Ensuring competency: Are fundamentals of laparoscopic surgery training and certification necessary for practicing surgeons and operating room personnel?
Background Certification in fundamentals of laparoscopic surgery (FLS) is required by the American board of surgery for graduating residents. This study aimed to evaluate the feasibility and need for certifying practicing surgeons and to assess proficiency of operating room (OR) personnel. Methods T...
Gespeichert in:
| Veröffentlicht in: | Surgical endoscopy 2013, Vol.27 (1), p.118-126 |
|---|---|
| Hauptverfasser: | , , , , , , |
| Format: | Artikel |
| Sprache: | eng |
| Schlagworte: | |
| Online-Zugang: | Volltext |
| Tags: |
Tag hinzufügen
Keine Tags, Fügen Sie den ersten Tag hinzu!
|
| container_end_page | 126 |
|---|---|
| container_issue | 1 |
| container_start_page | 118 |
| container_title | Surgical endoscopy |
| container_volume | 27 |
| creator | Hafford, Melanie L. Van Sickle, Kent R. Willis, Ross E. Wilson, Todd D. Gugliuzza, Kristine Brown, Kimberly M. Scott, Daniel J. |
| description | Background
Certification in fundamentals of laparoscopic surgery (FLS) is required by the American board of surgery for graduating residents. This study aimed to evaluate the feasibility and need for certifying practicing surgeons and to assess proficiency of operating room (OR) personnel.
Methods
Through a patient safety and health care delivery effectiveness grant, investigators at four state medical schools received funding for FLS certification of all attending surgeons and OR personnel credentialed in laparoscopy. Data were voluntarily collected under an institutional review board-approved protocol. Surgeons performed a single repetition of the FLS tasks oriented to the FLS proficiency-based curriculum and online cognitive materials and were encouraged to self-practice. The FLS certification examination was administered 2 months later under standard conditions. Operating room nurses and scrub technicians were enrolled in a curriculum with cognitive materials and a multistation skills practicum. Baseline and completion questionnaires were administered. Performance was assessed using signed-rank and χ
2
analysis.
Results
The study aimed to enroll 99 surgeons. Subsequently, 87 surgeons completed at least one portion of the curriculum, 72 completed the entire curriculum (73 % compliance), 83 completed the baseline skills assessment, and 27 (33 %) failed. The self-reported practice time was 3.7 ± 2.5 h. At certification (
n
= 76), skills performance had improved from 317 ± 102.9 to 402 ± 54.2 (
p
|
| doi_str_mv | 10.1007/s00464-012-2437-7 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_miscellaneous_1273741636</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>1273741636</sourcerecordid><originalsourceid>FETCH-LOGICAL-c372t-f88e3550b99c571edc1b4b7549611f708562c2a9ff0af2b86052466f9e20a3023</originalsourceid><addsrcrecordid>eNp1kc1qFjEUhoMo9rN6AW4k4MbNaP4mmbiRUuoPFNzoOmTynZSUmWRMZha9Ey_XM_2qiOAqnPC8b8J5CHnJ2VvOmHnXGFNadYyLTihpOvOIHLiSOAk-PCYHZiXrhLHqjDxr7ZYhbnn_lJwJYYwUUh_Iz6vctpryDQ1lXmCFHO7e04sKNG756GfIq58aLZFOfvG1tFCWFChmbqDe0bX6lPe0z0caoK4ppuDXVDLNEKA1j1AslS7VhzWFHb3PltzuM2WBijxe11JmilMrOcP04Tl5EvFlePFwnpPvH6--XX7urr9--nJ5cd0FacTaxWEA2fdstDb0hsMx8FGNpldWcx4NG3otgvA2RuajGAfNeqG0jhYE85IJeU7enHqXWn5s0FY3pxZgmnyGsjXHhZFGcS01oq__QW_LVjP-bqeYlFhtkeInKuC2WoXolppm3IPjzO3a3EmbQ21u1-YMZl49NG_jDMc_id-eEBAnoC27LKh_Pf3f1l-IyqVU</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>1270335249</pqid></control><display><type>article</type><title>Ensuring competency: Are fundamentals of laparoscopic surgery training and certification necessary for practicing surgeons and operating room personnel?</title><source>MEDLINE</source><source>SpringerLink Journals</source><creator>Hafford, Melanie L. ; Van Sickle, Kent R. ; Willis, Ross E. ; Wilson, Todd D. ; Gugliuzza, Kristine ; Brown, Kimberly M. ; Scott, Daniel J.</creator><creatorcontrib>Hafford, Melanie L. ; Van Sickle, Kent R. ; Willis, Ross E. ; Wilson, Todd D. ; Gugliuzza, Kristine ; Brown, Kimberly M. ; Scott, Daniel J.</creatorcontrib><description>Background
Certification in fundamentals of laparoscopic surgery (FLS) is required by the American board of surgery for graduating residents. This study aimed to evaluate the feasibility and need for certifying practicing surgeons and to assess proficiency of operating room (OR) personnel.
