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Jin CS, Uzuner C, Condous G. Safety of methotrexate administration in women with pregnancy of unknown location at high risk of ectopic pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 64:97-103. [PMID: 38279942 DOI: 10.1002/uog.27593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 12/22/2023] [Accepted: 01/02/2024] [Indexed: 01/29/2024]
Abstract
OBJECTIVES To evaluate the safety of current guidelines on methotrexate (MTX) administration in women with pregnancy of unknown location (PUL) who are considered to have a high risk of underlying ectopic pregnancy (EP), and to investigate whether implementation of these guidelines would result in inadvertent exposure to MTX of viable intrauterine pregnancies (IUPs). METHODS This was a retrospective observational study of consecutive clinically stable women who were classified with PUL at the early pregnancy unit of Nepean Hospital, Sydney, Australia, between 2007 and 2021. PUL was defined as a positive pregnancy test in the absence of signs of IUP or EP on transvaginal ultrasound. Patients with a PUL that behaved biochemically like an EP, but for which the location of pregnancy was not confirmed on ultrasound, were eligible for MTX to minimize the risk of subsequent tubal rupture. Criteria discussed in the guidelines of the American College of Obstetricians and Gynecologists (ACOG), American Society for Reproductive Medicine (ASRM), Royal College of Obstetricians and Gynaecologists (RCOG) and National Institute for Health and Care Excellence (NICE) were applied to the PUL database. The number of patients eligible to receive MTX and the number with an underlying viable IUP who would be inadvertently prescribed MTX were calculated. RESULTS A total of 816 women with PUL were reviewed, of whom 724 had complete data and were included in the final analysis. Six patients had persistent PUL and the remaining 718 had a diagnosis of viable IUP, non-viable IUP, EP or failed PUL. According to the ACOG, ASRM, RCOG and NICE guidelines, the rate of MTX administration among patients with PUL would have been 2.76%, 4.56%, 0.41% and 35.36%, respectively. However, no persistent PUL would have received MTX according to the ACOG, ASRM and RCOG protocols (the NICE protocol identified patients with persistent PUL with a sensitivity of 100%), and the majority of MTX treatments were unnecessary because those patients were later classified as having non-viable IUP or failed PUL. Application of ACOG and ASRM guidance could result theoretically in inadvertent MTX administration to women with an underlying viable IUP at a rate of 4.1/1000 (3/724). CONCLUSIONS Current guidelines used to predict high risk of EP in the PUL population lead to inadvertent MTX administration to women with an underlying viable IUP. These guidelines should be used wisely to ensure that no wanted pregnancy is exposed to MTX. Women with PUL should be monitored carefully, and MTX should be used judiciously when the location of pregnancy is yet to be confirmed. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C S Jin
- Nepean Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia
| | - C Uzuner
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Sydney, NSW, Australia
| | - G Condous
- Nepean Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Sydney, NSW, Australia
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Kameda T, Ishii H, Oya S, Katabami K, Kodama T, Sera M, Takei H, Taniguchi H, Nakao S, Funakoshi H, Yamaga S, Senoo S, Kimura A. Guidance for clinical practice using emergency and point-of-care ultrasonography. Acute Med Surg 2024; 11:e974. [PMID: 38933992 PMCID: PMC11201855 DOI: 10.1002/ams2.974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/11/2024] [Accepted: 06/03/2024] [Indexed: 06/28/2024] Open
Abstract
Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision-making and improving the quality of invasive procedures is now called point-of-care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound-guided central venous cannulation. The Committee for the Promotion of POCUS in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the "Clinical Guidance for Emergency and Point-of-Care Ultrasonography" was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound-guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.
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Affiliation(s)
- Toru Kameda
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Clinical Laboratory MedicineJichi Medical UniversityShimotsukeJapan
| | - Hiromoto Ishii
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical Care MedicineNippon Medical SchoolTokyoJapan
| | - Seiro Oya
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency MedicineShizuoka Medical CenterShizuokaJapan
| | - Kenichi Katabami
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical Care CenterHokkaido University HospitalSapporoJapan
| | - Takamitsu Kodama
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and General Internal MedicineTajimi City HospitalTajimiJapan
| | - Makoto Sera
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency MedicineFukui Prefectural HospitalFukuiJapan
| | - Hirokazu Takei
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency MedicineHyogo Prefectural Kobe Children's HospitalKobeJapan
| | - Hayato Taniguchi
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Advanced Critical Care and Emergency CenterYokohama City University Medical CenterYokohamaJapan
| | - Shunichiro Nakao
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Hiraku Funakoshi
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical Care MedicineTokyo Bay Urayasu Ichikawa Medical CenterUrayasuJapan
| | - Satoshi Yamaga
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Radiation Disaster Medicine, Research Institute for Radiation Biology and MedicineHiroshima UniversityHiroshimaJapan
| | - Satomi Senoo
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical Care MedicineSaiseikai Yokohamashi Tobu HospitalYokohamaJapan
| | - Akio Kimura
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical CareCenter Hospital of the National Center for Global Health and MedicineTokyoJapan
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Gottlieb M, Duanmu Y. Beyond the Numbers: Assessing Competency in Point-of-Care Ultrasound. Ann Emerg Med 2023; 81:427-428. [PMID: 36805290 DOI: 10.1016/j.annemergmed.2023.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 02/19/2023]
Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL.
| | - Youyou Duanmu
- Department of Emergency Medicine, Stanford University, Palo Alto, CA
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Harel-Sterling M, Kwan C, Pirie J, Tessaro M, Cho DD, Coblentz A, Halabi M, Cohen E, Nield LE, Pusic M, Boutis K. Competency Standard Derivation for Point-of-Care Ultrasound Image Interpretation for Emergency Physicians. Ann Emerg Med 2023; 81:413-426. [PMID: 36774204 DOI: 10.1016/j.annemergmed.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/19/2022] [Accepted: 11/03/2022] [Indexed: 02/12/2023]
Abstract
STUDY OBJECTIVE Because number-based standards are increasingly controversial, the objective of this study was to derive a performance-based competency standard for the image interpretation task of point-of-care ultrasound (POCUS). METHODS This was a prospective study. Operating on a clinically-relevant sample of POCUS images, we adapted the Ebel standard-setting method to derive a performance benchmark in 4 diverse pediatric POCUS applications: soft tissue, lung, cardiac and focused assessment with sonography in trauma (FAST). In Phase I (difficulty calibration), cases were categorized into interpretation difficulty terciles (easy, intermediate, hard) using emergency physician-derived data. In Phase II (significance), a 4-person expert panel categorized cases as low, medium, or high clinical significance. In Phase III (standard setting), a 3x3 matrix was created, categorizing cases by difficulty and significance, and a 6-member panel determined acceptable accuracy for each of the 9 cells. An overall competency standard was derived from the weighted sum. RESULTS We obtained data from 379 emergency physicians resulting in 67,093 interpretations and a median of 184 (interquartile range, 154, 190) interpretations per case. There were 78 (19.5%) easy, 272 (68.0%) medium, and 50 (12.5%) hard-to-interpret cases, and 237 (59.3%) low, 65 (16.3%) medium, and 98 (24.5%) cases of high clinical significance across the 4 POCUS applications. The panel determined an overall performance-based competency score of 85.0% for lung, 89.5% for cardiac, 90.5% for soft tissue, and 92.7% for FAST. CONCLUSION This research provides a transparent chain of evidence that derived clinically relevant competency standards for POCUS image interpretation.
