Structural Basis of the Differential Function of the Two C. elegans Atg8 Homologs, LGG-1 and LGG-2, in Autophagy.

Multicellular organisms have multiple homologs of the yeast ATG8 gene, but the differential roles of these homologs in autophagy during development remain largely unknown. Here we investigated structure/function relationships in the two C. elegans Atg8 homologs, LGG-1 and LGG-2. lgg-1 is essential for degradation of protein aggregates, while lgg-2 has cargo-specific and developmental-stage-specific roles in aggregate degradation. Crystallography revealed that the N-terminal tails of LGG-1 and LGG-2 adopt the closed and open form, respectively. LGG-1 and LGG-2 interact differentially with autophagy substrates and Atg proteins, many of which carry a LIR motif. LGG-1 and LGG-2 have structurally distinct substrate binding pockets that prefer different residues in the interacting LIR motif, thus influencing binding specificity. Lipidated LGG-1 and LGG-2 possess distinct membrane tethering and fusion activities, which may result from the N-terminal differences. Our study reveals the differential function of two ATG8 homologs in autophagy during C. elegans development.

Inhibition of visfatin alleviates sepsis-induced intestinal damage by inhibiting Hippo signaling pathway.

BACKGROUND: The aim of this study is to investigate role of Visfatin, one of the pro-inflammatory adipokines, in sepsis-induced intestinal injury and to clarify the potential mechanism. METHODS: C57BL/6 mice underwent cecal ligation and puncture (CLP) surgery to establish sepsis model in vivo. Intestinal epithelial cells were stimulated with LPS to mimic sepsis-induced intestinal injury in vitro. FK866 (the inhibitor of Visfatin) with or without XMU-MP-1 (the inhibitor of Hippo signaling) was applied for treatment. The expression levels of Visfatin, NF-κB and Hippo signaling pathways-related proteins were detected by western blot or immunohistochemistry. The intestinal cell apoptosis and intestinal injury were investigated by TUNEL staining and H&E staining, respectively. ELISA was used to determine the production of inflammatory cytokines. RESULTS: The expression of Visfatin increased in CLP mice. FK866 reduced intestinal pathological injury, inflammatory cytokines production, and intestinal cell apoptosis in sepsis mice. Meanwhile, FK866 affected NF-κB and Hippo signaling pathways. Additionally, the effects of FK866 on inflammatory response, apoptosis, Hippo signaling and NF-κB signaling were partly abolished by XMU-MP-1, the inhibitor of Hippo signaling. In vitro experiments also revealed that FK866 exhibited a protective role against LPS-induced inflammatory response and apoptosis in intestinal cells, as well as regulating NF-κB and Hippo signaling, whereas addition of XMU-MP-1 weakened the protective effects of FK866. CONCLUSION: In short, this study demonstrated that inhibition of Visfatin might alleviate sepsis-induced intestinal injury through Hippo signaling pathway, supporting a further research on Visfatin as a therapeutic target.

Effectiveness of intraoperative cell salvage combined with a modified leucocyte depletion filter in metastatic spine tumour surgery.

BACKGROUND: To compare the effectiveness of intraoperative cell salvage (IOCS) combined with a modified leucocyte depletion filter (MLDF) with IOCS combined with a regular leucocyte depletion filter (RLDF) in eliminating tumour cells from blood salvage during metastatic spine tumour surgery (MSTS). METHODS: Patients with a known primary epithelial tumour who underwent MSTS were recruited for this study. Blood samples were collected in 5 stages: from the patients' vein before anaesthesia induction (S1), from the operative field at the time of maximum tumour manipulation (S2), and from the operative blood after IOCS processing (S3) and after IOCS+RLDF (S4) and IOCS+MLDF (S5) processing. The polyploids of tumour cells in the blood samples were collected and counted with immunomagnetic separation enrichment and fluorescence in situ hybridization. RESULTS: We recruited 20 patients. Tumour cells were detected in 14 patients (70%) in S1, 16 patients (80%) in S2, 13 patients (65%) in S3, and 12 patients (60%) in S4. MLDF was added in 8 patients. Tumour cells were detected in only 1 of 8 patients in S5 (12.5%). There were significantly fewer tumour cells in the samples collected after MLDF processing (S5) than in the samples collected after RLDF (S4) and around the tumour (S2) (P = 0.016 and P = 0.039, respectively). Although no significant difference was observed between S4 and S1, a downward trend was observed after IOCS+RLDF processing. CONCLUSIONS: Tumour cells could be removed by IOCS combined with RLDF from blood salvaged during MSTS, but residual tumour cells remained. The findings support the notion that MLDF eliminates tumour cells more effectively than RLDF. Hence, this technique can be applied to MSTS. TRIAL REGISTRATION: ChiCTR1800016162 Chinese Clinical Trial Registry.

