Evaluating Clinical Reasoning in Undergraduate Medical Education: The Value of a Virtual Oral Assessment.

BACKGROUND: Oral assessments are essential components of board certification in numerous fields, as they provide insight into problem-solving capacity and clinical reasoning. The development of clinical reasoning often begins in undergraduate medical education and remains a challenge to assess. OBJECTIVE: We developed a pilot oral assessment to evaluate medical student oral presentations and systematically assess clinical reasoning. This was incorporated into a previously existing cumulative assessment at the conclusion of the third year of medical school, with the intent to demonstrate feasibility and future reliability of this exam format. METHODS: This pilot oral assessment was developed using content taught during third year clerkships. A modified Assessment of Reasoning Tool (ART) was used as the evaluation metric. It was conducted virtually to include faculty members from multiple disciplines and accommodate schedules and space limitations. RESULTS: A total of 152 third year medical students completed the exam, with a total of 15 faculty examiners. 89% of medical students scored as complete in hypothesis directed history, 93% in problem representation, 86% in prioritized differential diagnoses, and 67% in effectively directing management. Most examiners felt an oral assessment is effective to determine a medical student's clinical reasoning ability. CONCLUSIONS: Virtual oral assessments of clinical reasoning can be incorporated in undergraduate medical education to identify students struggling with components of clinical reasoning, while also allowing maximum flexibility for the clinician educator workforce as examiners. Longitudinal use of these exams would be valuable to track the development of clinical reasoning across the medical school curriculum.

Cheiloscopy: A crucial technique in forensics for personal identification and its admissibility in the Court of Justice.

In every criminal inquiry, identification is of utmost importance. Cheiloscopy is a technique used in forensic investigation that focuses on identifying people from their lip prints. Just like fingerprints, each person's lip crease pattern is unique. Moreover, Lip prints are seen to remain consistent throughout an individual's life. Lip prints can therefore be used to confirm if a person was at the crime scene or not. Cheiloscopy is used to examine the sulci labiorum, or "lip prints," which are the wrinkling and furrows on the labial mucosa that produce a distinctive pattern. The current review article focuses on the potential of cheiloscopy as a vital role player in the process of criminal investigation by detecting and identifying individual(s).

Development of the Patient Scale of the Patient and Observer Scar Assessment Scale (POSAS) 3.0: a qualitative study.

PURPOSE: The Patient and Observer Scar Assessment Scale (POSAS) is widely used for measurements of scar quality. This encompasses visual, tactile and sensory characteristics of the scar. The Patient Scale of previous POSAS versions was lacking input from patients. Therefore, the aim of this study was to develop the POSAS3.0, Patient Scale with involvement of adults patients with all scar types, complying with the highest clinimetric standards. METHODS: From February 2018 to April 2019, a series of six focus group interviews were performed in the Netherlands and Australia to identify scar quality characteristics that adults with scars consider to be important. All focus groups were transcribed, anonymized and analysed using a thematic analysis. Relevant characteristics were formulated into items, resulting in a Dutch and English version of the Patient Scale. These drafts were pilot tested in Australia, the Netherlands and the United Kingdom, and refined accordingly. RESULTS: A total of 21 relevant scar quality characteristics were identified during the focus groups. Two distinct versions of the POSAS3.0, Patient Scale were developed. The Generic version contains 16 items and can be used for all scar types, except linear scars. The Linear Scar version of the Patient Scale contains the same 16 items, with an extra item referring to the widening of scar margins. All included items are rated on a verbal rating scale with five response options. CONCLUSION: Two versions of the POSAS3.0 Patient Scale were developed. Further field tests are being performed to establish the measurement properties and scoring algorithm of the scales.

Monochrome computer vision for detecting common external defects of mango.

