BackgroundClinical reasoning plays a major role in the ability of doctors to make a diagnosis and reach treatment decisions. This paper describes the use of four clinical reasoning tests in the second National Medical Science Olympiad in Iran: key features (KF), script concordance (SCT), clinical reasoning problems (CRP) and comprehensive integrative puzzles (CIP). The purpose of the study was to design a multi instrument for multiple roles approach in clinical reasoning field based on the theoretical framework, KF was used to measure data gathering, CRP was used to measure hypothesis formation, SCT and CIP were used to measure hypothesis evaluation and investigating the combined use of these tests in the Olympiad. A bank of clinical reasoning test items was developed for emergency medicine by a scientific expert committee representing all the medical schools in the country. These items were pretested by a reference group and the results were analyzed to select items that could be omitted. Then 135 top-ranked medical students from 45 medical universities in Iran participated in the clinical domain of the Olympiad. The reliability of each test was calculated by Cronbach's alpha. Item difficulty and the correlation between each item and the total score were measured. The correlation between the students' final grade and each of the clinical reasoning tests was calculated, as was the correlation between final grades and another measure of knowledge, i.e., the students' grade point average.ResultsThe combined reliability for all four clinical reasoning tests was 0.91. Of the four clinical reasoning tests we compared, reliability was highest for CIP (0.91). The reliability was 0.83 for KF, 0.78 for SCT and 0.71 for CRP. Most of the tests had an acceptable item difficulty level between 0.2 and 0.8. The correlation between the score for each item and the total test score for each of the four tests was positive. The correlations between scores for each test and total score were highest for KF and CIP. The correlation between scores for each test and grade point average was low to intermediate for all four of the tests.ConclusionThe combination of these four clinical reasoning tests is a reliable evaluation tool that can be implemented to assess clinical reasoning skills in talented undergraduate medical students, however these data may not generalizable to whole medical students population. The CIP and KF tests showed the greatest potential to measure clinical reasoning skills. Grade point averages did not necessarily predict performance in the clinical domain of the national competitive examination for medical school students.

Background The incessant and stressful nature of providing care to patients with chronic diseases can cause fatigue in caregivers. Caregivers’ fatigue and reduced quality of life can reduce the patient’s quality of care. Since it is important to pay attention to the mental health of family caregivers, this study investigated the relationship between fatigue and quality of life and their related factors in family caregivers of patients on hemodialysis. Methods This cross-sectional descriptive-analytical study was performed in 2020–2021. One hundred seventy family caregivers were recruited by convenience sampling from two hemodialysis referral centers in the east of Mazandaran province, Iran. The data collection tools were the Family Caregiver Quality of Life questionnaire and Krupp’s fatigue severity scale. Results The majority (88%) of caregivers had moderate to severe fatigue. Caregivers’ fatigue was a major factor influencing their quality of life. There was a significant fatigue difference between some categories of kinship and the caregiver’s income level (P < 0.05). Caregivers with lower income and education levels, those who were the patient’s spouse, and those who could not leave the patient alone had significantly worse quality of life than other caregivers (P < 0.05). Also, caregivers living with the patient in the same house had a worse quality of life than those living separately (P = 0.05). Conclusion Considering the high prevalence of fatigue among family caregivers of patients on hemodialysis and its adverse effect on their quality of life, it is recommended to perform routine screenings and implement fatigue alleviation interventions for these caregivers.

We present a case of aspergillus brain abscess in a 48‐year‐old woman with a history of kidney transplantation and no underlying central nervous system (CNS) disease. Follow‐up of the patient for 4 years shows normal findings. Early diagnosis and aggressive treatment could improve the prognosis of this fatal complication.

Introduction: Chronic kidney disease (CKD) may increase morbidity and mortality. Therefore, early detection of inflammation in kidney transplant recipients with a high risk of transplant rejection is important. Objectives: This study was conducted to compare serum levels of pentraxin-3 (PTX-3), mannose binding lectin (MBL) and high sensitivity C-reactive protein (hs-CRP) in patients with chronic renal failure before and after transplantation. Patients and Methods: This cross-sectional study was carried on 18-80 years old patients receiving immunosuppressive therapy who underwent kidney transplantation in Shahid Beheshti hospital of Babol in 2016. Before transplantation, one week later and two months after transplantation, the serum levels of PTX-3, MBL and hs-CRP were determined. Complications including acute transplant rejection and urinary tract infection were recorded since inflammatory markers were evaluated and compared at the time of complication. Results: The mean age of the patients was 42.07±12.47 years. Transplant rejection and urinary tract infection occurred in 3 (10%) and 4 (13.3%) of patients, respectively. Patients over 55 years of age and those with hypertension had significantly more complications (P=0.03 and P=0.02 respectively). Two months after transplantation, PTX-3 and MBL levels were significantly lower (PTX-3; 10.84±15.88 versus18.75±24.31 ng/dL, P=0.001 and MBL; 764.3±771.35 versus 1157.9±1299.75 ng/dL, P=0.006). In patients with complications, PTX-3, MBL and hs-CRP levels were 16.73±27.98 ng/dL, 710.0±613.19 ng/dL and 8.43±12.10 mg/L, respectively. No significant difference was found between inflammatory markers in complicated and uncomplicated patients. Comparison of changes in PTX-3, MBL and hs-CRP levels before and after transplantation showed a significant difference two months following transplantation compared to pre-transplantation and also one week after it for PTX-3 and MBL (PTX-3: P=0.001 and P=0.009, respectively; MBL: P=0.006 and P=0.03, respectively). Conclusion: Based on the results of this study, PTX-3 and MBL levels can be considered for determining the inflammatory status of kidney transplant patients and the prognosis of transplantation.

Introduction: Cardiovascular disorder(CVD) is one of the most important comorbidities in patients with hemodialysis(HD). Several markers for kidney disease and kidney transplantation have been investigated. Objectives: This study aimed to evaluate the association between three inflammatory biomarkers including C-reactive protein (CRP), pentraxin 3 (PTX-3) and mannose-binding lectin (MBL) with CVD events and mortality in HD patients. Patients and Methods: This study was carried on patients with immunosuppressive therapy aged between 18-80 years with chronic renal failure undergoing HD. Patients were visited at baseline and every six month for 12 months. The levels of biomarkers and complications were recorded before, one week later and 2 months after transplantation. Echocardiography and calculation of ejection fraction(EF) were performed to determine the occurrence of CVD events. Results: Ninety patients with the mean age of 54.0±3.24 years were included. All biomarkers had significant area under the curve for accurate diagnosis between the patients with low EF (with a decreasing measure) and normal EF patients (p<0.05); however, none of them had a significant accurate diagnosis between patients with low EF (with a constant measure) and normal EF patients (P>0.05). PTX-3 and MBL showed a significant correlation to detect CVD events (r=0.987; p<0.0001). Also, PTX-3 and MBL had significant correlations with hs-CRP (P<0.05). None of these markers had significant accuracy for prediction of mortality. Conclusion: Serum level of PTX-3 and MBL not only increase reactive protein, but also may be considered as diagnostic biomarkers for early detection of CVD events in patients with end stage renal disorders.