Effect of Mechanical Ventilation Mode Type on Postoperative Pulmonary Complications After Cardiac Surgery: A Randomized Controlled Trial.

OBJECTIVES: It is unknown whether there is a difference in pulmonary outcome in different intraoperative ventilation modes for cardiac surgery with cardiopulmonary bypass (CPB). The aim of this trial was to determine whether patients undergoing cardiac surgery with CPB could benefit from intraoperative optimal ventilation mode. DESIGN: This was a single-center, prospective, randomized controlled trial. SETTING: The study was conducted at a single-center tertiary-care hospital. PARTICIPANTS: A total of 1,364 adults undergoing cardiac surgery with CPB participated in this trial. INTERVENTIONS: Patients were assigned randomly (1:1:1) to receive 1 of 3 ventilation modes: volume-controlled ventilation (VCV), pressure-controlled ventilation (PCV), and pressure-controlled ventilation-volume guaranteed (PCV-VG). All arms of the study received the lung-protective ventilation strategy. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a composite of postoperative pulmonary complications (PPCs) within the first 7 postoperative days. Pulmonary complications occurred in 168 of 455 patients (36.9%) in the PCV-VG group, 171 (37.6%) in the PCV group, and 182 (40.1%) in the VCV group, respectively. There was no statistical difference in the risk of overall pulmonary complications among groups (p = 0.585). There were no significant differences in the severity grade of PPCs within 7 days, postoperative ventilation duration, intensive care unit stay, postoperative hospital stay, or 30-day postoperative mortality. CONCLUSIONS: Among patients scheduled for cardiac surgery with CPB, intraoperative ventilation mode type did not affect the risk of postoperative pulmonary complications.

Comparison of S-ketamine and midazolam for intravenous preoperative sedative and anxiolytic effects in preschool children: study protocol for a randomized controlled clinical trial.

BACKGROUND: Preoperative anxiety management is gaining particular attention in paediatric anaesthesia. Pharmacological and non-pharmacological resorts can be implemented to address this special issue. Despite the various approaches currently used for preoperative sedation in children, the different sedative and anti-anxiety effects between the newly marketed anaesthetic, S-ketamine, and the traditional sedative, midazolam, are still unclear. METHODS: This is a patient- and assessor-blinded randomized controlled clinical trial. Participants (n = 110) will receive S-ketamine (0.5 mg/kg) or midazolam (0.08 mg/kg) intravenously administrated at a ratio of 1:1 in the anaesthesia holding area. The primary outcome of this study is the sedative effect evaluated via the change in the modified Yale preoperative anxiety scale. It will be performed at two timepoints: in the pre-anaesthetic holding area before premedication (baseline, marked as T0) and about 5 min after premedication in the operating room without the existence of their guardians (marked as T1). Our secondary objectives include the parent separation anxiety score, postoperative agitation, caregivers' and anaesthesia care providers' satisfaction, and mask compliance. DISCUSSION: This randomized controlled trial is the first study to compare the anti-anxiety effect of intravenous S-ketamine and midazolam. We will provide a new approach for the clinical management of preoperative anxiety in preschool children posted for elective surgery. TRIAL REGISTRATION: ChiCTR2300069998. Registered on 30 March 2023.

A comparative study of the ameliorative effects of hyaluronic acid oligosaccharides and hyaluronic acid on DSS-induced colitis in mice and research on relevant mechanisms.

As a dietary supplement, hyaluronic acid (HA) has exhibited appreciable immunomodulatory activity and an ameliorative effect on rodent colitis. However, its high viscosity is not only refractory to absorb through the gut, but also causes flatulence. In contrast to HA, hyaluronic acid oligosaccharides (o-HAs) can overcome the above-mentioned constraints, but their treatment effect still remains ill-defined contemporarily. Herein, the current study intends to compare the modulatory effects of HA and o-HA on colitis and assess the underlying molecular mechanism. We first showed that o-HA had a better preventive effect than HA in alleviating colitis symptoms, as evidenced by lower body weight loss, lower disease activity index scores, a lower inflammatory response (TNF-α, IL-6, IL-1ß, p-NF-κB), and more intact colon epithelial integrity in vivo. The best efficiency was observed in the o-HA treated group with a dosage of 30 mg kg-1. In an in vitro barrier function assay, o-HA exerted a better protective effect on the transepithelial electrical resistance (TEER), FITC permeability, and wound healing and modulated the expression of tight junction (TJ) proteins (ZO-1, occludin) in lipopolysaccharide (LPS)-stimulated Caco-2 cells. In summary, both HA and o-HA showed the potential to reduce inflammation and ameliorate intestinal damage in DSS-induced colitis and LPS-induced inflammation, but o-HA had improved outcomes. The results also provided a glimpse of the latent mechanism by which HA and o-HA enhanced intestinal barrier function via MLCK/p-MLC signaling pathway suppression.

