[Application of Erector Spinae Plane Block in Spine Surgery:A Review].

Spine surgery may lead to moderate to severe pain.Poorly controlled postoperative pain seriously affects the prognosis and recovery of patients.The erector spinae plane block (ESPB),firstly proposed in 2016 as a novel interfascial plane block,has been widely used in the management of intraoperative and postoperative pain in spine surgery.It has been confirmed as a safe,simple,and effective block.This review describes the anatomic basis,mechanism,and methods of ESPB,summarizes the clinical application of ESPB in spine surgery,and makes an outlook on the potential role of ESPB as a part in the multimodal management of postoperative pain in spine surgery.

Relationship between postpartum psychological disorders and emotion regulation strategies: A cross-sectional study.

To explore the relationship between postpartum psychological disorders and emotion regulation strategies and analyze the influencing factors of postpartum psychological disorders. This study was conducted using a cross-sectional design. A total of 230 postpartum women hospitalized in the Second Affiliated Hospital of Xuzhou Medical University from October 2022 to March 2023 were selected as the investigation objects. A general data questionnaire, Hamilton Anxiety Scale, Hamilton Depression Scale, Pittsburgh Sleep Quality Index, and Emotion Regulation Questionnaire were administered to the enrolled women. Pearson correlation analysis was used to assess the association between the Hamilton Anxiety Scale, Hamilton Depression Scale, Pittsburgh Sleep Quality Index, and Emotion Regulation Questionnaire. Furthermore, logistic regression was employed to assess the influencing factors of postpartum psychological disorders. Pearson correlation analysis showed that cognitive reappraisal was negatively correlated and expression inhibition was positively associated with anxiety, depression, and sleep quality symptoms (all P < .05). Logistic regression results demonstrated that the mode of delivery, number of births, feeding method, and pressure to breastfeed were risk factors affecting postpartum psychological disorders (P < .05). Cognitive reappraisal is an effective emotion regulation strategy that can relieve postpartum psycho-neurological symptoms by reducing the symptoms of anxiety, depression, and sleep disorders. Along with encouraging pregnant women to adopt positive emotional regulation strategies, medical personnel should focus on the stress associated with cesarean section, artificial feeding, and pressure to breastfeed and adopt required intervention measures to decrease the occurrence of postpartum psychological and neurological symptoms.

Electrochemistry Beyond Solutions: Modeling Particle Self-Crowding of Nanoparticle Suspensions.

Nanoparticle suspensions hold promise to transform functionality of next-generation electrochemical systems including batteries, capacitors, wastewater treatment, and sensors, challenging the limits of existing electrochemical models. Classical solution-based electrochemistry assumes that charge is transported and transferred by point-like carriers. Herein, we examine the electrochemistry of a model aqueous suspension of nondissolvable electroactive nanoparticles over a wide concentration range using a rotating disk electrode. Past a concentration and rotation rate threshold, the electrochemistry deviates from solution theory with a maximum attainable current due to particle "self-crowding" where reacted particles on the electrode surface reduce the area accessible for charge transfer by unreacted particles. The observed response is rationalized with an analytical model considering the physical adsorption/desorption kinetics and interfacial transport of nondissolvable finite-size charge carriers. Experimental validation shows the model to be applicable across a range of electrode sizes and thus suitable for engineering electrochemical systems employing nondissolvable nanoparticle suspensions.

Management strategies and outcomes in pregnancy-related acute aortic dissection: a multicentre cohort study in China.

BACKGROUND: Acute aortic dissection (AD) in pregnancy poses a lethal risk to both mother and fetus. However, well-established therapeutic guidelines are lacking. This study aimed to investigate clinical features, outcomes and optimal management strategies for pregnancy-related AD. METHODS: We conducted a retrospective multicentre cohort study including 67 women with acute AD during pregnancy or within 12 weeks postpartum from three major cardiovascular centres in China between 2003 and 2021. Patient characteristics, management strategies and short-term outcomes were analysed. RESULTS: Median age was 31 years, with AD onset at median 32 weeks gestation. Forty-six patients (68.7%) had type A AD, of which 41 underwent immediate surgery. Overall maternal mortality was 10.4% (7/67) and fetal mortality was 26.9% (18/67). Compared with immediate surgery, selective surgery was associated with higher risk of composite maternal and fetal death (adjusted RR: 12.47 (95% CI 3.26 to 47.73); p=0.0002) and fetal death (adjusted RR: 8.77 (95% CI 2.33 to 33.09); p=0.001). CONCLUSIONS: Immediate aortic surgery should be considered for type A AD at any stage of pregnancy or postpartum. For pregnant women with AD before fetal viability, surgical treatment with the fetus in utero should be considered. Management strategies should account for dissection type, gestational age, and fetal viability. TRIAL REGISTRATION NUMBER: NCT05501145.

