The double-stapled (DS) anastomotic technique associates with lower odds of anastomotic leak and stricture. SS, Single posterior stapled.

OBJECTIVE:Existing approaches for assessing surgical performance are subjective and prone to bias. In contrast, utilizing digital kinematic and system data from the surgical robot allows the calculation of objective performance indicators (OPIs) that may differentiate technical skill and competency. This study compared OPIs of trainees and attending surgeons to assess differences during robotic lobectomy (RL).METHODS:There were 50 cardiothoracic surgery residents and 7 attending surgeons who performed RL on a left upper lobectomy of an ex vivo perfused model. A novel recorder simultaneously captured video and data from the system and instruments. The lobectomy was annotated into discrete tasks, and OPIs were analyzed for both hands during 6 tasks: exposure of the superior pulmonary vein, upper division of the pulmonary artery and bronchus, and the stapling of these structures.RESULTS:There were significant differences between attendings and trainees in all tasks. Among 20 OPIs during exposure tasks, significant differences were observed for the left hand in 31 of 60 (52%) of OPIs and for the right hand in 42 of 60 (70%). During stapling tasks, significant differences were observed for the stapling hand in 28 of 60 (47%) of OPIs and for the nonstapling hand in 14 of 60 (25%).CONCLUSIONS:Use of a novel data and video recorder to generate OPIs for both hands revealed significant differences in the operative gestures performed by trainees compared to attendings during RL. This method of assessing performance has potential for establishing objective competency benchmarks and use for tracking progress.

BACKGROUND: Appropriate risk stratification of indeterminate pulmonary nodules (IPNs) is necessary to direct diagnostic evaluation. Currently available models were developed in populations with lower cancer prevalence than that seen in thoracic surgery and pulmonology clinics and usually do not allow for missing data. We updated and expanded the Thoracic Research Evaluation and Treatment (TREAT) model into a more generalized, robust approach for lung cancer prediction in patients referred for specialty evaluation.RESEARCH QUESTION: Can clinic-level differences in nodule evaluation be incorporated to improve lung cancer prediction accuracy in patients seeking immediate specialty evaluation compared with currently available models?STUDY DESIGN AND METHODS: Clinical and radiographic data on patients with IPNs from six sites (N = 1,401) were collected retrospectively and divided into groups by clinical setting: pulmonary nodule clinic (n = 374; cancer prevalence, 42%), outpatient thoracic surgery clinic (n = 553; cancer prevalence, 73%), or inpatient surgical resection (n = 474; cancer prevalence, 90%). A new prediction model was developed using a missing data-driven pattern submodel approach. Discrimination and calibration were estimated with cross-validation and were compared with the original TREAT, Mayo Clinic, Herder, and Brock models. Reclassification was assessed with biascorrected clinical net reclassification index and reclassification plots.RESULTS: Two-thirds of patients had missing data; nodule growth and fluorodeoxyglucose-PET scan avidity were missing most frequently. The TREAT version 2.0 mean area under the receiver operating characteristic curve across missingness patterns was 0.85 compared with that of the original TREAT (0.80), Herder (0.73), Mayo Clinic (0.72), and Brock (0.68) models with improved calibration. The bias-corrected clinical net reclassification index was 0.23. INTERPRETATION: The TREAT 2.0 model is more accurate and better calibrated for predicting lung cancer in high-risk IPNs than the Mayo, Herder, or Brock models. Nodule calculators such as TREAT 2.0 that account for varied lung cancer prevalence and that consider missing data may provide more accurate risk stratification for patients seeking evaluation at specialty nodule evaluation clinics. CHEST 2023; 164(5):1305-1314

