Use of hand-carried ultrasound devices to augment the accuracy of medical student bedside cardiac diagnoses

Lung ultrasound teaching in medical education: a pilot study at a Brazilian medical school

OBJECTIVE

To evaluate cognitive learning, ability to perform and interpret lung ultrasound exams, and self-perception of learning among medical students after a short pedagogical intervention at a medical school in Brazil.

METHODS

An experimental pilot study was conducted with medical students at different stages of their education (basic cycle, clinical cycle, and medical internship). The participants underwent a cognitive test before and after the intervention, a practical test, a test to recognize lung ultrasound pathologies, and a qualitative evaluation test at the end of the intervention. Statistical analysis was performed using a significance level of p < 0.05.

RESULTS

A total of 42 students were included in the study, with a median age of 23 years and a predominance of males. The mean score of the pre-intervention cognitive test was 2.97 ± 0.87, and that of the post-intervention test was 6.57 ± 1.41, showing significant improvement (p < 0.001). The score of the practical test and that of the recognition of pathologies test also showed significant improvement after the intervention. There was no significant difference in execution time between the groups. Students in the clinical cycle had a better self-perception of learning.

CONCLUSIONS

Theoretical teaching and practical training of lung ultrasound in a short pedagogical intervention can improve cognitive performance, practical skills, and interpretation of the exam. The level of learning achievement was higher among more advanced students in medical education. Additionally, the students in the clinical cycle had a better perception of their learning.

The assessment of point-of-care-ultrasound (POCUS) in acute care settings is benefitted by early medical school integration and fellowship training

CONTEXT

Point-of-care ultrasound (POCUS) has widespread utilization in multiple clinical settings. It has been shown to positively influence clinician confidence in diagnosis and can help appropriately manage patients in acute care settings. There has been a growing trend of increased emphasis on incorporating POCUS training in the first 2 years of the medical school curriculum.

OBJECTIVES

This article aims to analyze the clinical use of POCUS in acute settings and how training early in medical school may strengthen clinician confidence and utilization.

METHODS

An anonymous 10-question survey on POCUS use was conducted via a secure online platform and distributed to board-certified practicing physicians (MDs and DOs) with educational agreements with Midwestern University (MWU) across acute care specialties. This included preceptors within the MWU graduate medical education clinical consortium. Survey questions were aimed at assessing frequency of use, machine type, reasons for utilizing POCUS, initial ultrasound training, confidence in performing/interpreting POCUS, and perceived impact on patient outcomes. Surveys less than 50% complete were excluded. All surveys returned were more than 50% complete and thus included in the study. Statistical analyses were conducted utilizing the statistical software R version 4.0.

RESULTS

Surveys were sent out to 187 participants with 68 responses (36.4% response rate). The survey results demonstrated a relationship between learning POCUS earlier in one's medical career (medical school, residency, or fellowship) to increased use in acute settings when compared to learning POCUS during clinical practice. Of the 68 respondents, 65 (95.6%) indicated that they agree or strongly agree that POCUS use improves patient care, and 64 (94.1%) indicated that they agree or strongly agree that the use of POCUS can improve patient outcomes.

CONCLUSIONS

Our survey of acute care physicians indicated that most respondents utilize POCUS daily or weekly (90.8%), and this was related to fewer years of practice (under 10 years from medical school graduation, 94.6%). Moreover, POCUS was utilized primarily in acute care settings for procedures (25%, n=17/68 respondents). These survey results indicate that early integration of POCUS education in osteopathic medical school curricula and throughout fellowship training could likely enhance POCUS utilization in acute care settings.

The Use of Ultrasound in Undergraduate Medical Anatomy Education: a Systematic Review with Narrative Synthesis

This systematic review aimed to synthesize the literature on how ultrasound is currently used in anatomy education within medical schools. A systematic search of Ovid MEDLINE, Scopus, and Educational Resources Information Centre was conducted. Thirty-four relevant unique articles were included from the 1,272 identified from the databases and analyzed via narrative synthesis. Thematic analysis generated two domain summaries: "Successful Aspects of Ultrasound Teaching" and "Barriers to Implementation," each with additional subthemes, aimed to help educators inform best teaching practices from the current evidence base in this field.

International consensus conference recommendations on ultrasound education for undergraduate medical students

OBJECTIVES

The purpose of this study is to provide expert consensus recommendations to establish a global ultrasound curriculum for undergraduate medical students.

METHODS

64 multi-disciplinary ultrasound experts from 16 countries, 50 multi-disciplinary ultrasound consultants, and 21 medical students and residents contributed to these recommendations. A modified Delphi consensus method was used that included a systematic literature search, evaluation of the quality of literature by the GRADE system, and the RAND appropriateness method for panel judgment and consensus decisions. The process included four in-person international discussion sessions and two rounds of online voting.

RESULTS

A total of 332 consensus conference statements in four curricular domains were considered: (1) curricular scope (4 statements), (2) curricular rationale (10 statements), (3) curricular characteristics (14 statements), and (4) curricular content (304 statements). Of these 332 statements, 145 were recommended, 126 were strongly recommended, and 61 were not recommended. Important aspects of an undergraduate ultrasound curriculum identified include curricular integration across the basic and clinical sciences and a competency and entrustable professional activity-based model. The curriculum should form the foundation of a life-long continuum of ultrasound education that prepares students for advanced training and patient care. In addition, the curriculum should complement and support the medical school curriculum as a whole with enhanced understanding of anatomy, physiology, pathophysiological processes and clinical practice without displacing other important undergraduate learning. The content of the curriculum should be appropriate for the medical student level of training, evidence and expert opinion based, and include ongoing collaborative research and development to ensure optimum educational value and patient care.

CONCLUSIONS

The international consensus conference has provided the first comprehensive document of recommendations for a basic ultrasound curriculum. The document reflects the opinion of a diverse and representative group of international expert ultrasound practitioners, educators, and learners. These recommendations can standardize undergraduate medical student ultrasound education while serving as a basis for additional research in medical education and the application of ultrasound in clinical practice.

The use of point-of-care ultrasound in new-onset dyspnea: an unexpected diagnosis

In this article, we report a patient with new-onset dyspnea and symptoms suggestive of heart failure, who had an unexpected diagnosis of a large left atrial myxoma with diastolic protrusion into the left ventricle. We further underline the role of cardiac Point-of-Care Ultrasound (POCUS) in the initial evaluation of patients with cardiac complaints in the emergency room setting. It can help to differentiate the patients' symptoms in order to achieve a more accurate diagnosis and thus increase the efficacy of the established therapy. In some cases, as with this patient, it can help to establish a diagnosis which needs prompt therapy.

