Teaching clinical reasoning: principles from the literature to help improve instruction from the classroom to the bedside.

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.

Exploring 40 years of Korean medical education conference themes.

PURPOSE: The Korean Society of Medical Education (KSME) was founded in 1983 and celebrated its 40th anniversary in 2023. This study examines the evolution of topics discussed at KSME conferences from 1971 through 2023, highlighting shifts in the focus of medical education. METHODS: We analyzed 90 KSME conferences over 5 decades (1970s, 1980s, 1990s, 2000s, and 2010s), categorizing the topics into three eras based on emerging themes and continuity. RESULTS: Consequently, 37 topics covered at the conference were categorized. Ten topics continuously appeared from the 1970s to the 2010s, including future directions of medical education, teaching methods, faculty development, and curriculum. The topics from the 1970s to the 1990s included 14 areas, such as medical education evaluation, non-undergraduate curriculum, community-related, and research. Thirteen new topics emerged after the 2000s, such as social accountability, student support, professionalism, and quality improvements. The most common topics under innovations in medical education, a case of curriculum innovation at universities that began after 2000, were clinical clerkship, curriculum development, and medical humanities. CONCLUSION: KSME's selection of conference topics has been strategically aligned with societal needs and the evolving landscape of medical education. Future topics should continue to address relevant societal and educational challenges.

Biocompatible Electronic Skins for Cardiovascular Health Monitoring.

Cardiovascular diseases represent a significant threat to the overall well-being of the global population. Continuous monitoring of vital signs related to cardiovascular health is essential for improving daily health management. Currently, there has been remarkable proliferation of technology focused on collecting data related to cardiovascular diseases through daily electronic skin monitoring. However, concerns have arisen regarding potential skin irritation and inflammation due to the necessity for prolonged wear of wearable devices. To ensure comfortable and uninterrupted cardiovascular health monitoring, the concept of biocompatible electronic skin has gained substantial attention. In this review, biocompatible electronic skins for cardiovascular health monitoring are comprehensively summarized and discussed. The recent achievements of biocompatible electronic skin in cardiovascular health monitoring are introduced. Their working principles, fabrication processes, and performances in sensing technologies, materials, and integration systems are highlighted, and comparisons are made with other electronic skins used for cardiovascular monitoring. In addition, the significance of integrating sensing systems and the updating wireless communication for the development of the smart medical field is explored. Finally, the opportunities and challenges for wearable electronic skin are also examined.

Analyzing the characteristics of mission statements in Korean medical schools based on the Korean Doctor's Role framework.

PURPOSE: This study assessed the alignment between Korean medical schools' mission statements (MSs) and Korean Doctor's Role (KDR) domains, considering school characteristics. METHODS: We analyzed the South Korean medical school's MS characteristics using a mixed-methods approach. Quantitative analysis preprocessed MS text data to identify concept words, while qualitative content analysis categorized information into predefined KDR domains and extracted themes from other parts. RESULTS: At the KDR domain level, "social accountability" was the most frequent, followed by "education and research" and "patient care," while "professionalism" had the least frequency. At the competency level, the most frequent domains were "involvement in public and global health initiatives," while "self-regulation based on professional leadership" and "professionalism and self-management" were not present. CONCLUSION: The study found that the majority of MSs had a homogeneous pattern and included traditional themes. Medical schools should evaluate and incorporate missing elements in their MSs to reflect the institution's own purpose and current societal needs.

Ultrafast underwater self-healing piezo-ionic elastomer via dynamic hydrophobic-hydrolytic domains.

