***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objectives To evaluate construct validity of the Voxelman TempoSurg Virtual Reality ( VR ) temporal bone simulator by determining whether generated objective metrics can distinguish experienced otologic surgeons from intermediate and novice surgeons . Design Prospect i ve assessment study . Setting Two university-affiliated teaching hospitals . Participants Sixty-five participants were recruited ; 40 novice surgeons , 15 trainees in otolaryngology , and 10 experienced otolaryngology consultants with a specialist interest in otology were individually assessed on a st and ardized simulated temporal bone task . The task involved identification and delineation of the sigmoid sinus in a virtual left-sided temporal bone . Main Outcome Measures Objective data were produced using a scoring matrix incorporated into the VOXEL MAN TempoSurg software . The simulator measured the total time taken to complete the task , the volume and efficiency of bone removal and error data for excessive force or injury to the facial nerve , dura , and sigmoid sinus . Results Experts and intermediates outperformed novices with respect to the total time taken to complete the task ( expert versus novice : p < 0.001 ; intermediate versus novice : p < 0.001 ) , total volume of bone removed ( p < 0.001 and p = 0.03 ) , efficiency of bone removal ( p < 0.001 and p < 0.001 ) , time spent with the drill tip obscured ( p = 0.002 and p < 0.001 ) , and number of injuries to the sigmoid sinus ( p < 0.001 and p < 0.001 ) . The intermediate group injured the sigmoid sinus on more occasions than the experts ( p = 0.008 ) and were less efficient than experienced surgeons ( p = 0.005 ) . Conclusion Simulator-generated objective metrics can be used to differentiate individuals of differing levels of experience using a st and ardized temporal bone task . VR simulation has potential as a training tool and may have a role in both formative and summative assessment OBJECTIVES /HYPOTHESIS Surgical simulation is becoming an increasingly common training tool in residency programs . The first objective was to implement real-time soft-tissue deformation and cutting into a virtual reality myringotomy simulator . The second objective was to test the various implemented incision algorithms to determine which most accurately represents the tympanic membrane during myringotomy . STUDY DESIGN Descriptive and face-validity testing . METHODS A deformable tympanic membrane was developed , and three soft-tissue cutting algorithms were successfully implemented into the virtual reality myringotomy simulator . The algorithms included element removal , direction prediction , and Delaunay cutting . The simulator was stable and capable of running in real time on inexpensive hardware . A face-validity study was then carried out using a vali date d question naire given to eight otolaryngologists and four senior otolaryngology residents . Each participant was given an adaptation period on the simulator , was blinded to the algorithm being used , and was presented the three algorithms in a r and omized order . RESULTS A virtual reality myringotomy simulator with real-time soft-tissue deformation and cutting was successfully developed . The simulator was stable , ran in real time on inexpensive hardware , and incorporated haptic feedback and stereoscopic vision . The Delaunay cutting algorithm was found to be the most realistic algorithm representing the incision during myringotomy ( P < .05 ) . The Likert and visual analog scales had strong correlations , suggesting good internal reliability . CONCLUSIONS The first virtual reality myringotomy simulator is being developed and now integrates a real-time deformable tympanic membrane that appears to have face validity . Further development and validation studies are necessary before the simulator can be studied with respect to training efficacy and clinical impact Objective : To assess the impact of warm-up on laparoscopic performance in the operating room ( OR ) . Background : Implementation of simulation-based training into clinical practice remains limited despite evidence to show that the improvement in skills is transferred to the OR . The aim of this study was to evaluate the impact of a short virtual reality warm-up training program on laparoscopic performance in the OP . Methods : Sixteen Laparoscopic Cholecystectomies were performed by 8 surgeons in the OR . Participants were r and omized to a group which received a preprocedure warm-up using a virtual reality simulator and no warm-up group . After the initial laparoscopic cholecystectomy all surgeons served as their own controls by performing another procedure with or without preoperative warm-up . All OR procedures were videotaped and assessed by 2 independent observers using the generic OSATS global rating scale ( from 7 to 35 ) . Results : There was significantly better surgical performance