A combined pre- and intra-operative nomogram in evaluation of degrees of liver cirrhosis predicts post-hepatectomy liver failure: a multicenter prospective study.

Background: Adequate evaluation of degrees of liver cirrhosis is essential in surgical treatment of hepatocellular carcinoma (HCC) patients. The impact of the degrees of cirrhosis on prediction of post-hepatectomy liver failure (PHLF) remains poorly defined. This study aimed to construct and validate a combined pre- and intra-operative nomogram based on the degrees of cirrhosis in predicting PHLF in HCC patients using prospective multi-center's data. Methods: Consecutive HCC patients who underwent hepatectomy between May 18, 2019 and Dec 19, 2020 were enrolled at five tertiary hospitals. Preoperative cirrhotic severity scoring (CSS) and intra-operative direct liver stiffness measurement (DSM) were performed to correlate with the Laennec histopathological grading system. The performances of the pre-operative nomogram and combined pre- and intra-operative nomogram in predicting PHLF were compared with conventional predictive models of PHLF. Results: For 327 patients in this study, histopathological studies showed the rates of HCC patients with no, mild, moderate, and severe cirrhosis were 41.9%, 29.1%, 22.9%, and 6.1%, respectively. Either CSS or DSM was closely correlated with histopathological stages of cirrhosis. Thirty-three (10.1%) patients developed PHLF. The 30- and 90-day mortality rates were 0.9%. Multivariate regression analysis showed four pre-operative variables [HBV-DNA level, ICG-R15, prothrombin time (PT), and CSS], and one intra-operative variable (DSM) to be independent risk factors of PHLF. The pre-operative nomogram was constructed based on these four pre-operative variables together with total bilirubin. The combined pre- and intra-operative nomogram was constructed by adding the intra-operative DSM. The pre-operative nomogram was better than the conventional models in predicting PHLF. The prediction was further improved with the combined pre- and intra-operative nomogram. Conclusions: The combined pre- and intra-operative nomogram further improved prediction of PHLF when compared with the pre-operative nomogram. Trial Registration: Clinicaltrials.gov Identifier: NCT04076631.

Adjuvant Transarterial Chemoembolization Plus Immunotherapy for Huge Hepatocellular Carcinoma: A Propensity Score Matching Cohort Study.

Purpose: The prognosis of patients with huge hepatocellular carcinoma (huge HCC, diameter ≥10 cm) is poor owing to the high early recurrence rate. This study aimed to explore the clinical value of postoperative adjuvant transarterial chemoembolization (PA-TACE) plus programmed cell death-1 (PD-1) inhibitors for huge HCC. Patients and Methods: Data from consecutive huge HCC patients treated with hepatectomy during June 2017 and July 2022 were retrospectively collected. Baseline differences were balanced between huge HCC patients who underwent PA-TACE with (AIT group) or without PD-1 inhibitors (AT group) by propensity-score matching (PSM). We compared recurrence-free survival (RFS), overall survival (OS) and recurrence patterns between the two groups. Independent risk factors for RFS and OS were confirmed by Cox regression analysis, and subgroup analysis was also conducted. Results: A total of 294 patients were enrolled, and 77 pairs of patients in the AIT and AT groups were matched by PSM. The 1-year and 2-year RFS were 49.9% and 35.7% in the AIT group compared to 24.7% and 15.5% in the AT group respectively (p<0.001). The 1-year and 2-year OS were 83.6% and 66.9% in the AIT group compared to 50.6% and 36.8% in the AT group respectively (p<0.001). There were no significant differences in recurrence patterns between the two groups. Multivariable analysis demonstrated that combined therapy of PA-TACE plus PD-1 inhibitors was a protective factor related to both RFS and OS. Conclusion: PA-TACE plus PD-1 inhibitors could improve survival outcomes for huge HCC patients.

Dexmedetomidine inhibits paraventricular corticotropin-releasing hormone neurons that attenuate acute stress-induced anxiety-like behavior in mice.

