Enantioselective Cross-[4 + 2]-Cycloaddition/Decarboxylation of 2-Pyrones by Cooperative Catalysis of the Pd(0)/NHC Complex and Chiral Phosphoric Acid.

Here, we describe a cooperative Pd(0)/chiral phosphoric acid catalytic system that allows us to realize the first chemo-, regio-, and enantioselective sequential cross-[4 + 2]-cycloaddition/decarboxylation reaction between 2-pyrones and unactivated acyclic 1,3-dienes. The key to the success of this transformation is the utilization of an achiral N-heterocyclic carbene (NHC) as the ligand and a newly developed chiral phosphoric acid as the cocatalyst. Experimental investigations and computational studies support the idea that the Pd(0)/NHC complex acts as a π-Lewis base to increase the nucleophilicity of 1,3-dienes via η2 coordination, while the chiral phosphoric acid simultaneously increases the electrophilicity of 2-pyrones by hydrogen bonding. By this synergistic catalysis, the sequential cross-[4 + 2]-cycloaddition and decarboxylation reaction proceeds efficiently, enabling the preparation of a wide range of chiral vinyl-substituted 1,3-cyclohexadienes in good yields and enantioselectivities. The synthetic utility of this reaction is demonstrated by synthetic transformations of the product to various valuable chiral six-membered carbocycles.

Enantioselective Synthesis of cis-Decalins by Merging the Birch Reduction and Inverse-Electron-Demand Diels-Alder Reaction.

Herein, we show that the combination of the Birch reduction of readily available anisole derivatives and the catalytic asymmetric inverse-electron-demand Diels-Alder reaction of 2-pyrones can serve as a powerful platform for the diverse synthesis of synthetically important cis-decalin scaffolds. Enabled by a well-modified chiral bis(oxazoline) ligand/CuII complex, a wide range of polysubstituted cis-decalin scaffolds with up to six contiguous stereocenters were generated efficiently. The synthetic potential of this method is demonstrated by the concise synthesis of the sesquiterpene (+)-occidentalol and a key intermediate for seven triterpenes. Mechanistic studies suggest the 1,3-cyclohexadienes formed in situ are the key intermediates, and efficient kinetic resolution occurs when C2- and/or C3-substituted 1,4-cyclohexadienes are utilized as substrates. DFT calculations elucidated that the Diels-Alder reaction proceeds in a stepwise fashion and revealed the origins of the stereoselectivities.

Glycemic biomarkers in children with drug-resistant epilepsy on various types of ketogenic diet therapies: A cross-sectional study.

OBJECTIVE: This study was undertaken to determine the hemoglobin A1c (HbA1c) and modified glucose-ketone index (mGKI) in children on different types of ketogenic diet (KD) for treatment of drug-resistant epilepsy, with attempts to evaluate their relationships with components of diet regime and other biomarkers. METHODS: We conducted a cross-sectional study in children with drug resistant epilepsy aged between 6 months and 18 years, who were on various types of KD therapies without any change in regime for at least 3 months. Parental interview, review of medical records, and a single measurement for blood ketone, HbA1c, and plasma carnitine were performed. mGKI was the ratio of an average plasma glucose estimated from HbA1c to blood ß-hydroxybutyrate level. RESULTS: Thirty-four patients were recruited with a median blood ketone of 2.90 mmol·L-1 and median HbA1c of 4.55%. Those on classical KD (cKD) had higher blood ketone (p = .031) and lower HbA1c (p = .010) and mGKI (p = .021) than those receiving modified Atkins diet, although both shared similar percentages of calories from carbohydrate (p = .211). The cKD and medium-chain triglyceride (MCT) KD groups had similar HbA1c (p = .252) and mGKI (p = .510). Blood ketone (p = .045) and the percentage of calories from MCT (p = .037) were the two main independent variables, inversely correlating with HbA1c. Other than plasma acylcarnitine (p = .047), neither blood ketone (p = .188) nor HbA1c (p = .170) could predict seizure reduction reliably. Both plasma acylcarnitine ≥ 6 µmol·L-1 (p = .013) and mGKI ≤ 2.2 (p = .013) were significantly associated with good seizure control. SIGNIFICANCE: HbA1c could potentially be useful for monitoring KD adherence or, indirectly, systemic ketosis in nondiabetic children on KD for drug-resistant epilepsy. Plasma acylcarnitine and mGKI could be important biomarkers in the management of KD therapy.

