Hypoxemia, Bradycardia, and Multiple Laryngoscopy Attempts during Anesthetic Induction in Infants: A Single-center, Retrospective Study.

BACKGROUND: The infant airway is particularly vulnerable to trauma from repeated laryngoscopy attempts. Complications associated with elective tracheal intubations in anesthetized infants may be underappreciated. We conducted this study of anesthetized infants to determine the incidence of multiple laryngoscopy attempts during routine tracheal intubation and assess the association of laryngoscopy attempts with hypoxemia and bradycardia. METHODS: We conducted a retrospective cross-sectional cohort study of anesthetized infants (age less than or equal to 12 months) who underwent direct laryngoscopy for oral endotracheal intubation between January 24, 2015, and August 1, 2016. We excluded patients with a history of difficult intubation and emergency procedures. Our primary outcome was the incidence of hypoxemia or bradycardia during induction of anesthesia. We evaluated the relationship between laryngoscopy attempts and our primary outcome, adjusting for age, weight, American Society of Anesthesiologists status, staffing model, and encounter location. RESULTS: A total of 1,341 patients met our inclusion criteria, and 16% (n = 208) had multiple laryngoscopy attempts. The incidence of hypoxemia was 35% (n = 469) and bradycardia was 8.9% (n = 119). Hypoxemia and bradycardia occurred in 3.7% (n = 50) of patients. Multiple laryngoscopy attempts were associated with an increased risk of hypoxemia (adjusted odds ratio: 1.78, 95% CI: 1.30 to 2.43, P < 0.001). There was no association between multiple laryngoscopy attempts and bradycardia (adjusted odds ratio: 1.23, 95% CI: 0.74 to 2.03, P = 0.255). CONCLUSIONS: In a quaternary academic center, healthy infants undergoing routine tracheal intubations had a high incidence of multiple laryngoscopy attempts and associated hypoxemia episodes.

Predictors of transfusion outcomes in pediatric complex cranial vault reconstruction: a multicentre observational study from the Pediatric Craniofacial Collaborative Group.

PURPOSE: Pediatric patients undergoing complex cranial vault reconstruction (CCVR) are at risk of significant perioperative blood loss requiring blood product transfusion. Minimizing allogeneic blood product transfusion is an important goal because of the associated risks and cost. The impact of patient and surgical variables on transfusion is unknown in this population. Our primary aim was to examine relationships between demographic and perioperative variables and blood product transfusion outcomes in CCVR. METHODS: The multicentre Pediatric Surgery Perioperative Registry was checked for children undergoing CCVR between June 2012 and September 2016. Univariable and multivariable analyses were performed examining patient, procedure, and blood conservation variables and their relationship to three outcomes: intraoperative red blood cell-containing product (RBC-CP) transfusion, total perioperative blood donor exposures, and transfusion-free hospitalization. RESULTS: The registry search returned data from 1,814 cases. Age and surgical duration were the only variables significantly associated with all three outcomes studied. Predictors of reduced RBC-CP transfusion included lower American Society of Anesthesiologists (ASA) physical status and antifibrinolytic administration. Total cranial vault reconstruction, intraoperative vasoactive infusion, and presence of a tracheostomy predicted increased donor exposures. Increased body weight, higher preoperative hematocrit, and utilization of intraoperative cell saver and transfusion protocols were associated with transfusion-free hospitalization. CONCLUSION: Clinical factors associated with increased allogeneic blood product transfusion in pediatric CCVR include: age ≤ 24 months, ASA status ≥ III, preoperative anemia, prolonged surgical duration, lack of intraoperative antifibrinolytic use, lack of intraoperative cell saver use, and the lack of transfusion protocols.

