Patient Simulation Research Articles

Utility of Intermediate Risk Volumes in Human Papilloma Associated Oropharyngeal Cancer: A Pattern of Failure Analysis

<h3>Purpose/Objective(s)</h3> Head/neck radiotherapy contouring guidelines recommend the use of an intermediate risk volume and dose around the primary target in head and neck radiotherapy. Patients with human papilloma virus (HPV) related oropharyngeal squamous cell carcinoma (OPSCC) have locoregional control (LRC) rates that are in excess of 90% with definitive radiotherapy. We hypothesized that intermediate risk volume and doses would have limited utility in these patients. <h3>Materials/Methods</h3> Following institutional review board approval, a database of p16+ and/or HPV OPSCC AJCC Stage I-III patients treated with definitive radiotherapy with or without chemotherapy was queried. Patient with documented locoregional recurrence (LRR) after the end of RT were identified. Diagnostic imaging at recurrence (rDI) was co-registered to the patient's simulation CT (sCT). The recurrence gross tumor volume (rGTV) on the rDI was contoured. In-field failure was defined as ≥95% of the recurrence volume, marginal as 20–95%, and out-of-field as ≤20% lying within the 95% high-dose prescription isodose lines. Patients with marginal or out-of-field recurrences were identified, and the initial treatment GTV was expanded by 1.3 cm to create a PTV intermediate dose (PTV-ID). The coverage of the rGTV by the PTV-ID was assessed, with potential benefit defined as near-total encompassing of the rGTV by the PTV-ID. <h3>Results</h3> A total of 534 patients with a median follow-up of 30 months were available for analysis. Actuarial LRC at 3 years was 91.2%. A total of 57 patients with LRR were identified, of which 41 had available RT treatment plans and recurrence imaging. 25 patients (61%) had in-field recurrences, 6 (14.6%) had marginal recurrences, and 10 (24.3%) had out-of-field recurrences. Of the 10 out-of-field recurrences, 4 were within elective neck volumes, 3 were in un-targeted neck regions, and 3 in areas adjacent to the primary. The combined crude marginal and out of field recurrence rate was 3%. In patients with marginal and out-of-field recurrences, none would have been ≥95% encompassed by the PTV-ID expansion. <h3>Conclusion</h3> In this large retrospective evaluation of an intermediate dose volume for patients with HPV-related OPSCC, we found no potential patients whose recurrences may have been prevented with a PTV-ID. The omission of an intermediate risk volume/dose around the primary or at-risk nodal echelons may be reasonable.

Augmented reality-guided positioning system for radiotherapy patients.

In modern radiotherapy, error reduction in the patients’ daily setup error is important for achieving accuracy. In our study, we proposed a new approach for the development of an assist system for the radiotherapy position setup by using augmented reality (AR). We aimed to improve the accuracy of the position setup of patients undergoing radiotherapy and to evaluate the error of the position setup of patients who were diagnosed with head and neck cancer, and that of patients diagnosed with chest and abdomen cancer. We acquired the patient's simulation CT data for the three‐dimensional (3D) reconstruction of the external surface and organs. The AR tracking software detected the calibration module and loaded the 3D virtual model. The calibration module was aligned with the Linac isocenter by using room lasers. And then aligned the virtual cube with the calibration module to complete the calibration of the 3D virtual model and Linac isocenter. Then, the patient position setup was carried out, and point cloud registration was performed between the patient and the 3D virtual model, such the patient's posture was consistent with the 3D virtual model. Twenty patients diagnosed with head and neck cancer and 20 patients diagnosed with chest and abdomen cancer in the supine position setup were analyzed for the residual errors of the conventional laser and AR‐guided position setup. Results show that for patients diagnosed with head and neck cancer, the difference between the two positioning methods was not statistically significant (P > 0.05). For patients diagnosed with chest and abdomen cancer, the residual errors of the two positioning methods in the superior and inferior direction and anterior and posterior direction were statistically significant (t = −5.80, −4.98, P < 0.05). The residual errors in the three rotation directions were statistically significant (t = −2.29 to −3.22, P < 0.05). The experimental results showed that the AR technology can effectively assist in the position setup of patients undergoing radiotherapy, significantly reduce the position setup errors in patients diagnosed with chest and abdomen cancer, and improve the accuracy of radiotherapy.

