Background: There is limited data in the literature evaluating outcomes of bariatric surgery in s... more Background: There is limited data in the literature evaluating outcomes of bariatric surgery in severely obese patients with left ventricular assist device (LVAD) as a bridge to make them acceptable candidates for heart transplantation. This study aims to assess the safety and effectiveness of laparoscopic sleeve gastrectomy (LSG) in patients with previously implanted LVAD at our institution. Methods: All the patients with end-stage heart failure (ESHF) and implanted LVAD who underwent LSG from2013 to January 2017 were studied. Results: Seven patients with end stage heart failure (ESHF) and implanted LVAD were included. The median age and median preoperative BMI were 39 years (range: 26-62) and 43.6 kg/m2 (range 36.7-56.7), respectively. The median interval between LVAD implantation and LSG was 38 months (range 15-48). The median length of hospital stay was 9 days (rang: 6-23) out of which 4 patients had planned postoperative ICU admission. Thirty-day complications were noted in 5 patients (3 major and 2 minor) without any perioperative mortality. The median duration of follow-up was 24 months (range 2-30). At the last available follow-up, the median BMI, %EWL, and %TWL were 37 kg/m2 , 47%, and 16%, respectively. The median LVEF before LSG and at the last follow-up point (before heart transplant) was 19% (range 15-20) and 22% (range, 16-35), respectively. In addition, the median NYHA class improved from 3 to 2 after LSG. Three patients underwent successful heart transplantations. Conclusion: Patients with morbid obesity, ESHF, and implanted LVAD constitute a high-risk cohort. Our results with 7 patients and result from other studies (19 patients) suggested that bariatric surgery may be a reasonable option for LVAD patients with severe obesity. Bariatric surgery appears to provide significant weight loss in these patients and may improve candidacy for heart transplantation.
Dear Editor, We read with great interest the letter by Weigl et al. comparing ICU mortality in se... more Dear Editor, We read with great interest the letter by Weigl et al. comparing ICU mortality in selected European countries. The authors reported a significantly higher mortality in Poland (42%) as compared to other countries (6.7-17.8%) . They concluded that the results "could be useful for stimulating improvement of critical care services in Poland" . While Weigl et al. should be commended for their effort to inform the readers about variability in ICU mortality across Europe, we are very concerned about the fact that they reported and interpreted unadjusted mortality rates. We do not question the presented ICU mortality rates in Poland and we concur with the authors' statement that the rates are high; however, we want to point out why such a simplistic interpretation is unsatisfactory and scientifically incorrect. The problem with the report, in our opinion, is the fact that authors failed to present the severity of the patients' condition at the time of ICU admission in each country. It is well documented that objectively assessed patient condition (for instance with the APACHE II scale) correlates with ICU mortality. Rowan et al. demonstrated that mortality in patients with
As survival after orthotopic liver transplantation (OLT) improves, cardiovascular (CV) disease ha... more As survival after orthotopic liver transplantation (OLT) improves, cardiovascular (CV) disease has emerged as the leading cause of non-graft-related deaths. The aims of our study were to determine the cumulative risk of CV events after OLT and to analyze predictive risk factors for those experiencing a CV event after OLT. We identified all adult patients who underwent OLT at our institution for end-stage liver disease between October 1996 and July 2008. The cumulative risk of CV events after OLT was analyzed with the Kaplan-Meier method. Multivariate logistic regression analysis was used to identify factors independently associated with CV events after OLT. In all, 775 patients were included in our study cohort (mean age of 53.3 years, female proportion ¼ 44%, Caucasian proportion ¼ 84%, median follow-up ¼ 40 months). The most common indications for OLT were hepatitis C virus (33.2%), alcohol (14.5%), and cryptogenic cirrhosis (12.7%). Eighty-three patients suffered 1 or more CV events after OLT. Posttransplant metabolic syndrome was more prevalent in patients with CV events versus patients with no CV events (61.4% versus 34.1%, P < 0.001). According to a multivariate analysis, independent predictors of CV events were an older age at transplantation [odds ratio (OR) ¼ 1.2, addition of 95% confidence interval (CI) ¼ 1.1-1.3, P ¼ 0.006], male sex (OR ¼ 2.0, 95% CI ¼ 1.2-3.3, P ¼ 0.01), posttransplant diabetes (OR ¼ 2.0, 95% CI ¼ 1.3-3.3, P ¼ 0.003), posttransplant hypertension (OR ¼ 1.8, 95% CI ¼ 1.1-3.0, P ¼ 0.02), and mycophenolate mofetil (OR ¼ 2.0, 95% CI ¼ 1.3-3.2, P ¼ 0.003). Among post-OLT patients, the cumulative risk at 5 years of 13.5%, respectively. In conclusion, cardiac complications after liver transplantation are common (Approximately 10% of patients experience 1 or move cv events). Patients with posttransplant hypertension and diabetes, which are modifiable risk factors, are approximately twice as likely to experience a CV event.
