Virtual reality (VR) applications could be beneficial for education, training, and treatment. How... more Virtual reality (VR) applications could be beneficial for education, training, and treatment. However, VR may induce symptoms of simulator sickness (SS) such as difficulty focusing, difficulty concentrating, or dizziness that could impair autonomic nervous system function, affect mental workload, and worsen interventional outcomes. In the original randomized controlled trial, which explored the effectiveness of using a 360° VR video versus a two-dimensional VR video to learn history taking and physical examination skills, only the former group participants had SS. Therefore, 28 undergraduate medical students who participated in a 360° VR learning module were included in this post hoc study using a repeated measures design. Data of the Simulator Sickness Questionnaire (SSQ), heart rate variability (HRV) analysis, Task Load Index, and Mini-Clinical Evaluation Exercise were retrospectively reviewed and statistically analyzed. Ten (36%) participants had mild SS (total score > 0 and ≤...
Before caring for patients, video instruction is commonly used for undergraduate medical students... more Before caring for patients, video instruction is commonly used for undergraduate medical students, and 360° virtual reality (VR) videos have gained increasing interest in clinical medical education. Therefore, the effect of immersive 360° VR video learning compared with two-dimensional (2D) VR video learning in clinical skills acquisition should be evaluated. This randomized, intervention-controlled clinical trial was aimed to assess whether immersive 360° VR video improves undergraduate medical students' learning effectiveness and reduces the cognitive load in history taking and physical examination (H&P) training. From May 1 2018 to October 30 2018, 64 senior undergraduate medical students in a tertiary academic hospital were randomized to receive a 10-min immersive 360° (360° VR video group; n = 32) or 2D VR instructional video (2D VR video group; n = 32), including essential knowledge and competency of H&P. The demographic characteristics of the two groups were comparable fo...
Background Learning through a 360° virtual reality (VR) or 2D video represents an alternative way... more Background Learning through a 360° virtual reality (VR) or 2D video represents an alternative way to learn a complex medical education task. However, there is currently no consensus on how best to assess the effects of different learning materials on cognitive load estimates, heart rate variability (HRV), outcomes, and experience in learning history taking and physical examination (H&P) skills. Objective The aim of this study was to investigate how learning materials (ie, VR or 2D video) impact learning outcomes and experience through changes in cognitive load estimates and HRV for learning H&P skills. Methods This pilot system–design study included 32 undergraduate medical students at an academic teaching hospital. The students were randomly assigned, with a 1:1 allocation, to a 360° VR video group or a 2D video group, matched by age, sex, and cognitive style. The contents of both videos were different with regard to visual angle and self-determination. Learning outcomes were evalu...
Helicobacter pylori (H. pylori) infection involves the development of gastric cancer and may be a... more Helicobacter pylori (H. pylori) infection involves the development of gastric cancer and may be associated with laryngeal cancer. However, laryngeal H. pylori infection in Taiwanese patients with newly diagnosed laryngeal cancer has not been reported. This study was aimed to investigate the possible association between laryngeal H. pylori infection and laryngeal cancer in Taiwan and perform a systematic review of previous reports in other countries. An analysis of 105 patients with laryngeal lesions found the positive rates of H. pylori DNA (determined by polymerase chain reaction) and antigen (determined by immunohistochemistry) of the laryngeal lesions were relatively low (vocal polyps: 3% and 3%; vocal fold leukoplakia: 0% and 0%; laryngeal cancers: 0% and 2%). Furthermore, H. pylori-associated laryngopharyngeal reflux and the expression of E-cadherin and CD1d (determined by immunohistochemistry) were comparable among the three subgroups. Fifteen studies were involved in the syst...
Acute lymphoblastic leukemia (ALL) is a hemopoietic malignancy of the bone marrow that rarely inv... more Acute lymphoblastic leukemia (ALL) is a hemopoietic malignancy of the bone marrow that rarely invades the sinonasal area. If infiltration of paranasal sinuses occurs, it may lead to rhinosinusitis and orbital complications that need aggressive treatment. In this report, a 26-year-old male patient who had a history of ALL and had one relapse, suffered from rapid progression of right periorbital pain and exophthalmos, which usually presented in patients with orbital complications of sinusitis. A sinus computed tomography showed right maxillary and ethmoid sinus opacification with orbital bone destruction. Urgent endoscopic sinus surgery (ESS) was performed for orbital decompression and histopathologic diagnosis. Pathology revealed lymphoblast infiltration and inflammation of respiratory mucosa. Subsequent bone marrow aspiration cytology confirmed the diagnosis of a second relapse of ALL. Obstructive causes of sinusitis should be evaluated in patients with ALL. ESS has proven to be eff...
