Novel Insights in Venous Thromboembolism Risk Assessment Methods in Ambulatory Cancer Patients: From the Guidelines to Clinical Practice.

Many cancer patients will experience venous thromboembolism (VTE) at some stage, with the highest rate in the initial period following diagnosis. Novel cancer therapies may further enhance the risk. VTE in a cancer setting is associated with poor prognostic, a decreased quality of life, and high healthcare costs. If thromboprophylaxis in hospitalized cancer patients and perioperative settings is widely accepted in clinical practice and supported by the guidelines, it is not the same situation in ambulatory cancer patient settings. The guidelines do not recommend primary thromboprophylaxis, except in high-risk cases. However, nowadays, risk stratification is still challenging, although many tools have been developed. The Khrorana score remains the most used method, but it has many limits. This narrative review aims to present the current relevant knowledge of VTE risk assessment in ambulatory cancer patients, starting from the guideline recommendations and continuing with the specific risk assessment methods and machine learning models approaches. Biomarkers, genetic, and clinical features were tested alone or in groups. Old and new models used in VTE risk assessment are exposed, underlining their clinical utility. Imaging and biomolecular approaches to VTE screening of outpatients with cancer are also presented, which could help clinical decisions.

Novel Biomarkers and Advanced Cardiac Imaging in Aortic Stenosis: Old and New.

Currently, the symptomatic status and left ventricular ejection fraction (LVEF) play a crucial role in aortic stenosis (AS) assessment. However, the symptoms are often subjective, and LVEF is not a sensitive marker of left ventricle (LV) decompensation. Over the past years, the cardiac structure and function research on AS has increased due to advanced imaging modalities and potential therapies. New imaging parameters emerged as predictors of disease progression in AS. LV global longitudinal strain has proved useful for risk stratification in asymptomatic severe AS patients with preserved LVEF. The assessment of myocardial fibrosis by cardiac magnetic resonance is the most studied application and offers prognostic information on AS. Moreover, the usage of biomarkers in AS as objective measures of LV decompensation has recently gained more interest. The present review focuses on the transition from compensatory LV hypertrophy (H) to LV dysfunction and the biomarkers associated with myocardial wall stress, fibrosis, and myocyte death. Moreover, we discuss the potential impact of non-invasive imaging parameters for optimizing the timing of aortic valve replacement and provide insight into novel biomarkers for possible prognostic use in AS. However, data from randomized clinical trials are necessary to define their utility in daily practice.

The Role of the Cardiac Biomarkers in the Renal Cell Carcinoma Multidisciplinary Management.

Renal cell carcinoma, an aggressive malignancy, is often incidentally diagnosed. The patient remains asymptomatic to the late stage of the disease, when the local or distant metastases are already present. Surgical treatment remains the choice for these patients, although the plan must adapt to the characteristics of the patients and the extension of the neoplasm. Systemic therapy is sometimes needed. It includes immunotherapy, target therapy, or both, with a high level of toxicity. Cardiac biomarkers have prognosis and monitoring values in this setting. Their role in postoperative identification of myocardial injury and heart failure already have been demonstrated, as well as their importance in preoperative evaluation from the cardiac point of view and the progression of renal cancer. The cardiac biomarkers are also part of the new cardio-oncologic approach to establishing and monitoring systemic therapy. They are complementary tests for assessment of the baseline toxicity risk and tools to guide therapy. The goal must be to continue the treatment as long as possible with the initiation and optimisation of the cardiological treatment. Cardiac atrial biomarkers are reported to have also antitumoral and anti-inflammatory properties. This review aims to present the role of cardiac biomarkers in the multidisciplinary management of renal cell carcinoma patients.

AKI3-Risk Predictors and Scores in Radical Nephrectomy with High Thrombectomy under Extracorporeal Circulation for Renal Cell Carcinoma with Supradiaphragmatic Inferior Vena Cava/Right Atrial Thrombus: A Single-Centre Retrospective Study.

