Real-time artificial intelligence predicts adverse outcomes in acute pancreatitis in the emergency department: Comparison with clinical decision rule.

OBJECTIVE: Artificial intelligence (AI) prediction is increasingly used for decision making in health care, but its application for adverse outcomes in emergency department (ED) patients with acute pancreatitis (AP) is not well understood. This study aimed to clarify this aspect. METHODS: Data from 8274 ED patients with AP in three hospitals from 2009 to 2018 were analyzed. Demographic data, comorbidities, laboratory results, and adverse outcomes were included. Six algorithms were evaluated, and the one with the highest area under the curve (AUC) was implemented into the hospital information system (HIS) for real-time prediction. Predictive accuracy was compared between the AI model and Bedside Index for Severity in Acute Pancreatitis (BISAP). RESULTS: The mean ± SD age was 56.1 ± 16.7 years, with 67.7% being male. The AI model was successfully implemented in the HIS, with Light Gradient Boosting Machine (LightGBM) showing the highest AUC for sepsis (AUC 0.961) and intensive care unit (ICU) admission (AUC 0.973), and eXtreme Gradient Boosting (XGBoost) showing the highest AUC for mortality (AUC 0.975). Compared to BISAP, the AI model had superior AUC for sepsis (BISAP 0.785), ICU admission (BISAP 0.778), and mortality (BISAP 0.817). CONCLUSIONS: The first real-time AI prediction model implemented in the HIS for predicting adverse outcomes in ED patients with AP shows favorable initial results. However, further external validation is needed to ensure its reliability and accuracy.

Implementing a Novel Machine Learning System for Nutrition Education in Diabetes Mellitus Nutritional Clinic: Predicting 1-Year Blood Glucose Control.

(1) Background: Persistent hyperglycemia in diabetes mellitus (DM) increases the risk of death and causes cardiovascular disease (CVD), resulting in significant social and economic costs. This study used a machine learning (ML) technique to build prediction models with the factors of lifestyle, medication compliance, and self-control in eating habits and then implemented a predictive system based on the best model to forecast whether blood glucose can be well-controlled within 1 year in diabetic patients attending a DM nutritional clinic. (2) Methods: Data were collected from outpatients aged 20 years or older with type 2 DM who received nutrition education in Chi Mei Medical Center. Multiple ML algorithms were used to build the predictive models. (3) Results: The predictive models achieved accuracies ranging from 0.611 to 0.690. The XGBoost model with the highest area under the curve (AUC) of 0.738 was regarded as the best and used for the predictive system implementation. SHAP analysis was performed to interpret the feature importance in the best model. The predictive system, evaluated by dietitians, received positive feedback as a beneficial tool for diabetes nutrition consultations. (4) Conclusions: The ML prediction model provides a promising approach for diabetes nutrition consultations to maintain good long-term blood glucose control, reduce diabetes-related complications, and enhance the quality of medical care.

Real-time artificial intelligence system for bacteremia prediction in adult febrile emergency department patients.

BACKGROUND: Artificial intelligence (AI) holds significant potential to be a valuable tool in healthcare. However, its application for predicting bacteremia among adult febrile patients in the emergency department (ED) remains unclear. Therefore, we conducted a study to provide clarity on this issue. METHODS: Adult febrile ED patients with blood cultures at Chi Mei Medical Center were divided into derivation (January 2017 to June 2019) and validation groups (July 2019 to December 2020). The derivation group was utilized to develop AI models using twenty-one feature variables and five algorithms to predict bacteremia. The performance of these models was compared with qSOFA score. The AI model with the highest area under the receiver operating characteristics curve (AUC) was chosen to implement the AI prediction system and tested on the validation group. RESULTS: The study included 5,647 febrile patients. In the derivation group, there were 3,369 patients with a mean age of 61.4 years, and 50.7% were female, including 508 (13.8%) with bacteremia. The model with the best AUC was built using the random forest algorithm (0.761), followed by logistic regression (0.755). All five models demonstrated better AUC than the qSOFA score (0.560). The random forest model was adopted to build a real-time AI prediction system integrated into the hospital information system, and the AUC achieved 0.709 in the validation group. CONCLUSION: The AI model shows promise to predict bacteremia in adult febrile ED patients; however, further external validation in different hospitals and populations is necessary to verify its effectiveness.

