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Thứ Hai, ngày 22 tháng 9 năm 2014



Background: As medical schools seek to standardize ultrasound training and incorporate clinical correlations into the basic science years, we proposed that ultrasonography should have a greater role in the anatomy curriculum.

Objectives: To describe the introduction of ultrasound into the curriculum of a first-year medical student anatomy course and evaluate the utility of this introduction.

Methods: First-year medical students attended two ultrasound lectures and three small-group hands-on sessions that focused on selected aspects ofmusculoskeletal, thoracic,abdominal, and neck anatomy. Pre and post surveys were administered to assess student perception of their ability to obtain and interpret ultrasound images and the utility of ultrasound in the anatomy course. Understanding of basic ultrasound techniques and imaging was tested in the practical examinations.

 Results: Of the 269 first-year medical students who completed the course, 144 students completed both surveys entirely, with a response rate of 53%. Students’interest and self-perceived experience, comfort, and confidence in ultrasound skills significantly increased (p under 0.001). 

Conclusions: Ultrasound can be effectively incorporated into an anatomy course for first-year medical students by utilizing didactics and hands-on exposure.Medical students found the addition of ultrasound training to be valuable, not only in enhancing their understanding of anatomy, but also in increasing their interest and experience in ultrasound imaging.  
2014 Elsevier Inc.

All first-year medical students were assigned to a small group consisting of 10–12 first-year medical students and one senior medical student proctor. Senior medical students, residents, and faculty proctored the ultrasound laboratory sessions that focused on the use of ultrasound to study selected aspects of musculoskeletal anatomy, thoracic and abdominal anatomy, and neck anatomy. First-year medical students received a list of objectives prior to each scanning session and proctors received specific hands-on training and scanning guidelines prior to each session. Several resident and attending physicians circulated in the laboratory during each session to provide overall guidance.

During ‘‘Block 1 – Musculoskeletal,’’ at which time students were participating in cadaveric extremity dissections, first-year medical students viewed a proctor demonstration of ultrasound imaging of the shoulder, wrist, and elbow. Each student was then provided the opportunity to scan one of the three joints during individual scanning timewhile observing others as they imaged the other joints noted above. Focal anatomy during shoulder imaging included the humeral head, the biceps tendon within the bicipital groove, the subscapularis tendon inserting onto the lesser tuberosity of the humerus, and the supraspinatus tendon inserting onto the greater tuberosity of the humerus. Elbow imaging included the biceps brachii tendon, brachial artery, median nerve, and humerus, radius, and ulna in the anticubital fossa. Wrist imaging included the components of the carpal tunnel, as well as the radial artery, radius, and ulna.

During ‘‘Block 2 – Abdomen/Thorax,’’ when students were completing their abdominal cadaveric dissections, first-year medical students viewed a proctor demonstration of ultrasound imaging of the liver, great vessels, and kidneys. Each student was then given the opportunity to perform this imaging on a live model with proctor guidance. Specific liver anatomy included the portal triad, differentiating portal from hepatic veins, hepatic veins draining into the inferior vena cava (IVC), and the effect of deep respiration on liver imaging. Focal kidney imaging included the liver–kidney interface and the psoas muscle.
Abdominal vessel imaging focused on locating the aorta anterior to the vertebral bodies, scanning the aorta distally to image the aortic bifurcation, and proximally to identify the inferior mesenteric artery, the superior mesenteric artery, and the celiac trunk branching from the aorta,and drainage of the IVC into the right atrium.

Finally, during ‘‘Block 3 – Head/Neck,’’ when students were completing cadaveric neck dissections, first-yearintroduction of ultrasound into the medical curriculum at this College of Medicine. Beginning in 2006, we introduced a clinical correlation of a case of cholecystitis that included ultrasound imaging as part of the patient work-up. In subsequent years, we added optional hands-on laboratory experience using the device. Students learned to image the extremities, torso, and neck anatomy on a live model as part of a curriculum that paralleled their dissections in the cadaver laboratory. Based on student feedback, ultrasound remained part of the anatomy curriculum as an introductory exposure to ultrasound in medical school.
The study describes and evaluates the current version of our introduction of ultrasound into the anatomy course of first-year medical students. Currently, students receiveinstruction on basic elements of ultrasound imaging, on how to use the ultrasound device, and how to obtain ultrasound images of targeted areas of musculoskeletal, trunk, and neck anatomy, all in parallel with their dissections.

