Clinical reasoning in real-world practice: a primer for medical trainees and practitioners.

Clinical reasoning is a crucial skill and defining characteristic of the medical profession, which relates to intricate cognitive and decision-making processes that are needed to solve real-world clinical problems. However, much of our current competency-based medical education systems have focused on imparting swathes of content knowledge and skills to our medical trainees, without an adequate emphasis on strengthening the cognitive schema and psychological processes that govern actual decision-making in clinical environments. Nonetheless, flawed clinical reasoning has serious repercussions on patient care, as it is associated with diagnostic errors, inappropriate investigations, and incongruent or suboptimal management plans that can result in significant morbidity and even mortality. In this article, we discuss the psychological constructs of clinical reasoning in the form of cognitive 'thought processing' models and real-world contextual or emotional influences on clinical decision-making. In addition, we propose practical strategies, including pedagogical development of a personal cognitive schema, mitigating strategies to combat cognitive bias and flawed reasoning, and emotional regulation and self-care techniques, which can be adopted in medical training to optimize physicians' clinical reasoning in real-world practice that effectively translates learnt knowledge and skill sets into good decisions and outcomes.

Providing family updates: a primer for the medical trainee.

Providing family updates is a common clinical task for medical trainees and practitioners working in hospital settings. Good clinical communication skills are essential in clinical care as it is associated with improved patient satisfaction, understanding of condition, treatment adherence, and better overall clinical outcomes. Moreover, poor communications are often the source of medical complaints. However, while patient-centred communication skills training has generally been incorporated into clinical education, there hitherto remains inadequate training on clinical communications with patients' families, which carry different nuances. In recent years, it is increasingly recognized that familial involvement in the care of hospitalized patients leads to better clinical and psychological outcomes. In fact, in Asian populations with more collectivistic cultures, families are generally highly involved in patient care and decision-making. Therefore, effective clinical communications and regular provision of family updates are essential to build therapeutic rapport, facilitate familial involvement in patient care, and also provide a more holistic understanding of the patient's background and psychosocial set-up. In this article, we herein describe a seven-step understand the clinical context, gather perspectives, deliver medical information, address questions, concerns and expectations, provide tentative plans, demonstrate empathy, postcommunication reflections model as a practical guide for medical trainees and practitioners in provision of structured and effective family updates in their clinical practice.

Drought reduces productivity and anti-herbivore defences, but not mycorrhizal associations, of perennial prairie forbs.

During drought, plants allocate resources to aboveground biomass production and belowground carbohydrate reserves, often at the expense of production of defence traits. Additionally, drought has been shown to alter floral resources, with potential implications for plant-pollinator interactions. Although soil symbionts, such as arbuscular mycorrhizal (AM) fungi, can alleviate drought stress in plants, certain levels of drought may negatively impact this relationship, with potential cascading effects. Because of their importance to plant and animal community diversity, we examined effects of drought on biomass production, physical defence properties, nectar production, and associated AM fungal abundance of five common prairie forb species in a greenhouse study. Reduced soil moisture decreased vegetative biomass production. Production of trichomes and latex decreased under drought, relative to well-watered conditions. Ruellia humilis flowers produced less nectar under drought, relative to well-watered conditions. Intra-radical AM fungal colonization was not significantly affected by drought, although extra-radical AM fungal biomass associated with S. azurea decreased following drought. Overall, grassland forb productivity, defence, and nectar production were negatively impacted by moderate drought, with possible negative implications for biotic interactions. Reduced flower and nectar production may lead to fewer pollinator visitors, which may contribute to seed limitation in forb species. Reduced physical defences increase the likelihood of herbivory, further decreasing the ability to store energy for essential functions, such as reproduction. Together, these results suggest drought can potentially impact biotic interactions between plants and herbivores, pollinators, and soil symbionts, and highlights the need for direct assessments of these relationships under climate change scenarios.

'Insight' in medical training: what, why, and how?