We present a 14-year-old girl whose initial diagnosis was obstructive sleep apnea syndrome (OSAS)... more We present a 14-year-old girl whose initial diagnosis was obstructive sleep apnea syndrome (OSAS) with symptoms of habitual snore, sleep breath holding, shortness of breath, and lump in throat. Lingual thyroid was diagnosed by thyroid scan and histology, and was treated by radioactive iodine therapy and endoscopic carbon dioxide laser therapy. Her OSAS completely subsided after lingual thyroid surgery. Physicians should be aware of rare causes of OSAS in children, such as lingual thyroid and certainly if accompanied by difficulties in swallowing and speech problems.
To investigate the efficacy of relocation pharyngoplasty as a surgical technique both to enlarge ... more To investigate the efficacy of relocation pharyngoplasty as a surgical technique both to enlarge pharyngeal airspace and to decrease pharyngeal collapse in the treatment of obstructive sleep apnea (OSA). Prospective comparative study performed in a tertiary referred sleep center. Ten adult male OSA patients (median age of 38 years, median apnea-hypopnea index [AHI] of 41.6 events/hour, and median body mass index of 25.8 kg/m(2)) with favorable oropharyngeal structure were enrolled. Principal procedures of the relocation pharyngoplasty include tonsillectomy, removal of supratonsillar mucosa and adipose tissue, splinting the lateral pharyngeal wall by suturing the placating superior pharyngeal constrictor muscle to the anterior pillar, and advancing the soft palate by suturing the posterior pillar flap cephalad laterally to the supratonsillar fossa. No patients experienced swallowing disturbance or change of voice after 3 months postoperatively. The median time for patients to return to normal nourishment was 15 days. Six months after the operation, there were statistically significant improvements in snoring (P = .005) and daytime sleepiness (P = .008). Repeated polysomnography revealed significant improvement in AHI (P = .005) and rapid eye movement period (P = .037). Furthermore, reduction in AHI following relocation pharyngoplasty was found in all patients. In selected patients, relocation pharyngoplasty by advancing the soft palate and splinting the lateral pharyngeal wall obtains significant improvement in subjective snoring and daytime sleepiness, as well as objective adverse sleep respiratory events and sleep architecture, while retaining normal pharyngeal function.
To assess if relocation pharyngoplasty (RP) causes velopharyngeal dysfunction in patients with ob... more To assess if relocation pharyngoplasty (RP) causes velopharyngeal dysfunction in patients with obstructive sleep apnea (OSA) by evaluating perioperative nasalance, nasality, voice, and articulation. Prospective, comparative study. Twenty-four OSA patients selected for RP (two women and 22 men; mean age, 35 years) were enrolled for the study of velopharyngeal function in speech. The RP procedure involved removal of supratonsillar adipose tissue, preservation of all palatal muscular structure, splinting the lateral pharyngeal wall, and anterior advancing of the soft palate. Measurements of nasalance (vowel /a/, /i/, consonant /m/, oronasal, oral, and nasal texts), nasality (mirror-fogging test, degree of nasality, Gutzmann test and Bzoch hypernasality test), voice (acoustic analysis), and articulation (velar sound) were taken before RP and 3 months after the procedure and compared. Comparative analysis of clinical measures showed that no significant differences were found following RP in nasalance (except for the vowel /a/), nasality, articulation, and voice. The only difference with regard to vowel /a/ showed, instead of an increase, a significant decrease of nasalance from 17.3 + or - 10.8 to 11.3 + or - 6.7 (P = .004), which may be attributed to the advancing and lifting of the soft palate in RP, leading to relaxation of the levator veli palatine and uvular muscles, which facilitates their contraction in velopharyngeal closure during particular vowel phonation. RP for OSA does not cause velopharyngeal insufficiency in terms of voice, nasality, and articulation in spite of anterior advancement of the soft palate, but does induce a nondetrimental change in nasalance.
