***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Simulation-based training has been an important part of the solution to address the shortfalls in cardiac surgery training . This review was conducted to identify and systematic ally summarize existing evidence on outcomes and method ological quality of  simulation-based skills training  for cardiac surgery trainees . METHODS MEDLINE , Embase , and ERIC ( Education Re sources Information Center ) data bases were search ed . Studies included peer- review ed publications with simulation-based skill training in cardiac surgery programs with outcome measures of performance . Data extraction covered the type of skills training , simulator type and fidelity , the level of trainees , assessment tools , assessors , study design and its components , strengths and limitations , and elements required for the Medical Education Research Study Quality Instrument score . The review followed the Preferred Reporting Items for Systematic Review s and Meta-Analyses guidelines . RESULTS Of 16 studies that met the criteria , only four ( 25 % ) r and omized controlled trials were identified , and the remaining were observational studies . Seven observational studies ( 43.7 % ) were single-group pre-post tests . The  mean number of trainees was 20.4 ( SD , 14.1 ) .  Low-fidelity simulators were used in 13 studies ( 81.2 % ) . Most of the studies ( 81.3 % ) were high quality based on a Medical Education Research Study Quality Instrument score of 12 or more . Evidence of assessment tool validation was absent among all studies . No study outcome measures were directed to skills transfer to the operating room or patient outcomes . Overall learning outcomes ' effect sizes were consistently high ( 2.2 ; SD , 1.6 ) , with junior residents benefitting most ( effect size , 2.8 ; SD , 2.2 ) CONCLUSIONS : Simulation-based skill training is associated with improved learning outcomes for cardiac surgery trainees with large effect sizes , but more behavior-level outcomes are required to fully assess its value Background The purpose of this study was to design and implement a vitreoretinal training module that would be useful for ophthalmology residents and fellows to learn the basic maneuvers required in vitreoretinal surgery . Methods A prospect i ve pilot study evaluating the training module was undertaken in 13 ophthalmology trainees ( residents and vitreoretinal fellows ) with varying levels of vitreoretinal training experience . A vitreoretinal training module was design ed and consisted of a three-port vitrectomy setup ( sclerotomy wound construction , infusion placement ) , intraocular tasks ( core vitrectomy , driving the operating microscope , membrane peel , air – fluid exchange ) , and wound closure . St and ard vitrectomy instrumentation , the VitRet eye ( Phillips Studio , Bristol , UK ) and vitreous-like fluid using dairy creamer and balanced saline were utilized . A five-point Likert scale , ie , the Casey Eye Institute Vitrectomy Indices Tool for Skills Assessment ( CEIVITS ) , was devised to evaluate each component of the module . Vitreoretinal surgical maneuvers were digitally recorded and grade d by an attending vitreoretinal surgeon . Linear regression and correlation were performed to evaluate the relationship between prior vitreoretinal experience and CEIVITS performance . The main outcome measures were correlation of vitreoretinal surgical experience and CEIVITS performance on simulated tasks using a basic vitreoretinal training module . Results Thirteen participants from postgraduate year 2 to postgraduate year 6 levels were evaluated . Nine participants were male and four were female . The median age of participants was 32 ( range 30–36 ) years and surgical experience was 0–410 prior vitreoretinal surgical procedures . A positive correlation ( P < 0.05 ) was observed between vitreoretinal surgical experience and CEIVITS performance on the following tasks : total score ( P = 0.021 ) , sclerotomy wound construction ( P = 0.047 ) , infusion line placement ( P = 0.012 ) , air – fluid exchange ( P = 0.004 ) , and wound closure ( P = 0.032 ) . Post module surveys showed that the majority of trainees felt that the vitreoretinal training module improved their underst and ing of vitreoretinal surgery . The nonbiohazardous nature of the setup was advantageous from sanitation and cost perspectives . Conclusion The implementation of our training module for residency and vitreoretinal fellowship was feasible and the CEIVITS adequately assessed basic vitrectomy maneuvers . Given that ophthalmologic and subspecialty instruction migrates from an apprenticeship to a competency-based model , the face and content validity makes the CEIVITS module a promising one in vitreoretinal surgical instruction Purpose To evaluate the efficacy of the virtual reality training simulator Eyesi to prepare surgeons for performing pars plana vitrectomies and its potential to predict the surgeons ’ performance . Methods In a preparation phase , four participating vitreoretinal surgeons performed repeated simulator training with predefined tasks . If a surgeon was assigned to perform a vitrectomy for the management of complex retinal detachment after a surgical break of at least 60 hours it was r and omly decided whether a warmup training on the simulator was required ( n = 9 ) or not ( n = 12 ) . Performance at the simulator was measured using the built-in scoring metrics . The surgical performance was determined by two blinded observers who analyzed the video-recorded interventions . One of them repeated the analysis to check for intra-observer consistency . The surgical performance of the interventions with and without simulator training was compared . In addition , for the surgeries with simulator training , the simulator performance was compared to the performance in the operating room . Results Comparing each surgeon ’s performance with and without warmup trainingshowed a significant effect of warmup training onto the final outcome in the operating room . For the surgeries that were preceeded by the warmup procedure , the performance at the simulator was compared with the operating room performance . We found that there is a significant relation . The governing factor of low scores in the simulator were iatrogenic retinal holes , bleedings and lens damage . Surgeons