Postoperative accurate pain assessment of children and artificial intelligence: A medical hypothesis and planned study.

Although the pediatric perioperative pain management has been improved in recent years, the valid and reliable pain assessment tool in perioperative period of children remains a challenging task. Pediatric perioperative pain management is intractable not only because children cannot express their emotions accurately and objectively due to their inability to describe physiological characteristics of feeling which are different from those of adults, but also because there is a lack of effective and specific assessment tool for children. In addition, exposure to repeated painful stimuli early in life is known to have short and long-term adverse sequelae. The short-term sequelae can induce a series of neurological, endocrine, cardiovascular system stress related to psychological trauma, while long-term sequelae may alter brain maturation process, which can lead to impair neurodevelopmental, behavioral, and cognitive function. Children's facial expressions largely reflect the degree of pain, which has led to the developing of a number of pain scoring tools that will help improve the quality of pain management in children if they are continually studied in depth. The artificial intelligence (AI) technology represented by machine learning has reached an unprecedented level in image processing of deep facial models through deep convolutional neural networks, which can effectively identify and systematically analyze various subtle features of children's facial expressions. Based on the construction of a large database of images of facial expressions in children with perioperative pain, this study proposes to develop and apply automatic facial pain expression recognition software using AI technology. The study aims to improve the postoperative pain management for pediatric population and the short-term and long-term quality of life for pediatric patients after operational event.

Comparison effects of two muscle relaxant strategies on postoperative pulmonary complications in transapical transcatheter aortic valve implantation: a propensity score-matched analysis.

BACKGROUND: Prior studies have reported conflicting results on the effect of sugammadex on postoperative pulmonary complications (PPCs) and research on this topic in transapical-transcatheter aortic valve implantation (TA-TAVI) was sparse. The current study aimed to investigate whether there were differences in the incidence of PPCs between two muscle relaxant strategies (rocuronium/sugammadex vs. cisatracurium/neostigmine) in patients undergoing TA-TAVI. METHODS: This retrospective observational study enrolled 245 adult patients underwent TA-TAVI between October 2018 and January 2021. The patients were grouped according to the type of muscle relaxant strategies (115 with rocuronium/sugammadex in the R/S group and 130 with cisatracurium/neostigmine in the C/N group, respectively). Pre- and intraoperative variables were managed by propensity score match (PSM) at a 1:2 ratio. PPCs (i.e., respiratory infection, pleural effusion, pneumothorax, atelectasis, respiratory failure, bronchospasm and aspiration pneumonitis) were evaluated from the radiological and laboratory findings. RESULTS: After PSM, 91 patients in the R/S group were selected and matched to 112 patients in the C/N group. Patients in the R/S group showed lower PPCs rate (45.1% vs. 61.6%, p = 0.019) compared to the C/N group. In addition, the R/S group showed significant shorter extubation time (7.2 ± 6.2 vs. 10.3 ± 8.2 min, p = 0.003) and length of hospital stay (6.9 ± 3.3 vs. 8.0 ± 4.0 days, p = 0.034). CONCLUSION: The rocuronium/sugammadex muscle relaxant strategy decreases the incidence of PPCs in patients undergoing TA-TAVI when compared to cisatracurium/neostigmine strategy. Trial registration ChiCTR, ChiCTR2100044269. Registered March 14, 2021-Prospectively registered, http://www.Chictr.org.cn .

A case of unexpected intraoperative airway obstruction in a patient with an aneurysm of the ascending aorta and aortic arch.

Upper airway compression is one of the clinical manifestations of thoracic aortic aneurysm, which is associated with poor prognosis and high mortality. A 44-year-old patient with ascending aortic and arch aneurysm who was scheduled for Bentall surgery and total arch replacement under cardiopulmonary bypass suffered difficult ventilation after endotracheal intubation. The patient did not exhibit any positional dyspnoea or orthopnoea, did not show any difficulties in the supine position, and had no noteworthy medical history. However, we encountered unexpected hypoventilation after intubation. Isoprenaline infusion was effective while emergency cardiopulmonary bypass was established to deal with this crisis. Fibreoptic bronchoscopy revealed complete obstruction of the carina and confirmed the supracarinal position of the tube. Complete airway obstruction may occur even if there are no symptoms before surgery in patients with thoracic aortic aneurysm. Comprehensive preoperative assessment, a well-developed airway management plan, and responses to possible emergencies are essential to reduce unnecessary events or complications.

