High-Fidelity Cleft Simulation Maintains Improvements in Performance and Confidence: A Prospective Study.

OBJECTIVE: High-fidelity simulation has a growing role in plastic surgical education. This study tests the hypothesis that cleft lip repair simulation followed by structured debriefing improves performance and self-confidence and that gains are maintained. DESIGN: Prospective, single-blinded interventional study with repeated measures. Trainees performed cleft lip repair on a high-fidelity simulator followed by debriefing, immediately completed a second repair, and returned 3 months later for a third session. Anonymized simulation videos were rated using the modified Objective Structured Assessment of Technical Skills (OSATS) and the Unilateral Cleft Lip Repair competency assessment tool (UCLR). Self-assessed cleft lip knowledge/confidence and procedural self-confidence were surveyed after each simulation. SETTING: Boston Children's Hospital, a tertiary care academic hospital in Boston, MA, USA. PARTICIPANTS: All trainees rotating through the study setting were eligible. Twenty-six participated; 21 returned for follow-up. RESULTS: Significant improvements (p < 0.05) occurred between the first and second simulations for OSATS, UCLR, and procedural self-confidence. Significant improvement occurred between the second and third simulations cleft lip knowledge/confidence. Compared to the first simulation, improvements were maintained at the third simulation for all variables. Training level moderately correlated with score for UCLR for the first simulation (r = 0.55, p < 0.01), deteriorated somewhat with the second (r = 0.35, p = 0.08), and no longer corelated by the third (r = 0.02, p = 0.92). CONCLUSIONS: Objective performance and subjective self-assessed knowledge and confidence improve with high-fidelity simulation plus structured debriefing and improvement is maintained. Differences in procedure-specific performance seen with increasing training level are reduced with simulation, suggesting it may accelerate knowledge and skill acquisition.

Male and Female Toddlers with DSM-5 Autism Spectrum Disorder have Similar Developmental Profiles and Core Autism Symptoms.

Compare developmental profiles and core ASD symptom manifestation between male and female toddlers with DSM-5 ASD. Retrospective record review of 500 toddlers (79% male) at time of ASD diagnosis. There were no differences in developmental functioning between males and females. When adjusting for multiple comparisons, sex differences were only noted for sensory seeking behavior occurring at a higher frequency in females. Overall, there were no significant differences in demographic characteristics, developmental functioning, or manifestation of core ASD symptoms between males versus female toddlers at the time of DSM-5 ASD diagnosis.

Cleft Lip Repair Competence Can Be Evaluated with High-fidelity Simulation.

Background: Demonstrating competency before independent practice is increasingly important in surgery. This study tests the hypothesis that a high-fidelity cleft lip simulator can be used to discriminate performance between training levels, demonstrating its utility for assessing procedural competence. Methods: During this prospective cohort study, participants performed a unilateral cleft lip repair on a high-fidelity simulator. Videos were blindly rated using the Objective Structured Assessment of Technical Skills (OSATS) and the Unilateral Cleft Lip Repair Competency Assessment Tool (UCLR). Digital measurement of symmetry was estimated. Influence of training level and cumulative prior experience on each score was estimated using Pearson r. Results: Participants (n = 26) ranged from postgraduate year 3 to craniofacial fellow. Training level correlated best with UCLR (R = 0.4842, P = 0.0122*) and more weakly with OSATS (R = 0.3645, P = 0.0671), whereas cumulative prior experience only weakly correlated with UCLR (R = 0.3450, P = 0.0843) and not with OSATS (R = 0.1609, P = 0.4323). UCLR subscores indicated marking the repair had little correlation with training level (R = 0.2802, P = 0.1656), whereas performance and result did (R = 0.5152, P = 0.0071*, R = 0.4226, P = 0.0315*, respectively). Correlation between symmetry measures and training level was weak. Conclusions: High-fidelity simulation paired with an appropriate procedure-specific assessment tool has the construct validity to evaluate performance for cleft lip repair. Simply being able to mark a cleft lip repair is not an accurate independent assessment method nor is symmetry of the final result.

