Feasibility and accuracy of point-of-care pocket-size ultrasonography performed by medical students

Efficacy of Handheld Ultrasound in Medical Education: A Comprehensive Systematic Review and Narrative Analysis

Miniaturization has made ultrasound (US) technology ultraportable and, in association with their relatively low cost, made handheld devices attractive for medical education training programs. However, performing an ultrasound requires complex skills, and it is unclear whether handheld devices are suitable for the training of novices. Our study aimed to identify to what extent handheld US devices can be employed in medical undergraduates' and residents' education. We selected studies that evaluate the results obtained by students and/or residents who have participated in ultrasound training programs using handheld devices. The studies were included if they reported post-test (pre-test optional) achievements or a comparison with a control group (a group of experts or novices who underwent a different intervention). Twenty-six studies were selected, and their characteristics were summarized. Handheld ultrasound devices were used in training programs to learn echocardiography, abdominal, and/or musculoskeletal ultrasound. Statistically significant progress was noted in the ability of naïve participants to capture and interpret ultrasound images, but training duration influenced the outcomes. While ultrasound training using handheld devices has proven to be feasible for various body regions and purposes (e.g., better understanding of anatomy, clinical applications, etc.), the long-term impacts of handheld education interventions must be considered in addition to the short-term results to outline guidelines for targeted educational needs.

A Simulation Model for the Handheld Ultrasound Diagnosis of Pediatric Forearm Fractures

INTRODUCTION

Handheld ultrasound (HHU) devices have gained prominence in emergency care settings and post-graduate training, but their application in the diagnosis of pediatric fractures remains under-explored. The aim of this study is to evaluate the effectiveness and accuracy of an HHU device for diagnosing pediatric forearm fractures using a simulation model.

METHODS

The materials for the basic pediatric fracture model include turkey bones soaked in white vinegar to make them pliable, food-grade gelatine, and plastic containers. Ultrasound analysis of the models was done with an HHU device, Sonosite İViz US (FUJIFILM Sonosite, Inc.; Bothell, Washington USA). Four different fracture patterns (transverse fracture, oblique fracture, greenstick fracture, and a torus fracture) and one model without fracture were used in this study. Twenty-six Emergency Medicine residents sonographically evaluated different bone models in order to define the presence and absence of fracture and the fracture subtype. The participants' ability to obtain adequate images and the time taken to create and recognize the images were evaluated and recorded. After the sonographic examination, the residents were also asked for their opinion on the model as a teaching tool.

RESULTS

All participants (100%) recognized the normal bone model and the fracture, regardless of the fracture type. The consistency analysis between the practitioners indicated a substantial agreement (weighted kappa value of 0.707). The duration to identify the target pathology in fracture models was significantly longer for the greenstick fracture (78.57 [SD = 30.45] seconds) model compared to other models. The majority of participants (92.3%) agreed that the model used would be a useful teaching tool for learning ultrasound diagnosis of pediatric forearm fractures.

CONCLUSIONS

All participants successfully identified both the normal bone model and the presence of fractures, irrespective of the fracture type. Significantly, the identification of the greenstick fracture took longer compared to other fracture types. Moreover, the majority of participants acknowledged the model's utility as a teaching tool for learning ultrasound diagnosis of pediatric forearm fractures.

Accuracy of Wireless Hand-Held Guided Ultrasound Injections in the Trapeziometacarpal Joint: A Cadaveric Study

Background Symptomatic trapeziometacarpal osteoarthrosis can be treated with an ultrasound-guided injection in the early stages. This cadaveric study aimed to assess the hypothesis suggesting enhanced accuracy and reliability of hand-held ultrasound (HHUS) injections compared to blind injections into the trapeziometacarpal joint (TMC). Materials and method Our series included 20 fresh cadaveric hands, with a total of 20 TMC randomly assigned to two groups. In group A, 10 TMC received a blinded injection, and in group B, 10 TMC received an ultrasound-guided injection with HHUS. Methylene blue was injected, and anatomical dissection was performed to assess the intra-articular location of the dye. The injection was considered accurate if the intra-articular synovial fluid was stained after opening the articular capsule on the dorsal approach. If there was no injection, it was inaccurate. A statistical analysis was performed, and p <.05 indicated a significant difference. Results Two thumbs were excluded during the study due to an existing trapeziectomy. In group A, 10 blind injections of TMC were performed, with 70% (7/10) of injections graded as accurate. In group B, eight ultrasound-guided injections were performed, with 75% (6/8) achieving accuracy. A Fisher's exact test was performed, and the results indicated no statistically significant difference in injection accuracy between the two groups (P = 1, odds ratio = 0.788). Conclusion Hand-held ultrasound guided TMC injections were not more accurate than blind injections performed by an experienced hand surgeon. Nonetheless, additional studies with a larger sample and comparative studies with conventional cart-based machines are necessary to evaluate the potential of this newly accessible device.

Point-of-Care-ultrasound in undergraduate medical education: a scoping review of assessment methods

BACKGROUND

Point-of-Care-Ultrasound (POCUS) curricula have rapidly expanded in undergraduate medical education (UME). However, the assessments used in UME remain variable without national standards. This scoping review characterizes and categorizes current assessment methods using Miller's pyramid for skills, performance, and competence of POCUS in UME. A structured protocol was developed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). A literature search of MEDLINE was performed from January 1, 2010, to June 15, 2021. Two independent reviewers screened all titles and abstracts for articles that met inclusion criteria. The authors included all POCUS UME publications in which POCUS-related knowledge, skills, or competence were taught and objectively assessed. Articles were excluded if there were no assessment methods used, if they exclusively used self-assessment of learned skills, were duplicate articles, or were summaries of other literature. Full text analysis and data extraction of included articles were performed by two independent reviewers. A consensus-based approach was used to categorize data and a thematic analysis was performed.

RESULTS

A total of 643 articles were retrieved and 157 articles met inclusion criteria for full review. Most articles (n = 132; 84%) used technical skill assessments including objective structured clinical examinations (n = 27; 17%), and/or other technical skill-based formats including image acquisition (n = 107; 68%). Retention was assessed in n = 98 (62%) studies. One or more levels of Miller's pyramid were included in 72 (46%) articles. A total of four articles (2.5%) assessed for students' integration of the skill into medical decision making and daily practice.

