There is a rising incidence of coronary artery diseases and myocardial infarction (MI). Mortality associated with acute MI (AMI) is directly linked to the time to receive treatment and missed diagnoses. Although health professionals are aware of typical AMI presentation, atypical MI is difficult to diagnose, which on the other hand, is likely to have an impact on morbidity and mortality. Therefore, it is prudent to know such atypical presentations, especially for emergency and primary care physicians. We aimed to systematically evaluate the clinical presentations of atypical MI and analyze them to characterize the common clinical presentations of atypical MI. We researched the PubMed database, did citation tracking, and performed Google Scholar advanced search to find the cases reported on the atypical presentation of MI published from January 2000 to September 2022. Articles of all languages were included; Google Translate was used to translate articles published in languages other than English. A total of 496 (56 PubMed articles, 340 citations from included PubMed articles, and 100 articles from Google Scholar advanced search) were screened; 52 case reports were evaluated, and their data were analyzed. Atypical presentations of myocardial infarction are vast; patients may have chest pain without typical characteristics of angina pain or may not have chest pain. No typical characterization could be done. Most patients were in their fifth decade or above of their life and commonly presented with pain and discomfort in the abdomen, head, and neck regions. Prodromal symptoms were consistent findings, and many patients had two to three comorbidities out of four common comorbidities, i.e., diabetes, hypertension, dyslipidemia, and substance abuse. A patient who is 50 years old or more, having comorbidities such as diabetes, hypertension, dyslipidemia, history of tobacco or marijuana usage, presenting with prodromal symptoms like shortness of breath, dizziness, fatigue, syncope, gastrointestinal discomfort or head/neck pain should be suspected for atypical MI.
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Unlike general anaesthesia, neuraxial anaesthesia (NA) reduces the burden and risk of respiratory adverse events in the post-operative period. However, both patients affected by chronic obstructive pulmonary disease (COPD) and chest wall disorders and/or neuromuscular diseases may experience the development or the worsening of respiratory failure, even during surgery performed under NA; this latter negatively affects the function of accessory respiratory muscles, resulting in a blunted central response to hypercapnia and possibly in an exacerbation of cardiac dysfunction (NA-induced relative hypovolemia). According to European Respiratory Society (ERS) and American Thoracic Society (ATS) guidelines, non-invasive ventilation (NIV) is effective in the post-operative period for the treatment of both impaired pulmonary gas exchange and ventilation, while the intra-operative use of NIV in association with NA is just anecdotally reported in the literature. Whilst NIV does not assure a protected patent airway and requires the patient's cooperation, it is a handy tool during surgery under NA: NIV is reported to be successful for treatment of acute respiratory failure; it may be delivered through the patient's home ventilator, may reverse hypoventilation induced by sedatives or inadvertent spread of anaesthetic up to cervical dermatomes, and allow the avoidance of intubation in patients affected by chronic respiratory failure, prolonging the time of non-invasiveness of respiratory support (i.e., neuromuscular patients needing surgery). All these advantages could make NIV preferable to oxygen in carefully selected patients.
BackgroundKnowing the predicting factors for difficult neuraxial blocks might help better plan the procedure. This study aimed to determine the predictors of failed spinal arachnoid puncture procedures using artificial neural network (ANN) analysis. MethodologyWith approvals, prospectively collected data from 300 spinal arachnoid punctures in the operation theater of an academic institute having postgraduate anesthesia training were retrospectively evaluated. Fifteen variables from anthropo-demographic, spinal surface anatomy, procedure, and performers' experiences were fed as input for the ANN. A failed spinal arachnoid puncture procedure was defined as the requirement of more than three punctures, with three punctures but more than six passes, or if the performer handed over the procedure to another, considering it difficult after the second puncture. STATCRAFT v.2 software (Predictive Analytics Solutions Pvt. Ltd., Bengaluru, India) was used for ANN model generation. Considering the overfitting tendency of the ANN, Pr(>|z|) < 0.01 in the ANN was considered significant. The area under the receiver operating characteristic (AuROC) curve of the ANN model and its sensitivity and specificity were also assessed. Significant factors with multiple gradings were also evaluated for their statistical significance across the grades or classes using INSTAT software (Graphpad Prism, La Jolla, CA, USA); a two-tailed P-value of <0.05 was considered significant. ResultsInterspinous process-based spine grade, performers' experience, and positioning difficulty were significant determinants of failed spinal arachnoid puncture procedures in the ANN model. The ANN model had an AuROC of 0.907, specificity of 0.976, and sensitivity of 0.385. The interclass comparison showed that increasing spinal grades and decreasing experiences were associated with increased pass and puncture. ConclusionsThe ANN model found the determinants of the failed spinal arachnoid puncture procedure well with good AuROC and specificity but poor sensitivity.
Background: Despite negative recommendations, routine preoperative testing practice is nearly universal. Our aim is to bring the healthcare providers on one platform by using information-technology based preanaesthetic assessment and evaluate the routine preoperative testing’s impact on patient outcome and cost. Methods: A prospective, non-randomised study was conducted in a teaching hospital during January 2019-August 2020. A locally developed software and cloud-computing were used as a tool to modify preanaesthesia evaluation. The number of investigations ordered, time taken, cost incurred, were compared with the routine practice. Further data were matched as per surgical invasiveness and the patient's physical status. Appropriate tests compared intergroup differences and p-value <0.05 was considered significant. Results: Data from 114 patients (58 in routine and 56 in patient and surgery specific) were analysed. Patient and surgery specific investigation led to a reduction in the investigations by 80-90%, hospital visit by 50%, and the total cost by 80%, without increasing the day of surgery cancellation or complications. Conclusion: Information technology-based joint preoperative assessment and risk stratification are feasible through locally developed software with minimal cost. It helps in applying patient and surgery specific investigation, reducing the number of tests, hospital visit, and cost, without adversely affecting the perioperative outcome. The application of the modified method will help in cost-effective, yet quality and safe perioperative healthcare delivery. It will also benefit the public from both service and economic perspective.
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