Sunday, 22 November 2020

Using Social Media in Medical Education

 Sterling M, Leung P, Wright D, Bishop TF. The Use of Social Media in Graduate Medical Education: A Systematic Review. Academic Medicine : Journal of the Association of American Medical Colleges. 2017 Jul;92(7):1043-1056. DOI: 10.1097/acm.0000000000001617.

Guraya S. Y. (2016). The Usage of Social Networking Sites by Medical Students for Educational Purposes: A Meta-analysis and Systematic Review. North American journal of medical sciences, 8(7), 268–278.

Latif, M. Z., Hussain, I., Saeed, R., Qureshi, M. A., & Maqsood, U. (2019). Use of Smart Phones and Social Media in Medical Education: Trends, Advantages, Challenges and Barriers. Acta informatica medica : AIM : journal of the Society for Medical Informatics of Bosnia & Herzegovina : casopis Drustva za medicinsku informatiku BiH, 27(2), 133–138.

Rajendran R, Joena V. Effectiveness of social media as a medical teaching tool. Int J Med Res Rev 2017;5(04):381-385. doi:10.17511/ijmrr. 2017.i04.02.

Whyte W, Hennessy C, 2017, 'Social Media use within medical education: A systematic review to develop a pilot questionnaire on how social media can be best used at BSMS', MedEdPublish, 6, [2], 21,

What is social media, why should health professionals care and how does one engage effectively?Anderson N1. Swiss Sports & Exercise Medicine. 2017, Vol. 65 Issue 4, p14-19. 6p. (Review)

Tuesday, 17 November 2020

Neuroradiology Resident Case-Based Tutorials - during COVID-19 Round 1 (Tuesday 10 November 2020 - Monday 16 November 2020)


Case 1 - Spinal cord AVM

Singh B, Behari S, Jaiswal AK, et al. Spinal arteriovenous malformations: Is surgery indicated? Asian Journal of Neurosurgery. 2016 Apr-Jun;11(2):134-142. DOI: 10.4103/1793-5482.177663.

Case 2 - Spinal dural AVF

Jeng, Y., Chen, D. Y., Hsu, H. L., Huang, Y. L., Chen, C. J., & Tseng, Y. C. (2015). Spinal Dural Arteriovenous Fistula: Imaging Features and Its Mimics. Korean journal of radiology, 16(5), 1119–1131.

Case 3 - Spinal dural AVF

Spinal Dural Arteriovenous Fistulas. T. Krings and S. Geibprasert. American Journal of Neuroradiology April 2009, 30 (4) 639-648; DOI:

Case 4 - venous angioma + cavernous angioma (which then presents with acute bleed)

Idiculla P, S, Gurala D, Philipose J, Rajdev K, Patibandla P: Cerebral Cavernous Malformations, Developmental Venous Anomaly, and Its Coexistence: A Review. Eur Neurol 2020;83:360-368. 

Case 5 - parenchyma AVM (presenting with acute bleed), also obstructive hydrocephalus

Radiologic Assessment of Brain Arteriovenous Malformations: What Clinicians Need to Know
Sasikhan Geibprasert, Sirintara Pongpech, Pakorn Jiarakongmun, Manohar M. Shroff, Derek C. Armstrong, and Timo Krings. RadioGraphics 2010 30:2, 483-501

Contemporary Imaging of Cerebral Arteriovenous Malformations
Eric Tranvinh, Jeremy J. Heit, Lotfi Hacein-Bey, James Provenzale, and Max Wintermark
American Journal of Roentgenology 2017 208:6, 1320-1330

Case 6 - Extensive acute left MCA territorial infarct, with haemorrhagic conversion, midline shift to right, subfalcine and uncal herniation; on background of earlier, and smaller MCA infarct, see also old cerebellar infarct. There are several learning points. Differentiating acute from old infarcts, in same territory, over time; identifying haemorrhagic transformation, and mass effect -

Lin, M. P., & Liebeskind, D. S. (2016). Imaging of Ischemic Stroke. Continuum (Minneapolis, Minn.), 22(5, Neuroimaging), 1399–1423.

