Department of Clinical Sciences, A.T. Still University School of Osteopathic Medicine, Mesa, AZ, USA.
Department of Emergency Medicine, University of Arizona, Tucson, AZ, USA.
J Osteopath Med. 2023 Jul 7;123(10):475-484. doi: 10.1515/jom-2022-0186. eCollection 2023 Sep 1.
Patients frequently present to the outpatient clinic, urgent care, or emergency department with a painful, swollen knee. Differentiating the underlying etiology can be a challenge for both medical students and seasoned clinicians alike. Because this scenario can represent a time-sensitive emergency, developing skills to diagnose the underlying cause quickly and accurately is essential for proper management, whether the patient would benefit from osteopathic manipulation, prompt administration of antibiotics, or a more invasive procedure like joint aspiration or surgery.
The objectives are to determine the effects of a focused ultrasound training on first-year osteopathic medical students' ability to identify normal sonographic anatomy of the anterior knee and to differentiate between three common pathologies: joint effusion, prepatellar bursitis, and cellulitis.
First-year osteopathic medical students voluntarily participated in this cross-sectional study. The study protocol included a focused ultrasound training (online materials, brief didactic and single hands-on sessions) followed by a hands-on assessment. A written test and 5-point Likert scale questionnaire were administered before and after the focused training. Nine weeks later, students completed a follow-up written test. The proportion of students who correctly identified common pathologies on written tests before (pretest) and after (posttest) training and on the follow-up written test were compared utilizing the Fisher's exact test. A t test was utilized to compare data from the pretraining and posttraining questionnaires.
Of 101 students completing the written pretest and pretraining questionnaire, 95 (94.1 %) completed the written posttest and posttraining questionnaire, and 84 (83.2 %) completed the follow-up written test. Students had limited previous experience with ultrasound; 90 (89.1 %) students had performed six or fewer ultrasound examinations before the focused ultrasound training. On written tests, students accurately identified joint effusion (22.8 % [23/101] pretest, 65.3 % [62/95] posttest, 33.3 % [28/84] follow-up test), prepatellar bursitis (14.9 % [15/101] pretest, 46.3 % [44/95] posttest, 36.9 % [31/84] follow-up test), and cellulitis (38.6 % [39/101] pretest, 90.5 % [86/95] posttest, 73.8 % [62/84] follow-up test). Differences were found between pretest and posttest for identification of all three pathologies (all p<0.001) and between the pretest and 9-week follow-up test for identification of prepatellar bursitis and cellulitis (both p≤0.001). For questionnaires, (where 1=strongly agree, 5=strongly disagree), the mean (standard deviation [SD]) confidence for correctly identifying normal sonographic anatomy of the anterior knee was 3.50 (1.01) at pretraining and 1.59 (0.72) at posttraining. Student confidence in the ability to differentiate joint effusion, prepatellar bursitis, and cellulitis utilizing ultrasound increased from 4.33 (0.78) at pretraining to 1.99 (0.78) at posttraining. For the hands-on assessment, 78.3 % (595 correct/760 aggregated responses) of the time students correctly identified specific sonographic landmarks of the anterior knee. When the evaluation combined real-time scanning with a prerecorded sonographic video clip of the anterior knee, 71.4 % (20/28) accurately identified joint effusion, 60.9 % (14/23) correctly diagnosed prepatellar bursitis, 93.3 % (28/30) recognized cellulitis, and 47.1 % (8/17) diagnosed the normal knee.
Our focused training was effective at immediately increasing basic knowledge, as well as confidence of first-year osteopathic medical students when assessing the anterior knee with point-of-care ultrasound. However, spaced repetition and deliberate practice may be useful for learning retention.
患者常因疼痛、肿胀的膝关节而到门诊、紧急护理或急诊就诊。对于医学生和经验丰富的临床医生来说，区分潜在病因都是一个挑战。由于这种情况可能代表着需要紧急处理的情况，因此快速准确地诊断潜在病因对于正确管理至关重要，无论患者是否受益于整骨疗法、及时给予抗生素治疗，还是更具侵入性的程序，如关节抽吸或手术。
本研究旨在确定聚焦超声培训对一年级整骨医学专业学生识别前膝关节正常超声解剖结构以及区分三种常见病理情况（关节积液、髌前滑囊炎和蜂窝织炎）的能力的影响。
一年级整骨医学专业学生自愿参加了这项横断面研究。研究方案包括聚焦超声培训（在线材料、简短的理论和单次实践课程），然后进行实践评估。在培训前后进行了书面测试和 5 分李克特量表问卷调查。9 周后，学生完成了随访书面测试。通过 Fisher 精确检验比较学生在培训前后书面测试（预测试）和随访书面测试中正确识别常见病理情况的比例。通过 t 检验比较预测试和后测试问卷的数据。
在完成书面预测试和预培训问卷的 101 名学生中，95 名（94.1%）完成了书面后测试和后培训问卷，84 名（83.2%）完成了随访书面测试。学生之前的超声检查经验有限；90 名（89.1%）学生在聚焦超声培训前仅进行了 6 次或更少的超声检查。在书面测试中，学生准确识别关节积液（22.8%[101 名学生中的 23 名]预测试、65.3%[95 名学生中的 62 名]后测试、33.3%[84 名学生中的 28 名]随访测试）、髌前滑囊炎（14.9%[101 名学生中的 15 名]预测试、46.3%[95 名学生中的 44 名]后测试、36.9%[84 名学生中的 31 名]随访测试）和蜂窝织炎（38.6%[101 名学生中的 39 名]预测试、90.5%[95 名学生中的 86 名]后测试、73.8%[84 名学生中的 62 名]随访测试）。在所有三种病理情况下，预测试和后测试之间的差异均有统计学意义（均 p<0.001），并且在预测试和 9 周随访测试之间，髌前滑囊炎和蜂窝织炎的差异也有统计学意义（均 p≤0.001）。对于问卷，（其中 1=非常同意，5=非常不同意），正确识别前膝关节正常超声解剖结构的置信度平均值（标准差[SD]）在前训练时为 3.50（1.01），在后训练时为 1.59（0.72）。学生利用超声区分关节积液、髌前滑囊炎和蜂窝织炎的能力的置信度从训练前的 4.33（0.78）增加到训练后的 1.99（0.78）。在实践评估中，78.3%（760 次聚合应答中的 595 次正确）的时间学生能够正确识别前膝关节的特定超声标志。当评估结合实时扫描和前膝关节的预先录制超声视频剪辑时，71.4%（20/28）准确识别关节积液，60.9%（14/23）正确诊断髌前滑囊炎，93.3%（28/30）识别蜂窝织炎，47.1%（8/17）诊断正常膝关节。
我们的聚焦培训在提高一年级整骨医学专业学生使用即时护理超声评估前膝关节时的基础知识和信心方面非常有效。然而，间隔重复和刻意练习可能有助于学习保持。
