Point-of-care utrasound use over six-month training period in Rwandan district hospitals

Introduction: Point-of-care ultrasound (POCUS) is an effective diagnostic technology in resource-limited settings. There is increasing interest in introducing ultrasound training in such environments, but few reports describing long-term follow-up and impact of a POCUS program in a resource-limited setting. We introduced a POCUS program in Rwanda, and sought to determine the number and type of ultrasounds performed, the impact of a remote quality assurance (QA) program, and the effect of POCUS on patient management. Methods: Seventeen Rwandan physicians underwent a ten-day training course in POCUS in Kigali, Rwanda. Post-course, participants tracked the ultrasounds they performed using a cloud-based storage system, recorded clinical impressions,and received periodic QA with on-site proctoring over a six-month follow-up. Remote QA to evaluate image quality was performed by five emergency ultrasound fellowshiptrained clinicians. Images were graded on a scale of 0­4. (0=no meaningful image, 2= adequate, 4= outstanding). Trainees also documented how POCUS changed clinical management. Results: Over six months, 1158 ultrasounds were performed and logged by fifteen participants at eleven regional hospitals. 590(50.9%) had matched images and interpretations available for review. Abdominal ultrasound was the most frequently performed application (19.7%), followed by liver (14.6%), obstetrics (14.5%), renal (12.4%),and spleen (11%). Across all applications, the mean score was 2.5 (SD± 0.11, 95% confidence interval, 2.39­2.54). Ultrasound result in a management change in 84% of cases. Major changes in management related to medication choice (42.4%), admission (30%), transfer to a higher level of care (28.1%), and performance of procedures (23.3%). Conclusions: During this six-month training program in Rwanda, participants used POCUS for a range of applications. The remote QA process captured 51% of ultrasounds performed. Of scans with QA, the average score was adequate to good. POCUS routinely changed clinical management. This study demonstrates the impact of POCUS in a resource-limited setting

Decreased synthesis of interleukin-2 (IL-2) in insulin-dependent diabetes mellitus.

Synthesis of interleukin-2 (IL-2) by lymphocytes from 26 insulin-dependent diabetic subjects (IDDM) was compared with that by lymphocytes from 24 nondiabetic control subjects. The control group produced 1.001 +/- 0.071 U/ml (mean +/- SEM). The IDDM group, containing patients diagnosed between 5 days and 10 yr before testing, produced only 0.59 +/- 0.050 U/ml (P less than 0.002). IL-2 synthesis by 6 non-insulin-dependent diabetic subjects (NIDDM) was not decreased (mean +/- SEM, 1.20 +/- 0.04 U/ml). Moreover, decreased levels of IL-2 production was found with lymphocytes of patients in good control, as well as those in poor control. These data suggest that decreased IL-2 synthesis is specific for IDDM, not explainable solely as a consequence of poor metabolic control, and thus, might be involved in the pathogenesis of the disease.

The use of cytotoxic T cell lines to detect the segregation of a human minor alloantigen within families.

A cytotoxic T cell (CTL) line, which detected a minor alloantigen provisionally called W was generated in vitro with lymphocytes from a multiply transfused individual, S1. Lymphocytes from S1 were first stimulated with cells from an unrelated known from previous studies to express the minor antigen. The primary CTL were then restimulated with cells from a W +/ve HLA identical sib, S2, in the presence of IL-2. As in previous work, recognition of the W antigen by these CTL was restricted by HLA-B7. Antigen assignments of W + W -, based upon cold target inhibition studies, confirmed previous assignments which had depended upon the ability of lymphocytes either to stimulate the generation of or to be killed by anti-W CTL effectors. Testing of lymphocyte targets from members of several unrelated families in which HLA-B7 segregated showed that the CTL lines could detect the expression of W on cells of individuals in the general population. In 3 of 5 cases, members of an HLA identical sib pair differed for W. These results open up the possibility of designing studies using CTL lines to determine whether differences for minor alloantigens play a role in clinical transplantation.