Yogic agnisara increases blood flow in the superior mesenteric artery.

OBJECTIVES: Medieval yoga texts claim that a special exercise of the muscles of the anterior abdominal wall, called agnisara, improves digestive function. Main objective of the study was to demonstrate change in the blood flow through superior mesenteric artery (if any) after performance of agnisara. METHODS: Ultrasound examination of the linear and volumetric indicators of blood flow in the superior mesenteric artery (SMA) before and after performing the agnisara yoga exercise 100 times was carried out in 12 healthy volunteers of both sexes (8 of them women). RESULTS: A significant increase in the diameter of the SMA, peak systolic and diastolic velocities, and blood flow in the superior mesenteric artery after performing the agnisara exercise 100 times was found, which contrasts with the established data on a decrease in splanchnic blood flow in humans in response to normal physical activity. CONCLUSION: Properly performed agnisara increases blood flow to the splanchnic region, registered by the SMA, which should contribute to adequate blood supply to the gastrointestinal tract for successful performance of digestive function.

Language of transducer manipulation 2.0: continuing to codify terms for effective teaching.

OBJECTIVES: Accurate communication is an integral component of ultrasound education. In light of the recent global pandemic, this has become even more crucial as many have moved to virtual education out of necessity. Several studies and publications have sought to establish common terminology for cardinal ultrasound probe motions. To date, no studies have been performed to determine which of these terms have been adopted by the ultrasound community at large. METHODS: A survey was developed which asked respondents to describe videos of six common probe motions in addition to providing basic demographic and training data. The survey was disseminated electronically across various academic listservs and open access resources. RESULTS: Data were collected over a 6-week period and yielded 418 unique responses. Responses demonstrated significant variation in terminology related to all 6 cardinal probe motions. While some degree of difference in response can be accounted for by discipline of training, inter-group variation still exists in terminology to describe common probe motions. Of the survey respondents, 57.5% felt that inconsistent probe motion terminology made teaching ultrasound more difficult. CONCLUSIONS: The results demonstrate that despite efforts to codify probe motions, variation still exists between ultrasound practitioners and educators in the description of cardinal probe motions. This lack of consensus can contribute to challenges in both virtual and in-person ultrasound education.

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

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

Efficacy of an Integrated Hands-On Thyroid Ultrasound Session for Medical Student Education.

As ultrasound has gained popularity with improving technology and ease-of-use, a push has been made to integrate ultrasound into the medical school curriculum. Many institutions are reporting one- to four-year integrated ultrasound curricula to augment anatomy and pathophysiology teaching. Our goal was to integrate a thyroid ultrasound scanning session into the endocrinology block of our institution's medical school curriculum to enhance medical student understanding of thyroid anatomy and pathophysiology. We conducted a prospective, single-center cohort (pre-experimental) study to evaluate student performance and knowledge acquisition using a pretest-posttest design. These multimodal sessions, consisting of a didactic, hands-on scanning sessions, and knowledge integration tests, covered ultrasound technique and thyroid evaluation and advanced to diagnosing an abnormal thyroid and working up a thyroid nodule. There were 26 to 27 second-year medical students per session who rotated between three stations proctored by credentialled physicians. Students participated in hands-on scanning of patients with or without thyroid pathology at each station. Out of the 209 students who participated in the ultrasound sessions, 114 (54.5%) consented to participate in the research project and completed both the pretest and posttest. Test data from the 114 students showed a mean pretest score of 57.5% ± 14.6% and the mean posttest score of 73.9% ± 17.4%. They had a 16.5% ± 19.6% (p < 0.001) increase in score between the two tests. Our study demonstrates that a multimodal thyroid ultrasound scanning session is an effective tool to augment the medical school endocrinology curriculum and to improve students' knowledge of thyroid anatomy, pathophysiology, and diagnostic workup of thyroid nodules.

Protocol Failure Detection: The Conflation of Acute Respiratory Distress Syndrome, SARS-CoV-2 Pneumonia and Respiratory Dysfunction.

