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in addition to being noninvasive&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Moreover&#44; USG is a painless procedure that does not require the administration of medicines and is safe since it does not involve ionizing radiation&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5&#8211;7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Proper use of POCUS provides image generation in real-time&#44; which enables a quick diagnosis and provides guidance during procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;12</span></a> Finally&#44; the exams can be performed at any time and repeated several times&#44; avoiding unnecessary tests&#44; promoting better clinical decision-making&#44; and decreasing medical errors&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Pediatricians working in intensive care who have technical USG knowledge to recognize the main pathologies and urgent conditions using USG can be essential to patient prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;15</span></a> Furthermore&#44; in recent years&#44; USG has been more commonly used in medical education&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> In addition&#44; USG methods are useful in many medical specialties&#44; including pediatrics&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Therefore&#44; the objectives of the present study are to evaluate the inclusion of TU POCUS as an extension of the physical examination and to present a protocol for teaching medical students and novice users&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">In the current study&#44; 27 medical students and 15 pediatricians &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; without USG training were invited between 2018 and 2019 to perform bedside &#8220;point of care&#8221; TU on newborns from Terezinha de Jesus Maternity Hospital&#44; Brazil&#46; The pediatricians and interns in this hospital were enrolled if they met the inclusion and exclusion criteria&#46; Inclusion criteria were that all medical students were&#44; at the time of enrollment&#44; in their second year of study and were familiar with neuroanatomy&#44; but not with diagnostic imaging&#44; which could influence the results&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Exclusion criteria were that subjects that had not agreed to participate&#44; that had not performed all the research stages&#44; or that had previously participated in USG training and were excluded from the study&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In addition&#44; newborns from the hospital intensive care unit were only enrolled after legal guardians or parents provided written consent&#46; Eight &#40;8&#41; healthy low-risk newborns were included in the study&#46; The procedure was performed in the anterior fontanelle&#44; with the patient in the supine position&#44; and all images were taken in the coronal and sagittal planes&#46; Students were expected to recognize the differences by the sagittal and coronal planes and to determine the corpus callosum&#44; cerebellum&#44; brain stem&#44; and lateral ventricles &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">All those legally responsible were informed that the TU in this study would not replace comprehensive USG and that the method&#44; being noninvasive and with minimal risk for patients&#44; would be performed through the anterior fontanelle&#46; There was no financial reward for parents or legal guardians&#44; and the TU was performed with no obligation for the patients and complemented with additional examinations in case of suspicion for another diagnosis&#46; Pediatricians&#8217; and students&#8217; performance and evaluation were not revealed to maintain confidentiality&#46; The study was approved by the ethics committee&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Study protocol</span><p id="par0050" class="elsevierStylePara elsevierViewall">The study was divided into stages for its realization&#46; The medical students were separated into two groups&#44; the A group &#40;12 students&#41; and the B group &#40;15 students&#41;&#46; The first group only received theoretical training&#44; while the second group received theoretical and practical training to identify any additional factors that practical training could provide&#46; The C group&#44; which was formed by 15 pediatricians and interns&#44; also received theoretical and practical training&#46; Finally&#44; all 42 selected participants were randomly distributed into 6 classes&#46; All classes received the same teaching method and practice time&#44; 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practical demonstration in newborns&#46; After this training&#44; the participants were able to study the subject for 3 days&#46; It is important to emphasize that all the groups had USG physical management&#44; knobology&#44; image adjustment&#44; and TU classes&#44; but only the B and C groups had hands-on sessions using an endocavitary probe with the GE Logiq-E device &#40;Logiq-E GE 2014&#44; Contagem&#44; Brazil&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The next morning&#44; there was a second meeting&#44; where the main topics were reviewed with a lecture lasting approximately 15<span class="elsevierStyleHsp" style=""></span>min&#46; Then&#44; the participants received an educational intervention to begin theoretical-practical training lasting 105<span class="elsevierStyleHsp" style=""></span>min&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">That afternoon&#44; after the short course had been performed&#44; there was a second cognitive multiple-choice test about USG aiming to evaluate knowledge evolution&#44; using similar but not the same questions as the previous test&#46; Later&#44; on the same day&#44; all participants underwent a theoretical-practical performance evaluation&#44; composed of nine parameters &#40;four alternatives each&#41; in four domains&#58; neuroanatomy &#40;D1&#41;&#44; knobology &#40;D2&#41;&#44; altered &#40;hemorrhage&#44; calcifications&#44; hydrocephalus&#41; TU images &#40;D3&#41; and