Production of Indigo by Recombinant Escherichia coli with Expression of Monooxygenase, Tryptophanase, and Molecular Chaperone.

Indigo is an important pigment widely used in industries of food, cosmetics, and textile. In this work, the styrene monooxygenase StyAB from Pseudomonas putida was co-expressed with the tryptophanase TnaA and the chaperone groES-groEL in Escherichia coli for indigo production. Over-expression of the gene styAB endowed the recombinant E. coli AB with the capacity of indigo biosynthesis from indole and tryptophan. Tryptophan fermentation in E. coli AB generated about five times more indigo than that from indole, and the maximum 530 mg/L of indigo was obtained from 1.2 mg/mL of tryptophan. The gene TnaA was then co-expressed with styAB, and the tryptophanase activity significantly increased in the recombinant E. coli ABT. However, TnaA expression led to a decrease in the activity of StyAB and indigo yield in E. coli ABT. Furthermore, the plasmid pGro7 harboring groES-groEL was introduced into E. coli AB, which obviously promoted the activity of StyAB and accelerated indigo biosynthesis in the recombinant E. coli ABP. In addition, the maximum yield of indigo was further increased to 550 mg/L from 1.2 mg/mL of tryptophan in E. coli ABP. The genetic manipulation strategy proposed in this work could provide new insights into construction of indigo biosynthesis cell factory for industrial production.

Killer hiding under normal oxygen saturation: a case report about methemoglobinemia.

Background: Inhaled nitric oxide (iNO) is a choice for the treatment of pulmonary hypertension (PH), especially in cases after cardiac surgery. Potential side effects include the formation of higher oxides of nitrogen and methemoglobin (MetHb). Methemoglobinemia is the oxidation of ferrous iron to iron within hemoglobin, impairing its ability to transport oxygen and resulting in tissue hypoxemia. A level of MetHb >10% will induce clinical hypoxia manifestations, and MetHb >70% may be fatal. Case Description: Herein we report a rare case of methemoglobinemia due to iNO therapy in a child after cardiac surgery. We found that as MetHb concentrations increased, pulse oximetry overestimated oxygen supplementation without warning clinicians that dangerous hypoxia was developing. Finally, MetHb and oxyhemoglobin (O2Hb) in arterial blood gas (ABG) provide diagnostic clues. Methylene blue and low dose vitamin C (VC) were used to successfully save the life of the child. Conclusions: iNO administration in the intensive care unit should be managed with close monitoring of MetHb levels during treatment. We emphasize the limitations of traditional methods used to assess oxygenation status, especially in the context of methemoglobinemia. In addition, treatment for methemoglobinemia in acute settings should be initiated as soon as possible.

A giant right atrial appendage aneurysm in an infant: A case report.

Right atrial appendage aneurysms (RAAAs) are extremely rare in cardiac anomalies. According to the literature, a few dozen cases have been reported thus far, among which only four cases were infants or neonates. Here, we report an infant with a giant RAAA and severe symptoms. The RAAA was diagnosed by echocardiography and surgically resected under cardiopulmonary bypass (CPB). The role of transesophageal echocardiography was very important during aneurysm resection surgery, which helped surgeons to plan surgical procedures during surgery and evaluate the surgical effect postoperatively.

Impact of Perioperative Massive Transfusion on Long Term Outcomes of Liver Transplantation: a Retrospective Cohort Study.

