Medicine and Health Sciences Commons^™

Hypertension As A Sequela In Patients Of Sars-Cov-2 Infection., Ganxiao Chen, Xun Li, Zuojiong Gong, Hao Xia, Yao Wang, Xuefen Wang, Yan Huang, Hector Barajas-Martinez, Dan Hu

Department of Medicine Faculty Papers

BACKGROUND: COVID-19 is a respiratory infectious disease caused by SARS-CoV-2, and cardiovascular damage is commonly observed in affected patients. We sought to investigate the effect of SARS-CoV-2 infection on cardiac injury and hypertension during the current coronavirus pandemic.

STUDY DESIGN AND METHODS: The clinical data of 366 hospitalized COVID-19-confirmed patients were analyzed. The clinical signs and laboratory findings were extracted from electronic medical records. Two independent, experienced clinicians reviewed and analyzed the data.

RESULTS: Cardiac injury was found in 11.19% (30/268) of enrolled patients. 93.33% (28/30) of cardiac injury cases were in the severe group. The laboratory findings indicated that …

Acupuncture For Pain, Julita Mitchell, Md

Department of Family & Community Medicine Presentations and Grand Rounds

Objectives

➢ To introduce basic acupuncture theory and proposed mechanisms.

➢ To describe a typical acupuncture encounter.

➢ To outline the indications for acupuncture.

➢ To explore clinical evidence behind acupuncture for pain
○ Knee osteoarthritis, low back pain, headache

➢ Review AAFP Clinical Recommendations for acupuncture.

➢ To discuss logistical aspects of acupuncture referral.

Isolation And Characterization Of Human Colon Adenocarcinoma Stem-Like Cells Based On The Endogenous Expression Of The Stem Markers., Sergei A. Koshkin, Olga V. Anatskaya, Alexander E. Vinogradov, Vladimir N. Uversky, Guy W. Dayhoff, Margarita A. Bystriakova, Valery A. Pospelov, Elena N. Tolkunova

Department of Medical Oncology Faculty Papers

BACKGROUND: Cancer stem cells' (CSCs) self-maintenance is regulated via the pluripotency pathways promoting the most aggressive tumor phenotype. This study aimed to use the activity of these pathways for the CSCs' subpopulation enrichment and separating cells characterized by the OCT4 and SOX2 expression.

METHODS: To select and analyze CSCs, we used the SORE6x lentiviral reporter plasmid for viral transduction of colon adenocarcinoma cells. Additionally, we assessed cell chemoresistance, clonogenic, invasive and migratory activity and the data of mRNA-seq and intrinsic disorder predisposition protein analysis (IDPPA).

RESULTS: We obtained the line of CSC-like cells selected on the basis of the expression …

Life During The Pandemic: An International Photo-Elicitation Study With Medical Students., M Dworkin, T Akintayo, D Calem, C Doran, A Guth, E M Kamami, J Kar, J Larosa, J C Liu, I N Pérez Jiménez, R Frasso

College of Population Health Faculty Papers

BACKGROUND: The SARS-CoV-2 (COVID-19) pandemic is a global event with unprecedented impact on individuals and communities around the world. The purpose of this study is to use a modified photo-elicitation methodology to examine the impact of the COVID-19 pandemic on the lives of medical students and their communities around the world.

METHODS: Participating medical students were asked to take photographs for 14 days. In lieu of an interview, which is customary for photo-elicitation projects, participants were asked to share a reflection (a paragraph or two) for each photograph they contributed to the study.

RESULTS: Between April 27th, 2020 and May …

Gray Matter Sampling Differences Between Subdural Electrodes And Stereoelectroencephalography Electrodes., Mohamed Tantawi, Jingya Miao, Caio Matias, Christopher T. Skidmore, Michael R. Sperling, Ashwini Sharan, Chengyuan Wu

Department of Neurosurgery Faculty Papers

Objective: Stereoelectroencephalography (SEEG) has seen a recent increase in popularity in North America; however, concerns regarding the spatial sampling capabilities of SEEG remain. We aimed to quantify and compare the spatial sampling of subdural electrode (SDE) and SEEG implants.

