Deep Needle Procedures: Improving Safety With Ultrasound Visualization

Implementation of a Virtual Point-of-Care Ultrasound Curriculum at Black Lion Hospital, Ethiopia

Introduction In low- and middle-income countries (LMICs), the availability of formal point-of-care ultrasound (POCUS) training remains limited, and there is limited data on how to train providers in these countries to use POCUS. This study aimed to describe a virtual training workshop for physicians in Ethiopia, with the intention of serving as a model that could guide similar initiatives. Methods The authors developed and implemented a three-day virtual workshop in 2022 for physicians in the Department of Medicine at Addis Ababa University in Ethiopia. Participants in the workshop completed pre-workshop and post-workshop surveys, as well as knowledge assessments. The authors examined POCUS use prior to the workshop, the impact of the workshop on ratings of comfort level in performing POCUS, and the change in scores on a knowledge assessment before and after the workshop. Results We found that very few of the participants had prior formal POCUS training. Participants reported a significantly higher level of comfort in using POCUS for the assessment of patients (p < 0.001) and for procedural guidance (p < 0.001) after attending the workshop, compared to before. Scores on the post-test knowledge assessment were significantly higher than scores on the pre-test knowledge assessment (p < 0.001). Conclusion Our POCUS workshop was successfully implemented and delivered virtually to a group of physicians in Ethiopia, and it increased comfort levels in performing POCUS and POCUS knowledge. We hope that similar workshops can be implemented in other LMICs.

Multiorgan Point-of-Care Ultrasound Assessment in Critically Ill Adults

Traditional point-of-care ultrasound (POCUS) training highlights discrete techniques, single-organ assessment, and focused protocols. More recent developments argue for a whole-body approach, where the experienced clinician-ultrasonographer crafts a personalized POCUS protocol depending on specific clinical circumstances. This article describes this problem-based approach, focusing on common acute care scenarios while highlighting practical considerations and performance characteristics.

Efficacy of ultrasound-guided galvanic electrolysis technique and physical therapy in patients with Achilles' tendinopathy: A pilot randomised controlled trial

BACKGROUND

Ultrasound-guided galvanic electrolysis technique (USGET) is an innovative mini-invasive intervention with the potential to optimise outcomes in the treatment of Achille's tendinopathy (AT).

OBJECTIVE

The aim of this pilot study is to evaluate the efficacy of adding USGET to conventional eccentric exercise treatment in patients with chronic AT.

METHODS

Inclusion criteria were patients with unilateral non-insertional AT, pain lasting > 3 months, aged 25-60 years. Patients were randomised in two groups receiving the same physiotherapy treatment (2 sessions per week for 8 weeks). In addition, the experimental group received three USGET stimulations, one every 15 days. Outcome measures were assessment of Achilles tendinopathy severity using the Victorian Institute of Sport Assessment-Achilles (VISA-A) and pain intensity using the Visual Analogue Scale (VAS). Assessment points occurred at the onset of treatment (T0), its conclusion (T1), and subsequent follow-ups at one (T2) and two months (T3).

RESULTS

Out of the 52 patients who met the study inclusion criteria, two participants withdrew from the study, resulting in a total of 50 subjects who completed the research. None of the parameters showed a different distribution at T1 (p> 0.337). At T2, there was a statistical difference in VISA-A (p= 0.010) and its subscales and VAS (p= 0.002) in the USGET group. At T3, both groups improved with a statistical difference observed in VISA-A (p< 0.001) and its subscales Pain (p= 0.004), Function (p= 0.003) and Sport (p= 0.002), but the EG patients showed a greater improvement. No adverse events were reported.

CONCLUSION

The effect of USGET combined with eccentric exercise appears to be a safe and effective technique for achieving pain relief and functional recovery in the medium term, supporting the integrated use of USGET as a rehabilitative treatment option for patients with chronic AT.

