By Tate Skinner and Dr. Adam Dubrowski
1.Nurse
Educ Today. 2016 Dec 20;50:17-24. doi: 10.1016/j.nedt.2016.12.011. [Epub ahead
of print]
Effect
of simulation training on the development of nurses and nursing students'
critical thinking: A systematic literature review.
Adib-Hajbaghery M1, Sharifi N2.
Author information:
1Trauma Nursing Research Center, Faculty
of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, Iran.
Electronic address: adib1344@yahoo.com.
2Department of Nursing, College of
Nursing, Falavarjan Branch, Islamic Azad University, Isfahan, Iran. Electronic
address: najmehsharifi@gmail.com.
Abstract
OBJECTIVE:
To gain insight into the existing
scientific evidence on the effect of simulation on critical thinking in nursing
education.
DESIGN:
A systematic literature review of
original research publications.
DATA SOURCES:
In this systematic review, the papers
published in English and Farsi databases of PubMed, Science Direct, ProQuest,
ERIC, Google Scholar and Ovid, MagIran and SID, from 1975 to 2015 were reviewed
by two independent researchers.
REVIEW METHODS:
Original research publications were
eligible for review when they described simulation program directed on nursing
student and nurses; used a control group or a pretest post-test design; and
gave information about the effects of simulation on critical thinking. Two
reviewers independently assessed the studies for inclusion. Methodological
quality of the included studies was also independently assessed by the
reviewers, using a checklist developed by Greenhalgh et al. and the checklist
of Cochrane Center. Data related to the original publications were extracted by
one reviewer and checked by a second reviewer. No statistical pooling of
outcomes was performed, due to the large heterogeneity of outcomes.
RESULTS:
After screening the titles and abstracts
of 787 papers, 16 ones were included in the review according to the inclusion
criteria. These used experimental or quasi-experimental designs. The studies
used a variety of instruments and a wide range of simulation methods with
differences in duration and numbers of exposures to simulation. Eight of the
studies reported that simulation training positively affected the critical
thinking skills. However, eight studies reported ineffectiveness of simulation
on critical thinking.
CONCLUSION:
Studies are conflicting about the effect
of simulation on nurses and nursing students' critical thinking. Also, a large
heterogeneity exists between the studies in terms of the instruments and the
methods used. Thus, more studies with careful designs are needed to produce
more credible evidence on the effectiveness of simulation on critical thinking.
Copyright © 2016. Published by Elsevier
Ltd.
PMID: 28011333 [PubMed - as supplied by
publisher]
2.J Surg Educ. 2016 Dec 20. pii:
S1931-7204(16)30201-X. doi: 10.1016/j.jsurg.2016.11.013. [Epub ahead of print]
Cost
Comparison of Fundamentals of Laparoscopic Surgery Training Completed With
Standard Fundamentals of Laparoscopic Surgery Equipment versus Low-Cost
Equipment.
Franklin BR1, Placek SB2, Wagner MD2,
Haviland SM3, O'Donnell MT2, Ritter EM2.
Author information:
1Division of General Surgery, USU/Walter
Reed Department of Surgery, Bethesda, Maryland; National Capital Region
Simulation Consortium, Bethesda, Maryland. Electronic address:
brentonfranklin@gmail.com.
2Division of General Surgery, USU/Walter
Reed Department of Surgery, Bethesda, Maryland; National Capital Region
Simulation Consortium, Bethesda, Maryland.
3Division of General Surgery, USU/Walter
Reed Department of Surgery, Bethesda, Maryland; Weill Cornell Medical College,
Cornell University, New York, New York.
Abstract
OBJECTIVE:
Training for the Fundamentals of
Laparoscopic Surgery (FLS) skills test can be expensive. Previous work
demonstrated that training on an ergonomically different, low-cost platform
does not affect FLS skills test outcomes. This study compares the average
training cost with standard FLS equipment and medical-grade consumables versus
training on a lower cost platform with non-medical-grade consumables.
DESIGN:
Subjects were prospectively randomized
to either the standard FLS training platform (n = 19) with medical-grade
consumables (S-FLS), or the low-cost platform (n = 20) with training-grade
products (LC-FLS). Both groups trained to proficiency using previously
established mastery learning standards on the 5 FLS tasks. The fixed and
consumable cost differences were compared.