Lack of rapid, non-destructive, and precision sorting and grading automatic tools for quality and safety assurance of mango fruit, in India, limits its share in the global market (< 1%) despite being the world's largest producer. External defects on the surface of mango fruit are very common and a major cause of quality deterioration as well as degradation of market value. The goal of this work is, thus, to develop a computer vision system for defect detection of mangoes using monochrome cameras and to check its potential for detecting the defect. Considering the above facts an algorithm was developed and its performance was evaluated based on accuracy, efficiency, and average inspection time. The average accuracy and efficiency of the developed algorithm for defect detection was obtained as 88.75% and 97.88%, respectively. Monochrome computer vision systems are very successful and have great potential to detect various common external defects such as a black lesions, mechanical damage, etc. SUPPLEMENTARY INFORMATION: The online version of this article (10.1007/s13197-020-04939-9) contains supplementary material, which is available to authorized users.

Foam stability in filtered lubricants containing antifoams.

Lubricant formulations are filtered to remove deleterious particulate matter. An unintended consequence of this important process is the detrimental effect of fine filtration on the foaming performance of lubricants with antifoam additives. Here we outline a method to study this phenomenon in detail by probing the coalescence stability of single bubbles in filtered antifoam laden lubricants. Initially, we establish the validity of Garrett's hypothesis for the tested antifoam laden lubricants. Subsequently, we show that the bubble stability in filtered lubricants are positively correlated to the number of filtration cycles - with the most dramatic changes in bubble stability accompanying the initial few cycles of filtration. Further, we show that post filtration, the stability of bubbles in lubricants is inversely correlated to the pore size of the filter and the volume fraction of antifoam in the lubricant prior to filtration. The results also reveal that in the presence of antifoam additives, the bubble coalescence times span multiple Rayleigh distributions. We also provide visual evidence that shows the tested antifoams employ a bridging-stretching mechanism to rupture non-aqueous foams. Finally, a simple probabilistic model is introduced that helps in analyzing the distribution of coalescence times of single bubbles to obtain insights into the volume fraction of antifoams in the lubricant. We believe these results are valuable in guiding the design of lubricants with robust and superior foaming performance.

Modeling the solid-to-plasma transition for laser imprinting in direct-drive inertial confinement fusion.

Laser imprinting possesses a potential danger for low-adiabat and high-convergence implosions in direct-drive inertial confinement fusion (ICF). Within certain direct-drive ICF schemes, a laser picket (prepulse) is used to condition the target to increase the interaction efficiency with the main pulse. Whereas initially the target is in a solid state (of ablators such as polystyrene) with specific electronic and optical properties, the current state-of-the-art hydrocodes assume an initial plasma state, which ignores the detailed plasma formation process. To overcome this strong assumption, a model describing the solid-to-plasma transition, eventually aiming at being implemented in hydrocodes, is developed. It describes the evolution of main physical quantities of interest, including the free electron density, collision frequency, absorbed laser energy, temperatures, and pressure, during the first stage of the laser-matter interaction. The results show that a time about 100 ps is required for the matter to undergo the phase transition, the initial solid state thus having a notable impact on the subsequent plasma dynamics. The nonlinear absorption processes (associated to the solid state) are also shown to have an influence on the thermodynamic quantities after the phase transition, leading to target deformations depending on the initial solid state. The negative consequences for the ICF schemes consist in shearing of the ablator and possibly preliminary heating of the deuterium-tritium fuel.

Experimental evidence on promotion of electric and improved biomass cookstoves.

Improved cookstoves (ICS) can deliver "triple wins" by improving household health, local environments, and global climate. Yet their potential is in doubt because of low and slow diffusion, likely because of constraints imposed by differences in culture, geography, institutions, and missing markets. We offer insights about this challenge based on a multiyear, multiphase study with nearly 1,000 households in the Indian Himalayas. In phase I, we combined desk reviews, simulations, and focus groups to diagnose barriers to ICS adoption. In phase II, we implemented a set of pilots to simulate a mature market and designed an intervention that upgraded the supply chain (combining marketing and home delivery), provided rebates and financing to lower income and liquidity constraints, and allowed households a choice among ICS. In phase III, we used findings from these pilots to implement a field experiment to rigorously test whether this combination of upgraded supply and demand promotion stimulates adoption. The experiment showed that, compared with zero purchase in control villages, over half of intervention households bought an ICS, although demand was highly price-sensitive. Demand was at least twice as high for electric stoves relative to biomass ICS. Even among households that received a negligible price discount, the upgraded supply chain alone induced a 28 percentage-point increase in ICS ownership. Although the bundled intervention is resource-intensive, the full costs are lower than the social benefits of ICS promotion. Our findings suggest that market analysis, robust supply chains, and price discounts are critical for ICS diffusion.

