Predictors of Survival After Liver Transplantation in Patients With the Highest Acuity (MELD ≥40).

OBJECTIVE: To identify factors that accurately predict 1-year survival for liver transplant recipients with a MELD score ≥40. BACKGROUND: Although transplant is beneficial for patients with the highest acuity (MELD ≥40), mortality in this group is high. Predicting which patients are likely to survive for >1 year would be medically and economically helpful. METHODS: The Scientific Registry of Transplant Recipients database was reviewed to identify adult liver transplant recipients from 2002 through 2016 with MELD score ≥40 at transplant. The relationships between 44 recipient and donor factors and 1-year patient survival were examined using random survival forests methods. Variable importance measures were used to identify the factors with the strongest influence on survival, and partial dependence plots were used to determine the dependence of survival on the target variable while adjusting for all other variables. RESULTS: We identified 5309 liver transplants that met our criteria. The overall 1-year survival of high-acuity patients improved from 69% in 2001 to 87% in 2016. The strongest predictors of death within 1 year of transplant were patient on mechanical ventilator before transplantation, prior liver transplant, older recipient age, older donor age, donation after cardiac death, and longer cold ischemia. CONCLUSIONS: Liver transplant outcomes continue to improve even for patients with high medical acuity. Applying ensemble learning methods to recipient and donor factors available before transplant can predict survival probabilities for future transplant cases. This information can be used to facilitate donor/recipient matching and to improve informed consent.

Neuromonitoring in the ambulatory anesthesia setting: a pro-con discussion.

PURPOSE OF REVIEW: Various neurologically focused monitoring modalities such as processed electroencephalography (pEEG), tissue/brain oxygenation monitors (SbO2), and even somatosensory evoked responses have been suggested as having the potential to improve the well tolerated and effective delivery of care in the setting of outpatient surgery. The present article will discuss the pros and cons of such monitors in this environment. RECENT FINDINGS: There is a paucity of evidence from rigorous, well designed clinical trials demonstrating that the routine use of any neuromonitoring technique in an ambulatory surgery setting leads to meaningful cost savings or a reduction in morbidity or mortality. SUMMARY: The use of advanced neuromonitoring techniques (primarily pEEG) may be considered reasonable in two instances: for the prevention of intraoperative awareness during the administration of total intravenous anesthesia coupled with the use of a neuromuscular blocking drug, and for the prevention of relative drug overdose (and possibly postoperative delirium) in the elderly.

Preparation, characterization, molecular and electronic structures, TDDFT, and TDDFT/PCM study of the solvatochromism in cyanovinylferrocenes.

Cis and trans isomers of ferrocene-based donor-acceptor assemblies, Fc-C(I)=CH(I), Fc-C(I)=CH(CN), and Fc-C(CN)=CH(CN) (Fc is ferrocene), along with the Fc-C(CN)=C(CN)2 complex have been prepared and characterized by 1H, 13C, gHMQC, and gHMBC NMR spectra, IR, UV-vis, and MCD spectroscopy methods, as well as elemental analyses. The oxidation potentials, investigated by cyclic voltammetry, of all donor-acceptor assemblies are in agreement with the electron-acceptor strength of the substituents attached to the ferrocene core. X-ray crystallography studies of cis and trans isomers of Fc-C(I)=CH(CN) and Fc-C(CN)=CH(CN) reveal a significant rotational flexibility of the cyanovinyl group, which was explained on the basis of semiempirical PM3 calculations. Electronic structures and solvatochromic properties of all complexes were investigated by UV-vis spectroscopy, density functional theory (DFT), time-dependent DFT (TDDFT), and polarized continuum model (PCM) TDDFT approaches. The calculated vertical excitation energies and magnitudes of solvatochromic effect are consistent with the experimental data and clearly suggest the dominance of metal-to-ligand charge-transfer bands in the visible region of the UV-vis spectra for all complexes.