The term 'insight' is generically defined in English language as the ability to perceive deeper truths about people and situations. In clinical practice, patient insight is known to have important implications in treatment compliance and clinical outcomes, and can be assessed clinically by looking for the presence of illness awareness, correct attribution of symptoms to underlying condition, and acceptance of treatment. In this article, we suggest that cultivating insight is actually a highly important, yet often overlooked, component of medical training, which may explain why some consistently learn well, communicate effectively, and quickly attain clinical competency, while others struggle throughout their clinical training and may even be difficult to remediate. We herein define 'insight' in the context of medical training as having an astute perception of personal cognitive processes, motivations, emotions, and ability (strengths, weaknesses, and limitations) that should drive self-improvement and effective behavioural regulation. We then describe the utility of cultivating 'insight' in medical training through three lenses of (i) promoting self-regulated, lifelong clinical learning, (ii) improving clinical competencies and person-centred care, and (iii) enhancing physician mental health and well-being. In addition, we review educational pedagogies that are helpful to create a medical eco-system that promotes the cultivation of insight among its trainees and practitioners. Finally, we highlight several tell-tale signs of poor insight and discuss psychological and non-psychological interventions that may help those severely lacking in insight to become more amenable to change and remediation.

The gravitationally unstable gas disk of a starburst galaxy 12 billion years ago.

Galaxies in the early Universe that are bright at submillimetre wavelengths (submillimetre-bright galaxies) are forming stars at a rate roughly 1,000 times higher than the Milky Way. A large fraction of the new stars form in the central kiloparsec of the galaxy1-3, a region that is comparable in size to the massive, quiescent galaxies found at the peak of cosmic star-formation history4 and the cores of present-day giant elliptical galaxies. The physical and kinematic properties inside these compact starburst cores are poorly understood because probing them at relevant spatial scales requires extremely high angular resolution. Here we report observations with a linear resolution of 550 parsecs of gas and dust in an unlensed, submillimetre-bright galaxy at a redshift of z = 4.3, when the Universe was less than two billion years old. We resolve the spatial and kinematic structure of the molecular gas inside the heavily dust-obscured core and show that the underlying gas disk is clumpy and rotationally supported (that is, its rotation velocity is larger than the velocity dispersion). Our analysis of the molecular gas mass per unit area suggests that the starburst disk is gravitationally unstable, which implies that the self-gravity of the gas is stronger than the differential rotation of the disk and the internal pressure due to stellar-radiation feedback. As a result of the gravitational instability in the disk, the molecular gas would be consumed by star formation on a timescale of 100 million years, which is comparable to gas depletion times in merging starburst galaxies5.

Millimeter-Wave Polarimeters Using Kinetic Inductance Detectors for TolTEC and Beyond.

Microwave Kinetic Inductance Detectors (MKIDs) provide a compelling path forward to the large-format polarimeter, imaging, and spectrometer arrays needed for next-generation experiments in millimeter-wave cosmology and astronomy. We describe the development of feedhorn-coupled MKID detectors for the TolTEC millimeter-wave imaging polarimeter being constructed for the 50-meter Large Millimeter Telescope (LMT). Observations with TolTEC are planned to begin in early 2019. TolTEC will comprise ∼7,000 polarization sensitive MKIDs and will represent the first MKID arrays fabricated and deployed on monolithic 150 mm diameter silicon wafers - a critical step towards future large-scale experiments with over 105 detectors. TolTEC will operate in observational bands at 1.1, 1.4, and 2.0 mm and will use dichroic filters to define a physically independent focal plane for each passband, thus allowing the polarimeters to use simple, direct-absorption inductive structures that are impedance matched to incident radiation. This work is part of a larger program at NIST-Boulder to develop MKID-based detector technologies for use over a wide range of photon energies spanning millimeter-waves to X-rays. We present the detailed pixel layout and describe the methods, tools, and flexible design parameters that allow this solution to be optimized for use anywhere in the millimeter and sub-millimeter bands. We also present measurements of prototype devices operating in the 1.1 mm band and compare the observed optical performance to that predicted from models and simulations.

Topsin-M: the new benomyl for mycorrhizal-suppression experiments.

The fungicide benomyl was the most commonly used biocide for both field and greenhouse experiments in which arbuscular mycorrhizal fungal (AMF) suppression is desired. Unfortunately benomyl is no longer manufactured and therefore is not available for experimental use and no fungicide has been proposed as a successful alternative for experimentally suppressing mycorrhizal fungi. In this study we examined the potential for the fungicide Topsin M (topsin) to suppress mycorrhizal symbiosis in both field and greenhouse experiments. Topsin reduced AMF colonization of the obligately mycotrophic, warm-season grass Andropogon gerardii with a large and significant reduction in plant biomass production. Topsin reduced AMF colonization of the facultatively mycotrophic, cool-season grass Pascopyron smithii but did not significantly reduce biomass production. Fertilization with nitrogen and phosphorus was able to compensate for reductions in biomass due to the application of fungicide because biomass production of plants that received topsin fungicide was not significantly different from fertilized controls not receiving topsin. While we are not advocating that topsin fungicide is a universal mechanism for mycorrhizal-suppressed controls, in systems where benomyl was found to be successful topsin appears to be a useful, available and successful alternative.