Special Education Services and School-Related Quality of Life in Children With Learning Disorders and Their Families: A One-Year Follow-Up Study.

Learning disorders can have adverse impacts on children and families extending beyond the academic skills deficits. The goal of the present study was to assess the impact of the school's response, following an independent evaluation, for child and family school-related quality of life (QOL). We hypothesized that a positive school response would be associated with improved QOL. Parents completed the LDQOL/15, a brief measure of school-related QOL, at the time that their child received an independent evaluation and again a year later (N = 155). At follow-up, parents reported the tenor of the school's response to the evaluation and whether special education services had changed. QOL problems were very high in this referred population, with 66% of respondents rating a level of problems in the clinical range at baseline. Predicted interactions between time of assessment (baseline/follow-up) and the school's response to the evaluation were confirmed for all outcome variables; a positive school response was associated with improved QOL. Nevertheless, the overall prevalence of school-related QOL problems remained high a year after the evaluation. These findings indicate that special education interventions can mitigate learning disabilities' impacts, but even with these services, many children with learning disorders and their families continue to be significantly affected.

Identifying Student Subgroups as a Function of School Level Attributes: A Multilevel Latent Class Analysis.

The purpose of the present study was to profile high school students' achievement as a function of their demographic characteristics, parent attributes (e.g., education), and school behaviors (e.g., number of absences). Students were nested within schools in the Saudi Arabia Kingdom. Out of a large sample of 500k, participants involved 3 random samples of 2,000 students measured during the years 2016, 2017, and 2018. Randomization was conducted at the student level to ensure that all school units will be represented and at their respective frequency. Students were nested within 50 high schools. We adopted the multilevel latent profile analysis protocol put forth by Schmiege et al. (2018) and Mäkikangas et al. (2018) that account for nested data and tested latent class structure invariance over time. Results pointed to the presence of a 4-profile solution based on BIC, the Bayes factor, and several information criteria put forth by Masyn (2013). Latent profile separation was mostly guided by parents' education and the number of student absences (being positive and negative predictors of high achievement classes, respectively). Two models tested whether the proportions of level 1 profiles to level 2 units are variable and whether level 2 profiles vary as a function of level 1 profiles. Results pointed to the presence of significant variability due to schools.

Infant circulating MicroRNAs as biomarkers of effect in fetal alcohol spectrum disorders.

Prenatal alcohol exposure (PAE) can result in cognitive and behavioral disabilities and growth deficits. Because alcohol-related neurobehavioral deficits may occur in the absence of overt dysmorphic features or growth deficits, there is a need to identify biomarkers of PAE that can predict neurobehavioral impairment. In this study, we assessed infant plasma extracellular, circulating miRNAs (exmiRNAs) obtained from a heavily exposed Cape Town cohort to determine whether these can be used to predict PAE-related growth restriction and cognitive impairment. PAE, controlling for smoking as a covariate, altered 27% of expressed exmiRNAs with clinically-relevant effect sizes (Cohen's d ≥ 0.4). Moreover, at 2 weeks, PAE increased correlated expression of exmiRNAs across chromosomes, suggesting potential co-regulation. In confirmatory factor analysis, the variance in expression for PAE-altered exmiRNAs at 2 weeks and 6.5 months was best described by three-factor models. Pathway analysis found that factors at 2 weeks were associated with (F1) cell maturation, cell cycle inhibition, and somatic growth, (F2) cell survival, apoptosis, cardiac development, and metabolism, and (F3) cell proliferation, skeletal development, hematopoiesis, and inflammation, and at 6.5 months with (F1) neurodevelopment, neural crest/mesoderm-derivative development and growth, (F2) immune system and inflammation, and (F3) somatic growth and cardiovascular development. Factors F3 at 2 weeks and F2 at 6.5 months partially mediated PAE-induced growth deficits, and factor F3 at 2 weeks partially mediated effects of PAE on infant recognition memory at 6.5 months. These findings indicate that infant exmiRNAs can help identify infants who will exhibit PAE-related deficits in growth and cognition.

Identifying Subgroups of Toddlers with DSM-5 Autism Spectrum Disorder Based on Core Symptoms.