Construction of gem-Difluoroenol Esters through Catalytic O-Selective Addition of Difluoroenoxysilanes to Ketenes.

The O-site reactivity of difluoroenoxysilanes is disclosed for the first time, which enabled the direct construction of versatile gem-difluoroalkenes through an unprecedented highly efficient addition reaction with ketenes. A series of valuable gem-difluoroenol esters were achieved in good to excellent yields. The synthetic versatility of this protocol is further demonstrated by the gram-scale synthesis and good functional group tolerance.

Catalyst-Free and Solvent-Controlled Divergent Synthesis of Difluoromethylene-Containing S-Heterocycles.

An unprecedented catalyst-free reaction of benzo[b]thiophene-2,3-diones with difluoroenoxysilanes has been developed using either MeOH or H2O as the solvent, which constitutes a facile and efficient protocol for the solvent-controlled divergent synthesis of five- and seven-membered S-heterocycles featuring a gem-difluoromethylene group. A gram-scale synthesis and the diversification of the product transformations to other difluorinated S-heterocycles further highlight its utility.

Detection of Asymptomatic Carotid Artery Stenosis in High-Risk Individuals of Stroke Using a Machine-Learning Algorithm.

Objective Asymptomatic carotid stenosis (ACS) is closely associated to the incidence of severe cerebrovascular diseases. Early identifying the individuals with ACS and its associated risk factors could be beneficial for primary prevention of stroke. This study aimed to investigate a machine-learning algorithm for the detection of ACS among high-risk population of stroke based on the associated risk factors.Methods A novel model of machine learning was utilized to screen the associated predictors of ACS based on 30 potential risk factors. The algorithm of this model adopted a random forest pattern based on the training data and then was verified using the testing data. All of the original data were retrieved from the China National Stroke Screening and Prevention Project (CNSSPP), including demographic, clinical and laboratory characteristics. The individuals with high risk of stroke were enrolled and randomly divided into a training group and a testing group at a ratio of 4:1. The identification of carotid stenosis by carotid artery duplex scans was set as the golden standard. The receiver operating characteristic (ROC) curve and the area under the curve (AUC) was used to evaluate the efficacy of the model in detecting ACS.Results Of 2841 high risk individual of stroke enrolled, 326 (11.6%) were diagnosed as ACS by ultrasonography. The top five risk factors contributing to ACS in this model were identified as family history of dyslipidemia, high level of low-density lipoprotein cholesterol (LDL-c), low level of high-density lipoprotein cholesterol (HDL-c), aging, and low body mass index (BMI). Their weights were 11.8%, 7.6%, 7.1%, 6.1%, and 6.1%, respectively. The total weight of the top 15 risk factors was 85.5%. The AUC values of the model for detecting ACS with training dataset and testing dataset were 0.927 and 0.888, respectively.Conclusions This study demonstrated that the machine-learning algorithm could be used to identify the risk factors for ACS among high risk population of stroke. Family history of dyslipidemia may be the most important risk factor for ACS. This model could be a suitable tool to optimize the clinical approach for the primary prevention of stroke.

Brain astrocytoma misdiagnosed as anti-NMDAR encephalitis: a case report.

BACKGROUND: Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis, which is the most common type of autoimmune encephalitis, is caused by the production of autoantibodies against NMDA receptor. Anti-NMDAR encephalitis patients present with various non-specific symptoms, such as abnormal psychiatric or behaviour, speech dysfunction, cognitive dysfunction, seizures, movement disorders, decreased level of consciousness, and central hypoventilation or autonomic dysfunction. CASE PRESENTATION: A 67-year-old man presented with new-onset focal seizures. The brain magnetic resonance imaging (MRI) plain scan and enhanced scan showed abnormal signal on the proximal midline frontoparietal junction region. Anti-NMDAR antibody was detected in cerebrospinal fluid (CSF) and serum using a commercial kit (Euroimmune, Germany) by indirect immunofluorescence testing (IIFT) according to the manufacturer's instructions for twice. Both of the test results were positive in CSF and serum. The patient was diagnosed as anti-NMDAR encephalitis and then was treated repeatedly with large dose of intravenous corticosteroids and gamma globulin. Accordingly, the refractory nature of seizures in this case may be attributed to NMDAR autoantibodies. When the patient presented at the hospital for the third time, the brain MRI revealed an increase in the size of the frontal parietal lesion and one new lesion in the left basal ganglia. The patient underwent a surgical biopsy and astrocytoma was confirmed by histopathology. CONCLUSIONS: Although the sensitivity and specificity of anti-NMDAR-IgG antibodies in CSF to diagnose anti-NMDAR encephalitis are close to 100%, it is not absolute. Anti-NMDAR antibodies were positive, which might make the diagnosis more complex. The diagnosis of atypical presentation of anti-NMDAR encephalitis requires reasonable exclusion of other disorders.