In medicine, protocols are applied to assure the provision of the treatment with the greatest probability of success. However, the development of protocols is based on the determination of the best intervention for the group. If the group is heterogeneous, there will always be a subset of patients for which the protocol will fail. Furthermore, over time, heterogeneity of the group may not be stable, so the percentage of patients for which a given protocol may fail may change depending on the dynamic patient mix in the group. This was thrown into stark focus during the severe acute respiratory syndrome-2 coronavirus (SARS-CoV-2) pandemic. When a COVID-19 patient presented meeting SIRS or the Berlin Criteria, these patients met the criteria for entry into the sepsis protocol and/or acute respiratory distress syndrome (ARDS) protocol, respectively and were treated accordingly. This was perceived to be the correct response because these patients met the criteria for the "group" definitions of sepsis and/or ARDS. However, the application of these protocols to patients with SARS-CoV-2 infection had never been studied. Initially, poor outcomes were blamed on protocol noncompliance or some unknown patient factor. This initial perception is not surprising as these protocols are standards and were perceived as comprising the best possible evidence-based care. While the academic response to the pandemic was robust, recognition that existing protocols were failing might have been detected sooner if protocol failure detection had been integrated with the protocols themselves. In this review, we propose that, while protocols are necessary to ensure that minimum standards of care are met, protocols need an additional feature, integrated protocol failure detection, which provides an output responsive to protocol failure in real time so other treatment options can be considered and research efforts rapidly focused.

Designing a Low-Cost Thyroid Ultrasound Phantom for Medical Student Education.

Using ultrasound for the diagnostic workup of thyroid lesions is a widely accepted technique. An inexpensive phantom model of thyroid lesions would be an invaluable tool for engaging medical students in learning the diagnostic algorithm for thyroid lesions and how to perform fine needle aspiration (FNA). The aim of this study was to devise an inexpensive and reproducible training phantom model for thyroid lesion detection, image interpretation and in vitro FNA using ultrasound guidance. A simple phantom model imitating benign cystic lesions, intermediately suspicious lesions and highly suspicious lesions was developed using a chicken breast, red seedless grapes, pimento olives and blackberries. The phantom was constructed for a total cost of $4.09 per unit and constructed in approximately 3 min. Nine models were constructed in total, demonstrating that the model design is replicable. This thyroid FNA phantom is an inexpensive, easy-to-produce model that allows medical students to practice measuring lesions and performing FNAs using ultrasonography. Future studies could be explored to assess this model's role in medical student education.

Teaching neurological disorders with ultrasound: A novel workshop for medical students.

INTRODUCTION: The goal of this study was to assess if a neurological disorder ultrasound workshop for the first-year medical students significantly enhanced the students' ability to retain and apply concepts related to neuroanatomy and neurophysiology. MATERIALS AND METHODS: We performed a prospective study to evaluate student performance before and after an optional ultrasound workshop. Data were collected through a within-population pretest-posttest design. Purposive sampling was used to recruit first-year medical students for this study. The six stations were transcranial doppler ultrasound, ocular ultrasound, ultrasound-guided external ventricular drain placement, high-intensity focused ultrasound for brain lesions, carotid artery scan with ultrasound, and ultrasound-guided central line placement. We used a pre-post workshop survey to identify opinions and perceptions about ultrasound and a pre-post workshop test to assess knowledge about neuroanatomy, neurophysiology, and related ultrasound topics. RESULTS: Twenty-two 22 first-year medical students consented to participate in this study. The Wilcoxon signed-rank test showed a statistically significant difference in pre- and posttest scores, suggesting that participants demonstrated higher levels of medical knowledge related to neurological physiology, anatomy, and ultrasound after participating in the workshop. The analysis of the pre-post survey showed participants attributed greater value to ultrasound as a useful tool for their future medical practice after participation in the event (Z = -2.45, P = 0.014). CONCLUSIONS: There is value in integrating experiences with ultrasound into the neurological disorder block of medical school. Future studies, with a larger sample size, are needed to further explore the efficacy of this workshop in enhancing knowledge retention.

Billing I-AIM: a novel framework for ultrasound billing.