The objective of this study was to identify subgroups of toddlers with DSM-5 ASD based on core ASD symptoms using a person-based analytical framework. This is a retrospective study of 500 toddlers (mean age 26 months, 79% male) with DSM-5 ASD. Data were analyzed using latent class analyses in which profiles were formed based on ASD symptomatology. Social communication (SC) symptoms favored a three-class solution, while restricted/repetitive behaviors (RRBs) favored a two-class solution. Classes with higher consistency of SC deficits were younger, with lower developmental functioning. The class with more RRBs was older, with higher functioning. If confirmed in other populations, these classes may more precisely characterize subgroups within the heterogeneous group of toddlers at time of ASD diagnosis.

Incorporating Cleft Lip Simulation Into a "Bootcamp-Style" Curriculum.

INTRODUCTION: The traditions of surgical education have changed little over the years. However, the increasing focus on patient safety and duty hour restrictions mandates that residents start developing complex skill sets earlier to ensure they graduate with procedural competency. Surgical training is poised to exploit high-fidelity simulation technology to mitigate these pressures. METHODS: By revisiting principles of adult learning theory, the authors created a "bootcamp-style" cleft lip curriculum that sought to (1) maximize educational impact and (2) pilot a high-fidelity procedural trainer permitting resident operative autonomy as part of that curriculum. Trainees participated in small group educational sessions comprised of a standard cleft didactic lecture, augmented by instructional video. Participants immediately processed knowledge from the lecture/video by "operating" on the simulator, allowing opportunities for questions and self-reflection, completing the learning cycle. A self-assessment survey was taken before and after each component of the session, including a self-confidence survey to conclude the session. Anthropometric measures of lip/nasal symmetry were assessed. RESULTS: Sixteen trainees participated in the program. Little increase in self-assessed knowledge/skill was seen after the lecture, but significant increases in most aspects of cleft lip repair were seen after simulation. The greatest increase in self-assessment was seen for the program as a whole, with significant differences across all aspects of the self-assessment. Higher levels of training were associated with both higher self-assessment scores and better lip symmetry. Regardless of level of training, all participants strongly agreed that simulation helped them actively engage in learning and should be a required aspect of training, whereas 94% (n = 15) thought simulation was much more effective than standard preparation alone. CONCLUSIONS: This pilot curriculum illustrates a mechanism to incorporate lessons from adult learning theory into plastic surgery training using a high-fidelity simulator for deliberate practice of cleft lip repair. Further evaluation is warranted to determine whether this didactic model can accelerate the acquisition of the complex skill set required for cleft lip repair and other surgical procedures.

Pathogenic Yield of Genetic Testing in Autism Spectrum Disorder.

BACKGROUND AND OBJECTIVES: Genetic testing is recommended for individuals with autism spectrum disorder (ASD). Pathogenic yield varies by clinician and/or patient characteristics. Our objectives were to determine the pathogenic yield of genetic testing, the variability in rate of pathogenic results based on subject characteristics, and the percentage of pathogenic findings resulting in further medical recommendations in toddlers with a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis of ASD. METHODS: We conducted a retrospective chart review of 500 toddlers, 18 to 36 months, diagnosed with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ASD (mean age: 25.8 months, 79% male). Subject demographics, medical and neuropsychological characteristics, and genetic test results were abstracted. Genetic results were divided into negative or normal, variants of unknown significance, and pathogenic. Subject characteristics were compared across results. Manual chart review determined if further recommendations were made after pathogenic results. RESULTS: Over half of subjects (59.8%, n = 299) completed genetic testing, and of those, 36 (12.0%) had pathogenic findings. There were no significant differences in Bayley Scales of Infant Development cognitive (P = .112), language (P = .898), or motor scores (P = .488) among children with negative or normal findings versus a variant of unknown significance versus pathogenic findings. Medical recommendations in response to the genetic finding were made for 72.2% of those with pathogenic results. CONCLUSIONS: Our findings reinforce the importance of genetic testing for toddlers diagnosed with ASD given the 12% yield and lack of phenotypic differences between subjects with and without pathogenic findings. The majority of pathogenic results lead to further medical recommendations.