[Effect of Compound Tongfu Granule on Intestinal Permeability in Elderly Sepsis Patients].

OBJECTIVE: To explore the effect of Compound Tongtu Granule (CTG) on intestinal permeability in elderly sepsis patients. METHODS: Eighty elderly sepsis patients were randomly assigned to the experimental group and the control group by randomized double blinded method, 40 in each group. On the basis of conventional antiseptic treatment program, patients in the experimental group took CTG, while those in the control group took placebos. The dosage for CTG or placebos was 14.3 g each package, one package each time, twice daily for 14 successive days. Patients' abdominal symptoms and signs, levels of serum inflammatory factors (high-sensitivity C-reactive protein and procalcitonin), levels of plasma endotoxin, and the intestinal permeability (IP, represented by urinary lactulose/mannitol excretion rate) were compared between the two groups before and after treatment. RESULTS: After 14-day treatment, patients in the experimental group had improved abdominal symptoms, increased frequency of defecation, significantly decreased levels of plasma endotoxin and IP, when compared with the control group (P < 0.05). CONCLUSION: CTG could improve the intestinal barrier function in elderly sepsis patients.

Exploring the chemodiversity and biological activities of the secondary metabolites from the marine fungus Neosartorya pseudofischeri.

The production of fungal metabolites can be remarkably influenced by various cultivation parameters. To explore the biosynthetic potentials of the marine fungus, Neosartorya pseudofischeri, which was isolated from the inner tissue of starfish Acanthaster planci, glycerol-peptone-yeast extract (GlyPY) and glucose-peptone-yeast extract (GluPY) media were used to culture this fungus. When cultured in GlyPY medium, this fungus produced two novel diketopiperazines, neosartins A and B (1 and 2), together with six biogenetically-related known diketopiperazines,1,2,3,4-tetrahydro-2, 3-dimethyl-1,4-dioxopyrazino[1,2-a]indole (3), 1,2,3,4-tetrahydro-2-methyl-3-methylen e-1,4-dioxopyrazino[1,2-a]indole (4), 1,2,3,4-tetrahydro-2-methyl-1,3,4-trioxopyrazino[1,2-a] indole (5), 6-acetylbis(methylthio)gliotoxin (10), bisdethiobis(methylthio)gliotoxin (11), didehydrobisdethiobis(methylthio)gliotoxin (12) and N-methyl-1H-indole-2-carboxamide (6). However, a novel tetracyclic-fused alkaloid, neosartin C (14), a meroterpenoid, pyripyropene A (15), gliotoxin (7) and five known gliotoxin analogues, acetylgliotoxin (8), reduced gliotoxin (9), 6-acetylbis(methylthio)gliotoxin (10), bisdethiobis(methylthio) gliotoxin (11) and bis-N-norgliovictin (13), were obtained when grown in glucose-containing medium (GluPY medium). This is the first report of compounds 3, 4, 6, 9, 10 and 12 as naturally occurring. Their structures were determined mainly by MS, 1D and 2D NMR data. The possible biosynthetic pathways of gliotoxin-related analogues and neosartin C were proposed. The antibacterial activity of compounds 2-14 and the cytotoxic activity of compounds 4, 5 and 7-13 were evaluated. Their structure-activity relationships are also preliminarily discussed.

Current Global Research Trends of Tethered Cord Syndrome Surgery: A Scientometric and Visual Analysis.

