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The study of rigid body dynamics in soft tissue is an essential part of orthopaedic imaging. Our focus is the foot and ankle structure, which consists of 28 bones surrounded by a variety of soft tissue such as 30 muscles, numerous ligaments, bursae and nerves. The importance of understanding the involved dynamics is evident by the frequent need to find functional joint replacements to fight diseases such as hindfoot arthritis. We study a simplified problem by constructing a phantom with two”bones” submerged in silicone and a remotely controlled LEGO robot that moves one of the two bones. We perform motion registration by manipulating the bone segmented from an initial static scan and matching its digitally reconstructed radiographs to a sequence of scanned X-ray projections. The registration of the 3D volume to 2D projections requires the right combination of optimization and interpolation to achieve an optimal result. We test four different approaches with the help of the Flexible Algorithms for Image Registration (FAIR) toolbox.

STATEMENT Many techniques and modifications commonly used by the simulation community have been identified as deceptive. Deception is an important issue addressed by both the newly adopted Healthcare Simulationist Code of Ethics and the American Psychological Association Code of Conduct. Some view these approaches as essential whereas others question their necessity as well as their untoward psychological effects. In an attempt to offer guidance to simulation-based healthcare educators, we explore educational practices commonly identified as deceptive along with their potential benefits and detriments. We then address important decision points and high-risk situations that should be avoided to uphold ethical boundaries and psychological safety among learners. These are subsequently analyzed in light of the Code of Ethics and used to formulate guidelines for educators that are intended to ensure that deception, when necessary, is implemented in as psychologically safe a manner as possible.

Background Deception can be defined as causing someone to accept a falsehood as true. Within simulation, a deception is an aspect of the environment for which there is no clear agreement or knowledge among facilitators and learners about its ground rules, boundaries, or existence. The psychological literature surrounding deception is mixed, and little simulation-specific research exists. Methods This mixed-methods survey-based research explored attitudes for and against deception's use and facilitator perceptions of psychological risk and ethical harm. Subjects consisted of a random sample of members from three international simulation societies that included nurses, physicians, standardized patients, and educational specialists. The survey was designed and tested using an iterative process and distributed using SurveyMonkey™. Descriptive statistics and thematic analyses were performed. Results Eighty-four (11%) of surveys were completed. Thirty-three percent of respondents currently use modification/deception, whereas 61 to 75% of respondents expressed psychological and ethical concerns. Thematic analysis yielded five themes: types of modification/deception, decision-making considerations and guardrails, never events (high risk), potential detriments, and potential benefits. Conclusions The use of deception appears relatively prevalent in the simulation community, but significant concerns also exist. Careful consideration of all relevant factors is needed if deception is to be used responsibly.

Background Simulation is an important component of postgraduate medical education, but optimal parameters for simulation are not known. Managing simulations independently and allowing simulated morbidity and mortality have been shown to improve follow-up performance in simulation. We hypothesised that allowing simulated mortality improves performance in follow-up simulations more than independent practice. Methods Using a randomised, controlled, observer-blinded design, 48 first-year residents in anaesthesia were exposed to a hyperkalaemia scenario. Subjects were divided into two groups (n=24) that allowed for independent practice or support from an attending physician. Each of these groups was then subdivided into two groups (n=12) that allowed for simulated mortality or did not. All groups received a standardised debriefing. Six months later, the subjects returned to manage a different hyperkalaemia scenario independently with potential simulated mortality. The primary outcome was total treatment score; secondary outcomes included subjects' time to request diagnostic information, time to treatment, and simulator mortality rate. Results Subject characteristics were not statistically different. The independent practice–mortality possible group had the highest total treatment score (P=0.004), fastest time to treatment (P=0.009), and lowest mortality rate (P=0.002) compared with all groups. Two-way analysis of variance and least-squares means were calculated for each combination of variables. The overall practice effect was contrasted to the potential for mortality and was insignificant; however, their interaction effect (P=0.003) was significant and produced the best results. Conclusions Independence and the potential for simulated mortality have a greater impact on performance in follow-up simulations when combined than either factor alone.