The development of advanced materials capable of autonomous self-healing and mechanical stimulus sensing in aquatic environments holds great promise for applications in underwater soft electronics, underwater robotics, and water-resistant human-machine interfaces. However, achieving superior autonomous self-healing properties and effective sensing simultaneously in an aquatic environment is rarely feasible. Here, we present an ultrafast underwater molecularly engineered self-healing piezo-ionic elastomer inspired by the cephalopod's suckers, which possess self-healing properties and mechanosensitive ion channels. Through strategic engineering of hydrophobic C-F groups, hydrolytic boronate ester bonds, and ions, the material achieves outstanding self-healing efficiencies, with speeds of 94.5% (9.1 µm/min) in air and 89.6% (13.3 µm/min) underwater, coupled with remarkable pressure sensitivity (18.1 kPa-1) for sensing performance. Furthermore, integration of this mechanosensitive device into an underwater submarine for signal transmission and light emitting diode modulation demonstrates its potential for underwater robotics and smarter human-machine interactions.

TP53 mutation is frequent in mantle cell lymphoma with EZH2 expression and have dismal outcome when both are present.

Enhancer of zeste homolog 2 (EZH2) expression is found in about 40% of mantle cell lymphoma (MCL) patients, which is associated with aggressive histology, high Ki-67 proliferation rate, p53 mutant pattern and inferior overall survival (OS). We conducted 11-gene (ATM, BIRC3, CCND1, KMT2C, KMT2D, NOTCH1, NOTCH2, RB1, TP53, TRAF2 and UBR5) next generation sequencing panel to shed more light on MCL with EZH2 expression (EZH2+ MCL). EZH2+ MCL more frequently harbor TP53 mutation compared to EZH2(-) MCL (41.2% vs. 19.1%, respectively, p = 0.045). TP53 mutation and EZH2 expression demonstrated overlapping features including aggressive histology, high Ki-67 proliferation rate and p53 mutant pattern by immunohistochemistry. Comparative analysis disclosed that EZH2 expression correlates with high Ki-67 proliferation rate irrespective of TP53 mutation. Aggressive histology is associated with EZH2 expression or TP53 mutation, possibly via independent mechanisms. p53 mutant pattern is due to TP53 mutation. MCL patients with EZH2 expression or TP53 mutation show inferior outcome and when both are present, patients have dismal outcome.

Acute myeloid leukemia with mast cell differentiation is characterized by interstitial mast cells, complex karyotype, TP53 alterations and poor prognosis.

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Highly conductive, conformable ionic laser-induced graphene electrodes for flexible iontronic devices.

Iontronic devices, recognized for user-friendly soft electronics, establish an electrical double layer (EDL) at the interface between ion gels and electrodes, significantly influencing device performance. Despite extensive research on ion gels and diverse electrode materials, achieving a stable interfacial formation remains a persistent challenge. In this work, we report a solution to address this challenge by employing CO2 irradiation as a bottom-up methodology to directly fabricate highly conductive, conformable laser-induced graphene (LIG) electrodes on a polyimide (PI)-based ion gel. The PI ion gel exhibits exceptional EDL formation at the electrode interface, primarily attributable to efficient ion migration. Particularly, ionic laser-induced graphene (i-LIG) electrodes, derived from the PI ion gel as a precursor, yield high-quality graphene with enhanced crystallinity and an expanded porous structure in the upward direction. This outcome is achieved through a pronounced thermal transfer effect and intercalation phenomenon between graphene layers, facilitated by the presence of ionic liquids (ILs) within the PI ion gel. Ultimately, in comparison to alternative soft electrode-based vertical capacitors, the utilization of i-LIGs and PI ion gels in the vertical capacitor demonstrates reduced interfacial resistance and increased EDL capacitance, emphasizing the extensive potential of iontronic devices. These results not only highlight these features but also introduce a new perspective for advancing next-generation iontronic devices.

The hidden hurdles of clinical clerkship: unraveling the types and distribution of professionalism dilemmas among South Korean medical students.