A Competency Assessment Tool for Unilateral Cleft Lip Repair.

Objective evaluation of operative performance is increasingly important in surgical training. Evaluation tools include global rating scales of performance and procedure-specific skills checklists. For unilateral cleft lip repair, the numerous techniques make universal evaluation challenging. Thus, we sought to create a unilateral cleft lip evaluation tool agnostic to specific repair technique. METHODS: Four surgeons with expertise in 3 common cleft lip repair techniques participated in a 3-round Delphi process to generate consensus evaluation points spanning all techniques. Items were categorized as marking the repair, performing the repair, and final result. Two blinded raters then scored videos of simulated cleft lip repairs using both the 21-item novel checklist and the modified Objective Structured Assessment of Technical Skills. Kappa and T values were calculated for both scales to determine level of agreement. RESULTS: Ten videos of repairs performed by novice residents through experienced craniofacial fellows were scored. Moderate (κ = 0.41-0.60) to substantial (κ = 0.61-0.80) interrater reliability was seen for the majority of questions in both the novel tool and the Objective Structured Assessment of Technical Skills. A single question in the novel tool had almost perfect agreement (κ = 0.81-1.00), 8 had moderate agreement, and 6 had substantial agreement. Poorly scoring questions were discarded from the final 18-item tool. CONCLUSIONS: Despite variations in unilateral cleft lip repair technique, common themes exist that can be used to assess performance and outcome. A universal evaluation tool has potential implications for trainee assessment, surgeon credentialing, and screening for surgical missions.

Accounting for Differential Item Functioning Using Bayesian Approximate Measurement Invariance.

The main thesis of the present study is to use the Bayesian structural equation modeling (BSEM) methodology of establishing approximate measurement invariance (A-MI) using data from a national examination in Saudi Arabia as an alternative to not meeting strong invariance criteria. Instead, we illustrate how to account for the absence of measurement invariance using relative compared to exact criteria. A secondary goal was to compare latent means across groups using invariant parameters only and through utilizing exact and relative evaluative-MI protocol suggested equivalence of the thresholds using prior variances equal to 0.10. Subsequent differences between groups were evaluated using effect size criteria and the prior-posterior predictive p-value (PPPP), which proved to be invaluable in attesting for differences that are beyond zero, some meaningless nonzero estimate, and the three commonly used indices of effect sizes described by Cohen in 1988 (i.e., .20, .50, and .80). Results substantiated the use of the PPPP for evaluating mean differences across groups when utilizing nonexact evaluative criteria.

Measurement Invariance and Differential Item Functioning Across Gender Within a Latent Class Analysis Framework: Evidence From a High-Stakes Test for University Admission in Saudi Arabia.

The main aim of the present study was to investigate the presence of Differential Item Functioning (DIF) using a latent class (LC) analysis approach. Particularly, we examined potential sources of DIF in relation to gender. Data came from 6,265 Saudi Arabia students, who completed a high-stakes standardized admission test for university entrance. The results from a Latent Class Analysis (LCA) revealed a three-class solution (i.e., high, average, and low scorers). Then, to better understand the nature of the emerging classes and the characteristics of the people who comprise them, we applied a new stepwise approach, using the Multiple Indicator Multiple Causes (MIMIC) model. The model identified both uniform and non-uniform DIF effects for several items across all scales of the test, although, for the majority of them, the DIF effect sizes were negligible. Findings from this study have important implications for both measurement quality and interpretation of the results. Particularly, results showed that gender is a potential source of DIF for latent class indicators; thus, it is important to include those direct effects in the latent class regression model, to obtain unbiased estimates not only for the measurement parameters but also of the structural parameters. Ignoring these effects might lead to misspecification of the latent classes in terms of both the size and the characteristics of each class, which in turn, could lead to misinterpretations of the obtained latent class results. Implications of the results for practice are discussed.

Alignment of a Language Instrument Scores to CEFR Levels: Methodological and Empirical Considerations.