Background Appropriate risk stratification of indeterminate pulmonary nodules (IPNs) is necessary to direct diagnostic evaluation. Currently available models were developed in populations with lower cancer prevalence than that seen in thoracic surgery and pulmonology clinics and usually do not allow for missing data. We updated and expanded the Thoracic Research Evaluation and Treatment (TREAT) model into a more generalized, robust approach for lung cancer prediction in patients referred for specialty evaluation. Research Question Can clinic-level differences in nodule evaluation be incorporated to improve lung cancer prediction accuracy in patients seeking immediate specialty evaluation compared with currently available models? Study Design and Methods Clinical and radiographic data on patients with IPNs from six sites (N = 1,401) were collected retrospectively and divided into groups by clinical setting: pulmonary nodule clinic (n = 374; cancer prevalence, 42%), outpatient thoracic surgery clinic (n = 553; cancer prevalence, 73%), or inpatient surgical resection (n = 474; cancer prevalence, 90%). A new prediction model was developed using a missing data-driven pattern submodel approach. Discrimination and calibration were estimated with cross-validation and were compared with the original TREAT, Mayo Clinic, Herder, and Brock models. Reclassification was assessed with bias-corrected clinical net reclassification index and reclassification plots. Results Two-thirds of patients had missing data; nodule growth and fluorodeoxyglucose-PET scan avidity were missing most frequently. The TREAT version 2.0 mean area under the receiver operating characteristic curve across missingness patterns was 0.85 compared with that of the original TREAT (0.80), Herder (0.73), Mayo Clinic (0.72), and Brock (0.68) models with improved calibration. The bias-corrected clinical net reclassification index was 0.23. Interpretation The TREAT 2.0 model is more accurate and better calibrated for predicting lung cancer in high-risk IPNs than the Mayo, Herder, or Brock models. Nodule calculators such as TREAT 2.0 that account for varied lung cancer prevalence and that consider missing data may provide more accurate risk stratification for patients seeking evaluation at specialty nodule evaluation clinics.

Background: Patients who are symptomatic from diaphragmatic dysfunction may benefit from diaphragmatic plication. We recently modified our plication approach from open thoracotomy to robotic transthoracic. We report our short-term outcomes.Methods: We conducted a single-institution retrospective review of all patients who underwent transthoracic plications from 2018, when we began using the robotic approach, to 2022. The primary outcome was short-term recurrence of diaphragm elevation with symptoms noted before or during the first planned postoperative visit. We also compared proportions of short-term recurrences in patients that underwent plication with extracorporeal knot-tying device alone versus those that used intracorporeal instrument tying (alone or supplemental). Secondary outcomes included subjective postoperative improvement of dyspnea at follow-up visit and by postoperative patient questionnaire, chest tube duration, length of stay (LOS), 30-day readmission, operative time, estimated blood loss (EBL), intraoperative complications, and perioperative complications.Results: Forty-one patients underwent robotic-assisted transthoracic plication. Four patients experienced recurrent diaphragm elevation with symptoms before or during their first routine postoperative visit, occurring on POD 6, 10, 37, and 38. All four recurrences occurred in patients whose plications were performed with the extracorporeal knot-tying device without supplemental intracorporeal instrument tying. Proportion of recurrences in the group that used extracorporeal knot-tying device alone was significantly greater than the recurrences in the group that used intracorporeal instrument tying (alone or supplemental) (P=0.016). The majority (36/41) reported clinical improvement postoperatively and 85% of questionnaire respondents also agreed they would recommend the surgery to others with similar condition. The median LOS and of chest tube duration were 3 days and 2 days, respectively. There were two patients with 30-day readmissions. Three patients developed postoperative pleural effusion necessitating thoracenteses and 8 patients (20%) had postoperative complications. No mortalities were observed.Conclusions: While our study shows the overall acceptable safety and favorable outcomes in patients undergoing robotic-assisted transthoracic diaphragmatic plications, the incidence of short-term recurrences and its association with the use of extracorporeally knot-tying device alone in diaphragm plication warrant further investigation.

Pulmonary hypertension (PH) is a recognized risk factor for perioperative morbidity and mortality. Select patients with PH can safely undergo pulmonary resection, but they remain at increased risk for postoperative complications.1

