Advanced Technical Skills Research Articles

Ten Core Competencies for Hospital Administrators.

Ever-increasing complexity and contradiction in the health care industry often leave hospital administrators wondering whether they can still make a positive difference for patients. In this context, hospital administrators can regain both perspective and enthusiasm by revitalizing their direct connections with the patients, caregivers, and organizations they serve. Hospital administration remains a special calling, and this article profiles 10 core competencies that will keep health professionals close to their customers, colleagues, and the reasons they entered the helping professions. This intimate knowledge of the organization and its resources coupled with the ability to communicate effectively typically trump advanced education or technical skills in successfully navigating genuinely consequential situations. Hospital administrators who master and practice the 10 competencies can indeed make a positive difference for patients and find great personal reward in doing so.

Purpose and Process in Exemplary Teen Writings

Exemplary adolescent creative writers’ stories and poems demonstrate a connection between personal purposes for writing and the development of advanced technical skills. This hermeneutic analysis of 33 student texts (which were chosen because of their relation to the topic of literacy) reveals three main reasons for writing (remembrance, reinvention, and communion) as well as an understanding of the writing process as fickle. Writings that focus on remembrance include depictions of qualia through sensory imagery and poetic techniques. Writings that express reinvention and communion reveal an understanding of the history of words, forms, and the canon. Writings that depict writing as fickle invite discussions of the writing process and the value of perseverance, observation, and empathy. A practical implication of this research is that creativity and identity development through writing are compatible with comprehension, analysis, and technical mastery.

Complex Spine Pathology Simulator: An Innovative Tool for Advanced Spine Surgery Training.

Background Technical advancements in spine surgery have made possible the treatment of increasingly complex pathologies with less morbidity. Time constraints in surgeons' training have made it necessary to develop new training models for spine pathology. Objective To describe the application of a novel compound, Stratathane resin ST-504 derived polymer (SRSDP), that can be injected at different spinal target locations to mimic spinal epidural, subdural extra-axial, and intra-axial pathologies for the use in advanced surgical training. Material and Methods Fresh-frozen thoracolumbar and cervical spine segments of human and sheep cadavers were used to study the model. SRSDP is initially liquid after mixing, allowing it to be injected into target areas where it expands and solidifies, mimicking the entire spectrum of spinal pathologies. Results Different polymer concentrations have been codified to vary adhesiveness, texture, spread capability, deformability, and radiologic visibility. Polymer injection was performed under fluoroscopic guidance through pathology-specific injection sites that avoided compromising the surgical approach for subsequent excision of the artificial lesion. Inflation of a balloon catheter of the desired size was used to displace stiff cadaveric neurovascular structures to mimic pathology-related mass effect. Conclusion The traditional cadaveric training models principally only allow surgeons to practice the surgical approach. The complex spine pathology simulator is a novel educational tool that in a user-friendly, low-cost fashion allows trainees to practice advanced technical skills in the removal of complex spine pathology, potentially shortening some of the aspects of the learning curve of operative skills that may otherwise take many years to acquire.

Westminster Serious Games Platform (wmin-SGP) a tool for real-time authoring of roleplay simulations for learning

The use of serious games in education and their pedagogical benefit is being widely recognized. However, effective integration of serious games in education depends on addressing two big challenges: the successful incorporation of motivation and engagement that can lead to learning; and the highly specialised skills associated with customised development to meet the required pedagogical objectives. This paper presents the Westminster Serious Games Platform (wmin-SGP) an authoring tool that allows educators/domain experts without games design and development technical skills to create bespoke roleplay simulations in three dimensional scenes featuring fully embodied virtual humans capable of verbal and non-verbal interaction with users fit for specific educational objectives. The paper presents the wmin-SGP system architecture and it evaluates its effectiveness in fulfilling its purpose via the implementation of two roleplay simulations, one for Politics and one for Law. In addition, it presents the results of two types of evaluation that address how successfully the wmin-SGP combines usability principles and game core drives based on the Octalysis gamification framework that lead to motivating games experiences. The evaluation results shows that the wmin-SGP: provides an intuitive environment and tools that support users without advanced technical skills to create in real-time bespoke roleplay simulations in advanced graphical interfaces; satisfies most of the usability principles; and provides balanced simulations based on the Octalysis framework core drives. The paper concludes with a discussion of future extension of this real time authoring tool and directions for further development of the Octalysis framework to address learning.