Methods: Patients with drug-resistant epilepsy who underwent invasive monitoring were included in this retrospective case-control study. Ten SEEG cases were compared with ten matched SDE cases based on clinical presentation and pre-implantation hypothesis. To quantify gray matter sampling, MR and CT images were coregistered and a 2.5mm radius sphere was superimposed over the center of each electrode contact. The estimated recording …

An Insulator Blocks Access To Enhancers By An Illegitimate Promoter, Preventing Repression By Transcriptional Interference., Miki Fujioka, Anastasiya Nezdyur, James B. Jaynes

Department of Biochemistry and Molecular Biology Faculty Papers

Several distinct activities and functions have been described for chromatin insulators, which separate genes along chromosomes into functional units. Here, we describe a novel mechanism of functional separation whereby an insulator prevents gene repression. When the homie insulator is deleted from the end of a Drosophila even skipped (eve) locus, a flanking P-element promoter is activated in a partial eve pattern, causing expression driven by enhancers in the 3' region to be repressed. The mechanism involves transcriptional read-through from the flanking promoter. This conclusion is based on the following. Read-through driven by a heterologous enhancer is sufficient to repress, even …

The Influence Of Axial Myopia On Optic Disc Characteristics Of Glaucoma Eyes., Jasmin Rezapour, Christopher Bowd, Jade Dohleman, Akram Belghith, James A Proudfoot, Mark Christopher, Leslie Hyman, Jost B Jonas, Massimo A Fazio, Robert N Weinreb, Linda M Zangwill

Wills Eye Hospital Papers

This study characterizes differences in glaucomatous eyes with and without high axial myopia using custom automated analysis of OCT images. 452 eyes of 277 glaucoma patients were stratified into non (n = 145 eyes), mild (n = 214 eyes), and high axial myopia (axial length (AL) > 26 mm, n = 93 eyes). Optic disc ovality index, tilt and rotation angle of Bruch´s membrane opening (BMO) and peripapillary choroidal thickness (PCT) were calculated using automated and deep learning strategies. High myopic optic discs were more oval and had larger BMO tilt than mild and non-myopic discs (both p < 0.001). Mean PCT was thinnest in high myopic eyes followed by mild and non-myopic eyes (p < 0.001). BMO rotation angle, global retinal nerve fiber layer (RNFL) thickness and BMO-minimum rim width (MRW) were similar among groups. Temporal RNFL was thicker and supranasal BMO-MRW was thinner in high myopic eyes. BMO tilt and PCT showed moderate and temporal RNFL and nasal BMO-MRW showed weak but significant associations with AL in multivariable analyses (all p < 0.05). Large BMO tilt angle and thin PCT are characteristics of highly myopic discs and were not associated with severity of glaucoma. Caution should be exercised when using sectoral BMO-MRW and RNFL thickness for glaucoma management decisions in myopic eyes.

Service Use By Medicaid Recipients With Serious Mental Illness During An Rct Of The Bridge Peer Health Navigator Intervention, Erin L Kelly, Benjamin Hong, Lei Duan, Laura Pancake, Heather Cohen, John S Brekke

Department of Family & Community Medicine Faculty Papers

OBJECTIVE: Integration of general medical care and mental health care is a high priority for individuals with serious mental illnesses because of their high risk of morbidity and early mortality. The Bridge is a peer-led, health navigator intervention designed to improve access to and use of health care and self-management of medical services by individuals with serious mental illnesses. This study expands on a previous study in which the authors examined participants' self-reported outcomes from a 12-month randomized controlled trial of the Bridge. In the study reported here, Medicaid data were used to assess the impact of the intervention on …

The Quandary Of Dna-Based Treatment Assessment In De Novo Metastatic Prostate Cancer In The Era Of Precision Oncology., Sigve Nakken, Wolfgang Lilleby, Marta D. Switlyk, Karen E Knudsen, Oscar Lilleby, Sen Zhao, Fatemeh Kaveh, Per O. Ekstrøm, Alfonso Urbanucci, Eivind Hovig

Department of Cancer Biology Faculty Papers

Guidelines for genetic testing have been established for multiple tumor types, frequently indicating the most confident molecularly targeted treatment options. However, considering the often-complex presentation of individual cancer patients, in addition to the combinatorial complexity and inherent uncertainties of molecular findings, deriving optimal treatment strategies frequently becomes very challenging. Here, we report a comprehensive analysis of a 68-year-old male with metastatic prostate cancer, encompassing pathology and MRI findings, transcriptomic results, and key genomics findings from whole-exome sequencing, both somatic aberrations and germline variants. We identify multiple somatic aberrations that are known to be enriched in prostate cancer, including a deletion …

A Shocking Case Of Far-Field Atrial Oversensing In Giant-Cell Myocarditis, Tanuka Datta, Md, S. Melnick, Do, Bharaniabirami Rajaram, Md, Behzad B. Pavri

Division of Cardiology Faculty Papers

We report a unique case of delivery of inappropriate implantable cardioverter-defibrillator therapies related to a “perfect storm”: presence of an integrated lead, insufficient lead slack related to right heart dilation resulting in shock coil misplacement, myocarditis with loss of R waves, and the concomitant occurrence of an incessant atrial tachycardia. (Level of Difficulty: Advanced.)