BACKGROUND: Point-of-care ultrasound (POCUS) has an ever-growing footprint in medicine. With this growth POCUS billing and reimbursement has become an area gaining quite a bit of attention as a means of funding and sustaining quality and education programs. Standardization across providers is needed to improve the financial viability of POCUS. RESULTS: We created an institutional collaborative which developed a framework to identify critical POCUS billing and reimbursement checkpoints. The framework, Billing I-AIM, provides a feasible structure to enhance provider-based reimbursement and perform quality improvement efforts across variable POCUS environments. CONCLUSIONS: POCUS billing using the Billing I-AIM technique allows administrative oversight, quality assurance, and educational functions as well. A discussion of the framework and respective application is provided.

Toward a Consensus for Musculoskeletal Ultrasonography Education in Physical Medicine and Rehabilitation: A National Poll of Residency Directors.

OBJECTIVES: The aims of the study were to evaluate integration of musculoskeletal ultrasonography education in physical medicine and rehabilitation training programs in 2014-2015, when the American Academy of Physical Medicine & Rehabilitation and Accreditation Council for Graduate Medical Education Residency Review Committee both recognized it as a fundamental component of physiatric practice, to identify common musculoskeletal ultrasonography components of physical medicine and rehabilitation residency curricula, and to identify common barriers to integration. DESIGN: Survey of 78 Accreditation Council for Graduate Medical Education-accredited physical medicine and rehabilitation residency programs was conducted. RESULTS: The 2015 survey response rate was more than 50%, and respondents were representative of programs across the United States. Most programs (80%) reported teaching musculoskeletal ultrasonography, whereas a minority (20%) required mastery of ultrasonography skills for graduation. Ultrasonography curricula varied, although most programs agreed that the scope of resident training in physical medicine and rehabilitation should include diagnostic and interventional musculoskeletal ultrasonography, especially for key joints (shoulder, elbow, knee, wrist, hip, and ankle) and nerves (median, ulnar, fibular, tibial, radial, and sciatic). Barriers to teaching included insufficient expertise of instructors, poor access to equipment, and lack of a structured curriculum. CONCLUSIONS: Musculoskeletal ultrasonography has become a required component of physical medicine and rehabilitation residency training. Based on survey responses and expert recommendations, we propose a structure for musculoskeletal ultrasonography curricular standards and milestones for trainee competency.

Headstand (Sirshasana) Does Not Increase the Blood Flow to the Brain.

Objectives: Most yoga practitioners believe that headstand (Sirshasana) results in increased cerebral perfusion. This, however, is not consistent with autoregulation of the cerebral blood flow. The intent of this study was to demonstrate the effect of Sirshasana on the blood flow to the brain through ultrasound examination of the internal carotid artery (ICA). Design, location, and subjects: The ICA blood flow was measured with pulsed Doppler in 20 men and women aged 10 to 59 years (median 43) while performing the headstand (Sirshasana). Seventeen subjects were studied in 2018 in Spain at the altitude of 2,000 m, whereas the other three females were studied at sea level. Results: Although the diameter of the artery under examination during the headstand remained almost unchanged, the decrease in peak flow velocities in systole and diastole caused a significant decrease in arterial blood flow to the brain, followed by return to baseline values immediately after the antiorthostatic postural effect, likely due to the expected consequences of the cerebral blood flow autoregulation of the cerebral blood supply as well as the intracranial pressure. Conclusions: Contrary to popular belief, Sirshasana does not increase blood flow to the brain through the ICA, but results in predictable reduction in cerebral blood delivery in compliance with known mechanisms of autoregulation of cerebral blood flow. Moreover, increased ICA blood flow while performing the headstand is likely to be a contraindication to this exercise.

CLEAR: A Novel Approach to Ultrasound Equipment Homeostasis.

Protocols for the sanitation and maintenance of point-of-care ultrasound (US) equipment are lacking. This study introduces the CLEAR protocol (clean, locate, energize, augment supplies, and remove patient identifiers) as a tool to improve the readiness of US equipment, termed US equipment homeostasis. The state of US equipment homeostasis in the emergency department of a single academic center was investigated before and after implementing this protocol, with an improvement in outcomes. These findings demonstrate that the CLEAR protocol can improve US homeostasis. CLEAR can function as a teaching tool to promote homeostasis as well as a checklist to assess compliance.

Beyond Bones: Assessing Whether Ultrasound-Aided Instruction and Practice Improve Unassisted Soft Tissue Palpation Skills of First-Year Medical Students.