Ultrasonography in undergraduate medical education: a comprehensive review and the education program implemented at Jichi Medical University

The concept of point-of-care ultrasound has been widely accepted owing to the development of portable ultrasound systems and growing body of evidence concerning its extensive utility. Thus, it is reasonable to suggest that training to use this modality be included in undergraduate medical education. Training in ultrasonography helps medical students learn basic subjects such as anatomy and physiology, improve their physical examination skills, and acquire diagnostic and procedural skills. Technological advances such as simulators, affordable handheld devices, and tele-ultrasound systems can facilitate undergraduate ultrasound education. Several reports have indicated that some medical schools have integrated ultrasound training into their undergraduate medical curricula. Jichi Medical University in Japan has been providing medical students with ultrasound education to fulfill part of its mission to provide medical care to rural areas. Vertical integration of ultrasound education into a curriculum seems reasonable to ensure skill retention and improvement. However, several issues have hampered the integration of ultrasound into medical education, including a lack of trained faculty, the need to recruit human models, requisition of ultrasound machines for training, and limited curricular space; proposed solutions include peer teaching, students as trained simulated patients, the development of more affordable handheld devices, and a flipped classroom approach with access to an e-learning platform, respectively. A curriculum should be developed through multidisciplinary and bottom-up student-initiated approaches. Formulating national and international consensuses concerning the milestones and curricula can promote the incorporation of ultrasound training into undergraduate medical education at the national level.

Handheld Echocardiography in a Clinical Practice Scenario: Concordances Compared to Standard Echocardiographic Reports

BACKGROUND

The purpose of this study was to assess the utility of a handheld device (HH) used during common daily practice and its agreement with the results of a standard echocardiography study (STD) performed by experienced sonographers and echocardiographer.

METHODS

A prospective follow-up was conducted in an adult outpatient echocardiography clinic. Experienced sonographers performed the STD and an experienced echocardiographer performed the HH. STD included 2-dimensional images, Doppler and hemodynamics analysis. Hemodynamic assessment was not performed with the HH device because the HH does not include such technology. The images were interpreted by blinded echocardiographers, and the agreement between the reports was analyzed.

RESULTS

A total of 108 patients were included; and the concordance for left ventricle (LV) ejection fraction (EF), wall motion score index, LV and right ventricle (RV) function, RV size, and mitral and aortic stenosis was excellent with κ values greater than 0.80. Wall motion abnormalities had good concordance (κ value 0.78). The agreement for LV hypertrophy, mitral and aortic regurgitation was moderate, and tricuspid and pulmonary regurgitation agreements were low (κ values of 0.26 and 0.25, respectively).

CONCLUSIONS

In a daily practice scenario with experienced hands, HH demonstrated good correlation for most echocardiography indications, such as ventricular size and function assessment and stenosis valve lesion analyses.

Impact of simulator-based training on acquisition of transthoracic echocardiography skills in medical students

Introduction:

Due to the expanding role of ultrasound as a diagnostic tool in modern medicine, medical schools rapidly include ultrasound training in their curriculum. The objective of this study was to compare simulator-based training along with classical teaching, using human models, to impart focused transthoracic echocardiography examination.

Subject and Methods:

A total of 22 medical students, with no former transthoracic echocardiography training, undertook a 90-min e-learning module, dealing with focused echocardiography and important echocardiographic pathologies. Subsequently, they had to complete a multiple-choice-questioner, followed by a 120-min practical training session either on the Heartworks™, (Cardiff, UK) and the CAE Vimedix^®, (Québec, Canada) simulator (n = 10) or on a live human model (n = 12). Finally, both groups had to complete a post-test consisting of ten video-based multiple-choice-questions and a time-based, focused echocardiography examination on another human model. Two blinded expert observers scored each acquired loop which recorded 2 s of each standard view. Statistical analysis was performed with SPPS 24 (SPSS™ 24, IBM, USA) using the Mann-Whitney-Test to compare both groups.

Results:

Analysis of measurable outcome skills showed no significant difference between transthoracic echocardiography training on human models and high-fidelity simulators for undergraduate medical students.

Conclusions:

Both teaching methods are effective and lead to the intended level of knowledge and skills.

Team-Based Ultrasound Objective Structured Practice Examination (OSPE) in the Anatomy Course

The clinical use of ultrasound has dramatically increased, necessitating early ultrasound education and the development of new tools in ultrasound training and assessment. The goal of this study was to devise a novel low-resource examination that tested the anatomical knowledge and technical skill of early undergraduate medical students in a gross anatomy course. The team-based ultrasound objective structured practice examination (OSPE) was created as a method for assessing practical ultrasound competencies, anatomical knowledge, and non-technical skills such as teamwork and professionalism. The examination utilized a rotation of students through four team roles as they scanned different areas of the body. This station-based examination required four models and four instructors, and tested ultrasound skills in the heart, abdominal vessels, abdominal organs, and neck regions. A Likert scale survey assessed student attitudes toward the examination. Survey data from participants (n = 46) were examined along with OSPE examination grades (n = 52). Mean and standard deviations were calculated for examination items and survey responses. Student grades were high in both technical (96.5%). and professional (96.5%) competencies with structure identification scoring the lowest (93.8%). There were no statistical differences between performances in each of the body regions being scanned. The survey showed that students deemed the examination to be fair and effective. In addition, students agreed that the examination motivated them to practice ultrasound. The team-based OSPE was found to be an efficient and student-favored method for evaluating integrated ultrasound competencies, anatomical knowledge, team-work, and professional attributes.

A survey of general practitioners' knowledge and clinical practice in relation to valvular heart disease

INTRODUCTION

General practice has a key role in diagnosing patients with valvular heart disease (VHD) and referring them to appropriate services.

METHODS

An anonymous survey was conducted to assess the knowledge and clinical practice behaviour of Irish general practitioners (GPs) in relation to VHD. In addition to demographic data, the survey captured information in the following domains: knowledge of VHD prevalence, knowledge of contemporary VHD treatments, barriers to diagnosis, and referral patterns. To augment responses, a monetary prize (donated to charity) was offered and the survey was also disseminated using social media and by the Irish College of General Practitioners.

RESULTS

Valid survey responses were received from 197 GPs. The sample was well-balanced by gender, number of years in practice, and practice setting. A small proportion of GPs (16.8%) used a stethoscope to examine for VHD in all patients over 60 years, a figure that rose to 22.3% in patients over 75. Approximately half of participants (48%) felt confident in their ability to detect and diagnose VHD using a stethoscope, and 74% felt lack of access to echocardiography was a major barrier to making a VHD diagnosis. There was a high level of awareness among GPs of minimally invasive nonsurgical interventions now available for VHD treatment.

DISCUSSION

Irish GPs displayed good understanding of contemporary VHD treatment options but reported low confidence and inconsistent practices in evaluating patients for VHD. Improved access to echocardiography might help address these deficiencies, but reorganisation of services will be required in a resource-limited public health service.

Artificial Intelligence-Powered Measurement of Left Ventricular Ejection Fraction Using a Handheld Ultrasound Device

The aim of this study was to assess the accuracy of an algorithm for automated measurement of left ventricular ejection fraction (LVEF) available on handheld ultrasound devices (HUDs). One hundred twelve patients admitted to the cardiology department underwent assessment performed with an HUD. In each case, the four-chamber apical view was obtained, and LVEF was calculated with LVivo software. Subsequently, during the examination performed with the use of the stationary echocardiograph, the 3-D measurement of LVEF was recorded. The average LVEFs measured with LVivo and the 3-D reference method were 46 ± 14% and 48 ± 14%, respectively. The correlation between the measurements obtained with the HUD and 3-D evaluation was high (r = 0.92, 95% confidence interval: 0.87-0.95, p < 0.0001). The mean difference between the LVEF obtained with LVivo and the 3-D LVEF was not significant (mean difference: -0.61%, 95% confidence interval: -1.89 to 0.68, p = 0.31). The LVivo software despite its limitations is capable of the accurate LVEF measurement when the acquired views are of at least good imaging quality.

