Successful treatment of gastric cancer 10 years after heart transplantation: A case report.

BACKGROUND: While survival rates among cardiac allograft recipients have improved, there has been a rise in post-transplant malignancies, with gastric cancer being less commonly reported. This study presented a successful treatment of gastric cancer in an individual 10 years after undergoing a heart transplant. CASE PRESENTATION: A 66-year-old Chinese man presented to the gastrointestinal clinic with a complaint of diagnosis of gastric cancer for 4 months and treated with neoadjuvant therapy for 1 month. He has undergone orthotopic heart transplantation 10 years earlier due to a myocardial infarction. Physical examination and laboratory tests did not reveal any significant abnormalities. Abdominal contrast-enhanced computed tomography (CT) imaging indicated a gastric mass near the greater curvature, with gastroscopy suggesting a carcinoma at the esophagogastric junction, Siewert III. An echocardiogram indicated left atrial enlargement with mild mitral and tricuspid regurgitation. The diagnosis suggested that his gastric cancer at the esophagogastric junction was a consequence of long-term immunosuppressive therapy. A multidisciplinary team (MDT) consultation recommended a proximal radical gastrectomy. Postoperatively, the patient received 4 cycles of adjuvant chemotherapy with XELOX combined with Herceptin, initiated a month after surgery. During the 1-year follow-up, the patient showed commendable recovery, with no signs of tumor recurrence or metastasis. CONCLUSION: This case underscores the potential risk of malignancy from immunosuppressive agents in transplant recipients. The successful management of this complex scenario underscores the indispensable role of an MDT approach in treating such unique and challenging cases.

Different doses of nalmefene combined with hydromorphone hydrochloride for postoperative analgesia after colorectal surgery: a randomized controlled study.

BACKGROUND: Hydromorphone hydrochloride has a satisfactory postoperative analgesic effect for patients with colorectal cancer but is accompanied by a relatively high incidence of adverse events. Low-doses of naloxone combined with opioids for patient-controlled analgesia can reduce the incidence of drug-related adverse events. Nalmefene is a more selective opioid receptor antagonist than naloxone. The aim of this study was to determine the impact of low-doses of nalmefene on the analgesic effect and incidence of adverse events of patients with hydromorphone patient-controlled analgesia (PCA) undergoing colorectal radical surgery. METHODS: Ninety-nine patients undergoing elective laparoscopic or hand-assisted laparoscopic radical surgery under general anaesthesia were randomly divided into three groups. Group N1 received hydromorphone hydrochloride 0.15 mg/kg + nalmefene 2 µg/kg; Group N2 received hydromorphone hydrochloride 0.15 mg/kg + nalmefene 0.5 µg/kg; and the control group (Group C) received hydromorphone hydrochloride 0.15 mg/kg. All medications were diluted to 100 ml with normal saline. The primary outcome was pain intensity at 12 h after surgery; the secondary outcomes were the occurrence of nausea, vomiting and pruritus and the total analgesic consumption of the PCA pump at 1 h, 6 h, 12 h, 24 and 48 h after surgery. RESULTS: The NRS scores of Group N1 (2 µg/kg) were significantly lower than those of Group C (P = 0.025), and no difference was found between group N2 and group C (P > 0.05). Among the three groups, the NRS scores of Group N1 (2 µg/kg) were significantly lower than those of Group C at 12 h (P = 0.01) and 48 h (P = 0.01) postoperatively. Compared with 12 h postoperatively, the NRS scores were lower at 24 h postoperatively in Group N1 and Group C (P < 0.05) and significantly lower at 48 h postoperatively in all three groups (P < 0.001). There was a significant difference in the incidence of pruritus among the three groups (P = 0.036). CONCLUSIONS: Nalmefene at a dosage of 2 µg/kg enhances the postoperative analgesic effect of hydromorphone hydrochloride and reduces the occurrence of postoperative pruritus. TRIAL REGISTRATION: The trial was registered with the Chinese Clinical Trial Registry (Registration number: ChiCTR2000033520, date: 03/06/2020).