Rupture of a previously undiagnosed intracranial aneurysm during endoscopic dacryocystorhinostomy: A case report.

Endoscopic endonasal dacryocystorhinostomy (EE-DCR) is an effective treatment for dacryocystitis. Aneurysmal rupture is generally not considered a complication of EE-DCR under general anesthesia. Here, we present a patient with intracerebral and subarachnoid hemorrhage secondary to the rupture of an undiagnosed intracranial aneurysm during EE-DCR. Clinicians should be aware of such fatal complications when using any vasoconstrictor intraoperatively.

Acute air embolism caused by autotransfusion during percutaneous atrial septal defect closure: A case report.

Atrial septal defect is a common congenital heart disease in adults and it is often asymptomatic. Percutaneous device closure is gaining popularity, but percutaneous repair of atrial septal defect leading to left atrial rupture and subsequent autotransfusion under high pressure leading to air embolism has not been reported yet.

Effects of methylprednisolone on early postoperative pain and recovery in patients undergoing thoracoscopic lung surgery: A randomized controlled trial.

STUDY OBJECTIVE: Evidence from previous studies indicates that glucocorticoids offer effective postoperative analgesia and improve the quality of recovery (QoR). The aim of this study was to evaluate the efficacy of preoperative methylprednisolone on early postoperative pain and QoR following thoracoscopic lung surgery. DESIGN: A prospective, single-center, three-arm, double-blinded, randomized trial. SETTING: Tertiary university hospital. PATIENTS: Adult patients aged ≥18 years undergoing thoracoscopic lung surgery were eligible for participation. INTERVENTIONS: Patients enrolled in this study were randomized to receive preoperative methylprednisolone (40 mg or 120 mg) or identical volumes of 0.9% saline. MEASUREMENTS: The primary outcome was the proportion of moderate-to-severe pain (numerical rating scale [NRS] ≥ 4 when coughing during pulmonary rehabilitation exercises) on the first day postoperatively. The postoperative pain scores, QoR-15 scores and other secondary outcomes were also recorded. MAIN RESULTS: Of the 180 enrolled patients, 173 patients were included in the primary analysis. The results showed that the proportion of moderate-to-severe pain was not significantly different between the combined methylprednisolone group and the placebo group (51.7% vs. 64.9%; absolute difference, 13.2%; 95% CI, -2.1% to 29.3%; P = 0.10). Patients who received methylprednisolone treatment had lower pain scores at rest and coughing on the first day after surgery than those who received placebo treatment, with mean differences of 0.5 and 0.7, respectively (P < 0.01). QoR-15 scores were higher in patients treated with methylprednisolone at day 1 (mean difference, 6.9; P < 0.001) and day 2 (mean difference, 7.2; P < 0.001) than in patients who received placebo treatment. No side-effects associated with methylprednisolone treatment were observed. CONCLUSIONS: Our findings suggested that preoperative methylprednisolone (either high or low dose) has limited impact on early postoperative pain and recovery in patients undergoing thoracoscopic lung surgery, with no clinically relevant benefits detected when compared with placebo. TRIAL REGISTRATION: Chinese Clinical Trail Register (identifier: ChiCTR1900021020).

Effect of ventilation strategy during cardiopulmonary bypass on postoperative pulmonary complications after cardiac surgery: a randomized clinical trial.

BACKGROUND: To determine whether maintaining ventilation during cardiopulmonary bypass (CPB) with a different fraction of inspired oxygen (FiO2) had an impact on the occurrence of postoperative pulmonary complications (PPCs). METHODS: A total of 413 adult patients undergoing elective cardiac surgery with CPB were randomly assigned into three groups: 138 in the NoV group (received no mechanical ventilation during CPB), 138 in the LOV group (received a tidal volume (VT) of 3-4 ml/kg of ideal body weight with the respiratory rate of 10-12 bpm, and the positive end-expiratory pressure of 5-8 cmH2O during CPB; the FiO2 was 30%), and 137 in the HOV group (received the same ventilation parameters settings as the LOV group while the FiO2 was 80%). RESULTS: The primary outcomes were the incidence and severity of PPCs during hospitalization. The composite incidence of PPCs did not significantly differ between the NoV (63%), LOV (49%) and HOV (57%) groups (P = 0.069). And there was also no difference regarding the incidence of PPCs between the non-ventilation (NoV) and ventilation (the combination of LOV and HOV) groups. The LOV group was observed a lower proportion of moderate and severe pulmonary complications (grade ≥ 3) than the NoV group (23.1% vs. 44.2%, P = 0.001). CONCLUSION: Maintaining ventilation during CPB did not reduce the incidence of PPCs in patients undergoing cardiac surgery. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR1800015261. Prospectively registered 19 March 2018. http://www.chictr.org.cn/showproj.aspx?proj=25982.