Using an Artificial Intelligence Approach to Predict the Adverse Effects and Prognosis of Tuberculosis.

BACKGROUND: Tuberculosis (TB) is one of the leading causes of death worldwide and a major cause of ill health. Without treatment, the mortality rate of TB is approximately 50%; with treatment, most patients with TB can be cured. However, anti-TB drug treatments may result in many adverse effects. Therefore, it is important to detect and predict these adverse effects early. Our study aimed to build models using an artificial intelligence/machine learning approach to predict acute hepatitis, acute respiratory failure, and mortality after TB treatment. MATERIALS AND METHODS: Adult patients (age ≥ 20 years) who had a TB diagnosis and received treatment from January 2004 to December 2021 were enrolled in the present study. Thirty-six feature variables were used to develop the predictive models with AI. The data were randomly stratified into a training dataset for model building (70%) and a testing dataset for model validation (30%). These algorithms included XGBoost, random forest, MLP, light GBM, logistic regression, and SVM. RESULTS: A total of 2248 TB patients in Chi Mei Medical Center were included in the study; 71.7% were males, and the other 28.3% were females. The mean age was 67.7 ± 16.4 years. The results showed that our models using the six AI algorithms all had a high area under the receiver operating characteristic curve (AUC) in predicting acute hepatitis, respiratory failure, and mortality, and the AUCs ranged from 0.920 to 0.766, 0.884 to 0.797, and 0.834 to 0.737, respectively. CONCLUSIONS: Our AI models were good predictors and can provide clinicians with a valuable tool to detect the adverse prognosis in TB patients early.

The height of the operating table affects the performance of residents in combined spinal and epidural anesthesia training by affecting the vision of the puncture needle: a randomized controlled trial.

BACKGROUND: The present study aimed to evaluate whether the operating table height affected the success rate and incidences of complications of combined spinal-epidural anesthesia administered by residents during training. METHODS: One-hundred-and-eighty patients were randomly allocated according to landmarks on the resident's body: umbilicus (group U), lowest rib margin (R), and xiphoid process (X). The success rates of combined spinal-epidural anesthesia, and the incidences of paresthesia and vessel trauma were recorded. RESULTS: There were no differences between the three groups in the success rates of combined spinal-epidural anesthesia, and the incidences of paresthesia and vessel trauma. However, paresthesia during epidural catheter advancement was more common on the left side (66.7%) than the right side (33.3%) (P = 0.03). In group R, the success rate of epidural anesthesia was higher during the residents' third time (100%) than their first time (50%; P = 0.01). Most residents (83%) preferred the table height at which the needle insertion point was at the level of their lowest rib margin. CONCLUSIONS: Neither the success nor the complication of combined spinal-epidural anesthesia in lateral decubitus position during residents' training affected by the operating table height. However, paresthesia was more likely to occur on the left side when a stiff catheter was inserted into the epidural space. It may be better to keep the table height at residents' lowest rib margin. It was not just preferred by most of residents but also better for their training of performing epidural anesthesia. TRIAL REGISTRATION: The trial was registered prior to patient enrollment at Chinese Clinical Trial Registry (NCT: ChiCTR1800016078, Principal investigator: Juan Gu, Date of registration: 9 May 2018). Registry URL http://www.chictr.org.cn.

Design and Implementation of a Comprehensive AI Dashboard for Real-Time Prediction of Adverse Prognosis of ED Patients.

