Profound postinduction hypotension precipitated by immune checkpoint inhibitors: a case report

BACKGROUND

With the increasing use of immune checkpoint inhibitors (ICIs) in cancer therapy, perioperative healthcare professionals need to be vigilant about potential immune-related adverse events (irAEs). We report a case of severe postinduction hypotension in a patient undergoing laparotomy due to suspected intraabdominal bleeding from gastric cancer and Krukenberg tumors, caused by unrecognized hypothyroidism precipitated by ICIs.

CASE PRESENTATION

A 65-year-old Chinese female with a history of gastric adenocarcinoma and Krukenberg tumors, previously treated with nivolumab, presented to the emergency room with abdominal pain and hypotension. Despite ruling out other causes, including hypovolemia and anaphylaxis, her hypotension persisted. The patient was found to have severe hypothyroidism, likely an irAE from the use of nivolumab. Thyroxine replacement therapy resolved the hypotension, and the patient recovered uneventfully after surgery.

CONCLUSIONS

This case underscores the importance of considering irAEs, such as hypothyroidism, in patients treated with ICIs. Perioperative healthcare providers must remain vigilant for potential complications and promptly recognize and manage irAEs to optimize patient outcomes.

Space-time mapping on the sagittal axis in congenital blindness

Previous evolutionary perspectives proposed that the space-time mapping on the sagittal axis originates from visuo-locomotion coupling when walking/running forward. Accordingly, the congenitally blind could not have developed a sagittal mental timeline if the latter depends on such a visuo-locomotion coupling. However, this conclusion was reached in only a single empirical study (Rinaldi et al. in J Exp Psychol General 147:444-450, 2018), and its theoretical underpinnings are not entirely convincing as locally static and continuous auditory input undergoes a relatively similar change as function of self-locomotion, but this type of sensory-locomotion coupling is spared even in congenital blindness. Therefore, the present study systematically explored whether the congenitally blind show space-time mappings on the sagittal axis using different paradigms in three experiments. In Experiment 1, using a typical implicit RT task, the congenitally blind showed the same preferred space-time mapping in the sagittal dimension as normally sighted participants did. In Experiment 2, this space-time mapping occurred even automatically when temporal relations were task-irrelevant in a naming task. In Experiment 3, in an explicit space-time mapping task, the congenitally blind were more likely to locate the past behind and the future in front of their bodies. Moreover, most blind participants used spatial metaphors for their space-time mapping on the sagittal axis. These results supported the conclusion that the congenitally blind have a sagittal mental timeline, and that their sensory-locomotion coupling experience was either more similar to that of sighted participants or not critical for the space-time mapping. The present study, thus, also helps to clarify the origin of the sagittal mental timeline.

Intraoperative management during liver transplantation in the child with mitochondrial depletion syndrome: A case report

INTRODUCTION

Mitochondrial DNA depletion syndrome (MDS) is a kind of autosomal recessive genetic disorder associated with a reduction in mitochondrial DNA (mtDNA) copy number caused by mutations in nuclear genes during nucleotide synthesis, which affects the energy production of tissues and organs. Changes in hemodynamics during liver transplantation may lead to high energy-demanding organs and tissues being vulnerable. This report described the intraoperative management during liver transplantation in a child with MDS. Ultimately, the child was discharged smoothly without any complications.

PRESENTATION OF THE CASE

A five-year-old boy was diagnosed with mitochondrial depletion syndrome preoperatively and scheduled for living donor liver transplantation. The incidence of postreperfusion syndrome (PRS) could not be avoided for 30 min after opening, despite our best efforts to aggressively prevent it before opening. While ensuring hemodynamic stability, we actively prevented and adopted high-energy-demand organ protection strategies to reduce the incidence of postoperative complications. Finally, the child was discharged 28 days after the operation, and no other complications were found.

DISCUSSION

Liver transplantation can be performed for liver failure in this disease to improve the quality of life and prolong the life of patients. As this child has mitochondrial DNA depletion syndrome, the disruption of cellular energy generation caused by mitochondrial malfunction puts high-energy-demanding organs and tissues at risk during surgery. It motivates us to pay closer attention to the prevention and treatment of PRS in anesthetic management to minimize damage to the child's organs and tissues with high energy demands.

CONCLUSIONS

This report describes the intraoperative management during liver transplantation in a child with mitochondrial depletion syndrome. To increase the safety of perioperative anesthesia and reduce mortality in patients with mitochondrial disease, for such patients, maintaining an acid-base balance and a stable internal environment is essential. We should also pay attention to protecting body temperature, using vasoactive drugs beforehand to lessen the incidence of PRS, and protecting high-energy-demanding organs afterward.

Paying attention to the value of thrombelastography and the impact of postreperfusion syndrome on outcomes of liver transplantation

Only limited information is available about the connection between massive blood transfusion and postoperative survival rates in pediatric liver transplantation. The aim of Gordon's study was to examine the potential impact of perioperative transfusion on postoperative complications and death in young children receiving pediatric living-donor liver transplantation (PLDLT). The authors concluded that transfusion of a red blood cell volume higher than 27.5 mL/kg during the perioperative period is associated with a significant increase in short- and long-term postoperative morbidity and mortality after PLDLT. However, viscoelastic coagulation monitoring was not utilized in the study; instead, only conventional coagulation monitoring was conducted. Overall, the choice of blood coagulation monitoring method during blood transfusion can have a significant impact on patient prognosis. Several studies have shown that the viscoelastic coagulation testing such as thrombelastography (TEG) is highly sensitive and accurate for diagnosing coagulation dysfunction. Indeed, a TEG-guided blood transfusion strategy can improve prognosis. Moreover, postreperfusion syndrome is one of the most common complications of liver transplantation and an important factor affecting the prognosis of patients and should also be included in regression analysis.

Intraoperative Blood Pressure Lability Acts as a Key Mediator in the Impacts of Goal-Directed Fluid Therapy on Postoperative Complications in Patients Undergoing Major Spine Surgery

Objective Although goal-directed fluid therapy (GDFT) has been proven to be effective in reducing the incidence of postoperative complications, the underlying mechanisms remain unknown. The aim of this study was to examine the mediating role of intraoperative hemodynamic lability in the association between GDFT and the incidence of postoperative complications. We further tested the role of this mediation effect using mean arterial pressure, a hemodynamic indicator. Methods This secondary analysis used the dataset of a completed nonrandomized controlled study to investigate the effect of GDFT on the incidence of postoperative complications in patients undergoing posterior spine arthrodesis. We used a simple mediation model to test whether there was a mediation effect of average real variability between the association of GDFT and postoperative complications. We conducted mediation analysis using the mediation package in R (version 3.1.2), based on 5,000 bootstrapped samples, adjusting for covariates. Results Among the 300 patients in the study, 40% (120/300) developed postoperative complications within 30 days. GDFT was associated with fewer 30-day postoperative complications after adjustment for confounders (odds ratio: 0.460, 95% CI: 0.278, 0.761; P = 0.003). The total effect of GDFT on postoperative complications was -0.18 (95% CI: -0.28, -0.07; P < 0.01). The average causal mediation effect was -0.08 (95% CI: -0.15, -0.04; P < 0.01). The average direct effect was -0.09 (95% CI: -0.20, 0.03; P = 0.17). The proportion mediated was 49.9% (95% CI: 18.3%, 140.0%). Conclusions The intraoperative blood pressure lability mediates the relationship between GDFT and the incidence of postoperative complications. Future research is needed to clarify whether actively reducing intraoperative blood pressure lability can prevent postoperative complications.