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Affiliation(s)
- Maya Harel-Sterling
- Department of Pediatrics, Division of Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Charisse Kwan
- Department of Pediatric Emergency Medicine, Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Jonathan Pirie
- Department of Pediatrics, Division of Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mark Tessaro
- Department of Pediatrics, Division of Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Dennis D Cho
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ailish Coblentz
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mohamad Halabi
- Department of Pediatric Emergency Medicine, Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Eyal Cohen
- Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lynne E Nield
- Division of Cardiology, Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Martin Pusic
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kathy Boutis
- Department of Pediatrics, Division of Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
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Dessie AS, Calhoun AW, Kanjanauptom P, Gilbert GE, Ekpenyong A, Lewiss RE, Rabiner JE, Tsze DS, Kessler DO. Development and Validation of a Point-of-Care-Ultrasound Image Quality Assessment Tool: The POCUS IQ Scale. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:135-145. [PMID: 36165271 DOI: 10.1002/jum.16095] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 08/04/2022] [Accepted: 08/24/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES We aimed to develop a standardized scoring tool to measure point-of-care ultrasound (POCUS) image quality and to determine validity evidence for its use to assess lung ultrasound image quality. METHODS The POCUS Image Quality (POCUS IQ) scale was developed by POCUS-trained physicians to assess sonographers' image acquisition skills by evaluating image quality for any POCUS application. The scale was piloted using lung images of healthy standardized patients acquired by three expert sonographers compared to three novices before and after training. All images (experts, novices pre-training, novices post-training) were scored on the POCUS IQ scale by three blinded POCUS-trained physicians. Reliability was assessed with fully-crossed generalizability and decision studies. Validity was assessed using Messick's framework. RESULTS Content validity was supported by the tool's development process of literature review, expert consensus, and pilot testing. Response process was supported by reviewer training and the blinded scoring process. Relation to other variables was supported by scores relating to sonographer experience: median expert score = 10.5/14 (IQR: 4), median novice pre-training score = 6/14 (IQR: 2.25), and novices' improvement after training (median post-training score = 12/14, IQR: 3.25). Internal structure was supported by internal consistency data (coefficient alpha = 0.84, omega coefficient = 0.91) and the generalizability study showing the main contributor to score variability was the sonographer (51%). The G-coefficient was 0.89, suggesting very good internal structure, however, Gwet's AC2 was 0.5, indicating moderate interrater reliability. The D study projected a minimum of 1 reviewer and 2 patients are needed for good psychometric reliability. CONCLUSIONS The POCUS scale has good preliminary validity evidence as an assessment tool for lung POCUS image acquisition skills. Further studies are needed to demonstrate its utility for other POCUS applications and as a feedback tool for POCUS learners.
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Affiliation(s)
- Almaz S Dessie
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, New York, USA
| | - Aaron W Calhoun
- University of Louisville, Department of Pediatrics, Louisville, Kentucky, USA
| | - Panida Kanjanauptom
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Gregory E Gilbert
- Biostatistics and Medical Writing, ∑igma∑tats™, LLC, Charleston, South Carolina, USA
- ICON, plc, New Wales, Pennsylvania, USA
| | - Atim Ekpenyong
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Resa E Lewiss
- Department of Pediatrics, University of California-San Diego, San Diego, California, USA
| | - Joni E Rabiner
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, New York, USA
| | - Daniel S Tsze
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, New York, USA
| | - David O Kessler
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, New York, USA
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Derr C, Shteyman A, Jackson SA, Lu Y, Campbell T, De Lucia A, Merritt R, Lupez K, Elkes J, Hansen A, Jelic T, DeRespino A, Grant A. Determination of Endovaginal Ultrasound Proficiency and Learning Curve Among Emergency Medicine Trainees. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:1741-1752. [PMID: 34698417 DOI: 10.1002/jum.15857] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/30/2021] [Accepted: 09/20/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Performing and interpreting endovaginal ultrasound is an important skill used during the evaluation of obstetric and gynecologic emergencies. This study aims to describe the level of proficiency and confidence achieved after performing 25 endovaginal examinations. METHODS This is a prospective study at a single urban academic emergency department. Participants performed a minimum of 25 endovaginal ultrasounds under the supervision of a point-of-care ultrasound expert. Anatomical structures were identified by the expert under ultrasound prior to each session. Each examination was scored for agreement of findings between the participant and expert. The data were used to develop a performance curve identifying when proficiency was achieved, where experiential benefit diminished, and when participants felt confident. RESULTS A total of 1117 endovaginal ultrasound examinations were performed by 50 participants. Agreement after 25 examinations was highest (>95%) for probe insertion and preparation, bladder and uterus identification, and directionality. Agreement was lowest for identification of the ovaries (76%). Experiential benefit plateaus occurred earliest (10 exams) for preparation and insertion followed by bladder identification and directionality. Surprisingly, ovarian experiential benefit plateaued at 16 exams. Participant confidence improved overall and was lowest for the identification of ovaries and abnormal pelvic anatomy. CONCLUSIONS There is a significant learning curve when performing endovaginal ultrasound. Our data do not support the use of 25 examinations as a minimum standard for identification of the ovaries or abnormal ovarian pathology.
