Teaching clinical reasoning to medical students: A brief report of case-based clinical reasoning approach.

BACKGROUND: Case-based clinical reasoning (CBCR) is the proposed method to improve clinical reasoning. This brief report aimed to evaluate CBCR effectiveness to improve clinical reasoning via an online course. SETTINGS AND DESIGN: This study is a brief report of a before-after quasi-experimental study to evaluate CBCR in medical students of Shahid Beheshti University of Medical Sciences. MATERIALS AND METHODS: Ten online weekly 2-hour sessions of CBCR presentations were instructed to medical students. Each session started with an illness script, and then, the instructor posed the students' five clinical questions in five steps according to the CBCR approach. The clinical reasoning ability of students was evaluated before and 2 weeks after the online courses using four types of standard clinical questions. STATISTICAL ANALYSIS USED: A Wilcoxon signed-rank test was used to assess the difference between pretest and posttest examination scores. RESULTS: This brief report revealed that twenty-one medical students participated in all ten sessions of the CBCR online course and were evaluated in pretest and posttest examinations. A significant improvement in the clinical reasoning total scores in the posttest examination compared with the pretest examination was observed (P = 0.001). In terms of specific types of clinical questions, the mean posttest scores for clinical reasoning problem (CRP) and key feature (KF) examinations were higher than the pretest scores (P = 0.001 and P = 0.005, respectively). CONCLUSIONS: Applying the CBCR approach improved the total clinical reasoning score of medical students during the course. Further studies are needed to evaluate whether this improvement would persist in workplace settings or not.

Quality of in-hospital care in traumatic spinal column and cord injuries (TSC/SCI) in I.R Iran.

PURPOSE: This study aimed to implement the Quality of Care (QoC) Assessment Tool from the National Spinal Cord/Column Injury Registry of Iran (NSCIR-IR) to map the current state of in-hospital QoC of individuals with Traumatic Spinal Column and Cord Injuries (TSCCI). METHODS: The QoC Assessment Tool, developed from a scoping review of the literature, was implemented in NSCIR-IR. We collected the required data from two primary sources. Questions regarding health system structures and care processes were completed by the registrar nurse reviewing the hospital records. Questions regarding patient outcomes were gathered through patient interviews. RESULTS: We registered 2812 patients with TSCCI over six years from eight referral hospitals in NSCIR-IR. The median length of stay in the general hospital and intensive care unit was four and five days, respectively. During hospitalization 4.2% of patients developed pressure ulcers, 83.5% of patients reported satisfactory pain control and none had symptomatic urinary tract infections. 100%, 80%, and 90% of SCI registration centers had 24/7 access to CT scans, MRI scans, and operating rooms, respectively. Only 18.8% of patients who needed surgery underwent a surgical operation in the first 24 h after admission. In-hospital mortality rate for patients with SCI was 19.3%. CONCLUSION: Our study showed that the current in-hospital care of our patients with TSCCI is acceptable in terms of pain control, structure and length of stay and poor regarding in-hospital mortality rate and timeliness. We must continue to work on lowering rates of pressure sores, as well as delays in decompression surgery and fatalities.

Does hazelnut consumption affect brain health and function against neurodegenerative diseases?

INTRODUCTION: A healthy daily diet and consuming certain nutrients, such as polyphenols, vitamins, and unsaturated fatty acids, may help neuronal health maintenance. Polyphenolic chemicals, which have antioxidant and anti-inflammatory properties, are involved in the neuroprotective pathway. Because of their nutritional value, nuts have been shown in recent research to be helpful in neuroprotection. OBJECTIVE: Hazelnut is often consumed worldwide in various items, including processed foods, particularly in bakery, chocolate, and confectionery products. This nut is an excellent source of vitamins, amino acids, tocopherols, phytosterols, polyphenols, minerals, and unsaturated fatty acids. Consuming hazelnut may attenuate the risk of neurodegenerative disorders including Alzheimer's disease, Parkinson's disease, amyotrophic lateral sclerosis, multiple sclerosis, and Huntington's disease due to its anti-inflammatory and anti-oxidant qualities. RESULTS: Many documents introduce hazelnut as an excellent choice to provide neuroprotection against neurodegenerative disorders and there is some direct proof of its neuroprotective effects. DISCUSSION: So hazelnut consumption in daily diet may reduce neurodegenerative disease risk and be advantageous in reducing the imposed costs of dealing with neurodegenerative diseases.

