The safety of preoperative carbohydrate drinks in extremely elderly patients assessed by gastric ultrasonography: a randomized controlled trial.

BACKGROUND: Modern perioperative guidelines encourage drinking oral carbohydrates 2 h before management. Nevertheless, research on the safety of preoperative carbohydrate drinks, particularly in extremely elderly patients is lacking. We aimed to evaluate the safety of carbohydrate drinks 2 h before surgery in extremely elderly patients (≥ 80 years) using gastric ultrasonography. METHODS: We conducted a randomized prospective comparative study of 70 patients aged over 80 years who were scheduled for total knee arthroplasty, hip fracture or humerus fracture surgery. These patients were randomly assigned to the carbohydrate group (n = 35), which fasted from midnight, except for drinking 355 mL of a carbohydrate-containing fluid 2 h before surgery, or the fasting group (n = 35), which fasted from midnight and drank no fluid before surgery. The primary outcome of the study was the cross-sectional area (CSA) of the gastric antrum in the right lateral decubitus position (RLDP) before surgery. The secondary outcomes included CSA in the supine position, intraoperative blood glucose levels and their variability coefficients, Perlas grade, and the visual analog scale of subjective feelings. RESULTS: The CSA in the RLDP and supine positions revealed no differences between the carbohydrate and fasting groups at 0 h preoperatively (P > 0.05). In the qualitative assessment, preoperative 0-h Perlas grading did not differ significantly between the groups (P > 0.05). From 2 h before surgery to transfer out of the post-anesthesia care unit, the average blood glucose level of patients in the carbohydrate group was significantly higher than that in the fasting group (P < 0.001) but remained within the normal range. Moreover, the blood glucose variability coefficient was significantly lower in the carbohydrate group than in the fasting group (P = 0.009). Oral intake of 355 mL carbohydrates before surgery significantly relieved patients' feelings (P < 0.001). CONCLUSION: Preoperative consumption of carbohydrate drinks 2 h before surgery is safe in "healthy" extremely elderly patients. In addition, preoperative drinking has potential value in maintaining ideal blood glucose levels and stable blood glucose fluctuations perioperatively and improving subjective perceptions of preoperative preparation. This finding warrants further investigation in clinical practice. TRIAL REGISTRATION: Chinese Clinical Trial Registry (Registration Number ChiCTR1900024812), first registered on 29/07/2019.

Comparison of 95% effective dose of remimazolam besylate and propofol for gastroscopy sedation on older patients: A single-centre randomized controlled trial.

AIMS: Advanced age is an important risk factor for adverse events during procedural sedation. Remimazolam is safe and effective in gastroscopic sedation. However, the ideal dose and application for older patients are not well known. We aim to investigate its 95% effective dose (ED95) for older patients undergoing gastroscopy and to assess its safety and efficacy, with propofol as the comparison. METHODS: The trial consists of 2 parts, patients aged >65 years and scheduled for outpatient painless gastroscopy were enrolled. In the first part, Dixon's up-and-down methodology was used to determine the ED95 of remimazolam besylate and propofol for gastroscopic insertion, in combination with 0.2 µg/kg remifentanil. In the second part, patients in each group received 0.2 µg/kg remifentanil and ED95 dose of the study drugs for sedation induction, supplemental doses were added to maintain sedation depth when necessary. The primary outcome was the incidence of adverse events. The secondary outcome was the recovery time. RESULTS: The ED95 of remimazolam besylate and propofol induction were 0.2039 (95% confidence interval 0.1753-0.3896) mg/kg and 1.9733 (95% confidence interval 1.7346-3.7021) mg/kg respectively. Adverse events were reported in 26 (40.6%) patients in the remimazolam group and 54 (83.1%) in the propofol group (P < .0001), whereas the remimazolam group presented a higher incidence of hiccups (P = .0169). Besides, the median time to awakening was approximately 1 min shorter with remimazolam than with propofol (P < .05). CONCLUSION: For older patients undergoing gastroscopy, the ED95 dose of remimazolam is a safer alternative than propofol when inducing the same sedation depth.

Inadvertent perioperative hypothermia and surgical site infections after liver resection.