Continuing Education Needs Identified During the Initial Experience of Delivering 3D Conformal Radiotherapy for Cervical Cancer Patients in Tanzania

In resource-limited settings where experience with 3D conformal radiation therapy (3DCRT) is still growing, review of simulation CTs and radiation therapy plans may illuminate topics for continuing education. We conducted a review of an early cohort of cervical cancer patients treated with 3DCRT in Tanzania to identify education needs that may be generalizable to similar resource-limited settings.In Tanzania, 3DCRT capabilities began in August 2018. A retrospective review of 30 consecutive patients who received definitive whole pelvis 3DCRT for cervical cancer from 2019 to 2020 was conducted after IRB approval. Each patient's simulation CT was evaluated for evidence of advanced disease not detected on initial diagnostic work-up, including pelvic or para-aortic lymphadenopathy (LAD) defined as axial dimension > = 1 cm. An independent set of contours was generated according to United States national consensus guidelines. DICE similarity coefficient (DSC) agreement analysis was conducted between contours. As non-systematic variations in planning target volume (PTV) labelling, summations, and expansions precluded direct comparisons, only clinical target volume (CTV) contours were compared in this analysis. Clinically treated 3DCRT plans were evaluated using original and consensus-based contours, and dosimetric coverage was compared using Wilcoxon signed-rank testing.Simulation CT was the sole means of pre-treatment cross-sectional abdominopelvic imaging in 24/30 patients (80%). The pre-simulation clinical stages were FIGO IB (n = 6), IIA (n = 10), IIB (n = 12), IIIA (n = 1), and IVA (n = 1). Simulation CT upstaged 20 of 30 patients (66.7%) to IIIC1 or IIIC2 disease, identifying eight patients with para-aortic LAD and 13 patients with pelvic LAD. Agreement analysis between clinical and consensus-based contours revealed high agreement in the primary CTV (DSC median 0.83, IQR 0.68 - 0.87), bladder (0.93, IQR 0.88 - 0.95), and femur (0.86) contours, but lower agreement in lymph node CTV (CTVn) contours (DSC 0.59, IQR 0.46 - 0.67). The median volume of clinical-CTVn covered by 45 Gy was 99.7% (IQR 97.5 - 100) while the median volume of consensus-CTVn covered by 45 Gy was 83.3% (IQR 80.1 - 90.1) (P < 0.001). The most frequently undercovered regions were the superior and inferior pre-sacral nodal regions.In resource-limited settings, early case review after 3DCRT initiation may reveal key elements in radiation planning that can guide continuing education topics. In our setting, high yield interventions include systematic evaluation of pelvic and para-aortic LAD on simulation CTs, educational refreshers about nodal contouring, and development of resource-appropriate treatment paradigms when advanced nodal disease is detected.

Abstract LB-319: Predicting clinical outcomes in cancer patients based on a novel computational biology method of mapping the cancer mutanome

Abstract Background: Despite three FDA approved standard of care (SOC) therapeutics, 60% of patients with myelodysplastic syndromes (MDS) fail to achieve hematologic improvement and nearly all patients die of refractory disease. The ability to predict patient responses to SOC therapy would improve treatment efficacy, avoid treatment-related adverse events and reduce health care costs. Ideally, a patient's prediction would be based on their cancer mutanome. Methods: A prospective clinical trial was initiated in June 2015 to (1) predict patient response to SOC, and (2) identify a personalized therapy of FDA approved drugs that target the patient's unique dysregulated pathways. Currently, 50 patients have been recruited to iCare For Cancer Patients (NCT02435550). Bone marrow and/or peripheral blood are collected from each patient and utilized for whole-exome sequencing (Agilent OneSeq) and copy number variation (Agilent array CGH) analysis. Cytogenetics, FISH, gene mutations, and CNV data are inputted into a new computational biology computer program, which generates a patient-specific map of multiple and intersecting protein networks. Mathematical modeling is then used to simulate cancer cell proliferation, viability and apoptosis. The patient's simulation results are then used to determine if the cancer is sensitive or resistant to SOC. Additionally, each patient's cancer model is used to digitally screen for FDA approved drugs with therapeutic potential. A database of de-identified was created that includes genomic information from each patient with thorough clinical annotation. Results: Genomic profiling was completed in 49/50 patients, indicating high feasibility of this functional genomics workflow. To date, 18/50 patients are evaluable. Of 18 patients, 7 have clinical response information available. 2/7 patients were predicted to respond to therapy, and 2/2 had a clinical response to therapy, yielding a 100% positive predictive value. 5/7 patients were predicted to not respond to therapy, and 5/5 had no clinical response to therapy, yielding a 100% positive predictive value. 7/7 patient outcomes (100%) were correctly matched to their predicted response, showing a sensitivity and specificity of 100%. Conclusion: These results demonstrate the feasibility of a new precision oncology method of functional genomics and computational biology. Preliminary results in this prospective study support high accuracy of prediction in retrospective studies by our group. These data also support an upcoming randomized phase II clinical trial of physician's choice versus prediction model-informed treatment in patients with refractory/relapsed cancer. Citation Format: Leylah Drusbosky, Regina Martuscello, Taher Abbasi, Shireen Vali, Christopher R. Cogle. Predicting clinical outcomes in cancer patients based on a novel computational biology method of mapping the cancer mutanome. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr LB-319.