Open Source Software for Mapping Human Impacts on Marine Ecosystems with an Additive Model

This paper describes an easy-to-use open source software tool implementing a commonly used additive model (Halpern et al., Science , 2008) for mapping human impacts on marine ecosystems. The tool has been used to map the potential for cumulative human impacts in Arctic marine waters and can support future human impact mapping projects by 1) making the model easier to use; 2) making updates of model results straightforward when better input data become available; 3) storing input data and information about processing steps in a defined format and thus facilitating data sharing and reproduction of modeling results; 4) supporting basic visualization of model inputs and outputs without the need for advanced technical skills. The tool, called EcoImpactMapper, was implemented in Java and is thus platform-independent. A tutorial, example data, the tool and the source code are available online.

Gastroduodenopancreatectomy: Results in a tertiary hospital in northeast of Brazil in the years of 2014 and 2015

Introduction: Gastroduodenopancreatectomy (GDP) is indicated in cases of tumors that affect the periampular region, requiring technical expertise by the surgeon due its complexity. The main complication is the pancreatic fistula. Objective: To present the experience and results obtained in the GDP made in a tertiary hospital in Northeast of Brazil. Methods: From January 2014 to July 2015, there were 15 GDP in our service. By analyzing records, the following data were investigated: epidemiological factors, the need for perioperative transfusion, postoperative complications, length of stay and number of deaths. Results: Of the 15 procedures performed, 53% of patients were male, the mean age was 63 years (47–77 years), 33% of patients were smokers and the tumors were preferentially located in pancreatic head (40%) and papilla (47%). All patients underwent classic GDP with lymphadenectomy, requiring vascular resection in 20% of cases. The preferred pancreatojejunal anastomosis was duct-mucosal (87%)with external drainage of the cavity in all cases analyzed. 27% of patients required perioperative transfusion. 33% of patients developed a benign pancreatic fistula, 20% had bleeding that required surgical reoperation and one patient underwent another surgery by afferent loop obstruction. The average hospital stay was 19 days (range 8–45 days). In the analyzed group, there were two deaths, both more than 30 days after surgery. Conclusion: GDP is considered by many as one of the most complex and challenging intra-abdominal surgeries, requiring advanced technical skills and an important postoperative follow-up seeking favorable results.

Simulation as a set-up for technical proficiency: can a virtual warm-up improve live fibre-optic intubation?

BackgroundFibre-optic intubation (FOI) is an advanced technical skill, which anaesthesia residents must frequently perform under pressure. In surgical subspecialties, a virtual ‘warm-up’ has been used to prime a practitioner’s skill set immediately before performance of challenging procedures. This study examined whether a virtual warm-up improved the performance of elective live patient FOI by anaesthesia residents. MethodsClinical anaesthesia yr 1 and 2 (CA1 and CA2) residents were recruited to perform elective asleep oral FOI. Residents either underwent a 5 min, guided warm-up (using a bronchoscopy simulator) immediately before live FOI on patients with predicted normal airways or performed live FOI on similar patients without the warm-up. Subjects were timed performing FOI (from scope passing teeth to viewing the carina) and were graded on a 45-point skill scale by attending anaesthetists. After a washout period, all subjects were resampled as members of the opposite cohort. Multivariate analysis was performed to control for variations in previous FOI experience of the residents. ResultsThirty-three anaesthesia residents were recruited, of whom 22 were CA1 and 11 were CA2. Virtual warm-up conferred a 37% reduction in time for CA1s (mean 35.8 (sd 3.2) s vs. 57 (sd 3.2) s, P<0.0002) and a 26% decrease for CA2s (mean 23 (sd 1.7) s vs. 31 (sd 1.7) s, P+0.0118). Global skill score increased with warm-up by 4.8 points for CA1s (mean 32.8 (sd 1.2) vs. 37.6 (sd 1.2), P+0.0079) and 5.1 points for CA2s (37.7 (sd 1.1) vs. 42.8 (sd 1.1), P+0.0125). Crossover period and sequence did not show a statistically significant association with performance. ConclusionsVirtual warm-up significantly improved performance by residents of FOI in live patients with normal airway anatomy, as measured both by speed and by a scaled evaluation of skills.