BACKGROUND: To improve the medical professionalism of medical students, it is essential to understand the dilemmas they face in various situations. This study explored the types and distribution of dilemmas Korean medical students encounter during their clinical clerkships. It then compared these with previous dilemma frameworks and identified the types and distribution of "complexity dilemmas," wherein two dilemma themes emerge in a single clinical situation. METHODS: The researchers organized and recorded a group discussion with 106 third-year medical students who had completed their clinical clerkships. These students participated in the discussion as part of an assignment, focusing on the dilemmas they encountered during their clerkships. For data analysis and visualization, the researchers employed the MAXQDA software program and utilized the template analysis method, a qualitative research methodology. RESULTS: A total of seven dilemma themes and sixteen sub-themes were identified. The identity-related dilemma concerning student-doctors had the highest frequency. The themes "mismatch" and "Nun-chi" emerged as new additions not found in previous dilemma frameworks. The complexity dilemmas appeared in the sequence of "identity-dignity," "identity-abuse," and "identity-consent". CONCLUSIONS: To navigate the unique dilemmas present within South Korea's clinical culture, several key issues need consideration: elevating the role of student-doctors, balancing the primary emphasis of educational hospitals on delivering medical services, and understanding interpersonal strategies, such as "Nun-chi".

Phase Electronic Structure Tuning via Pt, P-Doped Ni4 Mo-Implanted Ti4 O7 for Highly Efficient Water Splitting and Mg/Seawater Batteries.

Fine-tuning nanoscale structures, morphologies, and electronic states are crucial for creating efficient water-splitting electrocatalysts. In this study, a method for electronic structure engineering to enhance overall water splitting in a corrosion-resistant electrocatalyst matrix by integrating Pt, P dual-doped Ni4 Mo electrocatalysts onto a Ti4 O7 nanorod grown on carbon cloth (Pt, P-Ni4 Mo-Ti4 O7 /CC) is introduced. By optimizing platinum and phosphorus concentrations to 1.18% and 2.42%, respectively, low overpotentials are achieved remarkably: 24 mV at 10 mA cm-2 for the hydrogen evolution reaction and 290 mV at 20 mA cm-2 for the oxygen evolution reaction in 1.0 m KOH. These values approach or surpass those of benchmark Pt-C and IrO2 catalysts. Additionally, the Pt, P-Ni4 Mo-Ti4 O7 /CC bifunctional electrocatalyst displays low cell potentials across various mediums, maintaining excellent current retention (96% stability after 40 h in mimic seawater at 20 mA cm-2 ) and demonstrating strong corrosion resistance and suitability for seawater  electrolysis. As a cathode in magnesium/seawater batteries, it achieves a power density of 7.2 mW cm-2 and maintains stability for 100 h. Density functional theory simulations confirm that P, Pt doping-assisted electronic structure modifications augment electrical conductivity and active sites in the hybrid electrocatalysts.

Novel bioequivalent oral disintegrating tablet of aripiprazole prepared by direct compression technique with shortened disintegration time.

Herein, we aimed to formulate a novel oral disintegrating tablet (ODT) of aripiprazole (ARP) capable of rapid disintegration using a direct compression technique. Different ODTs were fabricated with directly compressible excipients, and their disintegration time, wettability (water absorption ratio and wetting time), and mechanical properties (hardness and friability) were evaluated. The optimized ODT comprised F-Melt® type C, Prosolv® SMCC HD90, and Na croscarmellose (10 mg of ARP in a 130 mg tablet). The ODT with 3.1-5.2 kp hardness exhibited rapid disintegration (14.1-17.2 sec), along with appropriate mechanical strength (friability < 0.24%). In a bioequivalent study in Korean healthy subjects (randomized, single-dose, two-period crossover design, n = 37), the novel ODT offered the equivalent pharmacokinetic profile to that of a conventional immediate release tablet (Otsuka, Abilify®, Japan), despite different disintegration and dissolution profiles. The 90% confidence intervals of the geometric mean test to reference ratios considering the area-under-the-curve and maximum plasma drug concentrations were 1.0306-11051 and 0.9448-1.1063, respectively, satisfying FDA regulatory criteria for bioequivalence. The novel ART ODT was physicochemically stable under the accelerated storage condition (40 °C, RH75%) for 24 weeks. Therefore, the novel ARP-loaded ODT is expected to be an alternative to oral ARP therapy, providing improved patient adherence.