This study aimed to compare the differences in vocal quality between Mandarin-speaking children w... more This study aimed to compare the differences in vocal quality between Mandarin-speaking children with cochlear implants and normal-hearing peers and to understand which cochlear implant usage parameters may predict unfavourable voice outcomes. A cross-sectional, case-controlled study. A tertiary medical centre. Thirty-five pre-lingually deaf children (age = 10.3 ± 1.6 years; 17 boys and 18 girls) who had used cochlear implants for >2 years and 35 age- and gender-matched controls with normal hearing. Through sustained phonation of /a/ and reading of the Hare and Tortoise passage, the subjects' voice quality was analysed with aerodynamics and acoustics. A six-point scale was used for auditory-perceptual evaluation. A Pediatric Voice-Related Quality of Life Survey was filled out by the caregivers. The implanted subjects had significantly lower mean airflow rate (P = 0.006), higher phonation threshold pressure (P < 0.001), higher fundamental frequency variations (P < 0.001) and peak-amplitude variations (P < 0.001), wider fundamental frequency range (P = 0.043), wider speaking intensity range (P = 0.015) and greater perceptual severity level of monotone (P < 0.001), resonance (P < 0.001), loudness (P < 0.001) and strain (P = 0.006) than their normal-hearing peers. Duration of postoperative rehabilitation was an independent predictor of unfavourable mean speaking fundamental frequency (odds ratio = 8.56, P = 0.008). Inadequate postoperative rehabilitation may hinder the normalisation of Mandarin-speaking implantees' voice quality. A multidimensional analysis may precisely evaluate the voice of paediatric implantees; however, the generalisability of these findings requires different forms of validation, including data from other languages and other institutions.
The aim of this study was to document receptive and expressive language levels and reading skills... more The aim of this study was to document receptive and expressive language levels and reading skills achieved by Mandarin-speaking children who had received cochlear implants (CIs) and used them for 4.75–7.42 years. The effects of possible associated factors were also analyzed. Standardized Mandarin language and reading tests were administered to 39 prelingually deaf children with Nucleus 24 devices. The Mandarin Chinese version of the Peabody Picture Vocabulary Test was used to assess their receptive vocabulary knowledge and the Revised Primary School Language Assessment Test for their receptive and expressive language skills. The Graded Chinese Character Recognition Test was used to test their written word recognition ability and the Reading Comprehension Test for their reading comprehension ability. Raw scores from both language and reading measurements were compared to normative data of nor- mal-hearing children to obtain standard scores. The results showed that the mean standard s...
The aim of this study was to assess the verbal and performance intelligence of young Mandarin-spe... more The aim of this study was to assess the verbal and performance intelligence of young Mandarin-speaking cochlear implant users with the Wechsler Intelligence Scale for Children (WISC). We also analyzed whether related factors helped develop verbal and performance IQs. We studied 60 children implanted with Nucleus 24 devices; the children represented a consecutive sample of every implantee aged 6 or older from 2002 to 2006. All subjects had 1 year to 8 years and 7 months of implant experience. Five children with known neurological, developmental delay and multiple handicaps were excluded. Intellectual functions were evaluated using the Mandarin version of the WISC-III, which includes 5 subsets for verbal IQ (information, comprehension, similarities, arithmetic and vocabulary) and 5 subsets for performance IQ (picture completion, picture arrangement, block design, object assembly and coding). After conversion, we found that the mean verbal IQ was 85.1 ± 19.9 (range 56–133), and the mea...
BACKGROUND The use of mobile technology in e-learning (M-TEL) can add new levels of experience an... more BACKGROUND The use of mobile technology in e-learning (M-TEL) can add new levels of experience and significantly increase the attractiveness of e-learning in medical education. Whether an innovative interactive e-learning multimedia (IM) module or a conventional PowerPoint show (PPS) module using M-TEL to teach emergent otorhinolaryngology–head and neck surgery (ORL-HNS) disorders is feasible and efficient in undergraduate medical students is unknown. OBJECTIVE The aim of this study was to compare the impact of a novel IM module with a conventional PPS module using M-TEL for emergent ORL-HNS disorders with regard to learning outcomes, satisfaction, and learning experience. METHODS This pilot study was conducted at an academic teaching hospital and included 24 undergraduate medical students who were novices in ORL-HNS. The cognitive style was determined using the Group Embedded Figures Test. The participants were randomly allocated (1:1) to one of the two groups matched by age, sex, ...