Do compare and contrast (side by side, at the same time) between Case 6, 7 and 8

Notice the small (deliberate) text (spelling) differences between each screenshot

Case 7 - Meningioma - (pay attention to spectrum of histological subtypes, reflected in typical to atypical radiology presentations); Typical, atypical, and misleading features in meningioma. M P Buetow, P C Buetow, and J G Smirniotopoulos. RadioGraphics 1991 11:6, 1087-1106

Use similar search 'key word(s) for Google text, and image search. As part of the process of developing "digital literacy", I would like you all to develop deeper insights into not only why certain online resources appear on the "first page" of an online search (more later), but to also develop a deeper understanding of the use of "key words", and appreciation of "quality online resources", and improve your judgement and skill in assessing these online resources - as relevant, useful and of value.

Toh CH, Castillo M, Wong AM, Wei KC, Wong HF, Ng SH, Wan YL. Differentiation between classic and atypical meningiomas with use of diffusion tensor imaging. AJNR Am J Neuroradiol. 2008 Oct;29(9):1630-5. doi: 10.3174/ajnr.A1170. Epub 2008 Jun 26. PMID: 18583409.

Case 8 - Arachnoid Cyst - (start with key radiology features on CT and MRI);

Mastery Training and Deliberate Practice

'By reviewing research on medical performance and education, the author describes evidence for these representations and their development within the expert- performance framework. He uses the research to generate suggestions for improved training of medical students and professionals. Two strategies— designing learning environments with libraries of cases and creating opportunities for individualized teacher-guided training—should enable motivated individuals to acquire a full set of refined mental representations. Providing the right resources to support the expert- performance approach will allow such individuals to become self-regulated learners—that is, members of the medical community who have the tools to improve their own and their team members’ performances throughout their entire professional careers.'
above quoted from abstract of
Ericsson KA. Acquisition and maintenance of medical expertise: a perspective from the expert-performance approach with deliberate practice. Acad Med. 2015 Nov;90(11):1471-86. doi:10.1097/ACM.0000000000000939. PubMed PMID: 26375267.

Learning Science

1. Use textbooks and a wide variety of online resources to improve your diagnostic and interpretative skills. Practice, practice, practice with reflection and feedback, using a range of resources, to increase your exposure to the variety and spectrum of clinical and imaging findings, both normal and abnormal, from typical, to less common and atypical (as you progress to increase your experience and mastery of clinical practice, and improve your knowledge and skills from undergraduate, through postgraduate to continuing professional development and lifelong learning settings).
2. Compare and contrast is one of the simplest and most effective methods to learn to recognise and differentiate between normal and abnormal XRs and scans. Review a series of normal XRs and scans, and then do side by side comparison between examples of normal, normal and abnormal, and examples of abnormal XRs and scans. (mixed practice or interleaving superior to blocked practice)



Tuesday, 6 October 2020

Imaging of Respiratory Tract Disorders - Online resources to support lecture for year 2 MBBS (NUS)


NUSMed Entrada link for November 3, 2020 M2 lecture scheduled for 2pm

above and below as at 0643am on 3 November 2020
"live" lecture on Zoom at 1400hrs on 3 November 2020

below as at 1231pm on 3 November 2020
"live" lecture on Zoom at 1400hrs on 3 November 2020

below as at 2055pm on 3 November 2020

Dear students,

The aim of the session is to link the pathology which you have learnt in the chest, to what is visible on the two most commonly used imaging tests you will use as doctors in day to day clinical practice - the CXR, and CT scan of the Chest. 

As preparation for this session, please revise the material from the year 1 session 2020: Imaging of the Chest and Lungs - Online resources to support lecture for year 1 MBBS (NUS). The material below is for the 2020 cohort, which I hope you find useful to refresh your memory of Chest Anatomy-Radiology correlation.

The aim of the year 1 material is to link the anatomy which you have learnt in the chest, to what is visible on the two most commonly used imaging tests you will use as doctors in day to day clinical practice - the CXR, and CT scan of the Chest.  Radiology allows you to see 'living anatomy' and pathology, of your patients in vivo. The CXR allows you to look inside your patient in 2D, while the CT scan gives you multi-planar sectional details, and a '3D-like' appreciation of both anatomy and pathology. You should aim to develop the ability to orientate yourself to the visible structures when viewing both the CXR, and CT scans; and be able to identify normal anatomy. This forms the foundation for the study of pathology, and the appreciation of visible pathology in your patients using CXRs and CT scans in year 2, and subsequent clinical years.

Year 1 learning path: Start with CXR video 1, then CXR video 2, then CXR anatomy website (see chest section) (using illustrations as drill and quiz examples, by viewing CXR first without annotations, then mousing over each image, then read text); then view CT chest video 1, then CT chest video 2, then attempt to identify CT anatomy here.

