Prediction model for mild cognitive impairment in patients with type 2 diabetes using the autonomic function test.

OBJECTIVE: Type 2 diabetes mellitus (T2DM) is a risk factor for cognitive impairment, and reduced heart rate variability (HRV) has been correlated with cognitive impairment in elderly individuals. This study investigated risk factors and validated a predictive model for mild cognitive impairment (MCI) in patients with T2DM using an autonomic function test. METHODS: Patients with T2DM, 50-85 years of age, who attended the diabetes clinic at Gyeongsang National University Hospital between March 2018 and December 2019, were included. A total of 201 patients had been screened; we enrolled 124 patients according to the inclusion and exclusion criteria in this study. Cognitive function was assessed using the Montreal Cognitive Assessment-Korean version (MOCA-K); MCI was defined as a total MOCA-K score ≤ 23. Risk factors for MCI in patients with T2DM, including demographic- and diabetes-related factors, and autonomic function test results, were analyzed. Based on multivariate logistic regression, a nomogram was developed as a prediction model for MCI. RESULTS: Thirty-nine of 124 patients were diagnosed with MCI. Age, education, and decreased cardiovagal function were associated with a high risk for MCI, with cardiovagal function exerting the greatest influence. However, diabetes-related factors, such as glycemic control, duration of diabetes, or medications, were not associated with the risk for MCI. The nomogram demonstrated excellent discrimination (area under the curve, 0.832) and was well calibrated. CONCLUSION: Approximately one-third of patients had MCI; as such, carefully evaluating cognitive function in elderly T2DM patients with reduced HRV is important to prevent progression to dementia.

A machine learning model for prediction of sarcopenia in patients with Parkinson's Disease.

OBJECTIVE: Patients with Parkinson's disease (PD) have an increased risk of sarcopenia which is expected to negatively affect gait, leading to poor clinical outcomes including falls. In this study, we investigated the gait patterns of patients with PD with and without sarcopenia (sarcopenia and non-sarcopenia groups, respectively) using an app-derived program and explored if gait parameters could be utilized to predict sarcopenia based on machine learning. METHODS: Clinical and sarcopenia profiles were collected from patients with PD at Hoehn and Yahr (HY) stage ≤ 2. Sarcopenia was defined based on the updated criteria of the Asian Working Group for Sarcopenia. The gait patterns of the patients with and without sarcopenia were recorded and analyzed using a smartphone application. The random forest model was applied to predict sarcopenia in patients with PD. RESULTS: Data from 38 patients with PD were obtained, among which 9 (23.7%) were with sarcopenia. Clinical parameters were comparable between the sarcopenia and non-sarcopenia groups. Among various clinical and gait parameters, the average range of motion of the hip joint showed the highest association with sarcopenia. Based on the random forest algorithm, the combined difference in knee and ankle angles from standing still before walking to the maximum angle during walking (Kneeankle_diff), the difference between the angle when standing still before walking and the maximum angle during walking for the ankle (Ankle_dif), and the min angle of the hip joint (Hip_min) were the top three features that best predict sarcopenia. The accuracy of this model was 0.949. CONCLUSIONS: Using smartphone app and machine learning technique, our study revealed gait parameters that are associated with sarcopenia and that help predict sarcopenia in PD. Our study showed potential application of advanced technology in clinical research.

TonEBP Haploinsufficiency Attenuates Microglial Activation and Memory Deficits in Middle-Aged and Amyloid ß Oligomer-Treated Mice.

Age-related microglial activation is associated with cognitive impairment. Tonicity-responsive enhancer-binding protein (TonEBP) is a critical mediator of microglial activation in response to neuroinflammation. However, the precise role of TonEBP in the middle-aged brain is not yet known. We used TonEBP haploinsufficient mice to investigate the role of TonEBP in middle-aged or amyloid ß oligomer (AßO)-injected brains and examined the effect of TonEBP knockdown on AßO-treated BV2 microglial cells. Consistent with an increase in microglial activation with aging, hippocampal TonEBP expression levels were increased in middle-aged (12-month-old) and old (24-month-old) mice compared with young (6-month-old) mice. Middle-aged TonEBP haploinsufficient mice showed reduced microglial activation and fewer memory deficits than wild-type mice. Electron microscopy revealed that synaptic pruning by microglial processes was reduced by TonEBP haploinsufficiency. TonEBP haploinsufficiency also reduced dendritic spine loss and improved memory deficits in AßO-treated mice. Furthermore, TonEBP knockdown attenuated migration and phagocytosis in AßO-treated BV2 cells. These findings suggest that TonEBP plays important roles in age-related microglial activation and memory deficits.