The emergency department (ED) is at the forefront of medical care, and the medical team needs to make outright judgments and treatment decisions under time constraints. Thus, knowing how to make personalized and precise predictions is a very challenging task. With the advancement of artificial intelligence (AI) technology, Chi Mei Medical Center (CMMC) adopted AI, the Internet of Things (IoT), and interaction technologies to establish diverse prognosis prediction models for eight diseases based on the ED electronic medical records of three branch hospitals. CMMC integrated these predictive models to form a digital AI dashboard, showing the risk status of all ED patients diagnosed with any of these eight diseases. This study first explored the methodology of CMMC's AI development and proposed a four-tier AI dashboard architecture for ED implementation. The AI dashboard's ease of use, usefulness, and acceptance was also strongly affirmed by the ED medical staff. The ED AI dashboard is an effective tool in the implementation of real-time risk monitoring of patients in the ED and could improve the quality of care as a part of best practice. Based on the results of this study, it is suggested that healthcare institutions thoughtfully consider tailoring their ED dashboard designs to adapt to their unique workflows and environments.

An Investigation into the Densification-Affected Deformation and Fracture in Fused Silica under Contact Sliding.

Subsurface damage of fused silica optics is one of the major factors restricting the performance of optical systems. The densification-affected deformation and fracture in fused silica under a sliding contact are investigated in this study, via three-dimensional finite element analysis (FEA). The finite element models of scratching with 70.3° conical and Berkovich indenters are established. A refined elliptical constitutive model is used to consider the influence of densification. The finite element models are experimentally verified by elastic recovery, and theoretically verified by hardness ratio. Results of densification and plastic deformation distributions indicate that the accuracy of existent sliding stress field models may be improved if the spherical/cylindrical yield region is replaced by an ellipsoid/cylindroid, and the embedding of the yield region is considered. The initiation sequence, and the locations and stages of radial, median, and lateral cracks are discussed by analyzing the predicted sliding stress fields. Median and radial cracks along the sliding direction tend to be the first cracks that emerge in the sliding and unloading stages, respectively. They coalesce to form a big median-radial crack that penetrates through the entire yield region. The fracture behavior of fused silica revealed in this study is essential in the low-damage machining of fused silica optics.

Anesthesia management for cesarean section in a pregnant woman with odontogenic infection: A case report.

BACKGROUND: In recent years, people have paid more attention to oral health with the development of stomatology. Due to the various physiological changes during pregnancy, such as changing hormone levels and immune functions, oral diseases have a high incidence during pregnancy, and the prevention and treatment of oral diseases have also received the attention of both dentists and obstetricians. However, the anesthetic management of pregnant patients with oral disease, especially severe maxillofacial infections, and patients who need surgical treatment or have obstetric emergencies and need to terminate their pregnancy is not clear. CASE SUMMARY: This article describes a parturient patient with a severe masseteric space infection who had an emergency cesarean section. CONCLUSION: This case report aims to discuss the important anesthetic considerations for these patients.

Cytokine/chemokine levels in the CSF and serum of anti-NMDAR encephalitis: A systematic review and meta-analysis.

Objectives: To summarize the cytokine/chemokine levels of anti-N-methyl-Daspartate receptor encephalitis (NMDAR-E) and explore the potential role of these molecules and immune cells in the pathogenic mechanism. Methods: The PubMed, Cochrane Library, Embase, and Web of Science databases were searched for various articles that assessed the concentrations of cytokines/chemokines in the unstimulated cerebrospinal fluid (CSF) or serum of patients with NMDAR-E in this systematic review and meta-analysis. The standardized mean difference (SMD) and 95% confidence interval (CI) were calculated by Stata17.0. Results: A total of 19 articles were included in the systematic review from 260 candidate papers, and cytokine/chemokine levels reported in the CSF/serum were examined in each article. This meta-analysis included 17 eligible studies comprising 579 patients with NMDAR-E, 367 patients with noninflammatory neurological disorders, and 42 healthy controls from China, Spain, South Korea, Australia, Czechia, and Sweden. The results indicated that the levels of different cytokines interleukin (IL)-6, tumor necrosis factor (TNF)-α, IL-10, IL-13, IL-1ß, IL-12, and IL-17 and chemokine C-X-C motif ligand (CXCL)10 in the CSF were significantly higher in NMDAR-E patients with a large effect size. In addition, B cell activating factor (BAFF), CXCL13, and interferon (IFN)-γ levels in the CSF were higher in NMDAR-E patients with a middle effect size. In contrast, levels of IL-2 and IL-4 in the CSF and CXCL13 and BAFF in the serum did not show a significant difference between cases and controls. Conclusions: These analyses showed that the central immune response in NMDAR-E is a process that involves multiple immune cell interactions mediated by cytokines/chemokines, and T cells play an important role in the pathogenesis of immunity. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier (CRD42022342485).