Risk factors for myocardial injury during living donor liver transplantation in pediatric patients with biliary atresia

BACKGROUND

Cold ischemia-reperfusion of the liver is an inevitable occurrence in liver transplantation that may also cause damage to the heart. Perioperative myocardial injury during liver transplantation can increase the incidence of postoperative mortality, but there is little research on the incidence of myocardial injury in children who undergo living donor liver transplantation (LDLT). Therefore, this study mainly explores the independent risk factors for myocardial injury in children who undergo LDLT.

AIM

To analyze the data of children who underwent LDLT to determine the risk factors for intraoperative myocardial injury.

METHODS

We retrospectively analyzed the inpatient records of pediatric patients who underwent LDLT in Tianjin First Central Hospital from January 1, 2020, to January 31, 2022. Recipient-related data and donor-related data were collected. The patients were divided into a myocardial injury group and a nonmyocardial injury group according to the value of the serum cardiac troponin I at the end of surgery for analysis. Univariate analysis and multivariate logistic regression were used to evaluate the risk factors for myocardial injury during LDLT in pediatric patients.

RESULTS

A total of 302 patients met the inclusion criteria. The myocardial injury group had 142 individuals (47%), and the nonmyocardial injury group included 160 patients (53%). Age, height, and weight were significantly lower in the myocardial injury group (P < 0.001). The pediatric end-stage liver disease (PELD) score, total bilirubin, and international standardized ratio were significantly higher in the myocardial injury group (P < 0.001). The mean arterial pressure, lactate, hemoglobin before reperfusion, duration of the anhepatic phase, cold ischemic time, incidence of postreperfusion syndrome (PRS), and fresh frozen plasma transfusion were significantly different between the two groups (P < 0.05). The postoperative intensive care unit stay and peak total bilirubin values in the first 5 d after LDLT were significantly higher in the myocardial injury group (P < 0.05). The pediatric patients with biliary atresia in the nonmyocardial injury group who underwent LDLT had a considerably higher one-year survival rate than those in the myocardial injury group (P = 0.015). Multivariate logistic regression revealed the following independent risk factors for myocardial injury: a high PELD score [odds ratio (OR) = 1.065, 95% confidence interval (CI): 1.013-1.121; P = 0.014], a long duration of the anhepatic phase (OR = 1.021, 95%CI: 1.003-1.040; P = 0.025), and the occurrence of intraoperative PRS (OR = 1.966, 95%CI: 1.111-3.480; P = 0.020).

CONCLUSION

A high PELD score, a long anhepatic phase duration, and the occurrence of intraoperative PRS were independent risk factors for myocardial injury during LDLT in pediatric patients with biliary atresia.

Impact of patent foramen ovale on short-term outcomes in children with biliary atresia undergoing living donor liver transplantation: a retrospective cohort study

OBJECTIVE

To investigate the impact of patent foramen ovale (PFO) on the short-term outcomes of living donor liver transplantation (LDLT) in children with biliary atresia.

METHODS

With the approval of the hospital ethics committee, 304 children with biliary atresia who underwent LDLT in our center from January 2020 to December 2021 were enrolled. According to the results of echocardiography before the operation, the subjects were divided into the PFO group (n = 73) and the NoPFO group (n = 231). The baseline characteristics; intraoperative recipient-related data and donor-related data; incidence of postreperfusion syndrome (PRS); postoperative mechanical ventilation time; ICU stay duration; postoperative hospital stay duration; liver function index; incidences of postoperative complications including acute renal injury (AKI), graft dysfunction, hepatic artery thrombosis (HAT) and portal vein thrombosis (PVT); and one-year survival rate were compared between the two groups.

RESULTS

The median age in the PFO group was 6 months and that in the NoPFO group was 9 months (P < 0.001), and the median height (65 cm) and weight (6.5 kg) in the PFO group were significantly lower than those in the NoPFO group (68 cm, 8.0 kg) (P < 0.001). The preoperative total bilirubin level (247 vs. 202 umol/L, P = 0.007) and pediatric end-stage liver disease (PELD) score (21 vs. 16, P = 0.001) in the PFO group were higher than those in the NoPFO group. There were no significant differences in the intraoperative PRS incidence (46.6% vs. 42.4%, P = 0.533 ), postoperative mechanical ventilation time (184 vs. 220 min, P = 0.533), ICU stay duration (3.0 vs. 2.5 d, P = 0.267), postoperative hospital stay duration (22 vs. 21 d, P = 0.138), AKI incidence (19.2% vs. 24.7%, P = 0.333), graft dysfunction incidence (11.0% vs. 12.6%, P = 0.716), HAT incidence (5.5% vs. 4.8%, P = 0.762), PVT incidence (2.7% vs. 2.2%, P = 0.675) or one-year survival rate (94.5% vs. 95.7%, P = 0.929) between the two groups.

CONCLUSION

The presence of PFO has no negative impact on short-term outcomes in children with biliary atresia after LDLT.

Association between post-COVID-19 status and perioperative morbidity and mortality: protocol for an ambispective cohort study

INTRODUCTION

With COVID-19 bringing persistent impact on the worldwide population, perioperative management after SARS-CoV-2 infection needs to be revisited in the new period of different circulating coronavirus variants, vaccination status, increased reinfection rate and new disease control policies. This study aims to explore the association between time to surgery after COVID-19 diagnosis and the risk of postoperative morbidity and mortality.

METHODS AND ANALYSIS

This is a single-centre ambispective cohort study. Patients with preoperative SARS-CoV-2 infection who require inpatient surgical intervention from 1 December 2022 to 28 February 2023 will be included. Baseline assessment will include the time interval between preoperative SARS-CoV-2 infection and surgery, COVID-19 diagnosis and symptoms, vaccination status and routine preoperative evaluations. The primary outcome will be postoperative composite complications within 30 days after surgery. Association between post-COVID-19 interval and the outcomes will be explored using logistic regression after adjusting for confounding variables.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Research Ethics Committee of Peking Union Medical College Hospital (IRB K3570). We aim to publish and disseminate the findings in peer-reviewed journals, scientific conferences and on social media.

TRIAL REGISTRATION NUMBER

NCT05689840.

Burnout Among Chinese Anesthesiologists After the COVID-19 Pandemic Peak: A National Survey

BACKGROUND

Evidence has shown that large-scale pandemics can have prolonged psychological impacts on health care professionals. The current study aimed to evaluate the prevalence of burnout after the coronavirus disease 2019 (COVID-19) epidemic peak and to explore the prolonged impact of COVID-19 on burnout among Chinese anesthesiologists.

METHODS

From August 2021 to October 2021, a nationwide cross-sectional survey was conducted. Burnout was measured using the Maslach Burnout Inventory-Human Service Survey. Basic demographic information, exposure to COVID-19, and perceived institutional support were documented. Validated tools measuring mental health status, including anxiety, depression, post-traumatic stress disorder (PTSD) and resilience, were also used to provide additional information on psychological distress.