BACKGROUND: In the overall surgical population, inadvertent perioperative hypothermia has been associated with an increased incidence of surgical site infection (SSI). However, recent clinical trials did not validate this notion. This study aimed to investigate the potential correlation between inadvertent perioperative hypothermia and SSIs following liver resection. METHODS: This retrospective cohort study included all consecutive patients who underwent liver resection between January 2019 and December 2021 at the First Affiliated Hospital, Zhejiang University School of Medicine. Perioperative temperature managements were implemented for all patients included in the analysis. Estimated propensity score matching (PSM) was performed to reduce the baseline imbalances between the normothermia and hypothermia groups. Before and after PSM, univariate analyses were performed to evaluate the correlation between hypothermia and SSI. Multivariate regression analysis was performed to determine whether hypothermia was an independent risk factor for postoperative transfusion and major complications. Subgroup analyses were performed for diabetes mellitus, age > 65 years, and major liver resection. RESULTS: Among 4000 patients, 2206 had hypothermia (55.2%), of which 150 developed SSI (6.8%). PSM yielded 1434 individuals in each group. After PSM, the hypothermia and normothermia groups demonstrated similar incidence rates of SSI (6.3% vs. 7.0%, P = 0.453), postoperative transfusion (13.3% vs. 13.7%, P = 0.743), and major complications (9.0% vs. 10.1%, P = 0.309). Univariate regression analysis revealed no significant effects of hypothermia on the incidence of SSI in the group with the highest hypothermia exposure [odds ratio (OR) = 1.25, 95% confidence interval (CI): 0.84-1.87, P = 0.266], the group with moderate exposure (OR = 1.00, 95% CI: 0.65-1.53, P = 0.999), or the group with the lowest exposure (OR = 1.11, 95% CI: 0.73-1.65, P = 0.628). The subgroup analysis revealed similar results. Regarding liver function, patients in the hypothermia group demonstrated lower γ-glutamyl transpeptidase (37 vs. 43 U/L, P = 0.001) and alkaline phosphatase (69 vs. 72 U/L, P = 0.016). However, patients in the hypothermia group exhibited prolonged activated partial thromboplastin time (29.2 vs. 28.6 s, P < 0.01). CONCLUSIONS: In our study of patients undergoing liver resection, we found no significant association between mild perioperative hypothermia and SSI. It might be due to the perioperative temperature managements, especially active warming measures, which limited the impact of perioperative hypothermia on the occurrence of SSI.

Global research trends in perioperative care for the elderly: a bibliometric and visualized study.

PURPOSE: Aged surgical patients are at a relatively higher risk of morbidity and mortality than younger surgical patients. The present study aimed to investigate the trends and research status of perioperative care for the elderly in the anesthesiology field. METHODS: We screened manuscripts published between May 31, 1991, and May 31, 2020, from the Web of Science Core Collection (WoSCC). A clustered network was derived from all references cited in all of the included manuscripts. The top authors, journals, institutions, countries, keywords, co-cited articles, and trends were identified through bibliometric analysis and visualization using CiteSpace 5.8.R3 and VOSviewer 1.6.15. RESULTS: We included a total of 1860 manuscripts published between 1991 and 2020. The number of publications on perioperative care for the elderly sharply increased from 2014 onwards. The United States of America and the University of California, San Francisco were the leading publication country (24.8%, 461/1860) and institution (2.6%, 48/1860), respectively. High-frequency keywords in cluster analysis included the type of anesthesia, postoperative pain management, postoperative cognitive dysfunction, and postoperative delirium, indicating postoperative cognitive dysfunction and postoperative delirium remain the focus areas for research in perioperative care for the elderly. Organ function protection was the new research focus according to the burst detection analysis of top keywords. CONCLUSIONS: The number of studies on perioperative care for the elderly has increased apparently worldwide. Postoperative cognitive dysfunction and postoperative delirium remain primary research focus areas. Organ function protection appears to be the second most highly researched topic in the perioperative care for the elderly.

Confocal laser endomicroscopy under propofol-based sedation for early gastric cancer and pre-cancerous lesions is associated with better diagnostic accuracy: a retrospective cohort study in China.

