Sound Clinical Judgment Research Articles

The Future of Neurology

Yogi Berra, the former New York Yankees baseball manager, known for his interesting phraseology, famously once said, “It's tough to make predictions, especially about the future.” While this has become somewhat of a tired cliche, there is an inherent validity to the argument that makes us somewhat cautious and humble in any discussion regarding the future of Neurology. At the risk of fumbling our way toward the truth, we remind ourselves that in order to find the truth, we need to ask the right questions. Other colleagues have written eloquently about the changing role of neurologists (Engstrom and Hauser, 1994; Bradley, 2000; Freeman and Vatz, 2010), and the fundamental changes facing Child Neurology (Ridel and Gilbert, 2010). A continuous stream of advances in basic neuroscience research, gene identification, neurogenomics, cutting-edge genetic techniques, neurodiagnostic tools including advanced neuroimaging technologies (Masdeu and Bakshi, 2005), and longitudinal biomarkers, coupled with new treatment modalities and paradigms for neurologic disease, suggests increased demands on available practitioners. In view of the growing aging population, associated with declines in infant mortality and treatment of infectious disease, more people will suffer from age related neurologic disorders such as stroke, dementia, Parkinson's disease, epilepsy, and autoimmune disorders (Engstrom and Hauser, 1994; Bradley, 2000; Freeman and Vatz, 2010; Weiner, 2007). In the past, a neurologist was recognized particularly for skilled diagnoses using clues derived from a thorough and elaborate history and physical examination, but treatment options were limited. Colloquially, the neurologist would “diagnose and adios.” With the advent of advanced neuroimaging and laboratory techniques, there has been much lament about the disappearance of the neurologists’ much vaunted skill in clinical diagnosis. And yet, the various tests, coupled with advanced treatment techniques, have certainly led to an explosion of opportunity, with both increased demand for neurologists and an increased number of people interested in the field. In the near future, the role of diagnostic testing in clinical neurology (as in all of medicine) will only further accelerate. There will be some value to the diagnostic prowess of neurologists in determining the appropriateness and meaning of complex and potentially unnecessary tests and procedures. As noted by Gooch and Amato (2010), in a discussion of the utility of anti-ganglioside antibodies in the diagnosis of multifocal motor neuropathy: “In this era of limited resources, the judicious exercise of sound clinical judgment in crafting a logical and efficient diagnostic evaluation has never been more important. Careful selection of the best path to the final diagnosis will not only most benefit our patients but will also as health reform continues to advance, insure that our precious (and finite) medical resources are not necessarily wasted” (Gooch and Amato, 2010). Still, academicians simply become Luddites if they lament how testing has superseded the neurologic history and physical examination which were never as accurate as we cared to admit. We respectfully suggest that the future of neurology will be critically dependent on harmonizing the tensions between clinical skills and an over-reliance on testing paradigms. The future of Neurology will also be reflected in the greater opportunities to develop therapeutic interventions, delay, or ideally prevent progressive neurodegenerative diseases, and the roles to be played by the new breed of neurologists in providing these interventions. There will likely be explosive growth in potential medical therapies including novel drugs, human pluripotent stem cell technology and gene therapies, and new immunosuppressant modalities in the near future (Mallarkey, 2008). There will also be an increased role for neurologists in interventional fields such as stroke, pain, neurostimulation, and even neuroregeneration. There will also be a continued separation between the practice of intensive and hospital-based neurology and office-based general and specialty neurology. The parallels with Cardiology/Internal Medicine combined with the growth of procedural non-surgical focused specialists in these fields are both obvious and inevitable given the profound shift toward a treatment oriented focus for neurology in the near future. The challenge for neurology will be whether we can satisfy the need for neurologic expertise in providing these treatments or whether others will pick up the slack for this pent-up demand for aggressive treatment of neurologic disease. The field of neurology remains one of the most dynamic areas of medicine, with advances on many fronts. Frontiers in Neurology offers an unprecedented opportunity for a more accessible, more manageable, and more useful dynamic interactive seminal exchange between the world community of neurologists and neuroscientists striving toward a common goal of excellence. Only by sharing your expertise and knowledge with the neurological community, can we achieve our ultimate goal of improving the quality of life and outcomes for patients with neurological disorders.