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Affiliation(s)
- Charlotte Derr
- Division of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa General Hospital, Tampa, FL, USA
| | - Alan Shteyman
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Saundra A Jackson
- Department of Emergency Medicine, Emergency Resources Group, Jacksonville, FL, USA
| | - Yuanyuan Lu
- Study Design and Data Analysis Center, University of South Florida Morsani College of Medicine, Knoxville, TN, USA
| | | | - Anthony De Lucia
- Department of Emergency Medicine, C.W. Bill Young Department of Veterans Affairs Medical Center, Bay Pines, FL, USA
| | - Raymond Merritt
- Division of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa General Hospital, Tampa, FL, USA
| | - Kathryn Lupez
- Department of Emergency Medicine, Tufts Medical Center, Boston, MA, USA
| | - Johnathon Elkes
- Division of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa General Hospital, Tampa, FL, USA
| | - Allyson Hansen
- Division of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa General Hospital, Tampa, FL, USA
| | - Tomislav Jelic
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Allison DeRespino
- Department of Emergency Medicine, James A. Haley Veterans Hospital, Tampa, FL, USA
| | - Ashley Grant
- Department of Emergency Medicine, Florida State University College of Medicine, Sarasota Memorial Hospital, Sarasota, FL, USA
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Snelling PJ, Jones P, Moore M, Gimpel P, Rogers R, Liew K, Ware RS, Keijzers G. Describing the learning curve of novices for the diagnosis of paediatric distal forearm fractures using point-of-care ultrasound. Australas J Ultrasound Med 2022; 25:66-73. [PMID: 35722050 PMCID: PMC9201201 DOI: 10.1002/ajum.12291] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Purpose The learning curve of nurse practitioners (NPs) to accurately diagnose paediatric distal forearm fractures using point-of-care ultrasound (POCUS) was investigated. Methods Each NP's learning curve was calculated as cumulative diagnostic accuracy against a number of scans performed. The curve's plateau represented the attainment of competency. Secondary outcomes were the comparisons before and after this cut-off of diagnostic accuracy, classification of diagnostic errors, pain scores, duration and preference. Results Five NPs performed 201 POCUS studies with diagnostic accuracy plateauing at 90%, providing a 'cut-off' point at scan 15. Accuracy of POCUS scanning before and after the fifteenth scan was 81% (95% CI 70%-89%) and 90% (95% CI 84%-94%), respectively, demonstrating 9% improvement (P = 0.07). There was a 10% reduction in image interpretation errors. After fifteen scans, POCUS became faster (mean difference (MD) 2.6 min [95% CI 2.0-3.3], P < 0.001), less painful (MD 0.61 points FPSR scale [95% CI 0.04-1.18], P = 0.04) and more preferred by NPs (63% vs 77%, P = 0.03). Discussion The learning curve of POCUS-novice NPs independently scanning paediatric distal forearm injuries plateaued with mean diagnostic accuracy of 90% after 15 scans, suggesting competency was attained at this cut-off, supported by higher accuracy, being faster, less painful and more preferred by NPs. Future training packages in forearm POCUS should further address image interpretation and provide ongoing expert feedback. Conclusions The findings from this study suggest that competency in paediatric distal forearm POCUS can be attained by novices after a short training course and approximately 15 scans.
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Affiliation(s)
- Peter J Snelling
- School of Medicine and Dentistry and Menzies Health Institute Queensland Griffith University Southport Queensland Australia.,Emergency Department Gold Coast University Hospital Southport Queensland Australia.,Sonography Innovation and Research (Sonar) Group Southport Queensland Australia.,Child Health Research Centre University of Queensland Southport Queensland Australia.,Emergency Department Queensland Children's Hospital South Brisbane Queensland Australia
| | - Philip Jones
- School of Medicine and Dentistry and Menzies Health Institute Queensland Griffith University Southport Queensland Australia.,Emergency Department Gold Coast University Hospital Southport Queensland Australia.,Emergency and Trauma Centre Royal Brisbane and Women's Hospital Herston Queensland Australia
| | - Mark Moore
- Emergency Department Queensland Children's Hospital South Brisbane Queensland Australia
| | - Peta Gimpel
- Emergency Department Queensland Children's Hospital South Brisbane Queensland Australia
| | - Rosemary Rogers
- Emergency Department Queensland Children's Hospital South Brisbane Queensland Australia
| | - Kong Liew
- Emergency Department Queensland Children's Hospital South Brisbane Queensland Australia
| | - Robert S Ware
- School of Medicine and Dentistry and Menzies Health Institute Queensland Griffith University Southport Queensland Australia
| | - Gerben Keijzers
- School of Medicine and Dentistry and Menzies Health Institute Queensland Griffith University Southport Queensland Australia.,Emergency Department Gold Coast University Hospital Southport Queensland Australia.,Faculty of Health Sciences and Medicine Bond University Gold Coast Queensland Australia
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Kwan C, Weerdenburg K, Pusic M, Constantine E, Chen A, Rempell R, Herman JE, Boutis K. Learning Pediatric Point-of-Care Ultrasound: How Many Cases Does Mastery of Image Interpretation Take? Pediatr Emerg Care 2022; 38:e849-e855. [PMID: 35100784 DOI: 10.1097/pec.0000000000002396] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Using an education and assessment tool, we examined the number of cases necessary to achieve a performance benchmark in image interpretation of pediatric soft tissue, cardiac, lung, and focused assessment with sonography for trauma (FAST) point-of-care ultrasound (POCUS) applications. We also determined interpretation difficulty scores to derive which cases provided the greatest diagnostic challenges. METHODS Pediatric emergency physicians participated in web-based pediatric POCUS courses sponsored by their institution as a credentialing priority. Participants deliberately practiced cases until they achieved diagnostic interpretation scores of combined 90% accuracy, sensitivity, and specificity. RESULTS Of the 463 who enrolled, 379 (81.9%) completed cases. The median (interquartile range) number of cases required to achieve the performance benchmark for soft tissue was 94 (68-128); cardiac, 128 (86-201); lung, 87 (25-118); and FAST, 93 (68-133) (P < 0001). Specifically, cases completed to achieve benchmark were higher for cardiac relative to other applications (P < 0.0001 for all comparisons). In soft tissue cases, a foreign body was more difficult to diagnose than cobblestoning and hypoechoic collections (P = 0.036). Poor cardiac function and abnormal ventricles were more difficult to interpret with accuracy than normal (P < 0.0001) or pericardial effusion cases (P = 0.01). The absence of lung sliding was significantly more difficult to interpret than normal lung cases (P = 0.028). The interpretation difficulty of various FAST imaging findings was not significantly different. CONCLUSIONS There was a significant variation in number of cases required to reach a performance benchmark. We also identified the specific applications and imaging findings that demonstrated the greatest diagnostic challenges. These data may inform future credentialing guidelines and POCUS learning interventions.