Delirium in Older Patients after Combined Epidural-General Anesthesia or General Anesthesia for Major Surgery: A Randomized Trial.

BACKGROUND: Delirium is a common and serious postoperative complication, especially in the elderly. Epidural anesthesia may reduce delirium by improving analgesia, reducing opioid consumption, and blunting stress response to surgery. This trial therefore tested the hypothesis that combined epidural-general anesthesia reduces the incidence of postoperative delirium in elderly patients recovering from major noncardiac surgery. METHODS: Patients aged 60 to 90 yr scheduled for major noncardiac thoracic or abdominal surgeries expected to last 2 h or more were enrolled. Participants were randomized 1:1 to either combined epidural-general anesthesia with postoperative epidural analgesia or general anesthesia with postoperative intravenous analgesia. The primary outcome was the incidence of delirium, which was assessed with the Confusion Assessment Method for the Intensive Care Unit twice daily during the initial 7 postoperative days. RESULTS: Between November 2011 and May 2015, 1,802 patients were randomized to combined epidural-general anesthesia (n = 901) or general anesthesia alone (n = 901). Among these, 1,720 patients (mean age, 70 yr; 35% women) completed the study and were included in the intention-to-treat analysis. Delirium was significantly less common in the combined epidural-general anesthesia group (15 [1.8%] of 857 patients) than in the general anesthesia group (43 [5.0%] of 863 patients; relative risk, 0.351; 95% CI, 0.197 to 0.627; P < 0.001; number needed to treat 31). Intraoperative hypotension (systolic blood pressure less than 80 mmHg) was more common in patients assigned to epidural anesthesia (421 [49%] vs. 288 [33%]; relative risk, 1.47, 95% CI, 1.31 to 1.65; P < 0.001), and more epidural patients were given vasopressors (495 [58%] vs. 387 [45%]; relative risk, 1.29; 95% CI, 1.17 to 1.41; P < 0.001). CONCLUSIONS: Older patients randomized to combined epidural-general anesthesia for major thoracic and abdominal surgeries had one third as much delirium but 50% more hypotension. Clinicians should consider combining epidural and general anesthesia in patients at risk of postoperative delirium, and avoiding the combination in patients at risk of hypotension.

Long-term Survival after Combined Epidural-General Anesthesia or General Anesthesia Alone: Follow-up of a Randomized Trial.

BACKGROUND: Experimental and observational research suggests that combined epidural-general anesthesia may improve long-term survival after cancer surgery by reducing anesthetic and opioid consumption and by blunting surgery-related inflammation. This study therefore tested the primary hypothesis that combined epidural-general anesthesia improves long-term survival in elderly patients. METHODS: This article presents a long-term follow-up of patients enrolled in a previous trial conducted at five hospitals. Patients aged 60 to 90 yr and scheduled for major noncardiac thoracic and abdominal surgeries were randomly assigned to either combined epidural-general anesthesia with postoperative epidural analgesia or general anesthesia alone with postoperative intravenous analgesia. The primary outcome was overall postoperative survival. Secondary outcomes included cancer-specific, recurrence-free, and event-free survival. RESULTS: Among 1,802 patients who were enrolled and randomized in the underlying trial, 1,712 were included in the long-term analysis; 92% had surgery for cancer. The median follow-up duration was 66 months (interquartile range, 61 to 80). Among patients assigned to combined epidural-general anesthesia, 355 of 853 (42%) died compared with 326 of 859 (38%) deaths in patients assigned to general anesthesia alone: adjusted hazard ratio, 1.07; 95% CI, 0.92 to 1.24; P = 0.408. Cancer-specific survival was similar with combined epidural-general anesthesia (327 of 853 [38%]) and general anesthesia alone (292 of 859 [34%]): adjusted hazard ratio, 1.09; 95% CI, 0.93 to 1.28; P = 0.290. Recurrence-free survival was 401 of 853 [47%] for patients who had combined epidural-general anesthesia versus 389 of 859 [45%] with general anesthesia alone: adjusted hazard ratio, 0.97; 95% CI, 0.84 to 1.12; P = 0.692. Event-free survival was 466 of 853 [55%] in patients who had combined epidural-general anesthesia versus 450 of 859 [52%] for general anesthesia alone: adjusted hazard ratio, 0.99; 95% CI, 0.86 to 1.12; P = 0.815. CONCLUSIONS: In elderly patients having major thoracic and abdominal surgery, combined epidural-general anesthesia with epidural analgesia did not improve overall or cancer-specific long-term mortality. Nor did epidural analgesia improve recurrence-free survival. Either approach can therefore reasonably be selected based on patient and clinician preference.