Introducing echocardiography to medical students: A novel echocardiography E-Learning experience

BACKGROUND

Echocardiography is fundamental in the understanding of cardiology; however, echocardiography is not routinely taught in medical schools. The aim of this study is to assess whether teaching echocardiography to preclinical medical students using an e-learning software (ELS) is practical and appropriate.

METHODS

From 2017 to 2019, 1084 second-year medical students at Indiana University School of Medicine were introduced to echocardiography by using the ELS. In 2017 and 2018 students had a postcourse survey to assess echocardiography appropriateness and cardiology learning. Students in 2018 and 2019 were assessed for any association between the use of the ELS and learning cardiology by comparing examination scores.

RESULTS

In 2017-2018, 127 students responded to the survey (18% response rate). In 2017, 79% of responders and in 2018, 89% reported that introducing echocardiography to medical students is appropriate. In 2017, 78% and in 2018, 87% reported that it improved the understanding of cardiology. Student ELS usage was high for 2017-2018 (93% and 70%) but dropped in 2019 (30%). In 2018 and 2019, students who used ELS did statistically significantly better on the examination (total scores 84% vs. 82% (P = .008) in 2018; 84% vs. 81% (P = .002) in 2019).

CONCLUSIONS

Many 2nd year medical students felt learning echocardiography with ELS was appropriate and enhanced their learning cardiology. Using echocardiography to help learn cardiology appears to be supported with an association of ELS usage and improved examination scores. Our study suggests that echocardiography learning can and probably should begin in medical school.

Bedside POCUS during ward emergencies is associated with improved diagnosis and outcome: an observational, prospective, controlled study

Background

Rapid response teams are intended to improve early diagnosis and intervention in ward patients who develop acute respiratory or circulatory failure. A management protocol including the use of a handheld ultrasound device for immediate point-of-care ultrasound (POCUS) examination at the bedside may improve team performance. The main objective of the study was to assess the impact of implementing such a POCUS-guided management on the proportion of adequate immediate diagnoses in two groups. Secondary endpoints included time to treatment and patient outcomes.

Methods

A prospective, observational, controlled study was conducted in a single university hospital. Two teams alternated every other day for managing in-hospital ward patients developing acute respiratory and/or circulatory failures. Only one of the team used an ultrasound device (POCUS group).

Results

We included 165 patients (POCUS group 83, control group 82). Proportion of adequate immediate diagnoses was 94% in the POCUS group and 80% in the control group (p = 0.009). Time to first treatment/intervention was shorter in the POCUS group (15 [10–25] min vs. 34 [15–40] min, p < 0.001). In-hospital mortality rates were 17% in the POCUS group and 35% in the control group (p = 0.007), but this difference was not confirmed in the propensity score sample (29% vs. 34%, p = 0.53).

Conclusion

Our study suggests that protocolized use of a handheld POCUS device at the bedside in the ward may improve the proportion of adequate diagnosis, the time to initial treatment and perhaps also survival of ward patients developing acute respiratory or circulatory failure.

Clinical Trial Registration NCT02967809. Registered 18 November 2016, https://clinicaltrials.gov/ct2/show/NCT02967809.

The Impact of an Ultrasound Curriculum on the Accuracy of Resident Joint Line Palpation

BACKGROUND

Ultrasound education has been used as a tool to help improve physical examination skills. However, its utility in increasing accuracy of joint line palpation has yet to be investigated.

OBJECTIVE

To evaluate the accuracy of resident palpation and identification of the lateral knee joint line before and after introducing a musculoskeletal ultrasound (MSUS) curriculum.

DESIGN

Cohort study.

SETTING

A physical medicine and rehabilitation (PM&R) residency program at an academic institution.

PARTICIPANTS

Seventeen PM&R residents.

INTERVENTIONS

Residents underwent a knee-focused MSUS workshop.

MAIN OUTCOME MEASURES

Distance from needle placement to joint line confirmed with ultrasound.

RESULTS

All residents demonstrated improved accuracy in lateral knee joint line palpation after completing a knee-focused MSUS workshop, with statistically significant (P < .05) improvement in postgraduate year (PGY) 2 (P = .02), PGY-3 (P = .04), and across all residents (P = .001).

CONCLUSIONS

MSUS education significantly improved lateral knee joint line palpation accuracy in resident physicians.

Importance of Ultrasound Education in Undergraduate Medical Curriculum: A Survey Study Based on First-Year Medical Students' Perception of the 6-Year Doctor of Medicine Program of the University of Nicosia Medical School in Cyprus

Ultrasound imaging modality is a tool used in clinical practice and is being introduced gradually in the undergraduate curriculum of several medical schools worldwide. This study aims to assess medical students' perception regarding the integration of ultrasound training as part of undergraduate education. A questionnaire was given to first-year medical students after a 2-hour-long session, which was developed to introduce them in the fundamental physics theory and function of ultrasound equipment in the clinical practice. Analysis of the results indicated that students acknowledged that ultrasound training would improve their knowledge of internal medicine (P = 0.027) and of different diagnostic modalities (P = 0.019), and enhance their medical decision making (P = 0.0004). Moreover, students found beneficial the ultrasound education regarding correlating clinical knowledge with basic sciences (P = 0.0004). The study pointed out that the majority of first-year students have the opinion that the integration of ultrasound training in the medical program is valuable in medical education and patient care. However, work is needed to determine how to provide an optimal learning environment and to assess the competency of the training sessions.

Point-of-Care Ultrasound

Purpose of the Review

Point-of-care ultrasound using small ultrasound devices has expanded beyond emergency and critical care medicine to many other subspecialties. Awareness of the strengths and limitations of the technology and knowledge of the appropriate settings and common indications for point-of-care ultrasound is important.

Recent Findings

Point-of-care ultrasound is widely embraced as an extension of the physical exam and is employed in acute care and medical education settings. Echocardiography laboratories involved in education must individualize training to the intended scope of practice of the user. Advances in artificial intelligence may assist in image acquisition and interpretation by novice users.

Summary

Point-of-care ultrasound is widely available in a variety of clinical settings. The field has advanced substantially in the past 2 decades and will likely continue to expand with advancement in technology, reduced cost, and improved opportunities to assist new users.

Handheld ultrasound in training - The future is getting smaller!

Traditional ultrasound teaching is normally delivered using large, costly and often quite advanced cart-based systems. These carts are often large systems on wheels, usually limited to the departments that own them i.e. clinics, wards or radiology. Portability has been further improved by the development of laptop style systems, which are easier to wheel in-between patients/departments. In our experience and anecdotally, many of these systems can be intimidating to the novice and can lead to early attrition or poor uptake of ultrasound into clinical practice. Carts can also restrict the amount of training deliverable to practitioners, as they are limited in number due to cost and can take quite some time to boot up, reducing convenience. This dogma is being progressively changed with the advent of smaller handheld devices, some clearly within the financial grasps of most practitioners, and even to the point of medical schools offering students their own personal device.^1,2 This relative inexpensiveness can lead to the purchase of these devices for novelty and convenience, over need. Obvious caution is needed in these circumstances, but with increased ease of purchase, better availability and inbuilt simplicity, ultrasound learning can be seamlessly integrated into day-to-day practice. This review discusses how one of the most disruptive innovations in modern medicine is changing ultrasound from a classic imaging modality to become integrated as the fifth pillar of clinical examination, and how these new devices can serve as springboards to more advanced ultrasound training. In fact, within what has become a bigger area of clinical examination, things are getting smaller.

