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American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 20131428470 Ultrasound Knowledge and Image Interpretation Gains byStudents on Emergency Medicine RotationUche Blackstock,* Jaclyn Munson, Nina Yeboah, DemianSzyld Emergency Medicine, Bellevue Hospital/New York UniversityMedical Center, New York, New York USAObjectives—Bedside ultrasound (BUS) competency is consideredintegral to emergency medicine (EM) practice, and EM residenciesrequire BUS training. However, medical students are rarely formallytaught BUS. We sought to develop and evaluate a BUS curriculum formedical students on their EM rotation.Methods—We prospectively enrolled a convenience sample of26 medical students (second year, 8 [30.8%]; third year, 11 [42.3%]; andfourth year, 7 [26.9%]) on their EM rotation. Students completed a 33–multiple-choice question Web-based pretest assessing knowledge ofphysics (Ph; 17 items [51.5%]) and image interpretation (Im; 16 items[49.5%]). On pretest completion, participants viewed video tutorials covering(1) Ph, 2) focused assessment with sonography for trauma, and (3)ultrasound-guided vascular access. Next, participants attended a 3-hourhands-on BUS session covering the tutorial topics. Subsequently, participantscompleted a Web-based posttest, containing identical questions asthe pretest. To validate results, a sample of 15 EM residents took the sameWeb-based posttest (5 postgraduate year 1 [PGY-1, 33.3%]; 3 PGY-2[20%], 5 PGY-3 [33.3%], and 2 PGY-4 [13.3%]) We performed a withingroupanalysis of participants’ pretest and posttest performance and between-groupanalysis as compared to the EM residents.Results—The students’ pretest mean score was 21.6/33 (65.6%;SD, 11.1%) made up of a Ph mean score of 11.5/17 (67.9%; SD, 14.1%)and an Im mean score of 10.1/16 (63.2%; SD, 15.6%). The students’posttest mean score was 28.4/33 (86.3%; SD, 9.35%), with a Ph meanscore of 15.0/17 (88.0%; SD, 10.8%) and an Im mean score of 13.4/16(84.1%; SD, 12.8%), corresponding to an overall effect size of d = 1.7(95% confidence interval [CI], 1.1, 2.3), Ph effect size of d = 1.5 (95% CI,0.9, 2.0), and Im effect size of d = 1.2 (95% CI, 0.7, 1.7). There were nostatistically significant differences between students’ and residents’ posttestscores (P = .47) or in any subcategory (Ph, P = .13; Im, P = .93).Conclusions—A standardized formal curriculum in BUS significantlyimproved medical students’ Ph knowledge and ability to interpretultrasound images. Medical students performed as well as a sampleof EM residents.1540627 Enhancing Third-Year Medical Student Primary CareClerkships With Handheld UltrasoundMary Elizabeth Poston, 1 Duncan Howe, 2 * Victor Rao, 2Richard Hoppmann, 2 Chung Yoon 1 1 Internal Medicine,2Ultrasound Institute, University of South Carolina School ofMedicine, Columbia, South Carolina USAObjectives—Future physicians may be better prepared to providesafer, higher-quality patient care if point-of-care ultrasound (US) isincluded in the medical school curricula. We piloted a handheld US curriculumfor third-year medical students. The primary objective was to determinestudents’ ability to learn to perform and interpret point-of-care USimages of the heart and assess global heart function. Secondary objectivesincluded determining patterns of use (number/types of scans performed,indications for scans, and impact on patient management) and assessingimpact on student learning.Methods—Fifty-four third-year medical students each receivedhandheld US for 22 weeks during the M3 year (8 weeks each for internalmedicine and pediatrics, 6 weeks for family medicine). During the M1and M2 years, these students had previously been taught cardiac and abdominalscanning techniques with laptop US on live patient models. Duringeach clerkship, students received didactic lectures on the use of thedevice and were instructed to view Web-based modules on global heartfunction assessment. Additional Web-based modules on other US-appropriatescans were also available. Students received hands-on instruction atleast once per clerkship using standardized patients. Students were instructedto save at least 1 cardiac and 2 other images and to record thetype, indication, and impact of scans.Results—Students submitted information on patterns of use andpathology evaluated for 305 cardiovascular (heart/inferior vena cava [IVC]),131 abdominal, 97 nonobstetric genitourinary, 9 lung, and 6 obstetric scans.In an end-of-the-year objective structured clinical examination, M3 studentsdemonstrated the ability to obtain images of the heart (parasternal long-axisview) as well as IVC and comment on global heart function and volumestatus. In end-of-year surveys, students stated that their ability to recognize,understand, and manage patient problems improved with US, but lack ofUS-trained faculty to supervise was a major limitation.Conclusions—M3 students with some prior experience canlearn to assess global heart function with handheld US. Students felt thatunderstanding of patient pathology and management was improved. Lackof trained faculty is a barrier to this