Continuous epidural anesthesia with double catheters for cesarean section in a patient with severe pulmonary hypertension: A case report.

RATIONALE: Pregnancy in a woman with pulmonary hypertension (PH) carries prohibitively high risks of cardiopulmonary complications and high maternal and fetal morbidity and mortality. Anaesthetic management during delivery or cesarean section is very important for the prognosis of pregnant women with PH. The choice between general anesthesia or intraspinal anesthesia is controversial. There have been few case reports of anesthetic management under continuous epidural anesthesia with double catheters in such patients. PATIENT CONCERNS: A 35-year-old pregnant woman presented to the emergency department with fatigue and shortness of breath for 10 days at 16 weeks of gestation. DIAGNOSIS: According to transthoracic echocardiogram, her pulmonary artery pressure (PAP) was 75 mm Hg, and she had a dilated left ventricle (67 mm) and a ventricular septal defect (1.7 mm) with a bidirectional shunt. INTERVENTIONS: Elective cesarean section under continuous epidural anesthesia with double catheters to terminate a pregnancy in order to avoid development of cardiac failure. OUTCOMES: The pregnant woman underwent cesarean section safely and steadily under continuous epidural anesthesia with double catheters. She was discharged on the seventh postoperative day. LESSONS: The advantages of continuous epidural anesthesia with double catheters are stable hemodynamics and complete analgesia. The continuous epidural anesthesia with double catheters can be applied to patients with cardiopulmonary disease like severe PH. Compared with general anesthesia, spinal anesthesia, and single-catheter epidural anesthesia continuous epidural anesthesia is a better option for patients with both PH and heart failure.

The surgical safety checklist: a quantitative study on attitudes and barriers among gynecological surgery teams.

BACKGROUND: Implementation of the surgical safety checklist (SSC) plays a significant role in improving surgical patient safety, but levels of compliance to a SSC implementation by surgical team members vary significantly. We aimed to investigate the factors affecting satisfaction levels of gynecologists, anesthesiologists, and operating room registered nurses (OR-RNs) with SSC implementation. METHODS: We conducted a survey based on 267 questionnaires completed by 85 gynecologists from 14 gynecological surgery teams, 86 anesthesiologists, and 96 OR-RNs at a hospital in China from March 3 to March 16, 2020. The self-reported questionnaire was used to collect respondent's demographic information, levels of satisfaction with overall implementation of the SSC and its implementation in each of the three phases of a surgery, namely sign-in, time-out, and sign-out, and reasons for not giving a satisfaction score of 10 to its implementation in all phases. RESULTS: The subjective ratings regarding the overall implementation of the SSC between the surgical team members were different significantly. "Too many operations to check" was the primary factor causing gynecologists and anesthesiologists not to assign a score of 10 to sign-in implementation. The OR-RNs gave the lowest score to time-out implementation and 82 (85.42%) did not assign a score of 10 to it. "Surgeon is eager to start for surgery" was recognized as a major factor ranking first by OR-RNs and ranking second by anesthesiologists, and 57 (69.51%) OR-RNs chose "Too many operations to check" as the reason for not giving a score of 10 to time-out implementation. "No one initiates" and "Surgeon is not present for 'sign out'" were commonly cited as the reasons for not assigning a score of 10 to sign-out implementation. CONCLUSION: Factors affecting satisfaction with SSC implementation were various. These factors might be essentially related to heavy workloads and lack of ability about SSC implementation. It is advisable to reduce surgical team members' excessive workloads and enhance their understanding of importance of SSC implementation, thereby improving surgical team members' satisfaction with SSC implementation and facilitating compliance of SSC completion.

