to screen for pregnancy complications in primary antenatal care clinics and to refer appropriately.Trial registrationClinicaltrials.gov (NCT # 01990625)

The diagnostic impact of limited, screening obstetric ultrasound when performed by midwives in rural Uganda

Objective:To evaluate the diagnostic impact of limited obstetric ultrasound (US) in identifying high-risk pregnancies when used as a screening tool by midwives in rural Uganda.Study Design:This was an institutional review board-approved prospective study of expecting mothers in rural Uganda who underwent clinical and US exams as part of their standard antenatal care visit in a local health center in the Isingiro district of Uganda. The midwives documented clinical impressions before performing a limited obstetric US on the same patient. The clinical findings were then compared with the subsequent US findings to determine the diagnostic impact. The midwives were US-naive before participating in the 6-week training course for limited obstetric US.Result:Midwife-performed screening obstetric US altered the clinical diagnosis in up to 12% clinical encounters. This diagnostic impact is less (6.7 to 7.4%) if the early third trimester diagnosis of malpresentation is excluded. The quality assurance review of midwives’ imaging demonstrated 100% sensitivity and specificity in the diagnosing gestational number, and 90% sensitivity and 96% specificity in the diagnosis of fetal presentation.Conclusion:Limited, screening obstetric US performed by midwives with focused, obstetric US training demonstrates the diagnostic impact for identifying conditions associated with high-risk pregnancies in 6.7 to 12% of patients screened. The limited obstetric US improved diagnosis of early pregnancy complication as well as later gestation twins and malpresentation. Midwives who have undergone focused 6-week limited obstetric US training proved capable of diagnosing twins and fetal presentation with high sensitivity and specificity.

Therapeutic Impact of CT of the Appendix in a Community Hospital Emergency Department

OBJECTIVE The purpose of this study was to prospectively evaluate the therapeutic impact of CT of the appendix in a community hospital. SUBJECTS AND METHODS For each of 100 consecutive adult patients who presented to a community hospital emergency department from August 2006 to November 2006 and underwent CT of the appendix, the proposed treatment plan and the likelihood of appendicitis were recorded before CT and were compared with the actual treatment after CT. The primary outcome assessed was change in patient management after CT. The percentage likelihood of appendicitis, whether patient disposition changed after CT, and the presence or absence of appendicitis were examined. The accuracy of CT was also calculated. RESULTS The treatment plans of the emergency clinicians changed in 29 patients (29%). Appendicitis was ruled out on the basis of CT findings in 50% (9/18) of patients when appendicitis was considered probable and in 60% (3/5) when appendicitis was considered very likely. When appendicitis was considered unlikely, appendicitis was ruled out by CT in 100% (20/20) of patients. CT of the appendix was shown to have high sensitivity (94%), specificity (100%), positive predictive value (100%), negative predictive value (99%), and accuracy (99%). CONCLUSION CT of the appendix had an important therapeutic impact on patients presenting to a community hospital emergency department. The data suggest that CT can be withheld in patients in whom emergency clinicians rate the likelihood of appendicitis as unlikely but that CT findings are often of benefit even when appendicitis is judged to be very likely.

Impact of point-of-care ultrasound training on surgical residents' confidence.

