The Impact of Simulation Based Training on the Fundamentals of Endoscopic Surgery Performance Examination.

OBJECTIVE: To determine if simulation training is required to pass the FES skills test and assess the relationship between simulation training, clinical training, and FES skills test performance. SUMMARY OF BACKGROUND DATA: The ABS began requiring completion of the Flexible Endoscopy Curriculum for all applicants beginning in 2018. The role of simulation-based training in FES skills test performance after this requirement has not been evaluated. METHODS: De-identified data from the initial FES skills tests after the Flexible Endoscopy Curriculum requirement was reviewed, and 731 unique participants with reported simulation experience demographics were identified. Self-reported data included sex, upper (UE) and lower (LE) endoscopy experience, and simulator training hours (SE). Final FES skills exam scores and pass/fail designations for each participant were reported by the FES program staff. RESULTS: There was a statistically discernible difference in mean FES total scores between those reporting no SE and more experienced groups ( P = 0.002), and between less and more experienced UE and LE groups ( P < 0.001). There was no statistically discernible difference in FES skills exam pass rates between SE groups ( P = 0.2), but there was a strong relationship between clinical experience (UE & LE) and pass rate ( P < 0.001). Finally, on logistic regression analysis, LE was a discernible predictor of passing [odds ratio (OR) = 1.4, 95% confidence interval (CI) 1.1-1.8, P = 0.02], while UE [odds ratio (OR) = 1, 95% CI 0.8-1.3, P = 0.9] and SE (OR = 1,95% CI 0.9- 1.3, P = 0.7) were not. CONCLUSIONS: There is no threat to the validity of the FES skills test from a need for simulation training to pass the FES skills test. Similarly, the amount of simulation practice is not predictive of passing, but can improve performance on certain FES tasks.

Evidence-based Surgical Competency Outcomes from the Clinical Readiness Program.

OBJECTIVES: 1) Evaluate the value and strength of a competency framework for identifying and measuring performance requirements for expeditionary surgeons; 2) Verify psychometric integrity of assessment instrumentation for measuring domain knowledge and skills; 3) Identify gaps in knowledge and skills capabilities using assessment strategies; 4) Examine shared variance between knowledge and skills outcomes, and the volume and diversity of routine surgical practice. BACKGROUND: Expeditionary military surgeons provide care for patients with injuries that extend beyond the care requirements of their routine surgical practice. The readiness of these surgeons to independently provide accurate care in expeditionary contexts is important for casualty care in military and civilian situations. Identifying and closing performance gap areas are essential for assuring readiness. METHODS: We implemented evidence-based processes for identifying and measuring the essential performance competencies for expeditionary surgeons. All assessment instrumentation was rigorously examined for psychometric integrity. Performance outcomes were directly measured for expeditionary surgical knowledge and skills and gap areas were identified. Knowledge and skills assessment outcomes were compared, and also compared to the volume and diversity of routine surgical practice to determine shared variance. RESULTS: Outcomes confirmed the integrity of assessment instrumentation and identified significant performance gaps for knowledge and skills in the domain. CONCLUSIONS: Identification of domain competencies and performance benchmarks, combined with best-practices in assessment instrumentation, provided a rigorous and defensible framework for quantifying domain competencies. By identifying and implementing strategies for closing performance gap areas, we provide a positive process for assuring surgical competency and clinical readiness.

The American Board of Surgery flexible endoscopy curriculum prepares individuals to pass the fundamentals of endoscopic surgery manual skills test.