RESULTS

Of the 8850 anesthesiologists from the 218 institutions who were invited to participate, 6331 (74.93%) completed the surveys and were included in the analysis. A total of 52.7% (95% confidence interval [CI], 51.5-53.9) met the criteria for burnout. Depression, anxiety, and PTSD were positively associated with burnout. After pooled multivariate analysis adjusting for potential confounding factors, among the COVID-19 exposure parameters, redeployment outside normal professional boundaries remained associated with an increased risk of burnout (odds ratio, 0.84; 95% CI, 0.72-0.92; P = .039). Higher perceived institutional support and resilience could act as protective factors against burnout.

CONCLUSIONS

The impact of the COVID-19 epidemic on the psychological well-being of anesthesiologists still exists more than 1 year after the outbreak. Building better institutional support and cultivating stronger resilience may be helpful future intervention measures.

Risk factors for postreperfusion syndrome during living donor liver transplantation in paediatric patients with biliary atresia: a retrospective analysis

BACKGROUND

Living donor liver transplantation (LT) is the main treatment for paediatric biliary atresia (BA) in Asia. During LT, a series of haemodynamic changes often occur during LT reperfusion, which is called postreperfusion syndrome (PRS), and PRS is related to a prolonged postoperative hospital stay, delayed recovery of graft function and increased mortality. To reduce adverse reactions after paediatric living donor LT (LDLT), our study's objectives were to ascertain the incidence of PRS and analyse possible risk factors for PRS.

METHODS

With the approval of the Ethics Committee of our hospital, the clinical data of 304 paediatric patients who underwent LDLT from January 2020 to December 2021 were analysed retrospectively. According to the presence or absence of PRS, the paediatric patients were divided into the non-PRS group and the PRS group. Independent risk factors of PRS were analysed using logistic regression analysis.

RESULTS

PRS occurred in 132 recipients (43.4%). The peak values of AST (816 (507-1625) vs 678 (449-1107), p=0.016) and ALT (675 (415-1402) vs 545 (389-885), p=0.015) during the first 5 days after LDLT in paediatric patients with PRS were significantly higher than those in the non-PRS group. Meanwhile, the paediatric patients in the PRS group had longer intensive care unit stays and hospital stays, as well as lower 1-year survival rates. Graft cold ischaemic time (CIT) ≥90 min (OR (95% CI)=5.205 (3.094 to 8.754)) and a temperature <36°C immediately before reperfusion (OR (95% CI)=2.973 (1.669 to 5.295)) are independent risk factors for PRS.

CONCLUSIONS

The occurrence of hypothermia (<36.0℃) in children immediately before reperfusion and graft CIT≥90 min are independent risk factors for PRS. PRS was closely related to the postoperative adverse outcomes of paediatric patients.

Association between preoperative autonomic nervous system function and post-induction hypotension in elderly patients: a protocol for a cohort study

INTRODUCTION

Post-induction hypotension (PIH), which is prevalent among elderly patients, is associated with adverse perioperative outcomes. As a critical part of blood pressure regulation, baroreflex control is believed to be closely related to intraoperative blood pressure fluctuations. Spontaneous baroreflex sensitivity and heart rate variability measurement can aid evaluation of patients' autonomic function. This study aims to determine the association between preoperative decreased baroreflex function and PIH in elderly patients.

METHODS AND ANALYSIS

This prospective cohort study will enrol patients who are 65 years old and above, scheduled for elective non-cardiac surgery under general anaesthesia, and American Society of Anesthesiologists physical status I-III (n=180). Baseline assessment will include routine preoperative evaluations as well as symptoms and anamneses associated with baroreflex failure. Preoperative autonomic function monitoring will be performed through 20 min of continuous beat-to-beat heart rate and blood pressure monitoring using LiDCO rapid (Masimo Corporation, USA). The primary outcome will be PIH. Detailed use of anaesthetic agents during induction and maintenance will be documented for adjustment in multivariable analyses.

ETHICS AND DISSEMINATION

The Research Ethics Committee of Peking Union Medical College Hospital approved the study protocol (I-22PJ008). We aim to publish and disseminate our findings in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05425147.

Goal-Directed Intraoperative Fluid Therapy Benefits Patients Undergoing Major Gynecologic Oncology Surgery: A Controlled Before-and-After Study

Background

Fluid management during major gynecologic oncology surgeries faces great challenges due to the distinctive characteristics of patients with gynecologic malignancies as well as features of the surgical procedure. Intraoperative goal-directed fluid therapy (GDFT) has been proven to be effective in reducing postoperative complications among major colorectal surgeries; however, the efficacy of GDFT has not been fully studied in gynecologic malignancy surgeries. This study aimed to discuss the influence of GDFT practice in patients undergoing major gynecologic oncology surgery.

Methods

This study was a controlled before-and-after study. From June 2015 to June 2018 in Peking Union Medical College Hospital, a total of 300 patients scheduled for elective laparotomy of gynecological malignancies were enrolled and chronologically allocated into two groups, with the earlier 150 patients in the control group and the latter 150 patients in the GDFT group. The GDFT protocol was applied by Vigileo/FloTrac monitoring of stroke volume and fluid responsiveness to guide intraoperative fluid infusion and the use of vasoactive agents. The primary outcome was postoperative complications within 30 days after surgery. The secondary outcome included length of stay and time of functional recovery.

Results

A total of 249 patients undergoing major gynecologic oncology surgery were analyzed in the study, with 129 in the control group and 120 patients in the GDFT group. Patients in the GDFT group had higher ASA classifications and more baseline comorbidities. GDFT patients received significantly less fluid infusion than the control group (15.8 vs. 17.9 ml/kg/h), while fluid loss was similar (6.9 vs. 7.1 ml/kg/h). GDFT was associated with decreased risk of postoperative complications (OR = 0.572, 95% CI 0.343 to 0.953, P = 0.032), especially surgical site infections (OR = 0.127, 95% CI 0.003 to 0.971, P = 0.037). The postoperative bowel function recovery and length of hospital stay were not significantly different between the two groups.

Conclusion

Goal-directed intraoperative fluid therapy is associated with fewer postoperative complications in patients undergoing major gynecologic oncology surgery.

The Improved Catheterization Is Associated With the Deeper Radial Arteries in Ultrasound-Guided Dynamic Needle Tip Positioning Technique

Objective

This study aimed to determine the associations between the first-attempt success and arterial depth in ultrasound-guided radial artery catheterization (RAC) with dynamic needle tip positioning (DNTP) technique. This study also aimed to further explore the cut-off depth correlated to improved first-attempt success catheterization in less time.

Methods

The cases undertaken by RAC within the DNTP technique between March 2019 and July 2020 were extracted from our institutional cohort database. Relevant variables were collected, including patients' demographics and catheterized information. Univariable and multivariable logistic regression analyses were performed to determine the association. The receiver operating characteristic (ROC) curve and the Youden index were used to explore the cut-off values of the arterial depth. Categorized cases according to the cut-off values, the Kaplan-Meier analysis, and the log-rank test were used to determine the difference of first-attempt success with limited catheterized time between groups.

Results

In this study, 119 patients were enrolled and 98 achieved first-attempt success. The first-attempt success catheterization was observed to be correlated to arterial depth (p < 0.01, odds ratio 6.47). An optimal cut-off depth of 2.25 mm was found using the Youden index (0.53) by ROC curve (area under curve 0.77). Arterial depth of more than 2.25 mm was correlated to improved first-attempt success catheterization in less time (log-rank p < 0.01).

Conclusion

To achieve first-attempt success catheterization using the DNTP technique, an arterial depth of more than 2.25 mm was associated with less catheterized time.