Scholarship is a key element in the development of young thoracic surgeons as they mature as clinicians, scientists, and educators.Its importance cannot be overstated in the complex development of these young, critical thinkers who must assimilate knowledge, judgment, and skills in the practice of lifelong learning for the care and betterment of their patients.The Accreditation Council for Graduate Medical Education has recognized the importance of scholarly activity as an integral part of thoracic surgery training and as part of its core requirements. 1Residents are expected to achieve scholarship activities in areas that include discovery, integration, application, and teaching, and latitude is provided to every program to fulfill these goals and objectives; arguably, the most challenging activity occurs with research that ultimately results in peer-reviewed publications.The expectation is that each program provides the opportunities and resources to facilitate resident participation in scholarly activities consistent with its mission and aims.Yet, program directors frequently struggle with ways to satisfy the requirements.Residents are not permitted to have a protected research rotation as part of their clinical training, and scholarly activity does not occur except in arenas in which dedicated program support is available.Coyan and colleagues 2 report the results of their structured protocol that significantly increased the academic productivity of their cardiothoracic surgery residents (I-6 and traditional) measured primarily by the number of peer-reviewed publications.Their methods included the provision of a

Surgical training relies on subjective feedback on resident technical performance by attending surgeons. A novel data recorder connected to a robotic-assisted surgical platform captures synchronized kinematic and video data during an operation to calculate quantitative, objective performance indicators (OPIs). The aim of this study was to determine if OPIs during initial task of a resident's robotic-assisted lobectomy (RL) correlated with bleeding during the procedure. Forty-six residents from the 2019 Thoracic Surgery Directors Association Resident Boot Camp completed RL on an ex vivo perfused porcine model while continuous video and kinematic data were recorded. For this pilot study, RL was segmented into 12 tasks and OPIs were calculated for the initial major task. Cases were reviewed for major bleeding events and OPIs of bleeding cases were compared to those who did not. Data from 42 residents were complete and included in the analysis. 10/42 residents (23.8%) encountered bleeding: 10/40 residents who started with superior pulmonary vein exposure and 0/2 residents who started with pulmonary artery exposure. Twenty OPIs for both hands were assessed during the initial task. Six OPIs related to instrument usage or smoothness of motion were significant for bleeding. Differences were statistically significant for both hands (p < 0.05). OPIs showing bimanual asymmetry indicated lower proficiency. This study demonstrates that kinematic and video analytics can establish a correlation between objective performance metrics and bleeding events in an ex vivo perfused lobectomy. Further study could assist in the development of focused exercises and simulation on objective domains to help improve overall performance and reducing complications during RL.

Background: Lung cancer patients often have comorbidities that may impact survival. This observational cohort study examines whether coronary artery calcifications (CAC) impact all-cause mortality in patients with resected stage I non-small cell lung cancer (NSCLC). Methods: Veterans with stage I NSCLC who underwent resection at a single institution between 2005 and 2018 were selected from a prospectively collected database. Radiologists blinded to patient outcomes graded CAC severity (mild, moderate, or severe) in preoperative CT scans using a visual estimation scoring system. Inter-rater reliability was calculated using the kappa statistic. All-cause mortality was the primary outcome. Kaplan-Meier survival analysis and Cox proportional hazards regression were used to compare time-to-death by varying CAC. Results: The Veteran patients (n=195) were predominantly older (median age of 67) male (98%) smokers (96%). The majority (68%) were pathologic stage IA. Overall, 12% of patients had no CAC, 27% mild, 26% moderate, and 36% severe CAC. Median unadjusted survival was 8.8 years for patients with absent or mild CAC versus 6.3 years for moderate and 5.9 years for severe CAC (P=0.01). The adjusted hazard ratio for moderate CAC was 1.44 (95% CI, 0.85-2.46) and for severe CAC was 1.73 (95% CI, 1.03-2.88; P for trend <0.05). Conclusions: The presence of severe CAC on preoperative imaging significantly impacted the all-cause survival of patients undergoing resection for stage I NSCLC. This impact on mortality should be taken into consideration by multidisciplinary teams when making treatment plans for patients with early-stage disease.