Background and Objectives: The recommended therapeutic management in renal cell carcinoma (RCC) with supradiaphragmatic inferior vena cava/right atrial thrombus (IVC/RA) is surgery. Extracorporeal circulation is required. Acute kidney injury (AKI), a frequent complication after nephrectomy and cardiac surgery is associated with long-term kidney disease. This study aims to identify the risk factors involved in the occurrence of the severe postoperative AKI (AKI3) and to analyse various preoperative validated risk scores from cardiac and noncardiac surgery in predicting this endpoint. Materials and Methods: The medical data of all patients with RCC with supradiaphragmatic IVC/RA thrombus who underwent radical nephrectomy with high thrombectomy, using extracorporeal circulation, between 2004-2018 in the Prof. C. C. Iliescu Emergency Institute for Cardiovascular Diseases, Bucharest, were retrospectively analysed. The patients who died intraoperatively were excluded from the study. The predefined study endpoint was the postoperative AKI3. Preoperative, intraoperative and postoperative data were collected according to the stratification of study population in two subgroups: AKI3-present and AKI3- absent patients. EuroSCORE, EuroSCORE II, Logistic EuroSCORE, NSQIP any-complications and NSQIP serious-complications were analysed. Results: We reviewed 30 patients who underwent this complex surgery between 2004-2018 in our institute. Two patients died intraoperatively. Nine patients (32.14%) presented postoperative AKI3. Age (OR 1.151, CI 95%: 1.009-1.312), preoperative creatinine clearance (OR 1.066, CI 95%: 1.010-1.123) and intraoperative arterial hypotension (OR 13.125, CI 95%: 1.924-89.515) were risk factors for AKI3 (univariable analysis). Intraoperative arterial hypotension emerged as the only independent risk factor in multivariable analysis (OR 11.66, CI 95%: 1.400-97.190). Logistic EuroSCORE (ROC analysis: AUC = 0.813, p = 0.008, CI 95%: 0.633-0.993) best predicted the endpoint. Conclusions: An integrated team effort is essential to avoid intraoperative arterial hypotension, the only independent risk factor of AKI3 in this highly complex surgery. Some risk scores can predict this complication. Further studies are needed.

Efficient Dynamics Estimation with Adaptive Model Sets.

Robotic systems frequently operate under changing dynamics, such as driving across varying terrain, encountering sensing and actuation faults, or navigating around humans with uncertain and changing intent. In order to operate effectively in these situations, robots must be capable of efficiently estimating these changes in order to adapt at the decision-making, planning, and control levels. Typical estimation approaches maintain a fixed set of candidate models at each time step; however, this can be computationally expensive if the number of models is large. In contrast, we propose a novel algorithm that employs an adaptive model set. We leverage the idea that the current model set must be expanded if its models no longer sufficiently explain the sensor measurements. By maintaining only a small subset of models at each time step, our algorithm improves on efficiency; at the same time, by choosing the appropriate models to keep, we avoid compromising on performance. We show that our algorithm exhibits higher efficiency in comparison to several baselines, when tested on simulated manipulation, driving, and human motion prediction tasks, as well as in hardware experiments on a 7 DOF manipulator.

Abdominal paraaortic paraganglioma: Management of intraoperative hemodynamic emergencies during elective resection procedures (A case presentation).

Paragangliomas are extremely rare neuroendocrine tumors. We report a case of a 44-year-old man with hypertension who presented a tumoral mass located retroperitoneally at the aortic bifurcation which included both the common iliac arteries and the posterior left iliac vein, who experienced an unpredictable intraoperative cardiac arrest with electromechanical dissociation at 5 min after laparotomy. After successful resuscitation and hemodynamic stability, the lesion was fully excised. In the course of tumor manipulation, the patient developed a major hypertensive crisis with peak systolic blood pressure over 280 mmHg. Pathologic examination revealed the presence of diffuse proliferation of large and medium-sized mature adipocytes consistent with paraganglioma diagnosis. The patient was discharged at home on the seventh postoperative day. He did not present evidence of recurrence at the one-year follow-up. In conclusion, paragangliomas can require particular management due to their location but also due to their capacity to discharge substances which might induce life-threatening intraoperative complications.

A Digital Improvement-Trimming a Digital Temperature Sensor with EEPROM Reprogrammable Fuses.