Methods
Through a patient safety and health care delivery effectiveness grant, investigators at four state medical schools received funding for FLS certification of all attending surgeons and OR personnel credentialed in laparoscopy. Data were voluntarily collected under an institutional review board-approved protocol. Surgeons performed a single repetition of the FLS tasks oriented to the FLS proficiency-based curriculum and online cognitive materials and were encouraged to self-practice. The FLS certification examination was administered 2 months later under standard conditions. Operating room nurses and scrub technicians were enrolled in a curriculum with cognitive materials and a multistation skills practicum. Baseline and completion questionnaires were administered. Performance was assessed using signed-rank and χ
2
analysis.
Results
The study aimed to enroll 99 surgeons. Subsequently, 87 surgeons completed at least one portion of the curriculum, 72 completed the entire curriculum (73 % compliance), 83 completed the baseline skills assessment, and 27 (33 %) failed. The self-reported practice time was 3.7 ± 2.5 h. At certification (
n
= 76), skills performance had improved from 317 ± 102.9 to 402 ± 54.2 (
p
< 0.0001). One surgeon (1.3 %) failed the skills certification, and nine (11.8 %) failed the cognitive exam. Remediation was completed by six surgeons. Of the 64 enrolled OR personnel, 22 completed the curriculum (34 % compliance). All achieved proficiency at skills, and 60 % passed the cognitive exam.
Conclusions
This study demonstrated that FLS certification for practicing surgeons and proficiency verification for OR personnel are feasible. A baseline skills failure rate of 33 % and a certification failure rate of 13 % suggest that FLS certification may be necessary to ensure surgeon competency. Fortunately, with only moderate practice, significant improvement can be achieved.</description><identifier>ISSN: 0930-2794</identifier><identifier>EISSN: 1432-2218</identifier><identifier>DOI: 10.1007/s00464-012-2437-7</identifier><identifier>PMID: 22773236</identifier><language>eng</language><publisher>New York: Springer-Verlag</publisher><subject>Abdominal Surgery ; Attitude of Health Personnel ; Certification ; Clinical Competence - standards ; Competency-Based Education - methods ; Curricula ; Education, Medical, Continuing - methods ; Endoscopy ; Feasibility Studies ; Female ; Gastroenterology ; General Surgery - education ; General Surgery - standards ; Gynecology ; Hepatology ; Humans ; Laparoscopy ; Laparoscopy - education ; Laparoscopy - standards ; Male ; Medical Staff, Hospital - education ; Medical Staff, Hospital - standards ; Medicine ; Medicine & Public Health ; Middle Aged ; Nurses ; Operating Rooms ; Patient safety ; Proctology ; Skills ; Surgeons ; Surgery ; Surgical outcomes ; Texas</subject><ispartof>Surgical endoscopy, 2013, Vol.27 (1), p.118-126</ispartof><rights>Springer Science+Business Media, LLC 2012</rights><rights>Springer Science+Business Media New York 2013</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c372t-f88e3550b99c571edc1b4b7549611f708562c2a9ff0af2b86052466f9e20a3023</citedby><cites>FETCH-LOGICAL-c372t-f88e3550b99c571edc1b4b7549611f708562c2a9ff0af2b86052466f9e20a3023</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://link.springer.com/content/pdf/10.1007/s00464-012-2437-7$$EPDF$$P50$$Gspringer$$H</linktopdf><linktohtml>$$Uhttps://link.springer.com/10.1007/s00464-012-2437-7$$EHTML$$P50$$Gspringer$$H</linktohtml><link.rule.ids>314,776,780,27901,27902,41464,42533,51294</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/22773236$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Hafford, Melanie L.</creatorcontrib><creatorcontrib>Van Sickle, Kent R.</creatorcontrib><creatorcontrib>Willis, Ross E.</creatorcontrib><creatorcontrib>Wilson, Todd D.</creatorcontrib><creatorcontrib>Gugliuzza, Kristine</creatorcontrib><creatorcontrib>Brown, Kimberly M.</creatorcontrib><creatorcontrib>Scott, Daniel J.</creatorcontrib><title>Ensuring competency: Are fundamentals of laparoscopic surgery training and certification necessary for practicing surgeons and operating room personnel?</title><title>Surgical endoscopy</title><addtitle>Surg Endosc</addtitle><addtitle>Surg Endosc</addtitle><description>Background
Certification in fundamentals of laparoscopic surgery (FLS) is required by the American board of surgery for graduating residents. This study aimed to evaluate the feasibility and need for certifying practicing surgeons and to assess proficiency of operating room (OR) personnel.
