Can medical learners achieve point-of-care ultrasound competency using a high-fidelity ultrasound simulator?: a pilot study

Background

Point-of-care ultrasound (PoCUS) is currently not a universal component of curricula for medical undergraduate and postgraduate training. We designed and assessed a simulation-based PoCUS training program for medical learners, incorporating image acquisition and image interpretation for simulated emergency medical pathologies. We wished to see if learners could achieve competency in simulated ultrasound following focused training in a PoCUS protocol.

Methods

Twelve learners (clerks and residents) received standardized training consisting of online preparation materials, didactic teaching, and an interactive hands-on workshop using a high-fidelity ultrasound simulator (CAE Vimedix). We used the Abdominal and Cardiothoracic Evaluation by Sonography (ACES) protocol as the curriculum for PoCUS training. Participants were assessed during 72 simulated emergency cardiorespiratory scenarios. Their ability to complete an ACES scan independently was assessed. Data was analyzed using R software.

Results

Participants independently generated 574 (99.7%) of the 576 expected ultrasound windows during the 72 simulated scenarios and correctly interpreted 67 (93%) of the 72 goal-directed PoCUS scans.

Conclusions

Following a focused training process using medical simulation, medical learners demonstrated an ability to achieve a degree of competency to both acquire and correctly interpret cardiorespiratory PoCUS findings using a high-fidelity ultrasound simulator.     

Analysis of trainees' memory after classroom presentations of didactical ultrasound courses

Background

Emergency ultrasound is gaining importance in medical education. Widespread teaching methods are frontal presentations and hands-on training. The primary goal of our study was to evaluate the impact of frontal presentations (PS) by analysis of retained knowledge rate (RKR) and learning load (LL).

Methods

Our study was conducted during four introductory courses in emergency ultrasound covering Extended Focused Assessment with Sonography for Trauma (E-FAST) and Focused Echocardiography Evaluation in Life Support (FEEL). Standardized PS (length of 10 to 50 min) were presented by experienced trainers, who were asked to provide keywords, key messages, and images and assign a score to each. Group 1 consisted of 11 medical students with no prior ultrasound experience, and group 2 consisted of 80 physicians. Each group was audience to seven to eight standard PS and requested to answer a free text questionnaire after 0 h, 2.5 h, 24 h, and 14 days.

Results

In group 1, 168/176 questionnaires were analyzed, and 161/202 were analyzed in group 2. RKR in group 1 was 32.5%, 15%, 16%, and 12% at 0 h, 2.5 h, 24 h, and 2 weeks. The physicians'' RKR were 23%, 20.5%, and 22.4% after 0, 2.5, and 24 h of a respective PS. The LL was 1.6/min for students and 1.2/min for physicians. There was no difference in RKR when comparing PS with higher and lower LL for both groups; shorter or case-based PS were associated with a higher RKR (p < 0.01).

Conclusions

Our study provides evidence that only a limited amount of information can be processed at a time. Only 12% of knowledge is retained after 2 weeks. Presentations of short duration can increase the retained knowledge rate. Therefore, frontal presentations and classroom-based ultrasound training and teaching should be adapted.     

A low cost,high fidelity nerve block model

Background

We have constructed a simple, inexpensive simulation model for ultrasound guided nerve blocks. To date there are no low cost, high fidelity models for nerve block simulations. The models that do exist are expensive and vaguely resemble actual anatomy. As ultrasound guided nerve blocks become more common in medical education it is essential to develop better training models to help increase the comfort level of the individual provider and increase the chances for success during live-patient procedures [Anaesth Intensive Care 37: 824-829, 2009].

Methods

The nerve block model was produced with a single pork loin with pressure-injected ultrasound gel through both CAT 5 cable and IV tubing inserted length-wise into the pork loin.

Results

Our nerve block model had a realistic, life-like feel simulating human tissue.

Conclusion

This ultrasound nerve block model was inexpensive with life-like feel allowing resident trainees to develop more confidence and tactile skill to increase the chance for success.     

Dental students' knowledge and attitudes towards cone beam computed tomography in Turkey

Objective

The aim of this study was to evaluate students'' knowledge and attitudes regarding cone beam CT (CBCT).

Methods

A questionnaire consisting of 11 questions was given to 472 dental students (280 pre-graduate and 192 post-graduate) at two institutions located in Ankara, Turkey (Ankara University, Faculty of Dentistry, and Gazi University, Faculty of Dentistry). Differences in responses by institution, education level and sex were statistically assessed with the χ² test.

