Bioinformatics analysis highlights CCNB1 as a potential prognostic biomarker and an anti-kidney renal papillary cell carcinoma drug target.

Kidney renal papillary cell carcinoma (KIRP) is a common urinary tumor that causes lymph node invasion. Once metastatic, the prognosis is poor and there is a lack of effective early diagnostic markers for this tumor. The expression of CCNB1 in KIRP tumor tissues was significantly higher than that in normal tissues in The Cancer Genome Atlas database with or without the genotype-tissue expression database, and a consistent result was obtained in 32 paired tissues. In addition, CCNB1 expression increased remarkably with the progression of the T and M stages. Moreover, using the online HPA database, we verified that the immunohistochemical scores of CCNB1 in KIRP were higher than those in the normal kidney tissues. The higher expression group of CCNB1 showed a worse prognosis in KIRP. Moreover, the receiver operating characteristic curve, univariate and multivariate analyses, and construction of the column diagram further illustrated that CCNB1 was an independent prognostic factor for KIRP. Meanwhile, CCNB1 could better predict the 1- and 3-year survival rates of KIRP. Six genes were significantly and positively co-expressed with CCNB1. We also found that the CCNB1 high-expression group was enriched in the ECM_RECEPTOR_INTERACTION and FOCAL_ADHESION pathways. Finally, drug sensitivity analysis combined with molecular docking identified 5 targeting drugs with the strongest binding activity to CCNB1. CCNB1 is a potential and reliable biomarker for KIRP diagnosis and can be used to predict the survival of patients with KIRP. The 5 selected drugs targeting CCNB1 may provide new hopes for patients with KIRP metastasis.

Effect of pneumoperitoneum pressure and the depth of neuromuscular block on renal function in patients with diabetes undergoing laparoscopic pelvic surgery: study protocol for a double-blinded 2 × 2 factorial randomized controlled trial.

BACKGROUND: Patients with diabetes mellitus are at a high risk of developing postoperative acute kidney injury. For patients receiving laparoscopic surgery, standard-pressure pneumoperitoneum (SPP) currently applied in clinical practice also undermines renal perfusion. Several studies have shown that low-pressure pneumoperitoneum (LPP) might reduce pressure-related ischemic renal injury. However, LPP may compromise the view of the surgical field. Previous studies have indicated that deep neuromuscular blockade (NMB) can ameliorate this issue. However, the conclusion is still uncertain. The hypothesis of this study is that the joint use of LPP and deep NMB can reduce perioperative renal injury in diabetic patients undergoing laparoscopic pelvic surgery without impeding the view of the surgical field. METHODS: This is a double-blinded, randomized controlled trial using a 2 × 2 factorial trial design. A total of 648 diabetes patients scheduled for major laparoscopic pelvic surgeries at Peking Union Medical College Hospital will be randomized into the following four groups: SPP (12-15 mmHg) + deep-NMB (post-tetanic count of 1-2) group, LPP (7-10 mmHg) + deep-NMB group, SPP + moderate-NMB (train-of-four of 1-2) group, and LPP + moderate-NMB group. The primary outcome is serum cystatin C level measured before insufflation, after deflation, 24 h postoperatively, and 72 h postoperatively. The secondary outcomes are serum creatinine level, intraoperative urine output, erythrocytes in urinary sediment, renal tissue oxygen saturation, Leiden's surgical condition rating scale, surgery duration, and occurrence of bucking or body movement. DISCUSSION: This study will provide evidence for the effect of LPP on renal function protection in patients with diabetes undergoing laparoscopic pelvic surgery. The trial can also help us to understand whether deep NMB can improve surgical conditions. TRIAL REGISTRATION: ClinicalTrials.gov : NCT04259112 . Prospectively registered on 5 February 2020.

Anesthesia Considerations and Infection Precautions for Trauma and Acute Care Cases During the COVID-19 Pandemic: Recommendations From a Task Force of the Chinese Society of Anesthesiology.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread worldwide. During the ongoing COVID-19 epidemic, most hospitals have postponed elective surgeries. However, some emergency surgeries, especially for trauma patients, are inevitable. For patients with suspected or confirmed COVID-19, a standard protocol addressing preoperative preparation, intraoperative management, and postoperative surveillance should be implemented to avoid nosocomial infection and ensure the safety of patients and the health care workforce. With reference to the guidelines and recommendations issued by the National Health Commission and Chinese Society of Anesthesiology, this article provides recommendations for anesthesia management of trauma and emergency surgery cases during the COVID-19 pandemic.

