AbstractProfessional statements guide neonatal resuscitation thresholds at the border of viability. A 2015 systematic review of international guidelines by Guillen et al. found considerable variability between statements\' clinical recommendations for infants at 23-24 weeks gestational age (GA). The authors concluded that differences in the type of data included were one potential source for differing resuscitation thresholds within this \"ethical gray zone.\" How statements present ethical considerations that support their recommendations, and how this may account for variability, has not been as rigorously explored. We performed a mixed-methods exploratory analysis of 25 current international guidelines for neonatal resuscitation at 22+0-25+0 weeks GA. Qualitative analysis using a modified grounded theory yielded 34 distinct codes, eight categories, and four overarching themes. Three themes, consequentialism, principlism, and rights-based, consisted of concepts central to these ethical frameworks. The fourth theme, clinical reasoning, described counseling practices, medical management, outcomes data, and prognostic uncertainty, without any ethical context. The theme of clinical reasoning appeared in 22 of 25 guidelines. Ten guidelines lacked any ethical theme. Guidelines with an identified ethical theme were more likely to recommend comfort care than guidelines without an identified ethical theme, and recommended it at a higher average GA (22.7 weeks vs. 22.0 weeks, p = 0.03). Thus, how ethical concepts are incorporated into guidelines potentially impacts resuscitation thresholds. We argue that inclusion of explicit discussion of ethical considerations surrounding resuscitation in the \"gray zone\" would clarify values that inform recommendations and facilitate discussions about how neonatology ought to approach periviability as outcomes continue to evolve.

BACKGROUND: The purpose of this study was to reach consensus on the most appropriate terminology and issues related to clinical reasoning, examination, and treatment of the kinetic chain (KC) in people with shoulder pain among an international panel of experts.
METHODS: A 3-round Delphi study that involved an international panel of experts with extensive clinical, teaching, and research experience in the study topic was conducted. A search equation of terms related to the KC in Web of Science and a manual search were used to find the experts. Participants were asked to rate items across 5 different domains (terminology, clinical reasoning, subjective examination, physical examination, and treatment) using a 5-point Likert-type scale. An Aiken coefficient of validity (V) ≥0.7 was considered indicative of group consensus.
RESULTS: The participation rate was 30.2% (n = 16), whereas the retention rate was high throughout the 3 rounds (100%, 93.8%, and 100%). A total of 15 experts from different fields and countries completed the study. After the 3 rounds, consensus was reached on 102 items: 3 items were included in the \"terminology\" domain; 17 items, in the \"rationale and clinical reasoning\" domain; 11 items, in the \"subjective examination\" domain; 44 items, in the \"physical examination\" domain; and 27 items, in the \"treatment\" domain. Terminology was the domain with the highest level of agreement, with 2 items achieving an Aiken V of 0.93, whereas the domains of physical examination and treatment of the KC were the 2 areas with less consensus. Together with the terminology items, 1 item from the treatment domain and 2 items from the rationale and clinical reasoning domain reached the highest level of agreement (V = 0.93 and V = 0.92, respectively).
CONCLUSIONS: This study defined a list of 102 items across 5 different domains (terminology, rationale and clinical reasoning, subjective examination, physical examination, and treatment) regarding the KC in people with shoulder pain. The term \"KC\" was preferred and a agreement on a definition of this concept was reached. Dysfunction of a segment in the chain (ie, weak link) was agreed to result in altered performance or injury to distal segments. Experts considered it important to assess and treat the KC in particular in throwing or overhead athletes and agreed that no one-size-fits-all approach exists when implementing shoulder KC exercises within the rehabilitation process. Further research is now required to determine the validity of the identified items.

Web-based modified Delphi study.
Therapy is widely considered the first choice of treatment for posttraumatic stiffness of the elbow since loss of motion is a common sequela following traumatic elbow injuries. There is high variability in practice patterns for the management of the posttraumtic elbow.
The aim of this study is to identify the current therapeutic management of posttraumatic elbow stiffness using expert consensus.
This study surveyed experts using a web-based 3 round modified Delphi method. Quantitative data and comments were collected during the first round. Questions with Likert scaling were used to identify consensus (defined as 75% agreement) with each statement and comment boxes enabled open-ended responses to gather expert opinion. Lack of consensus and data from comments guided the second-round of the survey. This process was repeated after Round 2 to develop the Round 3 survey. Consensus was achieved at Round 3 and no further rounds were needed.
Round 1 included 34 experts (response rate 20%), not all experts were able to continue through all rounds. Round 2 included 18 experts and Round 3 included 15 experts. Survey items were categorized as follows: examination procedures, therapeutic interventions, orthotic intervention considerations, contributing patient factors, and clinical decisions and rehabilitation challenges. Twenty-five percent of items achieved consensus after Round 1, 30% after Round 2 and 52% after Round 3. Although most participants agreed that orthotic intervention is critical to patient outcomes, there were conflicting thoughts about the orthotic design and wearing schedule.
The findings of this web-based modified Delphi study helped to establish a current body of knowledge using expert consensus to guide practice and identify specific questions that can be studied in future clinical studies on posttraumatic elbow stiffness.