BACKGROUND: Since tethered cord syndrome (TCS) may lead to neurologic and motor dysfunction, surgeries often are applied to relieve the symptoms. The aim of the research was to explore the current global research trends of TCS surgery. METHODS: In this article, articles on TCS surgery in the Web of Science Core Collection from 1980 to 2023 were searched. Research trends, countries, institutions, journals, authors, highly cited articles, and key words were analyzed using bibliometric methods. The literature co-citation network was mapped using VOSviewer, and research hotspots and trends were analyzed using CiteSpace. RESULTS: A total of 432 publications were included. The number of publications and related research interest in the field of TCS surgery has increased globally year by year. The United States is the largest contributor (154 publications). The journal Childs Nervous System has the greatest number of publications (48 publications) and the most frequently cited journal is Neurosurgery (973 citations). In network visualization, the institution with the greatest contribution is University of California System (16 publications). Lee JY and Wang KC are the authors with the greatest number of publications (8 publications), and the most frequently cited author is Klekamp J (268 citations). Neurogenic bladder and spina bifida may be the next hot spot in this field. CONCLUSIONS: This study will help researchers to identify the mainstream research directions and the latest hotspots in the field of TCS surgery and provide a reference for further research.

Potential of semen coicis in enhancing the anti-tumor effects of PD-1 inhibitor on A549 cell lines by blocking the PI3K-AKT-mTOR pathway.

BACKGROUND: The objective of this research was to investigate how the combination of semen coicis extract and PD-1 inhibitors can potentially work together to enhance the anti-tumor effects, with a focus on understanding the underlying mechanism. METHODS: We obtained the active components and specific targets of semen coicis in the treatment of NSCLC from various databases, namely TCMSP, GeneCard, and OMIM. By utilizing the STRING database and Cytoscape software, we established a protein interaction network (PPI) for the active ingredient of semen coicis and the target genes related to NSCLC. To explore the potential pathways involved, we conducted gene ontology (GO) and biological pathway (KEGG) enrichment analyses, which were further supported by molecular docking technology. Additionally, we conducted cyto-inhibition experiments to verify the inhibitory effects of semen coicis alone or in combination with a PD-1 inhibitor on A549 cells, along with examining the associated pathways. Furthermore, we investigated the synergistic mechanism of these two drugs through cytokine release experiments and the PD-L1 expression study on A549 cells. RESULTS: Semen coicis contains two main active components, Omaine and (S)-4-Nonanolide. Its primary targets include PIK3R1, PIK3CD, PIK3CA, AKT2, and mTOR. Molecular docking experiments confirmed that these ingredients and targets form stable bonds. In vitro experiments showed that semen coicis demonstrates inhibitory effects against A549 cells, and this effect was further enhanced when combined with PD-1 inhibitors. PCR and WB analysis confirmed that the inhibition of the PI3K-AKT-mTOR pathway may contribute to this effect. Additionally, semen coicis was observed to decrease the levels of IFN-γ, IL-6, and TNF-α, promoting the recovery of the human anti-tumor immune response. And semen coicis could inhibit the induced expression of PD­L1 of A549 cells stimulated by IFN­Î³ as well. CONCLUSION: Semen coicis not only has the ability to kill tumor cells directly but also alleviates the immunosuppression found in the tumor microenvironment. Additionally, it collaboratively enhances the effectiveness of PD-1 inhibitors against tumors by blocking the activation of PI3K-AKT-mTOR.

Effect of the combination of he-sea and front-mu points on enteral nutrition feeding intolerance in critical illness patients. / åˆå‹Ÿé ç©´æ²»ç–—å±é‡ç—‡æ‚£è€ è‚ å† è¥å »å–‚å »ä¸è€å—çš„ç–—æ•ˆè§‚å¯Ÿ.