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Affiliation(s)
- Charisse Kwan
- From the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital at London Health Sciences Centre, London, Ontario
| | - Kirstin Weerdenburg
- Department of Emergency Medicine, IWK Health and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Martin Pusic
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Boston and Harvard University, Boston, MA
| | - Erika Constantine
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI
| | - Aaron Chen
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Rachel Rempell
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | | | - Kathy Boutis
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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9
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Schleifer J, Haney RM, Shokoohi H, Huang CK, Ratanski D, Kimberly H, Liteplo AS. Longitudinal accuracy analysis of ultrasound performed during a four-year emergency medicine residency. AEM EDUCATION AND TRAINING 2021; 5:e10574. [PMID: 34124520 PMCID: PMC8171790 DOI: 10.1002/aet2.10574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/09/2020] [Accepted: 01/04/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND The objective of this study was to analyze patterns of point-of-care ultrasound (POCUS) performance over 4 years of emergency medicine (EM) residency. Specifically, we aimed to study how accuracy and adherence to standards of scanning changed by postgraduate year (PGY). METHODS This was a retrospective observational study of resident-performed POCUS at an academic emergency department over 6 years. We reviewed records of POCUS scans performed by PGY-1 to -4 residents that had been collected for quality assurance purposes. Data that were collected about EM residents' performance included the total number and type of scans per year, rate of technically limited scans (TLS), and accuracy on interpreting ultrasound images. Resident performances in each year (PGY-1 to -4) were independently evaluated and reported. RESULTS During a 6-year period, 137 different EM residents performed 50,815 ultrasound scans. The median number of scans was 177 for PGY-1, 124 for PGY-2, 118 for PGY-3, and 76 for residents in PGY-4. The accuracy of scan interpretations were high across all PGY levels (>97%), but slight degradation was observed as residents progressed through residency. The TLS rate increased from 4.7% among PGY-1s to 13.6% as PGY-4s. CONCLUSIONS In this large cohort of POCUS studies by EM residents, POCUS accuracy rates decreased and rates of TLS significantly increased as residents progressed through residency.
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Affiliation(s)
- Jessica Schleifer
- Department of Anesthesia and Intensive Care MedicineUniversity HospitalBonnGermany
- Department of Emergency MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Rachel M. Haney
- Department of Emergency MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
- Department of Emergency MedicinePeaceHealth Southwest Medical CenterVancouverWashingtonUSA
| | - Hamid Shokoohi
- Department of Emergency MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Calvin K. Huang
- Department of Emergency MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Daniel Ratanski
- Department of Emergency MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Heidi Kimberly
- Department of Emergency MedicineNewton Wellesley HospitalHarvard Medical SchoolNewtonMassachusettsUSA
| | - Andrew S. Liteplo
- Department of Emergency MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
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Damewood SC, Leo M, Bailitz J, Gottlieb M, Liu R, Hoffmann B, Gaspari RJ. Tools for Measuring Clinical Ultrasound Competency: Recommendations From the Ultrasound Competency Work Group. AEM EDUCATION AND TRAINING 2020; 4:S106-S112. [PMID: 32072114 PMCID: PMC7011402 DOI: 10.1002/aet2.10368] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 06/04/2019] [Accepted: 06/06/2019] [Indexed: 05/09/2023]
Abstract
Competency in clinical ultrasound is essential to ensuring safe patient care. Competency in clinical ultrasound includes identifying when to perform a clinical ultrasound, performing the technical skills required for ultrasound image acquisition, accurately interpreting ultrasound images, and incorporating sonographic findings into clinical practice. In this concept paper, we discuss the advantages and limitations of existing tools to measure ultrasound competency. We propose strategies and future directions for assessing competency in clinical ultrasound.
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Affiliation(s)
- Sara C. Damewood
- University of Wisconsin School of Medicine and Public HealthMadisonWI
| | - Megan Leo
- Boston University School of MedicineBoston Medical CenterBostonMA
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Ultrasound Guidelines: Emergency, Point-of-Care and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med 2017; 69:e27-e54. [PMID: 28442101 DOI: 10.1016/j.annemergmed.2016.08.457] [Citation(s) in RCA: 402] [Impact Index Per Article: 57.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Indexed: 02/06/2023]
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12
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Gómez Betancourt M, Moreno-Montoya J, Barragán González AM, Ovalle JC, Bustos Martínez YF. Learning process and improvement of point-of-care ultrasound technique for subxiphoid visualization of the inferior vena cava. Crit Ultrasound J 2016; 8:4. [PMID: 27034059 PMCID: PMC4816947 DOI: 10.1186/s13089-016-0040-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 03/13/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Medical residents' training in ultrasonography usually follows the recommendations of the American College of Emergency Physicians (ACEP), even though these do not provide specific technical guidelines. Adequate training is considered to require 25 practical iterations in the majority of ultrasound procedures. However, the effectiveness of this approach has not been verified experimentally. We set out to determine the number of repetitions required for an acceptable ultrasound procedure of the inferior vena cava (IVC), as an important and emerging ultrasound procedure in cardiology. METHODS Using three human models, each of eight medical residents in the Emergency Medicine (EM) Program at the Universidad del Rosario performed 25 iterations of the recommended procedure, with image quality evaluation by an EM physician expert in the technique. Logistic regression analysis was used to determine the lowest number of repetitions required to achieve an adjusted probability of success of 80 and 90 %, respectively. RESULTS We obtained 200 ultrasound images. The percentage success by each resident ranged from 52 to 96 %. There was no statistical significance in the relation between gender and success (p = 0.83), but there was an association between year of residency and success (p < 0.001). The average time taken for each procedure was 17.3 s (SD 8.1); there was no association between the time taken and either repetition number or image quality. We demonstrate that eleven repetitions are required to achieve acceptable image quality in 80 %, and that 21 repetitions are required to achieve acceptable image quality in 90 %. CONCLUSIONS This is the first study to formally evaluate the effectiveness of recommended training in ultrasound techniques. Our findings demonstrate that training comprising 25 procedural repetitions is easily sufficient to achieve optimal image quality, and they also provide empiric knowledge toward elucidating the times and minimum repetitions needed to acquire and improve ultrasonographic technique in novice operators to a level which fulfills quality requirements for interpretation.
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Affiliation(s)
| | - José Moreno-Montoya
- />Epidemiology, Biostatistics and Public Health Research Group, EPIBIOS_UR, Escuela de Medicina y Ciencias de la Salud (EMCS), Universidad del Rosario, Bogotá, Colombia
| | - Ana-María Barragán González
- />Epidemiology, Biostatistics and Public Health Research Group, EPIBIOS_UR, Escuela de Medicina y Ciencias de la Salud (EMCS), Universidad del Rosario, Bogotá, Colombia
| | - Juan Carlos Ovalle
- />Emergency Medicine Specialist, Universidad del Rosario, Bogotá, Colombia
| | - Yury Forlan Bustos Martínez
- />Chief of the Department of Emergency Medicine and Director of the Simulation Center, Escuela de Medicina y Ciencias de la Salud (EMCS), Universidad del Rosario, Bogotá, Colombia
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13
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Marin JR, Abo AM, Arroyo AC, Doniger SJ, Fischer JW, Rempell R, Gary B, Holmes JF, Kessler DO, Lam SHF, Levine MC, Levy JA, Murray A, Ng L, Noble VE, Ramirez-Schrempp D, Riley DC, Saul T, Shah V, Sivitz AB, Tay ET, Teng D, Chaudoin L, Tsung JW, Vieira RL, Vitberg YM, Lewiss RE. Pediatric emergency medicine point-of-care ultrasound: summary of the evidence. Crit Ultrasound J 2016; 8:16. [PMID: 27812885 PMCID: PMC5095098 DOI: 10.1186/s13089-016-0049-5] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 09/01/2016] [Indexed: 12/19/2022] Open
Abstract
The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers. To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations. Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.
