The Use of Ultrasound Simulators to Strengthen Scanning Skills in Medical Students: A Randomized Controlled Trial.

OBJECTIVES: This study evaluates the use of ultrasound simulators for retaining and improving ultrasound skills acquired in undergraduate ultrasound training. METHODS: Fourth-year medical students (n = 19) with prior training in point-of-care sonography for shock assessment were recruited for this study. Students were randomly assigned to a study group (n = 10) that followed an undergraduate ultrasound training curriculum, then used a simulator to complete 2 self-directed practice ultrasound sessions over 4 weeks. The control group (n = 9) followed the same undergraduate ultrasound training curriculum and received no additional access to a simulator or ultrasound training. A blinded assessment of the students was performed before and after the 4-week study period to evaluate their image acquisition skills on standardized patients (practical examination). To evaluate the student's clinical understanding of pathological ultrasound images, students watched short videos of prerecorded ultrasound scans and were asked to complete a 22-point questionnaire to identify their findings (visual examination). RESULTS: All results were adjusted to pretest performance. The students in the study group performed better than those in the control group on the visual examination (80.1% versus 58.9%; P = .003) and on the practical examination (77.7% versus 57.0%; P = .105) after the 4-week study period. The score difference on the postintervention practical examinations was significantly better for the study group compared to the control group (11.6% versus -9.9%; P = .0007). CONCLUSION: The use of ultrasound simulators may be a useful tool to help previously trained medical students retain and improve point-of-care ultrasound skills and knowledge.

Accuracy of Medical Students in Detecting Pleural Effusion Using Lung Ultrasound as an Adjunct to the Physical Examination.

OBJECTIVES: This study compared the accuracy of medical students in identifying pleural effusion in hospitalized patients using the physical examination versus lung ultrasound (US). METHODS: Fourth-year medical students (n = 14) received 20 hours of general practical US training (including 2 hours of specialized lung US training) plus theoretical and video documentation. The students used the physical examination alone versus the physical examination plus lung US to document the presence or absence of pleural effusion in the right and left hemithoraces of hospitalized patients (n = 11 patients; 22 hemithoraces examined 544 times in total). The reference standard for identification of pleural effusion was a lung US examination by 2 expert point-of-care sonographers. RESULTS: The odds of correctly identifying the presence versus absence of pleural effusion was 5 times greater with lung US as an adjunct to the physical examination compared to the physical examination alone (odds ratio [OR], 5.1 from multivariate logistic regression; 95% confidence interval, 3.3-8.0). The addition of lung US to the physical examination resulted in an increase in sensitivity from 48% to 90%, in specificity from 73% to 86%, and in accuracy from 60% to 88%. The benefits of using US were greater when pleural effusion was present versus absent (OR, 10.8 versus 2.4) and when examining older versus younger patients (OR, 10.2 versus 2.8). CONCLUSIONS: These results demonstrate that medical students' ability to detect the presence or absence of pleural effusion is superior when using lung US as an adjunct to the physical examination than when using the physical examination alone.

The benefits of doing ultrasound exams in your office.

Family medicine ultrasound is more accurate, more cost-effective, and less time-consuming than you might imagine. Here's how it can improve your care.

Acquisition and Long-term Retention of Bedside Ultrasound Skills in First-Year Medical Students.

OBJECTIVES: The purpose of this study was to assess bedside ultrasound skill acquisition and retention in medical students after completion of the first year of a new undergraduate bedside ultrasound curriculum at McGill University. METHODS: Skill acquisition was assessed in first-year medical students (n = 195) on completion of their bedside ultrasound instruction. Instruction included 6 clinically based 60-minute practical teaching sessions evenly spaced throughout the academic year. Students' ability to meet course objectives was measured according to a 4-point Likert rating scale. Evaluations were performed by both instructors and the students themselves. Retention of skill acquisition was evaluated 8 months later on a year-end practical examination. RESULTS: The mean percentage ± SD of students assigned a rating of "strongly agree" or "agree" by instructors was 98% ± 0.4% for all 6 teaching sessions (strongly agree, 52% ± 3%; agree, 46% ± 3%). According to student self-evaluations, the mean percentage of students assigned a rating of strongly agree was significantly greater than the percentage assigned by instructors for all teaching sessions (86% ± 2% versus 52% ± 3%; P < .0005). Evaluation of skill retention on the year-end examination showed that 91% ± 2% of students were assigned a rating of strongly agree or agree for their ability to demonstrate skills learned 8 months previously. Ninety-five percent of students reported that bedside ultrasound improved their understanding of anatomy for all 6 teaching sessions (mean, 95% ± 0.01%). CONCLUSIONS: These results demonstrate that first-year medical students show acquisition and long-term retention of basic ultrasound skills on completion of newly implemented bedside ultrasound instruction.

