The Association of Preoperative Diabetes With Postoperative Delirium in Older Patients Undergoing Major Orthopedic Surgery: A Prospective Matched Cohort Study

BACKGROUND

Postoperative delirium (POD) is a common form of postoperative brain dysfunction, especially in the elderly. However, its risk factors remain largely to be determined. This study aimed to investigate whether (1) preoperative diabetes is associated with POD after elective orthopedic surgery and (2) intraoperative frontal alpha power is a mediator of the association between preoperative diabetes and POD.

METHODS

This was a prospective matched cohort study of patients aged 60 years or more, with a preoperative diabetes who underwent elective orthopedic surgery. Nondiabetic patients were matched 1:1 to diabetic patients in terms of age, sex, and type of surgery. Primary outcome was occurrence of POD, assessed using the 3-minute Diagnostic Confusion Assessment Method (3D-CAM) once daily from 6 pm to 8 pm during the postoperative days 1-7 or until discharge. Secondary outcome was the severity of POD which was assessed for all participants using the short form of the CAM-Severity. Frontal electroencephalogram (EEG) was recorded starting before induction of anesthesia and lasting until discharge from the operating room. Intraoperative alpha power was calculated using multitaper spectral analyses. Mediation analysis was used to estimate the proportion of the association between preoperative diabetes and POD that could be explained by intraoperative alpha power.

RESULTS

A total of 138 pairs of eligible patients successfully matched 1:1. After enrollment, 6 patients in the diabetes group and 4 patients in the nondiabetes group were excluded due to unavailability of raw EEG data. The final analysis included 132 participants with preoperative diabetes and 134 participants without preoperative diabetes, with a median age of 68 years and 72.6% of patients were female. The incidence of POD was 16.7% (22/132) in patients with preoperative diabetes vs 6.0% (8/134) in patients without preoperative diabetes. Preoperative diabetes was associated with increased odds of POD after adjustment of age, sex, body mass index, education level, hypertension, arrhythmia, coronary heart disease, and history of stroke (odds ratio, 3.2; 95% confidence interval [CI], 1.4-8.0; P = .009). The intraoperative alpha power accounted for an estimated 20% (95% CI, 2.6-60%; P = .021) of the association between diabetes and POD.

CONCLUSIONS

This study suggests that preoperative diabetes is associated with an increased risk of POD in older patients undergoing major orthopedic surgery, and that low intraoperative alpha power partially mediates such association.

Adjuvant Transarterial Chemoembolization Plus Immunotherapy for Huge Hepatocellular Carcinoma: A Propensity Score Matching Cohort Study

Purpose

The prognosis of patients with huge hepatocellular carcinoma (huge HCC, diameter ≥10 cm) is poor owing to the high early recurrence rate. This study aimed to explore the clinical value of postoperative adjuvant transarterial chemoembolization (PA-TACE) plus programmed cell death-1 (PD-1) inhibitors for huge HCC.

Patients and Methods

Data from consecutive huge HCC patients treated with hepatectomy during June 2017 and July 2022 were retrospectively collected. Baseline differences were balanced between huge HCC patients who underwent PA-TACE with (AIT group) or without PD-1 inhibitors (AT group) by propensity-score matching (PSM). We compared recurrence-free survival (RFS), overall survival (OS) and recurrence patterns between the two groups. Independent risk factors for RFS and OS were confirmed by Cox regression analysis, and subgroup analysis was also conducted.

Results

A total of 294 patients were enrolled, and 77 pairs of patients in the AIT and AT groups were matched by PSM. The 1-year and 2-year RFS were 49.9% and 35.7% in the AIT group compared to 24.7% and 15.5% in the AT group respectively (p<0.001). The 1-year and 2-year OS were 83.6% and 66.9% in the AIT group compared to 50.6% and 36.8% in the AT group respectively (p<0.001). There were no significant differences in recurrence patterns between the two groups. Multivariable analysis demonstrated that combined therapy of PA-TACE plus PD-1 inhibitors was a protective factor related to both RFS and OS.

Conclusion

PA-TACE plus PD-1 inhibitors could improve survival outcomes for huge HCC patients.

A combined pre- and intra-operative nomogram in evaluation of degrees of liver cirrhosis predicts post-hepatectomy liver failure: a multicenter prospective study

Background

Adequate evaluation of degrees of liver cirrhosis is essential in surgical treatment of hepatocellular carcinoma (HCC) patients. The impact of the degrees of cirrhosis on prediction of post-hepatectomy liver failure (PHLF) remains poorly defined. This study aimed to construct and validate a combined pre- and intra-operative nomogram based on the degrees of cirrhosis in predicting PHLF in HCC patients using prospective multi-center's data.

Methods

Consecutive HCC patients who underwent hepatectomy between May 18, 2019 and Dec 19, 2020 were enrolled at five tertiary hospitals. Preoperative cirrhotic severity scoring (CSS) and intra-operative direct liver stiffness measurement (DSM) were performed to correlate with the Laennec histopathological grading system. The performances of the pre-operative nomogram and combined pre- and intra-operative nomogram in predicting PHLF were compared with conventional predictive models of PHLF.

Results

For 327 patients in this study, histopathological studies showed the rates of HCC patients with no, mild, moderate, and severe cirrhosis were 41.9%, 29.1%, 22.9%, and 6.1%, respectively. Either CSS or DSM was closely correlated with histopathological stages of cirrhosis. Thirty-three (10.1%) patients developed PHLF. The 30- and 90-day mortality rates were 0.9%. Multivariate regression analysis showed four pre-operative variables [HBV-DNA level, ICG-R15, prothrombin time (PT), and CSS], and one intra-operative variable (DSM) to be independent risk factors of PHLF. The pre-operative nomogram was constructed based on these four pre-operative variables together with total bilirubin. The combined pre- and intra-operative nomogram was constructed by adding the intra-operative DSM. The pre-operative nomogram was better than the conventional models in predicting PHLF. The prediction was further improved with the combined pre- and intra-operative nomogram.

Conclusions

The combined pre- and intra-operative nomogram further improved prediction of PHLF when compared with the pre-operative nomogram.

Trial Registration

Clinicaltrials.gov Identifier: NCT04076631.

Clinical application of a connection device consisting of a bag valve mask and nebulizer in first aid: Two case reports

In clinical practice, several emergencies may threaten the life of patients, and these emergencies can be unpredictable and challenging. During the coronavirus disease 2019 pandemic, in January 2023, a patient developed respiratory distress caused by coronavirus, but was unable to access respiratory support due to shortages of medical resources, intensive care unit beds and ventilators. The medical staff quickly created a portable high-flow atomized oxygen therapy apparatus consisting of a simple breathing bag connected to a nebulizer to provide breathing support. In addition, the Ambulatory Surgery Center, The First Affiliated Hospital of Anhui Medical University (Hefei, China) witnessed a case of severe laryngeal spasm after tracheal extubation during the recovery period from general anesthesia. Due to the lack of an anesthesia machine nebulizer, the aforementioned device was used to provide oxygen under pressure and initiate treatment to quickly relieve the symptoms of laryngeal obstruction. The present case report describes how the medical staff quickly applied emergency airway management skills and knowledge to create a portable high-flow atomized oxygen therapy apparatus in a resource-poor setting to save the lives of two patients.

Dexmedetomidine inhibits paraventricular corticotropin-releasing hormone neurons that attenuate acute stress-induced anxiety-like behavior in mice

BACKGROUND

Dexmedetomidine has repeatedly shown to improve anxiety but the precise neural mechanisms underlying this effect remain incompletely understood. Here, we aim to explore the role of corticotropin-releasing hormone-producing hypothalamic paraventricular (CRHPVN) neurons in mediating the anxiolytic effects of dexmedetomidine.

METHODS

A social defeat stress mouse model was employed to evaluate the anxiolytic effects induced by dexmedetomidine through the elevated plus-maze, open-field test, and measurement of serum stress hormone levels. In vivo Ca2+ signal fibre photometry and ex vivo patch-clamp recordings were utilized to determine the excitability of CRHPVN neurons and investigate the specific mechanism involved. CRHPVN neuron modulation was achieved through chemogenetic activation or inhibition.

