Development of Hands-On Skills in Diagnostics of Lung Diseases Using Ultrasonography in Undergraduate Medical Education.

This study evaluated advanced pulmonary ultrasonography training for COVID-19 lung examination. Students completed identical pretests and post-tests and a survey. Changes were found for individual questions and overall scores (all P≤.02), specifically image identification, previous material, and COVID-19 questions. Students were receptive to the training for education and future practice (P<.001), and they felt capable using ultrasound for diagnosis and management of COVID-19 patients. Pulmonary ultrasonography training should be considered for the medical school curriculum.

Variations in the cerebrospinal fluid dynamics of the American alligator (Alligator mississippiensis).

BACKGROUND: Studies of mammalian CSF dynamics have been focused on three things: paravascular flow, pressure and pulsatility, and "bulk" flow; and three (respective) potential motive forces have been identified: vasomotor, cardiac, and ventilatory. There are unresolved questions in each area, and few links between the different areas. The American alligator (Alligator mississippiensis) has pronounced plasticity in its ventilatory and cardiovascular systems. This study was designed to test the hypothesis that the greater cardiovascular and ventilatory plasticity of A. mississippiensis would result in more variation within the CSF dynamics of this species. METHODS: Pressure transducers were surgically implanted into the cranial subarachnoid space of 12 sub-adult alligators; CSF pressure and pulsatility were monitored along with EKG and the exhalatory gases. In four of the alligators a second pressure transducer was implanted into the spinal subarachnoid space. In five of the alligators the CSF was labeled with artificial microspheres and Doppler ultrasonography used to quantify aspects of the spinal CSF flow. RESULTS: Both temporal and frequency analyses of the CSF pulsations showed highly variable contributions of both the cardiac and ventilatory cycles. Unlike the mammalian condition, the CSF pressure pulsations in the alligator are often of long (~ 3 s) duration, and similar duration CSF unidirectional flow pulses were recorded along the spinal cord. Reduction of the duration of the CSF pulsations, as during tachycardia, can lead to a "summation" of the pulsations. There appears to be a minimum duration (~ 1 s) of isolated CSF pulsations. Simultaneous recordings of cranial and spinal CSF pressures reveal a 200 ms delay in the propagation of the pressure pulse from the cranium to the vertebral canal. CONCLUSIONS: Most of the CSF flow dynamics recorded from the alligators, are similar to what has been reported from studies of the human CSF. It is hypothesized that the link between ventilatory mechanics and CSF pulsations in the alligator is mediated by displacement of the spinal dura. The results of the study suggest that understanding the CSF dynamics of Alligator may provide unique insights into the evolutionary origins and functional regulation of the human CSF dynamics.

Effect of occipitoatlantal decompression on cerebral blood flow dynamics as evaluated by Doppler ultrasonography.

Context: Osteopathic manipulative treatment reduces symptoms in patients with headache disorders, but the underlying mechanisms are unclear. Objective: To evaluate blood flow in the intracranial and extracranial vasculature before and after occipitoatlantal decompression (OAD) using Doppler ultrasonography. Methods: Healthy, first-year osteopathic medical students from A.T. Still University's Kirksville College of Osteopathic Medicine participated in a randomized, single-blinded, two-period, two-treatment crossover study. The participants were randomly assigned to 1 of 2 treatment interventions: OAD or sham touch. After one week, participants returned to have the other intervention performed. Blood flow parameters-peak systolic velocity (PSV) and end-diastolic velocity (EDV)-in the middle cerebral artery (MCA), internal carotid artery (ICA), and vertebral artery (VA) were evaluated before, immediately after, 5 minutes after, and 10 minutes after treatment. Differences in PSV, EDV, heart rate (HR), and blood pressure (BP) for both interventions were analyzed for the four time points using mixed-effects models. Results: Thirty healthy medical students (11 men, 19 women; mean age, 24 years) participated in this study. EDV increased after OAD in the MCA, ICA, and VA (all p<0.001); no change occurred after sham touch (all p>0.05). EDV was greater for all post-treatment timepoints after OAD in the MCA, ICA, and VA than after sham touch (all p<0.001). Although baseline PSV in the MCA measured before treatment was different between treatment interventions (p=0.01), no difference was found between interventions at any post-treatment time point (all p>0.59). Changes in PSV in the ICA and VA and for HR and BP did not depend on treatment intervention (p>0.06). Conclusion: Increases in EDV occurred in major cranial arteries after OAD but not after sham touch, indicating that OAD improves blood flow to the brain. The exact mechanism of this increase is unknown; however, it can be explained by either parasympathetic stimulation through the secretion of vasodilating neurotransmitters or by a decrease in external tissue pressure on ICA and VA, with the resulting flow causing further dilation in the MCA.