BACKGROUND: Dexmedetomidine has repeatedly shown to improve anxiety but the precise neural mechanisms underlying this effect remain incompletely understood. Here, we aim to explore the role of corticotropin-releasing hormone-producing hypothalamic paraventricular (CRHPVN) neurons in mediating the anxiolytic effects of dexmedetomidine. METHODS: A social defeat stress mouse model was employed to evaluate the anxiolytic effects induced by dexmedetomidine through the elevated plus-maze, open-field test, and measurement of serum stress hormone levels. In vivo Ca2+ signal fibre photometry and ex vivo patch-clamp recordings were utilized to determine the excitability of CRHPVN neurons and investigate the specific mechanism involved. CRHPVN neuron modulation was achieved through chemogenetic activation or inhibition. RESULTS: Compared with saline, dexmedetomidine (40 µg/kg) alleviated anxiety-like behaviors. Additionally, dexmedetomidine reduced CRHPVN neuronal excitability. Chemogenetic activation of CRHPVN neurons decreased the time spent in the open arms of the elevated plus-maze and in the central area of the open-field test. Conversely, chemogenetic inhibition of CRHPVN neurons had the opposite effect. Moreover, the suppressive impact of dexmedetomidine on CRHPVN neurons was attenuated by the α2 receptor antagonist yohimbine. CONCLUSIONS: Our results indicate that the anxiety-like effects of dexmedetomidine are mediated via α2 adrenergic receptor-triggered inhibition of CRHPVN neuronal excitability in the hypothalamus.

Clinical application of a connection device consisting of a bag valve mask and nebulizer in first aid: Two case reports.

In clinical practice, several emergencies may threaten the life of patients, and these emergencies can be unpredictable and challenging. During the coronavirus disease 2019 pandemic, in January 2023, a patient developed respiratory distress caused by coronavirus, but was unable to access respiratory support due to shortages of medical resources, intensive care unit beds and ventilators. The medical staff quickly created a portable high-flow atomized oxygen therapy apparatus consisting of a simple breathing bag connected to a nebulizer to provide breathing support. In addition, the Ambulatory Surgery Center, The First Affiliated Hospital of Anhui Medical University (Hefei, China) witnessed a case of severe laryngeal spasm after tracheal extubation during the recovery period from general anesthesia. Due to the lack of an anesthesia machine nebulizer, the aforementioned device was used to provide oxygen under pressure and initiate treatment to quickly relieve the symptoms of laryngeal obstruction. The present case report describes how the medical staff quickly applied emergency airway management skills and knowledge to create a portable high-flow atomized oxygen therapy apparatus in a resource-poor setting to save the lives of two patients.

The Association of Preoperative Diabetes With Postoperative Delirium in Older Patients Undergoing Major Orthopedic Surgery: A Prospective Matched Cohort Study.

BACKGROUND: Postoperative delirium (POD) is a common form of postoperative brain dysfunction, especially in the elderly. However, its risk factors remain largely to be determined. This study aimed to investigate whether (1) preoperative diabetes is associated with POD after elective orthopedic surgery and (2) intraoperative frontal alpha power is a mediator of the association between preoperative diabetes and POD. METHODS: This was a prospective matched cohort study of patients aged 60 years or more, with a preoperative diabetes who underwent elective orthopedic surgery. Nondiabetic patients were matched 1:1 to diabetic patients in terms of age, sex, and type of surgery. Primary outcome was occurrence of POD, assessed using the 3-minute Diagnostic Confusion Assessment Method (3D-CAM) once daily from 6 pm to 8 pm during the postoperative days 1-7 or until discharge. Secondary outcome was the severity of POD which was assessed for all participants using the short form of the CAM-Severity. Frontal electroencephalogram (EEG) was recorded starting before induction of anesthesia and lasting until discharge from the operating room. Intraoperative alpha power was calculated using multitaper spectral analyses. Mediation analysis was used to estimate the proportion of the association between preoperative diabetes and POD that could be explained by intraoperative alpha power. RESULTS: A total of 138 pairs of eligible patients successfully matched 1:1. After enrollment, 6 patients in the diabetes group and 4 patients in the nondiabetes group were excluded due to unavailability of raw EEG data. The final analysis included 132 participants with preoperative diabetes and 134 participants without preoperative diabetes, with a median age of 68 years and 72.6% of patients were female. The incidence of POD was 16.7% (22/132) in patients with preoperative diabetes vs 6.0% (8/134) in patients without preoperative diabetes. Preoperative diabetes was associated with increased odds of POD after adjustment of age, sex, body mass index, education level, hypertension, arrhythmia, coronary heart disease, and history of stroke (odds ratio, 3.2; 95% confidence interval [CI], 1.4-8.0; P = .009). The intraoperative alpha power accounted for an estimated 20% (95% CI, 2.6-60%; P = .021) of the association between diabetes and POD. CONCLUSIONS: This study suggests that preoperative diabetes is associated with an increased risk of POD in older patients undergoing major orthopedic surgery, and that low intraoperative alpha power partially mediates such association.

Activating astrocytic α2A adrenoceptors in hippocampus reduces glutamate toxicity to attenuate sepsis-associated encephalopathy in mice.