CONCLUSIONS

Our findings demonstrate a lack of clinical assessment in UME POCUS that focus on integration of skills in daily clinical practice of medical students corresponding to the highest level of Miller's Pyramid. There exists opportunities to develop and integrate assessment that evaluate higher level competencies of POCUS skills of medical students. A mixture of assessment methods that correspond to multiple levels of Miller's pyramid should be used to best assess POCUS competence in UME.

Clinical Influence of Handheld Ultrasound, Supported by Automatic Quantification and Telemedicine, in Suspected Heart Failure

Early and correct heart failure (HF) diagnosis is essential to improvement of patient care. We aimed to evaluate the clinical influence of handheld ultrasound device (HUD) examinations by general practitioners (GPs) in patients with suspected HF with or without the use of automatic measurement of left ventricular (LV) ejection fraction (autoEF), mitral annular plane systolic excursion (autoMAPSE) and telemedical support. Five GPs with limited ultrasound experience examined 166 patients with suspected HF (median interquartile range = 70 (63-78) y; mean ± SD EF = 53 ± 10%). They first performed a clinical examination. Second, they added an examination with HUD, automatic quantification tools and, finally, telemedical support by an external cardiologist. At all stages, the GPs considered whether the patients had HF. The final diagnosis was made by one of five cardiologists using medical history and clinical evaluation including a standard echocardiography. Compared with the cardiologists' decision, the GPs correctly classified 54% by clinical evaluation. The proportion increased to 71% after adding HUDs, and to 74 % after telemedical evaluation. Net reclassification improvement was highest for HUD with telemedicine. There was no significant benefit of the automatic tools (p ≥ 0.58). Addition of HUD and telemedicine improved the GPs' diagnostic precision in suspected HF. Automatic LV quantification added no benefit. Refined algorithms and more training may be needed before inexperienced users benefit from automatic quantification of cardiac function by HUDs.

Implementation of Ultrasound in Preclinical Education at Osteopathic Medical Schools: A Scoping Review

Ultrasound (US) is recognized as a practical and safe form of medical imaging that utilizes ultrasound waves to develop images for diagnostic and procedural purposes. The clinical use of US has dramatically increased over recent years, secondary to the ease of use, portability, and functionality of US. The success of point-of-care ultrasound implementation into residency curricula has further underscored the importance of US education and its potential for use earlier in medical instruction. Osteopathic medical education places a significant emphasis on anatomy, thus a scoping review of the literature regarding the use of US in osteopathic preclinical years is warranted. The goal of this scoping study is to assess the current literature regarding the implementation and benefit of US instruction in preclinical osteopathic medical curricula. Four resources were utilized for the review, including PubMed, Google Scholar, JOM (formerly JAOA), and AMED, each with contiguous criteria for applicable literature. The searches were performed before the end of January 2023. Inclusion criteria for researched literature focused on osteopathic preclinical utilization of US technologies. Articles were subsequently evaluated using thematic and contextual analysis. Of the 2,968 articles evaluated, 22 articles met the inclusion criteria. There were several themes associated with the implementation of US within osteopathic curricula, including positive student perceptions of the modality, improved learning outcomes, and adaptations of US instruction into anatomical sciences courses. There is a need for continued research regarding US implementation in preclinical osteopathic medical school education, including within anatomical sciences. A minority of osteopathic schools have published details regarding how US has been applied in their curriculum.

Reasons for disagreement between screening and standard echocardiography in primary care: data from the PROVAR + study : Disagreement between screening and standard echo

We aimed to evaluate the reasons for disagreement between screening echocardiography (echo), acquired by nonexperts, and standard echo in the Brazilian primary care (PC). Over 20 months, 22 PC workers were trained on simplified handheld (GE VSCAN) echo protocols. Screening groups, consisting of patients aged 17-20, 35-40 and 60-65 years, and patients referred for clinical indications underwent focused echo. Studies were remotelyinterpreted in US and Brazil, and those diagnosed with major or severe HD were referred for standard echoperformed by an expert. Major HD was defined as moderate to severe valve disease, ventriculardysfunction/hypertrophy, pericardial effusion or wall-motion abnormalities. A random sample of exams wasselected for evaluation of variables accounting for disagreement. A sample of 768 patients was analyzed, 651(85%) in the referred group. Quality issues were reported in 5.8%, and the random Kappa for major HD between screening and standard echo was 0.51. The most frequent reasons for disagreement were: overestimation of mitral regurgitation (MR) (17.9%, N=138), left ventricular (LV) dysfunction (15.7%, N=121), aortic regurgitation (AR) (15.2%, N=117), LV hypertrophy (13.5%, N=104) and tricuspid regurgitation (12.7%, N=98). Misdiagnosis of mitral and aortic morphological abnormalities was observed in 12.4% and 3.0%, and underestimation of AR and MR occurred in 4.6% and 11.1%. Among 257 patients with suspected mild/moderate MR, 129 were reclassified to normal. In conclusion, although screening echo with task-shifting in PC is a promising tool in low-income areas, estimation of valve regurgitation and LV function and size account for considerable disagreement with standard exams.

Technology Complements Physical Examination and Facilitates Skills Development among Health Sciences Clerkship Students: An Integrative Literature Review

Background

Technology is increasingly present in the clinical environment. There is a dearth of investigation of the relationship between technology and touch concerning student learning of physical examination practices.

Method

Integrative review methods were used to synthesise empirical literature to provide a comprehensive understanding of the relationship between physical examination, learning and technology in the context of health professional student clerkships.

Results

Three databases including MEDLINE, CINAHL and Eric were searched for all articles published from 2014 to 2021 using terms relating to (i) physical examination, (ii) technology, and (iii) student clerkships. Thirty-three studies met the inclusion criteria. From the analysis, it is evident that technologies that intersect with learning of physical examination may broadly be apportioned into two categories: 1) technologies that mediate physical examination practices; and 2) technologies that mediate the learning of physical examination.

Conclusions

This review indicates that technologies may have multiple roles in the student learning of physical examination, including technology mediating increased diagnostic accuracy and access to supplementary learning material relating to physical examination that is integrated for the clinical clerkship environment. It highlights a need to further understand the touch versus technology relationship and explore the dynamic intersection.

The Point-of-Care Ultrasound (POCUS) by the Handheld Ultrasound Devices (HUDs) in the COVID-19 Scenario: a Review of the Literature

The use of portable ultrasound (US) devices is increasing, due to its accessibility, versatility, non-invasiveness, and its significant support in the patient management, extending the traditional physical examination through the POCUS (point-of-care ultrasound). The pocket-size or handheld ultrasound devices (HUDs) can easily perform focused exams, not aiming to substitute for the high-end US systems (gold standard), since the HUDs usually have more limited functions. The HUDs are promising tools for the diagnosis, prognosis, and monitoring of the COVID-19 infection and its related disorders. In conclusion, the routine use of HUDs may ameliorate the management of COVID-19 pandemic, according to the guidelines for the POCUS approach and the procedures for the protection of the patients and the professionals.