Detection of MET Gene Copy Number in Cancer Samples Using the Droplet Digital PCR Method.

PurposeThe analysis of MET gene copy number (CN) has been considered to be a potential biomarker to predict the response to MET-targeted therapies in various cancers. However, the current standard methods to determine MET CN are SNP 6.0 in the genomic DNA of cancer cell lines and fluorescence in situ hybridization (FISH) in tumor models, respectively, which are costly and require advanced technical skills and result in relatively subjective judgments. Therefore, we employed a novel method, droplet digital PCR (ddPCR), to determine the MET gene copy number with high accuracy and precision.MethodsThe genomic DNA of cancer cell lines or tumor models were tested and compared with the MET gene CN and MET/CEN-7 ratio determined by SNP 6.0 and FISH, respectively.ResultsIn cell lines, the linear association of the MET CN detected by ddPCR and SNP 6.0 is strong (Pearson correlation = 0.867). In tumor models, the MET CN detected by ddPCR was significantly different between the MET gene amplification and non-amplification groups according to FISH (mean: 15.4 vs 2.1; P = 0.044). Given that MET gene amplification is defined as MET CN >5.5 by ddPCR, the concordance rate between ddPCR and FISH was 98.0%, and Cohen's kappa coefficient was 0.760 (95% CI, 0.498–1.000; P <0.001).ConclusionsThe results demonstrated that the ddPCR method has the potential to quantify the MET gene copy number with high precision and accuracy as compared with the results from SNP 6.0 and FISH in cancer cell lines and tumor samples, respectively.

Single-incision laparoscopic resection of small bowel tumours: Making it easier for patient and surgeon.

BACKGROUND:Patients with small bowel tumours frequently require surgical intervention. Minimally invasive techniques require advanced skills and may not be offered to many patients. We present a laparoscopic single-incision technique that is minimally invasive without requiring intracorporeal anastomosis.MATERIALS AND METHODS:The cases of all patients with laparoscopic small bowel resections performed by one surgeon from 2008 to 2012 were reviewed. A single-port technique was introduced after it became available at our institution in 2009. Before that, conventional laparoscopy (LAP) was performed with extension of the periumbilical incision to allow externalisation of the bowel.RESULTS:Totally, 10 patients were identified who underwent laparoscopic resection of small bowel tumours: 9 in the small bowel and 1 in the terminal ileum near the cecum. Three tumours were resected before 2009 using LAP, and 7 were resected using the single-port technique. Median length of stay was 3 days, median follow-up was 16.5 months, and no patients had a recurrence. Operative time, post-operative complications, hospital length of stay, and narcotic utilisation were similar between the single-port and traditional laparoscopic groups.CONCLUSION:Laparoscopic removal of small bowel tumours with a small, periumbilical trocar incision is both effective and feasible without advanced technical skill.

Robot-assisted Laparoscopic Inferior Vena Cava Thrombectomy: Different Sides Require Different Techniques