Low-Cost Hydrogen Production from Alkaline/Seawater over a Single-Step Synthesis of Mo3 Se4 -NiSe Core-Shell Nanowire Arrays.

The rational design and steering of earth-abundant, efficient, and stable electrocatalysts for hydrogen generation is highly desirable but challenging with catalysts free of platinum group metals (PGMs). Mass production of high-purity hydrogen fuel from seawater electrolysis presents a transformative technology for sustainable alternatives. Here, a heterostructure of molybdenum selenide-nickel selenide (Mo3 Se4 -NiSe) core-shell nanowire arrays constructed on nickel foam by a single-step in situ hydrothermal process is reported. This tiered structure provides improved intrinsic activity and high electrical conductivity for efficient charge transfer and endows excellent hydrogen evolution reaction (HER) activity in alkaline and natural seawater conditions. The Mo3 Se4 -NiSe freestanding electrodes require small overpotentials of 84.4 and 166 mV to reach a current density of 10 mA cm-2 in alkaline and natural seawater electrolytes, respectively. It maintains an impressive balance between electrocatalytic activity and stability. Experimental and theoretical calculations reveal that the Mo3 Se4 -NiSe interface provides abundant active sites for the HER process, which modulate the binding energies of adsorbed species and decrease the energetic barrier, providing a new route to design state-of-the-art, PGM-free catalysts for hydrogen production from alkaline and seawater electrolysis.

Manganese-Doped Bimetallic (Co,Ni)2P Integrated CoP in N,S Co-Doped Carbon: Unveiling a Compatible Hybrid Electrocatalyst for Overall Water Splitting.

Rational design of highly efficient noble-metal-unbound electrodes for hydrogen and oxygen production at increased current density is crucial for robust water-splitting. A facile hydrothermal and room-temperature aging method is presented, followed by chemical vapor deposition (CVD), to create a self-sacrificed hybrid heterostructure electrocatalyst. This hybrid material, (Mn-(Co,Ni)2P/CoP/(N,S)-C), comprises manganese-doped cobalt nickel phosphide (Mn-(Co,Ni)2P) nanofeathers and cobalt phosphide (CoP) nanocubes embedded in a nitrogen and sulfur co-doped carbon matrix (N,S)-C on nickel foam. The catalyst exhibits excellent performance in both the hydrogen evolution reaction (HER; η10 = 61 mV) and oxygen evolution reaction (OER; η10 = 213 mV) due to abundant active sites, high porosity, and enhanced hetero-interface interaction between Mn-(Co2P-Ni2P) CoP, and (N,S)-C supported by significant synergistic effects observed among different phases through density functional theory (DFT) calculations. Impressively, (Mn-(Co,Ni)2P/CoP/(N,S)-C (+,-) shows an extra low cell voltage of 1.49 V@10 mA cm-2. Moreover, the catalyst exhibits remarkable stability at 100 and 300 mA cm-2 when operating as a single stack cell electrolyzer. The superior electrochemical activity is attributed to the enhanced electrode-electrolyte interface among the multiple phases of the hybrid structure.

Highly Reliable 3D Channel Memory and Its Application in a Neuromorphic Sensory System for Hand Gesture Recognition.

