Factors Associated with Perioperative Transfusions in Veterans.

Background: Private sector literature demonstrates an association between perioperative transfusions and poor clinical outcomes. Hemostatic agents, surgeon training, and patient blood management programs (PBMPs) may mitigate perioperative bleeding. This study attempts to identify preoperative risk factors associated with perioperative transfusions in Veterans. Study Design and Methods: This study is a retrospective review of the prospectively maintained Veterans Affairs Surgical Quality Improvement Project database. Included patients were older than 18 years and underwent noncardiac surgery between April 1, 2016, and March 31, 2021. Data collected included demographics, surgery variables, preoperative clinical variables, postoperative outcomes, and perioperative transfusions. Cohorts were created based on transfusion status. Univariate and multivariate analyses were performed to characterize the similarities, differences, and potential predictors of perioperative transfusion. Results: Of 6108 patients included, 153 patients received perioperative transfusions. The risks for transfusion included older age, male sex, black race, smoking, and low body mass index (BMI). The highest percent of transfused patients underwent vascular (43.4%), orthopedic (22%), and general surgeries (20%). Transfusion increased risk for postoperative cerebral vascular accident (P = .041) and 30-day mortality (P < .001). Multivariate regression analysis revealed American Society of Anesthesiology class, chemotherapy within 30 days, increased age, tobacco smoking, and decreased BMI were predictive of perioperative transfusions. Discussion: Perioperative transfusions are associated with increased morbidity and mortality in the Veteran population. These retrospective data describe the complex relationships between perioperative transfusions and outcomes after noncardiac surgery. These results serve as a foundation to create predictive models and PBMP within the veteran population to decrease transfusion requirements and associated complications.

Integrating POLE/POLD1 mutated for immunotherapy treatment planning of advanced stage non-small cell lung cancer.

BACKGROUND: In this study, we evaluated the potential of DNA polymerase epsilon (POLE) and DNA polymerase delta 1 (POLD1) as prognostic biomarkers for immune checkpoint inhibitor (ICI) treatment in patients with advanced stage non-small cell lung cancer (NSCLC). METHODS: Disease stage, PD-L1 positivity, histological subtypes, POLE/POLD1 mutation status, tumor mutation burden (TMB), and response to ICIs in NSCLC cases were derived from AACR GENIE dataset (n = 24 120), TCGA-Pan Lung Cancer dataset (n = 1144), AACR GENIE BPC NSCLC v2.0-public (n = 2004), and Memorial Sloan Kettering-Integrated Mutation Profiling of Actionable Cancer Targets dataset (n = 350). The smoking history from TCGA and AACR GENIE datasets was grouped into current, former or never-smokers. RESULTS: POLE and POLD1 genetic alterations were identified in 5% and 2.6% of NSCLC patients, respectively. Current smokers had 9% and 4% of POLE/POLD1 mutations, respectively, versus 1.7% for both POLE and POLD1 mutations prevalence in never-smokers. POLE/POLD1 mutations were associated with elevated mutation counts than those with wild-type (median mutation counts 16 vs. 7, p < 0.0001), more advanced disease stages (stage I disease 15.19% vs. 29.42%), more prevalent squamous histology subtype (21.69% vs. 9.05%, p = 0.0427), and a higher percentage of PD-L1 positivity (66.67% vs. 43.87%, p < 0.001). Treatment with ICIs improved survival in patients with both POLE/POLD1 mutated and those with TMB > 18 (p < 0.001). CONCLUSION: Current smokers have a five-fold increased risk of having POLE mutations than never-smokers. POLE/POLD1 mutation status and TMB > 18 can be a composite biomarker for selecting NSCLC patients with survival benefits to ICI treatment.

Image-Based Deep Neural Network for Individualizing Radiotherapy Dose Is Transportable Across Health Systems.