High-Resolution Imaging Insights into Shoulder Joint Pain: A Comprehensive Review of Ultrasound and Magnetic Resonance Imaging (MRI)

Shoulder joint pain is a complex and prevalent clinical concern affecting individuals across various ages and lifestyles. This review delves into the pivotal role of high-resolution imaging techniques, namely ultrasound and magnetic resonance imaging (MRI), in the comprehensive assessment and management of shoulder joint pain. We explore the anatomical foundations of the shoulder, common etiologies of pain, and the significance of precise diagnosis. High-resolution imaging facilitates the identification of various shoulder pathologies and is crucial in treatment planning, surgical interventions, and long-term prognosis assessment. We examine emerging technologies, discuss challenges and limitations, and chart potential future developments, emphasizing the ongoing evolution of imaging in this critical healthcare domain. In conclusion, high-resolution imaging is an indispensable tool, continually advancing to meet the diagnostic and therapeutic needs of individuals grappling with shoulder joint pain.

Development of a novel observed structured clinical exam to assess clinical ultrasound proficiency in undergraduate medical education

OBJECTIVES

A pilot study was performed to develop and test an observed structured clinical exam (OSCE) for clinical ultrasound in second-year medical students. The goal was to assess a longitudinal clinical ultrasound curriculum for medical students and to help determine readiness to perform ultrasound during clinical clerkships.

METHODS

The OSCE contained 40 tasks over 30 min in a one-to-one examiner to examinee environment using standardized patients covering cardiac, pulmonary, and inferior vena cava (IVC) ultrasound exams along with 6 critical diagnoses. Examinees were assessed using a binary checklist approach. A two-way ANOVA analysis was performed to determine if there were differences between the day and session the OSCE was administered. Results are presented as mean ± standard deviation.

RESULTS

One hundred fifty-two students were tested with an overall mean score of 64.9 ± 17.6%. Scores between the cardiac, IVC, and lung sections varied-67.8% ± 18.8%, 62.4% ± 26.2%, and 57.1% ± 20.6%, respectively. One hundred twenty-six (82.9%) answered at least one critical diagnosis incorrectly. Students in the late session performed better than the early session (1: 60% vs 2: 69%, p = .001).

CONCLUSIONS

Students performed better in later sessions. Additionally, the number of questions left blank at the end of the exam suggests that the length of the OSCE should be evaluated. Incorporating critical diagnoses was challenging for examinees. The proposed OSCE is a valuable assessment tool that could be adapted to assess student's readiness to use clinical ultrasound prior to clerkships.

Point-of-Care Ultrasound for Tuberculosis Management in Sub-Saharan Africa-A Balanced SWOT Analysis

Point-of-care ultrasound (POCUS) is an increasingly accessible skill, allowing for the decentralization of its use to non-specialist healthcare workers to guide routine clinical decision making. The advent of ultrasound-on-a-chip has transformed the technology into a portable mobile health device. Due to its high sensitivity to detect small consolidations, pleural effusions and sub pleural nodules, POCUS has recently been proposed as a sputum-free likely triage tool for tuberculosis (TB). To make an objective assessment of the potential and limitations of POCUS in routine TB management, we present a Strengths, Weaknesses, Opportunities & Threats (SWOT) analysis based on a review of the relevant literature and focusing on Sub-Saharan Africa (SSA). We idenitified numerous strengths and opportunities of POCUS for TB management e.g.; accessible, affordable, easy to use & maintain, expedited diagnosis, extra-pulmonary TB detection, safer pleural/pericardial puncture, use in children/pregnant women/PLHIV, targeted screening of TB contacts, monitoring TB sequelae, and creating AI decision support. Weaknesses and external threats such as operator dependency, lack of visualization of central lung pathology, poor specificity, lack of impact assessments and data from Sub-Saharan Africa must be taken into consideration to ensure that the potential of the technology can be fully realized in research as in practice.

Implementing ultrasound sessions to highlight living anatomy for large medical student cohorts

Background

There is an intrinsic link between radiology and anatomy and the importance of being able to convert knowledge from 3D structure to 2D image, and vice versa. Medical students must learn how to use anatomical knowledge to interpret radiological images, and with the increasing use of point-of-care ultrasound in clinical practice, the ability to interpret ultrasound scans is becoming more of a core skill for graduating doctors.

