Disinfection efficiency of chlorine dioxide and peracetic acid against MNV-1 and HAV in simulated soil-rich wash water.

Wash water from fresh vegetables and root vegetables is an important vehicle for foodborne virus transmission. However, there is lack of assessing rapid viral inactivation strategies in wash water characterized by a high soil content at the post-harvest stage. Considering the significance of food safety during the washing stage for fresh and root vegetable produce prior to marketing, we assessed the inactivation efficacy by using chlorine dioxide (ClO2) and peracetic acid (PAA) against a surrogate of human norovirus (murine norovirus 1, MNV-1) and hepatitis A virus (HAV), in wash water containing black soil and clay loam. The results indicated that MNV-1 and HAV were reduced to the process limit of detection (PLOD), with reductions ranging from 4.89 to 6.35 log10 PFU, and 4.63 to 4.96 log10 PFU when treated with ClO2 at 2.5 ppm for 10 mins. Comparatively, when treated with 500 ppm of PAA for 10 mins, MNV-1 and HAV were maximum reduced to 1.75 ± 0.23 log10 PFU (4.50 log10 PFU reduction) and 2.13 ± 0.12 log10 PFU (2.72 log10 PFU reduction). This demonstrated the efficacy of ClO2 in eliminating foodborne viruses in soil-rich wash water. When we validated the recovery of the virus from two types of wash water, the pH (9.24 ± 0.33 and 5.95 ± 0.05) had no impact on the recovery of MNV-1, while the recovery of HAV was less than 1 %. By adjusting the pH to a neutral level, recovery of HAV and its RNA levels was increased to 15.94 and 3.89 %. Thus, this study emphasized the critical role of pH in the recovery of HAV from the complex soil-rich aqueous environment, and the efficacy of ClO2 serving as a pivotal reference for the development of control strategies against foodborne viruses in the supply chain of fresh and root vegetables.

Comparative Evaluation of Egg Quality in Response to Temperature Variability: From Farm to Table Exposure Scenarios.

This study aimed to develop appropriate temperature management practices and provide scientific evidence to support the development of sell-by-date guidance for eggs. Washed and unwashed eggs were subjected to storage under six different scenarios, and both types of eggs were stored at temperatures up to 35°C to evaluate the sell-by-date. Despite temperature fluctuations or continuous storage at 30°C for 5 days, subsequent storage at 10°C resulted in significantly higher Haugh unit and yolk index on day 15. These results indicate that refrigerating eggs from retail sales until consumption is effective for egg quality management, despite the exposure of up to 35°C during distribution. In terms of sell-by-date evaluation, washed eggs retained class B quality for an additional 37 days beyond the recommended sell-by-date at 15°C, which is above the regulated storage temperature. However, unwashed eggs maintained class B quality for approximately 20 days at 30°C-35°C, emphasizing the need for sell-by-date guidelines for unwashed eggs. This study is the first to provide appropriate egg-handling practices based on the actual distribution environment in Korea.

Specialty impact on residents' perceived quality of life, stress, and job satisfaction: a comparative study.

Purpose: Specialty choice in residency training has a significant impact on an individual's career and satisfaction, as well as the supply-demand imbalance in the healthcare system. The current study aimed to investigate the quality of life (QOL), stress, self-confidence, and job satisfaction of residents, and to explore factors associated with such variables, including postgraduate year, sex, and especially specialty, through a cross-sectional survey. Methods: An online survey was administered to residents at 2 affiliated teaching hospitals. The survey had a total of 46 items encompassing overall residency life such as workload, QOL, stress, confidence, relationship, harassment, and satisfaction. Related survey items were then reconstructed into 4 key categories through exploratory factor analysis for comparison according to group classification. Results: The weekly work hours of residents in vital and other specialties were similar, but residents in vital specialties had significantly more on-call days per month. Residents in vital specialties had significantly lower scores for QOL and satisfaction. Specifically, vital-surgical residents had significantly lower QOL scores and higher stress scores than the other specialty groups. Satisfaction scores were also lowest among vital-surgical residents, with a marginal difference from vital-medical, and a significant difference from other-surgical residents. Female residents had significantly lower satisfaction scores than their male counterparts. Conclusion: Residents in vital specialties, particularly vital-surgical specialties, experience significantly worse working conditions across multiple dimensions. It is necessary to improve not only the quantity but also the quality of the system in terms of resource allocation and prioritization.