BACKGROUND: Confocal laser endomicroscopy (CLE) has advantages in detecting gastric neoplastic lesions, meanwhile it requires strict patient cooperation. Sedation could improve patient cooperation and quality of endoscopy. However, sedation is still not very popular in some resource-limited countries and regions. The purpose of this study was to compare propofol-based sedated versus un-sedated CLE in the value of diagnosing early gastric cancer (EGC) and precancerous lesions. METHODS: A retrospective, cohort, single center study of 226 patients who underwent CLE between January 1, 2015 and December 31, 2017 was performed. Patients enrolled were allocated into the propofol-based sedated group (n = 126) and the un-sedated group (n = 100). The comparison of validity and reliability of CLE for identifying EGC and precancerous lesions between the two groups was performed through analyzing CLE diagnosis and pathological diagnosis. Reporting followed the STROBE guidelines. RESULTS: The area under receiver operating characteristic curve (AUROC) of diagnosing EGC in the sedated group was 0.97 (95 % CI: 0.95 to 0.99), which was higher than that in the un-sedated group (0.88 (95 % CI: 0.80 to 0.97), P = 0.0407). CLE with sedation performed better than without sedation in diagnosing intraepithelial neoplasia and intestinal metaplasia (P = 0.0008 and P = 0.0001, respectively). For patients considered as high-grade intraepithelial neoplasia or EGC by endoscopists, they would not get biopsy during CLE but receive endoscopic submucosal dissection (ESD) subsequently, and the misdiagnosis rate of CLE was 0 % in the sedated group and 27.59 % (95 % CI: 10.30-44.91 %) in the un-sedated group (P = 0.006). CONCLUSIONS: Propofol based sedation was associated with improved diagnostic value of CLE for detecting EGC as well as precancerous lesions (intraepithelial neoplasia OR intestinal metaplasia).

Postoperative infectious complications in elderly patients after elective surgery in China: results of a 7-day cohort study from the International Surgical Outcomes Study.

AIM: Despite initiatives to increase elderly patients' access to surgical treatments, the prevalence and impact of postoperative infectious complications (PICs) in elderly patients in China are poorly described. The aim of our study was to describe PICs and associated mortality in elderly patients undertaking elective surgery in China. METHODS: We analyzed data about elderly patients from China during the International Surgical Outcomes Study (ISOS), a 7-day prospective cohort study of outcomes after elective surgery in in-patient adults. All elderly patients (age ≥60 years) from 28 hospitals in China included in the ISOS study were included in this study as well. A review of 2014 elderly patients who underwent elective surgery in April 2014 was conducted. RESULTS: Of 2014 elderly patients, 209 (10.4%) developed at least one postoperative complication. Infectious complications were most frequent, affecting 154 patients (7.6%); there was one death, or 0.6% 30-day mortality, which was a significantly higher rate than among patients without PICs (0%). The most frequent infectious complication was superficial surgical-site infection (3.3%). The length of hospital stay was longer in elderly patients with PICs than in those without PICs. Moreover, a total of 142 elderly patients (7.1%) were routinely sent to critical care after surgery, of whom 97 (68.3%) developed PICs. Compared to elderly patients admitted to a standard ward, those admitted to critical care immediately after surgery had a higher postoperative complication rate and critical care admission rate to treat complications. CONCLUSIONS: The present prospective, multicentre study found that 7.6% of elderly patients in China had PICs after elective surgery that could prolong hospital stay and increase 30-day mortality. The clinical effectiveness of admission to critical care after surgery on elderly patients is not identified. Initiatives to increase elderly patients' access to surgical interventions should also enhance safe perioperative care to reduce PICs in China.

Heat stress decreases metabolic flexibility in skeletal muscle of growing pigs.

Heat-stressed pigs experience metabolic alterations, including altered insulin profiles, reduced lipid mobilization, and compromised intestinal integrity. This is bioenergetically distinct from thermal neutral pigs on a similar nutritional plane. To delineate differences in substrate preferences between direct and indirect (via reduced feed intake) heat stress effects, skeletal muscle fuel metabolism was assessed. Pigs (35.3 ± 0.8 kg) were randomly assigned to three treatments: thermal neutral fed ad libitum (TN; 21°C, n = 8), heat stress fed ad libitum (HS; 35°C, n = 8), and TN, pair-fed/HS intake (PF; n = 8) for 7 days. Body temperature (TB) and feed intake (FI) were recorded daily. Longissimus dorsi muscle was biopsied for metabolic assays on days -2, 3, and 7 relative to initiation of environmental treatments. Heat stress increased TB and decreased FI ( P < 0.05). Heat stress inhibited incomplete fatty acid oxidation and glucose oxidation ( P < 0.05). Metabolic flexibility decreased in HS pigs compared with TN and PF controls ( P < 0.05). Both phosphofructokinase and pyruvate dehydrogenase (PDH) activities increased in PF ( P < 0.05); however, TN and HS did not differ. Heat stress inhibited citrate synthase and ß-hydroxyacyl-CoA dehydrogenase (ß-HAD) activities ( P < 0.05). Heat stress did not alter PDH phosphorylation or carnitine palmitoyltransferase 1 abundance but reduced acetyl-CoA carboxylase 1 (ACC1) protein abundance ( P < 0.05). In conclusion, HS decreased skeletal muscle fatty acid oxidation and metabolic flexibility, likely involving ß-HAD and ACC regulation.