BACKGROUND: The American Board of Surgery (ABS) has required Fundamentals of Endoscopic Surgery (FES) certification for general surgery applicants since 2018. Flexible Endoscopy Curriculum (FEC) completion is recommended prior to taking the FES exam. The objective of the study was to determine if FEC completion prepares individuals to pass the FES manual skills test. METHODS: Participants included first-attempt FES examinees from June 2014 to February 2019. De-identified data were reviewed, Self-reported data included gender, PGY, glove size, upper (UE) and lower (LE) endoscopy experience, simulation training time, and participation in an endoscopy rotation (ER). FES skills exam performance was reported by FES staff. Those completing all vs. none of the FEC were compared. RESULTS: Of 2023 participants identified, 809 (40.0%) reported completion of all FEC components, 1053 (52.1%) completed of some, and 161 (8.0%) completed none. Men and candidates taking FES later in residency were more likely to complete all FEC requirements (p = 0.002, p < 0.001). FES pass rates were higher for those who completed all FEC components compared to those who completed none (88.4% vs 72.7%, p < 0.001). On logistic regression analysis, completion of all components (OR 2.3, 95% CI 1.5-3.7, p < 0.001) and male gender (OR 3.1, 95% CI 1.7-5.7, p < 0.001) were predictors of passing, while glove size (OR 1.5, 95% CI 1.0-2.5, p = 0.08), simulator time (OR 1.1, 95% CI 0.9-1.4, p = 0.37) and PGY were not (OR 1.1, 95% CI 0.9-1.4, p = 0.38). On multivariate analysis controlling for glove size and gender, completion of all FEC components was still associated with a higher likelihood of passing the FES skills exam (OR 1.6, 95% CI 1.2-2.1, p < 0.001). CONCLUSIONS: Completion of FEC is strongly associated with passing the FES skills test. This study supports the ABS recommendation for completion of FEC prior to taking the FES skills test.

Resolution and recurrence of anemia following repair of paraesophageal hernias.

BACKGROUND: Iron deficiency anemia is a common paraesophageal hernia (PEH) symptom and may improve after repair. When present, anemia has also been proposed to be associated with an increase in length of hospital stay, morbidity, and mortality after PEH repair. This study aimed to determine anemia-related factors in patients with PEH, the rate of anemia resolution after PEH repair, and the risk of anemia recurrence when repair failed. METHODS: We included patients who received a PEH repair between June 2019 and June 2020 and had 24 months of postoperative follow-up. Demographics and comorbidities were recorded. Anemia was defined as pre-operative hemoglobin values < 12.0 for females and < 13.0 for males, or if patients were receiving iron supplementation. Anemia resolution was determined at 6 months post-op. Length of hospital stay, morbidity, and mortality was recorded. Logistic regression and ANCOVA were used for binary and continuous outcomes respectively. RESULTS: Of 394 patients who underwent PEH repair during the study period, 101 (25.6%) had anemia before surgery. Patients with pre-operative anemia had larger hernia sizes (6.55 cm ± 2.77 vs. 4.34 cm ± 2.50; p < 0.001). Of 68 patients with available data by 6 months after surgery, anemia resolved in 36 (52.9%). Hernia recurred in 6 patients (16.7%), 4 of whom also had anemia recurrence (66.7%). Preoperative anemia was associated with a higher length of hospital stay (3.31 days ± 0.54 vs 2.33 days ± 0.19 p = 0.046) and an increased risk of post-operative all-cause mortality (OR 2.7 CI 1.08-6.57 p = 0.05). Fundoplication type (p = 0.166), gastropexy, or mesh was not associated with an increased likelihood of resolution (OR 0.855 CI 0.326-2.243; p = 0.05) (OR 0.440 CI 0.150-1.287; p = 0.05). CONCLUSIONS: Anemia occurs in 1 out of 4 patients with PEH and is more frequent in patients with larger hernias. Anemia is associated with a longer hospital stay and all-cause mortality after surgery. Anemia recurrence coincided with hernia recurrence in roughly two-thirds of patients.

What are essential laparoscopic skills these days? Results of the SAGES Fundamentals of Laparoscopic Surgery (FLS) Committee technical skills survey.

INTRODUCTION: The Fundamentals of Laparoscopic Surgery (FLS) program tests basic knowledge and skills required to perform laparoscopic surgery. Educational experiences in laparoscopic training and development of associated competencies have evolved since FLS inception, making it important to review the definition of fundamental laparoscopic skills. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) assigned an FLS Technical Skills Working Group to characterize technical skills used in basic laparoscopic surgery in current practice contexts and their possible application to future FLS tests. METHODS: A group of subject matter experts defined an inventory of 65 laparoscopic skills using a Nominal Group Technique. From these, a survey was developed rating these items for importance, frequency of use, and priority for testing for FLS certification. This survey was distributed to SAGES members, recent recipients of FLS certification, and members of the Association of Program Directors in Surgery (APDS). Results were collected using a secure web-based survey platform. RESULTS: Complete data were available for 1742 surveys. Of these, 1143 comprised results for post-residency participants who performed advanced procedures. Seventeen competencies were identified for FLS testing prioritization by determining the proportion of respondents who identified them of highest priority, at median (50th percentile) of the maximum survey scale rating. These included basic peritoneal access, laparoscope and instrument use, tissue manipulation, and specific problem management skills. Sixteen could be used to show appropriateness of the domain construct by confirmatory factor analysis. Of these 8 could be characterized as manipulative tasks. Of these 5 mapped to current FLS tasks. CONCLUSIONS: This survey-identified competencies, some of which are currently assessed in FLS, with a high level of priority for testing. Further work is needed to determine if this should prompt consideration of changes or additions to the FLS technical skills test component.