PURPOSE: We developed a deep neural network that queries the lung computed tomography-derived feature space to identify radiation sensitivity parameters that can predict treatment failures and hence guide the individualization of radiotherapy dose. In this article, we examine the transportability of this model across health systems. METHODS: This multicenter cohort-based registry included 1,120 patients with cancer in the lung treated with stereotactic body radiotherapy. Pretherapy lung computed tomography images from the internal study cohort (n = 849) were input into a multitask deep neural network to generate an image fingerprint score that predicts time to local failure. Deep learning (DL) scores were input into a regression model to derive iGray, an individualized radiation dose estimate that projects a treatment failure probability of < 5% at 24 months. We validated our findings in an external, holdout cohort (n = 271). RESULTS: There were substantive differences in the baseline patient characteristics of the two study populations, permitting an assessment of model transportability. In the external cohort, radiation treatments in patients with high DL scores failed at a significantly higher rate with 3-year cumulative incidences of local failure of 28.5% (95% CI, 19.8 to 37.8) versus 10.2% (95% CI, 5.9 to 16.2; hazard ratio, 3.3 [95% CI, 1.74 to 6.49]; P < .001). A model that included DL score alone predicted treatment failures with a concordance index of 0.68 (95% CI, 0.59 to 0.77), which had a similar performance to a nested model derived from within the internal cohort (0.70 [0.64 to 0.75]). External cohort patients with iGray values that exceeded the delivered doses had proportionately higher rates of local failure (P < .001). CONCLUSION: Our results support the development and implementation of new DL-guided treatment guidance tools in the image-replete and highly standardized discipline of radiation oncology.

Promoting Silk Fibroin Adhesion to Stainless Steel Surfaces by Interface Tailoring.

Bonding dissimilar materials has been a persistent challenge for decades. This paper presents a method to modify a stainless steel surface (316 L), routinely used in medical applications to enable the significant adhesion of a biopolymer (silk fibroin). The metallic surface was first covalently grafting with polyacrylamide, to enable a hydrogen bonding compatible surface. The polymerisation was initiated via the irreversible electrochemical reduction of a 4-nitrobenzene diazonium salt (20 mM), in the presence of an acrylamide monomer (1 M) at progressively faster scan rates (0.01 V/s to 1 V/s). Examination of the modified samples by FT-IR was consistent with successful surface modification, via observations of the acrylamide carbonyl (1600-1650 cm-1 ) was observed, with more intense peaks correlating to slower scan rates. Similar observations were made with respect to increasing surface polarity, assessed by water contact angle. Reductions of >60° were observed for the grafted surfaces, relative to the unmodified control materials, indicating a surface able to undergo significant hydrogen bonding. The adhesion of silk to the metallic surface was quantified using a lap shear test, effectively using silk fibroin as an adhesive. Adhesion improvements of 5-7-fold, from 4.1 MPa to 29.3 MPa per gram of silk fibroin, were observed for the treated samples, highlighting the beneficial effect of this surface treatment. The methods developed in this work can be transferred to any metallic (or conductive) surface and can be tailored to complement any desired interface.

History of Technological Advancements towards MR-Linac: The Future of Image-Guided Radiotherapy.

Image-guided radiotherapy (IGRT) enables optimal tumor targeting and sparing of organs-at-risk, which ultimately results in improved outcomes for patients. Magnetic resonance imaging (MRI) revolutionized diagnostic imaging with its superior soft tissue contrast, high spatiotemporal resolution, and freedom from ionizing radiation exposure. Over the past few years there has been burgeoning interest in MR-guided radiotherapy (MRgRT) to overcome current challenges in X-ray-based IGRT, including but not limited to, suboptimal soft tissue contrast, lack of efficient daily adaptation, and incremental exposure to ionizing radiation. In this review, we present an overview of the technologic advancements in IGRT that led to MRI-linear accelerator (MRL) integration. Our report is organized in three parts: (1) a historical timeline tracing the origins of radiotherapy and evolution of IGRT, (2) currently available MRL technology, and (3) future directions and aspirations for MRL applications.

Deterministic small-scale undulations of image-based risk predictions from the deep learning of lung tumors in motion.