OBJECTIVES: To explore the effects of the combination of he-sea and front-mu points on the feeding compliance rate, the intra-abdominal pressure, the enteral nutrition tolerance score, the score of acute physiological and chronic health evaluation (APACHE)-Ⅱ and gastrointestinal function impairment grade in the patients with enteral nutrition feeding intolerance (ENFI) of critical illness and evaluate clinical effect on ENFI after acupuncture at the he-sea and front-mu points. METHODS: Seventy patients of ENFI were randomized into a control group and an observation group, 35 cases in each one. In the control group, the patients were treated with routine regimen combined with intestinal nutrition support. In the observation group, on the basis of the treatment as the control group, acupuncture was applied to Shangwan (CV13), Zhongwan (CV12), Xiawan (CV10), Qihai (CV6) and Guanyuan (CV4), as well as bila-teral Neiguan (PC6), Zusanli (ST36), Xiajuxu (ST39), Shangjuxu (ST37), Tianshu (ST25) and Daheng (SP15). Of those acupoints, ST25 and SP15 on the same side were attached to one pair of electrodes (20 Hz/100 Hz). Acupuncture was delivered once daily, 30 min each time and for consecutive 7 days. During treatment, the numbers of the cases up to the feeding standard were observed everyday to calculate the feeding compliance rate. The score of enteral nutrition tolerance, the intra-abdominal pressure, the score of APACHE-Ⅱ and the level of acute gastriointestinal injury(AGI) grading were recorded. RESULTS: After treatment, the enteral feeding compliance rate was increased in comparison with that before treatment in the two groups, and the rate in the observation group was higher than that of the control group (P<0.05) except that on the 2nd day. The score of the enteral nutrition tolerance, the intra-abdominal pressure, the score of APACHE-Ⅱ and the level of AGI were all reduced (P<0.05, P<0.01) when compared with those before treatment in the two groups, and these indicators in the observation group were lower (P<0.05) than those of the control group. CONCLUSIONS: Acupuncture at the he-sea and front-mu points relieves the conditions of ENFI, improves the feeding and the recovery of gastrointestinal function, and benefits the prognosis through increasing the amount of enteral nutrition in ENFI patients.

Enriched switching in a donor-acceptor Stenhouse adduct via reversible covalent bonding.

We have utilized reversible covalent bonding to expand the accessible states of a molecular switch. Introducing a hydroxyl group onto the donor moiety of a donor-acceptor Stenhouse adduct (DASA) imparts an acidity response by forming an oxazolidine ring through intramolecular nucleophilic addition. Furthermore, we observed distinct color changes under cryogenic conditions, extending the thermal responsiveness beyond the cyclization equilibrium observed at elevated temperatures. These unique responses present promising prospects for diverse applications compared to traditional photoinduced binary isomerization.

Effect and cerebral mechanism of moxibustion at heat-sensitized Yaoyangguan (GV3) in patients with lumbar disc herniation and myofascial pain syndrome by resting-state functionality magnetic resonance imaging: protocol for an observational study.

We want to explore the analgesic brain effect of the moxibustion at heat-sensitized Yaoyangguan (GV3) in patients with lumbar disc herniation (LDH) and myofascial pain syndrome (MPS). In an assessor-blinded observational study, we will include 15 LDH and 15 MPS. They will accept same treatment of heat-sensitive moxibustion at Yaoyangguan (GV3). The resting-state functionality magnetic resonance imaging image data of brain activities before and after treatment will be analyzed by mean fractional amplitude of low-frequency fluctuation, regional homogeneity analysis and brain functional connection. We select seed of first sensory cortex, second sensory cortex, insula cortex, periaqueductal gray and anterior cingulate cortex as the regions of interest to analyse the relationship between brain functional connectivity of pain-related networks and clinical data. Our study could disclose key brain targets and central response characteristics of the analgesic brain effect and the brain functional connection of heat-sensitive moxibustion.

Prediction of lymph node metastasis in early esophageal cancer.

BACKGROUND: Given the poor prognosis of patients with lymph node metastasis, estimating the lymph node status in patients with early esophageal cancer is crucial. Indicators that could be used to predict lymph node metastasis in early esophageal cancer have been reported in many recent studies, but no recent studies have included a review of this subject. AIM: To review indicators predicting lymph node metastasis in early esophageal squamous cell carcinoma (ESCC) and early esophageal adenocarcinoma (EAC). METHODS: We searched PubMed with "[early esophageal cancer (Title/Abstract)] and [lymph node (Title/Abstract)]" or "[early esophageal carcinoma (Title/Abstract)] and [lymph node (Title/Abstract)]" or "[superficial esophageal cancer (Title/Abstract)] and [lymph node (Title/Abstract)]." A total of 29 studies were eligible for analysis. RESULTS: Preoperative imaging (size), serum markers (microRNA-218), postoperative pathology and immunohistochemical analysis (depth of invasion, tumor size, differentiation grade, lymphovascular invasion, neural invasion, expression of PIM-1 < 30%) were predictive factors for lymph node metastasis in both early ESCC and EAC. Serum markers (thymidine kinase 1 ≥ 3.38 pmol/L; cytokeratin 19 fragment antigen 21-1 > 3.30 ng/mL; stathmin-1) and postoperative pathology and immunohistochemical analysis (overexpression of cortactin, mixed-lineage leukaemia 2, and stanniocalcin-1) were predictive for lymph node metastasis in early ESCC. Transcription of CD69, myeloid differentiation protein 88 and toll-like receptor 4 and low expression of olfactomedin 4 were predictive of lymph node metastasis in early EAC. A total of 6 comprehensive models for early ESCC, including logistic regression model, nomogram, and artificial neural network (ANN), were reviewed. The areas under the receiver operating characteristic curve of these models reached 0.789-0.938, and the ANN performed best. As all these models relied on postoperative pathology, further models focusing on serum markers, imaging and immunohistochemical indicators are still needed. CONCLUSION: Various factors were predictive of lymph node metastasis in early esophageal cancer, and present comprehensive models predicting lymph node metastasis in early ESCC mainly relied on postoperative pathology. Further studies focusing on serum markers, imaging and immunohistochemical indicators are still in need.