Catheter-directed thrombolysis for deep vein thrombosis

Strong proof-of-concept evidence suggests that catheter-directed thrombolysis (CDT) may enable prevention of the post-thrombotic syndrome (PTS) in patients with deep vein thrombosis (DVT). The goal of this review is to summarize recent publications and thereby improve physicians' ability to make sound clinical judgments on employing CDT. Anticoagulation and compression therapy are necessary elements of PTS prevention efforts, but are not sufficient to prevent PTS in many DVT patients. Patients with acute iliofemoral DVT represent a subgroup at particularly high risk of developing recurrent venous thromboembolism and PTS. Three comparative studies and the preliminary results of one ongoing European randomized controlled trial (RCT) (the CaVenT trial) suggest that CDT is reasonably well tolerated and that it may provide superior clinical outcomes for patients with extensive proximal DVT. In the US, the ongoing NIH-sponsored ATTRACT trial should clarify the risk-benefit ratio of pharmacomechanical CDT for acute proximal DVT. In the meantime, the preponderance of available evidence suggests that CDT (with anticoagulation) should be routinely considered as first-line therapy for patients with extensive acute iliofemoral DVT, low expected bleeding risk, and good functional status. CDT should be employed for DVT patients who have severe clinical manifestations such as acute circulatory limb threat, for patients who have not achieved therapeutic objectives with initial anticoagulation, and as first-line therapy for selected patients with acute iliofemoral DVT.

Bleeding risk for surgical dialysis procedures in children with hemolytic uremic syndrome

Children with hemolytic uremic syndrome (HUS) frequently develop acute kidney injury (AKI) requiring renal replacement therapy (RRT). Peritoneal dialysis (PD) is commonly used. Despite high rates of thrombocytopenia, there is concern that platelet transfusions may worsen HUS by exacerbating microthrombi formation. We evaluated bleeding risk for PD catheter placement with or without central venous catheter (CVC) placement in children with HUS. Records from 1998 to 2007 were searched. Data regarding patient demographics, PD catheter placement, CVC placement, occurrence of procedure-associated bleeding, and time from insertion to removal of PD catheter were collected. Patients were stratified according to those who received and those who did not receive platelet transfusions. Seventy-three patients were identified. Twenty-two (30%) patients received platelet transfusion while 51 (70%) did not. Mean preoperative platelet counts were 37,600+/-21,900/mm(3) in patients receiving transfusions and 64,800 +/- 38,800/mm(3) in patients not receiving transfusions. Sixty-seven children (92%) also underwent CVC placement. There were no bleeding complications related to these procedures in either group. No differences in time to removal of the PD catheter were detected. Although caution and sound clinical judgment must be exercised, our findings suggest that PD catheter and CVC placement can be accomplished safely in most children with HUS, without need for platelet transfusion in spite of the associated thrombocytopenia.

The challenge of evidence in clinical medicine

The primary goal of evidence-based medicine (EBM) has been to change the way clinicians make decisions. But EBM has inappropriately privileged the results of clinical research for medical decision making and has undermined the importance of other kinds of medical knowledge, pathophysiologic understanding and clinical experience, to clinical practice. Here, the specific advantages and limitations of each kind of medical knowledge are examined. No particular kind of medical knowledge is necessarily more compelling than the others when it comes to making specific patient care decisions. Several cases where medical knowledge is conflicting are examined to demonstrate the weighting and negotiation necessary for sound clinical judgement. Expert clinicians must utilize a variety of reasons and methods of reasoning in arriving at the best clinical decision or recommendation for an individual patient. The process can be formalized and made explicit, but it cannot be narrowed, simplified and focused only on the results of clinical research.