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Affiliation(s)
- Jennifer R. Marin
- Children’s Hospital of Pittsburgh, 4401 Penn Ave, AOB Suite 2400, Pittsburgh, PA 15224 USA
| | - Alyssa M. Abo
- Children’s National Medical Center, Washington DC, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Lorraine Ng
- Morgan Stanley Children’s Hospital, New York, NY USA
| | | | | | | | | | | | | | | | - David Teng
- Cohen Children’s Medical Center, New Hyde Park, USA
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14
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Woo MY, Hecht N, Hurley B, Stitt D, Thiruganasambandamoorthy V. Test characteristics of point-of-care ultrasonography for the diagnosis of acute posterior ocular pathology. Can J Ophthalmol 2016; 51:336-341. [DOI: 10.1016/j.jcjo.2016.03.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 03/02/2016] [Accepted: 03/12/2016] [Indexed: 10/21/2022]
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Rating scale for the assessment of competence in ultrasound-guided peripheral vascular access - a Delphi Consensus Study. J Vasc Access 2016; 17:440-445. [PMID: 27516142 DOI: 10.5301/jva.5000581] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2016] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Peripheral vascular access is vital for treatment and diagnostics of hospitalized patients. Ultrasound-guided vascular access (UGVA) is superior to the landmark technique. To ensure competence-based education, an assessment tool of UGVA competence is needed. We aimed to develop a global rating scale (RS) for assessment of UGVA competence based on opinions on the content from ultrasound experts in a modified Delphi consensus study. METHODS We included experts from anesthesiology, emergency medicine and radiology across university hospitals in Denmark. Nine elements were drafted based on existing literature and recommendations from international societies. In a multi-round survey, the experts rated the elements on a five-point Likert scale according to importance, and suggested missing elements. The final Delphi round occurred when >80% of the experts rated all elements ≥4 on the Likert scale. RESULTS Sixteen experts consented to participate in the study, one withdrew consent prior to the first Delphi round, and 14 completed all three Delphi rounds. In the first Delphi round the experts excluded one element from the scale and changed the content of two elements. In the second Delphi round, the experts excluded one element from the scale. In the third Delphi round, consensus was obtained on the eight elements: preparation of utensils, ergonomics, preparation of the ultrasound device, identification of blood vessels, anatomy, hygiene, coordination of the needle, and completion of the procedure. CONCLUSIONS We developed an RS for assessment of UGVA competence based on opinions of ultrasound experts through a modified Delphi consensus study.
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Bélard S, Tamarozzi F, Bustinduy AL, Wallrauch C, Grobusch MP, Kuhn W, Brunetti E, Joekes E, Heller T. Point-of-Care Ultrasound Assessment of Tropical Infectious Diseases--A Review of Applications and Perspectives. Am J Trop Med Hyg 2016; 94:8-21. [PMID: 26416111 PMCID: PMC4710450 DOI: 10.4269/ajtmh.15-0421] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 08/18/2015] [Indexed: 12/28/2022] Open
Abstract
The development of good quality and affordable ultrasound machines has led to the establishment and implementation of numerous point-of-care ultrasound (POCUS) protocols in various medical disciplines. POCUS for major infectious diseases endemic in tropical regions has received less attention, despite its likely even more pronounced benefit for populations with limited access to imaging infrastructure. Focused assessment with sonography for HIV-associated TB (FASH) and echinococcosis (FASE) are the only two POCUS protocols for tropical infectious diseases, which have been formally investigated and which have been implemented in routine patient care today. This review collates the available evidence for FASH and FASE, and discusses sonographic experiences reported for urinary and intestinal schistosomiasis, lymphatic filariasis, viral hemorrhagic fevers, amebic liver abscess, and visceral leishmaniasis. Potential POCUS protocols are suggested and technical as well as training aspects in the context of resource-limited settings are reviewed. Using the focused approach for tropical infectious diseases will make ultrasound diagnosis available to patients who would otherwise have very limited or no access to medical imaging.
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Affiliation(s)
- Sabine Bélard
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Pediatric Pneumology and Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, World Health Organization Collaborating Centre for Clinical Management of Cystic Echinococcosis, University of Pavia, Pavia, Italy; Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George's University of London, London, United Kingdom; Department of Medicine, Klinikum Muenchen-Perlach, Munich, Germany; Center for Operational Medicine, Medical College Georgia, Georgia Regents University, Augusta, Georgia; Division of Infectious and Tropical Diseases, University of Pavia/IRCCS San Matteo Hospital Foundation, Pavia, Italy; Department of Radiology, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | - Francesca Tamarozzi
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Pediatric Pneumology and Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, World Health Organization Collaborating Centre for Clinical Management of Cystic Echinococcosis, University of Pavia, Pavia, Italy; Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George's University of London, London, United Kingdom; Department of Medicine, Klinikum Muenchen-Perlach, Munich, Germany; Center for Operational Medicine, Medical College Georgia, Georgia Regents University, Augusta, Georgia; Division of Infectious and Tropical Diseases, University of Pavia/IRCCS San Matteo Hospital Foundation, Pavia, Italy; Department of Radiology, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | - Amaya L Bustinduy
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Pediatric Pneumology and Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, World Health Organization Collaborating Centre for Clinical Management of Cystic Echinococcosis, University of Pavia, Pavia, Italy; Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George's University of London, London, United Kingdom; Department of Medicine, Klinikum Muenchen-Perlach, Munich, Germany; Center for Operational Medicine, Medical College Georgia, Georgia Regents University, Augusta, Georgia; Division of Infectious and Tropical Diseases, University of Pavia/IRCCS San Matteo Hospital Foundation, Pavia, Italy; Department of Radiology, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | - Claudia Wallrauch
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Pediatric Pneumology and Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, World Health Organization Collaborating Centre for Clinical Management of Cystic Echinococcosis, University of Pavia, Pavia, Italy; Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George's University of London, London, United Kingdom; Department of Medicine, Klinikum Muenchen-Perlach, Munich, Germany; Center for Operational Medicine, Medical College Georgia, Georgia Regents University, Augusta, Georgia; Division of Infectious and Tropical Diseases, University of Pavia/IRCCS San Matteo Hospital Foundation, Pavia, Italy; Department of Radiology, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | - Martin P Grobusch
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Pediatric Pneumology and Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, World Health Organization Collaborating Centre for Clinical Management of Cystic Echinococcosis, University of Pavia, Pavia, Italy; Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George's University of London, London, United Kingdom; Department of Medicine, Klinikum Muenchen-Perlach, Munich, Germany; Center for Operational Medicine, Medical College Georgia, Georgia Regents University, Augusta, Georgia; Division of Infectious and Tropical Diseases, University of Pavia/IRCCS San Matteo Hospital Foundation, Pavia, Italy; Department of Radiology, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | - Walter Kuhn