Spontaneous spinal epidural hematoma is a rare occurrence during pregnancy with only five cases d... more Spontaneous spinal epidural hematoma is a rare occurrence during pregnancy with only five cases described in the literature since 1900. Even in the general population, the frequency of spontaneous spinal epidural hematoma is extremely low and the etiology unclear. Several theories exist for the cause of spontaneous spinal epidural hematoma, however, none has gained uniform acceptance. A case of spontaneous spinal epidural hematoma during pregnancy in a 27-year-old, gravida 2, para 1, female at term with 36 hours duration of both paresthesia and progressive weakness of the lower extremities is presented. In addition, all previous known cases are summarized, including outcome. We hypothesize that the cause of spontaneous spinal epidural hematoma is multifactorial, and pregnancy-induced structural changes in arterial walls and hemodynamic changes may play a role. In addition, we postulate that the origin of the bleeding is arterial, rather then venous. Lastly, the symptoms, diagnosis, and management of spontaneous spinal epidural hematoma during pregnancy are discussed.
Cleveland Clinic Journal of Medicine, May 20, 2020
The statements and opinions expressed in COVID-19 Curbside Consults are based on experience and t... more The statements and opinions expressed in COVID-19 Curbside Consults are based on experience and the available literature as of the date posted. While we try to regularly update this content, any offered recommendations cannot be substituted for the clinical judgment of clinicians caring for individual patients.
The statements and opinions expressed in COVID-19 Curbside Consults are based on experience and t... more The statements and opinions expressed in COVID-19 Curbside Consults are based on experience and the available literature as of the date posted. While we try to regularly update this content, any offered recommendations cannot be substituted for the clinical judgment of clinicians caring for individual patients.
This study presents a multimodal machine learning model to predict ICD-10 diagnostic codes. We de... more This study presents a multimodal machine learning model to predict ICD-10 diagnostic codes. We developed separate machine learning models that can handle data from different modalities, including unstructured text, semi-structured text and structured tabular data. We further employed an ensemble method to integrate all modality-specific models to generate ICD codes. Key evidence was also extracted to make our prediction more convincing and explainable. We used the Medical Information Mart for Intensive Care III (MIMIC-III) dataset to validate our approach. For ICD code prediction, our best-performing model (micro-F1 = 0.7633, micro-AUC = 0.9541) significantly outperforms other baseline models including TF-IDF (micro-F1 = 0.6721, micro-AUC = 0.7879) and Text-CNN model (micro-F1 = 0.6569, micro-AUC = 0.9235). For interpretability, our approach achieves a Jaccard Similarity Coefficient (JSC) of 0.1806 on text data and 0.3105 on tabular data, where well-trained physicians achieve 0.2780 and 0.5002 respectively.
BackgroundCOVID-19 is now one of the leading causes of mortality amongst adults in the United Sta... more BackgroundCOVID-19 is now one of the leading causes of mortality amongst adults in the United States for the year 2020. Multiple epidemiological models have been built, often based on limited data, to understand the spread and impact of the pandemic. However, many geographic and local factors may have played an important role in higher morbidity and mortality in certain populations.ObjectiveThe goal of this study was to develop machine learning models to understand the relative association of socioeconomic, demographic, travel, and health care characteristics of different states across the United States and COVID-19 mortality.MethodsUsing multiple public data sets, 24 variables linked to COVID-19 disease were chosen to build the models. Two independent machine learning models using CatBoost regression and random forest were developed. SHAP feature importance and a Boruta algorithm were used to elucidate the relative importance of features on COVID-19 mortality in the United States.R...
Incorporating serum sodium concentrations into the model for end-stage liver disease (MELD) score... more Incorporating serum sodium concentrations into the model for end-stage liver disease (MELD) score may increase its sensitivity for identifying priority patients for orthotopic liver transplantation (OLT). We, therefore, evaluated and compared the ability of the sodium MELD and MELD scores to predict graft and patient survival after OLT. The United Network for Organ Sharing (UNOS) registry includes all US adult OLTs performed between January 2000 and August 2008. For 15,156 patients who met inclusion criteria, MELD score was calculated; for 6,193 patients whose serum sodium concentrations was between 120 and 135 mEq/dl, immediately before OLT, sodium MELD score was calculated. The corresponding hazard ratios (HR) for MELD and sodium MELD on graft and patient survival were assessed using the Cox proportional hazards regression models. The concordance probability estimate (CPE) was used to evaluate predictive ability of each time-to-event model. MELD and sodium MELD scores were both si...
Background The relationship between intraoperative physiology and postoperative stroke is incompl... more Background The relationship between intraoperative physiology and postoperative stroke is incompletely understood. Preliminary data suggest that either hypo- or hypercapnia coupled with reduced cerebrovascular inflow (e.g., due to hypotension) can lead to ischemia. This study tested the hypothesis that the combination of intraoperative hypotension and either hypo- or hypercarbia is associated with postoperative ischemic stroke. Methods We conducted a retrospective, case–control study via the Multicenter Perioperative Outcomes Group. Noncardiac, nonintracranial, and nonmajor vascular surgical cases (18 yr or older) were extracted from five major academic centers between January 2004 and December 2015. Ischemic stroke cases were identified via manual chart review and matched to controls (1:4). Time and reduction below key mean arterial blood pressure thresholds (less than 55 mmHg, less than 60 mmHg, less than 65 mmHg) and outside of specific end-tidal carbon dioxide thresholds (30 mmH...
