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The current shift towards competency-based residency training has increased the need for objective assessment of skills. In this study, we developed and validated an assessment tool that measures technical andnon-technical competency in transurethral resection of bladder tumour (TURBT). The ‘Test Objective Competency’ (TOCO)–TURBT tool was designed by means of cognitive task analysis (CTA), which included expert consensus. The tool consists of 51 items, divided into 3 phases: preparatory (n= 15), procedural (n= 21), and completion (n= 15). For validation of the TOCO–TURBT tool, 2 TURBT procedures were performed and videotaped by 25 urologists and 51 residents in a simulated setting. The participants’ degree of competence was assessed by a panel of eight independent expert urologists using the TOCO–TURBT tool. Each procedure was assessed by two raters. Feasibility, acceptability and content validity were evaluated by means of a quantitative cross-sectional survey. Regression analyses were performed to assess the strength of the relation between experience and test scores (construct validity). Reliability was analysed by generalizability theory. The majority of assessors and urologists indicated the TOCO–TURBT tool to be a valid assessment of competency and would support the implementation of the TOCO–TURBT assessment as a certification method for residents. Construct validity was clearly established for all outcome measures of the procedural phase (all r> 0.5, p< 0.01). Generalizability-theory analysis showed high reliability (coefficient Phi ≥ 0.8) when using the format of two assessors and two cases. This study provides first evidence that the TOCO–TURBT tool is a feasible, valid and reliable assessment tool for measuring competency in TURBT. The tool has the potential to be used for future certification of competencies for residents and urologists. The methodology of CTA might be valuable in the development of assessment tools in other areas of clinical practice.

Abstract Objective--To examine whether successful coronary reperfusion after thrombolytic treatment in patients with confirmed acute myocardial infarction can be diagnosed from the plasma marker fatty acid binding protein (FABP), for [...]

Although simulation training is increasingly used to meet modern technology and patient safety demands, its successful integration within surgical curricula is still rare. The Dutch Urological Practical Skills (D-UPS) curriculum provides modular simulation-based training of technical andnon-technical basic urological skills in the local hospital setting. This study aims to assess the educational impact of implementing the D-UPS curriculum in the Netherlands and to provide focus points for improvement of the D-UPS curriculum according to the participants. Educational impact was assessed by means of qualitative individual module-specific feedback and a quantitative cross-sectional survey among residents and supervisors. Twenty out of 26 Dutch teaching hospitals participated. The survey focussed on practical aspects, the D-UPS curriculum in general, and the impact of the D-UPS curriculum on the development of technical and non-technical skills. A considerable survey response of 95 % for residents and 76 % for supervisors was obtained. Modules were attended by junior and senior residents, supervised by a urologist, and peer teaching was used. Ninety percent of supervisors versus 67 % of residents judged the D-UPS curriculum as an important addition to current residency training (p= 0.007). Participants’ aggregated general judgement of the modules showed a substantial percentage favorable score (M± SE: 57 ± 4 %). The impact of training on, e.g., knowledge of materials/equipment and ability to anticipate on complications was high, especially for junior residents (77 ± 5 and 71 ± 7 %, respectively). Focus points for improvement of the D-UPS curriculum according to the participants include adaptation of the training level to residents’ level of experience and focus on logistics. The simulation-based D-UPS curriculum has a high educational impact. Residents and supervisors consider the curriculum to be an important addition to current residency training. Focus points for improvement of the D-UPS curriculum according to the participants include increased attention to logistics and integration of a spiral learning approach.

Purpose:General practitioners are increasingly called upon to deliver genetic services and could play a key role in translating potentially life-saving advancements in oncogenetic technologies to patient care. If general practitioners are to make an effective contribution in this area, their genetics competencies need to be upgraded. The aim of this study was to investigate whether oncogenetics training for general practitioners improves their genetic consultation skills.Methods:In this pragmatic, blinded, randomized controlled trial, the intervention consisted of a 4-h training (December 2011 and April 2012), covering oncogenetic consultation skills (family history, familial risk assessment, and efficient referral), attitude (medical ethical issues), and clinical knowledge required in primary-care consultations. Outcomes were measured using observation checklists by unannounced standardized patients and self-reported questionnaires.Results:Of 88 randomized general practitioners who initially agreed to participate, 56 completed all measurements. Key consultation skills significantly and substantially improved; regression coefficients after intervention were equivalent to 0.34 and 0.28 at 3-month follow-up, indicating a moderate effect size. Satisfaction and perceived applicability of newly learned skills were highly scored.Conclusion:The general practitioner–specific training proved to be a feasible, satisfactory, and clinically applicable method to improve oncogenetics consultation skills and could be used as an educational framework to inform future training activities with the ultimate aim of improving medical care.Genet Med 16 1, 45–52.