Real-time automatic quantification of left ventricular function by hand-held ultrasound devices in patients with suspected heart failure: a feasibility study of a diagnostic test with data from general practitioners, nurses and cardiologists

OBJECTIVES

To evaluate the feasibility and reliability of hand-held ultrasound (HUD) examinations with real-time automatic decision-making software for ejection fraction (autoEF) and mitral annular plane systolic excursion (autoMAPSE) by novices (general practitioners), intermediate users (registered cardiac nurses) and expert users (cardiologists), respectively, compared to reference echocardiography by cardiologists in an outpatient cohort with suspected heart failure (HF).

DESIGN

Feasibility study of a diagnostic test.

SETTING AND PARTICIPANTS

166 patients with suspected HF underwent HUD examinations with autoEF and autoMAPSE measurements by five novices, three intermediate-skilled users and five experts. HUD results were compared with a reference echocardiography by experts. A blinded cardiologist scored all HUD recordings with automatic measurements as (1) discard, (2) accept, but adjust the measurement or (3) accept the measurement as it is.

PRIMARY OUTCOME MEASURE

The feasibility of automatic decision-making software for quantification of left ventricular function.

RESULTS

The users were able to run autoEF and autoMAPSE in most patients. The feasibility for obtaining accepted images (score of ≥2) with automatic measurements ranged from 50% to 91%. The feasibility was lowest for novices and highest for experts for both autoEF and autoMAPSE (p≤0.001). Large coefficients of variation and wide coefficients of repeatability indicate moderate agreement. The corresponding intraclass correlations (ICC) were moderate to good (ICC 0.51-0.85) for intra-rater and poor (ICC 0.35-0.51) for inter-rater analyses. The findings of modest to poor agreement and reliability were not explained by the experience of the users alone.

CONCLUSION

Novices, intermediate and expert users were able to record four-chamber views for automatic assessment of autoEF and autoMAPSE using HUD devices. The modest feasibility, agreement and reliability suggest this should not be implemented into clinical practice without further refinement and clinical evaluation.

TRIAL REGISTRATION NUMBER

NCT03547076.

Medical student medium-term skill retention following cardiac point-of-care ultrasound training based on the American Society of Echocardiography curriculum framework

Background

No studies have demonstrated medium- or long-term skill retention of cardiac point-of-care ultrasound (POCUS) curriculum for medical student. Based on the American Society of Echocardiography (ASE) curriculum framework, we developed a blended-learning cardiac POCUS curriculum with competency evaluation. The objective of this study was to investigate the curriculum impact on image acquisition skill retention 8 weeks after initial training.

Methods

This study was a prospective, pre-post education intervention study for first- and second-year medical students, with blinded outcome assessment. The curriculum included a pre-training ASE online module and healthy volunteer hands-on training to obtain 5 views: parasternal long-axis (PLAX), parasternal short-axis (PSAX), apical 4-chamber (A4C), subcostal 4-chamber (S4C), and subcostal inferior vena cava (SIVC) views. Students took 5-view image acquisition skill tests at pre-, immediate post-, and 8-week post-training, using a healthy volunteer. Three blinded assessors rated the image quality using a validated 10-point maximum scoring system. Students used a hand-held ultrasound probe (Butterfly iQ).

Results

Fifty-four students completed hands-on training, and pre- and immediate post-training skill tests. Twenty-seven students completed 8-week post-training skill tests. Skill test score improvement between pre- and 8-week post-training was 2.11 points (95% CI, 1.22–3.00; effect size, 1.13).

Conclusion

The cardiac POCUS curriculum demonstrated medium-term skill retention. The curriculum was sufficient for S4C and SIVC skill retention, but inadequate for PLAX, PSAX, and A4C. Therefore, instructional design modifications or re-training for PLAX, PSAX, and A4C are needed to make the curriculum more effective for clinically relevant skill retention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12947-022-00296-z.

Left ventricular systolic function affects right atrial pressure as prognosticator in patients with heart failure

The effect of the left ventricular ejection fraction (LVEF) on the prognostic impact of the right atrial pressure (RAP) in patients with heart failure (HF) requires clarification. We aimed to investigate whether LVEF affects the prognostic impact of RAP estimated from inferior vena cava (IVC) measurements in patients hospitalized with HF. Initially, this observational study included 1349 consecutive patients urgently hospitalized with HF. After patient exclusions, 506 and 484 patients with reduced (< 40%) and with non-reduced (≥ 40%) LVEF, respectively, were assigned according to maximum IVC diameter and its collapsibility, to the Normal-RAP (diameter ≤ 2.1 cm; collapsibility ≥ 50%), High-RAP (diameter > 2.1 cm; collapsibility < 50%), and Intermediate-RAP (others) groups. The endpoint comprised cardiovascular death after discharge and hospitalization for HF recurrence. During the observation period, 247 (49%) patients with LVEF < 40% and 178 (37%) patients with LVEF ≥ 40% experienced the endpoint. The patient subgroups with LVEF < 40% had comparable event rates (ptrend = 0.10). The High-RAP subgroup with LVEF ≥40% had a higher event rate than the other subgroups (p < 0.001). The RAP independently predicted the endpoint in patients with LVEF ≥ 40% (hazard ratio: 1.26; 95% confidence interval: 1.01-1.59). The interaction between the RAP groups and LVEF regarding the primary endpoint was significant (pinteraction = 0.007). Stratifying patients with HF according to IVC measurements may predict the post-discharge cardiovascular prognoses of patients with non-reduced LVEF, but not that of patients with reduced LVEF.

International consensus conference recommendations on ultrasound education for undergraduate medical students

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Automated versus manual B-lines counting, left ventricular outflow tract velocity time integral and inferior vena cava collapsibility index in COVID-19 patients

Background and Aims:

The incorporation of artificial intelligence (AI) in point-of-care ultrasound (POCUS) has become a very useful tool to quickly assess cardiorespiratory function in coronavirus disease (COVID)-19 patients. The objective of this study was to test the agreement between manual and automated B-lines counting, left ventricular outflow tract velocity time integral (LVOT-VTI) and inferior vena cava collapsibility index (IVC-CI) in suspected or confirmed COVID-19 patients using AI integrated POCUS. In addition, we investigated the inter-observer, intra-observer variability and reliability of assessment of echocardiographic parameters using AI by a novice.