Potential of reflected UV imaging technique for detection of defects on the surface area of mango.

Surface defects such as mechanical damage, black lesion, latex stains and shriveling of mango fruit are very common and responsible for lowering of market prices as well as postharvest losses. Current research, thus, focused on the study of reflected ultraviolet imaging (UV) technique, its potential of detecting defected mangoes and to develop a computer vision system which could find the reflected area on injured or defected mango's surface. The visual visualization of the bruised areas was noticed different when viewed under 15 W fluorescent UV tube (100-400 nm) light by UV camera. Hidden defects on fruit's surface detected just after the image acquisition by UV camera and brightness enhancement. Defected or injured surface of mangoes recognized easily by reflected UV imaging at 400 nm band-pass filter. The seriousness of injuries which were not detected by RGB color camera, detected by reflected UV imaging technique exactly.

Evaporation-induced foam stabilization in lubricating oils.

Foaming in liquids is ubiquitous in nature. Whereas the mechanism of foaming in aqueous systems has been thoroughly studied, nonaqueous systems have not enjoyed the same level of examination. Here we study the mechanism of foaming in a widely used class of nonaqueous liquids: lubricant base oils. Using a newly developed experimental technique, we show that the stability of lubricant foams can be evaluated at the level of single bubbles. The results obtained with this single-bubble technique indicate that solutocapillary flows are central to lubricant foam stabilization. These solutocapillary flows are shown to originate from the differential evaporation of multicomponent lubricants-an unexpected result given the low volatility of nonaqueous liquids. Further, we show that mixing of some combinations of different lubricant base oils, a common practice in the industry, exacerbates solutocapillary flows and hence leads to increased foaming.

Attitude of Indian Medical Students Towards Homosexuality.

INTRODUCTION: It is important to understand the attitude of medical students towards homosexuality, as this may affect patient care. METHODS: Year 2 and 3 students at Calcutta National Medical College, Kolkata, India were asked to selfadminister an 18-item questionnaire anonymously. Internal consistency of the questionnaire statements was high (Cronbach's alpha of 0.91). There were five responses for each statement: strongly agree, generally agree, unsure, generally disagree, and strongly disagree. RESULTS: Of 290 students, 270 (93.1%) [148 males and 122 females] completed the questionnaire and were included in the analysis. Overall, 55.6% strongly disagreed that homosexuality was an illness; 70.8% agreed that homosexuals were capable of forming stable relationships. Only 31.1% believed that homosexual doctors would better understand homosexual patients. About 71.8% reported that talking about homosexuality did not embarrass them, and 81.8% believed that problems associated with homosexuality could be reduced if society was more liberal. Nonetheless, negative attitudes were reflected in the stereotypical image of homosexuality. About 15.9% of respondents believed that homosexuality was an illness; 24.8% considered homosexuals neurotic, 28.1% considered homosexuals promiscuous; and 8.2% thought that they posed a danger to children. CONCLUSION: Although the overall attitude of Indian medical students towards homosexuality is positive, the percentage of students with negative attitudes remains quite high. Further work on the medical curriculum is needed to change these negative attitudes so that patients receive appropriate care.

Facility disparities in reporting comorbidities to the National Trauma Data Bank.