SETTING:
Training occurred in a surgical
simulation center.
PARTICIPANTS:
Laparoscopic novice medical student and
resident physician health care professionals who had not completed the national
FLS proficiency curriculum and who had performed less than 10 laparoscopic
cases.
RESULTS:
The fixed cost of the platform was
considerably higher in the S-FLS group (S-FLS, $3360; LC-FLS, $879), and the
average consumable training cost was significantly higher for the S-FLS group
(S-FLS, $1384.52; LC-FLS, $153.79; p < 0.001). The LC-FLS group had a
statistically discernable cost reduction for each consumable (Gauze $9.24 vs.
$0.39, p = 0.002; EndoLoop $540.00 vs. $40.60, p < 0.001; extracorporeal
suture $216.45 vs. $25.20, p < 0.001; intracorporeal suture $618.83 vs.
$87.60, p < 0.001). The annual fixed and consumable cost to train 5
residents is $10,282.60 in the S-FLS group versus $1647.95 in the LC-FLS group.
CONCLUSIONS:
This study shows that the average cost
to train a single trainee to proficiency using a lower fixed-cost platform and
non-medical-grade equipment results in significant financial savings. A
5-resident program will save approximately $8500 annually. Residency programs
should consider adopting this strategy to reduce the cost of FLS training.
Published by Elsevier Inc.
PMID: 28011260 [PubMed - as supplied by
publisher]
3.Surgery. 2016 Dec 20. pii:
S0039-6060(16)30791-7. doi: 10.1016/j.surg.2016.11.022. [Epub ahead of print]
Early
crisis nontechnical skill teaching in residency leads to long-term skill
retention and improved performance during crises: A prospective, nonrandomized
controlled study.
Doumouras AG1, Engels PT2.
Author information:
1Department of Surgery, McMaster
University, Hamilton, Ontario, Canada.
2Department of Surgery, McMaster
University, Hamilton, Ontario, Canada; Department of Critical Care, McMaster
University, Hamilton, Ontario, Canada. Electronic address: engelsp@mcmaster.ca.
Abstract
BACKGROUND:
Medical error is common in crises, and
the majority of observed errors are nontechnical in nature. The long-term
impact of teaching crisis nontechnical skills to residents has not been
evaluated. The objective of this study was to determine the effect of
simulation-based teaching of crisis nontechnical skills compared to controls
one year after initial teaching.
METHODS:
This was a prospective study using both
historical controls and a before-and-after methodology to evaluate the effect
of a high-fidelity simulation curriculum that used crisis resource management
principles to teach nontechnical skills. Postgraduate year 2 and 3 residents
were invited to take part in a prospective training course over 2 years. The
primary outcome was leader performance evaluated by expert raters using the
previously validated 7-point Ottawa Global Rating Scale.
RESULTS:
Overall, 23 residents performed 30
simulations over the 2 years with the intervention group of 7 residents being
assessed in both years. After adjustment, the postgraduate year 3 intervention
group who received training the previous year had significantly higher overall
performance scores than all postgraduate year 2 scores (1.09 95% confidence
interval 0.70-1.47, P < .001) and the historical postgraduate year 3 cohort
who received no prior training (1.20, 95% confidence interval 0.37-2.03, P =
.005). There was no decay of skills noted over the course of the study.
CONCLUSION:
Postgraduate year 3 residents who had
prior training had significantly improved crisis performance compared to
historical postgraduate year 3 controls and untrained postgraduate year 2
residents. There were no significant differences between the crisis performance
of postgraduate year 2 residents and the untrained postgraduate year 3
controls. This confirms the beneficial effect and long-term retention after
crisis nontechnical skill training.
Copyright © 2016 Elsevier Inc. All
rights reserved.
PMID: 28011009 [PubMed - as supplied by
publisher]
4.Am J Surg. 2016 Nov 30. pii:
S0002-9610(16)30953-9. doi: 10.1016/j.amjsurg.2016.10.018. [Epub ahead of
print]
Skill
learning from kinesthetic feedback.
Pinzon D1, Vega R2, Sanchez YP1, Zheng
B3.
Author information:
1Surgical Simulation Research Lab,
Department of Surgery, University of Alberta, Canada.
2Department of Computing Science,
University of Alberta, Canada.
3Surgical Simulation Research Lab,
Department of Surgery, University of Alberta, Canada. Electronic address:
bzheng1@ualberta.ca.
