Major Perioperative Cardiac Risk Assessment: A Review for Cardio-Oncologists and Perioperative Physicians.

The Revised Cardiac Risk Index (RCRI) and the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) preoperative risk assessment tools are the most widely used methods for quantifying the risk of major negative perioperative cardiac outcomes that a patient may face during and after noncardiac surgery. However, these tools were created to include as wide a range of surgical factors as possible; thus, some predictive accuracy is sacrificed when it comes to certain surgical subpopulations. In this review, we explore the various surgical oncology patient populations for whom these assessment tools can be reliably applied and for whom they demonstrate poor reliability.

Rumen fermentation and microbiota in Shami goats fed on condensed tannins or herbal mixture.

BACKGROUND: Phytochemical compounds can modify the rumen microbiome and improve rumen fermentation. This study evaluated the impact of supplementation with tannin and an herbal mixture containing ginger (Zingiber officinale), garlic (Allium sativum), Artemisia (Artemisia vulgaris), and turmeric (Curcuma longa) on the rumen fermentation and microbiota, and histology of rumen tissue of goats. Eighteen Shami male goats were divided into three groups (n = 6): non-supplemented animals fed the basal diet (C, control); animals fed basal diet and supplemented with condensed tannin (T); and animals fed basal diet and supplemented with herbal mixture (HM). Each animal received a basal diet composed of Alfalfa hay and a concentrate feed mixture. RESULTS: Group HM revealed higher (P < 0.05) rumen pH, total volatile fatty acids (VFA), acetic, propionic, isobutyric, butyric, isovaleric, and valeric. Principal Co-ordinate analysis (PCoA) showed that rumen microbial communities in the control group and supplemented groups were distinct. The supplementation increased (P < 0.05) the relative abundances of phylum Bacteroidota and Proteobacteria and declined (P < 0.05) Firmicutes and Fibrobacterota. Additionally, the dominant genus Prevotella and Rikenellaceae RC9 gut group were increased (P < 0.05) and the family Ruminococcaceae was declined (P < 0.05) due to the supplementation. The supplementation decreased (P < 0.05) the archaeal genus Methanobrevibacter and increased (P < 0.05) Candidatus Methanomethylophilus. Tannin supplementation in T group shortened the rumen papillae. CONCLUSIONS: The results revealed that the herbal mixture might be used to alter the rumen microbiota to improve rumen fermentation.

Preoperative Nutritional Status and Enhanced Recovery after Surgery (ERAS) Prior to Radical Cystectomy: A Review of the Literature.

Preoperative nutritional status is an important and modifiable risk factor of a patient's recovery and outcome after radical cystectomy. There are multiple malnutrition screening tools and treatment options. In this review, we discuss the best indicators of this condition and how to optimize nutrition status prior to radical cystectomy.

Atrial fibrillation in the elderly population: Challenges and management considerations.

IMPORTANCE: Atrial fibrillation is the most clinically significant arrhythmia in humans when viewed both from a global and also a national perspective. In the United States, approximately 2.7-6.1 million people are estimated to have atrial fibrillation. With the aging of the population, this prevalence is on an increasing trend and remains an obstacle to cardiovascular health despite significant advancements specific to cardiovascular disease management. OBSERVATION: In this specific group of patients, healthcare utilization is a concern from the public health perspective. Unfortunately, misconceptions dominate clinical decision making; for instance, the avoidance of safe and effective anticoagulation strategies in patients at the highest risk for embolic strokes continues to be widespread in clinical practice and is often based on a skewed assessment of risk versus benefit. Also, when there are contraindications to standard interventions for atrial fibrillation, a clear and nuanced understanding of second- and third-line interventions with proven benefit is often lacking. CONCLUSIONS AND RELEVANCE: An individualized approach should be followed by physicians when managing atrial fibrillation in the elderly patient, taking into consideration the risk of complications, particularly the embolic stroke and the availability of treatment options for stroke prevention whether through pharmacological anticoagulation or left atrial appendage occluding devices. The following review sets out to clarify these issues.

Effective Management of High-Grade Left Common Carotid and Brachiocephalic Arterial Stenosis With Endovascular Stenting.

Multi-vessel disease including the brachiocephalic artery remains a relatively rare finding in atherosclerotic disease when compared to stenosis of other major vasculature. Its management presents many difficulties. Endovascular intervention is a highly preferred choice of therapy in these patients although it is dependent on operator experience. We present a case of left common carotid and brachiocephalic arterial stenosis in a patient who presented with neurological alterations that was treated with endovascular stenting. Technical difficulty was encountered during intervention but was successful.