Management of Atrial Fibrillation: Focus on Rate Versus Rhythm Contr

Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults and accounts for approximately one-third of all arrhythmias requiring admission to the hospital. Treatment strategies are determined by the classification of AF, whether paroxysmal or persistent, as well as numerous patient-specific cardiac and medical considerations (eg, pre-existing congestive heart failure or previous myocardial infarction). Thromboembolic risk also influences whether patients are treated with antiplatelet or anticoagulant medications. Several large clinical trials have deemed both rate and rhythm control acceptable treatment strategies for AF. Additionally, nonpharmacologic approaches such as surgical and electroablative options also exist. The clinician must exercise sound clinical judgment when deciding which treatment approach is best suited for a particular patient.

Rate of conversion and complications of laparoscopic cholecystectomy in a tertiary care center in Saudi Arabia.

BACKGROUND AND OBJECTIVES:Problems during laparoscopic cholecystectomy include bile duct injury, conversion to open operation, and other postoperative complications. We retrospectively evaluated the causes for conversion and the rate of conversion from laparoscopic to open cholecystectomy and assessed the postoperative complications.METHODS:Of 340 patients who presented with symptomatic gall bladder disease over a 2-year period, 290 (85%) patients were evaluated on an elective basis and scheduled for surgery, while the remaining 50 (14.7%) patients were admitted emergently with a diagnosis of acute cholecystitis.RESULTS:The mean age of the patients was 41.9 (12.6) years. Conversion to laparotomy occurred in 17 patients (5%). The incidence of complications was 3.2%. The most common complication was postoperative transient pyrexia, which was seen in four patients (1.2%) followed by postoperative wound infection in three patients (0.9%), postoperative fluid collection and bile duct injury in two patients each (0.6%).CONCLUSION:Laparoscopic cholecystectomy remains the ‘gold standard’ by which all other treatment modalities are judged. Conversion from laparoscopic to open cholecystectomy should be based on the sound clinical judgment of the surgeon and not be due to a lack of individual expertise.

JRCALC: advice or requirement?

The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) is the body that develops and reviews clinical guidelines for use by paramedics working in the UK and it has been instrumental in moving ambulance services from locally-derived protocol and guidance to a national, systematically developed set of guidelines based upon current best evidence. The evidence is based upon systematic reviews, meta-analyses and randomized, controlled trials, where available. JRCALC states that its ‘guidance is advisory and has been developed to assist health care professionals, together with patients, to make decisions about the management of the patient's health, including treatments’ (JRCALC, 2006). The guidance is intended to support decisions and sound clinical judgement, not replace it. This begs the common question: what are the consequences for me if I make a clinical decision that deviated from the JRCALC guidance?