Regional anesthesia and cancer recurrence in patients with late-stage cancer: a systematic review and meta-analysis

BACKGROUND

Whether regional anesthesia may help to prevent disease recurrence in cancer patients is still controversial. The stage of cancer at the time of diagnosis is a key factor that defines prognosis and is one of the most important sources of heterogeneity for the treatment effect. We sought to update existing systematic reviews and clarify the effect of regional anesthesia on cancer recurrence in late-stage cancer patients.

METHODS

Medline, Embase, and Cochrane Library were searched from inception to September 2020 to identify randomized controlled trials (RCTs) and cohort studies that assessed the effect of regional anesthesia on cancer recurrence and overall survival (OS) compared with general anesthesia. Late-stage cancer patients were primarily assessed according to the American Joint Committee on Cancer Cancer Staging Manual (eighth edition), and the combined hazard ratio (HR) from random-effects models was used to evaluate the effect of regional anesthesia.

RESULTS

A total of three RCTs and 34 cohort studies (including 64,691 patients) were identified through the literature search for inclusion in the analysis. The risk of bias was low in the RCTs and was moderate in the observational studies. The pooled HR for recurrence-free survival (RFS) or OS did not favor regional anesthesia when data from RCTs in patients with late-stage cancer were combined (RFS, HR = 1.12, 95% confidence interval [CI]: 0.58-2.18, P = 0.729, I2 = 76%; OS, HR = 0.86, 95% CI: 0.63-1.18, P = 0.345, I2 = 48%). Findings from observational studies showed that regional anesthesia may help to prevent disease recurrence (HR = 0.87, 95% CI: 0.78-0.96, P = 0.008, I2 = 71%) and improve OS (HR = 0.88, 95% CI: 0.79-0.98, P = 0.022, I2 = 79%).

CONCLUSIONS

RCTs reveal that OS and RFS were similar between regional and general anesthesia in late-stage cancers. The selection of anesthetic methods should still be based on clinical evaluation, and changes to current practice need more support from large, well-powered, and well-designed studies.

The nature and reported incidence of suspected perioperative allergic reactions: A cross-sectional survey

STUDY OBJECTIVE

Perioperative allergic reactions (POHs) are common and can lead to severe intraoperative instability and even mortality. In contrast to the situation in developed countries, where databases of perioperative anaphylaxis are well documented and analyzed, relevant data are lacking in China. Therefore, we aimed to conduct a national survey to explore the characteristics of perioperative allergic reactions, as well as the knowledge and attitudes toward management and reporting among anesthesiologists.

DESIGN

Cross-sectional survey.

SETTING

Anesthesia department.

PATIENTS

A nationally representative sample comprising anesthesiologists from 12 province-level regions was selected.

MEASUREMENTS

A 20-item questionnaire was designed and validated using the Delphi method. Survey distribution was performed between June 2019 and January 2020 by the Chinese Society of Anesthesiology (CSA), which is the official academic society of Chinese anesthesiologists. Responses were compiled and analyzed.

MAIN RESULTS

We received responses from 4389 anesthesiologists across China. The estimated rate of suspected POH was 2/1000 patients (0.2%). On average, an anesthesiologist encountered 2.1 suspected POH cases per year. Neuromuscular blocking agents (NMBAs) were perceived as the most common causative agents, followed by antibiotics and succinylated gelatin. The rates of referral and allergy consultations were very low. Institutional support, including protocol development, cognitive aids, and tool kits, was not ideal. Additionally, the management of POH varied substantially. Most anesthesiologists believed that reporting and documenting POH was necessary.

CONCLUSIONS

Our survey revealed that POH is commonly encountered by Chinese anesthesiologists, but few patients are referred to allergy specialists or clinics for further investigation. A standardized recommendation based on research and data derived from Chinese patients is required.

Effects of replacing soybean meal with pumpkin seed cake and dried distillers grains with solubles on milk performance and antioxidant functions in dairy cows

Pumpkin seed cake (PSC), a byproduct of pumpkin seed oil processing, is used in ruminant feed as a beneficial protein source. Experiments were conducted to evaluate PSC as a substitute for soybean meal in the diets of lactating cows based on performance, rumen fermentation, antioxidant function and nitrogen partitioning. Six multiparous lactating cows were used in a replicated 3 × 3 Latin square experiment with 27-day periods. The cows were randomly divided into three treatment groups: group (1) was fed a diet containing no PSC (0PSC), and groups (2) and (3) were fed diets in which soybean meal was replaced with PSC and dried distillers grains with solubles (DDGS) at levels of 50% (50PSC) and 100% (100PSC), respectively. The diets were isonitrogenous and contained identical roughage but different proportions of PSC and DDGS. Replacement of soybean meal with PSC and DDGS did not influence rumen degradation, milk performance, rumen fermentation, DM intake or apparent total tract digestibility, and nitrogen partitioning between milk, feces and urine did not differ in the animals fed the three diets. However, compared with a diet containing no PSC, the total antioxidant capacity (P < 0.05) and antioxidant enzymes (total superoxide dismutase, glutathione peroxidase and catalase) activities (P < 0.05) were increased in the animals that received the 50PSC and 100PSC diets. In contrast, addition of PSC significantly reduced concentrations of aspartate transaminase (P < 0.05), alkaline phosphatase (P < 0.05) and malondialdehyde (P < 0.05) in the plasma. These results demonstrate that PSC can be completely substituted for soybean meal in the diet of dairy cows without any negative impact on milk performance, rumen fermentation or apparent digestibility and that this dietary change improves antioxidant functions and blood parameters in dairy cows, indicating that PSC has the potential for use as a feed source for dairy cows.

Risk factors for unplanned reintubation caused by acute airway compromise after general anesthesia: a case-control study

Background

This study aimed to identify the risk factors and evaluate the prognosis of unplanned reintubation caused by acute airway compromise (AAC) after general anesthesia.

Methods

This case-control study included surgical patients who underwent unplanned reintubation in the operating room and postanesthesia care unit after general anesthesia between January 1, 2014, and December 31, 2018. Cases due to AAC were matched 1:4 with randomly selected controls.

Results

A total of 123,068 patients were included, and reintubation due to AAC was performed in 36 patients (approximate incidence 0.03%). Univariable analysis revealed that male sex, age > 65, ASA physical status 3, sepsis, heart disease history, cerebral infarction history, Cormack Lehane grade, surgery type, fresh frozen plasma infusion, increased intubation duration, white blood cell count, and creatinine clearance rate were related to AAC-caused unplanned reintubation. Multivariable analysis revealed that age > 65 (OR = 7.50, 95% CI 2.47–22.81, P < 0.001), ASA physical status 3 (OR = 6.51, 95% CI 1.18–35.92, P = 0.032), head-neck surgery (OR = 4.94, 95% CI 1.33–18.36, P = 0.017) or thoracic surgery (OR = 12.56, 95% CI 2.93–53.90, P < 0.001) and a high fluid load (OR = 3.04, 95% CI 1.16–7.99, P = 0.024) were associated with AAC-caused unplanned reintubation. AAC-caused unplanned reintubation patients had longer postoperative hospital (OR = 5.26, 95% CI 1.57–8.95, P < 0.001) and intensive care unit days (OR = 3.94, 95% CI 1.69–6.18, P < 0.001).

Conclusions

Age > 65, ASA physical status 3, head-neck or thoracic surgery and high fluid load were found to be associated with AAC-caused unplanned reintubation.