normal TU images &#40;D4&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In the cognitive and practical tests for the TU study&#44; 70 points were set as the minimum score&#44; which is the required grade to demonstrate competency in the subjects at our institution&#46; If any of the participants did not achieve the required score&#44; new training would be performed until everyone reached it&#46; Finally&#44; all participants answered a questionnaire based on a Likert scale about their satisfaction with the course&#46; There were four sentences to determine their satisfaction on a scale from one to five&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Six months later&#44; another cognitive evaluation was performed with the same students and pediatricians&#47;interns to verify their knowledge retention&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In summary&#44; the variables presented were&#58; Improvement of the scores of the cognitive assessment&#59; Evolution of the average grades 6 months after the course compared with the second test&#59; Rate of correct answers in the image interpretation&#59; Performance between Groups&#59; Satisfaction evaluation and all that was described as a percentage&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The data were stored and analyzed using Stata 9&#46;1 software &#40;Stata Corp&#46; College Station&#44; United States&#41;&#46; The descriptive analysis of the variables was presented using means and standard deviations&#46; The normality of the data was assessed using the Shapiro-Wilk test&#46; To compare the means of the test domains among the groups&#44; the Kruskal-Wallis test was used&#44; followed by the post hoc Bonferroni test&#46; To determine if there was a change in the cognitive test before&#44; after&#44; and in the follow-up&#44; ANOVA with repeated measures was used&#46; The accepted level of significance was 5&#37;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">A total of 27 students &#40;Group A&#58; mean age 22&#46;58 years&#44; 58&#46;3&#37; female&#59; Group B&#58; mean age 22&#46;2 years&#44; 60&#46;0&#37; female&#41; and 15 pediatricians &#40;Group C&#58; mean age 31&#46;1 years&#44; 66&#46;6&#37; female&#41; participated in the study&#46; There were no differences between sex among the groups&#46; Group C had an older average age than groups A and B&#44; which were composed only of students&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> shows the improvement of the scores of the cognitive assessment from before the course and after its completion for the three groups &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> also demonstrates the evolution of the average grades 6 months after the course compared with the second test&#44; highlighting the drop in knowledge retention only in group A &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0019&#41;&#46; In all groups&#44; there was significant retention of knowledge in relation to each first test &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The general rate of correct answers in the image interpretation&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; was 75&#44;9&#37; in group A&#44; 89&#44;8&#37; in group B&#44; and 92&#44;5&#37; in group C &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;045&#41;&#46; Then&#44; we divided the questions about knowledge domains into D1 &#40;neuroanatomy&#41;&#44; D2 &#40;knobology&#41;&#44; D3 &#40;altered TU exams&#41;&#44; and D4 &#40;normal TU exams&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> demonstrates that the capacity to dismiss a completely normal exam was the parameter with the lowest success rate&#44; with correct answers of approximately 41&#46;6&#37; in group A&#44; 60&#37; in group B&#44; and 66&#46;6&#37; in group C&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> highlights that the performance between Groups &#40;A<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>B&#41; and &#40;A<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>C&#41; was significantly different regarding the domains of knobology &#40;D2&#41;&#44; interpretation of pathological images by TU &#40;D3&#41; and in the total count &#40;Total&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The satisfaction evaluation by the Likert scale demonstrates that all questionnaire sentences had a global positive rate higher than 80&#37;&#46; Items&#58; 1&#46; The course meets expectations&#58; 88&#46;0&#37;&#59; 2&#46; Practical theoretical training enables brain structures to be identified by TU&#58; 97&#46;5&#37;&#59; 3&#46; TU should be included in medical education&#58; 83&#46;3&#37;&#59; 4&#46; The participant has added knowledge and believes to be better able to evaluate a newborn&#8217;s brain&#58; 80&#46;9&#37;&#46; The second sentence about the capacity of structure identification in USG had the highest global positive rate &#40;97&#46;5&#37;&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">We developed a TU USG training protocol&#46; TU indication criteria remain visible on the ICU general bulletin board&#46; Every six months&#44; transfontanellar USG classes are provided for pediatricians&#47;interns&#46; Once a week&#44; all of the interns could watch a USG performed by a radiologist and should participate in case report discussions&#46; Finally&#44; the hospital-acquired the USG device and made it fully available to those who perform permanent training in POCUS &#40;pediatric and adult ICU&#44; anesthesiologists&#44; and surgeons&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">The main study findings were as follows&#58; according to cognitive evaluation before and after classes&#44; there was learning evolution&#44; with knowledge retention for 6 months&#59; practical training results in a higher number of correct answers and can influence knowledge retention&#59; the capacity to dismiss a normal TU &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; was the most difficult parameter for the participants&#59; questions related to the technique of using the USG device were easily addressed and quickly learned by the participants&#59; according