In situ Synchrotron X-ray Metrology Boosted by Automated Data Analysis for Real-time Monitoring of Cathode Calcination.

Synchrotron X-ray-based in situ metrology is advantageous for monitoring the synthesis of battery materials, offering high throughput, high spatial and temporal resolution, and chemical sensitivity. However, the rapid generation of massive data poses a challenge to on-site, on-the-fly analysis needed for real-time process monitoring. Here, a weighted lagged cross-correlation (WLCC) similarity approach is presented for automated data analysis, which merges with in situ synchrotron X-ray diffraction metrology to monitor the calcination process of the archetypal nickel-based cathode, LiNiO2. The WLCC approach, incorporating variables that account for peak shifts and width changes associated with structural transformations, enables rapid extraction of phase progression within 10 seconds from tens of diffraction patterns. Details are captured, from initial precursors to intermediates and the final layered LiNiO2, providing information for agile on-site adjustments during experiments and complementing post hoc diffraction analysis by offering insights into early-stage phase nucleation and growth. Expanding this data-powered platform paves the way for real time calcination process monitoring and control, which is pivotal to quality control in battery cathode manufacturing.

A rice amino acid transporter OsMP1 acts as a quantitative trait locus against blast fungus and leaf-blight bacterium.

Amino acid homeostasis is interconnected with the immune network of plants. During plant-pathogen interaction, amino acid transporters (AATs) have been shown to be involved in plant immune responses. However, the molecular mechanism by which how AATs function in this process remains elusive. In this study, we identify OsMP1 that acts as a quantitative trait locus against blast fungus from a joint analysis of GWAS and QTL mapping in rice. Heterogeneous expression of OsMP1 in yeast supports its function in transporting a wide range of amino acids, including Thr, Ser, Phe, His and Glu. OsMP1 could also mediate 15N-Glu efflux and influx in Xenopus oocyte cells. The expression of OsMP1 is dramatically induced by Magnaporthe oryzae in the resistant landrace Heikezijing, while remaining unresponsive in the susceptible landrace Suyunuo. Overexpressing OsMP1 in Suyunuo enhances disease resistance to blast fungus and leaf-blight bacterium without yield penalty. Furthermore, the overexpression of OsMP1 leads to increased accumulation of Thr, Ser, Phe and His in the leaves. And the heightened levels of these amino acids contribute to reduced disease susceptibility, which is associated with upregulated jasmonic acid pathway. Thus, our results elucidate the pivotal role of OsMP1 in disease resistance and provide a potential target for breeding more resistant rice cultivars without compromising yield.

Wide-Range Excitation-Dependent Phosphorescence of Coordination Polymers Exhibiting Dynamic Anticounterfeiting, White-Light Emission, and Antibacterial Performance.

Multicolor-tunable room-temperature phosphorescence (RTP) is attracting wide attention in optoelectronic applications. Here, we propose a coordination-oriented assembly approach to achieve wide-range RTP with a benzimidazole derivative (2,7-diazabenzimidazole, DZBIM) as a luminogen. These two compounds exhibit unexpected excitation-responsive RTP emission, and the phosphorescence emission nearly covers the entire visible region with the change of the excitation wavelength from 360 to 620 nm. To the best of our knowledge, this is the first report of coordination polymers with such a full-color-tunable RTP. Compound 1 also shows white-light emission upon excitation at 280 nm. Experimental and theoretical results demonstrate that multiple intermolecular interactions and emission centers from different aggregates are responsible for the generation of multicolor emission. The white-light emission and multiple anticounterfeiting are explored. Besides, compound 1 exhibits high antibacterial activity benefiting from efficient 1O2 generation. This work provides an efficient way to prepare a color-tunable RTP.

Elucidating the Transition of 3D Morphological Evolution of Binary Alloys in Molten Salts with Metal Ion Additives.