BACKGROUND: Glutamate metabolism disorder is an important mechanism of sepsis-associated encephalopathy (SAE). Astrocytes regulate glutamate metabolism. In septic mice, α2A adrenoceptor (α2A-AR) activation in the central nervous system provides neuroprotection. α2A-ARs are expressed abundantly in hippocampal astrocytes. This study was performed to determine whether hippocampal astrocytic α2A-AR activation confers neuroprotection against SAE and whether this protective effect is astrocyte specific and achieved by the modulation of glutamate metabolism. METHODS: Male C57BL/6 mice with and without α2A-AR knockdown were subjected to cecal ligation and puncture (CLP). They were treated with intrahippocampal guanfacine (an α2A-AR agonist) or intraperitoneal dexmedetomidine in the presence or absence of dihydrokainic acid [DHK; a glutamate transporter 1 (GLT-1) antagonist] and/or UCPH-101 [a glutamate/aspartate transporter (GLAST) antagonist]. Hippocampal tissue was collected for the measurement of astrocyte reactivity, GLT-1 and GLAST expression, and glutamate receptor subunit 2B (GluN2B) phosphorylation. In vivo real-time extracellular glutamate concentrations in the hippocampus were measured by ultra-performance liquid chromatography tandem mass spectrometry combined with microdialysis, and in vivo real-time hippocampal glutamatergic neuron excitability was assessed by calcium imaging. The mice were subjected to the Barnes maze and fear conditioning tests to assess their learning and memory. Golgi staining was performed to assess changes in the hippocampal synaptic structure. In vitro, primary astrocytes with and without α2A-AR knockdown were stimulated with lipopolysaccharide (LPS) and treated with guanfacine or dexmedetomidine in the presence or absence of 8-bromo- cyclic adenosine monophosphate (8-Br-cAMP, a cAMP analog). LPS-treated primary and BV2 microglia were also treated with guanfacine or dexmedetomidine. Astrocyte reactivity, PKA catalytic subunit, GLT-1 an GLAST expression were determined in primary astrocytes. Interleukin-1ß, interleukin-6 and tumor necrosis factor-alpha in the medium of microglia culture were measured. RESULTS: CLP induced synaptic injury, impaired neurocognitive function, increased astrocyte reactivity and reduced GLT-1 and GLAST expression in the hippocampus of mice. The extracellular glutamate concentration, phosphorylation of GluN2B at Tyr-1472 and glutamatergic neuron excitability in the hippocampus were increased in the hippocampus of septic mice. Intraperitoneal dexmedetomidine or intrahippocampal guanfacine administration attenuated these effects. Hippocampal astrocytes expressed abundant α2A-ARs; expression was also detected in neurons but not microglia. Specific knockdown of α2A-ARs in hippocampal astrocytes and simultaneous intrahippocampal DHK and UCPH-101 administration blocked the neuroprotective effects of dexmedetomidine and guanfacine. Intrahippocampal administration of DHK or UCPH-101 alone had no such effect. In vitro, guanfacine or dexmedetomidine inhibited astrocyte reactivity, reduced PKA catalytic subunit expression, and increased GLT-1 and GLAST expression in primary astrocytes but not in primary astrocytes that received α2A-AR knockdown or were treated with 8-Br-cAMP. Guanfacine or dexmedetomidine inhibited microglial reactivity in BV2 but not primary microglia. CONCLUSIONS: Our results suggest that neurocognitive protection against SAE after hippocampal α2A-AR activation is astrocyte specific. This protection may involve the inhibition of astrocyte reactivity and alleviation of glutamate neurotoxicity, thereby reducing synaptic injury. The cAMP/protein kinase A (PKA) signaling pathway is a potential cellular mechanism by which activating α2A-AR modulates astrocytic function.

Donor and recipient age matching in lung transplantation: A retrospective study.

Purpose: This study aimed to clarify the effect of donor and recipient age combinations on the short-term survival rates of patients undergoing lung transplantation. Patients and methods: We retrospectively reviewed the 2017-2020 data of the Affiliated Wuxi People's Hospital of Nanjing Medical University database for all adults (≥18 years), lung transplant recipients, and their associated donors. The impact of donor and recipient ages on survival was analyzed using a multivariable Cox proportional hazards regression model. Subgroup analysis was also performed based on recipient and donor ages. Results: Different donor and recipient age combinations affected the short-term postoperative survival rates. When recipients were ≤55 years, the survival rates of the younger donor age group were significantly higher than the older donor age group at 30 days after surgery (P = 0.040); when the donors were ≤40 years, the postoperative survival rates of the younger recipient age group were significantly higher than the older recipient age group (P = 0.031, P = 0.026, P = 0.034, and P = 0.018 for 30 days, 90 days, 180 days, and 1 year after surgery, respectively). Conclusion: Younger recipients had a higher survival rate after transplantation than older recipients, and this benefit could be compromised by older donors. Furthermore, the influence of donor age on patient survival rate was limited and more pronounced in younger recipients and shortly after surgery.

