Teaching hypothesis-oriented thinking to medical students: the University of Florida's clinical investigation program.

Recent studies show alarming decreases in the proportions of physicians applying for federal resources and of graduating medical students who declare strong interest in pursuing careers as physician-scientists. To expose medical students in their formative years to hypothesis-driven experimental investigations in a clinical setting, the first-year curriculum at the University of Florida has involved students as both investigators and study subjects in patient-oriented research conducted in the General Clinical Research Center (GCRC). Each year a hypothesis-driven experiment is conceived by first-year medical students in the university's MD-PhD program. Later in the year, the protocol is implemented in the GCRC by the entire freshman class, whose members serve as volunteer study subjects or as investigators. The experimental data are analyzed by the MD-PhD students, who report their findings at national biomedical research meetings and submit a manuscript on their project to a peer-reviewed journal. The authors describe students' research projects over the first six years of this GCRC-based program. They also describe the responses of former students to a questionnaire about their perceptions of the value of the research program. Most respondents considered the GCRC research exercise to have been useful and relevant to their overall education, and many more declared a current interest in pursuing research careers compared with the number who had declared such interest as freshmen. The authors conclude that early integration of hands-on, patient-oriented research into the medical school curriculum is a positive educational experience for students, and may contribute to their ultimate pursuit of academic research careers.

Guidelines for cardiac sonographer education: recommendations of the American Society of Echocardiography Sonographer Training and Education Committee.

In 1992, the American Society of Echocardiography published a report of the Sonographer Education and Training Committee's recommendations for education of sonographers who perform echocardiographic procedures. Since the publication of the original document, there has been continual progress in technology with the development of more sophisticated diagnostic applications that allow more information to be obtained from echocardiographic procedures. These recent changes in the clinical application of echocardiography should be included in all cardiac sonographer education programs. The American Society of Echocardiography, a professional society that currently represents approximately 2500 cardiac sonographers, provides these updated guidelines.

Digital analysis of myocardial contrast echocardiography: a clinical study using an air-filled agent in normal subjects.

The purpose of the present study was to determine whether direct digital image analysis would allow improved detection of myocardial contrast. Eighteen normal subjects were recruited and separated into two groups. In group 1, the time-brightness curves of the left ventricular cavity and three myocardial perfusion beds were formed from digitized video tape, with output power and imaging time as secondary variables. In group 2, curves constructed from direct polar digital data were compared, with fundamental and second harmonic image formation as variables. In group 1 subjects, using fundamental imaging, the area under the curve in the left ventricular cavity increased slightly with intermittent imaging. No consistent myocardial opacification was identified. In group 2 subjects, using intermittent imaging, the area under the myocardial curve and peak intensity increased with high output, second harmonic imaging in the left anterior descending and right coronary artery regions. Intermittent, second harmonic imaging and digital processing can demonstrate myocardial contrast even with an air-filled agent.

Dobutamine stress echocardiography in patients undergoing liver transplantation evaluation.

BACKGROUND: Coronary artery disease has an important impact on perioperative morbidity and mortality in patients undergoing liver transplantation. To assess the role of dobutamine stress echocardiography (DSE) in these patients, DSE was included in the preoperative evaluation. METHODS: Patients under consideration for liver transplantation underwent detailed clinical history, electrocardiography, and echocardiography. Patients with documented coronary disease or symptoms of myocardial ischemia underwent angiography. The remaining patients with cardiac risk factors, atypical chest pain, or age > or = 60 years underwent DSE. RESULTS: These 121 patients (77 men and 44 women) ranged in age from 34 to 73 years (mean 53). Among the 61 patients who underwent liver transplantation, DSE was normal in 25, nondiagnostic in 34 because of inadequate heart rate response, and abnormal in two patients. Major perioperative events occurred in eight patients, all with normal or nondiagnostic DSE studies (negative predictive value 86%). CONCLUSIONS: In patients with low to moderate risk of cardiac disease, DSE performed as part of an evaluation for liver transplantation is a poor predictor of major perioperative events.

Speckle reduction and contrast enhancement of echocardiograms via multiscale nonlinear processing.