A novel simple risk model to predict the prognosis of patients with paraquat poisoning

To identify risk factors and develop a simple model to predict early prognosis of acute paraquat (PQ) poisoning patients, we performed a retrospective cohort study of acute PQ poisoning patients (n = 1199). Patients (n = 913) with PQ poisoning from 2011 to 2018 were randomly divided into training (n = 609) and test (n = 304) samples. Another two independent cohorts were used as validation samples for a different time (n = 207) and site (n = 79). Risk factors were identified using a logistic model with Markov Chain Monte Carlo (MCMC) simulation and further evaluated using a latent class analysis. The prediction score was developed based on the training sample and was evaluated using the testing and validation samples. Eight factors, including age, ingestion volume, creatine kinase-MB [CK-MB], platelet [PLT], white blood cell [WBC], neutrophil counts [N], gamma-glutamyl transferase [GGT], and serum creatinine [Cr] were identified as independent risk indicators of in-hospital death events. The risk model had C statistics of 0.895 (95% CI 0.855-0.928), 0.891 (95% CI 0.848-0.932), and 0.829 (95% CI 0.455-1.000), and predictive ranges of 4.6-98.2%, 2.3-94.9%, and 0-12.5% for the test, validation_time, and validation_site samples, respectively. In the training sample, the risk model classified 18.4%, 59.9%, and 21.7% of patients into the high-, average-, and low-risk groups, with corresponding probabilities of 0.985, 0.365, and 0.03 for in-hospital death events. We developed and evaluated a simple risk model to predict the prognosis of patients with acute PQ poisoning. This risk scoring system could be helpful for identifying high-risk patients and reducing mortality due to PQ poisoning.

Octreotide alleviates pancreatic damage caused by paraquat in rats by reducing inflammatory responses and oxidative stress

This study explores the efficacy and mechanism by which octreotide (OCT) alleviates paraquat (PQ)-induced pancreatic injury. Twenty-four adult male rats were randomly divided into three groups: the normal control (NC), PQ poisoning, and OCT treatment groups. The PQ-induced pancreatic injury rat model was established by administering PQ (120 mg/kg). Treatment group rats received OCT (8 μg/kg body weight) every 8 h by subcutaneous injection, 1 h after PQ administration. Rats were euthanized 24 h after PQ injection. Serum amylase, lipase, tumor necrosis factor-α, and interleukin-6 levels were markedly increased in the PQ group versus the NC group. In pancreatic tissue, PQ poisoning drastically induced necrosis and increased inflammatory cytokine and oxidative stress marker levels. Compared with the PQ group, OCT reduced pancreatic damage and histological scores, serum amylase, lipase, and inflammatory cytokine levels, as well as oxidative stress. OCT demonstrates protective effects against PQ-induced pancreatic damage through anti-inflammatory and antioxidant actions.

Immunosuppressive drugs to reduce the mortality rate in patients with moderate to severe paraquat poisoning: A Meta-analysis

The benefits and adverse effects of immunosuppressive drugs (ISDs) in patients with paraquat (PQ) poisoning have not been thoroughly assessed. This meta-analysis study aims to evaluate the effect of ISDs in patients with moderate to severe PQ poisoning. We searched PubMed, Embase, Cochrane Library, Ovid Medline, CNKI and Wanfang Data from inception to January 2019. The Mantel-Haenszel method with a random-effects model was used to calculate the pooled relative risks (RRs) and 95% Confidence Intervals (CIs) as described by DerSimonian and Laird. An L'Abbé plot was drawn to explore the relationship between the degree of poisoning and mortality. Four randomized controlled trials, two prospective and seven retrospective studies were identified. ISDs were significantly associated with reduced mortality (RR 0.76; 95% CI, 0.58-0.99) and the incidence rate of multiple-organ dysfunction syndrome (MODS) (RR 0.63; 95% CI, 0.48-0.83) in patients with moderate to severe PQ poisoning. They were not associated with an increased incidence rate of hepatitis and reduced incidence rate of acute renal failure and hypoxia. The L'Abbé plot results showed a slight increase in mortality rate in the ISD group with increased mortality in the placebo group. This indicates a possible advantage of ISDs in most of the patients with severe PQ poisoning. These findings suggest that ISDs may reduce the mortality and incidence rate of MODS in moderate to severe PQ poisoning patients, and severe PQ poisoning patients might benefit more from ISDs.

Outcome impact of individualized fluid management during spine surgery: a before-after prospective comparison study

Background

Individualized fluid management (IFM) has been shown to be useful to improve the postoperative outcome of patients undergoing major abdominal surgery. A limited number of clinical studies have been done in orthopaedic patients and have yielded conflicting results. We designed the present study to investigate the clinical impact of IFM in patients undergoing major spine surgery.

Methods

This is a before-after study done in 300 patients undergoing posterior spine arthrodesis. Postoperative outcomes were compared between control group implementing standard fluid management (n = 150) and IFM group (n = 150) guided by fluid protocol based on continuous stroke volume monitoring and optimization. The primary outcome measure was the proportion of patients who developed one or more complications within 30 days following surgery.

Results

During surgery, patients received on average the same volume of crystalloids (7.4 vs 7.2 ml/kg/h) and colloids (1.6 vs 1.6 ml/kg/h) before and after the implementation of IFM. During 30 days following surgery, the proportion of patients who developed one or more complications was lower in the IFM group (32 vs 48%, p < 0.01). This difference was mainly explained by a significant decrease in post-operative nausea and vomiting (from 38 to 19%, p < 0.01), urinary tract infections (from 9 to 1%, p < 0.01) and surgical site infections (from 5 to 1%, p < 0.05). Median hospital length of stay was not affected by the implementation of IFM.

Conclusion

In patients undergoing major spine surgery, the implementation of IFM was associated with a significant decrease in postoperative morbidity.

Trial registration

ClinicalTrials.gov Identifier: NCT02470221. Prospectively registered on June 12, 2015.

Anesthesia Considerations and Infection Precautions for Trauma and Acute Care Cases During the COVID-19 Pandemic: Recommendations From a Task Force of the Chinese Society of Anesthesiology

Coronavirus Disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread worldwide. During the ongoing COVID-19 epidemic, most hospitals have postponed elective surgeries. However, some emergency surgeries, especially for trauma patients, are inevitable. For patients with suspected or confirmed COVID-19, a standard protocol addressing preoperative preparation, intraoperative management, and postoperative surveillance should be implemented to avoid nosocomial infection and ensure the safety of patients and the health care workforce. With reference to the guidelines and recommendations issued by the National Health Commission and Chinese Society of Anesthesiology, this article provides recommendations for anesthesia management of trauma and emergency surgery cases during the COVID-19 pandemic.