RESULTS

Compared with saline, dexmedetomidine (40 µg/kg) alleviated anxiety-like behaviors. Additionally, dexmedetomidine reduced CRHPVN neuronal excitability. Chemogenetic activation of CRHPVN neurons decreased the time spent in the open arms of the elevated plus-maze and in the central area of the open-field test. Conversely, chemogenetic inhibition of CRHPVN neurons had the opposite effect. Moreover, the suppressive impact of dexmedetomidine on CRHPVN neurons was attenuated by the α2 receptor antagonist yohimbine.

CONCLUSIONS

Our results indicate that the anxiety-like effects of dexmedetomidine are mediated via α2 adrenergic receptor-triggered inhibition of CRHPVN neuronal excitability in the hypothalamus.

Activating astrocytic α2A adrenoceptors in hippocampus reduces glutamate toxicity to attenuate sepsis-associated encephalopathy in mice

BACKGROUND

Glutamate metabolism disorder is an important mechanism of sepsis-associated encephalopathy (SAE). Astrocytes regulate glutamate metabolism. In septic mice, α2A adrenoceptor (α2A-AR) activation in the central nervous system provides neuroprotection. α2A-ARs are expressed abundantly in hippocampal astrocytes. This study was performed to determine whether hippocampal astrocytic α2A-AR activation confers neuroprotection against SAE and whether this protective effect is astrocyte specific and achieved by the modulation of glutamate metabolism.

METHODS

Male C57BL/6 mice with and without α2A-AR knockdown were subjected to cecal ligation and puncture (CLP). They were treated with intrahippocampal guanfacine (an α2A-AR agonist) or intraperitoneal dexmedetomidine in the presence or absence of dihydrokainic acid [DHK; a glutamate transporter 1 (GLT-1) antagonist] and/or UCPH-101 [a glutamate/aspartate transporter (GLAST) antagonist]. Hippocampal tissue was collected for the measurement of astrocyte reactivity, GLT-1 and GLAST expression, and glutamate receptor subunit 2B (GluN2B) phosphorylation. In vivo real-time extracellular glutamate concentrations in the hippocampus were measured by ultra-performance liquid chromatography tandem mass spectrometry combined with microdialysis, and in vivo real-time hippocampal glutamatergic neuron excitability was assessed by calcium imaging. The mice were subjected to the Barnes maze and fear conditioning tests to assess their learning and memory. Golgi staining was performed to assess changes in the hippocampal synaptic structure. In vitro, primary astrocytes with and without α2A-AR knockdown were stimulated with lipopolysaccharide (LPS) and treated with guanfacine or dexmedetomidine in the presence or absence of 8-bromo- cyclic adenosine monophosphate (8-Br-cAMP, a cAMP analog). LPS-treated primary and BV2 microglia were also treated with guanfacine or dexmedetomidine. Astrocyte reactivity, PKA catalytic subunit, GLT-1 an GLAST expression were determined in primary astrocytes. Interleukin-1β, interleukin-6 and tumor necrosis factor-alpha in the medium of microglia culture were measured.

RESULTS

CLP induced synaptic injury, impaired neurocognitive function, increased astrocyte reactivity and reduced GLT-1 and GLAST expression in the hippocampus of mice. The extracellular glutamate concentration, phosphorylation of GluN2B at Tyr-1472 and glutamatergic neuron excitability in the hippocampus were increased in the hippocampus of septic mice. Intraperitoneal dexmedetomidine or intrahippocampal guanfacine administration attenuated these effects. Hippocampal astrocytes expressed abundant α2A-ARs; expression was also detected in neurons but not microglia. Specific knockdown of α2A-ARs in hippocampal astrocytes and simultaneous intrahippocampal DHK and UCPH-101 administration blocked the neuroprotective effects of dexmedetomidine and guanfacine. Intrahippocampal administration of DHK or UCPH-101 alone had no such effect. In vitro, guanfacine or dexmedetomidine inhibited astrocyte reactivity, reduced PKA catalytic subunit expression, and increased GLT-1 and GLAST expression in primary astrocytes but not in primary astrocytes that received α2A-AR knockdown or were treated with 8-Br-cAMP. Guanfacine or dexmedetomidine inhibited microglial reactivity in BV2 but not primary microglia.

CONCLUSIONS

Our results suggest that neurocognitive protection against SAE after hippocampal α2A-AR activation is astrocyte specific. This protection may involve the inhibition of astrocyte reactivity and alleviation of glutamate neurotoxicity, thereby reducing synaptic injury. The cAMP/protein kinase A (PKA) signaling pathway is a potential cellular mechanism by which activating α2A-AR modulates astrocytic function.

Prognosis and Prediction of Asymptomatic Intracranial Hemorrhage After Endovascular Thrombectomy: A Multi-Center Study

PURPOSE

The impact of asymptomatic intracranial hemorrhage (aICH) on functional outcomes after endovascular thrombectomy (EVT) remains unclear, and tools for forecasting this complication are lacking. We aim to evaluate the clinical relevance of aICH and establish a prediction model.

METHODS

Data of patients who received EVT for acute anterior-circulation large vessel occlusion in 3 comprehensive hospitals were retrospectively analyzed. Asymptomatic intracranial hemorrhage was defined as any hemorrhage detected after EVT that did not fulfill the definition of symptomatic intracranial hemorrhage in the European Cooperative Acute Stroke Study. Logistic regression models were performed to assess the impact of aICH on 90-day functional outcomes and identify the predictors of aICH, which were then used to establish a prediction model. The discrimination, calibration, and clinical utility of the model were evaluated.

RESULTS

This study included 460 patients, among whom 152 (33.0%) developed aICH after EVT. Asymptomatic intracranial hemorrhage was negatively associated with 90-day excellent outcomes (adjusted odds ratio [OR]: 0.414, 95% confidence interval [CI]: 0.230-0.745, p=0.003) and good outcome (adjusted OR: 0.603, 95% CI: 0.374-0.971, p=0.037), but not with mortality (adjusted OR: 1.110, 95% CI: 0.611-2.017, p=0.732) after adjusted for other predictors of functional outcome. Pre-stroke anticoagulant therapy (OR: 2.233, 95% CI: 1.073-4.647, p=0.032), Alberta stroke program early CT score (OR: 0.842, 95% CI: 0.754-0.939, p=0.002), site of occlusion (internal carotid artery occlusion as the reference; M1 segment of middle cerebral artery occlusion, OR: 2.827, 95% CI: 1.409-5.674, p=0.003; tandem occlusion, OR: 3.928, 95% CI: 1.752-8.806, p=0.001), intravenous thrombolysis (OR: 2.091, 95% CI: 1.362-3.209, p=0.001), and successful recanalization (OR: 0.383, 95% CI: 0.213-0.689, p=0.001) were identified as the predictors of aICH, which were incorporated into a nomogram model. The area under the receiver operating characteristic curve of the model was 0.707 (95% CI: 0.657-0.757), and the calibration plot demonstrated good consistency between actual observed and predicted probability of aICH. Decision curve analysis showed that patients might benefit from the model.

CONCLUSION

Asymptomatic intracranial hemorrhage was negatively associated with favorable functional outcome after EVT. We established a nomogram model for predicting aICH, which requires external clinical validation.

CLINICAL IMPACT

The impact of asymptomatic intracranial hemorrhage after endovascular thrombectomy on mid-term functional outcome has been controversial. We found that asymptomatic intracranial hemorrhage may also decreased the likelihood of 90-day favourable functional outcome after endovascular thrombectomy, supporting the notion that asymptomatic intracranial hemorrhage at the acute stage may not be benign. Moreover, we established a prediction model for this complication, which may improve clinical evaluation and management of patients who would receive endovascular thrombectomy for large vessel occlusion.

Successful hybrid endovascular treatment for refractory cerebral venous sinus thrombosis in pregnancy: A case report

Background

Cerebral venous sinus thrombosis (CVST) in pregnancy was common and endovascular treatment (EVT) could be an effective and safe treatment for patients with severe and refractory CVST. However, the efficacy and safety of hybrid EVT (craniotomy + endovascular treatment) for CVST were unknown. We represented a rare case of hybrid EVT through the incision of the superior sagittal sinus in a pregnant woman with CVST who failed to EVT through the femoral vein pathway.

