Effect of ropivacaine, mepivacaine or the combination of ropivacaine and mepivacaine for epidural anaesthesia on the postoperative recovery in patients undergoing caesarean section: a randomized, prospective, double-blind study.

BACKGROUND: Anaesthetic methods and drugs with rapid onset, rapid recovery and better postoperative analgesia are more suitable for rapid recovery in obstetric anaesthesia. We formulated the following hypothesis: a combination of mepivacaine and ropivacaine could provide a longer analgesic effect and have more advantages in terms of rapid-recovery indicators. METHODS: A total of 180 pregnant women scheduled to undergo elective caesarean sections were randomly assigned to three surgical groups, which received 2% mepivacaine (Group M), 2% mepivacaine + 0.75% ropivacaine (Group MR) (Volume 1:1) or 0.75% ropivacaine (Group R) through an epidural catheter. The situation of postoperative analgesia and other indicators of rapid recovery were recorded. RESULTS: One hundred and fifty patients were included in the final analysis. Their demographic data were similar. The visual analogue scale (VAS) scores of Group MR and Group R were lower than Group M at 1 and 2 h after surgery both at rest and with movement (P < 0.05), and the time to first ambulation in Group MR (17.38 ± 2.06 h) and Group M (17.20 ± 2.09 h) was shorter than that in Group R (22.18 ± 1.74 h) (P < 0.05). CONCLUSION: Application of 2% mepivacaine combined with 0.75% ropivacaine for epidural anaesthesia can provide longer postoperative analgesia and earlier ambulation, these effect may be more suitable than that of 2% mepivacaine or 0.75% ropivacaine alone for caesarean section. TRIAL REGISTRATION: This study was registered at Chinese Clinical Trial Registry (Registration number: ChiCTR 2300078288; date of registration: 04/12/2023).

Ulinastatin Alleviates Repetitive Ketamine Exposure-Evoked Cognitive Impairment in Adolescent Mice.

Ketamine (KET) is widely used for induction and maintenance of anesthesia, and long-term use is required for treatment of depression patients. Repeated use of KET is associated with mood and memory disorders. Ulinastatin (UTI), a urinary trypsin inhibitor, has been widely undertaken as an anti-inflammatory drug and proved to have neuroprotective effects. The aim of this work was to determine whether prophylactic use of UTI could attenuate KET-induced cognitive impairment. It was found that repetitive KET anesthesia cause cognitive and emotional disorders in adolescent mice in WMZ and OFT test, while UTI pretreatment reversed the poor performance compared to the AK group, and the platform finding time and center crossing time were obviously short in the CK+UTI group (P < 0.05). Our ELISA experiment results discovered that UTI pretreatment reduced the expression levels of IL-1ß and IL-6 induced by CK anesthesia compared to AK (P < 0.05). In addition, UTI pretreatment protected the cognitive function by restraining the expression levels of Tau protein, Tau phospho-396 protein, and Aß protein in the CK group compared to the AK group in Western blotting (P < 0.05). The results suggested that UTI could act as a new strategy to prevent the neurotoxicity of KET, revealing a significant neuroprotective effect of UTI.

The Effect of Colloids versus Crystalloids for Goal-Directed Fluid Therapy on Prognosis in Patients Undergoing Noncardiac Surgery: A Meta-Analysis of Randomized Controlled Trials.