Articular facet morphology plays a fundamental role in subtalar joint biomechanics and stability, and likely influences the development of hindfoot osteoarthritis. While multiple anatomical studies have shown wide variation in articular facet configuration, the clinico-radiological findings are rarely presented. We illustrate a case of bilateral subtalar joint middle facet agenesis in a 45-year-old woman, which was missed despite several presentations. We demonstrate the imaging findings to enable clinicians to distinguish this from the more common middle facet coalition. We summarise the developmental anatomy and discuss the potential implications on biomechanical function. Recognition of middle facet agenesis within the complex subtalar joint is important to prevent misdiagnosis and unnecessary surgery.

Objective: To evaluate the extent to which the inter-institutional, inter-disciplinary mobilisation of data and skills in the Farr Institute contributed to establishing the emerging field of data science for health in the UK. Design and Outcome measures: We evaluated evidence of six domains characterising a new field of science: defining central scientific challenges, demonstrating how the central challenges might be solved, creating novel interactions among groups of scientists, training new types of experts, re-organising universities, demonstrating impacts in society. We carried out citation, network and time trend analyses of publications, and a narrative review of infrastructure, methods and tools. Setting Four UK centres in London, North England, Scotland and Wales (23 university partners), 2013-2018. Population Subsets of the UK’s 65 million population with health records accessible for research. The Farr Institute published a research corpus around a central scientific challenge, demonstrating insights from electronic health record (EHR) and administrative data at each stage of the translational cycle in 593 papers with at least one Farr Institute author affiliation on PubMed. Sample sizes showed some evidence of increase but remained less than 10% of the UK population in primary care-hospital care linked studies. The Farr Institute established the first four ISO27001 certified trusted research environments in the UK, and approved more than 1000 approved research users, published on 102 unique EHR and administrative data sources and established open platforms for the scalable re-use of EHR phenotyping (>70 diseases, CALIBER). The co-author publication network expanded from 944 unique co-authors (based on 67 publications in the first 30 months) to 3839 unique co-authors (545 papers in the final 30 months). 4/5 Centres established 27 new faculty (tenured) positions, 3 new university institutes, and 3 new master’s courses, training >400 people at master’s, short-course and leadership level and 48 PhD students. There were over 2300 citations for the 10 most cited papers and Farr research informed eight practice-changing clinical guidelines and policies relevant to the health of millions of UK citizens. Conclusion: The Farr Institute played a major role in establishing and growing the field of data science for health in the UK, with some initial evidence of benefits for health and healthcare. The Farr Institute has now expanded into Health Data Research UK but a key challenge is to network such activities internationally. What is already known: • National research initiatives in data science for health are under way in several countries seeking to harness insights from electronic health record (EHR) and administrative data at regional and national scale for patient and public benefit. • One approach to grow this emerging field, adopted by the UK, is to establish a dedicated national research institute, the Farr Institute. • We do not know how effective such initiatives are: multi-centre, inter-disciplinary research initiatives are common, but there is a lack of research evaluating such initiatives (in general) and national research institutes (in particular). • The Farr Institute ran from 2013 until 2018 when its larger-scale successor, Health Data Research UK, was established. What this study adds: • We provide a framework of six domains relevant for evaluating new inter-institutional, inter-disciplinary initiatives seeking to establish and grow an emerging field of science: defining central scientific challenges, demonstrating how the central challenges might be solved, creating novel interactions among groups of scientists, training new types of experts, re-organising universities, demonstrating impacts in society. • We show that the Farr Institute created new activities in and across each of the six domains for developing a distinctive research field. • The Farr Institute demonstrated the ability of multiple UK health research funders and multiple universities to partner in mobilising data, methodology and expertise across disciplines, organisations and information governance domains, resulting in a larger scale of research and improved methodology. • We have demonstrated globally relevant challenges and opportunities for developing data science for health across institutional and disciplinary barriers, consistent with the need for big investigation not simply big data.