Results

Statistical results showed that only 63.3% of students had heard of CBCT. Of these, 59.9% said they had learned about CBCT in their classes, 31.0% in seminars and 20.9% from the internet; 76.8% felt that CBCT was not given adequate coverage in their courses; 69% thought that CBCT should be taught as part of their clinical education; 91% thought it essential for CBCT to be available at dental faculties; 53.5% believed that the use of CBCT would become more widespread in the near future; and 84.9% wished to use CBCT technology in their future careers.

Conclusion

This research suggests that efforts should be made to improve students'' knowledge base regarding CBCT and that the dental school curriculum should devote more curriculum time to this promising new technology.     

Lung ultrasound imaging in avian influenza A (H7N9) respiratory failure

Background

Lung ultrasound has been shown to identify in real-time, various pathologies of the lung such as pneumonia, viral pneumonia, and acute respiratory distress syndrome (ARDS). Lung ultrasound maybe a first-line alternative to chest X-ray and CT scan in critically ill patients with respiratory failure. We describe the use of lung ultrasound imaging and findings in two cases of severe respiratory failure from avian influenza A (H7N9) infection.

Methods

Serial lung ultrasound images and video from two cases of H7N9 respiratory failure requiring mechanical ventilation and extracorporeal membrane oxygenation in a tertiary care intensive care unit were analyzed for characteristic lung ultrasound findings described previously for respiratory failure and infection. These findings were followed serially, correlated with clinical course and chest X-ray.

Results

In both patients, characteristic lung ultrasound findings have been observed as previously described in viral pulmonary infections: subpleural consolidations associated or not with local pleural effusion. In addition, numerous, confluent, or coalescing B-lines leading to ‘white lung’ with corresponding pleural line thickening are associated with ARDS. Extension or reduction of lesions observed with ultrasound was also correlated respectively with clinical worsening or improvement. Coexisting consolidated pneumonia with sonographic air bronchograms was noted in one patient who did not survive.

Conclusions

Clinicians with access to point-of-care ultrasonography may use these findings as an alternative to chest X-ray or CT scan. Lung ultrasound imaging may assist in the efficient allocation of intensive care for patients with respiratory failure from viral pulmonary infections, especially in resource scarce settings or situations such as future respiratory virus outbreaks or pandemics.     

High school rugby players' understanding of concussion and return to play guidelines

Objective

To document high school players'' understanding and attitudes towards concussion return to play guidelines.

Methods

A questionnaire based survey was performed of national high school rugby players as to their knowledge of existing concussion return to play guidelines.

Results

A total of 600 male players were surveyed, and 477 responded (response rate 80%). Half (237/477) were aware of concussion guidelines, and 60% (288/477) identified the mandated stand down period that is part of the regulations governing rugby football. Players obtained their information primarily from: teachers/coaches (239 responses), medical personnel (200), and other players (116). Of those players who suspected that they had been concussed (296/477, 62%), only 66 returned to play after medical clearance.

Conclusions and implications

This sample of high school players showed a limited knowledge of the concussion guidelines covering their sport, and even when concussed did not follow recommended protocols. This indicates the need for an increased focus on player education.     

Detection of soft tissue foreign bodies by nurse practitioner-performed ultrasound

Background

This study aimed to evaluate the accuracy of emergency nurse practitioner (NP)-performed point-of-care ultrasound (POCUS) for the detection of soft tissue foreign bodies (FBs).

Methods

Following a 2-h training session, ten NPs were assessed on their ability to detect various FBs in an experimental model. FBs (wood, metal and plastic) were inserted randomly into eight experimental models (uncooked chicken thighs) by an independent observer. Control experimental models had no FB inserted, but all had a 1-cm incision made on their surface. NPs, blinded to the type of model, were then assessed on their ability to detect the FBs by ultrasound examination using high-frequency linear transducers (Toshiba Nemio). Models were also scanned by two experienced emergency physicians (EPs) as a further control.

Results

Overall, NP-performed POCUS detected 47 of the 60 foreign bodies with a sensitivity, specificity, positive predictive value and negative predictive value of 78.3%, 50%, 82% and 43%, respectively, compared with 83.3%, 75%, 90.9% and 60% for EPs. Sensitivity for detecting specific types of FB was 95%, 85% and 50% for wood, metal and plastic, respectively, for NP-performed POCUS, compared with 100%, 100% and 50% in the EP group.

