Pericardial Effusions in Patients With Cancer: Anesthetic Management and Survival Outcomes.

OBJECTIVES: The objective of this study was to describe practice patterns of anesthetic management during pericardial window creation. DESIGN: Retrospective observational cohort study. SETTING: Single tertiary cancer center. PARTICIPANTS: A total of 150 patients treated for cancer between 2011 and 2015 were included in the study. MEASUREMENTS AND MAIN RESULTS: The primary objective was to evaluate anesthetic management in pericardial window creation. Secondary outcomes were 30-day mortality and overall survival after pericardial window creation. Thirty-day mortality was 19.3%, and median survival was 5.84 months. Higher American Society of Anesthesiologists (ASA) physical status of patients was associated with preinduction arterial line placement (51% ASA 3 v 79% ASA 4; p = 0.002) and use of etomidate for anesthetic induction (34% ASA 3 v 60% ASA 4; p = 0.003). However, there was no association between anesthetic management and presence of tamponade in these patients. Cardiac aspirate volume (per 10 mL: odds ratio [OR], 1.02 [95% CI, 1.0-1.04]; p = 0.026) and intraoperative arrhythmia (atrial fibrillation: OR, 6.76 [95% CI, 1.2-37.49]; p = 0.029; sinus tachycardia: OR, 4.59 [95% CI, 1.25-16.90]; p = 0.022) were associated independently with increased 30-day mortality. High initial heart rate (per 10 beats per minute: hazard ratio [HR], 1.18 [95% CI, 1.05-1.33]; p = 0.005) in the operating room and intraoperative sinus tachycardia (HR, 1.86 [95% CI, 1.15-3.03]; p = 0.012) were associated independently with worse overall survival. CONCLUSION: Risk of death after pericardial window creation remains high in patients with cancer. Variations in anesthetic management did not affect survival in oncologic patients with pericardial effusions.

Machine learning approach to predicting persistent opioid use following lower extremity joint arthroplasty.

BACKGROUND: The objective of this study is to develop predictive models for persistent opioid use following lower extremity joint arthroplasty and determine if ensemble learning and an oversampling technique may improve model performance. METHODS: We compared various predictive models to identify at-risk patients for persistent postoperative opioid use using various preoperative, intraoperative, and postoperative data, including surgical procedure, patient demographics/characteristics, past surgical history, opioid use history, comorbidities, lifestyle habits, anesthesia details, and postoperative hospital course. Six classification models were evaluated: logistic regression, random forest classifier, simple-feedforward neural network, balanced random forest classifier, balanced bagging classifier, and support vector classifier. Performance with Synthetic Minority Oversampling Technique (SMOTE) was also evaluated. Repeated stratified k-fold cross-validation was implemented to calculate F1-scores and area under the receiver operating characteristics curve (AUC). RESULTS: There were 1042 patients undergoing elective knee or hip arthroplasty in which 242 (23.2%) reported persistent opioid use. Without SMOTE, the logistic regression model has an F1 score of 0.47 and an AUC of 0.79. All ensemble methods performed better, with the balanced bagging classifier having an F1 score of 0.80 and an AUC of 0.94. SMOTE improved performance of all models based on F1 score. Specifically, performance of the balanced bagging classifier improved to an F1 score of 0.84 and an AUC of 0.96. The features with the highest importance in the balanced bagging model were postoperative day 1 opioid use, body mass index, age, preoperative opioid use, prescribed opioids at discharge, and hospital length of stay. CONCLUSIONS: Ensemble learning can dramatically improve predictive models for persistent opioid use. Accurate and early identification of high-risk patients can play a role in clinical decision making and early optimization with personalized interventions.

Diaphragm muscle shortening modulates kinematics of lower rib cage in dogs.

We tested the hypothesis that diaphragm muscle shortening modulates volume displacement and kinematics of the lower rib cage in dogs and that posture and mode of ventilation affect such modulation. Radiopaque markers were surgically attached to the lower three ribs of the rib cage and to the midcostal region of the diaphragm in six dogs of ∼8 kg body masses, and the locations of these markers were determined by a biplane fluoroscopy system. Three-dimensional software modeling techniques were used to compute volume displacement and surface area of the midcostal diaphragm and the lower three ribs during quiet spontaneous breathing, mechanical ventilation, and bilateral phrenic nerve stimulation at different lung volumes spanning the vital capacity. Volume displaced by the diaphragm relative to that displaced by the lower ribs is disproportionately greater under mechanical ventilation than during spontaneous breathing in the supine position (P < 0.05). At maximal stimulation, diaphragm volume displacement grows disproportionately larger than rib volume displacement as lung volume increases (P < 0.05). Surface area of both the diaphragm and the lower ribs during maximal stimulation of the diaphragm is reduced compared with that at spontaneous breathing (P < 0.05). In the prone posture, mechanical ventilation results in a smaller change in diaphragm surface area than spontaneous breathing (P < 0.05). Our data demonstrate that during inspiration the lower rib cage moves not only through the pump- and bucket-handle motion, but also rotates around the spine. Taken together, these data support the observation that the kinematics of the lower rib cage and its mechanical interaction with the diaphragm are more complex than previously known.

Knowledge of malocclusion supports comprehensive dental hygiene care.

Occlusal assessments are often missed or neglected by dentists and dental hygienists. This short communication discusses how these assessments can be implemented through 4 planes of space: anterior-posterior/anteroposterior, vertical, transverse, and perimeter. Expanded occlusal knowledge can improve the referral process for early preventive care. A chairside guide has been defined for dental hygienists to conduct a systematic occlusal exam.

Il arrive souvent que les évaluations occlusales ne soient pas effectuées ou soient négligées par les dentistes et les hygiénistes dentaires. Ce bref article traite de la façon dont ces évaluations peuvent être effectuées au moyen de 4 dimensions de l'espace : antérieure-postérieure/ antéropostérieure, verticale, transverse et périmètre. Une connaissance approfondie de l'occlusion peut améliorer le processus de renvoi pour l'obtention de soins préventifs précoces. Un guide au fauteuil a été préparé à l'intention des hygiénistes dentaires pour leur permettre d'effectuer un examen occlusal systématique.

Metabolic Disorders and Anesthesia.

PURPOSE OF REVIEW: Metabolic disorders encompass a group of inherited inborn errors of metabolism that are uncommonly encountered but can pose challenges when encountered during the perioperative period. Hence, it is paramount that anesthesiologists are experienced and familiar with management of these conditions. RECENT FINDINGS: Hundreds of inborn errors of metabolism have already been identified, yet new metabolic disorders continue to be discovered with advancements in genomic science. SUMMARY: In our general review, we define the more common metabolic disorders encountered in perioperative medicine and discuss the perioperative anesthetic considerations and challenges associated with each disorder. The following disorders are covered in our review: disorders of carbohydrate metabolism, disorders of amino acid metabolism, disorders of branched-chain amino acid metabolism, organic acidemias, mitochondrial disorders, lysosomal storage disorders, metal metabolism disorders, and urea cycle disorders.