Expert Recommendations for Tracheal Intubation in Critically ill Patients with Noval Coronavirus Disease 2019

Coronavirus Disease 2019 (COVID-19), caused by a novel coronavirus (SARS-CoV-2), is a highly contagious disease. It firstly appeared in Wuhan, Hubei province of China in December 2019. During the next two months, it moved rapidly throughout China and spread to multiple countries through infected persons travelling by air. Most of the infected patients have mild symptoms including fever, fatigue and cough. But in severe cases, patients can progress rapidly and develop to the acute respiratory distress syndrome, septic shock, metabolic acidosis and coagulopathy. The new coronavirus was reported to spread via droplets, contact and natural aerosols from human-to-human. Therefore, high-risk aerosol-producing procedures such as endotracheal intubation may put the anesthesiologists at high risk of nosocomial infections. In fact, SARS-CoV-2 infection of anesthesiologists after endotracheal intubation for confirmed COVID-19 patients have been reported in hospitals in Wuhan. The expert panel of airway management in Chinese Society of Anaesthesiology has deliberated and drafted this recommendation, by which we hope to guide the performance of endotracheal intubation by frontline anesthesiologists and critical care physicians. During the airway management, enhanced droplet/airborne PPE should be applied to the health care providers. A good airway assessment before airway intervention is of vital importance. For patients with normal airway, awake intubation should be avoided and modified rapid sequence induction is strongly recommended. Sufficient muscle relaxant should be assured before intubation. For patients with difficult airway, good preparation of airway devices and detailed intubation plans should be made.

Laryngeal mask airway reduces incidence of post-operative sore throat after thyroid surgery compared with endotracheal tube: a single-blinded randomized controlled trial

BACKGROUND

Sore throat is a remarkable complication after thyroid surgery with endotracheal tube (ETT). Many studies revealed that laryngeal mask airway (LMA) might reduce the incidence and severity of postoperative sore throat. However, little is known about the use of a flexible reinforced LMA (FLMA) in thyroid surgery. The purpose of this study was to explore the potential benefits of FLMA compared with ETT on postoperative sore throat.

METHODS

In this prospective, single-blinded, randomized, controlled trial, ninety-six patients aged 20-80 years, scheduled for elective radical thyroidectomy under general anesthesia were enrolled. They were randomly divided into ETT group and FLMA group. All the included patients received total intravenous anesthesia (with propofol, fentanyl and rocuronium) and controlled mechanical ventilation during the surgery. Cuff pressure of ETT and FLMA were strictly controlled. Incidence and severity of postoperative sore throat, numbness and hoarseness at 1, 24, and 48 h after surgery was evaluated and compared between the two groups. Incidence and severity of buckling during extubation and the hemodynamic profile during intubation were also recorded and compared.

RESULTS

The incidence of sore throat and hoarseness was significantly lower in FLMA group than those in ETT group at 1 h, 24 h and 48 h postoperatively, as well as the severity of sore throat. Compared to ETT group, there was a significantly lower incidence of buckling during extubation and less fluctuation of HR and BP at 1 min and 3 min after intubation in FLMA group.

CONCLUSIONS

Patients undergoing thyroid surgery with FLMA had less postoperative laryngopharyngeal symptoms when compared with ETT. The use of FLMA also achieved less buckling during extubation and better hemodynamic profiles during intubation.

TRIAL REGISTRATION

The research was registered in Chinese Clinical Trial Registry (ChiCTR-IOR-15006602) on May 23th, 2015.

Anti-inflammatory and anti-apoptosis activity of taraxasterol in ulcerative colitis in vitro and in vivo

Ulcerative colitis is closely associated with colorectal cancer, the long-standing chronic inflammation being the key etiology of ulcerative colitis. The aim of the present study was to identify the anti-inflammatory and anti-apoptosis activity of taraxasterol in ulcerative colitis. MTT assay was used to obtain the optimal concentrations of lipopolysaccharide (LPS) and taraxasterol for cell treatments in vitro. A mouse model of colitis was established via dextran sodium sulphate (DSS) administration. Levels of IL-6 and TNF-α were detected through ELISA. Flow cytometry and western blotting were used to detect apoptosis and related protein expression levels, respectively. Hematoxylin and eosin staining was performed to detect the pathological damage. The results from the MTT assay identified the optimal concentration of LPS and taraxasterol, and ELISA results demonstrated that taraxasterol treatment decreased the expression levels of IL-6 and TNF-α in vitro and in vivo, in a dose-dependent manner. Taraxasterol treatment inhibited apoptosis, and reduced the protein levels of p53, Bcl-2 associated X (BAX) and caspase-3. Finally, pathological damages were reduced in colonic tissues of mice treated with taraxasterol. Taken together, taraxasterol treatment markedly inhibited inflammation and apoptosis in ulcerative colitis. Therefore, taraxasterol may be a promising agent for decreasing the inflammatory response in ulcerative colitis and other inflammation-related diseases.

Long non-coding RNA HCG11 suppresses the growth of glioma by cooperating with the miR-4425/MTA3 axis

BACKGROUND

Glioma is a type of malignant tumor that occurs in the central nervous system of adults. Long non-coding RNAs (lncRNAs) that potentially participate in the initiation and progression of glioma have been widely reported. As a now-found lncRNA, HLA complex group 11 (HCG11) has not yet been studied in glioma. The present study aimed to determine the role of HCG11 in the tumorigenesis of glioma.

METHODS

A quantitative real-time polymerase chain reaction assay was performed to examine the expression pattern of HCG11 in 84 glioma tissues and cell lines. The overall survival rate of glioma patients with a high or low level of HCG11 or metastasis-associated 1 family member 3 (MTA3) was analyzed by Kaplan-Meier analysis. The effect of HCG11 on glioma cell growth was determined by in vitro and in vivo experiments. MicroRNAs (miRNAs) that potentially interact with HCG11 were searched and determined by bioinformatics analysis and a luciferase reporter assay. Similarly, the target of miRNA-4425 was identified. Finally, rescue assays were conducted to determine the bio-function of the competing endogenous RNA pathway.

RESULTS

HCG11 was downregulated in 84 pairs of glioma tissues and cell lines. Moreover, a low level of HCG11 indicted the lower overall survival rate of glioma patients. Regarding the mechanism, HCG11 was abundant in the cytoplasm of glioma cells and interacted with miR-4425 to release the expression of MTA3. miR-4425 and MTA3 participated in HCG11-mediated glioma growth.

CONCLUSIONS

LncRNA HCG11 suppresses the growth of glioma by cooperating with the miR-4425/MTA3 axis.

Interspecific genetic maps in Miscanthus floridulus and M. sacchariflorus accelerate detection of QTLs associated with plant height and inflorescence

Miscanthus is recognized as a promising lignocellulosic crop for the production of bioethanol and bioproducts worldwide. To facilitate the identification of agronomical important traits and establish genetics knowledge, two genetic maps were developed from a controlled interspecific cross between M. floridulus and M. sacchariflorus. A total of 650 SSR markers were mapped in M. floridulus, spanning 19 linkage groups and 2053.31 cM with an average interval of 3.25 cM. The map of M. sacchariflorus comprised 495 SSR markers in 19 linkage groups covering 1684.86 cM with an average interval of 3.54 cM. The estimation on genome length indicated that the genome coverage of parental genetic maps were 93.87% and 89.91%, respectively. Eighty-eight bi-parental common markers were allowed to connect the two maps, and six pairs of syntenic linkage groups were recognized. Furthermore, quantitative trait loci (QTL) mapping of three agronomic traits, namely, plant height (PH), heading time (HT), and flowering time (FT), demonstrated that a total of 66 QTLs were identified in four consecutive years using interval mapping and multiple-QTL model. The LOD value of these QTLs ranged from 2.51 to 10.60, and the phenotypic variation explained varied from 9.50 to 37.10%. QTL cluster in syntenic groups MF19/MS7 contained six stable QTLs associated with PH, HT, and FT. In conclusion, we report for the first time the genetic mapping of biomass traits in M. floridulus and M. sacchariflorus. These results will be a valuable genetic resource, facilitating the discovery of essential genes and breeding of Miscanthus.

