Effect of Oxycodone-Based Multimodal Analgesia on Visceral Pain After Major Laparoscopic Gastrointestinal Surgery: A Randomised, Double-Blind, Controlled Trial.

Purpose: Oxycodone is a potent µ- and κ-opioid receptor agonist that can relieve both somatic and visceral pain. We assessed oxycodone- vs sufentanil-based multimodal analgesia on postoperative pain following major laparoscopic gastrointestinal surgery. Methods: In this randomised double-blind controlled trial, 40 adult patients were randomised (1:1, stratified by type of surgery) to receive oxycodone- or sufentanil-based multimodal analgesia, comprising bilateral transverse abdominis plane blocks, intraoperative dexmedetomidine infusion, flurbiprofen axetil, and oxycodone- or sufentanil-based patient-controlled analgesia. The co-primary outcomes were time-weighted average (TWA) of visceral pain (defined as intra-abdominal deep and dull pain) at rest and on coughing during 0-24 h postoperatively, assessed using the numerical rating scale (0-10) with a minimal clinically important difference of 1. Results: All patients completed the study (median age, 64 years; 65% male) and had adequate postoperative pain control. The mean (SD) 24-h TWA of visceral pain at rest was 1.40 (0.77) in the oxycodone group vs 2.00 (0.98) in the sufentanil group (mean difference=-0.60, 95% CI, -1.16 to -0.03; P=0.039). Patients in the oxycodone group had a significantly lower 24-h TWA of visceral pain on coughing (2.00 [0.83] vs 2.98 [1.26]; mean difference=-0.98, 95% CI, -1.66 to -0.30; P=0.006). In the subgroup analyses, the treatment effect of oxycodone vs sufentanil on the co-primary outcomes did not differ in terms of age (18-65 years or >65 years), sex (female or male), or type of surgery (colorectal or gastric). Secondary outcomes (24-h TWA of incisional and shoulder pain, postoperative analgesic usage, rescue analgesia, adverse events, and patient satisfaction) were comparable between groups. Conclusion: For patients undergoing major laparoscopic gastrointestinal surgery, oxycodone-based multimodal analgesia reduced postoperative visceral pain in a statistically significant but not clinically important manner. Trial Registration: Chinese Clinical Trial Registry (ChiCTR2100052085).

Effect of a reused insulin needle remaining in a patient's body.

Diabetes is one of the most common chronic diseases at present, and insulin pen injection therapy plays an important role in the treatment of diabetes. However, the majority of patients might reuse disposable insulin pen needles for various reasons, which leads to related complications. As far as we know, this article is the first to describe a patient whose needle remained in the right upper limb while reusing a disposable insulin injection needle for subcutaneous insulin injection with the non-dominant hand. The patient went to the doctor 1 week later. The needle moved from the lateral area of the proximal upper arm (the injection site) to the posterolateral area of the distal upper arm. The needle was then successfully removed by surgery. The reuse of disposable insulin pen needles might lead to serious complications. It is suggested to strengthen the education of people living with diabetes to help them use insulin pen needles safely.

You are what you eat: nutrient and water relations between mistletoes and hosts.

Mistletoes play important roles in biogeochemical cycles. Although many studies have compared nutrient concentrations between mistletoes and their hosts, no general patterns have been found and the nutrient uptake mechanisms in mistletoes have not been fully resolved. To address the water and nutrient relations in mistletoes compared with their hosts, we measured 11 nutrient elements, two isotope ratios and two leaf morphological traits for 11 mistletoe and 104 host species from four sites across a large environmental gradient in southwest China. Mistletoes had significantly higher phosphorus, potassium, and boron concentrations, nitrogen isotope ratio, and lower carbon isotope ratio (δ13 C) indicative of lower water-use efficiency than hosts, but other elements were similar to those in hosts. Sites explained most of the variation in the multidimensional trait space. With increasing host nitrogen concentration, both mistletoe δ13 C and the difference between mistletoe and host δ13 C increased, providing evidence to support the 'nitrogen parasitism hypothesis'. Host nutrient concentrations were the best predictors for that of the mistletoe nutrient elements in most cases. Our results highlight the important roles of environmental conditions and host nutrient status in determining mistletoe nutrient pools, which together explain their trophic interactions with hosts in subtropical and tropical ecosystems.

Ontogenetic trait variation and metacommunity effects influence species relative abundances during tree community assembly.

