Publications by authors named "Anthony Gallagher"

97 Publications

A Systematic Review and Meta-Analysis on the Impact of Proficiency-Based Progression Simulation Training on Performance Outcomes.

Ann Surg 2020 Dec 22. Epub 2020 Dec 22.

*Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy †ORSI Academy, Melle, Belgium ‡Department of Urology, OLV, Aalst, Belgium §Department of Urology, University of Modena and Reggio Emilia, Modena, Italy ¶School of Medicine, Faculty of Life and Health Sciences, Ulster University, Northern Ireland, UK ||Faculty of Medicine, KU Leuven, Leuven, Belgium.

Objective: To analyze all published prospective, randomized and blinded clinical studies on the PBP training using objective performance metrics.

Background: The benefit of 'proficiency-based progression' (PBP) methodology to learning clinical skills in comparison to conventional training is not settled.

Methods: Search of PubMed, Cochrane library's Central, EMBASE, MEDLINE and Scopus databases, from inception to 1st March 2020. Two independent reviewers extracted the data. The Medical Education Research Study Quality Instrument (MERSQI) was used to assess the methodological quality of included studies. Results were pooled using biased corrected standardized mean difference and ratio-of-means (ROM). Summary effects were evaluated using a series of fixed and random effects models. The primary outcome was the number of procedural errors performed comparing PBP and non-PBP-based training pathways. Secondary outcomes were the number of procedural steps completed and the time to complete the task/procedure.

Results: From the initial pool of 468 studies, 12 randomized clinical studies with a total of 239 participants were included in the analysis. In comparison to the non-PBP training, ROM results showed that PBP training reduced the number of performance errors by 60% (p < 0.001) and procedural time by 15% (p = 0.003) and increased the number of steps performed by 47% (p < 0.001).

Conclusions And Relevance: Our systematic review and meta-analysis confirms that PBP training in comparison to conventional or quality assured training improved trainees' performances, by decreasing procedural errors and procedural time, while increasing the number of correct steps taken when compared to standard simulation-based training.
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http://dx.doi.org/10.1097/SLA.0000000000004650DOI Listing
December 2020

A Proficiency-Based Progression Simulation Training Curriculum to Acquire the Skills Needed in Performing Arthroscopic Bankart and Rotator Cuff Repairs-Implementation and Impact.

Arthroscopy 2021 04 24;37(4):1099-1106.e5. Epub 2020 Dec 24.

Faculty of Life and Health Sciences, Ulster University, Londonderry, United Kingdom; ORSI Academy, Melle, Belgium.

Purpose: To investigate the impact of a proficiency-based progression (PBP) curriculum employed to teach trainees in the skills needed to demonstrate proficiency for an arthroscopic Bankart repair (ABR) and an arthroscopic rotator cuff repair (ARCR) by objectively comparing pre- and immediate postcourse performances.

Methods: In a prospective study, 16 arthroscopy/sports medicine fellows and 2 senior residents (complete group: N = 18) were randomly assigned to perform a precourse cadaveric ABR (Bankart subgroup: N = 6), ARCR (cuff subgroup: N = 6), or basic skills on a shoulder simulator (N = 6). After completing a PBP training curriculum, all 18 registrants performed both an ABR and ARCR scored in real time by trained raters using previously validated metrics.

Results: The Bankart subgroup made 58% fewer objectively assessed errors at the completion of the course than at baseline (P = .004, confidence interval -1.449 to -0.281), and performance variability was substantially reduced (standard deviation = 5.89 vs 2.81). The cuff subgroup also made 58% fewer errors (P = .001, confidence interval -1.376 to 0.382) and showed a similar reduction in performance variability (standard deviation = 5.42 vs 2.1). Only one subject's precourse baseline performance met the proficiency benchmark compared with 89% and 83% of the all registrants on the final ABR and ARCR cadaveric assessments, respectively.

Conclusions: The results of this study reject the null hypothesis. They demonstrate that the implementation of a PBP simulation curriculum to train the skills necessary to perform arthroscopic Bankart and rotator cuff repairs results in a large and statistically significant improvement in the trainee's ability to meet the 2 related performance benchmarks. Proficiency was demonstrated by 89% and 83% of the trainees for an ABR and an ARCR, respectively, in a two- and one-half day course.

Clinical Relevance: Surgical training employing a PBP curriculum is efficient, effective, and has the potential to improve patient safety.
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http://dx.doi.org/10.1016/j.arthro.2020.11.040DOI Listing
April 2021

Response to: "Proving the Effectiveness of the Fundamentals of Robotic Surgery (FRS) Skills Curriculum: A Single-blinded, Multispecialty, Multi-institutional Randomized Control Trial": Not only surgeon's manual skills..."

Ann Surg 2020 Dec 3. Epub 2020 Dec 3.

Department of Surgery, University of Washington Medical Center, Seattle, WA Department of Surgery, Indiana University School of Medicine, Indianapolis, IN Department of Ob/Gyn, Drexel University College of Medicine, Institute of Surgical Excellence, Philadelphia, PA Florida Hospital Nicholson Center, University of Central Florida College of Medicine, Celebration, FL Department of Surgery, Indiana University School of Medicine, Indianapolis, IN Department of Surgery, St. Mary's Hospital, Imperial College, London, United Kingdom EndoCAS Simulation Center, University of Pisa, Pisa, Italy Andersen Simulation Center, Madigan Army Medical Center, Tacoma, WA Center for Education, Simulation and Innovation, Hartford Hospital, Hartford, CT Penn Medicine Clinical Simulation Center, Philadelphia, PA Department of Colon and Rectal Surgery, Lahey Health and Medical Center, Burlington, MA National and Kapodistrian University of Athens, Athens, Greece Houston Methodist Hospital, Methodist Institute for Technology, Innovation, and Education, Houston, TX USF Health Center for Advanced Medical Learning and Simulation, Tampa, FL Lehigh Valley Health Network, Allentown PA Department of Surgery, Surgical Education and Activities Lab, Duke University Medical Center, Durham, NC Department of Surgery, St. Mary's Hospital, Imperial College, London, United Kingdom Director of Technology Enhanced Learning, ASSERT Centre, College of Medicine and Health, Brookfield Health Sciences Complex, University College Cork, Cork, Ireland.

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http://dx.doi.org/10.1097/SLA.0000000000004658DOI Listing
December 2020

Objective assessment of intraoperative skills for robot-assisted radical prostatectomy (RARP): results from the ERUS Scientific and Educational Working Groups Metrics Initiative.