Study of energy transfer by different light curing units into a class III restoration as a function of tilt angle and distance, using a MARC Patient Simulator (PS)

ObjectiveThe MARC Patient Simulator (MARC PS) enables researchers to observe the influence of handling errors on the radiant exposure that is delivered by light curing units (LCUs). Changes in the tilt angle and distance of the light guide exit face in relation to the surface of the composite increment have a distinct effect on the total amount of light delivered during polymerization and may cause insufficient conversion of the material. Therefore, the aim of the present study was to determine the influence of the tilt angle and distance of irradiance on the efficiency of light application by recording the total amount of energy using the anterior tooth sensor of the MARC PS. MethodsThe influence of the tilt angle and distance of the light guide to the sensor surface on the delivered radiant exposure was examined for three different LCUs (Celalux 2 [C2], Bluephase [BP] and Translux Powerblue [TPB]). The measurements were performed for 20s each with five different tilt angles (α=0°, 5°, 10°, 15°, 20°) and nine different distances (L=1, 2, 3, 4, 5, 6, 7, 8, 9mm). ResultsFor all LCUs, a distinct influence of the tilt angle on the delivered amount of fluence was found. At 0° tilt the C2 delivered a total light energy of 38.55J/cm2. By increasing the tilt of the light guide the amount of energy applied significantly decreased. At 20° tilt a reduction by 31.2% of the original light fluence was recorded. However, the C2 was the most powerful LCU measured. Even under optimum measurement conditions, the BP delivered a fluence of only 14.8J/cm2. At a tilt angle of 20°, though, the light sensor still registered 92.7% of the original output power. Under the same conditions, the TPB delivered 81.4%.With increasing distance of the light guide exit face to the surface of the sensor all LCUs showed a significant loss in delivered light energy. At a distance of 2mm the C2 showed a reduction by 46.7%, whereas total fluence of BP and TPB were reduced by 3.8% and 4.8%, respectively. SignificanceThe choice of LCU and the application of an appropriate curing time are important for successful polymerization. Nevertheless, a perpendicular positioning of the light guide as close as possible to the surface of the composite increment is of essential importance in order to ensure sufficient delivery of light.

Simple Method to Estimate Mean Heart Dose From Hodgkin Lymphoma Radiation Therapy According to Simulation X-Rays

To describe a new method to estimate the mean heart dose for Hodgkin lymphoma patients treated several decades ago, using delineation of the heart on radiation therapy simulation X-rays. Mean heart dose is an important predictor for late cardiovascular complications after Hodgkin lymphoma (HL) treatment. For patients treated before the era of computed tomography (CT)-based radiotherapy planning, retrospective estimation of radiation dose to the heart can be labor intensive. Patients for whom cardiac radiation doses had previously been estimated by reconstruction of individual treatments on representative CT data sets were selected at random from a case-control study of 5-year Hodgkin lymphoma survivors (n=289). For 42 patients, cardiac contours were outlined on each patient's simulation X-ray by 4 different raters, and the mean heart dose was estimated as the percentage of the cardiac contour within the radiation field multiplied by the prescribed mediastinal dose and divided by a correction factor obtained by comparison with individual CT-based dosimetry. According to the simulation X-ray method, the medians of the mean heart doses obtained from the cardiac contours outlined by the 4 raters were 30 Gy, 30 Gy, 31 Gy, and 31 Gy, respectively, following prescribed mediastinal doses of 25-42 Gy. The absolute-agreement intraclass correlation coefficient was 0.93 (95% confidence interval 0.85-0.97), indicating excellent agreement. Mean heart dose was 30.4 Gy with the simulation X-ray method, versus 30.2 Gy with the representative CT-based dosimetry, and the between-method absolute-agreement intraclass correlation coefficient was 0.87 (95% confidence interval 0.80-0.95), indicating good agreement between the two methods. Estimating mean heart dose from radiation therapy simulation X-rays is reproducible and fast, takes individual anatomy into account, and yields results comparable to the labor-intensive representative CT-based method. This simpler method may produce a meaningful measure of mean heart dose for use in studies of late cardiac complications.