curriculum.1541489 Cloud Documentation and iPad Telesonography From aTeaching Hospital in the Andes: A Culturally CompetentModel for Obstetric Ultrasound Education, Quality Assurance,and Practice Improvement in Remote EcuadorJohn Rodney, 1 * Erin Dooley, 2 John Simmons, 1 MatthewHorning, 3 Kelly Arnold, 4 William Rodney 2 1 Family Medicine,Texas A&M Health Science Center, Bryan, Texas USA;2Surgical Family Medicine, Obstetrics, Medicos Para la Familia,Memphis, Tennessee USA; 3 Family Medicine, St Luke’sHospital, Ashland, Wisconsin USA; 4 Family Medicine, Universityof Tennessee, Chattanooga, Tennessee USAObjectives—To create and implement a Spanish language–based obstetric ultrasound curriculum and record-keeping system by creatinga cloud-enhanced iPad application as well as a textbook and lectureseries translated into Spanish.Methods—Using AIUM guidelines for obstetric and gynecologicultrasound, we developed a cloud-based iPad application to addressthe educational and data storage needs of a geographically isolated teachinghospital in the mountains of remote Ecuador. After a brief ultrasoundseminar that included Spanish language–based lectures, texts, and demonstrations,the investigators used the iPad application to remotely monitorthe performance and documentation of obstetric ultrasound examinationsby family medicine trainees and physicians over a 6-week period.Results—We successfully addressed the educational and informationmanagement needs of family medicine trainees and physiciansin an isolated Spanish-speaking teaching hospital in remote Ecuador.Conclusions—Cloud-enhanced tablet technology is a feasiblemeans of overcoming geographic and cultural barriers for the purposes ofultrasound education, quality assurance, and practice improvement forfamily medicine trainees and physicians practicing in remote, resourcelimitedlocations.General and Abdominal UltrasoundModerator: Abid Irshad, MD1536712 European Federation of Societies for Ultrasound in Medicineand Biology Guidelines on the Clinical Use of ElastographyDavid Cosgrove, 1 * Christoph Dietrich, 2 Fabio Piscaglia 31Imaging Sciences, Imperial College, London, England; 2 Gastroenterology,S. Orsola-Malpighi, Bologna, Italy; 3 Medicine,Caritas Krankenhaus, Bad Mergentheim, GermanyObjectives—Elastography has emerged as a clinically usefuladdition to conventional ultrasound in many diagnostic applications. How-S65
American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013ever, there is a need to improve standards of practice and interpretation aswell as to standardize terminology.Methods—A steering committee commissioned experiencedEuropean users to submit sections of guidelines along the lines of thosepreviously published for contrast-enhanced ultrasound.1,2 An introductorysection on the basic principles was followed by sections coveringparts of the body in which elastography is widely used, including the liver,the breast, endoscopic uses, the bowel, the prostate, the thyroid, and themusculoskeletal system.Results—The basic principles section aims to improve understandingof clinical elastography by synthesizing the underlying principlesof the 2 most commonly used forms: strain and shear waveelastography. Each clinical section contains a survey of the literature,especially where there are meta-analyses, and practical advice on theperformance and interpretation of elasticity examinations. The editeddocument is to be submitted to the European Journal of Ultrasound (Ultraschallin der Medizin) with a target date of January 2013.Conclusions—It is hoped that the European Federation of Societiesfor Ultrasound in Medicine and Biology (EFSUMB) guidelines onelastography will be as useful as the contrast-enhanced ultrasound guidelinesin improving understanding and clinical practice. The contributions ofthe EFSUMB Elastography Guidelines Team are gratefully acknowledged.References1. Claudon M, Cosgrove D, Albrecht T, et al. Guidelines and good clinicalpractice recommendations for contrast-enhanced ultrasound(CEUS): update 2008. Ultraschall Med 2008; 29:28–44.2. Piscaglia F, Nolsoe C, Dietrich CF, et al. The EFSUMB guidelines andrecommendations on the clinical practice of contrast-enhanced ultrasound(CEUS): update 2011 on nonhepatic applications. UltraschallMed 2012; 33:33–59.1540689 Implementation of Bedside Ultrasonography Within anInternal Medicine Faculty and Residency: The IMBUSProgramDavid Tierney,* Terry Rosborough Medical Education,Abbott Northwestern Hospital, Minneapolis, Minnesota USAObjectives—Describe in detail and provide a rationale for acurriculum, structure, and successful implementation of an internal medicinebedside ultrasound (IMBUS) program in a residency program andits faculty.Methods—Design: Prospective cohort study in an internalmedicine (IM) residency program at a private academic 700-bed tertiarycare center. Participants: 33 residents and 13 full-time faculty memberswithout significant prior ultrasound experience. Intervention: (1) Developmentof an IM ultrasound curriculum to maximize sensitivity/specificityof our routine physical exam as well as critical time sensitivediagnoses; (2) overlap