Abstract
BACKGROUND:
It is important for a surgeon to perform
surgical tasks under appropriate guidance from visual and kinesthetic feedback.
However, our knowledge on kinesthetic (muscle) memory and its role in learning
motor skills remains elementary.
OBJECTIVES:
To discover the effect of exclusive
kinesthetic training on kinesthetic memory in both performance and learning.
METHODS:
In Phase 1, a total of twenty
participants duplicated five 2 dimensional movements of increasing complexity
via passive kinesthetic guidance, without visual or auditory stimuli. Five
participants were asked to repeat the task in the Phase 2 over a period of
three weeks, for a total of nine sessions.
RESULTS:
Subjects accurately recalled movement
direction using kinesthetic memory, but recalling movement length was less
precise. Over the nine training sessions, error occurrence dropped after the
sixth session.
CONCLUSIONS:
Muscle memory constructs the foundation
for kinesthetic training. Knowledge gained helps surgeons learn skills from
kinesthetic information in the condition where visual feedback is limited.
Copyright © 2016 Elsevier Inc. All
rights reserved.
PMID: 28007316 [PubMed - as supplied by
publisher]
5.J Educ Eval Health Prof. 2016 Dec 26.
doi: 10.3352/jeehp.2016.13.44. [Epub ahead of print]
A
cost-effectiveness analysis of self-debriefing versus instructor debriefing for
simulated crises in perioperative medicine.
Isaranuwatchai W1,2, Alam F3,4, Hoch
J1,2, Boet S5,6.
Author information:
1Centre for Excellence in Economic
Analysis Research , The HUB Health Research Solutions, Li Ka Shing Knowledge
Institute, St. Michael's Hospital, Ontario, Canada.
2Institute for Health Policy, Management
and Evaluation, University of Toronto, Ontario, Canada.
3Department of Anesthesia, Sunnybrook
Health Sciences Centre, Ontario, Canada.
4The Wilson Centre for Research in
Medical Education, University of Toronto, Ontario, Canada.
5Department of Anesthesiology, The
Ottawa Hospital Research Institute, The Ottawa Hospital, Ontario, Canada.
6Department of Innovation in Medical
Innovation, University of Ottawa, Ontario, Canada.
Abstract
Purpose:
High-fidelity simulation training is
effective for learning crisis resource management (CRM) skills. A major barrier
to implementing high-fidelity simulation training into curriculum is cost. This
study aims to examine the cost-effectiveness of self-debriefing and traditional
instructor-debriefing CRM training programs and to calculate the minimum
willingness to pay value when one debriefing type becomes more cost-effective
than the other.
Methods:
This study used previous data from a
randomized controlled trial involving 50 anaesthesia residents. Each
participant managed a pretest crisis scenario. Participants randomized to be
self-debriefed used the video of their pretest scenario with no instructor
present during their debriefing. Participants from the control group were
debriefed by a trained instructor using the video of their pretest scenario.
Participants individually managed a posttest simulated crisis scenario. We
compared the cost and effect of self-debriefing versus the
instructor-debriefing using the net benefit regression. The cost-effectiveness
estimate was reported as incremental net benefit and the uncertainty was
presented through a cost-effectiveness acceptability curve.
Results:
Self-debriefing costs less than
instructor debriefing. As decision maker's willingness-to-pay (WTP) increased,
the probability that self-debriefing would be cost-effective decreased. With
WTP ≤$200, the self-debriefing program was cost-effective. However, when
effectiveness was priced higher than cost-savings and with WTP >$300,
instructor-debriefing was the preferred alternative.
Conclusions:
With lower WTP (≤$200), when compared to
instructor-debriefing, self-debriefing was cost-effective in CRM simulation
training. This study provides evidence to inform decision makers and clinical
educators in their decision-making process, in term of cost-effectiveness, and
may optimize resource allocation in education.
Free Article
PMID: 28028288 [PubMed - as supplied by
publisher]
6.J Minim Invasive Gynecol. 2016 Dec 24.
pii: S1553-4650(16)31285-7. doi: 10.1016/j.jmig.2016.12.016. [Epub ahead of
print]
The
transferability of virtual reality simulation-based robotic suturing skills to
a live porcine model in novice surgeons: a single blind randomized controlled
trial1.
