Robotic mitral valve surgery.

Totally endoscopic robotic mitral valve repair is the least invasive surgical therapy for mitral valve disease. Robotic mitral valve surgery demonstrates faster recovery with shorter hospital stays, less morbidity, and equivalent mortality and mid-term durability compared to sternotomy. In this review, we will explore the advantages and disadvantages of robotic mitral valve surgery and consider important technical details of both operative set-up and mitral valve repair techniques. The number of robotic cardiac surgical procedures being performed globally is expected to continue to rise as experience grows with robotic techniques and increasing numbers of cardiac surgeons become proficient with this innovative technology. This will be facilitated by the introduction of newer robotic systems and increasing patient demand.

Telemedicine in the Wake of COVID-19: A Statewide Demographic Study on Provider Utilization and Perspective In South Dakota.

INTRODUCTION: The COVID-19 pandemic has ushered in a rapid evolution of regulations surrounding telemedicine and the public's need for affordable, accessible, high-quality care at a distance. This necessity led to a rise in telemedicine demand that forced health systems to adapt, and for providers to witness the potential benefits and limitations of such services. METHODS: In this analysis, Sanford Health EMR data was evaluated from Q2 of 2019 to Q2 of 2020 to compare specialty utilization of telemedicine and quantify percentage change within the midst of the COVID-19 pandemic. A survey was conducted to evaluate provider opinion within the Sanford Health system regarding demographics, usage, perceived benefits, and perceived barriers to this rapid adoption. RESULTS: Results suggest that Sanford Health experienced a significant, 1,600 percent increase of telemedicine usage. Additionally, with this increased usage of telemedicine, provider opinion of telemedicine and its potential has improved. During the pandemic, a greater percentage of providers believe telemedicine is highly beneficial to their practice and a majority believe telemedicine will continue to play a vital role in their practice in the future. However, the barriers found within the survey included limited patient access, technical difficulties, reimbursement, and insurance coverage. CONCLUSIONS: With the rapid increase in provider usage and the subsequent approval of providers, telemedicine has the potential to facilitate higher quality healthcare going forward. The COVID-19 pandemic has necessitated evolution and adoption of virtual media in medicine and has provided a unique glimpse into telemedicine's limitations and exceptional potential.

Robotic mitral valve surgery: a review and tips for safely negotiating the learning curve.

Totally endoscopic robotic mitral valve repair represents the least invasive surgical therapy for mitral valve disease. Comparative results for robotic mitral valve surgery against sternotomy are impressive, repeatedly demonstrating shorter hospital stay, faster return to normal activities, less morbidity and equivalent mortality and mid-term durability. We lack data comparing robotic approaches to totally endoscopic minimally invasive mitral valve surgery using 3D vision platforms. In this review, we explore the advantages and disadvantages of robotic mitral valve surgery and share technical tips that we have learned to help teams embarking on their robotic journey. We consider factors necessary for the successful implementation of a robotic programme including the importance of training a dedicated team, with the common goal to avoid any compromise in either patient safety or repair quality during the learning curve. As experience grows with robotic techniques and more cardiac surgeons become proficient with this innovative technology, the volume of robotic cardiac procedures around the world will increase helped by the introduction of new robotic systems and patient demand. Well informed patients will increasingly seek out the opportunity of robotic valve reconstruction in reference centres in the hands of a few highly experienced robotic surgeons.

Diagnostic Challenge With Auto-Immune Pancreatitis and IgG4-Related Disease.

IgG4-related disease (IgG4RD) is a chronic immune mediated condition primarily affecting the hepato-pancreatico-biliary system. We report a case of IgG4RD with extensive pancreatic and hepatic involvement masquerading as metastatic pancreatic malignancy posing a diagnostic and therapeutic dilemma.

Collaborating to Enhance Faculty Development through Structured Funding.