Simulation activities increase medical student question performance compared to paper clinical case conferences

The use and effectiveness of high fidelity patient simulators (PS) in preclinical medical education has not been as well studied as during the clinical years. The goal of this study was to determine whether a simulation activity (SIM) would enhance learning of cardiovascular function curves and acid base physiology better than a paper, clinical case conference (Con). Both the SIM and Con focused on the same clinical cases (heart failure in the CV module and COPD in the pulmonary module).MethodsThe Year 1 medical student class (n=192) was divided approximately into two halves with half doing a Con (group A) and the other half doing a SIM during the CV module (group B). During the pulmonary module group A did the SIM while group B did the Con. Switching of the groups allowed student participation in both modes of learning and served as a control. Student learning was assessed by performance on a quiz/exam question pertaining to the modules. We also asked a survey question to assess student perception of learning.ResultsA higher % of students in the SIM groups got the correct answer on both the cardiac module quiz (64.6% vs. 56.0%) and on the pulmonary module exam (77.6% vs. 72.3%) than students participating in the Con. Despite the higher % of students getting the answer correct following the SIM, student perception was that they had not learned the material as well in the SIM center. The only outstanding exception was that they felt that the SIM helped them to realize the importance of teamwork more than the Con.ConclusionThese data suggest that SIM activities may facilitate student understanding of CV function curves and acid base physiology better than a paper, clinical case Con. Additionally, SIM activities may be an avenue to develop team building skills in the preclinical years.

The Effects of Pain, Gender, and Age on Sleep/Wake and Circadian Rhythm Parameters in Oncology Patients at the Initiation of Radiation Therapy

To date, no studies have evaluated for differences in subjective and objective measures of sleep disturbance in oncology outpatients with and without pain. This descriptive study, recruited 182 patients from 2 radiation therapy (RT) departments at the time of the patient's simulation visit. Approximately 38% of the sample reported moderate to severe pain (ie, worst pain intensity of 6.2 ± 2.4). After controlling for age, patients in pain reported worse sleep quality and more sleep disturbance using the Pittsburgh Sleep Quality Index. With the General Sleep Disturbance Scale, patients in pain reported poorer sleep quality, increased use of sleep medications, and more daytime sleepiness. In addition using an objective measure of sleep disturbance (ie, actigraphy), significant gender × pain interactions were found for sleep onset latency, percentage of time awake at night, wake duration, total sleep time, and sleep efficiency. While no differences were found in female patients, males in pain had worse scores than males without pain. Findings from this study suggest that pain and sleep disturbance are prevalent in oncology outpatients and that a patient's age and gender need to be considered in any evaluation of the relationship between pain and sleep. The effects of pain on subjective and objective sleep parameters appear to be influenced by both patients' age and gender.

Assessment of Patient Simulation Use in Selected Baccalaureate Nursing Programs in the United States

Newly graduated nurses are expected to possess clinical skills and the ability to critically judge quality in patient care. There are an increasing number of baccalaureate nursing (BSN) schools that are integrating the use of patient simulation (PS) in the educational experience of their students. This descriptive study examines the use of PS technology in selected BSN programs in the United States. This study targeted National League for Nursing-accredited BSN schools with an online survey related to the current use of PS in course curriculum and how it is being used. Two hundred nine BSN schools were identified and 78 schools responded (37.3% response rate). Sixty (78.9%) BSN schools responded to the survey reported using patient simulators in core clinical nursing courses: health assessment, nursing fundamentals, medical/surgical nursing I and II, pediatrics, and obstetrics courses. Approximately 31% of schools reported using high-fidelity scenarios in more than 51% of their clinical courses. The responding schools indicate that they are using PS in the usual undergraduate nursing courses that coincide with clinical settings. The replacement of actual clinical hours with PS remains controversial and unresolved. Responses to an open-ended question indicated interest in using PS but that many schools are limited by not having a dedicated faculty to champion the way and resources to purchase the technology. Although there were limitations to this study, it is one of the first to describe the patterns of using PS in nursing schools for clinical education. As the use of this technology grows in BSN programs, addressing the issues resulting from this study are essential to understanding the use of this technology in nursing education.