Reducing Unnecessary Telemetry Utilization In A Community Hospital: A Value Enhancing Project, Deanna Blanchard, Md, Cpe, Facs

Master of Science in Healthcare Quality and Safety Capstone Presentations

Health care expenditures are growing at an unsustainable rate with one third of those expenditures directly attributed to overtreatment and waste. Waste associated with unnecessary telemetry utilization includes physical waste in garbage, process defects in false alarms, time in patient flow, motion in tasks, excessive work, and excessive cost. The American Heart Association (AHA) has published guidelines establishing best practices for telemetry use. American Board of Internal Medicine Foundation (ABIMF) and the Society of Hospital Medicine in the Choosing Wisely® campaign have deemed inappropriate telemetry use as a wasteful practice. A multidisciplinary task force was created at Hospital A to …

Impaired 26s Proteasome Assembly Precedes Neuronal Loss In Mutant Ubqln2 Rats., Wenjuan Zhang, Bo Huang, Limo Gao, Cao Huang

Department of Pathology, Anatomy, and Cell Biology Faculty Papers

Proteasomal dysfunction is known to be associated with amyotrophic lateral sclerosis and frontotemporal degeneration (ALS/FTD). Our previous reports have shown that a mutant form of ubiquilin-2 (UBQLN2) linked to ALS/FTD leads to neurodegeneration accompanied by accumulations of the proteasome subunit Rpt1 in transgenic rats, but the precise pathogenic mechanisms of how this mutation impairs the proteasome remains to be elucidated. Here, we reveal that this UBQLN2 mutation in rats disrupted the proteasome integrity prior to neurodegeneration, that it dissociated the 26S proteasome in vitro, and that its depletion did not affect 26S proteasome assembly. During both disease progression and in …

Hybrid Diffusion Imaging Reveals Altered White Matter Tract Integrity And Associations With Symptoms And Cognitive Dysfunction In Chronic Traumatic Brain Injury., Jennifer Muller, Devon Middleton, M. Alizadeh, George Zabrecky, Nancy Wintering, Anthony J. Bazzan, Ji Lang, Chengyuan Wu, Daniel A. Monti, Qianhong Wu, Andrew B. Newberg, Feroze B. Mohamed

Department of Radiology Faculty Papers

The detection and association of in vivo biomarkers in white matter (WM) pathology after acute and chronic mild traumatic brain injury (mTBI) are needed to improve care and develop therapies. In this study, we used the diffusion MRI method of hybrid diffusion imaging (HYDI)to detect white matter alterations in patients with chronic TBI (cTBI). 40 patients with cTBI presenting symptoms at least three months post injury, and 17 healthy controls underwent magnetic resonance HYDI. cTBI patients were assessed with a battery of neuropsychological tests. A voxel-wise statistical analysis within the white matter skeleton was performed to study between group differences …

Sarcopenia: A Functional Chronic Disease, Mike Haines, Md

Department of Family & Community Medicine Presentations and Grand Rounds

Objectives

• Define sarcopenia as a clinical diagnosis as described by the European Working Group on Sarcopenia in Older Persons (EWGSOP2)
• Recognize, identify, and describe sarcopenia as a distinct disease process
• Review impact on health outcomes and healthcare costs
• Explain tools used to aid in diagnosis in clinical practice
• Explore the nuances of therapeutic interventions
• Discuss role of the primary care physician

Outline

● What is sarcopenia?

• Definition provided by EWGSOP2
• Brief overview of pathophysiology

● Why is it important?