Preoperative evaluation of incidentalomas for pheochromocytoma is imperative. This case report describes a scheduled adrenalectomy in an asymptomatic patient with what was eventually determined to be an incomplete biochemical workup. The intraoperative course was complicated by labile and rapid increases in blood pressure and heart rate, suggesting the missed diagnosis of pheochromocytoma. It is important for anesthesiologists to ensure adequate preoperative biochemical workup before excluding the possibility of coexisting pheochromocytoma.

Liver transplantation (LT) is a complex procedure in a patient with multi-organ system dysfunction and coagulation defects. The surgical procedure involves dissection, major vessel manipulation, and pathophysiologic effects of graft storage and reperfusion. As a result, LT frequently involves significant hemorrhage. Subsequent massive transfusion carries high risk of transfusion-associated complications. Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) are the leading causes of transfusion associated mortality. In this case report and focused review, we present data that suggest that patients undergoing liver transplantation may be at higher risk for TRALI and TACO than the general population. Anesthesiologists can play a role in decreasing these risks by increasing recognition and reporting of TRALI and TACO, using point of care testing with thromboelastography to guide and decrease transfusion, and considering alternatives to traditional blood products like solvent/detergent plasma.

Background The utility of simulated mortality remains controversial in the literature. We therefore sought primarily to determine whether there was a difference in performance for residents exposed to varying levels of simulated mortality during training scenarios. As a secondary objective, we also sought to determine whether their self-reported anxiety levels, attitudes toward, and engagement in the simulated encounters differed based on group assignment. Methods Fifty junior anesthesiology residents were randomized to one of the three simulation cohorts. The residents were broken into groups that either always experienced simulated patient survival (never death), always experienced simulated mortality (always death), or had a variable result based on performance (variable death). All residents experienced 12 identical training simulations with only the predetermined outcome as the variable. Residents were brought back 6 weeks after initial training for four assessment scenarios and subsequently rated on nontechnical skills and anxiety levels. Results Residents in the always and never death groups showed no difference in nontechnical skills using the Anesthetists' Nontechnical Skills Score before and after the simulations. Residents in the variable death group, however, had improved nontechnical skill scores when brought back for the assessment (45.2 vs 41.5 and 42.9 respectively, P = 0.01). Although all three groups had higher State-Trait Anxiety Index scores from baseline after training, only the always death group had higher anxiety scores during the assessment (43 vs 37 vs 37 P = 0.008). Conclusions We found that participants who experienced simulated mortality that was variably delivered, and more directly related to performance, performed better on later assessment scenarios.

The American Society of Anesthesiologists physical status (ASA-PS) is associated with increased morbidity and mortality in the perioperative period. When surgeries are scheduled by surgeons and their staff at our large institution a presumed ASA-PS is chosen. This is because our institution (and, anecdotally, others in our hospital system and elsewhere), recognizing the relationship between higher ASA-PS and poorer postoperative outcomes, requires all patients with higher ASA-PS levels (≥3) to undergo enhanced preoperative workup. The patients may not, however, necessarily be seen in the anesthesia clinic prior to surgery. As a result, patients are assigned a presumed ASA-PS by a non-anesthesia provider (e.g., surgeons and physician extenders) that may not reflect the ASA-PS chosen by the anesthesiologist on the day of surgery. Errors in the accuracy of the ASA-PS prior to surgery lead to unnecessary and costly preoperative testing, delays in operative procedures, and potential case cancellations. Our study aimed to determine whether there are significant differences in the assignment of ASA-PS by non-anesthesia providers when compared to anesthesia providers.We administered an IRB-approved survey asking the ASA-PS of 20 hypothetical case vignettes to 229 clinicians in various departments. Responses by non-anesthesia providers were compared to the consensus of the department of anesthesiology.Faculty office spaces and conferences.No patients, physicians only.Survey administration.ASA-PS scores acquired from surveys.Residents and faculty in the department of anesthesiology demonstrated no statistical difference in the median ASA score in 19/20 case scenarios. All other departments were statistically different when compared to the department of anesthesiology (p0.05). The probability of a department either over- or under-rating the ASA-PS was calculated, and is summarized in Fig. 3. All departments, except anesthesiology, had a 30-40% chance of under-rating the ASA-PS of the patients in the clinical vignettes.Non-anesthesia providers assign ASA-PS with significantly less accuracy than do anesthesia providers, even when adjusted for multiple comparisons. Surgical and procedural departments were found to consistently under-rate the ASA-PS of patients in our clinical vignettes.