on the laparoscopic Cholecystectomy following preoperative warm-up , median 28.5 ( range = 18.5–32.0 ) versus median 19.25 ( range = 15–31.5 ) , P = 0.042 . The results demonstrated excellent reliability of the assessment tool used ( Cronbach 's & agr ; = 0.92 ) . Conclusion : This study showed a significant beneficial impact of warm-up on laparoscopic performance in the OP . The suggested program is short , easy to perform , and therefore realistic to implement in the daily life in a busy surgical department . This will potentially improve the procedural outcome and contribute to improved patient safety and better utilization of OR re sources Objective . To vali date the VOXEL-MAN TempoSurg simulator for temporal bone dissection . Study Design . Prospect i ve international study . Setting . Otolaryngology departments of 2 academic health care institutions in the United Kingdom and United States . Subjects and Methods . Eighty-five subjects were recruited consisting of an experienced and referent group . Participants performed a st and ardized familiarization session and temporal bone dissection task .  Realism , training effectiveness , and global impressions were evaluated across 21 domains using a 5-point Likert-type scale . A score of 4 was the minimum threshold for acceptability . Results . The experienced group comprised 25 otolaryngology trainers who had performed 150 mastoid operations . The referent group comprised 60 trainees ( mean otolaryngology experience of 2.9 years ) . Familiarization took longer in the experienced group ( P = .01 ) . User-friendliness was positively rated ( mean score 4.1 ) . Seventy percent of participants rated anatomical appearance as acceptable . Trainers rated drill ergonomics worse than did trainees ( P = .01 ) .  Simulation temporal bone training  scored highly ( mean score 4.3 ) . Surgical anatomy , drill navigation , and h and -eye coordination accounted for this . Trainees were more likely to recommend  temporal bone simulation  to a colleague than were trainers ( P = .01 ) . Transferability of skills to the operating room was undecided ( mean score 3.5 ) . Conclusion . Realism of the VOXEL-MAN virtual reality temporal bone simulator is suboptimal in its current version . Nonetheless , it represents a useful adjunct to existing training methods and is particularly beneficial for novice surgeons before performing cadaveric temporal bone dissection . Improvements in realism , specifically drill ergonomics and visual-spatial perception during deeper temporal bone dissection , are warranted OBJECTIVE The objective of this study is to determine the feasibility of computerized evaluation of  resident performance using h and motion analysis on a virtual reality temporal bone ( VR TB ) simulator . We hypothesized that both computerized analysis and expert ratings would discriminate the performance of novices from experienced trainees . We also hypothesized that performance on the virtual reality temporal bone simulator ( VR TB ) would differentiate based on previous drilling experience . STUDY DESIGN The authors conducted a r and omized , blind assessment study . METHODS Nineteen volunteers from the Otolaryngology-Head and Neck Surgery training program at the University of Toronto drilled both a cadaveric TB and a simulated VR TB . Expert review ers were asked to assess operative readiness of the trainee based on a blind video review of their performance . Computerized h and motion analysis of each participant 's performance was conducted . RESULTS Expert raters were able to discriminate novices from experienced trainees ( P < .05 ) on cadaveric temporal bones , and there was a trend toward discrimination on VR TB performance . H and motion analysis showed that experienced trainees had better movement economy than novices ( P < .05 ) on the VR TB . CONCLUSION Performance , as measured by h and motion analysis on the VR TB simulator , reflects trainees ' previous drilling experience . This study suggests that otolaryngology trainees could accomplish initial temporal bone training on a VR TB simulator , which can provide feedback to the trainee , and may reduce the need for constant faculty supervision and evaluation OBJECTIVES To establish discriminant validity of the endoscopic sinus surgery simulator ( ES3 ) ( Lockheed Martin , Akron , Ohio ) between various health care provider experience levels and to define benchmarking criteria for skills assessment . DESIGN Prospect i ve multi-institutional comparison study . SETTING University-based tertiary care institution . PARTICIPANTS Ten expert otolaryngologists , 14 otolaryngology residents , and 10 medical students . INTERVENTIONS Subjects completed the ES3 's virtual reality curriculum ( 10 novice mode , 10 intermediate mode , and 3 advanced mode trials ) . Performance scores were recorded on each trial . Performance differences were analyzed using analysis of variance for repeated measures ( experience level as between-subjects factor ) . MAIN OUTCOME MEASURES Simulator performance scores , accuracy , time to completion , and hazard disruption . RESULTS The novice mode accurately distinguished the 3 groups , particularly at the onset of training ( mean scores : senior otolaryngologists , 66.0 ; residents , 42.7 ; students , 18.3 ; for the paired comparisons between groups 1 and 2 and groups 1 and 3 , P = .04 and .03 , respectively ) . Subjects were not distinguished beyond trial 5 . The intermediate mode only discriminated students from other subjects ( P = .008 ) . The advanced mode did not show performance differences between groups . Scores on the novice mode predicted those on the intermediate mode , which predicted advanced mode scores ( r = 0.687 ) , but no relationship was found between novice and advanced scores . All groups performed equally well and with comparable consistency at the outset of training . Expert scores were used to define benchmark criteria of optimal performance . CONCLUSIONS This study completes the construct validity assessment of the ES3 by demonstrating its discriminant capabilities . It establishes expert surgeon benchmark performance criteria and shows that the ES3 can train novice subjects to attain those . The refined analysis of trial performance scores could serve educational and skills assessment purpose s. Current studies are evaluating the transfer of surgical skills acquired on the ES3 to the operating room ( predictive validity ) Objective : Establish the feasibility of a predictive validity study in sinus surgery simulation training and demonstrate the effectiveness of the Endoscopic Sinus Surgery Simulator ( ES3 ) as a training device . Study Design : Prospect i ve , multi-institutional controlled trial . Setting : Four tertiary academic centers with accredited otolaryngology-head and neck surgery residency programs . Subjects : Twelve ES3-trained novice residents were compared with 13 control novice residents . Methods : Subjects were assessed on the performance of basic sinus surgery tasks . Their first in vivo procedure was video recorded and su bmi tted to a blinded panel of independent experts after the panel established a minimum inter-rater reliability of 80 percent . The recordings were review ed by using a st and ardized computer-assisted method and customized metrics . Results were analyzed with the Mann-Whitney U test . Internal rater consistency was verified with Pearson moment correlation . Results : Completion time was significantly shorter in the experimental group ( injection P = 0.003 , dissection P < 0.001 ) , which , according to the rater panel , also demonstrated higher confidence ( P = 0.009 ) , demonstrated skill during instrument manipulation ( P = 0.011 ) , and made fewer technical mistakes during the injection task ( P = 0.048 ) compared with the control group . The raters ' post hoc internal consistency was deemed adequate ( r > 0.5 between serial measurements ) . Conclusion : The validity of the ES3 as an effective surgical trainer was verified in multiple instances , including those not depending on subjective rater evaluations . The ES3 is one of the few virtual reality simulators with a comprehensive validation record . Advanced simulation technologies need more rapid implementation in otolaryngology training , as they present noteworthy potential for high- quality surgical education while meeting the necessity of patient safety OBJECTIVES /HYPOTHESIS To assess whether practice on a virtual-reality ( VR ) temporal bone simulator improves acquisition of technical skills in mastoid surgery . STUDY DESIGN Prospect i ve blinded study . METHODS Using a previously vali date d objective structured assessment of technical skills ( OSATS ) tool , performance was assessed in 12 residents for two tasks of  cortical mastoidectomy : 1 ) identifying and defining the tegmen and 2 ) defining the sigmoid sinus and sinodural angle . These surgical tasks were chosen as key steps in mastoid dissection because they were of intermediate complexity . Videos of virtual dissections were captured at baseline and again after practicing each task four to six times . RESULTS OSATS scores for the tegmen task increased from 2.125 ± 1.25 to 3.1 ± 0.85 ( P = .026 ) , whereas for the sigmoid task scores increased from 2 ± 0.45 to 2.75 ± 1.125 ( P = .0098 ) . The time to complete the tasks decreased from 8.37 ± 4.78 minutes to 5.39 ± 3.06 minutes ( P = .018 ) 
    Output:
    
Construct validation studies performed on temporal bone and endoscopic sinus surgery simulators showed that performance measures reliably discriminated between different experience levels .
Simulation training  improved cadaver temporal bone dissection skills and operating room performance in sinus surgery .
Several simulator platforms particularly in temporal bone surgery and endoscopic sinus surgery are worthy of incorporation into training programmes .