Aptitude and attitude: predictors of performance during and after basic laparoscopic skills training.

BACKGROUND: Manual dexterity and visual-spatial ability are considered key to the development of superior laparoscopic skills. Nevertheless, these abilities do not reliably explain all the variance found in the technical performance of surgical trainees. Consequently, we must look beyond these abilities to improve our understanding of laparoscopic skills and to better identify/develop surgical potential earlier on. PURPOSE: To assess the individual and collective impact of physical, cognitive, visual, and psychological variables on performance during and after basic simulation-based laparoscopic skills training. METHOD: Thirty-four medical students (laparoscopic novices) completed a proficiency-based laparoscopic skills training program (using either a 2D or 3D viewing mode). This was followed by one testing session, a follow-up testing session with new (yet similar) tasks, and a series of physical, cognitive, visual, and psychological measures. RESULTS: The statistical models that best predicted variance in training performance metrics included four variables: viewing mode (2D vs 3D), psychological flexibility, perceived task demands, and manual dexterity (bimanual). In subsequent testing, a model that included viewing mode and manual dexterity (assembly) best predicted performance on the pre-practiced tasks. However, for a highly novel, spatially complex laparoscopic task, performance was best predicted by a model that comprised viewing mode, visual-spatial ability, and perceived task demands. At follow-up, manual dexterity (assembly) alone was the best predictor of performance on new (yet similar) tasks. CONCLUSION: By focussing exclusively on physical/cognitive abilities, we may overlook other important predictors of surgical performance (e.g. psychological variables). The present findings suggest that laparoscopic performance may be more accurately explained through the combined effects of physical, cognitive, visual, and psychological variables. Further, the results suggest that the predictors may change with both task demands and the development of the trainee. This study highlights the key role of psychological skills in overcoming initial training challenges, with far-reaching implications for practice.

Laparoscopic skills training: the effects of viewing mode (2D vs. 3D) on skill acquisition and transfer.

BACKGROUND: Three-dimensional (3D) visual displays have been suggested to aid laparoscopic skills training by providing the depth cues not present in traditional two-dimensional (2D) displays. However, few studies have robustly investigated the impact of viewing mode (2D vs. 3D) on learning outcomes. PURPOSE: To examine how viewing mode (2D vs. 3D) impacts the acquisition and transferability of basic laparoscopic skills by comparing performance between transfer and control groups on a complete proficiency-based training program. METHOD: A counterbalanced between-subjects design was employed. Each participant was randomly allocated to one of four groups, comprising two transfer groups (trained in one viewing mode and tested in the alternate mode: the 2D → 3D and 3D → 2D groups) and two control groups (trained and tested in one viewing mode: the 2D → 2D and 3D → 3D groups). Participants completed proficiency-based training in six laparoscopic training tasks. Testing included two further repetitions of all tasks under test conditions. Objective performance measures included the total number of repetitions to reach proficiency, and total performance scores (i.e. time + error penalties across all repetitions) in training and testing. RESULTS: The groups trained in 3D demonstrated superior training performance (i.e. less time + errors) and took fewer repetitions to reach proficiency than the groups trained in 2D. The groups tested in 3D also demonstrated superior test performance compared to those tested in 2D. However, training mode did not yield significant test differences between the groups tested in 2D (i.e. 2D → 2D vs. 3D → 2D), or between the groups tested in 3D (i.e. 3D → 3D vs. 2D → 3D). CONCLUSION: Novices demonstrate superior performance in laparoscopic skills training using a 3D viewing mode compared to 2D. However, this does not necessarily translate to superior performance in subsequent testing or enhanced learning overall. Rather, test performance appears to be dictated by the viewing mode used during testing, not that of prior training.

Quantitative systematic review: Sources of inaccuracy in manually measured adult respiratory rate data.

