Implementation of a Flipped Classroom for Nuclear Medicine Physician CME.

INTRODUCTION: Increasingly, emerging technologies are expanding instructional possibilities, with new methods being adopted to improve knowledge acquisition and retention. Within medical education, many new techniques have been employed in the undergraduate setting, with less utilization thus far in the continuing medical education (CME) sphere. This paper discusses the use of a new method for CME-the "flipped classroom," widely used in undergraduate medical education. This method engages learners by providing content before the live ("in class") session that aids in preparation and fosters in-class engagement. METHODS: A flipped classroom method was employed using an online image-rich case-based module and quiz prior to a live CME session at a national nuclear medicine meeting. The preparatory material provided a springboard for in-depth discussion at the live session-a case-based activity utilizing audience response technology. Study participants completed a survey regarding their initial experience with this new instructional method. In addition, focus group interviews were conducted with session attendees who had or had not completed the presession material; transcripts were qualitatively analyzed. RESULTS: Quantitative survey data (completed by two-thirds of the session attendees) suggested that the flipped method was highly valuable and met attendee educational objectives. Analysis of focus group data yielded six themes broadly related to two categories-benefits of the flipped method for CME and programmatic considerations for successfully implementing the flipped method in CME. DISCUSSION: Data from this study have proven encouraging and support further investigations around the incorporation of this innovative teaching method into CME for nuclear imaging specialists.

Use of Marrow Scintigraphy to Confirm Compensatory Marrow Rather than Active Myeloma.

We present the case of a 40-year-old male with multiple myeloma for whom bone marrow scintigraphy was utilized to help differentiate between active bony myelomatous disease versus treated lesions with compensatory marrow uptake. This case demonstrates technetium (Tc-99m) sulfur colloid imaging as an inexpensive technique to quickly distinguish between active focal bone disease and reactive marrow.

Reducing perceived pain levels during nonbreast lymphoscintigraphy.

PURPOSE: The aim of this study was to quantify the reduction of perceived pain levels during lymphoscintigraphy for melanoma by altering the pH of the Tc-sulfur colloid to near the physiologic value of 7.40. PATIENTS AND METHODS: This is an institutional review board- and Food and Drug Administration-approved randomized, double-blinded, prospective crossover trial, registered with clinicaltrials.org. Before beginning the procedure and after signing informed consent, 60 serial enrollees presenting for sentinel lymph node imaging of melanoma of the thorax and appendicular structures completed a questionnaire addressing background information, administered by a research support nurse.An investigator (N.H.) prepared the injections to be used and labeled them such that no one else could discover which injections contained standard-of-care solution and which contained the pH-altered solution (buffered to near pH 7.40 using sodium bicarbonate).After each injection, the enrollee was asked by a research support nurse to quantify the pain of each injection using a scale of 0 to 10. The injection site location (head, thorax, appendicular structures, and other) was also recorded. RESULTS: Sixty subjects were enrolled in the study, of which 57 had complete data. On average, there was a significant mean (SD) decrease of 1.42 (2.17) points (95% confidence interval, 0.85-2.00) on a pain scale of 0 to 10 when the buffered injections were used as compared with the standard-of-care injections (P < 0.0001). Ordering of injections did not significantly affect perceived pain scores. CONCLUSIONS: The use of sodium bicarbonate to buffer the pH of Tc-sulfur colloid to near the physiologic value of 7.40 significantly reduced perceived pain levels during nonbreast lymphoscintigraphy.

Localization of cardiac sodium channels in caveolin-rich membrane domains: regulation of sodium current amplitude.

This study demonstrates that caveolae, omega-shaped membrane invaginations, are involved in cardiac sodium channel regulation by a mechanism involving the alpha subunit of the stimulatory heterotrimeric G-protein, Galpha(s), via stimulation of the cell surface beta-adrenergic receptor. Stimulation of beta-adrenergic receptors with 10 micromol/L isoproterenol in the presence of a protein kinase A inhibitor increased the whole-cell sodium current by a "direct" cAMP-independent G-protein mechanism. The addition of antibodies against caveolin-3 to the cell's cytoplasm via the pipette solution abrogated this direct G protein-induced increase in sodium current, whereas antibodies to caveolin-1 or caveolin-2 did not. Voltage-gated sodium channel proteins were found to associate with caveolin-rich membranes obtained by detergent-free buoyant density separation. The purity of the caveolar membrane fraction was verified by Western blot analyses, which indicated that endoplasmic/sarcoplasmic reticulum, endosomal compartments, Golgi apparatus, clathrin-coated vesicles, and sarcolemmal membranes were excluded from the caveolin-rich membrane fraction. Additionally, the sodium channel was found to colocalize with caveolar membranes by immunoprecipitation, indirect immunofluorescence, and immunogold transmission electron microscopy. These results suggest that stimulation of beta-adrenergic receptors, and thereby Galpha(s), promotes the presentation of cardiac sodium channels associated with caveolar membranes to the sarcolemma.