INTRODUCTION: Deep learning (DL) models that use medical images to predict clinical outcomes are poised for clinical translation. For tumors that reside in organs that move, however, the impact of motion (i.e., degenerated object appearance or blur) on DL model accuracy remains unclear. We examine the impact of tumor motion on an image-based DL framework that predicts local failure risk after lung stereotactic body radiotherapy (SBRT). METHODS: We input pre-therapy free breathing (FB) computed tomography (CT) images from 849 patients treated with lung SBRT into a multitask deep neural network to generate an image fingerprint signature (or DL score) that predicts time-to-event local failure outcomes. The network includes a convolutional neural network encoder for extracting imaging features and building a task-specific fingerprint, a decoder for estimating handcrafted radiomic features, and a task-specific network for generating image signature for radiotherapy outcome prediction. The impact of tumor motion on the DL scores was then examined for a holdout set of 468 images from 39 patients comprising: (1) FB CT, (2) four-dimensional (4D) CT, and (3) maximum-intensity projection (MIP) images. Tumor motion was estimated using a 3D vector of the maximum distance traveled, and its association with DL score variance was assessed by linear regression. FINDINGS: The variance and amplitude in 4D CT image-derived DL scores were associated with tumor motion (R2  = 0.48 and 0.46, respectively). Specifically, DL score variance was deterministic and represented by sinusoidal undulations in phase with the respiratory cycle. DL scores, but not tumor volumes, peaked near end-exhalation. The mean of the scores derived from 4D CT images and the score obtained from FB CT images were highly associated (Pearson r = 0.99). MIP-derived DL scores were significantly higher than 4D- or FB-derived risk scores (p < 0.0001). INTERPRETATION: An image-based DL risk score derived from a series of 4D CT images varies in a deterministic, sinusoidal trajectory in a phase with the respiratory cycle. These results indicate that DL models of tumors in motion can be robust to fluctuations in object appearance due to movement and can guide standardization processes in the clinical translation of DL models for patients with lung cancer.

Towards Accurate and Precise Image-Guided Radiotherapy: Clinical Applications of the MR-Linac.

Advances in image-guided radiotherapy have brought about improved oncologic outcomes and reduced toxicity. The next generation of image guidance in the form of magnetic resonance imaging (MRI) will improve visualization of tumors and make radiation treatment adaptation possible. In this review, we discuss the role that MRI plays in radiotherapy, with a focus on the integration of MRI with the linear accelerator. The MR linear accelerator (MR-Linac) will provide real-time imaging, help assess motion management, and provide online adaptive therapy. Potential advantages and the current state of these MR-Linacs are highlighted, with a discussion of six different clinical scenarios, leading into a discussion on the future role of these machines in clinical workflows.

Effects of Liver Pathology on Sleeve Gastrectomy Outcomes.

Introduction: Sleeve gastrectomy engenders weight loss and improves comorbidities at 1 year postoperatively. A relationship has not been established between liver pathology and diabetic outcomes and weight loss following a sleeve gastrectomy. This study evaluates the association between liver pathology and both diabetic remission and weight loss in morbidly obese veterans. Methods: A prospective database of all patients undergoing sleeve gastrectomy with simultaneous liver biopsy at a Veterans Affairs Medical Center was analyzed from 2018 through 2020. The database included patient demographics, liver biopsy pathology, laboratory values, and antihyperglycemic medications. Patient outcomes at 12 months postoperatively were analyzed specifically for diabetic resolution and weight loss. Chi-square test and Fisher's exact test were used for categorical comparisons, and one-way analysis of variance test and two-tailed t-test were used for continuous variable comparisons. Multivariate linear regression models were created to assess the association between liver pathology and changes in body mass index (BMI) and diabetic status. A two-sided P-value of 0.05 indicated significance. Results: Of the 77 patients included in the study, 70.1% of patients achieved diabetic remission at 12 months. After condensing steatosis and fibrosis scores into low- and high-grade categories, patients with no hepatic disease had significantly lower BMI at 12 months postoperatively than patients with low- or high-grade hepatic disease (29.2 ± 3.6 kg/m2 versus 35.1 ± 4.0 kg/m2 versus 34.5 ± 3.7 kg/m2, respectively, P = .009). On multivariate linear regression model, low-grade overall hepatic disease (ß = 3.1 ± 1.5; P = .043) and preoperative oral glycemic medications (ß = 2.4 ± 1.0; P = .026) were associated with a significantly increased 12-month BMI. Also, Black or African American race compared with White race was associated with a significant decrease in postoperative BMI (ß = -1.9 ± 0.8; P = .023). Conclusions: Regardless of preexisting liver disease, most diabetic patients who undergo sleeve gastrectomy experience diabetic remission at 12 months postoperatively. Additionally, patients with no underlying liver disease lose more weight than those with low- or high-grade liver disease.