Comparative Effect of Propofol and Volatile Anesthetics on Postoperative Pulmonary Complications After Lung Resection Surgery: A Randomized Clinical Trial.

BACKGROUND: The effect of general anesthetics (propofol and volatile anesthetics) on pulmonary outcome after lung resection surgery with one-lung ventilation (OLV) is yet undetermined. We evaluated the effect of intravenous anesthesia (propofol) and volatile anesthesia (sevoflurane or desflurane) regimens on postoperative pulmonary complications (PPCs) in patients undergoing lung resection surgery. METHODS: This prospective, randomized controlled trial enrolled 555 adult patients scheduled for lung resection surgery with OLV. Participants were randomized to 1 of 3 general anesthetic regimens (propofol, sevoflurane, or desflurane). Standard anesthesia and ventilation protocols were followed in all groups. The primary outcome was a composite of PPCs in the first 7 postoperative days. Secondary outcomes included the severity of PPCs and major postoperative complications classification. Intergroup difference in the primary outcome was assessed for significance using the Pearson χ2 test. RESULTS: Of 837 patients who were assessed for eligibility, 555 were randomized and 545 were analyzed. One hundred and seventy-nine patients were assigned to the propofol group, 182 in the sevoflurane group, and 184 in the desflurane group. The incidence of PPCs did not differ between the combined volatile anesthetics (sevoflurane and desflurane) group and the propofol group (21.9% vs 24.0%; odds ratio, 0.89; 95% confidence interval, 0.58-1.35; P = .570). The PPCs grade and Clavien-Dindo scores did not differ significantly across groups. CONCLUSIONS: In patients undergoing lung resection surgery with OLV, general anesthesia with volatile anesthetics (sevoflurane or desflurane) did not reduce PPCs compared with propofol. No difference in secondary outcomes was observed.

Comparison of low and high inspiratory oxygen fraction added to lung-protective ventilation on postoperative pulmonary complications after abdominal surgery: A randomized controlled trial.

STUDY OBJECTIVE: Intraoperative lung-protective ventilation strategy has been recommended to reduce postoperative pulmonary complications (PPCs). However, the role of inspiratory oxygen fraction (FiO2) in this protection remains highly uncertain. We aimed to evaluate the effect of intraoperative low (30%) versus high (80%) FiO2 in the context of lung-protective ventilation strategy on PPCs in patients undergoing abdominal surgery. DESIGN: Prospective, two-arm, randomized controlled trial. SETTING: Tertiary university hospital in China. PATIENTS: A total of ASA I-III 252 patients aged ≥18, who were scheduled for elective abdominal surgery under general anesthesia were included in the study. INTERVENTION: Patients were randomly assigned to receive either 30% or 80% FiO2 during the intraoperative period. All patients received volume-controlled mechanical ventilation with lung-protective ventilation approach, which included a tidal volume of 8 ml kg-1 of predicted body weight, a positive end-expiratory pressure level of 6-8 cmH2O, and repeated recruitment maneuvers. MEASUREMENTS: The primary outcome was a composite of postoperative pulmonary complications within the first 7 postoperative days, consisting of respiratory infection, respiratory failure, bronchospasm, atelectasis, pleural effusion, pneumothorax, and aspiration pneumonitis. The severity grade of PPCs was measured as a key secondary outcome. MAIN RESULTS: Two hundred and fifty-one patients completed the trial. PPCs occurred in 43 of 125 (34.4%) patients assigned to receive 30% FiO2 compared with 59 of 126 (46.8%) patients receiving 80% FiO2 (relative risk 0.74, 97.5% confidence interval, 0.51-1.02, p = 0.045, > 0.025). The severity of PPCs within the first 7 days following surgery was attenuated significantly in the low (30%) FiO2 group (p = 0.001). CONCLUSIONS: Among patients undergoing abdominal surgery under general anesthesia, an intraoperative lung-protective ventilation strategy with 30% FiO2 compared with 80% FiO2 did not reduce the incidence of PPCs. And the use of 30% FiO2 resulted in less severe pulmonary complications.