SPS: Accurate and Real-Time Semantic Positioning System Based on Low-Cost DEM Maps.

This paper presents a Semantic Positioning System (SPS) to enhance the accuracy of mobile device geo-localization in outdoor urban environments. Although the traditional Global Positioning System (GPS) can offer a rough localization, it lacks the necessary accuracy for applications such as Augmented Reality (AR). Our SPS integrates Geographic Information System (GIS) data, GPS signals, and visual image information to estimate the 6 Degree-of-Freedom (DoF) pose through cross-view semantic matching. This approach has excellent scalability to support GIS context with Levels of Detail (LOD). The map data representation is Digital Elevation Model (DEM), a cost-effective aerial map that allows for fast deployment for large-scale areas. However, the DEM lacks geometric and texture details, making it challenging for traditional visual feature extraction to establish pixel/voxel level cross-view correspondences. To address this, we sample observation pixels from the query ground-view image using predicted semantic labels. We then propose an iterative homography estimation method with semantic correspondences. To improve the efficiency of the overall system, we further employ a heuristic search to speedup the matching process. The proposed method is robust, real-time, and automatic. Quantitative experiments on the challenging Bund dataset show that we achieve a positioning accuracy of 73.24%, surpassing the baseline skyline-based method by 20%. Compared with the state-of-the-art semantic-based approach on the Kitti dataset, we improve the positioning accuracy by an average of 5%.

Preoperative Oswestry Disability Index Cannot Reliably Predict Patient Satisfaction After Single and Double Level Lumbar Transforaminal Interbody Fusion Surgery.

Introduction: The role of patient-reported outcomes in preoperative assessment is not well studied. There is recent interest in studying whether Patient-reported outcomes scores can be used either independently, or in conjunction with clinical findings, in the assessment of patients for surgery. Aims: To investigate if improvement in clinically significant scores correlate with post-operative patient satisfaction in 1-2 level transforaminal lumbar interbody fusion (TLIF) surgery. We also aim to define a threshold Oswestry Disability Index (ODI) which correlate with achieving post-operative MCID and patient satisfaction. Methods: 1001 patients who underwent single or double level TLIF (Minimally invasive and Open) in our institution with at least 2 years follow up were included in this study. We studied self-reported measures including patient satisfaction and ODI score. Results: At 2-year follow-up, the overall mean ODI score improved from 49.7 ± 18.3 to 13.9 ± 15.2 (P < 0.001) with 74.6% of patients meeting the MCID. Patient satisfaction was achieved in 95.3% of all patients. In the MIS group, the preoperative cut-off was determined to be 37.2 at maximal Youden index associated with AUC of 0.72 (95% CI 0.65-0.86). In the open group, the preoperative cut-off was determined to be 37.2 at maximal Youden index associated with AUC of 0.70 (95% CI 0.62-0.77). Using the preoperative cut-offs found, there was no significant difference in patient satisfaction in both MIS and open groups. Conclusions: Overall, our patients undergoing TLIF had good 2-year ODI score improvement and patient satisfaction after surgery. While meeting the MCID for ODI score correlates with patients' satisfaction postoperatively, 75% of patients not meeting the MCID for ODI score remained satisfied with the surgery. We are unable to define a threshold pre-operative ODI which correlates with achieving post-operative MCID and patient satisfaction.

Dekyphosis operation combined with limited osteotomy to treat the symptomatic adult tethered cord syndrome with complicated malformations: A case report.