Hufsiella ginkgonis gen. nov., sp. nov. and Hufsiella arboris sp. nov., isolated from tree barks.

Two Gram-staining-negative, aerobic, rod-shaped, bacteria that formed pale-pinkish colonies, designated HMF7056T and HMF7647T were isolated from Ginkgo (Ginkgo biloba) and Korean cornel dogwood (Cornus offcinalis), respectively. Phylogenetic analyses based on sequences of 16S rRNA genes and 92 core genes indicated that two strains represent novel species within the family Sphingobacteriaceae. HMF7056T and HMF7647T showed high 16S rRNA sequence similarities to Daejeonella lutea N7d-4T (93.9 % and 95.7 %, respectively). The genomes of HMF7056T and HMF7647T were 5.2 and 4.8 Mbp in size with 50.5 and 42.5 % DNA G+C contents, respectively. Menaquinone-7 was the main respiratory quinone. The predominant fatty acids of HMF7056T and HMF7647T were iso-C15 : 0 and summed feature 3 (C16 : 1ω7c and/or C16 : 1ω6c). The major polar lipid of both strains was phosphatidylethanolamine. The average nucleotide identity and digital DNA-DNA hybridization values of HMF7056T, HMF7647T and related species were well below the threshold limit for species delineation (<68.9 and <20.8 %, respectively). The average amino acid identity values of HMF7056T, HMF7647T with related type strains were below 67.8 and 68.3 %, respectively. On the basis of the results of phenotypic and phylogenetic characterizations, the two strains are considered to represent members of a novel genus of the family Sphingobacteriaceae, for which the names Hufsiella ginkgonis gen. nov., sp. nov. and Hufsiella arboris sp. nov. are proposed. The type strains are HMF7056T (=KCTC 72282T =NBRC 113964T) and HMF7647T (=KCTC 72283T =NBRC 113965T), respectively.

The microRNA-485-3p concentration in salivary exosome-enriched extracellular vesicles is related to amyloid ß deposition in the brain of patients with Alzheimer's disease.

OBJECTIVES: Alzheimer's disease (AD) is an irreversible neurodegenerative disease characterized by progressive long-term memory loss and cognitive dysfunction. Neuroimaging tests for abnormal amyloid-ß (Aß) deposition are considered the most reliable methods for the diagnosis of AD; however, the cost for such testing is very high and generally not covered by national insurance systems. Accordingly, it is only recommended for individuals exhibiting clinical symptoms of AD supported by clinical cognitive assessments. Recently, it was suggested that dysregulated microRNA-485-3p (miRNA-485-3p) in the brain and cerebrospinal fluid is closely related to pathogenesis of AD. However, a relationship between circulating miRNA-485-3p in salivary exosome-enriched extracellular vesicles (EE-EV) and Aß deposition in the brain has not been observed. DESIGN & METHODS: Using quantitative real-time polymerase chain reaction, we analyzed miRNA-485-3p concentration in salivary EE-EV. We used receiver operating characteristic (ROC) curve analysis to evaluate its predictive value for Aß positron emission tomography (Aß-PET) positivity in patients with AD. RESULTS: Our results showed that the miRNA-485-3p concentration in salivary EE-EV isolated from patients with AD was significantly increased compared with that in the healthy controls (p < 0.0001). In the analysis of all participants, the miRNA-485-3p concentration was significantly increased in Aß-PET-positive participants compared to Aß-PET-negative participants (p < 0.0001). Further analysis using only AD patients also showed that the miRNA-485-3p concentration was significantly increased in Aß-PET-positive AD patients vs. Aß-PET-negative AD patients (p = 0.0063). The ROC curve analysis for differentiating Aß-PET-positive and negative participants showed that the area under the curve for miRNA-485-3p was 0.9217. CONCLUSION: These findings suggested that the miRNA-485-3p concentration in salivary EE-EV was closely related to Aß deposition in the brain and had high diagnostic accuracy for predicting Aß-PET positivity.

Prevalence and Characterization of Extended-Spectrum ß-Lactamase-Producing Escherichia coli Isolated from Dogs and Cats in South Korea.