Elevenin signaling modulates body color through the tyrosine-mediated cuticle melanism pathway.

Elevenin is a newly discovered novel neuropeptide. Knockdown of either elevenin or orphan receptor NlA42 transcript expression by RNA interference caused severe cuticle melanization in the brown planthopper (BPH). Injection of a synthetic elevenin peptide not only rescued the body color phenotype in dselevenin-pretreated individuals but also suppressed melanization of black insects grown in natural conditions. Real-time quantitative PCR results revealed that elevenin expression levels were highest in the brain and salivary gland. Immunohistochemistry analysis confirmed that a precursor peptide of elevenin was generated in the salivary gland, suggesting that the salivary gland might be an important neurosecretory tissue in addition to the brain in BPH. Furthermore, double-strand RNA-mediated silencing of elevenin and NlA42 resulted in down-regulation of arylalkylamine-N-acetyltransferase and up-regulation of tyrosine hydroxylase, whereas elevenin peptide injection resulted in up-regulation of N-ß-alanyldopamine synthase and aspartate 1-decarboxylase, indicating a complex regulation network for cuticle pigmentation. In addition, functional characterization demonstrated that NlA42 is a cognate receptor for elevenin, and couples to Gq and Gs proteins, triggering both PLC/Ca2+/PKC and AC/cAMP/PKA signaling pathways in response to elevenin treatment. These findings suggest that the elevenin signaling functions control BPH body color through the tyrosine-mediated cuticle melanism pathway.-Wang, S.-L., Wang, W.-W., Ma, Q., Shen, Z.-F., Zhang, M.-Q., Zhou, N.-M., Zhang, C.-X. Elevenin signaling modulates body color through the tyrosine-mediated cuticle melanism pathway.

Ventilation strategies with different inhaled Oxygen conceNTration during CardioPulmonary Bypass in cardiac surgery (VONTCPB): study protocol for a randomized controlled trial.

BACKGROUND: There is no consensus on the ventilation management during cardiopulmonary bypass (CPB), and the anesthesiologists or the surgeons usually ventilate the lungs with different ventilation strategies or keep them static. Better outcomes are more likely to occur when the ventilation is administered during CPB according to the existing literatures. However, the use of high fraction of inspired oxygen (FiO2) is debatable in cardiac surgery. And the potential effects of strategies combining low tidal volume (VT) ventilation with different FiO2 during CPB on postoperative pulmonary complications (PPCs) are unclear. DESIGN: The VONTCPB trial is a single-center, prospective, double-blinded, randomized, controlled trial. We are going to recruit total 420 elective cardiac surgery patients with median sternotomy under CPB, who will be equally randomized into three different ventilation strategy groups: NoV, LOV and HOV. (1) The NoV group receives no mechanical ventilation during CPB; (2) the LOV group receives a low VT of 3-4 ml/kg of ideal body weight (IBW) with the respiratory rate (RR) of 10-12 acts/min, and the positive end-expiratory pressure (PEEP) of 5-8 cmH2O during CPB; the FiO2 is 30%; (3) the HOV group receives a low VT of 3-4 ml/kg of IBW with the RR of 10-12 acts/min, and the PEEP of 5-8 cmH2O during CPB; the FiO2 is 80%. The primary endpoints are the incidence of the composite of PPCs and the PPCs score. The secondary endpoints refer to the incidence of the oxygenation index (PaO2/FiO2 ratio) < 300 mmHg at three time points (the moment arriving in the ICU, 6 and 12 h after arrival in the ICU), the surgical incision healing grade, the intubation time, the stay of ICU, the length of hospital stay, and mortality at 30 days after the surgery. DISCUSSION: The VONTCPB trial is the first study to assess the effects of strategies combining low tidal volume (VT) ventilation with different FiO2 during CPB on patients' outcomes. TRIAL REGISTRATION: ChiCTR1800015261 . Registered on 20 March 2018.

DDC plays vital roles in the wing spot formation, egg production, and chorion tanning in the brown planthopper.

The gene dopa decarboxylase (Nlddc) of the brown planthopper (BPH, Nilaparvata lugens) was identified in the genome and transcriptome of the insect. The open reading frame of Nlddc is 1,434 bp in length and, it has the potential to encode a protein of 477 amino acid with a conserved pyridoxal-dependent decarboxylase domain and a typical motif, NFNPHKW. Real-time quantification polymerase chain reaction analyses revealed that this gene was highly expressed in the integument and brain, and transcript level peaked in the late stages of egg period and each nymph instar with periodicity. RNA interference results revealed that Nlddc played essential roles in pigment synthesis, formation of wing spot, egg production, and tanning of the chorion. A rapid accumulation of Nlddc transcripts was detected, and it coincided with the injection of the hormone 20-hydroxyecdysone (20E), suggesting that Nlddc transcription was regulated by 20E.