Methods:

Two experienced sonographers in POCUS and one novice learner independently and consecutively performed ultrasound assessment of B-lines counting, LVOT-VTI and IVC-CI in 83 suspected and confirmed COVID-19 cases which included both manual and AI methods.

Results:

Agreement between automated and manual assessment of LVOT-VTI, and IVC-CI were excellent [intraclass correlation coefficient (ICC) 0.98, P < 0.001]. Intra-observer reliability and inter-observer reliability of these parameters were excellent [ICC 0.96-0.99, P < 0.001]. Moreover, agreement between novice and experts using AI for LVOT-VTI and IVC-CI assessment was also excellent [ICC 0.95-0.97, P < 0.001]. However, correlation and intra-observer reliability between automated and manual B-lines counting was moderate [(ICC) 0.52-0.53, P < 0.001] and [ICC 0.56-0.69, P < 0.001], respectively. Inter-observer reliability was good [ICC 0.79-0.87, P < 0.001]. Agreement of B-lines counting between novice and experts using AI was weak [ICC 0.18, P < 0.001].

Conclusion:

AI-guided assessment of LVOT-VTI, IVC-CI and B-lines counting is reliable and consistent with manual assessment in COVID-19 patients. Novices can reliably estimate LVOT-VTI and IVC-CI using AI software in COVID-19 patients.

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

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

Can Medical Students Learn and Perform POCUS in the Pediatric Emergency Department? Implementation of a Short Curriculum

Purpose: To determine medical student ability to accurately obtain and interpret POCUS exams of varying difficulty in the pediatric population after a short didactic and hands-on POCUS course. Methods: Five medical students were trained in four POCUS applications (bladder volume, long bone for fracture, limited cardiac for left ventricular function, & inferior vena cava collapsibility) and enrolled pediatric ED patients. Ultrasound-fellowship-trained emergency medicine physicians reviewed each scan for image quality and interpretation accuracy using the American College of Emergency Physicians' quality assessment scale. We report acceptable scan frequency and medical student vs. Ultrasound-fellowship-trained emergency medicine physician interpretation agreement with 95% confidence intervals (CI). Results: Ultrasound-fellowship-trained emergency medicine physicians graded 51/53 bladder volume scans as acceptable (96.2%; 95% CI 87.3-99.0%) and agreed with 50/53 bladder volume calculations (94.3%; 95% CI 88.1-100%). Ultrasound-fellowship-trained emergency medicine physicians graded 35/37 long bone scans as acceptable (94.6%; 95% CI 82.3-98.5%) and agreed with 32/37 medical student long bone scan interpretations (86.5%; 95% CI 72.0-94.1%). Ultrasound-fellowship-trained emergency medicine physicians graded 116/120 cardiac scans as acceptable (96.7%; 95% CI 91.7-98.7%) and agreed with 111/120 medical student left ventricular function interpretations (92.5%; 95% CI 86.4-96.0%). Ultrasound-fellowship-trained emergency medicine physicians graded 99/117 inferior vena cava scans as acceptable (84.6%; 95% CI 77.0-90.0%) and agreed with 101/117 medical student interpretations of inferior vena cava collapsibility (86.3%; 95% CI 78.9-91.4%). Conclusions: Medical students demonstrated satisfactory ability within a short period of time in a range of POCUS scans on pediatric patients after a novel curriculum. This supports the incorporation of a formal POCUS education into medical school curricula and suggests that novice POCUS learners can attain a measure of competency in multiple applications after a short training course.

Pre-clinical medical student cardiac point-of-care ultrasound curriculum based on the American Society of Echocardiography recommendations: a pilot and feasibility study

Background

Cardiac point-of-care ultrasound (POCUS) training has been integrated into medical school curricula. However, there is no standardized cardiac POCUS training method for medical students. To address this issue, the American Society of Echocardiography (ASE) proposed a framework for medical student cardiac POCUS training. The objective of this pilot study was to develop a medical student cardiac POCUS curriculum with test scoring systems and test the curriculum feasibility for a future definitive study.

Methods

Based on the ASE-recommended framework, we developed a cardiac POCUS curriculum consisting of a pre-training online module and hands-on training with a hand-held ultrasound (Butterfly iQ, Butterfly Network Inc., Guilford, CT, USA). The curriculum learning effects were assessed with a 10-point maximum skill test and a 40-point maximum knowledge test at pre-, immediate post-, and 8-week post-training. To determine the curriculum feasibility, we planned to recruit 6 pre-clinical medical students. We semi-quantitatively evaluated the curriculum feasibility in terms of recruitment rate, follow-up rate 8 weeks after training, instructional design of the curriculum, the effect size (ES) of the test score improvements, and participant satisfaction. To gather validity evidence of the skill test, interrater and test-retest reliability of 3 blinded raters were assessed.

Results

Six pre-clinical medical students participated in the curriculum. The recruitment rate was 100% (6/6 students) and the follow-up rate 8 weeks after training was 100% (6/6). ESs of skill and knowledge test score differences between pre- and immediate post-, and between pre- and 8-week post-training were large. The students reported high satisfaction with the curriculum. Both interrater and test-retest reliability of the skill test were excellent.

Conclusions

This pilot study confirmed the curriculum design as feasible with instructional design modifications including the hands-on training group size, content of the cardiac POCUS lecture, hands-on teaching instructions, and hand-held ultrasound usage. Based on the pilot study findings, we plan to conduct the definitive study with the primary outcome of long-term skill retention 8 weeks after initial training. The definitive study has been registered in ClinicalTrials.gov (Identifier: NCT04083924).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00910-3.

Point-of-care ultrasound assessment of the abdominal aorta by physician assistant students: a pilot study

OBJECTIVE

Point-of-care ultrasound (POCUS) decreases time to diagnosis and improves mortality of those diagnosed with abdominal aortic aneurysms and dissections. While medical students have demonstrated an ability to obtain adequate POCUS images of the abdominal aorta (AA), physician assistant (PA) student studies are lacking. This pilot study aims to evaluate the ability of PA students to acquire AA POCUS images.

METHODS

PA students, instructors, and models voluntarily participated. Student participants received online material to review several weeks before the study. During the study, students performed 4 precepted practice scans of the AA, and their fifth scan was recorded for review by three ultrasound fellowship trained Emergency Medicine physicians. Images were graded on proper identification and measurement of the AA, as well as interpretability of images.