Methods
Through a patient safety and health care delivery effectiveness grant, investigators at four state medical schools received funding for FLS certification of all attending surgeons and OR personnel credentialed in laparoscopy. Data were voluntarily collected under an institutional review board-approved protocol. Surgeons performed a single repetition of the FLS tasks oriented to the FLS proficiency-based curriculum and online cognitive materials and were encouraged to self-practice. The FLS certification examination was administered 2 months later under standard conditions. Operating room nurses and scrub technicians were enrolled in a curriculum with cognitive materials and a multistation skills practicum. Baseline and completion questionnaires were administered. Performance was assessed using signed-rank and χ
2
analysis.
Results
The study aimed to enroll 99 surgeons. Subsequently, 87 surgeons completed at least one portion of the curriculum, 72 completed the entire curriculum (73 % compliance), 83 completed the baseline skills assessment, and 27 (33 %) failed. The self-reported practice time was 3.7 ± 2.5 h. At certification (
n
= 76), skills performance had improved from 317 ± 102.9 to 402 ± 54.2 (
p
< 0.0001). One surgeon (1.3 %) failed the skills certification, and nine (11.8 %) failed the cognitive exam. Remediation was completed by six surgeons. Of the 64 enrolled OR personnel, 22 completed the curriculum (34 % compliance). All achieved proficiency at skills, and 60 % passed the cognitive exam.
Conclusions
This study demonstrated that FLS certification for practicing surgeons and proficiency verification for OR personnel are feasible. A baseline skills failure rate of 33 % and a certification failure rate of 13 % suggest that FLS certification may be necessary to ensure surgeon competency. Fortunately, with only moderate practice, significant improvement can be achieved.</description><subject>Abdominal Surgery</subject><subject>Attitude of Health Personnel</subject><subject>Certification</subject><subject>Clinical Competence - standards</subject><subject>Competency-Based Education - methods</subject><subject>Curricula</subject><subject>Education, Medical, Continuing - methods</subject><subject>Endoscopy</subject><subject>Feasibility Studies</subject><subject>Female</subject><subject>Gastroenterology</subject><subject>General Surgery - education</subject><subject>General Surgery - standards</subject><subject>Gynecology</subject><subject>Hepatology</subject><subject>Humans</subject><subject>Laparoscopy</subject><subject>Laparoscopy - education</subject><subject>Laparoscopy - standards</subject><subject>Male</subject><subject>Medical Staff, Hospital - education</subject><subject>Medical Staff, Hospital - standards</subject><subject>Medicine</subject><subject>Medicine & Public Health</subject><subject>Middle Aged</subject><subject>Nurses</subject><subject>Operating Rooms</subject><subject>Patient safety</subject><subject>Proctology</subject><subject>Skills</subject><subject>Surgeons</subject><subject>Surgery</subject><subject>Surgical outcomes</subject><subject>Texas</subject><issn>0930-2794</issn><issn>1432-2218</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2013</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><sourceid>BENPR</sourceid><recordid>eNp1kc1qFjEUhoMo9rN6AW4k4MbNaP4mmbiRUuoPFNzoOmTynZSUmWRMZha9Ey_XM_2qiOAqnPC8b8J5CHnJ2VvOmHnXGFNadYyLTihpOvOIHLiSOAk-PCYHZiXrhLHqjDxr7ZYhbnn_lJwJYYwUUh_Iz6vctpryDQ1lXmCFHO7e04sKNG756GfIq58aLZFOfvG1tFCWFChmbqDe0bX6lPe0z0caoK4ppuDXVDLNEKA1j1AslS7VhzWFHb3PltzuM2WBijxe11JmilMrOcP04Tl5EvFlePFwnpPvH6--XX7urr9--nJ5cd0FacTaxWEA2fdstDb0hsMx8FGNpldWcx4NG3otgvA2RuajGAfNeqG0jhYE85IJeU7enHqXWn5s0FY3pxZgmnyGsjXHhZFGcS01oq__QW_LVjP-bqeYlFhtkeInKuC2WoXolppm3IPjzO3a3EmbQ21u1-YMZl49NG_jDMc_id-eEBAnoC27LKh_Pf3f1l-IyqVU</recordid><startdate>2013</startdate><enddate>2013</enddate><creator>Hafford, Melanie L.</creator><creator>Van Sickle, Kent R.</creator><creator>Willis, Ross E.</creator><creator>Wilson, Todd D.