Bedside ultrasound education in Canadian medical schools: A national survey.

BACKGROUND: This study was carried out to determine the extent and characteristics of bedside ultrasound teaching in medical schools across Canada. METHODS: A cross-sectional, survey-based study was used to assess undergraduate bedside ultrasound education in the 17 accredited medical schools in Canada. The survey, consisting of 19 questions was pilot-tested, web-based, and completed over a period of seven months in 2014. RESULTS: Approximately half of the 13 responding medical schools had integrated bedside ultrasound teaching into their undergraduate curriculum. The most common trends in undergraduate ultrasound teaching related to duration (1-5 hours/year in 50% of schools), format (practical and theoretical in 67% of schools), and logistics (1:4 instructor to student ratio in 67% of schools). The majority of responding vice-deans indicated that bedside ultrasound education should be integrated into the medical school curriculum (77%), and cited a lack of ultrasound machines and infrastructure as barriers to integration. CONCLUSIONS: This study documents the current characteristics of undergraduate ultrasound education in Canada.

A comparison of telemedicine teaching to in-person teaching for the acquisition of an ultrasound skill - a pilot project.

Telemedicine is widely used for medical education but few studies directly investigate how telemedicine teaching compares to conventional in-person teaching. Here we determine whether telemedicine teaching is as effective as in-person teaching for the acquisition of an ultrasound skill important in trauma care. Nurses with no prior ultrasound experience (n = 10) received study material and a teaching session on how to locate and image the hepatorenal space (Morison's pouch). One group of nurses was taught in-person (In-person Group) and the other group was taught via telemedicine (Telemedicine Group). Telemedicine allowed two-way audio and visual communication between the instructor and the nurses. A comparison of the teaching techniques showed that telemedicine teaching was equivalent to in-person teaching for the acquisition of practical and theoretical skills required to locate Morison's pouch. The average time required to locate Morison's pouch after teaching was similar between both groups. The results demonstrate that telemedicine teaching is as effective as in-person teaching for the acquisition of bedside ultrasound skills necessary to identify Morison's pouch. Remote teaching of these bedside ultrasound skills may help in the diagnosis of intra-abdominal bleeding in rural healthcare centers.

Presynaptic Ca2+ influx and vesicle exocytosis at the mouse endbulb of Held: a comparison of two auditory nerve terminals.

The functional properties of mammalian presynaptic nerve endings remain elusive since most terminals of the central nervous system are not accessible to direct electrophysiological recordings. In this study, direct recordings were performed for the first time at endbulb of Held terminals to characterize passive membrane properties, voltage-gated Ca(2+) channels (VGCCs) and Ca(2+)-dependent exocytosis. Endbulb of Held terminals arise from endings of auditory nerve fibres contacting spherical bushy cells (SBCs) in the anterior ventral cochlear nucleus (AVCN). These terminals had a high mean input resistance (1.1 G) and a small mean capacitance (4.3 pF). Presynaptic VGCCs were predominantly of the P/Q type (86%) and expressed at a high density with an estimated average number of 6400 channels per terminal. Presynaptic Ca(2+) currents (I(Ca(V))) activated and deactivated rapidly. Simulations of action potential (AP)-driven gating of VGCCs suggests that endbulb APs trigger brief Ca(2+) influx with a mean half-width of 240 µs and a peak amplitude of 0.45 nA which results from the opening of approximately 2600 channels. Unlike Ca(2+) currents at the calyx of Held, I(Ca(V)) of endbulb terminals showed no inactivation during trains of AP-like presynaptic depolarizations. Endbulb terminals are endowed with a large readily releasable vesicle pool (1064 vesicles) of which only a small fraction (<10%) is consumed during a single AP-like stimulus. Fast presynaptic APs together with rapidly gating VGCCs will generate brief intracellular Ca(2+) transients that favour highly synchronous transmitter release. Collectively these characteristics ensure sustained and precise transmission of timing information from auditory stimuli at the endbulbSBC synapse.