OBJECTIVE Point-of-care ultrasound (POCUS) is a vital tool for diagnosis and management of critically ill patients, particularly in resource-limited settings where access to diagnostic imaging may be constrained. We aimed to develop a novel POCUS training curriculum for surgical practice in the United States and in resource-limited settings in low- and middle-income countries and to determine its effect on surgical resident self-assessments of efficacy and confidence. DESIGN We conducted an observational cohort study evaluating a POCUS training course that comprised 7 sessions of 2 hours each with didactics and proctored skills stations covering ultrasound applications for trauma (Focused Assessement with Sonography for Trauma (FAST) examination), obstetrics, vascular, soft tissue, regional anesthesia, focused echocardiography, and ultrasound guidance for procedures. Surveys on attitudes, prior experience, and confidence in point-of-care ultrasound applications were conducted before and after the course. SETTING General Surgery Training Program in Seattle, Washington. PARTICIPANTS A total of 16 residents participated in the course; 15 and 10 residents completed the precourse and postcourse surveys, respectively. RESULTS The mean composite confidence score from pretest compared with posttest improved from 23.3 (±10.2) to 37.8 (±6.7). Median confidence scores (1-6 scale) improved from 1.5 to 5.0 in performance of FAST (p < 0.001). Residents reported greater confidence in their ability to identify pericardial (2 to 4, p = 0.009) and peritoneal fluid (2 to 4.5, p < 0.001), to use ultrasound to guide procedures (3.5 to 4.0, p = 0.008), and to estimate ejection fraction (1 to 4, p = 0.004). Both before and after training, surgical residents overwhelmingly agreed with statements that ultrasound would improve their US-based practice, make them a better surgical resident, and improve their practice in resource-limited settings. CONCLUSIONS After a POCUS course designed specifically for surgeons, surgical residents had improved self-efficacy and confidence levels across a broad range of skills.

Portable antenatal ultrasound platform for village midwives

Ultrasound imaging is an effective tool for identifying maternal mortality risk factors. Unfortunately, ultrasound is nearly absent in many rural healthcare facilities in developing regions due to the high costs of both equipment and required training. To leverage existing healthcare systems commonly found in these contexts, we have focused our efforts on increasing the diagnostic capabilities of midwives -- often central medical figures in rural and low-income communities. We have designed and built a low-cost portable ultrasound device consisting of a USB ultrasound probe and a touchscreen netbook for a total cost of around USD3500. Compared to currently available ultrasound devices, we simplified the user interface while maintaining functionality to allow midwives to detect three common obstetrical conditions: placenta previa, multiple gestations, and breech presentation. To evaluate our solution, we tested the accuracy of ultrasound measurements, image quality, and whether midwives could use ultrasound. Testing performed by nine clinicians indicated our device would be appropriate for identifying the three conditions. Our modular design approach allows for easy modification, and the device is designed to utilize existing local healthcare resources in order to create a sustainable solution that does not depend on continuous foreign assistance.

Adapting collaborative radiological practice to low-resource environments

We describe how current radiological best practices are predicated on a sophisticated technological ecosystem usually comprised of multiple large-scale displays, and integrated record keeping and communication systems driven by high-speed networks. At the same time, current development of low-cost ultrasound (U/S) devices for low-resource settings trends towards small-scale, independent devices with palm-sized screens. We reviewed existing literature, analyzed findings from two years of fieldwork in Uganda, and conducted an interview study with clinicians about radiology work practices to determine which patterns and technologies contribute to the efficacy of ultrasound. We use these findings to inform how ultrasound technology in low-resource settings can most usefully be developed and deployed. In addition, findings are relevant for creating medical technologies for low-resource environments generally, as we make clear the importance of considering not just technology development aspects like power consumption and interface, but also larger technology and work ecosystems.

Screening obstetric ultrasound training for a 5-country cluster randomized controlled trial.

Abstract With decreased equipment cost, provision of ultrasound is now feasible in some low resource settings. Screening obstetric ultrasound may identify potential pregnancy complications and, with this knowledge, allow women to plan to deliver at the appropriate level of care. In this article, we describe a 10-day course with quality assurance activities to train ultrasound-naïve, nonphysician healthcare professionals at midlevel health facilities to perform screening obstetric ultrasound. Those trained will participate in a cluster randomized controlled trial to assess the impact of screening obstetric ultrasound on maternal and newborn outcomes.