Intrathecal Analgesia via a Percutaneous Port With Patient-Controlled Intrathecal Analgesia for the Management of Movement-Evoked Breakthrough Cancer Pain of Refractory Lower Extremity Cancer Pain: A Retrospective Review.

BACKGROUND: Intrathecal analgesia (ITA) is a valuable treatment option for refractory cancer-related pain. However, there is still no general consensus on the analgesic effect of movement-evoked breakthrough pain (MEBTP) in the ITA setting. OBJECTIVES: This study aimed to conduct a retrospective observational study to examine the effect of ITA via percutaneous port (ITAPP) with patient-controlled ITA (PCIA) on analgesic efficacy, emphasizing MEBTP in patients with refractory lower extremity cancer pain. STUDY DESIGN: A retrospective chart review included all patients with refractory lower extremity cancer pain who received ITAPP at our hospital between January 2017 and December 2020. METHODS: Data on the Numeric Rating Scale scores of spontaneous resting pain intensity (SRPI) and MEBTP intensity (MEPI), opioid doses, and perceived time to onset were collected from medical records prior to ITAPP and at a one-month postimplant visit. RESULTS: A total of 16 patients were included in the study group. Mean SRPI decreased from 8.75 pre-ITAPP to 3.75 post-ITAPP (P < 0.05); mean MEPI fell from 8.83 pre-ITAPP to 4.25 post-ITAPP (P < 0.05); mean daily morphine equivalent dosing decreased from 360 mg/d to 48 mg/d (P < 0.05); and mean daily morphine equivalent dosing for MEBTP decreased from 87 mg/d to 6 mg/d (P < 0.05). Both total and breakthrough dosing of conventional opioid medications significantly decreased following the initiation of ITAPP with PCIA. The mean perceived time to onset with conventional MEBT medications was 38 minutes, and the mean perceived time to onset with PCIA was 8 minutes (P < 0.05). LIMITATIONS: An effective analysis of IT opioid efficacy was not possible because the power of such a small sample size was low. Second, it is a retrospective study without long-term follow-ups. CONCLUSIONS: In patients with refractory lower extremity cancer pain, ITAPP with PCIA was associated with improved pain control. Compared with conventional MEBTP regimens, appropriate ITAPP with PCIA provided superior analgesia and a much faster onset of action.

Multiscale Deblurred Feature Extraction Network for Automatic Four-Rod Target Detection in MRTD Measuring Process of Thermal Imagers.

The minimum resolvable temperature difference (MRTD) at which a four-rod target can be resolved is a critical parameter used to assess the comprehensive performance of thermal imaging systems, which is important for technological innovation in military and other fields. Recently, there have been some attempts to use an automatic objective approach based on deep learning to take the place of the classical manual subjective MRTD measurement approach, which is strongly affected by the psychological subjective factors of the experimenter and is limited in accuracy and speed. However, the scale variability of four-rod targets and the low pixels of infrared thermal cameras have turned out to be a challenging problem for automatic MRTD measurement. We propose a multiscale deblurred feature extraction network (MDF-Net), a backbone based on a yolov5 neural network, in an attempt to solve the aforementioned problem. We first present a global attention mechanism (GAM) attention module to represent strong images of the four-rod targets. Next, a Rep VGG module is introduced to decrease the blur. Our experiments show that the proposed method achieves the desired effect and state-of-the-art detection results, which innovatively improve the accuracy of four-rod target detection to 82.3% and thus make it possible for the thermal imagers to see further and to respond faster and more accurately.

Safety and Efficacy of Dexmedetomidine for Bronchoscopy: A Systematic Review and Meta-Analysis.