Virtual reality (VR) applications could be beneficial for education, training, and treatment. How... more Virtual reality (VR) applications could be beneficial for education, training, and treatment. However, VR may induce symptoms of simulator sickness (SS) such as difficulty focusing, difficulty concentrating, or dizziness that could impair autonomic nervous system function, affect mental workload, and worsen interventional outcomes. In the original randomized controlled trial, which explored the effectiveness of using a 360° VR video versus a two-dimensional VR video to learn history taking and physical examination skills, only the former group participants had SS. Therefore, 28 undergraduate medical students who participated in a 360° VR learning module were included in this post hoc study using a repeated measures design. Data of the Simulator Sickness Questionnaire (SSQ), heart rate variability (HRV) analysis, Task Load Index, and Mini-Clinical Evaluation Exercise were retrospectively reviewed and statistically analyzed. Ten (36%) participants had mild SS (total score > 0 and ≤...
Before caring for patients, video instruction is commonly used for undergraduate medical students... more Before caring for patients, video instruction is commonly used for undergraduate medical students, and 360° virtual reality (VR) videos have gained increasing interest in clinical medical education. Therefore, the effect of immersive 360° VR video learning compared with two-dimensional (2D) VR video learning in clinical skills acquisition should be evaluated. This randomized, intervention-controlled clinical trial was aimed to assess whether immersive 360° VR video improves undergraduate medical students' learning effectiveness and reduces the cognitive load in history taking and physical examination (H&P) training. From May 1 2018 to October 30 2018, 64 senior undergraduate medical students in a tertiary academic hospital were randomized to receive a 10-min immersive 360° (360° VR video group; n = 32) or 2D VR instructional video (2D VR video group; n = 32), including essential knowledge and competency of H&P. The demographic characteristics of the two groups were comparable fo...
Background Learning through a 360° virtual reality (VR) or 2D video represents an alternative way... more Background Learning through a 360° virtual reality (VR) or 2D video represents an alternative way to learn a complex medical education task. However, there is currently no consensus on how best to assess the effects of different learning materials on cognitive load estimates, heart rate variability (HRV), outcomes, and experience in learning history taking and physical examination (H&P) skills. Objective The aim of this study was to investigate how learning materials (ie, VR or 2D video) impact learning outcomes and experience through changes in cognitive load estimates and HRV for learning H&P skills. Methods This pilot system–design study included 32 undergraduate medical students at an academic teaching hospital. The students were randomly assigned, with a 1:1 allocation, to a 360° VR video group or a 2D video group, matched by age, sex, and cognitive style. The contents of both videos were different with regard to visual angle and self-determination. Learning outcomes were evalu...
Helicobacter pylori (H. pylori) infection involves the development of gastric cancer and may be a... more Helicobacter pylori (H. pylori) infection involves the development of gastric cancer and may be associated with laryngeal cancer. However, laryngeal H. pylori infection in Taiwanese patients with newly diagnosed laryngeal cancer has not been reported. This study was aimed to investigate the possible association between laryngeal H. pylori infection and laryngeal cancer in Taiwan and perform a systematic review of previous reports in other countries. An analysis of 105 patients with laryngeal lesions found the positive rates of H. pylori DNA (determined by polymerase chain reaction) and antigen (determined by immunohistochemistry) of the laryngeal lesions were relatively low (vocal polyps: 3% and 3%; vocal fold leukoplakia: 0% and 0%; laryngeal cancers: 0% and 2%). Furthermore, H. pylori-associated laryngopharyngeal reflux and the expression of E-cadherin and CD1d (determined by immunohistochemistry) were comparable among the three subgroups. Fifteen studies were involved in the syst...
Acute lymphoblastic leukemia (ALL) is a hemopoietic malignancy of the bone marrow that rarely inv... more Acute lymphoblastic leukemia (ALL) is a hemopoietic malignancy of the bone marrow that rarely invades the sinonasal area. If infiltration of paranasal sinuses occurs, it may lead to rhinosinusitis and orbital complications that need aggressive treatment. In this report, a 26-year-old male patient who had a history of ALL and had one relapse, suffered from rapid progression of right periorbital pain and exophthalmos, which usually presented in patients with orbital complications of sinusitis. A sinus computed tomography showed right maxillary and ethmoid sinus opacification with orbital bone destruction. Urgent endoscopic sinus surgery (ESS) was performed for orbital decompression and histopathologic diagnosis. Pathology revealed lymphoblast infiltration and inflammation of respiratory mucosa. Subsequent bone marrow aspiration cytology confirmed the diagnosis of a second relapse of ALL. Obstructive causes of sinusitis should be evaluated in patients with ALL. ESS has proven to be eff...