Oral biopsy: A dental gawk

Sir, Dermatologists are often confronted with neoplasms and diseases of the oral cavity. Although many may be reluctant to perform oral surgical procedures, a biopsy is often needed to establish a definitive diagnosis, and biopsy of the oral cavity is a safe and useful technique that can be easily employed by dermatologists. Biopsies should be kept superficial, and neurovascular structures must be avoided to prevent complications. The primary step in oral cancer detection and diagnosis is patient history and thorough soft-tissue examination. If a suspicious lesion is discovered, it is biopsied and a histological examination of the sample is performed. Currently, a biopsy with histopathology is considered the gold standard for diagnosis of squamous cell carcinoma. The word biopsy originates from the Greek terms bios (life) and opsis (vision): vision of life. A biopsy consists of the obtainment of tissue from a living organism with the purpose of examining it under the microscope, in order to establish a diagnosis based on the sample. [1] There are oral lesions whose diagnosis can be made relying on data gathered during the history and/or physical examination, but there are others where histopathological studies are needed to confirm the presumed clinical diagnosis. The aim of biopsy is to define a lesion on the basis of its histopathological aspect, to establish a prognosis in malignant or premalignant lesions, facilitate the prescription of specific treatment, contribute to the assessment of the efficacy of the treatment, and act as a document with medical-legal value. Thorough inspection of the oral cavity should be a part of any complete head and neck examination. Close visual inspection should be performed with adequate lighting, and each of the anatomic regions in the oral cavity should be palpated. Approximately 10% of patients who are examined have some abnormality of the oral mucosa. Some lesions can be diagnosed on the basis of the history and clinical findings alone. For other lesions, additional information may be required to properly guide any indicated therapy. Often, biopsy with ample tissue for microscopic analysis is the definitive procedure. Numerous methods can be used to collect tissue samples from the oral mucosa for histopathologic examination. Performing biopsy with a scalpel is the standard and generally produces the most satisfactory specimen. Other techniques include the use of a needle, biopsy punch, biopsy forceps, laser, or electrocautery device. Needles may be appropriate in sampling cells from mass lesions, but they are of no benefit in the evaluation of surface lesions. Electrocautery produces thermal damage and artifact, which make evaluation of the specimen difficult; therefore, electrosurgery should be avoided during oral mucosal biopsy. Electrosurgery may be of benefit for wide local excisions of known intraoral malignancies after a scalpel is used to atraumatically obtain marginal specimens for frozen sections. Oral biopsy is considered essential for the definitive diagnosis of diseases of the oral mucosa, and for the subsequent planning of appropriate treatment. Although the obtainment of biopsies is widely used in all medical fields, the practice is not so widespread in dental practice––fundamentally because of a lack of awareness of the procedure among dental professionals. In this context, it must be taken into account that the early diagnosis of invasive oral malignancy may be critical for improving the patient prognosis. [1,2] When considering biopsy, a little forward planning and thought can greatly improve the diagnostic value obtained. Careful handling of the tissue and prompt appropriate fixation will enable a confident histological diagnosis to be reached. Inadequate care at any stage could result in a nondiagnostic biopsy and may necessitate the patient having a repeat procedure with its ensuing physical and psychological morbidity. [2] Lastly, the screening tool of greatest benefit is cautious oral examination and sound clinical judgment. The clinician’s knowledge and training may eliminate the need for biopsy in cases where lesions are clinically definable. For entities of uncertain significance or etiology, a biopsy provides the simplest and most speedy means of obtaining the perfect diagnosis. In the concern of the patient’s welfare, correct diagnosis is of extreme importance.

“Imaging of the Intervention” a new paradigm for our specialty

Interventional Radiology (IR) is a subspecialty of diagnostic Radiology. It has dramatically developed in the recent past and has became part of daily practice in most Health Care centres in Europe and worldwide. Because of its major role in various diseases, IR has gained wide acceptance and despite turf battles on some intervention, IR are in a central position to create, perform, determine the indication and the follow-up of mini-invasive image guided interventions. It is common sense that optimized results and appropriate levels of activity of Interventional Radiology relies on sound clinical judgement but also in a large part on the results of Imaging workup. Unfortunately, Interventional Radiologists today share the experience that imaging is not optimized in several aspects and that there is a need for better understanding of the principle, the indications, results and complications of Interventional procedures. First of all, there is not enough awareness of the indications for IR procedures among diagnostic radiologists. How many cases are not referred to IR for advice, despite obvious feasibility? How many pelvic MR patients are not referred for possible Uterine Fibroid Embolization? How many aortic imaging studies are not referred for possible EVAR/TEVAR? How many typical osteoporotic fractures? How many complex biliary stenoses ?…. These missed opportunities are patients who lose the potential benefit of undergoing minimally invasive intervention. In addition the field of IR does not develop appropriately. Secondly, when reading the report from our diagnostic radiology colleagues, we know that we often have to re-analyse/re-interpret the images for our own purpose, in order to answer our own specific IR related questions. Examples include: CTA workup for Abdominal Aortic Aneurysms reporting on the “length of the aneurysm” but not on the infra-renal neck; Lower limb CTA reporting on “calcified arteries” and “infiltration” of the Superficial Femoral Artery with no attempt to search for a tight stenosis that could be amenable for balloon dilatation; Liver imaging reporting on “2 metastasis in the left liver” or HCC workup before chemo-embolisation that do not search for extra hepatic feeding arteries. There are many other examples covering the whole field of IR with all types of imaging techniques. Such reports which do not consider IR factors do not prompt referring clinicians to propose Intervention Radiological procedures for their patients, thereby reducing the appropriate growth and appreciation of IR. If all this is true for pre operative imaging it is certainly equally important for follow- up imaging. How many reports will really help us when we see the patient in consultation after an intervention? How many of our diagnostic colleagues truly understand which complications needs to be ruled out. How many diagnostic radiologists specifically assess tumour response the way Interventional Radiologists require it according to international consensus and to the way a specific intervention was performed in a specific patient? Here again, we often need to re-analyse the images and use our own “diagnostic radiology hat” to ensure that optimum/ focused information is derived from the images. All these considerations demonstrate each day that there is a need for a specific effort of teaching and training of all radiologists toward a better understanding of imaging tailored to the need of IR. The concept of “Imaging of the Intervention” that we propose today is a way to address this problem in all its aspect. “Imaging of the Intervention” would concentrate on proposing tailored training opportunities on all its aspects including lectures, courses, focused review articles, books and virtual material. This effort would deserve dedicated time during pre a post graduate programs of all Radiologists in order to widespread this specific knowledge in all its aspects in our Radiological Community world wide. We believe that the Radiology community must identify this need and this new opportunity for both diagnostic and Interventional Radiologists: the demand on diagnostic imaging and the expertise will increase just as the number and quality of intervention will increase in parallel for the global benefit of our specialty. Both diagnostic and interventional communities are missing major opportunities each day due to this absence of specific knowledge. All of us need to push forward the agenda on the concept of “Imaging of the Intervention” and put it into practice not only in our daily clinical practice but also at the academic level in national and European scientific societies.