to the satisfaction questionnaire&#44; theoretical-practical short-courses are well received by the participants&#44; with even higher results when there is a practical component&#59; and the proposed teaching protocol was well received and can be an interesting way to improve hospital compliance&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In a study performed in 2011&#44; 95&#37; of emergency service departments in the United States of America &#40;USA&#41; that included &#8220;fellow&#8221; training programs performed some kind of service with &#8220;point-of-care&#8221; techniques&#44; and 88&#37; of specialized training programs provided specific training for this purpose&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> This study corroborates other research in the literature&#44; such as the studies by Nunes et al&#46; with intern physicians and Heinzow et al&#46; with students&#44; that demonstrates how USG short training has significantly improved cognitive evaluations before and after practical training&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">There is enormous variability in the protocols between several USG studies in medical education&#44; and the necessary number of exams performed by professionals to reach a level of competence for safe and confident performance has not been established&#44; although it is well known that practice examinations are effective in the evaluation of the participants&#8217; knowledge&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Many USG studies have involved medical students and physicians&#44; and there has been an extensive utilization of practical simulations&#44; including on real patients in emergency situations&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a> Therefore&#44; it was reasonable to predict that practical training would produce better results than only theoretical training&#44; as our study has confirmed&#46; Finally&#44; as we observed in our study&#44; determining that an exam is normal is&#44; in fact&#44; a complex and challenging task&#44; even for those with experience in diagnosis&#44; and only continuous training will produce a significant increase in technical knowledge and diagnostic confidence&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">There is not an established consensus about the duration of the course&#44; which can be explained by the high variability in training that aims between the medical specialties&#44; or about the need to obtain certification by medical societies&#46; However&#44; short courses have already demonstrated efficacy&#44; as in the study by Thomas et al&#46;&#44; which achieved excellent results after a single 8-h trauma course through didactic classes and practical training performed by surgeons&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">There is increasing interest in USG training among medical students and interns&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a> Recent research about POCUS training and implementation between scholarship programs in the USA has suggested limited scope but high levels of interest&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;29</span></a> Therefore&#44; our study corroborates the literature by demonstrating the high interest and acceptance for those courses&#44; with positive satisfaction rates higher than 80&#37; for all the questionnaire statements&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Our study had some practical limitations&#46; First&#44; it should be discussed that the number of participants is not large&#44; although previous POCUS studies have a similar number of participants&#44; and all of our hospital pediatricians and interns were selected &#40;according to the inclusion and exclusion criteria&#41; with equivalence in the number of students in the other groups&#46; Second&#44; the follow-up at six months may not be long enough to analyze knowledge retention&#59; however&#44; we obtained results with statistical relevance even with few participants and in a short evaluation time&#46; Third&#44; there is difficulty in the qualitative assessment of the ability of new apprentices to perform the USG&#44; and only continuing education and continuous assessment can attest to the quality of POCUS courses&#46; This is a pioneering study in developing the training and proficiency regimes necessary for the implementation of the POCUS protocol in an ICU with an emphasis on TU&#44; as has been necessary for pediatric practice and emphasized in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The point-of-care modality is already a reality in many hospital services around the world for most medical specialties&#46; In pediatrics&#44; the method has enormous importance since it is inherently safe&#44; with no radiation emission and no drug administration&#46; Finally&#44; knowledge dissemination is necessary for the education of academics and physicians&#44; and short courses have been considered effective regarding this dissemination&#44; although it is necessary to emphasize permanent education and cooperation between different medical specialties&#46; We reinforce that POCUS improves the pediatric physical examination&#44; verified in this study through the TU and that it can be taught in short courses with serial monitoring of studies by a radiologist&#44; which is fundamental whenever the pediatrician or clinician finds its limit on USG&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The protocol below is suggested according to the experience of the present study and bibliographic review&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">First day&#58; cognitive test before the course and&#44; after that&#44; theory class and practical class lasting 60<span class="elsevierStyleHsp" style=""></span>min each&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">Three days of personal study&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">Fifth day&#58; review&#44; cognitive test&#44; and another theoretical-practical performance evaluation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0180" class="elsevierStylePara