BackgroundEffective communication is critical for patient safety. One potential threat to communication in the operating room is incivility. Although examined in other industries, little has been done to examine how incivility impacts the ability to deliver safe care in a crisis. We therefore sought to determine how incivility influenced anaesthesiology resident performance during a standardised simulation scenario of occult haemorrhage.MethodsThis is a multicentre, prospective, randomised control trial from three academic centres. Anaesthesiology residents were randomly assigned to either a normal or ‘rude’ environment and subjected to a validated simulated operating room crisis. Technical and non-technical performance domains including vigilance, diagnosis, communication and patient management were graded on survey with Likert scales by blinded raters and compared between groups.Results76 participants underwent randomisation with 67 encounters included for analysis (34 control, 33 intervention). Those exposed to incivility scored lower on every performance metric, including a binary measurement of overall performance with 91.2% (control) versus 63.6% (rude) obtaining a passing score (p=0.009). Binary logistic regression to predict this outcome was performed to assess impact of confounders. Only the presence of incivility reached statistical significance (OR 0.110, 95% CI 0.022 to 0.544, p=0.007). 65% of the rude group believed the surgical environment negatively impacted performance; however, self-reported performance assessment on a Likert scale was similar between groups (p=0.112).ConclusionAlthough self-assessment scores were similar, incivility had a negative impact on performance. Multiple areas were impacted including vigilance, diagnosis, communication and patient management even though participants were not aware of these effects. It is imperative that these behaviours be eliminated from operating room culture and that interpersonal communication in high-stress environments be incorporated into medical training.

Computing driving directions in road networks is a fundamental problem. Although it can be solved in essentially linear time by Dijkstra's algorithm, this is not fast enough to enable interactive queries on large-scale inputs. Instead, modern algorithms typically work in two stages: first an offline preprocessing routine computes some auxiliary data, which is then used to answer exact queries in real time. The past decade has seen a surprisingly diverse set of techniques that follow this approach, mostly relying on the fact that road networks tend to have a strong hierarchy. These methods work very well when minimizing driving times, but are much less efficient with other cost functions. We present a practical algorithm that has no such drawbacks, and can compute shortest paths on continental road networks with arbitrary metrics (cost functions). Our customizable route planning approach works in three stages. The first, metric-independent preprocessing, uses graph partitioning to define the topology of a multilevel overlay graph, which is the same regardless of the cost function. The second stage, customization, uses the metric to compute the actual costs of the overlay arcs. Finally, the query stage uses the output of the first two stages to compute shortest paths in real time (milliseconds). The first stage uses a recent partitioning algorithm based on the notion of natural cuts, which are sparse regions separating much denser areas. It may take a few minutes (or even hours), but only needs to be run (or updated) when new road segments are built. Metric changes (which are much more frequent) require running only customization, which takes a second or less even on continental road networks. Since it does not rely on strong hierarchies, CRP is robust to metric changes. Unlike most other methods, it can also handle turn costs (and restrictions) quite naturally, with little effect on performance and space usage. It is thus ideal for a real-world routing engine, and is indeed in use by Bing Maps. This extended abstract includes results first published at SEA 2011 and SEA 2013.

