Teaching the basics of echocardiography in the undergraduate: Students as mentors

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Arias Felipe, J. Doménech García, I. Sánchez los Arcos, D. Luordo, F.J. García Sánchez, J. Villanueva Martínez, A. Forero de la Sotilla, V. Villena Garrido, J. Torres Macho, G. García de Casasola Sánchez" "autores" => array:10 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Arias Felipe" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Doménech García" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Sánchez los Arcos" ] 3 => array:2 [ "nombre" => "D." "apellidos" => "Luordo" ] 4 => array:2 [ "nombre" => "F.J." "apellidos" => "García Sánchez" ] 5 => array:2 [ "nombre" => "J." "apellidos" => "Villanueva Martínez" ] 6 => array:2 [ "nombre" => "A." "apellidos" => "Forero de la Sotilla" ] 7 => array:2 [ "nombre" => "V." "apellidos" => "Villena Garrido" ] 8 => array:2 [ "nombre" => "J." "apellidos" => "Torres Macho" ] 9 => array:2 [ "nombre" => "G." 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"apellidos" => "García de Casasola Sánchez" "email" => array:1 [ 0 => "ggcasasolaster@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Facultad de Medicina, Universidad Complutense, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Grupo de Trabajo de Ecografía Clínica de la Sociedad Española de Medicina Interna, Servicio de Medicina Interna, Hospital Universitario Infanta Cristina, Parla, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "CIBERES, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enseñanza de las bases de la ecocardioscopia en el pregrado: los estudiantes como mentores" ] ] "textoCompleto" => "BackgroundIn current clinical practice, portable ultrasound devices are available for use at the patient's bedside. This availability helps integrate ultrasonography into the diagnostic process, which could be called “clinical ultrasonography”.<a class="elsevierStyleCrossRefs" href="#bib0185">1–3</a> This ultrasound modality focuses on basic and clinically relevant aspects without the need for a steep learning curve,<a class="elsevierStyleCrossRefs" href="#bib0200">4,5</a> facilitates the teaching of anatomy, helps with understanding the pathophysiology of organs and systems and improves the performance and reliability of physical examinations performed by students.<a class="elsevierStyleCrossRefs" href="#bib0210">6–8</a>The training of medical students in ultrasonography is being progressively implemented in various medical schools.<a class="elsevierStyleCrossRefs" href="#bib0195">3,7,9–18</a> However, the main limitations for its widespread teaching are a lack of professors and the time required for their training. A possible solution is the integration of students into the practical teaching of ultrasonography. Thus, after a small group of students have been trained, these students can then teach others, using what could be called “peer mentoring”.<a class="elsevierStyleCrossRefs" href="#bib0275">19–23</a>The aim of this study was to analyze the ability of medical students to incorporate the practical teaching of basic echocardiography planes and identify the most important cardiac structures using a peer mentoring design, with a subsequent assessment of its efficacy. The term “echocardiography” has been recently coined by the Spanish Society of Cardiology to refer to basic cardiac ultrasound examinations performed by the bedside with portable equipment. In echocardiography, four elementary planes are employed (parasternal long and short axes, apical four chamber and subxiphoid), and their objectives are well defined.<a class="elsevierStyleCrossRef" href="#bib0300">24</a>MethodologyDesignA prospective observational study was conducted with 126 fifth-year medical students who had prior training in basic abdominal ultrasonography,<a class="elsevierStyleCrossRef" href="#bib0305">25</a> in which an educational intervention in echocardiography was conducted for its subsequent assessment.Mentors and studentsThe mentors were 36 sixth-year medical students (Complutense University, University Hospital 12 de Octubre and Infanta Cristina, Madrid) who had agreed to join a training program in echocardiography, which consisted of an online course and supervised practice. The online course was a theoretical module with the following content: anatomical memory, technique, echocardiographic planes and usefulness of applied echocardiography. At the end of the module, the students had to pass a test. The supervised practice sessions were directed by students previously trained and evaluated in echocardiography in a preliminary study conducted in the same center.<a class="elsevierStyleCrossRef" href="#bib0295">23</a> These practices consisted of at least 20 echocardiographic examinations on various models, during several sessions (at least 15h of practices).The mentors trained all fifth-year medical students from the mentioned centers. None of them had prior knowledge of echocardiography, although they did have knowledge of the basic planes of abdominal ultrasonography.Organization of the teachingThe teaching of the echocardiography was ordered into three phases. The first phase was theoretical. All fifth-year medical students were given access to the same online course (12h), with its corresponding examination, which had been previously performed by the mentors.In the second phase, the practical training was conducted in a laboratory with 2 ultrasound machines and 2 stretchers. Fifteen hours of practical training per student were scheduled, divided in three 5-h training sessions, under the supervision of the student mentor. The objective was for the students to learn the basic components of an ultrasound machine and its functions, the echocardiographic planes, the normal location and morphology of anatomical structures visualized in each slice (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) and the correct technique for placing the probe to optimize the cardiac windows.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The third phase was the assessment. All students were assessed at a fifth-year objective structured clinical assessment (OSCA) station.<a class="elsevierStyleCrossRefs" href="#bib0195">3,11,26</a> During the practical assessment, the students had 8min to perform the basic echocardiographic planes learned on a healthy subject. Each student was awarded a score based on the appropriateness of the obtained planes and the ability to identify 16 structures (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) in the various planes, which consisted of the following: 1 point (poor) if the student did not obtain the plane and therefore could not identify the corresponding structures; 2 points (normal) if the student obtained the plane but did not correctly identify the structures or obtained a deficient plane and the definition of the structures was also deficient; and 3 points (good) if the student obtained appropriate planes and correctly identified the structures. Thus, the minimum score that could be achieved was 16 points, and the maximum was 48 points.The practical assessment was conducted by 4 physicians who were experts in echocardiography who had no link or relationship of any sort with the students or mentors.To check that the examiners used similar assessment criteria, their results underwent an OSCA independent multiple analysis of interobserver agreement in which the 4 examiners simultaneously assessed 15 additional students with the same criteria.To assess the degree of student satisfaction with this training system, an online survey was conducted among the students who had taken the examination. The practical training was conducted with 2 MyLab25 Gold (Esaote) ultrasound machines.Statistical analysisThe quantitative data are presented as means±standard deviation, and the qualitative data are presented as proportions and percentages. For the comparison means with normal distribution, we used Student's t-test. To assess the level of interobserver agreement among the examiners, we calculated the kappa coefficient. A kappa coefficient between 0.41 and 0.60 was considered acceptable (moderate), a coefficient between 0.61 and 0.8 was considered good (substantial), and a coefficient >0.81 was considered almost perfect.The statistical analysis was performed using the SPSS version 22 program (SPSS Inc., Chicago, IL, USA). The study was approved by the Research Committee of the University Hospital Infanta Cristina (file no. 199.2016).ResultsOf the initial sample of 126 students who constituted all fifth-year medical students, 7 students did not show up for the examination. The analysis of the results was conducted on the remaining 119 students.The student scores for each of the 16 examined structures (on a scale from 1 to 3) were converted to a decimal scale, such that 16 points corresponded to “0” and 48 points corresponded to “10” (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The maximum score achieved was 10 points, and the minimum score was 0.31. The mean score was 8.66±1.98. Only 10 students (8.4%) scored below 5, and 15 (12.6%) scored below 7. Fifty students achieved the highest possible score (42%).