Conformational Space of a Polyphilic Molecule with a Fluorophilic Side Chain Integrated in a DPPC Bilayer.

We investigate the conformational space of a polyphilic molecule with hydrophilic, lipophilic and fluorophilic parts inserted as a transmembrane agent into a dipalmitoylphosphatidylcholine bilayer by means of all-atom molecular dynamics simulations. Special focus is put on the competing structural driving forces arising from the hydrophilic, lipophilic and fluorophilic side chains and the aromatic backbone of the polyphile. We observe a significant difference between the lipophilic and the fluorophilic side chains regarding their intramembrane distribution. While the lipophilic groups remain membrane-centered, the fluorophilic parts tend to orient toward the phosphate headgroups. This trend is important for understanding the influence of polyphile agents on the properties of phospholipid membranes. From a fundamental point of view, our computed distribution functions of the side chains are related to the interplay of sterical, enthalpic and entropic driving forces. Our findings illustrate the potential of rationally designed membrane additives which can be exploited to tune the properties of phospholipid membranes. © 2017 Wiley Periodicals, Inc.

Neck circumference to inter-incisor gap ratio: a new predictor of difficult laryngoscopy in cervical spondylosis patients.

BACKGROUND: Preoperative airway assessment help anticipate a difficult airway. We hypothesized that a close association existed between difficult laryngoscopy and the neck circumference/inter-incisor gap ratio (RNIIG). Our aim was to determine its utility in predicting difficult laryngoscopy in cervical spondylosis patients. METHODS: Two hundred thirteen consecutive patients, aged 20-70 years, scheduled to undergo cervical spine surgery under general anesthesia, were recruited. Preoperative assessments included inter-incisor gap (IIG), thyromental distance (TMD), neck circumference (NC), NC/IIG ratio (RNIIG), NC/TMD ratio (RNTMD) and modified Mallampati test (MMT). Cormack-Lehane scales were assessed during intubation. The anesthesiologist was blinded to the airway assessments. RNIIG's ability to predict difficult laryngoscopy was compared with that of established predictors. RESULTS: Difficult laryngoscopy incidence was 16.4%. Univariate analysis showed that male gender, increased age, weight, NC, RNIIG and RNTMD, decreased IIG and TMD, and MMT 3 and 4 were associated with difficult laryngoscopy. Binary multivariate logistic regression analyses identified only one factor that was independently associated with difficult laryngoscopy: RNIIG. The odds ratio and 95% confidence interval (95% CI) were 1.932 (1.504-2.482). RNIIG (≥9.5) exhibited the largest area under the curve (0.80; 95% CI 0.73-0.86) and the highest sensitivity (88.6%; 95% CI 78.1-99.1) and negative predictive value (96.6%; 95% CI 94.0-99.2), confirming its better predictive ability. CONCLUSIONS: RNIIG is a new and simple predictor with a higher level of efficacy, and could help anesthetists plan for difficult laryngoscopy management in cervical spondylosis patients. TRIAL REGISTRATION: ChiCTR-OON-16008320 (April 19th, 2016).

[The Advancement of Attenuated Total Reflection Fourier Transform Infrared Technology in Clinical Application].