Design, Development, and Evaluation of an Online Virtual Emergency Department for Training Trauma Teams

Training interdisciplinary trauma teams to work effectively together using simulation technology has led to a reduction in medical errors in emergency department, operating room, and delivery room contexts. High-fidelity patient simulators (PSs)-the predominant method for training healthcare teams-are expensive to develop and implement and require that trainees be present in the same place at the same time. In contrast, online computer-based simulators are more cost effective and allow simultaneous participation by students in different locations and time zones. In this pilot study, the researchers created an online virtual emergency department (Virtual ED) for team training in crisis management, and compared the effectiveness of the Virtual ED with the PS. We hypothesized that there would be no difference in learning outcomes for graduating medical students trained with each method. In this pilot study, we used a pretest-posttest control group, experimental design in which 30 subjects were randomly assigned to either the Virtual ED or the PS system. In the Virtual ED each subject logged into the online environment and took the role of a team member. Four-person teams worked together in the Virtual ED, communicating in real time with live voice over Internet protocol, to manage computer-controlled patients who exhibited signs and symptoms of physical trauma. Each subject had the opportunity to be the team leader. The subjects' leadership behavior as demonstrated in both a pretest case and a posttest case was assessed by 3 raters, using a behaviorally anchored scale. In the PS environment, 4-person teams followed the same research protocol, using the same clinical scenarios in a Simulation Center. Guided by the Emergency Medicine Crisis Resource Management curriculum, both the Virtual ED and the PS groups applied the basic principles of team leadership and trauma management (Advanced Trauma Life Support) to manage 6 trauma cases-a pretest case, 4 training cases, and a posttest case. The subjects in each group were assessed individually with the same simulation method that they used for the training cases. Subjects who used either the Virtual ED or the PS showed significant improvement in performance between pretest and posttest cases (P < 0.05). In addition, there was no significant difference in subjects' performance between the 2 types of simulation, suggesting that the online Virtual ED may be as effective for learning team skills as the PS, the method widely used in Simulation Centers. Data on usability and attitudes toward both simulation methods as learning tools were equally positive. This study shows the potential value of using virtual learning environments for developing medical students' and resident physicians' team leadership and crisis management skills.

Goal-Directed Therapy for General ICU Patients Using Aggregated Multi-Objective Optimisation

SOPAVent (Simulation ofPatients under Artificial Ventilation) is a blood gas model able to simulate patient ventilatory parameters subject to mechanical ventilation in the intensive care unit (ICU). In this paper, the SOPAVent model is further developed into a continuously updated model of patient ventilatory condition. The extended version of the model is used as the core component for a goal-directed optimisation strategy which aims to provide adaptive decision support for ventilatory therapy. Two objective functions are aggregated in an effort to interpret medical goals into an optimisation problem. The settings of the optimisation strategy are fine-tuned based on medical-goals and medical prioritization rather than mathematical optimality of solutions. The final decision support system is tested via a series of closed-loop simulations by assuming different clinical scenarios. Results show that the decision support system provides the correct advice for ventilator settings following adequate prioritization of competing medical goals.

The Patient Simulator for Training of Anesthesia Residents in the Management of One Lung Ventilation

Simulators are used extensively for the training of medical personnel. All anesthesia providers should be prepared and trained in the management of one lung ventilation for pulmonary surgery, yet familiarization with one lung ventilation may not be possible on a routine basis in the operating room. Therefore, this reports details the first use of the patient simulator (PS) to enhance the training of anesthesia residents in the management of one lung ventilation. A detailed report of our computer program for simulating one lung ventilation is included.