Successful hybrid endovascular treatment for refractory cerebral venous sinus thrombosis in pregnancy: A case report.

Background: Cerebral venous sinus thrombosis (CVST) in pregnancy was common and endovascular treatment (EVT) could be an effective and safe treatment for patients with severe and refractory CVST. However, the efficacy and safety of hybrid EVT (craniotomy + endovascular treatment) for CVST were unknown. We represented a rare case of hybrid EVT through the incision of the superior sagittal sinus in a pregnant woman with CVST who failed to EVT through the femoral vein pathway. Case presentation: A 26-year-old woman, in her second month of pregnancy, complained of a headache for 5 days and aggravation with coma combined with convulsions for 2 days. She was diagnosed with CVST in the local hospital by digital subtraction angiography (DSA) and treated with anticoagulation. She had no history of illness and the biochemical tests were normal. Hybrid EVT (craniotomy + EVT) was attempted after failing to conduct EVT through the femoral vein pathway due to difficulty to reach the target cerebral venous sinus. Briefly, a small hole was made in the frontotemporal head to expose the superior sagittal sinus and a 6F sheath was inserted into 2cm of superior sagittal sinus incision and fixed on the scalp, after repeated aspiration by 5F intermediate catheter and balloon dilatation of stenosis in the right transverse sinus and right sigmoid sinus, the cerebral venous system got successful recanalization. No obvious complications were found and the patient recovered very well after the surgery. Conclusion: Anticoagulation was the standard treatment for CVST. EVT could rapidly restore venous flow and improve the prognosis for refractory and severe CVST. EVT by hybrid surgery through the superior sagittal sinus incision may be safe and effective for desperate patients with severe CVST.

Prognosis and Prediction of Asymptomatic Intracranial Hemorrhage After Endovascular Thrombectomy: A Multi-Center Study.

PURPOSE: The impact of asymptomatic intracranial hemorrhage (aICH) on functional outcomes after endovascular thrombectomy (EVT) remains unclear, and tools for forecasting this complication are lacking. We aim to evaluate the clinical relevance of aICH and establish a prediction model. METHODS: Data of patients who received EVT for acute anterior-circulation large vessel occlusion in 3 comprehensive hospitals were retrospectively analyzed. Asymptomatic intracranial hemorrhage was defined as any hemorrhage detected after EVT that did not fulfill the definition of symptomatic intracranial hemorrhage in the European Cooperative Acute Stroke Study. Logistic regression models were performed to assess the impact of aICH on 90-day functional outcomes and identify the predictors of aICH, which were then used to establish a prediction model. The discrimination, calibration, and clinical utility of the model were evaluated. RESULTS: This study included 460 patients, among whom 152 (33.0%) developed aICH after EVT. Asymptomatic intracranial hemorrhage was negatively associated with 90-day excellent outcomes (adjusted odds ratio [OR]: 0.414, 95% confidence interval [CI]: 0.230-0.745, p=0.003) and good outcome (adjusted OR: 0.603, 95% CI: 0.374-0.971, p=0.037), but not with mortality (adjusted OR: 1.110, 95% CI: 0.611-2.017, p=0.732) after adjusted for other predictors of functional outcome. Pre-stroke anticoagulant therapy (OR: 2.233, 95% CI: 1.073-4.647, p=0.032), Alberta stroke program early CT score (OR: 0.842, 95% CI: 0.754-0.939, p=0.002), site of occlusion (internal carotid artery occlusion as the reference; M1 segment of middle cerebral artery occlusion, OR: 2.827, 95% CI: 1.409-5.674, p=0.003; tandem occlusion, OR: 3.928, 95% CI: 1.752-8.806, p=0.001), intravenous thrombolysis (OR: 2.091, 95% CI: 1.362-3.209, p=0.001), and successful recanalization (OR: 0.383, 95% CI: 0.213-0.689, p=0.001) were identified as the predictors of aICH, which were incorporated into a nomogram model. The area under the receiver operating characteristic curve of the model was 0.707 (95% CI: 0.657-0.757), and the calibration plot demonstrated good consistency between actual observed and predicted probability of aICH. Decision curve analysis showed that patients might benefit from the model. CONCLUSION: Asymptomatic intracranial hemorrhage was negatively associated with favorable functional outcome after EVT. We established a nomogram model for predicting aICH, which requires external clinical validation. CLINICAL IMPACT: The impact of asymptomatic intracranial hemorrhage after endovascular thrombectomy on mid-term functional outcome has been controversial. We found that asymptomatic intracranial hemorrhage may also decreased the likelihood of 90-day favourable functional outcome after endovascular thrombectomy, supporting the notion that asymptomatic intracranial hemorrhage at the acute stage may not be benign. Moreover, we established a prediction model for this complication, which may improve clinical evaluation and management of patients who would receive endovascular thrombectomy for large vessel occlusion.

