Focused cardiac ultrasound training in medical students: Using an independent, simulator-based curriculum to objectively measure skill acquisition and learning curve.

BACKGROUND: Using simulators built and validated at the University of Washington (UW), the study sought to test whether medical students can learn the basic skills of focused cardiac ultrasound (FoCUS) from an individually paced, simulator-based curriculum, how skills improve, and the rate at which these skills are acquired. METHODS: The curriculum presented didactic material interspersed with hands-on practice. Psychomotor skill was measured by the angle error of the acquired image view plane relative to the correct image view plane. The rate of learning was assessed at baseline, after 7 practice cases, and after 10 cases. To assess the rate of learning, the same case was repeatedly presented at all three tests. To assess students' ability to apply their learning, a previously unseen post-test was included. RESULTS: A total of 41 students completed the course. Average angle error improved from 43° ± 24 pretraining to 23° ± 16 post-training, with most students falling within one SD of the view angle acquired by sonographers. Regarding learning curve, or the rate of skill acquisition, an angle error of 43 ± 24° (pre) changed to 22 ± 14° (interim test, P < .0001 vs. pretest) and remained at that level for the post-test evaluation on both the repeated case (23 ± 16°) and the new case (26 ± 18°). CONCLUSIONS: This study describes the learning curve and technical skill acquisition in FoCUS. A simulator-based curriculum improved medical student's skills in an objective and quantifiable manner. The individually paced curriculum allowed for independent knowledge and skill attainment, without facilitator oversight.

Left ventricular hypertrophy is a possible biomarker for early mortality after type B aortic dissection.

OBJECTIVE: Data regarding the cardiac abnormalities associated with Stanford type B aortic dissection (TBAD) and whether these abnormalities are related to outcomes are limited. We describe the prevalence of cardiac abnormalities in patients with TBAD as detected by echocardiography. METHODS: This retrospective review included patients with TBAD presenting between 1990 and 2016. Echocardiograms performed within 6 weeks of acute TBAD were reviewed. Cardiac function, valve abnormalities, and stigmata of hypertensive heart disease including left ventricular hypertrophy (LVH) were ascertained. Characteristics of patients who did and did not receive echocardiograms were compared. Outcomes of patients with and without evidence of LVH on echocardiography were also compared. RESULTS: Of 239 patients with TBAD, 90 had echocardiograms performed within 6 weeks of acute TBAD (74% male; mean age, 57.8 ± 13.2 years). Echocardiograms were obtained at a median of 2 days (range, 0-41 days) from acute TBAD. Patients who had echocardiograms were more likely to present with malperfusion (28% vs 14%; P < .01) and had a trend toward increased operative repair during the subacute phase (17.4% vs 9.5%; P = .07) compared with patients who did not receive an echocardiogram. A majority of patients (57%) had at least mild LVH, including 39% of patients without a prior diagnosis of hypertension. Fibrocalcific changes associated with hypertension, including aortic sclerosis and mitral annular calcification, were noted in 40% and 11% of the patients, respectively. Among patients with LVH, there was a trend toward higher all-cause mortality (35% vs 23%; P = .21) and a younger age at death (58 ± 14 years vs 66 ± 13 years; P = .19) despite a similar age at TBAD onset. In a multivariable analysis controlling for age, sex, and admission estimated glomerular filtration rate, LVH independently predicted all-cause mortality (hazard ratio, 2.38; 95% confidence interval, 1.02-5.56; P = .04). CONCLUSIONS: LVH and other findings of hypertensive heart disease are common in patients with TBAD. LVH predicted all-cause mortality after TBAD in this small group of patients. Further exploration of the relationship between the chronic effects of hypertension and using LVH as an objective biomarker to risk stratify patients with TBAD and long-term outcomes after TBAD is warranted.

Getting to the Heart of the Matter: A 20-Year-Old Man With Fever, Rash, and Chest Pain.

Infection with Helicobacter cinaedi can encompass a wide spectrum of clinical manifestations, including fever, rash, endocarditis, osteomyelitis, and meningitis. The present case demonstrates the ability of H cinaedi to masquerade as acute rheumatic fever and represents the first reported case of cardiac tamponade caused by H cinaedi.

