OBJECTIVES Spontaneous sternoclavicular joint infection (SSCJI) is a rare and poorly understood disease process. This study aims to identify factors guiding effective management strategies for SSCJI by using data mining. METHODS An Institutional Review Board-approved retrospective review of patients from 2 large hospitals (2010-2022) was conducted. SSCJI is defined as a joint infection without direct trauma or radiation, direct instrumentation or contiguous spread. An interdisciplinary team consisting of thoracic surgeons, radiologists, infectious disease specialists, orthopaedic surgeons, hospital information experts and systems engineers selected relevant variables. Small set data mining algorithms, utilizing systems engineering, were employed to assess the impact of variables on patient outcomes. RESULTS A total of 73 variables were chosen and 54 analysed against 11 different outcomes. Forty-seven patients [mean age 51 (22-82); 77% male] met criteria. Among them, 34 underwent early joint surgical resection (<14 days), 5 patients received delayed surgical intervention (>14 days) and 8 had antibiotic-only management. The antibiotic-only group had comparable outcomes. Indicators of poor outcomes were soft tissue fluid >4.5 cm, previous SSCJI, moderate/significant bony fragments, HgbA1c >13.9% and moderate/significant bony sclerosis. CONCLUSIONS This study suggests that targeted antibiotic-only therapy should be considered initially for SSCJI cases while concurrently managing comorbidities. Patients displaying indicators of poor outcomes or no symptomatic improvement after antibiotic-only therapy should be considered for surgical joint resection.

PURPOSE:Simulation-based education (SBE) provides experiential learning, improvement in quality of care, and reduction in errors. In 2011, the Association of American Medical Colleges described adoption of SBE in 68.0% of medical schools and 25.0% of teaching hospitals. We sought to examine current trends of SBE integration in American undergraduate medical education since previous publications.METHODS:From 2016 to 2019, University of Texas Southwestern Medical Center postgraduate year 1 residents were invited to participate in a survey assessing medical school simulation experience with 26 clinical tasks from three categories: procedural, communication, and other. Deidentified results were analyzed to assess demographics including sex, specialty, residency program type, allopathic versus osteopathic medical school, and medical school region.RESULTS:Nine hundred sixty-seven of 1047 (92.3%) responses were obtained, representing 139 US medical schools, 91% from allopathic training. Of procedural tasks, most simulated was suturing (n = 848, 89.6%) and least simulated was thoracentesis (n = 737, 80.9%). Of communication tasks, most simulated was taking a history (n = 475, 51.1% reporting simulation >30) and least simulated (never or ≤1) were obtaining a consent (n = 669, 73.2%) and disclosing a medical error (n = 666, 72.4%). Of other tasks, most simulated was chest compressions (n = 898, 96.0%) and least simulated was operating a defibrillator (n = 206, 22.1%). Results were similar regardless of procedural or nonprocedural program. There was no significant difference in SBE exposure between allopathic and osteopathic students ( P = 0.89). Two participants (0.002%) reported no simulation exposure.CONCLUSIONS:Our study is the first to describe a high prevalence of SBE adoption in medical schools nationwide since the Association of American Medical Colleges' 2011 publication, with overall equal exposure for students regardless of residency type and allopathic or osteopathic medical school. Despite widespread adoption of simulation, opportunities remain to expand SBE use to teach critically important communication skills.

Objective: Our objective was to evaluate for any changes in quality or cost when robotic lung resection is used with significant trainee participation. Methods: All anatomic lung resections between January 2006 and June 2016 were identified from a prospectively maintained database. Clinical data were recorded by double entry. Cost and cancer-related data were gathered from the business analytics department and tumor registry. Robotic outcomes were compared to an ongoing thoracotomy and video-assisted thoracic surgery (VATS) experience. Propensity scores using age, sex, and comorbidities were assigned for statistical analysis. Survival was evaluated using the Kaplan-Meier method. Results: Of 523 consecutive cases, 483 were included (211 robotic, 210 thoracotomy, 62 VATS). There were 74 robotic cases (35%) performed by trainees as the console surgeon. Length of stay was shortest for robotics (3 days) compared to thoracotomy (7 days, P < 0.001) and VATS (5 days, P = 0.010). Complications occurred in 33% of robotic cases, 42% of VATS cases (P = 0.854), and 52% of thoracotomy cases (P < 0.001). Stage I non-small cell lung cancer 3-year overall survival for robotics, thoracotomy, and VATS was 79.5%, 74.3%, and 74.0%, respectively (P > 0.25). There was no significant difference in negative margin rates. Total cost related to the hospitalization for surgery was $5,721 less for robotics compared to thoracotomy (P = 0.003) but comparable to VATS. Trainees served as console surgeon in 0% of cases in the first 2 years of robotics but increased to 79% in the last year of the study. Conclusions: Robotic lung resection can be safely performed and taught in an academic medical center without sacrificing quality or cost.