Increased body mass index predicts prolonged survival in patients with head and neck squamous cell carcinoma.

BACKGROUND: Higher body mass index (BMI) may have a protective effect on survival in patients with head and neck cancer. The aim of this study was to determine the effect of BMI on overall survival (OS) in veterans with head and neck squamous cell carcinoma (HNSCC). METHODS: A cohort of 702 patients diagnosed with HNSCC between 1995 and 2019 were identified at the Washington DC Veterans Affairs Medical Center, and 342 patients were included for analysis. Records were queried for clinical-demographic data, BMI, and outcomes. RESULTS: HNSCC patients categorized as overweight or obese at time of diagnosis had a lower 3-year risk of death (p = 0.033) and improved OS (p < 0.001) compared to patients who were underweight or normal weight. The majority of locoregional recurrences occurred in patients with low or normal pretreatment BMI. CONCLUSIONS: Higher BMI at diagnosis may have a protective effect on OS in veterans with HNSCC.

Phase II trial of proton therapy versus photon IMRT for GBM: secondary analysis comparison of progression-free survival between RANO versus clinical assessment.

BACKGROUND: This secondary image analysis of a randomized trial of proton radiotherapy (PT) versus photon intensity-modulated radiotherapy (IMRT) compares tumor progression based on clinical radiological assessment versus Response Assessment in Neuro-Oncology (RANO). METHODS: Eligible patients were enrolled in the randomized trial and had MR imaging at baseline and follow-up beyond 12 weeks from completion of radiotherapy. "Clinical progression" was based on a clinical radiology report of progression and/or change in treatment for progression. RESULTS: Of 90 enrolled patients, 66 were evaluable. Median clinical progression-free survival (PFS) was 10.8 (range: 9.4-14.7) months; 10.8 months IMRT versus 11.2 months PT (P = .14). Median RANO-PFS was 8.2 (range: 6.9, 12): 8.9 months IMRT versus 6.6 months PT (P = .24). RANO-PFS was significantly shorter than clinical PFS overall (P = .001) and for both the IMRT (P = .01) and PT (P = .04) groups. There were 31 (46.3%) discrepant cases of which 17 had RANO progression more than a month prior to clinical progression, and 14 had progression by RANO but not clinical criteria. CONCLUSIONS: Based on this secondary analysis of a trial of PT versus IMRT for glioblastoma, while no difference in PFS was noted relative to treatment technique, RANO criteria identified progression more often and earlier than clinical assessment. This highlights the disconnect between measures of tumor response in clinical trials versus clinical practice. With growing efforts to utilize real-world data and personalized treatment with timely adaptation, there is a growing need to improve the consistency of determining tumor progression within clinical trials and clinical practice.

Analysis of the Prognostic Significance of Circulating Tumor DNA in Metastatic Castrate Resistant Prostate Cancer.

BACKGROUND: There has been considerable interest in ctDNA next generation sequencing platforms to assess genomic alterations in mCRPC given its accessibility and identification of temporal genomic data. PATIENTSAND METHODS: In this retrospective analysis, we analyzed 63 patients who underwent ctDNA genomic profiling during their mCRPC disease course using a CLIA-certified commercial assay. The primary objective was to assess the feasibility of commercial ctDNA analysis in a real world mCRPC cohort. Key secondary objectives included assessment of the landscape of pathogenic ctDNA alterations and the prognostic significance of ctDNA detection on overall survival (OS). RESULTS: Among the cohort, at the time of ctDNA collection, median age was 70 years, and 47.6% (N = 30/63) had bone-only metastases. ctDNA was detected in the majority of patients with at least 1 pathogenic alteration detected in 90.5% (N = 57/63) of individuals. The most common alterations detected were in AR, TP53, and PIK3CA. Actionable alterations with FDA-approved therapies were found in 15.8% (N = 10) of the cohort. The presence of ≤ 1 versus > 1 alteration on ctDNA analysis was strongly associated with inferior OS with a median OS of 26.1 versus 8.8 months, respectively (HR = 7.0, 95% CI, 2.2-23.1, P < .001). In multivariate analysis, the number of detected alterations remained a significant predictor for OS. Lastly, there was weak correlation between Prostate-Specific Antigen (PSA), and ctDNA characteristics. CONCLUSION: ctDNA is a viable next generation sequencing (NGS) platform in mCRPC and can be utilized to identify actionable alterations. The presence and extent of ctDNA alterations appear to be prognostic of OS in mCRPC.