Interprofessional Approach to Learning Vascular Access with Ultrasonography by Medical Students and Nurses.

The current study evaluated an interprofessional approach involving medical students and nurses for learning vascular access with ultrasonography. Vascular access laboratories included needle-guidance training and provided an efficient way to master technically difficult venipuncture cases. Most agreed ultrasound technology was useful for these venipuncture cases. Participants felt prepared to perform venipuncture using ultrasonography in a clinical setting after training. Such laboratories should be considered for interprofessional learning of difficult procedures in the medical school curriculum.

Development of Competency in Needle-Guided Procedures Through the Use of Soft-Embalmed Cadavers.

This study evaluated soft-embalmed human cadavers for ultrasound needle-guidance training. Second-year medical students used peripherally inserted central catheter (PICC) line and central line models and a Thiel-embalmed cadaver for training and provided feedback. Most (85%) agreed the cadaver was useful. There were positive correlations between performing the PICC line (r=0.44, P=.11) and central line (r=0.63, P=.03) procedures on a cadaver and in a clinical setting. Thiel-embalmed cadavers may provide important hands-on training.

Educational Value of Ultrasonography Used as a Diagnostic Tool by Medical Students at a Student-Run Free Clinic.

At A.T. Still University's Kirksville College of Osteopathic Medicine, Still Caring Health Connection is a student-run organization that hosts free clinic nights for the underserved. The clinics are beneficial for patients and medical students because patients receive needed medical attention and medical students get early clinical exposure. During the clinics, medical students use portable ultrasound machines to guide diagnoses. When surveyed about their use of ultrasound on clinic nights, most students responded positively.

The myodural bridge of the American alligator (Alligator mississippiensis) alters CSF flow.

Disorders of the volume, pressure or circulation of the cerebrospinal fluid (CSF) lead to disease states in both newborns and adults; despite this significance, there is uncertainty regarding the basic mechanics of the CSF. The suboccipital muscles connect to the dura surrounding the spinal cord, forming a complex termed the 'myodural bridge'. This study tests the hypothesis that the myodural bridge functions to alter the CSF circulation. The suboccipital muscles of American alligators were surgically exposed and electrically stimulated simultaneously with direct recordings of CSF pressure and flow. Contraction of the suboccipital muscles significantly changed both CSF flow and pressure. By demonstrating another influence on CSF circulation and pulsatility, the present study increases our understanding of the mechanics underlying the movement of the CSF.

Developing Neuraxial and Regional Pain Procedural Skills Through Innovative 3-Dimensional Printing Technology.