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The analysis of the scores for each of the anatomical structures of the various echocardiographic planes was conducted by obtaining the percentages of “good”, “normal” and “poor” (3, 2 and 1 point, respectively) for each plane (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>The planes in which the structures were best identified were the parasternal long axis (left and right ventricles, left atrium, aorta and mitral valve) and parasternal short axis (left and right ventricles and mitral valve). The structure with the highest percentage of correct identifications was the left ventricle in the parasternal short axis plane, with 89.9% success. The structures with the poorest results were the tricuspid and mitral valve in the subxiphoid slice, with 72.3% and 69.7% success, respectively.An analysis was conducted on the scores for each basic echocardiographic plane, taking into account the number of anatomical structures of each plane and the score achieved in the plane. A maximum score of 10 was assigned for each plane (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). The planes in which the students had the best results were the parasternal long and short axes, with mean scores of 9.12±2.09 and 9±2.31, respectively, and 89.9% and 84.9% of students with scores ≥7.5 for the axes, respectively. The echocardiographic planes with the poorest results were the subxiphoid and apical four chamber, with mean scores of 8.18±3.14 and 8.36±2.94, with 78.2% and 74.8% of students with scores ≥7.5 for the 2 planes, respectively.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>In the previous academic year (4th year), these same students were taught basic abdominal ultrasonography with the same methodology.<a class="elsevierStyleCrossRef" href="#bib0305">25</a> One of the abdominal planes that was taught and assessed was the subxiphoid, in which the students also had to identify the right and left cardiac cavities. In the 4th-year OSCA, the students obtained the poorest grade in this plane compared with the other planes: 6.6±4 (n=129). This plane coincides with the one evaluated by the examiners in this study with the same criteria; however, in the 5th-year OSCA, the media grade was 8.1±3, significantly higher than in the previous year (p<.001).The results of the multiple interobserver agreement analysis were acceptable, with kappa coefficients between 0.47 and 0.72.Fifty-two (41.2%) of the 126 students who were sent the satisfaction survey answered it, giving the course an overall quality score of 8.92±1.20 out of 10. All students stated that the training method was appropriate and sufficient for satisfactorily passing the final examination, giving the instructors an overall assessment of 9.34±0.92 out of 10. Some 86.53% of the students awarded more than 8 points out of 10 the degree to which the course helped them understand the technical, anatomical and physiological aspects of ultrasonography, and 94.23% wanted to further their training in this technique.DiscussionVarious universities have been able to demonstrate the enormous potential that students have for teaching other students (peer mentoring).<a class="elsevierStyleCrossRefs" href="#bib0280">20–22</a> This study has shown that students (mentors), initially trained by physicians with experience in echocardiography, can assume the responsibility of teaching other students how to obtain the basic planes and identify the most important cardiac structures. This is an innovative teaching method that can enable the teaching of basic aspects of ultrasonography, and likely other practical skills, to large groups of students, thereby reducing the need for resources (personnel, time, equipment, etc.). Similar experiences have already been published on this topic.<a class="elsevierStyleCrossRefs" href="#bib0275">19,27–29</a> The satisfaction survey showed that the mentors and students were very satisfied with their participation in a project that encompassed all students in an academic year and in which they were the true protagonists.During the training, emphasis was placed pragmatically on the teaching of slices employed in echocardiography, which have proven clinical utility.<a class="elsevierStyleCrossRef" href="#bib0205">5</a> With these essential layers, it is possible to qualitatively estimate the ejection fraction, assess the size of the cardiac cavities, determine left ventricular thickness, detect pericardial effusion, identify significant valvular lesions and estimate central venous pressure, aspects that constitute the essence of the echocardiography.<a class="elsevierStyleCrossRef" href="#bib0300">24</a>A high percentage of students correctly obtained the planes and identified the proposed anatomical structures. These results reflect the effectiveness and efficiency of this training system. The most difficult echocardiographic layers to obtain were the subxiphoid and apical four chamber. Nevertheless, the scores were considered good. In a preliminary study that assessed the teaching of basic abdominal ultrasound images to 4th-year students,<a class="elsevierStyleCrossRef" href="#bib0305">25</a> the score for the subxiphoid plane was low (6.6±4) compared with the other planes. A year later with more hours of practice, the score on this plane increased substantially (8.3±3), which reinforced the validity of the teaching method.Clinical ultrasonography is increasingly gaining importance in numerous specialties, and there are studies that have shown it improves the diagnostic yield when compared with the traditional method of assessing patients.<a class="elsevierStyleCrossRef" href="#bib0330">30</a> For medical students, training in ultrasonography facilitates learning basic materials such as anatomy and physiology<a class="elsevierStyleCrossRefs" href="#bib0220">8,31</a> and enables them to improve the effectiveness of physical examinations and their diagnostic capacity.<a class="elsevierStyleCrossRef" href="#bib0340">32</a> Therefore, ultrasonography in medicine can constitute a natural bridge between the basic sciences and clinical practice.<a class="elsevierStyleCrossRef" href="#bib0245">13</a>For some teachers of medicine, ultrasound will change the method of teaching and practicing medicine for the coming decade.<a class="elsevierStyleCrossRefs" href="#bib0195">3,7,11</a> We need to consider the possibility of establishing a number of changes in the contents and objectives of medical curricula, as well as determining the method for teaching and assessing ultrasonography.<a class="elsevierStyleCrossRef" href="#bib0345">33</a>This study's limitations include the fact that the practical lessons were conducted exclusively in healthy models, given that the objective was for the students to learn how to obtain the basic planes and correctly identify selected cardiac structures. Obviously, the results would have been different if actual patients had been chosen as models. Unfortunately, standardizing the teaching of ultrasonography with actual patients is complicated due to the large number of students. However, the increasingly numerous studies on the implementation of ultrasonography in the training curriculum of medical students have established no significant differences in the most effective learning method<a class="elsevierStyleCrossRef" href="#bib0265">17</a>; however, the studies have indicated the obvious benefits that ultrasound training has on students, even during the initial academic years.<a class="elsevierStyleCrossRefs" href="#bib0220">8,18</a> Numerous studies have shown the students’ ability to detect lesions in actual patients after relatively short training periods.