The Flipped Classroom Approach to Improve Fundus Examination Skills for Medical Students: a Mixed-methods Study

BACKGROUND: Training for the fundus examination using traditional teaching is challenging, resulting in low generalist physicians’ confidence in performing the funduscopic exam. At the same time, there is growing evidence suggesting flipped classrooms’ value in teaching physical examination procedures. However, whether the flipped classroom is superior to the traditional, lecture-based teaching for the funduscopic exam and the cognitive processes supporting its effectiveness has not yet been determined. METHODS: We conducted a sequential explanatory mixed-method study to compare the flipped classroom approach’s effectiveness versus the traditional lecture-based classroom for teaching the funduscopic exam to the medical students at Chiba University in Japan. Medical students were randomly assigned to either a flipped classroom group or a traditional teaching group. We then quantitatively measured the diagnostic accuracy of funduscopic findings, the length of time to perform the fundus examination, and students’ confidence in performing funduscopic examinations, before and after attending the specific classrooms. Next, we conducted student focus groups to explore the students’ thinking processes in the flipped classroom and traditional teaching of fundus examination, respectively. The qualitative data were analyzed using the qualitative content analysis method.RESULTS: Diagnostic accuracy was significantly higher using the flipped classroom method (flipped: 36.6% to 63.4%, traditional: 28.3% to 34.6%, F (1,310) = 11.0, p = .001). The total examination time was significantly shorter using the flipped classroom teaching (flipped: 85.4s to 66.9s, traditional: 85.3s to 76.3s, F (1,310) = 14.7, p <.001). Six semi-structured focused group interviews were conducted (n=36). In the flipped classroom group, we identified 12 categories corresponding to five levels of the revised Bloom’s taxonomy: remember, understand, apply, analyze, evaluate. Five categories were identified in the traditional classroom group corresponding only to three levels of the revised Bloom’s taxonomy: understand, apply, analyze. Interrater reliability was substantial (Cohen’s kappa = 0.81). CONCLUSIONS: Teaching medical students funduscopic examination using the flipped classroom methodology leads to improved diagnostic accuracy, confidence, and motivation for funduscopic examinations, while reducing total examination time. The flipped classroom teaching method enabled higher levels of cognitive activity than the traditional, lecture-based classroom, as assessed using the revised Bloom’s taxonomy.

Virtual bronchoscopic navigation versus non-virtual bronchoscopic navigation assisted bronchoscopy for the diagnosis of peripheral pulmonary lesions: a systematic review and meta-analysis

Background: Image-guided bronchoscopy techniques such as virtual bronchoscopic navigation (VBN) has emerged as a means of assisting in the biopsy of peripheral pulmonary lesions. However, the role of VBN-assisted (VBNA) bronchoscopy in the diagnosing of peripheral pulmonary lesions (PPLs) has not been well established. This meta-analysis investigated the diagnostic yield of VBN-assisted versus non-VBN-assisted (NVBNA) bronchoscopy for PPLs. Methods: PubMed, Embase, Cochrane library, and Web of Sciences databases were searched up to and including August 2020 to identify randomized controlled trials (RCTs) evaluating the performance of VBNA compared with an NVBNA group. Results were expressed as risk ratio (RR) or mean difference (MD) with accompanying 95% confidence interval (CI). Results: Six RCTs with 1626 patients were included. The overall diagnostic rate was similar in the VBNA (74.17%) and NVBNA (69.51%) groups, with risk ratio of 1.07 (95% CI: 0.98–1.17). However, in the VBNA group, the total examination time was significantly shorter (MD = −3.94 min, 95% CI: −6.57 to −1.36; p = 0.003) than in the NVBNA group. VBNA had superior diagnostic yield than NVBNA for PPLs ⩽ 20 mm (RR = 1.18, 95% CI: 1.05–1.32). In addition, diagnostic yield according to nature of lesion, lesion location in the lung lobe, distance from the hilum, bronchus sign and complications were similar between VBNA and NVBNA groups. Conclusion: VBNA bronchoscopy did not increase overall diagnostic yield in patients with PPLs compared with NVBNA bronchoscopy. The superiority of VBNA over NVBNA was evident among patients with PPLs ⩽ 20 mm. Future multicenter RCTs are needed for further investigation. The reviews of this paper are available via the supplemental material section.