Brain-inspired neuromorphic computing systems, based on a crossbar array of two-terminal multilevel resistive random-access memory (RRAM), have attracted attention as promising technologies for processing large amounts of unstructured data. However, the low reliability and inferior conductance tunability of RRAM, caused by uncontrollable metal filament formation in the uneven switching medium, result in lower accuracy compared to the software neural network (SW-NN). In this work, we present a highly reliable CoOx-based multilevel RRAM with an optimized crystal size and density in the switching medium, providing a three-dimensional (3D) grain boundary (GB) network. This design enhances the reliability of the RRAM by improving the cycle-to-cycle endurance and device-to-device stability of the I-V characteristics with minimal variation. Furthermore, the designed 3D GB-channel RRAM (3D GB-RRAM) exhibits excellent conductance tunability, demonstrating high symmetricity (624), low nonlinearity (ßLTP/ßLTD ∼ 0.20/0.39), and a large dynamic range (Gmax/Gmin ∼ 31.1). The cyclic stability of long-term potentiation and depression also exceeds 100 cycles (105 voltage pulses), and the relative standard deviation of Gmax/Gmin is only 2.9%. Leveraging these superior reliability and performance attributes, we propose a neuromorphic sensory system for finger motion tracking and hand gesture recognition as a potential elemental technology for the metaverse. This system consists of a stretchable double-layered photoacoustic strain sensor and a crossbar array neural network. We perform training and recognition tasks on ultrasonic patterns associated with finger motion and hand gestures, attaining a recognition accuracy of 97.9% and 97.4%, comparable to that of SW-NN (99.8% and 98.7%).

Ions-Silica Percolated Ionic Dielectric Elastomer Actuator for Soft Robots.

Soft robotics systems are currently under development using ionic electroactive polymers (i-EAP) as soft actuators for the human-machine interface. However, this endeavor has been impeded by the dilemma of reconciling the competing demands of force and strain in i-EAP actuators. Here, the authors present a novel design called "ions-silica percolated ionic dielectric elastomer (i-SPIDER)", which exhibits ionic liquid-confined silica microstructures that effectively resolve the chronic issue of conventional i-EAP actuators. The i-SPIDER actuator demonstrates remarkable electromechanical conversion capacity at low voltage, thanks to improved ion accumulation facilitated by interpreting electrode polarization at the electrolyte-electrode interface. This approach concurrently enhances both strain (by approximately 1.52%) and force (by roughly 1.06 mN) even at low Young's modulus (merely 5.9 MPa). Additionally, by demonstrating arachnid-inspired soft robots endowed with user-desired tasks through control of various form factors, the development of soft robots using the i-SPIDER that can concomitantly enhance strain and force holds promise as a compelling avenue for ushering in the next generation of miniaturized, low-powered soft robotics.

Trimetallic Oxide Electrocatalyst for Enhanced Redox Activity in Zinc-Air Batteries Evaluated by In Situ Analysis.

Researchers are investigating innovative composite materials for renewable energy and energy storage systems. The major goals of this studies are i) to develop a low-cost and stable trimetallic oxide catalyst and ii) to change the electrical environment of the active sites through site-selective Mo substitution. The effect of Mo on NiCoMoO4 is elucidated using both in situ X-ray absorption spectroscopy and X-ray diffraction analysis. Also, density functional theory strategies show that NiCoMoO4 has extraordinary catalytic redox activity because of the high adsorption energy of the Mo atom on the active crystal plane. Further, it is demonstrated that hierarchical nanoflower structures of NiCoMoO4 on reduced graphene oxide can be employed as a powerful bifunctional electrocatalyst for oxygen reduction/evolution reactions in alkaline solutions, providing a small overpotential difference of 0.75 V. Also, Zn-air batteries based on the developed bifunctional electrocatalyst exhibit outstanding cycling stability and a high-power density of 125.1 mW cm-2 . This work encourages the use of Zn-air batteries in practical applications and provides an interesting concept for designing a bifunctional electrocatalyst.

Ion trap and release dynamics enables nonintrusive tactile augmentation in monolithic sensory neuron.

An iontronic-based artificial tactile nerve is a promising technology for emulating the tactile recognition and learning of human skin with low power consumption. However, its weak tactile memory and complex integration structure remain challenging. We present an ion trap and release dynamics (iTRD)-driven, neuro-inspired monolithic artificial tactile neuron (NeuroMAT) that can achieve tactile perception and memory consolidation in a single device. Through the tactile-driven release of ions initially trapped within iTRD-iongel, NeuroMAT only generates nonintrusive synaptic memory signals when mechanical stress is applied under voltage stimulation. The induced tactile memory is augmented by auxiliary voltage pulses independent of tactile sensing signals. We integrate NeuroMAT with an anthropomorphic robotic hand system to imitate memory-based human motion; the robust tactile memory of NeuroMAT enables the hand to consistently perform reliable gripping motion.