An EEPROM (electrically erasable programmable read-only memory) reprogrammable fuse for trimming a digital temperature sensor is designed in a 0.18-µm CMOS EEPROM. The fuse uses EEPROM memory cells, which allow multiple programming cycles by modifying the stored data on the digital trim codes applied to the thermal sensor. By reprogramming the fuse, the temperature sensor can be adjusted with an increased trim variation in order to achieve higher accuracy. Experimental results for the trimmed digital sensor showed a +1.5/-1.0 ℃ inaccuracy in the temperature range of -20 to 125 ℃ for 25 trimmed DTS samples at 1.8 V by one-point calibration. Furthermore, an average mean of 0.40 ℃ and a standard deviation of 0.70 ℃ temperature error were obtained in the same temperature range for power supply voltages from 1.7 to 1.9 V. Thus, the digital sensor exhibits similar performances for the entire power supply range of 1.7 to 3.6 V.

How to Be Helpful to Multiple People at Once.

When someone hosts a party, when governments choose an aid program, or when assistive robots decide what meal to serve to a family, decision-makers must determine how to help even when their recipients have very different preferences. Which combination of people's desires should a decision-maker serve? To provide a potential answer, we turned to psychology: What do people think is best when multiple people have different utilities over options? We developed a quantitative model of what people consider desirable behavior, characterizing participants' preferences by inferring which combination of "metrics" (maximax, maxsum, maximin, or inequality aversion [IA]) best explained participants' decisions in a drink-choosing task. We found that participants' behavior was best described by the maximin metric, describing the desire to maximize the happiness of the worst-off person, though participant behavior was also consistent with maximizing group utility (the maxsum metric) and the IA metric to a lesser extent. Participant behavior was consistent across variation in the agents involved and  tended to become more maxsum-oriented when participants were told they were players in the task (Experiment 1). In later experiments, participants maintained maximin behavior across multi-step tasks rather than shortsightedly focusing on the individual steps therein (Experiment 2, Experiment 3). By repeatedly asking participants what choices they would hope for in an optimal, just decision-maker, and carefully disambiguating which quantitative metrics describe these nuanced choices, we help constrain the space of what behavior we desire in leaders, artificial intelligence systems helping decision-makers, and the assistive robots and decision-makers of the future.

The value of a superior vena cava collapsibility index measured with a miniaturized transoesophageal monoplane continuous echocardiography probe to predict fluid responsiveness compared to stroke volume variations in open major vascular surgery: a prospective cohort study.

Superior vena cava collapsibility index (SVC-CI) and stroke volume variation (SVV) have been shown to predict fluid responsiveness. SVC-CI has been validated only with conventional transoesophageal echocardiography (TEE) in the SVC long axis, on the basis of SVC diameter variations, but not in the SVC short axis or by SVC area variations. SVV was not previously tested in vascular surgery patients. Forty consecutive adult patients undergoing open major vascular surgical procedures received 266 intraoperative volume loading tests (VLTs), with 500 ml of gelatine over 10 min. The hSVC-CI was measured using a miniaturized transoesophageal echocardiography probe (hTEE). The SVV and cardiac index (CI) were measured using Vigileo-FloTrac technology. VLTs were considered 'positive' (≥ 11% increase in CI) or 'negative' (< 11% increase in CI). We compared SVV and hSVC-CI measurements in the SVC short axis to predict fluid responsiveness. Areas under the receiver operating characteristic curves for hSVC-CI and SVV were not significantly different (P = 0.56), and both showed good predictivity at values of 0.92 (P < 0.001) and 0.89 (P < 0.001), respectively. The cutoff values for hSVC-CI and SVV were 37% (sensitivity 90%, specificity of 83%) and 15% (sensitivity 78%, specificity of 100%), respectively. Our study validated the value of the SVC-CI measured as area variations in the SVC short axis to predict fluid responsiveness in anesthetized patients. An hTEE probe was used to monitor and measure the hSVC-CI but conventional TEE may also offer this new dynamic parameter. In our cohort of significant preoperative hypovolemic patients undergoing major open vascular surgery, hSVC-CI and SVV cutoff values of 37% and 15%, respectively, predicted fluid responsiveness with good accuracy.