Background: Goal-directed fluid therapy (GDFT) contributes to improvements in intraoperative fluid infusion based on objective parameters and has been widely recommended in clinical practice. In addition, increasing evidence reveals that GDFT can improve the prognosis of surgical patients. However, considering the individual characteristics of colloids and crystalloids in clinical use, it is uncertain as to which type of fluids administered is associated with better outcomes in the condition of GDFT. Objectives: To evaluate the effect of colloids versus crystalloids under GDFT on prognosis in patients undergoing noncardiac surgery. Data Sources. Randomized controlled trials (RCTs) from PubMed, EMBASE, Ovid MEDLINE, CNKI, Cochrane library, and reference lists of relevant articles. Methods: Two investigators independently screened and reviewed studies for inclusion and performed data extraction. Our primary outcome was a composite of postoperative complications. The secondary outcomes were (1) mortality at the follow-up duration; (2) postoperative complications of several organ systems, including cardiac, pulmonary, digestive, urinary, nervous system, and postoperative infection events; and (3) hospital and ICU length of stay. Heterogeneity was assessed by the I 2 and chi-square tests. The odds ratio (OR) of the dichotomous data, mean difference (MD) of continuous data, and 95% confidence intervals (CI) were calculated to assess the pooled data. Results: Of 332 articles retrieved, 15 RCTs (involving 2,956 patients undergoing noncardiac surgery) were included in the final analysis. When the data were pooled, patients in the colloids and crystalloids group revealed no difference in postoperative composite complications (OR = 0.84, 95% CI = 0.51-1.38, P=0.49) under GDFT. Regarding the secondary outcomes, patients in the colloids group were associated with fewer digestive system complications (OR = 0.64, 95% CI = 0.41-0.98, P=0.04). However, no difference was found in mortality (OR = 1.37, 95% CI = 0.72-2.58, P=0.34), complications of the cardiac system (OR = 1.49, 95% CI = 0.66-3.37, P=0.34), pulmonary system (OR = 0.89, 95% CI = 0.62-1.28, P=0.53), urinary system (OR = 1.05, 95% CI = 0.61-1.80, P=0.87), nervous system (OR = 1.04, 95% CI = 0.55-1.98, P=0.90), postoperative infection events (OR = 0.89, 95% CI = 0.75-1.07, P=0.22), length of hospital stay (difference in mean = -0.71, 95% CI = -1.49-0.07, P=0.07), and ICU stay (difference in mean = -0.01, 95% CI = -0.20-0.18, P=0.95) between patients receiving GDFT with colloids or crystalloids. Conclusion: There is no evidence of a benefit in using colloids over crystalloids under GDFT in patients undergoing noncardiac surgery, despite its use resulting in lower digestive system complications.

Higher Atherogenic Index of Plasma Is Associated with Hyperuricemia: A National Longitudinal Study.

Background: The association between atherogenic index of plasma (AIP) and hyperuricemia remains indistinct. This study was aimed to examine the relationship between AIP and hyperuricemia among the middle-aged and the elderly Chinese population. Methods: Datasets were retrieved from the China Health and Retirement Longitudinal Study (CHARLS) survey conducted in 2011 and 2015. 13,021 participants in the CHARLS in 2011 and 7,017 participants involved both in 2011 and 2015 were included, respectively. The measurement of AIP and hyperuricemia was based on the test of fasting blood. Association between AIP and hyperuricemia was assessed by logistic regression, and the nonlinear association was examined by restricted cubic splines (RCS). The cutoff point of AIP was calculated using receiver operator curve (ROC). 1 : 1 propensity score matching (PSM) was adopted to further explore the relationship between AIP and hyperuricemia. Results: In the section of a cross-sectional study, a positive association between AIP and hyperuricemia was found. The odds ratios (ORs) of hyperuricemia were 1.00 (reference), 1.52 (1.10-2.10), 1.80 (1.31-2.47), and 3.81 (2.84-5.11). Nonlinear association was not detected using RCS analysis. There were 664 hyperuricemia cases during the four years follow-up. The hyperuricemia prevalence was 9.5%. In the fully adjusted longitudinal analysis, the ORs for hyperuricemia across the quartiles of AIP were 1.00 (reference), 1.00 (0.74-1.37), 1.59 (1.20-2.11), and 2.55 (1.94-3.35), respectively. In the longitudinal analysis after PSM, the OR of hyperuricemia were 1.91 (1.45, 2.51) and 1.92 (1.45, 2.54) in the univariate and multivariate model, respectively. Conclusion: AIP can predict the prevalence of hyperuricemia in the Chinese middle-aged and elderly population.