We present a 14-year-old girl whose initial diagnosis was obstructive sleep apnea syndrome (OSAS)... more We present a 14-year-old girl whose initial diagnosis was obstructive sleep apnea syndrome (OSAS) with symptoms of habitual snore, sleep breath holding, shortness of breath, and lump in throat. Lingual thyroid was diagnosed by thyroid scan and histology, and was treated by radioactive iodine therapy and endoscopic carbon dioxide laser therapy. Her OSAS completely subsided after lingual thyroid surgery. Physicians should be aware of rare causes of OSAS in children, such as lingual thyroid and certainly if accompanied by difficulties in swallowing and speech problems.
To investigate the efficacy of relocation pharyngoplasty as a surgical technique both to enlarge ... more To investigate the efficacy of relocation pharyngoplasty as a surgical technique both to enlarge pharyngeal airspace and to decrease pharyngeal collapse in the treatment of obstructive sleep apnea (OSA). Prospective comparative study performed in a tertiary referred sleep center. Ten adult male OSA patients (median age of 38 years, median apnea-hypopnea index [AHI] of 41.6 events/hour, and median body mass index of 25.8 kg/m(2)) with favorable oropharyngeal structure were enrolled. Principal procedures of the relocation pharyngoplasty include tonsillectomy, removal of supratonsillar mucosa and adipose tissue, splinting the lateral pharyngeal wall by suturing the placating superior pharyngeal constrictor muscle to the anterior pillar, and advancing the soft palate by suturing the posterior pillar flap cephalad laterally to the supratonsillar fossa. No patients experienced swallowing disturbance or change of voice after 3 months postoperatively. The median time for patients to return to normal nourishment was 15 days. Six months after the operation, there were statistically significant improvements in snoring (P = .005) and daytime sleepiness (P = .008). Repeated polysomnography revealed significant improvement in AHI (P = .005) and rapid eye movement period (P = .037). Furthermore, reduction in AHI following relocation pharyngoplasty was found in all patients. In selected patients, relocation pharyngoplasty by advancing the soft palate and splinting the lateral pharyngeal wall obtains significant improvement in subjective snoring and daytime sleepiness, as well as objective adverse sleep respiratory events and sleep architecture, while retaining normal pharyngeal function.
To assess if relocation pharyngoplasty (RP) causes velopharyngeal dysfunction in patients with ob... more To assess if relocation pharyngoplasty (RP) causes velopharyngeal dysfunction in patients with obstructive sleep apnea (OSA) by evaluating perioperative nasalance, nasality, voice, and articulation. Prospective, comparative study. Twenty-four OSA patients selected for RP (two women and 22 men; mean age, 35 years) were enrolled for the study of velopharyngeal function in speech. The RP procedure involved removal of supratonsillar adipose tissue, preservation of all palatal muscular structure, splinting the lateral pharyngeal wall, and anterior advancing of the soft palate. Measurements of nasalance (vowel /a/, /i/, consonant /m/, oronasal, oral, and nasal texts), nasality (mirror-fogging test, degree of nasality, Gutzmann test and Bzoch hypernasality test), voice (acoustic analysis), and articulation (velar sound) were taken before RP and 3 months after the procedure and compared. Comparative analysis of clinical measures showed that no significant differences were found following RP in nasalance (except for the vowel /a/), nasality, articulation, and voice. The only difference with regard to vowel /a/ showed, instead of an increase, a significant decrease of nasalance from 17.3 + or - 10.8 to 11.3 + or - 6.7 (P = .004), which may be attributed to the advancing and lifting of the soft palate in RP, leading to relaxation of the levator veli palatine and uvular muscles, which facilitates their contraction in velopharyngeal closure during particular vowel phonation. RP for OSA does not cause velopharyngeal insufficiency in terms of voice, nasality, and articulation in spite of anterior advancement of the soft palate, but does induce a nondetrimental change in nasalance.