Ethical dilemma of identity disclosure faced by medical students in clinical clerkships: A nationwide multicenter study in China

Objective

Medical students in China are currently facing a dilemma of whether to clarify their identity as students to patients. Further investigation is needed to support policy-making. The aim was to identify factors influencing medical students’ decision on whether or not to clarify their identity to patients and to examine the effects of their decision.

Methods

The study was a cross-sectional nationwide multicenter survey consisting of 947 medical students. A self-designed questionnaire was composed of 19 structured questions investigating the present situation and participants’ perception of the ethical dilemma surrounding medical student identity. The questionnaires were distributed randomly in teaching hospitals affiliated with 13 medical schools across China from June 2015 to January 2016.

Results

A total of 947 valid questionnaires were retrieved with a valid response rate of 83.7%. Most medical students (71.4%) tended to be ambiguous about their student identity in front of patients. The frequency of encountering distrust and patients’ or patient relatives’ refusal to allow students to perform procedures was significantly lower for students who explicitly stated their identity than for those who were ambiguous about their identity (p<0.001). Less experience in clinical rotations (<0.5 y/0.5–1 y, OR 2.7, 95% CI 1.7–4.3; <0.5 y/>1 y, OR 3.6, 95% CI 2.0–6.5), preceptors’ straightforward introduction of the students (OR 8.7, 95% CI 5.4–13.8) and students’ acknowledgment of patients’ right to know (OR 2.3, 95% CI 1.2–4.5) were related to students’ clear self-introduction to patients.

Conclusion

It is beneficial for medical students to clearly explain their identity to patients in order to decrease patient distrust and prevent the refusal to have certain appropriate procedures performed. Several methods, including emphasizing the role of mentors, developing curriculum for medical students, and creating clear regulations and guidelines for revealing the identity of medical students on the healthcare team can help address and ideally resolve this ethical dilemma of identity disclosure.

Efficacy of initial haemopurification strategy for acute paraquat poisoning in adults: study protocol for a randomised controlled trial (HeSAPP)

INTRODUCTION

Paraquat (PQ) is a widely used herbicide which is inexpensive and easily accessible for people in rural areas. A small amount of PQ ingestion could be lethal, yet currently, the optimal treatment is still controversial. Extracorporeal therapies (ECTR) have been practised in PQ poisoning management, though limited evidence could be obtained to suggest its superiority over conservative therapy. Haemodialysis (HD) and haemoperfusion (HP) are most commonly used, while some institutions also choose HP-HD concurrent therapy. The object of the present trial is to investigate whether haemopurification therapy can reduce mortality compared with conservative therapy.

METHODS AND ANALYSIS

This is a planned single-centre, non-blinded, randomised controlled trial. Acute PQ poisoned adults who have orally ingested PQ within 24 hours would be recruited. A total of 360 patients would be recruited and randomly assigned to four groups, that is, HP, HD, concurrent HP-HD and control, at a 1:1:1:1 ratio. Subjects would be also stratified by their urine dithionite test results. Primary outcome is 28-day all-cause mortality. Secondary outcomes include survival time, all-cause mortality at the 3rd, 7th and 60th day, rate of major complications, Acute Physiologic and Chronic Health Evaluation score and Poisoning Severity Score, etc. ETHICS AND DISSEMINATION: The protocol and informed consent documents have been approved by the Ethics Committee of The First Affiliated Hospital of Zhengzhou University in September 2017 (approval number: 2017-KY-10). The result of this trial would be submitted to peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03314909; Pre-results.

Genistein attenuates brain damage induced by transient cerebral ischemia through up-regulation of Nrf2 expression in ovariectomized rats

OBJECTIVE

Postmenopausal women possess higher incidence of stroke and worse prognosis. Although estrogen replacement therapy has obvious neuroprotective effects against stroke, it is always accompanied with several adverse effects and undesired outcomes. Genistein, a natural phytoestrogen, has been indicated to be a potential neuroprotective alternative for postmenopausal women against stroke. However, the role and mechanism of genistein's neuroprotective effects against stroke in ovariectomized rats have rarely been explored.

METHODS

In this study, ovariectomized rats were treated with genistein (10 mg/kg) or vehicle daily for two weeks before they received middle cerebral artery occlusion (MCAO) and reperfusion. After 72 hours of reperfusion, the neurological function was evaluated by Garcia test, infarct volume was detected by 2,3,5-triphenyltetrazolium chloride staining, and neuronal damage was detected by Nissl staining. In addition, ROS production and the expression of Nrf2, NQO1 and cleaved-Caspase3 in the ischemic penumbra were detected.

RESULTS

The results showed that genistein treatment significantly improved the neurological outcome, reduced infarct volume, increased Nrf2 and NQO1 expression, and reduced ROS production and cleaved-Caspase3 expression in ovariectomized rats.

DISCUSSION

Our findings indicated that treatment with genistein could alleviated oxidative stress injury induced by cerebral ischemia in ovariectomized rats via promoting Nrf2 and NQO1 expression, which provide a new molecular mechanism for the neuroprotective effects of genistein against stroke in postmenopausal women.

SIRT1-mediated downregulation of p27Kip1 is essential for overcoming contact inhibition of Kaposi's sarcoma-associated herpesvirus transformed cells

Kaposi's sarcoma-associated herpesvirus (KSHV) is an oncogenic virus associated with Kaposi's sarcoma (KS), a malignancy commonly found in AIDS patients. Despite intensive studies in the last two decades, the mechanism of KSHV-induced cellular transformation and tumorigenesis remains unclear. In this study, we found that the expression of SIRT1, a metabolic sensor, was upregulated in a variety of KSHV-infected cells. In a model of KSHV-induced cellular transformation, SIRT1 knockdown with shRNAs or knockout by CRISPR/Cas9 gene editing dramatically suppressed cell proliferation and colony formation in soft agar of KSHV-transformed cells by inducing cell cycle arrest and contact inhibition. SIRT1 knockdown or knockout induced the expression of cyclin-dependent kinase inhibitor 1B (p27^Kip1). Consequently, p27 knockdown rescued the inhibitory effect of SIRT1 knockdown or knockout on cell proliferation and colony formation. Furthermore, treatment of KSHV-transformed cells with a SIRT1 inhibitor, nicotinamide (NAM), had the same effect as SIRT1 knockdown and knockout. NAM significantly inhibited cell proliferation in culture and colony formation in soft agar, and induced cell cycle arrest. Significantly, NAM inhibited the progression of tumors and extended the survival of mice in a KSHV-induced tumor model. Collectively, these results demonstrate that SIRT1 suppression of p27 is required for KSHV-induced tumorigenesis and identify a potential therapeutic target for KS.

Clinical utility of the revised cardiac risk index in older Chinese patients with known coronary artery disease

Objectives

The revised Cardiac Risk Index (RCRI) is the most widely used risk prediction tool for postoperative cardiac adverse events. We aim to explore the predictive ability of the RCRI in older Chinese patients with coronary artery disease (CAD) undergoing noncardiac surgery, which has not been previously evaluated.