Evaluation of a novel colonoscope offering flexibility adjuster – a retrospective observational study

Background: Although colonoscopy is the gold standard for colorectal cancer screening, colonic looping may make complete colonoscopy challenging. Commonly available stiffening device colonoscopy has been described as helpful but not effective enough to prevent looping. In this context the effect on cecal intubation time and rate was described differently in various studies and in some studies had no impact on cecal intubation time at all. The aim of this study was to evaluate whether a novel colonoscope with gradual stiffness (Fujifilm EC760R-V/I- flexibility adjuster, Tokyo, Japan) using four significantly different grades of stiffness can be an alternative to established devices in terms of loop prevention, cecal intubation rate and time, adverse events, and patient/examiner satisfaction. Methods: Consecutive patients without previous colorectal surgery were analyzed retrospectively. Colonoscopy was performed with the new colonoscope and performance characteristics, including time to cecum, withdrawal time, total examination time, and patient and endoscopist satisfaction were recorded. Results: Among 180 consecutive procedures, 98.3% of examinations were complete to the cecum. The endoscopic flexibility adjuster was used in 150 of 180 cases (83.3%). Overall, the device was scored by the examiner as helpful to prevent looping in 146 of the 150 cases (97.7%). Mean cecal intubation time was 6.5 min, with 35% of examination performed in under 5 min with a mean withdrawal time of 7 min. Mean total examination time was 18 min. Patient satisfaction was rated as high in all examinations performed. Conclusion: The new flexibility adjuster colonoscope was shown to be helpful in loop prevention, allowed for fast and successful cecal intubation, and led to a high rate of patients satisfaction.

Tapering body stiffness shortens upper gastrointestinal examination via transoral insertion with ultrathin endoscope

Background and study aims Ultrathin endoscopes are commonly used for surveillance esophagogastroduodenoscopy (EGD) to reduce discomfort associated with scope insertion. However, the flexibility of an ultrathin endoscope is a trade-off between reducing discomfort and lengthening examination time. Patients and methods The EG17-J10 (EG17) is a novel ultrathin endoscope characterized by its tapering body stiffness; however, the flexibility of its tip is comparable to that of the traditional ultrathin endoscope EG16-K10 (EG16). We compared EGD examination time between EG17 and EG16. A total of 319 examinees who underwent EGD from November 2019 to January 2020 at the Chiba-Nishi General Hospital were enrolled. Six examinees were excluded due to past history of surgical resection of the upper gastrointestinal tract or too much food residues; 313 examinees (EG17, 209; EG16,104) were retrospectively analyzed. The examination time was divided into three periods: esophageal insertion time (ET), gastroduodenal insertion time (GDT), and surveillance time of the stomach (ST). The total amount of ET, GDT, and ST was defined as total examination time (TT). Results TT of EGD using EG17 was significantly shorter compared to EGD using EG16 (222.7 ± 68.9 vs. 245.7 ± 78.5 seconds) (P = 0.004). Among the three periods of examination time, ET (66.7 ± 24.1 vs. 76.0 ± 24.1 seconds) (P = 0.001) and GDT (47.9 ± 17.4 vs. 55.2 ± 35.2 seconds) (P = 0.007) of EGD using EG17 were significantly shorter compared to EGD using EG16, except for ST (108.1 ± 51.5.1 vs. 114.5 ± 50.1 seconds) (P = 0.148). Conclusion An ultrathin endoscope with tapering body stiffness can shorten EGD examination time, mainly due to the shortening of insertion time.

Radial EBUS combined with a GS and VBN for diagnosis of peripheral lung lesions: a retrospective study

Background More and more peripheral pulmonary lesions (PPL) have been found following the increased utilization of chest CT in China. But how to identify the nature of PPL accurately, safely and economically is the concern of Chinese doctors. The combination of radial endobronchial ultrasonography with a guide sheath and virtual bronchoscopic navigation was a deluxe scheme to indicate the pathology of peripheral pulmonary lesions in nation’s current medical level. This study aimed to compare the diagnostic yield, safety and health economics of EBUS-GS-VBN versus radial ultrasonic small probe plus thin bronchoscopy (EBUS) for diagnosis of PPLs. Methods This study was a single-institution retrospective review of PLLs examined by using EBUS-GS-VBN or radial EBUS between March 2018 and September 2018 consecutive. The diagnostic yields, accuracy, operation time, complications, factors influencing the diagnostic outcome, tissue genetic test rate and medical cost were analyzed separately. Results there was no significant difference in the diagnostic yield between the two groups (92.31% vs 88.57%, p = 0.594). Although the searching time of EBUS-GS-VBN was shorter (1.47 ± 0.49 min vs 2.12 ± 1.36 min, p < 0.001), procedure time was extended (24.07 ± 5.53 min vs 17.41 ± 4.38 min, p < 0.001). The diagnosis yield of malignancy and benign disease were equal (84.62% vs 100% and 95.35% vs 84%). There was no difference in the rate of gene testing between the two groups (75% vs 70.58%), while the incidence of Intrapulmonary hemorrhage in the EBUS-GS-VBN group was significantly descended. Moreover, the average expense of EBUS-GS-VBN was higher than that of EBUS-GS (6315 ± 1817 RMB vs 3128 ± 1086RMB). Conclusion When performing TBLB of PLLs, we found EBUS-GS-VBN to be similar to EBUS in accuracy. Although the founding lesion time of EBUS-GS-VBN group were significantly shorter, the total examination time was longer. Furthermore, the complications of EBUS-GS-VBN group were fewer. There was no difference in genetic testing between the two groups. It is worth noting that the cost and radiation exposure was lower of EBUS group patients. Trial registration: retrospectively registered

