Commitment to inclusion: The importance of collaboration in gender equity work.

Despite decades of faculty professional development programs created to prepare women for leadership, gender inequities persist in salary, promotion, and leadership roles. Indeed, men still earn more than women, are more likely than women to hold the rank of professor, and hold the vast majority of positions of power in academic medicine. Institutions demonstrate commitment to their faculty's growth by investing resources, including creating faculty development programs. These programs are essential to help prepare women to lead and navigate the highly matrixed, complex systems of academic medicine. However, data still show that women persistently lag behind men in their career advancement and salary. Clearly, training women to adapt to existing structures and norms alone is not sufficient. To effectively generate organizational change, leaders with power and resources must commit to gender equity. This article describes several efforts by the Office of Faculty in the Johns Hopkins University School of Medicine to broaden inclusivity in collaborative work for gender equity. The authors are women and men leaders in the Office of Faculty, which is within the Johns Hopkins University School of Medicine dean's office and includes Women in Science and Medicine. Here, we discuss potential methods to advance gender equity using inclusivity based on our institutional experience and on the findings of other studies. Ongoing data collection to evaluate programmatic outcomes in the Johns Hopkins University School of Medicine will be reported in the future.

Correcting for Rater Effects in Operating Room Surgical Skills Assessment.

OBJECTIVE: To estimate and adjust for rater effects in operating room surgical skills assessment performed using a structured rating scale for nasal septoplasty. METHODS: We analyzed survey responses from attending surgeons (raters) who supervised residents and fellows (trainees) performing nasal septoplasty in a prospective cohort study. We fit a structural equation model with the rubric item scores regressed on a latent component of skill and then fit a second model including the rating surgeon as a random effect to model a rater-effects-adjusted latent surgical skill. We validated this model against conventional measures including the level of expertise and post-graduation year (PGY) commensurate with the trainee's performance, the actual PGY of the trainee, and whether the surgical goals were achieved. RESULTS: Our dataset included 188 assessments by 7 raters and 41 trainees. The model with one latent construct for surgical skill and the rater as a random effect was the best. Rubric scores depended on how severe or lenient the rater was, sometimes almost as much as they depended on trainee skill. Rater-adjusted latent skill scores increased with attending-estimated skill levels and PGY of trainees, increased with the actual PGY, and appeared constant over different levels of achievement of surgical goals. CONCLUSION: Our work provides a method to obtain rater effect adjusted surgical skill assessments in the operating room using structured rating scales. Our method allows for the creation of standardized (i.e., rater-effects-adjusted) quantitative surgical skill benchmarks using national-level databases on trainee assessments. LEVEL OF EVIDENCE: N/A Laryngoscope, 134:3548-3554, 2024.

Geographic Variation in Costs of Transsphenoidal Pituitary Surgery in the United States.

BACKGROUND: Geographic variations in health care costs have been reported for many surgical specialties. OBJECTIVE: In this study, we sought to describe national and regional costs associated with transsphenoidal pituitary surgery (TPS). METHODS: Data from the Truven-MarketScan 2010-2014 were analyzed. We examined overall total, hospital/facility, physician, and out-of-pocket payments in patients undergoing TPS including technique-specific costs. Mean payments were obtained after risk adjustment for patient-level and system-level confounders and estimated differences across regions. RESULTS: The estimated overall annual burden was $43 million/year in our cohort. The average overall total payment associated with TPS was $35,602.30, hospital/facility payment was $26,980.45, physician payment was $4685.95, and out-of-pocket payment was $2330.78. Overall total and hospital/facility costs were highest in the West and lowest in the South (both P < 0.001), whereas physician reimbursements were highest in the North-east and lowest in the South (P < 0.001). There were no differences in out-of-pocket expenses across regions. On a national level, there were significantly higher overall total and hospital/facility payments associated with endoscopic compared with microscopic procedures (both P < 0.001); there were no significant differences in physician payments or out-of-pocket expenses between techniques. There were also significant within-region cost differences in overall total, hospital/facility, and physician payments in both techniques as well as in out-of-pocket expenses associated with microsurgery. There were no significant regional differences in out-of-pocket expenses associated with endoscopic surgery. CONCLUSIONS: Our results show significant geographic cost disparities associated with TPS. Understanding factors behind disparate costs is important for developing cost containment strategies.