Overall, 836 Escherichia coli isolates (695 isolates from dogs and 141 from cats) were recovered from the diarrhea, skin/ear, urine, and genitals of dogs and cats between 2018 and 2019. Cefovecin and enrofloxacin resistance were noted in 17.1% and 21.2% of E. coli isolates, respectively. The cefovecin and enrofloxacin resistance rates were higher in dog isolates (18.1% and 22.9%) compared with the rates in cat isolates (12.1%, 12.8%). Interestingly, resistance to both antimicrobials was noted in 10.8% (90/836) of the isolates, predominantly in isolates from dogs. blaCTX-M-14, blaCTX-M-15, and blaCMY-2 were the most frequent extended-spectrum ß-lactamase/plasmid-mediated AmpC ß-lactamase (ESBL/AmpC)- gene types. The co-existence of blaCTX-M andblaCMY-2 was noted in six E. coli isolates from dogs. Sequencing analysis demonstrated that S83L and D87N in gyrA and S80I in parC were the most frequent point mutations in the quinolone resistance-determining regions of the cefovecin and enrofloxacin-resistant isolates. A total of 11 isolates from dogs carried the plasmid-mediated quinolone resistance genes (six aac(6')-Ib-cr, four qnrS, and one qnrB), while only two cat isolates carried the qnrS gene. Multilocus sequence typing of the cefovecin and enrofloxacin-resistant isolates revealed that sequence type (ST)131 E. coli carrying blaCTX-M-14 and blaCTX-M-15 genes and ST405 E. coli carrying blaCMY-2 gene were predominant among the isolated E. coli strains. The majority of the ESBL/AmpC-producing isolates displayed diverse pulsed-field gel electrophoresis profiles. This study demonstrated that third-generation cephalosporin- and fluoroquinolone-resistant E. coli were widely distributed in companion animals. The detection of the pandemic ST131 clone carrying blaCTX-M-14/15 in companion animals presented a public health threat.

[Effects of a Nursing Simulation Learning Module on Clinical Reasoning Competence, Clinical Competence, Performance Confidence, and Anxiety in COVID-19 Patient-Care for Nursing Students].

PURPOSE: This study aimed to develop a nursing simulation learning module for coronavirus disease 2019 (COVID-19) patient-care and examine its effects on clinical reasoning competence, clinical competence, performance confidence, and anxiety in COVID-19 patient care for nursing students. METHODS: A non-equivalent control group pre- and post-test design was employed. The study participants included 47 nursing students (23 in the experimental group and 24 in the control group) from G City. A simulation learning module for COVID-19 patient-care was developed based on the Jeffries simulation model. The module consisted of a briefing, simulation practice, and debriefing. The effects of the simulation module were measured using clinical reasoning competence, clinical competence, performance confidence, and anxiety in COVID-19 patient-care. Data were analyzed using χ²-test, Fisher's exact test, t-test, Wilcoxon signed-rank test, and Mann-Whitney U test. RESULTS: The levels of clinical reasoning competence, clinical competence, and performance confidence of the experimental group were significantly higher than that of the control group, and the level of anxiety was significantly low after simulation learning. CONCLUSION: The nursing simulation learning module for COVID-19 patient-care is more effective than the traditional method in terms of improving students' clinical reasoning competence, clinical competence, and performance confidence, and reducing their anxiety. The module is expected to be useful for educational and clinical environments as an effective teaching and learning strategy to empower nursing competency and contribute to nursing education and clinical changes.

Deinococcus betulae sp. nov. and Deinococcus arboris sp. nov., novel bacteria isolated from bark of birch tree (Betula platyphylla).

