The American Heart Association recommends routine provocative cardiac testing in accelerated diagnostic protocols for coronary ischemia. The diagnostic and therapeutic yield of this approach are unknown. Objective: To assess the yield of routine provocative cardiac testing in an emergency department-based chest pain unit. Design and Setting: We examined a prospectively collected database of patients evaluated for possible acute coronary syndrome between March 4, 2004, and May 15, 2010, in the emergency department-based chest pain unit of an urban academic tertiary care center. Participants: Patients with signs or symptoms of possible acute coronary syndrome and without an ischemic electrocardiography result or a positive biomarker were enrolled in the database. Exposures: All patients were evaluated by exercise stress testing or myocardial perfusion imaging. Main Outcomes and Measures: Demographic and clinical features, results of routine provocative cardiac testing and angiography, and therapeutic interventions Results: In total, 4181 patients were enrolled in the study. Chest pain was initially reported in 93.5%, most (73.2%) were at intermediate risk for coronary artery disease, and 37.6% were male. Routine provocative cardiac testing was positive for coronary ischemia in 470 (11.2%), of whom 123 underwent coronary angiography. Obstructive disease was confirmed in 63 of 123 (51.2% true positive), and 28 (0.7% overall) had findings consistent with the potential benefit from revascularization (American Heart Association class I or IIa). Conclusions and Relevance: In an emergency department-based chest pain unit, routine provocative cardiac testing generated a small therapeutic yield, new diagnoses of coronary artery disease were uncommon, and false-positive results were common.

A Consensus Among Directors in the United States oint-of-care ultrasound imaging is an important technical skill being incorporated into the undergraduate medical education curricula at an increasing rate in recent years. 1,2 Studies have been published demonstrating how point-of-care ultrasound improves patient safety during procedures and facilitates enhanced diagnostic abilities. 3,4 The advantages of point-of-care ultrasound is that is safely used at the bedside, obviates the need for transport to computed tomography or magnetic resonance imaging suites, does not use radiation, and gives immediate results that can be interpreted and used by the operator. 5 With the increasing use of point-of-care ultrasound by all types of providers throughout Vi Am Dinh, MD, RDMS, RDCS, Daniel Lakoff, MD, Jamie Hess, MD, David P. Bahner, MD, RDMS, Richard Hoppmann, MD, Michael Blaivas, MD, John S. Pellerito, MD, Alfred Abuhamad, MD, Sorabh Khandelwal, MD Received July 30, 2015, ORIGINAL RESEARCHObjectives-Many medical schools are implementing point-of-care ultrasound in their curricula to help augment teaching of the physical examination, anatomy, and ultimately clinical management. However, point-of-care ultrasound milestones for medical students remain unknown. The purpose of this study was to formulate a consensus on core medical student clinical point-of-care ultrasound milestones across allopathic and osteopathic medical schools in the United States. Directors who are leading the integration of ultrasound in medical education (USMED) at their respective institutions were surveyed.Methods-An initial list of 205 potential clinical ultrasound milestones was developed through a literature review. An expert panel consisting of 34 USMED directors across the United States was used to produce consensus on clinical ultrasound milestones through 2 rounds of a modified Delphi technique, an established anonymous process to obtain consensus through multiple rounds of quantitative questionnaires.Results-There was a 100% response rate from the 34 USMED directors in both rounds 1 and 2 of the modified Delphi protocol. After the first round, 2 milestones were revised to improve clarity, and 9 were added on the basis of comments from the USMED directors, resulting in 214 milestones forwarded to round 2. After the second round, only 90 milestones were found to have a high level of agreement and were included in the final medical student core clinical ultrasound milestones.Conclusions-This study established 90 core clinical milestones that all graduating medical students should obtain before graduation, based on consensus from 34 USMED directors. These core milestones can serve as a guide for curriculum deans who are initiating ultrasound curricula at their institutions. The exact method of implementation and competency assessment needs further investigation.

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