AIMS: To identify the potential sources of inaccuracy in manually measured adult respiratory rate (RR) data and quantify their effects. DESIGN: Quantitative systematic review with meta-analyses where appropriate. DATA SOURCES: Medline, CINAHL, and Cochrane Library (from database inception to 31 July 2019). REVIEW METHODS: Studies presenting data on individual sources of inaccuracy in the manual measurement of adult RR were analysed, assessed for quality, and grouped according to the source of inaccuracy investigated. Quantitative data were extracted and synthesized and meta-analyses performed where appropriate. RESULTS: Included studies (N = 49) identified five sources of inaccuracy. The awareness effect creates an artefactual reduction in actual RR, and observation methods involving shorter counts cause systematic underscoring. Individual RR measurements can differ substantially in either direction between observations due to inter- or intra-observer variability. Value bias, where particular RRs are over-represented (suggesting estimation), is a widespread problem. Recording omission is also widespread, with higher average rates in inpatient versus triage/admission contexts. CONCLUSION: This review demonstrates that manually measured RR data are subject to several potential sources of inaccuracy. IMPACT: RR is an important indicator of clinical deterioration and commonly included in track-and-trigger systems. However, the usefulness of RR data depends on the accuracy of the observations and documentation, which are subject to five potential sources of inaccuracy identified in this review. A single measurement may be affected by several factors. Hence, clinicians should interpret recorded RR data cautiously unless systems are in place to ensure its accuracy. For nurses, this includes counting rather than estimating RRs, employing 60-s counts whenever possible, ensuring patients are unaware that their RR is being measured, and documenting the resulting value. For any given site, interventions to improve measurement should take into account the local organizational and cultural context, available resources, and the specific measurement issues that need to be addressed.

The effects of awareness and count duration on adult respiratory rate measurements: An experimental study.

AIMS AND OBJECTIVES: To investigate whether awareness of manual respiratory rate monitoring affects respiratory rate in adults, and whether count duration influences respiratory rate estimates. BACKGROUND: Nursing textbooks typically suggest that the patient should ideally be unaware of respiratory rate observations; however, there is little published evidence of the effect of awareness on respiratory rate, and none specific to manual measurement. In addition, recommendations about the length of the respiratory rate count vary from text to text, and the relevant empirical evidence is scant, inconsistent and subject to substantial methodological limitations. DESIGN: Experimental study with awareness of respiration monitoring (aware, unaware; randomised between-subjects) and count duration (60 s, 30 s, 15 s; within-subjects) as the independent variables. Respiratory rate (breaths/minute) was the dependent variable. METHODS: Eighty-two adult volunteers were randomly assigned to aware and unaware conditions. In the baseline block, no live monitoring occurred. In the subsequent experimental block, the researcher informed aware participants that their respiratory rate would be counted, and did so. Respirations were captured throughout via video recording, and counted by blind raters viewing 60-, 30- and 15-s extracts. The data were collected in 2015. RESULTS: There was no baseline difference between the groups. During the experimental block, the respiratory rates of participants in the aware condition were an average of 2.13 breaths/minute lower compared to unaware participants. Reducing the count duration from 1 min to 15 s caused respiratory rate to be underestimated by an average of 2.19 breaths/minute (and 0.95 breaths/minute for 30-s counts). The awareness effect did not depend on count duration. CONCLUSIONS: Awareness of monitoring appears to reduce respiratory rate, and shorter monitoring durations yield systematically lower respiratory rate estimates. RELEVANCE TO CLINICAL PRACTICE: When interpreting and acting upon respiratory rate data, clinicians should consider the potential influence of these factors, including cumulative effects.

Assessment of colorectal polyp recognition skill: development and validation of an objective test.