Fusion transcripts and transcribed retrotransposed loci discovered through comprehensive transcriptome analysis using Paired-End diTags (PETs).

Identification of unconventional functional features such as fusion transcripts is a challenging task in the effort to annotate all functional DNA elements in the human genome. Paired-End diTag (PET) analysis possesses a unique capability to accurately and efficiently characterize the two ends of DNA fragments, which may have either normal or unusual compositions. This unique nature of PET analysis makes it an ideal tool for uncovering unconventional features residing in the human genome. Using the PET approach for comprehensive transcriptome analysis, we were able to identify fusion transcripts derived from genome rearrangements and actively expressed retrotransposed pseudogenes, which would be difficult to capture by other means. Here, we demonstrate this unique capability through the analysis of 865,000 individual transcripts in two types of cancer cells. In addition to the characterization of a large number of differentially expressed alternative 5' and 3' transcript variants and novel transcriptional units, we identified 70 fusion transcript candidates in this study. One was validated as the product of a fusion gene between BCAS4 and BCAS3 resulting from an amplification followed by a translocation event between the two loci, chr20q13 and chr17q23. Through an examination of PETs that mapped to multiple genomic locations, we identified 4055 retrotransposed loci in the human genome, of which at least three were found to be transcriptionally active. The PET mapping strategy presented here promises to be a useful tool in annotating the human genome, especially aberrations in human cancer genomes.

Optical performance of frequency-selective bolometers.

Frequency-selective bolometers (FSBs) are a new type of detector for millimeter and submillimeter wavelengths that are transparent to all but a narrow range of frequencies as set by characteristics of the absorber itself. Therefore stacks of FSBs tuned to different frequencies provide a low-loss compact method for utilizing a large fraction of the light collected by a telescope. Tests of prototype FSBs indicate that the absorption spectra are well predicted by models, that peak absolute absorption efficiencies of the order of 50% are attainable, and that their out-of-band transmission is high.

Interaction of Heterodera glycines and Glomus mosseae on Soybean.

The effects of the arbuscular mycorrhizal (AM) fungus Glomus mosseae on Heterodera glycines-soybean interactions were investigated in greenhouse experiments. Mycorrhizal and nonmycorrhizal soybean cultivars that were either resistant or susceptible to H. glycines were exposed to initial nematode population densities (Pi) of 0, 100, 1,000, or 10,000 eggs and infective juveniles. Soybean growth, nematode reproduction, and AM fungal colonization were determined after 35 (experiment I) and 83 (experiment II) days. Soybean shoot and root weights were reduced an average 29% across H. glycines Pi but were 36% greater overall in the presence of G. mosseae. Analyses of variance indicated that root colonization and stimulation of soybean growth by G. mosseae were inhibited at high H. glycines Pi, while the combined effects of the nematode and fungus on soybean growth were best described as additive in linear regression models. No evidence for increased nematode tolerance of mycorrhizal soybean plants was observed. Nematode population densities and reproduction were lower on a nematode-resistant soybean cultivar than on a susceptible cultivar, but reproduction was comparable on mycorrhizal and nonmycorrhizal plants. Root colonization by G. mosseae was reduced at high nematode Pi. The results suggest that nematode antagonism to the mycorrhizal symbiosis is a more likely consequence of interactions between H. glycines and AM fungi on soybean than is nematode suppression by the fungus.

Effects of mycorrhizae on growth and demography of tallgrass prairie forbs.