elsevierViewall">Monitor the performance and perform TU exams at least once a week&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0185" class="elsevierStylePara elsevierViewall">Every six months&#58; another cognitive test&#46;</p></li></ul></p><p id="par0190" class="elsevierStylePara elsevierViewall">Finally&#44; we suggest if any author wants to replicate the study that adds a fourth group with physicians that already know the method and perform TU&#46; This would allow new comparisons between subgroups with different degrees of knowledge&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The authors aim to evaluate the &#8220;point-of-care&#8221; transfontanellar ultrasound &#40;TU&#41; as an extension to pediatric physical examination and suggest a TU teaching protocol&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The students were randomly divided into two groups&#44; group A &#40;12 participants&#41; and group B &#40;15 participants&#41;&#46; The first group only received theoretical training&#44; while the second group received theoretical and practical training&#46; A third group&#44; group C&#44; included 15 pediatricians and interns who also received theoretical and practical training&#46; All the participants underwent multiple-choice testing before and after a four-hour short course on TU&#46; Six months later&#44; another evaluation was performed to analyze the retained knowledge&#46; Furthermore&#44; a questionnaire based on the Likert scale was administered to evaluate satisfaction&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The cognitive evaluation &#40;maximum score<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10 points&#41; before and after training increased in group A from 4&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;04 to 7&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;2 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and&#44; 6 months later&#44; to 6&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;16 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#59; in group B from 3&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;24 to 8&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;01 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and&#44; 6 months later&#44; to 8&#44;46<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;91 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#59; and in group C from 6&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;75 to 9&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;75 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and&#44; 6 months later&#44; to 8&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;77 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The average satisfaction estimated by the Likert scale was over 80&#37; for all questions&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Cognitive assessment before and after classes and training reveals progress in learning&#44; with knowledge retention in 6 months&#46; Theoretical-practical courses are well accepted&#46;</p></span>"
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Group C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">GA<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>GB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">GA<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>GC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">GB<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>GC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">D1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">94&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">95&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">97&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;33&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;13&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;341&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">75&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">93&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">97&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">D3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">90&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">96&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">D4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">41&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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Original article
Teaching point-of-care transfontanellar ultrasound for pediatricians and medical students
Gustavo Bittencourt Camiloa,d,
Corresponding author
gustavoscamilo@gmail.com

Corresponding author.
, Gabriela Cumani Toledoa,b,c, Hebert Olímpio Júniord, Eleusa Nogueira Diasb, Bianca Lopes de Oliveirab, Júlia Perches Ferreirab, Pedro de Freitas Batista Mendese, Marcus Gomes Bastosa,e
a Universidade Federal de Juiz de Fora (UFJF), Programa de Pós-graduação em Saúde Brasileira, Juiz de Fora, MG, Brazil
b Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (Suprema), Departamento de Radiologia, Juiz de Fora, MG, Brazil
c Hospital e Maternidade Teresinha de Jesus (HMTJ), Departamento de Radiologia, Juiz de Fora, MG, Brazil
d Universidade do Estado do Rio de Janeiro (UERJ), Departamento de Pneumologia, Programa de Pós-graduação em Ciências Médica, Rio de Janeiro, RJ, Brazil
e Universidade Federal de Juiz de Fora (UFJF), Departamento de Nefrologia, Juiz de Fora, MG, Brazil