Key Points 1. Transfusion of blood products can be lifesaving, however, it is not risk free. Ther... more Key Points 1. Transfusion of blood products can be lifesaving, however, it is not risk free. Therefore it is the responsibility of the physician to use appropriate triggers for blood component therapy. 2. ABO and the Rh systems are the most important in the majority of blood transfusions, although human red cell membranes contain as many as 300 different antigenic determinants. 3. Indication for red blood cell (RBC) transfusion is the need to increase the oxygen-carrying capacity. 4. The US Food and Drug Administration (FDA) recommends avoiding HES in critically ill adult patients and septic patients requiring ICU care. 5. Transfusion-related acute lung injury (TRALI) is currently the leading cause of transfusion-related death. Clinical presentation of TRALI may be indistinguishable from acute respiratory distress syndrome (ARDS) and is characterized by acute onset, bilateral pulmonary infiltrates and hypoxia without evidence of congestive heart failure (CHF).
A ttention to the heart before, during, and after liver transplantation can pay off in terms of b... more A ttention to the heart before, during, and after liver transplantation can pay off in terms of better outcomes. This, even though today's liver transplant patients are older than those in the past and more likely to have fatty liver disease as the cause of their liver failure, and even though liver failure, the transplant procedure, and the posttransplant regimen can all predispose to heart disease. The changing demographics of patients receiving liver transplants and the unique cardiac pathophysiology of patients with advanced liver disease pose signifi cant challenges in managing these patients perioperatively, as we will discuss in the following sections.
STUDY OBJECTIVE To measure the possible association between subhypnotic propofol infusion during ... more STUDY OBJECTIVE To measure the possible association between subhypnotic propofol infusion during general balanced anesthesia and the incidence of PONV. DESIGN Retrospective Cohort Analysis Using Propensity Score Matching. SETTING Postanesthesia care unit and inpatient unit. PATIENTS Patients with American Society of Anesthesiologists (ASA) physical status I-IV, undergoing non-cardiac surgery lasting >2 h were included. Patients were excluded if transferred to the intensive care unit after surgery or received ketamine. Initially 70,976 patients were screened, and a cohort of 51,707 eligible adult patients undergoing non-cardiac surgery under general balanced anesthesia between 2015 and 2019 were included. Using a propensity score matching, 3185 patients who received subhypnotic propofol during general balanced anesthesia were matched with 5826 patients who did not receive subhypnotic propofol in a 1:2 ratio. INTERVENTIONS None. MEASUREMENTS The primary outcome was the incidence of PONV during PACU stay. The secondary outcome was the incidence of PONV within the first 24 h after surgery. Exploratory outcomes were time-to-extubation and length of hospital stay. MAIN RESULTS A total of 9011 patients were included (3185 patients who received propofol infusion, and 5826 patients who did not receive propofol infusion) after propensity score matching. The adjusted odds ratio for PONV incidence was 1.03 (95% CI: 0.90, 1.18; p = 0.635) in PACU, and 1.05 (95% CI: 0.90, 1.23; P = 0.50) within 24 h after surgery. The length of hospital stay was 6 h shorter (ratio of means (95% CI) of 0.92, 0.89, 0.94), p < 0.001) and time-to-extubation was 2 min longer (ratio of means 1.24 (1.20, 1.28), p < 0.001) in patients receiving subhypnotic propofol infusion. CONCLUSIONS Our study suggests that subhypnotic propofol infusion during general balanced anesthesia is not associated with a reduction in the incidence of PONV during PACU stay and within the first 24 h after surgery. However, it is associated with decreased LOS and increased time-to-extubation, but differences in neither outcome were clinically important.
Background The Hypotension Prediction Index is a commercially available algorithm, based on arter... more Background The Hypotension Prediction Index is a commercially available algorithm, based on arterial waveform features, that predicts hypotension defined as mean arterial pressure less than 65 mmHg for at least 1 min. We therefore tested the primary hypothesis that index guidance reduces the duration and severity of hypotension during noncardiac surgery. Methods We enrolled adults having moderate- or high-risk noncardiac surgery with invasive arterial pressure monitoring. Participating patients were randomized to hemodynamic management with or without index guidance. Clinicians caring for patients assigned to guidance were alerted when the index exceeded 85 (range, 0 to 100) and a treatment algorithm based on advanced hemodynamic parameters suggested vasopressor administration, fluid administration, inotrope administration, or observation. Primary outcome was the amount of hypotension, defined as time-weighted average mean arterial pressure less than 65 mmHg. Secondary outcomes were...