Surgical endoscopy education research: how are we doing?

BACKGROUND: Surgical endoscopy (SE), the official journal of the Society of American Gastrointestinal and Endoscopic Surgeons and the European Association for Endoscopic Surgery, is an important source of new evidence pertaining to surgical education in the field. However, qualitative deficiencies in medical education research have prompted medical education leaders to advocate for increased methodological rigor. The purpose of this study is to review the quality of education-focused research published through SE. METHODS: A PubMed search examining all SE articles categorized as education-related research from 2010 to 2019 was conducted; studies not meeting inclusion criteria were excluded. Remaining publications were independently reviewed, classified, and scored by 7 raters using the medical education research study quality instrument (MERSQI). Intraclass correlation was calculated and data were examined with descriptive statistics. RESULTS: A total of 227 studies met inclusion criteria. There was no significant difference in number of publications by year (average 25.88 [SD 5.6]); 60% were conducted outside of the United States, and 47% (n = 106) were funded. The average MERSQI was 12.5 (SD 2). Most studies used two-group non-random (42%, n = 96) or post/cross-sectional designs (29%, n = 65). Thirty-six (16%) were randomized controlled trials. Multi-institutional studies comprised 24% (n = 54). Of the manuscripts, 96% (n = 217) reported at least one measure of validity evidence and 28% (n = 67) described three levels of validity evidence. Studies primarily reported changes in skills or knowledge (45%, n = 103) or satisfaction or general facts (44%, n = 99), while patient-related outcomes encompassed 3% (n = 6) of studies. ICC between raters was 0.93 (CI 0.90-0.93, p < 0.001). CONCLUSIONS: Based on publications to date, this journal's peer review process appears to facilitate the dissemination of education-related studies of moderate to good quality. However, there were uncovered deficits, ranging from validity evidence to study designs and level of outcomes. This journal's breadth of viewership offers a potential venue to advance education-related research.

The Fundamentals of Endoscopic Surgery (FES) skills test: factors associated with first-attempt scores and pass rate.

BACKGROUND: The Fundamentals of Endoscopic Surgery (FES) program became required for American Board of Surgery certification as part of the Flexible Endoscopy Curriculum (FEC) for residents graduating in 2018. This study expands prior psychometric investigation of the FES skills test. METHODS: We analyzed de-identified first-attempt skills test scores and self-reported demographic characteristics of 2023 general surgery residents who were required to pass FES. RESULTS: The overall pass rate was 83%. "Loop Reduction" was the most difficult sub-task. Subtasks related to one another only modestly (Spearman's ρ ranging from 0.11 to 0.42; coefficient α = .55). Both upper and lower endoscopic procedural experience had modest positive association with scores (ρ = 0.14 and 0.15) and passing. Examinees who tested on the GI Mentor Express simulator had lower total scores and a lower pass rate than those tested on the GI Mentor II (pass rates = 73% vs. 85%). Removing an Express-specific scoring rule that had been applied eliminated these differences. Gender, glove size, and height were closely related. Women scored lower than men (408- vs. 489-point averages) and had a lower first-attempt pass rate (71% vs. 92%). Glove size correlated positively with score (ρ = 0.31) and pass rate. Finally, height correlated positively with score (r = 0.27) and pass rate. Statistically controlling for glove size and height did not eliminate gender differences, with men still having 3.2 times greater odds of passing. CONCLUSIONS: FES skills test scores show both consistencies with the assessment's validity argument and several remarkable findings. Subtasks reflect distinct skills, so passing standards should perhaps be set for each subtask. The Express simulator-specific scoring penalty should be removed. Differences seen by gender are concerning. We argue those differences do not reflect measurement bias, but rather highlight equity concerns in surgical technology, training, and practice.