Year 2 pre-session preparation, and self learning path:  either review material below as segmented text and illustrations, or presented as a segmented video.

I highlight some of this material during the session, and will take 'live Q and A' during the scheduled 'lecture time'. 


(e)Lecture Outline

Section 1: Introduction 
Pre-lecture reflection questions / recall and review if necessary Y1 material

Section 2: Learning objectives

Section 3: Pre-test

Section 4: Lecture proper

Part 1 - review of basic principles of CXR production and tissue characterization

Part 2 - review of the CXR findings in six major diseases

Section 5: Post-test


Section 1: Introduction 

Please reflect on each of the following questions, pause after each question, write down your answer, and reflect upon your answer. 

1. What is the relevance of diagnostic imaging/radiology in your future clinical practice?

2. How are CXRs and CT scans of the chest produced?

3. How do different tissues appear on CXRs and CT scans? Why does bone appear white? Air black? Soft tissues varying shades of grey?

4. Can you identify normal anatomy on a CXR? CT scan of the chest?

5. Do you know where to find the lecture material on this topic presented in Year 1?

If you are unsure of the answer to any of these questions, please revisit and review the relevant sections in the Y1 lecture online resources on the websites below.

Year 1 learning path: Start with CXR video 1, then CXR video 2, then CXR anatomy website (see chest section) (using illustrations as drill and quiz examples, by viewing CXR first without annotations, then mousing over each image, then read text); then view CT chest video 1, then CT chest video 2, then attempt to identify CT anatomy here.

Section 2 : Learning objectives of this (e)Lecture

Recall that radiology allows you (as future doctors), to see "living" anatomy, and "in vivo" pathology.

This ability to visualise what is going on in the patient in front of you, in both health and disease will be a useful diagnostic tool for you as doctors.

The easiest way to make sense of what you see on a radiology examination is to recall what you have been exposed to and learnt recently in gross pathology.

We will focus on the Chest Radiograph in this lecture. This is the most commonly requested radiology investigation. While this lecture won't show you every possible abnormality visible on CXRs, it is the start of a learning and skill development process. We will spend time on typical presentations of several common and important clinical conditions, and use these to illustrate the basics of CXR interpretation. As you develop experience over the next few years, you will gradually become more familiar with more subtle or gross presentations of disease, with more atypical features.

As you no doubt realise, an XR or scan is a snapshot of a point in time of a developing disease process. Early on, the manifestations of a disease on an XR or scan might be small, ill defined, or difficult to visualise. Later in the disease process, an abnormal feature might be large, and also difficult to define (for example a small, moderate size or large pleural effusion). It may be initially difficult for you to determine with a completely opaque hemithorax whether you are dealing with pneumonia, a large effusion or complete collapse of the lung.

For those of you who are focused on more immediate concerns, the assessment items on radiology that you will be faced with will evaluate your ability to recognise major examples of pathology on common radiological examinations. For example on the chest radiograph or CXR.

To review again the learning objectives of the undergraduate radiology program in the medical curriculum, you can see how radiology translates what you have learnt in Y1 anatomy, to give you the ability to see "in vivo" living anatomy in your future patients.

And visualise in vivo pathology in your patients. 

Section 3 : Pre-test

Let us do an assessment exercise now to not only show you what potential future examination assessment items might be, but also to illustrate how radiology (on the following CXRs) allows you to visualise gross pathology in your patient.

Google image search "lung gross pathology lung cancer"
Google image search "patient with lung cancer"

Google image search for "lung gross pathology pneumothorax"
Google image search "patient with pneumothorax"
Google image search "patient with tension pneumothorax"

Google image search for "lung gross pathology pneumonia"
Google image search "patient with pneumonia"

Google image search for "lung gross pathology pleural effusion"
Google image search "patient with pleural effusion"

Google image search "lung gross pathology cardiac failure pulmonary odema"
Google image search "patient with pulmonary oedema"

Google image search "lung gross pathology cardiac failure alveolar pulmonary odema"
Google image search "lung gross pathology cardiac failure interstitial pulmonary oedema"

Google image search for "gross pathology rib fractures"
Google image search for "patient with rib fractures"

Google image search for "cadaver rib fractures"

Please try and match the five diagnoses (A to E) with the CXRs provided (1 to 6). There are two examples on the CXRs provided of one of the five diagnoses.