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Scores of cognitive assessment of the 3 groups&#44; before the course&#44; after the course and follow up in 6 months showing mean&#44; standard deviation and statistical relevance in the comparison between the three tests&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">&#8220;Point-of-care ultrasound&#8221; &#40;POCUS&#41; has indispensable qualities that make it capable of answering specific questions in an interactive way&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> POCUS is a bedside technology that allows non-radiologist physicians to integrate physical examination findings with sonographic imaging&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Unlike computed tomography &#40;CT&#41; and magnetic resonance &#40;MR&#41;&#44; ultrasound &#40;USG&#41; is less expensive&#44; portable&#44; and provides vascular or blood flow information&#44; in addition to being noninvasive&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Moreover&#44; USG is a painless procedure that does not require the administration of medicines and is safe since it does not involve ionizing radiation&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5&#8211;7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Proper use of POCUS provides image generation in real-time&#44; which enables a quick diagnosis and provides guidance during procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;12</span></a> Finally&#44; the exams can be performed at any time and repeated several times&#44; avoiding unnecessary tests&#44; promoting better clinical decision-making&#44; and decreasing medical errors&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Pediatricians working in intensive care who have technical USG knowledge to recognize the main pathologies and urgent conditions using USG can be essential to patient prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;15</span></a> Furthermore&#44; in recent years&#44; USG has been more commonly used in medical education&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> In addition&#44; USG methods are useful in many medical specialties&#44; including pediatrics&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Therefore&#44; the objectives of the present study are to evaluate the inclusion of TU POCUS as an extension of the physical examination and to present a protocol for teaching medical students and novice users&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">In the current study&#44; 27 medical students and 15 pediatricians &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; without USG training were invited between 2018 and 2019 to perform bedside &#8220;point of care&#8221; TU on newborns from Terezinha de Jesus Maternity Hospital&#44; Brazil&#46; The pediatricians and interns in this hospital were enrolled if they met the inclusion and exclusion criteria&#46; Inclusion criteria were that all medical students were&#44; at the time of enrollment&#44; in their second year of study and were familiar with neuroanatomy&#44; but not with diagnostic imaging&#44; which could influence the results&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Exclusion criteria were that subjects that had not agreed to participate&#44; that had not performed all the research stages&#44; or that had previously participated in USG training and were excluded from the study&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In addition&#44; newborns from the hospital intensive care unit were only enrolled after legal guardians or parents provided written consent&#46; Eight &#40;8&#41; healthy low-risk newborns were included in the study&#46; The procedure was performed in the anterior fontanelle&#44; with the patient in the supine position&#44; and all images were taken in the coronal and sagittal planes&#46; Students were expected to recognize the differences by the sagittal and coronal planes and to determine the corpus callosum&#44; cerebellum&#44; brain stem&#44; and lateral ventricles &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">All those legally responsible were informed that the TU in this study would not replace comprehensive USG and that the method&#44; being noninvasive and with minimal risk for patients&#44; would be performed through the anterior fontanelle&#46; There was no financial reward for parents or legal guardians&#44; and the TU was performed with no obligation for the patients and complemented with additional examinations in case of suspicion for another diagnosis&#46; Pediatricians&#8217; and students&#8217; performance and evaluation were not revealed to maintain confidentiality&#46; The study was approved by the ethics committee&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Study protocol</span><p id="par0050" class="elsevierStylePara elsevierViewall">The study was divided into stages for its realization&#46; The medical students were separated into two groups&#44; the A group &#40;12 students&#41; and the B group &#40;15 students&#41;&#46; The first group only received theoretical training&#44; while the second group received theoretical and practical training to identify any additional factors that practical training could provide&#46; The C group&#44; which was formed by 15 pediatricians and interns&#44; also received theoretical and practical training&#46; Finally&#44; all 42 selected participants were randomly distributed into 6 classes&#46; All classes received the same teaching method and practice time&#44; with the exception that group A did not receive practical training&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">On the first day&#44; before the course&#44; there was a cognitive test lasting 15<span class="elsevierStyleHsp" style=""></span>min&#44; with ten questions &#40;four choices each&#41;&#44; to verify previous knowledge about neuroanatomy&#44; USG&#44; knobology&#44; and neonatal pathologies&#46; After the test&#44; there was a theory class lasting 60<span class="elsevierStyleHsp" style=""></span>min with a radiologist with more than 5 years of experience to teach the above knowledge&#46; Later&#44; there was a practical class and training lasting 60<span class="elsevierStyleHsp" style=""></span>min&#44; with a basic orientation about the theory relating to the use of USG devices&#44; basic physics&#44; main buttons and components&#44; techniques to improve image resolution&#44; and required measures for USG in pediatrics&#44; with an emphasis on TU evaluation and &#8220;hands-on&#8221; practical demonstration in newborns&#46; After this training&#44; the participants were able to study the subject for 3 days&#46; It is important to emphasize that all the groups had USG physical management&#44; knobology&#44; image adjustment&#44; and TU classes&#44; but only the B and C groups had hands-on sessions using an endocavitary probe with