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, 2024.

A suicidal mechanism for the exquisite temperature sensitivity of TRPV1.

The vanilloid receptor TRPV1 is an exquisite nociceptive sensor of noxious heat, but its temperature-sensing mechanism is yet to define. Thermodynamics dictate that this channel must undergo an unusually energetic allosteric transition. Thus, it is of fundamental importance to measure directly the energetics of this transition in order to properly decipher its temperature-sensing mechanism. Previously, using submillisecond temperature jumps and patch-clamp recording, we estimated that the heat activation for TRPV1 opening incurs an enthalpy change on the order of 100 kcal/mol. Although this energy is on a scale unparalleled by other known biological receptors, the generally imperfect allosteric coupling in proteins implies that the actual amount of heat uptake driving the TRPV1 transition could be much larger. In this paper, we apply differential scanning calorimetry to directly monitor the heat flow in TRPV1 that accompanies its temperature-induced conformational transition. Our measurements show that heat invokes robust, complex thermal transitions in TRPV1 that include both channel opening and a partial protein unfolding transition and that these two processes are inherently coupled. Our findings support that irreversible protein unfolding, which is generally thought to be destructive to physiological function, is essential to TRPV1 thermal transduction and, possibly, to other strongly temperature-dependent processes in biology.

Efficacy of prayer in inducing immediate physiological changes: a systematic analysis of objective experiments.

OBJECTIVES: To assess the immediate impact of prayer on physiological state by systematically reviewing objective, controlled experimental studies in the literature. CONTENT: Experimental studies measuring objective physiological changes induced by prayer. Studies containing the keyword, "Prayer" anywhere in the title or abstract were curated from the following databases: Public/Publisher Medline (PubMed), Excerpta Medica Database (EMBASE) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) in May 2019. Titles and abstracts were screened with the remaining 30 articles analyzed for inclusion. Only experimental studies were included. SUMMARY: Eight experimental studies were identified of which five investigated neurocognitive changes and three investigated systemic physiological changes during prayer. The five studies focusing on neuroactivity used functional MRI (fMRI), electroencephalography or SPECT imaging to obtain measurements. The remaining three studies analyzed an array of systemic physiological metrics, including blood pressure, heart rate, respiratory rate, peripheral resistance, baroreceptor sensitivity and/or cardiovascular rhythm variability during prayer. All studies aside from one saw objective changes during prayer. Neurocognitive changes were mainly associated with improved mental functioning, control and pain tolerance. Prayer was found to slow down physiological functions in two of the three vital-based studies, with the third reporting no change in physiological status. None of the studies measured blood marker changes. OUTLOOK: Experimental studies show prayer to induce healthy neurocognitive and physiological changes. Additional studies exploring objective measures from prayer are encouraged to provide practitioners with a more nuanced, scientific perspective when it comes to prescribing prayer as a complementary and alternative medicine (CAM) therapy.

Comparison of quantitative measurements of four manufacturer's metal artifact reduction techniques for CT imaging with a self-made acrylic phantom.

BACKGROUND: Metal artifact reduction (MAR) techniques can improve metal artifacts of computed tomography (CT) images. OBJECTIVE: This work focused on conducting a quantitative analysis to compare the effectiveness of four commercial MAR techniques on three types of metal implants (hip implant, spinal implant, and dental filling) with a self-made acrylic phantom. METHODS: A cylindrical phantom was made from acrylic with a groove in the middle, and then three types of metal implants were placed in the groove. The phantom was scanned by four CT scanners and four commercialized MAR techniques were used to analyze the images. The techniques used were single-energy metal artifact reduction (SEMAR, Canon), smart metal artifact reduction software (Smart-MAR, GE), iterative metal artifact reduction (IMAR, Siemens), and metal artifact reduction for orthopedic implants (OMAR, Philips). Quantitative analysis methods included objective and subjective analysis. RESULTS: The expected value of SEMAR, Smart-MAR, IMAR, and OMAR were 36.6, 37.8, 5.0, and 2.3, respectively. SEMAR and Smart-MAR achieved optimal results. CONCLUSION: This study successfully evaluated the effects of four commercial MAR techniques on three types of metal implants in a phantom. All MAR techniques effectively reduced metal artifacts, but the effect was not significant with dental fillings due to high-density material.