BackgroundSimulation is increasingly employed in healthcare provider education, but usage as a means of identifying system-wide practitioner gaps has been limited. We sought to determine whether practice gaps could be identified, and if meaningful improvement plans could result from a simulation course for anaesthesiology providers.MethodsOver a 2-year cycle, 288 anaesthesiologists and 67 certified registered nurse anaesthetists (CRNAs) participated in a 3.5 hour, malpractice insurer-mandated simulation course, encountering 4 scenarios. 5 anaesthesiology departments within 3 urban academic healthcare systems were represented. A real-time rater scored each individual on 12 critical performance items (CPIs) representing learning objectives for a given scenario. Participants completed a course satisfaction survey, a 1-month postcourse practice improvement plan (PIP) and a 6-month follow-up survey.ResultsAll recorded course data were retrospectively reviewed. Course satisfaction was generally positive (88–97% positive rating by item). 4231 individual CPIs were recorded (of a possible 4260 rateable), with a majority of participants demonstrating remediable gaps in medical/technical and non-technical skills (97% of groups had at least one instance of a remediable gap in communication/non-technical skills during at least one of the scenarios). 6 months following the course, 91% of respondents reported successfully implementing 1 or more of their PIPs. Improvements in equipment/environmental resources or personal knowledge domains were most often successful, and several individual reports demonstrated a positive impact on actual practice.ConclusionsThis professional liability insurer-initiated simulation course for 5 anaesthesiology departments was feasible to deliver and well received. Practice gaps were identified during the course and remediation of gaps, and/or application of new knowledge, skills and resources was reported by participants.

With pulseless electrical activity (PEA) emerging as one of the leading cardiac arrest arrhythmias, the rapid response and accurate diagnosis of PEA is essential to improve survival rates. Although the use of invasive blood pressure monitoring to more quickly detect changes in blood pressure is widespread, evidence for its use is largely anecdotal and placement is not without risk. This is a prospective, multi-center, randomized controlled trial involving 58 senior anesthesiology residents undergoing a simulation of intraoperative PEA using high-fidelity simulation. Of the total 58 participants, 28 subjects were randomized to invasive blood pressure monitoring and 30 to non-invasive blood pressure monitoring in order to investigate the effects of arterial line information on the response time of ACLS-trained anesthesiology residents. Response times of subjects in the group provided with invasive blood pressure monitoring were faster to palpate pulses (6.5 s faster, p = .0470), initiate chest compressions (17 s faster, p = .004), and administer 1 mg of epinephrine (21 s faster, p = .0005. The absolute number of pharmacologic interventions was increased in the group with invasive blood pressure monitoring (p = .020). These findings suggest that noninvasive blood pressure monitoring and other readily available monitors are not as powerful as invasive blood pressure monitoring in influencing decision-making during a PEA event. As there is currently no specific blood pressure at which the patient is considered to be in PEA, future studies are necessary to clarify the correlation between the arterial line tracing and the appropriate trigger for ACLS initiation.

Thoracic anesthesia is a continually evolving field due to the development of new surgical and anesthetic technologies. Advances in lung isolation techniques, ventilation strategies, and postoperative pain management have improved patient outcomes. Airway management continues to progress as different devices provide advantages and disadvantages for lung isolation, surgical visualization, and access to the operative lung. Optimal ventilation strategies are moving toward lung protection, where oxygenation and ventilation are maintained with lower, more physiologic lung volumes with judicious use of alveolar recruitment, positive end-expiratory pressure, and lower FiO2. Neuraxial and regional anesthetics are the mainstays of postoperative analgesia, with adjuvants having roles in the acute period, but chronic post-thoracotomy pain remains challenging to treat. The role of perioperative inflammation has grown in importance, and volatile anesthetics have protective effects at the cellular and molecular levels, however the debate between the use of volatiles versus a total intravenous anesthetic technique continues.