Perioperative Management of Patients Infected with the Novel Coronavirus: Recommendation from the Joint Task Force of the Chinese Society of Anesthesiology and the Chinese Association of Anesthesiologists.

The outbreak of the new Coronavirus disease, COVID-19, has been involved in 77,262 cases in China as well as in 27 other countries as of February 24, 2020. Because the virus is novel to human beings, and there is no vaccine yet available, every individual is susceptible and can become infected. Healthcare workers are at high risk, and unfortunately, more than 3,000 healthcare workers in China have been infected. Anesthesiologists are among healthcare workers who are at an even higher risk of becoming infected because of their close contact with infected patients and high potential of exposure to respiratory droplets or aerosol from their patients' airways. In order to provide healthcare workers with updated recommendations on the management of patients in the perioperative setting as well as for emergency airway management outside of the operating room, the two largest anesthesia societies, the Chinese Society of Anesthesiology (CSA) and the Chinese Association of Anesthesiologists (CAA) have formed a task force to produce the recommendations. The task force hopes to help healthcare workers, particularly anesthesiologists, optimize the care of their patients and protect patients, healthcare workers, and the public from becoming infected. The recommendations were created mainly based on the practice and experience of anesthesiologists who provide care to patients in China. Therefore, adoption of these recommendations outside of China must be done with caution, and the local environment, culture, uniqueness of the healthcare system, and patients' needs should be considered. The task force will continuously update the recommendations and incorporate new information in future versions.

Expert Recommendations for Tracheal Intubation in Critically ill Patients with Noval Coronavirus Disease 2019.

Coronavirus Disease 2019 (COVID-19), caused by a novel coronavirus (SARS-CoV-2), is a highly contagious disease. It firstly appeared in Wuhan, Hubei province of China in December 2019. During the next two months, it moved rapidly throughout China and spread to multiple countries through infected persons travelling by air. Most of the infected patients have mild symptoms including fever, fatigue and cough. But in severe cases, patients can progress rapidly and develop to the acute respiratory distress syndrome, septic shock, metabolic acidosis and coagulopathy. The new coronavirus was reported to spread via droplets, contact and natural aerosols from human-to-human. Therefore, high-risk aerosol-producing procedures such as endotracheal intubation may put the anesthesiologists at high risk of nosocomial infections. In fact, SARS-CoV-2 infection of anesthesiologists after endotracheal intubation for confirmed COVID-19 patients have been reported in hospitals in Wuhan. The expert panel of airway management in Chinese Society of Anaesthesiology has deliberated and drafted this recommendation, by which we hope to guide the performance of endotracheal intubation by frontline anesthesiologists and critical care physicians. During the airway management, enhanced droplet/airborne PPE should be applied to the health care providers. A good airway assessment before airway intervention is of vital importance. For patients with normal airway, awake intubation should be avoided and modified rapid sequence induction is strongly recommended. Sufficient muscle relaxant should be assured before intubation. For patients with difficult airway, good preparation of airway devices and detailed intubation plans should be made.

Laryngeal mask airway reduces incidence of post-operative sore throat after thyroid surgery compared with endotracheal tube: a single-blinded randomized controlled trial.

BACKGROUND: Sore throat is a remarkable complication after thyroid surgery with endotracheal tube (ETT). Many studies revealed that laryngeal mask airway (LMA) might reduce the incidence and severity of postoperative sore throat. However, little is known about the use of a flexible reinforced LMA (FLMA) in thyroid surgery. The purpose of this study was to explore the potential benefits of FLMA compared with ETT on postoperative sore throat. METHODS: In this prospective, single-blinded, randomized, controlled trial, ninety-six patients aged 20-80 years, scheduled for elective radical thyroidectomy under general anesthesia were enrolled. They were randomly divided into ETT group and FLMA group. All the included patients received total intravenous anesthesia (with propofol, fentanyl and rocuronium) and controlled mechanical ventilation during the surgery. Cuff pressure of ETT and FLMA were strictly controlled. Incidence and severity of postoperative sore throat, numbness and hoarseness at 1, 24, and 48 h after surgery was evaluated and compared between the two groups. Incidence and severity of buckling during extubation and the hemodynamic profile during intubation were also recorded and compared. RESULTS: The incidence of sore throat and hoarseness was significantly lower in FLMA group than those in ETT group at 1 h, 24 h and 48 h postoperatively, as well as the severity of sore throat. Compared to ETT group, there was a significantly lower incidence of buckling during extubation and less fluctuation of HR and BP at 1 min and 3 min after intubation in FLMA group. CONCLUSIONS: Patients undergoing thyroid surgery with FLMA had less postoperative laryngopharyngeal symptoms when compared with ETT. The use of FLMA also achieved less buckling during extubation and better hemodynamic profiles during intubation. TRIAL REGISTRATION: The research was registered in Chinese Clinical Trial Registry (ChiCTR-IOR-15006602) on May 23th, 2015.