RATIONALE: Tethered cord syndrome (TCS) represents a spectrum of neurological symptoms that are caused by constant or intermittent axial traction of the terminal cone of the spinal cord due to abnormal positioning. It is uncommon for abnormal structures of TCS to be accompanied by split cord malformation, thoracic spinal stenosis, and other spinal cord diseases. PATIENT CONCERNS: A 45-year-old male patient visited our hospital due to severe lower back pain, extensive left lower limb muscle weakness, and intermittent claudication. DIAGNOSES: TCS combined with stenosis of the thoracic canal, split cord malformation, and kyphosis deformity. INTERVENTIONS: The patient underwent Dekyphosis operation combined with limited osteotomy symptoms. OUTCOMES: The patient felt the right lower limb improved after surgery. At 4-month follow-up, a radiological examination showed adequate decompression of the spinal cord and a good internal fixation position. Overall, the patient's clinical symptoms significantly improved. CONCLUSION: This is a rare case of TCS combined with thoracic disc herniation and bony mediastinum. A more conservative invasive surgical approach was elected and markedly improved the patient's symptoms. Additional clinical cases are needed to confirm the stability and feasibility of this surgical approach.

Comparison of 2 Anesthetic Methods for Transforaminal Endoscopic Lumbar Discectomy: A Prospective Randomized Controlled Study.

STUDY DESIGN: Randomized controlled trial. OBJECTIVES: To compare the effect and safety of 2 anesthetic methods using in the operation of Transforaminal Endoscopic Lumbar Discectomy. METHODS: From the January of 2020 to the December of 2021, 230 consecutive patients that underwent TELD were applied with two methods of anesthesia. All the patients were divided into two groups. The Monitored Anesthesia Care (MAC) group used the local anesthesia (LA) with MAC that based on the combination of dexmedetomidine and butorphanol tartrate. The LA group used the local anesthesia only. Then the Visual Analogic Scale (VAS) through the operating period was compared between the two groups at the time points of before operation (T0), inserting of the puncture needle (T1), establishing of the working cannula (T2), excision of the fibrous rings (T3) and immediately postoperatively (T4). Also, the satisfaction degree of the patients for the course of the operations and the occurrence of the complications were compared between the two groups. RESULTS: There were no differences of the VAS around the operating area at the time point of T0. Then the MAC group expressed lower scores at all other points of T1, T2, T3 and T4. Then the satisfaction degree of the MAC group was superior than the LA group. No difference was observed for the occurrence of the complications. CONCLUSIONS: MAC based on the combination of dexmedetomidine and butorphanol tartrate is an ideal method of anesthesia for TELD with enough effect and safety.

Severe and rare neurological manifestations following COVID-19 infection in children: A Malaysian tertiary centre experience.

INTRODUCTION: Since the emergence of COVID-19, we have experienced potent variants and sub-variants of the virus with non-specific neurological manifestations. We observed a surge of the Omicron variant of COVID-19 patients with neurological manifestations where less cases of multisystem inflammatory syndrome in children (MIS-C) were reported. This article describes our experience of children with severe and rare neurological manifestations following COVID-19 infection. METHODS: This is a retrospective observational case series of patients under 18 years old who fulfilled the WHO COVID-19 case definition and were referred to our paediatric neurology unit at Hospital Tunku Azizah Kuala Lumpur. Their demographic data, neurological symptoms, laboratory and supporting investigations, neuroimaging, treatment and outcomes were collected and analysed. RESULTS: There were eleven patients with neurological manifestations who fulfilled the WHO COVID-19 case definition. Nine patients presented with seizures and/or encephalopathy, one patient with eye opsoclonus and another patient with persistent limbs myokymia. Based on the history, clinical, electrophysiological and radiological findings, two of them had febrile infection-related epilepsy syndrome, two had acute disseminated encephalomyelitis, two had acute necrotising encephalopathy of childhood, one each had hemiconvulsion-hemiplegia-epilepsy syndrome, acute encephalopathy with bilateral striatal necrosis, hemi-acute encephalopathy with biphasic seizures and reduced diffusion, infection-associated opsoclonus and myokymia. CONCLUSIONS: This case series highlighted a wide spectrum of neurological manifestations of COVID-19 infection. Early recognition and prompt investigations are important to provide appropriate interventions. It is essential that these investigations should take place in a timely fashion and COVID-19 quarantine period should not hinder the confirmation of various presenting clinical syndromes.