Predicting species abundance is one of the most fundamental pursuits of ecology. Combining the information encoded in functional traits and metacommunities provides a new perspective to predict the abundance of species in communities. We applied a community assembly via trait selection model to predict quadrat-scale species abundances using functional trait variation on ontogenetic stages and metacommunity information for over 490 plant species in a subtropical forest and a lowland tropical forest in Yunnan, China. The relative importance of trait-based selection, mass effects, and stochasticity in shaping local species abundances is evaluated using different null models. We found both mass effects and trait selection contribute to local abundance patterns. Trait selection was detectable at all studied spatial scales (0.04-1 ha), with its strength stronger at larger scales and in the subtropical forest. In contrast, the importance of stochasticity decreased with spatial scale. A significant mass effect of the metacommunity was observed at small spatial scales. Our results indicate that tree community assembly is primarily driven by ontogenetic traits and metacommunity effects. Our findings also demonstrate that including ontogenetic trait variation into predictive frameworks allows ecologists to infer ecological mechanisms operating in community assembly at the individual level.

Analysis of the clinical efficacy of two-stage revision surgery in the treatment of periprosthetic joint infection in the knee: A retrospective study.

BACKGROUND: Periprosthetic joint infection (PJI) is a catastrophic complication that can occur following total knee arthroplasty (TKA). Currently, the treatment for PJI mainly includes the use of antibiotics alone, prosthetic debridement lavage, primary revision, secondary revision, joint fusion, amputation, etc. AIM: To explore the clinical effect of two-stage revision surgery for the treatment of PJI after TKA. METHODS: The clinical data of 27 patients (3 males and 24 females; age range, 47-80 years; mean age, 66.7 ± 8.0 years; 27 knees) with PJI treated with two-stage revision surgery in our hospital between January 1, 2010 and December 31, 2020 were analyzed retrospectively. The following outcomes were compared for changes between preoperative and last follow-up results: Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), visual analogue scale (VAS) scores, Hospital for Special Surgery (HSS) scores, knee range of motion (ROM), and infection cure rates. RESULTS: All 27 patients were followed up (range, 13-112 mo). The ESR (14.5 ± 6.3 mm/h) and CRP (0.6 ± 0.4 mg/dL) of the patients at the last follow-up were significantly lower than those at admission; the difference was statistically significant (P < 0.001). The postoperative VAS score (1.1 ± 0.7), HSS score (82.3 ± 7.1), and knee ROM (108.0° ± 19.7°) were significantly improved compared with those before the surgery; the difference was statistically significant (P < 0.001). Of the 27 patients, 26 were cured of the infection, whereas 1 case had an infection recurrence; the infection control rate was 96.3%. CONCLUSION: Two-stage revision surgery can effectively relieve pain, control infection, and retain good joint function in the treatment of PJI after TKA.

Mitoquinone alleviates vincristine-induced neuropathic pain through inhibiting oxidative stress and apoptosis via the improvement of mitochondrial dysfunction.

Chemotherapy drugs such as vincristine (Vin) could cause neuropathic pain. However, it is still lack of ideal therapeutic strategy to treat it. Mitochondrial dysfunction has been involved in the pathogenesis of neuropathic pain. The mitochondrial-targeted antioxidant, mitoquinone (MitoQ), is able to modify mitochondrial signaling, showing beneficial effects on various diseases. In the study, we investigated whether MitoQ could regulate Vin-induced neuropathic pain, and the underlying molecular mechanisms. The results showed that MitoQ significantly improved Vin-induced pain hypersensitivity and glial activation in mice. In addition, Vin resulted in severe oxidative stress in spinal cord tissues of mice, which were inhibited by MitoQ treatment through improving Nrf2 (NF-E2-related factor 2) expression in nuclear. Also, MitoQ treatment dose-dependently reduced the expression of pro-inflammatory cytokines, indicating its anti-inflammatory effects. Importantly, Vin stimulation contributed to mitochondrial fission, as evidenced by the increased expression of phosphorylated Drp1 (dynamin related protein 1) and Fis (mitochondrial fission protein 1), whereas mitochondrial fussion was inhibited. However, these effects were notably abrogated by MitoQ, subsequently improving mitochondrial dysfunction. Moreover, neuron death evoked by Vin was significantly rescued by MitoQ treatment. We also observed significantly reduced expression of cleaved Caspase-3 and Bax expression in spinal cord of MitoQ-treated mice with Vin stimulation. In contrast, anti-apoptotic factor Bcl-2 protein levels decreased by Vin were restored by MitoQ. The process of Cyto-c release from mitochondria triggered by Vin was effectively inhibited in mice treated with MitoQ. These in vivo results were further verified in the primary neurons using the in vitro and ex vivo experiments. Furthermore, MitoQ treatment alleviated axonal degeneration and mitochondria dysfunction induced by Vin. Thus, mitoquinone could alleviate vincristine-induced neuropathic pain by inhibiting oxidative stress and apoptosis via the improvement of mitochondrial dysfunction.