The Valuation of Rhytidectomy in Different Economic Markets.

This study demonstrates that the trend of how rhytidectomy is valued can be used to determine not only the pricing of this good but also how receptive developing economic markets are to the export of cosmetic facial plastic surgery. This study seeks to analyze and compare the value of rhytidectomy in an established market and an emerging market. A cross-sectional survey was administered through public online forums to 162 casual observers in the United States and 74 casual observers in India. Participants were shown pre- and postoperative photos of 10 patients who underwent cosmetic rhinoplasty and 2 patients who did not undergo surgery. Observers were asked to quantify the perceived change in attractiveness, change in age, and willingness to pay (WTP). There is a similar nonlinear trend between WTP and change in attractiveness in both the United States and India. Baseline values of rhytidectomy in the United States and India have a similar ratio of 2.122 compared with the ratio between both countries in the 2018 Big Mac index. The comparison of the trend in WTP in the United States and India shows that facial cosmetic surgery functions as a luxury good in both an established market and an emerging market. Our model successfully approximates the relationship between each country's purchasing power parity. Since the market behavior of rhytidectomy can be predicted based on purchasing power parity, there may be an untapped market for facial cosmetic surgery among populations with growing economies.

The Health Utility and Valuation of Cosmetic Rhinoplasty.

Importance: The importance of this study is to understand the impact of rhinoplasty as perceived by society and to conceptualize the health utility metric of cosmetic rhinoplasty in relation to other health interventions. Objective: This novel study seeks to measure and quantify the health state utility and valuation of cosmetic rhinoplasty. Design, Setting, Participants: This is a cross-sectional survey administered through public online forums to 161 casual observers in America. Main Outcomes and Measures: Participants were shown pre- and postoperative photographs of six patients who underwent cosmetic rhinoplasty and two patients who did not undergo surgery. Observers were asked to imagine that the external nose in each image was on their own face and rated (1) their health state utility and (2) how much they were willing to pay (WTP) to have the ideal nose. Results: Established metrics of standard gamble and visual analog scale were explored in detail. Using these valuation and health utility data, we calculated WTP per quality-adjusted-life-year (WTP/QALY). The WTP/QALY for cosmetic rhinoplasty is $12,264 per QALY, which is significantly below cost-effective thresholds. Participants were willing to accept 10% risk of death to undergo cosmetic rhinoplasty. Conclusions and Relevance: Calculating WTP/QALY as a metric, we assess and quantify the social importance of rhinoplasty. This is the first study to demonstrate that elective cosmetic rhinoplasty can be a high-value intervention as perceived by society. Furthermore, the high percentage of risk of death that participants are willing to accept for cosmetic rhinoplasty suggests there is a profound psychosocial impact of external nasal deformity. These findings have implications for patients, surgeons, and health policy makers.

Exploring Patient Motivations and Impact of Asian Blepharoplasty.

To date, patient motivations for Asian blepharoplasty and the surgery's impact on quality of life have not been quantified. Here, we employed structured interviews and a web-based survey to better characterize patient motivations for Asian blepharoplasty and the impact of Asian blepharoplasty on self-reported domains of happiness, self-esteem, attractiveness, social life, and professional life. Structured interviews were conducted to inform a web-based survey regarding Asian blepharoplasty. Survey respondents used visual analog scales to rate their satisfaction with their eye shape, motivations for undergoing Asian blepharoplasty, and perceived outcomes after surgery. A total of 315 participants (mean 25.7 [18-58] years) of East or Southeast Asian descent were included. 185 participants expressed no desire for Asian blepharoplasty, 76 expressed some desire, and 54 had already undergone surgery. There were statistically significant differences regarding baseline satisfaction, perceived social limitation, and perceived professional limitations regarding eye shape (p < 0.0001). The Looking Glass Self index (comprised of media exposure, low self-esteem, and negative stereotypes related to eye shape) is negatively associated with preoperative satisfaction with eye shape (rho = -0.29, p < 0.01). The desire for social-professional advancement and the Looking Glass Self index significantly predict self-reported improvements in professional and social life, respectively (both p < 0.01). Asian blepharoplasty may be driven by functional, social, or economic patient motivations. Some patients may see Asian blepharoplasty as a potential solution for sociological concerns. These expectations should be further explored in physician-patient discussions regarding candidacy for surgery and establishing expectations for postoperative outcomes.