The authors systemically reviewed the fast development of attenuated total reflection Fourier transform infrared (ATR-FTIR) spectroscopy and its clinical application in the past decades. The advantages of this objective technique include real time scanning, easy manipulation and no harm to the subjects examined. Combined with pattern recognition methodology and further confirmation with the clinical and pathological diagnosis, the goal of fast differentiation of malignancy from benign lesions could be achieved. ATR-FTIR spectroscopy technique has shown high differential capacity for benign and malignant tissues such as thyroid, breast and pulmonary diseases. ATR-FTIR spectroscopy has being applied in investigating the differential value (the sensitivity, specificity, and accuracy) of metastatic lymph nodes in thyroid and breast cancer with encouraging results. ATR-FTIR technique would become a promising tool in tissue diagnosis intra-operatively. ATR-FTIR spectroscopy has also been widely applied in detecting bio-fluid to differentiate diseases. The serum ATR-FTIR spectroscopy has the ability of reflecting disease-related information in a fingerprint manner with little amount of blood. Several published articles have covered diseases such as glioma, chest pain, prostate cancer, renal failure, Alzheimer's disease, and ovarian cancer. The results of these researches have proved the efficacious discriminate value of this method. As ATR-FTIR spectroscopy has the potential of fast analysis, accurate diagnosis, and low cost-effective value. It would become one of the most important assisting diagnosis tools in future. Follow-up study should focus on enhancing sample quality and enlarging sample size to have further prospective clinical application.

Dexmedetomidine versus remifentanil for sedation during awake intubation using a Shikani optical stylet: a randomized, double-blinded, controlled trial.

BACKGROUND: The purpose of this study was to compare the efficacy and safety of dexmedetomidine versus remifentanil for sedation during awake intubation using a Shikani optical stylet (SOS). METHODS: Sixty-eight patients with cervical trauma or severe cervical spondylosis undergoing cervical spinal surgery were enrolled in this prospective study. They were randomly assigned to receive dexmedetomidine (Group D) or remifentanil (Group R). In Group D, the patients received an intravenous loading dose of dexmedetomidine 1 µg · kg(-1) over 10 min followed by a continuous infusion of 0.7 µg · kg(-1) · h(-1). In Group R, a target-controlled infusion of remifentanil was administered to achieve a plasma concentration of 2.5 ng · ml(-1), increased to 3 ng · ml(-1) 10 min later. An endotracheal tube was inserted using a SOS under dexmedetomidine or remifentanil sedation after topical anesthesia to the airway. Midazolam was given as rescue sedation. We recorded the first attempt intubation success rate, the dose of midazolam, duration of intubation, Ramsay Sedation Scale (RSS) score, tracheal tube tolerance score, duration of drug infusion, adverse events and patient satisfaction score. RESULTS: The RSS score was significantly higher in Group D than in Group R. First attempt success rate, rescue midazolam dose and the duration of intubation did not differ between the groups. Patients in Group R were significantly more tolerant of the tracheal tube. The incidence of hypoxia was significantly higher in Group R than Group D, but there was no significant difference in the incidence of other adverse events between the groups. The hemodynamic responses of the two groups were similar, but more patients in Group R were able to recall airway instrumentation. CONCLUSIONS: Both dexmedetomidine and remifentanil are effective sedatives for awake intubation using an SOS. Although the first attempt success rates were similar, patients sedated with remifentanil tolerated the tracheal tube better after intubation with moderately increased risk of desaturation. TRIAL REGISTRATION: www.chictr.org.cn ; ChiCTR-TRC-13003052 (February 4th, 2013).

Low-dose Simvastatin Increases Skeletal Muscle Sensitivity to Caffeine and Halothane.

Objective To determine whether the myotoxic side effects of statin simvastatin affect skeletal muscle's sensitivity to caffeine and halothane.Methods Primary cultured neonate rat skeletal myotubes were treated with 0.01-5.0 µmol/L simvastatin for 48 hours. MTT was used to evaluate cellular viability. The gross morphology and microstructure of the myotubes were observed with a light and electron microscope, respectively. The intracellular calcium concentrations ([Ca2+]i) at rest and in response to caffeine and halothane were investigated by fluorescence calcium imaging. Data were analyzed by analysis of variance (ANOVA) test.Results Simvastatin (0.01-5.0 µmol/L) decreased myotube viability, changed their morphological features and microstructure, and increased the resting [Ca2+]i in a dose-dependent manner. Simvastatin did not change myotube's sensitivity to low doses of caffeine (0.625-2.5 mmol/L) or halothane (1.0-5.0 mmol/L). In response to high-dose caffeine (10.0 mmol/L, 20.0 mmol/L) and halothane (20.0 mmol/L, 40.0 mmol/L), myotubes treated with 0.01 µmol/L simvastatin showed a significant increase in sensitivity, but those treated with 1.0 µmol/L and 5.0 µmol/L simvastatin showed a significant decrease. The sarcoplasmic reticulum Ca2+ storage peaked in the myotubes treated with 0.01 µmol/L simvastatin, but it decreased when cells were treated with higher doses of simvastatin (0.1-5.0 µmol/L).Conclusions The myotoxic side effect of simvastatin was found to change the sensitivity of myotubes in response to high-dose caffeine and halothane. When dose was low, sensitivity increased mainly because of increased Ca2+ content in the sarcoplasmic reticulum, which might explain why some individuals with statin-induced myotoxic symptoms may show positive caffeine-halothane contracture test results. However, when the dose was high and the damage to the myotubes was severer, sensitivity was lower. It is here supposed that the damage itself might put individuals with statin-induced myotoxic symptoms at greater risks of presenting with rhabdomyolysis during surgery or while under anesthesia.