STUDY OBJECTIVE To test whether patients who experience hypotension in the post-anesthesia care u... more STUDY OBJECTIVE To test whether patients who experience hypotension in the post-anesthesia care unit or during surgery are most likely to experience hypotension on surgical wards. DESIGN A prediction study using data from two randomized controlled trials. SETTING Operating room, post-anesthesia care unit, and surgical ward. PATIENTS 550 adult patients having abdominal surgery with ASA physical status I-IV. INTERVENTIONS Blood pressure measurement per routine intraoperatively, and with continuous non-invasive monitoring postoperatively. MEASUREMENTS The primary predictors were minimum mean arterial pressure (<60, <65, <70 and < 80 mmHg) and minimum systolic blood pressure (<70, <75, <80, <85 mmHg) in the post-anesthesia care unit. The secondary predictors were intraoperative minimum blood pressures with the same thresholds as the primary ones. Our outcome was ward hypotension defined as mean pressure < 70 mmHg or systolic pressure < 85 mmHg. A threshold was considered clinically useful if both sensitivity and specificity exceeded 0.75. MAIN RESULTS Minimum mean and systolic pressures in the post-anesthesia care unit similarly predicted ward mean or systolic hypotension, with the areas under the curves near 0.74. The best performing threshold was mean pressure < 80 mmHg in the post-anesthesia care unit which had a sensitivity of 0.41 (95% confidence interval [CI], 0.35, 0.47) and specificity of 0.91 (95% CI, 0.87, 0.94) for ward mean pressure < 70 mmHg and a sensitivity of 0.44 (95% CI, 0.37, 0.51) and specificity of 0.88 (95% CI, 0.84, 0.91) for ward systolic pressure < 85 mmHg. The areas under the curves using intraoperative hypotension to predict ward hypotension were roughly similar at about 0.60, with correspondingly low sensitivity and specificity. CONCLUSIONS Intraoperative hypotension poorly predicted ward hypotension. Pressures in the post-anesthesia care unit were more predictive, but the combination of sensitivity and specificity remained poor. Unless far better predictors are identified, all surgical inpatients should be considered at risk for postoperative hypotension.
EDITOR’S PERSPECTIVE What We Already Know about This Topic Intraoperative triple-low events (mean... more EDITOR’S PERSPECTIVE What We Already Know about This Topic Intraoperative triple-low events (mean arterial pressure less than 75 mmHg, Bispectral Index less than 45, and minimum alveolar fraction of anesthetic less than 0.8) have been found to be associated with increased risk of mortality What This Article Tells Us That Is New A randomized electronic alert of triple-low events to treating clinicians did not reduce 90-day mortality The alerts minimally influenced clinician responses, assessed as vasopressor administration or reduction in end-tidal volatile anesthetic partial pressure, and there was no association between response to alerts and mortality Triple-low events predict mortality but do not appear to be causally related Background Triple-low events (mean arterial pressure less than 75 mmHg, Bispectral Index less than 45, and minimum alveolar fraction less than 0.8) are associated with mortality but may not be causal. This study tested the hypothesis that providing triple-lo...
Intraoperative hypotension is associated with postoperative mortality. Early detection of hypoten... more Intraoperative hypotension is associated with postoperative mortality. Early detection of hypotension by continuous hemodynamic monitoring might prompt timely therapy, thereby reducing intraoperative hypotension. We tested the hypothesis that continuous noninvasive blood pressure monitoring reduces intraoperative hypotension. Patients ≥45 years old with American Society of Anesthesiologists physical status III or IV having moderate-to-high-risk noncardiac surgery with general anesthesia were included. All participating patients had continuous noninvasive hemodynamic monitoring using a finger cuff (ClearSight, Edwards Lifesciences, Irvine, CA) and a standard oscillometric cuff. In half the patients, randomly assigned, clinicians were blinded to the continuous values, whereas the others (unblinded) had access to continuous blood pressure readings. Continuous pressures in both groups were used for analysis. Time-weighted average for mean arterial pressure <65 mm Hg was compared usin...
Preoperative smoking cessation is commonly advised in an effort to improve postoperative outcomes... more Preoperative smoking cessation is commonly advised in an effort to improve postoperative outcomes. However, it remains unclear for how long smoking cessation is necessary, and even whether a brief preoperative period of abstinence is helpful and well tolerated. We evaluated associations between various periods of preoperative smoking cessation and major morbidity and death. Retrospective cohort analysis. Adults who had noncardiac surgery at the Cleveland Clinic Main Campus between May 2007 and December 2013. A total of 37 511 patients whose smoking history was identified from a preoperative Health Quest questionnaire. Of these patients, 26 269 (70%) were former smokers and 11 242 (30%) were current smokers. Of the current smokers, 9482 (84%) were propensity matched with 9482 former smokers (36%). We excluded patients with American Society of Anesthesiologists' physical status exceeding four, patients who did not have general anaesthesia, and patients with missing outcomes and/or...