The objectives of this study were 1) to demonstrate the utility of incorporating ultrasound into preclinical medical students’ anatomy education; and 2) to determine if ultrasound imaging enhances first-year medical students’understanding of anatomy.


Thư viện MEDIC (Bs Võ Khôi Bửu) có nhã ý  cung cấp 2 links để các bạn download sách về học:

Color Atlas of Ultrasound Anatomy(Block)296p,2004  CAUA.pdf

Review of Gross AnatomyPansky)681p,1996  RGAP.pdf


To our knowledge, this study is novel because the impact of ultrasound with cross sectional anatomy images and line diagrams for teaching anatomy of upper and lower limbs has not been reported. It has shown that this can be a useful adjunct in teaching anatomy to medical students. Anatomy teaching using ultrasound in Phase 1 (year 1 and year 2)  medical curriculum can act as bridging tool to integrate anatomy learning and clinical practice by helping the students to apply anatomical knowledge to interpret normal ultrasound images and to be more prepared when they encounter abnormalities during their clinical years of medicine and as clinicians in their future practice. It can also increase the students’awareness of the importance of anatomy knowledge in clinical practice.


The utilization of bedside ultrasound by an increasing number of medical specialties has created the need for more ultrasound exposure and teaching in medical school. Although there is a widespread support for more vertical integration of ultrasound teaching throughout the undergraduate curriculum, little is known about whether the quality of ultrasound teaching differs if performed by anatomists or clinicians. The purpose of this study is to compare medical students' evaluation of ultrasound anatomy teaching by clinicians and anatomists. Hands-on interactive ultrasound sessions were scheduled as part of the gross anatomy course following principles of adult learning and instructional design. Seven teachers (three anatomists and four clinicians) taught in each session. Before each session, anatomists were trained in ultrasound by clinicians. Students were divided into groups, rotated teachers between sessions, and completed evaluations. Results indicated students perceived the two groups as comparable for all factors except for knowledge organization and the helpfulness of ultrasound for understanding anatomy (P < 0.001). However, results from unpaired samples t-tests demonstrated a nonstatistically significant difference between the groups within each session for both questions. Moreover, students' test performance for both groups was similar. This study demonstrated that anatomists can teach living anatomy using ultrasound with minimal training as well as clinicians, and encourage the teaching of living anatomy by anatomists in human anatomy courses using ultrasound. Repeating this study at a multicenter level is currently being considered to further validate our conclusion. Anat Sci Educ 7: 340-349. © 2013 American Association of Anatomists.
© 2013 American Association of Anatomists.

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Thứ Sáu, ngày 12 tháng 9 năm 2014