Case presentation

A 26-year-old woman, in her second month of pregnancy, complained of a headache for 5 days and aggravation with coma combined with convulsions for 2 days. She was diagnosed with CVST in the local hospital by digital subtraction angiography (DSA) and treated with anticoagulation. She had no history of illness and the biochemical tests were normal. Hybrid EVT (craniotomy + EVT) was attempted after failing to conduct EVT through the femoral vein pathway due to difficulty to reach the target cerebral venous sinus. Briefly, a small hole was made in the frontotemporal head to expose the superior sagittal sinus and a 6F sheath was inserted into 2cm of superior sagittal sinus incision and fixed on the scalp, after repeated aspiration by 5F intermediate catheter and balloon dilatation of stenosis in the right transverse sinus and right sigmoid sinus, the cerebral venous system got successful recanalization. No obvious complications were found and the patient recovered very well after the surgery.

Conclusion

Anticoagulation was the standard treatment for CVST. EVT could rapidly restore venous flow and improve the prognosis for refractory and severe CVST. EVT by hybrid surgery through the superior sagittal sinus incision may be safe and effective for desperate patients with severe CVST.

Influence of low-dose esketamine on postoperative depressive symptoms in patients with breast cancer (EASE): study protocol for a randomised controlled trial

INTRODUCTION

Depressive symptoms have surfaced as the principal mental health concern among patients with breast cancer, with surgical interventions potentially exacerbating these symptoms and adversely influencing clinical outcomes. This study protocol is designed to investigate the efficacy of low-dose esketamine administered perioperatively on depressive symptoms in patients with breast cancer. It also aims to illuminate the potential neurobiological underpinnings of this effect.

METHODS AND ANALYSIS

This research represents a single-centre, prospective, randomised, double-blind, placebo-controlled study. The trial anticipates enrolling 108 female patients exhibiting mild-to-severe depressive symptoms who are slated for radical mastectomy. Through stratified randomisation, eligible patients will be systematically assigned to either the esketamine group (0.25 mg/kg) or placebo group (0.9% saline) in a 1:1 ratio. The primary outcome is the response rate at the third postoperative day. Secondary outcomes encompass the remission rate, depression-related scores, depression severity and safety-related endpoints. Tertiary (exploratory) outcomes involve alterations in brain-derived neurotrophic factor and resting-state functional brain connectivity.

ETHICS AND DISSEMINATION

The Clinical Trial Ethics Committee at The First Affiliated Hospital of Anhui Medical University has conferred ethical approvals for this trial (approval number: PJ2023-05-25). Results from this trial will be disseminated in peer-reviewed journals and presented at professional symposiums.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trials Registry (ChiCTR2300071062).

Case report: Retrograde endovascular recanalization of vertebral artery occlusion with non-tapered stump via the deep cervical collateral

Introduction

Vertebral artery (VA) occlusive disease is the major cause of posterior circulation ischemic stroke. Endovascular recanalization has been reported as a feasible treatment for patients with symptomatic VA occlusion refractory to optimal medical therapy. However, VA occlusion with non-tapered stump exhibits a low technique success rate when treated by antegrade endovascular therapy because of increased difficulty in passing the guidewire into the occluded segment. Herein, we presented a novel endovascular approach to recanalize chronically occluded VA with a non-tapered stump using a retrograde method via the deep cervical collateral, which has not been reported before.

Case presentation

The present case was a patient with VA ostial occlusion with non-tapered stump and distal severe stenosis of the left VA who had recurrent posterior circulation transit ischemic attacks under optimal medical therapy. CT angiography demonstrated proximal non-tapered occlusion and distal severe stenosis of the left VA, and that the right VA did not converge with the left VA into basilar artery. Endovascular treatment was recommended and performed on this patient. However, antegrade endovascular recanalization of the left VA origin occlusion failed because the micro guidewire was unable to traverse the occluded segment. Fortunately, robust collateral from the deep cervical artery to the V3 segment of the left VA developed, in which we advanced the micro guidewire to the V3 segment of the left VA and reversely passed the micro guidewire through the occluded segment. Then, the occlusion and stenosis of the left VA were successfully resolved with angioplasty and stenting. After the procedure, the patient reported no neurological symptoms under medical therapy during 3-month follow-up.

Conclusion

Antegrade endovascular recanalization of VA occlusion with a non-tapered stump is a challenge. The retrograde endovascular method via the cervical collateral may be an alternative for this type of VA occlusion, which requires further exploration.

Proximal hyperdense middle cerebral artery sign is associated with increased risk of asymptomatic hemorrhagic transformation after endovascular thrombectomy: a multicenter retrospective study

OBJECTIVE

To investigate whether hyperdense middle cerebral artery sign (HMCAS) on pretreatment no-contrast CT (NCCT) is associated with hemorrhagic transformation (HT) after endovascular thrombectomy (EVT).

METHODS

Patients with acute middle cerebral artery (MCA) occlusion who received EVT in three comprehensive hospitals were retrospectively evaluated. They were divided into four groups based on the presence or absence of HMCAS and corresponding CTA findings, among whom differences were compared. Univariate and multivariate logistic regression analyses were performed to investigate the association between HMCAS and HT and its subtypes.

RESULTS

318 patients were included, among whom 149 (46.9%) had HMCAS. Patients in the proximal positive HMCAS group had higher National Institute of Health Stroke Scale scores and lower Alberta Stroke Program Early CT Scores (ASPECTS) than those in the proximal negative HMCAS group. The rate of HT was higher in the proximal positive HMCAS group than that in the proximal negative HMCAS group. In multivariate logistic regression analysis, the proximal HMCAS were independently associated with HT (adjusted OR = 2.073, 95% CI 1.211-3.551, p = 0.008) and aHT (adjusted OR = 2.271, 95% CI 1.294-3.986, p = 0.004), but not with sHT. Patients who developed HT, including aHT and sHT, had a lower rate of good outcome.

CONCLUSION

Proximal HMCAS on initial NCCT was independently associated with aHT in patients who received EVT for acute MCA occlusion. Both aHT and sHT had a detrimental effect on clinical outcome.

Risk Assessment of Major Adverse Cardiovascular and Cerebrovascular Events and Bleeding for Acute Myocardial Infarction With or Without Active Tuberculosis

PURPOSE

The underlying ischemic and bleeding risks of acute myocardial infarction (AMI) with active tuberculosis (TB) are unknown. The goal of this study was to explore the ischemic and bleeding risks, as well as treatment strategies during hospitalization, in patients with AMI with or without active TB.

METHODS

Patients were recruited from a tuberculosis hospital from 2014 to 2021. The primary outcomes were major cardiovascular and cerebrovascular events (MACE) and Bleeding Academic Research Consortium (BARC)-defined type 3 or 5 bleeding. Multivariate logistic regression and propensity score matching were performed for risk adjustment. Subgroups were defined according to AMI with active pulmonary TB and AMI with active TB undergoing percutaneous coronary intervention (PCI).

FINDINGS

A total of 242 patients were enrolled. Compared with AMI without active TB, AMI with active TB had a higher risk of MACE and BARC type 3 or 5 bleeding (P < 0.001 and P = 0.002, respectively). Multivariate logistic regression analysis showed that, compared with AMI without active TB, the odds ratio (OR) was 6.513 (95% CI, 2.195-19.331) for MACE in patients with AMI with active TB, and the OR was 16.074 (95% CI 3.337-77.436) for BARC type 3 or 5 bleeding in patients with AMI with active TB. After propensity score matching, AMI with active TB tended to increase the risk of MACE, although not statistically significantly (P = 0.189), and increased BARC type 3 or 5 bleeding (P < 0.001), compared with AMI without active TB. Results of subgroup analyses showed that active TB had outcomes consistent with those of the total cohort. AMI patients with active pulmonary TB who underwent PCI had a lower risk of MACE without an increase in the risk of bleeding compared with those not undergoing PCI.

IMPLICATIONS

Patients with AMI with active TB have a higher risk of MACE (or severe MACE) and bleeding than patients with AMI without active TB. However, AMI patients with active TB are still advised to undergo PCI for a high net clinical benefit.

Clot Meniscus Sign Is Associated With Thrombus Permeability and Choice of Mechanical Thrombectomy Technique in Acute Middle Cerebral Artery Occlusion

Background and Purpose

The method of mechanical thrombectomy (MT) is related to vascular anatomy and stroke etiology. Meniscus sign and thrombus permeability as imaging markers may be instructive for the selection of MT. This study aims to clarify the relationship among meniscus sign, thrombus permeability, and choice of MT in patients with acute middle cerebral artery occlusion.

