Factors influencing the length of stay (LOS) undergoing robot-assisted thoracoscopic lung surgery in the setting of enhanced recovery after surgery (ERAS) protocol for pediatric patients: a retrospective study.

Background: A prolonged length of stay (LOS) after surgery may result in higher hospital costs and hospital-acquired complications. This study aims to identify the risk factors associated with a prolonged hospital stay after robot-assisted thoracoscopic lung surgery for pediatric patients in the context of enhanced recovery after surgery. Methods: The data for this retrospective study were collected from pediatric patients undergoing robot-assisted thoracoscopic lung surgery. Patients were divided into two subgroups based on median postoperative LOS (Group I: LOS > median 5 days and Group II: LOS ≤ median 5 days). Logistic regression analysis was used to identify the potential factors associated with increased LOS. Results: This study included 241 patients, 71 (29.46%) with an LOS of >5 days. The proportion of older children was significantly higher in Group I than that in Group II (P=0.004). Patients in Group I were more likely to experience a longer duration of anesthesia and surgery (P<0.001). They also had significantly higher rates of pneumonia, pleural effusion, and liver function damage (P<0.05). Several factors were identified to be associated with an increased LOS after robot-assisted thoracoscopic lung surgery: age >6 years [odds ratio (OR) =3.214, 95% confidence interval (CI): 1.464-7.502, P=0.004], surgery duration >100 min (OR =2.138, 95% CI: 1.296-4.387, P=0.005), intra-albumin (OR =13.778, 95% CI: 1.470-129.116, P=0.022), and blood loss >5 mL (OR =2.184, 95% CI: 1.082-4.409, P=0.029). Conclusions: The results revealed that older age, longer surgery duration, use of intra-albumin, and more blood loss predict longer postoperative hospital stay in pediatric patients with congenital lung lesions after robot-assisted thoracoscopic lung surgery.

Risk factors for intraoperative hypothermia in infants during general anesthesia: A retrospective study.

This study aimed to determine the incidence and evaluate the risk factors and outcomes of intraoperative hypothermia (IH) during general anesthesia in infants. Retrospective analysis of prospectively collected data. A total of 754 infants younger than 1 year old who underwent surgery under general anesthesia were included. Intraoperative body temperature fluctuations, surgical and anesthetic data, postoperative complications, and infant outcomes were recorded. Logistic regression algorithms were used to evaluate potential risk factors. Among the 754 infants, 47.88% developed IH (<36 °C) and 15.4% of them experienced severe hypothermia (<35 °C). The average lowest temperature in hypothermia patients was 35.06 ± 0.69°C with a duration of 82.23 ± 50.59 minutes. Neonates tended to experience hypothermia (37.7% vs 7.6%, P < .001) and prematurity was more common in patients with IH (29.4% vs 16.8%, P < .001). Infants with hypothermia experienced a longer length of stay in the post anesthesia care units and intensive care units, postoperative hospitalizations, and tracheal extubation as well as a higher rate of postoperative hemorrhage than those with normothermia (all P < .05). Several factors were proved to be associated with an increased risk of IH after multivariate analysis: neonate (odds ratio [OR] = 3.685, 95% CI 1.839-7.382), weight (OR = 0.599, 95% CI 0.525-0.683), American society of anesthesiologists (OR = 3.418, 95% CI 2.259-5.170), fluid > 20 mL/kg (OR = 2.380, 95% CI 1.389-4.076), surgery time >60 minutes (OR = 1.785, 95% CI 1.030-3.093), and pre-warming (OR = 0.027, 95% CI 0.014-0.052). This retrospective study found that neonates, lower weight, longer surgery times, more fluid received, higher American society of anesthesiologists stage, and no pre-warming were all significant risk factors for IH during general anesthesia in infants.

Risk factors and outcomes of intraoperative hypothermia in neonatal and infant patients undergoing general anesthesia and surgery.

Objective: The incidence of intraoperative hypothermia remains high in pediatric patients during anesthesia and surgery even though core body temperature monitoring and warming systems have been greatly improved in recent years. We analyzed the risk factors and outcomes of intraoperative hypothermia in neonates and infants undergoing general anesthesia and surgery. Methods: The data on the incidence of intraoperative hypothermia, other clinical characteristics, and outcomes from electronic records of 1,091 patients (501 neonates and 590 infants between 28 days and 1 year old), who received general anesthesia and surgery, were harvested and analyzed. Intraoperative hypothermia was defined as a core temperature below 36°C during surgery. Results: The incidence of intraoperative hypothermia in neonates was 82.83%, which was extremely higher than in infants (38.31%, p < 0.001)-the same as the lowest body temperature (35.05 ± 0.69°C vs. 35.40 ± 0.68°C, p < 0.001) and the hypothermia duration (86.6 ± 44.5 min vs. 75.0 ± 52.4 min, p < 0.001). Intraoperative hypothermia was associated with prolonged PACU, ICU, hospital stay, postoperative bleeding, and transfusion in either age group. Intraoperative hypothermia in infants was also related to prolonged postoperative extubation time and surgical site infection. After univariate and multivariate analyses, the age (OR = 0.902, p < 0.001), weight (OR = 0.480, p = 0.013), prematurity (OR = 2.793, p = 0.036), surgery time of more than 60 min (OR = 3.743, p < 0.001), prewarming (OR = 0.081, p < 0.001), received >20 mL/kg fluid (OR = 2.938, p = 0.004), and emergency surgery (OR = 2.142, p = 0.019) were associated with hypothermia in neonates. Similar to neonates, age (OR = 0.991, p < 0.001), weight (OR = 0.783, p = 0.019), surgery time >60 min (OR = 2.140, p = 0.017), pre-warming (OR = 0.017, p < 0.001), and receive >20 mL/kg fluid (OR = 3.074, p = 0.001) were relevant factors to intraoperative hypothermia in infants along with the ASA grade (OR = 4.135, p < 0.001). Conclusion: The incidence of intraoperative hypothermia was still high, especially in neonates, with a few detrimental complications. Neonates and infants each have their different risk factors associated with intraoperative hypothermia, but younger age, lower weight, longer surgery time, received more fluid, and no prewarming management were the common risk factors.