Conclusions

NPs with no previous ultrasound experience can detect soft tissue FBs with accuracy comparable to that of EPs in an experimental model. Test sensitivity was high for wood and metal foreign bodies. Specificity was generally low.     

A comparison of free-hand vs laser-guided long-axis ultrasound techniques in novice users

Objective:

The increasing use of point-of-care ultrasonography for targeted procedures justifies a device that helps both novices in training and experts perform the long-axis needle approach. The initial success of traditional needle guidance devices in reducing the time of target procedures is not universal and they can be cumbersome. We aim to investigate whether the less bulky and previously untested laser guide can succeed in reducing procedure time in novice ultrasonographers.

Methods:

82 medical students with no ultrasound experience volunteered. Random allocation determined whether, during a targeted procedure in a turkey breast and olive phantom, participants were assisted by the laser guide or not. The time taken to pierce the target was recorded at 1-cm depth.

Results:

The mean procedure time in the laser-assisted (LA) group was 25.1 s (14.0 s; 18.0–25.0 s). The mean procedure time in the free-hand group was 45.5 s (23.0 s; 7.0–55.0 s). The procedure time in the LA group was significantly reduced (p<0.01).

Conclusion:

The laser guide significantly improved procedure times. It is felt that the cheaper, smaller, easy to integrate, sterile and more user-friendly laser guidance unit may be a better alternative to the needle guide in improving procedure times for the novice ultrasonographer or to assist the expert, during training for, or performance of, ultrasound-guided targeted procedures.

Advances in knowledge:

Following from the prototype paper, this is the first study to investigate the effectiveness of attaching a laser-guidance device to an ultrasound probe. The device succeeded in reducing the procedure times of targeted procedures.Over the past 20 years, the development of ultrasound equipment that is both affordable and compact has permitted the development of point-of-care ultrasonography, a technology that is increasingly used by a variety of medical specialities and performed by clinicians whose primary specialisation is not radiology [1]. Point-of-care ultrasonography in the form of ultrasound guidance can improve the success rate, and reduce the complication rate, of many clinical procedures [2].This partnership of needle tip and imaging permits the clinician to achieve direct continuous observation of the needle tip and, more importantly, its relation to the target site and surrounding anatomy. However, although most novices master basic ultrasound skills easily, it was found that under ultrasound guidance, 70% of beginners failed accurately to locate an advancing needle tip. Education in basic needle insertion techniques is therefore a priority [3].Needle insertion can be performed in one of two ways. The long-axis, or in-plane, approach, which aligns the needle and the long axis of the ultrasound beam, achieves a more complete view of the needle. By contrast, during the short-axis, or out-of-plane, approach, where the needle is aligned perpendicular to the ultrasound beam, the on-screen image of the needle is only a small white dot and therefore the exact location of the needle tip in relation to collateral structures is less certain.However, even during the long-axis approach, the location of the needle tip is only a certainty if the clinician can align the needle within the short axis of the ultrasound beam, which may be only 0.3 mm wide. This difficult skill may be learned and/or performed more quickly by attaching one of the two types of assisting apparatus (a needle guide or a portable laser guide) down the midline of the ultrasound probe [4–8]; a line present on most probes, which marks the location and orientation of the ultrasound beam. By eliminating some of the potential planes of error, these devices can assist the operator in the long-axis alignment of the needle and the ultrasound beam.The needle guide fixes the needle in place, whereas the portable laser guide, as used in this study (Figure 1), assists the operator by projecting onto the skin a laser line that mimics the invisible ultrasound beam. Using the laser, the operator can only remove two planes of error if, whilst keeping the probe stationary, they penetrate the skin, bisect the projected line and ensure that the length of the needle shaft remains within the projected laser beam at all times during the procedure. This requires more hand–eye co-ordination than the needle guide; however, the laser guide does permit some flexibility of movement which, over time, will improve the operator''s hand–eye co-ordination (for use when assisting apparatus is unavailable) and also allows the laser guide to be ignored, should the more experienced operator prefer. With this in mind, the laser guide might not only be of use in training the novice but also appeal more than the needle guide to the specialist ultrasonographer. There are currently no published trials investigating the success of using an in-plane laser guide in either novices or experts.Open in a separate windowFigure 1.Diagram of ultrasound probe, laser and needle. The ultrasound probe (top left) is attached to the activated laser guidance device (bottom right), which is in-plane with the invisible ultrasound beam (bottom left). If the user bisects the projected laser beam (bottom right) when penetrating the skin with the needle and keeps the shaft of the needle (bottom right) within the laser beam during the procedure, then the laser can assist the user in keeping the needle in-plane with the ultrasound beam as demonstrated.In this in vitro study, we investigate whether a portable laser guidance unit can assist novices in performing an in-plane ultrasound-guided targeted procedure using a turkey breast and olive phantom [9]. The null hypothesis is that the portable laser guidance unit does not significantly improve the time taken to puncture the target.     