Materials and Methods

A total of 111 patients with acute middle cerebral artery occlusion (MCAO) who underwent MT were retrospectively analyzed. Clot meniscus sign was defined as the appearance of meniscoid/edge-like or single- or double-wall contrast channels besides or around insular blood clots. The radiographic, clinical, and surgical data of patients with MCAO with or without meniscus sign were compared.

Results

The meniscus sign positive group (n = 26) has higher thrombus permeability (HUs) (26.92 ± 9.69 vs. 22.84 ± 7.88, p = 0.031) than those without it. Shorter puncture-to-recanalization (P2R) time (65.5 vs. 88, p = 0.012), higher complete recanalization rate (85.71 vs. 33.33%, p &lt; 0.01), and better clinical outcome (p &lt; 0.01) were obtained by selecting contact aspiration (CA) over stent retriever (SR) in patients with positive meniscus sign. In patients with negative meniscus sign, there was no significant difference in clinical outcome after receiving CA or SR.

Conclusion

Patients with MCAO with positive meniscus sign have higher thrombus permeability and are more suitable for CA to acquire better clinical outcomes.

Development and performance of timber REITs in the United States: a review and some prospects

Timber real estate investment trusts (REITs) are companies that own and manage timberland and generate revenue by harvesting and selling timber or other forest-related products. Due to their popularity with investors, timber REITs in the United States have attracted growing research interest in the recent decades. This necessitates a review of existing knowledge on the evolution of timber REITs and their financial performance over the years. In this review, we summarize the history and development of timber REITs, discuss the tax policies applicable to timber REIT growth and their implications. We also review past studies that focused on the financial performance of timber REITs and synthesize the methodologies used in those studies. At the end, we posit the possibility of consolidation waves in the timber industry and identify some opportunities for future research. This review can shed some new light on the evolution of public timber REITs and their financial performance.

The Impact of Morning Surgery or Afternoon Surgery on Postoperative Sleep Quality and Melatonin Levels of Elderly Patients: A Prospective, Randomized Study

OBJECTIVE

Postoperative sleep disturbance after surgery is not conducive to the recovery of patients. The purpose of this study was to determine the influence of the timing of surgery (morning vs afternoon) on the postoperative sleep quality of elderly patients and to analyze the relationship between the timing of surgery and the change in the melatonin level.

METHODS

Sixty patients who received hip surgery were randomly assigned to the Morning Group (Group M) or the Afternoon Group (Group A). The sleep quality was assessed by the Richards-Campbell Sleep Questionnaire. Before and after surgery, the nocturnal urine was collected over a 12-h period, and the 6-sulfatoxymelatonin concentration was measured. Also, the incidence of postoperative delirium (POD) was observed.

RESULTS

On the first and second nights after surgery, the sleep quality scores of the patients in Group A were greater than those in Group M, and there was no difference in the sleep quality scores between the two groups on the third night after surgery (P=0.000, P=0.002, P>0.05, respectively). In addition, the urine 6-sulphatoxymelatonin concentration was found to be greater in Group A than in Group M on the first night of surgery (P=0.00). Both the postoperative sleep quality scores and urine 6-sulphatoxymelatonin concentration were significantly less than those before surgery (P=0.00, P=0.00).

CONCLUSION

The postoperative sleep quality scores and melatonin levels of elderly patients who received hip surgery under general anesthesia were significantly less than those of the patients before surgery. Furthermore, the short-term sleep quality of the patients who received surgery in the afternoon was better than that of the patients who received surgery in the morning. This difference may be related to the short-term change of the melatonin level after surgery.

Effect of Different Modes of Administration of Dexmedetomidine Combined with Nerve Block on Postoperative Analgesia in Total Knee Arthroplasty

INTRODUCTION

Dexmedetomidine (DEX) as a nerve block adjuvant can significantly prolong analgesia. However, whether perineural or systemic administration of DEX is more beneficial in patients undergoing total knee arthroplasty (TKA) has not been thoroughly investigated. To this end, we evaluated the effects of perineural and systemic DEX administration on postoperative analgesia in patients undergoing TKA surgery.

METHODS

We randomly assigned patients undergoing TKA under general anesthesia combined with femoral nerve block and sciatic nerve block to one of three groups: (1) ropivacaine plus perineural dexmedetomidine (DP): 0.25% ropivacaine 40 mL plus 0.5 μg/kg dexmedetomidine; (2) ropivacaine plus systemic dexmedetomidine (DS): 0.25% ropivacaine 40 mL plus systemic 0.5 μg/kg dexmedetomidine; (3) control group (C): 0.25% ropivacaine 40 mL.

RESULTS

The average length of time until patients first experienced postoperative pain was significantly longer in the DP group (26.0 h [22.0-30.0 h]) than in the DS group (22.4 h [18-26.8 h]) and the control group (22.9 h [19.5-26.3 h], P = 0.001). For this result there was no significant difference between the DS and the control group. Compared with the DS and control groups, patients in the DP group had lower resting visual analogue scale (VAS) scores at 24, 48, and 72 h after surgery (P < 0.05). VAS activity scores at 12, 24, and 48 h after surgery in the DP group were lower than those in the DS and control groups, with a statistically significant difference (P < 0.05). Compared with the DS and control groups, the amount of postoperative opioids in the DP group was also significantly reduced, and the number of people needing postoperative rescue analgesia was significantly lower, with a statistical difference (P < 0.05). Meanwhile, the sleep satisfaction of patients in the DP group on the first night after surgery and the satisfaction with pain control at 72 h after surgery were both higher than those in the DS group and control group (P < 0.05).

CONCLUSIONS

Perineural administration of DEX can significantly prolong the interval until patients report pain for the first time after TKA, relieve postoperative pain, reduce postoperative opioid dosage, and improve postoperative sleep quality and satisfaction with pain control.

TRIAL REGISTRATION

The trial was registered at the Chinese Clinical Trial Registry, identifier ChiCTR1900025808.

Clinical Characteristics and Factors Associated with Disease Progression of Mild to Moderate COVID-19 Patients in a Makeshift (Fangcang) Hospital: A Retrospective Cohort Study

Objective

Information regarding the epidemiology and clinical features of mild to moderate patients caused by COVID-19 in Fangcang Hospital is scarce. Through a retrospective cohort study, the clinical characteristics of COVID-19 patients in Dongxihu Fangcang shelter hospitals were analyzed, and the factors that affected the disease progression of COVID-19 patients were explored.

Methods

The clinical characteristics of 714 patients with COVID-19 were retrospectively analyzed at Dongxihu Fangcang Hospital between February 7 and March 8, 2020. We described the clinical characteristics and distribution of discharge or transfer times for each patient. According to the disease progression of COVID-19 patients, we divided all patients into Non-Deteriorated group and Deteriorated group. Furthermore, binary logistic regression was used for a single outcome and multiple response variables.

Results

We treated 789 patients with mild and moderate COVID-19, of which 714 were included in this study, which included 326 (45.66%) deteriorated patients and 388 (54.34%) non-deteriorated patients. The mean age of the study population was 48.16±12.44 years. Of all patients, 319 (44.7%) were men and 395 (55.3%) were women. The average length of the patient’s stay was 16.08±5.13 days. The most common clinical feature on admission was fever (593 of 714, 83.05%). It is worth noting that 80 (11.20%) of the 714 patients were asymptomatic from exposure to admission. Multivariate logistic regression analysis showed that gender, age, diabetes, respiratory system disease, fever, dyspnea, and nasal congestion were risk factors associated with deterioration in cases with COVID-19 patients, and asymptomatic (OR: 0.058; 95% CI: 0.022–0.155; P<0.001) was the protective factor for deterioration of COVID-19 patients.

Conclusion

Accompanied by chronic diseases, old age, fever, nasal congestion, and dyspnea were factors that influenced the aggravation of COVID-19 patients, and more attention and treatment should be given to these patients.

Characteristics of 1738 Patients With Coronavirus Disease 2019 (COVID-19) in Wuhan, China

OBJECTIVE

Since December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been discovered in Wuhan and spread rapidly across China and worldwide. Characteristics of infected patients are needed to get insight into the full spectrum of the disease.

METHODS

Epidemiological and clinical information of 1738 diagnosed patients during February 7-26, 2020 in Wuhan Dongxihu Fangcang Hospital were analyzed. A total of 709 patients were followed up on symptom, mental health, isolation site, and medication after discharge.