Investigation of focused cardiac ultrasound in the emergency room for differentiation of respiratory and cardiac causes of respiratory distress in dogs

OBJECTIVE

To determine whether focused cardiac ultrasound (FOCUS) performed by emergency and critical care (ECC) specialists or residents in training improves differentiation of cardiac (C) versus non-cardiac (NC) causes of respiratory distress in dogs compared to medical history and physical examination alone.

DESIGN

Prospective cohort study (May 2014 to February 2016).

SETTING

University hospital.

ANIMALS

Thirty-eight dogs presenting with respiratory distress.

INTERVENTIONS

FOCUS.

MEASUREMENTS AND MAIN RESULTS

Medical history, physical examination, and FOCUS were obtained at presentation. Emergency and critical care clinicians, blinded to any radiographic or echocardiographic data, categorized each patient (C vs NC) before and after FOCUS. Thoracic radiography (within 3 h) and echocardiography (within 24 h) were performed. Percent agreement was calculated against a reference diagnosis that relied on agreement of a board-certified cardiologist and ECC specialist with access to all diagnostic test results. Reference diagnosis included 22 dogs with cardiac and 13 dogs with noncardiac causes of respiratory distress. In 3 dogs a reference diagnosis was not established. Prior to FOCUS, positive and negative percent agreement to detect cardiac causes was 90.9% (95% CI, 70.8-98.9) and 53.9% (25.1-80.8), respectively. Overall agreement occurred in 27 of 35 dogs (77.1%). Two C and 6 NC cases were incorrectly categorized. Following FOCUS, positive and negative percent agreement to detect cardiac causes was 95.5% (77.2-99.9) and 69.2% (38.6-90.9), respectively. Overall agreement occurred in 30 of 35 dogs (85.7%). Three dogs with discrepant pre-FOCUS diagnoses were correctly re-categorized post-FOCUS. One C and 4 NC cases remained incorrectly categorized. No correctly categorized dogs were incorrectly re-categorized following FOCUS. The proportions of dogs correctly classified pre- versus post-FOCUS were not significantly different (P = 0.25).

CONCLUSIONS

FOCUS did not significantly improve differentiation of C vs NC causes of respiratory distress compared to medical history and physical examination alone.

Three different ways of training ultrasound student-tutors yield significant gains in tutee's scanning-skills

Aim: Many medical universities rely these days on trained student tutors to enable faculty-wide undergraduate ultrasound training. However, there is neither consensus on an optimal method nor any developed and agreed standard in the training of these student tutors. Usually internships and courses are employed which have both a specific set of advantages and disadvantages. We conducted a prospective quasi-randomized study of assess the effects of three types of tutor training on the resulting improvement in scanning skills of their tutees. Methods: Three batches of student tutors were trained by a course only (C-group), by an internship only (I-group) or by a course and an internship (CI-group). The respective gains in ultrasound scanning skills of the tutees were measured prospectively. A total 75 of the 124 5^th year medical students (60.5%) who attended the mandatory ultrasound course completed both pre- and post-exams on a voluntary basis. Within a limit of eight minutes and three images, they were asked to depict and label a maximum of 14 anatomical structures. Two blinded raters independently awarded two points for each label with an identifiable structure and one point for each label with a possibly identifiable structure. Results: In all three groups, the tutees improved significantly by more than doubling their pre-score results and comparably (Gains: C-group 9.19±5.73 points, p<.0001, I-group 9.77±4.81 points, p<.0001, CI-group 8.97±5.49 points, p<.0001). Conclusion: Student tutors, who were trained with a course or an internship or a course and an internship could teach scanning skills to 5th year medical students very effectively and with similar success.

Image quality to estimate ventricular ejection fraction by last year medical students improves after short courses of training

BACKGROUND

Transthoracic echocardiography is the primary imaging modality for diagnosing cardiac conditions but medical education in this field is limited. We tested the hypothesis that a structured theoretical and supervised practical course of training in focused echocardiography in last year medical students results in a more accurate assessment and more precise calculation of left ventricular ejection fraction after ten patient examinations.

METHODS

After a theoretical introduction course 25 last year medical students performed ten transthoracic echocardiographic examination blocks in postsurgical patients. Left ventricular function was evaluated both with an eye-balling method and with the calculated ejection fraction using diameter and area of left ventricles. Each examination block was controlled by a certified and blinded tutor. Bias and precision of measurements were assessed with Bland and Altman method.

RESULTS

Using the eye-balling method students agreed with the tutor's findings both at the beginning (88%) but more at the end of the course (95.7%). The variation between student and tutor for calculation of area, diameter and ejection fraction, respectively, was significantly lower in examination block 10 than in examination block 1 (each p < 0.001). Students underestimated both the length and the area of the left ventricle at the outset, as complete imaging of the left heart in the ultrasound sector was initially unsuccessful.

CONCLUSIONS

A structured theoretical and practical transthoracic echocardiography course of training for last year medical students provides a clear and measurable learning experience in assessing and measuring left ventricular function. At least 14 examination blocks are necessary to achieve 90% agreement of correct determination of the ejection fraction.

First Year Medical Students, Personal Handheld Ultrasound Devices, and Introduction of Insonation in Medical Education

Background:

Ultrasound education has been provided to students in medical schools within and beyond the United States. A formal experiment with use of personal handheld ultrasound equipment by all first-year medical students has not been reported. Employing insonation (an application of ultrasound) at the personal leisure by medical school freshmen enables self-directed learning throughout the academic year.

Methods:

We describe a peer-led ultrasound curriculum with handheld devices. The students’ perceptions were gathered through quarterly Likert-style questionnaires, and the differences in the categories were tested using Analysis of Variance.

Results:

The response rate was 58.5% for the first survey (n = 32), 56% (n = 30) for the second survey, and 62.3% (n = 33) for the final survey, respectively, with an average response rate of 58.9%. At the baseline survey, overall agreement was observed for enhancement on performance (62.5%) and interpretation (56.3) of ultrasounds, understanding (68.8%) and learning of anatomy (61.3%), ease (78.1%), comfort (59.4%) and benefit of incorporation of insonation in the medical school curricula (all p-values < 0.001). Neutral response (38.7%) or disagreement (38.7%) was observed when assessing the effect of the integration in medical curriculum on specialty choice (p < 0.01). These trends remained constant over follow-up with the exception that the perceived benefit for integration of insonation into the longitudinal curricula (p < 0.05) increased significantly over time. Majority of disagreement was observed regarding current access to the personal ultrasound devices (38.7%) (p < 0.001).

Conclusions:

The introduction of insonation through personal handheld ultrasound devices in the first-year medical school curriculum was received enthusiastically by students, with the majority of respondents finding the devices both easy to use and a valuable aid to improving their understanding of the three-dimensional anatomy.

Hand-held cardiac ultrasound examinations performed in primary care patients by nonexperts to identify reduced ejection fraction

BACKGROUND

Early identification of patients with reduced left ventricular ejection fraction (LVEF) could facilitate the care of patients with suspected heart failure (HF). We examined if (1) focused cardiac ultrasound (FCU) performed with a hand-held device (Vscan 1.2) could identify patients with LVEF < 50%, and (2) the distribution of HF types among patients with suspected HF seen at primary care clinics.

