Clinical reasoning has been characterized as being an essential aspect of being a physician. Despite this, clinical reasoning has a variety of definitions and medical error, which is often attributed to clinical reasoning, has been reported to be a leading cause of death in the United States and abroad. Further, instructors struggle with teaching this essential ability which often does not play a significant role in the curriculum. In this article, we begin with defining clinical reasoning and then discuss four principles from the literature as well as a variety of techniques for teaching these principles to help ground an instructors’ understanding in clinical reasoning. We also tackle contemporary challenges in teaching clinical reasoning such as the integration of artificial intelligence and strategies to help with transitions in instruction (e.g., from the classroom to the clinic or from medical school to residency/registrar training) and suggest next steps for research and innovation in clinical reasoning.

In the last quarter of a century, the backdrop of appropriate ambulatory and office-based surgeries has changed dramatically. Procedures that were traditionally done in hospitals or patients being admitted after surgery are migrating to the outpatient setting and being discharged on the same day, respectively, at a remarkable rate. In the face of this exponential growth, anesthesiologists are constantly being challenged to maintain patient safety by understanding the appropriate patient selection, procedure, and surgical location. Recently published literature supports the trend of higher, more medically complex patients, and more complicated procedures shifting towards the outpatient arena. Several reasons that may account for this include cost incentives, advancement in anesthesia techniques, enhanced recovery after surgery (ERAS) protocols, and increased patient satisfaction. Anesthesiologists must understand that there is a lack of standardized state regulations regarding ambulatory surgery centers (ASCs) and office-based surgery (OBS) centers. Current and recently graduated anesthesiologists should be aware of the safety concerns related to the various non-hospital-based locations, the sustained growth and demand for anesthesia in the office, and the expansion of mobile anesthesia practices in the US in order to keep up and practice safely with the professional trends. Continuing procedural ambulatory shifts will require ongoing outcomes research, likely prospective in nature, on these novel outpatient procedures, in order to develop risk stratification and prediction models for the selection of the proper patient, procedure, and surgery location.

INTRODUCTION: Chest radiographs (CXRs) are widely used for the screening and management of COVID-19. This article describes the radiographic features of COVID-19 based on an initial national cohort of patients. METHODS: This is a retrospective review of swab-positive patients with COVID-19 who were admitted to four different hospitals in Singapore between 22 January and 9 March 2020. Initial and follow-up CXRs were reviewed by three experienced radiologists to identify the predominant pattern and distribution of lung parenchymal abnormalities. RESULTS: In total, 347 CXRs of 96 patients were reviewed. Initial CXRs were abnormal in 41 (42.7%) out of 96 patients. The mean time from onset of symptoms to CXR abnormality was 5.3 ± 4.7 days. The predominant pattern of lung abnormality was ground-glass opacity on initial CXRs (51.2%) and consolidation on follow-up CXRs (51.0%). Multifocal bilateral abnormalities in mixed central and peripheral distribution were observed in 63.4% and 59.2% of abnormal initial and follow-up CXRs, respectively. The lower zones were involved in 90.2% of initial CXRs and 93.9% of follow-up CXRs. CONCLUSION In a cohort of swab-positive patients, including those identified from contact tracing, we found a lower incidence of CXR abnormalities than was previously reported. The most common pattern was ground-glass opacity or consolidation, but mixed central and peripheral involvement was more common than peripheral involvement alone.
COVID-19 ; Humans ; Lung/diagnostic imaging* ; Radiography, Thoracic ; Retrospective Studies ; SARS-CoV-2 ; Singapore

BACKGROUND: The application of image analysis technologies for the interpretation of microbiological cultures is evolving rapidly. The primary aim of this study was to establish whether the image analysis system named Automated Plate Assessment System (APAS; LBT Innovations Ltd., Australia) could be applied to screen urine cultures. A secondary aim was to evaluate differences between traditional plate reading (TPR) and the reading of cultures from images, or digital plate reading (DPR). METHODS: A total of 9,224 urine samples submitted for culture to three clinical laboratories, two in Australia and one in the USA, were included in the study. Cultures were prepared on sheep blood and MacConkey agar plates and read by panels of three microbiologists. The plates were then presented to APAS for image capture and analysis, and the images and results were stored for later review. RESULTS: Image analysis of cultures using APAS produced a diagnostic sensitivity and specificity of 99.0% and 84.5%, respectively. Colonies were detected by APAS on 99.0% of blood agar plates with growth and on 99.5% of MacConkey agar plates. DPR agreed with TPR for colony enumeration on 92.1% of the plates, with a sensitivity of 90.8% and specificity of 92.8% for case designation. However, several differences in the classification of colony morphologies using DPR were identified. CONCLUSIONS: APAS was shown to be a reliable screening system for urine cultures. The study also showed acceptable concordance between DPR and TPR for colony detection, enumeration, and case designation.
Agar ; Australia ; Classification ; Mass Screening ; Sensitivity and Specificity ; Sheep