OBJECTIVES: Our purpose was to determine whether ultrasound (US)-aided instruction and practice on musculoskeletal anatomy would improve first-year medical students' ability to locate and identify specific soft tissue structures by unaided palpation in the upper and lower extremities of healthy human models. METHODS: This study was a randomized crossover design with 49 first-year medical students randomly assigned to 1 of 2 groups. Each group was provided expert instruction and hands-on practice using US to scan and study soft tissue structures. During session 1, group A learned the anatomy of the upper extremities, whereas group B learned the lower. Students were then tested on their proficiency in locating 4 soft tissue structures (2 upper and 2 lower extremities) through palpation of a human model. During session 2, group A learned lower extremities, and group B learned upper. At the end of session 2, students repeated the assessment. RESULTS: After the first instructional session, neither group performed significantly better on identifying and locating the soft tissue landmarks they learned aided by US. After the second instructional session, however, scores for both groups increased approximately 20 percentage points, indicating that both groups performed significantly better on palpating and identifying both the upper and lower extremity soft tissue landmarks (Cohen d = 0.89 and 0.82, respectively). CONCLUSIONS: Time and practice viewing soft tissue structures with US assistance seems to have a "palpation-with-eyes" effect that improves students' abilities to correctly locate, palpate, and identify limb-specific soft tissue structures once the US assistance is removed.

Documenting the Growth of Ultrasound Research in Emergency Medicine Through a Bibliometric Analysis of Accepted Academic Conference Abstracts.

OBJECTIVES: Ultrasound (US) has become an indispensable skill for emergency physicians. Growth in the use of US in emergency medicine (EM) has been characterized by practice guidelines, education requirements, and the number of EM US practitioners. Our purpose was to further document the growth of EM US by profiling the breadth, depth, and quality of US-related research presented at EM's most prominent annual research conference: the Society for Academic Emergency Medicine Annual Meeting. METHODS: We reviewed published research abstracts from the annual Society for Academic Emergency Medicine conferences from 1999 to 2015. Abstracts related to US were identified and examined for the number of authors and rigor of the research design. Designs were categorized as experimental, quasiexperimental, and nonexperimental. Abstract submissions were analyzed by the average rate of change over time. RESULTS: From 1999 to 2015, we observed a 10.2% increase in the number of accepted abstracts related to US research. This rate compared to a 3.2% average rate of change for all abstracts in general. The number of unique authors engaged in US research increased at a rate of 26.6%. Of the 602 abstracts identified as US related, only 12% could be considered experimental research. CONCLUSIONS: We observed larger increases in the number of US-related research relative to the total number of abstracts presented at a national conference. The number of investigators engaging in this research has also steadily increased. The research design of these studies was found to be primarily quasiexperimental. To improve the quality of EM's use of point-of-care US, more rigorous research with experimental designs is needed.

Does Ultrasound-Enhanced Instruction of Musculoskeletal Anatomy Improve Physical Examination Skills of First-Year Medical Students?

OBJECTIVES: Ultrasound imaging is commonly used to teach basic anatomy to medical students. The purpose of this study was to determine whether learning musculoskeletal anatomy with ultrasound improved performance on medical students' musculoskeletal physical examination skills. METHODS: Twenty-seven first-year medical students were randomly assigned to 1 of 2 instructional groups: either shoulder or knee. Both groups received a lecture followed by hands-on ultrasound scanning on live human models of the assigned joint. After instruction, students were assessed on their ability to accurately palpate 4 anatomic landmarks: the acromioclavicular joint, the proximal long-head biceps tendon, and the medial and lateral joint lines of the knee. Performance scores were based on both accuracy and time. A total physical examination performance score was derived for each joint. Scores for instructional groups were compared by a 2-way analysis of variance with 1 repeated measure. Significant findings were further analyzed with post hoc tests. RESULTS: All students performed significantly better on the knee examination, irrespective of instructional group (F = 14.9; df = 1.25; P = .001). Moreover, the shoulder instruction group performed significantly better than the knee group on the overall assessment (t = -3.0; df = 25; P < .01). Post hoc analyses revealed that differences in group performance were due to the shoulder group's higher scores on palpation of the biceps tendon (t = -2.8; df = 25; P = .01), a soft tissue landmark. Both groups performed similarly on palpation of all other anatomic structures. CONCLUSIONS: The use of ultrasound appears to provide an educational advantage when learning musculoskeletal physical examination of soft tissue landmarks.