This paper presents an algorithm for speckle reduction and contrast enhancement of echocardiographic images. Within a framework of multiscale wavelet analysis, we apply wavelet shrinkage techniques to eliminate noise while preserving the sharpness of salient features. In addition, nonlinear processing of feature energy is carried out to enhance contrast within local structures and along object boundaries. We show that the algorithm is capable of not only reducing speckle, but also enhancing features of diagnostic importance, such as myocardial walls in two-dimensional echocardiograms obtained from the parasternal short-axis view. Shrinkage of wavelet coefficients via soft thresholding within finer levels of scale is carried out on coefficients of logarithmically transformed echocardiograms. Enhancement of echocardiographic features is accomplished via nonlinear stretching followed by hard thresholding of wavelet coefficients within selected (midrange) spatial-frequency levels of analysis. We formulate the denoising and enhancement problem, introduce a class of dyadic wavelets, and describe our implementation of a dyadic wavelet transform. Our approach for speckle reduction and contrast enhancement was shown to be less affected by pseudo-Gibbs phenomena. We show experimentally that this technique produced superior results both qualitatively and quantitatively when compared to results obtained from existing denoising methods alone. A study using a database of clinical echocardiographic images suggests that such denoising and enhancement may improve the overall consistency of expert observers to manually defined borders.

Autonomous epicardial and endocardial boundary detection in echocardiographic short-axis images.

An autonomous endocardial and epicardial boundary detection (ABD) method is reported. One hundred ten cycles from 55 clinical studies were selected retrospectively. Image sequences were digitized at 512 x 480 pixel resolution. The point-by-point boundary positions of the ABD and the areas enclosed were compared with positions and enclosed areas drawn by three independent observers. Correlation coefficients for epicardial end-diastolic (ED) and end-systolic (ES) areas, endocardial ED and ES areas, muscle area, and fractional area change were 0.970, 0.976, 0.951, 0.985, 0.887, and 0.878, respectively. Bland-Altman analysis showed negligible biases with standard deviations comparable to those of the observers. The mean difference between the ABD border and the consensus observer border positions in 64 directions falls within the mean range of interobserver border positions, suggesting that shape is also well defined by the ABD.

Dobutamine echocardiography for prediction of ischemic events in heart transplant recipients.

The purpose of this study was to assess the use of dobutamine stress echocardiography in predicting cardiac events in heart transplant recipients. Dobutamine echocardiography was performed in 63 consecutive heart transplant recipients, 52 males and 11 females ranging in age from 12 to 77 years (mean 54), undergoing routine yearly evaluation. Twenty-one patients had abnormal wall motion at baseline or during dobutamine infusion. Over a mean follow-up of 8 months (range 4 to 14), there were six major cardiac events: five occurred among patients with abnormal echocardiography study results; only one event occurred in a patient with a normal echocardiography result. These data suggest that normal wall motion during dobutamine echocardiography identifies a subset of heart transplant recipients at low risk for development of cardiac events, whereas an abnormal study result serves as an important predictor of subsequent cardiac events.

Inhaled gases affect the ultrasound contrast produced by Albunex in anesthetized dogs.

In anesthetized animals maintained with isoflurane using 100% oxygen as a carrier gas, Albunex (Molecular Biosystems, Inc., San Diego, Calif.) produced no ultrasound contrast in the left ventricle after intravenous administration. The current study tested the hypothesis that the inhalation of gas mixtures with increased concentrations of oxygen decreased the quality and duration of Albunex-induced contrast. Albunex (0.22 mL/kg) was injected intravenously into anesthetized dogs (n = 9) breathing compressed air, oxygen, mixtures of oxygen and nitrogen, or combinations of oxygen and nitrous oxide. Albunex produced ultrasound contrast of shorter duration and decreased quality during the inhalation of gas mixtures containing increased amounts of oxygen. In the presence of inhaled gas mixtures containing nitrous oxide, Albunex produced no contrast in the left ventricle, regardless of the oxygen content. These data indicate that the inhalation of gas mixtures containing smaller amounts of nitrogen, compared with air, decreased the ability of Albunex to cause ultrasound contrast in the heart after intravenous administration.