PROBLEM: Faculty development is critical to individual career growth and success in academic medicine and it enhances the overall academic climate of an institution. Despite these well-recognized benefits, time and financial constraints often limit participation of faculty members. To address this issue, the University of South Dakota Sanford School of Medicine (SSOM) developed a novel policy and process to support participation in faculty development programs. APPROACH: In 2014, the SSOM Office of Continuing Professional Development (OCPD) implemented a process for funding faculty members' participation in external career and educational development programs. A subcommittee of the Faculty Development Committee reviewed and selected applications based on the benefit to the applicant's career and the SSOM as whole. Selected applicants were required to disseminate new knowledge from the external programs to other SSOM faculty, staff, and trainees. OUTCOMES: With the implementation of this program, 17 faculty members received funding. The race/ethnicities of the selected applicants reflected the overall demographics of the larger SSOM community. The majority of the selected applicants were female (n=12, 70 percent), assistant professors (n=9, 53 percent), and members of clinical departments (n=12, 70 percent). Upon completion of the program, five participants achieved academic promotion. This novel funding mechanism greatly increased faculty participation in external programs and participants reported enhanced networking opportunities, leadership experience, and career opportunities. NEXT STEPS: Challenges observed with implementation of the program have led to revision of the application process, tracking of participant demographic data, and confirmation of knowledge dissemination.

Non-surgical management of Boerhaave's syndrome: a case series study and review of the literature.

BACKGROUND AND STUDY AIMS: Boerhaave's syndrome (BS) is a life-threatening condition with morbidity and mortality rates as high as 50 % in some reports. Until recently, surgical intervention has been the mainstay of management plans. With advances in therapeutic endoscopy, however, there has been increasing interest in non-surgical options including endoscopic esophageal stenting. PATIENTS AND METHODS: We reviewed the medical records of all patients diagnosed with BS and managed with endoscopic interventions between November 2011 and November 2016. The following variables were collected: patient demographics, clinical presentations, locations of esophageal perforation, primary interventions, complications, and outcomes. RESULTS: Six patients were found to be diagnosed with BS during the study period. The median age at presentation was 55. There were 4 males and 2 females. The most common site of perforation was in the distal esophagus. The most common presenting symptom was chest pain (67 %) following an episode of vomiting or retching. Four patients (66.7 %) developed septic shock. Endoscopic treatment with a fully covered esophageal stent was the primary intervention in all patients (100 %). Interventional radiology was consulted in all cases for fluid drainage and chest tube placements. Clinical resolution of the BS was achieved in all patients (100 %) without any subsequent surgical interventions. There were no deaths within the study group, and the average follow-up duration was 2 years. CONCLUSION: Endoscopic treatment seems to be an effective management strategy in patients with BS. We also noted satisfactory results in patients presenting with sepsis, presumably due to urgent, interventional radiology-guided fluid drainage.

Clinical decision making in the management of pancreatic cystic neoplasms.

Pancreatic cystic lesions continue to pose diagnostic and management dilemmas for physicians. This may be related, in part, to the fact that these lesions represent a range of diagnostic possibilities, from inflammatory cysts and nonmucinous cysts to mucinous cysts, which may or may not have foci of invasive malignancy. Adequate characterization of cystic lesions is necessary to help devise a management plan. Moreover, patient-related factors such as comorbid conditions are often essential in deciding whether patients should be managed by a conservative approach of watchful waiting versus surgical resection, if so indicated. This review summarizes the recent advances in the management of pancreatic cystic neoplasms.

Heparin therapy during extracorporeal circulation: deriving an optimal activated clotting time during cardiopulmonary bypass for isolated coronary artery bypass grafting.

Bull's seminal work on heparin therapy during cardiopulmonary bypass (CPB) was carried out over 30 years ago and has not been updated in the modern era. No correlation with postoperative blood loss was performed. The optimal activated clotting time (ACT) with regard to blood loss has not been established for patients undergoing CPB. A minimum ACT of 400 is based on the lack of visible formation of clots in the CPB circuit. The effect of heparin dose, sensitivity, metabolism, patient size, elective/urgent, protamine reversal regime, returned pump blood volume and heparin content, and average ACT during CPB with regard to postoperative blood loss and resternotomy was examined in a consecutive series of patients undergoing isolated coronary artery bypass surgery. One hundred forty-four patients undergoing isolated CABG were studied. Resternotomy was too infrequent an event to analyze. Univariate analysis revealed that an average ACT less than 500 or greater than 700 was associated with significantly increased postoperative blood loss (p = .001). Multivariate analyses revealed that body mass index (p < .0001) and total loading dose of heparin (p = .0031) were also significant factors affecting postoperative blood loss. We extended his work by analyzing postoperative blood loss. An average ACT between 500 and 700 in our series was associated with significantly lower blood loss than an ACT higher or lower. We hypothesize that an ACT below 500 is probably associated with a low-grade coagulopathy but not macroscopic clot formation in the CPB circuit, and above 700 heparin rebound may become important. Each unit should evaluate blood loss and determine the optimal ACT target for their program.