RESULTS

There were 852 males and 886 females in the cohort. The average age of the patients was 48.8 y. A total of 79.98% of the patients were from Wuhan, Hubei Province. The most common initial symptoms were fever, cough, and shortness of breath. Among all the patients, 1463 had complications, with respiratory distress as the most common complication. The average duration of hospitalization was 15.95 ± 14.69 d. The most common postdischarge symptom is cough. After discharge, most patients were full of energy and chose hotel as their self-isolation site. Coronavirus disease 2019 (COVID-19) Chinese medicine No.2 prescription is the medication used most commonly by the patients after discharge.

CONCLUSIONS

The population is generally susceptible to SARS-CoV-2. After receiving aggressive treatment of combined Chinese and Western medicine, most patients had a good prognosis and mental health after discharge.

A small nucleolar RNA, SNORD126, promotes adipogenesis in cells and rats by activating the PI3K-AKT pathway

Small nucleolar RNA (snoRNA) plays important role in various histogenesis. Whether snoRNA plays a role in adipogenesis is unknown. SNORD126 is a C/D box snoRNA. We previously demonstrated that SNORD126 promoted hepatocellular carcinoma cell growth by activating the phosphoinositide 3-kinase-protein kinase B (Akt) pathway through upregulating fibroblast growth factor receptor 2 expression. In the present study, we found that the expression of SNORD126 was downregulated in the obesity-related tissues in high-fat diet-fed rats. Overexpression of SNORD126 in 3T3-L1 cells promoted adipocytes differentiation. SNORD126 significantly increased the expression of CCAAT/enhancer-binding protein α, fatty acid-binding protein 4, peroxisome proliferative-activated receptor-γ, and the phosphorylation of Akt and p70S6K. Overexpression of SNORD126 in human adipose-derived stem cells stimulated adipogenesis and increased phosphorylation of Akt. Meanwhile, SNORD126 increased the messenger RNA and protein levels of cyclin D1 and cyclin-dependent kinase 2, which promoted mitotic clonal expansion progression during the early stage of 3T3-L1 cell differentiation. We further found that SNORD126 accelerated the growth of the groin fat pad and increased phosphorylation of Akt and p70S6K in rats. Overall, our results suggested that SNORD126 promoted adipocyte differentiation through increasing phosphorylation of Akt and p70S6K both in vitro and in vivo.

Effects of Different Local Analgesic Techniques on Postoperative Quality of Life and Pain in Patients Undergoing Total Hip Arthroplasty Under General Anesthesia: A Randomized Controlled Trial

Background

Both lumbosacral plexus block (LSPB) and local infiltration analgesia (LIA) can provide postoperative analgesia for patients undergoing total hip arthroplasty (THA). The current study aimed to compare the differences between LSPB and LIA on postoperative pain and quality of life (QoL) in THA patients.

Methods

A total of 117 patients aged 40–80 years, ASA I-III, were prospectively randomized into two groups: a general anesthesia plus LSPB (Group LSPB) and a general anesthesia plus LIA (Group LIA). Pain intensity and opioid consumption were recorded Within 72 hours after surgery. QoL was measured by EQ-5D and EQ-VAS questionnaires, and the incidence of postoperative pain was measured as part of the EQ-5D on day 1, day 3, day 7, and month 1, month 3, and month 6 after surgery.

Results

EQ-5D scores: Mobility, Self-Care, Usual Activities, Pain/Discomfort, and Anxiety/Depression were higher in Group LSPB versus Group LIA throughout six-month follow-ups (p = 0.039). The pain intensity was lower in Group LSPB than in Group LIA 0–12 h after surgery (2.41 vs 2.79, p = 0.01), but was higher in Group LSPB than in Group LIA 12–24 h (2.59 vs 2.05, p = 0.02) and 24–48 h (2.18 vs 1.73, p = 0.02) after surgery. There were no differences in opioid consumption between the groups during the first 72 postoperative hours. In the first month after surgery, more patients in Group LSPB than in Group LIA had no pain (52 vs 40, p = 0.04).

Conclusion

Both LSPB and LIA can provide satisfactory postoperative analgesia. The LSPB is better than LIA for long-term QoL in THA patients undergoing general anesthesia.

Clinical Trial Registration Number

The Chinese Clinical Trial Registry (ChiCTR-INR-17012545).

Hemobilia due to Hepatic artery pseudoaneurysm secondary to collateral circulation formation after liver trauma: a case report

Background

Hemobilia due to rupture of hepatic artery pseudoaneurysm and recurrent hemorrhage caused by hepatic artery collateral circulation are both rare complications after liver trauma. There have been a number of separate reports of both complications, but no cases have been reported in which the two events occurred in the same patient. Here we report a recurrent hemorrhage in the bile duct due to hepatic artery pseudoaneurysm secondary to collateral circulation formation after hepatic artery ligation in a patient with liver trauma.

Case presentation

A 52-year-old male patient was admitted to our hospital for liver trauma (Grade IV according to the American Association for the Surgery of Trauma (AAST) grading system) with active bleeding after a traffic accident. Hepatic artery ligation was performed for hemostasis. Three months after the surgery, the patient was readmitted for melena and subsequent hematemesis. Selective angiography examination revealed the formation of collateral circulation between the superior mesenteric artery and right hepatic artery. Moreover, a ruptured hepatic artery pseudoaneurysm was observed and transcatheter arterial embolization (TAE) was performed for hemostasis at the same time. After the treatment, the patient recovered very well and had an uneventful prognosis until the last follow-up.

Conclusion

For patients with hepatic trauma, the selection of the site of hepatic artery ligation and the diagnosis and treatment methods of postoperative biliary hemorrhage are crucial for the prognosis of the disease.

GC-MS metabolomics identifies novel biomarkers to distinguish tuberculosis pleural effusion from malignant pleural effusion

Background

Tuberculous pleural effusions (TBPEs) and malignant pleural effusions (MPEs) are two of the most common and severe forms of exudative effusions. Clinical differentiation is challenging; however, metabolomics is a collection of powerful tools currently being used to screen for disease‐specific biomarkers.

Methods

17 TBPE and 17 MPE patients were enrolled according to the inclusion criteria. The normalization gas chromatography‐mass spectrometry (GC‐MS) data were imported into the SIMCA‐P + 14.1 software for multivariate analysis. The principal component analysis (PCA) and orthogonal partial least‐squares discriminant analysis (OPLS‐DA) were used to analyze the data, and the top 50 metabolites of variable importance projection (VIP) were obtained. Metabolites were qualitatively analyzed using the National Institute of Standards and Technology (NIST) databases. Pathway analysis was performed by MetaboAnalyst 4.0. The detection of biochemical indexes such as urea and free fatty acids in these pleural effusions was also verified, and significant differences were found between these two groups.

Results

1319 metabolites were screened by non‐targeted metabonomics of GC‐MS. 9 small molecules (urea, L‐5‐oxoproline, L‐valine, DL‐ornithine, glycine, L‐cystine, citric acid, stearic acid, and oleamide) were found to be significantly different (p < 0.05 for all). In OPLS‐DA, 9 variables were considered significant for biological interpretation (VIP≥1). However, after the ROC curve was performed, it was found that the metabolites with better diagnostic value were stearic acid, L‐cystine, citric acid, free fatty acid, and creatinine (AUC > 0.8), with good sensitivity and specificity.

Conclusion

Stearic acid, L‐cystine, and citric acid may be potential biomarkers, which can be used to distinguish between the TBPE and the MPE.

RT-PCR Combined with CT Examination in the Diagnosis and Prognosis Evaluation of COVID-19 Patients in Fangcang Hospital: A Case Series

Rationale

Currently, the "gold standard" is real-time reverse transcriptase-polymerase chain reaction (RT-PCR) amplification of the viral DNA for diagnosis of COVID-19 infection. However, early reports of test performance in the Wuhan outbreak showed variable sensitivities. Therefore, the simple use of RT-PCR as a discharge standard for COVID-19 patients may be risky. Early discussions suggested that CT should be the preferred modality for the diagnosis of COVID-19. However, the use of CT for COVID-19 discharge is controversial. In the Fangcang hospital, we performed multiple nucleic acid tests and chest CT examinations in all patients. For discharged patients, we performed multiple nucleic acid tests and chest CT scans on the basis of discharge standards to minimize the incidence of false negatives in nucleic acid tests.

