JOURNAL CLUB: Redefining the Radiology Curriculum in Medical School: Vertical Integration and Global Accessibility.

OBJECTIVE: Radiology interconnects medical disciplines given that a working understanding of imaging is essential to clinicians of every specialty. Using online education, we created a globally accessible, web-based undergraduate medical radiology curriculum modeled after the National Medical Student Curriculum in Radiology program of the Alliance of Medical Student Educators in Radiology. SUBJECTS AND METHODS: Seventy-four radiology faculty-mentored video modules were produced, 50 of which were integrated into the 1st-year anatomy course. We administered tests to medical students before and after students saw the videos to assess the effectiveness of the modules. We surveyed students on their interests in pursuing radiology as a career before and after participating in this curriculum. RESULTS: On the preexamination questions, the mean score was 58.0%, which increased to 83.6% on the pair-matched imaging-related questions on the actual examination. Before participating in the new curriculum, 88% of students did not express an interest in radiology, and 9% were undecided about radiology as a future career. There was an increase in students who reported that they would definitely or most likely pursue a career in radiology (7%) after they had viewed the lectures. CONCLUSION: Radiology education is now available to a greater number of multidisciplinary learners worldwide. This project produced a comprehensive, globally accessible radiology curriculum in a self-paced, flexible learning format for new generations of physicians.

Learner Improvement From a Simulation-Enhanced Ultrasonography Curriculum for First-Year Medical Students.

OBJECTIVES: We describe a simulation-enhanced ultrasonography (US) curriculum for first-year medical students as part of a comprehensive curricular integration of US skills. Our goal was to assess student knowledge and performance of US and determine their satisfaction with the integrated curriculum. METHODS: A committee of basic science, clinical, and interinstitutional faculty developed 7 educational US modules integrated into existing anatomy and physiology courses. First-year students in years 2012 through 2014 were administered a demographic survey and a knowledge-based pretest at the outset of the US program and assessed with a posttest, satisfaction survey, and their image acquisition abilities in an objective structured clinical examination with standardized patients on completion of the program. RESULTS: Data from 390 students showed a significant increase in knowledge from the pretest to the posttest [t(389) = 58.027; P < .0001]. Students with higher spatial abilities or some previous US experience performed better on the posttest. The objective structured clinical examination results showed that about 83% of the students were able to capture acceptable or marginally acceptable images. Ninety-five percent of students indicated that the US educational experience enhanced their medical education. CONCLUSIONS: Initial results show that we were able to successfully develop, implement, and evaluate performance of first-year medical students on their fundamental knowledge and performance of basic US using a model that emphasized hands-on simulation-enhanced training. Furthermore, most students found the experience to be a beneficial component of their education and indicated a desire for more US training in the medical curricula.

Shooting with sound: optimizing an affordable ballistic gelatin recipe in a graded ultrasound phantom education program.

OBJECTIVES: The goal of this study was to investigate the durability and longevity of gelatin formulas for the production of staged ultrasound phantoms for education. METHODS: Gelatin phantoms were prepared from Knox gelatin (Kraft Foods, Northfield, IL) and a standard 10%-by-mass ordinance gelatin solution. Phantoms were durability tested by compressing to a 2-cm depth until cracking was visible. Additionally, 16 containers with varying combinations of phenol, container type, and storage location were tested for longevity against desiccation and molding. Once formulation was determined, 4 stages of phantoms from novice to clinically relevant were poured, and clinicians with ultrasound training ranked them on a 7-point Likert scale based on task difficulty, phantom suitability, and fidelity. RESULTS: On durability testing, the ballistic gelatin outperformed the Knox gelatin by more than 200 compressions. On longevity testing, gelatin with a 0.5% phenol concentration stored with a lid and refrigeration lasted longest, whereas containers without a lid had desiccation within 1 month, and those without phenol became moldy within 6 weeks. Ballistic gelatin was more expensive when buying in small quantities but was 7.4% less expensive when buying in bulk. The staged phantoms were deemed suitable for training, but clinicians did not consistently rank the phantoms in the intended order of 1 to 4 (44%). CONCLUSIONS: Refrigerated and sealed ballistic gelatin with phenol was a cost-effective method for creating in-house staged ultrasound phantoms suitable for large-scale ultrasound educational training needs. Clinician ranking of phantoms may be influenced by current training methods that favor biological tissue scanning as easier.

