Ultrasound Elastography: The New Frontier in Direct Measurement of Muscle Stiffness

The use of brightness-mode ultrasound and Doppler ultrasound in physical medicine and rehabilitation has increased dramatically. The continuing evolution of ultrasound technology has also produced ultrasound elastography, a cutting-edge technology that can directly measure the mechanical properties of tissue, including muscle stiffness. Its real-time and direct measurements of muscle stiffness can aid the diagnosis and rehabilitation of acute musculoskeletal injuries and chronic myofascial pain. It can also help monitor outcomes of interventions affecting muscle in neuromuscular and musculoskeletal diseases, and it can better inform the functional prognosis. This technology has implications for even broader use of ultrasound in physical medicine and rehabilitation practice, but more knowledge about its uses and limitations is essential to its appropriate clinical implementation. In this review, we describe different ultrasound elastography techniques for studying muscle stiffness, including strain elastography, acoustic radiation force impulse imaging, and shear-wave elastography. We discuss the basic principles of these techniques, including the strengths and limitations of their measurement capabilities. We review the current muscle research, discuss physiatric clinical applications of these techniques, and note directions for future research.     

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.     

Emergency medicine in Oman: current status and future challenges

The Sultanate of Oman has a relatively young national health care system that could demonstrate its high performance at an international level. Emergency medicine as a specialty has developed rapidly in the country over the last decade. This has involved the parallel development of local emergency residency training, prehospital emergency care, and emergency nursing programs. This article reviews the progress of emergency care practice in this country from a general primary care system toward becoming an established specialty in hospital, prehospital, and private emergency care settings. It also describes aspects of undergraduate, postgraduate, and continuous emergency medicine education in the country. Further, a glimpse into academic emergency medicine and emergency nursing is provided. Since it describes a developing specialty, the article also attempts to address briefly major future challenges and their importance to the future development of the specialty in Oman.     

Diagnosis in a Heart Beat, or Focused Echocardiography: How Should it be Used in the Emergency Room?

Over the last few decades, ultrasound underwent rapid technological development and equipment miniaturization that lead to its wide spread use in virtually all spheres of patient care, including emergency medicine. In the specific scenarios, use of focused echocardiography by emergency department physicians may assist with triage, expedite the diagnostic assessment of the patient, facilitate emergent treatment, and overall improve patient care. Due to steep learning curve, well structured didactics and sufficient hands-on practice, either incorporated into the residency training or offered as a fellowship, is generally required to produce well trained physicians in this specialty. In this review article we intended to recap the latest evidence supporting use of cardiac ultrasound in the emergency department, overview common and some less known clinical applications of focused cardiac ultrasound (FOCUS), training recommendations, as well as future directions and possibilities of further development.     

Ultrasound in the ED can mean dramatic improvement in care, research shows

The practice of ultrasound in the ED is a quickly growing trend, and experts predict it will soon become the standard of care in the ED. Ultrasound results can provide evidence to specialists that a patient has a life-threatening emergency, such as an abdominal aortic aneurysm. Studies show that ED use of ultrasound can decrease morbidity and mortality, and reduce length of stay. Document gaps in ultrasound service provided by radiology that the ED can fill.     

The ultrasound cardioscope: A hand-held scanner for real-time cardiac imaging

A miniaturized hand-held ultrasound scanner that permits two-dimensional echocardiography is described. The device has been routinely used in our emergency department, coronary care unit, wards, and outpatient department. The device has advantages in situations where rapid decisions are demanded of the expert echocardiographer. It permits improved bedside analysis of patients with puzzling cardiac conditions. An important feature is that the instrument can be used as a substitute for cardiac fluoroscopy in office practice. Tests performed in 100 consecutive patients have demonstrated that reasonable semiquantitative estimation of the sizes of left-side heart structures is possible. This new-generation instrument can make diagnostic ultrasound more readily available in emergency situations and should have considerable influence on the use of cardiac ultrasound for bedside diagnosis. It will undoubtedly affect future developments in automatic, portable, and special dedicated ultrasound equipment.     