Video-based assessment for laparoscopic fundoplication: initial development of a robust tool for operative performance assessment.

INTRODUCTION: While better technical performance correlates with improved outcomes, there is a lack of procedure-specific tools to perform video-based assessment (VBA). SAGES is developing a series of VBA tools with enough validity evidence to allow reliable measurement of surgeon competence. A task force was established to develop a VBA tool for laparoscopic fundoplication using an evidence-based process that can be replicated for additional procedures. The first step in this process was to seek content validity evidence. METHODS: Forty-two subject matter experts (SME) in laparoscopic fundoplication were interviewed to obtain consensus on procedural steps, identify potential variations in technique, and to generate an inventory of required skills and common errors. The results of these interviews were used to inform creation of a task inventory questionnaire (TIQ) that was delivered to a larger SME group (n = 188) to quantify the criticality and difficulty of the procedural steps, the impact of potential errors associated with each step, the technical skills required to complete the procedure, and the likelihood that future techniques or technologies may change the presence or importance of any of these factors. Results of the TIQ were used to generate a list of steps, skills, and errors with strong validity evidence. RESULTS: Initial SMEs interviewed included fellowship program directors (45%), recent fellows (24%), international surgeons (19%), and highly experienced super SMEs with quality outcomes data (12%). Qualitative analysis of interview data identified 6 main procedural steps (visualization, hiatal dissection, fundus mobilization, esophageal mobilization, hiatal repair, and wrap creation) each with 2-5 sub steps. Additionally, the TIQ identified 5-10 potential errors for each step and 11 key technical skills required to perform the procedure. Based on the TIQ, the mean criticality and difficulty scores for the 11/21 sub steps included in the final scoring rubric is 4.66/5 (5 = absolutely essential for patient outcomes) and 3.53/5 (5 = difficulty level requires significant experience and use of alternative strategies to accomplish consistently), respectively. The mean criticality and frequency scores for the 9/11 technical skills included is 4.51/5 and 4.51/5 (5 = constantly used ≥ 80% of the time), respectively. The mean impact score of the 42/47 errors incorporated into the final rubric is 3.85/5 (5 = significant error that is unrecoverable, or even if recovered, likely to have a negative impact on patient outcome). CONCLUSIONS: A rigorous, multi-method process has documented the content validity evidence for the SAGES video-based assessment tool for laparoscopic fundoplication. Work is ongoing to pilot the assessment tool on recorded fundoplication procedures to establish reliability and further validity evidence.

The SAGES flexible endoscopy course for fellows: a worthwhile investment in furthering surgical endoscopy.

BACKGROUND: The SAGES flexible endoscopy course for minimally invasive surgery (MIS) fellows improves confidence and skills in performing gastrointestinal (GI) endoscopy. This study evaluated the long-term retention of these confidence levels and investigated how fellows changed practices within their fellowships due to the course. METHODS: Participating MIS fellows completed surveys 6 months after the course. Respondents rated their confidence to independently perform 16 endoscopic procedures (1 = not at all; 5 = very), barriers to use of endoscopy, and current uses of endoscopy. Respondents also noted participation in additional skills courses and status of fundamentals of endoscopic surgery (FES) certification. Comparisons of responses from the immediate post-course survey to the 6-month follow-up survey were examined. McNemar and paired t tests were used for analyses. RESULTS: 23 of 57 (40%) course participants returned to the 6-month survey. No major barriers to endoscopy use were identified. Fellows reported less competition with GI providers as a barrier to practice compared to their original post-course expectations (50% vs. 86%, p < 0.01). In addition, confidence was maintained in performing the majority of the 16 endoscopic procedures, although fellows reported significant decreases in confidence in independently performing snare polypectomy (- 26%; p < 0.05), control of variceal bleeding (- 39%; p < 0.05), colonic stenting (- 48%; p < 0.01), BARRX (- 40%; p < 0.05), and TIF (- 31%; p < 0.05). Fewer fellows used the GI suite to manage surgical problems than was anticipated post course (26% vs. 74%, p < 0.01). Fellows who passed FES noted no significant loss of independence, changes in use, or barriers to use. 18% made additional partnerships with industry after the course. 41% stated flexible endoscopy has influenced their post-fellowship job choice. CONCLUSIONS: The SAGES flexible endoscopy course for MIS fellows results in long-term practice changes with participating fellows maintaining confidence to perform the majority of taught endoscopic procedures 6 months later. Additionally, fellows experienced no major barriers to implementing endoscopy into practice.