RéSUMé: OBJECTIF: Les patients pédiatriques subissant une reconstruction complexe de la voûte crânienne courent un risque de pertes sanguines périopératoires importantes nécessitant la transfusion de produits sanguins. La minimisation de la transfusion de produits sanguins allogènes constitue un objectif majeur étant donné les risques et les coûts associés. L'impact des variables liées au patient et à la chirurgie sur la transfusion est inconnu dans cette population. Notre objectif principal était d'examiner les liens entre les variables démographiques et périopératoires, et les résultats des transfusions sanguines suite à une reconstruction complexe de la voûte crânienne. MéTHODE: Le Registre périopératoire multicentrique de chirurgie pédiatrique (Pediatric Surgery Perioperative Registry) a été consulté afin d'en extraire les dossiers de tous les enfants ayant subi une reconstruction complexe de la voûte crânienne entre juin 2012 et septembre 2016. Des analyses univariées et multivariées ont été réalisées et ont examiné les variables concernant les patients, l'intervention et la conservation du sang ainsi que les relations entre ces données et trois critères : la transfusion peropératoire de produits contenant des érythrocytes, l'exposition durant toute la période périopératoire aux dons de sang, et l'hospitalisation sans transfusion. RéSULTATS: L'examen du Registre a permis d'extraire les données de 1814 cas. L'âge et la durée de la chirurgie étaient les deux seules variables à afficher une association significative aux trois critères à l'étude. Les prédicteurs d'une transfusion réduite d'érythrocytes étaient un statut physique ASA (American Society of Anesthesiologists) plus bas et l'administration d'agents antifibrinolytiques. La reconstruction totale de la voûte crânienne, la perfusion peropératoire d'agents vasoactifs et la présence d'une trachéostomie constituaient des prédicteurs d'exposition plus importante aux dons de sang. Un poids corporel accru, un hématocrite préopératoire plus élevé et l'utilisation de systèmes d'autotransfusion peropératoire et de protocoles de transfusion étaient associés à une hospitalisation sans transfusion. CONCLUSION: Les facteurs cliniques associés à une augmentation des transfusions de produits sanguins allogènes dans les cas de reconstruction complexe de la voûte crânienne chez l'enfant sont : un âge ≤ 24 mois, un statut ASA ≥ III, une anémie préopératoire, la durée prolongée de la chirurgie, l'absence d'utilisation peropératoire d'antifibrinolytiques, l'absence d'utilisation de systèmes d'autotransfusion peropératoire, et l'absence de protocoles de transfusion.

The clinical assessment of amyotrophic lateral sclerosis patients' prognosis by ZNF512B gene, neck flexor muscle power score and body mass index (BMI).

BACKGROUND: Assessment on the prognosis of amyotrophic lateral sclerosis (ALS) is becoming a focus of research in recent years since there is no effective treatment. The aim of the research is to explore the major factors involving in prognosis of ALS patients through long-term follow-up. METHODS: ALS patients' DNA extracted from peripheral blood white cells were detected for the risk allele by single nucleotide polymorphism (SNP) analysis. Neck flexor muscle score and body mass index (BMI) were recorded during Medical Research Council follow-up using manual muscle testing method. RESULTS: ALS patients with risk alleles (C) deteriorated rapidly with poor clinical outcome. It seemed that the higher neck flexor muscle strength score in ALS patients with the longer survival time but without significant correlation (p > 0.05). The lower the basal body mass index, the shorter the survival time and the faster deterioration (p < 0.05). The patients with body mass index less than 22.04 seemed to have short survival time than those with BMI more than 22.04 (p < 0.05), however, the speed of deterioration in two groups of patients had no significant difference (p > 0.05). CONCLUSION: The risk (C) allele of the SNP (rs2275294) in the ZNF512B gene, cervical flexor muscle power and body weight index might have clinical potential for ALS prognostication, since these indicators is so simple to perform that they might be very suitable for primary clinics and even community medical institutions to carry out.

Perioperative Outcomes and Management in Pediatric Complex Cranial Vault Reconstruction: A Multicenter Study from the Pediatric Craniofacial Collaborative Group.