Abuse by care professionals. Part 5: implications for nurses

The fourth article in this short series of five articles focused on the support resources for those care professionals who abuse and on the support needs of, and resources for, a person abused by a care professional when she was younger. The view that such resource needs could become a 'wish list' devoid of financial contexts was briefly mentioned. This final paper in the series will use information gathered from previous articles to formulate some general suggestions for future practice and will discuss such a 'wish list' in terms of its implications for nurses and nursing practice, although as this series has aimed to highlight abuse by all care professionals and not just nurses, such practice implications can apply equally to all healthcare professionals and even beyond to include social, educational and religious professionals.     

New advances in anesthesia

Pharmacologic advances in anesthesia over the last decade have focused on drug safety, shorter durations of action, reversibility, and ease of administration. This is reflective of major changes in the focus of patient care from inpatient to outpatient settings as well as from available risk management data that support the investigation of these new drugs. The pharmacologic advances discussed included those drugs in current practice as well as experimental drugs yet to be released for general clinical use. Inhaled agents, such as isoflurane and perhaps the experimental agent, desflurane, will maintain or achieve their popularity because of the relative ease of administration and wide margins of safety. Propofol, the most recent intravenous anesthetic available for clinical use, has already gained wide acceptance because of its dual function as an induction and maintenance agent and its appropriateness for use in the ambulatory surgical population. The role of midazolam in anesthesia practice has increased to such an extent that it has largely supplanted the use of diazepam (Valium). The introduction of the antagonist, flumazenil, will undoubtedly enhance the safety and efficacy of midazolam as well as broaden its applicability of use across various patient populations. Several of the newer synthetic narcotics, such as alfentanil and sufentanil, have replaced other narcotics formerly used in anesthesia practice, such as meperidine and morphine, primarily because of their short action and lack of significant side effects. The use of muscle relaxants as a critical component of anesthetic management has led to the development of a number of new drugs in this classification. Pharmacologic management of patients under anesthesia will at some future date likely include the administration of alpha 2 agonists. Administration of these drugs can reduce anesthetic requirements of traditional agents by as much as 50%. As research continues, new drugs will be incorporated into the practice of anesthesia, ones that will promote rapid uptake, low toxicity, intense analgesia, easy reversibility, shorter durations, and fewer side effects. One measure of success relative to pharmacologic development in anesthesia is the recent and dramatic decreases in patient morbidity and mortality figures over the last decade. This attests to the rapid growth and development of not only improved patient monitoring systems but also newly improved "agents of sleep."     

Nursing work force in practice and education: what can we learn from the current crisis?

A major factor in the growing crisis in health care is the serious shortage of nurses in practice and education. The current work force shortage is different and more critical than previous cyclical deficits. Because it is projected to be of unprecedented severity and to endure long into the future, it demands significant attention and innovation. Nurses in clinical practice and in faculty roles are growing older, and the nursing work force in general is becoming relatively less educated. A strong nursing work force of the future will require new approaches to recruitment, preparation, and retention of nurses, interdisciplinary partnerships, and infusion of support from a variety of sources.     

Time to extend the 'process'?

During the past two decades, nurses and nursing students have been encouraged to organize care planning via the 'nursing process'. Although it is helpful to adopt a systematic approach to planning nursing care, it may be time to evaluate our use of the process; to consider whether strict adherence to it has shifted nursing's perspective from holism to an unduly mechanistic approach to care giving. Several research studies support the notion that intuitive processes are an important aspect of clinical judgement. In order to educate future generations of nurses for expertise in practice rather than mediocrity, these processes must be acknowledged and taken account of in curriculum planning; the nursing process should be recognized as merely a fraction of the equation for practice.     

A pilot study of comprehensive ultrasound education at the Wayne State University School of Medicine: a pioneer year review.

