Establishment of the Clinician-Scientist Investigator Opportunity Network to Develop Military Medical Research Leaders.

INTRODUCTION: The ability of military clinicians to conduct military medical research is often limited because of competing priorities and a lack of research mentorship. The Clinician-Scientist Investigator Opportunity Network (CSION) was developed with the intent of training clinicians how to engage in requirements-driven research within the DoD. MATERIALS AND METHODS: Three to five academic medical faculties were selected from a pool of applicants each year to participate in a 2-year research fellowship. To be eligible for the CSION program, applicants had to meet the following criteria: (1) Completed residency graduate medical education training, (2) not be currently enrolled as a graduate medical education trainee, and (3) obtained permission from their department leadership to focus 25% of their duty hours on CSION participation to include didactic and research efforts. The remaining 75% of fellows' time was dedicated to clinical duties. Monthly didactics, intensive mentorship, and consistent support were offered to each fellow by the CSION leadership team. Metrics were recorded to include both research and clinical productivity. RESULTS: Between January 2019 and December 2022, 12 CSION fellows graduated from the program (four in the class of 2020, three in 2021, and five in 2022). From 2019 to 2021, the 12 CSION fellows initiated 204 research protocols, generated 489 publications/presentations, and secured 33 research grants. All graduates of the program remain active in clinical research with multiple graduates currently assigned to research positions. CONCLUSIONS: The CSION research education program is a 2-year additional duty research fellowship producing clinician-scientists conducting military-relevant medical research and publications and may be considered a low-cost/highly efficient alternative to achieve the reported benefits of the MD-PhD tract. The expansion of the CSION program may improve the quality of military medical research and health care.

Local Effect of Ballistic Fragments Embedded Along the Carotid Sheath of a Porcine Animal Model.

INTRODUCTION: Energized ballistic fragments from improvised explosive devices were the most common cause of injury to coalition service personnel during conflicts in Iraq and Afghanistan. Surgical excision of retained fragments is not routinely performed unless there is a concern for injury to vital structures. However, no clear guidelines dictate when or if a fragment should be removed, reflecting a lack of objective evidence of their long-term effects. Using a porcine model, we aimed to evaluate changes to the carotid artery produced by retained fragments over time. MATERIALS AND METHODS: Institutional Animal Care and Use Committee approval for all experiments was obtained before commencement of the study. Eighteen female swine (mean mass 62.0 ± 3.4 kg) were randomized into three study groups corresponding to the time of survival after implantation of ballistic fragments: 1, 6, and 12 weeks. Two animals from each group were randomly assigned to have one of the three different fragments implanted within the right carotid sheath in zones 1-3 of the neck. The left carotid served as the control. The vascular flow rate and arterial diameter were measured at each level before implantation and again after the survival interval. Baseline and interval angiograms were performed to identify gross vascular changes. RESULTS: No abnormalities were identified on baseline or interval angiograms. No significant difference was found when the baseline was compared to interval measurements or when compared to the control side for all gross and physiological measures at 1 and 6 weeks (P = .053-.855). After 12 weeks, the flow and diameter changed significantly (P < .001-.03), but this significant change was found in both the control and affected carotid. CONCLUSIONS: The lack of significant gross anatomical and physiological changes at 6 weeks postimplantation lends evidence toward the current policy that early removal of retained ballistic fragments around cervical vessels is not required. Changes were significant after 12 weeks which suggest that surveillance may be required; however, such changes could be explained by physiological animal growth.

Proof of concept study for a closed ex vivo limb perfusion system for 24-hour subnormothermic preservation using acellular perfusate.