Molten salts serve as effective high-temperature heat transfer fluids and thermal storage media used in a wide range of energy generation and storage facilities, including concentrated solar power plants, molten salt reactors and high-temperature batteries. However, at the salt-metal interfaces, a complex interplay of charge-transfer reactions involving various metal ions, generated either as fission products or through corrosion of structural materials, takes place. Simultaneously, there is a mass transport of ions or atoms within the molten salt and the parent alloys. The precise physical and chemical mechanisms leading to the diverse morphological changes in these materials remain unclear. To address this knowledge gap, this work employed a combination of synchrotron X-ray nanotomography and electron microscopy to study the morphological and chemical evolution of Ni-20Cr in molten KCl-MgCl2, while considering the influence of metal ions (Ni2+, Ce3+, and Eu3+) and variations in salt composition. Our research suggests that the interplay between interfacial diffusivity and reactivity determines the morphological evolution. The summary of the associated mass transport and reaction processes presented in this work is a step forward toward achieving a fundamental comprehension of the interactions between molten salts and alloys. Overall, the findings offer valuable insights for predicting the diverse chemical and structural alterations experienced by alloys in molten salt environments, thus aiding in the development of protective strategies for future applications involving molten salts.

Sedentary behavior from television watching elevates GlycA levels: A bidirectional Mendelian randomization study.

BACKGROUND: Current evidence linking sedentary behavior (SB), physical activity (PA), and inflammation raises questions about their causal relationships, prompting concerns about potential residual confounding or reverse causation. METHODS: A bidirectional Mendelian randomization (MR) analysis was conducted. SB data (n = 408,815) from "computer use," "television watching," and "driving" were included. The PA data encompassed nine types of PA (n = 460,376) over the last four weeks and included data on the frequency of vigorous PA (n = 440,512) and moderate PA (n = 440,266) for over 10 min. Additionally, three genome-wide association study datasets (n = 64,949) on light, moderate, and vigorous exercise were included to minimize potential bias from changes in exercise intensity. Inflammation data included levels of C-reactive protein (CRP) (n = 575,531), glycoprotein acetyl (GlycA) (n = 115,082), interleukin (IL)-8, IL-6, IL-6 receptor (IL-6R), and soluble IL-6R (sIL-6R) (n = 35,278). All datasets represented participants of European ancestry. RESULTS: Television watching as an SB showed significant positive causal effects on GlycA and CRP (inverse variance weighted (IVW), odds ratios (OR): 1.34, 95% confidence intervals (CI): 1.25-1.44, p = 3.570 × 10-17; IVW, OR: 1.21, 95% CI: 1.16-1.26, p = 1.500 × 10-19, respectively), with more robust evidence for GlycA. In the direction from inflammation to PA, a negative causal relationship between CRP and"number of days/week of moderate PA 10+ minutes"was observed (IVW, OR: 0.92, 95% CI: 0.89-0.96, p = 3.260 × 10-5). Sensitivity analyses were used to verify the robustness and reliability of the results. However, other initially observed associations ceased to be significant after controlling for obesity-related confounders. CONCLUSION: Our MR analysis suggested a potential causal relationship between television watching and chronic low-grade inflammation, with more substantial evidence for GlycA. Additionally, different types of SB may have varying effects on inflammation. Obesity-related traits could partly or entirely influence the relationship between SB, PA, and inflammatory markers. Furthermore, Our findings indicate that SB is an independent risk factor for inflammation, separate from PA, and highlight the different mechanisms by which SB and PA affect disease.

Effects of waste oyster shell replacing fine aggregate on the dynamic mechanical characteristics of concrete.