(1) Background: Anesthetic sedatives are widely used for bronchoscopy, and controversy surrounds the safety and efficacy of dexmedetomidine compared to other sedatives. The aim of this study is to evaluate the safety and efficacy of dexmedetomidine in bronchoscopy through a systematic review. (2) Methods: PubMed, Embase, Google Scholar, and Cochrane Library electronic databases were searched for a randomized controlled study of dexmedetomidine (Group D) or other sedative drugs (Group C) for bronchoscopy. Data extraction, quality assessment, and risk of bias analysis were performed in accordance with the preferred reporting items for systematic review and meta-analysis requirements. Meta-analysis was performed using RevMan 5.2. (3) Results: Nine studies were included, with a total of 765 cases. Compared to Group C, the incidence of hypoxemia (OR = 0.40, 95% CI (0.25, 0.64) p = 0.0001, I2 = 8%) and tachycardia (OR = 0.44, 95% CI (0.26,0.74), p = 0.002, I2 = 14%) were lower, but bradycardia (OR = 3.71, 95% CI (1.84, 7.47), p = 0.0002, I2 = 0%) was higher in Group D; no significant difference was observed in other outcome indicators. (4) Conclusions: Dexmedetomidine reduces the incidence of hypoxemia and tachycardia during bronchoscopy but is more likely to provoke bradycardia.

Are two beneficial mutations (p.Q249R and 90-bp Indel) within the ovine BMPRIB gene associated with growth traits?

Background: The problem of achieving economic efficiency in sheep breeding can be largely solved by increasing sheep productivity. Recently, the BMPRIB gene has been revealed by GWAS as a potential candidate gene for sheep body morphometric traits. Therefore, the present study aimed to investigate whether genetic polymorphisms (p.Q249R SNP and 90-bp deletion) in the BMPRIB gene are associated with sheep growth traits. Methods: PCR-based genotyping was performed on 1,875 sheep, including 1,191 Guiqian semi-fine wool (GQSFW), 560 Luxi Blackhead (LXBH), 55 Lanzhou fat-tailed (LZFT), and 69 Weining (WN) sheep. Genotype-phenotype association was assessed using the independent samples t-test and ANOVA. The significance level was set at αoriginal < 0.05. The threshold p-value for significance was adjusted after correction for multiple comparisons using the Bonferroni correction. Results: After the Bonferroni correction, it was found that individuals with FecB+/FecB+ genotypes of the p.Q249R had significantly better growth traits in LXBH ewe lambs, including the body length, chest width, paunch girth, cannon circumference, and hip width (P<0.0005). Meanwhile, associations were observed between 90-bp deletion polymorphism and several growth traits (body length, body height, chest depth, and canon circumference) in GQSFW ewe adults after the Bonferroni correction (P < 0.0002), and individuals with the "DD" genotypes had greater growth traits. Conclusion: Our findings align with the experimental observations from GWAS, which identified the BMPRIB gene as a potential candidate gene for body measurement traits. These findings not only confirm the previous study's results but also expand on them. Therefore, further investigations regarding the impact of BMPRIB polymorphisms on growth traits are necessary in other sheep breeds.

Effect of Plateau Pika Disturbance on Plant Aboveground Biomass of Alpine Meadows at Two Different Scales.

Disturbance by small burrowing herbivores often has an impact on plant aboveground biomass of grassland because it makes grasslands into a mosaic of discrete vegetated surfaces and bare soil patches. This study focuses on the plateau pika (Ochotona curzoniae) to investigate the effect of the disturbance by a small burrowing herbivore on plant aboveground biomass through upscaling the quadrat scale to the plot scale across five sites. This study showed that the plateau pika disturbance reduced sedge biomass and increased forb biomass. In contrast, they did not affect plant community biomass, grass biomass and legume biomass at the quadrat scale across the five sites. At the plot scale, that is, when the bare soil patches with a lack of plants were considered, plateau pika disturbance induced lower aboveground biomass of the plant community, sedge and legumes, while it had no relationship with grass biomass and forb biomass. As the disturbance intensity increased, the aboveground biomass of the plant community and sedge decreased, whereas the grass biomass showed a hump-shaped trend. These results indicate that plateau pika disturbance might be not beneficial to alpine meadows given the aboveground biomass of the plant community at the plot scale. In contrast, the intermediate disturbance intensity improves the grazing quality of alpine meadows through the higher grass biomass. The findings of this study imply that the plot scale is better than the quadrat scale to investigate the influence of the disturbance by a small burrowing herbivore on the plant aboveground biomass, and that management of a small burrowing herbivore needs to consider its disturbance intensity.

Ketamine Regulates the Autophagy Flux and Polarization of Microglia through the HMGB1-RAGE Axis and Exerts Antidepressant Effects in Mice.