RESULTS

A total of 20 PA students participated. Ninety-five percent were able to obtain interpretable transverse images of the distal aorta and longitudinal views of the aorta, and 65% were able to obtain interpretable transverse images of the proximal and mid aorta.

CONCLUSIONS

In the most rigorous evaluation of student-obtained AA POCUS images to date, we found that PA students were able to obtain adequate AA images. PA students were able to image the distal and longitudinal aorta in the transverse plane where the majority of AAAs are found to a very high degree. Results demonstrate PA students' ability to learn POCUS and encourage PA education to take steps to incorporate POCUS education and development of competency standards for PA graduates.

Point-of-care ultrasound (POCUS) in Norwegian general practice

Objective: To assess the use of point-of-care ultrasound (POCUS) in Norwegian general practice.Design: Retrospective register study based on general practitioners' (GPs') reimbursement claims.Setting: Norwegian general practice excluding out-of-hours clinics in 2009, 2012 and 2016.Subjects: GPs who scanned patients for a given set of symptoms and medical conditions.Main outcome measures: Number and characteristics of GPs performing POCUS. Number and type of scans carried out.Results: The number of scanning GPs increased from 479 in 2009 to 2078 in 2016. The number of registered scans increased from 8962 to 55921. In 2016, approximately 30% of Norwegian GPs sent at least one reimbursement claim for POCUS. Seven out of 10 GPs did not scan every month. The gender distribution of scanning GPs was equal to that of the total GP population. Male GPs scanned four times more frequent than female GPs. Specialist in family medicine scanned twice as much as non-specialist. The use of POCUS among GPs in different counties varied from 31.6 to 198.5 per 10,000 citizens.Conclusions: The number of Norwegian GPs using POCUS and the number of scans have increased substantially from 2009 to 2016. The use of the various scans, based on the use of reimbursement claims, have evolved differently. The reasons for this are not known. The low number of scans carried out by most GPs raises a concern when it comes to the quality of the performed scans.KEY POINTS30% of Norwegian general practitioners (GPs) used point-of-care ultrasound (POCUS) in 2016.The use of POCUS increased six-fold from 2009 to 2016.Three out of four scanning GPs performed less than 10 scans annually.Male GPs performed 80% of the claimed scans.

Feasibility of renal resistive index measurements performed by an intermediate and novice sonographer in a volunteer population

Background

The Doppler-derived renal resistive index (RRI) is emerging as a promising bedside tool for assessing renal perfusion and risk of developing acute kidney injury in critically ill patients. It is not known what level of ultrasonography competence is needed to obtain reliable RRI values.

Objective

The aim of this study was to evaluate the feasibility of RRI measurements by an intermediate and novice sonographer in a volunteer population.

Methods

After a focused teaching session, an intermediate (resident), novice (medical student) and expert sonographer performed RRI measurements in 23 volunteers consecutively and blinded to the results of one another. Intraclass correlation coefficients and Bland–Altman plots were used to evaluate interobserver reliability, bias and precision.

Results

Both non-experts were able to obtain RRI values in all volunteers. Median RRI in the population measured by the expert was 0.58 (interquartile range 0.52–0.62). The intraclass correlation coefficient was 0.96 (95% confidence interval 0.90–0.98) for the intermediate and expert, and 0.85 (95% confidence interval 0.69–0.94) for the novice and expert. In relation to the measurements of the expert, both non-experts showed negligible bias (mean difference 0.002 [95% confidence interval − 0.005 to 0.009, p = 0.597] between intermediate and expert, mean difference 0.002 [95% confidence interval − 0.011 to 0.015, p = 0.752] between novice and expert) and clinically acceptable precision (95% limits of agreement − 0.031 to 0.035 for the intermediate, 95% limits of agreement − 0.056 to 0.060 for the novice).

Conclusions

RRI measurements by both an intermediate and novice sonographer in a volunteer population were reliable, accurate and precise after a brief course. RRI is easy to learn and feasible within the scope of point-of-care ultrasound.

Evaluation of a point-of-care ultrasound curriculum taught by medical students for physicians, nurses, and midwives in rural Indonesia

PURPOSE

In the Indonesian health-care system, nurses and midwives often serve as the primary health-care providers due to physician shortages. Seeking to address the need for medical care in resource-limited environments, some have advocated for portable equipment in the hands of health-care providers. We hypothesized that medical students are able to effectively teach point-of-care ultrasound (POCUS) to physicians, nurses, and midwives in rural Indonesia.

METHODS

We conducted a prospective, observational study using health-care practitioners from a clinic and accredited school for nursing and midwifery in Mojokerto, East Java, Indonesia. Enrolled practitioners took part in a 4-week POCUS course followed by postinstructional testing.

RESULTS

A total of 55 health-care practitioners completed the course. This included 19 physicians, 13 nurses, and 19 midwives. Of the 55 clinicians, 43 (72%) passed the course and 12 (28%) failed.

CONCLUSIONS

Physicians, nurses, and midwives in rural Indonesia showed significant acquisition of ultrasound (US) knowledge and skills following a 4-week US course. Following training, all three groups displayed skills in practical US use during a postcourse practical examination. This is one of the first studies to assess the efficacy of medical students teaching POCUS to midwives and nurses.

Feasibility of cardiac output measurements in critically ill patients by medical students

BACKGROUND

Critical care ultrasonography (CCUS) is increasingly applied also in the intensive care unit (ICU) and performed by non-experts, including even medical students. There is limited data on the training efforts necessary for novices to attain images of sufficient quality. There is no data on medical students performing CCUS for the measurement of cardiac output (CO), a hemodynamic variable of importance for daily critical care.

OBJECTIVE

The aim of this study was to explore the agreement of cardiac output measurements as well as the quality of images obtained by medical students in critically ill patients compared to the measurements obtained by experts in these images.

METHODS

In a prospective observational cohort study, all acutely admitted adults with an expected ICU stay over 24 h were included. CCUS was performed by students within 24 h of admission. CCUS included the images required to measure the CO, i.e., the left ventricular outflow tract (LVOT) diameter and the velocity time integral (VTI) in the LVOT. Echocardiography experts were involved in the evaluation of the quality of images obtained and the quality of the CO measurements.