METHODS

FCU performed by general practitioners (GPs)/GP registrars after a training programme comprising 20 supervised FCU examinations were compared with the corresponding results from conventional cardiac ultrasound by specialists. The agreement between groups of estimated LVEF < 50%, after visual assessment of global left ventricular function, was compared. Types of HF were determined according to the outcomes from the reference examinations and serum levels of natriuretic peptides (NT-proBNP).

RESULTS

One hundred patients were examined by FCU that was performed by 1-4 independent examiners as well as by the reference method, contributing to 140 examinations (false positive rate, 19.0%; false negative rate, 52.6%; sensitivity, 47.4% [95% confidence interval [CI]: 27.3-68.3]; specificity, 81.0% [95% CI: 73.1-87.0]; Cohen's κ measure for agreement = 0.22 [95% CI: 0.03-0.40]). Among patients with false negative examinations, 1/7 had HF with LVEF < 40%, while the others had HF with LVEF 40-49% or did not meet the full criteria for HF. In patients with NT-proBNP > 125 ng/L and fulfilling the criteria for HF (68/94), HF with preserved LVEF (≥50%) predominated, followed by mid-range (40-49%) or reduced LVEF (< 40%) HF types (53.2, 11.7 and 7.4%, respectively).

CONCLUSIONS

There was poor agreement between expert examiners using standard ultrasound equipment and non-experts using a handheld ultrasound device to identify patients with reduced LVEF. Asides from possible shortcomings of the training programme, the poor performance of non-experts could be explained by their limited experience in identifying left ventricular dysfunction because of the low percentage of patients with HF and reduced ejection fraction seen in the primary care setting.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (NCT02939157). Registered 19 October 2016.

The use of handheld ultrasound devices: a position statement of the European Association of Cardiovascular Imaging (2018 update)

Recent technological advances in echocardiography, with progressive miniaturization of ultrasound machines, have led to the development of handheld ultrasound devices (HUD). These devices, no larger than some mobile phones, can be used to perform partial, focused exams as an extension to the physical examination. The European Association of Cardiovascular Imaging (EACVI) acknowledges that the dissemination of appropriate HUD use is inevitable and desirable, because of its potential impact on patient management. However, as a scientific society of cardiac imaging, our role is to provide guidance in order to optimize patient benefit and minimize drawbacks from inappropriate use of this technology. This document provides updated recommendations for the use of HUD, including nomenclature, appropriateness, indications, operators, clinical environments, data management and storage, educational needs, and training of potential users. It also addresses gaps in evidence, controversial issues, and future technological developments.

Lessons Learned from a Study of the Integration of a Point-of-Care Ultrasound Course into the Undergraduate Medical School Curriculum

Background

Point-of-care ultrasound (POCUS) diagnosis, performed by a physician at the patient bedside, is routinely used in emergency medicine and critical care. Although training in ultrasonography has become part of the medical school curriculum, POCUS can be challenging for medical students. This study aimed to assess the effectiveness of a one-day POCUS course in a group of final-year medical students by pre-course and post-course assessment of both diagnostic ability and changes in student confidence levels in making a diagnosis.

Material/Methods

A prospective study recruited 57 final-year medical students who participated in a one-day POCUS course. Improvement in making decisions and levels of confidence were evaluated before and two weeks after the course, using image-based testing and a self- evaluation questionnaire.

Results

All 57 final-year medical students attended the course and completed the tests and surveys. The pre-training and post-training test scores of medical students improved from 41.78±12% to 58±13%. Student confidence scores in the post-training assessment significantly increased. The post-training confidence scores were significantly increased compared with the pre-training scores regardless of whether or not the questions were answered correctly (p<0.001). The Dunning-Kruger effect, or cognitive bias, might partially explain this phenomenon.

Conclusions

One day of POCUS training integrated into anesthesia curriculum for final-year medical students improved performance in the post-training test scores and improved their confidence scores. Further studies are needed to evaluate this effect and to develop adequate tools to assess medical students.

Development and implementation of a comprehensive ultrasound curriculum for undergraduate medical students - a feasibility study

BACKGROUND

Ultrasound is one of the most important imaging techniques in clinical medicine with unique advantages. Skills in ultrasound imaging are very usefull for physicians including novices and thus also mandated by the Task Force "National Competence-Based Learning Objectives for Undergraduate Medical Education" (NKLM) in Germany and as well as by the German Ultrasound Society (Deutsche Gesellschaft für Ultraschall in der Medizin, DEGUM). Since ultrasound is best learned hands-on in very small supervised groups, we developed and implemented a comprehensive ultrasound-curriculum for all undergraduate medical students of our faculty using a peer-teaching concept.

METHODS

We used Kern's six-step model of curricular development comprising (1) problem identification and general needs assessment, (2) needs assessment of the targeted learners, (3) goals and objectives, (4) educational stategies, (5) implementation, and (6) evaluation and feedback.

RESULTS

The developed curriculum covers basic ultrasound of the abdomen and the throat, eFAST (Extended Focused Assessment with Sonography for Trauma), lung-ultrasound, FEEL (Focused Echocardiography in Emergency Life Support) and compression duplex sonography of the thigh deep vein system. All 5th year medical students receive a 90 min lecture on ultrasound basics by a faculty member and then a 12.5 h hands-on course divided into three sessions with one student tutor for every 4 students. The students are provided with a script (PDF-File) that covers all the learning goals, including example images of pathologies. The student tutors are trained during a 1 week ultrasound course and a 21-day rotation through seven different ultrasound laboratories. In addition, they undergo a standardized 1.5 day didactical training. Prior to the implementation for all students, the overall course was tested on 27 volunteer students. These students rated (on a 6-point Likert scale from 1 = excellent to 6 = very poor) the satisfaction with the student tutors and the faculty members as 1.4 ± .9 (mean ± stddev) and 1.3 ± .5 respectively.

CONCLUSION

A comprehensive ultrasound curriculum for all undergraduate medical students using a peer-teaching concept is feasible. Further studies are needed to evaluate in detail the learning outcomes for students and student tutors.

Outcomes of three different ways to train medical students as ultrasound tutors

BACKGROUND

In order to provide faculty-wide undergraduate ultrasound training in times of scarce resources, many medical faculties employ trained peer-student tutors to oversee the hands-on training. However, data to guide the training of ultrasound peer-student tutors are scarce. We conducted a prospective quasi-randomized study to assess the gain in theoretical knowledge and practical scanning skills of peer-student tutors who were trained with a course only, an internship only, or the combination of a course and an internship.

METHODS

A total of 44 peer-student tutors were trained by a one-week course only (C-Group, n = 21), by an internship only (I-Group, n = 10) or by a course and an internship (CI-Group, n = 13). Prior to and after the completion of the training the peer-student tutors completed an MC-test (theoretical knowledge) and an OSCE (practical scanning skills).

RESULTS

With all three education concepts, the peer-student tutors had significant and comparable gains in theoretical knowledge (C-group + 90%, I-group + 61.5%, CI-group + 114.0%) and practical scanning skills (C-group + 112.0%, I-group + 155.0% and CI-group + 123.5%), all p < 0.001.

CONCLUSION

Peer-student tutors, who were trained with a course or an internship or a course and internship improved their theoretical knowledge and their practical scanning skills significantly and to a comparable degree.