Performance of Air Seal of Flexible Reinforced Laryngeal Mask Airway in Thyroid Surgery Compared With Endotracheal Tube: A Randomized Controlled Trial.

BACKGROUND: Flexible reinforced laryngeal mask airway (FLMA®) has gained popularity in thyroid surgery, but air leak and displacement are still concerns. METHODS: In this randomized, single-blinded, noninferiority, controlled trial, we randomized patients scheduled for elective radical thyroidectomy to an endotracheal tube (ETT) group or a FLMA group. The primary outcomes were ventilation leak volume, peak airway pressure, and partial pressure of end-tidal carbon dioxide (PetCO2). Data for primary outcomes were collected after insertion of ETT/FLMA, at incision, and at 10-minute intervals during surgery. Ten milliliters, 5 cm H2O, and 10 mm Hg were used as the noninferiority deltas for ventilation leak volume, peak airway pressure, and PetCO2, respectively. We assessed noninferiority of FLMA to ETT on the primary outcomes over time using the results of a linear mixed-effects model. The position of FLMA mask was evaluated before and after surgery, and the airway complications were recorded. RESULTS: A total of 132 patients were included: 65 in ETT group and 67 in FLMA group. Differences (FLMA group minus ETT group) of ventilation leak volume, peak airway pressure, and PetCO2 from the mixed-effects models were 2.09 mL (98.3% confidence interval [CI], -6.46 to 10.64), -0.60 cm H2O (98.3% CI, -2.15 to 0.96), and 1.02 mm Hg (98.3% CI, 0.04-1.99), respectively. Score of fiber-optic position of FLMA was significantly higher after surgery than before. There was no severe shift, loss of the mask seal, regurgitation, or aspiration in the FLMA group. One patient in the FLMA group experienced brief and easily controlled laryngospasm. CONCLUSIONS: In thyroid surgery, FLMA is noninferior to ETT in the peak airway pressure and PetCO2 although mild to moderate mask shift could occur during surgical manipulation. There is no evidence for a higher complication rate when FLMA is used.

Dilutional Hyponatremia during Hysteroscpic Surgery: Prevention and Treatment.

Dilutional hyponatremia caused by excess absorption of hypo-osmotic irrigation fluids is one of the severe complications during hysteroscopic surgery. Appropriate delivery system and distending media,proper distending pressure,and reducing destruction of uterine venous sinus may remarkably lower the morbidity. Meanwhile,early detection and timely treatment of moderate and severe hyponatremia to avoid the occurrence of secondary nervous system demyelination are particularly important during the surgery. This review summarizes the risk factors and the prevention and treatment strategies of dilutional hyponatremia during hysteroscopic surgery.

Effect of low dose rocuronium in preventing ventilation leak for flexible laryngeal mask airway during radical mastectomy.

The flexible laryngeal mask airway (FLMA) is becoming more and more popular in general anesthesia during surgery of head, neck and upper chest. But very limited information has been published about whether muscle relaxant was necessary or not for anesthesia with FLMA. To investigate whether low-dose muscle relaxant is necessary in preventing ventilation leak of FLMA in radical mastectomy, forty-eight female patients undergoing radical mastectomy were enrolled in the study. They were randomly divided into low-dose muscle relaxant (LD-MR) group and non-muscle relaxant (non-MR) group. All the included patients received total intravenous anesthesia (with propofol, fentanyl and remifentanil) and controlled mechanical ventilation with FLMA during the surgery. Patients in LD-MR group received 0.4 mg/kg rocuronium during anesthesia induction, while patients in non-MR group received equivalent volumes of physiological saline. Insertion time was shorter in LD-MR group than that in non-MR group (P < 0.05). Peak airway pressures and ventilation leak volumes at 10, 20 and 30 minutes were lower in LD-MR group than those in non-MR group (P < 0.05). No difference was found between LD-MR and non-MR group in terms of emergence time, FLMA extraction time, and maximum tidal volumes before FLMA extraction. The results show that low-dose rocuronium could reduce the ventilation leak for mechanical ventilation with FLMA during radical mastectomy without prolonging the emergence time.

Effectiveness of Two Training Methods for Avoiding Excessive Inflation of Laryngeal Mask Airway Supreme.