The flightin gene is necessary for the emission of vibrational signals in the rice brown planthopper (Nilaparvata lugens Stǻl).

In duet-based courtship, species- and sex-specific vibrational signals enable animals to identify the species and sex of the singer and also provide the necessary information with which to locate a partner. Substrate-borne communication has been described in a wide variety of insects. Here, we focus on the gene necessary for the emission of male vibrational signals and whether the male song fulfills such a functional role in the mating system of the brown planthopper (BPH, Nilaparvata lugens). We generated mute BPH adult males via RNA interference (RNAi) of the flightin gene, which encodes a myosin-binding protein expressed exclusively in the dorsal longitudinal muscle (DLM) in the basal two abdominal segments used for driving the vibration of the male-specific tymbal structure in short-winged (brachypterous) BPH adults. Transmission electron microscopy (TEM) observation showed that flightin knockdown disrupted the normal sarcomere structure of the abdominal DLM. No courtship song could be detected in the brachypterous males after RNAi treatment. Behavior and competition trials showed that the lack of male courtship songs prolonged copulation latency and even caused female rejection. Unexpectedly, the mute males exhibited greater competitiveness when competing against normal males.

Identification and functional analysis of the doublesex gene in the sexual development of a hemimetabolous insect, the brown planthopper.

In the sex determination cascade, the genes dsx (doublesex) in insects, mab-3 (male abnormal 3) in nematodes, and Dmrt1 (dsx/mab-3 related transcription factor-1) in vertebrates act as the base molecular switches and play important roles. Moreover, these genes share the same conserved feature domain-DNA-binding oligomerization domain (OD1), and female-specific dsx also has a conserved oligomerization domain 2 (OD2). Although sex determination and the functions of dsx in several holometabolous insects have been well documented, sex determination and the function of dsx in hemimetabolous insects remain a mystery. In this study, four dsx homologs were unexpectedly found in the Nilaparvata lugens (brown planthopper, BPH, order Hemiptera), which also showed a different evolutionary status. We found that only one of the four homologs, Nldsx, which has three alternative splicing variants (female-specific NldsxF, male-specific NldsxM, non-sex-specific NldsxC), was required in the sexual development of N. lugens. Compared with that of holometabolous species, the dsx of N. lugens contains a less conserved OD1, while the OD2 domain of BPH was not identifiable because the common region is poorly conserved, and the female-specific region is short. RNAi-mediated knockdown of Nldsx in female BPH resulted in a larger body size with a normal abdomen and reproductive system, while no changes in fertility were noted. However, adult males with RNA interference knockdown of NldsxM in nymphs became pseudofemales, were infertile, had abnormal copulatory organs, and had impassable deferent ducts with hyperplastic walls; additionally, the pseudofemales could not produce the normal courtship signals. Our results suggest that dsx plays a critical role in male BPH somatic development and mating behavior. This is the first study to show that dsx is essential for sexual development in a hemipteran species.

Tra-2 Mediates Cross-Talk Between Sex Determination and Wing Polyphenism in Female Nilaparvata lugens.

Sexual dimorphism and wing polyphenism are important and evolutionarily conserved features of many insect species. In this article, we found a cross-talk linking sexual differentiation with wing polyphenism in the brown planthopper (BPH) Nilaparvata lugens (order: Hemiptera). Knockdown of the sex determination gene Transformer-2 in N. lugens (NlTra-2) in nymph caused females to develop into infertile pseudomales containing undeveloped ovaries. Whereas males treated with dsNlTra-2 exhibited normal morphology, but lost fertility. Knockdown of NlTra-2 in adult females (maternal RNAi) resulted in long-winged female offspring, indicating that maternal RNAi changed the wing morphs in female offspring. In addition, silencing of NlTra-2 down-regulated the expression of the forkhead transcription factor FoxO (NlFoxO), and simultaneously up-regulated the expression of phosphatidylinositol-3-OH kinase (PI(3)K)-protein kinase B (NlAkt), the two critical genes in the insulin signaling pathway. Furthermore, the long-winged effect caused by maternal dsNlTra-2 RNAi could be reversed by silencing of NlInR1 and NlAkt, leading to short-winged morphs. We propose that there is a cross-talk between the sexual differentiation and wing polyphenism pathways mediated by NlTra-2 during embryonic stages.