Neurologic Dysfunction and Neuroprotection in Transcatheter Aortic Valve Implantation.

Transcatheter aortic valve implantation (TAVI) is a fast-growing procedure. Expanding to low-risk patients, it has surpassed surgical aortic valve implantation in frequency and has been associated with excellent outcomes. Stroke is a devastating complication after transcatheter aortic valve implantation. Silent brain infarcts identified by diffusion-weighted magnetic resonance imaging are present in most patients following TAVI. Postoperative delirium and cognitive dysfunction are common neurologic complications. The stroke and silent brain infarcts are likely caused by particulate emboli released during the procedure. Intravascularly positioned cerebral embolic protection devices are designed to prevent debris from entering the aortic arch vessels to avoid stroke. Despite promising design, randomized clinical trials have not demonstrated a reduction in stroke in patients receiving cerebral embolic protection devices. Similarly, the association of cerebral embolic protection devices with silent brain infarcts, postoperative delirium, and cognitive dysfunction is uncertain. Monitored anesthesia care or conscious sedation is as safe as general anesthesia and is associated with lower cost, but different anesthetic techniques have not been shown to decrease stroke risk, postoperative delirium, or cognitive dysfunction. Anesthesiologists play important roles in providing perioperative care including management of neurologic events in patients undergoing TAVI. Large randomized clinical trials are needed that focus on the correlation between perioperative interventions and neurologic outcomes.

SAGES Mini Med School: inspiring high school students through exposure to the field of surgery.

OBJECTIVE: The SAGES Mini Med School (SMMS) was designed to expose high school students to the field of surgery through mentoring, knowledge transfer, and hands-on experience with simulation. The objective of this paper is to profile the evolutionary development, performance metrics, and satisfaction queries of this innovative effort. METHODS: Sixty-one high school students, grades 9-12, took part in the (SMMS) program during the 2015 SAGES Annual Congress. The students completed a surgical skills lab session where they attempted tasks associated with the development of open surgical and laparoscopic skills. The lab included a warm-up with the validated Super Monkey Ball video game, Top Gun Pea Drop task, FLS Peg Transfer task, open knot tying station, and open instrument tie station. RESULTS: The following are the results of the surgical skills lab. For the Super Monkey Ball task, 60 students participated with an average score of 73.0 s (SD = 53.9; range 59.1-87.0; median = 74). Sixty students participated in the Surgeons Knot and Pea Drop tasks with average times of 26.6 s (SD = 19.3; range 21.7-31.6; median = 21.0) and 113.8 s (SD = 65.9; range 96.6-131.0; median = 101.0), respectively. Sixty students participated in the Instrument Tie and 56 students participated in the Peg Transfer stations with average times of 51.7 s (SD = 34.5; range 42.8-60.6; median = 39.5) and 173.1 s (SD = 25.0; range 166.4-179.8; median = 180.0), respectively. 51 (83.6%) agreed that the Mini Med School made them more likely to consider a career in medicine. When asked if the program made them more likely to consider a career in surgery 42 (68.8%) agreed. All 61 respondents (100%) said that they would recommend the program to others. CONCLUSIONS: The SMMS program showed that the students had an excellent aptitude for the performance of validated surgical subtasks with high satisfaction, and increased consideration of a career in medicine/surgery. Long-term studies are needed to evaluate the impact on workforce recruitment.

Editorial: Transitional Care Clinics to Reduce 30-day Readmissions in Heart Failure Patients.

Heart failure (HF) is one of the most prevalent chronic diseases in the United States (U.S.), with an estimated prevalence of five million patients in the U.S. and an annual healthcare cost of greater than 30 billion dollars. Readmission rates for HF patients are astronomically high, with up to 25% of hospitalized patients with HF requiring readmission within 30 days of discharge. The Hospital Readmissions Reduction Program (HRRP) of the Patient Protection and Affordable Care Act aims to address these concerns by financially penalizing institutions with unacceptably high risk-adjusted 30-day readmission rates for HF patients. The introduction of the HRRP contributed to increased efforts of healthcare systems to reduce their 30-day readmission rates, often by the utilization of "transitional care clinics." Although the motivation for the creation of these programs is understandable, there exists a paucity of robust clinical trials supporting the efficacy of these programs to reduce 30-day readmission rates for HF patients. There is even less evidence to support the use of these programs in the unique healthcare environment of the U.S. Large, multicenter randomized controlled trials should be conducted to evaluate these interventions before more resources are dispersed toward their implementation. Alternatively, resources could be used to evaluate other interventions that may be more efficacious at reducing 30-day readmissions, such as implantable hemodynamic monitoring devices.

A case of fatal internal jugular vein perforation during nasogastric tube insertion.

Nasogastric tube (NGT) insertion is a routine procedure in the management of surgical patients. We report the second case of internal jugular vein perforation during NGT insertion. A 79-year-old man presented with diffuse abdominal pain secondary to a perforated viscus. Abdominal CT revealed pneumoperitoneum, necessitating emergent exploratory laparotomy. On post-operative Day 7, the patient developed mild abdominal distension and subjective nausea for which NGT placement was ordered for decompression. Tube placement was confirmed by insufflation of air without aspiration of gastric contents. Output from the NGT upon placement revealed frank blood. The patient then developed respiratory distress requiring intubation, followed by a fatal arrhythmia. Post-mortem exam revealed the trajectory of the NGT through the pharyngeal wall into the right internal jugular vein. This case illustrates the importance of systematic evaluation of all procedures, as the outcome resulted from failure to recognize the initial error in tube placement.

Design and Development of a Novel Distance Learning Telementoring System Using Off-the-Shelf Materials and Software.

OBJECTIVE: To design and develop a distance learning (DL) system for the transference of laparoscopic surgery knowledge and skill constructed from off-the-shelf materials and commercially available software. INTRODUCTION: Minimally invasive surgery offers significant benefits over traditional surgical procedures, but adoption rates for many procedures are low. Skill and confidence deficits are two of the culprits. DL combined with simulation training and telementoring may address these issues with scale. MATERIALS AND METHODS: The system must be built to meet the instruction requirements of a proven laparoscopic skills course (Top Gun). Thus, the rapid sharing of multimedia educational materials, secure two-way audio/visual communications, and annotation and recording capabilities are requirements for success. These requirements are more in line with telementoring missions than standard distance learning efforts. RESULTS: A DL system with telementor, classroom, and laboratory stations was created. The telementor station consists of a desktop computer and headset with microphone. For the classroom station, a laptop is connected to a digital projector that displays the remote instructor and content. A tripod-mounted webcam provides classroom visualization and a Bluetooth® wireless speaker establishes audio. For the laboratory station, a laptop with universal serial bus (USB) expander is combined with a tabletop laparoscopic skills trainer, a headset with microphone, two webcams and a Bluetooth® speaker. The cameras are mounted on a standard tripod and an adjustable gooseneck camera mount clamp to provide an internal and external view of the training area. Internet meeting software provides audio/visual communications including transmission of educational materials. CONCLUSION: A DL system was created using off-the-shelf materials and commercially available software. It will allow investigations to evaluate the effectiveness of laparoscopic surgery knowledge and skill transfer utilizing DL techniques.