BACKGROUND: The two approaches to vascularized tissue machine perfusion use either the open (nonpressurized) or closed (pressurized) perfusion system. Most studies describing isolated limb perfusion preservation rely on open perfusion systems and report tissue edema exceeding 40% after 12 to 14 hours of preservation. A variant of machine perfusion places the limb and perfusate into a reservoir closed to atmosphere. It is hypothesized that the reservoir pressure, acting as a transmural pressure, has the advantage of reducing edema formation by counteracting the hydrostatic pressure gradient from the perfusion pressure. This proof-of-concept study aim was to demonstrate feasibility of the Universal Limb Stasis System for Extended Storage (ULiSSES) device (closed, vertical perfusion system) to preserve forelimbs of Sus scrofa swine for 24 hours of subnormothermic perfusion compared with an open, horizontal perfusion system. The ULiSSES is a compact, practical device that applies pulsatile, pressurized perfusion through the novel use of a diaphragm pump powered by compressed oxygen. METHODS: Forelimbs from swine were preserved in ULiSSES device (closed perfusion system) (n = 9) and in an open perfusion system (n = 4) using subnormothermic modified Krebs-Henseleit solution. Physiological parameters were measured at the start and every 3 hours for 24 hours. Limbs were weighed before and after perfusion to compare weight gain. Edema and cellular integrity were evaluated using histopathology pre and post perfusion. RESULTS: Closed perfusion system showed superiority compared with the open perfusion system in terms of oxygen consumption, reduction in vascular resistance, and overall tissue integrity. The closed perfusion system demonstrated a 21% reduction in weight gain compared with the open perfusion system and significantly reduced intracellular edema. CONCLUSION: The ULiSSES closed, pressurized perfusion technology has translatable military applications with the potential to preserve porcine limbs for 24 hours with improved results compared with an open perfusion system.

Battlefield Vital Sign Monitoring in Role 1 Military Treatment Facilities: A Thematic Analysis of After-Action Reviews from the Prehospital Trauma Registry.

INTRODUCTION: The Prehospital Trauma Registry (PHTR) captures after-action reviews (AARs) as part of a continuous performance improvement cycle and to provide commanders real-time feedback of Role 1 care. We have previously described overall challenges noted within the AARs. We now performed a focused assessment of challenges with regard to hemodynamic monitoring to improve casualty monitoring systems. MATERIALS AND METHODS: We performed a review of AARs within the PHTR in Afghanistan from January 2013 to September 2014 as previously described. In this analysis, we focus on AARs specific to challenges with hemodynamic monitoring of combat casualties. RESULTS: Of the 705 PHTR casualties, 592 had available AAR data; 86 of those described challenges with hemodynamic monitoring. Most were identified as male (97%) and having sustained battle injuries (93%), typically from an explosion (48%). Most were urgent evacuation status (85%) and had a medical officer in their chain of care (65%). The most common vital sign mentioned in AAR comments was blood pressure (62%), and nearly one-quarter of comments stated that arterial palpation was used in place of blood pressure cuff measurements. CONCLUSIONS: Our qualitative methods study highlights the challenges with obtaining vital signs-both training and equipment. We also highlight the challenges regarding ongoing monitoring to prevent hemodynamic collapse in severely injured casualties. The U.S. military needs to develop better methods for casualty monitoring for the subset of casualties that are critically injured.

The predictive utility of the 22-item sino-nasal outcome test (SNOT-22): A scoping review.

BACKGROUND: The 22-item sino-nasal outcome test (SNOT-22) is a widely used and powerful patient-reported outcomes measure for chronic rhinosinusitis (CRS). More recently; however, the SNOT-22 has been evaluated as a predictive tool for multiple conditions. The objective of this scoping review is to investigate the extent to which SNOT-22 is used in this manner and present this information in a way useful for clinicians. METHODS: A systematic search of PubMed, Scopus, Cochrane Library, and Web of Science was performed. Studies that evaluated SNOT-22s predictive utility were considered for eligibility in this scoping review. RESULTS: A total of 39 studies met eligibility. The SNOT-22 was found to be used as a predictive tool in three broad categories: (1) to predict a diagnosis, (2) to predict an outcome of an intervention, and (3) to predict a patient treatment preference. Thirteen studies were included in the diagnosis category, which made up ten different individual predictions. Twenty-four studies were included in the outcomes category and investigated 17 different individual predictions. Finally, two studies were included in the patient preferences category, which together made one prediction. CONCLUSIONS: The SNOT-22 is a versatile tool that has the potential to be used in predicting various diagnoses, outcomes, and patient preferences. However, care must be taken in applying these predictions to clinical practice, as further research must be done in validating these predictions based on SNOT-22 responses.