Comparison of the virucidal efficacy of essential oils (cinnamon, clove, and thyme) against hepatitis A virus in suspension and on food-contact surfaces.

Essential oils (EOs) have been used for centuries as flavor enhancers in foods, and owing to their antimicrobial properties, they have potential as natural food preservatives. However, their effect on food-borne viruses is unknown. Therefore, in this study, the virucidal effects of three EOs (cinnamon, clove, and thyme) on the infectivity of the hepatitis A virus (HAV) were investigated. Different concentrations of each EO (0.05, 0.1, 0.5, and 1%) were mixed with viral suspensions in accordance with ASTM E1052-11:2011 and incubated for 1 h at room temperature. The EOs exhibited a concentration-dependent effect in the suspension tests, and HAV titers decreased by approximately 1.60 log PFU/mL when treated with EOs at the highest concentration of 1%. The antiviral effect of EOs treated at 1% for 1 h was also evidenced in surface disinfection tests according to the OECD:2013, as approximately 2 log PFU/mL reduction on hard food-contact surfaces (stainless steel and polypropylene) and approximately 2 and 1.4 log PFU/mL reduction on low-density polyethylene and kraft (soft food-contact surfaces), respectively. Moreover, RT-qPCR results revealed that HAV genome copies were negligibly reduced until treated with a high concentration (1%) in suspension and carrier tests. Overall, our findings highlighted the potential of cinnamon, clove, and thyme EOs as natural disinfectants capable of limiting HAV (cross-) contamination conveyed by food-contact surfaces. These findings advance our knowledge of EOs as antimicrobials and their potential in the food sector as alternative natural components to reduce viral contamination and improve food safety.

Educational implications of assessing learning outcomes with multiple choice questions and short essay questions.

PURPOSE: This study investigates the characteristics of different item types to assess learning outcomes and explore the educational implications that can be obtained from the results of learning outcome assessments. METHODS: Forty-five second-year premedical students participated in this study. Multiple choice question (MCQ) and short essay question (SEQ) scores and pass rates for 10 learning outcomes were analyzed. Descriptive statistics and correlation analysis were used to analyze the data. RESULTS: The correlation analysis indicated that there was a significant correlation between SEQs and pass rate but there was no significant correlation between MCQs and pass rate. Some students with identical scores on the MCQs had different scores on the SEQs or on the learning outcomes. CONCLUSION: This study showed that students' achievement of learning outcomes can be assessed using various types of questions in outcome-based education.

Simulation of contamination and elimination of Escherichia coli, Listeria monocytogenes, and Murine norovirus 1 (MNV-1) from the washing process when handling of potatoes.

Root vegetables, which are in close contact with soil, are particularly vulnerable to soil contamination or decay as they can be contaminated from multiple sources, including primary production and processing. This study investigated effective washing conditions to reduce the microbial contamination of potatoes by using soaking and shaking in the washing process. The reduction of Escherichia coli, Listeria monocytogenes, and Murine norovirus 1 (MNV-1) in four washing processes (soaking only, shaking only, combined soaking-shaking I, and combined soaking-shaking I-shaking II) were compared. The numbers of E. coli and L. monocytogenes decreased by 0.55 and 0.49 log CFU/g after shaking only, 1.96 and 1.80 log CFU/g after soaking, 2.07 and 1.67 log CFU/g after soaking-shaking I, and 2.42 and 1.90 log CFU/g after soaking-shaking I-shaking II, respectively. The combined process reduced the microbial contamination more efficiently than shaking only. The reduction of E. coli in the washing process was higher than that of L. monocytogenes by approximately 0.5 logs. MNV-1 showed a reduction in the soaking and shaking steps by 1.34 and 1.98 log GC/100 g, with no significant reduction observed after the combination process. A combined process of soaking-shaking I-shaking II was effective to eliminate E. coli, L. monocytogenes, and MNV-1 from potatoes during the handling and washing process.

Combination of paper membrane-based filtration and ultrafiltration to enhance the detection of MNV, HAV, and HCoV from soil-rich post-washing water.