Patient Concerns

Two 42-year-old male patients with mild to moderate COVID-19 were treated in the Fangcang Hospital According to the treatment, one patient was cured and discharged, while the other patient was sent to a higher-level hospital for further treatment.

Diagnoses

Real-time reverse transcriptase-polymerase chain reaction amplification of the viral DNA for diagnosis of COVID-19 infection.

Interventions

The patients received Chinese medicine and antiviral treatment in the Fangcang Hospital.

Outcomes

At follow-up, both patients were cured after treatment and returned to normal life after 2 weeks of home isolation and a negative nucleic acid test.

Lessons

The use of nucleic acid testing combined with chest CT examination can quickly diagnose patients with COVID-19 infection and evaluate their treatment in the Fangcang Hospital.

Dexmedetomidine attenuates sepsis-associated inflammation and encephalopathy via central α2A adrenoceptor

Sepsis-associated encephalopathy (SAE) is a significant clinical issue that is associated with increased mortality and cost of health care. Dexmedetomidine, an α2 adrenoceptor agonist that is used to provide sedation, has been shown to induce neuroprotection under various conditions. This study was designed to determine whether dexmedetomidine protects against SAE and whether α2 adrenoceptor plays a role in this protection. Six- to eight-week old CD-1 male mice were subjected to cecal ligation and puncture (CLP). They were treated with intraperitoneal injection of dexmedetomidine in the presence or absence of α2 adrenoceptor antagonists, atipamezole or yohimbine, or an α2A adrenoceptor antagonist, BRL-44408. Hippocampus and blood were harvested for measuring cytokines. Mice were subjected to Barnes maze and fear conditioning 14 days after CLP to evaluate their learning and memory. CLP significantly increased the proinflammatory cytokines including tumor necrosis factor α, interleukin (IL)-6 and IL-1β in the blood and hippocampus. CLP also increased the permeability of blood-brain barrier (BBB) and impaired learning and memory. These CLP detrimental effects were attenuated by dexmedetomidine. Intracerebroventricular application of atipamezole, yohimbine or BRL-44408 blocked the protection of dexmedetomidine on the brain but not on the systemic inflammation. Astrocytes but not microglia expressed α2A adrenoceptors. Microglial depletion did not abolish the protective effects of dexmedetomidine. These results suggest that dexmedetomidine reduces systemic inflammation, neuroinflammation, injury of BBB and cognitive dysfunction in septic mice. The protective effects of dexmedetomidine on the brain may be mediated by α2A adrenoceptors in the astrocytes.

Combined resection for hepatocellular carcinoma with diaphragmatic invasion: a systematic review and meta-analysis

INTRODUCTION

According to the Staging System of Barcelona Clinic Liver Cancer (BCLC), diaphragmatic invasion (DI) is generally considered to be a manifestation of advanced hepatocellular carcinoma (HCC) with nearly no cure. However, some studies have indicated that combined liver and diaphragmatic resection may be a reasonably safe treatment option for HCC patients with diaphragmatic invasion. In this article, we conduct a systematic review to compare the short- and long-term surgical outcomes between HCC patients without diaphragmatic involvement who underwent hepatectomy alone and HCC patients with diaphragmatic involvement who underwent combined liver and diaphragmatic resection.

EVIDENCE ACQUISITION

PubMed, Web of Science, Embase and Cochrane library databases were searched. All related studies were checked. Hazard ratios (HR) with 95% confidence intervals were calculated for the comparison of cumulative overall survival (OS) and recurrence free survival (RFS). Odds ratios (OR) with 95% CI were calculated for the comparison of overall postoperative morbidity and mortality.

EVIDENCE SYNTHESIS

Seven studies met the inclusion criteria were included. There was no significant difference between the single hepatectomy group and combined liver and diaphragmatic resection group in the overall survival and recurrence free survival. Subgroup analysis showed a statistically significantly higher overall survival in HCC patients with diaphragmatic fibrous adhesion (DFA) compared with the DI group. However, there was no statistically significant difference in OS between the DI group and the single hepatectomy group.

CONCLUSIONS

For HCC patients with diaphragmatic involvement, combined liver and diaphragmatic resection might be considered no matter whether its diaphragmatic invasion or not.

Super-factors associated with transmission of occupational COVID-19 infection among healthcare staff in Wuhan, China

BACKGROUND

Globally, there have been many cases of coronavirus disease 2019 (COVID-19) among medical staff; however, the main factors associated with the infection are not well understood.

AIM

To identify the super-factors causing COVID-19 infection in medical staff in China.

METHODS

A cross-sectional study was conducted between January 1st and February 30th, 2020, in which front-line members of medical staff who took part in the care and treatment of patients with COVID-19 were enrolled. Epidemiological and demographic data between infected and uninfected groups were collected and compared. Social network analysis (SNA) was used to establish socio-metric social links between influencing factors.

FINDINGS

A total of 92 medical staff were enrolled. In all participant groups, the super-factor identified by the network was wearing a medical protective mask or surgical mask correctly (degree: 572; closeness: 25; betweenness centrality: 3.23). Touching the cheek, nose, and mouth while working was the super-factor in the infected group. This was the biggest node in the network and had the strongest influence (degree: 370; closeness: 29; betweenness centrality: 0.37). Self-protection score was the super-factor in the uninfected group but was the isolated factor in the infected group (degree: 201; closeness: 28; betweenness centrality: 5.64). For family members, the exposure history to Huanan Seafood Wholesale Market and the contact history to wild animals were two isolated nodes.

CONCLUSION

High self-protection score was the main factor that prevented medical staff from contracting COVID-19 infection. The main factor contributing to COVID-19 infections among medical staff was touching the cheek, nose, and mouth while working.

Association between red blood cell distribution width and white matter hyperintensities: A large-scale cross-sectional study

BACKGROUND

Red blood cell distribution width (RDW) is a strong prognostic marker for various medical conditions, such as ischemic strokes. However, the relationships between higher RDW and the subtypes of white matter hyperintensities (WMHs) remain unclear. Hence, this study aimed to thoroughly evaluate the relationships between RDW and the subtypes of WMHs.

PATIENTS AND METHODS

This cross-sectional study was a retrospective analysis of hospital database (Dongguan Medical System, from April 2015 to February 2017). The presence and subtypes of WMHs were evaluated using Fazekas score with the T2WI-FLAIR brain images from a 1.5-T MRI system. The overall sample was randomly split in half. One of the two split-half samples was used for determining the optimal cutoff value of higher RDW and another for further statistical analyses.

RESULTS

A total of 555 subjects with WMHs and 642 controls were recruited. The optimal cutoff value of higher RDW was 13.25%. Logistic regression revealed that higher RDW (≥13.25%) was positively associated with periventricular WMHs (adjusted OR = 1.81, 95% CI: 1.16-2.82, p = .009). However, higher RDW was not associated with total WMHs (adjusted OR = 1.52, 95% CI: 0.99-2.33, p = .057) and deep WMHs (adjusted OR = 1.21, 95% CI: 0.76-1.94, p = .426).

CONCLUSION

Our findings suggested that higher RDW may be independently associated with periventricular WMHs, but not with total WMHs and deep WMHs.

Neurological Implications of Non-critically Ill Patients With Coronavirus Disease 2019 in a Fangcang Shelter Hospital in Wuhan, China

Background: Coronavirus disease 2019 (COVID-19) is a new viral respiratory disease and has become a pandemic. Fever, weakness, and dry cough are the main clinical manifestations. However, little is known about neurological symptoms of non-critically ill COVID-19 patients.

Objective: To investigate the neurological symptoms and implications of patients with non-critically ill COVID-19 patients.

Materials and Methods: This retrospective cohort study investigated all COVID-19 patients admitted to Wuhan East-West Lake Fangcang shelter hospital. Demographic data, clinical manifestations, comorbidities, radiological data, the result of nucleic acid test, and treatments were collected and analyzed.

Results: Among 1,682 patients with confirmed non-critically ill COVID-19, 509 patients (30.3%) had neurological symptoms, including myalgia (311, 18.5%), headache (216, 12.8%), fatigue (83, 4.9%), and dizziness (15, 0.9%). One hundred and fourteen patients (6.8%) were the expansion of pulmonary infection according to their chest CT images and medical history. Compared with patients without neurological symptoms, patients with neurological symptoms had a significantly longer length of hospital stay, time of nucleic acid turning negative, and the mean time from onset of symptom to hospital admission (p < 0.05). Patients with neurological symptoms were more likely to occur the expansion of pulmonary infection compared with the patients without neurological symptoms (46/509 [9.0%] vs. 68/1,173 [5.8%]).