Retrograde intubation in a case of ankylosing spondylitis posted for correction of deformity of spine

Ankylosing spondylitis (AS) patients are most challenging. These patient present the most serious array of intubation and difficult airway imaginable, secondary to decrease or no cervical spine mobility, fixed flexion deformity of thoracolumbar spine and possible temporomandibular joint disease. Sound clinical judgment is critical for timing and selecting the method for airway intervention. The retrograde intubation technique is an important option when fiberoptic bronchoscope is not available, and other method is not applicable for gaining airway access for surgery in prone position. We report a case of AS with fixed flexion deformity of thoracic and thoracolumbar spine, fusion of posterior elements of cervical spine posted for lumbar spinal osteotomy with anticipated difficult intubation. An awake retrograde oral intubation with light sedation and local block is performed.

Unintended Hepatic Adverse Events Associated with Cancer Chemotherapy

Chemotherapy is meant to be toxic, but it is particularly aimed at the tumor cells. Collateral damage may occur to normal cells and tissues, especially if they are fairly rapidly regenerating, as is the case for bone marrow cells, intestinal epithelial cells, and liver cells after hepatic injury. The liver has a great capacity to resist injury, overcome it, and to regenerate, even after quite massive injury (resection of 50%-65%, for example). This capacity may make it susceptible to chemotherapeutic toxicity, and a struggle between injury and adaptation, leading to recovery and tolerance or to failure and death. If the chemotherapy is aimed just at delaying progression of the cancer for a few weeks or months, it may not be worth the risk of irreversible liver injury developing in that time. Close clinical observation and sound clinical judgment are required.

Management of hematological malignancies during pregnancy

The management of hematological malignancies during pregnancy is a challenging endeavor, which not only requires technical skills and knowledge by the clinicians but also requires sound clinical judgment and compassion, keeping in mind the patient and family preferences and, ultimately, the wellbeing of the neonate. The incidence of hematological malignancies during pregnancy is rare, ranging from 1 in 1,000 to 1 in 10,000 deliveries, impeding the design and execution of large prospective studies. The purpose of this review is to evaluate the limited existing data and make useful suggestions in the management of acute and chronic leukemias, Hodgkin and non-Hodgkin lymphomas, plasma cell myeloma, and other hematological malignancies, such as myelodysplastic syndromes and hairy cell leukemia, during pregnancy.