Endoscopic and three-dimensional radiographic imaging of the pterygopalatine and infratemporal fossae: improving surgical landmarks.

OBJECTIVES: We sought to define the surgical endoscopic anatomy of the pterygopalatine fossa (PPF) and infratemporal fossa (ITF) through endoscopic cadaver dissections and radiographic imaging analysis. METHODS: Eleven fresh cadavers were submitted to computed tomography (CT) and endoscopic dissection. We used 3-dimensional (3-D) CT reconstruction and endoscopic video imaging for analysis of the bony and soft tissue landmarks. One fixed cadaver head was grossly dissected to confirm the endoscopic anatomic findings. RESULTS: The CT and 3-D CT reconstruction measurements between the pterygoid canal and the foramen rotundum averaged 4.36 mm and 5.09 mm, respectively. An osseous ridge (pterygoid ridge) was identified on the anterior face of the pterygoid process as a novel identifiable anatomic landmark in all of the specimens. The average length of the pterygoid ridge on 3-D CT reconstruction was 7.84 mm. The internal maxillary artery entered the PPF posteromedial to the temporalis tendon and anterolateral to the lateral pterygoid muscle. The average distance from the anterior edge of the lateral pterygoid plate to the foramen ovale was 17.1 mm. CONCLUSIONS: The pterygoid ridge is a novel and reliable osseous landmark that could assist surgeons during endoscopic surgery on the PPF and ITF. The neurovascular and muscular anatomic relationships were characterized for both the PPF and the ITF.

E-FAST Ultrasound Training Curriculum for Prehospital Emergency Medical Service (EMS) Clinicians.

Audience and Type of Curriculum: Audience and type of curriculum: This hybrid, asynchronous curriculum is designed for prehospital clinician colleagues, including but not limited to emergency medical technicians (EMT), advanced EMTs (AEMT), EMT-paramedics (EMT-P), critical care EMT-Ps (CCEMTP), critical care transport nurses (CCTN), and certified flight registered nurses (CFRN) to learn and practice ultrasound fundamentals in the setting of a standardized extended focused assessment with sonography in trauma (E-FAST) exam. Length of Curriculum: Over a five-month curriculum, learners will perform a pre-test, review online module lectures, attend an ultrasound scanning workshop, and perform post-test examinations. Introduction: The extended-focused assessment with sonography in trauma (E-FAST) exam can identify intrathoracic and intraabdominal free fluid, as well as pneumothoraces. The E-FAST ultrasound exam has previously been taught to clinicians of various backgrounds in healthcare including emergency medical service (EMS). However, an open-access, systemized curriculum for teaching E-FAST exams to EMS clinicians has not been published. Educational Goals: By the end of these training activities, prehospital EMS learners will be able to demonstrate foundational ultrasound skills in scanning, interpretation, and artifact recognition by identifying pertinent organs and anatomically relevant structures for an E-FAST examination. Learners will differentiate between normal and pathologic E-FAST ultrasound images by identifying the presence of free fluid and lung sliding. Learners will also explain the clinical significance and application of detecting free fluid during an E-FAST scan. Educational Methods: The educational strategies used in this curriculum include a hybrid, asynchronous curriculum encompassing 2.5 hours of lectures derived from online learning modules and in-person review. In addition, learners will attend 2 hours of hands-on proctored ultrasound scanning practicing E-FAST examinations. Research Methods: An online 13-question pre-test was administered prior to the study. An online post-test and in-person scanning OSCEs were administered at least eight weeks after their scheduled workshop consisting of an online 13-question multiple-choice post-test, a confidence survey, and a hands-on E-FAST Objectively Structured Clinical Exam (OSCE) session. A non-parametric Wilcoxon signed-rank test was performed between each pre-test and post-test metric to examine the statistical differences of paired data. Results: Post-test scores demonstrated statistically significant improvement in both image interpretation exams and ultrasound self-efficacy from the pre-test. The mean pre-test and post-test scores were 55.46% (7.21 ± 1.99) and 84.23% (10.89 ± 1.59) correct out of 13 questions, respectively (p < 0.0001). Participants surveyed an increase in self-efficacy reflected by a Likert scale for ultrasound usage and image interpretation (p < 0.005). The average post-test OSCE E-FAST exam score was 37.89 ± 2.76 out of 42 points (90.21%). Discussion: This 4.5-hour hybrid asynchronous model demonstrates an effective curriculum for teaching E-FAST ultrasound to prehospital clinicians. Topics: Ultrasound, sonography, prehospital clinicians, emergency medical services (EMS), paramedics, critical care transport, extended focused assessment with sonography in trauma (E-FAST), free fluid, sliding lung sign, elective, pain.

