Fungal Endophthalmitis on Ocular Ultrasound: A Case Report

Introduction

Endophthalmitis is a rare intraocular infection caused by numerous organisms from several possible sources. Fungal endophthalmitis is a rare subset of this pathology with limited diagnostics available. One of the few options to make this diagnosis is vitreous sampling, which is invasive, and results are not immediately available.

Case Report

This case report describes the successful use of point-of-care ultrasound to visualize an intraocular fungal mass in a 60-year-old male who presented to the emergency department (ED) with two weeks of left eye pain and erythema approximately two months postoperative from a cataract extraction surgery.

Conclusion

Fungal endophthalmitis is a rare and challenging diagnosis. Methods of diagnosing this pathology are not readily available in the ED. Point-of-care ultrasound may be a useful adjunct for the prompt diagnosis of fungal endophthalmitis.

ITSUS: Integrated, Tiered, Self-Directed Ultrasound Scanning for Learning Anatomy

Ultrasound is being introduced into many medical schools and incorporated into the anatomy curriculum; however, in most cases, this consists of proctored sessions which can be limited by faculty time and availability. Additionally, the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic has significantly impacted medical education, especially ultrasound education, which has traditionally depended on hands-on practice and instruction. A structured, independent, hands-on learning curriculum using ultrasound would have many benefits. In this study, eight self-guided system-based modules were developed mirroring the undergraduate anatomy curriculum. For each scan, a beginner, intermediate, and advanced component was designed. Each module contains clear, stepwise directions for image acquisition, optimization, and interpretation of the anatomical structures and suggestions for troubleshooting. Students save ultrasound images as part of their digital portfolios for review with ultrasound faculty. This design provides an educational model to increase medical student opportunities for independent, structured, self-directed anatomy learning with ultrasound that can be integrated with existing educational programs.

Billing I-AIM: a novel framework for ultrasound billing

Background

Point-of-care ultrasound (POCUS) has an ever-growing footprint in medicine. With this growth POCUS billing and reimbursement has become an area gaining quite a bit of attention as a means of funding and sustaining quality and education programs. Standardization across providers is needed to improve the financial viability of POCUS.

Results

We created an institutional collaborative which developed a framework to identify critical POCUS billing and reimbursement checkpoints. The framework, Billing I-AIM, provides a feasible structure to enhance provider-based reimbursement and perform quality improvement efforts across variable POCUS environments.

Conclusions

POCUS billing using the Billing I-AIM technique allows administrative oversight, quality assurance, and educational functions as well. A discussion of the framework and respective application is provided.

Longitudinal Ultrasound Education Track Curriculum Implemented Within an Emergency Medicine Residency Program

Emergency Medicine residency programs offer ultrasound-focused curricula to address Accreditation Council for Graduate Medical Education (ACGME) milestones. Although some programs offer advanced clinical tracks in ultrasound, no standard curriculum exists. We sought to establish a well-defined ultrasound track curriculum to allow interested residents to develop advanced clinical skills and scholarship within this academic niche. The curriculum involves a greater number of clinical scans, ultrasound-focused scholarly and quality improvement projects, enhanced faculty-driven ultrasound focused didactics, and participation at a national ultrasound conference to receive certification. Successful ultrasound scholarly tracks can provide residents with the potential to obtain fellowships or competency beyond ACGME requirements.

Inferior Vena Cava Measurement with Ultrasound: What Is the Best View and Best Mode?

Introduction

Intravascular volume status is an important clinical consideration in the management of the critically ill. Point-of-care ultrasonography (POCUS) has gained popularity as a non-invasive means of intravascular volume assessment via examination of the inferior vena cava (IVC). However, there are limited data comparing different acquisition techniques for IVC measurement by POCUS. The goal of this evaluation was to determine the reliability of three IVC acquisition techniques for volume assessment: sub-xiphoid transabdominal long axis (LA), transabdominal short axis (SA), and right lateral transabdominal coronal long axis (CLA) (aka “rescue view”).

Methods

Volunteers were evaluated by three experienced emergency physician sonographers (EP). Gray scale (B-mode) and motion-mode (M-mode) diameters were measured and IVC collapsibility index (IVCCI) calculated for three anatomic views (LA, SA, CLA). For each IVC measurement, we calculated descriptive statistics, intra-class correlation coefficients (ICC), and two-way univariate analyses of variance.

Results

EPs evaluated 39 volunteers, yielding 351 total US measurements. Measurements of the three views had similar means (LA 1.9 ± 0.4cm; SA 1.9 ± 0.4cm; CLA 2.0 ± 0.5cm). For B-Mode, LA had the highest ICC (0.86, 95% CI [0.76–0.92]) while CLA had the poorest ICC (0.74, 95% CI [0.56–0.85]). ICCs for all M-mode IVCCI were low. Significant interaction effects between anatomical view and EP were observed for B-mode and M-mode measurements. Post-hoc analyses revealed difficulty in consistent view acquisition between EPs.