BACKGROUND:We examined how intercostal nerve block (ICNB) with standard bupivacaine and ICNB with extended-release liposomal bupivacaine, compared with thoracic epidural analgesia (TEA), were associated with postoperative opioid pain medication consumption and hospital length of stay (LOS) after thoracic surgery.METHODS:We studied 1935 patients who underwent thoracic surgery between January 1, 2010, and November 30, 2017, at a tertiary academic center. Primary and secondary outcomes were postoperative opioid consumption expressed as morphine milligram equivalents (MMEs) at 24, 48, and 72 hours after surgery, the LOS, and total MME consumption from surgery to discharge.RESULTS:Of these patients, 888 (45.9%) received TEA, 730 (37.7%) ICNB with standard bupivacaine, 127 (6.6%) ICNB with liposomal bupivacaine, and 190 (9.8%) no regional analgesia. Compared with epidural analgesia, in 2017, ICNB liposomal bupivacaine provided similar pain control in terms of MME consumption at 24 and 72 hours, but decreased MME consumption at 48 hours (odds ratio [OR] = 0.33; confidence interval [CI] = 0.14-0.81) and at discharge (OR = 0.28; CI = 0.12-0.68) and was associated with a higher likelihood for a shorter LOS (hazard ratio = 3.46; CI = 2.42-4.96). Compared with TEA, ICNB with standard bupivacaine and no regional analgesia use showed varying impact on MME consumption between 24 and 72 hours after surgery, and their use was not associated with a significantly reduced MME consumption at discharge but with a shorter hospital LOS.CONCLUSIONS:Multimodal analgesia involving regional anesthetic alternatives to TEA could help manage postoperative pain in thoracic surgery patients.

Central MessageThe transclavicular approach for anterior superior sulcus tumors provides excellent exposure of the critical neurovascular, skeletal, and pulmonary structures for dissection and resection.See Article page 527. The transclavicular approach for anterior superior sulcus tumors provides excellent exposure of the critical neurovascular, skeletal, and pulmonary structures for dissection and resection. See Article page 527. Winston Churchill stated, "out of complexities, intense simplicities emerge." Such a quote is applicable to the surgical management of superior sulcus tumors (SSTs). The 3-dimensional network of anatomy in this region coupled with an invasive lung cancer can be quite complex. Although the anatomy of the superior sulcus and thoracic inlet is relatively consistent, concurrent locally invasive tumors are variable. They distort and obscure the regional anatomy and require careful review of radiographs for understanding and surgical planning. The best approach for resection depends not only upon the location of the tumor but also, more importantly, upon the extent of local disease and abutment/invasion of the adjacent skeletal and neurovascular structures. Hashimoto and Sakamaki1Hashimoto K. Sakamaki H. Anterior transclavicular approach for lung cancer invading the superior sulcus.J Thorac Cardiovasc Surg Tech. 2021; 10: 527-529Scopus (2) Google Scholar discuss their use of a transclavicular approach for resection of an anterior SST invading the left subclavian vein, anterior first rib, and anterior second rib.1Hashimoto K. Sakamaki H. Anterior transclavicular approach for lung cancer invading the superior sulcus.J Thorac Cardiovasc Surg Tech. 2021; 10: 527-529Scopus (2) Google Scholar Staging studies confirmed no nodal or metastatic disease. Resection was performed to include the lateral half of the manubrium, medial clavicle, and anterior aspects of the first, second, and third ribs, along with the involved venous structures and en-bloc left upper lobectomy through the anterior thoracotomy. An intercostal nerve graft was employed for phrenic nerve reconstruction, but there are no data or evidence that such a technique succeeds. Articles referenced in the manuscript have extensively discussed the approaches and experiences resecting SSTs, techniques that have been used for decades and provided a roadmap for the resection used by Hashimoto and Sakamaki.1Hashimoto K. Sakamaki H. Anterior transclavicular approach for lung cancer invading the superior sulcus.J Thorac Cardiovasc Surg Tech. 2021; 10: 527-529Scopus (2) Google Scholar Locally invasive SSTs that reside primarily within the anterior superior sulcus are best resected through an anterior approach, as in this case and employed by the authors here. Access to the subclavian vasculature for dissection, resection, and reconstruction is best achieved through this exposure. Posterior SSTs are optimally managed through an extended posterolateral thoracotomy, through which access to the upper thoracic spine and first rib can be achieved, particularly if the spine is invaded by disease. Tumors that bridge both anterior and posterior regions often require a combined approach, although in selected circumstances an anterior approach can provide adequate exposure to the posterior elements to allow complete resection. Surgeons should always be prepared to use a posterior approach, in addition, if posterior components are obscured during anterior dissection. The authors note the impact of SST resection on shoulder motion. This issue occurs not uncommonly following resection of a posterior SST during which the scalene musculature is transected for exposure and resection of at least the first and second ribs posteriorly. Shoulder support is weakened with resultant drooping. When these elements of the chest wall are preserved, shoulder motion is minimally affected. We applaud the authors for highlighting the use of this valuable technique in managing tumors of the anterior superior sulcus. Their video and discussion should provide resources for surgeons who encounter this challenging surgical problem. Uncommonly used but valuable surgical techniques as described should be regularly revisited in the literature. Familiarity broadens the ability to overcome such complex surgical problems and perhaps brings a better understanding with some degree of intense simplicity. Anterior transclavicular approach for lung cancer invading the superior sulcusJTCVS TechniquesVol. 10PreviewComplete surgical resection following chemoradiation is recommended in patients with resectable non–small cell lung cancer that invades the superior sulcus. Several approaches have been proposed based on the site of invasion.1 We demonstrate a case who underwent anterior transclavicular approach (the Dartevelle approach) for non–small cell lung cancer invading the anatomical territory in the vicinity of the sternoclavicular joint (Video 1). Institutional review board approval was waived, owing to the single case report nature, individual informed consent was not required. Full-Text PDF Open Access