Long non-coding RNA FOXP4-AS1 is a prognostic biomarker and associated with immune infiltrates in ovarian serous cystadenocarcinoma.

BACKGROUND: FOXP4-AS1 expression participates in multiple signal pathways and has been previously reported in colorectal cancer, cervical cancer, and other cancer cells. However, its role on prognosis and immune infiltrates in ovarian serous cystadenocarcinoma (OVs) remains unclear. The purpose of our study was to investigate the expression of FOXP4-AS1 in OVs and its association with immune infiltrates, and determined its prognostic roles in OVs. METHODS: Using The Cancer Genome Atlas (TCGA) database, we retrieved FOXP4-AS1 expression and clinical information for 376 patients with OVs. Wilcoxon rank sum test was used to compare the expression of FOXP4-AS1 in OVs and normal ovarian tissue. Logistic regression was used to analyze the relationship between clinicopathologic features and FOXP4-AS1. Gene Set Enrichment Analysis (GSEA), and single sample Gene Set Enrichment Analysis (ssGSEA) was conducted to investigate the enrich pathways and functions and quantify the extent of immune cells infiltration for FOXP4-AS1. Kaplan-Meier method was used to generate survival curves, and Cox regression was used to analyze the relationship between FOXP4-AS1 and survival rate. RESULTS: High FOXP4-AS1 expression was significantly correlated with tumor FIGO stage (P = .026). Multivariate survival analysis showed that FOXP4-AS1was an independent prognostic marker for overall survival (OS; hazard ratio [HR]: 0.638; 95% confidence interval [CI]:0.467-0.871; P = .001) and disease-specific survival (DSS; HR: 0.649; CI: 0.476-0.885; P = .006). GSEA showed that High FOXP4-AS1 expression may active programmed cell death 1 (PD-1) signaling, the cytotoxic T lymphocyte-associated antigen-4 (CTLA4) pathway, the B cell receptor signaling pathway, apoptosis, fibroblast growth factor receptor (FGFR) signaling, and the Janus-activated kinase signal transducers and activators of transcription (JAK-STAT) signaling pathway. FOXP4-AS1 expression was negatively correlated with markers of immune cells, including aDC, cytotoxic cells and neutrophils. CONCLUSION: High FOXP4-AS1 expression has the potential to be a prognostic molecular marker of favorable survival in OVs.

Real-time interactive artificial intelligence of things-based prediction for adverse outcomes in adult patients with pneumonia in the emergency department.

BACKGROUND: Artificial intelligence of things (AIoT) may be a solution for predicting adverse outcomes in emergency department (ED) patients with pneumonia; however, this issue remains unclear. Therefore, we conducted this study to clarify it. METHODS: We identified 52,626 adult ED patients with pneumonia from three hospitals between 2010 and 2019 for this study. Thirty-three feature variables from electronic medical records were used to construct an artificial intelligence (AI) model to predict sepsis or septic shock, respiratory failure, and mortality. After comparisons of the predictive accuracies among logistic regression, random forest, support-vector machine (SVM), light gradient boosting machine (LightGBM), multilayer perceptron (MLP), and eXtreme Gradient Boosting (XGBoost), we selected the best one to build the model. We further combined the AI model with the Internet of things as AIoT, added an interactive mode, and implemented it in the hospital information system to assist clinicians with decision making in real time. We also compared the AIoT-based model with the confusion-urea-respiratory rate-blood pressure-65 (CURB-65) and pneumonia severity index (PSI) for predicting mortality. RESULTS: The best AI algorithms were random forest for sepsis or septic shock (area under the curve [AUC] = 0.781), LightGBM for respiratory failure (AUC = 0.847), and mortality (AUC = 0.835). The AIoT-based model represented better performance than CURB-65 and PSI indicators for predicting mortality (0.835 vs. 0.681 and 0.835 vs. 0.728). CONCLUSIONS: A real-time interactive AIoT-based model might be a better tool for predicting adverse outcomes in ED patients with pneumonia. Further validation in other populations is warranted.