Case report: Retrograde endovascular recanalization of vertebral artery occlusion with non-tapered stump via the deep cervical collateral.

Introduction: Vertebral artery (VA) occlusive disease is the major cause of posterior circulation ischemic stroke. Endovascular recanalization has been reported as a feasible treatment for patients with symptomatic VA occlusion refractory to optimal medical therapy. However, VA occlusion with non-tapered stump exhibits a low technique success rate when treated by antegrade endovascular therapy because of increased difficulty in passing the guidewire into the occluded segment. Herein, we presented a novel endovascular approach to recanalize chronically occluded VA with a non-tapered stump using a retrograde method via the deep cervical collateral, which has not been reported before. Case presentation: The present case was a patient with VA ostial occlusion with non-tapered stump and distal severe stenosis of the left VA who had recurrent posterior circulation transit ischemic attacks under optimal medical therapy. CT angiography demonstrated proximal non-tapered occlusion and distal severe stenosis of the left VA, and that the right VA did not converge with the left VA into basilar artery. Endovascular treatment was recommended and performed on this patient. However, antegrade endovascular recanalization of the left VA origin occlusion failed because the micro guidewire was unable to traverse the occluded segment. Fortunately, robust collateral from the deep cervical artery to the V3 segment of the left VA developed, in which we advanced the micro guidewire to the V3 segment of the left VA and reversely passed the micro guidewire through the occluded segment. Then, the occlusion and stenosis of the left VA were successfully resolved with angioplasty and stenting. After the procedure, the patient reported no neurological symptoms under medical therapy during 3-month follow-up. Conclusion: Antegrade endovascular recanalization of VA occlusion with a non-tapered stump is a challenge. The retrograde endovascular method via the cervical collateral may be an alternative for this type of VA occlusion, which requires further exploration.

Influence of low-dose esketamine on postoperative depressive symptoms in patients with breast cancer (EASE): study protocol for a randomised controlled trial.

INTRODUCTION: Depressive symptoms have surfaced as the principal mental health concern among patients with breast cancer, with surgical interventions potentially exacerbating these symptoms and adversely influencing clinical outcomes. This study protocol is designed to investigate the efficacy of low-dose esketamine administered perioperatively on depressive symptoms in patients with breast cancer. It also aims to illuminate the potential neurobiological underpinnings of this effect. METHODS AND ANALYSIS: This research represents a single-centre, prospective, randomised, double-blind, placebo-controlled study. The trial anticipates enrolling 108 female patients exhibiting mild-to-severe depressive symptoms who are slated for radical mastectomy. Through stratified randomisation, eligible patients will be systematically assigned to either the esketamine group (0.25 mg/kg) or placebo group (0.9% saline) in a 1:1 ratio. The primary outcome is the response rate at the third postoperative day. Secondary outcomes encompass the remission rate, depression-related scores, depression severity and safety-related endpoints. Tertiary (exploratory) outcomes involve alterations in brain-derived neurotrophic factor and resting-state functional brain connectivity. ETHICS AND DISSEMINATION: The Clinical Trial Ethics Committee at The First Affiliated Hospital of Anhui Medical University has conferred ethical approvals for this trial (approval number: PJ2023-05-25). Results from this trial will be disseminated in peer-reviewed journals and presented at professional symposiums. TRIAL REGISTRATION NUMBER: Chinese Clinical Trials Registry (ChiCTR2300071062).

Proximal hyperdense middle cerebral artery sign is associated with increased risk of asymptomatic hemorrhagic transformation after endovascular thrombectomy: a multicenter retrospective study.