Postoperative intra-abdominal hypertension predicts worse hospital outcomes in children after cardiac surgery: a pilot study†.

OBJECTIVES: Our goal was to determine the incidence and characteristics of postoperative intra-abdominal hypertension (IAH) in paediatric patients undergoing open-heart surgery. METHODS: This single-centre study included consecutive children (aged <16 years) who underwent open-heart surgery between July 2020 and February 2021. Patients who entered the study were followed until in-hospital death or hospital discharge. The study consisted of 2 parts. Part I was a prospective observational cohort study that was designed to discover the association between exposures and IAH. Postoperative intra-abdominal pressure was measured immediately after admission to the intensive care unit and every 6 h thereafter. Part II was a cross-sectional study to compare the hospital-related adverse outcomes between the IAH and the no-IAH cohorts. RESULTS: Postoperatively, 24.7% (38/154) of the patients exhibited IAH, whereas 3.9% (6/154) developed abdominal compartment syndrome. The majority (29/38, 76.3%) of IAH cases occurred within the first 24 h in the intensive care unit. Multivariable analysis showed that the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score [odds ratio (OR) = 1.86, 95% confidence interval (CI) 1.23-2.83, P = 0.004], right-sided heart lesion (OR = 5.60, 95% CI 2.34-13.43, P < 0.001), redo sternotomy (OR = 4.35, 95% CI 1.64-11.57, P = 0.003), high baseline intra-abdominal pressure (OR = 1.43, 95% CI 1.11-1.83, P = 0.005), prolonged cardiopulmonary bypass duration (OR = 1.01, 95% CI 1.00-1.01, P = 0.005) and deep hypothermic circulatory arrest (OR = 5.14, 95% CI 1.15-22.98, P = 0.032) were independent predictors of IAH occurrence. IAH was associated with greater inotropic support (P < 0.001), more gastrointestinal complications (P = 0.001), sepsis (P = 0.003), multiple organ dysfunction syndrome (P < 0.001) and prolonged intensive care unit stay (z = -4.916, P < 0.001) and hospitalization (z = -4.710, P < 0.001). The occurrence of a composite outcome (P = 0.009) was significantly increased in patients with IAH. CONCLUSIONS: IAH is common in children undergoing cardiac surgery and is associated with worse hospital outcomes. Several factors may be associated with the development of IAH, including basic cardiac physiology and perioperative factors. TRIAL INFORMATION: This study was registered in the Chinese Clinical Trial Registry (Trial number: ChiCTR2000034322)URL site: https://www.chictr.org.cn/hvshowproject.html?id=41363&v=1.4.

Activation of group II metabotropic glutamate receptors inhibits glutamatergic transmission in the rat entorhinal cortex via reduction of glutamate release probability.

Glutamate interacts with ionotropic and metabotropic glutamate receptors (mGluRs). Whereas the entorhinal cortex (EC) is a principal structure involved in learning and memory, the roles of mGluRs in synaptic transmission in the EC have not been completely determined. Here, we show that activation of group II mGluRs (mGluR II) induced robust depression of glutamatergic transmission in the EC. The mGluR II-induced depression was due to a selective reduction of presynaptic release probability without alterations of the quantal size and the number of release sites. The mechanisms underlying mGluR II-mediated suppression of glutamate release included the inhibition of presynaptic release machinery and the depression of presynaptic P/Q-type Ca(2+) channels. Whereas mGluR II-induced depression required the function of Gα(i/o) proteins, protein kinase A (PKA) pathway was only involved in mGluR II-mediated inhibition of release machinery and thereby partially required for mGluR II-induced inhibition of glutamate release. Presynaptic stimulation at 5 Hz for 10 min also induced depression of glutamatergic transmission via activation of presynaptic mGluR II suggesting an endogenous role for mGluR II in modulating glutamatergic transmission.