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Pediatric Pneumology and Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, World Health Organization Collaborating Centre for Clinical Management of Cystic Echinococcosis, University of Pavia, Pavia, Italy; Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George's University of London, London, United Kingdom; Department of Medicine, Klinikum Muenchen-Perlach, Munich, Germany; Center for Operational Medicine, Medical College Georgia, Georgia Regents University, Augusta, Georgia; Division of Infectious and Tropical Diseases, University of Pavia/IRCCS San Matteo Hospital Foundation, Pavia, Italy; Department of Radiology, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | - Enrico Brunetti
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Pediatric Pneumology and Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, World Health Organization Collaborating Centre for Clinical Management of Cystic Echinococcosis, University of Pavia, Pavia, Italy; Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George's University of London, London, United Kingdom; Department of Medicine, Klinikum Muenchen-Perlach, Munich, Germany; Center for Operational Medicine, Medical College Georgia, Georgia Regents University, Augusta, Georgia; Division of Infectious and Tropical Diseases, University of Pavia/IRCCS San Matteo Hospital Foundation, Pavia, Italy; Department of Radiology, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | - Elizabeth Joekes
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Pediatric Pneumology and Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, World Health Organization Collaborating Centre for Clinical Management of Cystic Echinococcosis, University of Pavia, Pavia, Italy; Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George's University of London, London, United Kingdom; Department of Medicine, Klinikum Muenchen-Perlach, Munich, Germany; Center for Operational Medicine, Medical College Georgia, Georgia Regents University, Augusta, Georgia; Division of Infectious and Tropical Diseases, University of Pavia/IRCCS San Matteo Hospital Foundation, Pavia, Italy; Department of Radiology, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | - Tom Heller
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Pediatric Pneumology and Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, World Health Organization Collaborating Centre for Clinical Management of Cystic Echinococcosis, University of Pavia, Pavia, Italy; Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George's University of London, London, United Kingdom; Department of Medicine, Klinikum Muenchen-Perlach, Munich, Germany; Center for Operational Medicine, Medical College Georgia, Georgia Regents University, Augusta, Georgia; Division of Infectious and Tropical Diseases, University of Pavia/IRCCS San Matteo Hospital Foundation, Pavia, Italy; Department of Radiology, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
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Lewiss RE, Chan W, Sheng AY, Soto J, Castro A, Meltzer AC, Cherney A, Kumaravel M, Cody D, Chen EH. Research Priorities in the Utilization and Interpretation of Diagnostic Imaging: Education, Assessment, and Competency. Acad Emerg Med 2015; 22:1447-54. [PMID: 26568277 DOI: 10.1111/acem.12833] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 07/10/2015] [Accepted: 07/12/2015] [Indexed: 01/22/2023]
Abstract
The appropriate selection and accurate interpretation of diagnostic imaging is a crucial skill for emergency practitioners. To date, the majority of the published literature and research on competency assessment comes from the subspecialty of point-of-care ultrasound. A group of radiologists, physicists, and emergency physicians convened at the 2015 Academic Emergency Medicine consensus conference to discuss and prioritize a research agenda related to education, assessment, and competency in ordering and interpreting diagnostic imaging. A set of questions for the continued development of an educational curriculum on diagnostic imaging for trainees and competency assessment using specific assessment methods based on current best practices was delineated. The research priorities were developed through an iterative consensus-driven process using a modified nominal group technique that culminated in an in-person breakout session. The four recommendations are: 1) develop a diagnostic imaging curriculum for emergency medicine (EM) residency training; 2) develop, study, and validate tools to assess competency in diagnostic imaging interpretation; 3) evaluate the role of simulation in education, assessment, and competency measures for diagnostic imaging; 4) study is needed regarding the American College of Radiology Appropriateness Criteria, an evidence-based peer-reviewed resource in determining the use of diagnostic imaging, to maximize its value in EM. In this article, the authors review the supporting reliability and validity evidence and make specific recommendations for future research on the education, competency, and assessment of learning diagnostic imaging.
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Affiliation(s)
- Resa E. Lewiss
- Department of Emergency Medicine; University of Colorado Hospital; Aurora CO
| | - Wilma Chan
- Department of Emergency Medicine; Hospital of the University of Pennsylvania; Philadelphia PA
| | - Alexander Y. Sheng
- Department of Emergency Medicine; Boston University Medical Center; Boston MA
| | - Jorge Soto
- Department of Radiology; Boston University Medical Center; Boston MA
| | - Alexandra Castro
- Department of Emergency Medicine; University of Pittsburgh Medical Center; Pittsburgh PA
| | - Andrew C. Meltzer
- Department of Emergency Medicine; George Washington University School of Medicine; Washington DC
| | - Alan Cherney
- Department of Emergency Medicine; Lehigh Valley Health Network; Allentown PA
| | - Manickam Kumaravel
- Department Sports, Orthopedics, and Emergency Imaging; University of Texas Health Science Center at Houston; Houston TX
| | - Dianna Cody
- Department of Imaging Physics; Division of Diagnostic Imaging; The University of Texas MD Anderson Cancer Center; Houston TX
| | - Esther H. Chen
- Department of Emergency Medicine; University of California San Francisco/San Francisco General Hospital; San Francisco CA
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Lam SHF, Bailitz J, Blehar D, Becker BA, Hoffmann B, Liteplo AS, Rajan KB, Lambert M. Multi-Institution Validation of an Emergency Ultrasound Image Rating Scale-A Pilot Study. J Emerg Med 2015; 49:32-39.e1. [PMID: 25907634 DOI: 10.1016/j.jemermed.2015.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Revised: 12/24/2014] [Accepted: 01/05/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND As bedside ultrasound (BUS) is being increasingly taught and incorporated into emergency medicine practice, measurement of BUS competency is becoming more important. The commonly adopted experiential approach to BUS competency has never been validated on a large scale, and has some limitations by design. OBJECTIVE Our aim was to introduce and report preliminary testing of a novel emergency BUS image rating scale (URS). METHODS Gallbladder BUS was selected as the test case. Twenty anonymous BUS image sets (still images and clips) were forwarded electronically to 16 reviewers (13 attendings, 3 fellows) at six training sites across the United States. Each reviewer rated the BUS sets using the pilot URS that consisted of three components, with numerical values assigned to each of the following aspects: Landmarks, Image Quality, and Annotations. Reviewers also decided whether or not each BUS set would be "Clinically Useful." Kendall τs were calculated as a measure of concordance among the reviewers. RESULTS Among the 13 attendings, image review experience ranged from 2-15 years, 5-300 scans per week, and averaged 7.8 years and 60 images. Kendall τs for each aspect of the URS were: Landmarks: 0.55; Image Quality: 0.57; Annotation: 0.26; Total Score: 0.63, and Clinical Usefulness: 0.45. All URS elements correlated significantly with clinical usefulness (p < 0.001). The correlation coefficient between each attending reviewer and the entire group ranged from 0.48-0.69, and was independent of image review experience beyond fellowship training. CONCLUSION Our novel URS had moderate-to-good inter-rater agreement in this pilot study. Based on these results, the URS will be modified for use in future investigations.