Dexmedetomidine sedation reduces atrial fibrillation after cardiac surgery compared to propofol: a randomized controlled trial.

BACKGROUND: Atrial fibrillation occurs frequently in patients following cardiac surgery and can be a cause of increased morbidity and mortality. The use of dexmedetomidine to prevent atrial fibrillation is unclear. The present study was designed to evaluate the effect of dexmedetomidine sedation on the incidence of atrial fibrillation after cardiac surgery. METHODS: Upon arrival to the intensive care unit (ICU), cardiac surgery patients without prior atrial fibrillation or flutter were randomized to receive either dexmedetomidine (0.2-1.5 µg/kg/h) or propofol (0.3-3 mg/kg/h) open-label titrated to a target Richmond agitation-sedation scale of 0 to -3. Our primary endpoint was the incidence of postoperative atrial fibrillation, and the secondary end points were the length of ICU stay, length of hospital stay, and hospital costs. RESULTS: Atrial fibrillation occurred in 6 of 44 patients (13.6 %) in the dexmedetomidine group compared to 16 of 44 patients (36.4 %) in the propofol group (odds ratio = 0.28; 95 % confidence interval, 0.10, 0.80; P = 0.025). The median (interquartile range) length of ICU stay in the dexmedetomidine group was significantly lower than in the propofol group (2.9 (2.4-3.5) vs 3.5 (2.7-4.5 days, P = 0.008), with a trend toward a decrease in median hospital costs (86,367 vs 77,874 Chinese yuan; P = 0.068). The incidence of hypotension was higher in the dexmedetomidine group than in the propofol group (25/44 (56.8 %) vs 13/44 (29.5 %); P = 0.017). CONCLUSIONS: Dexmedetomidine sedation reduced the incidence of new-onset postoperative atrial fibrillation and shortened the length of ICU stay in patients after cardiac surgery compared to propofol sedation. Dexmedetomidine treatment was associated with more episodes of hypotension. TRIAL REGISTRATION: chictr.org.cn: ChiCTR-IPR-16008231 , retrospectively registered: April 6, 2016. This trial was not prospectively registered due to a lack of importance applied to trial registration.

China's Contribution to Anesthesiology Research: A 10-Year Survey of the Literature.

BACKGROUND: Anesthesiology has advanced in China over the past decade. We compared the trends in publication of anesthesiology articles from China between 2005 and 2014 with the trends in 5 developed countries. METHODS: We included all journals listed in the ''Anesthesiology'' category of Journal Citation Reports. Anesthesiology-related publications from 2005 to 2014 were retrieved from the PubMed and Web of Knowledge online databases. The total number of articles, publication type categories, number of citations, and citation rate (number of citations/years since publication) were analyzed. The sample size was the n = 10 years for all confidence intervals and P values. We additionally evaluated the total number of articles published in the 10 top-ranking journals. RESULTS: From 2005 to 2014, 41,344 articles were published in anesthesiology journals. Of these, 3.07% were contributed by authors from Chinese institutions. Although this contribution was less than the Unites States, Great Britain, Germany, France, or Japan, publications from Chinese institutions grew at an annual rate of 13% (95% confidence interval: 3.08%-23.38%, P < 0.001, r = 0.903). Chinese institutions produced relatively more basic research reports than clinical investigations. China ranked before Great Britain (221 articles) and France (245 articles) in basic research, with 448 basic researches publications during the study period. The articles from China averaged 2.24 citations per year, comparable to the articles from the United States (2.71, P = 0.545), Great Britain (2.57, P = 0.999), Germany (2.35, P = 0.999), France (1.50, P = 0.520), and Japan (1.24, P = 0.065). In the 10 highest impact anesthesiology journals, China published 780 articles during the decade. The 3 journals with the most publications from Chinese institutions were Anesthesia & Analgesia, Anesthesiology, and Acta Anaesthesiologica Scandinavica. CONCLUSIONS: In the studied decade, anesthesiology research published by Chinese institutions lagged behind publications from developed countries. There was a steady increase in the number of articles every year, resulting in recent rates of publication similar to several developed countries. The citation rate of articles from Chinese institutions was similar to the citation rate of articles from developed countries, indicating that the quality of articles from China in these journals is comparable to the quality from developed countries.