Outcomes of Paraesophageal Hernia Repair: Analysis of the Veterans Affairs Surgical Quality Improvement Program Database.

BACKGROUND: While there have been many outcome studies on paraesophageal hernia repair in the civilian population, there is sparse recent data on the veteran population. This study analyzes the mortality and morbidities of veterans who underwent paraesophageal hernia repair in the Veterans Affairs Surgical Quality Improvement Program database. METHODS: Veterans who underwent paraesophageal hernia repair from 2010 to 2017 were identified using Current Procedural Terminology codes. Multivariable analysis was used to compare laparoscopic and open, including abdominal and thoracic approaches, groups. The outcomes were postoperative complications and mortality. RESULTS: There were 1607 patients in the laparoscopic group and 366 in the open group, with 84.1% men and mean age of 61 years. Gender and body mass index did not influence the type of surgical approach. The mortality rates at 30 and 180 days were 0.5% and 0.7%, respectively. Postoperative complications, including reintubation (2.2%), pneumonia (2.0%), intubation > 48 h (2.0%), and sepsis (2.0%) were higher in the open group (15.9% versus 7.2%, p < 0.001). The laparoscopic group had a significantly shorter length of stay (4.3 versus 9.6 days, p < 0.001) and a lower percentage of return to surgery within 30 days (3.9% versus 8.2%, p < 0.001) than the open group. The ratio of open versus laparoscopic paraesophageal hernia repairs varied significantly by different Veterans Integrated Services Network regions. CONCLUSIONS: Veterans undergoing laparoscopic paraesophageal hernia repair experience similar outcomes as patients in the private sector. Veterans who underwent laparoscopic paraesophageal hernia repair had significantly less complications compared to an open approach even after adjusting for patient comorbidities and demographics. The difference in open versus laparoscopic practices between various regions requires further investigation.

Outcomes of Sleeve Gastrectomy at a Veterans Affairs Medical Center.

Introduction: Bariatric surgery is the most effective treatment for obesity while improving comorbid conditions and decreasing mortality rates. The purpose of this analysis was to identify the predictive factors associated with the short-term outcomes of laparoscopic sleeve gastrectomy (LSG) at a single Veterans Affairs Medical Center (VAMC). Methods: This is a retrospective analysis of LSG performed at a VAMC from 2013 to 2019. Veterans were followed for 12 months postoperatively. The primary outcomes of interest were excess weight loss (EWL) and total weight loss (TWL) at 3, 6, 9, and 12 months along with resolution of comorbidities. Independent predictors included: demographics, pre- and postoperative findings, geographic distance from VAMC, and per-capita salary of the veteran's residence. Results: A total of 128 patients, including 50 males, completed 12 months' follow-up after LSG. There were no mortalities, transfusions, or conversions to open surgery. The mean length of stay was 2.3 days. At 3, 6, 9, and 12 months, EWL was 27.2%, 33.7%, 35.9%, and 36.6%, respectively; TWL was 12.3%, 15.3%, 16.3%, and 16.7%, respectively. Postoperative hemoglobin A1c and oral hyperglycemic medication usage significantly decreased. High-density lipoprotein levels significantly increased. At 6 months' follow-up, preoperative body mass index (BMI; odds ratio [OR] = 0.7 [95% confidence interval, CI 0.6-0.9]) and age (OR = 0.9 [95% CI 0.8-1.0]) were significant predictors of 50% EWL and EWL broadly (P = .002). Conclusion: Similar to the private sector, LSG is a safe and effective tool for morbid obesity with clinical and serological improvements. For Veterans, increasing BMI and age may portend less weight loss but does not affect resolution of some comorbidities.