Inhibition of the TLR4/NF-κB pathway promotes the polarization of LPS-induced BV2 microglia toward the M2 phenotype.

This study aimed to investigate whether the inhibition of the TLR4/NF-κB pathway can promote lipopolysaccharide (LPS)-induced microglial polarization from the M1 to M2 phenotype, and thus exert neuroprotection. LPS-induced microglia were used as a model for inflammation in vitro. TLR4-specific inhibitor resatorvid (TAK-242) and NF-κB inhibitor pyrrolidine dithiocarbamate (PDTC) were used to verify the effect of the TLR4/NF-κB pathway on microglia activation and polarization. Cell proliferation was measured by cell counting, and nitric oxide (NO) and reactive oxygen species (ROS) release was measured using the Griess reagent and ROS kit, respectively. Immunofluorescence and RT-qPCR analyses were used to detect the expression of microglial activation markers, phenotypic markers, related pathway molecules, and inflammatory factors. TLR4 specific inhibitor TAK-242 and NF-κB inhibitor PDTC alleviated LPS-induced microglia over-activation by inhibiting the TLR4/NF-κB pathway, and reduced LPS-stimulated cell proliferation and the release of NO, ROS, TNF-a, and IL-6 and IL-1ß. Meanwhile, TAK-242 and PDTC promoted LPS-induced polarization of microglia from M1 to M2 phenotype, decreased the expression of microglial activation marker Iba1 and M1 phenotypic markers (TNF-a and CD86), and increased the expression of M2 phenotypic markers (Arg-1 and CD206). The mechanism may be related to inhibiting the TLR4/NF-κB pathway. The inhibition of the TLR4/NF-κB pathway can promote LPS-induced polarization of BV2 microglia from M1 phenotype to M2 phenotype.

Thrombotic pulmonary embolism of inferior vena cava during caesarean section: A case report and review of the literature.

BACKGROUND: Thrombotic pulmonary embolism (TPE) is one of the most critical diseases in obstetrics but is rarely reported in caesarean section (CS) because TPE patients in CS have a high risk of death and are difficult to diagnose. This case report of TPE during CS was recorded by transthoracic echocardiography (TTE) and can provide a reference for the differential diagnosis of critical illnesses in CS. CASE SUMMARY: A 37-year-old pregnant woman with rheumatic heart disease (RHD), gravida 5 and para 1 (G5P1), presented for emergency CS at 33 wk and 3 d of gestation under general anesthesia because of acute heart failure, pulmonary hypertension and arrhythmia. After placental removal during CS, TTE revealed a nascent thrombus in the inferior vena cava (IVC) that elongated, detached and fragmented leading to acute thromboembolic events and acute TPE. This report presents the whole process and details of TPE during CS and successful rescue without any sequelae in the patient. This case gives us new ideas for the diagnosis of death or cardiovascular accidents during CS in pregnant women with heart disease and the detailed presentation of the rapid development of TPE may also elucidate new ideas for treatment. This case also highlighted the importance of prophylactic anticoagulation in the management of heart disease during pregnancy. CONCLUSION: Pregnancy with heart failure could trigger inferior vena cava (IVC)-origin TPE during CS. Detection and timely treatment can avoid serious consequences.

Successful ECMO-assisted open chest cardiopulmonary resuscitation in a postpartum patient with delayed amniotic fluid embolism.

BACKGROUND: Amniotic fluid embolism (AFE) is a rare but potentially dangerous severe obstetrics complication, which is accompanied by an incidence between 1.9 and 6.1 per 100,000 births. CASE PRESENTATION: Here, we report an AFE case after cesarean delivery diagnosed on a cardiac arrest complicated by acute respiratory distress syndrome and coagulopathy. Diagnosis, risk factors and pathophysiology for AFE have been fully discussed, besides, extracorporeal membrane oxygenation in the early management of cardiac arrest was used, describing the indication, efficacy and successful performed of open-chest cardiopulmonary resuscitation for the patient. CONCLUSION: In AFE with cute cardiovascular collapse, extracorporeal membrane oxygenation support can be considered as the alternative therapies.