Background: Liver transplantation (LT) is associated with a significant risk of intraoperative hemorrhage and massive blood transfusion. However, there are few relevant reports addressing the long-term impacts of massive transfusion (MT) on liver transplantation recipients. Aim: To assess the effects of MT on the short and long-term outcomes of adult liver transplantation recipients. Methods: We included adult patients who underwent liver transplantation at West China Hospital from January 2011 to February 2015. MT was defined as red blood cell (RBC) transfusion of ≥10 units within 48 hours since the application of LT. Preoperative, intraoperative and postoperative information were collected for data analyzing. We used one-to-one propensity-matching to create pairs. Kaplan-Meier survival analysis was used to compare long-term outcomes of LT recipients between the MT and non-MT groups. Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors associated with MT in LT. Results: Finally, a total of 227 patients were included in our study. After propensity score matching, 59 patients were categorized into the MT and 59 patients in non-MT groups. Compared with the non-MT group, the MT group had a higher 30-day mortality (15.3% vs 0, p=0.006), and a higher incidence of postoperative complications, including postoperative pulmonary infection, abdominal hemorrhage, pleural effusion and severe acute kidney injury. Furthermore, MT group had prolonged postoperative ventilation support (42 vs 25 h, p=0.007) and prolonged durations of ICU (12.9 vs 9.5 d, p<0.001) stay. Multivariate COX regression indicated that massive transfusion (OR: 2.393, 95% CI: 1.164-4.923, p=0.018) and acute rejection (OR: 7.295, 95% CI: 2.108-25.246, p=0.02) were significant risk factors affecting long-term survivals of LT patients. The 1-year and 3-year survival rates patients in MT group were 82.5% and 67.3%, respectively, while those of non-MT group were 93.9% and 90.5%, respectively. The MT group exhibited a lower long-term survival rate than the non-MT group (HR: 2.393, 95% CI: 1.164-4.923, p<0.001). Finally, the multivariate logistic regression revealed that preoperative hemoglobin <118 g/L (OR: 5.062, 95% CI: 2.292-11.181, p<0.001) and intraoperative blood loss ≥1100 ml (OR: 3.212, 95% CI: 1.586-6.506, p = 0.001) were the independent risk factor of MT in patients undergoing LT. Conclusion: Patients receiving MT in perioperative periods of LT had worse short-term and long-term outcomes than the non-MT patients. Massive transfusion and acute rejection were significant risk factors affecting long-term survivals of LT patients, and intraoperative blood loss of over 1100 ml was the independent risk factor of MT in patients undergoing LT. The results may offer valuable information on perioperative management in LT recipients who experience high risk of MT.

Deoxynivalenol (Vomitoxin)-Induced Anorexia Is Induced by the Release of Intestinal Hormones in Mice.

Deoxynivalenol (DON), also known as vomitoxin, is a mycotoxin that can cause antifeeding and vomiting in animals. However, the mechanism of DON inducing anorexia is complicated. Studies have shown that intestinal hormones play a significant part in the anorexia caused by DON. We adopted the "modeling of acute antifeeding in mice" as the basic experimental model, and used two methods of gavage and intraperitoneal injection to explore the effect of intestinal hormones on the antifeedant response induced by DON in mice. We found that 1 and 2.5 mg/kg·bw of DON can acutely induce anorexia and increase the plasma intestinal hormones CCK, PYY, GIP, and GLP-1 in mice within 3 h. Direct injection of exogenous intestinal hormones CCK, PYY, GIP, and GLP-1 can trigger anorexia behavior in mice. Furthermore, the PYY receptor antagonist JNJ-31020028, GLP-1 receptor antagonist Exendin(9-39), CCK receptor antagonist Proglumide, GIP receptor antagonist GIP(3-30)NH2 attenuated both intestinal hormone and DON-induced anorectic responses. These results indicate that intestinal hormones play a critical role in the anorexia response induced by DON.

Anorexic responses to trichothecene deoxynivalenol and its congeners correspond to secretion of tumor necrosis factor-α and interleukin-1ß.