Rationale

Several recent systematic reviews of the literature have been undertaken showing the benefits of incorporating ultrasound in anatomy teaching, including appreciation of the dynamic nature of living anatomy, better understanding of anatomical structure, and improved motivation to study. However, there is a lack of consensus in the way ultrasound teaching should be incorporated into undergraduate medical anatomy.

Approach

This article reflects on a pilot of integrating ultrasound into the medical undergraduate anatomy teaching in the School of Anatomy at the University of Bristol. It shares the experience and how some of the challenges cited in the literature have been approached.

Recommendation

To help others negotiate the challenges of implementing this valuable teaching experience, a 'Six Step Model' for developing a live ultrasound pilot for undergraduate medical anatomy is offered: Expertise, Education, Ethics, Environment, Equipment, Enlist.

A Review of Central Venous Access Using Ultrasound Guidance Technology

More than 5 million central lines are placed in the United States each year. Advanced practice providers place central lines and must understand the importance of ultrasound guidance technology. The use of anatomic landmarks to place central lines has been employed in the past and in some instances is still used. This method may make accessing the target vessel difficult in the patient with anomalous anatomy or in the obese patient. These characteristics decrease successful placement and increase complications. Different organizations have agreed that the use of ultrasound during central venous access has decreased rates of complication and cost. In addition to cannulating and accessing a central vein, ultrasound can be used to rapidly confirm placement and to rule out complications such as pneumothorax. Utilizing ultrasound to assist in performance of procedures, and in assessment of patients, is a skill that should be optimized by nurse practitioners.

The development of a provincial multidisciplinary framework of consensus-based standards for Point of Care Ultrasound at the University of Saskatchewan

OBJECTIVES

The development and adoption of Point-of-Care Ultrasound (POCUS) across disciplines have created challenges and opportunities in implementing training and utilization standards. Within the context of a large, geographically disparate province, we sought to develop a multidisciplinary POCUS framework outlining consensus-based standards.

METHODS

A core working group of local POCUS leaders from Anesthesia, Emergency Medicine, Family Medicine, Intensive Care, Internal Medicine, Pediatrics, and Trauma, in collaboration with western Canadian colleagues, developed a list of key domains for the framework along with a range of potential standards for each area. The members of the working group and the registrants for a multidisciplinary Roundtable discussion at the University of Saskatchewan's annual POCUS conference (SASKSONO19, Saskatoon, Saskatchewan, March 2nd, 2019) were invited to complete a survey on POCUS standards for each domain. The survey results were presented to and discussed by participants at the Roundtable discussion at SASKSONO19 who reached consensus on modified standards for each domain. The modified standards were considered for endorsement by all conference attendees using an audience-response system.

RESULTS

The working group proposed standards in eight domains: scope of use, credentialing and privileges, documentation, quality assurance, leadership and governance, teaching, research, and equipment maintenance. Consensus on modified standards was achieved in the 18 participant Roundtable. Each standard was then endorsed by > 90% of conference respondents.

CONCLUSION

The resulting framework will inform the utilization of POCUS within Saskatchewan. Both this process and its outcomes could inform the development of multidisciplinary POCUS standards within other jurisdictions.

Integration of Ultrasound Into the Physician Assistant Curriculum

PURPOSE

Over the past 10 years, successful ultrasound integration into medical education has resulted in 8 residencies and 52 undergraduate medical schools requiring ultrasound training for graduation. Physician assistants (PAs) are trained in the medical model, yet very little is known about the integration of ultrasound into their curricula. This study examined how ultrasound is used, if at all, in the PA education curricula.

METHODS

Physician assistant program directors (PDs) were sent a survey addressing ultrasound integration into their curricula. Questions focused on the use of ultrasound to teach didactic courses and on inclusion of point-of-care ultrasound (POCUS) scanning skills as an adjunct to the physical examination. The survey also asked about students' feelings toward ultrasound integration into the curricula.