Methylene blue enhances polyethylene glycol-fusion repair of completely severed rat sciatic nerves.

Complete transection of peripheral mixed nerves immediately produces loss of sensory perception, muscle contractions and voluntary behavior mediated by the severed distal axons. In contrast to natural regeneration (~1 mm/d) of proximal axons that may eventually reinnervate denervated targets, re-innervation is restored within minutes by PEG-fusion that consists of neurorrhaphy and a sequence of well specified hypo- and isotonic calcium-free or calcium-containing solutions, the anti-oxidant methylene blue (MB) and the membrane fusogen polyethylene glycol (PEG). In this study, we examined the relative efficacy of PEG-fusion with no MB (0%), 0.5% MB, or 1% MB on the recovery of voluntary behaviors by female Sprague-Dawley rats with a complete mid-thigh severance of their sciatic nerve bathed in extracellular fluid or calcium-containing isotonic saline. The recovery of voluntary behaviors is the most relevant measure of success of any technique to repair peripheral nerve injuries. We assessed recovery by the sciatic functional index, a commonly used measure of voluntary hindlimb behaviors following complete sciatic transections. We reported that both 1% MB and 0.5% MB in sterile distilled water in our PEG-fusion protocol with neurorrhaphy significantly increased the rate and extent of behavioral recovery compared to PEG plus neurorrhaphy alone. Furthermore, 0.5% MB was as effective as 1% MB in voluntary behavioral recovery as assessed by the sciatic functional index. Since sterile 1% MB is no longer clinically available, we therefore recommend that 0.5% MB be included in upcoming human clinical trials to evaluate the safety and efficacy of PEG-fusion. All animal procedures were approved by the University of Texas Institutional Animal Care and Use Committee (AUP-2019-00225) on September 9, 2020.

Neuroprotectin D1 Attenuates Blast Overpressure Induced Reactive Microglial Cells in the Cochlea.

OBJECTIVE/HYPOTHESIS: We examined a neuroinflammatory response associated with glial activation in the cochlea exposed to blast overpressure and evaluated the potential therapeutic efficacy of specialized pro-resolving mediators such as neuroprotectin D1, NPD1; (10R, 17S-dihydroxy-4Z, 7Z, 11E, 13E, 15Z, 19Z-docosahexaenoic acid) in a rodent blast-induced auditory injury model. STUDY DESIGN: Animal Research. METHODS: A compressed-air driven shock tube was used to expose anesthetized adult male Long-Evan rats to shock waves simulating an open-field blast exposure. Approximately 30 minutes after blast exposure, rats were treated with NPD1 (100 ng/kg body wt.) or vehicle delivered intravenously via tail vein injection. Rats were then euthanized 48 hours after blast exposure. Unexposed rats were included as controls. Tissue sections containing both middle and inner ear were prepared with hematoxylin-eosin staining to elucidate histopathological changes associated with blast exposure. Cochlear tissues were evaluated for relative expression of ionized calcium-binding adaptor 1 (Iba1), as an indicator of microglial activation by immunohistochemistry and western blot analyses. RESULTS: Our animal model resulted in an acute injury mechanism manifested by damage to the tympanic membrane, hemorrhage, infiltration of inflammatory cells, and increased expression of Iba1 protein. Moreover, therapeutic intervention with NPD1 significantly reduced Iba1 expression in the cochlea, suggesting a reduction of a neuroinflammatory response caused by blast overpressure. CONCLUSIONS: Blast overpressure resulted in an increased expression of proteins involved in gliosis within the auditory system, which were reduced by NPD1. Treatment of NPD1 suggests an effective strategy to reduce or halt auditory microglial cell activation due to primary blast exposure. LEVEL OF EVIDENCE: NA Laryngoscope, 131:E2018-E2025, 2021.

Wearable Sensors Incorporating Compensatory Reserve Measurement for Advancing Physiological Monitoring in Critically Injured Trauma Patients.