• Epidemiology
• Impact on health outcomes
• Healthcare costs

● Diagnosis

• Review EWGSOP2 framework for clinical practice
• Questionnaires
• Office based testing
• Imaging

● …

Spirituality And Opioid Addiction Recovery, Carol A. Ammon, Msn, Mba, Dnp, Stacey Boyer, Psyd, Stephen Dutton, Mdiv, Pd, Courtney Slater, Phd

Full-Text Theses & Dissertations

Purpose: Opioid Use Disorder (OUD) is chronic relapsing disease and requires intense rehabilitation. A link between spirituality and addiction recovery. The purpose of this study was to investigate whether addressing spiritual concerns among hospitalized patients with OUD warrants a specific intervention to assist patients with their unique spiritual needs.

Methods: This qualitative-only study recruited fourteen eligible participants and resulted in five qualitative interviews. The FICA Spiritual Assessment Tool© was used to conduct the interviews and all interviews were coded for theme development.

Results: The results of this study demonstrated that spirituality as a phenomenon in addiction recovery can be determined …

Proceedings Of The Eighth Annual Deep Brain Stimulation Think Tank: Advances In Optogenetics, Ethical Issues Affecting Dbs Research, Neuromodulatory Approaches For Depression, Adaptive Neurostimulation, And Emerging Dbs Technologies, Vinata Vedam-Mai, Karl Deisseroth, James Giordano, Gabriel Lazaro-Munoz, Winston Chiong, Nanthia Suthana, Jean-Philippe Langevin, Jay Gill, Wayne Goodman, Nicole R Provenza, Casey H Halpern, Rajat S Shivacharan, Tricia N Cunningham, Sameer A Sheth, Nader Pouratian, Katherine W Scangos, Helen S Mayberg, Andreas Horn, Kara A Johnson, Christopher R Butson, Ro'ee Gilron, Coralie De Hemptinne, Robert Wilt, Maria Yaroshinsky, Simon Little, Philip Starr, Greg Worrell, Prasad Shirvalkar, Edward Chang, Jens Volkmann, Muthuraman Muthuraman, Sergiu Groppa, Andrea A Kühn, Luming Li, Matthew Johnson, Kevin J Otto, Robert Raike, Steve Goetz, Chengyuan Wu, Peter Silburn, Binith Cheeran, Yagna J Pathak, Mahsa Malekmohammadi, Aysegul Gunduz, Joshua K Wong, Stephanie Cernera, Aparna Wagle Shukla, Adolfo Ramirez-Zamora, Wissam Deeb, Addie Patterson, Kelly D Foote, Michael S Okun

Department of Neurosurgery Faculty Papers

We estimate that 208,000 deep brain stimulation (DBS) devices have been implanted to address neurological and neuropsychiatric disorders worldwide. DBS Think Tank presenters pooled data and determined that DBS expanded in its scope and has been applied to multiple brain disorders in an effort to modulate neural circuitry. The DBS Think Tank was founded in 2012 providing a space where clinicians, engineers, researchers from industry and academia discuss current and emerging DBS technologies and logistical and ethical issues facing the field. The emphasis is on cutting edge research and collaboration aimed to advance the DBS field. The Eighth Annual DBS …

Correlations Between Coffee Consumption And Metabolic Phenotypes, Plasma Folate, And Vitamin B12: Nhanes 2003 To 2006., Pratibha V Nerurkar, Krupa Gandhi, John J Chen

Department of Pharmacology and Experimental Therapeutics Faculty Papers

Metabolic syndrome (MetS) is prevalent not only among the overweight and obese but also normal weight individuals, and the phenotype is referred to as a metabolically unhealthy phenotype (MUHP). Besides normal weight individuals, overweight/obese individuals are also protected from MetS, and the phenotype is known as a metabolically healthy phenotype (MHP). Epidemiological studies indicate that coffee and micronutrients such as plasma folate or vitamin B12 (vit. B12) are inversely associated with MetS. However, correlations among coffee consumption metabolic phenotypes, plasma folate, and vit. B12 remain unknown. Our objective was to investigate the correlation between coffee consumption, metabolic phenotypes, plasma folate, …

Effect Of A Virtual Reality-Enhanced Exercise And Education Intervention On Patient Engagement And Learning In Cardiac Rehabilitation: Randomized Controlled Trial., Victoria Gulick, Daniel Graves, Shannon Ames, Pavitra Parimala Krishnamani

Department of Rehabilitation Medicine Faculty Papers

BACKGROUND: Cardiac rehabilitation (CR) is clinically proven to reduce morbidity and mortality; however, many eligible patients do not enroll in treatment. Furthermore, many enrolled patients do not complete their full course of treatment. This is greatly influenced by socioeconomic factors but is also because of patients' lack of understanding of the importance of their care and a lack of motivation to maintain attendance.