Central MessageThe authors present results of a survey of cardiothoracic surgery resident physicians regarding the utility of practice of technical skills and propose low-cost simulators as a resource for training.See Article page 100. The authors present results of a survey of cardiothoracic surgery resident physicians regarding the utility of practice of technical skills and propose low-cost simulators as a resource for training. See Article page 100. The ancient phrase practice makes perfect overstates the simple fact that practice at most things produces skill improvement, not necessarily perfection. The goal is proficiency. In cardiac surgery training, as in many instructional domains, specific skills are frequently and best taught by breaking down procedures and techniques into component parts, to make tasks simple and understandable. Simplifying the simple in our complex world of thoracic surgery requires a creative mind, ingenuity, experience, and perhaps a few toys. Albert Einstein noted that "everything should be made as simple as possible, but no simpler." Such a statement emphasizes the point that we need not focus on such detail as to obfuscate the global message. First concentrate on the basics and introduce the complexities accordingly. Fundamental skills in performing cardiac surgery are optimally taught and applied through simulation, a proven and established methodology. This controlled environment for instructional practice provides the best opportunity for competence and proficiency before the real event. Resident physicians in cardiac surgery, particularly junior residents, need such time and instruction to establish aptitude in foundational tasks. As skills are established, more intricate training is introduced in addition to time and experience in operating rooms. Kelly and colleagues1Kelly J.J. Han J.J. Patrick W.L. Mays J.C. Iyengar A. Helmers M.R. et al.Do-it-yourself simulators and building a culture of practice in the virtual era.J Thorac Cardiovasc Surg Tech. 2021; 8: 100-111Google Scholar present the results of a survey of cardiothoracic resident physicians on attitudes regarding the utility and importance of practice of technical skills. Survey respondents overwhelmingly emphasized the importance of practice. The authors recognize known impediments to such endeavors (eg, time commitment, faculty instruction, and motivation) and propose simple, portable, low-cost, and reusable simulators that they developed to facilitate and to use as a resource for training basic cardiac surgery skills (eg, suturing and cannulation). Their models are versatile and allow ad hoc practice in any environment. Anecdotally, the authors point out that resident physicians in their program had a smoother entry into operating rooms after practicing with their low fidelity simulators. Simple task trainers in cardiac surgery have been available for many years. Annually, the Thoracic Surgery Directors Association provides pocket anastomosis trainers to all programs, and a well-vetted cardiac simulation curriculum exists on the Thoracic Surgery Directors Association website. The models proposed by Kelly and colleagues1Kelly J.J. Han J.J. Patrick W.L. Mays J.C. Iyengar A. Helmers M.R. et al.Do-it-yourself simulators and building a culture of practice in the virtual era.J Thorac Cardiovasc Surg Tech. 2021; 8: 100-111Google Scholar are additional alternatives at a low cost, with seemingly ease of use along with the ability to practice cannulation skills. Despite a creative set of models, the authors have an unproven and unvalidated commodity; there are no data or outcomes analytics from its use. A follow-up analysis of the devices with details of their use is essential before general acceptance and endorsement of their endeavor. I applaud the authors' initiative to improve colleague training and their ingenuity in prototype development. Yet whatever the model, practice with feedback remains the key to success. If creative, low-cost, low-fidelity simulators as proposed by the authors can affect surgical competence by facilitating access and use, such strategies should rule the day. The proof will remain with model testing, training, and ultimately real-time proficiency. It seems simple. Do-it-yourself simulators and building a culture of practice in the virtual eraJTCVS TechniquesVol. 8PreviewOur group has previously described how practice is essential to the development of expertise in a variety of domains.1 In this article, we present the results of a survey of current cardiothoracic surgical trainees on their attitudes regarding the utility of practice. Based on these findings, we describe our prototype "do-it-yourself" (DIY) simulator, emphasizing future directions for inculcating a habit of practice among trainees, especially given the increasing reliance on virtual platforms amidst the coronavirus disease 2019 (COVID-19) pandemic (Video 1). Full-Text PDF Open Access