</creator><creator>Gugliuzza, Kristine</creator><creator>Brown, Kimberly M.</creator><creator>Scott, Daniel J.</creator><general>Springer-Verlag</general><general>Springer Nature B.V</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7RV</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8AO</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>BENPR</scope><scope>CCPQU</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>K9.</scope><scope>KB0</scope><scope>M0S</scope><scope>M1P</scope><scope>NAPCQ</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>7X8</scope></search><sort><creationdate>2013</creationdate><title>Ensuring competency: Are fundamentals of laparoscopic surgery training and certification necessary for practicing surgeons and operating room personnel?</title><author>Hafford, Melanie L. ; Van Sickle, Kent R. ; Willis, Ross E. ; Wilson, Todd D. ; Gugliuzza, Kristine ; Brown, Kimberly M. ; Scott, Daniel J.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c372t-f88e3550b99c571edc1b4b7549611f708562c2a9ff0af2b86052466f9e20a3023</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2013</creationdate><topic>Abdominal Surgery</topic><topic>Attitude of Health Personnel</topic><topic>Certification</topic><topic>Clinical Competence - standards</topic><topic>Competency-Based Education - methods</topic><topic>Curricula</topic><topic>Education, Medical, Continuing - methods</topic><topic>Endoscopy</topic><topic>Feasibility Studies</topic><topic>Female</topic><topic>Gastroenterology</topic><topic>General Surgery - education</topic><topic>General Surgery - standards</topic><topic>Gynecology</topic><topic>Hepatology</topic><topic>Humans</topic><topic>Laparoscopy</topic><topic>Laparoscopy - education</topic><topic>Laparoscopy - standards</topic><topic>Male</topic><topic>Medical Staff, Hospital - education</topic><topic>Medical Staff, Hospital - standards</topic><topic>Medicine</topic><topic>Medicine & Public Health</topic><topic>Middle Aged</topic><topic>Nurses</topic><topic>Operating Rooms</topic><topic>Patient safety</topic><topic>Proctology</topic><topic>Skills</topic><topic>Surgeons</topic><topic>Surgery</topic><topic>Surgical outcomes</topic><topic>Texas</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Hafford, Melanie L.</creatorcontrib><creatorcontrib>Van Sickle, Kent R.</creatorcontrib><creatorcontrib>Willis, Ross E.</creatorcontrib><creatorcontrib>Wilson, Todd D.</creatorcontrib><creatorcontrib>Gugliuzza, Kristine</creatorcontrib><creatorcontrib>Brown, Kimberly M.</creatorcontrib><creatorcontrib>Scott, Daniel J.</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Nursing & Allied Health Database</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>ProQuest Pharma Collection</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>Nursing & Allied Health Premium</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central China</collection><collection>MEDLINE - Academic</collection><jtitle>Surgical endoscopy</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Hafford, Melanie L.</au><au>Van Sickle, Kent R.</au><au>Willis, Ross E.</au><au>Wilson, Todd D.</au><au>Gugliuzza, Kristine</au><au>Brown, Kimberly M.</au><au>Scott, Daniel J.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Ensuring competency: Are fundamentals of laparoscopic surgery training and certification necessary for practicing surgeons and operating room personnel?</atitle><jtitle>Surgical endoscopy</jtitle><stitle>Surg Endosc</stitle><addtitle>Surg Endosc</addtitle><date>2013</date><risdate>2013</risdate><volume>27</volume><issue>1</issue><spage>118</spage><epage>126</epage><pages>118-126</pages><issn>0930-2794</issn><eissn>1432-2218</eissn><abstract>Background
Certification in fundamentals of laparoscopic surgery (FLS) is required by the American board of surgery for graduating residents. This study aimed to evaluate the feasibility and need for certifying practicing surgeons and to assess proficiency of operating room (OR) personnel.