RESULTS

There was an opportunity for a CCUS attempt in 1155 of the 1212 eligible patients (95%) and in 1075 of the 1212 patients (89%) CCUS examination was performed by medical students. In 871 out of 1075 patients (81%) medical students measured CO. Experts measured CO in 783 patients (73%). In 760 patients (71%) CO was measured by both which allowed for comparison; bias of CO was 0.0 L min-1 with limits of agreement of - 2.6 L min-1 to 2.7 L min-1. The percentage error was 50%, reflecting poor agreement of the CO measurement by students compared with the experts CO measurement.

CONCLUSIONS

Medical students seem capable of obtaining sufficient quality CCUS images for CO measurement in the majority of critically ill patients. Measurements of CO by medical students, however, had poor agreement with expert measurements. Experts remain indispensable for reliable CO measurements. Trial registration Clinicaltrials.gov; http://www.clinicaltrials.gov; registration number NCT02912624.

Clinical correlates of hand-held ultrasound-guided assessments of the inferior vena cava in patients with acute decompensated heart failure

BACKGROUND

Accurately assessing volume status in acutely decompensated heart failure (ADHF) can be challenging. Inferior vena cava (IVC) dynamics by echocardiography allow indirect assessment of volume status in these patients. Recently introduced hand-held ultrasound devices are promising. We aimed to describe the clinical correlates of volume status assessment using a hand-held ultrasound device in ADHF.

METHODS

In this prospective study, we evaluated 106 patients admitted with ADHF. First scan was performed within 24 hours of admission and timed in reference to first dose of intravenous diuretic. Daily resting and inspiratory (sniff) IVC diameters were measured according to standard echocardiography methods during hospitalization including the day of discharge. IVC collapsibility index (IVC-CI = Maximum IVC diameter-Inspiratory IVC diameter/maximum diameter; <0.5 representing hypervolemia) was calculated. Primary study endpoint was 30-day readmission. Research activities were independent of clinical decision-making.

RESULTS

Data for 106 patients was analyzed. Mean age was 66.7 ± 13.8 years, of which 53.8% were females, and a mean ejection fraction was 39 ± 18%. Initial scan of the IVC was obtained at an average time of 5.2 ± 8.04 hours from first diuretic dose. 81.2% of patients at admission had an IVC-CI <0.5. 63.2% patients had an IVC-CI <0.5 at discharge. There were no significant differences in age, length of stay, diuretic dose, or 30-day readmissions between patients with a discharge IVC-CI <0.5 vs ≥ 0.5.

CONCLUSION

Hand-held ultrasound assessment of IVC-CI in ADHF patients, although a feasible concept, is unable to predict 30-day readmissions in our study. Further prospective studies are necessary.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Point-of-care ultrasound with pocket-size devices in emergency department

Point-of-care ultrasound is a useful tool for clinicians in the management of patients. Particularly in emergency department, the role of point-of-care ultrasound is strongly increasing due to the need for a rapid assessment of critically ill patients and to speed up the diagnostic process. Hand-carried ultrasound devices are particularly useful in emergency setting and allow rapid assessment of patient even in prehospital setting. This article will review the role of point-of-care ultrasonography, performed with pocket-size devices, in the management of patients presenting with acute onset of undifferentiating dyspnea, chest pain, and shock in emergency department.

The Geriatric Patient: The Ideal One for Chest Ultrasonography? A Review From the Chest Ultrasound in the Elderly Study Group (GRETA) of the Italian Society of Gerontology and Geriatrics (SIGG)

OBJECTIVES

To investigate the current evidence on the use of point-of-care chest ultrasonography in older patients and geriatric settings and present the current state of the art of chest ultrasound applications.

DESIGN

Special article based on a literature review with narrative analyses and expert clinical knowledge.

SETTING AND PARTICIPANTS

All studies performed in a geriatric setting were included. Observational and intervention studies and meta-analyses including participants aged ≥70 years were also considered, even if not specifically focused on a geriatric setting.

MEASURES

Data on participant characteristics, diagnostic accuracy of chest ultrasonography, and outcomes were collected for each considered study. Data were analyzed and discussed with a particular focus on the possible applications and advantages of chest ultrasonography in geriatric medicine, underlining the possible areas of future research.

RESULTS

We found only 5 studies on the diagnostic accuracy and prognostic relevance of chest ultrasonography in geriatrics. However, several studies performed in emergency departments, intensive care units, and internal medicine wards included a large number of participants ≥70 years old; they suggest that chest ultrasonography may represent a valid aid to the diagnostics of acute dyspnea, pneumonia, acute heart failure, pneumothorax, and pleural diseases, with an accuracy in some cases superior to standard x-rays, especially when mobility limitation is present. Diaphragm ultrasonography may also represent a valid tool to guide mechanical ventilation weaning in older patients with acute respiratory failure.

CONCLUSIONS AND IMPLICATIONS

Chest ultrasonography may represent a valid bedside diagnostic aid to the management of acute respiratory diseases in older patients. However, specific evidence is lacking for geriatric patients. Future research will need to focus on defining the reference standards and the diagnostic accuracy for older patients with frailty and multimorbidity, cost-efficacy and cost-effectiveness of the technique, its impact for clinical outcomes, and role for follow-up in the post-acute care.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

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

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

Hand-Held Ultrasound Devices Compared with High-End Ultrasound Systems: A Systematic Review

The aim of this study was to review the scientific literature available on the comparison of hand-held ultrasound devices with high-end systems for abdominal and pleural applications. PubMed, Embase, Web of Science and Cochrane were searched following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Original research describing hand-held ultrasound devices compared with high-end systems was included and assessed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2. The search was limited to articles published since 1 January 2012. A total of 2486 articles were found and screened by title and abstract. A total of 16 articles were chosen for final review. All of the included articles showed good overall agreement between hand-held and high-end ultrasound systems. Strong correlations were found when evaluating ascites, hydronephrosis, pleural cavities, in detection of abdominal aortic aneurysms and for use with obstetric and gynaecological patients. Other articles found good agreement for cholelithiasis and for determining the best site for paracentesis. QUADAS-2 analysis suggested few risks of bias and almost no concerns regarding applicability. For distinct clinical questions, hand-held devices may be a valuable supplement to physical examination. However, evidence is inadequate, and more research is needed on the abdominal and pleural use of hand-held ultrasound with more standardised comparisons, using only blinded reviewers.

Ability of non-physicians to perform and interpret lung ultrasound: A systematic review

BACKGROUND

Lung ultrasound is a useful tool in the assessment of pulmonary congestion in heart failure that is typically performed and interpreted by physicians at the point-of-care.

AIMS

To investigate the ability of nurses, students, and paramedics to accurately identify B-lines and pleural effusions for the detection of pulmonary congestion in heart failure and to examine the training necessary.