<a class="elsevierStyleCrossRefs" href="#bib0210">6,32,34,35</a> Perhaps in the not-too-distant future, the use of portable ultrasound devices will become widespread, even among students, who will be able to examine patients with the devices during the students’ practical training. Another study limitation was the need to use 4 examiners for the practical assessment of the students. Despite the use of very simple assessment criteria, estimating the quality of the obtained planes always has a certain degree of subjectivity. This bias could be avoided by using a single examiner. Nevertheless, the limited time and large number of students precluded this option. Moreover, by using a simple assessment system, it is likely that the qualification system is not very discriminative.In conclusion, the peer mentoring system is a relatively new concept that seems promising and effective, although more studies are needed to shed light on its advantages and benefits.<a class="elsevierStyleCrossRef" href="#bib0360">36</a> This system helps to appropriately train a significant number of medical students in obtaining the basic echocardiography planes and identifying the main cardiac structures. The students acquired these skills after a relatively short training period. As a result, this teaching method could facilitate the implementation of teaching on the basic aspects of ultrasonography among medical students of other universities.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres844927" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methodology" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec839858" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres844926" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Metodología" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec839859" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methodology" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Mentors and students" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Organization of the teaching" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-10-04" "fechaAceptado" => "2017-02-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec839858" "palabras" => array:4 [ 0 => "Echocardiography" 1 => "Medical education" 2 => "Students as mentors" 3 => "Peer mentoring" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec839859" "palabras" => array:4 [ 0 => "Ecocardioscopia" 1 => "Educación médica" 2 => "Estudiantes como mentores" 3 => "Mentoría paritaria" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo analyze the ability of medical students to incorporate the practical teaching of basic echocardiography planes using a peer mentoring design. MethodologyThirty-six medical students previously trained in obtaining echocardiography planes (mentors) taught the other 5th-year students (n=126). The teaching methodology included three stages: theory (online course), basic training (three 15h sessions of practical experience in ultrasound and at least 20 echocardiographic studies per mentor) and objective structured clinical assessment (OSCA), which scored the appropriateness of the basic ultrasound planes and the correct identification of 16 cardiac structures. ResultsThe students’ weighted mean score in the OSCA was 8.66±1.98 points (out of 10). Only 10 students (8.4%) scored less than 5, and 15 (12.6%) scored less than 7. Fifty students (42%) scored 10 points. The most easily identified structure was the left ventricle in the short-axis parasternal plane, with 89.9% of correct answers. The most poorly identified structure was the mitral valve in the subxiphoid plane, with 69.7% of correct answers. ConclusionsPeer mentoring-based teaching achieves an appropriate level of training in obtaining basic echocardiography planes. The training period is relatively short. The peer mentoring system can facilitate the implementation of teaching on basic aspects of ultrasound to a large number of undergraduate students." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methodology" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoAnalizar la capacidad de los alumnos de Medicina para integrarse en la enseñanza práctica de los planos básicos en ecocardioscopia mediante un diseño de mentoría paritaria. MetodologíaTreinta y seis alumnos de Medicina previamente adiestrados en la obtención de planos en ecocardioscopia (mentores) enseñaron al resto de alumnos de 5.o curso (n=126). La metodología docente incluyó 3 etapas: teoría (curso online), entrenamiento básico (3 sesiones con 15h de experiencia práctica en ultrasonidos y un mínimo de 20 estudios ecocardiográficos por mentor) y evaluación clínica objetiva estructurada (ECOE) en la que se puntuaba la adecuación de los planos ecográficos básicos y la correcta identificación de 16 estructuras cardiacas. ResultadosLa puntuación media ponderada obtenida por los alumnos en la ECOE fue de 8,66±1,98 puntos (sobre un máximo de 10). Solo 10 alumnos (8,4%) obtuvieron una puntuación inferior a 5 y 15 (12,6%) inferior a 7. Cincuenta alumnos (42%) obtuvieron 10 puntos. La estructura más fácilmente identificada fue el ventrículo izquierdo en el plano paraesternal eje corto, con un 89,9% de respuestas correctas. La estructura peor identificada fue la válvula mitral en el plano subxifoideo, con un 69,7% de respuestas correctas. ConclusionesLa enseñanza basada en la mentoría paritaria consigue un nivel de entrenamiento adecuado en la obtención de planos básicos en la ecocardioscopia. El periodo de formación es relativamente corto. El sistema de mentoría paritaria puede facilitar la implantación de la enseñanza sobre aspectos básicos en ultrasonidos a un elevado número de alumnos de pregrado." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Metodología" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Arias Felipe A, Doménech García J, Sánchez los Arcos I, Luordo D, García Sánchez FJ, Villanueva Martínez J, et al. Enseñanza de las bases de la ecocardioscopia en el pregrado: los estudiantes como mentores. Rev Clin Esp. 2017;217:245–251." ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Basic planes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Anatomical structures to be identified \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Subxiphoid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1. Right atrium and right ventricle 2. Left atrium and left ventricle 3. Tricuspid valve 4. Mitral valve \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Parasternal long axis (longitudinal) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5. Left ventricle 6. Right ventricle 7. Left atrium 8. Aorta 9. Mitral valve \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Parasternal short axis (transversal) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10. Right ventricle 11. Left ventricle 12. Mitral valve \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Apical four chamber \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13. Right atrium and right ventricle 14. Left atrium and left ventricle 15. Tricuspid valve 16. Mitral valve \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1426987.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Basic ultrasound planes with the anatomical structures that mentors should teach students." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Scores \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of students (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.84) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0.63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.84) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (1.68) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.84) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (2.52) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (1.68) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.84) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5.63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (1.68) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (1.68) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (4.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (5.88) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (2.52) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.84) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (2.52) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (10.92) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (5.04) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (4.