Vital signs historically served as the primary method to triage patients and resources for trauma and emergency care, but have failed to provide clinically-meaningful predictive information about patient clinical status. In this review, a framework is presented that focuses on potential wearable sensor technologies that can harness necessary electronic physiological signal integration with a current state-of-the-art predictive machine-learning algorithm that provides early clinical assessment of hypovolemia status to impact patient outcome. The ability to study the physiology of hemorrhage using a human model of progressive central hypovolemia led to the development of a novel machine-learning algorithm known as the compensatory reserve measurement (CRM). Greater sensitivity, specificity, and diagnostic accuracy to detect hemorrhage and onset of decompensated shock has been demonstrated by the CRM when compared to all standard vital signs and hemodynamic variables. The development of CRM revealed that continuous measurements of changes in arterial waveform features represented the most integrated signal of physiological compensation for conditions of reduced systemic oxygen delivery. In this review, detailed analysis of sensor technologies that include photoplethysmography, tonometry, ultrasound-based blood pressure, and cardiogenic vibration are identified as potential candidates for harnessing arterial waveform analog features required for real-time calculation of CRM. The integration of wearable sensors with the CRM algorithm provides a potentially powerful medical monitoring advancement to save civilian and military lives in emergency medical settings.

Failure Pressures of Dural Repairs in a Porcine Ex Vivo Model: Novel Use of Titanium Clips Versus Tissue Glue.

OBJECTIVE: Endoscopic skull base surgery is advancing, and it is important to have reliable methods to repair the resulting defect. The objective of this study was to determine the failure pressures of 2 commonly used methods to repair large dural defects: collagen matrix underlay with fibrin glue and collagen matrix underlay with polyethylene glue, as well as a novel repair method: fascia lata with nonpenetrating titanium vascular clips. METHODS: The failure pressure of the 3 dural repairs was determined in a closed testing apparatus. Defects in porcine dura were created and collagen matrix grafts were used as an underlay followed by either fibrin glue (FG/CMG) or polyethylene glycol glue (PEG/CMG). A third condition using a segment of fascia lata was positioned flush with the edges of the dural defect and secured with titanium clips (TC/FL). Saline was infused to simulate increasing intracranial pressure (ICP) applied to the undersurface of the grafts until the repairs failed. RESULTS: The mean failure pressure of the PEG/CMG repair was 34.506 ± 14.822 cm H2O, FG/CMG was 12.413 ± 5.114 cm H2O, and TC/FL was 8.330 ± 3.483 cm H2O. There were statistically significant differences in mean failure pressures among the 3 repair methods. CONCLUSION: In this ex vivo model comparing skull base repairs' ability to withstand cerebrospinal fluid leak, the repairs that utilized PEG/CMG tolerated the greatest amount of pressure and was the only repair that exceeded normal physiologic ICP's. Repair methods utilizing glues generally tolerated higher pressures compared to the novel repair using clips alone.

Is Skin the Most Allogenic Tissue in Vascularized Composite Allotransplantation and a Valid Monitor of the Deeper Tissues?

Since the 1960s, skin has been considered to be the most allogenic tissue in humans. This tenet has remained unquestioned in the reconstructive transplant arena, which has led to skin serving as the sole monitor for early rejection in vascularized composite allotransplantation. In this article, the authors question the validity of this belief. The authors' hypothesis is that skin is not always an accurate monitor of rejection in the deep tissues, thus questioning the positive and negative predictive value of the punch biopsy for suspected vascularized composite allotransplantation rejection. A search was carried out identifying vascularized composite allotransplantation publications where the allogenicity of transplanted skin was evaluated. Eighteen publications claimed skin was found to be the most allogenic tissue in humans, justifying its use as a superior monitor for rejection. Eight publications demonstrated skin to be a poor monitor of rejection deeper to the skin. Two vascularized composite allotransplantation animal studies reported skin rejecting simultaneously with the deeper tissues. Finally, three publications discussed a skin and kidney allograft, transplanted simultaneously, indicating skin allogenicity was equivalent to the that of the kidney allograft. Much of the literature in human vascularized composite allotransplantation claims skin to be an excellent monitor of the deep tissues. The conclusion from this study is that skin does not always function as a good monitor for what could be rejecting in the deep tissues. The authors believe continued research is necessary to focus on expanding novel monitoring techniques and technologies to accurately diagnose vascularized composite allotransplantation rejection without tissue destruction.