A Single Coronary Artery Anomaly: Right Coronary Artery as a Branch From the Left Anterior Descending Artery.

An anomalous origin of the right coronary artery (RCA) from the left anterior descending artery (LAD), also known as a single coronary artery, is an extremely rare finding in clinical practice. It is usually a benign anomaly; however, symptoms are highly dependent on the course that the anomalous RCA takes after branching off of the LAD. We present a case of a patient who had decompensated heart failure and was detected to have a single coronary artery. The patient was treated with guideline-directed medical therapy with notable improvement in clinical status in the following days. Enhanced awareness of congenital cardiac anomalies may help guide management.

Placement of a Double-Lumen Endotracheal Tube Using a Combined Bronchoscopy and Fluoroscopy Technique: A Case Report.

Bronchial artery embolization (BAE) is a well-established intervention for hemoptysis that requires airway management by a trained anesthesiologist. The use of fluoroscopic guidance for positioning a double-lumen endotracheal tube (DLT) has been described in previous studies. The case presented illustrates a combined fluoroscopic- and bronchoscopic-guided approach for positioning a DLT in a patient with active pulmonary hemorrhage causing obstruction of views on bronchoscopy. This combined technique proved valuable in a situation marked by high clinical urgency.

Intravascular ultrasound-guided mechanical thrombectomy using the INARI ClotTriever device of an iatrogenic deep venous thrombosis.

Deep vein thrombosis (DVT) is a common disorder affecting 1 to 2 per 1000 Americans annually, resulting in significant morbidity and mortality. Anticoagulation is the mainstay management strategy for DVT. However, this could prove insufficient in cases where a mechanical obstruction is responsible for the DVT. We are presenting an interesting case of iatrogenic DVT incurred after Prolene suturing of lacerated iliac vein and the management employed for this challenging case with a successful and significant improvement in the clinical outcome.

Retained Curved Needle After Balloon Kyphoplasty: A Complication with a Novel Device and Its Management.

To date, no case studies specifically describing a curved kyphoplasty needle becoming lodged in the vertebral body with the inability to be withdrawn have been reported. We describe a case involving a single level balloon kyphoplasty with a curved coaxial needle during which the cement delivery device could not be removed after cavity filling. In this case, a board-certified interventional pain management specialist was performing balloon kyphoplasty for an L2 osteoporotic vertebral compression fracture. The tools utilized in this procedure included flexible curved instruments designed to traverse the vertebral body and achieve uniform cement distribution through a unipedicular approach. Cannulation and cavity formation were completed without issue. Upon conclusion of cement filling, the curved cement delivery device was unable to be removed. After several attempts to remove the needle and consultation with both the device company and local spine surgeons, it was agreed that the device should be cut at the level of entry into the pedicle and left as a retained foreign object. The involved area was surgically exposed, the retained instrument was cut flush to the pedicle, and the free portion was removed without further complication. The patient followed up in clinic several months later without evidence of neurologic complications. Considerations when using a curved kyphoplasty device and a method of resolution when faced with the inability to remove such an instrument are discussed.

Mental Nerve Blocks for Lip Brachytherapy: A Case Report.

High dose rate interstitial brachytherapy is a commonly performed procedure for carcinoma of the lower lip. Placement of the brachytherapy catheters can be painful and may require monitored anesthesia care or general anesthesia. We present the use of bilateral mental nerve blocks with minimal sedation to facilitate placement of brachytherapy catheters.

Use of Laryngeal Mask Airway to Preoxygenate and Ventilate Through a Laryngeal Stoma in a Patient Undergoing General Anesthesia: A Case Report.

The use of the laryngeal mask airways is well established in routine and emergency airway management. Due to its traditional use as a supraglottic airway, it is often overlooked in patients with abnormal airway anatomy such as tracheostomies and laryngeal stomas. We present the unique method of using the laryngeal mask airways externally to facilitate preoxygenation and ventilation in a patient with a laryngeal stoma.

Spontaneous Otorrhagia after Laparoscopic Pelvic Surgery: A Report of Two Cases.

Spontaneous otorrhagia following laparoscopic pelvic surgery is a complication that is rarely reported and incompletely understood. Few case reports have described this phenomenon, though its true incidence is unknown. It has been hypothesized that a combination of extreme patient positioning and abdominal insufflation is the contributing factor. There does not appear to be any untoward consequences and patients can be managed conservatively. We present two cases of spontaneous otorrhagia associated with laparoscopic pelvic surgery, which occurred over a 1-week period at our institution.

Approach to Acute Heart Failure in the Emergency Department.