PROBLEM:Medical students often have preferences regarding the order of their clinical rotations, but assigning rotations fairly and efficiently can be challenging. To achieve a solution that optimizes assignments (i.e., maximizes student satisfaction), the authors present a novel application of the Hungarian algorithm, designed at the University of Texas Southwestern Medical Center (UTSW), to assign student schedules.APPROACH:Possible schedules were divided into distinct pathway options with k total number of seats. Each of n students submitted a ranked list of their top 5 pathway choices. An n × k matrix was formed, where the location (i, j) represented the cost associated with student i being placed in seat j. Progressively higher costs were assigned to students receiving less desired pathways. The Hungarian algorithm was then used to find the assignments that minimize total cost. The authors compared the performance of the Hungarian algorithm against 2 alternative algorithms (i.e., the rank and lottery algorithms). To evaluate the 3 algorithms, 4 simulations were conducted with different popularity weights for different pathways and were run across 1,000 trials. The algorithms were also compared using 3 years of UTSW student preference data for the classes of 2019, 2020, and 2021.OUTCOMES:In all 4 computer simulations, the Hungarian algorithm resulted in more students receiving 1 of their top 3 choices and fewer students receiving none of their preferences. Similarly, for UTSW student preference data, the Hungarian algorithm resulted in more students receiving 1 of their top 3 preferences and fewer students receiving none of their ranked preferences.NEXT STEPS:This approach may be broadly applied to scheduling challenges in undergraduate and graduate medical education. Furthermore, by manipulating cost values, additional constraints can be enforced (e.g., requiring certain seats to be filled, attempting to avoid schedules that begin with a student's desired specialty).

Background: Enhanced recovery pathways (ERPs) can decrease length of stay (LOS) and improve colorectal surgery outcomes in private health care; however, their efficacy in the public realm, comprised largely of underserved and uninsured patients, remains uncertain. Materials and methods: An ERP without social interventions was implemented at a private hospital (PH) and a safety-net hospital (SNH) within a large academic medical center in 2014. Process and outcome metrics from 100 patients in the 18 mo before ERP implementation at each institution were retrospectively compared with a similar group after ERP implementation. Primary outcomes were LOS, 30-d readmission, and reoperation. Results: Post-ERP groups were older than pre-ERP (P = 0.047, 0.034), with no difference in sex or body mass index. Rate of open versus minimally invasive was similar at the SNH (P = 0.067), whereas more post-ERP patients at PH underwent open surgery (P = 0.002). Ninety six percentage of PH patients were funded through private insurance or Medicare, verses 6% at the SNH. LOS at PH decreased from 8.1 to 5.9 d (P = 0.028) and at SNH from 7.0 to 5.1 d (P = 0.004). There was no change in 30-d all-cause readmission (PH P = 0.634; SNH P = 1) or reoperation (PH P = 0.610; SNH P = 0.066). Conclusions: ERP reduced LOS in both private and safety-net settings without addressing social determinants of health. Readmission and reoperation rates were unchanged. As health care moves toward a bundled payment model, ERP can help optimize outcomes and control costs in the public arena. Published by Elsevier Inc.

Shaikh et al1 claim that combining the American Society of Anesthesiologists Physical Status Classification System (ASA) and Caprini scores improves the ability to predict venous thromboembolism (VTE) in plastic surgery patients. The authors' Table 9 reports the sensitivity and specificity for both risk assessment models individually, and then a combined test using ASA and Caprini scores. The authors report a sensitivity of 86.6% for the combined test. No data are presented to support this dramatically improved index. According to the authors,1 such a combined screening test would be positive if the patient had both an ASA score ≥3 and a Caprini score ≥5. In fact, combining methods can only decrease the test sensitivity because the subset of patients meeting high-risk criteria for both models would be less than the number identified using either individually. The maximum possible number of true positives for the combined test would be 13, for a sensitivity of 54.2%, and this level would only be achieved in the unlikely event that all 13 patients with an ASA score ≥3 also had Caprini scores ≥5. Similarly, the authors …