Cellular and molecular atlas of the placenta from a COVID-19 pregnant woman infected at midgestation highlights the defective impacts on foetal health.

OBJECTIVES: The impacts of the current COVID-19 pandemic on maternal and foetal health are enormous and of serious concern. However, the influence of SARS-CoV-2 infection at early-to-mid gestation on maternal and foetal health remains unclear. MATERIALS AND METHODS: Here, we report the follow-up study of a pregnant woman of her whole infective course of SARS-CoV-2, from asymptomatic infection at gestational week 20 to mild and then severe illness state, and finally cured at Week 24. Following caesarean section due to incomplete uterine rupture at Week 28, histological examinations on the placenta and foetal tissues as well as single-cell RNA sequencing (scRNA-seq) for the placenta were performed. RESULTS: Compared with the gestational age-matched control placentas, the placenta from this COVID-19 case exhibited more syncytial knots and lowered expression of syncytiotrophoblast-related genes. The scRNA-seq analysis demonstrated impaired trophoblast differentiation, activation of antiviral and inflammatory CD8 T cells, as well as the tight association of increased inflammatory responses in the placenta with complement over-activation in macrophages. In addition, levels of several inflammatory factors increased in the placenta and foetal blood. CONCLUSION: These findings illustrate a systematic cellular and molecular signature of placental insufficiency and immune activation at the maternal-foetal interface that may be attributed to SARS-CoV-2 infection at the midgestation stage, which highly suggests the extensive care for maternal and foetal outcomes in pregnant women suffering from COVID-19.

Cholecystokinin facilitates neuronal excitability in the entorhinal cortex via activation of TRPC-like channels.

Cholecystokinin (CCK) is one of the most abundant neuropeptides in the brain, where it interacts with two G protein-coupled receptors (CCK-1 and CCK-2). Activation of both CCK receptors increases the activity of PLC, resulting in increases in intracellular calcium ion (Ca(2+)) release and activation of PKC. Whereas high density of CCK receptors has been detected in the superficial layers of the entorhinal cortex (EC), the functions of CCK in this brain region have not been determined. Here, we studied the effects of CCK on neuronal excitability of layer III pyramidal neurons in the EC. Our results showed that CCK remarkably increased the firing frequency of action potentials (APs). The effects of CCK on neuronal excitability were mediated via activation of CCK-2 receptors and required the functions of G proteins and PLC. However, CCK-mediated facilitation of neuronal excitability was independent of inositol trisphosphate receptors and PKC. CCK facilitated neuronal excitability by activating a cationic channel to generate membrane depolarization. The effects of CCK were suppressed by the generic, nonselective cationic channel blockers, 2-aminoethyldiphenyl borate and flufenamic acid, but potentiated by gadolinium ion and lanthanum ion at 100 µM. Depletion of extracellular Ca(2+) also counteracted CCK-induced increases in AC firing frequency. Moreover, CCK-induced enhancement of neuronal excitability was inhibited significantly by intracellular application of the antibody to transient receptor potential channel 5 (TRPC5), suggesting the involvement of TRPC5 channels. Our results provide a cellular and molecular mechanism to help explain the functions of CCK in vivo.

The common inhaled anesthetic isoflurane increases aggregation of huntingtin and alters calcium homeostasis in a cell model of Huntington's disease.