Interest in the areas of food animals (FA) and veterinary public health (VPH) appears to be declining among prospective students of veterinary medicine. To address the expected shortage of veterinarians in these areas, the Utrecht Faculty of Veterinary Medicine has developed an admissions procedure to select undergraduates whose aptitude and interests are suited to these areas. A study using expert meetings, open interviews, and document analysis identified personal characteristics that distinguished veterinarians working in the areas of FA and VPH from their colleagues who specialized in companion animals (CA) and equine medicine (E). The outcomes were used to create a written selection tool. We validated this tool in a study among undergraduate veterinary students in their final (sixth) year before graduation. The applicability of the tool was verified in a study among first-year students who had opted to pursue either FA/VPH or CA/E. The tool revealed statistically significant differences with acceptable effect sizes between the two student groups. Because the written selection tool did not cover all of the differences between the veterinarians who specialized in FA/VPH and those who specialized in CA/E, we developed a prestructured panel interview and added it to the questionnaire. The evaluation of the written component showed that it was suitable for selecting those students who were most likely to succeed in the FA/VPH track.

Cardiac tagging permits non‐invasive study of myocardial motion with high accuracy. Unfortunately, tagging contrast is impaired at later heart phases due to longitudinal relaxation. Histogram modification is presented as a method for improving contrast in later, faded images of a tagging series by altering these images such that their intensity histograms approximate the shape of the first, unfaded image of the series. This technique greatly improves the contrast and facilitates automatic detection of tags. Furthermore, a method is described for automatically tracking tag positions in short‐axis images of the left ventricle modulated with a tagging grid. The method differs from previously reported methods in that, in one single filtering process in the Fourier domain, both the grid crossings as well as the grid centers are detected, and thus increased sampling resolution is obtained. The method was validated by applying a mathematical model of left ventricular motion to tagged images of the thigh muscle. The average discrepancy between theoretically predicted and automatically detected tag positions was 0.04 ± 0.17 mm (mean ± SD). Magn Reson Med 41:973–982, 1999. © 1999 Wiley‐Liss, Inc.

A prospective longitudinal and standardized study is presented, dealing with ultrasonographic and hormonal characteristics of the luteinized unruptured follicle (LUF) syndrome. Among 600 cycles monitored in 270 infertility patients, 40 cycles in 27 patients showed no evidence of follicle rupture, in spite of signs of luteinization, as reflected by basal body temperature recordings and progesterone determinations. In this study, 20 LUF cycles in 20 infertile patients were compared with 45 ovulatory cycles in 45 control women. During the follicular phase, no substantial difference in follicle growth was found, but after the luteinizing hormone peak, LUF follicles, instead of rupturing, showed a typical accelerated growth pattern. Both mean luteinizing hormone peak levels and midluteal progesterone levels were significantly lower in LUF cycles than in the control cycles. However, the duration of the luteal phase was not affected. Both central and local factors can be held responsible for the lack of follicle rupture. Ultrasound offers new possibilities as a noninvasive method in diagnosing the LUF syndrome.

Spatial orientation of blood platelets flowing in small arterioles of the rabbit mesentery was investigated using intravital fluorescence microscopy. Only platelets were studied that could be localized objectively within a thin optical section around the median plane of the vessel. The orientation of a platelet was assessed from its microscopic image and described by an angle pair, assuming the platelet to be an ellipsoidal body and using an empirical frequency distribution for its thickness to diameter ratio. The orientation of the platelets was not random; they tended to align themselves with their equatorial planes parallel to the wall. The degree of alignment increased from the center of the vessel toward the wall. As a corollary a frequency distribution of their diameter (3.15±0.72µm(x¯±sd))was obtained in vivo.

Norm-referenced pass/fail decisions are quite common in achievement testing in health sciences education. The use of relative standards has the advantage of correcting for variations in test-difficulty. However, relative standards also show some serious drawbacks, and the use of an absolute and fixed standard is regularly preferred. The current study investigates the consequences of the use of an absolute instead of a relative standard. The performance of the developed standard setting procedure was investigated by using actual progress test scores obtained at the Maastricht medical school in an episode of eight years. When the absolute instead of the relative standard was used 6% of the decisions changed: 2.6% of the outcomes changed from fail to pass, and 3.4% from pass to fail. The failure rate, which was approximately constant when using the relative standard, varied from 2% to 47% for different tests when an absolute standard was used. It is concluded that an absolute standard is precarious because of the variations in difficulty of tests.