BJU Int 2020 Nov 29. Epub 2020 Nov 29.

Orsi Academy, Melle, Belgium.

Objective: To develop and seek consensus from procedure experts on the metrics that best characterise a reference robot-assisted radical prostatectomy (RARP) and determine if the metrics distinguished between the objectively assessed RARP performance of experienced and novice urologists, as identifying objective performance metrics for surgical training in robotic surgery is imperative for patient safety.

Materials And Methods: In Study 1, the metrics, i.e. 12 phases of the procedure, 81 steps, 245 errors and 110 critical errors for a reference RARP were developed and then presented to an international Delphi panel of 19 experienced urologists. In Study 2, 12 very experienced surgeons (VES) who had performed >500 RARPs and 12 novice urology surgeons performed a RARP, which was video recorded and assessed by two experienced urologists blinded as to subject and group. Percentage agreement between experienced urologists for the Delphi meeting and Mann-Whitney U- and Kruskal-Wallis tests were used for construct validation of the newly identified RARP metrics.

Results: At the Delphi panel, consensus was reached on the appropriateness of the metrics for a reference RARP. In Study 2, the results showed that the VES performed ~4% more procedure steps and made 72% fewer procedure errors than the novices (P = 0.027). Phases VIIa and VIIb (i.e. neurovascular bundle dissection) best discriminated between the VES and novices.

Limitations: VES whose performance was in the bottom half of their group demonstrated considerable error variability and made five-times as many errors as the other half of the group (P = 0.006).

Conclusions: The international Delphi panel reached high-level consensus on the RARP metrics that reliably distinguished between the objectively scored procedure performance of VES and novices. Reliable and valid performance metrics of RARP are imperative for effective and quality assured surgical training.
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http://dx.doi.org/10.1111/bju.15311DOI Listing
November 2020

Development and validation of the objective assessment of robotic suturing and knot tying skills for chicken anastomotic model.

Surg Endosc 2020 Aug 28. Epub 2020 Aug 28.

ORSI Academy, Melle, Belgium.

Background: To improve patient safety, there is an imperative to develop objective performance metrics for basic surgical skills training in robotic surgery.

Objective: To develop and validate (face, content, and construct) the performance metrics for robotic suturing and knot tying, using a chicken anastomotic model.

Design, Setting And Participants: Study 1: In a procedure characterization, we developed the performance metrics (i.e., procedure steps, errors, and critical errors) for robotic suturing and knot tying, using a chicken anastomotic model. In a modified Delphi panel of 13 experts from four EU countries, we achieved 100% consensus on the five steps, 18 errors and four critical errors (CE) of the task. Study 2: Ten experienced surgeons and nine novice urology surgeons performed the robotic suturing and knot tying chicken anastomotic task. The mean inter-rater reliability for the assessments by two experienced robotic surgeons was 0.92 (95% CI, 0.9-0.95). Novices took 18.5 min to complete the task and experts took 8.2 min. (p = 0.00001) and made 74% more objectively assessed performance errors than the experts (p = 0.000343).

Conclusions: We demonstrated face, content, and construct validity for a standard and replicable basic anastomotic robotic suturing and knot tying task on a chicken model. Validated, objective, and transparent performance metrics of a robotic surgical suturing and knot tying tasks are imperative for effective and quality assured surgical training.
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http://dx.doi.org/10.1007/s00464-020-07918-5DOI Listing
August 2020

Validation of phlebotomy performance metrics developed as part of a proficiency-based progression initiative to mitigate wrong blood in tube.

Postgrad Med J 2020 Aug 17. Epub 2020 Aug 17.

Faculty of Life and Health Sciences, University of Ulster - Magee Campus, Londonderry, UK.

Aims: The purpose of this study was to (1) characterise the procedure of phlebotomy, deconstruct it into its constituent parts and develop a performance metric for the purpose of training healthcare professionals in a large teaching hospital and to (2) evaluate the construct validity of the phlebotomy metric and establish a proficiency benchmark.

Method: By engaging with a multidisciplinary team with a wide range of experience of preanalytical errors in phlebotomy and observing video recordings of the procedure performed in the actual working environment, we defined a performance metric. This was brought to a modified Delphi meeting, where consensus was reached by an expert panel. To demonstrate construct validity, we used the metric to objectively assess the performance of novices and expert practitioners.

Results: A phlebotomy metric consisting of 11 phases and 77 steps was developed. The mean inter-rater reliability was 0.91 (min 0.83, max 0.95). The expert group completed more steps of the procedure (72 vs 69), made fewer errors (19 vs 13, p=0.014) and fewer critical errors (1 Vs 4, p=0.002) than the novice group.

Conclusions: The metrics demonstrated construct validity and the proficiency benchmark was established with a minimum observation of 69 steps, with no critical errors and no more than 13 errors in total.
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http://dx.doi.org/10.1136/postgradmedj-2019-137254DOI Listing
August 2020

Leisure craft sacrificial anodes as a source of zinc and cadmium to saline waters.

Mar Pollut Bull 2020 Sep 6;158:111433. Epub 2020 Jul 6.

Plymouth Univeristy, Drake Circus, Plymouth, Devon PL4 8AA, United Kingdom of Great Britain and Northern Ireland. Electronic address:

Sacrificial anodes are attached to the hulls of boats and marine structures to prevent corrosion. Their use inevitably leads to release of zinc as well as impurities in the zinc alloy such as cadmium to the saline environment. Risk assessments and source apportionment exercises require accurate assessments of the potential loads of chemicals into the environment. This research has surveyed a wide variety of zinc anodes for their composition to compare against a reported industry standard as well as using differing methodologies to determine the dissolution rate of zinc and cadmium from anodes. A zinc dissolution rate of 477 g/yr/kg of anode is proposed. Although most anodes tested had concentrations of cadmium within the prescribed limits set by the reported standard, calculated leaching rates from laboratory dissolution experiments suggested as much as 400 g per year of cadmium could leach from zinc anodes used on leisure vessels within UK waters.
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http://dx.doi.org/10.1016/j.marpolbul.2020.111433DOI Listing
September 2020

Proving the Effectiveness of the Fundamentals of Robotic Surgery (FRS) Skills Curriculum: A Single-blinded, Multispecialty, Multi-institutional Randomized Control Trial.