Effects of two different anesthesia-analgesia methods on incidence of postoperative delirium in elderly patients undergoing major thoracic and abdominal surgery: study rationale and protocol for a multicenter randomized controlled trial.

BACKGROUND: Delirium is a common complication in elderly patients after surgery and associated with increased morbidity and mortality. Studies suggest that deep anesthesia and intense pain are important precipitating factors of postoperative delirium. Neuraxial block is frequently used in combination with general anesthesia for patients undergoing major thoracic and abdominal surgery. Compared with general anesthesia alone and postoperative intravenous analgesia, combined epidural-general anesthesia and postoperative epidural analgesia decreases the requirement of general anesthetics during surgery and provided better pain relief after surgery. However, whether combined epidural-general anesthesia plus epidural analgesia is superior to general anesthesia plus intravenous analgesia in decreasing the incidence of postoperative delirium remains unknown. METHODS/DESIGN: This is a multicenter, open-label, randomized, parallel-controlled clinical trial. One thousand eight hundred elderly patients (age range 60-90 years) who are scheduled to undergo major thoracic or abdominal surgery are randomized to receive either general anesthesia plus postoperative intravenous analgesia or combined epidural-general anesthesia plus postoperative epidural analgesia. The primary outcome is the 7-day incidence of postoperative delirium. Secondary outcomes include the duration of postoperative delirium, the intensity of pain during the first three days after surgery, the 30-day incidences of postoperative non-delirium complications, the length of stay in hospital after surgery and 30-day all-cause mortality. DISCUSSION: Results of the present study will provide information to guide clinical practice in choosing appropriate anesthesia-analgesia method for elderly patients undergoing major thoracic and abdominal surgery. TRIAL REGISTRATION: The study is registered on ClinicalTrials.gov NCT01661907 and Chinese Clinical Trial Registry ChiCTR-TRC-12002371 .

[Perioperative management of abdominal aortic balloon occlusion in patients complicated with placenta percteta: a case report].

When placenta previa complicated with placenta percreta, the exposure of operative field is difficult and the routine methods are difficult to effectively control the bleeding, even causing life-threatening results. A 31-year-old woman, who had been diagnosed with a complete type of placenta previa and placenta percreta with bladder invasion at 34 weeks gestation. Her ultrasound results showed a complete type of placenta previa and there was a loss of the decidual interface between the placenta and the myometrium on the lower part of the uterus, suggestive of placenta increta. For further evaluation of the placenta, pelvis magnetic resonance imaging was performed, which revealed findings suspicious of a placenta percreta. She underwent elective cecarean section at 36 weeks of gestation. Firstly, two ureteral stents were placed into the bilateral ureter through the cystoscope. After the infrarenal abdominal aorta catheter was inserted via the femoral artery (9 F sheath ), subarachnoid anesthesia had been established. A healthy 2 510 g infant was delivered, with Apgar scores of 10 at 1 min and 10 at 5 min. Immediately after the baby was delivered, following which there was massive haemorrhage and general anaesthesia was induced. The balloon catheter was immediately inflated until the wave of dorsal artery disappeared. With the placenta retained within the uterus, a total hysterectomy was performed. The occluding time was 30 min. The intraoperative blood loss was 2 500 mL. The occluding balloon was deflated at the end of the operation. The patient had stable vital signs and normal laboratory findings during the recovery period and the hemoglobin was 116 g/L. She was discharged six days after delivery without intervention-related complications. This case illustrates that temporary occlusion of the infrarenal abdominal aorta using balloon might be a safe and effective treatment option for patients with placenta previa complicated with placenta percreta, who were at high risk for peripartum hemorrhage. Early removal of the endovascular catheter and close postoperative surveillance of the vascular system are required with this procedure to minimize the risk of vascular complications. However, further studies are needed to determine whether the potential benefits of temporary occlusion of the infrarenal abdominal aorta using balloon outweigh the potential risks.