Conclusions: Non-critically ill COVID-19 patients commonly have neurological symptoms. Neurological symptoms are significantly associated with the processes of COVID-19. Early identification and aggressive treatment are particularly important for COVID-19 patients with neurological symptoms.

Efficacy and Safety of Intravenous Thrombolysis on Acute Branch Atheromatous Disease: A Retrospective Case-Control Study

Background and Objective: Branch atheromatous disease (BAD) is distinctive from large-artery atherosclerosis and small-vessel disease, which is single subcortical infarction caused by the occlusion of perforator's orifice. This study aimed to indicate whether intravenous thrombolysis (IVT) with alteplase could prevent early neurological deterioration (END) and improve functional outcome for patients with BAD within 4.5 h after symptom onset. Methods: We retrospectively analyzed data collected from patients with BAD who were admitted to our hospital from January 2015 to August 2019. To investigate the efficacy and safety of IVT, subjects were classified into alteplase and control groups. A propensity score matching analysis was performed to control substantial heterogeneity of subgroup. The coprimary outcomes were END that is defined as an increase of ≥2 points in the National Institutes of Health Stroke Scale (NIHSS) score within 7 days after stroke, and favorable outcome at 3 months after stroke that defined by a score of 0-1 point on the modified Rankin scale (mRS). Results: A total of 135 patients were eventually enrolled in this study (n = 51 for the alteplase group and n = 84 for the control group). Additionally, 42 pairs of subjects were successfully matched by propensity score matching. Intravenous alteplase within 4.5 h after stroke onset reduced the incidence of END [unadjusted odds ratio (OR), 3.32; 95% confidence interval (CI), 1.06-10.37] and improved the clinical outcome at 3 months after stroke, with more patients achieving favorable functional prognosis (mRS, 0-1 point; unadjusted OR, 0.25; 95% CI, 0.10-0.62). Patients in the alteplase group were more likely to be independent (mRS, 0-2 points) at 3 months after stroke (unadjusted OR, 0.33; 95% CI, 0.12-0.90). The rate of death or dependence (mRS, ≥4 points) in the alteplase group was also markedly lower than that in the control group (unadjusted OR, 4.06; 95% CI, 1.03-16.02). Conclusion: Our findings indicated that intravenous thrombolysis may be a safe and effective therapy for patients with BAD.

Exploring the Rescue Strategy for Cardiac Arrest in Makeshift (FangCang) Hospital Workers during the Pneumonia Outbreak Associated with COVID-19

Background:

Beginning in Dec 2019, a novel coronavirus, designated SARS-CoV-2, has caused an international outbreak of respiratory illness termed COVID-19. The workers in the FangCang hospital have to work for more than 8 h and the work is high strength. Furthermore, to protect health and prevent serious cross-infection, they need to wear isolation equipment when working in FangCang hospital. These characteristics increase the risk of cardiac arrest (CA), which seriously endangers the lives of workers.

Methods:

We participated in the rescue of the patient and workers at first-line in FangCang hospital, and summarized the rescue strategies for workers rescuing.

Results:

Workers with CA were rescued in time according our guideline and showed zero dead in FangCang hospital.

Conclusion:

This study establishes the strategy for the CA of workers including the establishment of an in-FangCang resuscitation team, the establishment of a dedicated rescue room, and the formulation of rescue measures and procedures for CA of workers in the FangCang hospital. Therefore, we aimed to provide a strategy for the rescue of workers with CA in the FangCang hospital and share the success in rescuing with the world.

Identification of Vibrio alginolyticus virulent strain-specific DNA regions by suppression subtractive hybridization and PCR

AIMS

Vibrio alginolyticus was frequently isolated from diseased farmed fish in the coaster waters of Hainan Island over the past two decades. In this study, we attempted to identify candidates of virulent strain-specific DNA regions for this pathogen.

METHODS AND RESULTS

Suppression subtractive hybridization (SSH) and PCR were successively performed between the typical virulent strain and avirulent strain of V. alginolyticus, in which they shared 99·54% homology of 16S rDNAs. Out of 2873 subtracted clones, nine clones were finally indicated to harbour virulent strain-specific DNA fragments. The receivable functions of the major fragments in the nine clones were believed to encode methyl-accepting chemotaxis protein (n = 1), type VI secretion system-associated FHA domain protein TagH (n = 1), diguanylate cyclase (n = 1), AraC family transcriptional regulator (n = 1), ABC-type uncharacterized transport system permease component (n = 1) and hypothetical proteins (n = 4). Two hypothetical proteins contain several disordered regions.

CONCLUSIONS

Some specific DNA regions existed in the virulent strain of V. alginolyticus, and the SSH assay could be a highly sensitive method for identifying virulent regions in pathogens.

SIGNIFICANCE AND IMPACT OF THE STUDY

This report is the first to describe the identification of virulent strain-specific DNA regions in the V. alginolyticus genome, which is helpful in developing virulent strain-specific rapid detection methods and is a pivotal precondition for clarifying the molecular virulence mechanism of V. alginolyticus.

DrLLPS: a data resource of liquid-liquid phase separation in eukaryotes

Here, we presented an integrative database named DrLLPS (http://llps.biocuckoo.cn/) for proteins involved in liquid–liquid phase separation (LLPS), which is a ubiquitous and crucial mechanism for spatiotemporal organization of various biochemical reactions, by creating membraneless organelles (MLOs) in eukaryotic cells. From the literature, we manually collected 150 scaffold proteins that are drivers of LLPS, 987 regulators that contribute in modulating LLPS, and 8148 potential client proteins that might be dispensable for the formation of MLOs, which were then categorized into 40 biomolecular condensates. We searched potential orthologs of these known proteins, and in total DrLLPS contained 437 887 known and potential LLPS-associated proteins in 164 eukaryotes. Furthermore, we carefully annotated LLPS-associated proteins in eight model organisms, by using the knowledge integrated from 110 widely used resources that covered 16 aspects, including protein disordered regions, domain annotations, post-translational modifications (PTMs), genetic variations, cancer mutations, molecular interactions, disease-associated information, drug-target relations, physicochemical property, protein functional annotations, protein expressions/proteomics, protein 3D structures, subcellular localizations, mRNA expressions, DNA & RNA elements, and DNA methylations. We anticipate DrLLPS can serve as a helpful resource for further analysis of LLPS.

The regulatory mechanism and biological significance of the Snail-miR590-VEGFR-NRP1 axis in the angiogenesis, growth and metastasis of gastric cancer

Vascular endothelial growth factor receptor (VEGFR) and neuropilins (NRPs), a co-receptor of VEGF, play a key role in the formation and development of blood vessels and in tumour growth and metastasis. However, whether VEGFR1/2 and NRP1 are regulated by the same upstream mechanism is unclear, especially in gastric cancer. We used prediction tools to detect miRNAs that may simultaneously regulate VEGFR1/2 and NRP1, and we finally determined that miR-590 can simultaneously regulate VEGFR1/2 and NRP1 in gastric cancer. We discovered that miR-590 was downregulated in gastric cancer tissues and cell lines, and this was related to the dysregulation of the transcription factor SNAIL. In addition, the overexpression of miR-590 inhibits the migration, invasion, proliferation and D-MVA levels of gastric cancer cells in vivo and in vitro by targeting VEGFR1/2 and NRP1. We also demonstrated that miR-590 may be a useful marker for the prognosis of gastric cancer with Kaplan–Meier survival analysis. Since the epithelial-to-mesenchymal transition (EMT) is an important mechanism of tumour invasion and metastasis and VEGFR1/2 and NRP1 can promote the occurrence of EMT, we speculated that miR-590 can regulate the occurrence of EMT. Immunoblot and immunofluorescence analyses confirmed that the overexpression of miR-590 can inhibit the EMT in gastric cancer cells. Since SNAIL is also a mesenchymal marker, our results revealed a new, positive feedback loop. As a transcription factor, SNAIL inhibits the expression of miR-590, thereby upregulating the expression levels of NRP1 and VEGFR1/2; this leads to the development of EMT in gastric cancer and the upregulation of SNAIL.