This study aimed to compare the differences in vocal quality between Mandarin-speaking children w... more This study aimed to compare the differences in vocal quality between Mandarin-speaking children with cochlear implants and normal-hearing peers and to understand which cochlear implant usage parameters may predict unfavourable voice outcomes. A cross-sectional, case-controlled study. A tertiary medical centre. Thirty-five pre-lingually deaf children (age = 10.3 ± 1.6 years; 17 boys and 18 girls) who had used cochlear implants for >2 years and 35 age- and gender-matched controls with normal hearing. Through sustained phonation of /a/ and reading of the Hare and Tortoise passage, the subjects' voice quality was analysed with aerodynamics and acoustics. A six-point scale was used for auditory-perceptual evaluation. A Pediatric Voice-Related Quality of Life Survey was filled out by the caregivers. The implanted subjects had significantly lower mean airflow rate (P = 0.006), higher phonation threshold pressure (P < 0.001), higher fundamental frequency variations (P < 0.001) and peak-amplitude variations (P < 0.001), wider fundamental frequency range (P = 0.043), wider speaking intensity range (P = 0.015) and greater perceptual severity level of monotone (P < 0.001), resonance (P < 0.001), loudness (P < 0.001) and strain (P = 0.006) than their normal-hearing peers. Duration of postoperative rehabilitation was an independent predictor of unfavourable mean speaking fundamental frequency (odds ratio = 8.56, P = 0.008). Inadequate postoperative rehabilitation may hinder the normalisation of Mandarin-speaking implantees' voice quality. A multidimensional analysis may precisely evaluate the voice of paediatric implantees; however, the generalisability of these findings requires different forms of validation, including data from other languages and other institutions.
The aim of this study was to document receptive and expressive language levels and reading skills... more The aim of this study was to document receptive and expressive language levels and reading skills achieved by Mandarin-speaking children who had received cochlear implants (CIs) and used them for 4.75–7.42 years. The effects of possible associated factors were also analyzed. Standardized Mandarin language and reading tests were administered to 39 prelingually deaf children with Nucleus 24 devices. The Mandarin Chinese version of the Peabody Picture Vocabulary Test was used to assess their receptive vocabulary knowledge and the Revised Primary School Language Assessment Test for their receptive and expressive language skills. The Graded Chinese Character Recognition Test was used to test their written word recognition ability and the Reading Comprehension Test for their reading comprehension ability. Raw scores from both language and reading measurements were compared to normative data of nor- mal-hearing children to obtain standard scores. The results showed that the mean standard s...
The aim of this study was to assess the verbal and performance intelligence of young Mandarin-spe... more The aim of this study was to assess the verbal and performance intelligence of young Mandarin-speaking cochlear implant users with the Wechsler Intelligence Scale for Children (WISC). We also analyzed whether related factors helped develop verbal and performance IQs. We studied 60 children implanted with Nucleus 24 devices; the children represented a consecutive sample of every implantee aged 6 or older from 2002 to 2006. All subjects had 1 year to 8 years and 7 months of implant experience. Five children with known neurological, developmental delay and multiple handicaps were excluded. Intellectual functions were evaluated using the Mandarin version of the WISC-III, which includes 5 subsets for verbal IQ (information, comprehension, similarities, arithmetic and vocabulary) and 5 subsets for performance IQ (picture completion, picture arrangement, block design, object assembly and coding). After conversion, we found that the mean verbal IQ was 85.1 ± 19.9 (range 56–133), and the mea...
BACKGROUND The use of mobile technology in e-learning (M-TEL) can add new levels of experience an... more BACKGROUND The use of mobile technology in e-learning (M-TEL) can add new levels of experience and significantly increase the attractiveness of e-learning in medical education. Whether an innovative interactive e-learning multimedia (IM) module or a conventional PowerPoint show (PPS) module using M-TEL to teach emergent otorhinolaryngology–head and neck surgery (ORL-HNS) disorders is feasible and efficient in undergraduate medical students is unknown. OBJECTIVE The aim of this study was to compare the impact of a novel IM module with a conventional PPS module using M-TEL for emergent ORL-HNS disorders with regard to learning outcomes, satisfaction, and learning experience. METHODS This pilot study was conducted at an academic teaching hospital and included 24 undergraduate medical students who were novices in ORL-HNS. The cognitive style was determined using the Group Embedded Figures Test. The participants were randomly allocated (1:1) to one of the two groups matched by age, sex, ...
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