Postoperative Continuous Positive Airway Pressure Use and Nasal Saline Rinses After Endonasal Endoscopic Skull Base Surgery in Patients With Obstructive Sleep Apnea: A Practice Pattern Survey.

BACKGROUND: Endoscopic skull base surgery continues to evolve in its indications, techniques, instrumentation, and postoperative care. As surgery of the skull base will often violate dura, intraoperative and postoperative cerebrospinal fluid (CSF) leak is not uncommon and represents a potential conduit for air and bacterial contamination. Patients with obstructive sleep apnea (OSA) requiring continuous positive airway pressure (CPAP) therapy undergoing skull base surgery represent a challenging group. However, there appears to be a paucity of consensus regarding the postoperative management of this patient population. The objective of this study is to examine practice patterns and expert opinion on the use of postoperative CPAP and nasal saline in patients with OSA. METHODS: A 14-item survey was generated by consensus among expert authors and distributed online to members of the North American Skull Base society and other international skull base community members. Data were analyzed for median, mean, and standard deviation variables. Subgroup analysis was completed between surgeons from different geographical locations and operative experience. SPSS22 was utilized for all complex statistical analysis and figures. RESULTS: Seventy-one responses were collected from skull base surgeons. In patients with OSA, respondents would resume patients' CPAP therapy after a mean of 10.1 days (median, 7; standard deviation [SD], 10.2), without a CSF leak. In the presence of a small CSF leak, the mean duration would increase to 14.3 days (median, 14; SD, 9.8) and to 20.7 days (median, 21; SD, 11.8) in the presence of a larger leak. A surgeon's choice to attribute the relationship between delaying the start of nasal saline and CPAP after the endoscopic skull base surgery with progressively more challenging skull base repair was found to be statistically significant ( P < .001). CONCLUSION: Saline and CPAP therapies are initiated after the endoscopic skull base surgical repairs by surgeons at an increasing temporal delay in relation to the degree and complexity of the skull base defect repaired.

International assessment of inter- and intrarater reliability of the International Frontal Sinus Anatomy Classification system.

BACKGROUND: Inconsistencies in the nomenclature of structures of the frontal sinus have impeded the development of a validated "reference standard" classification system that surgeons can reliably agree upon. The International Frontal Sinus Anatomy Classification (IFAC) system was developed as a consensus document, based on expert opinion, attempting to address this issue. The purposes of this study are to: establish the reliability of the IFAC as a tool for classifying cells in the frontal recess among an international group of rhinologists; and improve communication and teaching of frontal endoscopic sinus surgery (ESS). METHODS: Forty-two computed tomography (CT) scans, each with a marked frontal cell, were reviewed by 15 international fellowship-trained rhinologists. Each marked cell was classified into 1 of 7 categories described in the IFAC, on 2 occasions separated by 2 weeks. Inter- and intrarater reliability were evaluated using Light's kappa (κ), the interclass correlation coefficient (ICC), and simple proportion of agreement. RESULTS: Interrater reliability showed pairwise κ values ranging from 0.7248 to 1.0, with a mean of 0.9162 (SD, 0.0537). The ICC was 0.98. Intrarater reliability showed κ values ranging from 0.8613 to 1.0, with a mean of 0.9407 (SD, 0.0376). The within-rater ICC was 0.98. CONCLUSION: Among a diverse sample of rhinologists (raters), there was substantial to almost perfect agreement between raters, and among individual raters at different timepoints. The IFAC is a reliable tool for classification of cells in the frontal sinus. Further outcome studies are still needed to determine the validity of the IFAC.

Construct validity of a low-cost medium-fidelity endoscopic sinus surgery simulation model.