Simulation Research in Gastrointestinal and Urologic Care-Challenges and Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases and National Institute of Biomedical Imaging and Bioengineering Workshop.

: A workshop on "Simulation Research in Gastrointestinal and Urologic Care: Challenges and Opportunities" was held at the National Institutes of Health in June 2016. The purpose of the workshop was to examine the extent to which simulation approaches have been used by skilled proceduralists (not trainees) caring for patients with gastrointestinal and urologic diseases. The current status of research findings in the use and effectiveness of simulation applications was reviewed, and numerous knowledge gaps and research needs were identified by the faculty and the attendees. The paradigm of "deliberate practice," rather than mere repetition, and the value of coaching by experts was stressed by those who have adopted simulation in music and sports. Models that are most useful for the adoption of simulation by expert clinicians have yet to be fully validated. Initial studies on the impact of simulation on safety and error reduction have demonstrated its value in the training domain, but the role of simulation as a strategy for increased procedural safety remains uncertain in the world of the expert practitioner. Although the basic requirements for experienced physicians to acquire new skills have been explored, the widespread availability of such resources is an unrealized goal, and there is a need for well-designed outcome studies to establish the role of simulation in improving the quality of health care.

Trends in the Fundamentals of Laparoscopic Surgery® (FLS) certification exam over the past 9 years.

BACKGROUND: The Fundamentals of Laparoscopic Surgery® (FLS) certification exam assesses both cognitive and manual skills, and has been administered for over a decade. The purpose of this study is to report results over the past 9 years of testing in order to identify trends over time and evaluate the need to update scoring practices. This is a quality initiative of the SAGES FLS committee. METHODS: A representative sample of FLS exam data from 2008 to 2016 was analyzed. The de-identified data included demographics and scores for the cognitive and manual tests. Standard descriptive statistics were used to compare trends over the years, training levels, and to assess the pass/fail rate. RESULTS: A total of 7232 FLS tests were analyzed [64% male, 6.4% junior (postgraduate year-PGY1-2), 84% senior (PGY3-5), 2.8% fellows (PGY6), and 6.7% attending surgeons (PGY7)]. Specialties included 93% general surgery (GS), 6.2% gynecology, and 0.9% urology. The Pearson correlation between cognitive and manual scores was 0.09. For the cognitive exam, there was an increase in scores over the years, and the most junior residents scored the lowest. For the manual skills, there were marginal differences in scores over the years, and junior residents scored the highest. The odds ratio of PGY3+ passing was 1.8 (CI 1.2-2.8) times higher than that of a PGY1-2. The internal consistency between tasks on the manual skills exam was 0.73. If any one of the tasks was removed, the Cronbach's alpha dropped to between 0.65 and 0.71, depending on the task being removed. CONCLUSION: The cognitive and manual components of FLS test different aspects of laparoscopy and demonstrate evidence for reliability and validity. More experienced trainees have a higher likelihood of passing the exam and tend to perform better on the cognitive skills. Each component of the manual skills contributes to the exam and should continue to be part of the test.

Simulation-based mastery learning significantly reduces gender differences on the Fundamentals of Endoscopic Surgery performance exam.

BACKGROUND: Analysis of the Fundamentals of Endoscopic Surgery (FES) performance exam showed higher scores for men than women. Gender differences have been reduced with task-specific practice. We assessed the effect of simulation-based mastery learning (SBML) on FES performance exam differences by gender. METHODS: Forty-seven surgical trainees [29 men (m), 18 women (w)] completed a SBML curriculum and were assessed by FES. Fourteen trained on the GI Mentor 2, 18 on the Endoscopy Training System, and 15 using the Surgical Training for Endoscopic Proficiency curriculum. Performance of male and female trainees was compared. RESULTS: On the pre-training assessment, there were large differences between genders in FES pass rates (m 77%, w 15%, p < 0.001), total scores (m 69 ± 11, w 50 ± 12; p < 0.001), and in four of five FES sub-task scores (Navigation, m 73 ± 19, w 55 ± 22, p = 0.02; Loop reduction, m 34 ± 29, w 14 ± 22, p = 0.02; Retroflexion, m 81 ± 17, w 47 ± 27, p < 0.001; Targeting, m 89 ± 10, w 66 ± 23, p = 0.002). No differences were discernible post training (Pass rate, m 100%, w 94%, p = 0.4; Total score, m 77 ± 8, w 72 ± 12, p = 0.2; Navigation, m 91 ± 13, w 80 ± 13, p = 0.009; Loop reduction, m 49 ± 26, w 46 ± 36, p = 0.7; Retroflexion, m 82 ± 18, w 81 ± 15, p = 0.9; Targeting, m 92 ± 15, w 86 ± 12, p = 0.12). Time needed to complete curricula was not discernably different by gender (m 3.8 ± 1.7 h, w 5.0 ± 2.6 h, p = 0.17). CONCLUSIONS: Gender-based differences are nearly eliminated through task-specific SBML training. This lends further evidence to the validity argument for the FES performance exam as a measure of basic endoscopic skills.