who caused minor damage in the simulation also performed well in the operating room . Conclusions Despite the large variation of conditions , the effect of a warmup training as well as a relation between the performance at the simulator and in the operating room was found with statistical significance . Simulator training is able to serve as a warmup to increase the average performance PURPOSE To evaluate whether microsurgical steps in vitreoretinal surgery can be taught by a computer-assisted training system . METHODS This prospect i ve , r and omized experimental study included 14 ophthalmic residents and medical students who were completely inexperienced in microsurgery . They were r and omized into two groups . The study group underwent training programmes in a computer-assisted training system for simulation of pars plana vitrectomy . The control group did not participate in any in vitro training . In the second phase of the study , participants of both groups performed a pars plana vitrectomy in three pig eyes , which included picking a metallic foreign body from the retinal surface . RESULTS The amount of retinal detachment and the number of retinal defects at the end of the vitrectomies were smaller , the time needed to remove the foreign body was shorter , the number of retinal lesions associated with the foreign body removal was lower , and the mark given was better in the trained study group than in the untrained group . The relatively small number of study participants did not allow the differences between the study and control groups to reach the 5 % level of error probability . CONCLUSIONS In an animal model , training by a computer-based medical work station for simulation of pars plana vitrectomy showed better outcome measures for trained study participants compared with untrained study participants . Future studies may show whether further refinements of such training programmes will result in statistically significantly better results in surgical outcome parameters Surgery has always been a dynamic discipline . It has a long history of groundbreaking innovations that dramatically improved the way patients were treated and surgery was practice d. However , nothing could have prepared the surgical community for the revolutionary advances of the last 2 decades . Almost overnight , the traditional open approach to surgery was replaced by a minimally invasive surgery ( MIS ) approach [ 2 ] . Practitioners quickly realized that this novel approach would require new types of training . Suddenly , the directors of surgical residency programs had to deal with faculty members who were question ing the training paradigm that had served surgery well for a century . The traditional Halsteadian method did not seem to be suitable for the new types of skills required for MIS . To make matters worse , the length of time allocated to training residents was contracting . In the European Union in 2001 the European Working time Directive was extended to include physicians in training and this year in the United States of America the m and atory 80 hour work week restriction has been instituted , both dramatically reducing work/training hours for residents . At the same time , the practice of surgery came under scrutiny in another , apparently unrelated area when the value and relevance of surgical research became an issue of controversy . In an unprecedented attack , the editor of the Lancet [ 6 ] publically called into question the quality of current surgical research . In an editorial entitled ‘ ‘ Surgical Research or Comic Opera ? ’ ’ Dr. Horton expressed grave reservations about its utility , validity , and usefulness . Although the editorial was met by the surgical community with the predictable indignant response , Horton did make some valid points . Not necessarily in response to this editorial but certainly contiguous to it , surgical research appears to be moving away from reliance on retrospective data to prospect i ve , r and omized , and —where possible— blinded data . It is our contention that these two issues , i.e. , MIS skills and surgical research , have now converged around the very essence of our surgical heritage — the stringent use of the ‘ ‘ scientific method ’’ and objective assessment . Perhaps this is best exemplified by the relatively new editorial practice of prioritizing prospect i ve , r and omized , blinded surgical trials for publication . Although blinded , r and omized , controlled trial design can be employed to answer definitively many surgical research questions , we must remember that this design is only one of a quiver full of research method ologies , and may not always be the experimental design of choice . The function of good science is to show clear cause- and -effect relationships , and this does not always require a prospect i ve , r and omized , double-blind experimental design . Indeed the optimal method may not even be experimental , but statistical , such as Structural Equation Models [ 3 ] . This methodology will almost certainly be required to answer the question of which fundamental psychological abilities predict MIS skills/performance or what factors predict obesity or treatment outcomes in obesity . In both of these examples the answer will be multifactorial , which precludes the use of traditional experimental design . The control exerted with traditional experimental design will be replaced with the equally powerful ( but method ologically more sophisticated ) ‘ ‘ statistical ’ ’ control . The point we want to make here is that there is no ‘ ‘ magic bullet ’ ’ experimental methodology for surgical research ; instead , there is a range of experimental design s that should be applied appropriately to answer the pertinent research question . Research design should therefore vary depending on the circumstances . An eloquent example can be found in a report form the Dundee MIS group , who used four subjects and , in essence , a single-subject design to evaluate the utility of three-dimensional camera systems [ 5 ] . The research design they used answered the question unequivocally , but Correspondence to : A. G. Gallagher Surg Endosc ( 2003 ) 17 : 1525–1529 DOI : 10.1007/s00464 - 003 - 0035 - 
    Output:
    
ConclusionS imulator-based training in VRS can assess and possibly assist acquisition of a variety of VRS skills .