OBJECTIVE: To investigate whether hyperdense middle cerebral artery sign (HMCAS) on pretreatment no-contrast CT (NCCT) is associated with hemorrhagic transformation (HT) after endovascular thrombectomy (EVT). METHODS: Patients with acute middle cerebral artery (MCA) occlusion who received EVT in three comprehensive hospitals were retrospectively evaluated. They were divided into four groups based on the presence or absence of HMCAS and corresponding CTA findings, among whom differences were compared. Univariate and multivariate logistic regression analyses were performed to investigate the association between HMCAS and HT and its subtypes. RESULTS: 318 patients were included, among whom 149 (46.9%) had HMCAS. Patients in the proximal positive HMCAS group had higher National Institute of Health Stroke Scale scores and lower Alberta Stroke Program Early CT Scores (ASPECTS) than those in the proximal negative HMCAS group. The rate of HT was higher in the proximal positive HMCAS group than that in the proximal negative HMCAS group. In multivariate logistic regression analysis, the proximal HMCAS were independently associated with HT (adjusted OR = 2.073, 95% CI 1.211-3.551, p = 0.008) and aHT (adjusted OR = 2.271, 95% CI 1.294-3.986, p = 0.004), but not with sHT. Patients who developed HT, including aHT and sHT, had a lower rate of good outcome. CONCLUSION: Proximal HMCAS on initial NCCT was independently associated with aHT in patients who received EVT for acute MCA occlusion. Both aHT and sHT had a detrimental effect on clinical outcome.

Risk Assessment of Major Adverse Cardiovascular and Cerebrovascular Events and Bleeding for Acute Myocardial Infarction With or Without Active Tuberculosis.

PURPOSE: The underlying ischemic and bleeding risks of acute myocardial infarction (AMI) with active tuberculosis (TB) are unknown. The goal of this study was to explore the ischemic and bleeding risks, as well as treatment strategies during hospitalization, in patients with AMI with or without active TB. METHODS: Patients were recruited from a tuberculosis hospital from 2014 to 2021. The primary outcomes were major cardiovascular and cerebrovascular events (MACE) and Bleeding Academic Research Consortium (BARC)-defined type 3 or 5 bleeding. Multivariate logistic regression and propensity score matching were performed for risk adjustment. Subgroups were defined according to AMI with active pulmonary TB and AMI with active TB undergoing percutaneous coronary intervention (PCI). FINDINGS: A total of 242 patients were enrolled. Compared with AMI without active TB, AMI with active TB had a higher risk of MACE and BARC type 3 or 5 bleeding (P < 0.001 and P = 0.002, respectively). Multivariate logistic regression analysis showed that, compared with AMI without active TB, the odds ratio (OR) was 6.513 (95% CI, 2.195-19.331) for MACE in patients with AMI with active TB, and the OR was 16.074 (95% CI 3.337-77.436) for BARC type 3 or 5 bleeding in patients with AMI with active TB. After propensity score matching, AMI with active TB tended to increase the risk of MACE, although not statistically significantly (P = 0.189), and increased BARC type 3 or 5 bleeding (P < 0.001), compared with AMI without active TB. Results of subgroup analyses showed that active TB had outcomes consistent with those of the total cohort. AMI patients with active pulmonary TB who underwent PCI had a lower risk of MACE without an increase in the risk of bleeding compared with those not undergoing PCI. IMPLICATIONS: Patients with AMI with active TB have a higher risk of MACE (or severe MACE) and bleeding than patients with AMI without active TB. However, AMI patients with active TB are still advised to undergo PCI for a high net clinical benefit.

The Impact of Morning Surgery or Afternoon Surgery on Postoperative Sleep Quality and Melatonin Levels of Elderly Patients: A Prospective, Randomized Study.

Objective: Postoperative sleep disturbance after surgery is not conducive to the recovery of patients. The purpose of this study was to determine the influence of the timing of surgery (morning vs afternoon) on the postoperative sleep quality of elderly patients and to analyze the relationship between the timing of surgery and the change in the melatonin level. Methods: Sixty patients who received hip surgery were randomly assigned to the Morning Group (Group M) or the Afternoon Group (Group A). The sleep quality was assessed by the Richards-Campbell Sleep Questionnaire. Before and after surgery, the nocturnal urine was collected over a 12-h period, and the 6-sulfatoxymelatonin concentration was measured. Also, the incidence of postoperative delirium (POD) was observed. Results: On the first and second nights after surgery, the sleep quality scores of the patients in Group A were greater than those in Group M, and there was no difference in the sleep quality scores between the two groups on the third night after surgery (P=0.000, P=0.002, P>0.05, respectively). In addition, the urine 6-sulphatoxymelatonin concentration was found to be greater in Group A than in Group M on the first night of surgery (P=0.00). Both the postoperative sleep quality scores and urine 6-sulphatoxymelatonin concentration were significantly less than those before surgery (P=0.00, P=0.00). Conclusion: The postoperative sleep quality scores and melatonin levels of elderly patients who received hip surgery under general anesthesia were significantly less than those of the patients before surgery. Furthermore, the short-term sleep quality of the patients who received surgery in the afternoon was better than that of the patients who received surgery in the morning. This difference may be related to the short-term change of the melatonin level after surgery.

