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This study aims to compare the effectiveness of Hybrid and Pure problem-based learning (PBL) in teaching clinical reasoning skills to medical students. The study sample consisted of 99 medical students participating in a clerkship rotation at the Department of General Medicine, Chiba University Hospital. They were randomly assigned to Hybrid PBL (intervention group, n = 52) or Pure PBL group (control group, n = 47). The quantitative outcomes were measured with the students’ perceived competence in PBL, satisfaction with sessions, and self-evaluation of competency in clinical reasoning. The qualitative component consisted of a content analysis on the benefits of learning clinical reasoning using Hybrid PBL. There was no significant difference between intervention and control groups in the five students’ perceived competence and satisfaction with sessions. In two-way repeated measure analysis of variance, self-evaluation of competency in clinical reasoning was significantly improved in the intervention group in "recalling appropriate differential diagnosis from patient’s chief complaint" (F(1,97) = 5.295, p = 0.024) and "practicing the appropriate clinical reasoning process" (F(1,97) = 4.016, p = 0.038). According to multiple comparisons, the scores of "recalling appropriate history, physical examination, and tests on clinical hypothesis generation" (F(1,97) = 6.796, p = 0.011), "verbalizing and reflecting appropriately on own mistakes," (F(1,97) = 4.352, p = 0.040) "selecting keywords from the whole aspect of the patient," (F(1,97) = 5.607, p = 0.020) and "examining the patient while visualizing his/her daily life" (F(1,97) = 7.120, p = 0.009) were significantly higher in the control group. In the content analysis, 13 advantage categories of Hybrid PBL were extracted. In the subcategories, "acquisition of knowledge" was the most frequent subcategory, followed by "leading the discussion," "smooth discussion," "getting feedback," "timely feedback," and "supporting the clinical reasoning process." Hybrid PBL can help acquire practical knowledge and deepen understanding of clinical reasoning, whereas Pure PBL can improve several important skills such as verbalizing and reflecting on one’s own errors and selecting appropriate keywords from the whole aspect of the patient.

Neither estrogen dependence nor clinical response to hormone therapy of the tumor is guaranteed by the mere presence of receptors for estrogens (ERs) or progesterones (PRs). Immunohistochemical staining of ER with polyclonal anti-ER antibodies after in vitro transformation has enabled the identification of two types of defective ER among human breast cancers: those that are unable to bind to the nucleus in a hormone-filled state and those that bind to the nucleus as naked ER. Preliminary clinical correlation studies demonstrate that a subclassification of ER(+) tumors based on functional abnormalities of ER may predict refractoriness to hormone therapy.

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Investigations to determine the cause of jaundice in an 83-year-old man led to the diagnosis of incomplete obstruction of the common bile duct due to stone formation around an ingested fish bone. Abdominal ultrasound and computed tomography performed preoperatively revealed evidence of chronic cholecystitis with a gallstone and calcification in the common bile duct. Endoscopic retrograde choangiopancreatography showed stone formation in the common bile duct. After normalizing the serum bilirubin level by endoscopic retrograde bile duct drainage, we performed cholecystectomy and choledocholithotomy, which revealed stone formation around an ingested bone in the common bile duct. To the best of our knowledge based on a computer-assisted search, this is only the third report of the formation of a choledocal stone around an ingested fish bone. We reviewed the literature on choledocholithiasis caused by a foreign body, in an attempt to classify this entity according to the pathways through which a foreign body can migrate into the common bile duct.