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Affiliation(s)
- Samuel H F Lam
- Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, Illinois; Department of Emergency Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - John Bailitz
- Department of Emergency Medicine, Cook County (Stroger) Hospital, Chicago, Illinois
| | - David Blehar
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Brent A Becker
- Department of Emergency Medicine, York Hospital (Wellspan Health), York, Pennsylvania
| | - Beatrice Hoffmann
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Andrew S Liteplo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kumar B Rajan
- Rush Institute for Healthy Aging, Department of Internal Medicine, Rush University, Chicago, Illinois
| | - Michael Lambert
- Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, Illinois
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Abstract
Emergency physicians have used point-of-care ultrasonography since the 1990 s. Pediatric emergency medicine physicians have more recently adopted this technology. Point-of-care ultrasonography is used for various scenarios, particularly the evaluation of soft tissue infections or blunt abdominal trauma and procedural guidance. To date, there are no published statements from national organizations specifically for pediatric emergency physicians describing the incorporation of point-of-care ultrasonography into their practice. This document outlines how pediatric emergency departments may establish a formal point-of-care ultrasonography program. This task includes appointing leaders with expertise in point-of-care ultrasonography, effectively training and credentialing physicians in the department, and providing ongoing quality assurance reviews.
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Akpata R, Neumayr A, Holtfreter MC, Krantz I, Singh DD, Mota R, Walter S, Hatz C, Richter J. The WHO ultrasonography protocol for assessing morbidity due to Schistosoma haematobium. Acceptance and evolution over 14 years. Systematic review. Parasitol Res 2015; 114:1279-89. [DOI: 10.1007/s00436-015-4389-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 02/05/2015] [Indexed: 01/26/2023]
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21
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Jang TB, Kaji AH. A 2-week elective experience provides comparable training as longitudinal exposure during residency for pelvic sonography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:221-224. [PMID: 25614394 DOI: 10.7863/ultra.34.2.221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The purpose of this study was to compare the accuracy of first-trimester pelvic sonography done by physicians after a 2-week emergency ultrasound elective to similarly numbered examinations done by physicians longitudinally over several years of residency training. METHODS We conducted a secondary analysis of a previously reported prospective study of pelvic sonography for symptomatic first-trimester pregnancy. The 21st through 40th examinations were compared between those who completed an emergency ultrasound elective and those who did not. The reference standard was pelvic sonography done by the department of radiology. RESULTS Eighty-six examinations (34%) were done by 12 operators who did not participate in an emergency ultrasound elective, and 171 examinations (67%) were done by 13 operators who completed an emergency ultrasound elective. There was no statistical difference between the groups with regard to identifying an intrauterine pregnancy, molar pregnancy, ectopic pregnancy, or adnexal mass. CONCLUSIONS The accuracy of pelvic sonography for first-trimester pregnancy was comparable between physicians who participated in a 2-week emergency ultrasound elective and those who performed the same number of examinations over a longer period during residency training.
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Affiliation(s)
- Timothy B Jang
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Olive View Medical Center and UCLA Medical Center, Sylmar, California USA (T.B.J.); and Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, California USA (T.B.J., A.H.K.).
| | - Amy H Kaji
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Olive View Medical Center and UCLA Medical Center, Sylmar, California USA (T.B.J.); and Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, California USA (T.B.J., A.H.K.)
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Tolsgaard MG, Ringsted C, Dreisler E, Klemmensen A, Loft A, Sorensen JL, Ottesen B, Tabor A. Reliable and valid assessment of ultrasound operator competence in obstetrics and gynecology. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:437-43. [PMID: 23996613 DOI: 10.1002/uog.13198] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 08/05/2013] [Accepted: 08/19/2013] [Indexed: 05/19/2023]
Abstract
OBJECTIVES To explore the reliability and validity of a recently developed instrument for assessment of ultrasound operator competence, the Objective Structured Assessment of Ultrasound Skills (OSAUS). METHODS Three groups of 10 doctors with different levels of ultrasound experience in obstetrics and gynecology were included. The novices had less than 1 month of experience, the intermediate group had 12-60 months of experience and the senior participants were all consultants. Fifteen participants performed transabdominal fetal biometry and the other 15 participants performed systematic transvaginal gynecological ultrasound scans. All scans were video-recorded and assessed by two blinded consultants using the OSAUS scale. The OSAUS scores were compared between the groups using the Kruskal-Wallis test, and pass/fail scores were determined using the contrasting-groups method of standard setting. RESULTS For the transabdominal fetal biometry examinations, the mean ± SD OSAUS scores of the novices, intermediates and senior participants were 1.5 ± 0.4, 3.3 ± 0.6 and 4.4 ± 0.4, respectively (P = 0.003). For the systematic transvaginal scans, the mean ± SD OSAUS scores of the novices, intermediates and senior participants were 1.8 ± 0.2, 3.1 ± 0.1 and 3.9 ± 0.5, respectively (P = 0.003). Post-hoc comparisons showed significant differences between each of the groups for both types of scans. The pass/fail score was 2.5 for the transvaginal scan and 3.0 for the transabdominal biometry examinations. The inter-rater reliability was 0.89. CONCLUSIONS Ultrasound competence can be assessed in a reliable and valid way using the OSAUS scale. The pass/fail scores may be used to help determine when trainees are qualified for independent practice.
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Affiliation(s)
- M G Tolsgaard
- Department of Obstetrics, Juliane Marie Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Tolsgaard MG, Rasmussen MB, Tappert C, Sundler M, Sorensen JL, Ottesen B, Ringsted C, Tabor A. Which factors are associated with trainees' confidence in performing obstetric and gynecological ultrasound examinations? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:444-51. [PMID: 24105723 DOI: 10.1002/uog.13211] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 08/28/2013] [Accepted: 09/04/2013] [Indexed: 05/19/2023]
Abstract
OBJECTIVE To explore the association between clinical training characteristics and trainees' level of confidence in performing ultrasound scans independently. METHODS A cross-sectional e-survey was distributed to members of the national societies of junior obstetricians/gynecologists in Denmark, Sweden and Norway (n = 973). Multiple linear regression models were used to explore the effect that amount of time spent in specialized ultrasound units and clinical experience had on trainees' confidence in performing ultrasonography independently. Exploratory factor analysis was used to identify factors that contributed to trainees' confidence in performing ultrasonography. Trainees' ultrasound confidence was finally compared with their expected levels of performance. RESULTS Of the 682 respondents (response rate 70.1%), 621 met the inclusion criteria. Clinical experience and time spent in specialized ultrasound units were predictors of trainees' confidence in performing ultrasonography independently (P < 0.001). Trainees required more than 24 months of clinical experience and 12-24 days of training in specialized ultrasound units in order to feel confident about performing transvaginal and transabdominal ultrasound scans independently. Three factors were related to ultrasound confidence: technical aspects, image perception and integration of scan into patient care. There were significant differences between trainees' level of confidence and their expected levels of performance (P < 0.001). CONCLUSIONS Clinical experience and time spent in specialized ultrasound units were predictors of trainees' confidence in performing ultrasonography independently. Discrepancies between trainees' confidence and their expected levels of performance raised concerns about the adequacy of current ultrasound training programs.
