Parvathy Nair

Directed self-regulated learning versus instructor-regulated learning in simulation training.

Medical Education 2012: 46:648–656

Use of simulator-based medical procedural curriculum: the learner's perspectives

BackgroundSimulation is increasingly used for teaching medical procedures. The goal of this study was to assess learner preferences for how simulators should be used in a procedural curriculum.MethodsA 26-item survey was constructed to assess the optimal use of simulators for the teaching of medical procedures in an internal medicine residency curriculum. Survey domains were generated independently by two investigators and validated by an expert panel (n = 7). Final survey items were revised based on pilot survey and distributed to 128 internal medicine residents.ResultsOf the 128 residents surveyed, 106 (83%) responded. Most responders felt that simulators should be used to learn technical skills (94%), refine technical skills (84%), and acquire procedural teaching skills (87%).Respondents felt that procedures most effectively taught by simulators include: central venous catheterization, thoracentesis, intubation, lumbar puncture, and paracentesis. The majority of learners felt that teaching should be done early in residency (97%).With regards to course format, 62% of respondents felt that no more than 3-4 learners per simulator and an instructor to learner ratio of 1:3-4 would be acceptable.The majority felt that the role of instructors should include demonstration of technique (92%), observe learner techniques (92%), teach evidence behind procedural steps (84%) and provide feedback (89%). Commonly cited barriers to procedural teaching were limitations in time, number of instructors and simulators, and lack of realism of some simulators.ConclusionsOur results suggest that residents value simulator-based procedural teaching in the form of small-group sessions. Simulators should be an integral part of medical procedural education.

Changes in Left Atrial Appendage Dimensions Following Volume Loading During Percutaneous Left Atrial Appendage Closure

OBJECTIVES This study sought to determine whether volume loading alters the left atrial appendage (LAA) dimensions in patients undergoing percutaneous LAA closure. BACKGROUND Percutaneous LAA closure is increasingly performed in patients with atrial fibrillation and contraindications to anticoagulation, to lower their stroke and systemic embolism risk. The safety and efficacy of LAA closure relies on accurate device sizing, which necessitates accurate measurement of LAA dimensions. LAA size may change with volume status, and because patients are fasting for these procedures, intraprocedural measurements may not be representative of true LAA size. METHODS Thirty-one consecutive patients undergoing percutaneous LAA closure who received volume loading during the procedure were included in this study. After an overnight fast and induction of general anesthesia, patients had their LAA dimensions (orifice and depth) measured by transesophageal echocardiography before and after 500 to 1,000 ml of intravenous normal saline, aiming for a left atrial pressure >12 mm Hg. RESULTS Successful implantation of LAA closure device was achieved in all patients. The average orifice size of the LAA at baseline was 20.5 mm at 90°, and 22.5 mm at 135°. Following volume loading, the average orifice size of the LAA increased to 22.5 mm at 90°, and 23.5 mm at 135°. The average increase in orifice was 1.9 mm (p < 0.0001). The depth of the LAA also increased by an average of 2.5 mm after volume loading (p < 0.0001). CONCLUSIONS Intraprocedural volume loading with saline increased the LAA orifice and depth dimensions during LAA closure. Operators should consider optimizing the left atrial pressure with volume loading before final device sizing.

Are two heads better than one? Comparing dyad and self‐regulated learning in simulation training

The optimal learner to simulator ratio for procedural skills training is not known. Research in motor learning suggests observational training in pairs, termed ‘dyad training’, may be as effective as directed self‐regulated learning (DSRL).

2010 Canadian Cardiovascular Society/Canadian Society of Echocardiography Guidelines for Training and Maintenance of Competency in Adult Echocardiography

Guidelines for the provision of echocardiography in Canada were jointly developed and published by the Canadian Cardiovascular Society and the Canadian Society of Echocardiography in 2005. Since their publication, recognition of the importance of echocardiography to patient care has increased, along with the use of focused, point-of-care echocardiography by physicians of diverse clinical backgrounds and variable training. New guidelines for physician training and maintenance of competence in adult echocardiography were required to ensure that physicians providing either focused, point-of-care echocardiography or comprehensive echocardiography are appropriately trained and proficient in their use of echocardiography. In addition, revision of the guidelines was required to address technological advances and the desire to standardize echocardiography training across the country to facilitate the national recognition of a physicians expertise in echocardiography. This paper summarizes the new Guidelines for Physician Training and Maintenance of Competency in Adult Echocardiography, which are considerably more comprehensive than earlier guidelines and address many important issues not previously covered. These guidelines provide a blueprint for physician training despite different clinical backgrounds and help standardize physician training and training programs across the country. Adherence to the guidelines will ensure that physicians providing echocardiography have acquired sufficient expertise required for their specific practice. The document will also provide a framework for other national societies to standardize their training programs in echocardiography and will provide a benchmark by which competency in adult echocardiography may be measured.

Cardiac examination and the effect of dual-processing instruction in a cardiopulmonary simulator

Use of dual-processing has been widely touted as a strategy to reduce diagnostic error in clinical medicine. However, this strategy has not been tested among medical trainees with complex diagnostic problems. We sought to determine whether dual-processing instruction could reduce diagnostic error across a spectrum of experience with trainees undertaking cardiac physical exam. Three experiments were conducted using a similar design to teach cardiac physical exam using a cardiopulmonary simulator. One experiment was conducted in each of three groups: experienced, intermediate and novice trainees. In all three experiments, participants were randomized to receive undirected or dual-processing verbal instruction during teaching, practice and testing phases. When tested, dual-processing instruction did not change the probability assigned to the correct diagnosis in any of the three experiments. Among intermediates, there was an apparent interaction between the diagnosis tested and the effect of dual-processing instruction. Among relative novices, dual processing instruction may have dampened the harmful effect of a bias away from the correct diagnosis. Further work is needed to define the role of dual-processing instruction to reduce cognitive error. This study suggests that it cannot be blindly applied to complex diagnostic problems such as cardiac physical exam.