BACKGROUND:Traditional journal clubs address individual articles and are limited in terms of breadth and depth of content covered. The present study describes the outcomes of a novel debate-style journal club in a multiinstitutional setting. METHODS:Participating institutions were recruited through the Thoracic Education Cooperative Group. The distributed curriculum included instructions, debate scenarios, suggested article lists, moderator slides, debate scoresheets, exams, and feedback surveys. RESULTS:Six institutions participated in the study (2015-2019), consisting of a total of 10 years' worth of cumulative debates. Cardiothoracic surgery trainees participated in 10 monthly debates over each academic year. Trainee performance on the written examination in the realm of evidence-based medicine and critical appraisal improved over the course of the academic year (beginning 55.2% vs end 76.3%; P = .040). Importantly, written examination after debates revealed a significant improvement in scores on questions relating to topics that were debated as compared with those that were not (+27.1% vs +2.5%; P = .006), emphasizing the importance of the debates as compared with other sources of knowledge gain. Surveys completed by trainees and faculty overall favored the debate-style journal club as compared with the traditional journal club in gaining familiarity with seminal literature in the field, improving on oral presentation skills, and applying published literature to questions encountered clinically. CONCLUSIONS:In this multiinstitutional prospective study, we demonstrate that the novel debate-style cardiothoracic surgery journal club is an effective educational intervention for cardiothoracic surgical trainees to acquire, retain, and gain practice in applying literature-based evidence to case-based scenarios.

Background. Single-site, dual-lumen venovenous extracorporeal membrane oxygenation ECMO) facilitates mobilization, reduces recirculation, and mitigates insertion and infectious risks of an additional access site. This study reports the experience with a bicaval dual-lumen cannula that comprises a robust physical design allowing for easy and safe cannulation, precise positioning and monitoring, and appropriate physiologic support for patients with acute respiratory failure. Methods. Statistical analysis was performed from data gathered retrospectively from the electronic medical records of 20 adult patients who were cannulated for ECMO with this bicaval dual-lumen cannula from August 2018 through May 2019. Results. Gas exchange and blood flow were optimized in all patients after cannulation (median pH, 7.42 [interquartile range {IQR}, 7.39, 7.44], ratio of arterial partial pressure of oxygen to fraction of inspired oxygen, 186.5 [Pao 2 :Fio(2), 116.5, 247.0]; pump flow, 3.9 L/min [IQR, 3.1, 4.3]). Eleven patients (55%) were able to be freed from mechanical ventilation after cannulation, 9 (45%) patients underwent a tracheostomy procedure while undergoing ECMO, and no patients required reintubation. No morbidity or mortality was related to the cannulation strategy or the catheter. Two patients required cannula repositioning. Survival to decannulation was 90%, and survival to hospital discharge was 80%. Conclusions. The bicaval dual-lumen cannula maintains the advantages of upper body single-site configuration to provide the adjunctive respiratory support necessary to facilitate awakening and rehabilitation while minimizing the use of invasive mechanical ventilation. This cannula introduces design qualities that may offer advantages for acute respiratory failure requiring venovenous ECMO. (C) 2020 by The Society of Thoracic Surgeons