Two reddish-coloured bacterial strains (HMF7604T and HMF7620T) were isolated from bark of birch tree (Betula platyphylla) together with two strains (designed as HMF7603 and HMF7618). Cells were observed to be Gram-stain-negative, oval- to short rod-shaped and non-motile. Phylogenetic analysis based on 16S rRNA gene sequences indicated that the four isolates belonged to the genus Deinococcus, family Deinococcaceae. They had the highest similarities (95.4-95.6 %) to Deinococcus multiflagellatus ID1504T, with which they formed a clade in phylogenetic trees. Menaquinone-8 was the only respiratory quinone. The predominant fatty acids were summed feature 3 (C16 : 1 ω7c and/or C16 : 1 ω6c), C15 : 1 ω6c, C17 : 0 and C16 : 0. Strain HMF7604T contained two unidentified phosphoglycolipids, nine unidentified glycolipids, one unidentified aminolipid, three unidentified phospholipids and three unidentified polar lipids, while strain HMF7620T contained one unidentified phosphoglycolipid, four unidentified glycolipids, one unidentified aminophospholipid, one unidentified phospholipid and one unidentified polar lipid. The DNA G+C contents of strains HMF7604T and HMF7620T were 65.6 and 65.7 mol%, respectively. The average nucleotide identity and digital DNA-DNA hybridization values between the two isolates and their close relative D. multiflagellatus were 81.1-95.3 and 24.5-61.6 %, respectively. Based on the results of phenotypic and phylogenetic characterizations, the four isolates are considered to represent two novel species of the genus Deinococcus, for which the names Deinococcus betulae sp. nov. and Deinococcus arboris sp. nov. are proposed. The type strains are HMF7604T (=KCTC 43354T=NBRC 115489T) and HMF7620T (=KCTC 43051T=NBRC 113959T).

Mucilaginibacter rivuli sp. nov., isolated from a water rivulet.

Strain HMF5004T was isolated from a rivulet located in Yongin, Republic of Korea. Phylogenetic analyses based on 16S rRNA gene sequences showed that strain HMF5004T belonged to the genus Mucilaginibacter. Strain HMF5004T was closely related to Mucilaginibacter paludis (97.7%) and Mucilaginibacter gracilis (97.2%). The values of average nucleotide identity and digital DNA-DNA hybridization between strain HMF5004T and M. paludis were 72.8 and 19.2 %, respectively. Cells of strain HMF5004T were Gram-stain-negative, rod-shaped, non-motile, catalase-positive and oxidase-positive. The DNA G+C content of strain HMF5004T was 42.4 mol%. Strain HMF5004T had menaquinone-7 as a major quinone. The major cellular fatty acids included iso-C15 : 0, summed feature 3 (C16 : 1 ω7c and/or C16 : 1 ω6c) and anteiso-C15 : 0. The polar lipids of strain HMF5004T contained phosphatidylethanolamine, five unidentified aminolipids, one unidentified aminophospholipid and four unidentified polar lipids. On the basis of the evidence presented in this polyphasic taxonomic study, strain HMF5004T is considered to represent a novel species for which the name Mucilaginibacter rivuli sp. nov. is proposed. The type strain is HMF5004T (=KCTC 82633T=NBRC 115091T).

Bacterial Prevalence in Skin, Urine, Diarrheal Stool, and Respiratory Samples from Dogs.

The emergence of bacterial infections in companion animals is a growing concern as humans can also be infected through the transmission of pathogenic bacteria. Because there have been few studies conducted on companion animals, the extent and significance of prevalence in veterinary practices remain unknown. This is the first nationwide surveillance report aimed at elucidating the prevalence pattern and associated infections of isolated bacteria from dogs in Korea. Bacterial isolates were collected from seven different laboratories participating in the Korean Veterinary Antimicrobial Resistance Monitoring System from 2018 to 2019. The samples were obtained from the diarrheal stool, skin/ear, urine, and respiratory samples of veterinary hospital-visited dogs. Isolation and identification of bacterial species was carried out using a bacterial culture approach and then confirmed with matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry (MALDI-TOF) and polymerase chain reaction (PCR). Out of 3135 isolates in dogs, 1085, 1761, 171, and 118 were extracted from diarrheal stool, skin/ear, urine, and respiratory samples, respectively. The overall prevalence of bacteria was higher among two age groups (1-5 and 6-10 years) with a 66.5 percent prevalence. This study showed that Escherichia coli was the most prevalent species among isolated bacterial species of diarrheal and urine origin, whereas Staphylococcus pseudintermedius was the most prevalent among skin and respiratory sample isolates. The data on the prevalence of bacteria for each dog specimen could provide basic information to estimate the extent of bacterial infection and antimicrobial resistance development and to guide veterinarians in therapeutic decisions in clinical practices throughout Korea.

Fibrella aquatilis sp. nov., Fibrella rubiginis sp. nov. and Fibrella forsythiae sp. nov., isolated from freshwater, rusty iron and forsythia flower.