BackgroundThe safety and feasibility of robot-assisted laparoscopic inferior vena cava (IVC) thrombectomy (RAL-IVCTE) have been investigated in limited reports. ObjectiveTo share our initial experience with RAL-IVCTE, as well as describe respectively the detailed techniques for RAL-IVCTE for left or right renal cell carcinoma (RCC). Design, setting, and participantsFrom May 2013 to July 2014, 17 patients with RCC involving IVC tumor thrombus were admitted to our hospital. Surgical procedureFor right RCC, the caudal IVC, left renal vein, and cephalic IVC were sequentially clamped. The IVC wall was cut, and the thrombus was removed. For left RCC, the left renal vein, which included the thrombus, was ligated with Endo-GIA. The caudal IVC, right renal artery, right renal vein, and cephalic IVC were sequentially clamped. MeasurementsThe detailed techniques for RAL-IVCTE for different sides were described and the perioperative outcomes recorded. Results and limitationsThe operations were successfully performed without open conversion. Median operation time was 131min (100–150min) and 250min (190–275min) for the right and left RCC, respectively. Median estimated blood loss was 240ml (145–320ml). Median IVC blocking time was 17min (12–25min). For left RCC, median warm ischemia time for the right kidney was 18min (14–22min). A grade IV complication—bleeding from tributaries of the IVC—developed in one case and was successfully resolved with intraoperative endoscopic suture. ConclusionsRAL-IVCTE is safe and feasible. For left RCC involving IVC thrombus, right renal warm ischemia time is necessary during the procedure, requiring a more advanced technical skill. The therapeutic effect and overall survival rate require further investigation with a larger sample size and longer follow-up. Patient summaryRobot-assisted laparoscopic inferior vena cava thrombectomy is technically challenging but safe and feasible. The therapeutic effect needs further investigation.

Training reduced subjectivity of comparative yield method of estimation of grassland biomass

Measuring grassland biomass using objective, quick and accurate methods is important for practical purposes in agriculture and ecology. Most existing techniques are either expensive or require advanced technical skills making them unaffordable and impractical for farmers in developing countries. The comparative yield method is a quick technique that involves the estimation of grassland biomass from visual scores. Despite its potential for use by farmers with minimal technical skills, it has been criticized for being subjective, thus limiting its use for research purposes only. We hypothesized that training and establishment of agreed-upon ground rules can reduce this subjectivity. We compared data collected by 36 farmers in northern Ethiopia, who participated under three instruction groups. Group 1 was involved both in the selection of reference plots and calibration plots and agreed-on ground rules. Group 2 was shown the reference plots and orientated about the ground rules. Group 3 was neither shown reference plots nor orientated on ground rules. Levene's test for equality of variance was performed among the estimations made by individuals. Mean values of scores and biomass measurements varied among groups. The variability of records was higher in groups 3 and 2 than in group 1, indicating the need for training and agreed-upon ground rules to achieve objectivity. We conclude that with minimal training and agreement on ground rules, the comparative yield method can be used by farmers and ecologists in developing countries to estimate grassland biomass with better precision and accuracy.

PTU-172 The “sunk” colostomy: a novel corrective approach to achieve satisfactory function

<h3>Introduction</h3> Gastrointestinal stomas are a frequently performed surgical procedure with associated early or late complications. Some of these complications demand advanced technical skills and expertise to manage. We present here a challenging case of sunken colostomy affecting patient’s quality of life and a novel approach to achieve a satisfactory functional outcome. <h3>Method</h3> <b>Case report</b>: A 63 year old male underwent defunctioning loop colostomy for locally advanced rectal cancer with liver metastasis. Three months later he presented with difficulties managing his stoma. He had developed a horizontal skin crease along the stoma leading to obliteration of stomal opening causing ineffective stoma bag adhesion, resulting in painful parastomal ulcers. The patient was reluctant to consider stoma resiting owing to his job which involved leaning against machinery on his right side. Urgent surgical intervention was required so that his neo-adjuvant therapy would not be delayed. <h3>Results</h3> Our novel approach involved the excision of large supero-lateral elliptical fold of anterior abdominal wall down to the fascia with resultant opening up of colostomy. Care was taken to ensure precise excision resulting in flattening of abdominal wall as well as avoidance of future stoma appliance impingement. <h3>Conclusion</h3> <b>Discussion</b>: This technique draws parallels to the principles of blepharoplasty of upper eyelids, where droopy eyelid tissue is recontoured to unblock the visual axis. This approach also carried the advantage of operating away from the stoma site thereby preventing potential complication of stomal injury and wound infections. <h3>Conclusion</h3> Early successful result has established the feasibility of this novel approach, which has not been reported before. <h3>Disclosure of interest</h3> None Declared.