Depression is a leading cause of disability worldwide. Here, we explored the role of the HMGB1-RAGE pathway in lipopolysaccharide (LPS)-induced depression-like behavior and microglial autophagy flux, neuroinflammation, and polarization in a mouse model. Male C57BL/6 mice were infused with LPS in the abdominal cavity to induce a depression model. They then underwent testing to assess behavior and cognition. Real-time fluorescent quantitative polymerase chain reaction was used to detect the expression of the M1/M2 microglia polarization markers, HMGB1, and RAGE. Microglial activation and phenotypic transformation in the hippocampus were identified. mRFP-GFP-LC3 and Western blotting were used to detect autophagy flux in each treatment group. Finally, an LPS-induced BV2 cell model was developed to verify the involvement of the HMGB1-RAGE pathway, autophagy flux, and polarization. Ketamine improved LPS-induced depression-like behavior, inhibited the LPS-induced upregulation of HMGB1 and RAGE and the nuclear translocation of HMGB1. Moreover, ketamine reversed the blocked autophagy flux of microglia caused by LPS and regulated microglial autophagy flux through the HMGB1-RAGE pathway and microglial polarization. These results suggest that ketamine may reduce HMGB1 and RAGE accumulation in patients with depression, thereby providing a new therapeutic target for preventing and treating this disease.

Identification of risk factors for postoperative delirium in elderly patients with hip fractures by a risk stratification index model: A retrospective study.

INTRODUCTION: Postoperative delirium is one of the most common and dangerous psychiatric complications after hip surgery. The aim of this study was to investigate the incidence of postoperative delirium in elderly patients after hip fracture surgery and to identify risk factors for such, as part of developing a risk stratification index (RSI) system to predict a patient's risk of postoperative delirium. METHODS: Elderly patients (aged 65 years or older) with hip fractures who had received surgical treatment in our hospital between March 2018 and December 2019 were retrospectively included. Clinical data were collected, and multivariate logistic regression analysis was performed to investigate the relevant risk factors of postoperative delirium. An RSI system was developed based on factors identified in the regression analysis. RESULTS: Of 272 patients included, 52 (19.12%) experienced postoperative delirium. Drinking history (> 3/ week), the perioperative lactic acid level (Lac > 2 mmol/L), postoperative visual analog score (VAS) > 3, American Society of Anesthesiologists (ASA) physical status > II, application of the bispectral index, and preoperative diabetes were independent risk factors of postoperative delirium. When RSI ≥ 5, the rate of postoperative delirium significantly increased (p < .05). CONCLUSION: The RSI system developed here can safely guide postoperative outcomes of elderly patients with hip fractures, and RSI ≥ 5 may be able to predict the onset of postoperative delirium.

Clonidine as an Additive to Local Anesthetics in Caudal Block for Postoperative Analgesia in Pediatric Surgery: A Systematic Review and Meta-Analysis.

Background: Clonidine is an anesthetic with favorable efficacy and safety profiles for caudal epidural block, but comparisons with other adjuvants need to be confirmed in pediatric patients. Aim: To investigate the effects of clonidine as an adjuvant in caudal epidural block to improve the intraoperative and postoperative analgesia in pediatric surgery. Methods: PubMed, Embase, and the Cochrane Library were searched for available papers published up to February 2021. The outcomes were pain score, duration of analgesia, complications, and number of analgesic requirements. The meta-analysis was performed using random-effects models. Results: Fifteen randomized controlled trials (RCTs) were included. There were no differences between clonidine and the control drug regarding the duration of analgesia (SMD = -0.71, 95%CI: -1.64, 0.23; I 2 = 95.5%, Pheterogeneity < 0.001), pain score (SMD = 0.35, 95%CI: -0.28, 0.98; I 2 = 80.8%, Pheterogeneity < 0.001), and requirement for additional analgesia (OR = 8.77, 95%CI: 0.70, 110.58, I 2 = 81.9%, Pheterogeneity = 0.004), but using clonidine resulted in fewer complications than the control drugs (OR = 0.33, 95%CI: 0.20, 0.54, I 2 = 21.8%, Pheterogeneity = 0.217). The sensitivity analysis showed that the results were robust. A publication bias was observed. Conclusion: Clonidine has the same efficacy as the other adjuvants for caudal epidural block for pediatric surgery but fewer complications. These results support clonidine as an adjuvant to local anesthetic, but additional studies should be conducted.

Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature.

BACKGROUND: Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery. METHODS: A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations. RESULTS: Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92). CONCLUSIONS: Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes. RECOMMENDATION: PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

Physiological Biochemistry-Combined Transcriptomic Analysis Reveals Mechanism of Bacillus cereus G2 Improved Salt-Stress Tolerance of Glycyrrhiza uralensis Fisch. Seedlings by Balancing Carbohydrate Metabolism.

Salt stress severely threatens the growth and productivity of Glycyrrhiza uralensis. Previous results found that Bacillus cereus G2 enhanced several carbohydrate contents in G. uralensis under salt stress. Here, we analyzed the changes in parameters related to growth, photosynthesis, carbohydrate transformation, and the glycolysis Embden-Meyerhof-Parnas (EMP) pathway-tricarboxylic acid (TCA) cycle by G2 in G. uralensis under salt stress. Results showed that G2 helped G. uralensis-accumulating photosynthetic pigments during photosynthesis, which could further increase starch, sucrose, and fructose contents during carbohydrate transformation. Specifically, increased soluble starch synthase (SSS) activity caused to higher starch content, which could induce α-amylase (AM) and ß-amylase (BM) activities; increased sucrose content due to the increase of sucrose synthase (SS) activity through upregulating the gene-encoding SS, which decreased cell osmotic potential, and consequently, induced invertase and gene-encoding α-glucosidase that decomposed sucrose to fructose, ultimately avoided further water loss; increased fructose content-required highly hexokinase (HK) activity to phosphorylate in G. uralensis, thereby providing sufficient substrate for EMP. However, G2 decreased phosphofructokinase (PFK) and pyruvate kinase (PK) activities during EMP. For inducing the TCA cycle to produce more energy, G2 increased PDH activity that enhanced CA content, which further increased isocitrate dehydrogenase (ICDH) activity and provided intermediate products for the G. uralensis TCA cycle under salt stress. In sum, G2 could improve photosynthetic efficiency and carbohydrate transformation to enhance carbohydrate products, thereby releasing more chemical energy stored in carbohydrates through the EMP pathway-TCA cycle, finally maintain normal life activities, and promote the growth of G. uralensis under salt stress.

Improving mucosal anesthesia for awake endotracheal intubation with a novel method: a prospective, assessor-blinded, randomized controlled trial.

BACKGROUND: Topical anesthesia is a crucial step in awake endotracheal intubation for providing favorable intubation conditions. The standard of care technique for awake intubation at our institution, which consists of oropharyngeal tetracaine spray, can result in inadequate mucosal anesthesia. Therefore, we sought to compare the effectiveness of dyclonine hydrochloride mucilage to the standard of care tetracaine in achieving anesthesia of the upper airways for awake endotracheal intubation. METHODS: This is a randomized, assessor-blinded, prospective study. From Jun. 1st, 2019 to Aug. 1st, 2019, patients scheduled for either endoscopic submucosal dissection or peroral endoscopic myotomy were enrolled and randomly allocated into two groups after obtaining written informed consent: patients allocated to novel awake intubation care (Group N-AIC) received a single administration of oral dyclonine hydrochloride mucilage, whereas patients allocated to standard awake intubation care (Group S-AIC) received three oropharyngeal tetracaine sprays before transcricoid tetracaine injection before awake intubation. Mean arterial pressure (MAP), which was the primary outcome of this study, as well as heart rate (HR) were recorded throughout the procedure and compared between the two groups. Feeling of numbness, nausea, and intubation conditions after topical anesthesia were also assessed. RESULTS: Sixty patients were enrolled and completed the study. Baseline MAP and HR were similar between the two groups. However, hemodynamic responses to intubation and gastrointestinal endoscopy, especially MAP, were significantly less elevated in Group N-AIC. The degree of numbness of the oropharyngeal mucosa after topical anesthesia did not differ between the two groups, neither did the feeling of nausea during laryngoscopy. The amount of pharyngeal secretions before intubation was less in Group N-AIC. Total intubation time was significantly shorter in Group N-AIC when compared to Group S-AIC (18.4 ± 2.86 vs. 22.3 ± 6.47, P < 0.05). Extubation bucking was significantly less frequent in Group N-AIC (13.3% vs. 76.7%). Patients received in Group N-AIC had a lower rate of post-extubation sore throat compared to Group S-AIC (6.7% vs. 43.3%). No adverse side effects attributable to either tetracaine or dyclonine were observed in this study. CONCLUSIONS: In awake endotracheal intubation, novel care using oral dyclonine hydrochloride mucilage can provide more favorable mucosal anesthesia and better intubation conditions compared to standard of care practice using oropharyngeal tetracaine spray. TRIAL REGISTRATION: ChiCTR1900023151 . Date of registration: May 14th, 2019.