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (9.24) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 (42.02) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">119 (100) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1426986.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Overall scores on the decimal scale obtained from the students (n=119), with their absolute and relative frequencies." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Planes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Number of students (%)</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Good \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Regular \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Poor \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">A. Subxiphoid slice</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Identification of RA and RV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 (75.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (15.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (9.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Identification of LA and LV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">91 (76.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (9.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Identification of tricuspid valve \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86 (72.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (16.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (10.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Identification of mitral valve \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83 (69.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (20.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (10.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">B. Parasternal long axis slice</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Identification of LV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99 (83.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (13.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Identification of RV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (84) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (10.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Identification of LA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (84) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (10.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Identification of the aorta \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98 (82.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Identification of the mitral valve \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">103 (86.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (10.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">C. Parasternal short axis slice</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Identification of RV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (84) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (11.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (4.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Identification of LV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">107 (89.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (5.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (4.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Identification of the mitral valve \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99 (83.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (15.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (1.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">D. Apical four chamber slice</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Identification of RA and RV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87 (73.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (20.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (6.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Identification of LA and LV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87 (73.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (20.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (6.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Identification of the tricuspid valve \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89 (74.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (19.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (5.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Identification of the mitral valve \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88 (73.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (19.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (6.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1426985.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Scores for each of the anatomical structures to be identified in the various ultrasound slices." ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "The scores are expressed in intervals; for each of the scores, the absolute frequencies are expressed in integers and the relative frequencies in percentages." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Scores \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Ultrasound slices</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Subxiphoid \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parasternal long axis (longitudinal) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parasternal short axis (transversal) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Apical four chamber \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0.0–2.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (9.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (3.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (3.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (6.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2.5–5.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (0.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (2.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (1.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5.0–7.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 (11.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (9.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 (18.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7.5–10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">93 (78.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">101 (84.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">107 (89.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">89 (74.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.18±3.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9±2.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.12±2.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.36±2.94 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1426988.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Student scores (n=119) according to the basic ultrasound planes." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:36 [ 0 => array:3 [ "identificador" => "bib0185" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Should a hand-carried ultrasound machine become standard equipment for every internist?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.S. Alpert" 1 => "J. Mladenovic" 2 => "D.B. Hellmann" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjmed.2008.05.013" "Revista" => array:6 [ "tituloSerie" => "Am J Med" "fecha" => "2009" "volumen" => "122" "paginaInicial" => "1" "paginaFinal" => "3" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19114160" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0190" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Point-of-care ultrasound in medical education — stop listening and look" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.D. Solomon" 1 => "F. 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Teaching the basics of echocardiography in the undergraduate: Students as mentors

Enseñanza de las bases de la ecocardioscopia en el pregrado: los estudiantes como mentores

A. Arias Felipea, J. Doménech Garcíaa, I. Sánchez los Arcosa, D. Luordoa,b, F.J. García Sáncheza,b, J. Villanueva Martíneza,b, A. Forero de la Sotillaa,b, V. Villena Garridoa,c,d, J. Torres Machoa,b, G. García de Casasola Sáncheza,b,

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ggcasasolaster@gmail.com

Corresponding author.