BACKGROUND: The quality of colonoscopy is known to vary. The extent to which colonoscopists can recognize the presence of subtle colorectal lesions by visually distinguishing them from the surrounding mucosa (i.e., polyp recognition skill) may be one of several attributes that influence polyp detection rates. The aim of the present study was to develop and validate the first objective test of polyp recognition skill. METHODS: Validation study. Twenty-eight experienced colonoscopists and eighty novices took a preliminary 280-item computer-based polyp recognition test. Items were genuine endoscopic images which participants assessed for the presence of "likely polyps." Half included clinically identified polyps. Participants clicked on a suspected lesion or a button marked "no likely polyp", and the main outcome measures were accuracy and response latency. The best items were selected for the final 50-item test. RESULTS: In the preliminary test, experienced colonoscopists correctly identified more polyps than novices (P < .0001) and better discriminated between clinically identified polyps and non-polyp features (as measured by d', P < .0001). For polyp items, the experienced group also responded faster (P < .01). Effect sizes were large for accuracy (Cohen's d = 3.22) and d' (Cohen's d = 3.22). The 50 final test items produced comparable results for accuracy, d', and response latency. For both versions of the test, score scale reliability was high for both polyp and non-polyp items (α = .82 to .97). CONCLUSIONS: The observed experienced-novice differences support the construct validity of the performance measures derived from the tests, indicating that polyp recognition skill can be quantified objectively. The final test may potentially be used to assess trainees, but test sensitivity may be insufficient to make fine-grained distinctions between different skill levels among experienced colonoscopists. More sensitive future tests may provide a valuable supplement to clinical detection rates, allowing objective comparisons between skilled colonoscopists.

A novel training device for tip control in colonoscopy: preliminary validation and efficacy as a training tool.

BACKGROUND: Effective control of the colonoscope tip is one of the most fundamental components of colonoscopy skill. Mastering fine tip control can be problematic for novice trainees, yet no validated training regimes exist for developing this specific skill component in isolation. We aimed to conduct a preliminary validation of a novel training device for colonoscopic tip control, and to assess its efficacy as a training tool. METHODS: In study 1 (validation), 13 experienced colonoscopists and 16 novices used a colonoscope to accurately track 28 targets on each of four concave "training surfaces" as quickly as possible, and we compared their performance. In study 2 (pre-post-training study), another 16 novices were tested before and after a six-session training program. In both studies, the main outcome measurements were completion time (measured automatically by the device) and variability of individual performance (the SD of each individual's completion times across trials). RESULTS: Compared with novices, experienced colonoscopists were faster (P < 0.0001) and their performances less variable (P < 0.0001). With training, novices became faster (P < 0.0001) and more consistent (P = 0.003), and these improvements also generalized to novel training surfaces (P's < 0.01). After training, the novices' tip control performance was indistinguishable from that of the experienced colonoscopists (P's > 0.05). The composite measures of completion time used in both studies all had acceptable to excellent internal consistency reliability (α's ranged from 0.72 to 0.93). CONCLUSIONS: We found that performance measures derived from using the device to assess skill can discriminate between experienced colonoscopists and novices in terms of their ability to control and guide the colonoscope tip precisely, providing preliminary evidence to support the construct validity of the metrics. The device is also an effective training tool for this fundamental component of colonoscopy skill.

Assessing colonoscopic inspection skill using a virtual withdrawal simulation: a preliminary validation of performance metrics.