OBJECTIVE: This study aims to explore the potential benefits of virtual reality (VR) walking trails within CR treatment, specifically with regard to patient knowledge retention, satisfaction with treatment, and the overall attendance of treatment sessions.

METHODS: New …

Presence And Implications Of Sarcopenia In Non-Alcoholic Steatohepatitis., Gregory Habig, Christa Smaltz, Dina Halegoua-De Marzio

Department of Medicine Faculty Papers

Sarcopenia, defined as the loss of muscle strength, mass, and functionality, confers a poor prognosis in the setting of cirrhosis. Given its clinical significance, a better understanding of the underlying mechanisms leading to cirrhosis, sarcopenia, and their co-occurrence may improve these patients' outcomes. Non-alcoholic steatohepatitis (NASH) shares many of the same etiologies as sarcopenia, including insulin resistance, chronic inflammation, and ectopic adipocyte deposition, which are hallmarks of metabolic syndrome (MS). NASH thus serves as a prime candidate for further exploration into the underlying pathophysiology and relationship between these three conditions. In this review, we discuss the natural history of NASH …

Designing A Strategic Plan For The Jefferson Center For Interprofessional Practice And Education (Jcipe), Larry M. Starr, Phd, John Pourdehnad, Phd

School of Continuing and Professional Studies Posters

No abstract provided.

Multifaceted Management Of Covid In The Medical Student Population Of Sidney Kimmel Medical College, Wayne Bond Lau, Kristin Desimone, Leonard Levine, Kathryn Trayes, Charlie Pohl

Department of Emergency Medicine Posters

COVID has created hardships in the lives of many persons. In a time of chaos, it was clear our institution needed an efficient workflow to track all students requiring quarantine, so that academic progress and student wellness would not be casualties.

This presentation reviews that workflow in detail, for the purpose of sharing strengths of the process for the greater GSA/OSR network’s benefit.

Novel And Emerging Therapies For Inflammatory Bowel Disease., Badr Al-Bawardy, Raina Shivashankar, Deborah D Proctor

Division of Gastroenterology and Hepatology Faculty Papers

Inflammatory bowel diseases (IBD) such as ulcerative colitis and Crohn's disease are chronic, relapsing and remitting disorders of intestinal inflammation with potential systemic manifestations. Despite the availability of current biologics, such as anti-tumor necrosis factor (anti-TNF), anti-integrins, anti-interleukins and small molecules such as tofacitinib, the rates of primary and secondary treatment failure remain high in IBD. This highlights the importance of continued development of new therapeutic targets and modifications of existing ones to improve the treatment response rates and to also improve the safety profile and tolerability of these medications. In this review we will discuss novel treatment target agents …

Reduction In Hospital System Opioid Prescribing For Acute Pain Through Default Prescription Preference Settings: Pre-Post Study, Benjamin Heritier Slovis, Jeffrey Riggio, Melanie Girondo, Cara Martino, Bracken Babula, Lindsey Roke, John C. Kairys

Department of Medicine Faculty Papers

BACKGROUND: The United States is in an opioid epidemic. Passive decision support in the electronic health record (EHR) through opioid prescription presets may aid in curbing opioid dependence.

OBJECTIVE: The objective of this study is to determine whether modification of opioid prescribing presets in the EHR could change prescribing patterns for an entire hospital system.

METHODS: We performed a quasi-experimental retrospective pre-post analysis of a 24-month period before and after modifications to our EHR's opioid prescription presets to match Centers for Disease Control and Prevention guidelines. We included all opioid prescriptions prescribed at our institution for nonchronic pain. Our modifications …

Violence Has No Home In Healthcare, Ellen Crowe, Mba, Ms, Carl J. Schiessl, Jd, Mary Reich Cooper, Md, Jd

Population Health Leadership Series: PopTalk Webinars

Throughout the COVID-19 pandemic, increased stress and anxiety has only further exacerbated the problem of violence in hospitals and other healthcare settings. Through the Safer Hospitals Initiative, Connecticut hospitals have united to develop and implement strategies to create a culture of safety for patients and staff within each of the institutions. This initiative applies the power of high reliability principles to standardize approaches to combatting violence in microsystems and macrosystems throughout an organization. We will share the strategies that may be replicated in your organizations to keep individuals working in healthcare organizations safer by stopping violence before it begins.