[Comparison of Shikani optical stylet and Macintosh laryngoscope for double-lumen endotracheal tube intubation].

OBJECTIVE: To compare the efficacy and safety of Shikani (S)optical stylet and Macintosh(M) laryngoscope for double-lumen endotracheal tube intubation. METHODS: In the study, 60 patients undergoing elective thoracic surgery were randomly allocated to group S(n=30) and group M (n=30). After general anesthesia induction, the patients in group S and group M were intubated double-lumen endotracheal tube (DLT) by Shikani optical stylet (SOS) and macintosh laryngoscope respectively. Intubation time, intubation attempts, cuff broken and oral mucosal or dental injury were recorded; Blood pressure and heart rate at baseline (T0), at the time of intubaiton onset (T1), 1 minute after intubaiton (T2), 3 minutes after intubation (T3) and 5 minutes after intubation (T3) were also recorded; Hoarseness and throat sore of the patients 24 hours after surgery were evaluated. RESULTS: The intubaiton time with the SOS was faster than with the Macintosh [(37.4±9.7) s vs. (43.9±13.7) s, P=0.039] and the first attempt success rate (87% vs. 80%, P=0.488) did not differ between the groups; No tube cuff broke in both the groups; Group S had fewer patients who suffered oral mucosal or dental injury than group M (8 vs.2, P=0.038); The blood pressure and heart rate at T0,T1,T2,T3 and T4 did not differ between the groups; Throat sore (7 vs.10, P=0.390) and hoarseness (5 vs.7, P=0.519) incidence did not differ between the groups. CONCLUSION: By comparison of the Macintosh laryngoscope, the SOS provides faster DLT intubation and causes less oral Mucosal or dental injury.

[Rocuronium anesthesia induced anaphylactic shock: a case report].

Anaphylaxis is an acute and fatal systemic allergic reaction to an allergen, and it could be an unpredictable and life-threatening cause during anesthesia. The main purpose of this paper is to report a case of anaphylactic shock during the anesthesia induction and to review the prophylaxis and treatment of anaphylactic reactions and anaphylactoid reactions during the anesthesia period. A 63-year-old man, with a mass on his adrenal, was scheduled to a laparoscopic adrenal tumor excision. During the anesthesia induction period, after administrated sulfentanil, propofol and rocuronium, the blood pressure was decreased and the heart rate was increased. Then, the patient had rash on his whole body and developed an anaphylactic shock. After being treated with the anti-allergic agents and norepinephrine, the rash disappeared and the vital sign become stable. The patient felt nothing uncomfortable during the two weeks'follow-up. Anaphylactic reactions and anaphylactoid reactions are not rare during the anesthesia period. The most common inducements are muscle relaxant, latex and antibiotics. Anaphylactic reactions in the perioperative period are often serious and potentially life-threatening conditions, involving multiple organ systems in which the clinical manifestations are the consequence of the release of preformed mediators from mast cells and basophils. Before anesthesia, we should acquire the allergic history. During the anesthesia period, the vital sign and the skin should be observed carefully.

[Anesthesia and perioperative management for cesarean section in patient with factor XI deficiency: a case report].

Factor XI deficiency is a hereditary blood coagulation disorders. Puerpera with factor XI deficiency is exceedingly rare. A case of a 28-year-old woman who was found to have factor XI deficiency coagulopathy at the end of 33 weeks of gestation was presented here, and was admitted to Peking University Third Hospital at the end of 38 weeks of gestation. The doctors from several departments conducted cooperative management, and prepared with supplement of the coagulant factor and fresh frozen plasma before operation. The woman had general anesthesia, the baby was delivered successfully and the mother's condition was kept stable. The amount of bleeding of puerpera was not much perioperation. Yet the management of cesarean section with factor XI deficiency at home and abroad is still lack of standard guideline by now.

Activation of the canonical nuclear factor-κB pathway is involved in isoflurane-induced hippocampal interleukin-1ß elevation and the resultant cognitive deficits in aged rats.