Vargas MV1, Moawad G2, Denny K3, Happ
L4, Misa NY3, Margulies S5, Opoku-Anane J6, Abi Khalil E2, Marfori C2.
Author information:
1Division of Gynecology, George
Washington University Medical Faculty Associates, Washington, DC, United
States, 20037. Electronic address: mvvargas@mfa.gwu.edu.
2Division of Gynecology, George
Washington University Medical Faculty Associates, Washington, DC, United
States, 20037.
3School of Medicine and Health Sciences,
George Washington University, Washington, DC, United States, 20037.
4Milken Institute of Public Health,
George Washington University, Washington, DC, United States, 20052.
5School of Medicine and Health Sciences,
George Washington University, Washington, DC, United States, 20037; S.M's
current institution: Department of Obstetrics, Gynecology, and Reproductive
Sciences, Yale School of Medicine, New Haven, CT, United States, 06520.
6Division of Gynecology, George Washington
University Medical Faculty Associates, Washington, DC, United States, 20037;
J.O.A's current institution: Department of Obstetrics and Gynecology, Division
of Gynecology, University of California San Francisco, San Francisco, CA,
United States, 94143.
Abstract
OBJECTIVE:
To assess whether a robotic simulation
curriculum for novice surgeons can improve performance of a suturing task in a
live porcine model.
DESIGN:
Randomized controlled trial: (Canadian
Task Force Classification I) SETTING: Academic medical center PATIENTS: 35
medical students without robotic surgical experience INTERVENTIONS:
Participants were enrolled in an online session of training modules followed by
an in-person orientation. Baseline performance testing on the Mimic Technologies
daVinci Surgical Simulator (dVSS) was also performed. Participants were then
randomly assigned to the completion of 4 dVSS training tasks (Camara clutching
1, Suture sponge 1 and 2, and Tubes) versus no further training. The
intervention group performed each dVSS task until proficiency or up to 10
times. A final suturing task was performed on a live porcine model, which was
video recorded and blindly assessed by experienced surgeons. The primary
outcomes were Global Evaluative Assessment of Robotic Skills (GEARS) scores and
task time. The study had 90% power to detect a mean difference of 3 points on
the GEARS scale, assuming a standard deviation (SD) of 2.65, and 80% power to
detect a mean difference of 3 minutes, assuming a SD of 3 minutes.
MEASUREMENTS & MAIN RESULTS:
There were no differences in
demographics and baseline skills between the two groups. No significant
differences in task time in minutes or GEARS scores were seen for the final
suturing task between the intervention and control groups respectively
(9.2(2.65) versus 9.9(2.07) minutes; p=0.406 and 15.37(2.51) versus
15.25(3.38); p=.603). The 95% confidence interval for the difference in mean
task times was -2.36 to 0.96 minutes, and mean GEARS scores was -1.91 to 2.15
points.
CONCLUSIONS:
Live suturing task performance was not
improved with a proficiency-based virtual reality simulation suturing
curriculum compared to standard orientation to the daVinci robotic console in a
group of novice surgeons.
Copyright © 2016. Published by Elsevier
Inc.
PMID: 28027975 [PubMed - as supplied by
publisher]
7.J Surg Educ. 2016 Dec 14. pii:
S1931-7204(16)30293-8. doi: 10.1016/j.jsurg.2016.11.003. [Epub ahead of print]
The
Effects of Spacing, Naps, and Fatigue on the Acquisition and Retention of
Laparoscopic Skills.
Spruit EN1, Band GP2, van der Heijden
KB3, Hamming JF4.
Author information:
1Cognitive Psychology, Institute of
Psychology, Leiden University, Leiden, The Netherlands; Leiden Institute for
Brain and Cognition (LIBC), Leiden, The Netherlands; Department of Surgery,
Leiden University Medical Center (LUMC), Leiden, The Netherlands. Electronic
address: e.n.spruit@fsw.leidenuniv.nl.
2Cognitive Psychology, Institute of
Psychology, Leiden University, Leiden, The Netherlands; Leiden Institute for
Brain and Cognition (LIBC), Leiden, The Netherlands.
3Leiden Institute for Brain and
Cognition (LIBC), Leiden, The Netherlands; Department of Clinical Child and
Adolescent Studies, Institute of Education and Child Studies, Leiden
University, Leiden, The Netherlands.