Intensive Care Unit Resource Utilization After Hip Fracture Surgery in Elderly Patients: Risk Factor Identification and Risk Stratification.

The objective of this study was to develop a risk stratification index (RSI) system to guide intensive care unit (ICU) resource use for elderly patients after hip fracture surgery. The authors' first study cohort consisted of 302 elderly patients with hip fractures who had surgical treatment at their hospital. The authors conducted multivariate logistic regression analysis to investigate relevant risk factors for ICU resource utilization postoperatively. An RSI system was developed based on the significant risk factors from regression analysis. A second study cohort consisted of 205 elderly patients, among whom the authors applied the RSI system to guide ICU resource assignment. Among the first cohort of 302 hip fracture patients, 89 were transferred to ICU postoperatively, of whom 81 were planned to be transferred to ICU and 8 were not. Multivariate stepwise regression analysis revealed that age (≥80 years), preoperative pulmonary disease, perioperative anemia (hemoglobin <8 g/dL), and perioperative lactic acid level (>2 mmol/L) were independent risk factors for postoperative ICU management. The authors then constructed a weighted RSI with these risk factors. In addition, they manually added American Society of Anesthesiologists classification (III/IV) and types of anesthesia as additional risk factors based on their clinical experience. It was determined that an RSI score greater than 4 required postoperative ICU care. The RSI system was then prospectively applied to an independent cohort of 205 elderly surgical patients with hip fractures, among whom only 40 required ICU care. More importantly, there were no later transfers from the general ward to ICU after the application of RSI. The RSI system is effective for guiding postoperative ICU transfer without compromising patient care and minimizes unexpected transfers from the general ward to the postoperative ICU. [Orthopedics. 2020;43(3):e159-e165.].

Sevoflurane Exerts an Anti-depressive Action by Blocking the HMGB1/TLR4 Pathway in Unpredictable Chronic Mild Stress Rats.

This study was performed to investigate whether sevoflurane has an anti-depressive effect and to elucidate its underlying mechanism. Unpredictable chronic mild stress (uCMS)-treated rats were used for inducing depressive-like behavior and subsequently treated with sevoflurane. A forced swimming test was conducted with the rats. An ELISA was performed to detect the levels of brain-derived neurotrophic factor (BDNF) and inflammatory cytokines in the hippocampus of the rats. Differentially expressed genes in uCMS and normal rats were analyzed by microarray. qRT-PCR, western blot, and flow cytometry, and gain and loss of function measurements were carried out to determine the association between sevoflurane and the HMGB1/TLR4 pathway. A forced swimming test with uCMS rats exposed to sevoflurane demonstrated that a 2% sevoflurane treatment resulted in an anti-depressive effect. In addition, ELISAs of TNF-α (tumor necrosis factor-α), IL-1ß (interleukin-1 beta), IL-6 (interleukin-6), and BDNF supported an effect of sevoflurane on inflammatory cytokines and a neurotrophic factor. HMGB1 was dramatically induced in uCMS rats, and the HMGB1/TLR4 pathway was implicated in sevoflurane exposure. A 2% sevoflurane treatment resulted in a restoration of HMGB1/TLR4 signaling and expression of cytokines and BDNF. HMGB1 overexpression partially prevented the protective effect of 2% SF, suggesting sevoflurane protects uCMS rats.