Ann Surg 2020 08;272(2):384-392

Technology Enhanced Learning, ASSERT Centre, College of Medicine and Health, Brookfield Health Sciences Complex, University College Cork, Cork, Ireland.

Objective: To demonstrate the noninferiority of the fundamentals of robotic surgery (FRS) skills curriculum over current training paradigms and identify an ideal training platform.

Summary Background Data: There is currently no validated, uniformly accepted curriculum for training in robotic surgery skills.

Methods: Single-blinded parallel-group randomized trial at 12 international American College of Surgeons (ACS) Accredited Education Institutes (AEI). Thirty-three robotic surgery experts and 123 inexperienced surgical trainees were enrolled between April 2015 and November 2016. Benchmarks (proficiency levels) on the 7 FRS Dome tasks were established based on expert performance. Participants were then randomly assigned to 4 training groups: Dome (n = 29), dV-Trainer (n = 30), and DVSS (n = 32) that trained to benchmarks and control (n = 32) that trained using locally available robotic skills curricula. The primary outcome was participant performance after training based on task errors and duration on 5 basic robotic tasks (knot tying, continuous suturing, cutting, dissection, and vessel coagulation) using an avian tissue model (transfer-test). Secondary outcomes included cognitive test scores, GEARS ratings, and robot familiarity checklist scores.

Results: All groups demonstrated significant performance improvement after skills training (P < 0.01). Participating residents and fellows performed tasks faster (DOME and DVSS groups) and with fewer errors than controls (DOME group; P < 0.01). Inter-rater reliability was high for the checklist scores (0.82-0.97) but moderate for GEARS ratings (0.40-0.67).

Conclusions: We provide evidence of effectiveness for the FRS curriculum by demonstrating better performance of those trained following FRS compared with controls on a transfer test. We therefore argue for its implementation across training programs before surgeons apply these skills clinically.
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http://dx.doi.org/10.1097/SLA.0000000000003220DOI Listing
August 2020

Proficiency based progression simulation training significantly reduces utility strikes; A prospective, randomized and blinded study.

PLoS One 2020 12;15(5):e0231979. Epub 2020 May 12.

School of Psychology, Coleraine, Co. Londonderry, Northern Ireland, United Kingdom.

Objectives: We evaluated a simulation-based training curriculum with quantitatively defined performance benchmarks for utility workers location and excavation of utility services.

Background: Damaging buried utilities is associated with considerable safety risks to workers and substantial cost to employers.

Methods: In a prospective, randomized and blinded study we assessed the impact of Proficiency Based Progression (PBP) simulation training on the location and excavation of utility services work.

Results: PBP simulation training reduced performance errors (33%, p = 0.006) in comparison a standard trained group. When implemented across all workers in the same division there was a 35-61% reduction in utility strikes (p = 0.028) and an estimated cost saving of £116,000 -£2,175,000 in the 12 months (47,000 work hours) studied.

Conclusions: The magnitude of the training benefit of PBP simulation training in the utilities sector appears to be the same as it is in surgery, cardiology and procedure-based medicine.

Application: Quality-assured utility worker simulation training significantly reduces utility damage and associated costs.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0231979PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7217447PMC
July 2020

Orsi Consensus Meeting on European Robotic Training (OCERT): Results from the First Multispecialty Consensus Meeting on Training in Robot-assisted Surgery.

Eur Urol 2020 11 21;78(5):713-716. Epub 2020 Feb 21.

Orsi Academy, Melle, Belgium; Faculty of Life and Health Sciences, Ulster University, Belfast, Northern Ireland, UK.

To improve patient outcomes in robotic surgery, robotic training and education need to be modernised and augmented. The skills and performance levels of trainees need to be objectively assessed before they operate on real patients. The main goal of the first Orsi Consensus Meeting on European Robotic Training (OCERT) was to establish the opinions of experts from different scientific societies on standardised robotic training pathways and training methodology. After a 2-d consensus conference, 36 experts identified 23 key statements allotted to three themes: training standardisation pathways, validation metrics, and implementation prerequisites and certification. After two rounds of Delphi voting, consensus was obtained for 22 of 23 questions among these three categories. Participants agreed that societies should drive and support the implementation of benchmarked training using validated proficiency-based pathways. All courses should deliver an internationally agreed curriculum with performance standards, be accredited by universities/professional societies, and, trainees should receive a certificate approved by professional societies and/or universities after successful completion of the robotic training courses. This OCERT meeting established a basis for bringing surgical robotic training out of the operating room by seeking input and consensus across surgical specialties for an objective, validated, and standardised training programme with transparent, metric-based training outcomes. PATIENT SUMMARY: The Orsi Consensus Meeting on European Robotic Training (OCERT) is an international, multidisciplinary, Delphi-panel study of scientific societies and experts focused on training in robotic surgery. The panel achieved consensus that standardised international training pathways should be the basis for a structured, validated, replicable, and certified approach to implementation of robotic technology.
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http://dx.doi.org/10.1016/j.eururo.2020.02.003DOI Listing
November 2020

A validation study of intraoperative performance metrics for training novice cardiac resynchronization therapy implanters.

Int J Cardiol 2020 05 3;307:48-54. Epub 2020 Feb 3.

Faculty of Life and Health Sciences, Ulster University, Magee Campus, Northland Rd, Londonderry BT48 7JL, United Kingdom; Orsi Academy, Proefhoevestraat 12, 9090 Melle, Belgium. Electronic address:

Aims: Pacing/cardiac resynchronization therapy (CRT) implant training currently lacks a common system to objectively assess trainee ability to perform required tasks at predetermined performance levels. The purpose of this study was to primarily examine construct validity and reliability, secondarily discriminative validity of novel intraoperative performance metrics, developed for a reference approach to training novice CRT implanters.

Methods: Fifteen novice and eleven experienced CRT implanters performed a 3-lead implant procedure on a virtual reality simulator. Performances were video-recorded, then independently scored using predefined metrics endorsed by an international panel of experts. First, Novice and Experienced group scores were compared for steps completed and errors made. Secondly, each group was split in two around the median score of the group and subgroup scores were compared.