training method using top-down and bottom-upmethodologies; (3) 35-hour “boot camp” including didactic, hands-onmodel-based, and simulator-based training; (4) bedside hands-on trainingwith faculty mentors until the trainee meets a prespecified exam count ineach component and is deemed competent in that exam area; (5) ongoingmentored and remotely submitted/reviewed images until adequate technicaland interpretive sensitivity/specificity are obtained; (6) final test-outusing bedside and simulator-based summative evaluation prior to certification;and (7) a robust ongoing quality assurance system. Measurements:Comparative effectiveness of multiple implementation strategies; time to,variation in, and predictive factors of competence in each exam component;clinical impact of chosen components on patient outcomes; and effectof implementation on resident/faculty work flow, efficiency, and jobsatisfaction.Results—We describe in detail and rigorously critique a full ultrasoundcurriculum and implementation strategy for an IM residency.Thirty IM residents and 12 faculty members were trained using theIMBUS program. Learning curves for each ultrasound exam componenthave been established. We are analyzing multiple outcomes, includingcompetency learning curves, skill decay, patient outcomes and experience,and physician impact of bedside ultrasound.Conclusions—We hope that by describing in detail our curriculum,methods, and learning, we can help other residency programsimplement bedside ultrasound in an efficient, focused, evidence-based,politically aware, and impactful manner.1506540 Prostate Cancer Responses to Testosterone and GrowthHormoneRobert Bard Biofoundation, New York, New York USAObjectives—Hypogonadal patients with low-grade prostatecancer are now treated with testosterone +/– growth hormone. It has beenestablished that high vascular density indicates a high-grade tumor. Ourstudy was to observe Doppler sonographic vessel density imaging inknown cancer sites to predict aggressive changes and arrest testosteroneand or growth hormone supplementation.Methods—Sixty-three patients treated with testosterone havinglow-grade (Gleason 6) disease were followed over a 3-year period.The vessel index was assessed on sonography by 3D histogram analysisand by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). Follow-up biopsies were obtained shortly after imaging studies,which occurred at 6-month intervals for 3 years on patients with prostatespecificantigen (PSA) rises. Nineteen of 63 patients were concomitantlytaking growth hormone formulations.Results—Forty-one of 63 testosterone patients had no increasein PSA or neovascularity at 6, 12, 24, and 36 months. Three of 63 patientshad increased PSA and vessel density at 6 months. Biopsy confirmedGleason 4+3 disease in 1 patient and Gleason 3+4 in 2 others. Testosteronewas discontinued. One of 19 patients taking testosterone and growth hormoneshowed increased PSA at 6 months. Biopsy showed Gleason 3+4.Testosterone and growth hormone were discontinued. None of the studiedgroup developed increased vessel densities after the initial 6-month period.Conclusions—Vessel density sonographic indexing and DCE-MRI analysis correlated well with the biochemical response to testosterone/growthhormone therapies. There was high correlation withhistologic findings. Vascular density increases may signal the need to discontinuehormone replacement therapies. Vascular density stability in theface of rising PSA most likely indicates progression of benign hyperplasiawith increased prostate glandular volume.1540891 Liver Sonography Is Predictive of Liver Steatosis; However,the Severity of Fatty Liver on Sonography Does Not CorrelateWith the Presence of SteatohepatitisRoberta diFlorio,* Robert Harris, David Kim, Eric Goodman,Alex Spinosa, Megan Murphy Radiology, Dartmouth-HitchcockMedical Center, Lebanon, New Hampshire USAObjectives—The spectrum of nonalcoholic fatty live disease(NAFLD) ranges from bland steatosis to cell injury and inflammation(steatohepatitis or nonalcoholic steatohepatitis [NASH]) to fibrosis/cirrhosis.End-stage disease is associated with increased risk of hepatocellularcarcinoma (HCC). Patients with NASH are far more likely to progressto fibrosis than patients with simple steatosis. Currently, liver biopsy isconsidered the gold standard for diagnosis of NAFLD and for differentiatingsteatosis from NASH. However, there is significant variability inliver biopsy due to the error of a small sample size of a heterogeneousprocess. A noninvasive marker of NAFLD would allow detection of globaldisease status and allow stratification of risk for the development of fibrosis.This would permit early drug therapy and allow for surveillance ofcirrhosis complications and HCC. Ultrasound findings that would differentiatesimple steatosis from NASH would be helpful in diagnosing andmonitoring the disease status of NAFLD.S66
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Small-Animal Preclinical High-Frequ
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2013 AIUM Award WinnersJoseph H. Ho
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