A Preliminary Study of Neonatal Cranial Venous System by Color Doppler

Aim. To present anatomic data in the ultrasound planes for the identification of the major veins and the venous sinuses in cerebrum and to establish the sonographic normal reference values for the visualization of vein vessels and vein sinuses and blood flow velocities. Methods. This study involved 55 healthy full-term neonates for transfontanellar color Doppler sonography. The imaging included both sagittal and coronal planes with LA332E probe, supplemented with PA240 probe as necessary. As low as reasonably achievable (ALARA) principle was obeyed, limiting Doppler exposure time and maximizing signal intensity by increasing gain rather than outputting transducer power settings. The output power was kept at a minimum level consistent with recording an adequate signal. Keeping the newborns in calm state, the total examination time which every neonate required was less than 5 min. All images were stored also in a workstation for further analysis. The description statistics and t-test for statistical analysis were used. Result. In all studied cases (100% cases), subependymal veins (SV), internal cerebral veins (ICV), Galen vein (GV), straight sinus (SS), superior sagittal sinus (SSS), and transverse sinuses (TS) were visualized. The visualization percentages of inferior sagittal sinus (ISS) or basal veins/Rosenthal veins (BV/RV) were lower than 100%. Based on vessel visualization percentage from high to low, the vessels were ordered as follows: SV, ICV, BV, SS, TS, ISS, and SSS. In SSS and TS, the pulsation percentage was 100%. The descending percentages of vessel pulsation were noted in SS, BV, ICV, and SV. On the basis of the mean of maximum velocities of the vessels from low to high, the vessels were ordered as follows: ISS, BV-L, BV-R, ICV-R, ICV-L, SV-L, SV-R, SSS, TS-L, TS-R, and SS. Conclusion. The measurements percent of visualization of cerebral deep veins was higher than the percent of cerebral venous sinuses. The pulsation percent of measurement and the velocities of cerebral venous sinuses were absolutely higher than the cerebral deep venous system. The pairs of vascular blood flow velocities were nonsignificantly different from one another.

Absorbed dose and image quality in examinations of the colon with digital and analogue techniques

Purpose: Image quality and the absorbed dose to the patient are issues of primary interest in the change-over from the conventional analogue technique to the digital technique in the examination of the colon by means of fluoroscopy. the aim of this study was to compare the incident radiation and to evaluate the image quality in two different X-ray equipment types, one digital and one analogue Material and Methods: A kerma-area product meter was used to measure the incident radiation to the patient. Both fluoroscopy and total-examination times were measured as was the number of images. an evaluation of image quality was made and statistically analysed Results and Conclusion: No significant difference in the irradiation dose was observed between the two techniques. the fluoroscopy time was significantly lower with the conventional technique but the total-examination time decreased by 18% with the digital technique. the total number of images taken was higher with the digital technique (25 images compared to 19) owing to the limited field of the image intensifier. Significantly more noise and less sharpness were observed with the digital system but there was no significant difference in contrast or image quality in the various anatomical structures. Although the change-over to the digital system produced a reduction in sharpness and an increase in noise, and no significant dose saving was measured, the digital system was faster to work with and could well be used for diagnostic purposes

Enteroclysis

In enteroclysis the flow rate of the barium is important but not easily controlled with an infusion bag system. To improve the technique, an electric flow inducer was used in 156 consecutive examinations to infuse the barium suspension at a constant rate of 75 ml/min. Detailed demonstration of mucosal folds was achieved in 90 per cent. The examinations were of moderate quality in 8 per cent and of poor quality in 2 per cent. The maximum transit time was 20 minutes and the total examination time never exceeded 35 minutes. Sensitivity and specificity were 94 and 97 per cent, respectively. Examinations indicated by specific small bowel symptoms had a positive yield of 49 versus 13 per cent with non-specific indications. Both examination performance and patient tolerance were improved.