BACKGROUND: The effectiveness of colonoscopy for diagnosing and preventing colon cancer is largely dependent on the ability of endoscopists to fully inspect the colonic mucosa, which they achieve primarily through skilled manipulation of the colonoscope during withdrawal. Performance assessment during live procedures is problematic. However, a virtual withdrawal simulation can help identify and parameterise actions linked to successful inspection, and offer standardised assessments for trainees. METHODS: Eleven experienced endoscopists and 18 endoscopy novices (medical students) completed a mucosal inspection task during three simulated colonoscopic withdrawals. The two groups were compared on 10 performance metrics to preliminarily assess the validity of these measures to describe inspection quality. Four metrics were related to aspects of polyp detection: percentage of polyp markers found; number of polyp markers found per minute; percentage of the mucosal surface illuminated by the colonoscope (≥0.5 s); and percentage of polyp markers illuminated (≥2.5 s) but not identified. A further six metrics described the movement of the colonoscope: withdrawal time; linear distance travelled by the colonoscope tip; total distance travelled by the colonoscope tip; and distance travelled by the colonoscope tip due to movement of the up/down angulation control, movement of the left/right angulation control, and axial shaft rotation. RESULTS: Statistically significant experienced-novice differences were found for 8 of the 10 performance metrics (p's < .005). Compared with novices, experienced endoscopists inspected more of the mucosa and detected more polyp markers, at a faster rate. Despite completing the withdrawals more quickly than the novices, the experienced endoscopists also moved the colonoscope more in terms of linear distance travelled and overall tip movement, with greater use of both the up/down angulation control and axial shaft rotation. However, the groups did not differ in the number of polyp markers visible on the monitor but not identified, or movement of the left/right angulation control. All metrics that yielded significant group differences had adequate to excellent internal consistency reliability (α = .79 to .90). CONCLUSIONS: These systematic differences confirm the potential of the simulated withdrawal task for evaluating inspection skills and strategies. It may be useful for training, and assessment of trainee competence.

Do self-reported concussions have cumulative or enduring effects on drivers' anticipation of traffic hazards?

AIM: To investigate the cumulative effect of multiple self-reported concussions and the enduring effect of concussion on drivers' hazard perception ability. It was hypothesized: (1) that individuals reporting multiple previous concussions would be slower to anticipate traffic hazards than individuals reporting either one previous concussion or none; and (2) that individuals reporting a concussion within the past 3 months would be slower to anticipate traffic hazards than individuals reporting either an earlier concussion or no prior concussion. METHOD: Two hundred and eighty-two predominantly young drivers (nconcussed = 68, Mage = 21.57 years, SDage = 6.99 years, 66% female) completed a validated hazard perception test (HPT) and measures of emotional, cognitive, health and driving status. RESULTS: A one-way analysis of variance showed that there was no significant effect of concussion number on HPT response times. Similarly, pairwise comparisons showed no significant differences between the HPT response times of individuals reporting a concussion within the previous 3 months, individuals reporting an earlier concussion and the never concussed group. CONCLUSION: The findings suggest that previous concussions do not adversely affect young drivers' ability to anticipate traffic hazards; however, due to reliance on self-reports of concussion history, further prospective longitudinal research is needed.

Observation chart design features affect the detection of patient deterioration: a systematic experimental evaluation.

AIM: To systematically evaluate the impact of several design features on chart-users' detection of patient deterioration on observation charts with early-warning scoring-systems. BACKGROUND: Research has shown that observation chart design affects the speed and accuracy with which abnormal observations are detected. However, little is known about the contribution of individual design features to these effects. DESIGN: A 2 × 2 × 2 × 2 mixed factorial design, with data-recording format (drawn dots vs. written numbers), scoring-system integration (integrated colour-based system vs. non-integrated tabular system) and scoring-row placement (grouped vs. separate) varied within-participants and scores (present vs. absent) varied between-participants by random assignment. METHODS: 205 novice chart-users, tested between March 2011-March 2014, completed 64 trials where they saw real patient data presented on an observation chart. Each participant saw eight cases (four containing abnormal observations) on each of eight designs (which represented a factorial combination of the within-participants variables). On each trial, they assessed whether any of the observations were physiologically abnormal, or whether all observations were normal. Response times and error rates were recorded for each design. RESULTS: Participants responded faster (scores present and absent) and made fewer errors (scores absent) using drawn-dot (vs. written-number) observations and an integrated colour-based (vs. non-integrated tabular) scoring-system. Participants responded faster using grouped (vs. separate) scoring-rows when scores were absent, but separate scoring-rows when scores were present. CONCLUSION: Our findings suggest that several individual design features can affect novice chart-users' ability to detect patient deterioration. More broadly, the study further demonstrates the need to evaluate chart designs empirically.