Quantitative Feedback Facilitates Acquisition of Skills in Focused Cardiac Ultrasound.

INTRODUCTION: With the development of portable, affordable ultrasound machines with good image quality, many physicians have adopted focused cardiac ultrasound (FoCUS). To facilitate acquisition of these skills, we developed a simulator-based, self-taught curriculum for FoCUS that provides immediate feedback for rapid performance improvement. METHODS: Twenty-two first-year residents participated in the study. The curriculum consisted of instructive modules teaching image acquisition and interpretation of standard echocardiography views and common cardiac pathology, 7 practice cases in which participants scanned a mannequin using a mock transducer, acquired specified views with feedback provided by visual guidance technology, and interpreted these images. Trainees were tested pretraining and posttraining on different cases, without visual guidance assistance or feedback. Previously validated metrics were used to assess psychomotor skill in terms of the angle error in degrees between the planes of the optimal view, defined anatomically, and of the acquired view, as well as cognitive skill in image interpretation. RESULTS: The average error in image acquisition decreased from a median of 81 degrees at the pretest to 28 degrees after training (P < 0.0001). Cognitive skill improved by 29% (21%, P < 0.0001). There was a significant correlation between cognitive and psychomotor skill (r = 0.64, P < 0.001). DISCUSSION: A novel, simulator-based curriculum that provides immediate feedback was effective in teaching both psychomotor and cognitive skills in FoCUS without need for direct expert oversight of the learner. The curriculum's components provide a useful tool that can be applied to improve, assess, and monitor physician skill in FoCUS.

Total Artificial Heart as Bridge to Transplantation for Severe Culture-Negative Prosthetic Valve Endocarditis Due to Gemella haemolysans.

We report a rare case of a patient with prosthetic valve endocarditis (PVE) requiring implantation of a total artificial heart (TAH) as a bridge to heart transplantation. Gemella haemolysans, an unusual cause of PVE, was identified as the organism responsible only by 16s rRNA polymerase chain reaction analysis of surgical tissue samples. We also describe one of the first uses of combined TAH and veno-venous extracorporeal membrane oxygenation therapy in the setting of severe respiratory and cardiac failure. Implantation of a TAH may be considered in situations where more traditional reconstructive methods are not feasible.

Echo simulator with novel training and competency testing tools.

We developed and validated an echo simulator with three novel tools that facilitate training and enable quantitative and objective measurement of psychomotor as well as cognitive skill. First, the trainee can see original patient images - not synthetic or simulated images - that morph in real time as the mock transducer is manipulated on the mannequin. Second, augmented reality is used for Visual Guidance, a tool that assists the trainee in scanning by displaying the target organ in 3-dimensions (3D) together with the location of the current view plane and the plane of the anatomically correct view. Third, we introduce Image Matching, a tool that leverages the aptitude of the human brain for recognizing similarities and differences to help trainees learn to perform visual assessment of ultrasound images. Psychomotor competence is measured in terms of the view plane angle error. The construct validity of the simulator for competency testing was established by demonstrating its ability to discriminate novices vs. experts.

Acquired aortic stenosis.

Aortic stenosis is the most commonly encountered valvular disease in the elderly, with approximately 2-3% of individuals over 65 years of age afflicted. The most common cause of acquired aortic stenosis is calcific degeneration, characterized by a slowly progressive, asymptomatic period which can last decades. Once symptomatic, the clinical manifestation of aortic stenosis is from functional obstruction of left ventricular outflow and the additional hemodynamic effects on the left ventricle and vasculature. With advances in echocardiography, individuals with aortic stenosis are increasingly diagnosed in the asymptomatic latent period. However, echocardiographic measures alone cannot identify clinically significant outflow obstruction as there is considerable overlap in hemodynamic severity between symptomatic and asymptomatic individuals. Current clinical guidelines predicate the timing of surgical valve replacement on the presence or absence of symptoms. Management for symptomatic, significant stenosis is surgical valve replacement as there are no current medical therapies reliably proven to decrease aortic stenosis severity or improve long-term outcomes. However, recent retrospective studies have demonstrated an association between atherosclerotic disease risk factors, such as hyperlipidemia and aortic stenosis. Given these findings, there are now advocates for prospective primary prevention trials for aortic stenosis in patients with mild or moderate valvular disease. The following paper will discuss etiology, diagnostic evaluation and therapeutic options of acquired aortic stenosis. This review will discuss etiology, diagnostic evaluation, and therapeutic options of acquired aortic stenosis.