METHODS AND RESULTS

We conducted a systematic review and searched online databases for studies that investigated the ability of nurses, students, and paramedics to perform lung ultrasound and detect B-lines and pleural effusions. Of 979 studies identified, 14 met our inclusion criteria: five in nurses, eight in students, and one in paramedics. After 0-12 h of didactic training and 58-62 practice lung ultrasound examinations, nurses were able to identify B-lines and pleural effusions with a sensitivity of 79-98% and a specificity of 70-99%. In image adequacy studies, medical students with 2-9 h of training were able to acquire adequate images for B-lines and pleural effusions in 50-100%. Only one eligible study investigated paramedic-performed lung ultrasound which did not support the ability of paramedics to adequately acquire and interpret lung ultrasound images after 2 h of training.

CONCLUSIONS

Our findings suggest that nurses and students can accurately acquire and interpret lung ultrasound images after a brief training period in a majority of cases. The examination of heart failure patients with lung ultrasound by non-clinicians appears feasible and warrants further investigation.

Peer-teaching cardiac ultrasound among medical students: A real option

INTRODUCTION

Teaching cardiac ultrasound (CU) image acquisition requires hands-on practice under qualified instructors supervision. We assessed the efficacy of teaching medical students by their previously trained classmates (teaching assistants [TAs]) compared to teaching by expert trainers (cardiologists or diagnostic medical sonographers.

METHODS

Sixty-six students received 8-hour CU training: 4-hour lectures on ultrasound anatomy and imaging techniques of 6 main CU views (parasternal long [PLAV] and short axis [PSAV]; apical 4-chamber [4ch], 2-chamber [2ch], and 3-chamber [3ch]; and sub costal [SC]) followed by 4 hours of hands-on exercise in groups of ≤5 students under direct supervision of a TA (group A: 44 students) or a qualified trainer (group B: 22 students). Students' proficiency was evaluated on a 6-minute test in which they were required to demonstrate 32 predetermined anatomic landmarks spread across the 6 views and ranked on a 0-100 scale according to a predetermined key.

RESULTS

The 6-minute test final grade displayed superiority of group A over group B (54±17 vs. 39±21, respectively [p = 0.001]). This trend was continuous across all 6 main views: PLAV (69±18 vs. 54±23, respectively), PSAV (65±33 vs. 41±32, respectively), 4ch (57±19 vs. 43±26, respectively), 2ch (37±29 vs. 33±27, respectively), 3ch (48±23 vs. 35±25, respectively), and SC (36±27 vs. 24±28, respectively).

CONCLUSIONS

Teaching medical students CU imaging acquisition by qualified classmates is feasible. Moreover, students instructors were superior to senior instructors when comparing their students' capabilities in a practical test. Replacing experienced instructors with TAs could help medical schools teach ultrasound techniques with minimal dependence on highly qualified trainers.

Assessing how emergency and trauma ultrasonography is taught to medical students

Objective

To evaluate a method aimed at teaching ultrasound techniques to medical students in emergency settings.

Methods

A prospective study conducted with 66 sixth-year undergraduate medical students. Students participated in theory and practicing sessions with a 5-hour load; knowledge acquisition was assessed through pre- and post-course and 90-day tests. A questionnaire were distributed to the students after course completion for theoretical and practical knowledge assessment.

Results

Average pre-test grade in theoretical content evaluation was 4.9, compared to 7.6 right after course completion, and 5.9 within 90 days (p<0.001). Questions addressing technical aspects and image acquisition were mostly answered correctly; in contrast, questions related to clinical management of patients tended to be answered incorrectly. In practical evaluation, 54 students (81.8%) were able to correctly interpret images.

Conclusion

Ultrasound applicability and image acquisition techniques can be taught to medical students in emergency settings. However, teaching should be focused on technical aspects rather than clinical management of patients.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Enhancement of Musculoskeletal Radiology Resident Education with the Use of an Individual Smart Portable Ultrasound Device (iSPUD)

RATIONALE AND OBJECTIVES

Many medical specialties have incorporated portable ultrasound into their educational curriculum. Our objective was to determine the utility of an individual smart portable ultrasound device (iSPUD) as an educational tool in resident and fellowship Musculoskeletal Radiology training.

MATERIALS AND METHODS

After Institutional Review Board approval, volunteer radiology trainees were instructed to use the iSPUD (Philips Lumify ultrasound probe and Samsung Galaxy Tab S2 8 inch tablet), asked to identify 10 wrist structures with the iSPUD and completed a Likert scale-based, pretest survey. Trainees were then given the iSPUD for 3 days of independent scanning practice. Afterward, trainees were asked to identify the same 10 wrist structures with the iSPUD and to complete a Likert scale-based, post-test survey.

RESULTS

Twenty trainees volunteered to participate. Trainee performance on the 10-wrist structure identification test with the iSPUD resulted in a pretest mean number correct of 2.5 ± 2.16 and a post-test mean number correct of 9.85 ± 0.37 (p < 0.001). On the pretest survey, 68.42% (13/20) had never performed and 42.11% (8/20) had never interpreted a musculoskeletal ultrasound. On the post-test survey, 18/20 (94.74%) strongly agreed that access to an iSPUD would improve their ability to perform musculoskeletal ultrasound, improve ultrasound-guided interventional skills, and help them become better Radiologists.

CONCLUSION

The use of an iSPUD as a tool in Musculoskeletal Radiology resident and fellow education can improve clinical ultrasound skills, build trainee technical confidence during diagnostic ultrasound procedures, and help trainees achieve their goal of becoming a competent Radiologist.

Ultrasonography in Undergraduate Medical Education: A Systematic Review

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pocket-size ultrasound device in cholelithiasis: diagnostic accuracy and efficacy of short-term training

Pocket-size ultrasound devices (PSUD) are now widely available becoming a useful tool for diagnostic and therapeutic purposes. We aim to investigate the accuracy of PSUD in diagnosing cholelithiasis as compared to traditional ultrasonography. Moreover, we tested the reliability of PSUD when performed by inexperienced internal medicine residents after a short-term training. We consecutively enrolled inpatients and outpatients referred to undergo abdominal ultrasonography for signs or symptoms of gallbladder diseases in two different hospitals. Every patient underwent two independent examinations with PSUD by both expert (EXP_PSUD) and nonexpert operators (N-EXP_PSUD), and a conventional examination with traditional abdominal ultrasound (AUS). Every naive operator underwent a short-term training with a 2-h theoretical lesson, and a practical training focused on gallbladder under expert operator supervision. Overall, 146 patients were consecutively enrolled. Considering conventional AUS as the reference standard, sensitivity and specificity of EXP_PSUD were, respectively, 93.75 and 100%. Sensitivity and specificity of N-EXP_PSUD were, respectively, 75 and 91.25%. Nevertheless, when considering outpatients, PSUD has a high diagnostic accuracy even when performed by N-EXP_PSUD with sensitivity of 93% and specificity of 88%. PSUD is a reliable tool for the diagnosis of cholelithiasis when used by expert operators potentially reducing the need for further diagnostic tests. It can even be successfully used by non-expert operators in outpatients setting after a short focussed training.