Risk-assessing and controlling virus transmission from soil-rich post-washing water (PWW) are crucial during harvesting raw vegetables. However, viruses are normally difficult to concentrate because of their low concentrations and complex backgrounds. Here, ultrafiltration (UF), virus adsorption-elution (VIRADEL), and optimized paper filtration-coupled ultrafiltration (PFC-UF) methods were employed to evaluate the recovery of non-enveloped murine norovirus (MNV-1), hepatitis A virus (HAV), and enveloped human coronavirus 229E (HCoV-229E) from soil-rich PWW. Among the three methods, PFC-UF outperformed the other methods in the recovery of viruses from PWW with soil content. Under the highest soil condition with virus seeded at a titer of 102 plaque-forming unit (PFU) or TCID50, the PFC-UF method exhibited an exceedingly consistent recovery rate of 78.8 ± 13.3 (MNV-1) and 44.4 ± 25.2% (HAV). However, the recovery of enveloped HCoV-229E was inferior to non-enveloped viruses. Overall, PFC-UF provided a reliable method for recovering viruses in soil-rich PWW.

The effect of dexmedetomidine and remifentanil on the postoperative sore throat after thyroidectomy.

BACKGROUND: Postoperative sore throat (POST) is an important concern in surgical patients undergoing endotracheal intubation. Its prevalence after thyroidectomy is up to 80%. The current study aimed to assess the effect of dexmedetomidine and remifentanil on postoperative sore throat. METHODS: Seventy-four patients who underwent thyroidectomy were randomized to receive either dexmedetomidine (group D) or remifentanil (group R). At anesthesia induction, group D received dexmedetomidine 1 µg/kg over 10 minutes, followed by continuous dexmedetomidine infusion at 0.3 to 0.6 µg/kg/hour during surgery. Group R received remifentanil of 3 to 4 ng/ml during induction, followed by 1.5 to 2.5 ng/ml remifentanil infusion during surgery. POST at rest and swallowing was assessed during the first 24 hours in serial time periods (0-1, 1-6, and 6-24 hours). Hoarseness and postoperative pain score were also assessed. RESULTS: POST incidence at rest (0-1, 1-6, and 6-24 hours) and swallowing (1-6 and 6-24 hours) was lower in group D than in group R. POST severity was significantly lower in group D than in group R during each time period. The incidence of postoperative hoarseness was also lower in group D than in group R at 1 to 6 and 6 to 24 hours. The postoperative pain score was lower in group D than in group R during each time period. CONCLUSION: Intraoperative dexmedetomidine infusion reduced the incidence and severity of POST for 24 hours after thyroidectomy.

Acute baroreflex-mediated hemodynamic instability during thyroid surgery: A case report.

During thyroid surgery, intraoperative hemodynamic instability can be attributed to episodic surges of thyroid hormones. Thyroid storms are emergency situations characterized by persistent hypertension, tachycardia, hyperthermia, and end-organ damage. However, baroreflex-mediated neurogenic phenomena due to surgical procedures near the carotid sinus are a likely cause of acute hemodynamic changes during thyroid surgery. We describe a case of sudden hemodynamic instability occurring after thyroid manipulation during thyroidectomy in a 61-year-old man who presented with a 6-cm-sized thyroid mass in a euthyroid state.

Development an instrument assessing residents' attitude towards professionalism lapses in training.

PURPOSE: Medical professionalism is a fundamental competency for all physicians and continuous development of professionalism during residency training is crucial. The purpose of this study was to develop an instrument assessing residents' attitudes toward unprofessional behaviors. METHODS: A questionnaire survey was conducted in cooperation with the Korea Resident Association from May to July 2013. A total of 317 residents from seven university-affiliated hospitals in South Korea participated in the survey. RESULTS: In the exploratory factor analysis, seven factors were extracted from the data; factor loadings of the 44 items ranged between 0.40 and 0.89. Through iterative discussion, three items below 0.45 were deleted and one additional item was removed due to its irrelevance. Twelve items included in Factor 1 were divided into two different categories. A final version of the questionnaire containing 40 items in eight categories was assessed using confirmatory factor analysis. It was deemed to have a good fit; the root mean square error of approximation and comparative fit index were 0.07 and 0.9, respectively. The reliability (Cronbach's α) of the inventory was 0.97. CONCLUSION: The items of this instrument encompass a broad range of residents' behaviors in clinical practice, research, and publication. In addition, it includes some types of misconduct that can be considered unique features of the authors' cultural backgrounds. We recommend this instrument as an assessment tool to diagnose residents' perceptions and attitudes towards professionalism lapses and to provide insight regarding potential improvement in professionalism education.