Background: There is limited data in the literature evaluating outcomes of bariatric surgery in s... more Background: There is limited data in the literature evaluating outcomes of bariatric surgery in severely obese patients with left ventricular assist device (LVAD) as a bridge to make them acceptable candidates for heart transplantation. This study aims to assess the safety and effectiveness of laparoscopic sleeve gastrectomy (LSG) in patients with previously implanted LVAD at our institution. Methods: All the patients with end-stage heart failure (ESHF) and implanted LVAD who underwent LSG from2013 to January 2017 were studied. Results: Seven patients with end stage heart failure (ESHF) and implanted LVAD were included. The median age and median preoperative BMI were 39 years (range: 26-62) and 43.6 kg/m2 (range 36.7-56.7), respectively. The median interval between LVAD implantation and LSG was 38 months (range 15-48). The median length of hospital stay was 9 days (rang: 6-23) out of which 4 patients had planned postoperative ICU admission. Thirty-day complications were noted in 5 patients (3 major and 2 minor) without any perioperative mortality. The median duration of follow-up was 24 months (range 2-30). At the last available follow-up, the median BMI, %EWL, and %TWL were 37 kg/m2 , 47%, and 16%, respectively. The median LVEF before LSG and at the last follow-up point (before heart transplant) was 19% (range 15-20) and 22% (range, 16-35), respectively. In addition, the median NYHA class improved from 3 to 2 after LSG. Three patients underwent successful heart transplantations. Conclusion: Patients with morbid obesity, ESHF, and implanted LVAD constitute a high-risk cohort. Our results with 7 patients and result from other studies (19 patients) suggested that bariatric surgery may be a reasonable option for LVAD patients with severe obesity. Bariatric surgery appears to provide significant weight loss in these patients and may improve candidacy for heart transplantation.
Dear Editor, We read with great interest the letter by Weigl et al. comparing ICU mortality in se... more Dear Editor, We read with great interest the letter by Weigl et al. comparing ICU mortality in selected European countries. The authors reported a significantly higher mortality in Poland (42%) as compared to other countries (6.7-17.8%) . They concluded that the results "could be useful for stimulating improvement of critical care services in Poland" . While Weigl et al. should be commended for their effort to inform the readers about variability in ICU mortality across Europe, we are very concerned about the fact that they reported and interpreted unadjusted mortality rates. We do not question the presented ICU mortality rates in Poland and we concur with the authors' statement that the rates are high; however, we want to point out why such a simplistic interpretation is unsatisfactory and scientifically incorrect. The problem with the report, in our opinion, is the fact that authors failed to present the severity of the patients' condition at the time of ICU admission in each country. It is well documented that objectively assessed patient condition (for instance with the APACHE II scale) correlates with ICU mortality. Rowan et al. demonstrated that mortality in patients with
As survival after orthotopic liver transplantation (OLT) improves, cardiovascular (CV) disease ha... more As survival after orthotopic liver transplantation (OLT) improves, cardiovascular (CV) disease has emerged as the leading cause of non-graft-related deaths. The aims of our study were to determine the cumulative risk of CV events after OLT and to analyze predictive risk factors for those experiencing a CV event after OLT. We identified all adult patients who underwent OLT at our institution for end-stage liver disease between October 1996 and July 2008. The cumulative risk of CV events after OLT was analyzed with the Kaplan-Meier method. Multivariate logistic regression analysis was used to identify factors independently associated with CV events after OLT. In all, 775 patients were included in our study cohort (mean age of 53.3 years, female proportion ¼ 44%, Caucasian proportion ¼ 84%, median follow-up ¼ 40 months). The most common indications for OLT were hepatitis C virus (33.2%), alcohol (14.5%), and cryptogenic cirrhosis (12.7%). Eighty-three patients suffered 1 or more CV events after OLT. Posttransplant metabolic syndrome was more prevalent in patients with CV events versus patients with no CV events (61.4% versus 34.1%, P < 0.001). According to a multivariate analysis, independent predictors of CV events were an older age at transplantation [odds ratio (OR) ¼ 1.2, addition of 95% confidence interval (CI) ¼ 1.1-1.3, P ¼ 0.006], male sex (OR ¼ 2.0, 95% CI ¼ 1.2-3.3, P ¼ 0.01), posttransplant diabetes (OR ¼ 2.0, 95% CI ¼ 1.3-3.3, P ¼ 0.003), posttransplant hypertension (OR ¼ 1.8, 95% CI ¼ 1.1-3.0, P ¼ 0.02), and mycophenolate mofetil (OR ¼ 2.0, 95% CI ¼ 1.3-3.2, P ¼ 0.003). Among post-OLT patients, the cumulative risk at 5 years of 13.5%, respectively. In conclusion, cardiac complications after liver transplantation are common (Approximately 10% of patients experience 1 or move cv events). Patients with posttransplant hypertension and diabetes, which are modifiable risk factors, are approximately twice as likely to experience a CV event.