Waste oyster shells (WOS) have the potential to serve as a construction material, offering a sustainable alternative to traditional fine aggregates in the production of WOS concrete. This can play a critical role in reducing environmental issues resulting from the overexploitation of river sand and the haphazard disposal of WOS. Although existing research has predominantly focused on understanding the static mechanical characteristics of concrete when WOS is employed, the dynamic mechanical properties have still received less attention. To understand the impact of WOS as a substitute for fine aggregates on the dynamic mechanical properties of concrete, a series of tests employing Split Hopkinson Pressure Bar (SHPB) were carried out. The findings demonstrate that the peak stress and elastic modulus increase as the WOS substitution ratio (Sr) increases from 0 to 20% but exhibit an exponential decline as Sr increases from 20 to 100%. This response can be explained by the joint effects of the pore-filling effect caused by WOS sand and the increasing air content caused by WOS sand. As Sr increases from 0 to 20%, the pore-filling mechanism becomes predominant as the water absorption rate decreases slightly from 4.31 to 3.83%. However, for Sr increasing from 20 to 100%, the negative influence of the air content becomes the primary contributing factor, where the water absorption rate increases from 3.83 to 14.68%. Furthermore, under the same impact pressure, the concrete with Sr = 20% absorbed the most energy, providing the best dynamic mechanical performance. These findings highlight the potential use of WOS in concrete for improving its dynamic characteristics, promoting both sustainable construction and enhancing the material properties in impact-resistant structures.

FACT mediates the depletion of macroH2A1.2 to expedite gene transcription.

The histone variant macroH2A is generally linked to transcriptionally inactive chromatin, but how macroH2A regulates chromatin structure and functions in the transcriptional process remains elusive. This study reveals that while the integration of human macroH2A1.2 into nucleosomes does not affect their stability or folding dynamics, it notably hinders the maintenance of facilitates chromatin transcription's (FACT's) function. We show that FACT effectively diminishes the stability of macroH2A1.2-nucleosomes and expedites their depletion subsequent to the initial unfolding process. Furthermore, we identify the residue S139 in macroH2A1.2 as a critical switch to modulate FACT's function in nucleosome maintenance. Genome-wide analyses demonstrate that FACT-mediated depletion of macroH2A-nucleosomes allows the correct localization of macroH2A, while the S139 mutation reshapes macroH2A distribution and influences stimulation-induced transcription and cellular response in macrophages. Our findings provide mechanistic insights into the intricate interplay between macroH2A and FACT at the nucleosome level and elucidate their collective role in transcriptional regulation and immune response of macrophages.

Low thermal quenching of metal halide-based metal-organic framework phosphor for light-emitting diodes.

Phosphor-converted white light-emitting diodes (PC-WLEDs) have attracted considerable attention in solid-state lighting and display. However, urgent issues of thermal quenching and high cost remain formidable challenges. Herein, a novel metal-organic framework (MOF) phosphor [CdCl2(AD)] was facilely prepared using a mixture of CdCl2 and acridine (AD) under solvothermal conditions. It shows intensive green emission with a long lifetime of 31.88 ns and quantum yield of 65% while maintaining 95% and 84% of its initial emission intensity after remaining immersed in water for 60 days and being heated to 150 °C, respectively. The low thermal quenching of this MOF material is comparable to or can even exceed that of commercial inorganic phosphors. The combination of experiments and theoretical calculations reveals that the alternating arrangement of delocalized AD π-conjugated systems and CdCl2 inorganic chains through strong coordination bonds and π⋯π stacking interactions imparts the MOF phosphor with high thermal stability and optoelectronic performance. The successful fabrication of green and white LED devices by coating [CdCl2(AD)] and/or N630 red phosphor on a 365/460 nm commercial diode chip suggests a promising and potential alternative to commercial phosphors.

Color-tunable and white circularly polarized luminescence through confining guests into chiral MOFs.

Herein, chiral metal-organic frameworks (MOFs), DCF-20 and LCF-20, were utilized as matrices for both chirality transfer and energy transfer. HBT1@MOFs and HBT2@MOFs emit excitation-dependent circularly polarized luminescence (CPL) due to excited-state intramolecular proton transfer (ESIPT). HBT1/C152/NIR@MOFs exhibit full-color and white CPL. The luminescence dissymmetry factors (glum) were significantly increased, benefiting from the efficient chirality space transfer and high luminescence efficiency.

Defect-Driven Configurational Entropy in the High-Entropy Oxide Li1.5MO3-δ.

Layered lithiated oxides are promising materials for next generation Li-ion battery cathode materials; however, instability during cycling results in poor performance over time compared to the high capacities theoretically possible with these materials. Here we report the characterizations of a Li1.47Mn0.57Al0.13Fe0.095Co0.105Ni0.095O2.49 high-entropy layered oxide (HELO) with the Li2MO3 structure where M = Mn, Al, Fe, Co, and Ni. Using electron microscopy and X-ray spectroscopy, we identify a homogeneous Li2MO3 structure stabilized by the entropic contribution of oxygen vacancies. This defect-driven entropy would not be attainable in the LiMO2 structure sometimes observed in similar materials as a secondary phase owing to the presence of fewer O sites and a 3+ oxidation state for the metal site; instead, a Li2-γMO3-δ is produced. Beyond Li2MO3, this defect-driven entropy approach to stabilizing novel compositions and phases can be applied to a wide array of future cathode materials including spinel and rock salt structures.