the GE Logiq-E device &#40;Logiq-E GE 2014&#44; Contagem&#44; Brazil&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The next morning&#44; there was a second meeting&#44; where the main topics were reviewed with a lecture lasting approximately 15<span class="elsevierStyleHsp" style=""></span>min&#46; Then&#44; the participants received an educational intervention to begin theoretical-practical training lasting 105<span class="elsevierStyleHsp" style=""></span>min&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">That afternoon&#44; after the short course had been performed&#44; there was a second cognitive multiple-choice test about USG aiming to evaluate knowledge evolution&#44; using similar but not the same questions as the previous test&#46; Later&#44; on the same day&#44; all participants underwent a theoretical-practical performance evaluation&#44; composed of nine parameters &#40;four alternatives each&#41; in four domains&#58; neuroanatomy &#40;D1&#41;&#44; knobology &#40;D2&#41;&#44; altered &#40;hemorrhage&#44; calcifications&#44; hydrocephalus&#41; TU images &#40;D3&#41; and normal TU images &#40;D4&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In the cognitive and practical tests for the TU study&#44; 70 points were set as the minimum score&#44; which is the required grade to demonstrate competency in the subjects at our institution&#46; If any of the participants did not achieve the required score&#44; new training would be performed until everyone reached it&#46; Finally&#44; all participants answered a questionnaire based on a Likert scale about their satisfaction with the course&#46; There were four sentences to determine their satisfaction on a scale from one to five&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Six months later&#44; another cognitive evaluation was performed with the same students and pediatricians&#47;interns to verify their knowledge retention&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In summary&#44; the variables presented were&#58; Improvement of the scores of the cognitive assessment&#59; Evolution of the average grades 6 months after the course compared with the second test&#59; Rate of correct answers in the image interpretation&#59; Performance between Groups&#59; Satisfaction evaluation and all that was described as a percentage&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The data were stored and analyzed using Stata 9&#46;1 software &#40;Stata Corp&#46; College Station&#44; United States&#41;&#46; The descriptive analysis of the variables was presented using means and standard deviations&#46; The normality of the data was assessed using the Shapiro-Wilk test&#46; To compare the means of the test domains among the groups&#44; the Kruskal-Wallis test was used&#44; followed by the post hoc Bonferroni test&#46; To determine if there was a change in the cognitive test before&#44; after&#44; and in the follow-up&#44; ANOVA with repeated measures was used&#46; The accepted level of significance was 5&#37;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">A total of 27 students &#40;Group A&#58; mean age 22&#46;58 years&#44; 58&#46;3&#37; female&#59; Group B&#58; mean age 22&#46;2 years&#44; 60&#46;0&#37; female&#41; and 15 pediatricians &#40;Group C&#58; mean age 31&#46;1 years&#44; 66&#46;6&#37; female&#41; participated in the study&#46; There were no differences between sex among the groups&#46; Group C had an older average age than groups A and B&#44; which were composed only of students&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> shows the improvement of the scores of the cognitive assessment from before the course and after its completion for the three groups &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> also demonstrates the evolution of the average grades 6 months after the course compared with the second test&#44; highlighting the drop in knowledge retention only in group A &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0019&#41;&#46; In all groups&#44; there was significant retention of knowledge in relation to each first test &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The general rate of correct answers in the image interpretation&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; was 75&#44;9&#37; in group A&#44; 89&#44;8&#37; in group B&#44; and 92&#44;5&#37; in group C &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;045&#41;&#46; Then&#44; we divided the questions about knowledge domains into D1 &#40;neuroanatomy&#41;&#44; D2 &#40;knobology&#41;&#44; D3 &#40;altered TU exams&#41;&#44; and D4 &#40;normal TU exams&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> demonstrates that the capacity to dismiss a completely normal exam was the parameter with the lowest success rate&#44; with correct answers of approximately 41&#46;6&#37; in group A&#44; 60&#37; in group B&#44; and 66&#46;6&#37; in group C&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> highlights that the performance between Groups &#40;A<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>B&#41; and &#40;A<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>C&#41; was significantly different regarding the domains of knobology &#40;D2&#41;&#44; interpretation of pathological images by TU &#40;D3&#41; and in the total count &#40;Total&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The satisfaction evaluation by the Likert scale demonstrates that all questionnaire sentences had a global positive rate higher than 80&#37;&#46; Items&#58; 1&#46; The course meets expectations&#58; 88&#46;0&#37;&#59; 2&#46; Practical theoretical training enables brain structures to be identified by TU&#58; 97&#46;5&#37;&#59; 3&#46; TU should be included in medical education&#58; 83&#46;3&#37;&#59; 4&#46; The participant has added knowledge and believes to be better able to evaluate a newborn&#8217;s brain&#58; 80&#46;9&#37;&#46; The second sentence about the capacity of structure identification in USG had the highest global positive rate &#40;97&#46;5&#37;&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">We developed a TU USG training protocol&#46; TU indication criteria