Correlation between Elevated D-Dimer and BNP Levels in Various Clinical Diagnoses

Background: D-Dimer level is most useful clinically in excluding the diagnosis of acute thromboembolism. The role of B-type natriuretic peptide (BNP) is well established in the diagnosis of heart failure. Heart failure state in itself predisposes one to thrombosis and may cause elevation in D-Dimer level. Pulmonary thromboembolism, on the other hand, may lead to elevated right sided heart pressure and cause an increase in BNP level. Despite this known potential interplay between BNP and D-Dimer levels, there is a paucity of data regarding their correlation in clinical setting. Methods: This is a single center retrospective study analyzing the correlation between elevated D-Dimer and BNP levels in patients who presented with admitting diagnosis of congestive heart failure, pulmonary embolism, sepsis syndrome and acute coronary syndromes. Spearman correlation coefficient was utilized to assess the correlation between the D-Dimer and BNP levels. All statistical analysis was done using SAS software. Results: A total of 145 consecutive patients with both elevated D-Dimer and BNP levels were included in this study. The most common admitting diagnosis was decompensated heart failure, followed by pulmonary embolism and sepsis syndrome. Among the reported co-morbidities, diabetes mellitus was present in 44%, hypertension in 77%, and coronary artery disease in 51%. Based on our analysis, there is a moderate correlation between the level of D-Dimer and BNP (Spearman correlation coefficient of 0.46) in all-various clinical diagnosis. The strongest correlation between these 2 biomarkers were found in decompensated heart failure patients, followed by pulmonary/deep venous thromboembolism, and sepsis syndrome patients. Conclusions: Based on this study, elevated levels of D-Dimer and BNP are commonly found in various clinical diagnosis, such as in decompensated heart failure, pulmonary embolism, and sepsis syndrome. This moderately strong correlation between the 2 biomarkers may mislead clinicians in achieving the correct diagnosis for their patients. Our finding should stress the importance of sound clinical judgment and the peril of over reliance in biomarkers to attain the correct diagnosis.

Morbid obesity and gross malnutrition are both poor predictors of outcomes after liver transplantation: What can we do about it?

Morbid obesity and gross malnutrition are both poor predictors of outcomes after liver transplantation: What can we do about it?

Risk stratification in surgically repaired tetralogy of Fallot

Tetralogy of Fallot is the most common form of congenital heart disease in implantable cardioverter–defibrillator (ICD) recipients. Indeed, sudden death of presumed arrhythmic etiology is the most frequent mode of demise in patients with surgically repaired tetralogy of Fallot, often in early-to-mid adulthood. Nevertheless, the overall annual incidence of sudden death is actually low. Therein lies the major challenge of risk stratification. This review highlights some of the complexities involved in risk stratifying patients with tetralogy of Fallot, underscoring the importance of avoiding oversimplification by means of a rigid algorithm that dictates therapy. To complement sound clinical judgment, a quantitative probabilistic approach is presented, which considers the body of literature from primary prevention ICD trials, risk factors identified by observational studies, the value of programmed ventricular stimulation and insights gleaned from studying ICD recipients with tetralogy of Fallot.

The Influence of Concept-Based Learning Activities on Students' Clinical Judgment Development

The traditional nursing clinical education model of total patient care is becoming inadequate. New models are needed to foster deeper clinical thinking, thereby affecting students' development of clinical judgment. Concept-based learning activities, first introduced in 1990, offer a focus on a specific concept. This study evaluated the effect of concept-based learning activities on the development of clinical judgment in baccalaureate nursing students. The clinical judgment of students who were and were not exposed to concept-based learning activities was compared. Quantitative data were analyzed using a univariate analysis. In addition, a focus group consisting of members of the treatment group provided qualitative data. Results suggest concept-based learning activities are a clinical learning strategy that should be considered by faculty to deepen clinical thinking in preparation for reaching sound clinical judgments.