Impact of endovascular reperfusion on low National Institutes of Health Stroke Scale score large-vessel occlusion stroke.

INTRODUCTION: Effectiveness of mechanical thrombectomy for mild-deficit stroke due to large-vessel occlusion is controversial. We present a single-center consecutive case series on thrombectomy for large-vessel occlusion mild stroke. We evaluated various thrombectomy parameters to better understand disagreement in the literature. METHODS: Data from a retrospective cohort of large-vessel occlusion mild stroke patients (National Institutes of Health Stroke Scale <6) treated with mechanical thrombectomy over 6 years and 2 months were analyzed. Patients were divided into 2 groups: successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b or 3) and failed reperfusion (modified Thrombolysis in Cerebral Infarction 0,1, or 2a). Ninety-day modified Rankin Scale in-hospital mortality, and symptomatic hemorrhage rates were compared between groups. Multivariate logistic regression was performed to evaluate reperfusion status as a predictor of 90-day favorable (modified Rankin Scale 0-2) and excellent (modified Rankin Scale 0-1) outcomes. RESULTS: We identified 61 patients with large-vessel occlusion mild stroke who underwent thrombectomy. Reperfusion was successful in 49 patients and a failure in 12. The successful group exhibited significantly higher rates of favorable outcome (83.7% vs. 25.0%; p < 0.001) and excellent outcome (69.4% vs.16.7%; p = 0.002) at 90 days. In-hospital mortality was significantly higher in the failure group (41.7% vs.10.2%; p = 0.019). Multivariate logistic regression identified successful reperfusion as a significant predictor (p = 0.001) of 90-day favorable outcome. CONCLUSION: Reperfusion success was significantly associated with improved functional outcomes in large-vessel occlusion mild stroke mechanical thrombectomy. Future studies should consider reperfusion rates when evaluating the effectiveness of thrombectomy against that of medical management in these patients.

Quantitative assessment of three vendor's metal artifact reduction techniques for CT imaging using a customized phantom.

A metal implant was placed in an acrylic phantom to enable quantitative analysis of the metal artifact reduction techniques used in computed tomography (CT) scanners from three manufacturers. Two titanium rods were placed in a groove in a cylindrical phantom made by acrylic, after which the groove was filled with water. The phantom was scanned using three CT scanners (Toshiba, GE, Siemens) under the abdomen CT setting. CT number accuracy, contrast-to-noise ratio, area of the metal rods in the images, and fraction of affected pixel area of water were measured using ImageJ. Different iterative reconstruction, dual energy, and metal artifact reduction techniques were compared within three vendors. The highest contrast-to-noise ratio of three scanners were 85.7 ± 8.4 (Toshiba), 85.9 ± 11.7 (GE), and 55.0 ± 14.8 (Siemens); and the most correct results of metal area were 157.1 ± 1.4 mm2 (Toshiba), 155.0 ± 1.0 (GE), and 170.6 ± 5.3 (Siemens). The fraction of affected pixel area obtained using single-energy metal artifact reduction of Toshiba scanner was 2.2% ± 0.7%, which is more favorable than 4.1% ± 0.7% obtained using metal artifact reduction software of GE scanner (p = 0.002). Among all quantitative results, the estimations with fraction of affected pixel areas matched the effect of metal artifact reduction in the actual images. Therefore, the single-energy metal artifact reduction technique of Toshiba scanner had a desirable effect. The metal artifact reduction software of GE scanner effectively reduced the effect of metal artifacts; however, it underestimated the size of the metal rods. The monoenergetic and dual energy composition techniques of Siemens scanner could not effectively reduce metal artifacts.