Simulation-based mastery learning for endoscopy using the endoscopy training system: a strategy to improve endoscopic skills and prepare for the fundamentals of endoscopic surgery (FES) manual skills exam.

INTRODUCTION: The fundamentals of endoscopic surgery (FES) program has considerable validity evidence for its use in measuring the knowledge, skills, and abilities required for competency in endoscopy. Beginning in 2018, the American Board of Surgery will require all candidates to have taken and passed the written and performance exams in the FES program. Recent work has shown that the current ACGME/ABS required case volume may not be enough to ensure trainees pass the FES skills exam. The aim of this study was to investigate the feasibility of a simulation-based mastery-learning curriculum delivered on a novel physical simulation platform to prepare trainees to pass the FES manual skills exam. METHODS: The newly developed endoscopy training system (ETS) was used as the training platform. Seventeen PGY 1 (10) and PGY 2 (7) general surgery residents completed a pre-training assessment consisting of all 5 FES tasks on the GI Mentor II. Subjects then trained to previously determined expert performance benchmarks on each of 5 ETS tasks. Once training benchmarks were reached for all tasks, a post-training assessment was performed with all 5 FES tasks. RESULTS: Two subjects were lost to follow-up and never returned for training or post-training assessment. One additional subject failed to complete any portion of the curriculum, but did return for post-training assessment. The group had minimal endoscopy experience (median 0, range 0-67) and minimal prior simulation experience. Three trainees (17.6%) achieved a passing score on the pre-training FES assessment. Training consisted of an average of 48 ± 26 repetitions on the ETS platform distributed over 5.1 ± 2 training sessions. Seventy-one percent achieved proficiency on all 5 ETS tasks. There was dramatic improvement demonstrated on the mean post-training FES assessment when compared to pre-training (74.0 ± 8 vs. 50.4 ± 16, p < 0.0001, effect size = 2.4). The number of ETS tasks trained to proficiency correlated moderately with the score on the post-training assessment (r = 0.57, p = 0.028). Fourteen (100%) subjects who trained to proficiency on at least one ETS task passed the post-training FES manual skills exam. CONCLUSIONS: This simulation-based mastery learning curriculum using the ETS is feasible for training novices and allows for the acquisition of the technical skills required to pass the FES manual skills exam. This curriculum should be strongly considered by programs wishing to ensure that trainees are prepared for the FES exam.

Micellization and Partition Equilibria in Mixed Nonionic/Ionic Micellar Systems: Predictions with Molecular Models.

In practical applications, surfactant solutions are mostly used in mixtures of nonionic and ionic surfactants because they have improved characteristics compared to those of single surfactant solutions. By adjusting the composition of the micelles and the pH value, the solubilization of solutes can be enhanced. Nevertheless, the partitioning of solutes between nonionic/ionic mixed micelles and the aqueous phase is studied to a much lesser extent than for single surfactant solutions. Theoretical methods to predict partition equilibria in mixed micelles are of interest for screening studies. For those, the composition of the mixed micelle has to be known. Here we investigate mixtures of TX-114 (Triton X-114), Brij35 (C12E23), SDS (sodium dodecyl sulfate), and CTAB (cetyltrimethylammonium bromide). First, to investigate the surfactant compositions in the micelles, molecular dynamics (MD) self-assembly simulations were applied. Thereafter, the predictive COSMO-RS model, which applies the pseudophase approach, and its extension to anisotropic systems termed COSMOmic were compared for the prediction of partition equilibria in mixed micelles, where various molar ratios of the surfactants were considered. It could be demonstrated that both methods are applicable and lead to reasonable predictions for neutral molecules. However, taking into account the three-dimensional structure of the micelle is beneficial because the calculations with COSMOmic are in better agreement with experimental results. Because the partitioning behavior of ionizable molecules in mixed micelles is of particular interest, the partitioning of ionized isovanillin in mixed Brij35/CTAB micelles at different micelle compositions was calculated with COSMOmic. Using a thermodynamic cycle, the position-dependent pKa of isovanillin within the micelle is calculated on the basis of COSMOmic free energy profiles. As a result, the protolytic equilibrium of isovanillin within the micelles can be taken into account, which is crucial for the reliable prediction of partition coefficients.