Impact of one-day course on medical student knowledge, attitudes and comfort with point-of-care ultrasound-guided procedures

Introduction

Given the ubiquity of procedural ultrasound in clinical practice, the importance of exposing medical students to the topic is increasingly relevant. We examined final-year medical student knowledge, attitudes and comfort level with procedural ultrasound before and after a one-day course.

Methods

This was a prospective cross-sectional survey of final-year students at a single university. We collected data regarding ultrasound experience, career goals and knowledge of procedural ultrasound, as well as attitudes and comfort (each assessed with three questions using a Likert scale). All students were sent a pre- and post-test survey, and we compared pre- and post-test results using the chi-square test, with a two-tailed P-value < 0.05 considered statistically significant.

Results

All of the 94 course participants completed both the pre- and post-tests. Of the 23 non-participants, 16 (70%) completed both pre- and post-tests. Almost all (99%) respondents reported some prior ultrasound exposure, but only 34% had previously performed at least one core procedure with ultrasound guidance. Among participants, we found a 13% average increase in knowledge score (P < 0.05) between pre- and post-tests; there was no significant change in knowledge score among non-participants. Among participants, we also found an increase in positive attitudes (P < 0.05 for two of three questions) and an increased comfort level with procedural ultrasound (P < 0.05 for all three questions).

Discussion

A one-day course can impact medical student knowledge, attitudes and comfort with the use of ultrasound for procedural guidance.

Conclusion

Further research is needed to assess long-term outcomes and explore alternative educational modalities.

Point-of-Care Ultrasound: Does it Affect Scores on Standardized Assessment Tests Used Within the Preclinical Curriculum?

OBJECTIVES

An increasing number of medical schools are incorporating point-of-care ultrasound (POCUS) into preclinical and clinical curricula. The ultimate effect of this teaching is unclear, and there has been no distinct link between ultrasound (US) learning and existing standardized student assessments. Additionally, neither optimal timing nor methods of POCUS integration have been established. We aimed to demonstrate the effect of US teaching on standardized objective assessments that already exist within the curriculum and, in doing so, discern a route for POCUS curricular integration.

METHODS

A longitudinal POCUS pilot curriculum was started in 2013, with the class of 2017. We collected basic science course results, standardized objective structured clinical examination scores, and United States Medical Licensing Examination step 1 scores from both the pilot group (n = 34) and matched control participants (n = 34) from the classes of 2017 and 2018. Scores between POCUS students and controls were analyzed by Student t tests.

RESULTS

Students participating in the longitudinal POCUS program scored significantly higher on the physical examination portion of their clinical skill objective structured clinical examination assessment than the control group (mean score, 89.2 versus 85.7; P < .05). This parameter was the only area with a statistically significant difference.

CONCLUSIONS

Point-of-care US program implementation may improve students' overall physical examination understanding and performance, even when US performance itself is not being tested. Introducing a POCUS curriculum may work best when designed in conjunction with the physical examination thread of a medical school curriculum.

Medical Student Ultrasound Education: A WFUMB Position Paper, Part I

The introduction of ultrasound into medical student education is well underway in many locations around the world, but is still in its infancy or has yet to begin in others. Proper incorporation of ultrasound education into medical training requires planning and resources, both capital and human. In this article, we discuss the state of the art of ultrasound in medical education throughout the world, as well as various methodologies utilized to improve student education and to incorporate ultrasound into every facet of training. Experiences from various educational systems and available evidence regarding the impact of ultrasound education are summarized. Representing multiple societies and specialties throughout the world, we discuss established modern as well as novel education structures and different successful approaches.

Ultrasonography in Undergraduate Medical Education: A Systematic Review

OBJECTIVES

The purpose of this study was to conduct a systematic review of the evidence of educational outcomes associated with teaching ultrasonography (US) to medical students.

METHODS

A review of databases through 2016 was conducted for research studies that reported data on teaching US to medical students. Each title and abstract were reviewed by teams of 2 independent abstractors to determine whether the article would be ordered for full-text review and subsequently by 2 independent authors for inclusion. Data were abstracted with a form developed a priori by the authors.

RESULTS

Ninety-five relevant unique articles were included (of 6936 identified in the databases). Survey data showed that students enjoyed the US courses and desired more US training. Of the studies that assessed US-related knowledge and skill, most of the results were either positive (16 of 25 for knowledge and 24 of 58 for skill) or lacked a control (8 of 25 for knowledge and 27 of 58 for skill). The limited evidence (14 of 95 studies) of the effect of US training on non-US knowledge and skill (eg, anatomy knowledge or physical examination skill) was mixed.

CONCLUSIONS

There is ample evidence that students can learn US knowledge and skills and that they enjoy and want US training in medical school. The evidence for the effect of US on external outcomes is limited, and there is insufficient evidence to recommend it for this purpose at this time.

Accuracy of Medical Students in Detecting Pleural Effusion Using Lung Ultrasound as an Adjunct to the Physical Examination

OBJECTIVES

This study compared the accuracy of medical students in identifying pleural effusion in hospitalized patients using the physical examination versus lung ultrasound (US).

METHODS

Fourth-year medical students (n = 14) received 20 hours of general practical US training (including 2 hours of specialized lung US training) plus theoretical and video documentation. The students used the physical examination alone versus the physical examination plus lung US to document the presence or absence of pleural effusion in the right and left hemithoraces of hospitalized patients (n = 11 patients; 22 hemithoraces examined 544 times in total). The reference standard for identification of pleural effusion was a lung US examination by 2 expert point-of-care sonographers.

RESULTS

The odds of correctly identifying the presence versus absence of pleural effusion was 5 times greater with lung US as an adjunct to the physical examination compared to the physical examination alone (odds ratio [OR], 5.1 from multivariate logistic regression; 95% confidence interval, 3.3-8.0). The addition of lung US to the physical examination resulted in an increase in sensitivity from 48% to 90%, in specificity from 73% to 86%, and in accuracy from 60% to 88%. The benefits of using US were greater when pleural effusion was present versus absent (OR, 10.8 versus 2.4) and when examining older versus younger patients (OR, 10.2 versus 2.8).

CONCLUSIONS

These results demonstrate that medical students' ability to detect the presence or absence of pleural effusion is superior when using lung US as an adjunct to the physical examination than when using the physical examination alone.

Echocardiogram-guided resuscitation versus early goal-directed therapy in the treatment of septic shock: a randomized, controlled, feasibility trial

Objective

Echocardiography is often used to guide septic shock resuscitation, but without evidence for efficacy. We conducted an intensive care unit (ICU)-based randomized controlled feasibility trial comparing echocardiography-guided septic shock resuscitation (ECHO) with early goal-directed therapy (EGDT).

Methods

We conducted a single center, randomized controlled feasibility trial at a 468-bed academic tertiary care center in Utah, USA. Adult patients with early septic shock were assessed and treated at defined intervals over 6 h using an echocardiogram-guided resuscitation protocol or a slightly modified EGDT protocol. Feasibility outcomes were fluid balance, dobutamine administration, and time to lactate clearance. The primary clinical outcome was changed in sequential organ failure assessment score at 48 h (delta SOFA). Secondary outcomes included inpatient mortality, ICU-free days, and ventilator-free days at 28 days.