Functional effects of adult human olfactory stem cells on early-onset sensorineural hearing loss.

Transplantation of exogenous stem cells has been proposed as a treatment to prevent or reverse sensorineural hearing loss. Here, we investigate the effects of transplantation of adult human olfactory mucosa-derived stem cells on auditory function in A/J mice, a strain exhibiting early-onset progressive sensorineural hearing loss. Recent evidence indicates that these stem cells exhibit multipotency in transplantation settings and may represent a subtype of mesenchymal stem cell. Olfactory stem cells were injected into the cochleae of A/J mice via a lateral wall cochleostomy during the time period in which hearing loss first becomes apparent. Changes in auditory function were assessed 1 month after transplantation and compared against animals that received sham injections. Hearing threshold levels in stem cell-transplanted mice were found to be significantly lower than those of sham-injected mice (p < .05) for both click and pure tone stimuli. Transplanted cells survived within the perilymphatic compartments but did not integrate into cochlear tissues. These results indicate that transplantation of adult human olfactory mucosa-derived stem cells can help preserve auditory function during early-onset progressive sensorineural hearing loss.

Effect of epithelial stem cell transplantation on noise-induced hearing loss in adult mice.

Noise trauma in mammals can result in damage to multiple epithelial cochlear cell types, producing permanent hearing loss. Here we investigate whether epithelial stem cell transplantation can ameliorate noise-induced hearing loss in mice. Epithelial stem/progenitor cells isolated from adult mouse tongue displayed extensive proliferation in vitro as well as positive immunolabelling for the epithelial stem cell marker p63. To examine the functional effects of cochlear transplantation of these cells, mice were exposed to noise trauma and the cells were transplanted via a lateral wall cochleostomy 2 days post-trauma. Changes in auditory function were assessed by determining auditory brainstem response (ABR) threshold shifts 4 weeks after stem cell transplantation or sham surgery. Stem/progenitor cell transplantation resulted in a significantly reduced permanent ABR threshold shift for click stimuli compared to sham-injected mice, as corroborated using two distinct analyses. Cell fate analyses revealed stem/progenitor cell survival and integration into suprastrial regions of the spiral ligament. These results suggest that transplantation of adult epithelial stem/progenitor cells can attenuate the ototoxic effects of noise trauma in a mammalian model of noise-induced hearing loss.

Stem and progenitor cell compartments within adult mouse taste buds.

Adult taste buds are maintained by the lifelong proliferation of epithelial stem and progenitor cells, the identities of which have remained elusive. It has been proposed that these cells reside either within the taste bud (intragemmal) or in the surrounding epithelium (perigemmal). Here, we apply three different in vivo approaches enabling single-cell resolution of proliferative history to identify putative stem and progenitor cells associated with adult mouse taste buds. Experiments were performed across the circadian peak in oral epithelial proliferation (04:00 h), a time period in which mitotic activity in taste buds has not yet been detailed. Using double label pulse-chase experiments, we show that defined intragemmal cells (taste and basal) and perigemmal cells undergo rapid, sequential cell divisions and thus represent potential progenitor cells. Strikingly, mitotic activity was observed in taste cells previously thought to be postmitotic (labelled cells occur in 30% of palatal taste buds after 1 h of BrdU exposure). Basal cells showed expression of the transcription factor p63, required for maintaining the self-renewal potential of various epithelial stem cell types. Candidate taste stem cells were identified almost exclusively as basal cells using the label-retaining cell approach to localize slow-cycling cells (0.06 +/- 0.01 cells per taste bud; n = 436 taste buds). Together, these results indicate that both stem- and progenitor-like cells reside within the mammalian taste bud.