Dexmedetomidine Versus Propofol Sedation Improves Sublingual Microcirculation After Cardiac Surgery: A Randomized Controlled Trial.

OBJECTIVES: To compare the effects of dexmedetomidine and propofol on sublingual microcirculation in patients after cardiac surgery. DESIGN: A prospective, randomized, single-blind study. SETTING: University hospital. PARTICIPANTS: Adult patients undergoing elective valve surgery with cardiopulmonary bypass. INTERVENTIONS: On arrival in the intensive care unit (ICU), patients were assigned randomly to receive either dexmedetomidine (0.2-1.5 µg/kg/h) or propofol (5-50 µg/kg/min) with open-label titration to a target Richmond Agitation-Sedation Scale of 0 to -3. MEASUREMENTS AND MAIN RESULTS: Sublingual microcirculation was recorded using sidestream dark-field imaging at ICU admission (baseline [T1]) and 4 hours (T2) and 24 hours after ICU admission (T3). At T2, median changes in perfused small-vessel density and the De Backer score from baseline were significantly greater in the dexmedetomidine group (n = 29) than in the propofol group (n = 32) (1.3 v 0 mm/mm2, p = 0.025; 0.9 v -0.1/mm, p = 0.005, respectively); median changes in small-vessel density and the proportion of perfused small vessels from baseline also tended to be higher in the dexmedetomidine group compared with the propofol group (1.0 v -0.1 mm/mm2, p = 0.050; 2.1% v 0.5%, p = 0.062, respectively). At T3, there still was a trend toward greater improvements in the small-vessel density, proportion of perfused small-vessels, perfused small-vessel density, and De Backer score from baseline in the dexmedetomidine group than in the propofol group. CONCLUSIONS: This trial demonstrated that dexmedetomidine sedation may be better able to improve microcirculation in cardiac surgery patients during the early postoperative period compared with propofol.

Sphingosine 1-phosphate Receptor 2 Signaling Suppresses Macrophage Phagocytosis and Impairs Host Defense against Sepsis.

BACKGROUND: Sepsis is characterized by an inappropriate systemic inflammatory response and bacteremia that promote multiorgan failure and mortality. Sphingosine 1-phosphate receptor 2 (S1PR2) modulates endotoxin-induced inflammation in endothelium. However, as a highly expressed S1P receptor in macrophages, its role in regulating macrophage response to bacterial infection remains unclear. METHODS: Cecal ligation and puncture or intratracheal instillation of Escherichia coli was induced in wild-type or S1pr2-deficient mice. The antibacterial ability of cell-specific S1PR2 was tested in bone marrow reconstitution mice or mice with macrophage-specific deletion. Signaling molecules responsible for S1PR2-mediated phagocytosis were also measured in the bone marrow-derived macrophages. In addition, S1PR2 expression levels and its correlation with severity of sepsis were determined in critically ill patients (n = 25). RESULTS: Both genetic deletion and pharmaceutical inhibition of S1PR2 significantly limited bacterial burden, reduced lung damage, and improved survival (genetic deletion, 0% in S1pr2 vs. 78.6% in S1pr2, P < 0.001; pharmaceutical inhibition, 9.1% in vehicle vs. 22.2% in S1PR2 antagonist, P < 0.05). This protection was attributed to the enhanced phagocytic function of S1PR2-deficient macrophages (mean fluorescent intensity, 2035.2 ± 202.1 vs. 407.8 ± 71.6, P < 0.001). Absence of S1PR2 in macrophage inhibits RhoA-dependent cell contraction and promotes IQGAP1-Rac1-dependent lamellipodial protrusion, whose signaling pathways depend on extracellular stimulators. In septic patients, increased S1PR2 levels in peripheral blood mononuclear cells were positively correlated with the severity of sepsis (r = 0.845, P < 0.001). CONCLUSIONS: This study implies that S1PR2, as a critical receptor in macrophage, impairs phagocytosis and antimicrobial defense in the pathogenesis of sepsis. Interventions targeting S1PR2 signaling may serve as promising therapeutic approaches for sepsis.

[The effect of two methods guided fluid therapy to the patient undergoing open gastrointestinal surgery].