Results: The mean number of scored metrics per performance was 108 and the inter-rater reliability for scoring was 0.947. Compared with novices, experienced implanters completed more procedural Steps correctly (mean 87% vs. 73%, p = 0.001), made fewer procedural Errors (6.3 vs. 11.2, p = 0.005), Critical Errors (1.8 vs. 4.4, p = 0.004), and total errors (8.1 vs. 15.6, p = 0.002). Furthermore, the differences between the two Novice subgroups were 25% for steps completed correctly and 94% for total errors made (p < 0.001); the differences between the two Experienced subgroups were respectively 16% and 191% (p < 0.001).

Conclusions: The procedure metrics used in this study reliably distinguish novice and experienced CRT implanters' performances. The metrics further differentiated performance levels within a group with similar experience. These performance metrics will underpin quality-assured novice implanter training.
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http://dx.doi.org/10.1016/j.ijcard.2020.02.003DOI Listing
May 2020

Arthroscopic Rotator Cuff Repair Metrics: Establishing Face, Content, and Construct Validity in a Cadaveric Model.

Arthroscopy 2020 01;36(1):71-79.e1

Faculty of Life and Health Sciences, Ulster University, Londonderry, Northern Ireland.

Purpose: To create and determine face validity and content validity of arthroscopic rotator cuff repair (ARCR) performance metrics, to confirm construct validity of the metrics coupled with a cadaveric shoulder, and to establish a performance benchmark for the procedure on a cadaveric shoulder.

Methods: Five experienced arthroscopic shoulder surgeons created step, error, and sentinel error metrics for an ARCR. Fourteen shoulder arthroscopy faculty members from the Arthroscopy Association of North America formed the modified Delphi panel to assess face and content validity. Eight Arthroscopy Association of North America shoulder arthroscopy faculty members (experienced group) were compared with 9 postgraduate year 4 or 5 orthopaedic residents (novice group) in their ability to perform an ARCR. Instructions were given to perform a diagnostic arthroscopy and a 2-anchor, 4-simple suture repair of a 2-cm supraspinatus tear. The procedure was videotaped in its entirety and independently scored in blinded fashion by trained, paired reviewers.

Results: Delphi panel consensus for 42 steps and 66 potential errors was obtained. Overall performance assessment showed a mean inter-rater reliability of 0.93. Novice surgeons completed 17% fewer steps (32.1 vs 37.5, P = .001) and enacted 2.5 times more errors than the experienced group (6.21 vs 2.5, P = .012). Fifty percent of the experienced group members and none of the novice group members achieved the proficiency benchmark of a minimum of 37 steps completed with 3 or fewer errors.

Conclusions: Face validity and content validity for the ARCR metrics, along with construct validity for the metrics and cadaveric shoulder, were verified. A proficiency benchmark was established based on the mean performance of an experienced group of arthroscopic shoulder surgeons.

Clinical Relevance: Validated procedural metrics combined with the use of a cadaveric shoulder can be used to accurately assess the performance of an ARCR.
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http://dx.doi.org/10.1016/j.arthro.2019.07.016DOI Listing
January 2020

Reliability of Observational Assessment Methods for Outcome-based Assessment of Surgical Skill: Systematic Review and Meta-analyses.

J Surg Educ 2020 Jan - Feb;77(1):189-201. Epub 2019 Aug 20.

ASSERT Centre, College of Medicine and Health, University College Cork, Cork, Ireland.

Background: Reliable performance assessment is a necessary prerequisite for outcome-based assessment of surgical technical skill. Numerous observational instruments for technical skill assessment have been developed in recent years. However, methodological shortcomings of reported studies might negatively impinge on the interpretation of inter-rater reliability.

Objective: To synthesize the evidence about the inter-rater reliability of observational instruments for technical skill assessment for high-stakes decisions.

Design: A systematic review and meta-analysis were performed. We searched Scopus (including MEDLINE) and Pubmed, and key publications through December, 2016. This included original studies that evaluated reliability of instruments for the observational assessment of technical skills. Two reviewers independently extracted information on the primary outcome (the reliability statistic), secondary outcomes, and general information. We calculated pooled estimates using multilevel random effects meta-analyses where appropriate.

Results: A total of 247 documents met our inclusion criteria and provided 491 inter-rater reliability estimates. Inappropriate inter-rater reliability indices were reported for 40% of the checklists estimates, 50% of the rating scales estimates and 41% of the other types of assessment instruments estimates. Only 14 documents provided sufficient information to be included in the meta-analyses. The pooled Cohen's kappa was .78 (95% CI 0.69-0.89, p < 0.001) and pooled proportion agreement was 0.84 (95% CI 0.71-0.96, p < 0.001). A moderator analysis was performed to explore the influence of type of assessment instrument as a possible source of heterogeneity.

Conclusions And Relevance: For high-stakes decisions, there was often insufficient information available on which to base conclusions. The use of suboptimal statistical methods and incomplete reporting of reliability estimates does not support the use of observational assessment instruments for technical skill for high-stakes decisions. Interpretations of inter-rater reliability should consider the reliability index and assessment instrument used. Reporting of inter-rater reliability needs to be improved by detailed descriptions of the assessment process.
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http://dx.doi.org/10.1016/j.jsurg.2019.07.007DOI Listing
August 2019

Effect of a proficiency-based progression simulation programme on clinical communication for the deteriorating patient: a randomised controlled trial.

BMJ Open 2019 07 9;9(7):e025992. Epub 2019 Jul 9.

School of Nursing and Midwifery, University College Cork National University of Ireland, Cork, Ireland.

Objective: This study aimed to determine the effectiveness of a proficiency-based progression (PBP) training approach to clinical communication in the context of a clinically deteriorating patient.

Design: This is a randomised controlled trial with three parallel arms.

Setting: This study was conducted in a university in Ireland.

Participants: This study included 45 third year nursing and 45 final year medical undergraduates scheduled to undertake interdisciplinary National Early Warning Score (NEWS) training over a 3-day period in September 2016.

Interventions: Participants were prospectively randomised to one of three groups before undertaking a performance assessment of the ISBAR (Identification, Situation, Background, Assessment, Recommendation) communication tool relevant to a deteriorating patient in a high-fidelity simulation facility. The groups were as follows: (i) E, the Irish Health Service national NEWS e-learning programme only; (ii) E+S, the national e-learning programme plus standard simulation; and (iii) E+PBP, the national e-learning programme plus PBP simulation.

Main Outcome Measures: The primary outcome was the proportion in each group reaching a predefined proficiency benchmark comprising a series of predefined steps, errors and critical errors during the performance of a standardised, high-fidelity simulation assessment case which was recorded and scored by two independent blinded assessors.