Automated threshold detection for auditory brainstem responses: comparison with visual estimation in a stem cell transplantation study.

BACKGROUND: Auditory brainstem responses (ABRs) are used to study auditory acuity in animal-based medical research. ABRs are evoked by acoustic stimuli, and consist of an electrical signal resulting from summated activity in the auditory nerve and brainstem nuclei. ABR analysis determines the sound intensity at which a neural response first appears (hearing threshold). Traditionally, threshold has been assessed by visual estimation of a series of ABRs evoked by different sound intensities. Here we develop an automated threshold detection method that eliminates the variability and subjectivity associated with visual estimation. RESULTS: The automated method is a robust computational procedure that detects the sound level at which the peak amplitude of the evoked ABR signal first exceeds four times the standard deviation of the baseline noise. Implementation of the procedure was achieved by evoking ABRs in response to click and tone stimuli, under normal and experimental conditions (adult stem cell transplantation into cochlea). Automated detection revealed that the threshold shift from pre- to post-surgery hearing levels was similar in mice receiving stem cell transplantation or sham injection for click and tone stimuli. Visual estimation by independent observers corroborated these results but revealed variability in ABR threshold shifts and significance levels for stem cell-transplanted and sham-injected animals. CONCLUSION: In summary, the automated detection method avoids the subjectivity of visual analysis and offers a rapid, easily accessible http://axograph.com/source/abr.html approach to measure hearing threshold levels in auditory brainstem response.

Microsurgical access for cell injection into the mammalian cochlea.

The potential use of stem cells to repair hearing loss requires surgical access to the cochlea. Here we describe a microsurgical technique for cell injection into the mouse cochlea. Green fluorescent cells (ZsGreen-MCF10A cells) were successfully injected via a lateral wall cochleostomy into the scala media, scala tympani and scala vestibuli compartments of the cochlea. The effect of surgery on auditory function was investigated with auditory brainstem responses (ABR) to click and tone stimuli. A computerised signal-to-noise ratio detection method was developed to measure ABR thresholds in conjunction with visual inspection. Signal-to-noise ratio detection showed ABR thresholds in control mice were similar for click (33+/-7 dB) and tone stimuli (33+/-6 dB), in agreement with visual inspection (click 39+/-7 dB, tone 35+/-6 dB). The mean ABR threshold for combined click and tone stimuli was 15-45 dB greater after surgery with minimum hearing loss achieved with a small sized cochleostomy (< or =0.4mm) and by sibling matching to control mice (control 33+/-4 dB, surgery 48+/-3 dB). The microsurgical technique will provide a basis for future studies on the use of stem cells in the treatment of hearing loss.

The role of spontaneous activity in development of the endbulb of Held synapse.

In the mouse brainstem cochlear nucleus, the auditory nerve to bushy cell synapse (endbulb of Held) is specialised for rapid, high-fidelity transmission. Development of this synapse is modulated by auditory nerve activity. Here we investigate the role of spontaneous auditory nerve activity in synaptic transmission using deafness (dn/dn) mutant mice that have abnormal hair cells and lack spontaneous auditory nerve activity. Evoked and miniature alpha amino-3-hydroxy-5-methyl-4-isoxazole propionate (AMPA) receptor-mediated excitatory post-synaptic currents (eEPSCs, mEPSCs) were compared in deafness and normal mice before the age of hearing onset (postnatal day 7-11: P7-11) using variance-mean, miniature event and tetanic depression analyses. Amplitudes were significantly greater in deafness mice for eEPSCs (2.1-fold), mEPSCs (1.4-fold) and quantal amplitudes (1.5-fold). eEPSCs in deafness mice decayed more rapidly with increasing age, indicating an input-independent transition in post-synaptic AMPA receptor properties. A comparison of normal mice before and after the onset of hearing showed a change in synaptic parameters with an increase in eEPSC (1.7-fold), mEPSC (1.6-fold) and quantal amplitude (1.7-fold) after hearing onset while release probability remained constant (0.5). Overall, the results in deafness mice suggest that synaptic strength is altered in the absence of spontaneous auditory nerve activity.