Assessment of the Influence of "Other-Race Effect" on Visual Attention and Perception of Attractiveness Before and After Rhinoplasty.

IMPORTANCE: The "other-race effect" describes the phenomenon in which individuals demonstrate greatest recognition ability among faces of their own race. Thus, in our multicultural world, it follows that race influences social interactions. However, the association of race with perception of plastic surgery outcomes has not been studied. OBJECTIVE: To objectively measure how the other-race effect influences perception of white and Latin American patients undergoing rhinoplasty by using eye-tracking technology and survey methodology. DESIGN, SETTING, AND PARTICIPANTS: In the first part of the study, 134 participants viewed 32 paired facial images of white and Latin American patients, either prerhinoplasty or postrhinoplasty, on an eye-tracking system that recorded observer scan paths. In the second part of this study, the same patient images were individually graded by a separate group of 134 participants for degree of racial identification and perceived attractiveness. MAIN OUTCOMES AND MEASURES: The primary outcome was to measure the influence of patient and observer race on perception of rhinoplasty outcomes. For the eye-tracking part, planned hypothesis testing was conducted using an analysis of variance to compare patient race, rhinoplasty status, and attractiveness with respect to visual fixation time. RESULTS: Of the 134 eye-tracking participants, 68 (51%) were women and the mean (SD) age was 26.4 (7.7) years; of the 134 graders, 64 (48%) were women and the mean (SD) age was 25.0 (6.9) years. Rhinoplasty did not affect racial identity scores among either same-race or other-race evaluators. Visual fixation times for white faces were significantly increased compared with Latin American faces among all casual observer groups (white observers mean change, -20.14 milliseconds; 95% CI, -29.65 to -10.62 milliseconds; P < .001; Asian observers mean change, -39.04 milliseconds; 95% CI, -48.95 to -29.15 milliseconds; P < .001; and African American observers mean change, -20.73 milliseconds; 95% CI, -37.78 to -3.69 milliseconds; P < .02), with the exception of Latin American observers (mean change, -7.8 milliseconds; 95% CI, -29.15 to 14.39 milliseconds; P < .51). With respect to attractiveness, white graders reported a significant postrhinoplasty increase across both races (white patients mean change, 8.07 points; 95% CI, 5.01-11.12 points; P < .001; and Latin American patients mean change, 3.69 points; 95% CI, 0.87-6.49 points; P = .01), whereas Latin American graders only observed a significant attractiveness increase in their own race (Latin American patients mean change, 10.50 points; 95% CI, 1.70-19.32 points; P = .02). Neither perceived attractiveness nor rhinoplasty status influenced fixation times. CONCLUSIONS AND RELEVANCE: Both patient and observer race influence visual attention and perception of attractiveness before and after rhinoplasty. These findings underscore the importance of counseling patients that the influence of rhinoplasty, as perceived by the casual observer, may vary by race or ethnicity of the observer group. LEVEL OF EVIDENCE: NA.

Assessment of Casual Observers' Willingness to Pay for Increased Attractiveness Through Rhinoplasty.