Less is more: the design of early-warning scoring systems affects the speed and accuracy of scoring.

AIM: To evaluate the effect of early-warning scoring system design on the speed and accuracy of scoring. BACKGROUND: Despite the widespread implementation of early-warning scoring systems in hospitals, the speed and accuracy with which chart-users determine patients' early-warning scores has received minimal research attention. DESIGN: Within-subjects, with scoring-system design as the independent variable. METHODS: Forty-seven novice chart-users were presented with realistic vital sign observations recorded on charts with three different scoring-system designs. The rows for recording individual vital sign scores were either: (1) grouped together beneath all of the vital sign rows; (2) separated, with each row presented immediately below the corresponding vital sign row; or (3) excluded altogether. Participants' response times and error rates for determining the overall scores were measured for 54 time-points per design. Data were collected in December 2012-January 2013. RESULTS: Contrary to predictions, participants responded fastest and made the fewest errors when using the chart design without individual vital sign scoring-rows. For the other two designs, participants were faster when the rows for scoring individual vital signs were separated (vs. grouped), but accuracy did not differ. For both of these designs, significantly more time-points were affected by scoring errors compared with adding errors. Finally, data for patients with more serious derangements yielded greater response times and error rates on all three charts. CONCLUSION: Early-warning scoring systems may be more effective without individual vital sign scoring-rows. Even when charts are designed by multi-disciplinary teams of human factors specialists and clinicians, empirical evaluations are essential.

A competency framework for colonoscopy training derived from cognitive task analysis techniques and expert review.

BACKGROUND: Colonoscopy is a difficult cognitive-perceptual-motor task. Designing an appropriate instructional program for such a task requires an understanding of the knowledge, skills and attitudes underpinning the competency required to perform the task. Cognitive task analysis techniques provide an empirical means of deriving this information. METHODS: Video recording and a think-aloud protocol were conducted while 20 experienced endoscopists performed colonoscopy procedures. "Cued-recall" interviews were also carried out post-procedure with nine of the endoscopists. Analysis of the resulting transcripts employed the constant comparative coding method within a grounded theory framework. The resulting draft competency framework was modified after review during semi-structured interviews conducted with six expert endoscopists. RESULTS: The proposed colonoscopy competency framework consists of twenty-seven skill, knowledge and attitude components, grouped into six categories (clinical knowledge; colonoscope handling; situation awareness; heuristics and strategies; clinical reasoning; and intra- and inter-personal). CONCLUSIONS: The colonoscopy competency framework provides a principled basis for the design of a training program, and for the design of formative assessment to gauge progress towards attaining the knowledge, skills and attitudes underpinning the achievement of colonoscopy competence.

Athletes' age, sex, and years of education moderate the acute neuropsychological impact of sports-related concussion: a meta-analysis.

The objective of this study is to determine which pre-existing athlete characteristics, if any, are associated with greater deficits in functioning following sports-related concussion, after controlling for factors previously shown to moderate this effect (e.g., time since injury). Ninety-one independent samples of concussion were included in a fixed+systematic effects meta-analysis (n = 3,801 concussed athletes; 5,631 controls). Moderating variables were assessed using analogue-to-ANOVA and meta-regression analyses. Post-injury assessments first conducted 1-10 days following sports-related concussion revealed significant neuropsychological dysfunction, postural instability and post-concussion symptom reporting (d = -0.54, -1.10, and -1.14, respectively). During this interval, females (d = -0.87), adolescent athletes competing in high school competitions (d = -0.60), and those with 10 years of education (d = -1.32) demonstrated larger post-concussion neuropsychological deficits than males (d = -0.42), adults (d = -0.25), athletes competing at other levels of competition (d = -0.43 to -0.41), or those with 16 years of education (d = -0.15), respectively. However, these sub-groups' differential impairment/recovery beyond 10 days could not be reliably quantified from available literature. Pre-existing athlete characteristics, particularly age, sex and education, were demonstrated to be significant modifiers of neuropsychological outcomes within 10 days of a sports-related concussion. Implications for return-to-play decision-making and future research directions are discussed.