There is considerable controversy as to whether the simulator should die during high-fidelity simulation (HFS). We sought to describe the physiologic and biochemical stress response induced by simulated patient death as well as the impact on long-term retention of Advanced Cardiovascular Life Support (ACLS) knowledge and skills.Twenty-six subjects received an American Heart Association (AHA) ACLS provider course. Following the course, subjects participated in HFS and were randomized to simulated death or survival. Heart rate and salivary cortisol (SC) and dihydroepiandrosterone (DHEA) were collected at this time. Subjects returned six months later for a follow-up simulation in which ACLS knowledge and skills were tested.For all participants, there was an increase in heart rate during simulation compared with baseline heart rate (+ 32 beats/minute), p0.0001. Similarly, SC and DHEA were higher compared with baseline levels (+ 0.115 μg/dL, p0.01 and + 97 pg/mL, p0.001, respectively). However, the only statistically significant difference between groups was an increase in heart rate response at the end of the simulation compared with baseline in the death group (+ 29.2 beats/minute versus + 18.5 beats/minute), p0.05. There was no difference on long-term knowledge or skills.Learners experience stress during high-fidelity simulation; however, there does not appear to be a readily detectable difference or negative response to a simulated patient death compared with simulated survival.

A 42-year-old obese woman (body mass index = 30.2 kg/m) presented for urgent anterior cervical diskectomy and fusion. She had been taking oral naltrexone-bupropion extended-release (Contrave, Orexigen Therapeutics Inc, La Jolla, CA) for the past 6 months and continued using it until 12 hours preoperatively. Despite discontinuation of this medication, and employing an intraoperative and postoperative multimodal analgesia strategy, immediate pain control was inadequately achieved. Patients taking opioid antagonists who present for surgery pose unique challenges to the anesthesiologist and require extensive preoperative interdisciplinary discussions and planning for pain control throughout the perioperative period.

Room modes cause audible artifacts in listening environments. Modal control approaches have\ud emerged in scientific literature over the years and, often, their performance is measured by criteria\ud that may be perceptually unfounded. Previous research has shown modal decay as a key perceptual\ud factor in detecting modal effects. In this work, perceptual thresholds for the effects of modes as a\ud function of modal decay have been measured in the region between 32 and 250 Hz. A test\ud methodology has been developed to include modal interaction and temporal masking from musical\ud events, which are important aspects in recreating an ecologically valid test regime. This method has\ud been deployed in addition to artificial test stimuli traditionally used in psychometric studies, which\ud provide unmasked, absolute thresholds. For artificial stimuli, thresholds decrease monotonically\ud from 0.9 s at 32Hz to 0.17 s at 200 Hz, with a knee at 63 Hz. For music stimuli, thresholds decrease\ud monotonically from 0.51 s at 63Hz to 0.12 s at 250 Hz. Perceptual thresholds are shown to be\ud dependent on frequency and to a much lesser extent on level. The results presented here define\ud absolute and practical thresholds, which are useful as perceptually relevant optimization targets for\ud modal control methods.

Significant advancements have been made in the diagnosis and management of congenital heart disease (CHD). As a result, a higher percentage of these patients are surviving to adulthood. Despite this improvement in management, these patients remain at higher risk of morbidity and mortality, particularly in the perioperative setting. One new area of interest in these patients is the implementation of simulation-based medical education. Simulation has demonstrated various benefits across high-acuity scenarios encountered in the hospital. In CHD, simulation has been used in the training of pediatrics residents, assessment of intraoperative complications, echocardiography, and anatomic modeling with 3-dimensional printing. Here, we describe the current state of simulation in CHD, its role in training care providers for the management of this population, and future directions of CHD simulation.

A SERIES of reports in the United States and Europe have linked Mycobacterium chimaera infections to contaminated heater-cooler devices used during cardiac surgery. Heater-cooler devices commonly are used for cardiopulmonary bypass during cardiac surgery. M. chimaera is a slow-growing nontuberculous mycobacterium that has been shown to cause cardiac complications that can lead to fatal disease following cardiac surgery. Given that more than 250,000 cardiothoracic surgical procedures requiring cardiopulmonary bypass take place each year in the United States, the estimated number of patient exposures to M. chimaera has prompted a public health crisis. The goal of this review is to summarize the present status of the M. chimaera outbreak and provide cardiothoracic surgeons, cardiac anesthesiologists, and other clinicians with current approaches to patient management and to discuss risk mitigation.