CONTEXT: Various forms of simulation-based training, including training models, increase training opportunities and help assess performance of a task. However, commercial training models for lumbar puncture and epidural procedures are costly. OBJECTIVE: To assess medical students' and residents' perception of 3-dimensional (3D)-printed lumbar, cervical, and pelvic models for mastering joint injection techniques and to determine the utility of ultrasonography-guided needle procedure training. METHODS: Osteopathic medical students and residents used in-house 3D-printed gel joint models during an injection ultrasonography laboratory for mastering lumbar epidural, caudal epidural, sacroiliac, and facet joint injection techniques. After the laboratory, they answered a 17-item survey about their perception of the importance of the models in medical education and future practice. The survey also evaluated comfort levels with performing joint injections after using the models, overall satisfaction with the models, and likelihood of using models in the future. RESULTS: Thirty-six medical students and residents participated. Both students and residents agreed that 3D-printed models were easy to use, aided understanding of corresponding procedures, and increased comfort with performing joint injections (all P<.001). Most participants (35 [97.2%]) believed that the models were reasonable alternatives to commercial models. Over half felt capable of successfully performing cervical or pelvic (22 [61.1%]) and lumbar epidural (23 [63.9%]) injections. The majority of participants (34 [94.4%]) would like to use the models in the future for personal training purposes. Overall, 100% believed that the 3D-printed models were a useful tool for injection training. CONCLUSIONS: Results suggest that 3D-printed models provided realistic training experience for injection procedures and seemed to allow participants to quickly master new injection techniques. These models offer a visual representation of human anatomy and could be a cost-saving alternative to commercial trainers.

Intracranial pressure in the American Alligator (Alligator mississippiensis): reptilian meninges and orthostatic gradients.

The cranial meninges of reptiles differ from the more widely studied mammalian pattern in that the intraventricular and subarachnoid spaces are, at least partially, isolated. This study was undertaken to investigate the bulk flow of cerebrospinal fluid, and the resulting changes in intracranial pressure, in a common reptilian species. Intracranial pressure was measured using ocular ultrasonography and by surgically implanting pressure cannulae into the cranial subarachnoid space. The system was then challenged by: rotating the animal to create orthostatic gradients, perturbation of the vascular system, administration of epinephrine, and cephalic cutaneous heating. Pressure changes determined from the implanted catheters and through quantification of the optic nerve sheath were highly correlated and showed a significant linear relationship with orthostatic gradients. The catheter pressure responses were phasic, with an initial rapid response followed by a much slower response; each phase accounted for roughly half of the total pressure change. No significant relationship was found between intracranial pressure and either heart rate or blood flow. The focal application of heat and the administration of epinephrine both increased intracranial pressure, the latter influence being particularly pronounced.

Dynamic assessment of cerebral blood flow and intracranial pressure during inversion table tilt using ultrasonography.

CONTEXT: Inversion tables are used as treatment for back pain, but there is a lack of agreement on systemic effects of inversion. OBJECTIVE: To assess intracranial pressure (ICP) and cerebral blood flow using ultrasonography during inversion table tilt. METHODS: Optic nerve sheath diameter (ONSD), heart rate (HR), blood pressure, internal carotid artery (ICA) and middle cerebral artery (MCA) blood flow of participants were measured in 3 positions: supine before inversion, during inversion with head down, and supine post-inversion. ONSD was evaluated with ocular ultrasonography and blood flow (ICA and MCA) with Doppler ultrasonography. RESULTS: The ONSD changed significantly between the supine position, at 3 min of inversion, and after returning to supine position (all P < .001). The post-inversion HR was less than pre-inversion (P = .03) and 3-min inversion HR (P = .003). There were significant changes in ICA and MCA flow caused by inversion, which affected blood flow velocity, resistance, and pulsatility index (all P ≤ .005). CONCLUSION: Inversion caused significant changes in ICP and blood flow. Thus, increased chance of complications may exist when using inversion as a therapeutic tool or during surgical procedures in patients with previous history of elevated ICP. These results demonstrate that inversion therapy should be used with caution.

Hemodynamics of tonic immobility in the American alligator (Alligator mississippiensis) identified through Doppler ultrasonography.