4Department of Surgery, Leiden
University Medical Center (LUMC), Leiden, The Netherlands.
Abstract
BACKGROUND:
Earlier research has shown that
laparoscopic skills are trained more efficiently on a spaced schedule compared
to a massed schedule. The aim of the study was to estimate to what extent the
spacing interval, naps, and fatigue influenced the effectiveness of spacing
laparoscopy training.
METHODS:
Overall 4 groups of trainees (aged
17-41y; 72% female; Nmassed = 40; Nbreak = 35; Nbreak-nap = 37; Nspaced = 37)
without prior experience were trained in 3 laparoscopic tasks using a physical
box trainer with different scheduling interventions. The first (massed) group
received three 100-minute training sessions consecutively on a single day. The
second (break) group received the sessions interrupted with two 45-minute
breaks. The third (break-nap) group had the same schedule as the second group,
but had two 35-minute powernap intervals during the breaks. The fourth (spaced)
group had the 3 sessions on 3 consecutive days. A retention session was
organized approximately 3 months after training.
RESULTS:
The results showed an overall pattern of
superior performance at the end of training and at retention for the spaced
group, followed by the break-nap, break, and massed group, respectively. The
spaced and break-nap group significantly outperformed the break and massed
group, with effect sizes ranging from 0.20 to 0.37.
CONCLUSIONS:
Spacing laparoscopic training over 3
consecutive days or weeks is superior to massed training, even if the massed
training contains breaks. Breaks with sleep opportunity (i.e., lying, inactive,
and muted sensory input) enhance performance over training with regular breaks
and traditional massed training.
Copyright © 2016 Association of Program
Directors in Surgery. Published by Elsevier Inc. All rights reserved.
PMID: 27988169 [PubMed - as supplied by
publisher]
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8.J Pain Symptom Manage. 2016 Dec 23.
pii: S0885-3924(16)31182-4. doi: 10.1016/j.jpainsymman.2016.12.322. [Epub ahead
of print]
Teaching
the Art of Difficult Family Conversations.
Dadiz R1, Spear ML2, Denney-Koelsch E3.
Author information:
1Simulation-based Emergency and Safety
Training Program, Department of Pediatrics, University of Rochester Medical
Center, Rochester, New York.
2C.O.R.E. Palliative Care Team,
Department of Pediatrics, St. Christopher's Hospital for Children and Drexel
University College of Medicine, Philadelphia, Pennsylvania.
3Palliative Care Education, Departments
of Medicine and Pediatrics, University of Rochester Medical Center, Rochester,
New York, USA. Electronic address: erin_denney@urmc.rochester.edu.
Abstract
CONTEXT:
Difficult family conversations are a
challenge for even the most seasoned clinicians. Teaching the skills of
successful communication between providers, family members, and patients are a vital
component of medical education. However, traditional teaching methods using
didactics and expert role modeling are often inadequate.
OBJECTIVES:
The train-the-educator workshop aimed to
teach educators how to create and conduct workshops on facilitating difficult
family conversations that target their own learners' needs.
METHODS:
This three-hour workshop included
instruction on scenario writing and on the use of standardized actors as
patients and family members. Workshop leaders presented examples of commonly
encountered clinical scenarios where difficult information is discussed. The
session used experiential teaching techniques. Outcomes were measured by
qualitative discussions and a questionnaire to demonstrate communication skills
learned from the sessions.
RESULTS:
The workshop was well-received by
participants who consisted of educators attending the annual meeting of the
Pediatric Academic Societies in May 2016. Evaluations revealed that 92% of
participants agreed or strongly agreed that the workshop achieved the learning
objectives. All participants believed that the workshop increased their
knowledge, competency and skills in teaching and facilitation as an educator,
with 86% of participants planning to apply the skills towards curriculum
development. The major themes that participants learned centered on
facilitation skills as an educator and techniques on how to communicate during
challenging family meetings (86% of comments).
CONCLUSION:
This train-the-educator workshop
addresses a critical need in both palliative care and general medicine by
enhancing the educators' skills in desiring and implanting a curriculum on
communication skills of health care providers using experiential techniques
with formative feedback. The authors hope that by outlining the implementation
of this three-hour interactive format, future educators will adapt and utilize
this workshop as it works best for their learners.