The effects of arbuscular mycorrhizal (AM) symbiosis on ramet and genet densities, vegetative growth rates, and flowering of three forb species were studied in native tallgrass prairie in northeastern Kansas. Mycorrhizal activity was experimentally suppressed for six growing seasons on replicate plots in an annually burned and an infrequently burned watershed with the fungicide benomyl. Benomyl reduced mycorrhizal root colonization to an average of 4.2%, approximately a two-thirds reduction relative to controls (13.7% colonization). Mycorrhizae influenced the population structure of these forbs. Although mycorrhizal suppression had no long-term effect on genet densities and no effect on ramet survivorship throughout the growing season, the number of ramets per individual was significantly increased such that ramet densities of all three species were approximately doubled in response to long-term mycorrhizal suppression. Effects of mycorrhizae on ramet growth and reproduction varied among species. Ramet growth rates, biomass, and flowering of Salvia azurea were greater in plots with active mycorrhizal symbiosis, whereas mycorrhizae reduced ramet growth rates and biomass of Artemesia ludoviciana. Aster sericeus ramet growth rates and biomass were unaffected by the fungicide applications, but its flowering was reduced.The pattern of responses of these three species to mycorrhizae differed considerably between the two sites of contrasting fire regime, indicating that the interaction of fire-induced shifts in resource availability and mycorrhizal symbiosis together modulates plant responses and the intensity and patterns of interspecific competition between and among tallgrass prairie grass and forb species. Further, the results indicate that effects of mycorrhizae on community structure are a result of interspecific differences in the balance between direct positive effects of the symbiosis on host plant performance and indirect negative effects mediated through altered competitive interactions.

One institution's perspective on fast tracking same-day surgery patients.

This article describes a project for fast tracking of patients in one ambulatory surgical setting. Fast tracking may be a new endeavor or a well-entrenched practice in same-day surgery settings, depending on the organization. However, there is little information on this presently found in literature. Fast tracking is also known as post anesthesia care unit bypass. It allows stable patients that meet a set criteria to proceed, in this instance, from the operating room to the ambulatory procedure unit. This is a US government work. There are no restrictions on its use.

Host plant species effects on arbuscular mycorrhizal fungal communities in tallgrass prairie.

Symbiotic associations between plants and arbuscular mycorrhizal (AM) fungi are ubiquitous in many herbaceous plant communities and can have large effects on these communities and ecosystem processes. The extent of species-specificity between these plant and fungal symbionts in nature is poorly known, yet reciprocal effects of the composition of plant and soil microbe communities is an important assumption of recent theoretical models of plant community structure. In grassland ecosystems, host plant species may have an important role in determining development and sporulation of AM fungi and patterns of fungal species composition and diversity. In this study, the effects of five different host plant species [Poa pratensis L., Sporobolus heterolepis (A. Gray) A. Gray, Panicum virgatum L., Baptisia bracteata Muhl. ex Ell., Solidago missouriensis Nutt.] on spore communities of AM fungi in tallgrass prairie were examined. Spore abundances and species composition of fungal communities of soil samples collected from patches within tallgrass prairie were significantly influenced by the host plant species that dominated the patch. The AM fungal spore community associated with B. bracteata showed the highest species diversity and the fungi associated with Pa. virgatum showed the lowest diversity. Results from sorghum trap cultures using soil collected from under different host plant species showed differential sporulations of AM fungal species. In addition, a greenhouse study was conducted in which different host plant species were grown in similar tallgrass prairie soil. After 4 months of growth, AM fungal species composition was significantly different beneath each host species. These results strongly suggest that AM fungi show some degree of host-specificity and are not randomly distributed in tallgrass prairie. The demonstration that host plant species composition influences AM fungal species composition provides support for current feedback models predicting strong regulatory effects of soil communities on plant community structure. Differential responses of AM fungi to host plant species may also play an important role in the regulation of species composition and diversity in AM fungal communities.

Interacting influence of mycorrhizal symbiosis and competition on plant diversity in tallgrass prairie.

In tallgrass prairie, plant species interactions regulated by their associated mycorrhizal fungi may be important forces that influence species coexistence and community structure; however, the mechanisms and magnitude of these interactions remain unknown. The objective of this study was to determine how interspecific competition, mycorrhizal symbiosis, and their interactions influence plant community structure. We conducted a factorial experiment, which incorporated manipulations of abundance of dominant competitors, Andropogon gerardii and Sorghastrum nutans, and suppression of mycorrhizal symbiosis using the fungicide benomyl under two fire regimes (annual and 4-year burn intervals). Removal of the two dominant C4 grass species altered the community structure, increased plant species richness, diversity, and evenness, and increased abundance of subdominant graminoid and forb species. Suppression of mycorrhizal fungi resulted in smaller shifts in community structure, although plant species richness and diversity increased. Responses of individual plant species were associated with their degree of mycorrhizal responsiveness: highly mycorrhizal responsive species decreased in abundance and less mycorrhizal responsive species increased in abundance. The combination of dominant-grass removal and mycorrhizal suppression treatments interacted to increase synergistically the abundance of several species, indicating that both processes influence species interactions and community organization in tallgrass prairie. These results provide evidence that mycorrhizal fungi affect plant communities indirectly by influencing the pattern and strength of plant competitive interactions. Burning strongly influenced the outcome of these interactions, which suggests that plant species diversity in tallgrass prairie is influenced by a complex array of interacting processes, including both competition and mycorrhizal symbiosis.