Elastography May Avoid Needless Biopsies of Thyroid Nodules

September 10, 2014 -- Thanks to its high negative predictive value, ultrasound elastography with intrinsic compression may be able to reduce by one-third the number of unnecessary biopsies performed on calcified thyroid nodules, according to research published in the October issue of Ultrasound in Medicine and Biology.
In a study involving 65 calcified thyroid nodules, a team of researchers led by Dr. Min-Hee Kim of Catholic University in Korea found that elastography yielded 95.8% negative predictive value in detecting malignancy. Furthermore, more than one-third of biopsies on calcified nodules could have been avoided based on elastography results.
"Intrinsic compression elastography can be used in conjunction with B-mode [ultrasound] to reduce the number of [fine-needle aspiration] biopsies of calcified thyroid nodules," wrote Kim and colleagues, who also came from the University of Washington and Pohang University of Science and Technology.
Confounding calcification
Although calcification in thyroid nodules is an important ultrasound feature that suggests malignancy, and current major guidelines strongly recommend that calcified nodules larger than 5 mm be biopsied, calcification can be present in both malignant and benign nodules. As a result, many benign nodules end up being biopsied unnecessarily (Ultrasound Med Biol, October 2014, Vol. 40:10, pp. 2329-2335).
Ultrasound elastography has been shown in a number of studies to provide high sensitivity and specificity for detecting malignant thyroid nodules. But the lack of interobserver agreement in elastography -- due to variability in data acquisition and scoring -- is a major reason why the method has not been widely adopted in clinical practice, according to the group.
Standard elastography utilizes external compression, with the pressure of the transducer providing the tissue compression that results in the tissue strain measured by elastography. But other researchers have found that elastography utilizing intrinsic compression -- with pressure provided by forces inside the body such as carotid artery pulsation -- could offer better performance. The payoff would be better interobserver and intraobserver agreement.
As a result, the team sought to determine if intrinsic compression elastography could perform well for characterizing thyroid nodules with calcification. The researchers recruited 188 patients with 229 thyroid nodules who were referred to Seoul St. Mary's Hospital from May 2011 through January 2012 for a fine-needle aspiration (FNA) biopsy.
All patients received both ultrasound and elastography exams prior to FNA biopsy. B-mode images were acquired using an iU22 ultrasound system (Philips Healthcare) with a 5- to 12-MHz high-resolution linear probe.
Blinded to the patient's clinical information as well as cytologic and elastography results, a radiologist with 15 years of experience retrospectively reviewed the B-mode ultrasound images and extracted nodule features such as echogenicity, margin, shape, and presence of calcification, according to the researchers. Based on those ultrasound features, the nodules were categorized into three groups: benign, indeterminate, and suspicious for malignancy.
The elastography studies were performed by three endocrinologists with more than one year of experience with intrinsic compression elastography. An Accuvix XG (Samsung Medison) scanner with an L5-13 linear transducer was used in the study, and no external compression was performed while the ultrasound data were acquired, according to the team.
The researchers employed a quantitative scoring method -- elastic contrast index (ECI) -- for the elastography results; a higher ECI value suggests a stiffer nodule and an increasing likelihood of malignancy. A minimum of two ECI measurements were gathered in the imaging plane that showed the thyroid nodule's largest diameter in the transverse view, according to the authors.
Diagnostic accuracy
Next, the researchers determined elastography's diagnostic accuracy by varying the ECI cut-off value in order to find the sensitivity and specificity combination that yielded the maximum geometric mean (sensitivity multiplied by specificity) in detecting malignant nodules. They also calculated positive and negative predictive values.
Of the 196 nodules in the study, 42 were malignant; all were papillary thyroid carcinoma. The mean nodule size was 9 ± 4.17 mm for malignant nodules, significantly smaller than the 11.31 ± 6.1 mm mean size for benign nodules.
The researchers observed that the mean ECI value of malignant nodules (4.51 ± 2.22) was significantly higher than the value for benign nodules (2.98 ± 1.47, p < 0.001). They then calculated elastography's performance, with a mean ECI cut-off value of 3.11 indicating malignancy.

The radiologist classified four of the 65 (45 benign and 20 malignant) nodules with calcification as benign; three of the four were found to be benign under elastography. The remaining 61 nodules with calcification were categorized as either indeterminate (29) or suspicious for malignancy (32). With elastography, however, nine of the 32 nodules classified as suspicious for malignancy were determined to be benign, a diagnosis that was confirmed by biopsy.
Furthermore, 12 of the 29 cases that were considered by the radiologist to be indeterminate were judged to be benign on elastography. Biopsy results confirmed the benign diagnosis in 11 of 12 cases; one malignant nodule with rim classification was incorrectly classified as benign using elastography, according to the group.
Elastography's performance in nodules with calcification was as follows:
  • Sensitivity: 95%
  • Specificity: 51.1%
  • Positive predictive value: 46.3%
  • Negative predictive value: 95.8%
In all, 23 benign calcified nodules (51.1% of benign calcified nodules) were correctly classified by elastography, whereas only four (8.9%) were correctly classified by B-mode ultrasound, the authors wrote.
The study demonstrates a potential role for elastography in the management of calcified thyroid nodules, according to the researchers.
"With the use of elastography on those calcified nodules, for which B-mode [ultrasound] has low specificity (i.e., 8.9%) in detecting malignancy, FNA biopsy could have been avoided in 23 (35.4%) of 65 calcified nodules," they wrote. "In terms of reducing the number of FNA biopsies, our study found that elastography had a clinical impact similar to that reported in a previous study that evaluated the usefulness of elastography in calcified breast lesions."

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