Use of ultrasound in needle placement in intercostal muscles: a method for increased accuracy in cadavers.

OBJECTIVE: To validate the use of ultrasound technology for the positioning and leveling of intercostal needle placement. DESIGN: Double-blinded experimental study. SETTING: An anatomy laboratory. PARTICIPANTS: Two board-certified physical medicine and rehabilitation physicians, 2 first-year medical students, 1 anatomist, and 8 cadavers. INTERVENTIONS: Four unfixed cadavers were used for unguided needle placement, and 3 unfixed and 1 partially fixed cadavers were used for ultrasound-guided needle placement. Ultrasound-guided needle placement was then confirmed with computed tomography and blind dissection. MAIN OUTCOME MEASURE: The accuracy of needle placement. RESULTS: The unguided study showed needle placement in an intercostal muscle 89% of the time, but in only 15.4% of the time was the correct level sampled. In the 96 needle placements completed, the unguided needle placements had an accuracy of 8.3%, while ultrasound-guided needle placements had an accuracy of 93% (χ(2) with P<.005). CONCLUSIONS: Ultrasound guidance dramatically increases needle placement accuracy for intercostal nerve blocks and intercostal muscle sampling for electromyography.

Evaluation of a point-of-care ultrasound curriculum and ocular phantom in residency training.

Specialized training in ocular ultrasound is not a focus for most emergency medicine residencies, despite the fact that it allows physicians to quickly and accurately identify ocular pathology and prioritize emergency ophthalmological consultations. Therefore, we tested the value of utilizing normal and pathologic ocular ultrasound phantoms as a training tool for residents. Twenty emergency medicine residents were given a pre-test including written and practical skills diagnosis of ocular phantom pathologies, a short video on common ocular pathologies, practice time with the phantoms and a post-test including written and scanning components. Residents were then asked to complete an overall evaluation of the learning activity. After didactic and hands-on training with phantoms, residents demonstrated a significant increase in knowledge, skills and preparedness for diagnosing real patients with ocular pathologies. Overall, the phantoms allowed residents an unrestricted opportunity to practice and refine their technique. This study provided a framework for teaching emergency medicine residents the basics of ocular US through a brief didactic and practical intervention using novel ocular pathology US phantoms. Our curriculum resulted in both objective and subjective improvement in residents' performance and understanding of ocular US.

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.

Computed tomographic characterization of mini-implant placement pattern and maximum anchorage force in human cadavers.