Results: 6.9% (2/29) of the E group and 13% (3/23) of the E+S group demonstrated proficiency in comparison to 60% (15/25) of the E+PBP group. The difference between the E and the E+S groups was not statistically significant (χ=0.55, 99% CI 0.63 to 0.66, p=0.63) but was significant for the difference between the E and the E+PBP groups (χ=22.25, CI 0.00 to 0.00, p<0.000) and between the E+S and the E+PBP groups (χ=11.04, CI 0.00 to 0.00, p=0.001).

Conclusions: PBP is a more effective way to teach clinical communication in the context of the deteriorating patient than e-learning either alone or in combination with standard simulation.

Trial Registration Number: NCT02886754; Results.
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http://dx.doi.org/10.1136/bmjopen-2018-025992DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6629454PMC
July 2019

Operational framework and training standard requirements for AI-empowered robotic surgery.

Int J Med Robot 2020 Oct 8;16(5):1-13. Epub 2020 Jun 8.

Faculty of Life and Health Sciences, Ulster University, Londonderry, UK.

Background: For autonomous robot-delivered surgeries to ever become a feasible option, we recommend the combination of human-centered artificial intelligence (AI) and transparent machine learning (ML), with integrated Gross anatomy models. This can be supplemented with medical imaging data of cadavers for performance evaluation.

Methods: We reviewed technological advances and state-of-the-art documented developments. We undertook a literature search on surgical robotics and skills, tracing agent studies, relevant frameworks, and standards for AI. This embraced transparency aspects of AI.

Conclusion: We recommend "a procedure/skill template" for teaching AI that can be used by a surgeon. Similar existing methodologies show that when such a metric-based approach is used for training surgeons, cardiologists, and anesthetists, it results in a >40% error reduction in objectively assessed intraoperative procedures. The integration of Explainable AI and ML, and novel tissue characterization sensorics to tele-operated robotic-assisted procedures with medical imaged cadavers, provides robotic guidance and refines tissue classifications at a molecular level.
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http://dx.doi.org/10.1002/rcs.2020DOI Listing
October 2020

International expert consensus on a scientific approach to training novice cardiac resynchronization therapy implanters using performance quality metrics.

Int J Cardiol 2019 08 12;289:63-69. Epub 2019 Apr 12.

Faculty of Life and Health Sciences, Ulster University, Magee Campus, Northland Rd, Londonderry BT48 7JL, United Kingdom; ASSERT Centre, College of Medicine and Health, Brookfield Health Sciences Complex, College Rd., University College Cork, Cork T12 K8AF, Ireland. Electronic address:

Aims: Pacing and Cardiac Resynchronization Therapy (CRT) procedural training for novice operators usually takes place in-vivo and methods vary across countries/institutions. No common system exists to objectively assess trainee ability to perform required tasks at predetermined performance levels prior to in-vivo practice. We sought to characterize and validate with experts a reference approach to pacing/CRT implants based on objective and explicit performance quality metrics, for the development of a reproducible, simulation-based, training curriculum aiming to operator proficiency.

Methods: Three experienced CRT implanters, a behavioural scientist and two engineers performed a detailed task deconstruction of the pacing/CRT procedure and identified the performance metrics (phases, steps, errors, critical errors) that constitute an optimal CRT implant for training purposes. The metrics were stress tested to determine reliability and score-ability and then subjected to detailed systematic review by an international panel of 15 expert implanters in a modified Delphi process.

Results: Thirteen procedure phases were identified, consisting of 196 steps, 122 errors, 50 critical errors. The expert panel deliberation added 16 metrics, deleted 12, and modified 43. Unanimous panel consensus on the resulting CRT procedure metrics was obtained, which verified face and content validity.

Conclusion: A reference pacing/CRT procedure and metrics created by a core group of experts accurately characterize the essential components of performance and were endorsed by an international panel of experienced peers. The metrics will underpin quality-assured novice implanter training.
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http://dx.doi.org/10.1016/j.ijcard.2019.04.036DOI Listing
August 2019

Acute surgical wound-dressing procedure: Description of the steps involved in the development and validation of an observational metric.

Int Wound J 2019 Jun 1;16(3):641-648. Epub 2019 Apr 1.

Catherine McAuley School of Nursing and Midwifery, University College Cork, Ireland.

The aim of this study was to develop an observational metric that could be used to assess the performance of a practitioner in completing an acute surgical wound-dressing procedure using aseptic non-touch technique (ANTT). A team of clinicians, academics, and researchers came together to develop an observational metric using an iterative six-stage process, culminating in a Delphi panel meeting. A scoping review of the literature provided a background empirical perspective relating to wound-dressing procedure performance. Video recordings of acute surgical wound-dressing procedures performed by nurses in clinical (n = 11) and simulated (n = 3) settings were viewed repeatedly and were iteratively deconstructed by the metric development group. This facilitated the identification of the discrete component steps, potential errors, and sentinel (serious) errors, which characterise a wound dressing procedure and formed part of the observational metric. The ANTT wound-dressing observational metric was stress tested for clarity, the ability to be scored, and interrater reliability, calculated during a further phase of video analysis. The metric was then subjected to a process of cyclical evaluation by a Delphi panel (n = 21) to obtain face and content validity of the metric. The Delphi panel deliberation verified the face and content validity of the metric. The final metric has three phases, 31 individual steps, 18 errors, and 27 sentinel errors. The metric is a tool that identifies the standard to be attained in the performance of acute surgical wound dressings. It can be used as both an adjunct to an educational programme and as a tool to assess a practitioner's performance of a wound-dressing procedure in both simulated and clinical practice contexts.
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http://dx.doi.org/10.1111/iwj.13072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6850176PMC
June 2019

Wearable technology-based metrics for predicting operator performance during cardiac catheterisation.

Int J Comput Assist Radiol Surg 2019 Apr 7;14(4):645-657. Epub 2019 Feb 7.

Application of Science to Simulation Based Education and Research on Training (ASSERT) Centre, University College Cork, Cork, Ireland.

Introduction: Unobtrusive metrics that can auto-assess performance during clinical procedures are of value. Three approaches to deriving wearable technology-based metrics are explored: (1) eye tracking, (2) psychophysiological measurements [e.g. electrodermal activity (EDA)] and (3) arm and hand movement via accelerometry. We also measure attentional capacity by tasking the operator with an additional task to track an unrelated object during the procedure.