OBJECTIVE: Ultrasound is a versatile diagnostic modality used in a variety of medical fields. Wayne State University School of Medicine (WSUSOM) is one of the first medical schools in the United States to integrate an ultrasound curriculum through both basic science courses and clinical clerkships. METHODS: In 2006, 25 portable ultrasound units were donated to WSUSOM. First-year medical students were provided an ultrasound curriculum consisting of 6 organ-system sessions that addressed the basics of ultrasound techniques, anatomy, and procedural skills. After the last session, students were administered 2 anonymous and voluntary evaluations. The first assessed their overall experience with the ultrasound curriculum, and the second assessed their technical skills in applying ultrasound techniques. RESULTS: Eighty-three percent of students agreed or strongly agreed that their experience with ultrasound education was positive. On the summative evaluation, nearly 91% of students agreed or strongly agreed that they would benefit from continued ultrasound education throughout their 4 years of medical school. Student performance on the technical assessment was also very positive, with mean class performance of 87%. CONCLUSIONS: As residency programs adopt ultrasound training, medical school faculty should consider incorporating ultrasound education into their curriculum. Portable ultrasound has the potential to be used in many different settings, including rural practice sites and sporting events. The WSUSOM committee's pilot ultrasound curriculum will continue to use student feedback to enhance the ultrasound experience, helping students prepare for challenges that they will face in the future.     

Implementation of nurse-delivered vestibular rehabilitation in primary care: a qualitative study of nurses' views on involvement in an innovative service

Aim: To explore practice nurses’ perceptions of vestibular rehabilitation and its place in relation to their general role development. Background: Vestibular rehabilitation has been known for a long time to be effective for chronically dizzy patients in secondary care, but its use in primary care has been limited. A recent pragmatic trial of vestibular rehabilitation delivered by practice nurses in primary care has confirmed its utility in a community setting. This type of role is increasingly common for practice nurses, but few studies explore the nurses’ perspective. Methods: A qualitative study was undertaken; 19 nurses took part in focus group sessions. Participants discussed their views on vestibular rehabilitation and its potential for integration with their existing role. A thematic analysis of the data was undertaken. Findings: Four main themes were identified: creating a unique nursing role; the therapeutic role; responsibility and role boundaries; and time. Nurses were positive about developing extended roles, but sought ways to achieve this without eroding fundamental nursing skills. Vestibular rehabilitation was seen as fulfilling both the need for a distinct nursing identity and professional development. Concerns over responsibility for patient assessment and time management constraints are potential obstacles to overcome in the wider development of this therapy in primary care. Conclusions: Understanding the perspective of nurses will be vital in future development of chronic disease management within primary care. Whilst nurses may be positive about such role expansion, the implementation of services of this type will require clarity about nurses’ responsibilities and flexibility in managing workload. Relevance to clinical practice: Vestibular rehabilitation is simple, low‐tech and appropriate for widespread development in primary care. Nurses wishing to provide vestibular rehabilitation or similar chronic disease management activities will need to work with medical colleagues to define role boundaries.     

The evolution of the hospitalist model in the United States

Emerging data support the hypothesis that the use of hospital-based physicians can lead to improved efficiency without compromising patient [table: see text] outcomes or satisfaction. Nevertheless, for the foreseeable future, hospital care in the United States will likely remain a highly pluralistic system in which the organization of care is determined by efforts to improve the value of care in the context of local culture, patient populations, and patient and provider preferences. The method of hospital care chosen by each institution and group of physicians should be the one that promotes the best clinical outcomes and highest patient satisfaction at the lowest costs. With these goals in mind, it is likely that hospitalists will play an increasingly important and visible role in many institutions across the country.     