IMPORTANCE: Contingent valuation, or willingness to pay, is an established economic concept that has been applied in other areas of medicine and may be useful for understanding the economic forces that determine the cost of cosmetic procedures. OBJECTIVE: To determine the monetary value of changes in attractiveness achieved through rhinoplasty, as perceived by society. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional survey administered via public online forums to 228 casual observers. MAIN OUTCOMES AND MEASURES: Participants were shown preoperative and postoperative photographs of 12 patients who underwent cosmetic rhinoplasty and 4 patients who did not undergo any surgery. They were asked to rate (1) the change in overall attractiveness of the patients, and (2) the monetary value they would associate with these changes. RESULTS: Completed surveys were obtained from 228 casual observers; 144 were female (63.2%); median age, 25 years (median income bracket, $50 000-$75 000). Multilevel, mixed-effects, linear regression was used to characterize the association between monetary value and change in attractiveness. There was a significant association between the change in attractiveness from a rhinoplasty and its monetary value as perceived by society. The baseline value of a rhinoplasty without any change in attractiveness was $3769.98 (95% CI, $3541.59-$4007.10; P < .001). To increase 1 standard deviation in attractiveness was worth an additional $2353.77 (95% CI, $2197.57-$2512.81; P < .001), while increasing 2 standard deviations in attractiveness was worth an additional $5453.07 (95% CI, $5052.57-$5865.51; P < .001). CONCLUSIONS AND RELEVANCE: There is a significant association between the societally perceived value of cosmetic rhinoplasty and the change in attractiveness after surgery. The average value of a rhinoplasty in our study approximates the actual average cost of cosmetic rhinoplasty, suggesting that willingness to pay may be a useful concept for studying the value of cosmetic procedures. LEVEL OF EVIDENCE: NA.

Costs and Their Predictors in Transsphenoidal Pituitary Surgery.

BACKGROUND: Contemporary surgical approaches to pituitary pathologies include transsphenoidal microsurgical and, more recently, endoscopic techniques. Data reporting direct costs in transsphenoidal pituitary surgery are limited. OBJECTIVE: To examine direct costs (including overall total, hospital/facility, and physician payments) of microscopic and endoscopic pituitary surgery and evaluate predictors of differential costs in transsphenoidal pituitary surgery using a national database. METHODS: The Truven MarketScan® database 2010-2014 (IBM, Armonk, New York) was queried and patients undergoing microscopic and/or endoscopic transsphenoidal pituitary surgery identified. Mean costs and predictors of differential costs were analyzed using analysis of variance and generalized linear models. Beta-coefficients (ß) assessed relative contributions of independent predictors. RESULTS: Mean overall total ($34 943.13 [SD ± 19 074.54]) and hospital/facility ($26 505.93 [SD ± 16 819.52]) payments were higher in endoscopic compared to microscopic surgeries (both P < .001). Lengths of hospital stay (LOS) were similar between groups. Predictors of overall total and hospital/facility payments were similar including surgical technique, age, geographical region, comorbidity index, postoperative surgical and medical complications, and LOS with LOS being the most significant predictor (ß = 0.27 and ß = 0.29, respectively). Mean physician payments ($4549.24 [SD ± 3956.27]) were similar in microscopic and endoscopic cohorts (P = .26). Predictors of physician payments included age, health plan, geographical region, postoperative surgical complications, and LOS with health plan being the most significant predictor (ß = -0.21). CONCLUSION: Higher overall total and hospital/facility costs are associated with endoscopic transsphenoidal pituitary surgery compared to microsurgery. In contrast, physician reimbursements are similar between techniques. Whereas LOS was the strongest predictor of overall total and hospital/facility costs, health plan was the strongest predictor of differential physician reimbursements.

Comparison of Complications, Trends, and Costs in Endoscopic vs Microscopic Pituitary Surgery: Analysis From a US Health Claims Database.

BACKGROUND: Microsurgical and endoscopic techniques are commonly utilized surgical approaches to pituitary pathologies. There are limited data comparing these 2 procedures. OBJECTIVE: To evaluate postoperative complications, associated costs, and national and regional trends of microscopic and endoscopic techniques in the United States employing a nationwide database. METHODS: The Truven MarketScan database 2010 to 2014 was queried and Current Procedural Terminology codes identified patients that underwent microscopic and/or endoscopic transsphenoidal pituitary surgery. International Classification of Diseases codes identified postoperative complications. Adjusted logistic regression and matched propensity analysis evaluated independent odds for complications. RESULTS: Among 5886 cases studied, 54.49% were microscopic and 45.51% endoscopic. The commonest surgical indications were benign pituitary tumors. Annual trends showed increasing utilization of endoscopic techniques vs microscopic procedures. Postoperative complications occurred in 40.04% of cases, including diabetes insipidus (DI; 16.90%), syndrome of inappropriate antidiuretic hormone (SIADH; 2.02%), iatrogenic hypopituitarism (1.36%), fluid/electrolyte abnormalities (hypoosmolality/hyponatraemia [5.03%] and hyperosmolality/hypernatraemia [2.48%]), and cerebrospinal fluid (CSF) leaks (CSF rhinorrhoea [4.42%] and other CSF leak [6.52%]). In our propensity-based model, patients that underwent endoscopic surgery were more likely to develop DI (odds ratio [OR] = 1.48; 95% confidence interval [CI] = 1.28-1.72), SIADH (OR = 1.53; 95% CI = 1.04-2.24), hypoosmolality/hyponatraemia (OR = 1.17; 95% CI = 1.01-1.34), CSF rhinorrhoea (OR = 2.48; 95% CI = 1.88-3.28), other CSF leak (OR = 1.59; 95% CI = 1.28-1.98), altered mental status (OR = 1.46; 95% CI = 1.01-2.60), and postoperative fever (OR = 4.31; 95% CI = 1.14-16.23). There were no differences in hemorrhagic complications, ophthalmological complications, or bacterial meningitis. Postoperative complications resulted in longer hospitalization and increased healthcare costs. CONCLUSION: Endoscopic approaches are increasingly being utilized to manage sellar pathologies relative to microsurgery. Postoperative complications occur in both techniques with higher incidences observed following endoscopic procedures.