Methods: Two aspects of performance are measured: (1) using eye gaze and psychophysiology metrics and (2) measuring attentional capacity via an additional unrelated task (to monitor a visual stimulus/playing cards). The aim was to identify metrics that can be used to automatically discriminate between levels of performance or at least between novices and experts. The study was conducted using two groups: (1) novice operators and (2) expert operators. Both groups made two attempts at a coronary angiography procedure using a full-physics virtual reality simulator. Participants wore eye tracking glasses and an E4 wearable wristband. Areas of interest were defined to track visual attention on display screens, including: (1) X-ray, (2) vital signs, (3) instruments and (4) the stimulus screen (for measuring attentional capacity).

Results: Experts provided greater dwell time (63% vs 42%, p = 0.03) and fixations (50% vs 34%, p = 0.04) on display screens. They also provided greater dwell time (11% vs 5%, p = 0.006) and fixations (9% vs 4%, p = 0.007) when selecting instruments. The experts' performance for tracking the unrelated object during the visual stimulus task negatively correlated with total errors (r = - 0.95, p = 0.0009). Experts also had a higher standard deviation of EDA (2.52 µS vs 0.89 µS, p = 0.04).

Conclusions: Eye tracking metrics may help discriminate between a novice and expert operator, by showing that experts maintain greater visual attention on the display screens. In addition, the visual stimulus study shows that an unrelated task can measure attentional capacity. Trial registration This work is registered through clinicaltrials.gov, a service of the U.S. National Health Institute, and is identified by the trial reference: NCT02928796.
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http://dx.doi.org/10.1007/s11548-019-01918-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6420895PMC
April 2019

Utilising the Delphi Process to Develop a Proficiency-based Progression Train-the-trainer Course for Robotic Surgery Training.

Eur Urol 2019 05 19;75(5):775-785. Epub 2019 Jan 19.

University of Washington Medical Center, Seattle, WA, USA.

Context: As the role of robot-assisted surgery continues to expand, development of standardised and validated training programmes is becoming increasingly important.

Objective: To provide guidance on an optimised "train-the-trainer" (TTT) structured educational programme for surgical trainers, in which delegates learn a standardised approach to training candidates in skill acquisition. We aim to describe a TTT course for robotic surgery based on the current published literature and to define the key elements within a TTT course by seeking consensus from an expert committee formed of key opinion leaders in training.

Evidence Acquisition: The project was carried out in phases: a systematic review of the current evidence was conducted, a face-to-face meeting was held in Philadelphia, and then an initial survey was created based on the current literature and expert opinion and sent to the committee. Thirty-two experts in training, including clinicians, academics, and industry, contributed to the Delphi process. The Delphi process underwent three rounds of survey in total. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. Consensus opinion was defined as ≥80% agreement.

Evidence Synthesis: There was 100% consensus that there was a need for a standardized TTT course in robotic surgery. A consensus was reached in multiple areas, including the following: (1) definitions and terminologies, (2) qualifications to attend, (3) course objectives, (4) precourse considerations, (5) requirement of e-learning, (6) theory and course content, and (7) measurement of outcomes and performance level verification. The resulting formulated curriculum showed good internal consistency among experts, with a Cronbach alpha of 0.90.

Conclusions: Using the Delphi methodology, we achieved an international consensus among experts to develop and reach content validation for a standardised TTT curriculum for robotic surgery training. This defined content lays the foundation for developing a proficiency-based progression model for trainers in robotic surgery. This TTT curriculum will require further validation.

Patient Summary: As the role of robot-assisted surgery continues to expand, development of standardised and validated training programmes is becoming increasingly important. There is currently a lack of high-level evidence on how best to train trainers in robot-assisted surgery. We report a consensus view on a standardised "train-the trainer" curriculum focused on robotic surgery. It was formulated by training experts from the USA and Europe, combining current evidence for training with experts' knowledge of surgical training.
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http://dx.doi.org/10.1016/j.eururo.2018.12.044DOI Listing
May 2019

Validation studies of virtual reality simulation performance metrics for mechanical thrombectomy in ischemic stroke.

J Neurointerv Surg 2019 Aug 17;11(8):775-780. Epub 2019 Jan 17.

Faculty of Life and Health Sciences, Ulster University, Londonderry, UK.

Introduction: Mechanical thrombectomy (MT) has transformed the treatment of ischemic stroke. However, patient access to MT may be limited due to a shortage of doctors specifically trained to perform MT. The studies reported here were done to (1) develop, operationally define, and seek consensus from procedure experts on the metrics which best characterize a reference procedure for the performance of an MT for ischemic stroke and (2) evaluate their construct validity when implemented in a virtual reality (VR) simulation.

Methods: In study 1, the metrics for a reference approach to an MT procedure for ischemic stroke of 10 phases, 46 steps, and 56 errors and critical errors, were presented to an international Delphi panel of 21 consultant level interventional neuroradiologists (INRs). In study 2, the metrics were used to assess 8 expert and 10 novice INRs performing a VR simulated routine MT procedure.

Results: In study 1, the Delphi panel reached consensus on the appropriateness of the procedure metrics for a reference approach to MT in ischemic stroke. Group differences in median scores in study 2 demonstrated that experienced INRs performed the case 19% faster (P=0.029), completed 40% more procedure phases (P=0.009), 20% more steps (P=0.012), and made 42% fewer errors (P=0.016) than the novice group.

Conclusions: The international Delphi panel agreed metrics implemented in a VR simulation of MT distinguished between the computer scored procedure performance of INR experts and novices. The studies reported here support the demonstration of face, content, and construct validity of the MT metrics.
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http://dx.doi.org/10.1136/neurintsurg-2018-014510DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6703121PMC
August 2019

Proficiency-based progression training: an 'end to end' model for decreasing error applied to achievement of effective epidural analgesia during labour: a randomised control study.

BMJ Open 2018 10 15;8(10):e020099. Epub 2018 Oct 15.

The ASSERT Centre, University College Cork, Cork, Ireland.

Background: Training procedural skills using proficiency-based progression (PBP) methodology has consistently resulted in error reduction. We hypothesised that implementation of metric-based PBP training and a valid assessment tool would decrease the failure rate of epidural analgesia during labour when compared to standard simulation-based training.