OBJECTIVE: Assess construct validity of a low-cost medium-fidelity silicone injection molded model task trainer for endoscopic sinus surgery (ESS) training. METHODS: Fellowship-trained rhinologists, otolaryngology attendings, and otolaryngology residents at various levels of training performed sinus endoscopy and seven procedures on the model. Construct validity was evaluated by comparing novice to various levels of experienced performance using a validated checklist. RESULTS: Thirty-two subjects participated in this study. Otolaryngology attendings and postgraduate year (PGY) 3 to 5 otolaryngology residents significantly outperformed PGY 1 to 2 otolaryngology residents on most tasks in the task-specific checklist. CONCLUSIONS: This study demonstrated the construct validity of the low-cost medium-fidelity ESS model. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1505-1509, 2019.

A challenge-response endoscopic sinus surgery specific checklist as an add-on to standard surgical checklist: an evaluation of potential safety and quality improvement issues.

BACKGROUND: The goal of this study was to develop and evaluate the impact of an aviation-style challenge and response sinus surgery-specific checklist on potential safety and equipment issues during sinus surgery at a tertiary academic health center. The secondary goal was to assess the potential impact of use of the checklist on surgical times during, before, and after surgery. This initiative is designed to be utilized in conjunction with the "standard" World Health Organization (WHO) surgical checklist. Although endoscopic sinus surgery is generally considered a safe procedure, avoidable complications and potential safety concerns continue to occur. The WHO surgical checklist does not directly address certain surgery-specific issues, which may be of particular relevance for endoscopic sinus surgery. METHODS: This prospective observational pilot study monitored compliance with and compared the occurrence of safety and equipment issues before and after implementation of the checklist. Forty-seven consecutive endoscopic surgeries were audited; the first 8 without the checklist and the following 39 with the checklist. The checklist was compiled by evaluating the patient journey, utilizing the available literature, expert consensus, and finally reevaluation with audit type cases. The final checklist was developed with all relevant stakeholders involved in a Delphi method. RESULTS: Implementing this specific surgical checklist in 39 cases at our institution, allowed us to identify and rectify 35 separate instances of potentially unsafe, improper or inefficient preoperative setup. These incidents included issues with labeling of topical vasoconstrictor or injectable anesthetics (3, 7.7%) and availability, function and/or position of video monitors (2, 5.1%), endoscope (6, 15.4%), microdebrider (6, 15.4%), bipolar cautery (6, 15.4%), and suctions (12, 30.8%). CONCLUSION: The design and integration of this checklist for endoscopic sinus surgery, has helped improve efficiency and patient safety in the operating room setting.

Algorithm for Management of the Refractive Aerosinusitis Patient.

Introduction: For some career military aviators, their ability to continue on flight status is limited by the pressure and pain of aerosinusitis, which is present only while in the flying environment. Failure to treat their disease process can mean the end of their flying careers and the loss of valuable assets trained with taxpayer dollars. Because some medications commonly used in treatment of sinus diseases are not allowed in aviation, this presents a unique problem for their medical management. Surgical treatment must be aimed at treating to symptom relief and not solely disease mitigation. One alternative is operating "beyond the scope of disease" present during a one-atmosphere clinic visit. Materials and Methods: A case series of nine career aviators with aerosinusitis treated at one academic military Otolaryngology department in a tertiary care facility. Results from a treatment algorithm that balances symptomatology and staged surgical intervention are reviewed. The primary endpoint was return to flight duty. Results: For patients treated according to this algorithm, the mean time to return to flight duty was 3.8 mo, requiring an average of 1.2 surgeries. To date, 100% of career aviators have returned to flight duty using this method. Conclusion: Refractory aerosinusitis represents a potentially career-ending medical condition for the aviator and lost training costs to the taxpayers. Using the treatment algorithm presented, 100% of aviators were able to return to flight duty; a savings of millions of dollars for taxpayers. Future work will focus on modifications to the surgical techniques to reduce the extent of surgery while maintaining satisfactory results. Additional study should be undertaken to assess generalizability of these results in the broader aviation community.

Teaching frontal sinus anatomy using the frontal sinus masterclass 3- D conceptualization model.