a Facultad de Medicina, Universidad Complutense, Madrid, Spain

b Grupo de Trabajo de Ecografía Clínica de la Sociedad Española de Medicina Interna, Servicio de Medicina Interna, Hospital Universitario Infanta Cristina, Parla, Madrid, Spain

c Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain

d CIBERES, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">In current clinical practice&#44; portable ultrasound devices are available for use at the patient&#39;s bedside&#46; This availability helps integrate ultrasonography into the diagnostic process&#44; which could be called &#8220;clinical ultrasonography&#8221;&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">1&#8211;3</span></a> This ultrasound modality focuses on basic and clinically relevant aspects without the need for a steep learning curve&#44;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">4&#44;5</span></a> facilitates the teaching of anatomy&#44; helps with understanding the pathophysiology of organs and systems and improves the performance and reliability of physical examinations performed by students&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">6&#8211;8</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The training of medical students in ultrasonography is being progressively implemented in various medical schools&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">3&#44;7&#44;9&#8211;18</span></a> However&#44; the main limitations for its widespread teaching are a lack of professors and the time required for their training&#46; A possible solution is the integration of students into the practical teaching of ultrasonography&#46; Thus&#44; after a small group of students have been trained&#44; these students can then teach others&#44; using what could be called &#8220;peer mentoring&#8221;&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">19&#8211;23</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of this study was to analyze the ability of medical students to incorporate the practical teaching of basic echocardiography planes and identify the most important cardiac structures using a peer mentoring design&#44; with a subsequent assessment of its efficacy&#46; The term &#8220;echocardiography&#8221; has been recently coined by the Spanish Society of Cardiology to refer to basic cardiac ultrasound examinations performed by the bedside with portable equipment&#46; In echocardiography&#44; four elementary planes are employed &#40;parasternal long and short axes&#44; apical four chamber and subxiphoid&#41;&#44; and their objectives are well defined&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">24</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methodology</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Design</span><p id="par0020" class="elsevierStylePara elsevierViewall">A prospective observational study was conducted with 126 fifth-year medical students who had prior training in basic abdominal ultrasonography&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">25</span></a> in which an educational intervention in echocardiography was conducted for its subsequent assessment&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Mentors and students</span><p id="par0025" class="elsevierStylePara elsevierViewall">The mentors were 36 sixth-year medical students &#40;Complutense University&#44; University Hospital 12 de Octubre and Infanta Cristina&#44; Madrid&#41; who had agreed to join a training program in echocardiography&#44; which consisted of an online course and supervised practice&#46; The online course was a theoretical module with the following content&#58; anatomical memory&#44; technique&#44; echocardiographic planes and usefulness of applied echocardiography&#46; At the end of the module&#44; the students had to pass a test&#46; The supervised practice sessions were directed by students previously trained and evaluated in echocardiography in a preliminary study conducted in the same center&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">23</span></a> These practices consisted of at least 20 echocardiographic examinations on various models&#44; during several sessions &#40;at least 15<span class="elsevierStyleHsp" style=""></span>h of practices&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The mentors trained all fifth-year medical students from the mentioned centers&#46; None of them had prior knowledge of echocardiography&#44; although they did have knowledge of the basic planes of abdominal ultrasonography&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Organization of the teaching</span><p id="par0035" class="elsevierStylePara elsevierViewall">The teaching of the echocardiography was ordered into three phases&#46; The first phase was theoretical&#46; All fifth-year medical students were given access to the same online course &#40;12<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; with its corresponding examination&#44; which had been previously performed by the mentors&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the second phase&#44; the practical training was conducted in a laboratory with 2 ultrasound machines and 2 stretchers&#46; Fifteen hours of practical training per student were scheduled&#44; divided in three 5-h training sessions&#44; under the supervision of the student mentor&#46; The objective was for the students to learn the basic components of an ultrasound machine and its functions&#44; the echocardiographic planes&#44; the normal location and morphology of anatomical structures visualized in each slice &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; and the correct technique for placing the probe to optimize the cardiac windows&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The third phase was the assessment&#46; All students were assessed at a fifth-year objective structured clinical assessment &#40;OSCA&#41; station&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">3&#44;11&#44;26</span></a> During the practical assessment&#44; the students had 8<span class="elsevierStyleHsp" style=""></span>min to perform the basic echocardiographic planes learned on a healthy subject&#46; Each student was awarded a score based on the appropriateness of the obtained planes and the ability to identify 16 structures &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; in the various planes&#44; which consisted of the following&#58; 1 point &#40;poor&#41; if the student did not obtain the plane and therefore could not identify the corresponding structures&#59; 2 points &#40;normal&#41; if the student obtained the plane but did not correctly identify the structures or obtained a deficient plane and the definition of the structures was also deficient&#59; and 3 points &#40;good&#41; if the student obtained appropriate planes and correctly identified the structures&#46; Thus&#44; the minimum score that could be achieved was 16 points&#44; and the maximum was 48 points&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The practical assessment was conducted by 4 physicians who were experts in echocardiography who had no link or relationship of any sort with the students or mentors&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">To check that the examiners used similar assessment criteria&#44; their results underwent an OSCA independent multiple analysis of interobserver agreement in which the 4 examiners simultaneously assessed 15 additional students with the same criteria&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">To assess the degree of student satisfaction with this training system&#44; an online survey was conducted among the students who had taken the examination&#46; The practical training was conducted with 2 MyLab25 Gold &#40;Esaote&#41; ultrasound machines&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">The quantitative data are presented as means<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#44; and the qualitative data are presented as proportions and percentages&#46; For the comparison means with normal distribution&#44; we used Student&#39;s <span class="elsevierStyleItalic">t</span>-test&#46; To assess the level of interobserver agreement among the examiners&#44; we calculated the kappa coefficient&#46; A kappa coefficient between 0&#46;41 and 0&#46;60 was considered acceptable &#40;moderate&#41;&#44; a coefficient between 0&#46;61 and 0&#46;8 was considered good &#40;substantial&#41;&#44; and a coefficient &#62;0&#46;81 was considered almost perfect&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The statistical analysis was performed using the SPSS version 22 program &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46; The study was approved by the Research Committee of the University Hospital Infanta Cristina &#40;file no&#46; 199&#46;2016&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">Of the initial sample of 126 students who constituted all fifth-year medical students&#44; 7 students did not show up for the examination&#46; The analysis of the results was conducted on the remaining 119 students&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The student scores for each of the 16 examined structures &#40;on a scale from 1 to 3&#41; were converted to a decimal scale&#44; such that 16 points corresponded to &#8220;0&#8221; and 48 points corresponded to &#8220;10&#8221; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The maximum score achieved was 10 points&#44; and the minimum score was 0&#46;31&#46; The mean score was 8&#46;66<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;98&#46; Only 10 students &#40;8&#46;4&#37;&#41; scored below 5&#44; and 15 &#40;12&#46;6&#37;&#41; scored below 7&#46; Fifty students achieved the highest possible score &#40;42&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The analysis of the scores for each of the anatomical structures of the various echocardiographic planes was conducted by obtaining the percentages of &#8220;good&#8221;&#44; &#8220;normal&#8221; and &#8220;poor&#8221; &#40;3&#44; 2 and 1 point&#44; respectively&#41; for each plane &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The planes in which the structures were best identified were the parasternal long axis &#40;left and right ventricles&#44; left atrium&#44; aorta and mitral valve&#41; and parasternal short axis &#40;left and right ventricles and mitral valve&#41;&#46; The structure with the highest percentage of correct identifications was the left ventricle in the parasternal short axis plane&#44; with 89&#46;9&#37; success&#46; The structures with the poorest results were the tricuspid and mitral valve in the subxiphoid slice&#44; with 72&#46;3&#37; and 69&#46;7&#37; success&#44; respectively&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">An analysis was conducted on the scores for each basic echocardiographic plane&#44; taking into account the number of anatomical structures of each plane and the score achieved in the plane&#46; A maximum score of 10 was assigned for each plane &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; The planes in which the students had the best results were the parasternal long and short axes&#44; with mean scores of 9&#46;12<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;09 and 9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;31&#44; respectively&#44; and 89&#46;9&#37; and 84&#46;9&#37; of students with scores &#8805;7&#46;5 for the axes&#44; respectively&#46; The echocardiographic planes with the poorest results were the subxiphoid and apical four chamber&#44; with mean scores of 8&#46;18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;14 and 8&#46;36<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;94&#44; with 78&#46;2&#37; and 74&#46;8&#37; of students with scores &#8805;7&#46;5 for the 2 planes&#44; respectively&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">In the previous academic year &#40;4th year&#41;&#44; these same students were taught basic abdominal ultrasonography with the same methodology&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">25</span></a> One of the abdominal planes that was taught and assessed was the subxiphoid&#44; in which the students also had to identify the right and left cardiac cavities&#46; In the 4th-year OSCA&#44; the students obtained the poorest grade in this plane compared with the other planes&#58; 6&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>129&#41;&#46; This plane coincides with the one evaluated by the examiners in this study with the same criteria&#59; however&#44; in the 5th-year OSCA&#44; the media grade was 8&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44; significantly higher than in the previous year &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The results of the multiple interobserver agreement analysis were acceptable&#44; with kappa coefficients between 0&#46;47 and 0&#46;72&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Fifty-two &#40;41&#46;2&#37;&#41; of the 126 students who were sent the satisfaction survey answered it&#44; giving the course an overall quality score of 8&#46;92<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;20 out of 10&#46; All students stated that the training method was appropriate and sufficient for satisfactorily passing the final examination&#44; giving the instructors an overall assessment of 9&#46;34<span class="elsevierStyleHsp" style=""></span>&#177;0&#46;92<span class="elsevierStyleHsp" style=""></span> out of 10&#46; Some 86&#46;53&#37; of the students awarded more than 8 points out of 10 the degree to which the course helped them understand the technical&#44; anatomical and physiological aspects of ultrasonography&#44; and 94&#46;23&#37; wanted to further their training in this technique&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">Various universities have been able to demonstrate the enormous potential that students have for teaching other students &#40;peer mentoring&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">20&#8211;22</span></a> This study has shown that students &#40;mentors&#41;&#44; initially trained by physicians with experience in echocardiography&#44; can assume the responsibility of teaching other students how to obtain the basic planes and identify the most important cardiac structures&#46; This is an innovative teaching method that can enable the teaching of basic aspects of ultrasonography&#44; and likely other practical skills&#44; to large groups of students&#44; thereby reducing the need for resources &#40;personnel&#44; time&#44; equipment&#44; etc&#46;&#41;&#46; Similar experiences have already been published on this topic&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">19&#44;27&#8211;29</span></a> The satisfaction survey showed that the mentors and students were very satisfied with their participation in a project that encompassed all students in an academic year and in which they were the true protagonists&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">During the training&#44; emphasis was placed pragmatically on the teaching of slices employed in echocardiography&#44; which have proven clinical utility&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">5</span></a> With these essential layers&#44; it is possible to qualitatively estimate the ejection fraction&#44; assess the size of the cardiac cavities&#44; determine left ventricular thickness&#44; detect pericardial effusion&#44; identify significant valvular lesions and estimate central venous pressure&#44; aspects that constitute the essence of the echocardiography&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">24</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">A high percentage of students correctly obtained the planes and identified the proposed anatomical structures&#46; These results reflect the effectiveness and efficiency of this training system&#46; The most difficult echocardiographic layers to obtain were the subxiphoid and apical four chamber&#46; Nevertheless&#44; the scores were considered good&#46; In a preliminary study that assessed the teaching of basic abdominal ultrasound images to 4th-year students&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">25</span></a> the score for the subxiphoid plane was low &#40;6&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#41; compared with the other planes&#46; A year later with more hours of practice&#44; the score on this plane increased substantially &#40;8&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#41;&#44; which reinforced the validity of the teaching method&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Clinical ultrasonography is increasingly gaining importance in numerous specialties&#44; and there are studies that have shown it improves the diagnostic yield when compared with the traditional method of assessing patients&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">30</span></a> For medical students&#44; training in ultrasonography facilitates learning basic materials such as anatomy and physiology<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">8&#44;31</span></a> and enables them to improve the effectiveness of physical examinations and their diagnostic capacity&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">32</span></a> Therefore&#44; ultrasonography in medicine can constitute a natural bridge between the basic sciences and clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">13</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">For some teachers of medicine&#44; ultrasound will change the method of teaching and practicing medicine for the coming decade&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">3&#44;7&#44;11</span></a> We need to consider the possibility of establishing a number of changes in the contents and objectives of medical curricula&#44; as well as determining the method for teaching and assessing ultrasonography&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">33</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">This study&#39;s limitations include the fact that the practical lessons were conducted exclusively in healthy models&#44; given that the objective was for the students to learn how to obtain the basic planes and correctly identify selected cardiac structures&#46; Obviously&#44; the results would have been different if actual patients had been chosen as models&#46; Unfortunately&#44; standardizing the teaching of ultrasonography with actual patients is complicated due to the large number of students&#46; However&#44; the increasingly numerous studies