Background: Anatomical studies show that facial fat is partitioned into distinct compartments, with the nasolabial fat pad in a superficial compartment and the deep medial cheek fat in a deep compartment. Gross morphologic differences may exist between these fat depots, but this has never been established at the cellular level.Methods: Adipose tissue specimens from nasolabial fat and deep medial cheek fat pads were obtained from 63 cadaveric specimens (38 female and 25 male cadavers) aged 47 to 101 years (mean, 71 years). Thirty-seven cadavers had a normal body mass index (<= 25 kg/m(2)) and 26 cadavers had a high body mass index (>25 kg/m(2)). Cross-sectional areas of individual adipocytes were calculated digitally and averaged from histologic sections of the adipose tissue samples.Results: The average adipocyte size of nasolabial fat is significantly (p < 0.0001) larger than that of deep medial cheek fat. The average adipocyte size in both nasolabial and deep medial cheek fat is significantly (p < 0.0001) larger in subjects with high compared with low body mass index. Although the overall average adipocyte size is significantly (p < 0.0001) larger in female than in male subjects, this sexual dimorphism is lost in the nasolabial fat depots of overweight subjects and in the deep medial cheek depots of normal-weight subjects.Conclusions: The significantly smaller adipocyte size in deep medial cheek fat relative to nasolabial fat in elderly subjects supports the theory that deep and superficial facial fat pads are morphologically different. Future investigation of the metabolic and structural properties of these fat compartments will help us understand the different patterns of volumetric facial aging.

Background: Little evidence within plastic surgery literature supports the precept that longer operative times lead to greater morbidity.Objective: The authors investigate surgery duration as a determinant of morbidity, with the goal of defining a clinically relevant time for increased risk.Methods: A retrospective chart review was conducted of patients who underwent a broad range of complex plastic surgical procedures (n = 1801 procedures) at UT Southwestern Medical Center in Dallas, Texas, from January 1, 2008 to January 31, 2012. Adjusting for possible confounders, multivariate logistic regression assessed surgery duration as an independent predictor of morbidity. To define a cutoff for increased risk, incidence of complications was compared among quintiles of surgery duration. Stratification by type of surgery controlled for procedural complexity.Results: A total of 1753 cases were included in multivariate analyses with an overall complication rate of 27.8%. Most operations were combined (75.8%), averaging 4.9 concurrent procedures. Each hour increase in surgery duration was associated with a 21% rise in odds of morbidity (P < .0001). Compared with the first quintile of operative time (<2.0 hours), there was no change in complications until after 3.1 hours of surgery (odds ratio, 1.6; P = .017), with progressively greater odds increases of 3.1 times after 4.5 hours (P < .0001) and 4.7 times after 6.8 hours (P < .0001). When stratified by type of surgery, longer operations continued to be associated with greater morbidity.Conclusions: Surgery duration is an independent predictor of complications, with a significantly increased risk above 3 hours. Although procedural complexity undoubtedly affects morbidity, operative time should factor into surgical decision making. Level of Evidence: 3

Background: The Caprini Risk Assessment Model is used to categorize patient risk for venous thromboembolism (VTE) events; its predictive associations have been repeatedly corroborated. Calculating scores involves consideration of systemic factors that may predict other postoperative complications.Objective: This study investigates whether Caprini scores can be applied to non-VTE complications.Methods: The authors undertook a retrospective chart review of 1598 encounters for a series of complex reconstructive and body contouring operations at an academic medical institution. Input variables included Caprini score components, patient comorbidities, and prophylactic use of antithrombotic drugs. Output variables were postoperative complications. Tests for proportions were performed on percentile data. Nonpercentile data were treated with comparison of means (t test). Odds ratios for complications were calculated for stratified risk groups and compared.Results: The overall complication rate was 28.03%. Deep vein thrombosis (DVT) incidence was 1.50%. Differences in age, body mass index (BMI), operation time, hypertension, diabetes, renal disease, and cancer were statistically significant between patients who experienced complications and those who did not. For DVT versus DVT-free patients, differences in sex, BMI, operation time, smoking status, diabetes, hypertension, and prior DVT were significant. Caprini scores identified 628 encounters as low risk (0-4) and 970 as high risk (>5). Dehiscence, infection, necrosis, seroma, hematoma, and overall complication rate significantly increased the incidence for the high-risk group.Conclusions: Caprini scores can be used as valuable predictors for some non-VTE postoperative complications (dehiscence, infection, seroma, hematoma, and necrosis). In addition to VTE events, clinicians should pay special attention to clinical signs indicative of the complications listed above when dealing with high-risk, high-Caprini score patients.