Cdc42 Promotes Schwann Cell Proliferation and Migration Through Wnt/ß-Catenin and p38 MAPK Signaling Pathway After Sciatic Nerve Injury.

Schwann cells (SCs) are unique glial cells in the peripheral nerve and may secrete multiple neurotrophic factors, adhesion molecules, extracellular matrix molecules to form the microenvironment of peripheral nerve regeneration, guiding and supporting nerve proliferation and migration. Cdc42 plays an important regulatory role in dynamic changes of the cytoskeleton. However, there is a little study referred to regulation and mechanism of Cdc42 on glial cells after peripheral nerve injury. The present study investigated the role of Cdc42 in the proliferation and migration of SCs after sciatic nerve injury. Cdc42 expression was tested, showing that the mRNA and protein expression levels of Cdc42 were significantly up-regulated after sciatic nerve injury. Then, we isolated and purified SCs from injuried sciatic nerve at day 7. The purified SCs were transfected with Cdc42 siRNA and pcDNA3.1-Cdc42, and the cell proliferation, cell cycle and migration were assessed. The results implied that Cdc42 siRNA remarkably inhibited Schwann cell proliferation and migration, and resulted in S phase arrest. While pcDNA3.1-Cdc42 showed a contrary effect. Besides, we also observed that Cdc42 siRNA down-regulated the protein expression of ß-catenin, Cyclin D1, c-myc and p-p38, which were up-regulated by pcDNA3.1-Cdc42. Meanwhile, the inhibitor of Wnt/ß-catenin and p38 MAPK signaling pathway IWP-2 and SB203580 significantly inhibited the effect of pcDNA3.1-Cdc42 on cell proliferation and migration. Overall, our data indicate that Cdc42 regulates Schwann cell proliferation and migration through Wnt/ß-catenin and p38 MAPK signaling pathway after sciatic nerve injury, which provides further insights into the therapy of the sciatic nerve injury.

Etomidate plus propofol versus propofol alone for sedation during gastroscopy: a randomized prospective clinical trial.

BACKGROUND AND AIMS: Sedation with propofol alone during gastroscopy has many side effects. Etomidate has advantages in terms of circulation and respiration compared to propofol. We hypothesized that etomidate plus propofol during gastroscopy would be more safe and effective than propofol alone. METHODS: Four hundred (n = 400) patients were randomly divided into a propofol group (P group) and a etomidate plus propofol group (EP group). The P group was given the first dose of 1 % propofol 1 mg/kg before gastroscopy, and the EP group was given 1 % propofol 0.5 mg/kg plus etomidate 0.1 mg/kg. Repeated doses of 10-20 mg propofol or 5-10 mg propofol plus 1-2 mg etomidate were administered to maintain an adequate level of sedation. The sedation depth was maintained by bispectral index value of 40-60. RESULTS: The EP group had a lower incidence of systolic hypotension (13.0 vs. 32.5 %; P < 0.0001), bradycardia (8.5 vs. 16.5 %; P = 0.0226), mild hypoxemia (6.5 vs. 18.0 %; P = 0.0007), and severe hypoxemia (2.5 vs. 10.0 %; P = 0.0031) compared to the P group. Also, the satisfaction of anesthetist and gastroscopist with EP was higher than that of P group (P < 0.0001; P = 0.018, respectively). CONCLUSION: Etomidate plus propofol had few effects on respiration and circulation in patients undergoing gastroscopy and was more safe and effective than propofol alone.

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Tree seedlings under forests serve as an important part of forest ecosystem and play a role in the natural regeneration of forests. To understand the altitudinal distribution patterns of tree seedlings and the response to seasonal variation, we investigated the species composition and individual numbers of tree seedlings, and their seasonal dynamics in Ailao Mountain (subtropical region) and Yulong Mountain (subalpine region) in Yunnan Province. The results showed that the species richness of tree seedlings increased with altitude, peaked in the middle of the mountains, and followed a decline at higher altitudes, and the dominant species also changed significantly. Species richness of tree seedlings was significantly higher at the end of rainy season than that at the end of dry season, and the dominant species had obvious seasonal difference.