OBJECTIVE: To investigate the effect of central venous blood oxygen saturation (ScvO2) and venous-arterial PCO2 (P(cv-a)CO2) guided fluid therapy on tissue perfusion, gastrointestinal function recovering and outcome of the patients who undergoing open gastrointestinal surgery. METHODS: Forty patients undergoing open gastrointestinal surgery were randomly divided into 2 groups (n = 20 each): ScvO2 guided fluid therapy (group S) and P(cv-a) CO2 guided fluid therapy (group P). All the patients were infused 10 ml/kg lactated Ringer's (LR) solution before anesthesia induction, they were all also given a continuous lactated Ringer's (LR) solution's infusion at the speed of 2 ml·kg(-1)·h(-1) during the operation. While, 6%HES 130/0.4 (free flex 6%HES 130/0.4, Fresenius Kabi) infusion was different between the 2 groups, when the patients of group S's central venous blood oxygen saturation < 75% or venous-arterial PCO2 in the patients of P group ≥6 mm Hg, then infused 6%HES 130/0.4. Arterial and central venous blood gas analyses were performed every 20 minutes after skin incision, measure the venous and arterial lactate value, and record the anal exhaust time after surgery, postoperative complications and mortality in 28 days. RESULTS: Compared with group S, the arterial lactate value in T4 (after operation began 80 min) were significantly decreased in group P (P = 0.013), and venous lactate value in T5 (after operation began 100 min) were also lower (P = 0.044), other lactate value were not different (P > 0.05) . The anal exhaust time was not different between the two groups (P = 0.673). All the patients were survival, and there were no obvious postoperative complications. CONCLUSION: Compared to group S, there was a transient improvement in tissue perfusion in group P, but there were no difference in complications and mortality.

[Combined inflating lung and insufflating calf pulmonary surfactant under general anesthesia in the treatment of postoperative intractable atelectasis].

OBJECTIVE: To explore the efficacy and safety of combined inflating lung and insufflating calf pulmonary surfactant under general anesthesia for treating postoperative intractable atelectasis. METHODS: From August 2006 to January 2013, 15 patients with obstinate postoperative atelectasis receiving pressure control lung expansion were enrolled. The bronchial cannula was intubated into the affected side to assist the expanding of the lung, and the calf pulmonary surfactant was insufflated selectively. The chest auscultation and computed tomography (CT) scan was performed at 1 d and 5 d after the procedure respectively, to evaluation the effect. The airway pressure, mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR) and oxygen saturation (SpO2) were recorded before the treatment, during the treatment and after the treatment.Monitoring arterial blood gas before and after treatment. RESULTS: After the expansion of the lung and insufflation of calf pulmonary surfactants, the iconographic scan showed that collapsed alveolar was reinflated in 12 (80.0%) patients at 1 d after the treatment and in 14 patients(93.3%) at 5 d after the procedure.There were not notable vital sign change and complications during the treatment.At after the treatment, 1, 3, 5 and 7 d after the treatment, PaO2 was higher (P < 0.05), and there were not significantly difference in the PaCO2 and pH (P > 0.05) . CONCLUSION: Combined pressure control lung expansion with selectively insufflating calf pulmonary surfactant under general anesthesia may be an effective therapy for postoperative intractable atelectasis.

Circular RNA and intervertebral disc degeneration: unravelling mechanisms and implications.

Low back pain (LBP) is a major public health problem worldwide and a significant health and economic burden. Intervertebral disc degeneration (IDD) is the reason for LBP. However, we have not identified effective therapeutic strategies to address this challenge. With accumulating knowledge on the role of circular RNAs in the pathogenesis of IDD, we realised that circular RNAs (circRNAs) may have tremendous therapeutic potential and clinical application prospects in this field. This review presents an overview of the current understanding of characteristics, classification, biogenesis, and function of circRNAs and summarises the protective and detrimental circRNAs involved in the intervertebral disc that have been studied thus far. This review is aimed to help researchers better understand the regulatory role of circRNAs in the progression of IDD, reveal their clinical therapeutic potential, and provide a theoretical basis for the prevention and targeted treatment of IDD.

Oxycodone is superior to morphine for pain relief following peroral oesophageal myotomy: a prospective, randomized, controlled trial.