Passivity, task segmentation, and relational capital: a study of interpersonal relationship formation among freshman medical students in team-based activities.

PURPOSE: Team-based learning in medical education facilitates the formation of interpersonal relationships, enhances academic achievement, and establishes future clinical connections. Despite medical schools' distinct educational environments and curricula, research investigating students' learning and behavioral characteristics within this context remains limited. This study aimed to investigate the specific characteristics of interpersonal relationship formation among freshmen medical students in team-based learning activities. METHODS: Focus group interviews were conducted with 11 students who participated in a team-based class held during the first semester of the premedical year. RESULTS: Medical students passively expressed their thoughts and feelings, such as active sympathy for the team's opinions and self-censorship of SNS (social networking service) conversations. When performing team activities, students were excessively conscious of others and focused on evenly dividing their work, minimizing their opinions, and fulfilling their share to prevent potential interpersonal conflicts. Interpersonal activities were only superficial, as students intentionally maintained a certain distance from team members or used team activities as an opportunity to accumulate relational capital. CONCLUSION: The results of this study are expected to provide a useful basis for designing and conducting team activity classes to enhance interpersonal relationship formation.

Exciton-Scissoring Perfluoroarenes Trigger Photomultiplication in Full Color Organic Image Sensors.

An unprecedented but useful functionality of perfluoroarenes to enable exciton scissoring in photomultiplication-type organic photodiodes (PM-OPDs) is reported. Perfluoroarenes that are covalently connected to polymer donors via a photochemical reaction enable the demonstration of high external quantum efficiency and B-/G-/R-selective PM-OPDs without the use of conventional acceptor molecules. The operation mechanism of the suggested perfluoroarene-driven PM-OPDs, how covalently bonded polymer donor:perfluoroarene PM-OPDs can perform as effectively as polymer donor:fullerene blend-based PM-OPDs, is investigated. By employing a series of arenes and conducting steady-state/time-resolved photoluminescence and transient absorption spectroscopy analyses, it is found that interfacial band bending between the perfluoroaryl group and polymer donor is responsible for exciton scissoring and subsequent electron trapping, which induces photomultiplication. Owing to the acceptor-free and covalently interconnected photoactive layer in the suggested PM-OPDs, superior operational and thermal stabilities are observed. Finally, finely patterned B-/G-/R-selective PM-OPD arrays that enable the construction of highly sensitive passive matrix-type organic image sensors are demonstrated.

Implantable Multi-Cross-Linked Membrane-Ionogel Assembly for Reversible Non-Faradaic Neurostimulation.

Neural interfaces play a major role in modulating neural signals for therapeutic purposes. To meet the demand of conformable neural interfaces for developing bioelectronic medicine, recent studies have focused on the performance of electrical neurostimulators employing soft conductors such as conducting polymers and electronic or ionic conductive hydrogels. However, faradaic charge injection at the interface of the electrode and nerve tissue causes irreversible gas evolution, oxidation of electrodes, and reduction of biological ions, thus causing undesired tissue damage and electrode degradation. Here we report a conformable neural interface engineering based on multicross-linked membrane-ionogel assembly (termed McMiA), which enables nonfaradaic neurostimulation without irreversible charge transfer reaction. The McMiA consists of a genipin-cross-linked biopolymeric ionogel coupled with a dopamine-cross-linked graphene oxide membrane to prevent ion exchange between biological and synthetic McMiA ions and to function as a bioadhesive forming covalent bonds with the target tissues. In addition, the demonstration of bioelectronic medicine via the McMiA-based neurostimulation of sciatic nerves shows the enhanced clinical utility in treating the overactive bladder syndrome. As the McMiA-based neural interface is soft, robust for bioadhesion, and stable in a physiological environment, it can offer significant advancement in biocompatibility and long-term operability for neural interface engineering.