Differentiation of adult mouse olfactory precursor cells into hair cells in vitro.

Many forms of deafness result from degeneration of the sensory cells for hearing, the hair cells in the cochlea. Stem cells offer a potential cell-based therapy for the treatment of deafness. Here, we investigate whether adult olfactory precursor cells can differentiate into hair cells in culture. Precursor cells were isolated from mouse olfactory neuroepithelium, were sphere-forming, showed proliferative capacity, and contained cells expressing neuronal and non-neuronal proteins. To induce differentiation, precursor cells were cocultured with cochlear cells and/or cochlear supernatant. Differentiated precursor cells were immunopositive for specific hair cell markers, including myosin VIIa, FM1-43, calretinin, phalloidin, and espin, and resembled hair cells anatomically and immunocytochemically in culture. The results demonstrate for the first time that adult olfactory precursor cells can differentiate into hair cell-like cells, thus providing a potential autotransplantation therapy for hearing loss.

Enhanced serotonin response in the hippocampus of Galphaz protein knock-out mice.

The serotonin-1A [5-hydroxytryptamine 1A (5HT1A)] receptor is important for emotional and homeostatic processes in the central nervous system. In the hippocampus, the 5HT1A receptor couples to inhibitory Gi/o proteins to decrease pyramidal cell excitability. Here we investigate the 5HT1A receptor in a mouse deficient in the alpha-subunit of Gz protein (Galphaz knock-out). Behavioural tests showed heightened anxiety and depression-like behaviour in the Galphaz knock-out mice. Whole-cell recording in CA1 pyramidal neurons showed a significantly greater 5HT1A receptor-mediated potassium current in Galphaz knock-out mice. The effect was independent of 5HT4 receptors as the slow after-hyperpolarization was unaffected and a slow depolarization was absent in the Galphaz knock-out mice. Other receptors linked to Gi/o proteins [gamma-aminobutyric acid type B receptor (GABAB), adenosine A1 and muscarinic acetylcholine receptors] were not affected in Galphaz knock-out mice. These results suggest that the 5HT1A receptor may be linked to Galphaz protein, as reported previously in cell culture but shown here in an intact neural network.

Differences in glycinergic mIPSCs in the auditory brain stem of normal and congenitally deaf neonatal mice.

We have investigated the fundamental properties of central auditory glycinergic synapses in early postnatal development in normal and congenitally deaf (dn/dn) mice. Glycinergic miniature inhibitory postsynaptic currents (mIPSCs) were recorded using patch-clamp methods in neurons from a brain slice preparation of the medial nucleus of the trapezoid body (MNTB), at 12-14 days postnatal age. Our results show a number of significant differences between normal and deaf mice. The frequency of mIPSCs is greater (50%) in deaf versus normal mice. Mean mIPSC amplitude is smaller in deaf mice than in normal mice (mean mIPSC amplitude: deaf, 64 pA; normal, 106 pA). Peak-scaled fluctuation analysis of mIPSCs showed that mean single channel conductance is greater in the deaf mice (deaf, 64 pS; normal, 45 pS). The mean decay time course of mIPSCs is slower in MNTB neurons from deaf mice (mean half-width: deaf, 2.9 ms; normal, 2.3 ms). Light- and electron-microscopic immunolabeling results showed that MNTB neurons from deaf mice have more (30%) inhibitory synaptic sites (postsynaptic gephyrin clusters) than MNTB neurons in normal mice. Our results demonstrate substantial differences in glycinergic transmission in normal and congenitally deaf mice, supporting a role for activity during development in regulating both synaptic structure (connectivity) and the fundamental (quantal) properties of mIPSCs at central glycinergic synapses.

Glycinergic mIPSCs in mouse and rat brainstem auditory nuclei: modulation by ruthenium red and the role of calcium stores.