Influence of concurrent renal dysfunction on outcomes of patients with acute coronary syndromes and implications of the use of glycoprotein IIb/IIIa inhibitors.

OBJECTIVES: The purpose of this study was to examine the in-hospital outcome and influence of glycoprotein (GP) IIb/IIIa antagonists on patients with acute coronary syndromes (ACS) across a range of renal function. BACKGROUND: Recent studies demonstrate increasing cardiovascular risk with progressive renal dysfunction. Previous studies investigating GP IIb/IIIa antagonist use have excluded patients with renal dysfunction. METHODS: Patients presenting with ACS between January 1999 and May 2000 were identified, and data on demographics, in-hospital management, and clinical events were collected using standardized definitions. Patients were stratified according to renal function assessed by calculated creatinine clearance (CrCl) at presentation. Primary outcome measures included in-hospital mortality and major bleeding events. RESULTS: Renal insufficiency was present in 312 of 889 patients. There were 40 in-hospital deaths. In non-dialysis-dependent patients, as CrCl worsened, there was a decline in utilization of routine diagnostics and therapeutics, an increase in in-hospital mortality (p = 0.002), and an increase in major bleeding (p = 0.03). Although the use of GP IIb/IIIa antagonists was associated with an increase in major bleeding (p < 0.001), there was a protective effect on in-hospital mortality (p = 0.04) after controlling for CrCl. CONCLUSIONS: Renal dysfunction is present in a substantial proportion of patients with ACS and is associated with increased in-hospital death. Although GP IIb/IIIa antagonist use in patients with ACS and renal insufficiency resulted in increased bleeding events, its administration was associated with a decreased risk of in-hospital mortality. These preliminary findings need to be confirmed in future randomized clinical trials.

Nephropathy requiring dialysis after percutaneous coronary intervention and the critical role of an adjusted contrast dose.

This study was undertaken to determine the incidence, risk factors, and in-hospital outcome of nephropathy requiring dialysis (NRD) after percutaneous coronary intervention (PCI), and to evaluate the role of a weight- and creatinine-adjusted maximum radiographic contrast dose (MRCD) on NRD. Data were obtained from a registry of 16,592 PCIs. The data were divided into development and test sets. Univariate predictors were identified and a multivariate logistic regression model was developed. The MRCD was calculated for each patient as: MRCD = 5 ml x body weight (kilograms)/serum creatinine (milligrams per deciliter). Predictive accuracy was assessed by receiver-operating characteristic curve analysis. In the development set, 41 patients (0.44%) developed NRD with a subsequent in-hospital mortality rate of 39.0%. NRD increased with worsening baseline renal dysfunction. Other risk factors included peripheral vascular disease, diabetes mellitus, congestive heart failure, and cardiogenic shock. There was a direct relation between the number of risk factors and NRD. After adjustment for baseline risk factors, MRCD was the strongest independent predictor of NRD (adjusted odds ratio 6.2, 95% confidence interval 3.0 to 12.8). NRD and in-hospital mortality were both significantly higher in patients who exceeded the MRCD compared with patients who did not (p <0.001). In conclusion, NRD following PCI is a rare complication with a poor prognosis. Baseline clinical characteristics identify patients at greatest risk for NRD. Optimization of procedural variables such as timing of the intervention relative to the diagnostic catheterization, staging coronary procedures, or dosing within the MRCD may help reduce the risk of this complication in high-risk patients. A risk prediction tool for NRD with guidelines for prevention is presented.