on the implementation of ultrasonography in the training curriculum of medical students have established no significant differences in the most effective learning method<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">17</span></a>&#59; however&#44; the studies have indicated the obvious benefits that ultrasound training has on students&#44; even during the initial academic years&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">8&#44;18</span></a> Numerous studies have shown the students&#8217; ability to detect lesions in actual patients after relatively short training periods&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">6&#44;32&#44;34&#44;35</span></a> Perhaps in the not-too-distant future&#44; the use of portable ultrasound devices will become widespread&#44; even among students&#44; who will be able to examine patients with the devices during the students&#8217; practical training&#46; Another study limitation was the need to use 4 examiners for the practical assessment of the students&#46; Despite the use of very simple assessment criteria&#44; estimating the quality of the obtained planes always has a certain degree of subjectivity&#46; This bias could be avoided by using a single examiner&#46; Nevertheless&#44; the limited time and large number of students precluded this option&#46; Moreover&#44; by using a simple assessment system&#44; it is likely that the qualification system is not very discriminative&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In conclusion&#44; the peer mentoring system is a relatively new concept that seems promising and effective&#44; although more studies are needed to shed light on its advantages and benefits&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">36</span></a> This system helps to appropriately train a significant number of medical students in obtaining the basic echocardiography planes and identifying the main cardiac structures&#46; The students acquired these skills after a relatively short training period&#46; As a result&#44; this teaching method could facilitate the implementation of teaching on the basic aspects of ultrasonography among medical students of other universities&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "palabras" => array:4 [
            0 => "Ecocardioscopia"
            1 => "Educaci&#243;n m&#233;dica"
            2 => "Estudiantes como mentores"
            3 => "Mentor&#237;a paritaria"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyze the ability of medical students to incorporate the practical teaching of basic echocardiography planes using a peer mentoring design&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methodology</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Thirty-six medical students previously trained in obtaining echocardiography planes &#40;mentors&#41; taught the other 5th-year students &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>126&#41;&#46; The teaching methodology included three stages&#58; theory &#40;online course&#41;&#44; basic training &#40;three 15<span class="elsevierStyleHsp" style=""></span>h sessions of practical experience in ultrasound and at least 20 echocardiographic studies per mentor&#41; and objective structured clinical assessment &#40;OSCA&#41;&#44; which scored the appropriateness of the basic ultrasound planes and the correct identification of 16 cardiac structures&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The students&#8217; weighted mean score in the OSCA was 8&#46;66<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;98 points &#40;out of 10&#41;&#46; Only 10 students &#40;8&#46;4&#37;&#41; scored less than 5&#44; and 15 &#40;12&#46;6&#37;&#41; scored less than 7&#46; Fifty students &#40;42&#37;&#41; scored 10 points&#46; The most easily identified structure was the left ventricle in the short-axis parasternal plane&#44; with 89&#46;9&#37; of correct answers&#46; The most poorly identified structure was the mitral valve in the subxiphoid plane&#44; with 69&#46;7&#37; of correct answers&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Peer mentoring-based teaching achieves an appropriate level of training in obtaining basic echocardiography planes&#46; The training period is relatively short&#46; The peer mentoring system can facilitate the implementation of teaching on basic aspects of ultrasound to a large number of undergraduate students&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methodology"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Analizar la capacidad de los alumnos de Medicina para integrarse en la ense&#241;anza pr&#225;ctica de los planos b&#225;sicos en ecocardioscopia mediante un dise&#241;o de mentor&#237;a paritaria&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Metodolog&#237;a</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Treinta y seis alumnos de Medicina previamente adiestrados en la obtenci&#243;n de planos en ecocardioscopia &#40;mentores&#41; ense&#241;aron al resto de alumnos de 5&#46;<span class="elsevierStyleSup">o</span> curso &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>126&#41;&#46; La metodolog&#237;a docente incluy&#243; 3 etapas&#58; teor&#237;a &#40;curso <span class="elsevierStyleItalic">online</span>&#41;&#44; entrenamiento b&#225;sico &#40;3 sesiones con 15<span class="elsevierStyleHsp" style=""></span>h de experiencia pr&#225;ctica en ultrasonidos y un m&#237;nimo de 20 estudios ecocardiogr&#225;ficos por mentor&#41; y evaluaci&#243;n cl&#237;nica objetiva estructurada &#40;ECOE&#41; en la que se puntuaba la adecuaci&#243;n de los planos ecogr&#225;ficos b&#225;sicos y la correcta identificaci&#243;n de 16 estructuras cardiacas&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La puntuaci&#243;n media ponderada obtenida por los alumnos en la ECOE fue de 8&#44;66<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;98 puntos &#40;sobre un m&#225;ximo de 10&#41;&#46; Solo 10 alumnos &#40;8&#44;4&#37;&#41; obtuvieron una puntuaci&#243;n inferior a 5 y 15 &#40;12&#44;6&#37;&#41; inferior a 7&#46; Cincuenta alumnos &#40;42&#37;&#41; obtuvieron 10 puntos&#46; La estructura m&#225;s f&#225;cilmente identificada fue el ventr&#237;culo izquierdo en el plano paraesternal eje corto&#44; con un 89&#44;9&#37; de respuestas correctas&#46; La estructura peor identificada fue la v&#225;lvula mitral en el plano subxifoideo&#44; con un 69&#44;7&#37; de respuestas correctas&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La ense&#241;anza basada en la mentor&#237;a paritaria consigue un nivel de entrenamiento adecuado en la obtenci&#243;n de planos b&#225;sicos en la ecocardioscopia&#46; El periodo de formaci&#243;n es relativamente corto&#46; El sistema de mentor&#237;a paritaria puede facilitar la implantaci&#243;n de la ense&#241;anza sobre aspectos b&#225;sicos en ultrasonidos a un elevado n&#250;mero de alumnos de pregrado&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Metodolog&#237;a"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Arias Felipe A&#44; Dom&#233;nech Garc&#237;a J&#44; S&#225;nchez los Arcos I&#44; Luordo D&#44; Garc&#237;a S&#225;nchez FJ&#44; Villanueva Mart&#237;nez J&#44; et al&#46; Ense&#241;anza de las bases de la ecocardioscopia en el pregrado&#58; los estudiantes como mentores&#46; Rev Clin Esp&#46; 2017&#59;217&#58;245&#8211;251&#46;</p>"
      ]
    ]
    "multimedia" => array:4 [
      0 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Basic planes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Anatomical structures to be identified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Subxiphoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46; Right atrium and right ventricle<br>2&#46; Left atrium and left ventricle<br>3&#46; Tricuspid valve<br>4&#46; Mitral valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Parasternal long axis &#40;longitudinal&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46; Left ventricle<br>6&#46; Right ventricle<br>7&#46; Left atrium<br>8&#46; Aorta<br>9&#46; Mitral valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Parasternal short axis &#40;transversal&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46; Right ventricle<br>11&#46; Left ventricle<br>12&#46; Mitral valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Apical four chamber&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#46; Right atrium and right ventricle<br>14&#46; Left atrium and left ventricle<br>15&#46; Tricuspid valve<br>16&#46; Mitral valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Basic ultrasound planes with the anatomical structures that mentors should teach students&#46;</p>"
        ]
      ]
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        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