Although intravenous administration of tissue plasminogen activator is the only proven treatment after acute ischemic stroke, there is always a concern of hemorrhagic risk after thrombolysis. Therefore, selection of patients with potential benefits in overcoming potential harms of thrombolysis is of great importance. Despite the practical issues in using magnetic resonance imaging (MRI) for acute stroke treatment, multimodal MRI can provide useful information for accurate diagnosis of stroke, evaluation of the risks and benefits of thrombolysis, and prediction of outcomes. For example, the high sensitivity and specificity of diffusion-weighted image (DWI) can help distinguish acute ischemic stroke from stroke-mimics. Additionally, the lesion mismatch between perfusion-weighted image (PWI) and DWI is thought to represent potential salvageable tissue by reperfusion therapy. However, the optimal threshold to discriminate between benign oligemic areas and the penumbra is still debatable. Signal changes of fluid-attenuated inversion recovery image within DWI lesions may be a surrogate marker for ischemic lesion age and might indicate risks of hemorrhage after thrombolysis. Clot sign on gradient echo image may reflect the nature of clot, and their location, length and morphology may provide predictive information on recanalization by reperfusion therapy. However, previous clinical trials which solely or mainly relied on perfusion-diffusion mismatch for patient selection, failed to show benefits of MRI-based thrombolysis. Therefore, understanding the clinical implication of various useful MRI findings and comprehensively incorporating those variables into therapeutic decision-making may be a more reasonable approach for expanding the indication of acute stroke thrombolysis.
Administration, Intravenous ; Biomarkers ; Combined Modality Therapy ; Diagnosis ; Hemorrhage ; Humans ; Magnetic Resonance Imaging* ; Patient Selection ; Reperfusion ; Risk Assessment ; Sensitivity and Specificity ; Stroke* ; Tissue Plasminogen Activator

The aims of this study were to analyze annual trends of charcoal burning (CB) suicide, 2000 to 2011, and to examine the risk factors of CB suicide in Korea. Data on suicides (n=138,938) were obtained from the Statistics Korea. The proportion of CB suicides among all suicide deaths reported was 0.7% (84 cases) in 2007, and since 2008 it has rapidly increased to 7.9% (1,251 cases) in 2011. Of significant risk factors of CB suicide, the presence of the media report of Ahn's suicide was the greatest risk factor (adjusted odds ratio, 11.69; 95% CI, 10.30-13.23) of the initial phase of the continuing CB suicides since 2008. Korean Government should urgently consider effective measures against CB suicide, including enforced media regulations on reporting such suicides.
Adolescent ; Adult ; Age Distribution ; Aged ; Aged, 80 and over ; Charcoal ; Child ; Female ; Humans ; Incidence ; Male ; Mass Media/*statistics & numerical data ; Middle Aged ; Republic of Korea/epidemiology ; Risk Assessment ; Risk Factors ; Sex Distribution ; Suicide/psychology/*statistics & numerical data/*trends ; Young Adult

The aims of this study were to analyze annual trends of charcoal burning (CB) suicide, 2000 to 2011, and to examine the risk factors of CB suicide in Korea. Data on suicides (n=138,938) were obtained from the Statistics Korea. The proportion of CB suicides among all suicide deaths reported was 0.7% (84 cases) in 2007, and since 2008 it has rapidly increased to 7.9% (1,251 cases) in 2011. Of significant risk factors of CB suicide, the presence of the media report of Ahn's suicide was the greatest risk factor (adjusted odds ratio, 11.69; 95% CI, 10.30-13.23) of the initial phase of the continuing CB suicides since 2008. Korean Government should urgently consider effective measures against CB suicide, including enforced media regulations on reporting such suicides.
Adolescent ; Adult ; Age Distribution ; Aged ; Aged, 80 and over ; Charcoal ; Child ; Female ; Humans ; Incidence ; Male ; Mass Media/*statistics & numerical data ; Middle Aged ; Republic of Korea/epidemiology ; Risk Assessment ; Risk Factors ; Sex Distribution ; Suicide/psychology/*statistics & numerical data/*trends ; Young Adult

