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IntroductionDespite recommendation that all women receive an ultrasound in pregnancy prior to 24 weeks', this remains unavailable to many women in low-income countries where trained practitioners are scarce. Although many programmes have demonstrated efficacy, few have achieved longterm sustainability, with a lack of information about how best to implement such programmes. This mixed-methods study aimed to evaluate the implementation of a novel education package to teach ultrasound-naive midwives in Malawi basic obstetric ultrasound, assessing its impact in the context of the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework.MethodsThe study ran across six sites in Malawi between October 2020 and June 2021, encompassing three phases; pre-implementation, implementation and post-implementation. Twenty nine midwives underwent a bespoke education package with matched pre and post course surveys assessed their knowledge, attitudes and confidence and “hands on” assessments evaluating practical skills. Training evaluation forms and in-depth interviews explored their satisfaction with the package, with repeat assessment and remote image review evaluating maintenance of skills.Results28/29 midwives completed the training, with significant increases in knowledge, confidence and practical skills. Adherence to the education package varied, however many changes to the proposed methodology were adaptive and appeared to facilitate the efficacy of the programme. Unfortunately, despite reporting approval regarding the training itself, satisfaction regarding supervision and follow up was mixed, reflecting the difficulties encountered with providing ongoing in-person and remote support.ConclusionThis programme was successful in improving trainees' knowledge, confidence and skill in performing basic obstetric ultrasound, largely on account of an adaptive approach to implementation. The maintenance of ongoing support was challenging, reflected by trainee dissatisfaction. By evaluating the success of this education package based on its implementation and not just its efficacy, we have generated new insights into the barriers to sustainable upscale, specifically those surrounding maintenance.

In patients presenting with chest pain, the presence of left bundle branch block (LBBB) on the electrocardiogram (ECG) may obscure the diagnosis of acute myocardial infarction (AMI). Patients with LBBB caused by AMI are shown to benefit significantly from rapid provision of reperfusion therapy, yet evidence suggests this is often underprovided. Difficulties in the identification of AMI in these patients is the most commonly cited reason. The aim of the research was to determine whether the application of the simplified Sgarbossa criteria to undifferentiated chest pain patients presenting with ECG changes of LBBB, transmitted during the prehospital phase of care, will be positively predictive of a discharge diagnosis of AMI.

Galectin-3 is a pro-inflammatory, pro-fibrotic molecule implicated in the pathogenesis of heart failure, and associated with poor prognostic outcome. When measured following ST-elevation myocardial infarction (STEMI), a high plasma galectin-3 predicts greater 30-day morbidity and mortality, and increased heart failure incidence at a median of 2 years. This study aims to elucidate the temporal aspects of galectin-3 expression immediately post-STEMI and how expression relates to severity of myocardial injury.Plasma galectin-3 levels were compared in 53 STEMI patients and 23 control patients with stable angina. Consecutive plasma galectin-3 levels, measured at a mean of 30 hours (sample A) and 54 hours (sample B) post pain, and analysis of galectin-3 vs time since onset of pain/time since reperfusion allowed assessment of temporal expression in STEMI patients. Myocardial injury markers included troponin and left ventricular ejection fraction (LVEF) at primary percutaneous coronary intervention (PCI).Circulating galectin-3 levels were significantly higher in STEMI patients than control patients when measured at a mean of 30 hours post pain (t = 2.72, df = 66, P = 0.008). However, levels had significantly decreased when measured 24 hours later (t = 2.13, df = 47, P = 0.039), with a negative linear relationship apparent between plasma galectin-3 levels and time since reperfusion on univariate analysis (OR = 0.871, 95% CI = 0.779-0.975, P = 0.021). A significantly lower circulating galectin-3 concentration was also found for sample A in those reperfused within 3 hours post-onset of pain (OR 0.045, 95% CI 0.003-0.669, P = 0.029).Plasma galectin-3 levels vary significantly following a STEMI over a short time period, in relation to timing of reperfusion.