Methods

We performed a multicenter, prospective study. We enrolled a total of 1,202 patients, aged >60 years, with a history of CAD who underwent noncardiac surgery. Perioperative data were extracted from an electronic database. The primary end point was defined as an occurrence of a postoperative major cardiac event (PoMCE) within 30 days. Logistic regression analysis was performed to evaluate the performance of the RCRI. A modified RCRI was created and compared with the original RCRI with regard to its ability to predict postoperative cardiac events.

Results

Of the enrolled patients, 4.3% experienced PoMCE. Most components of the RCRI were not predictive of postoperative cardiac events with the exception of insulin-dependent diabetes mellitus (odds ratio =2.38, 95% CI: 1.11-5.11; P=0.03). The RCRI performed no better than chance (area under the curve =0.53; 95% CI: 0.45-0.61) in identifying patients' cardiac risk. The modified score had a higher discriminatory ability toward PoMCE (c index, 0.69 versus 0.53; P<0.01).

Conclusion

The original RCRI shows poor predictive ability in Chinese patients with CAD undergoing noncardiac surgery.

Efficacy and Safety of a Continuous Wound Catheter in Open Abdominal Partial Hepatectomy

Objective To investigate the efficacy and safety of continuous local anesthetic wound infiltration following open abdominal partial hepatectomy. Methods We performed a prospective, non-randomized, concurrent and controlled study. Patients undergoing open abdominal partial hepatectomy, according to their willingness, accepted one of the following managements for the postoperative pain: continuous wound catheter (CWC) infiltration, patient-controlled epidural analgesia (PCEA), patient-controlled intravenous analgesia of morphine (PCIAM), and patient-controlled intravenous analgesia of sufentanil (PCIAS). The primary outcome was postoperative visual analogue scale (VAS) scores at rest and on movement. Secondary outcomes included consumption of rescue medication, side effects, and complications associated with postoperative pain management. Results From August 2013 to December 2013, 80 patients were allocated to receive CWC (n=10), PCEA (n=22), PCIAM (n=29), or PCIAS (n=19). After adjusting for age, sex, body mass index, percentage of resected liver, operation time, and Amsterdam Preoperative Anxiety and Information Scale, there was no significant difference in the VAS scores at rest or on movement between Group CWC and the other groups, namely PCEA, PCIAM, and PCIAS, at 4, 12, 48, and 72 hours postoperatively (all P>0.05). The need for rescue medication was not significantly different between Group CWC and the other three groups at 48 and 72 hours postoperatively (all P>0.05). There was no significant difference in the incidence of postoperative nausea and vomiting or anal exsufflation time between group CWC and the other three groups (all P>0.05). No severe adverse effects associated with continuous wound infiltration were observed during the study period. Conclusions CWC has a comparable analgesic effect compared with traditional analgesia Methods at most time points postoperatively. CWC is a safe alternative for the postoperative analgesic management of open liver surgery.

Dietary supplementation with tributyrin prevented weaned pigs from growth retardation and lethal infection via modulation of inflammatory cytokines production, ileal expression, and intestinal acetate fermentation

Weanling pigs, with an underdeveloped intestine and immature immune system, are usually subjected to depressed feed intake, growth retardation, and postweaning diarrhea. The aim of this study was to determine 1) the growth response of weaned pigs to supplemental tributyrin (TB) and 2) the potential effects and mechanisms of TB in modulating immune responses of lipopolysaccharide (LPS)-challenged piglets. A total of 240 piglets (Duroc × Large White × Landrace) were weaned at 21 d of age to a control (basal diet), supplemented with antibiotics (AB; +AB), supplemented with TB (+TB), or with supplemental AB and TB (+AB+TB) diets, with 10 replicate pens (6 piglets/pen) per diet. At 49 d of age, male pigs from the control and +TB groups were intraperitoneally injected with LPS (25 μg/kg BW) or saline ( = 6) and sacrificed at 4 h after injection to collect blood, intestine, and digesta samples for biochemical analysis. There were higher ( < 0.05) feed intake and lower ( < 0.05) percentage of negative growth piglets in the +TB groups than in the control group during the first week after weaning. For piglets without LPS challenge, there were higher ( < 0.05) ileal fibroblast growth factor 19 () mRNA abundance and total bile acid concentrations in the +TB groups than in the control group, whereas downregulated ( < 0.05) expression was observed in the +TB groups after LPS challenge. Lipopolysaccharide challenge in the control group increased ( < 0.05) plasma tumor necrosis factor α and IL-6 concentrations and colonic amount and decreased ( < 0.05) colonic goblet cells and colonic and cecal acetate concentrations, with no differences ( > 0.05) observed between +TB groups following LPS challenge. Taken together, dietary supplementation with TB prevented growth retardation through stimulating the appetite of weaned pigs and protected piglets against lethal infection via modulation of inflammatory cytokines production, ileal expression, and intestinal acetate fermentation.

The clinical research of Thinprep Cytology Test (TCT) combined with HPV-DNA detection in screening cervical cancer

Our objective is to explore the clinical value of thinprep cytologic test (TCT) combined with HPV-DNA detection in screening cervical cancer. 420 cervical cancer patients admitted in our hospital between April, 2011-April, 2014 were selected. All patients received TCT and HPV-DNA detection, and cervical tissue biopsy was used to confirm the diagnosis. TCT screening results showed that there were 175 patients were &gt;ASCUS and the positive rate was 41.7%, histopathological screening showed that there were 199 patients were ≥cervical intraepithelial neoplasia (CIN) I and the positive rate was 47.4%. HPV-DNA detection showed 180 patients were positive which was 42.9%, and the positive rate of HPV-DNA detection was increased as the disease severity increased. The sensitivity of TCT combined with HPV-DNA detection was higher than single TCT or HPV-DNA, however the specificity was relatively low, and the positive predictive value and negative predictive value were higher which were similar to pathological results. TCT combined with HPV-DNA detection has high sensitivity and accuracy in screening cervical cancer, which is worthy of clinical application.

Jagged 1 is a major Notch ligand along cholangiocarcinoma development in mice and humans

Intrahepatic cholangiocarcinoma (ICC) is a rare yet deadly malignancy with limited treatment options. Activation of the Notch signalling cascade has been implicated in cholangiocarcinogenesis. However, while several studies focused on the Notch receptors required for ICC development, little is known about the upstream inducers responsible for their activation. Here, we show that the Jagged 1 (Jag1) ligand is almost ubiquitously upregulated in human ICC samples when compared with corresponding non-tumorous counterparts. Furthermore, we found that while overexpression of Jag1 alone does not lead to liver tumour development, overexpression of Jag1 synergizes with activated AKT signalling to promote liver carcinogenesis in AKT/Jag1 mice. Histologically, tumours consisted exclusively of ICC, with hepatocellular tumours not occurring in AKT/Jag1 mice. Furthermore, tumours from AKT/Jag1 mice exhibited extensive desmoplastic reaction, an important feature of human ICC. At the molecular level, we found that both AKT/mTOR and Notch cascades are activated in AKT/Jag1 ICC tissues, and that the Notch signalling is necessary for ICC development in AKT/Jag1 mice. In human ICC cell lines, silencing of Jag1 via specific small interfering RNA reduces proliferation and increases apoptosis. Finally, combined inhibition of AKT and Notch pathways is highly detrimental for the in vitro growth of ICC cell lines. In summary, our study demonstrates that Jag1 is an important upstream inducer of the Notch signalling in human and mouse ICC. Targeting Jag1 might represent a novel therapeutic strategy for the treatment of this deadly disease.