Objective Assessment of Surgical Technical Skill and Competency in the Operating Room.

Training skillful and competent surgeons is critical to ensure high quality of care and to minimize disparities in access to effective care. Traditional models to train surgeons are being challenged by rapid advances in technology, an intensified patient-safety culture, and a need for value-driven health systems. Simultaneously, technological developments are enabling capture and analysis of large amounts of complex surgical data. These developments are motivating a "surgical data science" approach to objective computer-aided technical skill evaluation (OCASE-T) for scalable, accurate assessment; individualized feedback; and automated coaching. We define the problem space for OCASE-T and summarize 45 publications representing recent research in this domain. We find that most studies on OCASE-T are simulation based; very few are in the operating room. The algorithms and validation methodologies used for OCASE-T are highly varied; there is no uniform consensus. Future research should emphasize competency assessment in the operating room, validation against patient outcomes, and effectiveness for surgical training.

Assessment of frozen section margin analysis during olfactory neuroblastoma surgery.

OBJECTIVES: 1) assess the performance of the intraoperative frozen section procedure to correctly classify biopsies obtained during olfactory neuroblastoma (ONB) surgery; 2) define the relationship between posttest probabilities and pretest probabilities from frozen section analysis; and 3) review incorrectly classified specimens. STUDY DESIGN: Study of diagnostic accuracy. METHODS: We searched our institution's pathology database for patients who had ONB surgery between January 1, 2000 and November 16, 2012. We only included patients who had a definitive diagnosis of ONB prior to surgery and frozen sections obtained during surgery. All frozen sections in this study had corresponding permanent sections available to serve as a gold standard. This database was analyzed to obtain classification statistics. The confidence intervals for classification performance were obtained using the bootstrap sampling method. Confidence intervals for posttest probability curves were derived using the Taylor series expansion. Finally, we obtained and reviewed the slides from ambiguous or incorrect reads. RESULTS: A total of 459 specimens from 33 patients were analyzed. We found the following performance characteristics: sensitivity: 0.89 (0.81, 0.94); specificity: 0.96 (0.94, 0.98); accuracy: 0.95 (0.92, 0.96); likelihood ratio positive: 24.4 (14.5, 44.1); prevalence: 0.20 (0.17, 0.25); positive predictive value: 0.86 (0.78, 0.92); and negative predictive value: 0.97 (0.95, 0.99). Histopathologic review revealed that crush artifacts and inadequate specimen size were major sources of incorrect reads. CONCLUSION: We found frozen section assessment of ONB specimens to be an excellent tool for the assessment of intraoperative margins. LEVEL OF EVIDENCE: NA. Laryngoscope, 127:1735-1741, 2017.

A hybrid multibreath wash-in wash-out lung function quantification scheme in human subjects using hyperpolarized 3 He MRI for simultaneous assessment of specific ventilation, alveolar oxygen tension, oxygen uptake, and air trapping.