INTRODUCTION: The purpose of this investigation was to characterize the placement pattern and factors influencing the primary stability of mini-implants in human cadavers. The factors studied were mini-implant length, placement depth, bone density, and bone type. METHODS: Sixty standard mini-implants (6, 8, and 10 mm; 20 of each size) were placed into the maxillas and mandibles of 5 fresh human cadavers. Computed tomography imaging was used to measure the placement pattern, bone density, and thickness surrounding each device. The mini-implants were subsequently subjected to increasing tensile forces (pull-out force) until failure, and the maximum mechanical anchorage force of each was recorded with a dynamometer. A statistical model was realized by using MATLAB version 7.5.0 with Statistics Toolbox 7 (MathWorks, Natick, Mass) including the maximum anchorage force, mini-implant length, bone type, placement depth, and density surrounding each section of the mini-implant. RESULTS: Placement depth was strongly dependent on mini-implant length: 15% of the 6-mm implants failed to anchor their parallel sections into cortical bone, but 95% of the 10-mm mini-implant parallel sections penetrated beyond the buccal cortical bone; all 20 tips of the 6-mm mini-implants (100%) reached cancellous bone, whereas 75% of the 10-mm implants penetrated both cortical plates, reaching the lingual cortical bone. Longer mini-implants were associated with greater incidences of sinus and bicortical perforations. The correlation coefficients between the initial maximum mechanical anchorage force and the studied factors were as follows: bone density and placement depth combined (r = 0.65, P <0.001), mini-implant length (r = 0.45, P = 0.004), bone density (r = 0.42, P = 0.007), and placement depth (r = 0.29, P = 0.06). CONCLUSIONS: During mini-implant length selection, the clinician should consider the important trade-off between anchorage and risk of placement complications or damage to the tissues. Longer mini-implants enable more anchorage; however, they are associated with a higher risk of damage to neighboring structures. Placement depth and bone density at the site of mini-implant placement are the best predictors of primary stability.

The Evolution of Ultrasound in Medicine: A Case Report of Point-of-care Ultrasound in the Self-diagnosis of Acute Appendicitis.

INTRODUCTION: Point-of-care ultrasound (POCUS) education during medical school develops physicians who are properly prepared for the next generation of medicine. The authors present the case of a first-year medical student who self-diagnosed appendicitis using POCUS. CASE REPORT: A 25-year-old, first-year medical student presented to the emergency department with lower abdominal pain. What seemed like a straightforward appendicitis presentation came with a twist; the student brought self-performed ultrasound imaging of his appendix. CONCLUSION: The student's ultrasound skill set reflects favorably on the rapid evolution of ultrasound teaching in medical education.

The accuracy of needle placement in extremity muscles: a blinded study.

The authors evaluated the accuracy of EMG needle placement using the methods of two common EMG reference atlases. Fourteen cadavers were used to conduct needle placement by two board-certified electromyographers with a blinded anatomist completing the needle dissection. The two methods were found to be similarly accurate. Certain muscles were particularly difficult to sample by both methods. Certain muscles were uniquely difficult to sample by one or the other method. Many inaccuracies were not significant in that needle placement occurred in muscles of similar root and nerve innervation. Generally, lower extremity, superficial, and larger muscles were easier to sample than smaller or deeper muscles. Typical diagnostic difficulties are discussed with means to improve needle sampling accuracy with present technology and future study. Muscle needle placement, as would be conducted for electromyography, shows differential accuracy in needle placement depending on muscle location, size, depth, and local anatomy. Understanding these limitations allows the electromyographer to recognize patterns of inaccuracy and make corrections for a more accurate diagnosis.

Radiology's Emerging Role in 3-D Printing Applications in Health Care.

From its inception as a tool for prototype development in the early 1980s, three-dimensional (3-D) printing has made inroads into almost every sector of industry, including health care. Medical applications range from extra- and intracorporeal orthopedic devices to complex, temporal reconstructions of patient-specific anatomy that allow operative planning and education. In the contemporary climate of personalized medicine, the utility of tangible 3-D models extrapolated directly from patient imaging data seems boundless. The purpose of this review is to briefly outline the development of 3-D printing, discuss its applications across the many medical and surgical specialties, and attempt to address obstacles and opportunities facing radiology as this technology continues to be integrated into patient care.

Diaphragm needle placement techniques evaluated in cadaveric specimens.