Spontaneous miniature inhibitory postsynaptic currents (mIPSCs) recorded in central neurons are usually highly variable in amplitude due to many factors such as intrinsic postsynaptic channel fluctuations at each release site, site-to-site variability between release sites, electrotonic attenuation due to variable dendritic locations of synapses, and the possibility of synchronous multivesicular release. A detailed knowledge of these factors is essential for the interpretation of mIPSC amplitude distributions and mean quantal size. We have studied glycinergic mIPSCs in two auditory brainstem nuclei, the rat anteroventral cochlear nucleus (AVCN) and the mouse medial nucleus of the trapezoid body (MNTB). Our previous results have demonstrated the location of glycinergic synapses on these neurons to be somatic, thus avoiding electrotonic complications. Spontaneous glycinergic mIPSCs were recorded from AVCN and MNTB neurons in brainstem slices, in the presence of TTX to block action potentials, and 6-cyano-7-nitroquinoxaline-2, 3-dione, (+/-)-2-amino-5-phosphonopentanoic acid and bicuculline to block glutamatergic and GABAergic synaptic currents. Ruthenium red (RuR), which was used to increase the frequency of mIPSCs, significantly changed the shape of most (90 %) mIPSC amplitude distributions by increasing the proportion of large-amplitude mIPSCs. The possibility was investigated (following previous evidence at GABAergic synapses) that large-amplitude glycinergic mIPSCs are due to synchronous multivesicular release initiated by presynaptic calcium sparks from ryanodine-sensitive calcium stores. Interval analysis of mIPSCs indicated that the number of potentially undetected (asynchrony < 0.5 ms) multivesicular mIPSCs was low in comparison with the number of large-amplitude mIPSCs. Ryanodine, thapsigargin and calcium-free perfusate did not reduce the frequency of large-amplitude mIPSCs (> 150 pA), arguing against a significant role for presynaptic calcium stores. Our results support previous evidence suggesting that RuR increases miniature postsynaptic current (mSC) frequency by a mechanism that does not involve presynaptic calcium stores. Our results also indicate that at glycinergic synapses in the AVCN and MNTB, site-to-site variability in mIPSC amplitude, rather than multivesicular release, is a major factor underlying the large range of amplitudes of glycinergic mIPSCs.

Synaptic transmission in the auditory brainstem of normal and congenitally deaf mice.

The deafness (dn/dn) mutant mouse provides a valuable model of human congenital deafness. We investigated the properties of synaptic transmission in the anteroventral cochlear nucleus (AVCN) of normal and congenitally deaf dn/dn mice. Excitatory postsynaptic currents (EPSCs) were evoked by focal stimulation of single auditory nerve fibres, and measured by whole-cell recordings from neurones in AVCN slices (mean postnatal age = P13). Absolute amplitudes of both AMPA- and NMDA-mediated components of evoked EPSCs were greater (170 %) in deaf versus control animals. Enhanced transmission in deaf mice was due to a presynaptic mechanism. Variance-mean analysis revealed that the probability of transmitter release was significantly greater in deaf (P(r) = 0.8) versus control animals (P(r) = 0.5). Following high frequency stimulation, deaf mice showed a greater depression of evoked EPSCs, and a significant increase in the frequency of delayed-release (asynchronous) miniature EPSCs (aEPSCs) (deaf 100 Hz vs. control 7 Hz). The acetoxymethyl ester of EGTA (EGTA-AM) blocked the increase in miniature aEPSCs and returned tetanic depression to control values. In deaf mice, reduction of mean P(r) using cadmium caused an expected increase in paired-pulse ratio (PPR). However, in the same cells, a similar reduction in release by EGTA-AM did not result in a change in PPR, demonstrating that a change may occur in P(r) without a concomitant change in PPR. In many respects, transmission in deaf mice was found to be remarkably similar to control mice, implying that many parameters of synaptic transmission develop normally in these animals. The two significant differences (higher P(r) and asynchronous release in deaf mice) could both be reversed by the addition of EGTA-AM, suggesting that endogenous calcium buffering may be impaired or undeveloped in the presynaptic terminals of the auditory nerve in deaf mice.