BACKGROUND: The Pediatric Craniofacial Collaborative Group established the Pediatric Craniofacial Surgery Perioperative Registry to elucidate practices and outcomes in children with craniosynostosis undergoing complex cranial vault reconstruction and inform quality improvement efforts. The aim of this study is to determine perioperative management, outcomes, and complications in children undergoing complex cranial vault reconstruction across North America and to delineate salient features of current practices. METHODS: Thirty-one institutions contributed data from June 2012 to September 2015. Data extracted included demographics, perioperative management, length of stay, laboratory results, and blood management techniques employed. Complications and outlier events were described. Outcomes analyzed included total blood donor exposures, intraoperative and perioperative transfusion volumes, and length of stay outcomes. RESULTS: One thousand two hundred twenty-three cases were analyzed: 935 children aged less than or equal to 24 months and 288 children aged more than 24 months. Ninety-five percent of children aged less than or equal to 24 months and 79% of children aged more than 24 months received at least one transfusion. There were no deaths. Notable complications included cardiac arrest, postoperative seizures, unplanned postoperative mechanical ventilation, large-volume transfusion, and unplanned second surgeries. Utilization of blood conservation techniques was highly variable. CONCLUSIONS: The authors present a comprehensive description of perioperative management, outcomes, and complications from a large group of North American children undergoing complex cranial vault reconstruction. Transfusion remains the rule for the vast majority of patients. The occurrence of numerous significant complications together with large variability in perioperative management and outcomes suggest targets for improvement.

Risk factors for perioperative mortality and transfusion in sacrococcygeal teratoma resections.

BACKGROUND: Sacrococcygeal teratomas are a common congenital tumor. Surgical resection can occur in utero, in the neonatal period, or in the postneonatal period. AIMS: We describe patient and tumor factors associated with mortality and transfusion in this population. METHODS: We did a retrospective chart review of patients who underwent sacrococcygeal teratoma resection between January 1998 and March 2016. Demographic data, transfusion data, and tumor characteristics were collected. Descriptive statistics were calculated, and univariate comparisons were performed with chi-square test and Fisher's exact test. Variables significant at univariate level were used in multivariate logistic regression and negative binomial regression. RESULTS: Of the 112 cases, 6 were in utero repairs, 73 were neonatal repairs, and 33 were repairs at >30 days of life. There was 17%, 1%, and 0% intraoperative mortality and 33%, 5%, and 0% 30-day mortality in the in utero, neonatal, and >30 days of life repairs, respectively. All six patients who died within the first 30 days of life had a postmenstrual age of <32 weeks at time of surgery. All six patients who died had noncystic tumors. Patients with noncystic tumors were more likely to be born prior to 30-week gestation (23/65 vs 6/47; χ2 = 7.3; P = 0.007). Gestational age >30 weeks was associated with decreased intraoperative death (0% vs 10%; modified maximum likelihood estimate of OR 0.05; 95% CI 0.002-0.96; P = 0.02). Gestational age >30 weeks (2.4% vs 13.8%; OR 0.15; 95% CI 0.03-0.89; P = 0.04) and cystic morphology (0% vs 9.2%; modified maximum likelihood estimate of OR 0.1; CI 0.01-1.75; P = 0.04) were associated with decreased 30-day mortality and emergent surgery (17.9% vs 1.2%; OR 18; 95% CI 2-162.2; P = 0.004) was associated with increased 30-day mortality. Gestational age >30 weeks (33.7% vs 62.1%; OR 0.27; 95% CI 0.09-0.79; P = 0.02) and Altman class 3-4 (12.1% vs 52.7%; OR 0.1; 95% CI 0.03-0.34; P = 0.0002) were associated with decreased need for transfusion and noncystic tumor was associated with increased transfusion volume (131.6 ml·kg-1 [95% CI 94-184] vs 63 ml·kg-1 [95% CI 40-100.1]; P = 0.01). CONCLUSIONS: Prematurity is associated with increased intraoperative and 30-day mortality. Noncystic tumor morphology was the only significant factor associated with transfusion volume and all six patients who died had transfusion volumes of 240 ml·kg-1 or greater. In these patients at high risk of mortality due to blood loss, the anesthesia team should be prepared to manage massive transfusion and coagulopathy with blood components and pharmacologic measures.

Endovascular thrombectomy with versus without intravenous thrombolysis in patients with acute basilar artery occlusion: a systematic review and meta-analysis.