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

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

Usefulness of inferior vena cava ultrasonography in outpatients with chronic heart failure

BACKGROUND

Inferior vena cava (IVC) ultrasonography has been used for the diagnosis and prognosis of acute heart failure (HF). Its usefulness in chronic HF is less known.

HYPOTHESIS

IVC ultrasonography is a useful tool in the care of patients with chronic HF.

METHODS

For this prospective cohort study, 95 patients with chronic HF were included consecutively as they attended scheduled medical visits. Ultrasound was done with a 5-MHz convex probe device, calculating IVC collapse index (IVCCI). Follow-up time was 1 year. Outcome events were worsening HF, hospital admission for HF, HF mortality, and all-cause mortality.

RESULTS

Worsening HF occurred in 70.9% of patients with IVCCI <30% and 39.1% of patients with IVCCI >50%, with a hazard ratio (HR) of 2.8 (95% CI: 1.3-6.2) adjusted by multivariable analysis. Regarding hospitalization, 45.3% of patients with IVCCI <30% required admission, compared with 5.9% of patients with IVCCI >50%; the adjusted HR was 13.9 (95% CI: 1.7-113.0). Mortality was higher in the IVCCI <30% group, with 25.7% all-cause mortality and 18.6% HF mortality, whereas in the IVCCI >50% group these values were 13% and 4.7%, respectively. However, these differences did not reach statistical significance. ROC analysis was performed and the AUC for IVCCI was not higher than that for NTproBNP for any of the outcomes studied.

CONCLUSIONS

IVC ultrasonography is a useful tool in follow-up of patients with chronic HF, allowing identification of patients at high risk of worsening and hospitalization. However, its usefulness is not higher than that of NTproBNP.

Ultrasound Curricula in Undergraduate Medical Education: A Scoping Review

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

The Role of Affordable, Point-of-Care Technologies for Cancer Care in Low- and Middle-Income Countries: A Review and Commentary

As the burden of non-communicable diseases such as cancer continues to rise in low- and middle-income countries (LMICs), it is essential to identify and invest in promising solutions for cancer control and treatment. Point-of-care technologies (POCTs) have played critical roles in curbing infectious disease epidemics in both high- and low-income settings, and their successes can serve as a model for transforming cancer care in LMICs, where access to traditional clinical resources is often limited. The versatility, cost-effectiveness, and simplicity of POCTs warrant attention for their potential to revolutionize cancer detection, diagnosis, and treatment. This paper reviews the landscape of affordable POCTs for cancer care in LMICs with a focus on imaging tools, in vitro diagnostics, and treatment technologies and aspires to encourage innovation and further investment in this space.

Hand-held Ultrasound Scanners in Medical Education: A Systematic Review

Background

Ultrasound imaging devices are becoming popular in clinical and teaching settings, but there is no systematic information on their use in medical education. We conducted a systematic review of hand-held ultrasound (HHU) devices in undergraduate medical education to delineate their role, significance, and limitations.

Methods

We searched Cochrane, PubMed, Embase, and Medline using the strategy: [(Hand-held OR Portable OR Pocket OR "Point of Care Systems") AND Ultrasound] AND (Education OR Training OR Undergraduate OR "Medical Students" OR "Medical School"). We retained 12 articles focusing on undergraduate medical education. We summarised the patterns of HHU use, pooled and estimated sensitivity, and specificity of HHU for detection of left ventricular dysfunction.

Results

Features reported were heterogeneous: training time (1-25 hours), number of students involved (1-an entire cohort), number of subjects scanned (27-211), and type of learning (self-directed vs. traditional lectures + hands-on sessions). Most studies reported cardiac HHU examinations, but other anatomical areas were examined, e.g. abdomen and thyroid. Pooled sensitivity 0.88 [95% confidence interval (CI) 0.83-0.92] and specificity 0.86 (95% CI 0.81-0.90) were high for the detection of left ventricular systolic dysfunction by students.

Conclusion

Data on HHU devices in medical education are scarce and incomplete, but following training students can achieve high diagnostic accuracy, albeit in a limited number of (mainly cardiac) pathologies. There is no consensus on protocols best-suited to the educational needs of medical students, nor data on long-term impact, decay in proficiency or on the financial implications of deploying HHU in this setting.

Educational value of pocket-sized ultrasound devices to improve understanding of ultrasound examination principles and sonographic anatomy for medical student

Purpose

Medical students must understand the principles of ultrasonography (US), because US examinations are an important component of patient care in clinical practice. Pocket-sized ultrasound devices have the benefits of accessibility and ease of use. The primary objective of the present study was to evaluate the educational value of these devices in terms of improving medical student interest and understanding of US and sonographic anatomy.

Methods

We added a US training program comprised of a self-study learning module and a hands-on training session to a two-week block curriculum of medical imaging for first year medical students (n = 40). Multiple pocket-sized US devices were used on a small-group basis during a single afternoon. Students were asked to complete a questionnaire before and after the US training session; these two questionnaires contained 6 and 10 questions, respectively, which were rated by students using a five-point Likert scale. In addition, understanding of sonographic anatomy was tested before and after the training program.

Results

Forty students completed the two questionnaires and the anatomy-related tests. Students found the program educationally valuable (4.37 ± 0.54 of 5) and reported that US practice was useful for improving their understanding of the principles of US examinations (4.23 ± 0.66 of 5) and sonographic anatomy (4.40 ± 0.55 of 5). Overall confidence at performing US examinations and understanding of sonographic anatomy were significantly increased after US training (increased overall confidence score, 1.87 ± 0.91 and improvement in sonographic anatomy score, 6.55 ± 1.55, p values < 0.001).

Conclusion

US training using pocket-sized ultrasound devices was found to be educationally valuable for medical students in terms of improving understanding of US principles and familiarizing students with sonographic anatomy.