Quantified ultrasound elastography in the assessment of cutaneous carcinoma

Objective:

To evaluate the feasibility of high-frequency ultrasound and ultrasound elastography (USE) in discriminating benign from malignant skin lesions in a prospective cohort study and to introduce the use of a “strain ratio” for evaluation of skin lesions.

Methods:

A commercial ultrasound system with a 14-MHz transducer was used to visualize skin lesions requiring biopsy on clinical evaluation. Anatomic ultrasound and USE imaging of the skin lesions was performed using 2- to 4-mm gel stand-off pads. A region of interest was manually selected over the area of each lesion with the lowest strain. The concept of a strain ratio of the compressibility of the normal skin at the corresponding layer to that of the least compressible region of a lesion in question was created and applied. This ratio was subsequently correlated with blind histopathological evaluation for malignancy.

Results:

55 patients were included in the study with a total of 67 lesions evaluated. 29 lesions were malignant and 38 benign. All malignant lesions had strain ratios ≥3.9. All benign lesions had strain ratios ≤3.0. A diagnostic value between 3.0 and 3.9 would result in 100% sensitivity and specificity in the characterization of these lesions as malignant.

Conclusion:

This pilot study demonstrated that USE plus strain ratio appears to be a promising modality in providing diagnostic determination between cancerous and benign primary solitary skin lesions prior to biopsy.

Advances in knowledge:

This is the first reported study applying an original mathematical elastographic ratio, or strain ratio, to evaluate primary solitary skin lesions.     

Unusual new signs of pneumothorax at lung ultrasound

Background

The diagnosis of pneumothorax with a bedside lung ultrasound is a powerful methodology. The conventional lung ultrasound examination consists of a step-by-step procedure targeted towards the detection of four classic ultrasound signs, the lung sliding, the B lines, the lung point and the lung pulse. In most cases, a combination of these signs allows a safe diagnosis of pneumothorax. However, the widespread application of sonographic methodology in clinical practice has brought out unusual cases which raise new sonographic signs. The purpose of this article was to introduce some of these new signs that are described after the analysis of unusual and complex cases encountered during the clinical daily practice in an emergency department.

Findings

The double lung point consists of the alternating patterns of sliding and non-sliding lung intermittently appearing at the two opposite sides of the scan. The septate pneumothorax allows B lines and lung pulse to be still visible in a condition of pneumothorax with absent sliding. In hydropneumothorax, the air/fluid border is imaged by lung ultrasound as the interposition between an anechoic space and a non-sliding A-pattern, a sign that may be named hydro-point.

Conclusions

In bedside lung ultrasound, the operator should be aware and interpret double lung point, septate pneumothorax and hydro-point. The conventional diagnostic protocol of bedside lung ultrasound for pneumothorax should be occasionally adapted to such complex cases.     

Point-of-care ultrasound evaluation and puncture simulation of the internal jugular vein by medical students

Objectives

To show that medical students can evaluate the internal jugular vein (IJV) and its anatomical variations after rapid and focused training. We also aimed to evaluate the success rate of IJV puncture in simulation following traditional techniques (TTs) and monitored via ultrasound (US).

Materials and methods

Six medical students without experience with US were given 4 h of theoretical–practical training in US, and then evaluated the IJV and common carotid artery (CCA) of 105 patients. They also simulated a puncture of the IJV at a demarcated point, where a TT was theoretically performed.

Results

Adequate images were obtained from 95% of the patients; the IJV, on the right side, was more commonly found in the anterolateral position in relation to the CCA (38%). On the left side, the most commonly position observed was the anterior (36%). The caliber of the IJV relative to the CCA greatly varied. The success rate in the IJV puncture simulation, observed with US, by the TTs was 55%.