Do injury characteristics predict the severity of acute neuropsychological deficits following sports-related concussion? A meta-analysis.

The utility of injury characteristics for predicting the severity of post-concussion outcomes remains equivocal. The purpose of this meta-analysis was to quantify the predictive relationship between these variables to inform classification of acute injury severity. Thirty-one empirical samples of concussed athletes, for which rates of loss of consciousness and/or amnesia were reported, were included in a meta-analysis evaluating acute outcomes following sports-related concussion. Outcome measures of interest were neuropsychological tests first administered 1-10 days post-injury. Loss of consciousness and anterograde amnesia significantly predicted more severe neuropsychological deficits within 10 days of concussion in studies using pre-injury baseline, but not control group, comparisons. Retrograde amnesia significantly predicted acute neuropsychological dysfunction (d = -1.03) irrespective of comparison group. Although small sample sizes require conservative interpretation and future replication, the evidence suggests that retrograde amnesia, rather than loss of consciousness, may be used to classify the acute severity of concussion.

Observation charts with overlapping blood pressure and heart rate graphs do not yield the performance advantage that health professionals assume: an experimental study.

AIM: To investigate whether overlapping blood pressure and heart rate graphs improve chart-users' ability to recognize derangements in these vital signs on hospital observation charts. BACKGROUND: Many health professionals prefer blood pressure and heart rate graphs to overlap. One justification is the use of a visual cue called the 'Seagull Sign' to detect physiological abnormalities. DESIGN: A 3 × 2 × 2 mixed-design experiment, with three independent variables: participant group, graph format (separate vs. overlapping) and alerting system (integrated colour-based track-and-trigger system present vs. absent). METHODS: Over 64 experimental trials, 'Seagull-trained' nurses and novices randomly assigned to receive 'Seagull training' or remain untrained, viewed sequences of blood pressure and heart rate observations recorded on four different chart design extracts. The designs represented a crossing of the graph format and alerting system variables. For each design, eight cases contained normal data and eight contained an abnormal systolic blood pressure or heart rate observation (half of which yielded a Seagull Sign on overlapping plots). Participants (tested between January-May 2011) judged whether observations were physiologically normal or abnormal. RESULTS: Across all cases, participants from all groups responded faster and made fewer errors when blood pressure and heart rate observations were graphed separately, especially when a track-and-trigger system was present. Even for 'Seagull-trained' participants viewing 'Seagull Sign available' cases, no advantage of overlapping graphs was found. CONCLUSIONS: These findings suggest that overlapping graphs do not yield the performance advantage that many health professionals assume, either for novices or experienced nurses, even when the Seagull Sign is used.

A yellow filter improves response times to low-contrast targets and traffic hazards.

PURPOSE: Anecdotal evidence suggests that some sunglass users prefer yellow tints for outdoor activities, such as driving, and research has suggested that such tints improve the apparent contrast and brightness of real-world objects. The aim of this study was to establish whether yellow filters resulted in objective improvements in performance for visual tasks relevant to driving. METHODS: Response times of nine young (age [mean ± SD], 31.4 ± 6.7 years) and nine older (age, [mean ± SD], 74.6 ± 4.8) adults were measured using video presentations of traffic hazards (driving hazard perception task) and a simple low-contrast grating appeared at random peripheral locations on a computer screen. Response times were compared when participants wore a yellow filter (with and without a linear polarizer) versus a neutral density filter (with and without a linear polarizer). All lens combinations were matched to have similar luminance transmittances (~27%). RESULTS: In the driving hazard perception task, the young but not the older participants responded significantly more rapidly to hazards when wearing a yellow filter than with a luminance-matched neutral density filter (mean difference, 450 milliseconds). In the low-contrast grating task, younger participants also responded more quickly for the yellow filter condition but only when combined with a polarizer. Although response times increased with increasing stimulus eccentricity for the low-contrast grating task, for the younger participants, this slowing of response times with increased eccentricity was reduced in the presence of a yellow filter, indicating that perception of more peripheral objects may be improved by this filter combination. CONCLUSIONS: Yellow filters improve response times for younger adults for visual tasks relevant to driving.