Conclusion

Inter-rater reliability of the IVC by EPs was highest for B-mode LA and poorest for all M-Mode IVC collapsibility indices (IVCCI). These results suggest that B-mode LA holds the most promise to deliver reliable measures of IVC diameter. Future studies may focus on validation in a clinical setting as well as comparison to a reference standard.

The right team at the right time - Multidisciplinary approach to multi-trauma patient with orthopedic injuries

Integrated, multidisciplinary team approach to the multiply injured patient can help optimize care, minimize morbidity, and reduce mortality. It also provides a framework for accelerated postinjury rehabilitation course. The characteristics and potential benefits of this approach, including team dynamics and interactions, are discussed in this brief review. Emphasis is placed on synergies provided by specialty teams working together in the framework of care coordination, timing of surgical and nonsurgical interventions, and injury/physiologic considerations.

REPUBLISHED WITH PERMISSION FROM

Bach JA, Leskovan JJ, Scharschmidt T, Boulger C, Papadimos TJ, Russell S, Bahner DP, Stawicki SPA. Multidisciplinary approach to multi-trauma patient with orthopedic injuries: the right team at the right time. OPUS 12 Scientist 2012;6(1):6-10.

Language of Transducer Manipulation: Codifying Terms for Effective Teaching

There is a need for consistent, repetitive, and reliable terminology to describe the basic manipulations of the ultrasound transducer. Previously, 5 basic transducer motions have been defined and used in education. However, even with this effort, there is still a lack of consistency and clarity in describing transducer manipulation and motion. In this technical innovation, we describe an expanded definition of transducer motions, which include movements to change the transducer's angle of insonation to the target as well as the location on the body to optimize the ultrasound image. This new terminology may allow for consistent teaching and improved communication in the process of image acquisition.

Trained simulated ultrasound patients: medical students as models, learners, and teachers

OBJECTIVES

Medical educators must develop ultrasound education programs to ensure that future physicians are prepared to face the changing demands of clinical practice. It can be challenging to find human models for hands-on scanning sessions. This article outlines an educational model from a large university medical center that uses medical students to fulfill the need for human models.

METHODS

During the 2011-2012 academic year, medical students from The Ohio State University College of Medicine served as trained simulated ultrasound patients (TSUP) for hands-on scanning sessions held by the college and many residency programs. The extracurricular program is voluntary and coordinated by medical students with faculty supervision. Students receive a longitudinal didactic and hands-on ultrasound education program as an incentive for serving as a TSUP.

RESULTS

The College of Medicine and 7 residency programs used the program, which included 47 second-year and 7 first-year student volunteers. Participation has increased annually because of the program's ease, reliability, and cost savings in providing normal anatomic models for ultrasound education programs. A key success of this program is its inherent reproducibility, as a new class of eager students constitutes the volunteer pool each year.

CONCLUSIONS

The TSUP program is a feasible and sustainable method of fulfilling the need for normal anatomic ultrasound models while serving as a valuable extracurricular ultrasound education program for medical students. The program facilitates the coordination of ultrasound education programs by educators at the undergraduate and graduate levels.

Patellar tendon rupture: an ultrasound case report

This article discusses a case in which ultrasound was the primary modality for diagnosis of traumatic patellar tendon rupture. Traditionally, this diagnosis has been made using MRI. This case highlights the growing need for emergency medicine physicians to become facile with bedside ultrasound and its indications as a supplement to traditional musculoskeletal examination. Normal and pathological patellar tendon examinations with ultrasound are discussed in detail. Furthermore, the advantages of ultrasound over the more traditional imaging modalities of x-ray and MRI in cases where tendon rupture is suspected are discussed.

Educating the delivery of bad news in medicine: Preceptorship versus simulation

Simulation experiences have begun to replace traditional education models of teaching the skill of bad news delivery in medical education. The tiered apprenticeship model of medical education emphasizes experiential learning. Studies have described a lack of support in bad news delivery and inadequacy of training in this important clinical skill as well as poor familial comprehension and dissatisfaction on the part of physicians in training regarding the resident delivery of bad news. Many residency training programs lacked a formalized training curriculum in the delivery of bad news. Simulation teaching experiences may address these noted clinical deficits in the delivery of bad news to patients and their families. Unique experiences can be role-played with this educational technique to simulate perceived learner deficits. A variety of scenarios can be constructed within the framework of the simulation training method to address specific cultural and religious responses to bad news in the medical setting. Even potentially explosive and violent scenarios can be role-played in order to prepare physicians for these rare and difficult situations. While simulation experiences cannot supplant the model of positive, real-life clinical teaching in the delivery of bad news, simulation of clinical scenarios with scripting, self-reflection, and peer-to-peer feedback can be powerful educational tools. Simulation training can help to develop the skills needed to effectively and empathetically deliver bad news to patients and families in medical practice.

Ban Tu Wan hepatotoxicity

Medications are thought to contribute to approximately 50% of the cases of acute liver failure in the USA. This number includes some herbal medications and supplements. However, little regulatory oversight of these later substances occurs. This report describes a case of fulminant hepatic failure secondary to Ban Tu Wan (a Chinese herb). We discuss the use of this herbal supplement and the relationship to drug-induced hepatitis.