Spontaneous spinal epidural hematoma is a rare occurrence during pregnancy with only five cases d... more Spontaneous spinal epidural hematoma is a rare occurrence during pregnancy with only five cases described in the literature since 1900. Even in the general population, the frequency of spontaneous spinal epidural hematoma is extremely low and the etiology unclear. Several theories exist for the cause of spontaneous spinal epidural hematoma, however, none has gained uniform acceptance. A case of spontaneous spinal epidural hematoma during pregnancy in a 27-year-old, gravida 2, para 1, female at term with 36 hours duration of both paresthesia and progressive weakness of the lower extremities is presented. In addition, all previous known cases are summarized, including outcome. We hypothesize that the cause of spontaneous spinal epidural hematoma is multifactorial, and pregnancy-induced structural changes in arterial walls and hemodynamic changes may play a role. In addition, we postulate that the origin of the bleeding is arterial, rather then venous. Lastly, the symptoms, diagnosis, and management of spontaneous spinal epidural hematoma during pregnancy are discussed.
Cleveland Clinic Journal of Medicine, May 20, 2020
The statements and opinions expressed in COVID-19 Curbside Consults are based on experience and t... more The statements and opinions expressed in COVID-19 Curbside Consults are based on experience and the available literature as of the date posted. While we try to regularly update this content, any offered recommendations cannot be substituted for the clinical judgment of clinicians caring for individual patients.
The statements and opinions expressed in COVID-19 Curbside Consults are based on experience and t... more The statements and opinions expressed in COVID-19 Curbside Consults are based on experience and the available literature as of the date posted. While we try to regularly update this content, any offered recommendations cannot be substituted for the clinical judgment of clinicians caring for individual patients.
This study presents a multimodal machine learning model to predict ICD-10 diagnostic codes. We de... more This study presents a multimodal machine learning model to predict ICD-10 diagnostic codes. We developed separate machine learning models that can handle data from different modalities, including unstructured text, semi-structured text and structured tabular data. We further employed an ensemble method to integrate all modality-specific models to generate ICD codes. Key evidence was also extracted to make our prediction more convincing and explainable. We used the Medical Information Mart for Intensive Care III (MIMIC-III) dataset to validate our approach. For ICD code prediction, our best-performing model (micro-F1 = 0.7633, micro-AUC = 0.9541) significantly outperforms other baseline models including TF-IDF (micro-F1 = 0.6721, micro-AUC = 0.7879) and Text-CNN model (micro-F1 = 0.6569, micro-AUC = 0.9235). For interpretability, our approach achieves a Jaccard Similarity Coefficient (JSC) of 0.1806 on text data and 0.3105 on tabular data, where well-trained physicians achieve 0.2780 and 0.5002 respectively.
BackgroundCOVID-19 is now one of the leading causes of mortality amongst adults in the United Sta... more BackgroundCOVID-19 is now one of the leading causes of mortality amongst adults in the United States for the year 2020. Multiple epidemiological models have been built, often based on limited data, to understand the spread and impact of the pandemic. However, many geographic and local factors may have played an important role in higher morbidity and mortality in certain populations.ObjectiveThe goal of this study was to develop machine learning models to understand the relative association of socioeconomic, demographic, travel, and health care characteristics of different states across the United States and COVID-19 mortality.MethodsUsing multiple public data sets, 24 variables linked to COVID-19 disease were chosen to build the models. Two independent machine learning models using CatBoost regression and random forest were developed. SHAP feature importance and a Boruta algorithm were used to elucidate the relative importance of features on COVID-19 mortality in the United States.R...
Incorporating serum sodium concentrations into the model for end-stage liver disease (MELD) score... more Incorporating serum sodium concentrations into the model for end-stage liver disease (MELD) score may increase its sensitivity for identifying priority patients for orthotopic liver transplantation (OLT). We, therefore, evaluated and compared the ability of the sodium MELD and MELD scores to predict graft and patient survival after OLT. The United Network for Organ Sharing (UNOS) registry includes all US adult OLTs performed between January 2000 and August 2008. For 15,156 patients who met inclusion criteria, MELD score was calculated; for 6,193 patients whose serum sodium concentrations was between 120 and 135 mEq/dl, immediately before OLT, sodium MELD score was calculated. The corresponding hazard ratios (HR) for MELD and sodium MELD on graft and patient survival were assessed using the Cox proportional hazards regression models. The concordance probability estimate (CPE) was used to evaluate predictive ability of each time-to-event model. MELD and sodium MELD scores were both si...
Background The relationship between intraoperative physiology and postoperative stroke is incompl... more Background The relationship between intraoperative physiology and postoperative stroke is incompletely understood. Preliminary data suggest that either hypo- or hypercapnia coupled with reduced cerebrovascular inflow (e.g., due to hypotension) can lead to ischemia. This study tested the hypothesis that the combination of intraoperative hypotension and either hypo- or hypercarbia is associated with postoperative ischemic stroke. Methods We conducted a retrospective, case–control study via the Multicenter Perioperative Outcomes Group. Noncardiac, nonintracranial, and nonmajor vascular surgical cases (18 yr or older) were extracted from five major academic centers between January 2004 and December 2015. Ischemic stroke cases were identified via manual chart review and matched to controls (1:4). Time and reduction below key mean arterial blood pressure thresholds (less than 55 mmHg, less than 60 mmHg, less than 65 mmHg) and outside of specific end-tidal carbon dioxide thresholds (30 mmH...