RESULTS

Investigators contacted 201 PDs, and 107 (53.2%) PDs responded. Twenty-five of the respondents (23.4%) reported using ultrasound in the basic sciences. The top 3 reasons for not including ultrasound in preclinical courses were no ultrasound machine, expense, and no faculty trained in ultrasound. Seventy-three of the respondents (68.2%) thought that POCUS scanning skills should be included in the curriculum. More than 83% felt that faculty or adjunct faculty should teach those skills.

CONCLUSION

This survey demonstrated that there is great interest in integrating ultrasound into the PA curriculum but that many challenges inhibit implementation. Lack of access to ultrasound machines and to trained faculty are the biggest challenges to integrating ultrasound into the PA curriculum. Physician assistant programs face content and competency challenges similar to those that medical schools face, as well as several challenges that are unique to PA education. Future research is needed to address these issues.

Point-of-Care Ultrasound in Established Settings

The original and most widely accepted applications for point-of-care ultrasound (POCUS) are in the settings of trauma, shock, and bedside procedures. Trauma was the original setting for the introduction of POCUS and has been standardized under the four-plus view examination called the Focused Assessment with Sonography in Trauma (FAST). This examination was found to be especially practice changing for achieving rapid diagnoses in critically ill patients who are too unstable for the delays and transportation inherent in more advanced imaging with computed tomography. This application was broadened from the critically ill trauma patient to any critically ill patient, particularly the patient in undifferentiated shock. Although the Focused Assessment with Sonography in Trauma examination originally focused on sources of hemorrhage causing hypovolemic shock, POCUS also can quickly differentiate cardiogenic, obstructive, and distributive shock and help identify the more specific etiology such as massive pulmonary emboli, pericardial tamponade, and pneumothoraces. By expediting diagnosis, POCUS facilitates faster definitive treatment of life-threatening conditions. In pursuing treatment, US continues to serve a role in the form of visually guiding many procedures that were previously done blindly. US guidance of procedures has improved the safety of central line insertion, thoracentesis, and paracentesis, and has an emerging role in lumbar puncture. Experience in bedside US is becoming a vital tool in the clinician's bedside assessment and management, filling a void between the stethoscope and the more advanced studies and interventions available through radiology. Understanding the strengths and limitations of US enables clinicians to identify the appropriate situations in which they can apply this tool confidently.

Enhancing needle visualization during parasagittal approach in paravertebral block for patients undergoing simple mastectomy using in-plane, multiangle ultrasound needle guidance system

Background:

Ultrasound-guided paravertebral blocks during breast surgeries with in-plane needle approaches can be challenging due to difficult needle visualization. The purpose of this study was to assess the usefulness of using a needle guide while performing in-plane parasagittal approach paravertebral block for breast surgery.

Patients and Methods:

Eighty patients, American Society of Anesthesiologists physical status I-III, aged 20-40 years with breast mass scheduled for simple mastectomy surgery, were involved in prospective, controlled, randomized study, and were randomly divided by closed envelope method into two groups: Group I (n = 40): Scheduled for ultrasound-guided paravertebral block or group II (n = 40): Scheduled for ultrasound-guided paravertebral block using the needle guide. Both techniques compared as regards: (i) Needle visibility and block performance time; (ii) number of needle passes; (iii) duration of the block; (iv) doctor and patient satisfaction; and (v) incidence of complications.

Results:

Needle visibility score was better in group II (2.92 ± 0.26 vs. 1.9 ± 0.44, P < 0.0001). Block performance time was shorter in group II (90.92 ± 15 vs. 128.25 ± 16s, P < 0.0001). A number of needle passes were less in group II (1.27 ± 0.45 vs. 2.2 ± 0.68, P < 0.0001). Doctor and patient satisfaction were better in group II (P = 0.015). No differences were found regarding the duration of the block and incidence of complications between groups.

Conclusion:

A needle guide can help reduce the time needed to perform a parasagittal in-plane thoracic paravertebral block, with a significant reduction in the block performance time, the number of needle passes, better needle visibility and better doctor and patient's satisfaction. However, there was no significant difference regarding the duration of the block or incidence of complications.