Isoflurane is known to increase ß-amyloid aggregation and neuronal damage. We hypothesized that isoflurane will have similar effects on the polyglutamine huntingtin protein and will cause alterations in intracellular calcium homeostasis. We tested this hypothesis in striatal cells from the expanded glutamine huntingtin knock-in mouse (STHdh(Q111/Q111)) and wild type (STHdh(Q7/Q7)) striatal neurons. The primary cultured neurons were exposed for 24h to equipotent concentrations of isoflurane, sevoflurane, and desflurane in the presence or absence of extracellular calcium and with or without xestospongin C, a potent endoplasmic reticulum inositol 1,4,5-trisphosphate (InsP(3)) receptor antagonist. Aggregation of huntingtin protein, cell viability, and calcium concentrations were measured. Isoflurane, sevoflurane, and desflurane all increased the aggregation of huntingtin in STHdh(Q111/Q111) cells, with isoflurane having the largest effect. Isoflurane induced greater calcium release from the ER and relatively more cell damage in the STHdh(Q111/Q111) huntingtin cells than in the wild type STHdh(Q7/Q7) striatal cells. However, sevoflurane and desflurane caused less calcium release from the ER and less cell damage. Xestospongin C inhibited the isoflurane-induced calcium release from the ER, aggregation of huntingtin, and cell damage in the STHdh(Q111/Q111) cells. In summary, the Q111 form of huntingtin increases the vulnerability of striatal neurons to isoflurane neurotoxicity through combined actions on the ER IP(3) receptors. Calcium release from the ER contributes to the anesthetic induced huntingtin aggregation in STHdh(Q111/Q111) striatal cells.

CDCA2 protects against oxidative stress by promoting BRCA1-NRF2 signaling in hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) patients mostly suffer from poor survival outcomes. It is necessary to identify effective therapeutic targets to improve prognosis for HCC patients. Here, we report a new factor, CDCA2, in promoting HCC development. CDCA2 amplification is an independent risk factor for the recurrence and survival of HCC patients, which is positively correlated with elevated level of alpha-fetoprotein (AFP), high histological grade, large tumor size, advanced TNM stage, and poor prognosis for HCC patients. In HCC cells, CDCA2 promotes cell growth and inhibits apoptosis. Mechanistically, CDCA2's transcription is activated through the binding of E2F2/E2F8 with its promoter. CDCA2 depletion contributes to the suppression of cell proliferation and induction of apoptosis due to reactive oxygen species (ROS)-mediated stress, which can be reversed by antioxidants N-acetyl cysteine (NAC) and glutathione (GSH). Interestingly, we found that CDCA2 triggers the BRCA1-NRF2 cascade, which elevates antioxidant response and attenuates ROS levels. In response to oxidative stress, CDCA2 promotes BRCA1's chromatin relocalization to NRF2, activating NRF2-driven downstream signaling (HO-1, TXNRD1, and NQO1), which then protects HCC cells against oxidative damage. In conclusion, our results reveal that CDCA2 is a prognostic biomarker for HCC patients, and present the E2F2/E2F8-CDCA2-BRCA1-NRF2-ROS signaling axis that have implications for HCC therapeutics.

Synthesis and characterization of a novel crosslinkable side-chain sulfonated poly(arylene ether sulfone) copolymer proton exchange membranes.

A series of novel crosslinkable side-chain sulfonated poly(arylene ether sulfone) copolymers (S-SPAES(x/y)) was prepared from 4,4'-biphenol, 4,4'-difluorodiphenyl sulfone, and a new difluoro aromatic monomer 1-(2,6-difluorophenyl)-2-(3,5-dimethoxyphenyl)-1,2-ethanedione (DFDMED) via co-polycondensation, demethylation, and further nucleophilic substitution of 1,4-butane sultone. Meanwhile, quinoxaline-based crosslinked copolymers (CS-SPAES(x/y)) were obtained via cyclo-condensation between S-SPAES(x/y) and 3,3'-diaminobenzidine. Both the crosslinkable and crosslinked copolymer membranes exhibit good mechanical properties and high anisotropic membrane swelling. Crosslinkable S-SPAES(1/2) with an ion exchange capacity (IEC) of 2.01 mequiv. g-1 displays a relatively high proton conductivity of 180 mS cm-1 and acceptable single-cell performance, which is attributed to its good microphase separation resulting from the side-chain sulfonated copolymer structures. Compared with S-SPAES(1/1) (IEC of 1.68 mequiv. g-1), crosslinked CS-SPAES(1/2) with a comparable IEC exhibits a larger conductivity of 157 mS cm-1, and significantly higher oxidative stability and lower membrane swelling, suggesting a distinct performance improvement due to the quinoxaline-based crosslinking.