OBJECTIVE: To evaluate the safest and most accurate method of diaphragm needle placement for electromyography. DESIGN: Single blinded study. SETTING: University anatomy laboratory. CADAVERS: Five cadavers. INTERVENTIONS: Needle placement in the diaphragm by an American Board of Electrodiagnostic Medicine physician, blinded dissection by a doctoral candidate anatomist. MAIN OUTCOME MEASURES: Accurate needle placement in the diaphragm, proximity or penetration of organs, vessels, or nerves, defined as cautions (proximity) and dangers (penetration). RESULTS: The anterior axillary approach was most accurate at the above-the-seventh and eighth-rib locations. The risk of dangers of needle placement in the diaphragm was greater on the right than left side. CONCLUSIONS: Needle placement in the diaphragm is safe and most accurate at the anterior axillary line superior to the eighth rib. If the side of needle placement does not matter for the study being done, the left side should be chosen because it leads to a lower risk of danger to the patient.

Cadaver evaluation of EMG needle insertion techniques used to target muscles of the thorax.

STUDY DESIGN: Measure the accuracy of needle insertion in thoracic muscles of human cadavers. OBJECTIVES: Evaluate the effectiveness of known EMG techniques for sampling thoracic innervated muscles. SUMMARY OF BACKGROUND DATA: The evaluation of thoracic radiculopathies requires accurate electrodiagnostic techniques for evaluating the thoracic myotomes. METHODS: An American Board of Electrodiagnostic Medicine certified physician placed needles into pertinent muscles of the thorax and an anatomist serving as a blinded dissector recorded the path and accuracy of needle. RESULTS: Needle examination of thoracic muscles was as accurate as limb needle examination. No notable risks are noted in multifidus sampling. However, in the cadaver, some risks were noted in association with placements in the intercostal muscles. The target muscle was reliably sampled, but the rib or vertebral level was difficult to landmark in the cadaver. CONCLUSIONS: Needle examination of the thoracic multifidus and intercostals is reliable, although further confirmation is needed to accurately verify the appropriate vertebral or rib level being sampled.

Cadaveric study of methods for subscapularis muscle needle insertion.

OBJECTIVE: To evaluate the accuracy for three methods for needle insertion into the subscapularis muscle for electromyography, botulinum toxin injection, and phenol nerve block. DESIGN: Three needle insertion methods were evaluated by cadaver injection by an American Board of Electrodiagnostic Medicine certified physician. An anatomist, blinded to the method used, served as the dissector to evaluate the effectiveness of the methods tested. RESULTS: A posterior axillary approach was most effective for needle insertion into the subscapular muscle compared with a medial scapular or a superior scapular approach. No approach was ideal for subscapular nerve injection. CONCLUSIONS: A posterior axillary approach is best for needle insertion of the subscapularis muscle for electromyography or botulinum toxin injection. Subscapular nerve injection is difficult from all of the three approaches tested.

The accuracy of needle placement in lower-limb muscles: a blinded study.

OBJECTIVE: To assess the accuracy of common anatomic guides for electromyographic needle placement in muscles. DESIGN: Blinded study. The dissector identified different needle placements by a random number attached to a wire in the insertion site. SETTING: A university anatomy laboratory. CADAVERS: Ten cadaver lower limbs. INTERVENTIONS: By using techniques published in texts by Gieringer and Delagi and Perotto, clinical electromyographers palpated and measured appropriate locations for needle placement. A thin wire was inserted through the needle into 36 different muscles in 10 cadavers, resulting in 263 targeted muscles. An anatomist blinded to intended location dissected and recorded muscles and other tissues that the wire pierced or passed near. MAIN OUTCOME MEASURES: Targeted muscle penetration, final resting place of the wire tip, and proximity to vital structures. RESULTS: Fifty-seven percent of insertions penetrated the intended muscle. The wire tip was in the intended muscle 45% of the time. Seventeen percent of insertions penetrated or passed within 5mm of an important structure, including nerve (9.1%), tendon (3.0%), named artery (2.7%), vein (2.7%), or joint (0.8%). Specific muscle accuracy was highly variable, from 0% for 12 tries in various deep hip muscles to 100% of 10 tries in the vastus medialis. CONCLUSION: The accuracy of blind needle placement varied according to muscle. With the blind insertion technique, more accurate and safe needle placement strategies can be developed.