Intensive care in developing countries in the Western Pacific

The rapid economic, scientific, and technologic development in Asia probably is the most important in the world today. Eventually, the development of health care and critical care medicine in the Western Pacific will be affected. Even with the problems that have to be faced, the future of critical care medicine in the region looks promising.However, the leaders of critical care medicine in each country should identify the model of intensive care practice that is the most appropriate for their country. Each country needs to assign an appropriate rank of priority to intensive care. There is a great need for simple, inexpensive therapeutic interventions and methods for monitoring critically ill patients that can be shown to be effective. Efficient systems for transporting critically patients are also needed. Simple ventilators with inexpensive monitors and defibrillators are the technology that is most needed. Good referral systems and greater use of physician extenders, such as nurse practitioners, to provide enhanced access to specialist care for critical illness should be promoted. A few high-standard ICUs with good facilities for education and training should be organized on a regional basis in each country.     

Real Time Ultrasound: An Objective Measure of Skeletal Muscle

Abstract

Objective measurement of muscle size is an important aspect of physiotherapy, but current clinical assessment methods are unreliable. Whilst not in widespread clinical use, real-time ultrasound has the potential to determine accurately both the linear dimensions and crosssectional area of skeletal muscle, providing evidence for the effectiveness of physiotherapy interventions. This systematic review of current literature was undertaken to investigate the validity and reliability of real-time ultrasound as an objective measure in physiotherapy practice, to discuss the implications for practice and to identify future research requirements. Eight current databases were searched for studies that measured skeletal muscle. Eleven articles were identified which specifically met the search criteria, and these were reviewed systematically. All of the articles found real-time ultrasound to be a valid and reliable tool for measuring skeletal muscle size under controlled conditions; however, confounding variables, such as fat, fascia orientation, muscle shape and pathology, were identified which may affect the validity of measurements in the general population. Further research is needed into deep and irregular muscles, and into the wider population, including obese, physically trained and symptomatic subjects to validate its use as a generalised tool. Furthermore, the use of a strict protocol was highlighted to ensure valid and reliable measurements in clinical practice.     

Contribution of a lecturer- practitioner in implementing evidence-based health care

This article describes and discusses the role of a lecturer-practitioner (LP) in the context of a university and practice development unit within a primary care trust in contributing to evidence-based health care. Evidence-based health care is currently high on the political and professional agendas. Methods employed in practice to create an environment that encourages and supports innovation will be described. Methods used in the educational establishment will also be highlighted from a theoretical and practice perspective. Progress to date and expected future outcomes will be shared. The article concludes that progress is dependent on all those involved, sharing common goals in the implementation of evidence based health care as it will continue to remain high on the agenda in the educational and service sectors. This drive towards clinical effectiveness and evidence based practice puts the LP in an ideal position to reduce the practice–theory gap by the nature of their integrated role.     

Private practice use of real-time B scan ultrasound in obstetrics and gynecology.

An informal survey of 25 obstetrics and gynecology practices that use real time B scan ultrasound equipment was carried out to assess the economic and patient-care impact of such equipment. From this informal survey, it can be seen that the incorporation of real time B scan ultrasound scanning into private practice has become economically feasible and useful for the daily clinical management of obstetric patients. The implications and economics of such changes for obstetric health care costs remain to be assessed.     

Acute Dialysis Quality Initiative: methodology

The area of acute renal failure has lagged behind other areas of critical care medicine such as acute respiratory distress syndrome or sepsis in terms of clinical focus, assimilation and interpretation of currently available evidence, and availability of clinical trials. Furthermore, there has been a lack of attention concerning present therapeutic needs and future clinical research direction. These shortcomings stem, in part, from the fragmentation of acute renal failure care and expertise into the fields of nephrology and critical care medicine. To advance the quality of care, make the evidence base for clinical practice more readily available and suitably interpreted, reduce fragmentation, and refocus the goals of future research in this field, a new quality initiative, the Acute Dialysis Quality Initiative, was launched. This initiative brings together experts from different fields and continents, applying an expert-enhanced evidence analysis to achieve its goals. This brief report details the process of the Acute Dialysis Quality Initiative and its goals and methodology.