PURPOSE: To present a method for simultaneous acquisition of alveolar oxygen tension (PA O2 ), specific ventilation (SV), and apparent diffusion coefficient (ADC) of hyperpolarized (HP) gas in the human lung, allowing reinterpretation of the PA O2 and SV maps to produce a map of oxygen uptake (R). METHOD: An imaging scheme was designed with a series of identical normoxic HP gas wash-in breaths to measure ADC, SV, PA O2 , and R in less than 2 min. Signal dynamics were fit to an iterative recursive model that regionally solved for these parameters. This measurement was successfully performed in 12 subjects classified in three healthy, smoker, and chronic obstructive pulmonary disease (COPD) cohorts. RESULTS: The overall whole lung ADC, SV, PA O2 , and R in healthy, smoker, and COPD subjects was 0.20 ± 0.03 cm2 /s, 0.39 ± 0.06,113 ± 2 Torr, and 1.55 ± 0.35 Torr/s, respectively, in healthy subjects; 0.21 ± 0.03 cm2 /s, 0.33 ± 0.06, 115.9 ± 4 Torr, and 0.97 ± 0.2 Torr/s, respectively, in smokers; and 0.25 ± 0.06 cm2 /s, 0.23 ± 0.08, 114.8 ± 6.0Torr, and 0.94 ± 0.12 Torr/s, respectively, in subjects with COPD. Hetrogeneity of SV, PA O2 , and R were indicators of both smoking-related changes and disease, and the severity of the disease correlated with the degree of this heterogeneity. Subjects with symptoms showed reduced oxygen uptake and specific ventilation. CONCLUSION: High-resolution, nearly coregistered and quantitative measures of lung function and structure were obtained with less than 1 L of HP gas. This hybrid multibreath technique produced measures of lung function that revealed clear differences among the cohorts and subjects and were confirmed by correlations with global lung measurements. Magn Reson Med 78:611-624, 2017. © 2016 International Society for Magnetic Resonance in Medicine.

The Cost of Facial Deformity: A Health Utility and Valuation Study.

IMPORTANCE: The impact of facial defects on quality of life as perceived by society and the value society places on facial reconstruction are important outcomes measures. OBJECTIVE: To measure the health state utility and dollar value of surgically reconstructing facial defects as perceived by society. DESIGN, SETTING, AND PARTICIPANTS: A randomized observational study conducted in an academic tertiary referral center using a socioeconomically diverse group of 200 casual observers. MAIN OUTCOMES AND MEASURES: Observers viewed images of faces with defects of varying sizes and locations before and after surgical reconstruction. Observers imagined if the defect in each image were on their own face and rated (1) their health state utility with the defect and (2) how much they would be willing to pay to have the defect surgically repaired to normal (perfect repair). Established health state utility and contingent valuation metrics were used. RESULTS: Data from 200 observers were analyzed. Facial defects significantly decreased perceived health state utility with the greatest penalty attributed to large and centrally located defects. Surgical reconstruction of the facial defects increased health state utility to near-normal ranges for all groups except large central defects. Participants were willing to pay an average of $1170 (95% CI, $767-$1572) to repair a de novo small peripheral defect; they were willing to pay $4274 more than the average (95% CI, $3296-$5251) to repair a large defect and $2372 more (95% CI, $1379-$3366) to repair a central defect. Using these valuation and health utility data, we calculated willingness to pay per quality-adjusted life-year (WTP/QALY), a value-related metric. Mean WTP/QALY ratios ranged from $639/QALY for repairing small peripheral defects to $2838/QALY for repairing large central defects, well below all cost-effectiveness thresholds. CONCLUSIONS AND RELEVANCE: Casual observers perceived that facial defects significantly decrease quality of life, an effect improved by reconstructive surgery. Measuring WTP and calculating WTP/QALY provides novel data to assess the social importance and value of facial reconstructive surgery. To our knowledge, these are the first data demonstrating that surgical reconstruction of facial defects is a high-value intervention as perceived by society. These findings have implications for a broad range of stakeholders, including patients, surgeons, health policy makers, and payers. LEVEL OF EVIDENCE: NA.

Automated objective surgical skill assessment in the operating room from unstructured tool motion in septoplasty.