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        "tabla" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Scores&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of students &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;0&#46;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;0&#46;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;1&#46;68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;0&#46;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;2&#46;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&#46;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;1&#46;68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;0&#46;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;1&#46;68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;1&#46;68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;4&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;5&#46;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;2&#46;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;0&#46;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;2&#46;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;10&#46;92&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;5&#46;04&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;4&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&#46;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;9&#46;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50 &#40;42&#46;02&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">119 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Overall scores on the decimal scale obtained from the students &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>119&#41;&#44; with their absolute and relative frequencies&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; LA&#44; left atrium&#59; LV&#44; left ventricle&#59; RA&#44; right atrium&#59; RV&#44; right ventricle&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Planes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Number of students &#40;&#37;&#41;</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Good&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Regular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Poor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">A&#46; Subxiphoid slice</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Identification of RA and RV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90 &#40;75&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;15&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;9&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Identification of LA and LV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91 &#40;76&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;14&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;9&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Identification of tricuspid valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86 &#40;72&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;16&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;10&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Identification of mitral valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83 &#40;69&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24 &#40;20&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;10&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">B&#46; Parasternal long axis slice</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Identification of LV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99 &#40;83&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;13&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Identification of RV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100 &#40;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;10&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Identification of LA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100 &#40;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;10&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Identification of the aorta&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98 &#40;82&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;14&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Identification of the mitral valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">103 &#40;86&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;10&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">C&#46; Parasternal short axis slice</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Identification of RV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100 &#40;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;11&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;4&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Identification of LV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">107 &#40;89&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;5&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;4&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Identification of the mitral valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">99 &#40;83&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;15&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">D&#46; Apical four chamber slice</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Identification of RA and RV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87 &#40;73&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24 &#40;20&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;6&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Identification of LA and LV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87 &#40;73&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24 &#40;20&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;6&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Identification of the tricuspid valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89 &#40;74&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;19&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;5&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Identification of the mitral valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">88 &#40;73&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;19&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;6&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Scores for each of the anatomical structures to be identified in the various ultrasound slices&#46;</p>"
        ]
      ]
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        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
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            "identificador" => "at4"
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">The scores are expressed in intervals&#59; for each of the scores&#44; the absolute frequencies are expressed in integers and the relative frequencies in percentages&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Scores&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Ultrasound slices</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Subxiphoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parasternal long axis &#40;longitudinal&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parasternal short axis &#40;transversal&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Apical four chamber&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0&#46;0&#8211;2&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11 &#40;9&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;6&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&#46;5&#8211;5&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;0&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;2&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&#46;0&#8211;7&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14 &#40;11&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11 &#40;9&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22 &#40;18&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&#46;5&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">93 &#40;78&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">101 &#40;84&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">107 &#40;89&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">89 &#40;74&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;12<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;36<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Student scores &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>119&#41; according to the basic ultrasound planes&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:36 [
            0 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Should a hand-carried ultrasound machine become standard equipment for every internist&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46;S&#46; Alpert"
                            1 => "J&#46; Mladenovic"
                            2 => "D&#46;B&#46; Hellmann"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.amjmed.2008.05.013"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Med"
                        "fecha" => "2009"
                        "volumen" => "122"
                        "paginaInicial" => "1"
                        "paginaFinal" => "3"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19114160"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Point-of-care ultrasound in medical education &#8212; stop listening and look"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46;D&#46; Solomon"
                            1 => "F&#46; Saldana"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMp1311944"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2017.02.002

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