Effective synaptome analysis of itch-mediating neurons in the spinal cord: A novel immunohistochemical methodology using high-voltage electron microscopy

Transmission electron microscopy (TEM) is used for three-dimensional (3-D) analysis of synaptic connections in neuroscience research. However, 3-D reconstruction of the synapses using serial ultrathin sections is a powerful but tedious approach requiring advanced technical skills. High-voltage electron microscopy (HVEM) allows examination of thicker sections of biological specimens due to the increased penetration of the more accelerated electrons, which is useful to analyze the 3-D structure of biological specimens. However, it is still difficult to visualize the neural networks and synaptic connections in 3-D using HVEM because of insufficient and non uniform heavy metal staining in the membranous structures in semi-thin sections. Here, we present the successful chemical 3-D neuroanatomy of the rat spinal dorsal horn at the ultrastructural level as a first step for effective synaptome analysis by applying a high-contrast en bloc staining method to immune-HVEM tomography. Our new approach made it possible to examine many itch-mediating synaptic connections and neural networks in the spinal cord simultaneously using HVEM tomography. This novel 3-D electron microscopy is very useful for the analysis of synaptic structure and the chemical neuroanatomy at the 3-D ultrastructural level.

The role of the laparoscopy on circumferential resection margin positivity in patients with rectal cancer: long-term outcomes at a single high-volume institution.

The aim of this study was to evaluate the influence of laparoscopic rectal cancer surgery on circumferential resection margin (CRM) involvement. The data from 579 consecutive patients who underwent laparoscopic or open resection of rectal cancer from October 2002 to August 2008 were analyzed retrospectively. The primary endpoint was CRM status. The secondary endpoints were morbidity, local recurrence rate, overall survival, and disease-free survival. Laparoscopic resections were performed in 266 patients (46%), and the remainder of the patients underwent open resection. The rates of CRM involvement were similar between the laparoscopic and open groups (5.6% vs. 5.4%). The perioperative morbidity rates between the 2 groups were not significantly different (P=0.2). The incidence of local recurrence for the CRM-negative group was 8.4% (8.3% laparoscopic vs. 8.45% open; P=0.99), whereas the local recurrence rate was 34.3% for the CRM-positive group. The local recurrence rate was 20% for the CRM-positive patients in the laparoscopic group and 47% for the CRM-positive patients in the open group (P<0.001). We did not observe any significant differences in local recurrence rates between the Lap R and Open R groups after omitting CRM status. CRM positivity was correlated with both 5-year survival and the 5-year disease-free survival rate (P=0.009 and P=0.001, respectively). We did not observe any significant differences in morbidity, local recurrence, or overall or disease-free survival rates between the overall laparoscopic and open resection groups. Laparoscopic surgery for rectal cancer is associated with similar complication rates, CRM involvement status, and long-term outcomes as those associated with open surgery but with the advantages of minimally invasive surgery. Although laparoscopic surgery might necessitate more advanced technical skills, similar long-term oncological results can be obtained with this technique.

Development and Validation of a Novel Robotic Procedure Specific Simulation Platform: Partial Nephrectomy