Increased Expression of LYNX1 in Ovarian Serous Cystadenocarcinoma Predicts Poor Prognosis.

Few studies have reported the function of LYNX1 in ovarian cancer. We retrieved LYNX1 gene expression data and clinical information of 376 patients with ovarian cancer from The Cancer Genome Atlas (TCGA) project website. Wilcoxon signed-rank test and logistic regression were used to analyze the relationship between clinical pathologic features and LYNX1 expression. The Kaplan-Meier method was used to draw survival curves of patients, and Cox regression was used to calculate the relationship between LYNX1 expression and survival rate or the clinicopathological characteristics of the patients. Gene set enrichment analysis (GSEA) was performed, and the correlation between LYNX1 expression and cancer immune infiltrates was investigated via single sample gene set enrichment analysis (ssGSEA). High LYNX1 expression in ovarian serous cystadenocarcinoma (OVs) was associated with tumor residual disease (RD). In Kaplan-Meier survival analysis, patients with OVs who also displayed high LYNX1 expression had decreased overall survival (OS) and disease-specific survival (DSS) than those with low LYNX1 expression. Univariate analysis also supported that patients with high LYNX1 expression had lower OS than those with low LYNX1 expression. LYNX1 expression has the potential to be a prognostic molecular marker of poor survival in OVs.

Perioperative patient blood management during parallel transverse uterine incision cesarean section in patient with pernicious placenta previa: A retrospective cohort analysis.

Pernicious placenta previa (PPP) is the main cause of severe obstetric postpartum hemorrhage and hysterectomy and often requires donor blood transfusion. Prophylactic internal iliac artery (IIA) balloon occlusion (BO) combined with cell salvage is increasingly being deployed in parallel transverse uterine incision (PTUI) cesarean section (CS). The aim of this study was to explore the differences in blood management in PTUI CS with or without prophylactic IIA BO and to evaluate the safety and efficacy of cell salvage to reduce the need for donor blood transfusion during PTUI CS.This retrospective study included all women who were diagnosed with PPP and PA and underwent PTUI CS from October 1, 2016, to October 31, 2018. Sixty-four patients were included: 34 underwent prophylactic IIA BO (IIA group), whereas 30 were treated without prophylactic IIA BO (control group). The primary outcome was a composite measure of perioperative blood management outcomes, including the estimated blood loss (EBL), donor blood transfusion, salvaged blood returned, fresh frozen plasma (FFP), pre- and postoperative serum hemoglobin and hematocrit. In addition, the baseline conditions of mother and neonates were compared.EBL was significantly higher in the IIA group compared to the control group (2883.5 mL in the IIA group vs 1868.7 mL in the control group, P = .001). Overall, the donor blood transfusion rate was 23.5% (8/34), averaging 4.2 U, in the IIA group versus 30% (9/30), averaging 3.4 U, in the control group, which were not significantly different. The FFP transfusion rate was 47%, averaging 765.6 mL, in the IIA group versus 20%, averaging 816.7 mL, in the control group. In the IIA group, 97.1% used cell savage and had salvaged blood returned, averaging 954.9 mL. In the control group, 90% had salvaged blood returned, averaging 617.9 mL. No cases of amniotic fluid embolism were observed with leukocyte depletion filters.Prophylactic IIA BO during PTUI CS in women with PPP and PA does not lead to a statistically significant reduction in EBL. Cell salvage was associated with a reduction in the rate of donor blood transfusion during PTUI CS.

Anesthesia management of a premature neonate during minimally invasive sclerotherapy of a large chest wall mass: A case report.