Enhancing the Carbon Monoxide Oxidation Performance through Surface Defect Enrichment of Ceria-Based Supports for Platinum Catalyst.

Effective synthesis and application of single-atom catalysts on supports lacking enough defects remain a significant challenge in environmental catalysis. Herein, we present a universal defect-enrichment strategy to increase the surface defects of CeO2-based supports through H2 reduction pretreatment. The Pt catalysts supported by defective CeO2-based supports, including CeO2, CeZrOx, and CeO2/Al2O3 (CA), exhibit much higher Pt dispersion and CO oxidation activity upon reduction activation compared to their counterpart catalysts without defect enrichment. Specifically, Pt is present as embedded single atoms on the CA support with enriched surface defects (CA-HD) based on which the highly active catalyst showing embedded Pt clusters (PtC) with the bottom layer of Pt atoms substituting the Ce cations in the CeO2 surface lattice can be obtained through reduction activation. Embedded PtC can better facilitate CO adsorption and promote O2 activation at PtC-CeO2 interfaces, thereby contributing to the superior low-temperature CO oxidation activity of the Pt/CA-HD catalyst after activation.

S-Block Metal Mg-Mediated Co─N─C as Efficient Oxygen Electrocatalyst for Durable and Temperature-Adapted Zn-Air Batteries.

In the quest to enhance Zn-air batteries (ZABs) for operating across a wide spectrum of temperatures, synthesizing robust oxygen electrocatalysts is paramount. Conventional strategies focusing on orbital hybridization of d-d and p-d aim to moderate the excessive interaction between the d-band of the transition metal active site and oxygen intermediate, yet often yield suboptimal performance. Herein, an innovative s-block metal modulation is reported to refine the electronic structure and catalytic behavior of Co─NC catalysts. Employing density functional theory (DFT) calculations, it is revealed that incorporating Mg markedly depresses the d-band center of Co sites, thereby fine-tuning the adsorption energy of the oxygen reduction reaction (ORR) intermediate. Consequently, the Mg-modified Co─NC catalyst (MgCo─NC) unveils remarkable intrinsic ORR activity with a significantly reduced activation energy (Ea) of 10.0 kJ mol-1, outstripping the performance of both Co─NC (17.6 kJ mol-1), benchmark Pt/C (15.9 kJ mol-1), and many recent reports. Moreover, ZABs outfitted with the finely tuned Mg0.1Co0.9─NC realize a formidable power density of 157.0 mW cm-2, paired with an extremely long cycle life of 1700 h, and an exceptionally minimal voltage gap decay rate of 0.006 mV h-1. Further, the Mg0.1Co0.9─NC-based flexible ZAB presents a mere 2% specific capacity degradation when the temperature fluctuates from 25 to -20 °C, underscoring its robustness and suitability for practical deployment in diverse environmental conditions.

Psychosocial factors affect the occurrence of nonsuicidal self-injury in adolescents with major depressive disorder through chain mediation.

In the adolescent group, about half of adolescents with major depressive disorder (MDD) have NSSI. Psychosocial factors are associated with the development of NSSI. Clarifying the relationship between psychosocial factors and NSSI in adolescents with MDD can help us achieve early prevent. Demographic data, Hamilton Depression Scale-24 (HAMA24), childhood trauma questionnaire, emotional intelligence scale and interpersonal reactivity index were collected from 187 adolescents with MDD. Use ANOVA, Chi-square test, Binary Logistic Regression, Pearson correlation analysis, Mediation effect analysis and the Structural Equation Model for data analysis. The results of ANOVA showed that there was significant difference between the two groups in HAMD24 total score, impulsiveness, emotional intelligence, and empathy (p < 0.05). In the regression analysis, women, depression degree, motor impulsiveness (MI), personal distress (PD) and appraisal of other's emotions empathy were the risk factors for MDD adolescents to produce NSSI behavior. Among the indicators that were significantly related to MDD and NSSI, MI and PD mediate the relationship between MDD and NSSI. The structural equation model showed that MDD, PD and MI had a direct impact on NSSI, but PD and MI had multiple intermediary effected in the relationship between MDD and NSSI. Emotional intelligence, emotional neglect and cognitive impulsiveness indirectly affected the occurrence of NSSI behavior. Impulsiveness, personal distress, emotional neglect, and emotional intelligence are important risk factors that affect NSSI behavior in adolescents with MDD, and they affect the occurrence of NSSI in adolescents with MDD through chain mediation.