We developed a novel procedure specific simulation platform for robotic partial nephrectomy. In this study we prospectively evaluate its face, content, construct and concurrent validity. This hybrid platform features augmented reality and virtual reality. Augmented reality involves 3-dimensional robotic partial nephrectomy surgical videos overlaid with virtual instruments to teach surgical anatomy, technical skills and operative steps. Advanced technical skills are assessed with an embedded full virtual reality renorrhaphy task. Participants were classified as novice (no surgical training, 15), intermediate (less than 100 robotic cases, 13) or expert (100 or more robotic cases, 14) and prospectively assessed. Cohort performance was compared with the Kruskal-Wallis test (construct validity). Post-study questionnaire was used to assess the realism of simulation (face validity) and usefulness for training (content validity). Concurrent validity evaluated correlation between virtual reality renorrhaphy task and a live porcine robotic partial nephrectomy performance (Spearman's analysis). Experts rated the augmented reality content as realistic (median 8/10) and helpful for resident/fellow training (8.0-8.2/10). Experts rated the platform highly for teaching anatomy (9/10) and operative steps (8.5/10) but moderately for technical skills (7.5/10). Experts and intermediates outperformed novices (construct validity) in efficiency (p=0.0002) and accuracy (p=0.002). For virtual reality renorrhaphy, experts outperformed intermediates on GEARS metrics (p=0.002). Virtual reality renorrhaphy and in vivo porcine robotic partial nephrectomy performance correlated significantly (r=0.8, p <0.0001) (concurrent validity). This augmented reality simulation platform displayed face, content and construct validity. Performance in the procedure specific virtual reality task correlated highly with a porcine model (concurrent validity). Future efforts will integrate procedure specific virtual reality tasks and their global assessment.

Why interdisciplinary research enriches the study of crime: Comment on “Statistical physics of crime: A review” by M.R. D'Orsogna and M. Perc

The past several years have seen a rapidly growing interest in the use of advanced quantitative methodologies and formalisms adapted from the natural sciences to study a broad range of social phenomena. The research field of computational social science [1,2], for example, uses digital artifacts of human online activity to cast a new light on social dynamics. Similarly, the studies reviewed by D’Orsogna and Perc showcase a diverse set of advanced quantitative techniques to study the dynamics of crime. Methods used range from partial differential equations and self-exciting point processes to agent-based models, evolutionary game theory and network science [3]. The research reviewed should be seen within the larger context of and complimentary to a growing trend in the social sciences towards the use of ever more advanced and refined quantitative methodologies. Much of this is driven by a generation of researchers that in addition to their substantive subject interest, embrace interdisciplinary work and possess advanced technical skills. These three key themes – subject relevance, interdisciplinarity, advanced methodologies – reappear throughout the studies reviewed by D’Orsogna and Perc. The review, for example, repeatedly highlights that research in this emerging field is inherently interdisciplinary: studies use methodologies adapted from other disciplines but explicitly engage with existing work on the mechanisms and dynamics of criminal behavior. This is an important and critical prerequisite for generating results that are relevant for a wider, social science audience. At the same time, the studies demonstrate that the methodologies used may, in fact, shed new light on a number of relevant aspects of criminal activity. The review further emphasizes the importance of systemic dynamics for the understanding of emerging patterns of crime. Historically, much of the research on crime has focused on the structural conditions for crime or on the motivations of individuals to engage in criminal activity. A more systemic perspective additionally emphasizes the relevance of the dynamics that arise from complex interactions – among individuals and with the environment – for the understanding of patterns of crime. This is nicely illustrated by a number of studies reviewed by D’Orsogna and Perc. The research discussed in Section 4, for example, shows that very simple mechanisms paired with complex systemic interactions may help elucidate the effect of policing on levels of crime. Similarly, a number of studies explicitly highlight the relevance of endogenous “feedback” effects for our understanding of criminal activity – this is

QRTEngine: An easy solution for running online reaction time experiments using Qualtrics.

Performing online behavioral research is gaining increased popularity among researchers in psychological and cognitive science. However, the currently available methods for conducting online reaction time experiments are often complicated and typically require advanced technical skills. In this article, we introduce the Qualtrics Reaction Time Engine (QRTEngine), an open-source JavaScript engine that can be embedded in the online survey development environment Qualtrics. The QRTEngine can be used to easily develop browser-based online reaction time experiments with accurate timing within current browser capabilities, and it requires only minimal programming skills. After introducing the QRTEngine, we briefly discuss how to create and distribute a Stroop task. Next, we describe a study in which we investigated the timing accuracy of the engine under different processor loads using external chronometry. Finally, we show that the QRTEngine can be used to reproduce classic behavioral effects in three reaction time paradigms: a Stroop task, an attentional blink task, and a masked-priming task. These findings demonstrate that QRTEngine can be used as a tool for conducting online behavioral research even when this requires accurate stimulus presentation times.Electronic supplementary materialThe online version of this article (doi:10.3758/s13428-014-0530-7) contains supplementary material, which is available to authorized users.