Ketamine effect on HMGB1 and TLR4 expression in rats with acute lung injury.

Acute lung injury (ALI) is a common emergency and severe case in clinic. High mobility group protein box 1 (HMGB1) can be treated as a new anti-inflammatory treatment target. Toll-like receptor 4 (TLR4) is an important receptor of HMGB1. Ketamine is a widely used intravenous anesthetic with good anti-inflammatory and immune regulating function. Whether it can protect ALI through inhibiting HMGB1 and TLR4 expression in lung tissue still needs further investigation. Male SD rats were randomly divided into control, lipopolysaccharide (LPS) group and ketamine intervention group with 15 rats in each group. The rats were euthanatized at 24 h after modeling and the bronchoalveolar lavage fluid (BALF) was collected for HMGB1 and TLR4 level detection. Western Blot was applied to analyze HMGB1 and TLR4 protein expression in the lung tissue. HMGB1 and TLR4 concentration in BALF were 5.369 ± 1.564 ng/ml and 43.980 ± 7.524 pg/ml in the control, respectively. They were 12.358 ± 4.681 ng/ml and 102.538 ± 8.412 pg/ml in LPS group, and 7.399 ± 2.346 ng/ml and 87.208 ± 7.558 pg/ml in ketamine intervention group, respectively. Their levels increased significantly in LPS group and down-regulated after ketamine intervention. HMGB1 and TLR4 protein expression in lung tissue elevated obviously in LPS group, and decreased after ketamine treatment. HMGB1 and TLR4 protein level showed positive correlation in lung tissue (r = 0.921, P < 0.001). Ketamine can inhibit HMGB1 and TLR4 expression in ALI, and alleviate LPS induced rat lung injury.

Mannitol improves cerebral oxygen content and postoperative recovery after prolonged retroperitoneal laparoscopy.

BACKGROUND: Prolonged pneumoperitoneum has cerebral adverse effects that may delay recovery and cause postoperative cognitive changes. The purpose of this study was to investigate the effect of mannitol infusion after pneumoperitoneum initiation on cerebral oxygen balance and quality of postoperative recovery in patients undergoing prolonged retroperitoneal laparoscopy. METHODS: Forty patients scheduled for retroperitoneal laparoscopic radical excision of prostatic carcinoma were randomly divided into two groups (n = 20, each) to receive either 0.5 g/kg of 20% mannitol 150 min after the initiation of pneumoperitoneum or an equal volume of 0.9% normal saline. After surgery, time to extubation and recovery time were recorded. The Observer's Assessment of Alertness/Sedation (OAA/S) scale was used to assess the quality of recovery. The Mini-Mental State Exam (MMSE) was given to test cognitive function preoperatively and at 1, 2, and 3 h after extubation. Blood samples from the jugular bulb and the radial artery were collected for blood gas analysis before CO2 insufflation and at 10, 60, and 180 min after insufflation. RESULTS: In the control group (without mannitol), the difference between arterial and venous oxygen content (CaO2-CvO2) before insufflation (6.21 ± 2.58 mL/dL) was significantly greater than it was 3 h after insufflation (2.63 ± 1.29 mL/dL; p < 0.05). Furthermore, 3 h after insufflation, the CaO2-CvO2 also was higher in the group that had been administered mannitol (5.93 ± 1.98 mL/dL) than it was in the control group at that time (p < 0.05). Lactic acid in both arterial and jugular venous blood of the control group at 3 h postinsufflation (2.39 ± 0.89 and 2.51 ± 0.72 mg/dL, respectively) had increased significantly from the preinsufflation values (1.18 ± 0.82 and 1.1 ± 0.85 mg/dL). In the group that received mannitol, the lactic acid levels 3 h postinsufflation were essentially the same as the preinsufflation values. The recovery and extubation times in those receiving mannitol (12.19 ± 2.12 and 20.14 ± 3.62 min, respectively) were significantly shorter than in the control group (21.25 ± 3.61 and 28.79 ± 4.73 min; p < 0.05). The OAAS scores of the mannitol group at the time of extubation and 10 min afterward was significantly higher than these scores in the control group (p < 0.05). One hour and 2 h after extubation, the cognitive function score of the mannitol group was significantly higher than for the control group (p < 0.05). CONCLUSIONS: After prolonged retroperitoneal laparoscopy, there is an imbalance between oxygen supply and demand. A small dose of mannitol can effectively improve cerebral oxygen metabolism, recovery, and cognitive function after the operation.