BACKGROUND AND PURPOSE: The benefit and safety of intravenous thrombolysis before endovascular thrombectomy in patients with acute ischemic stroke caused by basilar artery occlusion (BAO) remains unclear. This article aims to investigate the clinical outcomes and safety of endovascular thrombectomy with versus without intravenous thrombolysis in acute BAO stroke patients. METHODS: We conducted a comprehensive search of PubMed, Embase, Cochrane, and Web of Science databases to identify relevant literature pertaining to patients with acute BAO who underwent endovascular thrombectomy alone or intravenous thrombolysis bridging with endovascular thrombectomy (bridging therapy), until January 10, 2024. The primary outcome was functional independence, defined as a score of 0-2 on the modified Rankin Scale at 90 days. The safety outcome was mortality at 90 days and symptomatic intracranial hemorrhage within 48 h. Effect sizes were computed as risk ratio (RR) with random-effect models. This study was registered in PROSPERO (CRD42023462293). RESULTS: A total of 528 articles were obtained through the search and articles that did not meet the inclusion criteria were excluded. Finally, 2 RCTs and 10 cohort studies met the inclusion criteria. The findings revealed that the endovascular thrombectomy alone group had a lower rate of functional independence compared to the bridging therapy group (29% vs 38%; RR 0.78, 95% CI 0.68-0.88, p < 0.001), lower independent ambulation (39% vs 45%; RR 0.89, 95% CI 0.82-0.98, p = 0.01), and higher mortality (36% vs 28%, RR 1.22, 95% CI 1.08-1.37, p = 0.001). However, no differences were detected in symptomatic intracranial hemorrhage between the two groups (6% vs 4%; RR 1.12, 95% CI 0.74-1.71, p = 0.58). CONCLUSION: Intravenous thrombolysis plus endovascular thrombectomy seemed to led to better functional independence, independent ambulation, and lower risk of mortality without increasing the incidence of intracranial hemorrhage compared to endovascular thrombectomy alone. However, given the non-randomized nature of this study, further studies are needed to confirm these findings.

Mucosa­associated lymphoid tissue in the central nervous system presenting as meningioma: A case report.

Mucosa-associated lymphoid tissue (MALT) lymphoma involving meningeal tissue is rare condition, easily mistaken for meningiomas upon imaging. In this report, a case of primary left temporal lobe MALT lymphoma that was initially misdiagnosed as temporal meningioma is presented, with subsequent investigation into the mechanism and treatments. Clinically, MALT lymphomas can be easily confused with meningiomas based solely on imaging and clinical manifestations. MALT lymphomas are indolent, localized lesions that can be cured through surgical resection and radiotherapy. Currently, radiotherapy is the most commonly used treatment; however, the patient in the present report did not receive any chemotherapy or radiotherapy after surgery, and recent related examinations revealed a recurrence of lymphomas that had metastasized throughout the body. As a result, future patients may benefit from chemotherapy or radiotherapy, and clinicians should be more meticulous regarding patient follow-up.

The Importance of M1-and M2-Polarized Macrophages in Glioma and as Potential Treatment Targets.

Glioma is the most common and malignant tumor of the central nervous system. Glioblastoma (GBM) is the most aggressive glioma, with a poor prognosis and no effective treatment because of its high invasiveness, metabolic rate, and heterogeneity. The tumor microenvironment (TME) contains many tumor-associated macrophages (TAMs), which play a critical role in tumor proliferation, invasion, metastasis, and angiogenesis and indirectly promote an immunosuppressive microenvironment. TAM is divided into tumor-suppressive M1-like (classic activation of macrophages) and tumor-supportive M2-like (alternatively activated macrophages) polarized cells. TAMs exhibit an M1-like phenotype in the initial stages of tumor progression, and along with the promotion of lysing tumors and the functions of T cells and NK cells, tumor growth is suppressed, and they rapidly transform into M2-like polarized macrophages, which promote tumor progression. In this review, we discuss the mechanism by which M1- and M2-polarized macrophages promote or inhibit the growth of glioblastoma and indicate the future directions for treatment.