BACKGROUND: The National Trauma Data Bank (NTDB) includes patient comorbidities. This study evaluates factors of trauma centers associated with higher rates of missing comorbidity data. METHODS: Proportions of missing comorbidity data from facilities in the NTDB from 2011 to 2014 were evaluated for associations with facility characteristics. Proportional impact analysis was performed to identify potential policy targets. RESULTS: Of 919 included facilities, 85% reported comorbidity data in 95% or more cases; only 31.3% were missing no data. Missing rates were significantly different based on most facility categories, but independently associated only with hospital size, region, and trauma center level. Only 15% of centers were responsible for over 80% of cases missing data. CONCLUSIONS: There is significant nonrandom variation in reporting trauma patient comorbidities to the NTDB. Missing data needs to be recognized and considered in studies of trauma comorbidities. Targeted intervention may improve data quality.

Prone Positioning of the Burn Patient With Acute Respiratory Distress Syndrome: A Review of the Evidence and Practical Considerations.

Acute respiratory distress syndrome (ARDS) is a common sequela of severe burns and inhalation injury. The massive inflammatory reaction that follows deep burn injury, compounded by episodes of sepsis and organ dysfunction, predisposes patients to the development of ARDS. Prone positioning as a means of improving gas exchange has shown benefit in refractory cases of ARDS, but it is not well described in the burn population. We present a case report of a patient with severe ARDS who underwent prone positioning, review the relevant literature, and provide a discussion of practical concerns.

1.9 µm waveguide laser fabricated by ultrafast laser inscription in Tm:Lu2O3 ceramic.

The ultrafast laser inscription technique has been used to fabricate channel waveguides in Tm3+-doped Lu2O3 ceramic gain medium for the first time to our knowledge. Laser operation has been demonstrated using a monolithic microchip cavity with a continuous-wave Ti:sapphire pump source at 796 nm. The maximum output power achieved from the Tm:Lu2O3 waveguide laser was 81 mW at 1942 nm. A maximum slope efficiency of 9.5% was measured with the laser thresholds observed to be in the range of 50-200 mW of absorbed pump power. Propagation losses for this waveguide structure are calculated to be 0.7 dB⋅cm-1 ± 0.3 dB⋅cm-1 at the lasing wavelength.

Postoperative single-dose interstitial high-dose-rate brachytherapy in therapy-resistant keloids.

PURPOSE: Patients with keloids complain of the cosmetic aspect, pain, and pruritus. Many different therapies are being used for keloids. The aim of this study was to evaluate the recurrence rate and outcome after resection followed by a single-dose brachytherapy. METHODS AND MATERIALS: Patients treated by resection of the keloid plus a single dose of 13 Gy high-dose-rate brachytherapy were evaluated at least 1 year after treatment. Clinical response and cosmesis were assessed by a plastic surgeon and by the patients using the Patient and Observer Scar Assessment Scale. RESULTS: Only 24 of the 61 invited patients responded to participate with the study; 29 keloids were evaluated. The recurrence rate was 24.1% after a median followup of 53 months (19-95 months). Patients scored on average 24.3 for their total Patient and Observer Scar Assessment Scale score (range 6-52), whereas the observer scored on average 14.6 (range 6-42). CONCLUSIONS: This treatment has a higher recurrence rate than that reported in most other studies. This may be explained by differences in recurrence definition, differences in followup time among studies, and selection bias because of not contributing to the study. The cosmetic outcome for evaluated patients is relatively good. This treatment policy has the advantage that patients are treated in a single day.

The impact of a haemophilia education intervention on the knowledge and health related quality of life of parents of Indian children with haemophilia.

INTRODUCTION: The impact of haemophilia education on the quality of life of parents of children with haemophilia from low income settings has not been studied. AIM: The purpose of this study was to determine the impact of an education intervention on health related quality of life (HRQOL) of parents of children with haemophilia, parent's knowledge about haemophilia and its management, and to determine whether education about haemophilia can positively impact these outcomes. METHODS: One hundred thirty-three parents from across Maharashtra state, India were provided information about haemophilia, care of child and self-care. The impact of the intervention was measured as changes occurring from baseline to 6 months and 1 year after intervention. Knowledge and practice of management of bleeding was measured using pretested structured questionnaires. HRQOL was measured using a validated Peds Quality of Life™ Family Impact Module (PedsQL™ FIM) tool. RESULTS: There was improvement in knowledge scores immediately after intervention, which remained significantly higher than baseline 1 year after intervention. HRQOL showed significant improvement at 6 months but reduced to baseline levels 1 year after intervention. There were statistically significant changes in terms of practice of management of bleeding episodes at 6 months and 1 year after intervention. CONCLUSION: Education about haemophilia resulted in improvement of knowledge, and practice of management of bleeding which was retained till a year after the intervention. However, a long-term effect on the HRQOL of parents could not be observed after administration of a single education intervention.