Type B trichothecene mycotoxins comprise deoxynivalenol ("Vomitoxin", DON) and four structually related congeners: 15-acetyl- and 3-acetyl-deoxynivalenol (15-ADON and 3-ADON), nivalenol (NIV), 4-acetyl-nivalenol (fusarenon X, FX). These foodborne mycotoxins has been linked to food poisoning leading to anorexic response in human and several animal species. However, the pathophysiological basis for anorexic effect is relatively unclear. The goal of this research was to compare anorexic effect to type B trichothecenes and relate these effects to two common cytokines tumor necrosis factor-α (TNF-α) and interleukin-1ß (IL-1ß) following oral and IP exposure. Both cytokines were increased within 1-2 h in plasma and returned to basal concentrations at 6 h following exposure to DON and ADONs. FX evoked both cytokines with initial time and duration at 1-2 h and > 6 h, respectively. Elevation of TNF-α and IL-1ß induced by orally exposure to NIV did not occur until 2 h and recovered to basal concentrations at 6 h. Both cytokines were elevated at 1 h and lasted more than 6 h following IP exposure to NIV. Type B trichothecenes stimulated plasma secretion of both cytokines that were consistent with reduction of food intake. In conclusion, our findings demonstrate that TNF-α and IL-1ß act critical roles in type B trichothecenes-induced anorexic response.

Expression of styAB is regulated by a two-component system during indigo biosynthesis in Pseudomonas putida.

A two-component regulatory system involving StyS and StyR is involved in the regulation of indigo synthesis in Pseudomonas sp. However, the function of the styR gene in indigo synthesis and the detailed mechanisms through which StyR enhances the expression of the styAB operon are unclear. Accordingly, in this study, we constructed a styR/styS gene knockout mutant strain. By comparing the differences in indigo yields between the wild-type and mutant strains, we found that the styR gene mutant strain had no indigo synthesis ability, whereas the yield in the wild-type strain was 5.4 mg/L. Thus, these findings indicate that the styR gene plays a key role in the regulation of indigo synthesis. The interactions among StyS, StyR, and the styAB promoter were verified by electrophoresis mobility shift assays. The results showed that StyR interacts with the styAB promoter by binding to the palindrome in the styAB promoter. Moreover, the kinase function of StyS regulated StyR by transphosphorylating StyR during indigo biosynthesis in P. putida B3. Taken together, these findings provide important insights into the establishment of environmentally friendly indigo synthesis methods using P. putida.

Role of neurotransmitters 5-hydroxytryptamine and substance P in anorexia induction following oral exposure to the trichothecene T-2 toxin.

Trichothecene mycotoxins, a family of common contaminants on cereal grains, are known to negatively impact human and animal health with adverse effect on food consumption being of particular concern. T-2 toxin has been previously demonstrated to induce anorectic response in several animal species including mouse, rat, rabbit. Although the T-2 toxin-induced anorectic response has been associated with the release of gut satiety hormone, much less is known about the role of neurotransmitter in this response. To address this gap, we employed a nocturnal mouse food refusal model to test the hypothesis that neurotransmitters 5-hydroxytryptamine (5-HT) and substance P (SP) mediate anorexia induction by T-2 toxin. Elevations of plasma 5-HT and SP markedly corresponded to anorexia induction following oral exposure to T-2 toxin. Direct administration of exogenous 5-HT and SP induced anorectic responses similar to T-2 toxin. The 5-HT3 receptor (5-HT3R) antagonist granisetron evoked a dose-dependent attenuation of both 5-HT- and T-2 toxin-induced anorectic responses. Pretreatment with neurokinin-1 receptor (NK-1R) antagonist Emend® dose-dependently attenuated both SP- and T-2 toxin-induced anorectic responses. To summarize, the results suggest that both 5-HT and SP play important roles in anorexia induction by T-2 toxin. 5-HT is more potent and long-acting than SP in this response.

Anorectic response to the trichothecene T-2 toxin correspond to plasma elevations of the satiety hormone glucose-dependent insulinotropic polypeptide and peptide YY3-36.