Introduction: Patients underwent peroral endoscopic myotomy (POEM) for treating achalasia suffered with mild to moderate, sometimes even severe postoperative pain. Aim: To evaluate the efficacy of oxycodone on postoperative analgesia of patients undergoing PEOM. Material and methods: In this prospective, double-blinded, randomized, controlled trial, patients with achalasia were recruited and received 0.08 mg/kg oxycodone or morphine 15 min before the end of the POEM procedure. The short-form McGill questionnaire (SF-MPQ) was used to measure the postoperative pain at 0, 2, 6, 24, and 48 h after surgery, which included the visual analogue scale (VAS), the present pain intensity (PPI) scale, and the pain rating index (PRI). Results: A total of 73 patients were included, of whom 36 received oxycodone, and 37 received morphine. Compared with morphine, patients received oxycodone were associated with lower VAS in the first 24 h postoperatively (1.64 ±0.76 vs. 2.14 ±1.23, p = 0.042) as well as PPI at 2 h (1.11 ±0.40 vs. 2.22 ±0.89, p < 0.001), 6 h (1.42 ±0.55 vs. 2.08 ±0.92, p < 0.001) and 24 h (1.06 ±0.23 vs. 1.30 ±0.46, p = 0.006). Patients who received oxycodone experienced lower sensory McGill pain score than those who received morphine at 2, 6, 24, and 48 h after surgery (p < 0.05). Significantly lowered affective McGill pain score was observed in the oxycodone group at 0, 2, and 24 h postoperatively. Regarding the PRI, the sum of both sensory and affective McGill pain scores, patients with oxycodone therapy were associated with better scores postoperatively. Conclusions: Oxycodone appears to be superior to morphine in dealing with post-POEM pain, which has distinct visceral pain characteristics.

Establishment of Difficult Caudal Epidural Blockade Prediction Model.

Background: We aimed to develop a predictive difficult caudal epidural blockade (pDCEB) model when ultrasound was not available and verified the role of ultrasound in difficult caudal epidural blockade (CEB). Methods: From October 2018 to March 2019, this study consisted of three phases. First, we prospectively enrolled 202 patients scheduled to undergo caudal epidural anesthesia and assessed risk factors by binary logistic regression to develop the predictive scoring system. Second, we enrolled 87 patients to validate it. The receiver operating characteristic (ROC) curve was used to evaluate the performance of the prediction model. Youden-index was used to determine the cut-off value. Third, we enrolled 68 patients with a high risk of difficult CEB (pDCEB score ≥3) and randomized them into ultrasound and landmark groups to verify the role of ultrasound. Result: The rate of difficult CEB was 14.98% overall 289 patients. We found a correlation between unclear palpation of the sacral hiatus (OR 9.688) and cornua (OR 4.725), the number of the sacral hiatus by palpation ≥1 (OR 4.451), and history of difficult CEB (OR 39.282) with a higher possibility of difficult CEB. The area under the receiver operating characteristic curve of the pDCEB model involving the aforementioned factors was 0.889 (95% CI, 0.827-0.952) in the development cohort and 0.862 (95% CI, 0.747-0.977) in the validation cohort. For patients with a pDCEB score ≥3, a preprocedure ultrasound scan could reduce the incidence of difficult CEB (55.56% in the Landmark group vs. 9.38% in the ultrasound group, p < 0.001). Conclusion: This novel pDCEB score, which takes into account palpation of the sacral hiatus/cornua, number of the sacral hiatus by palpation ≥1, and history of difficult CEB, showed a good predictive ability of difficult CEB. The findings suggested that performing an ultrasound scan is essential for patients with a pDCEB score ≥3. Trial registration: No: ChiCTR1800018871, Site URL: https://www.chictr.org.cn/edit.aspx?pid=31875&htm=4; Principal investigator: Jialian Zhao, Date of registration: 2018.10.14.

Noncoding RNA PVT1 in osteosarcoma: The roles of lncRNA PVT1 and circPVT1.

Osteosarcoma (OS) is the most common primary malignant bone tumor in children and teenagers and is characterized by high malignant potential, rapid disease progression and high disability and mortality rates. Recently, noncoding RNAs (ncRNAs) have attracted the attention of many scholars due to their major regulatory roles in gene expression. Among them, lncRNA PVT1 and circPVT1 encoded by the PVT1 gene have been the focus of many studies; they are upregulated in OS, and abundant evidence indicates that lncRNA PVT1 and circPVT1 play key roles in the occurrence and development of OS. This review summarizes the mechanisms of action of lncRNA PVT1 and circPVT1 in regulating apoptosis, proliferation, glycolysis, invasion, migration and epithelial-mesenchymal transition (EMT) in OS and discusses their clinical applications in diagnosis, prognosis determination and drug resistance treatment, with the aim of helping researchers better understand the regulatory roles of lncRNA PVT1 and circPVT1 in OS progression and providing a theoretical basis for the development of early screening and accurate targeted treatment strategies and prognostic biomarkers for OS based on lncRNA PVT1 and circPVT1.