Spatiotemporal variation of climate of different flanks and elevations of the Qinling-Daba mountains in China during 1969-2018.

Climate change exhibits great variation on different flanks and at different elevations in the same mountain range. To investigate the complexity of the geographic patterns of climate and phenology in the Qinling-Daba mountains (QDM), in the North-South transition zone of China, this study analyzed the spatiotemporal distribution characteristics of daily air temperature and precipitation data measured at 118 national weather stations (1969-2018). The principal findings were as follows. (1) Overall, a significant trend of warming was detected in all seasons over the past 50 years, with rates of increase of 0.347, 0.125, 0.200 and 0.302 °C/10a, in spring, summer, autumn and winter, respectively. Precipitation did not show significant variation at most stations in different seasons. (2) The rising rate of air temperature varied considerably between different flanks. Generally, air temperature change on northern flanks was greater than on southern flanks in all seasons. The tendency of air temperature change was greater in spring and winter than in summer and autumn on different flanks in the QDM. (3) The rate of increase in high-elevation regions was greater than in low-elevation regions in summer, autumn and winter, e.g., 0.440, 0.390 and 0.456 °C/10a at 3000-4000 m and 0.205, 0.218 and 0.303 °C/10a at 0-1000 m, respectively. However, in spring, the rate of increase in low-elevation regions were higher than in high-elevation regions, e.g., 0.369 °C/10a at 0-1000 m and 0.317 °C/10a at 3000-4000 m.

PKCα/ZFP64/CSF1 axis resets the tumor microenvironment and fuels anti-PD1 resistance in hepatocellular carcinoma.

BACKGROUND & AIMS: Despite remarkable advances in treatment, most patients with hepatocellular carcinoma (HCC) respond poorly to anti-programmed cell death 1 (anti-PD1) therapy. A deeper insight into the tolerance mechanism of HCC against this therapy is urgently needed. METHODS: We performed next-generation sequencing, multiplex immunofluorescence, and dual-color immunohistochemistry and constructed an orthotopic HCC xenograft tumor model to identify the key gene associated with anti-PD1 tolerance. A spontaneously tumorigenic transgenic mouse model, an in vitro coculture system, mass cytometry, and multiplex immunofluorescence were used to explore the biological function of zinc finger protein 64 (ZFP64) on tumor progression and immune escape. Molecular and biochemical strategies like RNA-sequencing, chromatin immunoprecipitation-sequencing and mass spectrometry were used to gain insight into the underlying mechanisms of ZFP64. RESULTS: We showed that ZFP64 is frequently upregulated in tumor tissues from patients with anti-PD1-resistant HCC. Elevated ZFP64 drives anti-PD1 resistance by shifting macrophage polarization toward an alternative activation phenotype (M2) and fostering an inhibitory tumor microenvironment. Mechanistically, we primarily demonstrated that protein kinase C alpha (PKCα) directly phosphorylates ZFP64 at S226, leading to its nuclear translocation and the transcriptional activation of macrophage colony-stimulating factor (CSF1). HCC-derived CSF1 transforms macrophages to the M2 phenotype to drive immune escape and anti-PD1 tolerance. Notably, Gö6976, a protein kinase inhibitor, and lenvatinib, a multi-kinase inhibitor, reset the tumor microenvironment and restore sensitivity to anti-PD1 by blocking the PKCα/ZFP64/CSF1 axis. CONCLUSIONS: We propose that the PKCα/ZFP64/CSF1 axis is critical for triggering immune evasion and anti-PD1 tolerance. Inhibiting this axis with Gö6976 or lenvatinib overcomes anti-PD1 resistance in HCC. LAY SUMMARY: Despite remarkable treatment progress, most patients with hepatocellular carcinoma respond poorly to anti-PD1 therapy (a type of immunotherapy). A deeper insight into the tolerance mechanisms to this therapy is urgently needed. Herein, we unravel a previously unexplored mechanism linking tumor progression, macrophage polarization, and anti-PD1 resistance, and offer an attractive novel target for anti-PD1 combination therapy, which may benefit patients with hepatocellular carcinoma.

Gender contexts, dowry and women's health in India: a national multilevel longitudinal analysis.

Gender-biased contexts may impact women's lives across a variety of domains. This study examined whether changes in district prevalence of a salient gendered practice - dowry - are associated with changes in poor health for women in India. Two waves of national multilevel panel data were used to assess the relationship between changes in district-level dowry prevalence and changes in self-rated health for 23,785 ever-married women aged 15-50 years. Increased dowry prevalence was found to be associated with increased poor self-rated health for women. This relationship remained when controlling for potentially confounding factors including household socioeconomic status, caste, infrastructure, mobility and state fixed-effects.