Serious gaming a tool that can be used to train new physicians in a manner that keeps patients out of harm's way. This is especially true when teaching procedures, which in the medical community if often done in a “see one, do one, teach one” manner. Additionally, many teachers focus on technical aspects of the procedure and may leave out or de-emphasize non-technical portions of the procedure such as hand washing and patient positioning. This chapter per the authors investigates the utility of serious gaming in teaching physicians technical procedures. The chapter begins with game development and will end with a discussion of the results of the prospective randomized study.

A patient with a body mass index (BMI) of 42 just underwent an uneventful hernia repair under sedation. She is a 34-year-old woman with a history of hypertension, non-insulin-dependent diabetes, hyperlipidemia, and anxiety. The post-anesthesia care unit (PACU) attending was discussing with his resident his plan to discharge the patient later that day when another attending, who overheard this, commented that it was not appropriate to discharge such a patient. Who is correct?

A 43-year-old woman with a past medical history of menorrhagia and uterine fibroids just underwent a laparoscopic myomectomy this morning under general anesthesia. Her anesthesia care included desflurane, nitrous oxide, and intermittent boluses of fentanyl and rocuronium. She received dexamethasone before surgical incision and ondansetron 20 min prior to emergence. She woke up comfortable and without complaints. Thirty minutes into her recovery in the post-anesthesia care unit (PACU), she began to experience nausea and had 2 episodes of non-bloody, non-bilious emesis. More ondansetron was given and the patient reported slight improvement of her symptoms, but the nausea returned shortly thereafter.

Anesthetic management of orthotopic liver transplantation (OLT) is complex. Given the unequal distributions of liver transplant surgeries performed at different centers, anesthesiology providers receive relatively uneven OLT training and exposure. One well-suited modality for OLT training is the "serious game," an interactive application created for the purpose of imparting knowledge or skills, while leveraging the self-motivating elements of video games. We therefore developed a serious game designed to teach best practices for the anesthetic management of a standard OLT and determined if the game would improve resident performance in a simulated OLT. Forty-four residents on the liver transplant rotation were randomized to either the gaming group (GG) or the control group (CG) prior to their introductory simulation. Both groups were given access to the same educational materials and literature during their rotation, but the GG also had access to the OLT Trainer. Performance on the simulations were recorded on a standardized grading rubric. Both groups experienced an increase in score relative to baseline that was statistically significant at every stage. The improvements in scores were greater for the GG participants than the CG participants. Overall score improvement between the GG and CG (mean [standard deviation]) was statistically significant (GG, 7.95 [3.65]; CG, 4.8 [4.48]; P = 0.02), as were scores for preoperative assessment (GG, 2.67 [2.09]; CG, 1.17 [1.43]; P = 0.01) and anhepatic phase (GG, 1.62 [1.01]; CG, 0.75 [1.28]; P = 0.02). Of the residents with game access, 81% were "very satisfied" or "satisfied" with the game overall. In conclusion, adding a serious game to an existing educational curriculum for liver transplant anesthesia resulted in significant learning gains for rotating anesthesia residents. The intervention was straightforward to implement and cost-effective. Liver Transplantation 23 430-439 2017 AASLD.

Reading provides information across the curriculum. Thus, to the extent that fundamental (i.e., generalizable) reading comprehension strategies can be taught, the benefits should be found in multiple domains. To test this claim, children in the third and fourth grades read by simulating text content using the two-part, embodied Moved by Reading intervention. While reading six initial texts, children literally manipulated pictures on a computer screen to simulate sentence content; next, for additional texts the children imagined the manipulation of the pictures. These additional texts were in the form of mathematical story problems. Compared to a control condition, children using Moved by Reading solved more problems correctly, and this improvement is mainly attributed to a 35% reduction in the use of irrelevant numerical information in solution attempts. Thus, Moved by Reading teaches a fundamental strategy that encourages the sense-making that can aid mathematical story problem solution.