Remembering., Emmanuel Philor

Jefferson Hospital Staff Papers and Presentations

This reflection heightens the value of the role of chaplain during the time of the pandemic.

Nbtxr3 Radiotherapy-Activated Functionalized Hafnium Oxide Nanoparticles Show Efficient Antitumor Effects Across A Large Panel Of Human Cancer Models., Ping Zhang, Julie Marill, Audrey Darmon, Naeemunnisa Mohamed Anesary, Bo Lu, Md, Sébastien Paris

Department of Radiation Oncology Faculty Papers

Purpose: The side effects of radiotherapy induced on healthy tissue limit its use. To overcome this issue and fully exploit the potential of radiotherapy to treat cancers, the first-in-class radioenhancer NBTXR3 (functionalized hafnium oxide nanoparticles) has been designed to amplify the effects of radiotherapy.

Patients and Methods: Thanks to its physical mode of action, NBTXR3 has the potential to be used to treat any type of solid tumor. Here we demonstrate that NBTXR3 can be used to treat a wide variety of solid cancers. For this, we evaluated different parameters on a large panel of human cancer models, such as …

Safety And Improved Efficacy Signals Following Gene Therapy In Childhood Blindness Caused By Gucy2d Mutations, Samuel G. Jacobson, Artur V. Cideciyan, Allen Ho, Igor V. Peshenko, Alexandra V. Garafalo, Alejandro J. Roman, Alexander Sumaroka, Vivian Wu, Arun Krishnan, Rebecca Sheplock, Sanford Boye, Alexander Dizhoor, Shannon Boye

Wills Eye Hospital Papers

A first-in-human clinical trial of gene therapy in Leber congenital amaurosis due to mutations in the GUCY2D gene is underway, and early results are summarized. A recombinant adeno-associated virus serotype 5 (rAAV5) vector carrying the human GUCY2D gene was delivered by subretinal injection to one eye in three adult patients with severe visual loss, nystagmus, but preserved retinal structure. Safety and efficacy parameters were monitored for 9 months post-operatively. No systemic toxicity was detected; there were no serious adverse events, and ocular adverse events resolved. P1 and P2 showed statistically significant rod photoreceptor vision improvement by full-field stimulus testing in …

Multi-Sector Partnerships And Networks To Support Social Health, Medical Education, And Return On Investment., David B. Nash, Jess Dobbins, Tray Cockerell, Lechauncy Woodard

College of Population Health Faculty Papers

No abstract provided.

A Stress-Free Strategy To Correct Point Mutations In Patient Ips Cells, Jingli Cai, Elizabeth Kropf, Ya-Ming Hou, Lorraine Iacovitti

Department of Biochemistry and Molecular Biology Faculty Papers

When studying patient specific induced pluripotent stem cells (iPS cells) as a disease model, the ideal control is an isogenic line that has corrected the point mutation, instead of iPS cells from siblings or other healthy subjects. However, repairing a point mutation in iPS cells even with the newly developed CRISPR-Cas9 technique remains difficult and time-consuming. Here we report a strategy that makes the Cas9 “knock-in” methodology both hassle-free and error-free. Instead of selecting a Cas9 recognition site close to the point mutation, we chose a site located in the nearest intron. We constructed a donor template with the fragment …

Analysis Of An Obstetrics Point-Of-Care Ultrasound Training Program For Healthcare Practitioners In Zanzibar, Tanzania., Elizabeth A Hall, Danielle Matilsky, Rachel Zang, Naomasa Hase, Ali Habibu Ali, Patricia C Henwood, Anthony J Dean

Department of Emergency Medicine Faculty Papers

BACKGROUND: A point-of-care ultrasound education program in obstetrics was developed to train antenatal healthcare practitioners in rural Zanzibar. The study group consisted of 13 practitioners with different training backgrounds: physicians, clinical officers, and nurse/midwives. Trainees received an intensive 2-week antenatal ultrasound course consisting of lectures and hands-on practice followed by 6 months of direct supervision of hands-on scanning and bedside education in their clinical practice environments. Trainees were given a pre-course written exam, a final exam at course completion, and practical exams at 19 and 27 weeks. Trainees were expected to complete written documentation and record ultrasound images of at …