Importance:Minimally invasive lobectomy for early-stage lung cancer has become more prevalent. Video-assisted thoracoscopic surgery has lower rates of morbidity, better long-term survival, and equivalent oncologic outcomes compared with thoracotomy. However, little has been published on the use and outcomes of video-assisted thoracoscopic surgery within Veterans Affairs. There is a public assumption that the the Veterans Affairs is slow to adopt new procedures and technologies. Objective:To determine the uptake of video-assisted thoracoscopic surgery within the Veterans Affairs for patients with known or suspected lung cancer. Design, Setting, and Participants:In this retrospective cohort study of national Veterans Affairs Corporate Data Warehouse data from January 2002 to December 2015, a total of 11 004 veterans underwent lung resection for known or suspected lung cancer. Data were analyzed from March to November 2018. Exposures:Open or video-assisted thoracoscopic lobectomy or wedge resection. Main Outcomes and Measures:Patient demographic characteristics and procedure and diagnosis International Classification of Diseases, Ninth Revision codes were abstracted from Corporate Data Warehouse data. Results:Of the 11 004 included veterans, 10 587 (96.2%) were male, and the median (interquartile range) age was 66.0 (61.0-72.0) years. Of 11 004 included procedures, 8526 (77.5%) were lobectomies and 2478 (22.5%) were wedge resections. The proportion of video-assisted thoracoscopic lung resections increased steadily from 15.6% in 2002 to 50.6% in 2015. Video-assisted thoracoscopic surgery use by Veterans Integrated Service Networks ranged from 0% to 81.7%, and higher Veterans Integrated Service Network volume was correlated with higher video-assisted thoracoscopic surgery use (Pearson r = 0.35; 95% CI, 0.15-0.52; P < .001). Video-assisted thoracoscopic surgery use and rate of uptake varied widely across Veteran Affairs regions (P < .001 by Wilcoxon signed rank test). Conclusions and Relevance:Paralleling academic hospitals, most lung resections are now performed in the Veterans Affairs using video-assisted thoracoscopic surgery. More research is needed to identify reasons behind the heterogeneous uptake of video-assisted thoracoscopic surgery across Veterans Affairs regions.

Appropriate risk-stratification of indeterminate pulmonary nodules (IPNs) is necessary to estimate the best diagnostic strategy. Validated models for patients with high-risk IPNs are poorly calibrated. We sought to expand our previous Thoracic Research Evaluation And Treatment (TREAT) model into a more generalized, robust model for lung cancer prediction, the TREAT 2.0. A total of 1402 patients with known or suspected lung cancer were used to recalibrate the TREAT 1.0 model. Clinical data and patient demographics were retrospectively collected from six clinics located in four U.S. states. Six datasets were divided into 3 clinical groups: patients who presented to a pulmonary nodule clinic (n=375), patients who presented to an outpatient thoracic surgery clinic (n=553) and patients who presented for surgical resection (n=474). A logistic regression model using multiple imputation was developed and validated. Model variables included age, body mass index, gender, smoking pack-years, size of nodule, spiculation, growth over time, location in upper lobe, prior cancer history, pre-operative FEV1, pre-operative symptoms, FDG-PET positivity, and clinical group. The discrimination and calibration of the TREAT 2.0 model was estimated and compared to two other common models for lung nodules, the Mayo Clinic and Herder models. Lung cancer prevalence was as follows: pulmonary nodule clinic 42%, thoracic surgery clinic 73%, and surgical resection cohort 90%. The strongest predictors of cancer were clinical group, age, nodule growth, PET positivity, and smoking pack-years. The median TREAT 2.0 area under the receiver operating curve (AUC) for the imputed dataset was 0.86 (95% confidence interval (CI), 0.86-0.87) and the Brier score was 0.13. The TREAT 2.0 model had better accuracy (p < 0.001) (Figure 1) and calibration than the Mayo Clinic (AUC =0.74 95% CI: 0.74-0.75; Brier score=0.21) or Herder models (AUC=0.75; 95%CI: 0.74-0.75 and Brier score=0.19). The TREAT 2.0 model is more accurate and better calibrated than the Mayo Clinic or Herder models in patients presenting with nodules at high risk for lung cancer. Nodule calculators such as the TREAT 2.0 that account for variation in lung cancer prevalence with a variable for clinical group may improve generalizability and increase use in clinical practice.