Interspecific variation in plant responses to mycorrhizal colonization in tallgrass prairie.

Symbiotic associations between plants and arbuscular mycorrhizal fungi are ubiquitous and ecologically important in many grasslands. Differences in species responses to mycorrhizal colonization can have a significant influence on plant community structure. The growth responses of 36 species of warm- and cool-season tallgrass prairie grasses and 59 tallgrass prairie forbs to arbuscular mycorrhizal (AM) fungal colonization were assessed in greenhouse studies to examine the extent of interspecific variation in host-plant benefit from the symbiosis and patterns of mycorrhizal dependence among host plant life history (e.g., annual, perennial) and taxonomic (e.g., grass, forb, legume, nonlegume) groups and phenological guilds. There was a strong and significant relationship between phenology of prairie grasses and mycorrhizal responsiveness, however this relationship was less apparent in forbs. Perennial warm-season C(4) grasses and forbs generally benefited significantly from the mycorrhizal symbiosis, whereas biomass production of the cool-season C(3) grasses was not affected. The root systems of the cool-season grasses were also less highly colonized by the AM fungi, as compared to the warm-season grasses or forbs. Unlike the native perennials, annuals were generally not responsive to mycorrhizal colonization and were lower in percentage root colonization than the perennial species. Plant growth responsiveness and AM root colonization were positively correlated for the nonleguminous species, with this relationship being strongest for the cool-season grasses. In contrast, root colonization of prairie legumes showed a significant, but negative, relationship to mycorrhizal growth responsiveness.

Suppression of the expression of a pancreatic beta-cell form of the kinesin heavy chain by antisense oligonucleotides inhibits insulin secretion from primary cultures of mouse beta-cells.

Granular/vesicular transport is thought to be supported by microtubule-based force-generating adenosine triphosphatases such as kinesin. Kinesin is a motor molecule that has been well studied in brain and other neuronal tissues. Although vesicular transport is important for pancreatic beta-cell secretory activities, the role of kinesin in beta-cell function has not been investigated. It is hypothesized that kinesin functions as a translocator that associates with both microtubules and insulin-containing granules in beta-cells and transports the secretory granules from deep within the cytoplasm, where insulin is synthesized and processed, to the surface of beta-cells upon secretory stimulation. To test this hypothesis, a mouse beta-cell kinesin heavy chain complementary DNA was cloned and sequenced. Kinesin expression in primary cultures of mouse beta-cells then was selectively suppressed by antimouse beta-cell kinesin heavy chain antisense oligonucleotide treatment. Analysis of insulin secretion determined that the basal level of insulin secretion from the treated cells was decreased by 50%. Furthermore, glucose-stimulated insulin release from treated beta-cells was reduced by almost 70% after suppression of kinesin expression by antisense treatment. The findings from this study provide the first direct evidence that kinesin, a microtubule-based motor protein, plays an important role in insulin secretion.

Role of expanded clay and porous ceramic amendments on plant establishment in minespoils.

Greenhouse experiments were conducted to examine the impact of expanded clay (Turface) or porous ceramic (Isolite) amendments on germination, biomass production, plant Zn concentration, and Zn accumulation by Festuca arundinacea grown in mine tailings. Because previous studies have demonstrated that fertilization is essential for plant growth in these tailings, manure was also added to the tailings. Plant growth and germination were greatest if the expanded clay was added topically to the tailings. To a lesser extent, plant growth and germination was also stimulated by topical additions of porous ceramic. However, no benefit was observed if either amendment was mixed into the top 10 cm of the mine tailings. The concentration of Zn in F. arundinacea tissues was lowest if the expanded clay was added topically to the mine tailings. Roots growing in the layer of clay or ceramic amendment appeared to be smaller, finer, and more abundant than the large, coarse roots found throughout the tailings-manure mixture. These results suggest that topical application of an expanded clay or porous ceramic product will increase seed germination and improve plant establishment and growth in contaminated minespoils.