American alligators (Alligator mississippiensis) held inverted exhibit tonic immobility, combining unresponsiveness with flaccid paralysis. We hypothesize that inverting the alligator causes a gravitationally promoted increase in right aortic blood flowing through the foramen of Panizza, with a concurrent decrease in blood flow through the primary carotid, and thereby of cerebral perfusion. Inverting the alligator results in displacement of the liver, post-pulmonary septum, and the heart. EKG analysis revealed a significant decrease in heart rate following inversion; this decrease was maintained for approximately 45 s after inversion which is in general agreement with the total duration of tonic immobility in alligators (49 s). Doppler ultrasonography revealed that following inversion of the alligator, there was a reversal in direction of blood flow through the foramen of Panizza, and this blood flow had a significant increase in velocity (compared to the foraminal flow in the prone alligator). There was an associated significant decrease in the velocity of blood flow through the primary carotid artery once the alligator was held in the supine position. Tonic immobility in the alligator appears to be a form of vasovagal syncope which arises, in part, from the unique features of the crocodilian heart.

Integration of Ultrasonography into the Undergraduate Medical Curriculum: Seven Years of Experience.

Ultrasound education has been part of the curriculum at A.T. Still University's Kirksville College of Osteopathic Medicine for over seven years (since 2011), and has been successfully integrated into the first two years of the four-year medical school curriculum. Students master ultrasound techniques through hands-on laboratories covering all body regions and systems. Ultrasound training has the potential to enhance the medical school learning experience for students and improve the quality of their future patient care.

Integration of 3-Dimensional/4-Dimensional Ultrasound Technology into Undergraduate Medical Education: Student Perception of Innovative Obstetrics Education.

The current study assessed level of comfort of medical students using 3-dimensional/4-dimensional (3D/4D) ultrasound technology after participating in an obstetrical ultrasound educational activity. The majority of students agreed that they were capable of performing and interpreting 2-dimensional and 3D/4D obstetrical ultrasounds and that the training benefited their clinical decision-making skills. Additionally, students agreed that access to 3D/4D ultrasound technology would encourage patients to seek physician care and act as a useful tool for patient education.

A Comparison of Point-of-Care Ultrasonography Use in Rural Versus Urban Emergency Departments Throughout Missouri.

We surveyed emergency department directors at 56 Missouri hospitals about availability of ultrasound equipment, primary uses for ultrasonography, and factors that could increase ultrasonography use in the emergency departments. Results indicated large-sized hospitals, typically in urban areas, used ultrasonography more than medium-sized or small-sized hospitals. Lack of ultrasound equipment and appropriately trained physicians contributed to limited use of ultrasonography in small-sized hospitals, typically in rural areas.

Ultrasonographic Evaluation of the Effect of Osteopathic Manipulative Treatment on Sacral Base Asymmetry.

CONTEXT: Patients with low back pain (LBP) may receive osteopathic manipulative treatment (OMT) to resolve or manage their pain. The indication for OMT for patients with LBP is the presence of somatic dysfunction, diagnosed using palpatory examination. Because palpatory findings commonly have poor interexaminer reliability, the current study used ultrasonography (US) to establish pre-OMT and post-OMT musculoskeletal measurements of relative asymmetry between pelvic and sacral bony landmarks. OBJECTIVE: To document objective musculoskeletal changes that occur in response to OMT using US and to compare palpatory assessment of landmark asymmetry with US assessment. METHODS: Sixty men and women aged 20 to 55 years with at least 1 episode of LBP in the past 2 weeks were assigned to a seated control, walking control, or OMT group (20 participants per group). Participants received an initial, bilateral US measurement of the skin to posterior superior iliac spine (SPSIS), skin to sacral base position (SBP), and sacral sulcus depth (SSD). Participants in seated control and OMT groups received a palpatory assessment of SBP and SSD prior to initial US assessment. After assessment, the seated control group sat in a waiting room for 30 minutes, the walking control group walked for 5 minutes, and the OMT group received OMT to address sacral base asymmetry using predominantly direct techniques for a maximum of 20 minutes. Participants then received a second US assessment of the same structures. RESULTS: Body mass index (BMI) was correlated with SPSIS (r=0.5, P=.001) and SBP (r=0.6, P<.001). More participants in seated control (75%) and OMT (65%) groups had an increase in asymmetry from first to second US assessment for SPSIS compared with participants in the walking control group (35%, P=.05). No significant differences were found between groups for absolute asymmetry or total change in asymmetry (all P>.10). The κ was -0.1 (95% CI, -0.2 to 0.03) for SBP and -0.01 (95% CI, -0.1 to 0.1) for SSD. CONCLUSION: Musculoskeletal changes in SPSIS and SBP measurements related to OMT could not be readily identified using US. The SPSIS and SBP measurements were dependent on BMI, which may have affected the accuracy of US to detect small changes in asymmetry. Qualitative palpatory assessments did not correlate with US measurements. Further study is needed to identify US measurements that demonstrate change with OMT. (ClinicalTrials.gov number NCT02820701).