Key Points 1. Transfusion of blood products can be lifesaving, however, it is not risk free. Ther... more Key Points 1. Transfusion of blood products can be lifesaving, however, it is not risk free. Therefore it is the responsibility of the physician to use appropriate triggers for blood component therapy. 2. ABO and the Rh systems are the most important in the majority of blood transfusions, although human red cell membranes contain as many as 300 different antigenic determinants. 3. Indication for red blood cell (RBC) transfusion is the need to increase the oxygen-carrying capacity. 4. The US Food and Drug Administration (FDA) recommends avoiding HES in critically ill adult patients and septic patients requiring ICU care. 5. Transfusion-related acute lung injury (TRALI) is currently the leading cause of transfusion-related death. Clinical presentation of TRALI may be indistinguishable from acute respiratory distress syndrome (ARDS) and is characterized by acute onset, bilateral pulmonary infiltrates and hypoxia without evidence of congestive heart failure (CHF).
A ttention to the heart before, during, and after liver transplantation can pay off in terms of b... more A ttention to the heart before, during, and after liver transplantation can pay off in terms of better outcomes. This, even though today's liver transplant patients are older than those in the past and more likely to have fatty liver disease as the cause of their liver failure, and even though liver failure, the transplant procedure, and the posttransplant regimen can all predispose to heart disease. The changing demographics of patients receiving liver transplants and the unique cardiac pathophysiology of patients with advanced liver disease pose signifi cant challenges in managing these patients perioperatively, as we will discuss in the following sections.
STUDY OBJECTIVE To measure the possible association between subhypnotic propofol infusion during ... more STUDY OBJECTIVE To measure the possible association between subhypnotic propofol infusion during general balanced anesthesia and the incidence of PONV. DESIGN Retrospective Cohort Analysis Using Propensity Score Matching. SETTING Postanesthesia care unit and inpatient unit. PATIENTS Patients with American Society of Anesthesiologists (ASA) physical status I-IV, undergoing non-cardiac surgery lasting >2 h were included. Patients were excluded if transferred to the intensive care unit after surgery or received ketamine. Initially 70,976 patients were screened, and a cohort of 51,707 eligible adult patients undergoing non-cardiac surgery under general balanced anesthesia between 2015 and 2019 were included. Using a propensity score matching, 3185 patients who received subhypnotic propofol during general balanced anesthesia were matched with 5826 patients who did not receive subhypnotic propofol in a 1:2 ratio. INTERVENTIONS None. MEASUREMENTS The primary outcome was the incidence of PONV during PACU stay. The secondary outcome was the incidence of PONV within the first 24 h after surgery. Exploratory outcomes were time-to-extubation and length of hospital stay. MAIN RESULTS A total of 9011 patients were included (3185 patients who received propofol infusion, and 5826 patients who did not receive propofol infusion) after propensity score matching. The adjusted odds ratio for PONV incidence was 1.03 (95% CI: 0.90, 1.18; p = 0.635) in PACU, and 1.05 (95% CI: 0.90, 1.23; P = 0.50) within 24 h after surgery. The length of hospital stay was 6 h shorter (ratio of means (95% CI) of 0.92, 0.89, 0.94), p < 0.001) and time-to-extubation was 2 min longer (ratio of means 1.24 (1.20, 1.28), p < 0.001) in patients receiving subhypnotic propofol infusion. CONCLUSIONS Our study suggests that subhypnotic propofol infusion during general balanced anesthesia is not associated with a reduction in the incidence of PONV during PACU stay and within the first 24 h after surgery. However, it is associated with decreased LOS and increased time-to-extubation, but differences in neither outcome were clinically important.
Background The Hypotension Prediction Index is a commercially available algorithm, based on arter... more Background The Hypotension Prediction Index is a commercially available algorithm, based on arterial waveform features, that predicts hypotension defined as mean arterial pressure less than 65 mmHg for at least 1 min. We therefore tested the primary hypothesis that index guidance reduces the duration and severity of hypotension during noncardiac surgery. Methods We enrolled adults having moderate- or high-risk noncardiac surgery with invasive arterial pressure monitoring. Participating patients were randomized to hemodynamic management with or without index guidance. Clinicians caring for patients assigned to guidance were alerted when the index exceeded 85 (range, 0 to 100) and a treatment algorithm based on advanced hemodynamic parameters suggested vasopressor administration, fluid administration, inotrope administration, or observation. Primary outcome was the amount of hypotension, defined as time-weighted average mean arterial pressure less than 65 mmHg. Secondary outcomes were...