RATIONALE: The most common critical incidents in pediatric anesthesia are perioperative respiratory adverse events (PRAE), which occur more often in neonates and account for one-third of anaesthesia-related cardiac arrests. It is crucial to maintain an open stable airway during anesthesia in neonates, as this population has a low oxygen reserve, small airways, and the loss of protective airway reflexes under general anesthesia. PATIENT CONCERNS: A 6-day-old premature newborn underwent minimally invasive sclerotherapy under general anesthesia. For high-risk premature neonates, the selections of the anesthesia and airway device are extremely important, as those factors directly affect the prognosis. DIAGNOSES: B ultrasound and computed tomography (CT) revealed a large mass from the left chest wall to axilla, which was suspected to be a lymphocele. INTERVENTIONS: Minimally invasive sclerotherapy was performed under inhalation anesthesia. After the initiation of anesthesia, a laryngeal mask was placed to control airway. Anesthesia was maintained intraoperatively via sevoflurane inhalation with spontaneous breathing. No accidental displacements or PRAE occurred. OUTCOME: The operation and anesthesia process was stable and safe. The patient discharged at 2 days postoperatively. LESSONS: Minimally invasive sclerotherapy in a premature neonate is an operation with an extremely short operation time and minimal trauma, but a very high anesthesia risk and risk of PRAE. Anesthesia management is very important in a premature neonate undergoing a very short surgery under general anesthesia. Total sevoflurane inhalation general anesthesia and laryngeal mask airway control with spontaneous breathing may be an ideal option to reduce PRAE during very short surgery in a premature neonate.

Use of nitroglycerin for parallel transverse uterine cesarean section in patients with pernicious placenta previa and placenta accrete and predicted difficult airway: A case report and review of literature.

RATIONALE: The incidence of obstetric hemorrhage due to pernicious placenta previa (PPP) and placenta accreta is currently increasing in China. Parallel transverse uterine incision (PTUI) cesarean section (CS) is a novel technique designed to avoid transecting the placenta and control postpartum hemorrhage during CS in these patients in our hospital. A key point of anesthesia management related to PTUI CS involves keeping the uterus relaxed. General anesthesia (GA) has often been performed, and inhaled volatile anesthetics have traditionally been recommended for this purpose; however, GA may be contraindicated in patients with difficult airways. PATIENT CONCERNS: The patient was predicted to have a difficult airway, and GA may have resulted in potentially life-threatening complications. An alternative and safer method of achieving uterine relaxation during PTUI CS was thus required. DIAGNOSES: The patient was diagnosed with PPP, and a predicted difficult airway was suspected preoperatively. INTERVENTIONS: PTUI CS was planned to control postpartum hemorrhage and preserve fertility during CS. Uterine relaxation during PTUI CS was achieved with intravenous nitroglycerin under combined spinal-epidural anesthesia. OUTCOME: Intravenous nitroglycerin and combined spinal-epidural anesthesia achieved uterine relaxation during the time from delivery of the neonate to making the second transverse incision in the lower segment of the uterus during PTUI CS. Both the parturient and neonate were well and were discharged 4 days later. LESSIONS: Intravenous nitroglycerin and combined spinal-epidural anesthesia may offer an alternative to GA for achieving uterine relaxation in patients with PPP and a predicted difficult airway undergoing PTUI CS to control postpartum hemorrhage.

Efficacy of premedication with intranasal dexmedetomidine for removal of inhaled foreign bodies in children by flexible fiberoptic bronchoscopy: a randomized, double-blind, placebo-controlled clinical trial.