Causes of resident lapses in professional conduct during the training: A qualitative study on the perspectives of residents.

BACKGROUND: The residency is a critical period for doctors to establish their professional identity and ethical standards, and yet during this time, residents are susceptible to engage in a diverse range of unprofessional behaviors. To prevent the misconduct of residents, it is critical to have a thorough understanding of the contributing factors or circumstances. METHODS: We conducted a qualitative study on 20 residents at one Korean university-affiliated tertiary hospital. During in-depth interviews, residents were asked to reveal their experiences or observations of misconduct, and describe their perceptions on the attributes of professional lapses. RESULTS: Diverse unethical and unprofessional behaviors were extracted from the transcripts and reported in a previous paper. In the current paper, the attributes that residents regarded as the causes of their unprofessional behaviors were identified within four categories: (1) inadequate systems within training hospitals; (2) lack of professionalism education; (3) strong hierarchical structure; and (4) poor character of individuals. The residents tended to perceive their misconduct as situation-sensitive, and emphasized the importance of systematic and cultural changes. CONCLUSIONS: To enhance medical professionalism among residents, the results of this study suggest the need of systematic and structured training programs, adequate professionalism education with clear codes of conduct, and active monitoring and feedback systems.

Additive interactions between PRKAA1 polymorphisms and Helicobacter pylori CagA infection associated with gastric cancer risk in Koreans.

Although several studies reported genetic polymorphisms in protein kinase AMP-activated alpha 1 catalytic subunit (PRKAA1) and their associations with gastric cancer risk, few have evaluated associations between Helicobacter pylori infection and PRKAA1 gene-environment interactions. Here, we evaluated the effects of interactions between H. pylori infection and PRKAA1 polymorphisms on gastric cancer risk in Koreans. In this hospital-based case-control study, PRKAA1 genotypes were analyzed and H. pylori infection and CagA status were examined using a serologic method in 846 pairs of gastric cancer patients and controls matched for age and sex. H. pylori seropositivity was associated with a 1.43-fold [95% confidence interval: 1.12-1.81] increase in the risk of gastric cancer, and CagA low-positive titers during H. pylori infection increased the risk by 1.85-fold (95% confidence interval, 1.38-2.48). Significant positive interaction between the PRKAA1 rs13361707 genotype and H. pylori infection was verified on an additive scale [relative excess risk due to interaction, 0.55; 95% confidence interval, 0.05-1.04; P = 0.030], and the gene-environment interaction between PRKAA1 rs13361707 and CagA status was also statistically significant (relative excess risk due to interaction, 0.50; 95% confidence interval, 0.30-0.70; P < 0.001). Our results indicated that H. pylori infection, CagA status, and PRKAA1 polymorphisms were risk factors for gastric cancer in Koreans, and that the combination of two of these factors rather than their independent effects synergistically increased the risk.

Asthma and risk of breakthrough varicella infection in children.

BACKGROUND: We recently reported a more rapid waning of vaccine-induced humoral immunity (measles vaccine) in children with asthma. It is unknown if asthma affects susceptibility to vaccine-preventable diseases. OBJECTIVE: To determine whether asthma is associated with an increased risk of vaccine-preventable disease, e.g., breakthrough varicella infection. METHODS: This was a retrospective population-based case-control study that examined cases of breakthrough varicella among children between 2005 and 2011. Children with a diagnosis of breakthrough varicella infection in Olmsted County, Minnesota (infection of >42 days after vaccination) between 2005 and 2011 and two age- and sex-matched controls were enrolled for each case. Asthma status was determined by using predetermined criteria. Conditional logistic regression models were used to calculate matched odds ratios (OR) and their corresponding 95% confidence intervals (CI). RESULTS: Of the 165 cases and their 330 matched controls, 48% were boys and the mean (standard deviation) age at the index date was 6.6 ± 3.5 years for both cases and controls. Of the 330 controls, 80 (24%) had two doses of the varicella vaccine compared with only 23 (14%) of the 165 cases (OR 0.29 [95% CI, 0.14-0.61]; p = 0.001). Children with a history of asthma ever had a higher risk of developing breakthrough varicella compared with those without a history of asthma (adjusted OR 1.63 [95% CI, 1.04-2.55]; p = 0.032) when adjusting for elapsed time since the first varicella vaccination and the number of varicella vaccine doses. CONCLUSIONS: A history of asthma might be an unrecognized risk factor for breakthrough varicella infection. Children with asthma should follow the two-dose varicella vaccine policy.