Increased genomic copy number of DEFA1/DEFA3 is associated with susceptibility to severe sepsis in Chinese Han population.

BACKGROUND: Human neutrophil peptides 1-3 are endogenous cationic antimicrobial peptides implicated in host defense against microbes. The genes encoding human neutrophil peptides 1-3 (DEFA1/DEFA3) exhibit copy number variations. This study was designed to determine whether DEFA1/DEFA3 copy number variations conferred susceptibility to infection-induced complications such as severe sepsis. METHODS: This case-control study was performed in 179 patients with severe sepsis and 233 healthy blood donors and was replicated in an independent cohort of 112 cases and 118 controls. Plasma levels of human neutrophil peptides 1-3, tumor necrosis factor-alpha, interleukin-6, and interleukin-10 were detected. RESULTS: The genotype of DEFA1/DEFA3 with more than eight copies was more frequent in patients with severe sepsis than in controls (55.9% vs. 31.3%; P = 1.13 x 10, odds ratio 2.77, 95% confidence interval 1.85-4.16). After adjustment for age and gender, logistic regression analysis confirmed the association of the genotype of more than eight copies with an increased risk of severe sepsis (P = 2.25 x 10, odds ratio 2.66, 95% confidence interval 1.69-4.19). This established association was replicated in a second age- and gender-matched case-control cohort (P = 0.02, odds ratio 1.90, 95% confidence interval 1.11-3.27). Furthermore, compared with those with fewer copies, the patients carrying more than eight copies of DEFA1/DEFA3 presented significantly lower plasma levels of human neutrophil peptides 1-3, tumor necrosis factor-alpha, interleukin-6, and interleukin-10 (P = 0.039, 0.017, 0.030, and 0.029, respectively). CONCLUSIONS: DEFA1/DEFA3 is an important genetic component participating in host immune response to severe sepsis. A higher copy number of DEFA1/DEFA3 (>8 copies) is significantly associated with the risk of severe sepsis.

Performance of Pediatric Risk of Mortality, Pediatric Index of Mortality and PIM2 in term Chinese neonates.

Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality (PIM) and PIM2 could be applicable to the subset of term neonates has not been well investigated. The purpose of this study is to access and compare the performance of these scoring systems in predicting mortality probability in term Chinese neonates with critical illness. PRISM, PIM and PIM2 scores were calculated prospectively during a 1-year period on 243 neonates admitted to the neonatal intensive care unit (NICU) in the Children's Hospital of Zhejiang University in China. Of these, 36 neonates (14.81%) died in the NICU, while the mortality rates estimated by PRISM, PIM and PIM2 were 16.19, 14.58 and 11.12%, respectively. The area under the receiver-operating characteristic (ROC) curve [95% confidence intervals (CIs)] were 0.834 (0.767-0.902), 0.851 (0.786-0.916) and 0.854 (0.790-0.918) for PRISM, PIM and PIM2, respectively. The Hosmer-Lemeshow test gave a chi-square of 1.35 (p = 0.930) for PRISM, 1.03 (p = 0.960) for PIM and 4.58 (p = 0.469) for PIM2. The standardized mortality rates (SMRs) (95% CI) using PRISM, PIM and PIM2 were 0.92 (0.79-1.08), 1.02 (0.88-1.20) and 1.33 (1.13-1.62), respectively. Although PRISM, PIM and PIM2 have displayed good discrimination and calibration in the present setting, PIM is considered as the most accurate and appropriate tool for predicting mortality in the studied NICU.

Importance of recognizing and managing delirium in intensive care unit.

Delirium is an acute and fluctuating change in mental status, with inattention and altered levels of consciousness. It is a common comorbidity in intensive care units (ICU), resulting in delayed withdrawal of mechanical ventilation, prolonged length of stay in ICU, increased ICU mortality and impaired long-term cognitive function of the survivors. Narcotic or psychoactive medication is one of the major risk factors that contribute to ICU delirium. Surveys conducted in several countries indicated that delirium in ICU was inadequately monitored, underdiagnosed and lacked standardized treatment. In order to improve the prevention and treatment of ICU delirium, it is imperative that the ICU professionals should enrich their knowledge about this comorbidity, familiarize themselves with its screening and management, as well as standardize the administration of narcotic and psychoactive medications.