Pre-Hospital and Post-Hospital Quality of Care in Traumatic Spinal Column and Cord Injuries in Iran.

STUDY DESIGN: A retrospective study. OBJECTIVES: The quality of care (QoC) for spinal column/cord injury patients is a major health care concern. This study aimed to implement the QoC assessment tool (QoCAT) in the National Spinal Cord/Column Injury Registry of Iran (NSCIR-IR) to define the current state of pre- and post-hospital QoC of individuals with Traumatic Spinal Column and Spinal Cord Injuries (TSC/SCIs). METHODS: The QoCAT, previously developed by our team to measure the QoC in patients with TSC/SCIs, was implemented in the NSCIR-IR. The pre-hospital QoC was evaluated through a retrospective analysis of NSCIR-IR registry data. Telephone interviews and follow-ups of patients with SCI evaluated the QoC in the post-hospital phase. RESULTS: In the pre-hospital phase, cervical collars and immobilization were implemented in 46.4% and 48.5% of the cases, respectively. Transport time from the scene to the hospital was documented as <1 hour and <8 hours in 33.4% and 93.9% of the patients, respectively. Post-hospital indicators in patients with SCI revealed a first-year mortality rate of 12.5% (20/160), a high incidence of secondary complications, reduced access to electrical wheelchairs (4.2%) and modified cars (7.7%), and low employment rate (21.4%). CONCLUSION: These findings revealed a significant delay in transport time to the first care facilities, low use of immobilization equipment indicating low pre-hospital QoC. Further, the high incidence of secondary complications, low employment rate, and low access to electrical wheelchairs and modified cars indicate lower post-hospital QoC in patients with SCI. These findings imply the need for further planning to improve the QoC for patients with TSC/SCIs.

BDNF and p-GSK3ß in the hippocampus mediate the impairment of delay-based decision making in morphine-dependent rats.

It has been shown that morphine addiction impairs cognitive brain functions. However, there is no document to consider the effect of morphine dependency and its withdrawal on cost-benefit decision making and its molecular pathways. The present study aimed to evaluate the influences of morphine dependency and its withdrawal on delay-based decision making and the BDNF, p-GSK3ß, and p-CREB levels during the decision making in the hippocampus. Different groups of rats were trained in a T-maze with the delay-based cost-benefit decision-making paradigm. After that, the animals were dependent on morphine, and the percentage of the high reward preference was evaluated. After behavioral tests, BDNF level, p-GSK3ß/GSK3ß ratio, and p-CREB/CREB ratio in the hippocampus measured by Western blot analysis. The gathered data showed that level of BDNF enhanced while p-GSK3ß/GSK3ß ratio and p-CREB/CREB ratio in the hippocampus did not change during delay-based decision making. In morphine-dependent rats, the p-GSK3ß/GSK3ß ratio increased, the BDNF level and p-CREB/CREB ratio did not change in the decision making procedure. After withdrawal from morphine, the BDNF level raised while p-GSK3ß/GSK3ß ratio and p-CREB/CREB ratio did not change compared to the addiction group. The data declared that BDNF in the hippocampus has a critical role in delay-based decision making. Change in p-CREB in the hippocampus is not related to decision making in normal and morphine-dependent rats. P-GSK3 in the hippocampus is not involved in the decision making in normal rats, but during decision making in morphine-dependent rats, its level increased.

Impairment of cost-benefit decision making in morphine-dependent rats is partly mediated via the alteration of BDNF and p-CREB levels in the nucleus accumbens.