Although much recent evidence has demonstrated that neuroinflammation contributes to volatile anesthetic-induced cognitive deficits, there are few existing mechanistic explanations for this inflammatory process. This study was conducted to investigate the effects of the volatile anesthetic isoflurane on canonical nuclear factor (NF)-κB signaling, and to explore its association with hippocampal interleukin (IL)-1ß levels and anesthetic-related cognitive changes in aged rats. After a 4-h exposure to 1.5% isoflurane in 20-month-old rats, increases in IκB kinase and IκB phosphorylation, as well as a reduction in the NF-κB inhibitory protein (IκBα), were observed in the hippocampi of isoflurane-exposed rats compared with control rats. These events were accompanied by an increase in NF-κB p65 nuclear translocation at 6h after isoflurane exposure and hippocampal IL-1ß elevation from 1 to 6h after isoflurane exposure. Nevertheless, no significant neuroglia activation was observed. Pharmacological inhibition of NF-κB activation by pyrrolidine dithiocarbamate markedly suppressed the IL-1ß increase and NF-κB signaling, and also mitigated the severity of cognitive deficits in the Morris water maze task. Overall, our results demonstrate that isoflurane-induced cognitive deficits may stem from upregulation of hippocampal IL-1ß, partially via activation of the canonical NF-κB pathway, in aged rats.

[Comparative study on two total intravenous anesthesia techniques in complex spine surgery].

OBJECTIVE: To compare anesthesia profiles of target-controlled infusion (TCI) and manual-controlled infusion (MCI) of propofol and remifentanil in kyphosis correction or scoliosis correction surgery, in which intraoperative spinal cord monitoring was employed. METHODS: In the study, 160 patients scheduled for kyphosis correction surgery or scoliosis correction were enrolled and randomly allocated into 2 groups, group TCI and group MCI. In group TCI, induction and maintenance of general anesthesia were carried out by target-controlled infusion of propofol and remifentanil. Marsh and Minto, three-compartment pharmacokinetic models for propofol and remifentanil were used respectively. In group MCI, the patients received propofol and remifentanil by conventional dose-weight infusion method. Muscle relaxants were only applied for ease of induction. In both the groups, anesthesia depth was monitored by bispectral index (BIS), and the change of hemodynamic parameters was kept in the range of 20% of the baseline. The control convenience of anesthesia depth and change amplitude of BIS in the main steps of the procedure were compared. The total amounts of propofol and remifentanil, influence on the hemodynamics, influence on the successful rates of somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) and electromyography (EMG) were compared too. RESULTS: The time of pump regulation in group TCI was significantly less than in group MCI (P<0.05). The BIS fluctuation in the main steps of the procedure was significantly smaller in Group TCI than in group MCI (P<0.05). There was no significant difference in the amounts of propofol and remifentanil(P=0.158 and P=0.168). The time to awake (P=0.972) and time to extubation (P=0.944) had no significant difference. The successful rates of SSEPs and MEPs had no significant difference between groups TCI amd MCI (P>0.05). CONCLUSION: Both TCI and MCI can offer practical anesthesia for spinal deformity correction surgery. TCI has the advantage in keeping smooth and steady depth of anesthesia.

[Combined efficacy of parecoxib and incisional ropivacaine infiltration on pain management after diagnostic hysteroscopy and laparoscopy].

OBJECTIVE: To evaluate the combined effect of premedication of parecoxib sodium and local infiltration of ropivocaine on postoperative shoulder pain and incisional pain in patients undergoing diagnostic hysteroscopy and laparoscopy. METHODS: In the study, 60 patients undergoing elective diagnostic hysteroscopy and laparoscopy were randomly allocated to two groups (each with 30 patients). The patients in group 1 were premedicated with 40 mg parecoxib sodium (diluted with 2 mL normal saline), and 0.5% ropivacaine (20 mL) were infiltrated around the incision site before establishment of CO2 pneumoperitoneum. The patients in group 2 received 2 mL normal saline intraveniously before anesthesia induction, and infiltration of 0.5% ropivacaine 20 mL were also applied as group 1. After anesthetic withdrawal, the patients' postoperative anesthesia recovery time and the time point of opening eyes on verbal command were noted. The intensities of postoperative shoulder pain and incisional pain were evaluated at 0, 2, 4, 8, 12, 24, and 48 h after surgery. The postoperative analgesic requirement was met by administration of tramadol. RESULTS: Compared with group 2, the incidence of postoperative shoulder pain was less in group 1 (37% vs. 67%, P=0.020), and the occurence of severe pain was lower (4 vs. 11, P=0.037). The numerical rating scales (NRS) of right shoulder pain of group 1 were significantly reduced than those of group 2 at 12 h postoperatively [0 (0, 2) vs. 0 (0, 8), P=0.012]. Left shoulder pain did not appear at 0 h and 2 h in both groups, while at 12 h and 24 h postoperatively, the NRS scores of group 1 were lower than those of group 2 [0 (0, 1) vs. 0 (0, 8), P=0.026; 0 (0, 4) vs. 2 (0, 9), P=0.014]. The dynamic and static abdominal pain scores of group 1 were significantly decreased than those of group 2 in post-anesthesia care unit (PACU) after surgery (P=0.001, P=0.005). The NRS scores of static abdominal pain of group 1 were significantly reduced than those of group 2 at 12 h and 24 h postoperatively (P=0.042, P=0.029). More patients in group 2 needed tramadol within 24 h postoperatively (8 vs. 0, P=0.002). CONCLUSION: Premedication of parecoxib sodium combined with local infiltration of ropinvocaine before incision could significantly reduce the postoperative shoulder pain and incisional pain as well as reduce opioid consumption in patients undergoing diagnostic hysteroscopy and laparoscopy.