Does simulation-based training have a future in Africa?

The term 'simulation', as it pertains to the training of healthcare professionals, appears in three of the 10 articles selected for publication in this edition of AJHPE. This provides an ideal opportunity to pause and reflect on some aspects of this teaching technique in the context of healthcare training in Africa, a key mandate of the journal. Simulation-based training is not new. The technique, widely known for its use in non-medical industries such as commercial aviation and nuclear power production, was first used to train healthcare professionals more than 40 years ago. 'Resusci-Annie' was born in 1960 and many of us can recall how we carefully wheeled her around the medical school while she patiently endured, and survived, endless resuscitation training sessions on a daily basis. More than 30 years later, a dynamic interactive 'gentleman' - 'SimMan' - replaced ageing Annie. Since then, the human body simulation industry has grown in leaps and bounds and clinician educators are now confronted by a bewildering array of equipment designed to teach an ever-increasing number of basic and advanced technical and clinical skills.

Quantitative and qualitative analysis of performance during advanced laparoscopic fellowship: a curriculum based on structured assessment and feedback

BackgroundThe objective of this study was to examine the acquisition of advanced laparoscopic technical and cognitive skills during a fellowship. MethodsDuring a yearlong fellowship, consecutive assessments were completed by a fellow and 1 attending for 3 advanced procedures. The Global Operative Assessment of Laparoscopic Skills, Objective Structured Assessment of Technical Skills, and procedure-specific rating tools and free-text feedback were used. Descriptive statistics, the t test, linear mixed-effects regression, and qualitative analysis of feedback were performed. ResultsSeventy-six cases were included. Average ratings increased for each assessment area every month (P < .001). There were significant differences between ratings by assessors with more stringent ratings by the fellow. While the attending focused on efficiency and safety, the fellow focused on technical issues, with later expanded attention to advanced cognitive aspects. ConclusionsThese assessment tools can be used as a quantitative index to monitor fellows' learning curve. In combination with narrative feedback, such data can provide measures to direct improvement during self-directed learning.

Concept mapping One-Carbon Metabolism to model future ontologies for nutrient–gene–phenotype interactions

Advances in the development of bioinformatic tools continue to improve investigators' ability to interrogate, organize, and derive knowledge from large amounts of heterogeneous information. These tools often require advanced technical skills not possessed by life scientists. User-friendly, low-barrier-to-entry methods of visualizing nutrigenomics information are yet to be developed. We utilized concept mapping software from the Institute for Human and Machine Cognition to create a conceptual model of diet and health-related data that provides a foundation for future nutrigenomics ontologies describing published nutrient-gene/polymorphism-phenotype data. In this model, maps containing phenotype, nutrient, gene product, and genetic polymorphism interactions are visualized as triples of two concepts linked together by a linking phrase. These triples, or "knowledge propositions," contextualize aggregated data and information into easy-to-read knowledge maps. Maps of these triples enable visualization of genes spanning the One-Carbon Metabolism (OCM) pathway, their sequence variants, and multiple literature-mined associations including concepts relevant to nutrition, phenotypes, and health. The concept map development process documents the incongruity of information derived from pathway databases versus literature resources. This conceptual model highlights the importance of incorporating information about genes in upstream pathways that provide substrates, as well as downstream pathways that utilize products of the pathway under investigation, in this case OCM. Other genes and their polymorphisms, such as TCN2 and FUT2, although not directly involved in OCM, potentially alter OCM pathway functionality. These upstream gene products regulate substrates such as B12. Constellations of polymorphisms affecting the functionality of genes along OCM, together with substrate and cofactor availability, may impact resultant phenotypes. These conceptual maps provide a foundational framework for development of nutrient-gene/polymorphism-phenotype ontologies and systems visualization.