A Nomogram for Predicting Symptomatic Intracranial Hemorrhage after Endovascular Thrombectomy.

BACKGROUND: Symptomatic intracranial hemorrhage (sICH) is a devastating complication of endovascular thrombectomy (EVT). We aim to develop and validate a nomogram for predicting sICH in patients with large vessel occlusion (LVO) in the anterior circulation. METHODS: We performed a single-center retrospective analysis on collected data from patients undergoing EVT for LVO in the anterior circulation between January 2018 and December 2021. Forward stepwise logistic regression was performed to identify independent predictors of sICH and establish a nomogram. The discrimination and calibration of the model was accessed using the area under the receiver operating characteristic curve (AUC-ROC) and calibration plot. The model was internally validated using bootstrap and 5-fold cross-validation. RESULTS: 243 patients were included, among whom 23 developed sICH (9.5%). After multivariate logistic regression, baseline glucose level (odds ratio [OR], 1.16; p = 0.022), Alberta Stroke Program Early CT Score (OR, 0.44; p < 0.001), regional Leptomeningeal Collateral score (OR, 0.74; p < 0.001) were identified as independent predictors of sICH, which were then incorporated into a predictive nomogram. The ROC curve of the model showed good discriminative ability with an AUC of 0.856 (95% CI: 0.785-0.928). The calibration plot of the model demonstrated good consistency between the actual observed and the predicted probability of sICH. The model was internally validated by using bootstrap (1000 resamples) with an AUC of 0.835 (95%CI: 0.782-0.887) and 5-fold cross-validation with an AUC of 0.831 (95%CI: 0.775-0.887). CONCLUSION: Our model is a reliable tool to predict sICH after EVT. Although the model was internally validated, further external validation is also warranted.

Clot Meniscus Sign Is Associated With Thrombus Permeability and Choice of Mechanical Thrombectomy Technique in Acute Middle Cerebral Artery Occlusion.

Background and Purpose: The method of mechanical thrombectomy (MT) is related to vascular anatomy and stroke etiology. Meniscus sign and thrombus permeability as imaging markers may be instructive for the selection of MT. This study aims to clarify the relationship among meniscus sign, thrombus permeability, and choice of MT in patients with acute middle cerebral artery occlusion. Materials and Methods: A total of 111 patients with acute middle cerebral artery occlusion (MCAO) who underwent MT were retrospectively analyzed. Clot meniscus sign was defined as the appearance of meniscoid/edge-like or single- or double-wall contrast channels besides or around insular blood clots. The radiographic, clinical, and surgical data of patients with MCAO with or without meniscus sign were compared. Results: The meniscus sign positive group (n = 26) has higher thrombus permeability (HUs) (26.92 ± 9.69 vs. 22.84 ± 7.88, p = 0.031) than those without it. Shorter puncture-to-recanalization (P2R) time (65.5 vs. 88, p = 0.012), higher complete recanalization rate (85.71 vs. 33.33%, p < 0.01), and better clinical outcome (p < 0.01) were obtained by selecting contact aspiration (CA) over stent retriever (SR) in patients with positive meniscus sign. In patients with negative meniscus sign, there was no significant difference in clinical outcome after receiving CA or SR. Conclusion: Patients with MCAO with positive meniscus sign have higher thrombus permeability and are more suitable for CA to acquire better clinical outcomes.

Effect of Different Modes of Administration of Dexmedetomidine Combined with Nerve Block on Postoperative Analgesia in Total Knee Arthroplasty.