Gender and compensation among surgical specialties in the Veterans Health Administration.

BACKGROUND: A gender pay gap has been reported across many professions, including medicine. METHODS: Surgeons employed at complex Veterans Affairs Medical Centers (VAMC) nationwide in 2016 were identified. Data on salary, gender, years since medical school graduation, professorship status, h-index, and geographic location were collected. RESULTS: Of 1993 surgeons nationwide, 23% were female. On average, female surgeons had significantly lower salaries compared to male surgeons ($268,429 ± 41,339 versus $287,717 ± 45,379, respectively; p < 0.001). Among each surgical specialty, there were no significant differences in salary on univariate analysis. Women were underrepresented in higher paying specialties and more heavily represented in lower paying specialties. On multivariate analysis, gender (p < 0.001), time since medical school graduation (p < 0.001), surgical specialty (p = 0.031), h-index (p < 0.001), and geographic location (p < 0.001) were significant predictors of salary. CONCLUSION: Female gender significantly predicted lower salary among VAMC surgeons, however within each surgical specialty, there was no significant gender pay gap. SENTENCE SUMMARY: Independent predictors of salary included gender, surgical specialty, experience, h-index, and geographic location. Although female surgeons had lower overall salaries compared to male surgeons in the Veterans Health Administration (VHA), there were no significant gender differences in salary among each surgical specialty. Pay transparency, unique to the VHA, along with the use of rational and objective criteria to establish and adjust salaries, may play a role in reducing the gender pay gap among VHA surgeons.

Detection of Glioblastoma Subclinical Recurrence Using Serial Diffusion Tensor Imaging.

Glioblastoma is an aggressive brain tumor with a propensity for intracranial recurrence. We hypothesized that tumors can be visualized with diffusion tensor imaging (DTI) before they are detected on anatomical magnetic resonance (MR) images. We retrospectively analyzed serial MR images from 30 patients, including the DTI and T1-weighted images at recurrence, at 2 months and 4 months before recurrence, and at 1 month after radiation therapy. The diffusion maps and T1 images were deformably registered longitudinally. The recurrent tumor was manually segmented on the T1-weighted image and then applied to the diffusion maps at each time point to collect mean FA, diffusivities, and neurite density index (NDI) values, respectively. Group analysis of variance showed significant changes in FA (p = 0.01) and NDI (p = 0.0015) over time. Pairwise t tests also revealed that FA and NDI at 2 months before recurrence were 11.2% and 6.4% lower than those at 1 month after radiation therapy (p < 0.05), respectively. Changes in FA and NDI were observed 2 months before recurrence, suggesting that progressive microstructural changes and neurite density loss may be detectable before tumor detection in anatomical MR images. FA and NDI may serve as non-contrast MR-based biomarkers for detecting subclinical tumors.

Systemic Treatment of Bone Disease in Metastatic Urinary Malignancies.

CONTEXT: Bone metastasis is a common site of metastatic disease in patients with genitourinary malignancies. Given that the presence of bone metastasis decreases survival and has a negative impact on quality of life impact, it is critical to optimize management of this patient population. OBJECTIVE: To systematically review literature on the systemic treatment of bone metastasis in prostate cancer, renal cell carcinoma, urothelial carcinoma, and germ cell tumors. EVIDENCE ACQUISITION: We performed a nonsystematic critical review of PubMed/Medline, clinicaltrials.gov, and the Cochrane Library from January 2001 to February 2019. Identified reports were reviewed according to the Consolidated Standards of Reporting Trials, and selected based on reporting skeletal related events and symptomatic skeletal events for patients with urologic malignancies. EVIDENCE SYNTHESIS: Skeletal metastases occur frequently in genitourinary malignancies, at rates around 80% for patients with metastatic prostate cancer and 30% for patients with metastatic renal cell and urothelial carcinoma, and are uncommon in patients with germ cell tumors. Skeletal related events and symptomatic skeletal events can occur in these patients. Optimization of bone health involves dietary and lifestyle modifications, and use of osteoclast-targeted agents in select individuals. Additionally, disease-modifying agents, such as radiopharmaceutical, immunotherapy, and cMET inhibitors, which have activity in the bone, have improved outcomes for patients, including skeletal-related events and symptomatic skeletal events. CONCLUSIONS: While the presence of bone metastases is associated with increased mortality and worse outcomes in patients with genitourinary malignancies, strategies have been developed to improve quality of life and survival for patients with skeletal metastases. Future studies investigating novel therapeutic options and bone supporting agents are warranted to target this patient population. PATIENT SUMMARY: In this report, we reviewed the current literature and recent clinical trials involving treatment of bone metastases in urinary cancers. The use of bone-targeting agents can improve outcomes for patients, and additional lifestyle modification can optimize bone health in this population.