Investigation of Unethical and Unprofessional Behavior in Korean Residency Training.

UNLABELLED: PHENOMENON: Medical ethics and professionalism are fundamental competencies for all physicians, and resident physicians have to develop these competencies during their training. Although Korea has a reputation for having the highest quality medical practice in East Asia, improvements in the technological aspects of care have outpaced the developments in institutional systems and education needed to fulfill social responsibility. Enhancing professionalism education during postgraduate training requires thorough exposition of this situation. APPROACH: Twenty residents from 17 clinical departments at 1 Korean tertiary university-affiliated hospital were recruited, and in-depth interviews were conducted in person by an interviewer who was a fellow resident with participants. Interviewees recalled and described personal experiences or observations of misbehaviors that had occurred during their residency training. Researchers recorded and transcribed all interviews, and 4 researchers conducted a thematic analysis. FINDINGS: Authors extracted 48 descriptors representing 8 categories of unethical and unprofessional behaviors from the transcripts: (a) substandard practice, (b) violation of work ethics, (c) misconduct related to conflict of interest, (d) dishonesty with patients, (e) violation of patient confidentiality, (f) lack of respect for patients, (g) lack of respect for colleagues, and (h) misconduct in research. Each of the interviewees mentioned between 3 and 18 descriptors. "Not fulfilling basic duties for patient care" was the most frequently mentioned misconduct, followed by "fabricating patient medical status or test results to meet preoperative criteria for anesthesia" and "verbal or physical abuse of junior doctors." INSIGHTS: Residents reported a diverse variety of unethical and unprofessional behaviors throughout their training and described the ethical distress they suffered in the real clinical situations. The results of this study support the notion that reinforcing ethics and professionalism education during postgraduate medical training in a practical and authentic way will help trainees manage the ethical conflicts or dilemmas they will inevitably encounter.

[Needs assessment of a core curriculum for residency training].

PURPOSE: The core curriculum in graduate medical education (GME) is an educational program that covers the minimum body of knowledge and skills that is required of all residents, regardless of their specialty. This study examined the opinions of stakeholders in GME regarding the core curriculum. METHODS: A questionnaire was administered at three tertiary hospitals that were affiliated with one university; 192 residents and 61 faculty members and attending physicians participated in the survey. The questionnaire comprised six items on physician competency and the needs for a core curriculum. Questions on subjects or topics and adequate training years for each topics were asked only to residents. RESULTS: Most residents (78.6%) and faculty members (86.9%) chose "medical expertise" as the "doctor's role in the 21st century." In contrast, communicator, manager, and collaborator were recognized by less than 30% of all participants. Most residents (74.1%) responded that a core curriculum is "necessary but not feasible," whereas 68.3% of faculty members answered that it is "absolutely needed." Regarding subjects that should be included in the core curriculum, residents and faculty members had disparate preferences- residents preferred more "management of a private clinic" and "financial management," whereas faculty members desired "medical ethics" and "communication skills." CONCLUSION: Residents and faculty members agree that residents should develop a wide range of competencies in their training. However, the perception of the feasibility and opinions on the contents of the core curriculum differed between groups. Further studies with larger samples should be conducted to define the roles and professional competencies of physicians and the needs for a core curriculum in GME.

Nasopharyngeal Carriage Rate and Serotypes of Streptococcus pneumoniae and Antimicrobial Susceptibility in Healthy Korean Children Younger than 5 Years Old: Focus on Influence of Pneumococcal Conjugate Vaccination.

