Search

Michael Stanley Ellis,1 Joseph T Nelson,2 Jeffrey Zane Kartchner,1 Karl Andrew Yousef,1 William J Adamas-Rappaport,3 Richard Amini4 1College of Medicine, The University of Arizona, Tucson, AZ, USA; 2Department of Orthopedic Surgery, The University of Michigan, Ann Arbor, MI, USA; 3Department of Surgery, 4Department of Emergency Medicine, The University of Arizona, Tucson, AZ, USA Abstract: Ultrasound imaging is a rapid and noninvasive tool ideal for the imaging of soft tissue infections and is associated with a change of clinician management plans in 50% of cases. We developed a realistic skin abscess diagnostic and therapeutic training model using fresh frozen cadavers and common, affordable materials. Details for construction of the model and suggested variations are presented. This cadaver-based abscess model produces high-quality sonographic images with internal echogenicity similar to a true clinical abscess, and is ideal for teaching sonographic diagnostic skills in addition to the technical skills of incision and drainage or needle aspiration. Keywords: undergraduate medical education, abscess model, ultrasound, ultrasound education, ultrasound-guided needle aspiration

Richard Amini, Lori A Stolz, Jeffrey Z Kartchner, Matthew Thompson, Nicholas Stea, Nicolaus Hawbaker, Raj Joshi, Srikar Adhikari Department of Emergency Medicine, University of Arizona Medical Center, Tucson, AZ, USA Background: Goal-directed ultrasound protocols have been developed to facilitate efficiency, throughput, and patient care. Hands-on instruction and training workshops have been shown to positively impact ultrasound training. Objectives: We describe a novel undifferentiated chest pain goal-directed ultrasound algorithm-focused education workshop for the purpose of enhancing emergency medicine resident training in ultrasound milestones competencies. Methods: This was a cross-sectional study performed at an academic medical center. A novel goal-directed ultrasound algorithm was developed and implemented as a model for teaching and learning the sonographic approach to a patient with undifferentiated chest pain. This algorithm was incorporated into all components of the 1-day workshop: asynchronous learning, didactic lecture, case-based learning, and hands-on stations. Performance comparisons were made between postgraduate year (PGY) levels. Results: A total of 38 of the 40 (95%) residents who attended the event participated in the chest pain objective standardized clinical exam, and 26 of the 40 (65%) completed the entire questionnaire. The average number of ultrasounds performed by resident class year at the time of our study was as follows: 19 (standard deviation [SD]=19) PGY-1, 238 (SD=37) PGY-2, and 289 (SD=73) PGY-3. Performance on the knowledge-based questions improved between PGY-1 and PGY-3. The application of the novel algorithm was noted to be more prevalent among the PGY-1 class. Conclusion: The 1-day algorithm-based ultrasound educational workshop was an engaging learning technique at our institution. Keywords: point-of care ultrasound, algorithm education, education, chest pain, bedside ultrasound, POCUS

Purpose: To illustrate a presentation of familial exudative vitreoretinopathy (FEVR) that can be mistaken for unilateral persistent fetal vasculature (PFV) and the importance of wide angle fluorescein angiography in making this distinction. A patient was referred with a unilateral retrolental membrane and retinal detachment from PFV but was found to have FEVR., Observations: A 4 month-old full-term infant was referred with the diagnosis of PFV based on findings of a dense retrolental membrane and microphthalmia in the left eye. The patient had a near-complete retinal detachment with some exudation. Wide-field fluorescein angiography of the right eye revealed avascular retina and leakage at the vascular/avascular junction. Genetic testing confirmed a mutation in FZD4 , supporting the clinical diagnosis of FEVR. Prompt laser therapy to the avascular area in the right eye was performed and lensectomy/vitrectomy with membrane dissection was performed in the left eye., Conclusions and Importance: FEVR can present with great variability between eyes. In patients presenting with findings suggestive of PFV, careful bilateral examination with wide-field fluorescein angiography is helpful. Early diagnosis and treatment are important to preserve visual acuity, especially in the less affected eye., Competing Interests: Conflict of Interest The following authors have no financial disclosures: JZK, MEH.

Objectives: The purpose of this study was to investigate the current practice of ultrasound (US)-guided regional anesthesia at academic emergency departments, including education, protocols, policies, and quality assessment., Methods: We conducted a cross-sectional study. A questionnaire on US-guided nerve blocks was electronically sent to all emergency US directors and emergency US fellowship directors., Results: A total of 121 of 171 academic institutions with an emergency medicine residency program participated in this study, representing a 71% response rate. Eighty-four percent (95% confidence interval [CI], 77%-91%) of programs perform US-guided nerve blocks at their institutions. The most common type of nerve block performed is a forearm nerve block (ulnar, median, or radial). The most common indication for US-guided nerve blocks is fracture pain management. Only 7% (95% CI, 2%-12%) of programs have a separate credentialing pathway for US-guided nerve blocks. Regarding quality assessment review of US-guided nerve blocks, none of the programs have a separate program in place. In 57% (95% CI, 48%-66%) of programs, it is a component of the emergency US quality assessment program. Eighty-four percent (95% CI, 77%-90%) of programs do not have specific agreements with other specialty services with regard to performing US-guided nerve blocks in the emergency department. The most common educational methods used to teach US-guided nerve blocks are didactic sessions, at 67% (95% CI, 59%-75%); online resources, at 54% (95% CI, 45%-63%); and supervised training with real patients, at 48% (95% CI, 39%-57%)., Conclusions: Ultrasound-guided nerve blocks are performed at most academic emergency departments. However, there is a substantial variation in the practices and policies within these institutions., (© 2016 by the American Institute of Ultrasound in Medicine.)

Background: Ultrasonography use is increasing in emergency departments, and ultrasound education is now recommended in resident training. Ultrasound phantoms are used in many institutions for training purposes. The purpose of this study is to describe an inexpensive and simple method to create ultrasound-imaging models for the purpose of education and practice using clear ballistic gel., Methods: Clear ballistic gel is used to simulate tissue for firing practice and other military evaluations., Results: The transparent and durable ultrasound phantom we produced was clear and contained four vessel lumens. The images obtained using the phantom were of high quality and compared well to normal sonographic anatomy., Conclusions: The clear ballistic brand gel is unique because it is inexpensive, does not dry out, does not decay, is odorless, and is reusable. The ultrasound images obtained using the phantom are realistic and useful for ultrasound education.

HtrA1, Ddr-2, and Mmp-13 are reliable biomarkers for osteoarthritis (OA), yet the exact mechanism for the upregulation of HtrA-1 is unknown. Some have shown that chondrocyte hypertrophy is associated with early indicators of inflammation including TGF-β and the Receptor for Advanced Glycation End-products (RAGE). To examine the correlation of inflammation with the expression of biomarkers in OA, we performed right knee destabilization surgery on 4-week-old-wild type and RAGE knock-out (KO) mice. We assayed for HtrA-1, TGF-β1, Mmp-13, and Ddr-2 in articular cartilage at 3, 7, 14, and 28 days post-surgery by immunohistochemistry on left and right knee joints. RAGE KO and wild type mice both showed staining for key OA biomarkers. However, RAGE KO mice were significantly protected against OA compared to controls. We observed a difference in the total number of chondrocytes and percentage of chondrocytes staining positive for OA biomarkers between RAGE KO and control mice. The percentage of cells staining for OA biomarkers correlated with severity of cartilage degradation. Our results indicate that the absence of RAGE did protect against the development of advanced OA. We conclude that HtrA-1 plays a role in lowering TGF-β1 expression in the process of making articular cartilage vulnerable to damage associated with OA progression.