Return-to-driving expectations following mild traumatic brain injury.

AIM: Although individuals recovering from mild traumatic brain injury (MTBI) could pose a risk to road safety, little is known about their intentions regarding return-to-driving. Reported are the expectations of a sample of emergency department patients with MTBI regarding their recovery and return-to-driving. METHOD: Eighty-one patients with MTBI were recruited from an emergency department. Participants completed an 11-item questionnaire measuring expectations regarding recovery from injury; five of the items addressed return-to-driving. RESULTS: Only 48% of the sample intended to reduce their driving following their injury. However, those that did intend to reduce their driving nominated a mean duration of 16.59 days (SD = 31.68) of reduced exposure. A logistic regression found that previous head injury experience and an interaction between pain and previous head injury experience predicted intentions to reduce driving. Similarly, a multiple regression revealed that pain level contributed significantly to the variance in time estimates of return-to-driving. CONCLUSION: The finding that half the individuals recovering from MTBI do not intend to moderate their driving exposure post-injury is cause for concern, as another study has shown that driving performance is compromised in this group immediately after injury.

Hazard Perception Skill and Driver Behavior in Patients With Functional Neurologic Disorders.

BACKGROUND AND OBJECTIVES: Driving in patients with functional neurologic disorders (FND) is a major concern, but current guidelines (where they exist) are based on expert consensus only due to a lack of relevant empirical evidence. This study aimed to provide such evidence by comparing drivers with FND with healthy controls on aspects of driving performance and behavior important to crash risk, including hazard perception skill. METHODS: Participants completed validated self-report questionnaires of driving behaviors (assessing lapses, errors, violations, and attentional issues) and 2 computer-based measures of hazard perception skill (both known to be associated with crash risk). RESULTS: We compared 43 patients who experience dissociative attacks or functional motor symptoms and 43 healthy controls. Patients with FND self-reported significantly more driving lapses and driving errors compared with healthy controls. However, there were no significant between-group differences in self-reports of ordinary violations, aggressive violations, or attention-related errors. Participants in the FND group and healthy controls exhibited a similar performance on a response time hazard perception test (6.27 vs 5.51 seconds, p = 0.245). However, participants with FND remarkably outperformed the controls in the number of plausible predictions they made in a verbal response hazard prediction test (1.55 vs 1.18 predictions per clip, p = 0.006). DISCUSSION: Our findings suggest that the ability of drivers with FND to predict traffic hazards in between attacks or flares is not worse than that of healthy individuals, with the possibility that it might even be better under some circumstances. Further studies with various populations are needed to replicate our findings.

Assessing the realism of colonoscopy simulation: the development of an instrument and systematic comparison of 4 simulators.