OBJECTIVE: To assess the quality of telephone triage by following the consecutive phases of its care process and the quality of the clinical questions asked about the patient’s clinical condition, of the triage outcome, of the content of the home management advice, and of the safety net advice given at out of hours centres. Design Cross sectional national study using telephone incognito standardised patients. Setting The Netherlands. Participants 17 out of hours centres. MAIN OUTCOME MEASURES: Percentages of clinical obligatory questions asked and items within home management and safety net advice, both in relation to pre-agreed standards, and of care advice given in relation to the required care advice. RESULTS: The telephone incognito standardised patients presented seven clinical cases three times each over a period of 12 months, making a total of 357 calls. The mean percentage of obligatory questions asked compared with the standard was 21%. Answers to questions about the clinical condition were not always correctly evaluated from a clinical viewpoint, either by triagists or by general practitioners. The quality of information on home management and safety net advice varied, but it was consistently poor for all cases and for all out of hours centres. Triagists achieved the appropriate triage outcome in 58% of calls. CONCLUSION: In determining the outcome of the care process, triagists often reached a conclusion after asking a minimal number of questions. By analysing the quality of different phases within the process of telephone triage, evaluation of whether an appropriate triage outcome has been arrived at by means of good clinical reasoning or by an educated guess is possible. In terms of enhancing the overall clinical safety of telephone triage, apart from obtaining an appropriate clinical history, adequate home management and safety net advice must also be given.

Presents a letter to the editor about the work to educate future priest in areas of sexual maturity.

Objective: Asynchronous electrical activation of the left ventricle (LV), induced by ventricular pacing (VP), reduces mechanical load in early- and enhances it in late-activated regions. Consequently, chronic VP leads to asymmetric hypertrophy. We investigated whether such locally induced myocardial hypertrophy also occurs in the presence of pressure overload hypertrophy (POH). Methods: POH was induced by aortic banding in puppies. At age 9 months, seven dogs were paced at the right ventricular (RV) apex at physiological heart rate for 6 months (POH-pace group), while four POH dogs served as POH-control group. Changes in volume of the LV cavity and the total LV wall and of five LV wall sectors were measured by means of 2D-echocardiography and X-ray marker detection. Results: During the last 6 months of the protocol the volume of the five LV wall sectors increased in the POH-control group, ranging from 27±9 to 30±5% (mean±S.D.). In POH-pace animals sector wall volume in the four sectors at intermediate to long distance from the pacing site increased to a similar extent (ranging from 31±16 to 35±17%), but wall volume in the early-activated apical septum increased significantly less (17±21%). In these hearts myocyte diameter was significantly smaller in the apical septum than in the lateral LV wall. The regional difference in wall volume changes (19±21%) was significantly smaller in the POH-pace group than in chronically paced, non-hypertrophic, canine hearts in a previous study from our laboratory (43±14%). Conclusions: In hypertrophying hearts chronic pacing at the RV apex suppresses the development of hypertrophy in the early-activated apical septum but does not cause additional hypertrophy in late-activated regions, as is the case in non-hypertrophic hearts. The latter suggests that the local growth response is reduced in hypertrophying hearts.

Estimation of infarct size from enzyme activities in plasma or serum presupposes known values of circulatory parameters such as the extravascular distribution volume V_e and the permeability constant P for the transport of enzyme between intravascular volume V_i and V_e. In man, parameter values are used that are extrapolated either from values found in the dog or from turnover studies of non-myocardial proteins. Large systematic errors can be introduced in this way, as demonstrated in this study. It is shown that by simultaneous determination of two different enzymes in the same patient, estimates of circulatory parameters are obtained. The method is applied to creatine kinase (CK) and -hydroxybutyrate dehydrogenase (HBDH) plasma activities in 36 patients with acute myocardial infarction (AMI). The following results are obtained: 1. Exchange of enzyme between V_i and V_e is much slower and clearance of CK is much faster than presently assumed in the literature. 2. Release of CK and HBDH into the circulation is proportional to the amounts of these enzymes present in the myocardium. This finding is supported by data on early enzyme release. 3. Quantitation of HBDH release needs a two-compartment model, while for CK a one-compartment model can be used in good approximation. 4. Release of CK and HBDH after AMI continues up to 96 hours. 5. Using obtained parameter values, a simulated model demonstrates that estimation of clearance rates of CK from exponential fits on plasma levels results in large errors. This may explain recent conflicting results in validation of enzymatic estimates of infarct size.