Conclusion

The training of medical students to recognize large neck vessels is a simple, quick, and feasible task and that can be integrated into the undergraduate medical curriculum.

     

An evaluation of efficacy of ultrasonography in the diagnosis of head and neck swellings

Objective

The aim of this study was to evaluate the efficacy of ultrasonography in the diagnosis of swellings in the head and neck regions.

Methods

For this study, 70 cases with clinically obvious swellings in head and neck regions were selected randomly. The ultrasonographic features considered were shape, boundary, echo intensity, ultrasound architecture of lesion, posterior echoes and ultrasound characteristic of tissues. Intergroup comparisons were made between four different types of swellings: inflammatory; cystic; benign; and malignant.

Results

A comparison was made between benign and malignant neoplasms, and the criteria of boundary, echo intensity and ultrasound architecture of lesions are statistically significant as the P-value is <0.05. The comparison of inflammatory swellings and malignant neoplasms shows that criteria of boundary and ultrasound architecture of lesions are statistically significant. The comparison of cystic swellings and benign neoplasms concluded that only the criterion of ultrasound characteristics of tissues is statistically significant. The comparison of inflammatory swellings and benign neoplasms shows that the criteria of boundary and echo intensity are statistically significant. The comparison of inflammatory swellings and cystic swellings concluded that the criteria of boundary, shape, echo intensity, posterior echoes and ultrasound characteristics of tissues are statistically significant. The comparison of cystic swellings and malignant neoplasms concluded that the criteria of ultrasonography, boundary, shape, echo intensity, ultrasound architecture of lesion, posterior echoes and ultrasound characteristics of tissues are statistically significant as the P-value is <0.05.

Conclusion

It can be concluded that clinical diagnosis had a sensitivity and accuracy of 85.7% and ultrasonographic diagnosis had a sensitivity and accuracy of 98.5%.     

Optimising a curriculum for clinical haematology and biochemistry in sports medicine: a Delphi approach

Objectives

To investigate issues of curriculum in the context of a postgraduate sports medicine training programme, specifically in the field of clinical biochemistry and haematology.

Methods

Following the Delphi methodology, a series of sequential questionnaires was administered to curriculum developers, clinical teachers, examiners, and registrars.

Results

Agreement on a core syllabus for this subject with an indication of the core aims and objectives of teaching and learning in this field and the associated required skills and competencies. An indication of current and ideal teaching and learning methods and reasons for these preferences. A consensus of key features of a teaching module for this field and of appropriate methods of examination.

Conclusions

The data derived from this study, as well as the experience of engaging in it, will better inform curriculum developers, teachers, and students of one another''s perceptions as to what is important in and appropriate to teaching and learning in this field of sports medicine. Engagement in the exercise and broader consideration of the outcomes by those who develop the curriculum, teach, and formulate the examination process will facilitate attainment of the ideal of well aligned teaching, learning, and examination in this specific field.     

Prehospital stroke diagnostics based on neurological examination and transcranial ultrasound

Background

Transcranial color-coded sonography (TCCS) has proved to be a fast and reliable tool for the detection of middle cerebral artery (MCA) occlusions in a hospital setting. In this feasibility study on prehospital sonography, our aim was to investigate the accuracy of TCCS for neurovascular emergency diagnostics when performed in a prehospital setting using mobile ultrasound equipment as part of a neurological examination.

Methods

Following a ‘911 stroke code’ call, stroke neurologists experienced in TCCS rendezvoused with the paramedic team. In patients with suspected stroke, TCCS examination including ultrasound contrast agents was performed. Results were compared with neurovascular imaging (CTA, MRA) and the final discharge diagnosis from standard patient-centered stroke care.

Results

We enrolled ‘232 stroke code’ patients with follow-up data available in 102 patients with complete TCCS examination. A diagnosis of ischemic stroke was made in 73 cases; 29 patients were identified as ‘stroke mimics’. MCA occlusion was diagnosed in ten patients, while internal carotid artery (ICA) occlusion/high-grade stenosis leading to reversal of anterior cerebral artery flow was diagnosed in four patients. The initial working diagnosis ‘any stroke’ showed a sensitivity of 94% and a specificity of 48%. ‘Major MCA or ICA stroke’ diagnosed by mobile ultrasound showed an overall sensitivity of 78% and specificity of 98%.