The midwife's assistant: designing integrated learning tools to scaffold ultrasound practice

Ultrasound imaging is an effective tool for identifying maternal mortality risk factors. However, the high cost of ultrasound devices and the scarcity of ultrasound training are two major barriers to adoption in the developing world; complicated and expensive medical technologies are unlikely to meet the needs of users with limited opportunities for formal training and continuing education. To address these particular barriers, we have designed an inexpensive ultrasound system composed of off-the-shelf hardware and custom software. Our system is designed for use by rural midwives---often central medical figures in resource-constrained communities. This paper presents our work integrating help and tutorial software into the ultrasound system we developed. Our goal is to supplement a midwifes conceptual and operational knowledge of diagnostic ultrasound through appropriate and adaptive scaffolding. The design of our help system is informed by interviews with sonographers and radiologists in the United States and Uganda, and data collected during two fieldwork visits to Uganda. Through our fieldwork and preliminary evaluations, we have found that in addition to in-context reference material accessible during an exam, midwives need in-depth learning materials that can be accessed outside of a medical exam scenario.

Web-Based Quality Assurance Process Drives Improvements in Obstetric Ultrasound in 5 Low- and Middle-Income Countries

Newly trained sonographers improved performance through a quality assurance process that merged (1) evaluation by remote experts of images uploaded to a website, with (2) periodic in-person skill tests. To promote sustainability, in-country supervisors gradually assumed more responsibility for image evaluation. The user-friendly and efficient interface used simple menus and forms, customized based on the users role. Newly trained sonographers improved performance through a quality assurance process that merged (1) evaluation by remote experts of images uploaded to a website, with (2) periodic in-person skill tests. To promote sustainability, in-country supervisors gradually assumed more responsibility for image evaluation. The user-friendly and efficient interface used simple menus and forms, customized based on the users role. ABSTRACT High quality is important in medical imaging, yet in many geographic areas, highly skilled sonographers are in short supply. Advances in Internet capacity along with the development of reliable portable ultrasounds have created an opportunity to provide centralized remote quality assurance (QA) for ultrasound exams performed at rural sites worldwide. We sought to harness these advances by developing a web-based tool to facilitate QA activities for newly trained sonographers who were taking part in a cluster randomized trial investigating the role of limited obstetric ultrasound to improve pregnancy outcomes in 5 low- and middle-income countries. We were challenged by connectivity issues, by country-specific needs for website usability, and by the overall need for a high-throughput system. After systematically addressing these needs, the resulting QA website helped drive ultrasound quality improvement across all 5 countries. It now offers the potential for adoption by future ultrasound- or imaging-based global health initiatives.

Impact of Introducing Routine Antenatal Ultrasound Services on Reproductive Health Indicators in Mpigi District, Central Uganda.

Abstract The preponderance of global maternal and neonatal deaths occurs in low-resource countries. The risk factors that lead to these deaths are often detectable with ultrasound (US) and potentially preventable. We assessed the impact of performing US scanning during antenatal care (ANC) on reproductive health service utilization in a rural Ugandan district. This pragmatic comparative study was conducted in 2 constituencies of Mpigi district in Uganda. In the 5 intervention sites located in the Mawokota North constituency, facility midwives were trained in limited obstetric US scanning. They were equipped with solar-powered portable US machines and redeployed to offer US scanning as an integral component of ANC. The 5 control sites in the Mawokota South constituency offered the same ANC services without US scanning. We compared the difference in the first and fourth ANC attendance, facility deliveries, and referral of obstetric complications in the intervention and the control sites before and after the introduction of US. There was a 32% increase in the first ANC attendance at the intervention sites compared with 7.4% in the controls sites (P < 0.001). In the intervention sites, the fourth antenatal attendance increased by 147% compared with 0.6% decline in the control sites (P < 0.001). Referrals of high-risk pregnancies increased by 40.7% in the intervention sites compared with 25% in the control site. The number of births at the interventional sites increased by 34.1% compared with 29.5% in the control sites. Integration of limited obstetric US into routine ANC visits is associated with an increase in ANC attendance.