TH‐D‐M100J‐03: High‐Quality Four‐Dimensional CBCT Reconstruction with Virtual Projections

Purpose: Due to significantly reduced number of projections per phase, the quality of 4DCBCT images is often degraded by view‐aliasing artifacts. Acquisitions using slow‐gantry‐rotation or multiple‐gantry‐rotations can improve the 4D images, but at the cost of extra scan time, which may render them clinically impractical. Here we report a new progress in developing high‐quality 4DCBCT without prolonging the acquisition time. Method and Materials: The technique developed here is to reduce the view‐aliasing artifacts resulted from insufficient sampling by properly “borrowing” projections from other phases. To do so, a motion model linking the data of different phases is derived from deformable registrations of coarse (conventional) 4DCBCT phases with consideration of patient's simulation 4DCT. This 4D patient model allows us to properly transform projections from other phases onto the phase under reconstruction, leading to increased sampling in 4DCBCT. The proposed approach is quantitatively evaluated with motion phantoms and two clinical lung cases for a number of metrics, including RMSE of CT numbers, image uniformity, and contrast‐to‐noise‐ratio (CNR). Results: An important finding of this work is that, by the aid of “virtual projection” derived from coarse 4DCBCT and 4D (or breath‐hold 3D) simulation CT images, the 4DCBCT view‐aliasing artifacts can be dramatically reduced, resulting in greatly improved CT‐number accuracy, image uniformity and CNR in all testing cases. Compared with the conventional 4DCBCT, the overall reduction in CT number fluctuation is ∼38% and the CNR increase is ∼65%. Conclusion: Improving the trade‐off between image quality and scan time is the key to making 4D onboard imaging practical and clinically useful. A novel strategy for enhancing 4DCBCT images without increasing scan time and radiation dose has been developed for onboard CBCT imaging system. The method should find valuable applications in patient setup, dose verification in 4D, as well as adaptive radiation therapy in the future.

SU-FF-T-60: A Simplified Frame Work Using Deep Inspiration Breath-Hold (DIBH) for the Treatment of Left Breast Cancer with Improved Heart Sparing

Purpose: To develop a simplified frame work using deep inspiration breath‐hold (DIBH) for left breast treatment. Materials and Methods: The current version of Varian's RPM system was rarely used in amplitude gating mode, especially with breath hold. The major reason is that the breathing amplitude is much less reproducible than breathing phase. Further, the same signal captured by the infrared camera in simulation room and that in treatment room could be different in amplitude. In this study, we presented a simplified frame work to improve the reproducibility of patient's breathing amplitude. First, an aqua‐plastic body mask of 1.0–1.5 in wide was made right before patient's simulation while the patient is in DIBH. The body mask was set at umbilicus right superior to the marker box. It will then be used to guide the patient herself for DIBH. The DIBH signal is also displayed on a computer monitor set close to patient, which is a duplicate display of the DIBH signal in the RPM computer. The patient can see her own signal and can therefore guide her breath such that relatively constant amplitude can be achieved. Results: The frame work was tested by a few volunteers and all agree that the system is feasible for left breast treatment. The DIBH can last 15–35s with good constant amplitude. In case the captured amplitude is different in treatment room, the two gating threshold lines set in simulation can be adjusted overlay to the DIBH signal before treatment. Conclusion: The system is feasible for the treatment of left breast cancer with DIBH. Further improvement can be made by wiring the gating cable through patient using two electrodes; one on patient's body and the other on the guiding mask so that the amplitude‐gated CT scans and treatment can be actively controlled by patient herself.

Integrating Echocardiography into Human Patient Simulator Training of Anesthesiology Residents Using a Severe Pulmonary Embolism Scenario

Echocardiographic images were integrated into patient simulation (PS)-based resident training with a goal of highlighting the applicability and limitations of pure pressure-based measurements in the management of different disease states. Relevant echocardiographic images were selected, categorized, and sequenced to best represent specific hemodynamic changes and incorporated into a Powerpoint slideshow. Appropriate PS scenarios were then created to represent the hemodynamic changes seen with the selected pathophysiologic states. Instructors then displayed the visual images along with PS scenarios during lecture and testing sessions at the PS bedside during standard didactic sessions with small groups of anesthesiology residents and informal resident testing sessions. The use of echo images to demonstrate, in real time, the hemodynamic consequences of changes in myocardial contractility, cardiac chamber volume, and valvular function is possible during PS in anesthesiology residency training. Echo imaging as a teaching tool during anesthesiology residency may yield a greater understanding of the pathophysiology of certain disease states, ultimately leading to faster diagnosis and more appropriate intervention by anesthesiologists.