Immunocastration is a considerable alternative to a surgical castration method especially in male animal species for alleviating unwanted male behaviors and characteristics. Induction of high titer of antibody specific for gonadotropin-releasing hormone (GnRH) correlates with the regression of testes. Fusion proteins composed of canine GnRH and T helper (Th) cell epitope p35 originated from canine distemper virus (CDV) F protein and goat rotavirus VP6 protein were produced in E. coli. When these fusion proteins were injected to male dogs which were previously immunized with CDV vaccine, the fusion protein of GnRH-CDV Th cell epitope p35 induced much higher antibody than that of GnRH-rotavirus VP6 protein or GnRH alone. The degeneration of spermatogenesis was also verified in the male dogs immunized with the fusion protein of GnRH-CDV Th cell epitope p35. These results indicate that canine GnRH conjugated to CDV Th cell epitope p35 acted as a strong immunogen and the antibody to GnRH specifically neutralized GnRH in the testes. This study also implies a potential application of GnRH-based vaccines for immunocastration of male pets.
Amino Acid Sequence ; Animals ; Antibodies/blood ; Base Sequence ; Contraception, Immunologic/methods/*veterinary ; Distemper Virus, Canine/*immunology ; Dogs/immunology/*physiology ; Epitopes, T-Lymphocyte/*immunology ; Fertility/immunology ; Gonadotropin-Releasing Hormone/chemistry/*immunology ; Male ; Molecular Sequence Data ; Organ Size ; Recombinant Proteins/immunology ; Spermatogenesis/immunology ; T-Lymphocytes, Helper-Inducer/immunology ; Testis/immunology ; Vaccines, Contraceptive/immunology

One of the hazards of colorectal surgery is ureteric injury. The aim of this study was to evaluate the results of ureteric catheterization regarding its safety and operative time. One-hundred sixty two patients underwent laparoscopic segmental left or right colectomy. The mean time for placement of ureteric catheters was 11.4 min for the right hemicolectomy and 11.3 min for the left hemicolectomy group. The mean preparation times for right hemicolectomy and left hemicolectomy (group 1 vs. group 2) were 54.7 vs. 39.1 min (p=0.00001) and 61.4 vs. 47.6 min (p=0.006), respectively. There were no significant differences in the laparoscopic operative time in either the right or left hemicolectomy groups (134.2 vs. 145.5 min and 198.4 vs. 170.1 min, respectively). There was no morbidity directly related to the ureteric catheters and in fact the incidence of postoperative urinary tract infection was lower in group 1 (1.5%) than in group 2 (5.3%) (p<0.05). Although the use of ureteric catheters added a mean of 11.3 min to the surgical procedure, the overall anesthetic time for right hemicolectomy was no longer than that for left hemicolectomy. The morbidity rate was quite acceptable. Thus, ureteric catheters may be useful in selected cases of laparoscopic left and right colorectal resections.
Adolescent ; Adult ; Aged ; Aged, 80 and over ; Colectomy/adverse effects/*methods ; Female ; Humans ; Laparoscopy ; Male ; Middle Aged ; Postoperative Complications/prevention & control ; Safety ; Time Factors ; Ureter/injuries ; *Urinary Catheterization

PURPOSE: To investigate that the effects of early wound healing stage after corneal epithelial scrape injury. METHODS: We studied the change of scraped corneal wound like corneal cells, corneal thickness, acelluar zone, and celluar morphology occurring at the time points of 1, 4, 12, 24, 48, 72 hours, and 7 days after corneal epithelial scrape injury by the confocal microscopy and EM findings in 4 each group rabbits. RESULTS: By normal confocal microscopy, the mean cell density was 891 cells/mm2 in the anterior stroma and decreased to 814 cells/mm2 in the middle stroma, 731 cells/mm2 in the posterior stroma, and the endothelial density was 3236 cells/mm2. The change in the morphology of the keratocyte nuclei from an elliptical shape anteriorly, to a more elongated shape posteriorly. Apoptosis revealed like as condensation or fragmentation of chromatin and nuclei, vesicle formation, apoptotic bodies after corneal scraped injury by EM findings. The mean thickness of normal cornea was as follow; 47 micrometer in the epithelium, 334 micrometer in the stroma, and 392 micrometer in total cornea. The thickness of postoperative cornea including stromal thickness and total thickness increased at the early wound healing stage, and then decreased to the postoperative 48 hours(P<0.001). Mean range of acellular zone in the stroma increased at the early wound healing, but significantly decreased at the postoperative 48 hours, 79 micrometer(P<0.001). CONCLUSIONS: Keratocyte cell density and corneal thickness at the three portions of cornea, the thickness of stromal acelluar zone, and the changes of cellular morphology were related with a kind of the early post-inflammatory reaction, especially 24 hours, of corneal scraped injury. It should be needed more studies concerned with control of early post-inflammatory reaction.
Apoptosis ; Cell Count ; Chromatin ; Cornea ; Epithelium ; Microscopy, Confocal ; Rabbits ; Wound Healing ; Wounds and Injuries