Acute heart failure (AHF) patients rarely present complaining of 'acute heart failure.' Rather, they initially present to the emergency department (ED) with a myriad of chief complaints, symptoms, and physical exam findings. Such heterogeneity prompts an initially broad differential diagnosis; securing the correct diagnosis can be challenging. Although AHF may be the ultimate diagnosis, the precipitant of decompensation must also be sought and addressed. For those AHF patients who present in respiratory or circulatory failure requiring immediate stabilization, treatment begins even while the diagnosis is uncertain. The initial diagnostic workup consists of a thorough history and exam (with a particular focus on the cause of decompensation), an EKG, chest X-ray, laboratory testing, and point-of-care ultrasonography performed by a qualified clinician or technologist. We recommend initial treatment be guided by presenting phenotype. Hypertensive patients, particularly those in severe distress and markedly elevated blood pressure, should be treated aggressively with vasodilators, most commonly nitroglycerin. Normotensive patients generally require significant diuresis with intravenous loop diuretics. A small minority of patients present with hypotension or circulatory collapse. These patients are the most difficult to manage and require careful assessment of intra- and extra-vascular volume status. After stabilization, diagnosis, and management, most ED patients with AHF in the United States (US) are admitted. While this is understandable, it may be unnecessary. Ongoing research to improve diagnosis, initial treatment, risk stratification, and disposition may help ease the tremendous public health burden of AHF.

Perioperative Management of a Patient With an Intrathecal Drug Delivery Device Infusing Ziconotide: A Case Report.

Intrathecal ziconotide is used for the treatment of chronic pain and is delivered by an implanted drug delivery device. Anesthesiologists should be familiar with the perioperative management of the pump as well as the potential adverse events related to continued ziconotide infusion during general anesthesia. A case is presented demonstrating the perioperative management of an intrathecal drug delivery device infusing ziconotide in a patient presenting for radical cystectomy with pelvic lymphadenectomy and ileal conduit diversion.

Removal and preconcentration of lead (II), copper (II), chromium (III) and iron (III) from wastewaters by surface developed alumina adsorbents with immobilized 1-nitroso-2-naphthol.

The potential removal and preconcentration of lead (II), copper (II), chromium (III) and iron (III) from wastewaters were investigated and explored. Three new alumina adsorbents of acidic, neutral and basic nature (I-III) were synthesized via physical adsorption and surface loading of 1-nitroso-2-naphthol as a possible chelating ion-exchanger. The modified alumina adsorbents are characterized by strong thermal stability as well as resistance to acidic medium leaching processes. High metal up-take was found providing this order: Cu(II)>Cr(III)>Pb(II) owing to the strong contribution of surface loaded 1-nitroso-2-naphthol. The outlined results from the distribution coefficient and separation factor evaluations (low metal ion concentration levels) were found to denote to a different selectivity order: Pb(II)>Cu(II)>Cr(III)) due to the strong contribution of alumina matrix in the metal binding processes. The potential applications of alumina adsorbents for removal and preconcentration of Pb(II), Cu(II), Cr(III) from wastewaters as well as drinking tap water samples were successfully accomplished giving recovery values of (89-100+/-1-3%) and (93-99+/-3-4%), respectively without any noticeable interference of the wastewater or drinking tap water matrices.

Hybrid inorganic/organic alumina adsorbents-functionalized-purpurogallin for removal and preconcentration of Cr(III), Fe(III), Cu(II), Cd(II) and Pb(II) from underground water.

Metal pollution is well recognized as one of the major environmental problems that must be imperatively addressed and solved. In this study, three types of alumina adsorbents (I-III) were physically immobilized with purporogallin as a chelating ion exchangers. These were found to exhibit strong capability and selectivity characters for a series of heavy metal ions. Surface modification of hybrid alumina was characterized and identified from the determination of surface coverage and infrared analysis. Hybrid alumina adsorbents were identified for their strong resistivity to acid leaching in pH>2-7 as well as their high thermal stability up to 350 degrees C. The ability of newly synthesized hybrid inorganic/organic alumina adsorbents (I-III) to bind and extract various metal ions was examined and evaluated in various buffer solutions (pH 1.0-7.0) via determination of the metal adsorption capacity values. These were identified as high as 420-560, 500-580 and 500-590 micromol g(-1) for alumina adsorbents (I), (II) and (III), respectively in the case of high concentration levels of Cr(III), Fe(III) and Cu(II). The influence of alumina matrices were highly characterized when low concentration levels (microg ml(-1) and ng ml(-1)) of metal ions were used. Hybrid alumina adsorbents were successfully applied for selective extraction, removal and preconcentration of various heavy metals from underground water samples with percentage recovery values of 92-100+/-1-3%.