Anesthesia-induced neurodegeneration in fetal rat brains.

We investigated the extent of isoflurane-induced neurodegeneration on the fetuses of pregnant rats exposed in utero. Pregnant rats at gestational d 21 were divided into three experimental groups. Rats in the control group spontaneously breathed 100% oxygen for 1 h. Rats in the treatment groups breathed either 1.3 or 3% isoflurane in 100% oxygen through an endotracheal tube, with mechanical ventilation for 1 h. Rat pups were delivered by cesarian section 6 h after treatment, and fetal blood was sampled from the left ventricle of each fetal heart and evaluated for S100beta. Fetal brains were then evaluated for apoptosis, using caspase-3 immunohistochemistry in the CA1 region of the hippocampus and the retrosplenial cortex (RS). The 3% isoflurane treatment group showed significantly higher levels of S100beta levels and significantly increased average densities of total caspase-3-positive cells in the CA1 hippocampus and RS cortex compared with the control and the 1.3% isoflurane groups. There were no differences in S100beta levels or densities of caspase-3-positive cells between the control and 1.3% isoflurane groups. Isoflurane at a concentration of 3% for 1 h increased neurodegeneration in the hippocampal CA1 area and the retrosplenial cortex in the developing brain of fetal rats.

The common inhalational anesthetic isoflurane induces apoptosis via activation of inositol 1,4,5-trisphosphate receptors.

BACKGROUND: Isoflurane induces cell apoptosis by an unknown mechanism. The authors hypothesized that isoflurane activates inositol 1,4,5-trisphosphate (IP3) receptors on the endoplasmic reticulum (ER) membrane, causing excessive calcium release, triggering apoptosis. METHODS: The authors determined isoflurane-induced cytotoxicity by measuring caspase-3 activity, lactate dehydrogenase release, MTS (3-(4,5-dimethylthiazol-2-yl)-5-(3carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium, inner salt) reduction, and imaging analysis of cell damage markers (annexin V and propidium iodide staining) in different cell types. The authors used the chicken B lymphocyte with a total knock-out of IP3 receptors, PC12 cells with elevated IP3 receptor activity (transfected with L286V presenilin 1), striatal cells with a knock-in of Q111 Huntingtin, and each cell line's corresponding wild-type controls. The authors also measured the isoflurane-evoked changes of calcium concentration in cytosol and/or mitochondria in these cells. RESULTS: Isoflurane induced apoptosis concentration- and time-dependently, and sequentially elevated cytosolic and then mitochondrial calcium in the chicken B-lymphocyte wild-type but not the IP3 receptor total knock-out cells. Thapsigargin, a calcium adenosine triphosphatase inhibitor on ER membranes, induced apoptosis and elevations of calcium in cytosol and mitochondria in both chicken B-lymphocyte wild-type and IP3 receptor total knock-out cells. Isoflurane induced significantly more neurotoxicity and greater calcium release from the ER in L286V PC12 and Q111 Huntingtin striatal cells than in their corresponding wild-type controls, both of which were significantly inhibited by the IP3 receptor antagonist xestospongin C. CONCLUSION: These findings suggest that isoflurane activates the ER membrane IP3 receptor, producing excessive calcium release and triggering apoptosis. Neurons with enhanced IP3 receptor activity, as in certain cases of familial Alzheimer or Huntington disease, may be especially vulnerable to isoflurane cytotoxicity.

The PIEPEAR Workflow: A Critical Care Ultrasound Based 7-Step Approach as a Standard Procedure to Manage Patients with Acute Cardiorespiratory Compromise, with Two Example Cases Presented.