OBJECTIVE: Frontal sinus anatomy is complex and often is a difficult subject to both teach and learn. The traditional surgical dogma of "see one, do one, teach one" is impractical and dangerous in the frontal sinus. Based on the building block three-dimensional conceptualization module, the Frontal Sinus Masterclass (FSMC) was created to teach this anatomy. METHODS: Study was performed at two academic centers among second- to fifth-year otolaryngology residents. A pretest assessed knowledge prior to the course. Computed tomography scans of the sinuses were evaluated in triplanar view, and participants attempted to reconstruct the anatomy. Subsequently, the course instructor explained the anatomy using the building block method and showed a short video of the surgical dissection, pointing out relevant anatomy. Cases progressed in anatomical difficulty and inflammatory load. A posttest determined knowledge after the course. RESULTS: Thirty of 50 participating residents completed the pre- and posttests (14 junior, 16 senior residents). Correct identification of the frontal sinus drainage pathway increased from 42% to 63% correct (P = 0.054). Anatomical assessment increased from 61% to 68% correct (P = 0.047), and overall assessment increased from 52% to 66% correct (P = 0.016). CONCLUSION: Objectively, participants of the FSMC expanded on their ability to recognize cells of the frontal recess on CT scans. Before the class, residents could answer less than half of the answers correctly, and by the end of the class they were answering over two-thirds of these complex questions correctly. Subjectively, participants reported benefit from the course and felt they would be better surgeons. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:1294-1298, 2018.

An ergonomic assessment of operating table and surgical stool heights for seated otolaryngology procedures.

BACKGROUND: Musculoskeletal injuries, such as neck and back pain, during a surgeon's career are common. However, studies on ergonomics are limited with regard to seated otolaryngologic procedures. Key elements of an ergonomic operating environment include the height of operating tables and surgical chairs. Surgeons benefit from proper support and positioning to prevent musculoskeletal injuries and reduce occupational risk. OBJECTIVE: The purpose of this study was to evaluate operating table and surgical seat heights, and determine whether adjustments can be made for various surgeon physiques. METHODS: Operating tables and surgical seat dimensions were measured at local hospitals, and the information was complemented by an online search of other models. RESULTS: Five unique operating tables and five unique surgical stools were identified, both in the local hospital and in a search on the Internet. Of available tables, the greatest range was 63.5-124.5 cm, which reaches above the maximum suggested working height of 76.2 cm. The surgical stool with the widest range was adjustable from heights of 50.8-72.4 cm. This combination of operative table and surgical stool provided the greatest range of heights. CONCLUSION: Of the available tables and stools measured, the combination of surgical table with a range of 63.5-125.7 cm and surgical stool with a range of 50.8-72.4 cm provided the greatest versatility for diverse physician heights. In ergonomic terms, this combination may reduce physical fatigue and create a potentially safer working environment for seated surgeons.

Introducing a Novel Applicant Ranking Tool to Predict Future Resident Performance: A Pilot Study.

The purposes of this study are to (1) introduce our novel Applicant Ranking Tool that aligns with the Accreditation Council for Graduate Medical Education competencies and (2) share our preliminary results comparing applicant rank to current performance. After a thorough literature review and multiple roundtable discussions, an Applicant Ranking Tool was created. Feasibility, satisfaction, and critiques were discussed via open feedback session. Inter-rater reliability was assessed using weighted kappa statistic (κ) and Kendall coefficient of concordance (W). Fisher's exact tests evaluated the ability of the tool to stratify performance into the top or bottom half of their class. Internal medicine and anesthesiology residents served as the pilot cohorts. The tool was considered user-friendly for both data input and analysis. Inter-rater reliability was strongest with intradisciplinary evaluation (W = 0.8-0.975). Resident performance was successfully stratified into those functioning in the upper vs. lower half of their class within the Clinical Anesthesia-3 grouping (p = 0.008). This novel Applicant Ranking Tool lends support for the use of both cognitive and noncognitive traits in predicting resident performance. While the ability of this instrument to accurately predict future resident performance will take years to answer, this pilot study suggests the instrument is worthy of ongoing investigation.