BACKGROUND: Tracheobronchial foreign body aspiration in children is a life-threatening, emergent situation. Currently, the use of fiberoptic bronchoscopy for removing foreign bodies is attracting increasing attention. Oxygen desaturation, body movement, laryngospasm, bronchospasm, and breath-holding are common adverse events during foreign body removal. Dexmedetomidine, as a highly selective α2-adrenergic agonist, produces sedative and analgesic effects, and does not induce respiratory depression. We hypothesized that intranasal dexmedetomidine at 1 µg kg - 1 administered 25 min before anesthesia induction can reduce the incidence of adverse events during fiberoptic bronchoscopy under inhalation general anesthesia with sevoflurane. METHODS: In all, 40 preschool-aged children (6-48 months) with an American Society of Anesthesiologists physical status of I or II were randomly allocated to receive either intranasal dexmedetomidine at 1 µg·kg - 1 or normal saline at 0.01 ml kg- 1 25 min before anesthesia induction. The primary outcome was the incidence of perioperative adverse events. Heart rate, respiratory rate, parent-child separation score, tolerance of the anesthetic mask, agitation score, consumption of sevoflurane, and recovery time were also recorded. RESULTS: Following pre-anesthesia treatment with either intranasal dexmedetomidine or saline, the incidences of laryngospasm (15% vs. 50%), breath-holding (10% vs. 40%), and coughing (5% vs. 30%) were significantly lower in patients given dexmedetomidine than those given saline. Patients who received intranasal dexmedetomidine had a lower parent-child separation score (P = 0.017), more satisfactory tolerance of the anesthetic mask (P = 0.027), and less consumption of sevoflurane (38.18 ± 14.95 vs. 48.03 ± 14.45 ml, P = 0.041). The frequency of postoperative agitation was significantly lower in patients given intranasal dexmedetomidine (P = 0.004), and the recovery time was similar in the two groups. CONCLUSIONS: Intranasal dexmedetomidine 1 µg·kg- 1, with its sedative and analgesic effects, reduced the incidences of laryngospasm, breath-holding, and coughing during fiberoptic bronchoscopy for FB removal. Moreover, it reduced postoperative agitation without a prolonged recovery time. TRAIL REGISTRATION: The study was registered with the Chinese Clinical Trial Registry (registration number: ChiCTR1800017273) on July 20, 2018.

Fetal giant right cervical cyst causing severe tracheal compression: A case report.

RATIONALE: Fetal giant cervical cyst (FGCC) is a rare congenital anomaly. Sometimes FGCC may extend into the mediastinum, and result in severe tracheal compression, which is a life-threatening event at birth. PATIENT CONCERNS: We present a rare case of FGCC, which extended from the right neck into the superior mediastinum, and resulted in severe tracheal compression. DIAGNOSES: An FGCC was observed by ultrasonography and magnetic resonance imaging (MRI) at 27+4 weeks' gestation (WG). Fetal MRI at 35+1 WG showed that the FGCC was 3.3 × 8.2 × 7.5 cm and extended from the right neck into the superior mediastinum. Severe tracheal compression was observed and the inside diameter of the narrowest section of tracheostenosis appeared thread-like and measured only 0.1 cm. INTERVENTIONS: Cervical cyst reduction was performed prenatally under ultrasound guidance to alleviate the tracheal compression and maximize the chance of fetal survival 2 days before birth. At 36+3 WG, cesarean section was performed, and a female neonate was immediately delivered and intubated (3.5-mm tube) by an experienced anesthesiologist. Neonatal intralesional sclerotherapy and cystic component aspiration as guided by digital subtraction angiography were performed under general anesthesia. Anesthesia was maintained only with sevoflurane 3% in 2 L/min oxygen. Extubation was performed soon after surgery. OUTCOME: The neonate recovered uneventfully and was discharged 2 days postoperatively. After 140 days of follow-up, the neonate had recovered completely. LESSONS: If an FGCC is suspected by abdominal ultrasound, a fetal MRI is recommended to assess the severity of tracheal compression before birth, if feasible. An anesthesiologist should assess the risk of intubation failure at birth according to those results. If fetal severe tracheal compression is detected and it may result in inability of intubation at birth, prenatal cervical cyst reduction under ultrasound guidance may be effective for alleviating tracheal compression at birth, if feasible. This could maximize the chance of fetal survival. Improvement of fetal short- and long-term outcomes is important.