Methods
Through a patient safety and health care delivery effectiveness grant, investigators at four state medical schools received funding for FLS certification of all attending surgeons and OR personnel credentialed in laparoscopy. Data were voluntarily collected under an institutional review board-approved protocol. Surgeons performed a single repetition of the FLS tasks oriented to the FLS proficiency-based curriculum and online cognitive materials and were encouraged to self-practice. The FLS certification examination was administered 2 months later under standard conditions. Operating room nurses and scrub technicians were enrolled in a curriculum with cognitive materials and a multistation skills practicum. Baseline and completion questionnaires were administered. Performance was assessed using signed-rank and χ
2
analysis.
Results
The study aimed to enroll 99 surgeons. Subsequently, 87 surgeons completed at least one portion of the curriculum, 72 completed the entire curriculum (73 % compliance), 83 completed the baseline skills assessment, and 27 (33 %) failed. The self-reported practice time was 3.7 ± 2.5 h. At certification (
n
= 76), skills performance had improved from 317 ± 102.9 to 402 ± 54.2 (
p
< 0.0001). One surgeon (1.3 %) failed the skills certification, and nine (11.8 %) failed the cognitive exam. Remediation was completed by six surgeons. Of the 64 enrolled OR personnel, 22 completed the curriculum (34 % compliance). All achieved proficiency at skills, and 60 % passed the cognitive exam.
Conclusions
This study demonstrated that FLS certification for practicing surgeons and proficiency verification for OR personnel are feasible. A baseline skills failure rate of 33 % and a certification failure rate of 13 % suggest that FLS certification may be necessary to ensure surgeon competency. Fortunately, with only moderate practice, significant improvement can be achieved.</abstract><cop>New York</cop><pub>Springer-Verlag</pub><pmid>22773236</pmid><doi>10.1007/s00464-012-2437-7</doi><tpages>9</tpages></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 0930-2794 |
| ispartof | Surgical endoscopy, 2013, Vol.27 (1), p.118-126 |
| issn | 0930-2794 1432-2218 |
| language | eng |
| recordid | cdi_proquest_miscellaneous_1273741636 |
| source | MEDLINE; SpringerLink Journals |
| subjects | Abdominal Surgery Attitude of Health Personnel Certification Clinical Competence - standards Competency-Based Education - methods Curricula Education, Medical, Continuing - methods Endoscopy Feasibility Studies Female Gastroenterology General Surgery - education General Surgery - standards Gynecology Hepatology Humans Laparoscopy Laparoscopy - education Laparoscopy - standards Male Medical Staff, Hospital - education Medical Staff, Hospital - standards Medicine Medicine & Public Health Middle Aged Nurses Operating Rooms Patient safety Proctology Skills Surgeons Surgery Surgical outcomes Texas |
| title | Ensuring competency: Are fundamentals of laparoscopic surgery training and certification necessary for practicing surgeons and operating room personnel? |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-02-03T10%3A17%3A15IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_cross&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Ensuring%20competency:%20Are%20fundamentals%20of%20laparoscopic%20surgery%20training%20and%20certification%20necessary%20for%20practicing%20surgeons%20and%20operating%20room%20personnel?&rft.jtitle=Surgical%20endoscopy&rft.au=Hafford,%20Melanie%20L.&rft.date=2013&rft.volume=27&rft.issue=1&rft.spage=118&rft.epage=126&rft.pages=118-126&rft.issn=0930-2794&rft.eissn=1432-2218&rft_id=info:doi/10.1007/s00464-012-2437-7&rft_dat=%3Cproquest_cross%3E1273741636%3C/proquest_cross%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=1270335249&rft_id=info:pmid/22773236&rfr_iscdi=true |