OBJECTIVE: To evaluate the effectiveness of two training methods for avoiding excessive inflation of laryngeal mask airway(LMA)Supreme. METHODS: Totally 41 anesthesiologists were randomly divided into hand touch group(H group,n=20)and short-term pressure gauge training group(G group,n=21). Before training,subjects were asked to inflate the cuff of LMA Supreme to two target pressures,30 cmH(2)O and 60 cmH(2)O, according to their own experiences. The actual cuff pressures were recorded as baseline pressures. Subjects in H group then received the training of hand touch:touch the vermilion of the lip and apex nasi with the left ring finger and feel the hardness. A cuff pressure with hardness similar to the vermilion of the lip was defined as 30 cmH(2)O, and similar to the apex nasi as 60 cmH(2)O. Subjects in G group were asked to inflate the cuff with a pressure gauge and feel the hardness of the cuff when the pressure reached 30 cmH(2)O and 60 cmH(2)O. After one-week training,two groups of subjects repeated the cuff inflation test. Actual cuff pressures after training were also recorded and compared with the baseline pressures. Results Actual cuff pressures after training[Group H:(39.7±15.7) cmH(2)O(P=0.00);Group G:(26.2±13.2) cmH(2)O(P=0.03)]were significantly lower than baseline pressures in both groups when the target cuff pressure was 30 cmH(2)O, and the differences were not statistically significant between these two groups(P=0.06). When the target pressure was 60 cmH(2)O,the actual cuff pressure of H group [(91.1±24.3)cmH(2)O] was significantly higher than that of G group [(58.1±15.4) cmH(2)O (P=0.01)]. However,the actual cuff pressure of G group was similar to the target pressure. CONCLUSION: The two training methods are equally effective when the target pressure is 30 cmH(2)O, while short-term pressure gauge training method is superior when the target pressure is 60 cmH(2)O.

Comparison of the Airtraq laryngoscope and the GlideScope for double-lumen tube intubation in patients with predicted normal airways: a prospective randomized trial.

BACKGROUND: The Airtraq laryngoscope and the GlideScope are commonly used in many airway scenarios. However, their features have not been fully described for double-lumen tube intubation. A prospective randomized study was designed to compare their intubation performances in thoracic surgery patients. METHODS: Seventy ASA physical status I and II patients with predicted normal airway were scheduled for thoracic surgeries with double-lumen tube intubation. They were randomly assigned to one of two groups and intubated with either the Airtraq laryngoscope (group A, n = 35) or the GlideScope (group G, n = 35). Airway assessments were performed prior to anesthesia, and all patients were induced with a standard anesthetic regimen. The Cormack-Lehane grades were initially evaluated with a Macintosh laryngoscope and subsequently with the group-specific laryngoscope before intubation. Intubation time was recorded as the primary outcome. The Cormack-Lehane grade, the success of the first intubation attempt, the intubation difficulty scales and ease of tube advancement were noted. Hemodynamic variables during intubation and incidence of post-operative sore throat were documented as well. RESULTS: The intubation time of group A was shorter than that of group G (36.6 ± 20.2 s vs. 54.6 ± 25.7 s, p = 0.002). The Cormack-Lehane grade (I/II/III/IV) was significantly better in group A (33/2/0/0 vs. 28/7/0/0, p = 0.042). The mean arterial pressure and heart rate rose to higher levels during intubation with the GlideScope than with the Airtraq laryngoscope. The success of the first intubation attempt and the intubation difficulty scales were comparable between the two groups. The numbers of patients who experienced postoperative sore throat were similar (6 vs. 8) in the two groups. CONCLUSIONS: Compared with the GlideScope, the specially designed Airtraq laryngoscope might be more suitable for double-lumen tube intubations in patients with predicted normal airway. TRIAL REGISTRATION: www.chictr.org Identifier: ChiCTR-TRC-11001628.

Impact of cuff pressure on airway leak pressure in laryngeal mask airway supreme and flexible.