Results

Thirty participants, 15 per group, were randomized and completed the study. Baseline characteristics were similar between groups. Patients were randomized within a median of 3.5 h of meeting inclusion criteria but had received a median of 3 L crystalloid by then. Fluid administration during the study protocol was similar in both groups (median ECHO 0 vs EGDT 1 L, p = 0.61). Eleven (73%) subjects in each arm received ≤ 1 L fluid. Dobutamine administration was also similar (20% vs 13%, p > 0.99). Twenty-one patients (70%) had lactate clearance prior to the first study assessment. No difference was observed in delta SOFA (median − 4 for ECHO vs − 6 for EGDT, p = 0.10) nor mortality (33% ECHO vs 20% EGDT, p = 0.68).

Conclusions

No experimental separation was observed in this randomized, controlled feasibility trial. Early lactate clearance, coupled with substantial fluid administration before randomization, suggests that patients were already resuscitated before arrival in the ICU. Future trials of echocardiogram-guided sepsis resuscitation will likely need to enroll in the emergency department.

Trial registration

This study was retrospectively registered at clinicaltrials.gov (identifier NCT02354742, title Echo vs EGDT in severe sepsis and septic shock) on February 3, 2015. Registration was completed before review or analysis of any data.

Electronic supplementary material

The online version of this article (10.1186/s40560-018-0319-3) contains supplementary material, which is available to authorized users.

Brief cardiovascular imaging with pocket-size ultrasound devices improves the accuracy of the initial assessment of suspected pulmonary embolism

Pulmonary embolism onset is frequently neglected due to the non-specific character of its symptoms. Pocket-size imaging devices (PSID) present an opportunity to implement imaging diagnostics into conventional physical examination. The aim of this study was to test the hypothesis that supplementation of the initial bedside assessment of patients with suspected pulmonary embolism (PE) with four-point compression venous ultrasonography (CUS) and right ventricular size assessment with the use of PSID equipped with dual probe could positively influence the accuracy of clinical predictions. A single-centre, prospective analysis was conducted on 100 patients (47 men, mean age 68 ± 13 years) with suspected PE. Clinical assessment on the basis of Wells and revised Geneva score and physical examination were supplemented with CUS and RV measurements by PSID. The mean time of PSID scanning was 4.9 ± 0.8 min and was universally accepted by the patients. Fifteen patients had deep venous thrombosis and RV enlargement was observed in 59 patients. PE was confirmed in 24 patients. If the both CUS was positive and RV enlarged, the specificity was 100% and sensitivity 54%, ROC AUC 0.771 [95% CI 0.68-0.85]. The Wells rule within our study population had the specificity of 86% and sensitivity of 67%, ROC AUC 0.776 (95% CI 0.681-0.853, p < 0.0001). Similar values calculated for the revised Geneva score were as follows: specificity 58% and sensitivity 63%, ROC AUC 0.664 (95% CI 0.563-0.756, p = 0.0104). Supplementing the revised Geneva score with additional criteria of CUS result and RV measurement resulted in significant improvement of diagnostic accuracy. The difference between ROC AUCs was 0.199 (95% Cl 0.0893-0.308, p = 0.0004). Similar modification of Wells score increased ROC AUC by 0.133 (95% CI 0.0443-0.223, p = 0.0034). Despite the well-acknowledged role of the PE clinical risk assessment scores the diagnostic process may benefit from the addition of basic bedside ultrasonographic techniques.

Hand-held ultrasonography: An opportunity for "hands-on" teaching of medicine

This article was migrated. The article was marked as recommended. Background: As ultrasound offers students an opportunity to study anatomy, physiology and pathophysiology actively, we used hand-held ultrasound (HHU) devices to augment current teaching of cardiac murmurs and pathology. Methods: Three types of teaching sessions (of different duration) were explored: 1) compulsory teaching on cardiac murmurs (n=40); 2) extra-curricular teaching of cardiac murmurs (n=8); 3) extra-curricular ultrasound course (n=6). We assessed students' ability to identify valvular lesions on auscultation, and anatomy and pathology on echocardiography, and sought qualitative feedback. Results: Using echocardiography to teach murmurs improved murmur recognition by auscultation alone from 23% pre-test to 93% post-test (p=0.017). Students were able to identify major cardiac anatomical landmarks on echo images (57% vs 98% ( p=0.027) in the voluntary teaching session lasting 90 minutes, and 40% vs 82% ( p=0.027) after the 3 week cardiac ultrasound course. The mean accuracy for diagnosing cardiac pathology on a printed image alone after the 3 week ultrasound course was 71%. Students unanimously found the sessions useful and engaging, and reported they would like further teaching about using ultrasound. Conclusion: Medical students found the sessions engaging, enjoyed this novel way of teaching and would like further teaching using ultrasound. Using hand-held ultrasound scanners to augment the teaching of cardiac murmurs to medical students is feasible and effective.

Junior medical student performed focused cardiac ultrasound after brief training to detect significant valvular heart disease

Background

Focused cardiac ultrasound (FOCUS) examination using a portable device is increasingly used for bedside diagnosis of cardiovascular diseases. This is a 4-week pilot project aiming to teach medical students to perform FOCUS to detect valvular heart lesions.

Methods

Patients undergoing routine transthoracic echocardiography (TTE) were recruited by third year medical students who performed physical examination (PE) and FOCUS after 6-hour training to detect significant (moderate-to-severe) valvular lesions. Performance of FOCUS and PE was compared to TTE as reference using kappa statistics.

Results

10 medical students performed 212 PE and FOCUS on 107 patients with mean age 63.7 ± 14.9 years. TTE detected 126 significant valvular lesions of which FOCUS correctly identified 54 lesions (κ = 0.45) compared to 32 lesions by PE (κ = 0.28, p < 0.01). FOCUS was better than PE in identifying mitral stenosis (κ = 0.51 vs. 0.17), aortic stenosis (κ = 0.45 vs. 0.16) and tricuspid regurgitation (κ = 0.39 vs. 0.09, all p < 0.01). Students became more proficient in performing FOCUS examination with time.

Conclusions

Teaching junior medical students to perform and interpret FOCUS was feasible after brief training and better than PE in detecting significant valvular lesions. Further studies are warranted to determine the utility of incorporating this new technology into mainstream medical training.

•

Teaching junior medical students to perform and interpret limited pocket-sized ultrasound was feasible after brief training.

•

Accuracy of student performed limited pocket-sized ultrasound was higher than physical examination in detecting significant valvular lesions.

Ultrasound Curricula in Undergraduate Medical Education: A Scoping Review

The clinical applications of point-of-care ultrasound (US) have expanded rapidly over the past decade. To promote early exposure to point-of-care US, there is widespread support for the integration of US curricula within undergraduate medical education. However, despite growing evidence and enthusiasm for point-of-care US education in undergraduate medical education, the curricular design and delivery across undergraduate medical education programs remain variable without widely adopted national standards and guidelines. This article highlights the educational and teaching applications of point-of-care US with a focus on outcomes. We then review the evidence on curricular design, delivery, and integration and the assessment of competency for point-of-care US in undergraduate medical education.

Echocardiographic Inferior Vena Cava Measurement As An Alternative to Central Venous Pressure Measurement in Neonates

OBJECTIVES

To evaluate the correlation between echocardiographic inferior vena cava (IVC) measurements and central venous pressure (CVP) in neonates. Also, to evaluate the correlation between IVC measurements and gestational age (GA) and body weight (BW).