Copyright © 2016. Published by Elsevier
Inc.
PMID: 28024994 [PubMed - as supplied by
publisher]
9.Teach Learn Med. 2017 Jan 4:1-11. doi:
10.1080/10401334.2016.1254636. [Epub ahead of print]
Shame
in Medical Education: A Randomized Study of the Acquisition of Intimate
Examination Skills and Its Effect on Subsequent Performance.
Hautz WE1, Schröder T2, Dannenberg KA2,
März M3, Hölzer H2, Ahlers O2, Thomas A4.
Author information:
1a Universitäres Notfallzentrum,
Inselspital Bern , Switzerland.
2b Department for Curriculum Management
, Charité - Universitätsmedizin Berlin , Germany.
3c Department of Assessment ,
Vice-Deanery for Teaching, Charité - Universitätsmedizin Berlin , Germany.
4d Department of Gynecology and
Obstetrics , Campus Charité Mitte, Charité - Universitätsmedizin Berlin ,
Germany.
Abstract
THEORY:
Although medical students are exposed to
a variety of emotions, the impact of emotions on learning has received little
attention so far. Shame-provoking intimate examinations are among the most
memorable events for students. Their emotions, however, are rarely addressed
during training, potentially leading to withdrawal and avoidance and,
consequently, performance deficits. However, emotions of negative valance such
as shame may be particularly valuable for learning, as they might prompt mental
rehearsal. We investigated the effect of shame on learning from the perspective
of cognitive load theory.
HYPOTHESES:
We hypothesized that (a) training
modality determines state shame, (b) state shame directly affects the quality
of a clinical breast examination as one example of a shame-provoking exam, and
(c) students who experience shame during training outperform those who just
discuss the emotion during subsequent performance assessments.
METHOD:
Forty-nine advanced medical students
participated in a randomized controlled, single-blinded study. After a basic,
low-fidelity breast examination training, students were randomized to further
practice either on a high-fidelity mannequin including a discussion of their
emotions or by examining a standardized patient's real breasts. Last, all
students conducted a breast examination in a simulated doctor's office.
Dependent variables were measures of outcome and process quality and of
situational shame.
RESULTS:
Students training with a standardized
patient experienced more shame during training (p < .001, d = 2.19), spent
more time with the patient (p = .005, d = 0.89), and documented more breast
lumps (p = .026, d = 0.65) than those training on a mannequin. Shame interacted
with training modality, F(1, 45) = 21.484, p < .001, η2 = 0.323, and
differences in performance positively correlated to decline in state shame (r =
.335, p = .022).
CONCLUSIONS:
Students experiencing state shame during
training do reenact their training and process germane load-in other words,
learn. Furthermore, altering simulation modality offers a possibility for
educators to adjust the affective component of training to their objectives
10.J Laryngol Otol. 2017 Jan 10:1-7.
doi: 10.1017/S002221511601001X. [Epub ahead of print]
Validation
of a new ENT emergencies course for first-on-call doctors.
Swords C1, Smith ME1, Wasson JD1, Qayyum
A2, Tysome JR1.
Author information:
1Department of Otolaryngology, Head and
Neck Surgery,Addenbrooke's Hospital,Cambridge.
2Department of Otolaryngology, Head and
Neck Surgery,Peterborough City Hospital,UK.
Abstract
BACKGROUND:
First-on-call ENT cover is often
provided by junior doctors with limited ENT experience; yet, they may have to
manage life-threatening emergencies. An intensive 1-day simulation course was
developed to teach required skills to junior doctors.
METHODS:
A prospective, single-blinded design was
used. Thirty-seven participants rated their confidence before the course,
immediately following the course and after a two-month interval. Blinded
assessors scored participant performance in two video-recorded simulated
scenarios before and after the course.
RESULTS:
Participant self-rated confidence was
increased in the end-of-course survey (score of 27.5 vs 53.0; p < 0.0001),
and this was maintained two to four months after the course (score of 50.5; p
< 0.0001). Patient assessment and management in video-recorded emergency
scenarios was significantly improved following course completion (score of 9.75
vs 18.75; p = 0.0093).
CONCLUSION:
This course represents an effective
method of teaching ENT emergency management to junior doctors. ENT induction
programmes benefit from the incorporation of a simulation component.
PMID: 28069096 [PubMed - as supplied by
publisher]