Three novel strains, designated as HMF5036T, HMF5335T and HMF5405T, were isolated from freshwater, rusty iron and forsythia flower, in Yong-in, Republic of Korea, respectively. They were Gram-stain-negative, facultatively anaerobic, non-motile, reddish-pigmented and rod-shaped bacteria. The predominant fatty acids of three strains were C16 : 1 ω5c and summed feature 3 (comprising C16 : 1 ω7c and/or C16 : 1 ω6c). They were found to contain MK-7 as the predominant menaquinone. The major polar lipids are phosphatidylethanolamine, an unidentified aminophospholipid and an unidentified lipid. Strains HMF5036T, HMF5335T and HMF5405T exhibited the highest 16S rRNA gene sequence similarities of 91.8, 92.6 and 93.6 % to Fibrella aestuarina BUZ 2T and less than 88.7 % to other members of the family Spirosomaceae. Similarity values among the three isolates ranged from 94.9 to 96.6 %. Phylogenetic analysis based on the 16S rRNA gene sequences of the three isolates revealed that they formed a distinct clade within the family Spirosomaceae. The genome sizes of strains HMF5036T, HMF5335T and HMF5405T were 6.8, 6.4 and 7.8 Mbp, and their DNA G+C contents were 54.9, 54.0 and 52.1 mol%, respectively. The average nucleotide identity, digital DNA-DNA hybridization and amino acid identity values between three isolates and F. aestuarina BUZ 2T were 73.8-82.2, 19.6-25.4 and 75.0-87.5 %, respectively. These values were lower than the recommended threshold values for species delimitation. Based on the results of the phenotypic, genotypic, chemotaxonomic and phylogenetic investigations, three novel species, Fibrella aquatilis sp. nov., Fibrella rubiginis sp. nov. and Fibrella forsythiae sp. nov. are proposed. The type strains are HMF5036T (=KCTC 82476T=NBRC 115092T), HMF5335T (=KCTC 82477T=NBRC 115093T) and HMF5405T (=KCTC 82478T=NBRC 115094T), respectively.

Role of Lipocalin-2 in Amyloid-Beta Oligomer-Induced Mouse Model of Alzheimer's Disease.

Lipocalin-2 (LCN2) is an inflammatory protein with diverse functions in the brain. Although many studies have investigated the mechanism of LCN2 in brain injuries, the effect of LCN2 on amyloid-toxicity-related memory deficits in a mouse model of Alzheimer's disease (AD) has been less studied. We investigated the role of LCN2 in human AD patients using a mouse model of AD. We created an AD mouse model by injecting amyloid-beta oligomer (AßO) into the hippocampus. In this model, animals exhibited impaired learning and memory. We found LCN2 upregulation in the human brain frontal lobe, as well as a positive correlation between white matter ischemic changes and serum LCN2. We also found increased astrocytic LCN2, microglia activation, iron accumulation, and blood-brain barrier disruption in AßO-treated hippocampi. These findings suggest that LCN2 is involved in a variety of amyloid toxicity mechanisms, especially neuroinflammation and oxidative stress.

Development of a Web-Based Korean Triage and Acuity Scale Learning Program for Emergency Department Nurses.

The Korean Triage and Acuity Scale is a tool developed to classify severity and urgency of emergency department patients, focusing on their symptoms. Considering the importance of the Korean Triage and Acuity Scale, learning for emergency department nurses who perform the Korean Triage and Acuity Scale must be structured to ensure that the knowledge they gain can be applied to various clinical situations of the emergency department. Moreover, Web-based learning is considered appropriate in this situation. This is a methodological research study that was conducted to develop a Web-based Korean Triage and Acuity Scale learning program for emergency department nurses. The learning program was developed using each of the five phases of the "analysis, design, development, implementation, and evaluation" model, that is, analysis, design, development, implementation, and evaluation. The learning program was composed of 22 cases of emergency situations based on the Korean Triage and Acuity Scale teaching material with an approval from the Korean Triage and Acuity Scale committee in the Korean Society of Emergency Medicine. The developed program was delivered in 4-hour sessions over 4 weeks. Emergency department nurses who were given the Web-based Korean Triage and Acuity Scale learning program showed improvement in work-site transfer and reported satisfactory learning. The findings indicate that the Web-based learning program for nurses can be used as an effective tool that is easily accessible and provides multiple learning opportunities.

Imipenem Resistance Mediated by blaOXA-913 Gene in Pseudomonas aeruginosa.