METHODS

This cross sectional analytical study was conducted from June 2014 through June 2016 in a level III NICU. All neonates requiring intensive hemodynamic monitoring and having umbilical venous catheter (UVC) in place for clinical indications were enrolled in the study. IVC measurements were recorded by echocardiography (ECHO) and CVP was measured concomitantly in neonates having appropriate sized UVC in place. IVC measurements were evaluated and compared for any correlation with the CVP, GA and BW.

RESULTS

Fifty neonates with median gestation of 37 wk [Q1 = 29.2, Q3 = 37.8, interquartile range (IQR) = 8.6 wk] and median birth weight of 2420 g (Q1 = 923.5, Q3 = 2850, IQR = 1926.5 g) were included in the study. A strong negative linear correlation was observed between IVC collapsibility index (IVC-CI) and CVP (r = -0.968, r² = -0.937, p 0.000). No correlation was observed between IVC-CI and GA or BW. IVC minimum and IVC maximum diameters did not correlate with CVP but correlated well with GA and BW.

CONCLUSIONS

Echocardiographic IVC-CI measurement has a good correlation with CVP measurement in neonates. The clinical use will depend on the ability of IVC-CI to predict surrogate markers of tissue perfusion in shock.

The feasibility and efficacy of implementing a focused cardiac ultrasound course into a medical school curriculum

BACKGROUND

Teaching cardiac ultrasound to medical students in a brief course is a challenge. We aimed to evaluate the feasibility of teaching large groups of medical students the acquisition and interpretation of cardiac ultrasound images using a pocket ultrasound device (PUD) in a short, specially designed course.

METHODS

Thirty-one medical students in their first clinical year participated in the study. All were novices in the use of cardiac ultrasound. The training consisted of 4 hours of frontal lectures and 4 hours of hands-on training. Students were encouraged to use PUD for individual practice. Finally, the students' proficiency in the acquisition of ultrasound images and their ability to recognize normal and pathological states were evaluated.

RESULTS

Sixteen of 27 (59%) students were able to demonstrate all main ultrasound views (parasternal, apical, and subcostal views) in a six-minute test. The most obtainable view was the parasternal long-axis view (89%) and the least obtainable was the subcostal view (58%). Ninety-seven percent of students correctly differentiated normal from severely reduced left ventricular function, 100% correctly differentiated a normal right ventricle from a severely hypokinetic one, 100% correctly differentiated a normal mitral valve from a rheumatic one, and 88% correctly differentiated a normal aortic valve from a calcified one, while 95% of them correctly identified the presence of pericardial effusion.

CONCLUSIONS

Training of medical students in cardiac ultrasound during the first clinical year using a short, focused course is feasible and enables students with modest ability to acquire the main transthoracic ultrasound views and gain proficiency in the diagnosis of a limited number of cardiac pathologies.

Ultrasound in undergraduate medical education: a systematic and critical review

CONTEXT

The use of point-of-care ultrasound (POCUS) in clinical care is growing rapidly and advocates have recently proposed the integration of ultrasound into undergraduate medical education (UME). The evidentiary basis for this integration has not been evaluated critically or systematically.

OBJECTIVES

We conducted a critical and systematic review framed by the rationales enumerated in academic publications by advocates of ultrasound in UME.

METHODS

This research was conducted in two phases. First, the dominant discursive rationales for the integration of ultrasound in UME were identified from an archive of 403 academic publications using techniques from Foucauldian critical discourse analysis (CDA). We then sought empirical evidence in support of these rationales, using a critical synthesis methodology also adapted from CDA.

RESULTS

We identified four dominant discursive rationales with different levels of evidentiary support. The use of ultrasound was not demonstrated to improve students' understanding of anatomy. The benefit of ultrasound in teaching physical examination was inconsistent and rests on minimal evidence. With POCUS, students' diagnostic accuracy was improved for certain pathologies, but findings were inconsistent for others. Finally, the rationale that ultrasound training in UME will improve the quality of patient care was difficult to evaluate.

CONCLUSIONS

Our analysis has shown that the frequently repeated rationales for the integration of ultrasound in UME are not supported by a sufficient base of empirical research. The repetition of these dominant discursive rationales in academic publications legitimises them and may preclude further primary research. As the value of clinical ultrasound use by medical students remains unproven, educators must consider whether the associated financial and temporal costs are justified or whether more research is required.

Can Limited Education of Lung Ultrasound Be Conducted to Medical Students Properly? A Pilot Study

Objectives. Lung ultrasonography (LUS) is a useful examination to identify lung problems. Unfortunately, there are currently no LUS educational programs for medical students. We designed a brief LUS training course for medical students during the ED rotation. The purpose of training was improving cognitive and psychomotor learning domains, knowledge of ultrasound, knowledge of LUS, image acquisition, and image interpretation. Methods. Forty students in their fourth year of medical school were enrolled in this study. Student achievement was evaluated through examinations of cognitive and psychomotor skills. A survey was administered following the training. Results. The average test result was 42.1 ± 13.7 before training and 82.6 ± 10.7 after training. With respect to the assessment of LUS performance, the acceptable rates for right and left anterior chest wall scanning and right and left posterolateral scanning were 95%, 97.5%, 92.5%, and 100%, respectively. The students felt a high level of confidence in their ability to administer LUS to patients after training and they agreed that inclusion of LUS training in the medical school curriculum is necessary. Conclusion. This study showed that, among the medical students without ultrasound experience, limited LUS education to improve their knowledge, image acquisition, and interpretation ability was successful.

Bedside screening with the use of pocket-size imaging device can be useful for ruling out carotid artery stenosis in patients scheduled for cardiac surgery

BACKGROUND

Patients (pts) scheduled for coronary artery bypass grafting, burdened with high risk of carotid stenosis, are recommended to undergo duplex ultrasonography (DUS) of carotid arteries.

PURPOSE

To validate pocket-size imaging device (PSID) equipped with linear probe as an easily accessible tool enabling bedside screening for carotid artery stenosis (CAS).

METHODS

A total of 100 pts (60 men, mean age 69±11 years) with multivessel coronary artery disease underwent bedside DUS of carotid arteries with the use of PSID performed by a cardiology resident trained in DUS. Subsequently, DUS with the use of stationary high-end ultrasound system was performed in all pts to verify findings of PSID examination.

RESULTS

Initial diagnosis of atherosclerotic plaque presence obtained with PSID in 59 patients was confirmed by high-end ultrasound system examination in all cases. There was a statistically significant correlation of intima-media thickness measurements between PSID and stationary system (r=.58; 95% CI: 0.48-0.66; P<.0001), but the coefficient of agreement (κ) between the two methods in classification of intima-media as normal or thickened (>0.9 mm) was only .38 (95% CI: 0.299-0.459). During PSID examination, turbulent flow was observed in 21 pts-CAS was confirmed in all these pts-5 pts were diagnosed with significant CAS, the rest with CAS ranging from 30% to 70%.

CONCLUSIONS

Pocket-size imaging device equipped with linear probe allows for identification of patients with atherosclerotic plaques and turbulent flow in carotid arteries; however, the degree of CAS cannot be reliably determined. The measurement accuracy of intima-media thickness is insufficient for a diagnostic purpose.