With the annual increase in medical imaging demand, the appropriateness of the lumbar spine magnetic resonance imaging LSMRI referrals is worldwide gaining attention. This study aims to determine the appropriateness of LSMRI referrals and compare radiology clinical decisions to iRefer compliance based solely on referral text content.
Referral text was extracted from 1021 LSMRI referrals. Two review panels were recruited: three expert radiologists and three MRI radiographers. Radiologists classified cases as indicated or not indicated for scanning based on their clinical judgement. The radiographers classified based solely on iRefer guidelines. Majority voting for each case was applied to both review panels and reviewer agreement was tested using Kappa analysis. Logistic regression models were developed to identify medical disciplines associated with high rates of indicated referrals.
21.7% and 11.9% of the cases were found not indicated for MRI for radiologists and radiographers, respectively. Radiology review identified 18% of the GPs referrals as not indicated and 17% in the radiographers\' review. Panel agreement was fair: Kappa values of 0.23 and0.26 for the radiologists and radiographers respectively. Neurosurgery was associated with the highest rate of indicated referrals across both review panels: oncology referrals raised the highest number of open comments.
The study identified a lower number of not indicated referrals compared to previous research. Findings indicate the importance of both guidelines compliance and clinical judgement to optimise practice.
Findings in this study found that even when strict instructions were given to the MR radiographers to vet referrals using the iRefer guidelines, ambiguity within the guidelines resulted in variations in decision-making. This suggests that detailed protocols are required to support radiographers in the vetting process to ensure a standardised approach.

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Effective clinical reasoning is required for safe patient care. Students and postgraduate trainees largely learn the knowledge, skills and behaviours required for effective clinical reasoning implicitly, through experience and apprenticeship. There is a growing consensus that medical schools should teach clinical reasoning in a way that is explicitly integrated into courses throughout each year, adopting a systematic approach consistent with current evidence. However, the clinical reasoning literature is \'fragmented\' and can be difficult for medical educators to access. The purpose of this paper is to provide practical recommendations that will be of use to all medical schools.
Members of the UK Clinical Reasoning in Medical Education group (CReME) met to discuss what clinical reasoning-specific teaching should be delivered by medical schools (what to teach). A literature review was conducted to identify what teaching strategies are successful in improving clinical reasoning ability among medical students (how to teach). A consensus statement was then produced based on the agreed ideas and the literature review, discussed by members of the consensus statement group, then edited and agreed by the authors.
The group identified 30 consensus ideas that were grouped into five domains: (1) clinical reasoning concepts, (2) history and physical examination, (3) choosing and interpreting diagnostic tests, (4) problem identification and management, and (5) shared decision making. The literature review demonstrated a lack of effectiveness for teaching the general thinking processes involved in clinical reasoning, whereas specific teaching strategies aimed at building knowledge and understanding led to improvements. These strategies are synthesised and described.
What is taught, how it is taught, and when it is taught can facilitate clinical reasoning development more effectively through purposeful curriculum design and medical schools should consider implementing a formal clinical reasoning curriculum that is horizontally and vertically integrated throughout the programme.

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Traumatic brain injury (TBI) is one of the leading causes of mortality and morbidity with a significant loss of functional capacity and a huge socioeconomic burden. Road traffic accidents are the most common (60%) cause followed by falls and violence in India and worldwide. This case discusses the story of a 23-year-old man with severe TBI-subdural haematoma, who presented in a comatose state. The patient was a purported candidate for emergency decompressive surgery as per Brain Trauma Foundation (BTF) guidelines but was managed conservatively. This case questions the plausibility of the BTF guidelines for severe TBI, particularly in rural hospitals in India and how such cases are often managed with clinical judgement based on the review of literature. The patient recovered well with a perfect 8/8 on Glasgow Outcome Scale Extended Score.