A procedural teaching tree to aid resident doctor peer-teachers

and 65% of interns agreed or strongly agreed that it was easier to interact with faculty members because of their earlier introduction at SWIFT. Interns’ openended comments following SWIFT were consistently positive (e.g. ‘I didn’t know how to go about approaching a faculty member regarding research, but I feel much more comfortable now’) and 39% of interns stated that SWIFT had changed their career plans. Faculty evaluations were also very positive. This ‘speed dating’-based model promoted informed self-selection of research mentors and was linked to desirable research outcomes. By May of their second postgraduate year, 48% of interns had submitted a paper for publication and 22% had published their research. Interns gained career advice, interview practice, networking opportunities and confidence in their abilities to perform research. In conclusion, SWIFT proved to be an efficient tool for introducing internal medicine interns to research faculty members. Given our initial success, we plan to make SWIFT a regular component of our residency programme’s promotion of scholarly activities.

Echocardiographic Assessment of Patients with Fabry Disease

&NA; Fabry disease is an X‐linked lysosomal storage disorder that results from a deficiency of &agr;‐galactosidase A. Increased left ventricular wall thickness has been the most commonly described cardiovascular manifestation of the disease. However, a variety of other structural and functional abnormalities have also been reported. Echocardiography is an effective noninvasive method of assessing the cardiac involvement of Fabry disease. A more precise and comprehensive characterization of Fabry cardiomyopathy using conventional and novel echocardiographic techniques may lead to earlier diagnosis, more accurate prognostication, and timely treatment. The aim of this review is to provide a comprehensive overview of the structural and functional abnormalities on echocardiography that have thus far been described in patients with Fabry disease and to highlight potential areas that would benefit from further research. HighlightsEchocardiography can effectively identify cardiac manifestations of Fabry disease.Increased ventricular wall thickness has been the most commonly described finding.Abnormalities in the atria, valves, aorta, and papillary muscles can also be seen.Advanced techniques such as strain imaging can detect subclinical cardiomyopathy.More research is needed to determine how these findings can best inform management.

Multimodality imaging of a pulmonary artery sarcoma

Pulmonary artery sarcoma is a rare malignant neoplasm. Here, we describe a patient with a pulmonary artery sarcoma, which was only subtly visible and therefore not fully appreciated on initial transthoracic echocardiogram. Characterization of the tumor was aided by the use of multimodality imaging that included computed tomography, magnetic resonance imaging, and positron emission tomography. Familiarity with its appearance on multiple imaging modalities including echocardiography is important to ensure timely diagnosis, although the optimal treatment strategy is still unknown, and the prognosis remains poor.

Doppler Parameters Derived from Transthoracic Echocardiography Accurately Detect Bioprosthetic Mitral Valve Dysfunction

Background: Detecting bioprosthetic mitral valve dysfunction on transthoracic echocardiography can be challenging because of acoustic shadowing of regurgitant jets and a wide normal range of transvalvular gradients. Several studies in mechanical mitral valves have demonstrated the utility of the transthoracically derived parameters E (peak early mitral inflow velocity), pressure half‐time, and the ratio of mitral inflow velocity‐time integral (VTIMV) to left ventricular outflow tract velocity‐time integral (VTILVOT) in detecting significant prosthetic dysfunction. Uncertainty exists as to their applicability and appropriate cutoff levels in bioprosthetic valves. This study was designed to establish the accuracy and appropriate normal limits of routinely collected transthoracic Doppler parameters when used to assess bioprosthetic mitral valve function. Methods: A total of 135 clinically stable patients with bioprosthetic mitral valves who had undergone both transthoracic and transesophageal echocardiography within a 6‐month period were retrospectively identified from the past 11 years of the echocardiography database. Transthoracic findings were labeled as normal (n = 81), regurgitant (n = 44), or stenotic (n = 10) according to the patients transesophageal echocardiographic findings. Univariate and multivariate analyses were performed to identify Doppler parameters that detected dysfunction; then receiver operating characteristic curves were created to establish appropriate normal cutoff levels. Results: The VTIMV/VTILVOT ratio was the most accurate Doppler parameter at detecting valvular dysfunction, with a ratio of >2.5 providing sensitivity of 100% and specificity of 95%. E > 1.9 m/sec was slightly less accurate (93% sensitivity, 72% specificity), while a pressure half‐time of >170 msec had both 100% specificity and sensitivity for detecting significant bioprosthetic mitral valve stenosis, (although it did not differentiate between regurgitant and normal). Conclusions: This study demonstrates that Doppler parameters derived from transthoracic echocardiography can accurately detect bioprosthetic mitral valve dysfunction. These parameters, particularly a VTIMV/VTILVOT ratio of >2.5, are a sensitive way of selecting patients to undergo more invasive examination with transesophageal echocardiography. HighlightsTransthoracic Doppler parameters identify dysfunctional mechanical mitral valves.The authors examined these parameters in normal and abnormal bioprosthetic mitral valves.The VTIMV/VTILVOT ratio was best at identifying valvular dysfunction.VTIMV/VTILVOT > 2.5 was 100% sensitive for bioprosthetic mitral valve dysfunction.VTIMV/VTILVOT > 2.5 was 95% specific for bioprosthetic mitral valve dysfunction.