Treatment of infectious diseases caused by carbapenem-resistant Pseudomonas aeruginosa is becoming a greater challenge. This study aimed to identify the imipenem resistance mechanism in P. aeruginosa isolated from a dog. Minimum Inhibitory Concentration (MIC) was determined by the broth microdilution method according to the Clinical and Laboratory Standards Institute recommendations. We performed polymerase chain reaction and whole-genome sequencing to detect carbapenem resistance genes. Genomic DNA of P. aeruginosa K19PSE24 was sequenced via the combined analysis of 20-kb PacBio SMRTbell and PacBio RS II. Peptide-Peptide Nucleic Acid conjugates (P-PNAs) targeting the translation initiation region of blaOXA-913 were synthesized. The isolate (K19PSE24) was resistant to imipenem and piperacillin/tazobactam yet was susceptible to most of the tested antimicrobials. Whole-genome sequencing revealed that the K19PSE24 genome comprised a single contig amounting to 6,815,777 base pairs, with 65 tRNA and 12 rRNA genes. K19PSE24 belonged to sequence type 313 and carried the genes aph(3)-IIb, fosA, catB7, crpP, and blaOXA-913 (an allele deposited in GenBank but not described in the literature). K19PSE24 also carried genes encoding for virulence factors (exoenzyme T, exotoxin A, and elastase B) that are associated with adhesion, invasion, and tissue lysis. Nevertheless, we did not detect any of the previously reported carbapenem resistance genes. This is the first report of the blaOXA-913 gene in imipenem-resistant P. aeruginosa in the literature. Notably, no viable colonies were found after co-treatment with imipenem (2 µg/mL) and either of the P-PNAs (12.5 µM or 25 µM). The imipenem resistance in K19PSE24 was primarily due to blaOXA-913 gene carriage.

Clinical utility of cerebrospinal fluid vitamin D-binding protein as a novel biomarker for the diagnosis of viral and bacterial CNS infections.

BACKGROUND: Rapid and accurate diagnosis of central nervous system (CNS) infections is important, and laboratory tests help diagnose CNS infections. Even when the patient has symptoms, laboratory tests often do not reveal any specific findings. The potential of vitamin D-binding protein (VDBP) to be used as a biomarker for viral and bacterial CNS infections was studied. METHODS: A total of 302 subjects with suspected CNS infection who underwent lumbar puncture were included. Clinical and laboratory data were collected retrospectively. VDBP levels were measured in the cerebrospinal fluid (CSF) samples. Genotyping for the GC gene encoding VDBP was also performed. VDBP levels were analyzed and compared by CNS infection, pathogen, CSF opening pressure, and GC genotype. RESULTS: A CNS infection group (n = 90) and a non-CNS infection group (n = 212) were studied. In terms of its receiver operating characteristic, CSF VDBP showed an area under the curve of 0.726 for the diagnosis of CNS infection. CSF VDBP levels were significantly different between the CNS infection and non-infection groups. The CNS infection group with enterovirus showed a statistically lower distribution of CSF VDBP levels than the other virus groups. The group with CSF opening pressure > 25 cmH2O showed higher CSF VDBP levels than the other groups. There was no significant difference in GC gene allele distribution between the CNS infection and non-infection groups. CONCLUSIONS: CSF VDBP levels were increased in patients with CNS infection. The CSF VDBP showed potential as a new biomarker for viral and bacterial CNS infections.

Effects of a transformative learning theory based debriefing in simulation: A randomized trial.

Debriefing, based on reflection, is imperative in simulation. Mezirow's transformative learning theory (TLT) uses critical reflection in providing care to patients, which involves clinical judgment in nursing. The aim of this study was to compare the effects of TLT-versus a non-TLT-based debriefing protocol on knowledge, problem-solving process, critical thinking disposition, and clinical judgment in nursing students. A randomized controlled trial was performed. Fifty-six junior nursing students were assigned to the TLT (n = 26) and the control (n = 30) groups in South Korea. Debriefing protocols based on Mezirow's TLT for the experimental group and gather-analyze-summarize-based debriefing for the control group were used for four weeks. Scores of the TLT group were significantly higher than those of the control group in the problem-solving process, critical thinking disposition, and clinical judgment of reflection. We identified the main effects of group, time, and time-by-group interaction for clinical judgment (noticing, interpreting, and responding), except for knowledge between the two groups. The TLT debriefing approach in simulation can be tailored to improve problem-solving, critical thinking, and clinical judgment outcomes, which are vital to nursing education related to the provision of care to patients.