Critical Thinking in Anesthesia

Critical Thinking in Anesthesia

A Critical Review: Does Thiopental Continuous Infusion Warrant Therapeutic Drug Monitoring in the Critical Care Population?

Thiopental is a barbiturate used in traumatic brain injuries (TBIs) to reduce intracranial pressure (ICP) and to manage cerebral ischemia. As thiopental follows Michaelis-Menten kinetics, therapeutic drug monitoring (TDM) has been used in practice to improve efficacy and reduce adverse effects. However, its role is still debatable, and TDM is not widely practiced. Current evidence suggests that thiopental therapy may improve mortality and functional outcome in a subpopulation of patients with severe TBI with elevated ICP refractory to conventional medical therapy. Several analytical methods are available to quantify thiopental concentrations. This review uses a previously published 9-step decision-making algorithm to determine whether TDM of thiopental in TBI is warranted. There seems to be poor correlation between thiopental concentration and pharmacological response in terms of neurological response, ICP, electroencephalography, and drug toxicity. There is no established therapeutic range for thiopental continuous infusion due to a wide range of plasma concentrations corresponding to efficacy (25-50 mg/L) and toxicity (30-70 mg/L) and the resulting overlap between the 2. Thiopental exhibits intrapatient and interpatient variability due to age, obesity, renal and hepatic dysfunction, Michaelis-Menten kinetics, and hepatic enzyme autoinduction. Available evidence suggests that TDM of thiopental continuous infusion is not beneficial in improving efficacy or avoiding toxicity. There are however 2 possible scenarios in which TDM may provide additional information to sound clinical judgment. The first is providing patient-specific plasma target concentration to guide titration of therapy. The second scenario is differentiating between brain death and barbiturate-induced coma.

Teaching laparoscopy to residents: How can we select good candidates?

Modern medicine incorporates minimally invasive approaches in virtually all areas of surgery, and its application will continue to expand. The laparoscopic approach to many complex procedures is accompanied by a long learning curve that is not easily overcome or bypassed. Current training methods involve box trainers, virtual reality simulators, and live animal models that all attempt to replicate laparoscopic scenarios with varying degrees of success. The emphasis in training is now on intensive fellowship courses in high-volume centers that may overcome the learning curves associated with de novo development of laparoscopy. The many attempts to devise tools to assess laparoscopic skills have at best served as tests to discriminate between existing skill levels but do not provide a reliable tool to predict eventual laparoscopic ability. The traditional attributes of sound knowledge and clinical judgement that make a good surgeon are true of a good laparoscopist with perhaps the added requirement of stamina and motivation to complete the arduous training programs that are now needed to become competent in laparoscopy.

Best Practice Guidelines for Forensic Neuropsychological Examinations of Patients With Traumatic Brain Injury

Forensic examiners generally agree that their contributions to the forensic process have to be based on scientific principles, high ethical values, and sound clinical skills and judgment. In part I, the challenges of maintaining high ethical standards as a scientist-practitioner are addressed. In part II, the scientific strengths and weaknesses of our neuropsychological assessments are explored within the context of the 4 articles published in this issue. Specifically, Wood points out that while most traumatic brain injuries (TBIs) compromise the prefrontal cortex (PFC), traditional neuropsychological examinations do not fully capture to what extent PFC damage disrupts cognitive, emotional, and social regulation. New advances in clinical neuroscience are presented to facilitate a more detailed understanding of PFC functioning. Schwarz et al examine how clinical neuropsychology services can adequately handle forensic consultations. Frederick and Bowden, meanwhile, identify the persistent weaknesses of various Symptom Validity Tests in reliably classifying poor effort and malingering. Bailey et al conclude that the findings from sport concussion studies cannot be generalized to clinical populations, who, as a rule, have more premorbid and comorbid vulnerabilities. Finally, part III provides guidelines based on the introductory article by Bigler and Brooks, as well as a synopsis of the main conclusions offered by the contributors in this journal issue. Guidelines for both the diagnosis of mild TBI and the diagnosis of postconcussional disorder are included.