Methods: Detailed, procedure-specific metrics for labour epidural catheter placement were developed based on carefully elicited expert input. Proficiency was defined using criteria derived from clinical performance of experienced practitioners. A PBP curriculum was developed to train medical personnel on these specific metrics and to eliminate errors in a simulation environment.Seventeen novice anaesthetic trainees were randomly allocated to undergo PBP training (Group P) or simulation only training (Group S). Following training, data from the first 10 labour epidurals performed by each participant were recorded. The primary outcome measure was epidural failure rate.

Results: A total of 74 metrics were developed and validated. The inter-rater reliability (IRR) of the derived assessment tool was 0.88. Of 17 trainees recruited, eight were randomly allocated to group S and six to group P (three trainees did not complete the study). Data from 140 clinical procedures were collected. The incidence of epidural failure was reduced by 54% with PBP training (28.7% in Group S vs 13.3% in Group P, absolute risk reduction 15.4% with 95% CI 2% to 28.8%, p=0.04).

Conclusion: Procedure-specific metrics developed for labour epidural catheter placement discriminated the performance of experts and novices with an IRR of 0.88. Proficiency-based progression training resulted in a lower incidence of epidural failure compared to simulation only training.

Trial Registration Number: NCT02179879. NCT02185079; Post-results.
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http://dx.doi.org/10.1136/bmjopen-2017-020099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6194403PMC
October 2018

Factors Associated With Variation in Outcomes in Bariatric Surgery Centers of Excellence.

JAMA 2018 10;320(13):1386-1387

Cardiology Department, Cork University Hospital, Cork, Ireland.

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http://dx.doi.org/10.1001/jama.2018.11194DOI Listing
October 2018

AO international consensus panel for metrics on a closed reduction and fixation of a 31A2 pertrochanteric fracture.

Injury 2018 Dec 11;49(12):2227-2233. Epub 2018 Sep 11.

Director of Research, ASSERT Centre, College of Medicine and Health, University College Cork, Ireland. Electronic address:

Background: The foundations of an effective and evidence-based training program are the metrics, which characterize optimal performance.

Purposes: To develop, operationally define, and seek consensus from procedure experts on the metrics that best characterize a reference approach to the performance of a closed reduction and internal fixation of a 31A2 unstable pertrochanteric fracture with a cephalomedullary nail with distal locking through the proximal guide.

Methods: A Metrics Group consisting of 3 senior orthopaedic surgeons, a surgeon/medical scientist, an education expert and a behavioural scientist deconstructed the performance of the selected fixation procedure and defined performance metrics. At a modified Delphi meeting, 32 senior orthopaedic and trauma surgeons from 18 countries critiqued these metrics and their operational definitions before reaching consensus.

Results: Initially performance metrics consisting of 14 Phases with 62 Steps, 84 errors and 20 Sentinel errors were identified that characterize the safe and effective performance of the procedure. During the Delphi panel meeting these were modified and consensus was reached on 15 Phases (1 added, p = 0.967)) with 75 Steps (14 added and 1 deleted; p = 0.028), 88 errors (10 added and 6 deleted; p = 0.47), and 28 Sentinel errors (8 added; p = 0.107). Pre and Post Delphi characterizations were highly correlated (r = 0.81-0.94).

Conclusions: Surgical procedures can be broken down into constituent, essential, and elemental tasks necessary for the safe and effective completion of a reference approach to a specified procedure. Procedure experts from 18 countries reached consensus on performance metrics for the fixation procedure. This metric-based characterization should form the basis of more quantitative validation studies to guide the construction of a proficiency-based progression training curriculum.
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http://dx.doi.org/10.1016/j.injury.2018.09.019DOI Listing
December 2018

Metric-Based Virtual Reality Simulation: A Paradigm Shift in Training for Mechanical Thrombectomy in Acute Stroke.

Stroke 2018 07 4;49(7):e239-e242. Epub 2018 Jun 4.

Application of Science to Simulation-Based Education and Research on Training (ASSERT) Centre and School of Medicine (A.G.G.)

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http://dx.doi.org/10.1161/STROKEAHA.118.021089DOI Listing
July 2018

Inter-rater Reliability for Metrics Scored in a Binary Fashion-Performance Assessment for an Arthroscopic Bankart Repair.

Arthroscopy 2018 07 2;34(7):2191-2198. Epub 2018 May 2.

ProOrtho Clinic, Kirkland, Washington, U.S.A.. Electronic address:

Purpose: To determine the inter-rater reliability (IRR) of a procedure-specific checklist scored in a binary fashion for the evaluation of surgical skill and whether it meets a minimum level of agreement (≥0.8 between 2 raters) required for high-stakes assessment.

Methods: In a prospective randomized and blinded fashion, and after detailed assessment training, 10 Arthroscopy Association of North America Master/Associate Master faculty arthroscopic surgeons (in 5 pairs) with an average of 21 years of surgical experience assessed the video-recorded 3-anchor arthroscopic Bankart repair performance of 44 postgraduate year 4 or 5 residents from 21 Accreditation Council for Graduate Medical Education orthopaedic residency training programs from across the United States.

Results: No paired scores of resident surgeon performance evaluated by the 5 teams of faculty assessors dropped below the 0.8 IRR level (mean = 0.93; range 0.84-0.99; standard deviation = 0.035). A comparison between the 5 assessor groups with 1 factor analysis of variance showed that there was no significant difference between the groups (P = .205). Pearson's product-moment correlation coefficient revealed a strong and statistically significant negative correlation, that is, -0.856 (P < .000), indicating that as intra-operative error rate scores increased, the IRR decreased.

Conclusions: Arthroscopy Association of North America shoulder faculty raters from across the United States showed high levels of IRR in the assessment of an arthroscopic 3-anchor Bankart repair procedure. All paired assessments were above the 0.8 level and the mean IRR of all resident assessments was 0.93, indicating that they could be used for high-stakes decisions.

Clinical Relevance: With the move toward outcomes-based performance evaluation for graduate medical education, high-stakes assessments of surgical skill will require robust, reliable measurement tools that are able to withstand challenge. Surgical checklists employing metrics scored in a binary fashion meet the need and can show a high (>80%) IRR.
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http://dx.doi.org/10.1016/j.arthro.2018.02.007DOI Listing
July 2018

Deliberate practice using validated metrics improves skill acquisition in performance of ultrasound-guided peripheral nerve block in a simulated setting.

J Clin Anesth 2018 Aug 1;48:22-27. Epub 2018 May 1.