This exercise begins the process to introducing you to the typical appearance of common and important clinical problems that your patient may present with.

Section 4: (e)Lecture proper

We will focus on two major areas. Firstly review basic principles of CXR production and interpretation. And then review the key features of six major clinical problems on CXRs.

We first very briefly review basic principles behind the production of a CXR, and why different tissues have different densities on XRs (white, shades of grey, and black).

Recall that XRs are produced by placing you patient between an XR source, and a recording medium; which may be an XR film, or digital recording plate.  The XR is therefore a record of the absorption of XRs as they pass through different organs and tissues in your patient.

By convention, on a XR, black represents areas of greatest XR absorption, and white the least absorption of XRs. On this normal CXR, you can see the radiographic densities of five categories of tissue. Air being blackest, with gradually lighter shades of grey with fat, soft tissue/blood/muscle, bone and metal. You will appreciate how fat being less dense than soft tissue will absorb less XRs, and appear a darker shade of grey than soft tissues or muscle.

This difference in XR absorption between different tissues and organs allows you to distinguish the edge or surface between different tissue layers and organs. Because XRs travel in straight lines through your patient, the interface between different tissues is highlighted and visible at tissue interfaces tangential to the path of the XR beam. This is referred to as the "silhouette sign". A simple analogy help you visualize this is to recall the what the silhouette of an object looks like when placed between a candle or light source and a background surface. The edge of the projected "shadow" is the silhouette making the edge between absorbed and transmitted light.

We use the silhouette phenomenon on a CXR to detect the edge between the normal left heart border, and adjacent aerated normal lung which contains air. We also use this to see the normal lung markings, due to difference in XR absorption between the blood within the pulmonary vessels and the adjacent normal lung. In disease, when the alveoli or air spaces in the lung are filled with fluid, blood or pus, we lose the ability of see these edges, allowing us to infer that the air spaces in the lung are not aerated or air filled.

Finally, an appreciation of the geometry of the XR beam passing through you patient allows you to understand how the heart, which you recall lies anteriorly on the front of the chest cavity is less magnified on a PA (posterior anterior) CXR, where the beam passes from back to front of the patient, compared to an AP (anterior posterior) CXR. Because patients have different chest front to back thicknesses, an AP film does not give you a good estimate of the transverse width of the heart, compared with the internal side to side chest diameter. The ratio of the widest side to side width of the heart divided by internal chest diameter (widest at that level) should be less than 50% in patients who do not have cardiomegaly; and is more reliably assessed on PA rather than AP CXRs, since we are not able to appreciate the front to back diameter of patients on CXRs; and cannot correct for this magnification factor when viewing AP CXRs.

We will now focus on the key radiological features of a few major disease categories on the CXR.

These 6 diseases are not only common, but need to be recognised quickly, accurately and confidently by you as future doctors in the EMD, wards and clinics; as you patient may require urgent treatment.

This is also why testing your ability to recognise these diseases on radiological examinations will take place not only in the radiology section of the examination, but radiology images will also be shown to you as part of the work up and assessment of your patients.

Pneumonia is described as an area of consolidation, or air space shadowing on a CXR. This appearance may be due to pus (pneumonia), fluid (pulmonary oedema), or blood (for example lung contusion or a pulmonary infarct). A definitive diagnosis is made by correlating the radiological appearance on the CXR with the clinical setting, or clinical findings.

Changing 'window' settings on CT allows you to highlight, and view different tissues. Lung on the 'lung window', and the mediastinum on the 'mediastinum window'. This takes advantage of the different densities of lung vs mediastinum or soft tissue density on CT scans (different XR absorption). Illustrated graphically here -

with Pulmonary Oedema segment @ 13 minutes on video)

above from (and is overview of examples shown)

In this second major section of the (e)Lecture, we will review six major diseases and their CXR findings. Please review the description of the key features of each disease, and then a typical CXR of each disease.

Section 5 : Answers to the pre-test

We conclude this (e)Lecture by revisiting the quiz presented to you at the beginning of this lecture. The answers should be quite obvious to you after this presentation, and are given on the single slide below. Please review the content of this lecture again, focusing on any area you might be unsure about. Please post any questions you might also have on the padlet digital wall below and you classmates are invited to discuss each question with you on the digital wall before the lecture. I will address these questions both live during the lecture, as well as on the digital wall link (also below).

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