Increasing Self-Awareness of Medical Students Through the Use of Ultrasonography.

CONTEXT: Self-awareness is vital for the health and development of medical students, but few reported modalities successfully increase medical student self-awareness. OBJECTIVE: To assess the effect of ultrasonography on medical student self-awareness and health status. METHODS: In 2016, first- and second-year osteopathic medical students completed a 9-item survey, created specifically for the current study, which included questions about the use of ultrasonography, health status, and self-awareness after completing at least 1 ultrasonography course. Differences between student responses by class were analyzed using χ2 analysis for items assessing experience with ultrasonography and t tests for items assessing self-awareness. RESULTS: Of the 329 students surveyed, 192 (58.4%) reported using ultrasonography to explore or monitor their own health or body. Forty-nine students (14.9%) found out something about their health that they did not know before their exposure to ultrasonography. Significant differences were found in the use of ultrasonography between first-year and second-year students; more second-year students reported using ultrasonography outside of laboratory hours (P<.05) and discovering incidental findings (P<.05). The largest portions of students reported average health status for exercise (106 of 325 [32.6%]), stress management (174 of 324 [53.7%]), and sleep (137 of 326 [42.0%]). The largest portions of students reported very good health status for tobacco use (282 of 322 [87.6%]), alcohol use (138 of 323 [42.7%]), and healthy relationships (118 of 326 [36.2%]). Statistically significant differences existed in responses between first- and second-year students regarding exercise (P=.007) and alcohol use (P=.001). The majority of students agreed or strongly agreed (182 of 326 [55.8%]) that access to ultrasonography equipment and ultrasonography training during the first and second years of medical school increased their self-awareness. CONCLUSIONS: The results suggest that the incorporation of ultrasonography into medical education could potentially increase medical student health status and self-awareness.

Feasibility of Using Ultrasonography to Establish Relationships Among Sacral Base Position, Sacral Sulcus Depth, Body Mass Index, and Sex.

CONTEXT: Identifying relationships among anatomical structures is key in diagnosing somatic dysfunction. Ultrasonography can be used to visualize anatomical structures, identify sacroiliac landmarks, and validate anatomical findings and measurements in relation to somatic dysfunction. As part of the osteopathic manipulative medicine course at A.T. Still University-Kirksville College of Osteopathic Medicine, first-year students are trained to use ultrasonography to establish relationships among musculoskeletal structures. OBJECTIVES: To determine the ability of first-year osteopathic medical students to establish sacral base position (SBP) and sacral sulcus depth (SSD) using ultrasonography and to identify the relationship of SBP and SSD to body mass index (BMI) and sex. METHODS: Students used ultrasonography to obtain the distance between the skin and the sacral base (the SBP) and the distance between the skin and the tip of the posterior superior iliac spine bilaterally. Next, students calculated the SSD (the distance between the tip of the posterior superior iliac spine and the SBP). Data were analyzed with respect to side of the body, BMI, sex, and age. The BMI data were subdivided into normal (18-25 mg/kg) and overweight (25-30 mg/kg) groups. RESULTS: Ultrasound images of 211 students were included in the study. The SBP was not significantly different between the left and right sides (36.5 mm vs 36.5 mm; P=.95) but was significantly different between normal and overweight BMI categories (33.0 mm vs 40.0 mm; P<.001) and between men and women (34.1 mm vs 39.0 mm; P<.001). The SSD was not significantly different between left and right sides (18.9 mm vs 19.8 mm; P=.08), normal and overweight BMI categories (18.9 mm vs 19.7 mm, P=.21), or men and women (19.7 mm vs 19.0 mm; P=.24). No significant relationship was identified between age and SBP (P=.46) or SSD (P=.39); however, the age range was narrow (21-33 years). CONCLUSION: The study yielded repeatable and reproducible results when establishing SBP and SSD using ultrasonography. The statistically significant relationship between SBP and higher BMI and between SBP and female sex may point to more soft tissue overlaying the sacrum in these groups. Further research is needed on the use of ultrasonography to establish criteria for somatic dysfunction.