Vacuum impregnation: a promising way for mineral fortification in potato porous matrix (potato chips).

Potato chips can be considered as an ideal carrier for targeted nutrient/s delivery as mostly consumed by the vulnerable group (children and teen agers). The present study was planned to fortifiy potato chips with calcium (Calcium lactate) and zinc (Zinc sulphate) using vacuum impregnation technique. At about 70-80 mm Hg vacuum pressure, maximum level of impregnation of both the minerals was achieved. Results showed that after optimization, calcium lactate at 4.81%, zinc sulphate at 0.72%, and vacuum of 33.53 mm Hg with restoration period of 19.52 min can fortify potato chips that can fulfil 10 and 21% need of calcium and zinc, respectively of targeted group (age 4-17 years). The present research work has shown that through this technique, fortification can be done in potato chips which are generally considered as a poor source of minerals. Further to make potato chips more fit to health conscious consumers, rather frying microwaving was done to develop mineral fortified low fat potato chips.

Does bupivacaine and fentanyl combination for epidural analgesia shorten the duration of labour?

In this study we aimed to explore the effects of epidural analgesia achieved by a combination of low-dose bupivacaine and fentanyl infused through an epidural catheter on mother, foetus and labour process in nulliparous at-term pregnant women during vaginal delivery. This study was designed in a prospective, randomised controlled manner. Epidural analgesia was achieved in 50 nulliparous women. Fifty nulliparous women did not undergo epidural analgesia procedure. The duration of the first stage of labour was significantly shortened, while the second stage was significantly lengthened in pregnant women who underwent epidural analgesia (p < 0.05). In conclusion, starting epidural analgesia application during the active phase of the first stage of labour may shorten the duration of the first stage compared with the group of nulliparous women not undergoing epidural analgesia. The factor that has an impact on this may be the addition of fentanyl to bupivacaine used for epidural analgesia.

Laser surface modification of medical grade alloys for reduced heating in a magnetic resonance imaging environment.

Nanoscale surface modification of medical grade metallic alloys was conducted using a neodymium-doped yttrium aluminum garnet laser-based dopant diffusion technique. The objective of this approach was to minimize the induction heating by reducing the absorbed radio frequency field. Such an approach is advantageous in that the dopant is diffused into the alloy and is not susceptible to detachment or spallation as would an externally applied coating, and is expected to not deteriorate the mechanical and electrical properties of the base alloy or device. Experiments were conducted using a controlled environment laser system with the ability to control laser properties (i.e., laser power, spot size, and irradiation time) and dopant characteristics (i.e., temperature, concentration, and pressure). The reflective and transmissive properties of both the doped and untreated samples were measured in a radio frequency (63.86 MHz) magnetic field using a system comprising a high power signal generator, a localized magnetic field source and sensor, and a signal analyzer. The results indicate an increase in the reflectivity of the laser-treated samples compared to untreated samples. The effect of reflectivity on the heating of the alloys is investigated through a mathematical model incorporating Maxwell's equations and heat conduction.

Flow effects in the laser-induced thermal loading of optical traps and optofluidic devices.

Flow effects on the thermal loading in different optofluidic systems (optical trap and various microfluidic channels) have been systematically explored by using dye-based ratiometric luminescence thermometry. Thermal images obtained by fluorescence microscopy demonstrate that the flow rate plays a key role in determining both the magnitude of the laser-induced temperature increment and its spatial distribution. Numerical simulations were performed in the case of the optical trap. A good agreement between the experimental results and those predicted by mathematical modelling was observed. It has also been found that the dynamics of thermal loading is strongly influenced by the presence of fluid flow.