The serum albumin threshold for increased perioperative complications after total hip arthroplasty is 3.0 g/dL.

INTRODUCTION:: Low serum albumin is associated with higher perioperative complications following total hip arthroplasty (THA). The distinct threshold for a significant rise in perioperative complications has not been defined for THA. The purpose of this study was to define the threshold at which perioperative complications rise after THA. METHODS:: We analysed the American College of Surgeons NSQIP database from 2006 to 2013. Our study cohort included unilateral primary THA with reported preoperative albumin levels. Patients were stratified by albumin level. We analysed mortality and 6 composite complication variables (any complication, any complication without transfusion, wound infection, systemic infection, cardiac/pulmonary complications, and any major complication). All data analysis was executed in STATA statistical software. Multivariable logistic regression analysis was used to adjust for odds ratios. RESULTS:: The final cohort included 24,586 patients who were stratified based upon serum albumin levels. Odds ratios after multivariable regression adjustment for age, gender, race, body mass index, ASA classification, and Charlson Comorbidity Index indicated a trend to elevated odds of complication for all composite complications (3 of which were statistically significant) when serum albumin level was <3.0 g/dL. CONCLUSION:: Low serum albumin is associated with increased perioperative complications following THA. The threshold associated with an increase in major perioperative complications appears to be an albumin level of <3.0 g/dL. With attempts to correct modifiable risk factors prior to surgery, the threshold value at which perioperative complications increase is important to define.

The impact of obesity on resource utilization among patients undergoing total joint arthroplasty.

PURPOSE: The presence of obesity poses a challenge for clinical and administrative staff in the peri-operative setting. Evidence indicates that obesity may increase peri-operative complications. However, data on resource utilization in patients undergoing total knee and hip arthroplasty remain rare. Using national data, we sought to determine whether increasing levels of patient obesity is associated with greater resource utilization. We hypothesized that patient care in individuals with a body mass index (BMI) greater than 40 is associated with longer operative and anaesthetic times, longer hospital stays, and greater readmission rates. METHODS: We utilized national data from the National Surgical Quality Improvement Project and identified patients who underwent primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). Patients were divided into three groups according to their BMI (18.5 BMI < 30, 40 BMI < 45, and 45 BMI). The groups were compared regarding associated operating room utilization, length of stay, and readmission rates. RESULTS: Our study showed that TKA and THA patients with higher BMI required significantly longer operation-related times and had higher total length of hospital stay. Higher BMI patients also carried higher odds of readmissions within 30 days in both TKA and THA groups. CONCLUSION: We conclude that BMI status needs to be considered for both medical and economic reasons by health care institutions and payers, in order to make prudent decisions in a world where health care expenses are rising rapidly alongside the increasing obesity epidemic, and resources are becoming increasingly scarce.

Postoperative Delirium in Severely Burned Patients Undergoing Early Escharotomy: Incidence, Risk Factors, and Outcomes.

The aim of this study is to investigate the incidence, related risk factors, and outcomes of postoperative delirium (POD) in severely burned patients undergoing early escharotomy. This study included 385 severely burned patients (injured <1 week; TBSA, 31-50% or 11-20%; American Society of Anesthesiologists physical status, II-IV) aged 18 to 65 years, who underwent early escharotomy between October 2014 and December 2015, and were selected by cluster sampling. The authors excluded patients with preoperative delirium or diagnosed dementia, depression, or cognitive dysfunction. Preoperative, perioperative, intraoperative, and postoperative information, such as demographic characteristics, vital signs, and health history were collected. The Confusion Assessment Method was used once daily for 5 days after surgery to identify POD. Stepwise binary logistic regression analysis was used to identify the risk factors for POD, t-tests, and χ tests were performed to compare the outcomes of patients with and without the condition. Fifty-six (14.55%) of the patients in the sample were diagnosed with POD. Stepwise binary logistic regression showed that the significant risk factors for POD in severely burned patients undergoing early escharotomy were advanced age (>50 years old), a history of alcohol consumption (>3/week), high American Society of Anesthesiologists classification (III or IV), time between injury and surgery (>2 days), number of previous escharotomies (>2), combined intravenous and inhalation anesthesia, no bispectral index applied, long duration surgery (>180 min), and intraoperative hypotension (mean arterial pressure < 55 mm Hg). On the basis of the different odds ratios, the authors established a weighted model. When the score of a patient's weighted odds ratios is more than 6, the incidence of POD increased significantly (P < .05). When the score of a patient's weighted odds ratios is more than 6, the incidence of POD increased significantly (P < .05). Further, POD was associated with more postoperative complications, including hepatic and renal function impairment and hypernatremia, as well as prolonged hospitalization, increased medical costs, and higher mortality.