[Influence of inhaled anesthesia on bispectral index of elderly patients with cognitive decline].

OBJECTIVE: To investigate the influence of inhaled anesthesia on bispectral index (BIS) of elderly patients with cognitive decline at loss of consciousness and regain of consciousness, and on deepening of sedation. METHODS: The patients aged more than 65 years undergoing elective operations from January 2012 to September 2012 were recruited, then 60 cognitive intact patients and 60 cognitive decline patients were screened by mini-mental state examinations. Inhaled anesthesia was administered using sevoflurane. BIS's of the two groups at loss of consciousness and regain of consciousness, and during end-tidal concentration of sevoflurane (CETSev) changing from 0.7% to 2.8% were recorded. The data were compared with independent-samples t test and repeated-measures general linear model of ANOVA. RESULTS: In the study, 117 patients finshed the investigation, The BIS's of the cognitive decline group at loss of consciousness were significantly higher than those of the cognitive intact group (P<0.01). There were no significant differences at regain of consciousness between the two groups (P>0.05). The BIS's of the cognitive decline group during CETSev changing from 0.7% to 2.8% were significantly lower than those of the cognitive intact group (P<0.05). The BIS's of the cognitive decline group at CETSev 0.7%, 1.05%, 1.4% and 1.75% were significantly lower than those of the cognitive intact group (P<0.05), but there were no significant differences at CETSev 2.1%, 2.45% and 2.8% between the two groups (P>0.05). CONCLUSION: During inhaled anesthesia, the BIS of the elderly patients with cognitive decline at loss of consciousness is higher than that of the patients with cognitive intact, The BIS of elderly patients with cognitive decline on deepening of anesthesia is lower than that of the patients with cognitive intact, especially during light anesthesia, and its mechanisms may attribute to cognitive decline related neurodegeneration and neurotransmitter system dysfunction.

Difficult airway due to cervical haemorrhage caused by spontaneous rupture of a parathyroid adenoma: A case report.

BACKGROUND: Cervical haemorrhage due to spontaneous rupture of a parathyroid adenoma is a rare complication that may cause life-threatening acute airway compromise. CASE SUMMARY: A 64-year-old woman was admitted to the hospital 1 day after the onset of right neck enlargement, local tenderness, head-turning difficulty, pharyngeal pain, and mild dyspnoea. Repeat routine blood testing showed a rapid decrease in the haemoglobin concentration, indicating active bleeding. Enhanced computed tomography images showed neck haemorrhage and a ruptured right parathyroid adenoma. The plan was to perform emergency neck exploration, haemorrhage removal, and right inferior parathyroidectomy under general anaesthesia. The patient was administered 50 mg of intravenous propofol, and the glottis was successfully visualised on video laryngoscopy. However, after the administration of a muscle relaxant, the glottis was no longer visible and the patient had a difficult airway that prevented mask ventilation and endotracheal intubation. Fortunately, an experienced anaesthesiologist successfully intubated the patient under video laryngoscopy after an emergency laryngeal mask placement. Postoperative pathology showed a parathyroid adenoma with marked bleeding and cystic changes. The patient recovered well without complications. CONCLUSION: Airway management is very important in patients with cervical haemorrhage. After the administration of muscle relaxants, the loss of oropharyngeal support can cause acute airway obstruction. Therefore, muscle relaxants should be administered with caution. Anaesthesiologists should pay careful attention to airway management and have alternative airway devices and tracheotomy equipment available.