remain visible on the ICU general bulletin board&#46; Every six months&#44; transfontanellar USG classes are provided for pediatricians&#47;interns&#46; Once a week&#44; all of the interns could watch a USG performed by a radiologist and should participate in case report discussions&#46; Finally&#44; the hospital-acquired the USG device and made it fully available to those who perform permanent training in POCUS &#40;pediatric and adult ICU&#44; anesthesiologists&#44; and surgeons&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">The main study findings were as follows&#58; according to cognitive evaluation before and after classes&#44; there was learning evolution&#44; with knowledge retention for 6 months&#59; practical training results in a higher number of correct answers and can influence knowledge retention&#59; the capacity to dismiss a normal TU &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; was the most difficult parameter for the participants&#59; questions related to the technique of using the USG device were easily addressed and quickly learned by the participants&#59; according to the satisfaction questionnaire&#44; theoretical-practical short-courses are well received by the participants&#44; with even higher results when there is a practical component&#59; and the proposed teaching protocol was well received and can be an interesting way to improve hospital compliance&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In a study performed in 2011&#44; 95&#37; of emergency service departments in the United States of America &#40;USA&#41; that included &#8220;fellow&#8221; training programs performed some kind of service with &#8220;point-of-care&#8221; techniques&#44; and 88&#37; of specialized training programs provided specific training for this purpose&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> This study corroborates other research in the literature&#44; such as the studies by Nunes et al&#46; with intern physicians and Heinzow et al&#46; with students&#44; that demonstrates how USG short training has significantly improved cognitive evaluations before and after practical training&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">There is enormous variability in the protocols between several USG studies in medical education&#44; and the necessary number of exams performed by professionals to reach a level of competence for safe and confident performance has not been established&#44; although it is well known that practice examinations are effective in the evaluation of the participants&#8217; knowledge&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Many USG studies have involved medical students and physicians&#44; and there has been an extensive utilization of practical simulations&#44; including on real patients in emergency situations&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a> Therefore&#44; it was reasonable to predict that practical training would produce better results than only theoretical training&#44; as our study has confirmed&#46; Finally&#44; as we observed in our study&#44; determining that an exam is normal is&#44; in fact&#44; a complex and challenging task&#44; even for those with experience in diagnosis&#44; and only continuous training will produce a significant increase in technical knowledge and diagnostic confidence&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">There is not an established consensus about the duration of the course&#44; which can be explained by the high variability in training that aims between the medical specialties&#44; or about the need to obtain certification by medical societies&#46; However&#44; short courses have already demonstrated efficacy&#44; as in the study by Thomas et al&#46;&#44; which achieved excellent results after a single 8-h trauma course through didactic classes and practical training performed by surgeons&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">There is increasing interest in USG training among medical students and interns&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a> Recent research about POCUS training and implementation between scholarship programs in the USA has suggested limited scope but high levels of interest&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;29</span></a> Therefore&#44; our study corroborates the literature by demonstrating the high interest and acceptance for those courses&#44; with positive satisfaction rates higher than 80&#37; for all the questionnaire statements&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Our study had some practical limitations&#46; First&#44; it should be discussed that the number of participants is not large&#44; although previous POCUS studies have a similar number of participants&#44; and all of our hospital pediatricians and interns were selected &#40;according to the inclusion and exclusion criteria&#41; with equivalence in the number of students in the other groups&#46; Second&#44; the follow-up at six months may not be long enough to analyze knowledge retention&#59; however&#44; we obtained results with statistical relevance even with few participants and in a short evaluation time&#46; Third&#44; there is difficulty in the qualitative assessment of the ability of new apprentices to perform the USG&#44; and only continuing education and continuous assessment can attest to the quality of POCUS courses&#46; This is a pioneering study in developing the training and proficiency regimes necessary for the implementation of the POCUS protocol in an ICU with an emphasis on TU&#44; as has been necessary for pediatric practice and emphasized in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The point-of-care modality is already a reality in many hospital services around the world for most medical specialties&#46; In pediatrics&#44; the method has enormous importance since it is inherently safe&#44; with no radiation emission and no drug administration&#46; Finally&#44; knowledge dissemination is necessary for the education of academics and physicians&#44; and short courses have been considered effective regarding this dissemination&#44; although it is necessary