Fibrous configuration of the fascia iliaca compartment: An epoxy sheet plastination and confocal microscopy study

Background and Objectives: The underlying anatomical mechanism of the ultrasound-guided fascia iliaca compartment (FIC) block for anaesthesia and analgesia in the lower limb has not been illuminated and numerous variations were attempted to achieve an optimal needle placement. This study aimed to define the fibrous configuration of the FIC. Methods: A total of 46 adult cadavers were studied using dissection, latex injection, epoxy sheet plastination and confocal microscopy. Results: (1) The fascia iliaca originated from the peripheral fascicular aponeurotic sheet of the iliopsoas. (2) The FIC was a funnel-shaped adipose space between the fascia iliaca and the epimysium of the iliopsoas, had a superior and an inferior opening and contained the femoral and lateral femoral cutaneous nerves but not obturator nerve. (3) The estimated volume of the FIC in the cadavers was about 23 mls, of which about one third was below the level of the anterior superior iliac spine. Conclusions: This study revealed that the fascia iliaca was aponeurotic and may be less permeable for the local anesthetics. Conclusions: The FIC contained only the femoral and lateral femoral cutaneous nerves and communicated with the extraperitoneal space and femoral triangle adipose space via its superior and inferior opening, respectively.

[Design and Implementation of Remote Firmware Update System Based on IAP Technology]

This paper introduces a network remote firmware update system based on IAP technology, which aims to solve the problems of low efficiency and high cost in the traditional upgraded medical device firmware (lower computer program) mode, and to improve the portability of the lower computer program upgrade maintenance. In order to better cope with market changes, customer needs, and solve software failures in medical devices, it is necessary to update and upgrade medical device software in a timely manner. Through the IAP technology and Internet communication technology of STM32 platform, this solution can complete the update of all instrument firmware in a short time, which not only saves a lot of travel expenses, mailing costs and labor costs, but also greatly shortens the update time.

Long non-coding RNA expression profile in permanent atrial fibrillation patients with rheumatic heart disease

OBJECTIVE

Atrial fibrillation (AF) is the most common type of arrhythmia, especially in rheumatic heart disease (RHD) patients. The differences in structural remodeling and electrical remodeling between the left and right atrium associated with AF in RHD patients are well known, and alterations in the expression profiles of long noncoding RNAs (lncRNAs) in the left atrium have also been investigated. However, the role of lncRNAs in the right atrium (RA) remains largely unknown.

PATIENTS AND METHODS

We identified differentially expressed lncRNAs in RA tissues of RHD patients with AF or a normal sinus rhythm (NSR) using microarray analysis. Then, we performed gene ontology (GO) and KEGG pathway analyses for functional annotation of the deregulated lncRNAs. Finally, we constructed a lncRNA-mRNA co-expression network.

RESULTS

Of the 22,829 human non-coding RNAs analyzed, a total of 1,909 long non-coding RNAs were detected. A total of 182 lncRNAs (117 downregulated and 65 upregulated) were shown to be differentially expressed (fold-change > 1.5) in AF patients compared with NSR patients. Many lncRNAs might be partially involved in an AF-related pathway.

CONCLUSIONS

AF dysregulates the expression of lncRNAs in the RA of RHD patients. These findings may be useful for exploring potential therapeutic treatments for AF in RHD patients.

Germline investigation in male breast cancer of DNA repair genes by next-generation sequencing

PURPOSE

In order to better define the breast cancer (BC) genetic risk factors in men, a germline investigation was carried out on 81 Male BC cases by screening the 24 genes involved in BC predisposition, genome stability maintenance and DNA repair mechanisms by next-generation sequencing.

METHODS

Germline DNAs were tested in a custom multi-gene panel focused on all coding exons and exon-intron boundaries of 24 selected genes using two amplicon-based assays on PGM-Ion Torrent (ThermoFisher Scientific) and MiSeq (Illumina) platforms. All variants were recorded and classified by using a custom pipeline.

RESULTS

Clinical pathological data and the family history of 81 Male BC cases were gathered and analysed, revealing the average age of onset to be 61.3 years old and that in 35 cases there was a family history of BC. Our genetic screening allowed us to identify a germline mutation in 22 patients (23%) in 4 genes: BRCA2, BRIP1, MUTYH and PMS2. Moreover, 12 variants of unknown clinical significance (VUS) in 9 genes (BARD1, BRCA1, BRIP1, CHEK2, ERCC1, NBN, PALB2, PMS1, RAD50) were predicted as potentially pathogenic by in silico analysis bringing the mutation detection rate up to 40%.

CONCLUSION

As expected, a positive family history is a strong predictor of germline BRCA2 mutations in male BC. Understanding the potential pathogenicity of VUS represents an extremely urgent need for the management of BC risk in Male BC cases and their own families.

Ultrasound-guided lumbar selective nerve root block plus T12 paravertebral and sacral plexus block for hip and knee arthroplasty: Three case reports

RATIONALE

For hip or knee arthroplasty, it is essential to develop a satisfied peripheral nerve block method that will benefit elderly patients or patients who are contraindicated to neuraxial anesthesia.

PATIENTS CONCERNS

Patient in Case 1 suffered from the right intertrochanteric fracture, combined with chronic obstructive pulmonary disease; Patient in Case 2 suffered from hip osteoarthritis; combined with ankylosing spondylitis; Patient in Case 3 suffered from rheumatoid arthritis, combined with ischemic encephalopathy.

DIAGNOSIS

Case 1: Right intertrochanteric fracture, chronic obstructive pulmonary disease. Case 2: hip osteoarthritis. Case 3: rheumatoid arthritis.

INTERVENTIONS

Ultrasound-guided lumbar selective nerve root block (SNRB) plus T12 paravertebral and sacral plexus block were performed in 2 patients who received hip arthroplasty and 1 patient who received knee arthroplasty.

OUTCOMES

All patients successfully received surgeries with this peripheral nerve block method and no postoperative complication was reported.

LESSONS

Ultrasound-guided lumbar SNRB plus T12 paravertebral and sacral plexus block not only satisfied the analgesia requirement of surgery, but also reduced the consumption of local anesthetic.

Efficacy of perineural dexamethasone with ropivacaine in thoracic paravertebral block for postoperative analgesia in elective thoracotomy: a randomized, double-blind, placebo-controlled trial

Purpose

The purpose of this study was to assess the efficacy of perineural dexamethasone with ropivacaine in multimodal analgesia for thoracic paravertebral block (TPVB) in patients undergoing elective thoracotomy.

Patients and methods

Ninety-six patients undergoing thoracotomy were enrolled in this trial and randomized to adjuvant therapy for TPVB: group S (saline), group R (0.5% ropivacaine), or group RD (5 mg dexamethasone and 0.5% ropivacaine). Postoperative analgesia, recovery duration, and chronic pain were recorded.

Results

Groups R and RD spent less time in the postanaesthesia care unit, had earlier out-of-bed activity, and had shorter postoperative hospital stays compared with group S. The RD group regained consciousness faster and had lower acute pain scores and used less patient-controlled analgesia during the first 72 h after surgery compared with group S. Postthoracotomy pain was decreased in group RD (19.0%) compared with group S (47.6%) 3 months postoperatively, p = 0.050.

Conclusion

Perineural dexamethasone with ropivacaine for TPVB improves postoperative analgesia quality, reduces recovery time, and may decrease the incidence of chronic pain after thoracotomy with an opioid-based anesthetic regimen.

Ultrasound-guided left lateral transversus abdominis plane block combined with rectus sheath block in peritoneal dialysis catheter placement

This study assessed the utility of ultrasound-guided lateral transversus abdominis plane (TAP) block combined with rectus sheath (RS) block for peritoneal dialysis catheter placement surgery. Thirty consecutive patients with end-stage renal disease scheduled to have peritoneal dialysis catheter placement received a left lateral TAP block combined with RS block performed under ultrasound guidance. The TAP and RS blocks were, respectively, conducted with 15 ml of 0.5% ropivacaine and 10 ml of 0.5% ropivacaine. Pain intensity was evaluated by verbal rating scale during operation, and the degree of patient and surgeon satisfaction was qualified by a categorical scale. Twenty-nine patients received successful blocks without any other adjuvant anesthetic drugs. One patient required rescue analgesia with lidocaine infiltration. No complications related to regional anesthesia were noted. Ultrasound-guided left lateral TAP block combined with RS block can serve as the primary anesthetic modality for peritoneal dialysis catheter placement surgery.