BACKGROUND: No useful comparative data exist on the relative realism of commercially available devices for simulating colonoscopy. OBJECTIVES: To develop an instrument for quantifying realism and provide the first wide-ranging empiric comparison. DESIGN: Repeated measures, observational study. Nineteen experienced colonoscopists completed cases on 4 colonoscopy simulators (AccuTouch, GI Mentor II, Koken, and Kyoto Kagaku) and evaluated each device. SETTING: A medical simulation center in a large tertiary hospital. MAIN OUTCOME MEASURES: For each device, colonoscopists completed the newly developed Colonoscopy Simulator Realism Questionnaire (CSRQ), which contains 58 items grouped into 10 subscales measuring the realism of different aspects of the simulation. Subscale scores are weighted and combined into an aggregated score, and there is also a single overall realism item. RESULTS: Overall, current colonoscopy simulators were rated as only moderately realistic compared with real human colonoscopy (mean aggregated score, 56.28/100; range, 48.39-60.45, where 0 = "extremely unrealistic" and 100 = "extremely realistic"). On both overall realism measures, the GI Mentor II was rated significantly less realistic than the AccuTouch, Kyoto Kagaku, and Koken (P < .001). There were also significant differences between simulators on 9 subscales, and the pattern of results varied between subscales. LIMITATIONS: The study was limited to commercially available simulators, excluding ex-vivo models. The CSRQ does not assess simulated therapeutic procedures. CONCLUSIONS: The CSRQ is a useful instrument for quantifying simulator realism. There is no clear "first choice" simulator among those assessed. Each has unique strengths and weaknesses, reflected in the differing results observed across 9 subscales. These findings may facilitate the targeted selection of simulators for various aspects of colonoscopy training.

Construct validation of a physical model colonoscopy simulator.

BACKGROUND: Previous studies have demonstrated the construct validity of virtual reality colonoscopy simulators by showing that they can distinguish between users according to their level of endoscopic experience. Although physical model simulators are known to simulate looping more realistically than these devices, they lack published validation evidence. OBJECTIVE: To assess the construct validity of a physical model simulator, the Kyoto Kagaku Colonoscope Training Model (Kyoto Kagaku Co. Ltd, Kyoto, Japan) and to determine its suitability for assessing the insertion skill of trainee colonoscopists. DESIGN: Validation study; 21 experienced colonoscopists and 18 novices made 2 attempts at each of 4 standard cases on the Kyoto Kagaku physical model simulator, and we compared their performance on each case. SETTING: A medical simulation center in a large tertiary hospital. MAIN OUTCOME MEASUREMENTS: Completion rates, times to cecum, and peak forces applied to the colon model. RESULTS: Compared with novices, experienced colonoscopists had significantly higher completion to cecum rates and shorter times to cecum for each of the 4 cases (all P < .005). For 2 cases, experienced colonoscopists also exerted significantly lower peak forces than did novices (both P = .01). LIMITATIONS: Two of the model's 6 "standard cases" were not included in the study. CONCLUSIONS: The 4 cases included in the study have construct validity in that they can distinguish between the performance of experienced colonoscopists and novices, reproducing experienced/novice differences found in real colonoscopy. These cases can be used to validly assess the insertion skill of colonoscopy trainees.

Designing observation charts to optimize the detection of patient deterioriation: reliance on the subjective preferences of healthcare professionals is not enough.

AIM: Observation charts are critical to detecting patient deterioration. Research suggests their design has a dramatic impact on user performance in terms of failure rates for detecting abnormal vital signs and how quickly users can interpret recorded observations. In this study, we examined the design preferences of professional chart users to assess their alignment with objective performance data. In addition, we tested the assumptions of prior knowledge that chart designers appear to have made about chart users. METHODS: We conducted an online survey of health professionals (n=347). Participants answered questions about their observation chart design preferences in general, and were randomly assigned to evaluate one of nine specific charts. RESULTS: Chart users' preferences for design features were not always consistent with objective performance data. While some views concurred with empirical findings (e.g., participants preferred to plot observations on a graph with graded colouring, where the colours corresponded with degrees of abnormality), others did not (e.g., participants preferred plotting blood pressure and pulse together on the same chart area, which the objective data suggest is problematic). Additionally, a substantial proportion of respondents were unfamiliar with some of the assumed knowledge required to interpret many charts (e.g., particular abbreviations). CONCLUSIONS: It is dangerous to rely solely on subjective opinions - even those of experienced health professionals - when developing patient observation charts, as optimal design may be counterintuitive and some preferences may merely reflect familiarity. Objective performance data is also required. In addition, the level of assumed knowledge required to use a chart should be minimized.