The purpose of the present report was to assess congruence between a language-based national examination (termed English placement test - EPT) and the Common European Framework of Reference for Languages (CEFR) levels. To this end, a series of methodological steps were put forth to accumulate evidence suggesting that language performance based on the EPT instrument can be split onto meaningful subgroups based on theoretical (expert judgement on difficulty level and CEFR correspondence) and empirical considerations (i.e., how well these levels and subgroups emerged). Participants were 2642 high school graduates who took on the EPT instrument as part of their entry criteria to the university and for the purposes of the present study only the structure subscale is presented. Items were classified as reflecting specific CEFR levels and a person-based analysis attempted to classify individuals sharing the same behavioral patterns. Results using a latent class analysis (LCA) indicated that a Pre-A1, an A1 an A2 a B1 and a B2 levels were present with regard to the structure domain of language. Results showed a strong alignment between the EPT structure domain and CEFR guidelines using various methodological approaches.

An Application of Reliability Estimation in Longitudinal Designs Through Modeling Item-Specific Error Variance.

The purpose of the present study was to apply the methodology developed by Raykov on modeling item-specific variance for the measurement of internal consistency reliability with longitudinal data. Participants were a randomly selected sample of 500 individuals who took on a professional qualifications test in Saudi Arabia over four different occasions. Data were analyzed by use of confirmatory factor analysis, and item error variance was corrected for item specificity. The estimation of reliability involved composite index omega. Results indicated that the initially low and unacceptable levels of internal consistency reliability approached acceptable levels after accounting for item-specific variance. Findings were verified by testing whether the difference estimates of internal consistency reliability deviated from a zero-mean distribution using 10,000 replicated samples assuming a known (symmetric) or unknown (asymmetric) population distribution of the difference reliability coefficients. Percentage improvement reliability estimates indices were also estimated along with their 95% confidence intervals. Two appendices provide annotated Mplus syntax files for future use.

Using Confidence Intervals of the Item and Test Information Functions to Test Differential Item and Test Functioning: Visual and Statistical Analyses.

The purpose of the present paper was twofold: (a) to use 95% confidence intervals of the item and test information functions as a means of visualizing differences between groups on the information provided at the item and test levels, and, (b) to statistically compare item and test information functions as a method for evaluating differential item and differential test functioning. Participants were 2,305 high school students who took a Mathematics National entrance examination in Saudi Arabia. Item and test information functions, conditional standard errors of measurement and reliability were estimated for both males and females. Differences between groups became evident when plotting 95% confidence intervals of the item and test information functions and the visual findings were confirmed using population-based Z-tests of point estimates using a Monte-Carlo simulation. It was concluded that differential group behavior at the item and test levels can be evidenced using information functions and inferential tests of significance can be constructed using the bootstrap distribution. The current procedure involves both item difficulties and discrimination indices and provides increased sensitivity over the traditional methods relying on item difficulties only.

Quality of Life in Children and Adolescents With Learning Problems: Development and Validation of the LD/QOL15 Scale.

Learning problems (LP) can have wider implications than the academic deficits per se. The goal of the present series of studies was to develop a reliable and valid quality-of-life measure targeted to children and adolescents with LP. In Study 1, using a 35-item questionnaire, we surveyed 151 parents/guardians of children referred for assessment of learning disorders. Exploratory factor analysis identified a three-factor model: Academic Performance, School Understanding, and Child/Family Psychological. These factors were validated against standardized measures of academic achievement and psychosocial functioning. The questionnaire was then reduced to 15 items-the LD/QOL15 -and administered to a community sample of 325 parents/guardians of children in Grades 1 to 8 (Study 2). The three-factor model was verified with confirmatory factor analysis. Comparison of general education ( n = 232) and LP ( n = 93) groups within the community sample documented substantial group differences ( p < .0001), with the LP group having higher mean scores. These differences were larger for older students (Grades 5-8) than younger students (Grades 1-4; p < .01). The LD/QOL15 is a brief and reliable measure that is valid to assess quality of life and, potentially, outcomes in children and adolescents with LP.