Innovative approach to teaching osteopathic manipulative medicine: the integration of ultrasonography.

CONTEXT: Noninvasive diagnostic methods and palpatory physical examination skills are especially important for osteopathic medical students intending to work in rural, underresourced, or underserved areas. The A.T. Still University-Kirksville College of Osteopathic Medicine integrates ultrasonography into the osteopathic manipulative medicine (OMM) courses required during the first 2 years of medical school, allowing students to learn the technology and to visualize anatomical structures and regions. OBJECTIVE: To assess the feasibility of integrating ultrasonography into the first-year and second-year OMM curriculum through the evaluation of students' success in demonstrating the technology and visualizing the anatomy. METHODS: As part of their OMM requirements at the A.T. Still University-Kirksville College of Osteopathic Medicine, all first- and second-year students in OMM courses were given ultrasonography assignments that required them to obtain images of musculoskeletal structures in different regions of the body. First-year students studied craniocervical structures and the thoracic, lumbar, and sacral regions. Second-year students studied the glenohumeral joint and the suprapatellar recess. The assignments focused on identifying structures of interest, making annotations, and measuring the structures of interest. Handouts with detailed instructions and a demonstration were provided before each assignment. RESULTS: A total of 183 first-year students and 165 second-year students participated. Of the first-year students, on average, 177 of 181 were able to successfully complete the assignments, with an average completion rate of 98%. The costotransverse joint assignment yielded the lowest completion rate (97%), and the craniocervical landmarks assignment had the highest completion rate (99%). Of the second-year students, 162 of 165 participants were able to successfully complete the assignments, with an average completion rate of 98%. Mean scores were the same for both second-year assignments. CONCLUSION: First-year and second-year osteopathic medical students successfully demonstrated their use and understanding of ultrasonography and found their assigned structures using live ultrasound imaging. The skills gained through these assignments added another dimension to students' understanding of normal and pathologic musculoskeletal anatomy and vasculature. The integration of ultrasonography into OMM courses may have created a foundation for learning ultrasound-guided injection techniques.

Impact of the clinical ultrasound elective course on retention of anatomical knowledge by second-year medical students in preparation for board exams.

Ultrasound has been integrated into a gross anatomy course taught during the first year at an osteopathic medical school. A clinical ultrasound elective course was developed to continue ultrasound training during the second year of medical school. The purpose of this study was to evaluate the impact of this elective course on the understanding of normal anatomy by second-year students. An anatomy exam was administered to students enrolled in the clinical ultrasound elective course before the start of the course and after its conclusion. Wilcoxon signed ranks tests were used to determine whether exam scores changed from the pre-test to the post-test. Scores from two classes of second-year students were analyzed. Students who took the elective course showed significant improvement in the overall anatomy exam score between the pre-test and post-test (P < 0.001). Scores for exam questions pertaining to the heart, abdomen, upper extremity, and lower extremity also significantly improved from the pretest to post-test (P < 0.001), but scores for the neck and eye showed no significant improvement. The clinical ultrasound elective course offered during the second year of medical school provided students with an important review of key anatomical concepts while preparing them for board exams. Our results suggested that more emphasis should be placed on head and neck ultrasound to improve student performance in those areas. Musculoskeletal, abdominal, and heart ultrasound labs were more successful for retaining relevant anatomical information.