to emphasize permanent education and cooperation between different medical specialties&#46; We reinforce that POCUS improves the pediatric physical examination&#44; verified in this study through the TU and that it can be taught in short courses with serial monitoring of studies by a radiologist&#44; which is fundamental whenever the pediatrician or clinician finds its limit on USG&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The protocol below is suggested according to the experience of the present study and bibliographic review&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">First day&#58; cognitive test before the course and&#44; after that&#44; theory class and practical class lasting 60<span class="elsevierStyleHsp" style=""></span>min each&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">Three days of personal study&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">Fifth day&#58; review&#44; cognitive test&#44; and another theoretical-practical performance evaluation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0180" class="elsevierStylePara elsevierViewall">Monitor the performance and perform TU exams at least once a week&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0185" class="elsevierStylePara elsevierViewall">Every six months&#58; another cognitive test&#46;</p></li></ul></p><p id="par0190" class="elsevierStylePara elsevierViewall">Finally&#44; we suggest if any author wants to replicate the study that adds a fourth group with physicians that already know the method and perform TU&#46; This would allow new comparisons between subgroups with different degrees of knowledge&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The authors aim to evaluate the &#8220;point-of-care&#8221; transfontanellar ultrasound &#40;TU&#41; as an extension to pediatric physical examination and suggest a TU teaching protocol&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The students were randomly divided into two groups&#44; group A &#40;12 participants&#41; and group B &#40;15 participants&#41;&#46; The first group only received theoretical training&#44; while the second group received theoretical and practical training&#46; A third group&#44; group C&#44; included 15 pediatricians and interns who also received theoretical and practical training&#46; All the participants underwent multiple-choice testing before and after a four-hour short course on TU&#46; Six months later&#44; another evaluation was performed to analyze the retained knowledge&#46; Furthermore&#44; a questionnaire based on the Likert scale was administered to evaluate satisfaction&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The cognitive evaluation &#40;maximum score<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10 points&#41; before and after training increased in group A from 4&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;04 to 7&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;2 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and&#44; 6 months later&#44; to 6&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;16 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#59; in group B from 3&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;24 to 8&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;01 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and&#44; 6 months later&#44; to 8&#44;46<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;91 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#59; and in group C from 6&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;75 to 9&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;75 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and&#44; 6 months later&#44; to 8&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;77 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The average satisfaction estimated by the Likert scale was over 80&#37; for all questions&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Cognitive assessment before and after classes and training reveals progress in learning&#44; with knowledge retention in 6 months&#46; Theoretical-practical courses are well accepted&#46;</p></span>"
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        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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            "identificador" => "at0005"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Flowchart&#46;</p>"
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      1 => array:8 [
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        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "detalles" => array:1 [
          0 => array:3 [
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        ]
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Normal TU image used in the theoretical-practical performance evaluation in sagittal &#40;I&#41; and coronal &#40;II&#41; sections&#44; respectively&#46; Personal archive&#46;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">cc&#44; corpus callosum&#59; C&#44; cerebellum&#59; be&#44; brain stem&#59; lv&#44; lateral ventricles&#46;</p>"
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        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1931
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Scores of cognitive assessment of the 3 groups&#44; before the course&#44; after the course and follow up in 6 months showing mean&#44; standard deviation and statistical relevance in the comparison between the three tests&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">94&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">97&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">D3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">D4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">41&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">60&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">75&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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Article information
ISSN: 00217557
Original language: English
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