Low Albumin Is a Risk Factor for Complications after Revision Total Knee Arthroplasty.

Low serum albumin has been shown in the primary joint arthroplasty setting to increase the rate of perioperative complications. Our present work examined a large national inpatient administrative dataset to study the relationship between serum albumin level and key outcome measures after revision total knee arthroplasty (RTKA). Our hypothesis was that lower serum albumin would be an independent risk factor for poor outcomes after RTKA. We analyzed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2006 to 2014, specifically evaluating patients undergoing RTKA. Patients were grouped as having hypoalbuminemia (serum albumin < 3.5 mg/dL) or normal albumin (serum albumin ≥ 3.5). We analyzed data on 22 complications as reported in the NSQIP database and developed composite complication variables (any infections, cardiac/pulmonary complications, and any major complications). For each complication, multivariable logistic regression analysis was used to evaluate its association. The cohort included 4,551 patients undergoing RTKA. Patients in the low serum albumin group were statistically more likely to develop deep surgical site infection, organ space surgical site infection, pneumonia, urinary traction infection, and sepsis. The hypoalbuminemic group was more likely to require unplanned intubation, blood transfusion intraoperatively or postoperatively, remain on a ventilator > 48 hours, and develop acute renal failure. There was also a higher risk of mortality and coma. Across the three composite complication variables, any complication (with or without transfusion), any major complication, and any infection (systemic, wound) were more prevalent among the patients with low serum albumin. This study confirms the relationship between suboptimal nutritional status and complications following RTKA. Hypoalbuminemia may be used as a potential preoperative predictor of outcomes. Understanding the effects of malnutrition on perioperative complications informs the choice of appropriate candidates for surgical intervention, timing of surgery, resource allocation, and risk counseling preoperatively.

The development and application of a risk stratification index system for outpatient shoulder arthroscopy patient management-a single academic center's experience.

BACKGROUND: Our goal was to develop a risk stratification index (RSI) that could guide management of our patients. We hypothesized that the risks of unexpected overstay admission (OS) and emergency department (ED) transfer are predictable on the basis of patient factors for elective outpatient shoulder arthroscopic surgery. METHODS: We first identified 124,860 subjects who received shoulder arthroscopic surgery in the Healthcare Cost and Utilization Project database. We next conducted multivariable regression analysis to identify risk factors associated with unanticipated OS or ED transfer. The risk factors were then adopted to construct the RSI. We last applied the RSI into our practice and prospectively collected outcome data between August 2014 and June 2015. RESULTS: The significant risk factors included arrhythmia, chronic obstructive pulmonary disease, diabetes, obesity, neurologic disease with function impairment, and general anesthesia. All significant risk factors were then adopted to calculate the RSI with equal weight assignment. Simulated analysis concluded that a patient with 2 or fewer risk factors would carry a theoretical rate for OS or ED events of 0.73%. A total of 583 shoulder arthroscopy procedures were performed, among which 472 (81.0%) patients passed the RSI and were successfully managed in the outpatient surgical center without any admission. There were 111 (19.0%) subjects with procedures performed in the main hospital, with 2 unexpected admissions (1.8%). CONCLUSION: We developed an RSI tool for shoulder arthroscopic surgery with an existing national database. It is our conclusion that the RSI system is an effective tool to optimize clinical practice. However, over time, a longer follow-up period might provide more convincing evidence.