Compensation of Otolaryngologists in the Veterans Health Administration: Is There a Gender Gap?

OBJECTIVES/HYPOTHESIS: To determine if gender pay disparity exists amongst otolaryngologists employed by the Veterans Health Administration (VHA). STUDY DESIGN: cross-sectional analysis. METHODS: Board-certified otolaryngologists employed at all complex Veterans Affairs Medical Centers (VAMCs) in 2016 were identified. Salaries were collated using the Enterprise Human Resources Integration-Statistical Data Mart dataset. Additional variables, including gender, years since medical school graduation, professorship status, h-index, and geographic location were collected. A multivariate linear regression analysis was performed where salary was the primary outcome of interest and gender was accounted for as an independent predictor while controlling for professional characteristics, geographic location, and seniority. RESULTS: Sixty-nine VHA surgical programs with an operative designation of "complex" were identified. Two hundred sixty board-certified otolaryngologists, including 197 (75.8%) men and 63 (24.2%) women, were identified. Salary data were available on 210 of these otolaryngologists. In 2016, the mean salary for male and female otolaryngologists was not significantly different ($266,707 ± $31,624 vs. $264,674 ± $27,027, P = .918) nor were salaries in early career ($243,979 ± $31,749 vs. $254,625 ± $24,558, respectively; P = .416). On multivariate linear regression analysis, number of years since graduation (P = .009) and h-index (P = .049) were independent predictors of salary, but gender, geographic location, and faculty rank were not. CONCLUSIONS: Although the gender pay gap persists in many areas of medicine and surgery, otolaryngologists employed at complex VAMCs do not experience gender pay disparity. The use of specific and objective criteria to establish and adjust salaries can reduce and potentially eliminate gender pay disparity. These findings may help to guide institutional policies in other practice environments. LEVEL OF EVIDENCE: 2b. Laryngoscope, 129:113-118, 2019.

A predictive model for patients with median arcuate ligament syndrome.

BACKGROUND: Due to the rarity of median arcuate ligament (MAL) syndrome, patient selection for surgery remains difficult. This study provides a predictive model to optimize patient selection and predict outcomes following a MAL release. METHODS: Prospective data from patients undergoing a MAL release included demographics, radiologic studies, and SF-36 questionnaires. Successful postoperative changes in SF-36 was defined as an improvement > 10% in the total SF-36 score. A logistic regression model was used to develop a clinically applicable table to predict surgical outcomes. Celiac artery (CA) blood flow velocities were compared pre- and postoperatively and Pearson correlations were examined between velocities and SF-36 score changes. RESULTS: 42 patients underwent a laparoscopic MAL release with a mean follow-up of 28.5 ± 18.8 months. Postoperatively, all eight SF-36 scales improved significantly. The logistic regression model for predicting surgical benefit was significant (p = 0.0244) with a strong association between predictors and outcome (R2 = 0.36). Age and baseline CA expiratory velocity were significant predictors of improvement and predicted clinical improvement. There were significant differences between pre- and postoperative CA velocities. Postoperatively, the bodily pain scale showed the most significant increase (64%, p < 0.0001). A table was developed using age and preoperative CA expiratory velocities to predict clinical outcomes. CONCLUSIONS: Laparoscopic MAL produces significant symptom improvement, particularly in bodily pain. This is one of the first studies that uses preoperative data to predict symptom improvement following a MAL release. Age and baseline CA expiratory velocity can be used to guide postoperative expectations in patients with MAL syndrome.