Simulation Research in Gastrointestinal and Urologic Care-Challenges and Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases and National Institute of Biomedical Imaging and Bioengineering Workshop.

A workshop on ''Simulation Research in Gastrointestinal and Urologic Care: Challenges and Opportunities'' was held at the National Institutes of Health in June 2016. The purpose of the workshop was to examine the extent to which simulation approaches have been used by skilled proceduralists (not trainees) caring for patients with gastrointestinal and urologic diseases. The current status of research findings in the use and effectiveness of simulation applications was reviewed, and numerous knowledge gaps and research needs were identified by the faculty and the attendees. The paradigm of ''deliberate practice,'' rather than mere repetition, and the value of coaching by experts was stressed by those who have adopted simulation in music and sports. Models that are most useful for the adoption of simulation by expert clinicians have yet to be fully validated. Initial studies on the impact of simulation on safety and error reduction have demonstrated its value in the training domain, but the role of simulation as a strategy for increased procedural safety remains uncertain in the world of the expert practitioner. Although the basic requirements for experienced physicians to acquire new skills have been explored, the widespread availability of such resources is an unrealized goal, and there is a need for well-designed outcome studies to establish the role of simulation in improving the quality of health care.

Psychometric properties of the Fundamentals of Endoscopic Surgery (FES) skills examination.

BACKGROUND: The Fundamentals of Endoscopic Surgery (FES) manual skills examination is a simulation-based assessment of five foundational skills in endoscopic surgery. With the FES skills exam becoming part of the board certification process in general surgery, continual investigation is needed to determine the validity with which the exam is supporting inferences and decision-making about examinees, as well as how it might be improved. METHODS: The present study retrospectively analyzed performance and demographic details for the initial 344 examinees completing the FES skills exam. RESULTS: The five tasks showed distinct degrees of difficulty, with Loop Reduction being especially difficult for examinees. Tasks related to one another positively but moderately, suggesting that the exam assesses both general and task-specific skills. The number of lower-endoscopic cases completed by an examinee strongly predicted performance, while upper endoscopy experience and career level (e.g., resident vs. fellow vs. practicing) did not. Hand dominance and the type of simulator used were not found to be related to scores. However, three demographic variables that related to one another-gender, glove size, and height-were also related to performance and pass/fail status. CONCLUSIONS: This study's results generally support the validity argument for the FES skills exam while pointing to additional investigations to be undertaken as the exam is applied more broadly.

Outcomes of Fundamentals of Laparoscopic Surgery (FLS) mastery training standards applied to an ergonomically different, lower cost platform.

OBJECTIVE: Using previously established mastery learning standards, this study compares outcomes of training on standard FLS (FLS) equipment with training on an ergonomically different (ED-FLS), but more portable, lower cost platform. METHODS: Subjects completed a pre-training FLS skills test on the standard platform and were then randomized to train on the FLS training platform (n = 20) or the ED-FLS platform (n = 19). A post-training FLS skills test was administered to both groups on the standard FLS platform. RESULTS: Group performance on the pretest was similar. Fifty percent of FLS and 32 % of ED-FLS subjects completed the entire curriculum. 100 % of subjects completing the curriculum achieved passing scores on the post-training test. There was no statistically discernible difference in scores on the final FLS exam (FLS 93.4, ED-FLS 93.3, p = 0.98) or training sessions required to complete the curriculum (FLS 7.4, ED-FLS 9.8, p = 0.13). CONCLUSIONS: These results show that when applying mastery learning theory to an ergonomically different platform, skill transfer occurs at a high level and prepares subjects to pass the standard FLS skills test.