BACKGROUND: Even after pneumococcal vaccination introduction, Streptococcus pneumoniae (pneumoccocus) is still an important cause of respiratory and invasive severe infection. Pneumococcus is resided in nasal mucosa and local or systemic infection begins with the nasal mucosa damage. We studied the indirect effect of pneumococcal conjugate vaccine (PCV) on pneumococcal nasopharyngeal carriage rates, serotypes and antimicrobial susceptibility between vaccinate and non-vaccinated children. MATERIALS AND METHODS: From January 2010 to October 2010, 379 healthy children under 5 years old from three university hospitals were recruited. Fully vaccinated children over 3 time doses of PCV and children with no vaccination history of PCV were enrolled, and nasopharyngeal aspirations were obtained from these children. Serotypes using multibead serotyping assay with multiplex PCR and antimicrobial susceptibility was analyzed. Antimicrobial susceptibilities were determined by the CLIS guideline. RESULTS: Two hundred seventy six children were received pneumococcal vaccination while 103 were not. 137 pneumococci were isolated from nasopharyngeal aspiration specimens. Nasal carriage rate was significantly low in vaccinated group (P-value; 0.001). Nasopharyngeal carriage rate was 28.6% (79/276) in vaccinate group and 56.3% (58/103) in non-vaccinated group. Among those vaccinated group, 13.0% (36/276) of the serotypes were vaccine or vaccine related type with the most common type 19F. In contrast, 31.1% (32/103) of the serotypes in non vaccinated group were vaccine or vaccine related type with the most common type 6A. The resistant rate of penicillin was 90.5%. For antimicrobial susceptibility, amoxicillin and amoxicillin/clavulanate showed high susceptibility (73.0%), but 19F and 19A serotypes were all resistant against amoxicillin. CONCLUSIONS: High nasopharyngeal carriage rate in non vaccinated group corresponded to the result of past study. However, 19F and 19A still came up as problematic serotypes with a high carriage rate and antimicrobial resistance in both vaccinated and non vaccinated groups. Also, this study showed that the resistance rate of primary oral antimicrobial agents was increased in compared to past. For solving these problems, the selective antimicrobial use with establishment of high dose amoxicillin/clavulanate regimen and active PCV immunization should be needed. Furthermore, pneumococcal carriage and serotype study concerning with antimicrobial susceptibility should be conducted in the future in 10 or 13-valent PCV received children.

Polycyclic aromatic hydrocarbon-induced oxidative stress, antioxidant capacity, and the risk of lung cancer: a pilot nested case-control study.

AIM: We conducted a pilot nested case-control study to prospectively evaluate the effects of polycyclic aromatic hydrocarbons (PAH) exposure, antioxidant capacity, and oxidative stress on lung carcinogenesis. MATERIALS AND METHODS: Thirty-five patients with lung cancer and 140 age- and sex-matched controls were selected from a sub-cohort of the Korean Multi-center Cancer Cohort. PAH metabolites (1-hydroxypyrene and 2-naphthol), oxidative stress markers, and total antioxidant capacity (TAC) were assessed using urine samples collected at baseline. RESULTS: The levels of urinary PAH metabolites and oxidative stress were not different between cases and controls. Urinary 1-hydroxypyrene and 2-naphthol levels were significantly associated with urinary oxidative stress markers only in lung cancer cases. Individuals with low urinary TAC and high urinary oxidative stress levels had significantly higher risk of lung cancer compared to those with high urinary TAC and low urinary oxidative stress levels. CONCLUSION: Oxidative stress induced by PAH exposure and TAC may be important determinants for the susceptibility to lung cancer.

Trends analysis on research articles in the korean journal of medical education.

The purpose of this study was to examine the chronological changes and progress in medical education research in Korea and to identify the less investigated topics that need further study and improvement with regard to methodological quality. Of the 590 articles that were published from 1989 to 2010 in the Korean Journal of Medical Education, 386 original research papers were extracted for the analysis. The extracted papers were systematically reviewed using 2 analysis schemes that we developed: one scheme was designed to classify research topics, and the other determined the methodology that was used. The main results were as follows: The most popular research areas were curriculum, educational method, and evaluation in basic medical education; in contrast, studies that addressed postgraduate education, continuous professional development, and educational administration were less frequent; The most frequently studied topics were clinical performance/skills evaluation, clerkship, curriculum development, and problem-based learning, Quantitative studies predominated over qualitative studies and mixed methods (265 vs. 95 vs. 26). Two hundred forty papers were descriptive, cross-sectional studies, and 17 were experimental studies. Most qualitative studies were non-participation observational studies. In conclusion, there has been dramatic growth in the extent of medical education research in Korea in the past two decades. However, more studies that investigate the graduate medical education and the continuous professional development should be performed. Moreover, robust experimental designs and methods should be applied to provide stronger evidence that can practice best-evidence medical education.