Critical care ultrasound (CCUS) has been widely used as a useful tool to assist clinical judgement. The utilization should be integrated into clinical scenario and interact with other tests. No publication has reported this. We present a CCUS based "7-step approach" workflow-the PIEPEAR Workflow-which we had summarized and integrated our experience in CCUS and clinical practice into, and then we present two cases which we have applied the workflow into as examples. Step one is "problems emerged?" classifying the signs of the deterioration into two aspects: acute circulatory compromise and acute respiratory compromise. Step two is "information clear?" quickly summarizing the patient's medical history by three aspects. Step three is "focused exam launched": (1) focused exam of the heart by five views: the assessment includes (1) fast and global assessment of the heart (heart glance) to identify cases that need immediate life-saving intervention and (2) assessing the inferior vena cava, right heart, diastolic and systolic function of left heart, and systematic vascular resistance to clarify the hemodynamics. (2) Lung ultrasound exam is performed to clarify the predominant pattern of the lung. Step four is "pathophysiologic changes reported." The results of the focused ultrasound exam were integrated to conclude the pathophysiologic changes. Step five is "etiology explored" diagnosing the etiology by integrating Step two and Step four and searching for the source of infection, according to the clues extracted from the focused ultrasound exam; additional ultrasound exams or other tests should be applied if needed. Step six is "action" supporting the circulation and respiration sticking to Step four. Treat the etiologies according step five. Step seven is "recheck to adjust." Repeat focused ultrasound and other tests to assess the response to treatment, adjust the treatment if needed, and confirm or correct the final diagnosis. With two cases as examples presented, we insist that applying CCUS with 7-step approach workflow is easy to follow and has theoretical advantages. The coming research on its value is expected.

Effects of fetal exposure to isoflurane on postnatal memory and learning in rats.

In a maternal fetal rat model, we investigated the behavioral and neurotoxic effects of fetal exposure to isoflurane. Pregnant rats at gestational day 21 were anesthetized with 1.3% isoflurane for 6h. Apoptosis was quantified in the hippocampus and cortex at 2 and 18h after exposure in the fetal brain and in the postnatal day 5 (P5) pup brain. Spatial memory and learning of the fetal exposed pups were examined with the Morris Water Maze at juvenile and adult ages. Rat fetal exposure to isoflurane at pregnancy day 21 through maternal anesthesia significantly decreased spontaneous apoptosis in the hippocampal CA1 region and in the retrosplenial cortex at 2h after exposure, but not at 18h or at P5. Fetal exposure to isoflurane did not impair subsequent juvenile or adult postnatal spatial reference memory and learning and, in fact, improved spatial memory in the juvenile rat. These results show that isoflurane exposure during late pregnancy is not neurotoxic to the fetal brain and does not impair memory and learning in the juvenile or adult rat.

Neonatal exposure to sevoflurane may not cause learning and memory deficits and behavioral abnormality in the childhood of Cynomolgus monkeys.

Results of animal studies have raised a significant concern that commonly used general anesthetics may induce neurotoxicity in children. It may be difficult to resolve this concern with human studies because randomizing children only for testing anesthetic toxicity may not be feasible. We randomized 6-day old male Cynomolgus monkeys to receive or not to receive sevoflurane anesthesia at surgical plane for 5 h. Sevoflurane is the most commonly used general anesthetic in children in the U.S.A. Here, we showed that sevoflurane anesthesia did not affect the behavior evaluated by holding cage method when the monkeys were 3 and 7 months old. However, there was an age-dependent decrease in the frequency of stress events and environmental exploration behavior during the test. Sevoflurane also did not affect the learning and memory of the monkeys when they were assessed from the age of 7 months. Finally, sevoflurane did not affect the expression of multiple neuron-specific proteins in the hippocampus and cerebral cortex of 10-month old monkeys after all behavioral and cognitive tests were completed. These results suggest that exposure of neonatal monkey to sevoflurane may not affect cognition, behavior and neuronal structures in childhood, indicating the safety of sevoflurane anesthesia in children.