PURPOSE: Previous work on surgical skill assessment using intraoperative tool motion has focused on highly structured surgical tasks such as cholecystectomy and used generic motion metrics such as time and number of movements. Other statistical methods such as hidden Markov models (HMM) and descriptive curve coding (DCC) have been successfully used to assess skill in structured activities on bench-top tasks. Methods to assess skill and provide effective feedback to trainees for unstructured surgical tasks in the operating room, such as tissue dissection in septoplasty, have yet to be developed. METHODS: We proposed a method that provides a descriptive structure for septoplasty by automatically segmenting it into higher-level meaningful activities called strokes. These activities characterize the surgeon's tool motion pattern. We constructed a spatial graph from the sequence of strokes in each procedure and used its properties to train a classifier to distinguish between expert and novice surgeons. We compared the results from our method with those from HMM, DCC, and generic metric-based approaches. RESULTS: We showed that our method--with an average accuracy of 91 %--performs better or equal than these state-of-the-art methods, while simultaneously providing surgeons with an intuitive understanding of the procedure. CONCLUSIONS: In this study, we developed and evaluated an automated approach to objectively assess surgical skill during unstructured task of tissue dissection in nasal septoplasty.

Alterations of regional alveolar oxygen tension in asymptomatic current smokers: assessment with hyperpolarized (3)He MR imaging.

PURPOSE: To assess the ability of helium 3 ((3)He) magnetic resonance (MR) imaging of regional alveolar partial pressure of oxygen (Pao2) to depict smoking-induced functional alterations and to compare its efficacy to that of current diagnostic techniques. MATERIALS AND METHODS: This study was approved by the local institutional review board and was compliant with HIPAA. All subjects provided informed consent. A total of 43 subjects were separated into three groups: nonsmokers, asymptomatic smokers, and symptomatic smokers. All subjects underwent a Pao2 imaging session followed by clinically standard pulmonary function tests (PFTs), the 6-minute walk test, and St George Respiratory Questionnaire (SGRQ). The whole-lung mean and standard deviation of Pao2 were compared with metrics derived from PFTs, the 6-minute walk test, and the SGRQ. A logistic regression model was developed to identify the predictors of alterations to the lungs of asymptomatic smokers. RESULTS: The whole-lung standard deviation of Pao2 correlated with PFT metrics (forced expiratory volume in 1 second [FEV1]/forced vital capacity [FVC], Pearson r = -0.69, P < .001; percentage predicted FEV1, Pearson r = -0.67, P < .001; diffusing capacity of lung for carbon monoxide [Dlco], Pearson r = -0.45, P = .003), SGRQ score (Pearson r = 0.67, P < .001), and distance walked in 6 minutes (Pearson r = -0.47, P = .002). The standard deviation of Pao2 was significantly higher in asymptomatic smokers than in nonsmokers (change in the standard deviation of Pao2 = 7.59 mm Hg, P = .041) and lower when compared with symptomatic smokers (change in the standard deviation of Pao2 = 10.72 mm Hg, P = .001). A multivariate prediction model containing FEV1/FVC and the standard deviation of Pao2 (as significant predictors of subclinical changes in smokers) and Dlco (as a confounding variable) was formulated. This model resulted in an area under the receiver operating characteristic curve with a significant increase of 29.2% when compared with a prediction model based solely on nonimaging clinical tests. CONCLUSION: The (3)He MR imaging heterogeneity metric (standard deviation of Pao2) enabled the differentiation of all three study cohorts, which indicates that it can depict smoking-related functional alterations in asymptomatic current smokers.

The social penalty of facial lesions: new evidence supporting high-quality reconstruction.