Department of Anaesthesia and Intensive Care, Cork University Hospital and University College Cork, Cork, Ireland.

Study Objectives: The aim of this study was to compare the effects of deliberate vs. self-guided practices (both using validated metrics) on the acquisition of needling skills by novice learners.

Design: Randomized Controlled Study.

Setting: Simulation lab, Department of Anesthesia, St.Vincent's Hospital, Dublin.

Subjects: Eighteen medical students.

Interventions: Students were assigned to either (i) deliberate practice (n = 10) or (ii) self-guided practice (n = 8) groups. After completion of a 'learning phase', subjects attempted to perform a predefined task, which entailed advancing a needle towards a target on a phantom gel under ultrasound guidance. Subsequently, all subjects practiced this task using predefined metrics. Only subjects in the deliberate practice group had an expert anesthesiologist during practice. Immediately after completing 'practice phase', all subjects attempted to perform the same task, and, on the following day, made two further attempts in succession. Two trained consultant anesthesiologists assessed a video of each performance independently using the pre-defined metrics.

Measurements: Number of procedural steps completed and number of errors made.

Main Results: Compared with novices who self-guided their practice using metrics, those who undertook expert-supervised deliberate practice using metrics completed more steps (performance metrics) immediately after practice (median [range], 14.5 [12-15] vs. 3 [1-10], p < 0.0001) and 24 h later (15 [12-15] vs. 4.5 [1-11], p < 0.0001 and 15 [11-15] vs. 4 [2-14], p < 0.0001). They also made fewer errors immediately after practice (median [range], 0 [0-0] vs. 5 [3-8], p < 0.0001) and 24 h later, (0 [0-3] vs. 6.5 [3-8], p < 0.0001 and 0 [0-3] vs. 4 [2-7], p < 0.0001).

Conclusion: Combining deliberate practice with metrics improved acquisition of needling skills.
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http://dx.doi.org/10.1016/j.jclinane.2018.04.015DOI Listing
August 2018

Outlier experienced surgeon's performances impact on benchmark for technical surgical skills training.

ANZ J Surg 2018 May 23;88(5):E412-E417. Epub 2018 Mar 23.

Department of Surgery, University of Washington Medical Center, Seattle, Washington, USA.

Background: Training in medicine must move to an outcome-based approach. A proficiency-based progression outcome approach to training relies on a quantitative estimation of experienced operator performance. We aimed to develop a method for dealing with atypical expert performances in the quantitative definition of surgical proficiency.

Methods: In study one, 100 experienced laparoscopic surgeons' performances on virtual reality and box-trainer simulators were assessed for two similar laparoscopic tasks. In study two, 15 experienced surgeons and 16 trainee colorectal surgeons performed one simulated hand-assisted laparoscopic colorectal procedure. Performance scores of experienced surgeons in both studies were standardized (i.e. Z-scores) using the mean and standard deviations (SDs). Performances >1.96 SDs from the mean were excluded in proficiency definitions.

Results: In study one, 1-5% of surgeons' performances were excluded having performed significantly below their colleagues. Excluded surgeons made significantly fewer correct incisions (mean = 7 (SD = 2) versus 19.42 (SD = 4.6), P < 0.0001) and a greater proportion of incorrect incisions (mean = 45.71 (SD = 10.48) versus 5.25 (SD = 6.6), P < 0.0001). In study two, one experienced colorectal surgeon performance was >4 SDs for time to complete the procedure and >6 SDs for path length. After their exclusions, experienced surgeons' performances were significantly better than trainees for path length: P = 0.031 and for time: P = 0.002.

Conclusion: Objectively assessed atypical expert performances were few. Z-score standardization identified them and produced a more robust quantitative definition of proficiency.
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http://dx.doi.org/10.1111/ans.14474DOI Listing
May 2018

Visual spatial ability for surgical trainees: implications for learning endoscopic, laparoscopic surgery and other image-guided procedures.

Surg Endosc 2018 08 12;32(8):3634-3639. Epub 2018 Feb 12.

Department of Surgery, Tallaght Hospital, Trinity College, University of Dublin, Dublin, Ireland.

Background: In image-guided procedures, a high level of visual spatial ability may be an advantage for surgical trainees. We assessed the visual spatial ability of surgical trainees.

Methods: Two hundred and thirty-nine surgical trainees and 61 controls were tested on visual spatial ability using 3 standardised tests, the Card Rotation, Cube Comparison and Map-Planning Tests.

Results: Two hundred and twenty-one, 236 and 236 surgical trainees and 61 controls completed the Card Rotation test, Cube Comparison test and Map-Planning test, respectively. Two percent of surgical trainees performed statistically significantly worse than their peers on card rotation and map-planning test, > 1% on Cube Comparison test. Surgical trainees performed statistically significantly better than controls on all tests.

Conclusions: Two percent of surgical trainees performed statistically significantly worse than their peers on visual spatial ability. The implication of this finding is unclear, further research is required that can look at the learning and educational portfolios of these trainees who perform poorly on visual spatial ability, and ascertain if they are struggling to learn skills for image-guided procedures.
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http://dx.doi.org/10.1007/s00464-018-6094-3DOI Listing
August 2018

An analysis of variable dissolution rates of sacrificial zinc anodes: a case study of the Hamble estuary, UK.

Environ Sci Pollut Res Int 2017 Sep 25;24(26):21422-21433. Epub 2017 Jul 25.

School of Maritime Science and Engineering, Southampton Solent University, East Park Terrace, Southampton, SO14 0YN, UK.

Sacrificial anodes are intrinsic to the protection of boats and marine structures by preventing the corrosion of metals higher up the galvanic scale through their preferential breakdown. The dissolution of anodes directly inputs component metals into local receiving waters, with variable rates of dissolution evident in coastal and estuarine environments. With recent changes to the Environmental Quality Standard (EQS), the load for zinc in estuaries such as the Hamble, UK, which has a large amount of recreational craft, now exceeds the zinc standard of 7.9 μg/l. A survey of boat owners determined corrosion rates and estimated zinc loading at between 6.95 and 7.11 t/year. The research confirms the variable anode corrosion within the Hamble and highlighted a lack of awareness of anode technology among boat owners. Monitoring and investigation discounted metal structures and subterranean power cables as being responsible for these variations but instead linked accelerated dissolution to marina power supplies and estuarine salinity variations.
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http://dx.doi.org/10.1007/s11356-017-9762-2DOI Listing
September 2017