INTRODUCTION: Dexmedetomidine (DEX) as a nerve block adjuvant can significantly prolong analgesia. However, whether perineural or systemic administration of DEX is more beneficial in patients undergoing total knee arthroplasty (TKA) has not been thoroughly investigated. To this end, we evaluated the effects of perineural and systemic DEX administration on postoperative analgesia in patients undergoing TKA surgery. METHODS: We randomly assigned patients undergoing TKA under general anesthesia combined with femoral nerve block and sciatic nerve block to one of three groups: (1) ropivacaine plus perineural dexmedetomidine (DP): 0.25% ropivacaine 40 mL plus 0.5 µg/kg dexmedetomidine; (2) ropivacaine plus systemic dexmedetomidine (DS): 0.25% ropivacaine 40 mL plus systemic 0.5 µg/kg dexmedetomidine; (3) control group (C): 0.25% ropivacaine 40 mL. RESULTS: The average length of time until patients first experienced postoperative pain was significantly longer in the DP group (26.0 h [22.0-30.0 h]) than in the DS group (22.4 h [18-26.8 h]) and the control group (22.9 h [19.5-26.3 h], P = 0.001). For this result there was no significant difference between the DS and the control group. Compared with the DS and control groups, patients in the DP group had lower resting visual analogue scale (VAS) scores at 24, 48, and 72 h after surgery (P < 0.05). VAS activity scores at 12, 24, and 48 h after surgery in the DP group were lower than those in the DS and control groups, with a statistically significant difference (P < 0.05). Compared with the DS and control groups, the amount of postoperative opioids in the DP group was also significantly reduced, and the number of people needing postoperative rescue analgesia was significantly lower, with a statistical difference (P < 0.05). Meanwhile, the sleep satisfaction of patients in the DP group on the first night after surgery and the satisfaction with pain control at 72 h after surgery were both higher than those in the DS group and control group (P < 0.05). CONCLUSIONS: Perineural administration of DEX can significantly prolong the interval until patients report pain for the first time after TKA, relieve postoperative pain, reduce postoperative opioid dosage, and improve postoperative sleep quality and satisfaction with pain control. TRIAL REGISTRATION: The trial was registered at the Chinese Clinical Trial Registry, identifier ChiCTR1900025808.

Clinical Characteristics and Factors Associated with Disease Progression of Mild to Moderate COVID-19 Patients in a Makeshift (Fangcang) Hospital: A Retrospective Cohort Study.

OBJECTIVE: Information regarding the epidemiology and clinical features of mild to moderate patients caused by COVID-19 in Fangcang Hospital is scarce. Through a retrospective cohort study, the clinical characteristics of COVID-19 patients in Dongxihu Fangcang shelter hospitals were analyzed, and the factors that affected the disease progression of COVID-19 patients were explored. METHODS: The clinical characteristics of 714 patients with COVID-19 were retrospectively analyzed at Dongxihu Fangcang Hospital between February 7 and March 8, 2020. We described the clinical characteristics and distribution of discharge or transfer times for each patient. According to the disease progression of COVID-19 patients, we divided all patients into Non-Deteriorated group and Deteriorated group. Furthermore, binary logistic regression was used for a single outcome and multiple response variables. RESULTS: We treated 789 patients with mild and moderate COVID-19, of which 714 were included in this study, which included 326 (45.66%) deteriorated patients and 388 (54.34%) non-deteriorated patients. The mean age of the study population was 48.16±12.44 years. Of all patients, 319 (44.7%) were men and 395 (55.3%) were women. The average length of the patient's stay was 16.08±5.13 days. The most common clinical feature on admission was fever (593 of 714, 83.05%). It is worth noting that 80 (11.20%) of the 714 patients were asymptomatic from exposure to admission. Multivariate logistic regression analysis showed that gender, age, diabetes, respiratory system disease, fever, dyspnea, and nasal congestion were risk factors associated with deterioration in cases with COVID-19 patients, and asymptomatic (OR: 0.058; 95% CI: 0.022-0.155; P<0.001) was the protective factor for deterioration of COVID-19 patients. CONCLUSION: Accompanied by chronic diseases, old age, fever, nasal congestion, and dyspnea were factors that influenced the aggravation of COVID-19 patients, and more attention and treatment should be given to these patients.

Characteristics of 1738 Patients With Coronavirus Disease 2019 (COVID-19) in Wuhan, China.

OBJECTIVE: Since December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been discovered in Wuhan and spread rapidly across China and worldwide. Characteristics of infected patients are needed to get insight into the full spectrum of the disease. METHODS: Epidemiological and clinical information of 1738 diagnosed patients during February 7-26, 2020 in Wuhan Dongxihu Fangcang Hospital were analyzed. A total of 709 patients were followed up on symptom, mental health, isolation site, and medication after discharge. RESULTS: There were 852 males and 886 females in the cohort. The average age of the patients was 48.8 y. A total of 79.98% of the patients were from Wuhan, Hubei Province. The most common initial symptoms were fever, cough, and shortness of breath. Among all the patients, 1463 had complications, with respiratory distress as the most common complication. The average duration of hospitalization was 15.95 ± 14.69 d. The most common postdischarge symptom is cough. After discharge, most patients were full of energy and chose hotel as their self-isolation site. Coronavirus disease 2019 (COVID-19) Chinese medicine No.2 prescription is the medication used most commonly by the patients after discharge. CONCLUSIONS: The population is generally susceptible to SARS-CoV-2. After receiving aggressive treatment of combined Chinese and Western medicine, most patients had a good prognosis and mental health after discharge.