OBJECTIVE: To investigate the impact of cuff pressure on airway leak pressure in laryngeal mask airway(LMA)Supreme and Flexible. METHODS: Patients about to have elective breast surgery were divided into Supreme group(35 cases)and Flexible group(33 cases). After general induction of anesthesia,LMA Supreme or Flexible was inserted by one anesthesiologist. We confirmed the LMA location,adjusted the cuff pressure,and recorded the peak airway leak pressures under different cuff pressures(10,20,30,40,and 50 cmH2O). RESULTS: In Supreme group,peak airway leak pressures [(24.46±5.43),(25.11±5.51),(25.86±5.57),(26.17±5.72)cmH2O] under 20,30,40,and 50 cmH2O cuff pressure showed no significant difference(P>0.05)between each other,but significantly higher than that under 10 cmH2O cuff pressure(20.80±4.63)cmH2O(P<0.05). And in the Flexible group,peak airway leak pressures [(20.09±2.98),(20.70±3.08),(21.21±3.15)cmH2O] under 30,40,50 cmH2O cuff pressure also showed no significant difference(P>0.05)between each other,but significantly higher than those under 10 or 20 cmH2O cuff pressure [(17.52±2.39),(18.61±2.42)cmH2O]. Mean peak airway leak pressure [(25.40±5.52) cmH2O] of LMA Supreme was significantly higher than that of LMA Flexible(20.67±3.06)cmH2O(P<0.05). CONCLUSIONS: Mean airway leak pressure of LMA Supreme is higher than LMA Flexible. The lowest cuff pressure to meet the tightness requirement with LMA Supreme is 20 cmH2O,which is lower than Flexible(30 cmH2O).

[Perioperative airway management for patients with morbid obesity].

The excess fatty tissues on the head, neck, thorax, and abdomen of morbid obese patients can impede the patency of the upper airway and impair lung functions. Meanwhile, these patients often have comorbidities such as obstructive sleep apnea, hypoventilation syndrome, chronic obstructive pulmonary disease, and asthma, which may result in difficult airway, intraoperative hypoventilation, and postoperative respiratory depression. Therefore, perioperative airway management for morbid obese patients may pose a big challenge to anesthesiologists. Anesthesiologists should know well about the pathophysiological features of respiratory system and grasp rational management principles, so as to improve the safety and effectiveness of perioperative airway management and optimize the clinical prognosis.

Antinociceptive effects of combination of tramadol and acetaminophen on painful diabetic neuropathy in streptozotocin-induced diabetic rats.

OBJECTIVE: The purpose of this study was to establish the streptozotocin (STZ)-induced diabetic model with rats and investigate the antinociceptive effect of combination of Tramadol (TR) and Acetaminophen (NAPA) on the animal model for the first time. METHODS: Diabetic model was induced by a single injection of STZ (60 mg/kg, intraperitoneal). Nociceptive thresholds were measured by means of electronic von Frey test, hot-plate test, and tail-flick test. On the 28th day of diabetes induction, diabetic rats with significant hyperalgesia were randomly divided into three groups: TR, NAPA, and TR-NAPA combination group. Each group was randomly divided into four subgroups. Three geometric series of drugs were given to each group respectively. Antinociceptive effects of the drugs were assessed at 15, 30, 60, 120, and 180 minutes after drug administration. 50% Maximum antinociceptive effect of each drug was determined by probit analysis, whereas interaction between TR and NAPA was evaluated by isobolographic analysis. RESULTS: Hyperalgesia, along with hyperglycemia, developed 4 days after STZ injection and persisted at all tested time points until 28 days. TR, NAPA, and TR-NAPA combination administration all produced dose-dependent antinociceptive effects. Isobolographic analysis showed a significant deviation of TR/NAPA 50% maximum antinociceptive effect (in tail-flick test, but not in von Frey test) from the additive line. CONCLUSIONS: Combination of the two drugs produces an additive antinociceptive effect in tail-flick test, whereas probable additive antinociceptive effect in von Frey test in painful diabetic neuropathy rats.

[Management of pulmonary thromboembolism in post-operative neurosurgical patients].

OBJECTIVE: To summarize the diagnosis and treatment of pulmonary thromboembolism (PTE) in post-operative neurosurgical patients. METHODS: We retrospectively analyzed the clinical data of 7 patients who experienced pulmonary thromboembolism after neurosurgical operations in our department from October 2009 to March 2010. RESULTS: Of these 7 patients, 6 were confirmed with computed tomographic pulmonary angiography (CTPA) and 1 was diagnosed according to the clinical manifestations and other diagnostic examinations. All the patients were treated initially with low-dose heparin or low-molecular-weight heparin and then with warfarin. Two patients were implanted with permanent inferior vena cava filters before anticoagulation. One received anticoagulant therapy and died of respiratory failure due to pulmonary embolism on the fourth post-operative day. Six patients were discharged after significant improvement. CONCLUSIONS: Many risk factors may cause PTE peri-operatively. Post-operative CTPA may be indicated. Anticoagulation and other management strategies may be applied to improve the outcome.