Conclusions

The study demonstrates the feasibility and high diagnostic accuracy of emergency transcranial ultrasound assessment combined with neurological examinations for major ischemic stroke. Future combination with telemedical support, point-of-care analysis of blood serum markers, and probability algorithms of prehospital stroke diagnosis including ultrasound may help to speed up stroke treatment.     

Pleuropulmonary and abdominal paragonimiasis: CT and ultrasound findings

Objectives

The purpose of this study was to review radiological images of patients with Paragonimus westermani (PW) that simultaneously involved the chest and abdomen.

Methods

Our study included four patients with serologically and histopathologically confirmed paragonimiasis. Abdomen CT (n=3) and chest CT (n=3) scans were available, and abdominal wall ultrasonography was performed in all patients. We retrospectively reviewed the clinical, radiological and histopathological findings of these patients.

Results

The most common abdominal CT findings were ascites and intraperitoneal or abdominal wall nodules. Low-attenuated serpentine lesions of the liver were another common and relatively specific feature.

Conclusion

Radiologists should consider the possibility of PW when these abdominal CT findings are noted, especially with pleural effusion or subpleural nodules in patients with initial abdominal symptoms.Paragonimiasis is a food-borne infection caused by the lung fluke Paragonimus westermani (PW). Human infection occurs by ingestion of raw or pickled freshwater crustaceans, such as crab or crayfish, that are infected with metacercariae. The disease is endemic in certain areas of the Far East and South-East Asia [1]. Recently, paragonimiasis has been detected worldwide owing to an increase in the number of travellers and the expansion of food trading [2]. Once ingested, the juvenile flukes travel through the small intestinal wall and diaphragm and reach the pleural cavity from the peritoneal cavity in 3–8 weeks [3]. The chest and abdomen are routine areas of migration of PW; however, few case reports are available on the CT findings in cases of pleuropulmonary paragonimiasis with simultaneously appearing abdominal lesions. We describe the CT and ultrasound findings of paragonimiasis in four patients who were hospitalised with initial abdominal manifestations and were subsequently confirmed to have pleuropulmonary and abdominal paragonimiasis.     

Attitudes towards exercise and physical activity behaviours in Greek schoolchildren after a year long health education intervention

Objective

To examine the short term effects of a health education programme on Greek primary schoolchildren

Methods

The school based intervention programme was applied to 29 children in the 6th grade of the 2nd Primary School of Agios Stefanos (∼12 000 inhabitants); 49 pupils from the 1st Primary School constituted the control group. To assess the effectiveness of the intervention, attitude and behavioural variables were measured before and after the intervention.

Results

After adjustment for initial differences in the assessed variables, pupils who took part in the intervention had more positive attitudes towards physical activity than the control group and scored significantly more highly on their intention to participate in physical activity. Moreover, pupils in the intervention group reported more hours/week spent in organised physical activities than pupils in the control group (mean (SD) 3.54 (0.32) v 2.54 (0.26), p<0.020). Finally, a higher proportion of pupils in the intervention classes matched the recommendations of 60 minutes of moderate to vigorous physical activity daily (77.4% v 55.1%, p<0.043).

Conclusions

Within the limitations of the study, the data show that school health education programmes have the potential to slow the age related decline in physical activity and help pupils establish lifelong, healthy physical activity patterns. Promoting healthy habits and physical activity behaviours during childhood may prevent some of the leading causes of morbidity and mortality in the Greek population, and also decrease direct healthcare costs and improve quality of life.     

Comparison of the sensitivity for detecting foreign bodies among conventional plain radiography,computed tomography and ultrasonography

Objective

The purpose of this study was to compare the sensitivity for detecting foreign bodies among conventional plain radiography, CT and ultrasonography in in vitro models.

Methods

Seven different materials were selected as foreign bodies with dimensions of approximately 1×1×0.1 cm. These materials were metal, glass, wood, stone, acrylic, graphite and Bakelite. These foreign bodies were placed into a sheep''s head between the corpus mandible and muscle, in the tongue and in the maxillary sinus. Conventional plain radiography, CT and ultrasonography imaging methods were compared to investigate their sensitivity for detecting these foreign bodies.

Results

Metal, glass and stone can be detected with all the visualization techniques used in the study in all of the zones. In contrast to this, foreign bodies with low radiopacity, which could be detected in air with CT, became less visible or almost invisible in muscle tissue and between bone and muscle tissue. The performance of ultrasonography for visualizing foreign bodies with low radiopacity is relatively better than CT.

