Feasibility study of minimally trained medical students using the Rural Obstetrical Ultrasound Triage Exam (ROUTE) in rural Panama.

BACKGROUND: Maternal and infant mortality rates reported in rural Panama are greater than those in urban regions. Bocas del Toro is a region of Panama inhabited by indigenous people at greater risk for pregnancy-related complications and deaths due to geographic isolation and limited access to health care. Portable ultrasound training programs have recently been implemented in low-resource settings to increase access to diagnostic imaging. The goal of this study is to determine the feasibility of teaching first-year medical students the Rural Obstetrical Ultrasound Triage Exam (ROUTE) to help identify pathology in pregnant women of the Bocas del Toro region of Panama. METHODS: Eight first-year medical students completed ROUTE training sessions. After training, the students were compared to professional sonographers to evaluate their accuracy in performing the ROUTE. Students then performed the ROUTE in mobile clinics within Bocas del Toro. They enrolled women pregnant in their 2nd or 3rd trimesters and measured biparietal diameter, head circumference, amniotic fluid index, fetal lie and placental position. Any abnormal measurement would be further analyzed by the lead physician for a potential hospital referral. RESULTS: A total of 60 women were enrolled in the study. Four women were detected as having a possible high-risk pregnancy and thus referred to a hospital for further evaluation. CONCLUSION: Based on our data, first-year medical students with additional training can use the ROUTE to identify complications in pregnancy using ultrasound in rural Panama. Additional studies are required to determine the optimal amount of training required for proficiency.

Feasibility study of minimally trained medical students using the Rural Obstetrical Ultrasound Triage Exam (ROUTE) in rural Panama / 世界急诊医学杂志（英文）

BACKGROUND:Maternal and infant mortality rates reported in rural Panama are greater than those in urban regions. Bocas del Toro is a region of Panama inhabited by indigenous people at greater risk for pregnancy-related complications and deaths due to geographic isolation and limited access to health care. Portable ultrasound training programs have recently been implemented in low-resource settings to increase access to diagnostic imaging. The goal of this study is to determine the feasibility of teaching first-year medical students the Rural Obstetrical Ultrasound Triage Exam (ROUTE) to help identify pathology in pregnant women of the Bocas del Toro region of Panama. METHODS:Eight first-year medical students completed ROUTE training sessions. After training, the students were compared to professional sonographers to evaluate their accuracy in performing the ROUTE. Students then performed the ROUTE in mobile clinics within Bocas del Toro. They enrolled women pregnant in their 2nd or 3rd trimesters and measured biparietal diameter, head circumference, amniotic fluid index, fetal lie and placental position. Any abnormal measurement would be further analyzed by the lead physician for a potential hospital referral. RESULTS:A total of 60 women were enrolled in the study. Four women were detected as having a possible high-risk pregnancy and thus referred to a hospital for further evaluation. CONCLUSION:Based on our data, first-year medical students with additional training can use the ROUTE to identify complications in pregnancy using ultrasound in rural Panama. Additional studies are required to determine the optimal amount of training required for proficiency.

Conditioning- and time-dependent increases in context fear and generalization.

A prominent feature of fear memories and anxiety disorders is that they endure across extended periods of time. Here, we examine how the severity of the initial fear experience influences incubation, generalization, and sensitization of contextual fear memories across time. Adult rats were presented with either five, two, one, or zero shocks (1.2 mA, 2 sec) during contextual fear conditioning. Following a recent (1 d) or remote (28 d) retention interval all subjects were returned to the original training context to measure fear memory and/or to a novel context to measure the specificity of fear conditioning. Our results indicate rats that received two or five shocks show an "incubation"-like enhancement of fear between recent and remote retention intervals, while single-shocked animals show stable levels of context fear memory. Moreover, when fear was tested in a novel context, 1 and 2 shocked groups failed to freeze, whereas five shocked rats showed a time-dependent generalization of context memory. Stress enhancement of fear learning to a second round of conditioning was evident in all previously shocked animals. Based on these results, we conclude that the severity or number of foot shocks determines not only the level of fear memory, but also the time-dependent incubation of fear and its generalization across distinct contexts.

Risk Factors for Surgical Site Infection in Patients Undergoing Sacral Nerve Modulation Therapy.

OBJECTIVES: The aim of this study was to identify risk factors for surgical site infection in patients undergoing sacral nerve modulation (SNM) surgery. METHODS: We conducted a retrospective cohort analysis of 290 patients undergoing a total of 669 SNM procedures between 2002 and 2012 by 2 fellowship-trained female pelvic medicine and reconstructive surgery attending physicians at the University of California-Irvine Medical Center. Infection was defined as a charted abnormal examination finding at the implantation site (erythema, induration, purulent discharge) resulting in prescription of antibiotics, hospitalization, or explantation. We extracted information from the medical record regarding possible risk factors for infection including age, body mass index, immunosuppression (diabetes mellitus, chronic steroid use, smoker, chemotherapy), number of procedures per patient, and number of days between stages 1 and 2. In addition, we compared infection rates before and after 2008 when a clinical practice change was made with the implementation of home chlorhexidine washing (CHW) prior to SNM surgery. RESULTS: Thirty infections occurred, 25 of which were managed with oral antibiotics. Nine required intravenous antibiotics, and 11 required removal of the implanted device. Three patients experienced infection on 2 separate occasions. Seventeen infections had culture data available. Nine of the patients who underwent explantation had wound cultures positive for methicillin-resistant Staphylococcus aureus.Thirteen of the 26 patients who developed infection had medical histories significant for immunosuppression. Three patients developed late-onset abscess formation at 234, 257, and 687 days after stage 2, respectively. The median time between the most recent SNM procedure and development of infection was 14 days (range, 6-88 days).Body mass index and immunosuppression were significant predictors of infection, whereas age, parity, indication for procedure, and number of days between stages 1 and 2 were not found to be independent predictors. Three hundred twenty-three procedures were performed prior to and 346 procedures were performed after institution of home CHW. Twenty-four (80%) of the 30 reported infections were prior to CHW, whereas only 6 infections (20%) occurred after this change in practice. Prior to institution of CHW, the infection rate was 7.4%, and after institution of CHW, it was 1.7% (P = 0.002). Of the 83 patients with compliance data available for CHW use, 71 reported using CHW, whereas 12 reported not using CHW. CONCLUSIONS: Surgical site infection is a significant risk of SNM surgery, although our infection rate is lower than previously reported. Chlorhexidine washing appears to reduce the risk of infection in this population. Because the majority of infections requiring explantation were methicillin-resistant S. aureus positive, prophylactic treatment for this organism should be considered as an additional strategy to reduce infection. Body mass index and immunosuppression appear to be independent risk factors for infection.