IMPORTANCE: To date, there have been no studies attempting to measure the multidimensional impact of facial lesions, before and after reconstruction, on social conversation. OBJECTIVE: To measure the direct social impact of facial lesions before and after surgical reconstruction. DESIGN, SETTING, AND PARTICIPANTS: Prospective randomized controlled experiment at an academic tertiary referral center. One hundred twenty casual observers viewed images of faces with lesions of varying sizes and locations before and after reconstruction as well as faces without lesions (normal faces) for comparison. MAIN OUTCOMES AND MEASURES: Observers rated faces using a battery of metrics, including how comfortable they would be having a conversation with the participant in each facial image. The conversation questions were answered on a scale from 0 to 100, where the higher the score, the more comfortable the observer would be conversing with the subject. RESULTS: The mean (SD) conversation score for participants with normal faces was 85.02 (17.95) of 100 points. Facial lesions had a negative effect (or, a penalty) on conversation (61.63 [29.50]). Structural equation modeling showed this conversation penalty varied with lesion size and location, with large and central lesions generating the greatest penalty. Reconstructive surgery increased observers' comfort and willingness to converse with individuals with facial lesion by an average of 19.83 (95% CI, 17.49-22.17), an improvement that also varied with preoperative lesion size and location. Planned hypothesis testing showed that reconstructive surgery normalized observer comfort in communicating with people with small peripheral, small central, and large peripheral lesions. However, substantial discomfort communicating with patients with large central lesions remained after surgery. Observer-rated facial attractiveness, affect, and perceived quality of life also influenced this social communication measure. CONCLUSIONS AND RELEVANCE: Facial lesions induce a significant social penalty as rated by the casual observer. Specifically, observers are less comfortable communicating with people who have facial lesions. Surgical reconstruction of facial lesions increased observers' comfort in conversing with people with facial lesions, an impact that varied with lesion size and location. LEVEL OF EVIDENCE: NA.

In-training assessment and predictors of competency in endoscopic sinus surgery.

OBJECTIVES: To evaluate the reliability and validity of the assessment tool for endoscopic sinus surgery when used in the operating room for in-training assessment of operative competency; to identify the tasks that may serve as the best indicators for overall surgical performance. STUDY DESIGN: Cross-sectional validation study. METHODS: We implemented the global and checklist parts of the endoscopic sinus surgery (ESS) assessment tool to evaluate the surgical skills of 13 Otolaryngology-Head & Neck Surgery residents (PGY 1-5) in the operating room over a period of 15 months. Rhinology faculty scored residents' performance of every step of ESS at the end of each procedure using a previously validated tool. Construct validity was calculated by comparing scores across training levels (using analysis of variance [ANOVA]). Regression analysis was performed to identify tasks on the ESS checklist that most strongly correlated to the overall surgical performance. RESULTS: Construct validity was demonstrated with senior residents performing better than junior residents. Average checklist and global scores improved with the number of days on rhinology rotation. "Identification of uncinate and boundaries" was found to be the strongest predictor of overall surgical performance. CONCLUSIONS: The results indicate that this evaluation tool is a reliable and valid instrument for the assessment of surgical competency in the operating room. It can be used to identify weak areas of performance for which additional training may be required early in the rotation/training.

Quantitative assessment of lung ventilation and microstructure in an animal model of idiopathic pulmonary fibrosis using hyperpolarized gas MRI.

RATIONALE AND OBJECTIVES: The use of hyperpolarized (3)He magnetic resonance imaging as a quantitative lung imaging tool has progressed rapidly in the past decade, mostly in the assessment of the airway diseases chronic obstructive pulmonary disease and asthma. This technique has shown potential to assess both structural and functional information in healthy and diseased lungs. In this study, the regional measurements of structure and function were applied to a bleomycin rat model of interstitial lung disease. MATERIALS AND METHODS: Male Sprague-Dawley rats (weight, 300-350 g) were administered intratracheal bleomycin. After 3 weeks, apparent diffusion coefficient and fractional ventilation were measured by (3)He magnetic resonance imaging and pulmonary function testing using a rodent-specific plethysmography chamber. Sensitized and healthy animals were then compared using threshold analysis to assess the potential sensitivity of these techniques to pulmonary abnormalities. RESULTS: No significant changes were observed in total lung volume and compliance between the two groups. Airway resistance elevated and forced expiratory volume significantly declined in the 3-week bleomycin rats, and fractional ventilation was significantly decreased compared to control animals (P < .0004). The apparent diffusion coefficient of (3)He showed a smaller change but still a significant decrease in 3-week bleomycin animals (P < .05). CONCLUSIONS: Preliminary results suggest that quantitative (3)He magnetic resonance imaging can be a sensitive and noninvasive tool to assess changes in an animal interstitial lung disease model. This technique may be useful for longitudinal animal studies and also in the investigation of human interstitial lung diseases.