Conclusions

Ultrasonography detects and localizes superficial foreign bodies with low radiopacity in the tissues of the body more effectively than CT and conventional plain radiography. However, CT is a more effective technique for visualization of foreign bodies in air than ultrasound and conventional plain radiography.     

Observer Variability and the Performance between Faculties and Residents: US Criteria for Benign and Malignant Thyroid Nodules

Objective

To evaluate the interobserver variability and performance in the interpretation of ultrasonographic (US) findings of thyroid nodules.

Materials and Methods

72 malignant nodules and 61 benign nodules were enrolled as part of this study. Five faculty radiologists and four residents independently performed a retrospective analysis of the US images. The observers received one training session after the first interpretation and then performed a secondary interpretation. Agreement was analyzed by Cohen''s kappa statistic. Degree of performance was analyzed using receiver operating characteristic (ROC) curves.

Results

Agreement between the faculties was fair-to-good for all criteria; however, between residents, agreement was poor-to-fair. The area under the ROC curves was 0.72, 0.62, and 0.60 for the faculties, senior residents, and junior residents, respectively. There was a significant difference in performance between the faculties and the residents (p < 0.05). There was a significant increase in the agreement for some criteria in the faculties and the senior residents after the training session, but no significant increase in the junior residents.

Conclusion

Independent reporting of thyroid US performed by residents is undesirable. A continuous and specialized resident training is essential to enhance the degree of agreement and performance.     

Diagnostic ultrasound patterns of parotid glands in human immunodeficiency virus-positive patients in Mulago,Uganda

Objectives

The purpose of this study was to determine sonographically, in parotid glands of human immunodeficiency virus-positive patients, the condition of glands with or without enlargement, and propose a classification system for the patterns observed using diagnostic ultrasound imaging.

Methods

In this prospective clinical study, ultrasound scans were performed on 200 patients aged 4–62 years at Mulago Hospital, Uganda.

Results

There were four main distinct ultrasound pathological patterns in the parotids, i.e. lymphocytic aggregations (LAs), lymphoepithelial cysts (LECs), fatty infiltration (FI) and lymphadenopathy only. There were additional subdivisions depending on the presence of echogenic foci and intraparotid lymphadenopathy. Of those patients (n = 64) without parotid enlargement, only 8% showed normal ultrasound features, whereas 34% showed LECs and 31% showed LAs. Of those (n = 136) with parotid enlargement, 46% showed LECs, 23% showed FI and 15% showed LAs. The overall prevalence of LECs in the study sample was 42%. LECs were multiple, mainly between 7 mm and 12 mm in diameter and 26% showed internal echogenic foci either mobile or stationary. In contrast, LAs tended to be ill-defined, less than 5 mm and were not associated with posterior acoustic enhancement. Features differentiating LAs from LECs have not been previously described. Parotid FI (lipodystrophy) was noted in patients on highly active antiretroviral therapy, who showed lesser prevalence of LECs after 12 months of treatment.

Conclusions

Our study of 200 patients is probably the largest such study in the English language literature. The wide spectrum of diagnostic ultrasound patterns was categorized into four main groups (ten subgroups).     

The utilisation of radiology for the teaching of anatomy in Canadian medical schools

Objective

To determine the utilisation of diagnostic imaging (radiology) as a department and/or imaging medium in the teaching of anatomy at the Canadian undergraduate medical education level.

Methods

The study objectives were achieved through the use of a questionnaire and a literature review. The anatomy department head at each English-based Canadian Medical School was contacted, and the individual most responsible for anatomy teaching in the medical school curriculum was identified. This individual was subsequently asked to complete a questionnaire that evaluated the involvement of radiology for anatomy teaching in their curriculum.

Results

The use and integration of radiology is a common practice in the teaching of anatomy in Canadian undergraduate medicine. Although the methods and extent of its use varied among institutions, every English-based Canadian medical school, except one, was using diagnostic imaging material in their instruction of anatomy. Furthermore, half of the institutions had a radiologist as a faculty member of their anatomy department to help teach and to use imaging to its full potential.

Discussion

This audit of anatomy departments suggests that diagnostic imaging has an important role to play in anatomy teaching in Canadian English-speaking medical schools.