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Affiliation(s)
- M G Tolsgaard
- Department of Obstetrics, Juliane Marie Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Hempel D, Pivetta E, Kimberly HH. Personalized peer-comparison feedback and its effect on emergency medicine resident ultrasound scan numbers. Crit Ultrasound J 2014; 6:1. [PMID: 24422791 PMCID: PMC3898777 DOI: 10.1186/2036-7902-6-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 12/27/2013] [Indexed: 11/10/2022] Open
Abstract
Background Clinician-performed ultrasound has become a widely utilized tool in emergency medicine and is a mandatory component of the residency curricula. We aimed to assess the effect of personalized peer-comparison feedback on the number of ultrasound scans performed by emergency medicine residents. Findings A personalized peer-comparison feedback was performed by sending 44 emergency medicine residents a document including personally identified scan numbers and class averages. The number of ultrasound scans per clinical shift for a 3-month period before and after the feedback intervention was calculated. The average number of ultrasound exams per shift improved from 0.39 scans/shift before to 0.61 scans/shift after feedback (p = 0.04). Among the second year residents, the scans/shift ratio improved from 0.35 to 0.87 (p = 0.07); for third year residents, from 0.51 to 0.58 (p = 0.46); and from 0.33 to 0.41 (p = 0.21) for the fourth year residents before and after the intervention, respectively. Conclusions A personalized peer-comparison feedback provided to emergency medicine residents resulted in increased ultrasound scan numbers per clinical shift. Incorporating this method of feedback may help encourage residents to scan more frequently.
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Affiliation(s)
| | | | - Heidi H Kimberly
- Harvard Affiliated Emergency Medicine Residency, Department of Emergency Medicine, Brigham and Women's Hospital/Massachusetts General Hospital, 75 Francis St, Boston, MA 02115, USA.
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Abstract
There has been an increase in the availability and use of bedside ultrasonography in the acute care setting. The approach to the female patient with a pelvic complaint (including pelvic pain, vaginal bleeding, vaginal bleeding in pregnancy, or vaginal discharge) has been transformed by the use of bedside ultrasonography. Providers familiar with the transabdominal and transvaginal (endocavitary) ultrasonographic examination can obtain more accurate information faster, thereby improving time to consultation or discharge and achieving an increase in patient satisfaction. This article reviews the use of ultrasonography for evaluation of obstetric and gynecologic complaints in the acute care setting.
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Sivitz AB, Tejani C, Cohen SG. Evaluation of hypertrophic pyloric stenosis by pediatric emergency physician sonography. Acad Emerg Med 2013; 20:646-51. [PMID: 23781883 DOI: 10.1111/acem.12163] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2012] [Revised: 12/17/2012] [Accepted: 01/23/2013] [Indexed: 01/22/2023]
Abstract
OBJECTIVES The objective was to evaluate the accuracy of pediatric emergency physician (EP) sonography for infants with suspected hypertrophic pyloric stenosis (HPS). METHODS This was a prospective observational pilot study in an urban academic pediatric emergency department (PED). Patients were selected if the treating physician ordered an ultrasound (US) in the department of radiology for the evaluation of suspected HPS. RESULTS Sixty-seven patients were enrolled from August 2009 through April 2012. When identifying the pylorus, pediatric EPs correctly identified all 10 positive cases, with a sensitivity of 100% (95% confidence interval [CI] = 62% to 100%) and specificity of 100% (95% CI = 92% to 100%). There was no statistical difference between the measurements obtained by pediatric EPs and radiology staff for pyloric muscle width or length (p = 0.5 and p = 0.79, respectively). CONCLUSIONS Trained pediatric EPs can accurately assess the pylorus with US in the evaluation of HPS with good specificity.
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Affiliation(s)
- Adam B. Sivitz
- Department of Emergency Medicine; Newark Beth Israel Medical Center; Children's Hospital of New Jersey; Newark; NJ
| | - Cena Tejani
- Department of Emergency Medicine; Newark Beth Israel Medical Center; Children's Hospital of New Jersey; Newark; NJ
| | - Stephanie G. Cohen
- Department of Pediatric Emergency Medicine; Emory University; Children's Healthcare of Atlanta; Atlanta; GA
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Jang TB, Coates WC, Liu YT. The competency-based mandate for emergency bedside sonography training and a tale of two residency programs. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2012; 31:515-521. [PMID: 22441907 DOI: 10.7863/jum.2012.31.4.515] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Timothy B Jang
- Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles Biomedical Institute at Harbor-UCLA, 1000 W Carson Ave, D-9A, Torrance, CA 90502, USA.
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Prospective outcomes of pregnant ED patients with documented fetal cardiac activity on ultrasound. Am J Emerg Med 2012; 30:472-5. [DOI: 10.1016/j.ajem.2010.12.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Revised: 12/14/2010] [Accepted: 12/15/2010] [Indexed: 11/17/2022] Open
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Bonnard P, Boutouaba S, Diakhate I, Seck M, Dompnier JP, Riveau G. Learning curve of vesico-urinary ultrasonography in Schistosoma haematobium infection with WHO practical guide: a "simple to learn" examination. Am J Trop Med Hyg 2012; 85:1071-4. [PMID: 22144446 DOI: 10.4269/ajtmh.2011.11-0282] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
In developing countries, it is difficult to rally a radiologist to conduct field studies. Here, we report how a radiologist taught a clinician to carry out the ultrasound examination as defined by the World Health Organization (WHO) record sheet for Schistosoma haematobium related lesions. In a population infected with S. haematobium, the learner and teacher performed two ultrasound exams and the results were compared. One hundred thirty-two children were prospectively included, during 8 ultrasonography sessions split over 23 days. After 51 examinations the learner's sensitivity was above 90%. After the fifth session the specificity reached 100% (results remained stable until the end of the study period). This study shows that a clinician can quickly learn how to carry out a simple ultrasound examination to gather the items needed for the follow-up of S. haematobium related lesions, suggesting that clinicians could implement networks of ultrasound-based surveillance on the field.
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