T-2 toxin, a potent type A trichothecene mycotoxin, is produced by various Fusarium species and can negatively impact animal and human health. Although anorexia induction is a common hallmark of T-2 toxin-induced toxicity, the underlying mechanisms for this adverse effect are not fully understood. The goal of this study was to determine the roles of two gut satiety hormones, glucose-dependent insulinotropic polypeptide (GIP) and Peptide YY3-36 (PYY3-36) in anorexia induction by T-2 toxin. Elevations of plasma GIP and PYY3-36 markedly corresponded to anorexia induction following oral exposure to T-2 toxin using a nocturnal mouse anorexia model. Direct administration of exogenous GIP and PYY3-36 similarly induced anorectic responses. Furthermore, the GIP receptor antagonist Pro3GIP dose-dependently attenuated both GIP- and T-2 toxin-induced anorectic responses. Pretreatment with NPY2 receptor antagonist JNJ-31020028 induced a dose-dependent attenuation of both PYY3-36- and T-2 toxin-induced anorectic responses. To summarize, these findings suggest that both GIP and PYY3-36 might be critical mediators of anorexia induction by T-2 toxin.

Continuous infusion of high-dose ulinastatin during surgery does not improve early postoperative clinical outcomes in patients undergoing radical lung cancer surgery: A pilot study.

BACKGROUND: Ulinastatin can prevent the perioperative increase in proinflammatory cytokines for lung resection surgery; however, its impact on early clinical outcomes remains unknown. METHODS: The study enrolled 108 non-small cell lung cancer (NSCLC) patients who were randomly allocated into two groups: ulinastatin (group U) and control (group C). Patients in group U ( n = 52) were continuously intravenously infused with ulinastatin at a rate of 20 000 U/kg/hour for the first hour after anesthesia induction, and then at a rate of 5000 U/kg/hour until the conclusion of surgery. Patients in group C ( n = 56) received an equivalent volume of normal saline. The primary outcome was to record the postoperative pulmonary complications that occurred during hospital stay. Other clinical courses, such as hospital mortality, blood loss, respiratory parameters, postoperative chest drainage, and duration of intensive care unit and postoperative hospital stay, were also observed and analyzed. RESULTS: There were no significant differences between the two groups in early postoperative pulmonary complications, hospital mortality, blood loss, or other perioperative laboratory values, except for the duration of postoperative chest drainage and serum creatinine level. The frequency of pulmonary complications was lower in patients treated with ulinastatin compared with the control (38.46% in group U vs. 48.21% in group C). CONCLUSION: Administration of high-dose ulinastatin during surgery did not reduce postoperative pulmonary complications, hospital mortality, or hospital stay for patients undergoing lung radical thoracotomy. However, a protective trend of ulinastatin was observed.

Plasma angiopoietin-2 is persistently elevated after non-small cell lung cancer surgery and stimulates angiogenesis in vitro.

Angiopoietin-2 (Ang2) is a key proangiogenic factor, but its role in surgery-induced angiogenesis, a possible cause of cancer recurrence, is still elusive.We measured the plasma Ang2 levels in healthy controls (n = 42) and stage I-IV perioperative nonsmall cell lung cancer (NSCLC) patients (n = 227) with enzyme-linked immunosorbent assay, and examined the impact of Ang2 in the plasmas on in vitro angiogenesis and proliferation of human umbilical vein endothelial cells and human microvascular endothelial cells.Ang2 plasma levels are significantly increased in untreated NSCLC patients (2697 ±â€Š1354 pg/mL) compared to control (1473 ±â€Š560.6 pg/mL) and positively associated with disease stage but not with histology. Ang2 plasma levels in stage I-IIIA NSCLC patients (n = 154) are elevated after the standard open thoracic surgery, following an approximate pattern to increase quickly in the 1st postoperative days (PODs, from preoperative 2342 ±â€Š1084 to POD1: 4485 ±â€Š1617 and POD3: 5370 ±â€Š1879 pg/mL), reach the peak about 2 weeks later (POD14: 6099 ±â€Š2280 pg/mL), drop slowly thereafter (POD28: 3877 ±â€Š1388 and POD42: 3365 ±â€Š1189 pg/mL), and remain significantly higher than preoperative 8 weeks after the procedure (POD56: 2937 ±â€Š943.3 pg/mL). The postoperative plasmas enhance in vitro angiogenesis and Ang2 removal from the plasmas can counteract the effect. The postoperative plasmas stimulate endothelial proliferation independently of Ang2.These results suggest that plasma Ang2 increases after NSCLC surgery and contributes to the proangiogenic property of the postoperative plasmas, thus supporting the possible administration of anti-Ang2 therapy for NSCLC in postoperative adjuvant setting.