Association of hemoglobin drift and outcomes in patients with aneurysmal subarachnoid hemorrhage.

The relationship between in-hospital hemoglobin (Hb) drift and outcomes in patients undergoing surgical clipping for aneurysmal subarachnoid hemorrhage (aSAH) is not well studied. This study aims to investigate the association between Hb drift and mortality in this patient population. We conducted a cohort study encompassing adult patients diagnosed with aSAH who were admitted to a university hospital. These patients were stratified into distinct groups based on their Hb drift levels. We employed logistic and Cox proportional hazard models to assess the relationship between Hb drift and outcomes. Additionally, propensity score matching (PSM) was utilized to ensure comparability between patient groups. The discriminative performance of different models was evaluated using C-statistics, integrated discrimination improvement (IDI), and net reclassification improvement (NRI). Overall, our cohort comprised 671 patients, of whom 165 (24.6%) demonstrated an in-hospital Hb drift exceeding 25%. The analyses revealed elevated Hb drift was independently associated with higher likelihood of follow-up mortality (aOR: 3.29, 95% CI: 1.65 to 6.56; P = 0.001) and in-hospital mortality (aOR: 3.44, 95% CI: 1.55 to 7.63; P = 0.002). PSM analysis yielded similar results. Additionally, patients with Hb drift exhibited a notable decrease in survival rate compared to those without Hb drift (aHR: 3.99, 95% CI 2.30 to 6.70; P < 0.001). Furthermore, the inclusion of Hb drift significantly improved the C-statistic (P = 0.037), IDI (2.78%; P = 0.004) and NRI metrics (41.86%; P < 0.001) for mortality prediction. In summary, our results highlight that an in-hospital Hb drift exceeding 25% serves as an independent predictor of mortality in patients who have undergone surgical clipping for aSAH.

Influence of tumor thrombus morphology on the surgical complexity in renal cell carcinoma with inferior vena cava tumor thrombus: a single-center, large-sample study from China.

BACKGROUND: The morphology of tumor thrombus varies from person to person and it may affect surgical methods and tumor prognosis. However, studies on the morphology of tumor thrombus are limited. The purpose of our study was to evaluate the impact of tumor thrombus morphology on surgical complexity. METHODS: We retrospectively reviewed the clinical data of 229 patients with renal cell carcinoma combined with inferior vena cava (IVC) tumor thrombus who underwent surgical treatment at Peking University Third Hospital between January 2014 and December 2021. The patients were divided into floating morphology (107 patients) and filled morphology (122 patients) tumor thrombi groups. Chi-square and Mann-Whitney U tests were used for categorical and continuous variables, respectively. Postoperative complications were evaluated using the Clavien-Dindo surgical complication classification method. RESULTS: Patients with filled morphology tumor thrombus required more surgical techniques than those with floating morphology tumor thrombus, which was reflected in more open surgeries (P < 0.001), more IVC interruptions (P <0.001), lesser use of the delayed occlusion of the proximal inferior vena cava (DOPI) technique (P < 0.001), and a greater need for cut-off of the short hepatic vein (P < 0.001) and liver dissociation (P = 0.001). Filled morphology significantly increased the difficulty of surgery in patients with renal cell carcinoma with tumor thrombus, reflected in longer operation time (P < 0.001), more surgical blood loss (P <0.001), more intra-operative blood transfusion (P < 0.001), and longer postoperative hospital stay (P < 0.001). Filled morphology tumor thrombus also led to more postoperative complications (53% vs. 20%; P < 0.001). CONCLUSION: Compared with floating morphology thrombus, filled morphology thrombus significantly increased the difficulty of surgery in patients with renal cell carcinoma with IVC tumor thrombus.