Identification and reproducibility of diagnostic DNA markers for tuber starch and yield optimization in a novel association mapping population of potato (Solanum tuberosum L.).

KEY MESSAGE: SNPs in candidate genes Pain - 1, InvCD141 (invertases), SSIV (starch synthase), StCDF1 (transcription factor), LapN (leucine aminopeptidase), and cytoplasm type are associated with potato tuber yield, starch content and/or starch yield. Tuber yield (TY), starch content (TSC), and starch yield (TSY) are complex characters of high importance for the potato crop in general and for industrial starch production in particular. DNA markers associated with superior alleles of genes that control the natural variation of TY, TSC, and TSY could increase precision and speed of breeding new cultivars optimized for potato starch production. Diagnostic DNA markers are identified by association mapping in populations of tetraploid potato varieties and advanced breeding clones. A novel association mapping population of 282 genotypes including varieties, breeding clones and Andean landraces was assembled and field evaluated in Northern Spain for TY, TSC, TSY, tuber number (TN) and tuber weight (TW). The landraces had lower mean values of TY, TW, TN, and TSY. The population was genotyped for 183 microsatellite alleles, 221 single nucleotide polymorphisms (SNPs) in fourteen candidate genes and eight known diagnostic markers for TSC and TSY. Association test statistics including kinship and population structure reproduced five known marker-trait associations of candidate genes and discovered new ones, particularly for tuber yield and starch yield. The inclusion of landraces increased the number of detected marker-trait associations. Integration of the present association mapping results with previous QTL linkage mapping studies for TY, TSC, TSY, TW, TN, and tuberization revealed some hot spots of QTL for these traits in the potato genome. The genomic positions of markers linked or associated with QTL for complex tuber traits suggest high multiplicity and genome wide distribution of the underlying genes.

Infrared dynamics study of thermally treated perfluoroimide acid proton exchange membranes.

The temperature induced dehydration process of the 3M Brand perfluoroimide acid (PFIA), an advanced proton exchange membrane for fuel cells, was studied by in situ infrared spectroscopy to understand proton transport processes under conditions of low hydration levels. A comprehensive assignment of the vibrational bands of PFIA in the mid infrared region is provided. Investigation of the kinetics in conjunction with 2D correlation spectroscopy methods revealed the sequential process of the hydration and dehydration in a conclusive model. The results indicate that at a lower water content the sulfonate group of the PFIA side chain is preferentially ionised and involved in a hydrogen bonding structure with the sulfonyl imide acid group, until a sufficient amount of water is present to ionise the second ionic site. Comparison to the well-understood NAFION™ membrane revealed that under low humidity conditions a higher amount of water is retained in PFIA in a state most similar to liquid water. The results contribute to a better understanding of water retention capability and thus proton conductivity under high-temperature and low-humidity conditions.

Remote FLS testing in the real world: ready for "prime time".

INTRODUCTION: Maintaining the existing FLS test centers requires considerable investment in human and financial resources. It can also be particularly challenging for those outside of North America to become certified due to the limited number of international test centers. Preliminary work suggests that it is possible to reliably score the FLS manual skills component remotely using low-cost videoconferencing technology. Significant work remains to ensure that testing procedures adhere to standards defined by SAGES for this approach to be considered equivalent to standard on-site testing. OBJECTIVE: To validate the integrity and validity of the FLS manual skills examination administered remotely in a real-world environment according to FLS testing protocols and to evaluate participants' experience with the setting. METHODS: Individuals with various levels of training from the University of Toronto completed a pre- and a post-test questionnaire. Participants presented to one of the two FLS testing rooms available for the study, each connected via Skype to a separate room with a FLS proctor who administered and scored the test remotely (RP). An on-site proctor (OP) was present in the room as a control. An invigilator was also present in the testing room to follow directions from the RP and ensure the integrity of test materials. RESULTS: Twenty-one participants were recruited, and 20 completed the test. There was no significant difference between scores by RP and OP. Interrater reliability between the RP and OP was excellent. One critical error was missed by the RP, but this would not have affected the test outcome. Participants reported being highly satisfied. CONCLUSION: We demonstrate that proctors located remotely can administer the FLS skills test in a secure and reliable fashion, with excellent interrater reliability compared to an on-site proctor. Remote proctoring of the FLS examination could become a strategy to increase certification rates while containing costs.