Each academic year, thoracic surgery residency programs receive an influx of eager new resident physicians who arrive with variable exposure to cardiac surgery and inconsistent operating abilities. For residents fresh into their cardiothoracic training, a cardiac operating room can be a daunting and intimidating place. Beginning resident physicians commonly lack familiarity with and understanding of the flow of an operating room or a cardiac operation, and such factors influence trainee involvement and integration in key elements of a procedure until sufficient experience has been achieved.

Mobile health (mHealth) apps have been adopted in healthcare areas such as the management of diabetes, the monitoring of physical activities and the treatment of HIV. The users of mHealth may be patients with handicaps such as motor impairments, difficulties to remember and psychiatric conditions. Hence, assumptions normally made on other types of apps, like the user’s ability to type or remember a password, might not hold in the mHealth area. This paper evaluates how different authentication approaches impact mHealth apps usability. Second, we present new metrics to evaluate ease-of-use and third, we evaluate the usability of two common authentication approaches for mHealth apps via several key process aspects and their impact on users. Based on these results, we propose a QR-Code based authentication approach for mHealth apps, which helps overcome common impediments faced by mHealth apps users.

Background. The Cardiac Surgery Simulation Curriculum was developed at 8 institutions from 2010 to 2013. A total of 27 residents were trained by 18 faculty members. A survey was conducted to gain insight into the initial experience.Methods. Residents and faculty were sent a 72- and 68-question survey, respectively. In addition to demographic information, participants reported their view of the overall impact of the curriculum. Focused investigation into each of the 6 modules was obtained. Participants evaluated the value of the specific simulators used. Institutional biases regarding implementation of the curriculum were evaluated.Results. Twenty (74%) residents and 14 (78%) faculty responded. The majority (70%) of residents completed this training in their first and second year of traditionaltrack programs. The modules were well regarded with no respondents having an unfavorable view. Both residents and faculty found low, moderate, and high fidelity simulators to be extremely useful, with particular emphasis on utility of high fidelity components. The vast majority of residents (85%) and faculty (100%) felt more comfortable in the resident skill set and performance in the operating room. Simulation of rare adverse events allowed for development of multidisciplinary teams to address them. At most institutions, the conduct of this curriculum took precedence over clinical obligations (64%).Conclusions. The Cardiac Surgery Simulation Curriculum was implemented with robust adoption among the investigating centers. Both residents and faculty viewed the modules favorably. Using this curriculum, participants indicated an improvement in resident technical skills and were enthusiastic about training in adverse events and crisis management. (C) 2017 by The Society of Thoracic Surgeons

Background. Operating room surgical training has significant limitations. This study hypothesized that some skills could be learned efficiently and safely by using simulation with component task training, deliberate practice, progressive complexity, and experienced coaching to produce safer cardiac surgeons.Methods. Training modules included cardiopulmonary bypass, coronary artery bypass grafting, aortic valve replacement, massive air embolism, acute intraoperative aortic dissection, and sudden deterioration in cardiac function. Using deliberate practice, first-year cardiothoracic surgical residents at eight institutions were trained and evaluated on component tasks for each module and later on full cardiac operations. Evaluations were based on five-point Likert-scale tools indexed by module, session, task items, and repetitions. Statistical analyses relied on generalized linear model estimation and corresponding confidence intervals.Results. The 27 residents who participated demonstrated improvement with practice repetitions resulting in excellent final scores per module (mean +/- two SEs): cardiopulmonary bypass, 4.80 +/- 0.12; coronary artery bypass grafting, 4.41 +/- 0.19; aortic valve replacement, 4.51 +/- 0.20; massive air embolism, 0.68 +/- 0.14; acute intraoperative aortic dissection, 4.52 +/- 0.17; and sudden deterioration in cardiac function, 4.76 +/- 0.16. The transient detrimental effect of time away from training was also evident.Conclusions. Overall performance in component tasks and complete cardiac surgical procedures improved during simulation-based training. Simulation-based training imparts skill sets for management of adverse events and can help produce safer surgeons. (C) 2017 by The Society of Thoracic Surgeons