STUDY OBJECTIVE To test whether patients who experience hypotension in the post-anesthesia care u... more STUDY OBJECTIVE To test whether patients who experience hypotension in the post-anesthesia care unit or during surgery are most likely to experience hypotension on surgical wards. DESIGN A prediction study using data from two randomized controlled trials. SETTING Operating room, post-anesthesia care unit, and surgical ward. PATIENTS 550 adult patients having abdominal surgery with ASA physical status I-IV. INTERVENTIONS Blood pressure measurement per routine intraoperatively, and with continuous non-invasive monitoring postoperatively. MEASUREMENTS The primary predictors were minimum mean arterial pressure (<60, <65, <70 and < 80 mmHg) and minimum systolic blood pressure (<70, <75, <80, <85 mmHg) in the post-anesthesia care unit. The secondary predictors were intraoperative minimum blood pressures with the same thresholds as the primary ones. Our outcome was ward hypotension defined as mean pressure < 70 mmHg or systolic pressure < 85 mmHg. A threshold was considered clinically useful if both sensitivity and specificity exceeded 0.75. MAIN RESULTS Minimum mean and systolic pressures in the post-anesthesia care unit similarly predicted ward mean or systolic hypotension, with the areas under the curves near 0.74. The best performing threshold was mean pressure < 80 mmHg in the post-anesthesia care unit which had a sensitivity of 0.41 (95% confidence interval [CI], 0.35, 0.47) and specificity of 0.91 (95% CI, 0.87, 0.94) for ward mean pressure < 70 mmHg and a sensitivity of 0.44 (95% CI, 0.37, 0.51) and specificity of 0.88 (95% CI, 0.84, 0.91) for ward systolic pressure < 85 mmHg. The areas under the curves using intraoperative hypotension to predict ward hypotension were roughly similar at about 0.60, with correspondingly low sensitivity and specificity. CONCLUSIONS Intraoperative hypotension poorly predicted ward hypotension. Pressures in the post-anesthesia care unit were more predictive, but the combination of sensitivity and specificity remained poor. Unless far better predictors are identified, all surgical inpatients should be considered at risk for postoperative hypotension.
EDITOR’S PERSPECTIVE What We Already Know about This Topic Intraoperative triple-low events (mean... more EDITOR’S PERSPECTIVE What We Already Know about This Topic Intraoperative triple-low events (mean arterial pressure less than 75 mmHg, Bispectral Index less than 45, and minimum alveolar fraction of anesthetic less than 0.8) have been found to be associated with increased risk of mortality What This Article Tells Us That Is New A randomized electronic alert of triple-low events to treating clinicians did not reduce 90-day mortality The alerts minimally influenced clinician responses, assessed as vasopressor administration or reduction in end-tidal volatile anesthetic partial pressure, and there was no association between response to alerts and mortality Triple-low events predict mortality but do not appear to be causally related Background Triple-low events (mean arterial pressure less than 75 mmHg, Bispectral Index less than 45, and minimum alveolar fraction less than 0.8) are associated with mortality but may not be causal. This study tested the hypothesis that providing triple-lo...
Intraoperative hypotension is associated with postoperative mortality. Early detection of hypoten... more Intraoperative hypotension is associated with postoperative mortality. Early detection of hypotension by continuous hemodynamic monitoring might prompt timely therapy, thereby reducing intraoperative hypotension. We tested the hypothesis that continuous noninvasive blood pressure monitoring reduces intraoperative hypotension. Patients ≥45 years old with American Society of Anesthesiologists physical status III or IV having moderate-to-high-risk noncardiac surgery with general anesthesia were included. All participating patients had continuous noninvasive hemodynamic monitoring using a finger cuff (ClearSight, Edwards Lifesciences, Irvine, CA) and a standard oscillometric cuff. In half the patients, randomly assigned, clinicians were blinded to the continuous values, whereas the others (unblinded) had access to continuous blood pressure readings. Continuous pressures in both groups were used for analysis. Time-weighted average for mean arterial pressure <65 mm Hg was compared usin...
Preoperative smoking cessation is commonly advised in an effort to improve postoperative outcomes... more Preoperative smoking cessation is commonly advised in an effort to improve postoperative outcomes. However, it remains unclear for how long smoking cessation is necessary, and even whether a brief preoperative period of abstinence is helpful and well tolerated. We evaluated associations between various periods of preoperative smoking cessation and major morbidity and death. Retrospective cohort analysis. Adults who had noncardiac surgery at the Cleveland Clinic Main Campus between May 2007 and December 2013. A total of 37 511 patients whose smoking history was identified from a preoperative Health Quest questionnaire. Of these patients, 26 269 (70%) were former smokers and 11 242 (30%) were current smokers. Of the current smokers, 9482 (84%) were propensity matched with 9482 former smokers (36%). We excluded patients with American Society of Anesthesiologists' physical status exceeding four, patients who did not have general anaesthesia, and patients with missing outcomes and/or...
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Papers by Jacek Cywinski