Critical aortic stenosis.

A case of a 52-year-old male with ventricular tachycardia and atrial fibrillation associated with aortic stenosis is outlined. Focused cardiac ultrasound images obtained in the emergency department are presented. A discussion of aortic stenosis and emergency ultrasound in the above clinical context is included. REPUBLISHED WITH PERMISSION FROM: Cooper RD, Macedo J, Bahner DP. Bedside sonography primer: Critical aortic stenosis. OPUS 12 Scientist 2011;5:11-2.

Point-of-Care Ultrasound in General Surgery Residency Training: A Proposal for Milestones in Graduate Medical Education Ultrasound.

The use of point-of-care ultrasound (US) in the clinical setting has undergone massive growth, although its incorporation into training and practice is variable. Surgeons are interested in using point-of-care US and can incorporate it effectively into clinical practice. However, the current state of point-of-care US training in general surgery is inadequate. The Accreditation Council for Graduate Medical Education introduced the Milestones Project to evaluate resident and fellow performance. Emergency medicine is the only specialty with a point-of-care US milestone. We have successfully implemented a US training program into our general surgery residency curriculum and now propose milestones in point-of-care US for all general surgery residents.

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

INTRODUCTION: Intravascular volume status is an important clinical consideration in the management of the critically ill. Point-of-care ultrasonography (POCUS) has gained popularity as a non-invasive means of intravascular volume assessment via examination of the inferior vena cava (IVC). However, there are limited data comparing different acquisition techniques for IVC measurement by POCUS. The goal of this evaluation was to determine the reliability of three IVC acquisition techniques for volume assessment: sub-xiphoid transabdominal long axis (LA), transabdominal short axis (SA), and right lateral transabdominal coronal long axis (CLA) (aka "rescue view"). METHODS: Volunteers were evaluated by three experienced emergency physician sonographers (EP). Gray scale (B-mode) and motion-mode (M-mode) diameters were measured and IVC collapsibility index (IVCCI) calculated for three anatomic views (LA, SA, CLA). For each IVC measurement, we calculated descriptive statistics, intra-class correlation coefficients (ICC), and two-way univariate analyses of variance. RESULTS: EPs evaluated 39 volunteers, yielding 351 total US measurements. Measurements of the three views had similar means (LA 1.9 ± 0.4cm; SA 1.9 ± 0.4cm; CLA 2.0 ± 0.5cm). For B-Mode, LA had the highest ICC (0.86, 95% CI [0.76-0.92]) while CLA had the poorest ICC (0.74, 95% CI [0.56-0.85]). ICCs for all M-mode IVCCI were low. Significant interaction effects between anatomical view and EP were observed for B-mode and M-mode measurements. Post-hoc analyses revealed difficulty in consistent view acquisition between EPs. CONCLUSION: Inter-rater reliability of the IVC by EPs was highest for B-mode LA and poorest for all M-Mode IVC collapsibility indices (IVCCI). These results suggest that B-mode LA holds the most promise to deliver reliable measures of IVC diameter. Future studies may focus on validation in a clinical setting as well as comparison to a reference standard.

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

Integrated, multidisciplinary team approach to the multiply injured patient can help optimize care, minimize morbidity, and reduce mortality. It also provides a framework for accelerated postinjury rehabilitation course. The characteristics and potential benefits of this approach, including team dynamics and interactions, are discussed in this brief review. Emphasis is placed on synergies provided by specialty teams working together in the framework of care coordination, timing of surgical and nonsurgical interventions, and injury/physiologic considerations. REPUBLISHED WITH PERMISSION FROM: Bach JA, Leskovan JJ, Scharschmidt T, Boulger C, Papadimos TJ, Russell S, Bahner DP, Stawicki SPA. Multidisciplinary approach to multi-trauma patient with orthopedic injuries: the right team at the right time. OPUS 12 Scientist 2012;6(1):6-10.