Can the Relationship Between Rapid Automatized Naming and Word Reading Be Explained by a Catastrophe? Empirical Evidence From Students With and Without Reading Difficulties.

The purpose of the present study was to explain the moderating role of rapid automatized naming (RAN) in word reading with a cusp catastrophe model. We hypothesized that increases in RAN performance speed beyond a critical point would be associated with the disruption in word reading, consistent with a "generic shutdown" hypothesis. Participants were 587 elementary schoolchildren (Grades 2-4), among whom 87 had reading comprehension difficulties per the IQ-achievement discrepancy criterion. Data were analyzed via a cusp catastrophe model derived from the nonlinear dynamics systems theory. Results indicated that for children with reading comprehension difficulties, as naming speed falls below a critical level, the association between core reading processes (word recognition and decoding) becomes chaotic and unpredictable. However, after the significant common variance attributed to motivation, emotional, and internalizing symptoms measures from RAN scores was partialed out, its role as a bifurcation variable was no longer evident. Taken together, these findings suggest that RAN represents a salient cognitive measure that may be associated with psychoemotional processes that are, at least in part, responsible for unpredictable and chaotic word reading behavior among children with reading comprehension deficits.

An IRT-Multiple Indicators Multiple Causes (MIMIC) Approach as a Method of Examining Item Response Latency.

The analysis of response time has received increasing attention during the last decades, since evidence from several studies supported the argument that there is a direct relationship between item response time and test performance. The aim of this study was to investigate whether item response latency affects person's ability parameters, in that it represents an adaptive or maladaptive practice. To examine the above research question data from 8,475 individuals completing the computerized version of the Postgraduate General Aptitude Test (PAGAT) were analyzed. To determine the extent to which response latency affects person's ability, we used a Multiple Indicators Multiple Causes (MIMIC) model, in which every item in a scale was linked to its corresponding covariate (i.e., item response latency). We ran the MIMIC model within the Item Response Theory (IRT) framework (2-PL model). The results supported the hypothesis that item response latency could provide valuable information for getting more accurate estimations for persons' ability levels. Results indicated that for individuals who invest more time on easy items, their likelihood of success does not improve, most likely because slow and fast responders have significantly different levels of ability (fast responders are of higher ability compared to slow responders). Consequently, investing more time for low ability individuals does not prove to be adaptive. The opposite was found for difficult items: individuals spending more time on difficult items increase their likelihood of success, more likely because they are high achievers (in difficult items individuals who spent more time were of significantly higher ability compared to fast responders). Thus, it appears that there is an interaction between the difficulty of the item and person abilities that explain the effects of response time on likelihood of success. We concluded that accommodating item response latency in a computerized assessment model, can inform test quality and test takers' behavior, and in that way, enhance score measurement accuracy.

Assessing Construct Validity in Math Achievement: An Application of Multilevel Structural Equation Modeling (MSEM).

The purpose of the present study was to model math achievement at both the person and university levels of the analyses in order to understand the optimal factor structure of math competency. Data involved 2,881 students who took a national mathematics examination as part of their entry at the university public system in Saudi Arabia. Four factors from the National math examination comprised the math achievement measure, namely, numbers and operations, algebra and analysis, geometry and measurement, and, statistics and probabilities. Data were analyzed using the aggregate method and by use of Multilevel Structural Equation Modeling (MSEM). Results indicated that both a unidimensional and a 4-factor correlated model fitted the data equally well using aggregate data, where for reasons of parsimony the unidimensional model was the preferred choice with these data. When modeling data including clustering, results pointed to alternative factor structures at the person and university levels. Thus, a unidimensional model provided the best fit at the University level, whereas a four-factor correlated model was most descriptive for person level data. The optimal simple structure was evaluated using the Ryu and West (2009) methodology for partially saturating the MSEM model and also met criteria for discriminant validation as described in Gorsuch (1983). Furthermore, a university level variable, namely the year of establishment, pointed to the superiority of older institutions with regard to math achievement. It is concluded that ignoring a multilevel structure in the data may result in erroneous conclusions with regard to the optimal factor structure and the tests of structural models following that.