The ability to choose goals based on decision usefulness or the time required to reach the goals chosen are important aspects of decision making. There is considerable evidence in the literature indicating the fact that drug abuse affects different aspects of cognition. In the current study, we assessed the effects of morphine dependence and its withdrawal on cost-benefit decision making and furthermore the involvement of BDNF and p-CREB in the nucleus accumbens, a key brain area involved in decision making was measured. Different groups of male Wistar rats were trained in an effort-based and/or delay-based form of cost-benefit T-maze decision-making task. Thereafter, the animals were morphine dependent and the percentage of the high reward preference was evaluated. After behavioral tests, the BDNF level, and p-CREB/CREB ratio were measured by Western blot analysis. The results showed that during effort-based but not delay-based decision making, BDNF and p-CREB levels increased. During effort-based decision making in morphine dependent rats, BDNF decreased but there was no significant change in p-CREB. Besides, during delay-based decision making in the morphine dependent group, both BDNF and p-CREB did not show any significant change. These findings revealed that BDNF and p-CREB/CREB ratio in the NAc are essential factors for effort-based but not delay-based decision making. In addition, impairment of effort-based decision making in morphine dependent rats is related to the decrease of BDNF level but not p-CREB/CREB ratio in the NAc. However, delay-based decision making defects in morphine dependent rats did not associate with the change in BDNF and p-CREB levels in the NAc.

Naloxone-precipitated withdrawal ameliorates impairment of cost-benefit decision making in morphine-treated rats: Involvement of BDNF, p-GSK3-ß, and p-CREB in the amygdala.

Several studies indicated that morphine administration impairs cognitive brain functions. Therefore, in the current study, we investigated the effect of subchronic exposure to morphine and its withdrawal on effort- and/or delay-based forms of cost-benefit decision making and alterations in p-CREB/CREB ratio, p-GSK3ß/GSK3ß ratio, and BDNF level during decision making in the amygdala. Our data displayed an impairment of both forms of cost-benefit decision making following subchronic exposure to morphine. However, preference of high reward/high effort and/or high delay reward increased after naloxone injection. In molecular section, levels of BDNF and p-CREB/CREB ratio increased during cost-benefit decision making while p-GSK3ß/GSK3ß ratio decreased in both forms of decision making. In morphine-treated rats, level of BDNF and p-CREB/CREB ratio reduced during both forms of decision making while p-GSK3ß/GSK3ß ratio increased during delay-based and did not have a significant difference with the control group during effort-based decision making. On the withdrawal day, BDNF level raised while p-GSK3ß/GSK3ß ratio attenuated compared to morphine-treated group in both form of decision making. In addition, p-CREB/CREB ratio increased only during delay-based decision making on the withdrawal day. In conclusion, our data revealed that subchronic exposure to morphine interferes with the cost-benefit decision making may be via changes in level of BDNF, p-CREB/CREB and p-GSK3ß/GSK3ß ratio in the amygdala.

Exercise training with concomitant nitric oxide synthase inhibition improved anxiogenic behavior, spatial cognition, and BDNF/P70S6 kinase activation in 20-month-old rats.

This study aimed to investigate the effect of exercise and nitric oxide synthase (NOS) inhibition on memory, anxiety, and protein levels of brain-derived neurotrophic factor (BDNF) and P70S6 kinase (P70S6K). Twenty-month-old rats were divided into 6 groups: a control group, 2 groups treated with l-nitro-arginine methyl ester (L-NAME) (25 or 100 mg/kg) for 63 days, 2 groups treated with L-NAME (25 or 100 mg/kg) for 63 days plus 2 months of exercise, and 1 group treated with exercise. Behavioral tests were conducted to determine the anxiolytic and memory-improving role of exercise and NOS inhibition. BDNF, P70S6K, and cleaved caspase-3 protein levels in the hippocampus and prefrontal cortex were evaluated by Western blotting. Exercise and L-NAME (25 mg/kg) or their combination had an anxiolytic effect and improved spatial memory in old rats compared with the control or exercised group, respectively. Exercise and treatment with a low dose of L-NAME (25 mg/kg) each increased BDNF and P70S6K in the hippocampus and prefrontal cortex compared with levels in control rats. In comparison with exercise alone, co-treatment with exercise and a low dose of L-NAME (25 mg/kg) also increased BDNF and P70S6K in the hippocampus. The neuronal level of cleaved caspase-3 was reduced in the L-NAME (25 mg/kg) + exercise group compared with the exercised group. The L-NAME (100 mg/kg) + exercise treatment had no positive behavioral or molecular effects compared with exercise alone. The protective role of NOS inhibition and aerobic exercise against aging is probably modulated via BDNF and P70S6K in the brain.