[MODIFIED Stoppa APPROACH WITH MEDIAL WALL SPRING PLATE FOR INVOLVING QUADRILATERAL OF ACETABULUM FRACTURE].

OBJECTIVE: To investigate the effectiveness of modified Stoppa approach with medial wall spring plate (MWSP) for involving quadrilateral of acetabulum fracture. METHODS: Between March 2008 and September 2013, 38 patients with involving quadrilateral of acetabulum fracture were treated, including of 23 males and 15 females with an average age of 36.08 years (range, 19-56 years). The causes included traffic accidents injury (21 cases), crash injury of heavy object (10 cases), and falling injury from height (7 cases). The interval of injury and admission was 3 hours to 2 days (mean, 11 hours). There were 12 cases of anterior column fracture (type D), 5 cases of transverse fractures (type E), 8 cases of T shaped fractures (type H), 6 cases of anterior column fracture with posterior transverse fractures (type I), and 7 cases of double column fractures (type J) according to Letournel-Judet classification. Based on fracture types, MWSP was used to fix fracture by modified Stoppa approach in 19 cases or combined with the ilioinguinal approach in 10 cases or combined with Kocher-Langenbeck approach in 9 cases. The operation time, blood loss, and complications were recorded. The effectiveness of reduction and the hip function were evaluated according to Matta score system and Merled' Aubigne and Postel score system. RESULTS: The operation time was 85-210 minutes (mean, 130 minutes).The intra-operative blood loss was 450-900 mL (mean, 650 mL). There were 1 case of vascular avulsion, and 1 case of bladder injury during operation; there were 8 cases of venous thrombosis and 2 cases of fat liquefaction of incision after operation. Screw was implanted into the articular joint in 1 case on CT after operation. Matta X-ray assessment showed anatomical reduction in 9 cases satisfactory reduction in 24 cases, and unsatisfactory reduction in 5 cases, and the satisfaction rate of reduction was 86.84%. Three patients had limb shorting of 0.8-1.0 cm when compared with normal limb. All patients were followed up for 7 to 18 months with an average of 10 months. Fractures healed well within 13-16 weeks with an average of 14 weeks. At 1 year after operation, the results were excellent in 9 cases, good in 21 cases, general in 5 cases, and poor in 3 cases, and the excellent and good rate was 78.95% according to the Merled' Aubigne and Postel hip score standards. CONCLUSION: Involving quadrilateral of acetabulum fracture can be fixed with MWSP by modified Stoppa approach or combined with other approaches to obtain good exposure, less invasion, satisfactory reduction, stable fixation, and low complications.

Pseudolarix acid B, a new tubulin-binding agent, inhibits angiogenesis by interacting with a novel binding site on tubulin.

Tubulin-binding agents have received considerable interest as potential tumor-selective angiogenesis-targeting drugs. Herein, we report that pseudolarix acid B (PAB), isolated from the traditional Chinese medicinal plant Pseudolarix kaempferi Gordon, is a tubulin-binding agent. We further demonstrate that PAB significantly and dose-dependently inhibits proliferation, migration, and tube formation by human microvessel enthothelial cells. It is noteworthy that PAB eliminated newly formed endothelial tubes and microvessels both in vitro and in vivo. In addition, PAB dramatically arrested the cell cycle at G2/M phase. PAB also induced endothelial cell retraction, intercellular gap formation, and promoted actin stress fiber formation in conjunction with disruption of the tubulin and actin cytoskeletons. All of these effects occurred at noncytotoxic concentrations of PAB. We found that these effects of PAB are attributable to depolymerization of tubulin by direct interaction with a distinct binding site on tubulin compared with those of colchicine and vinblastine. Taken together, these findings show that PAB is a candidate antiangiogenic agent for use in cancer therapy, and they provide proof of principle for targeting this novel binding site on tubulin as a new strategy for treating cancer.