Enantioselective Total Synthesis of (-)-Vinigrol: The Evolution of a Transannular Diels-Alder Strategy.

Vinigrol is a structurally and stereochemically complex diterpenoid that displays various potent pharmacological activities. Two generations of synthetic routes were designed and pursued based on a transannular Diels-Alder (TADA) cycloaddition strategy. An intramolecular [2 + 2]photocycloaddition in the presence of the chelating Lewis acid (MgBr2·Et2O) was first discovered to enable the reaction of sterically challenging substrates, which was followed by [2 + 2]cycloreversion to provide α-pyrones fused with a 10-membered ring. Eventually, a new and scalable synthetic route toward (-)-vinigrol was developed and provided over 600 mg materials, manifesting the power of macrocyclic stereocontrol and TADA reaction.

Differences between resident self-assessments and faculty- assessments on Anesthesiology Milestones and associated factors: a cross-sectional study.

BACKGROUND: Accurate self-assessment is crucial for the professional development of physicians. There has been sparse data on the accuracy of self-assessments on Anesthesiology Milestones. The aim of this study was to investigate the differences between resident self-assessments and faculty-assessments on Anesthesiology Milestones and the associated factors. METHODS: This was a cross-sectional study conducted in a general tertiary university-affiliated hospital. We included anesthesia residents who were enrolled in the standardized residency training program in postgraduate year two and three at the time of the Milestone evaluation. We requested evaluations of competencies from both the Clinical Competency Committee faculty and the anesthesia residents themselves, utilizing the Chinese version of Anesthesiology Milestones in January 2023 and January 2024. The primary outcome was the differences between self- and faculty-assessments, calculated by subtracting the faculty-rated score from the self-rated score on each subcompetency. RESULTS: A total of 46 and 42 residents were evaluated in year 2023 and 2024, respectively. The self-rated sum score was significantly higher than that rated by faculty [mean (standardized deviation): 120.39 (32.41) vs. 114.44 (23.71), P = 0.008 in paired t test] with an intraclass correlation coefficient of 0.55 [95% confidence interval (CI): 0.31 to 0.70]. The Bland-Altman plots revealed significant overestimation in patient care (bias 0.32, 95% CI: 0.05 to 0.60), practice-based learning and improvement (bias 0.45, 95% CI: 0.07 to 0.84), and professionalism (bias 0.37, 95% CI: 0.02 to 0.72). Ratings from residents with master's degrees (mean difference: -1.06, 95% CI: -1.80 to -0.32, P = 0.005) and doctorate degrees (mean difference: -1.14, 95% CI: -1.91 to -0.38, P = 0.003) were closer to the faculty-assessments than residents with bachelor's degrees. Compared with patient care, the differences between self- and faculty- rated scores were smaller in medical knowledge (mean difference: -0.18, 95% CI: -0.35 to -0.02, P = 0.031) and interpersonal and communication skills (mean difference: -0.41, 95% CI: -0.64 to -0.19, P < 0.001) in the generalized estimating equation logistic regression model. CONCLUSIONS: This study revealed that residents tended to overestimate themselves, emphasizing the need to improve the accuracy of Milestones self-assessment. The differences between self- and faculty-assessments were associated with residents' degrees and domains of competency.

[Nutritional components of 5 potatoes in Anqing City in 2021].

OBJECTIVE: To analyze the nutrient composition and nutritional value evaluation of 5 potatoes in Anqing City. METHODS: According to the requirements of the Technical Manual for Food Composition Monitoring Projects, 5 types of potato samples were collected from Anqing City, Anhui Province. National standard detection method were used to determine the nutritional components such as water, ash, protein, fat, dietary fiber, sugar, minerals, vitamins, and amino acids in the samples. The index of nutritional quality(INQ) method was used to evaluate proteins, vitamins, and minerals, and the amino acid scoring standard mode(FAO/WHO mode) was used to evaluate the nutritional value of amino acids. RESULTS: Among the 5 types of potatoes, purple potato had the highest protein(2.3 g/100 g) and dietary fiber content(3.6 g/100 g). Sweet potato(red) had the highest carotene content(4003 µg/100 g), sweet potato(white) had the highest content of vitamin C(15.4 mg/100 g). Sugar in potatoes mainly existed in three forms: fructose, glucose, and sucrose; Purple potatoes had the highest levels of calcium(47 mg/100 g) and phosphorus(74 mg/100 g), respectively. Potatoes(white) had the highest content of potassium(401 mg/100 g), while sweet potatoes(red) had the highest content of magnesium(31 mg/100 g). Sodium(104.0 mg/100 g), iron(0.9 mg/100 g), copper(0.17 mg/100 g), and manganese(0.40 mg/100 g) had the highest content in sweet potatoes(white). The Na/K ratio range of the 5 potato varieties was 0.003-0.456, and the INQ of phosphorus, potassium, magnesium, copper, and manganese were greater than 1. The detection result of 5 potatoes all contain 18 amino acids, and aspartic acid was the highest. The amino acid score(AAS) was 0.29-1.35, and the ratio coefficient(RC) was 0.47-1.69. CONCLUSION: The 5 types of potatoes are rich in dietary fiber, vitamin C and minerals, and belong to the high potassium and low sodium type of food. Potatoes can meet the daily needs of the human body for phosphorus, potassium, magnesium copper, and manganese elements. Lysine is rich in content and can be used as a nutritional supplement for grains. The AAS score and RC are close to 1, and the AAS evaluation mode is closer to the human amino acid composition mode, which can meet the daily needs of the human body for this essential amino acid.

Association between Storage Time of Transfused Red Blood Cells and Infection after Clean-contaminated Surgery: A Retrospective Cohort Study.

OBJECTIVE: The aim of this study was to investigate the association between storage time of transfused red blood cells and risks of infections after clean-contaminated surgery. SUMMARY BACKGROUND DATA: Storage lesions of red blood cells can aggravate transfusion-related immunomodulation. Very few randomized controlled trials have investigated the impacts of storage time on postoperative outcomes in non-cardiac patients. METHODS: We included adult patients who had undergone clean-contaminated surgery from 2014 to 2018 and received allogeneic red blood cell transfusion. In transfusion episode-level analysis, the exposure was the storage time of each transfusion episode. In patient-level analysis, the exposures were the mean, weighted mean, maximum storage time, and Scalar Age of Blood Index of red blood cells transfused into each patient. The primary outcome was infections that developed after transfusions within postoperative Day 30. RESULTS: The 4046 included patients received 11604 transfusion episodes. Of these, 1025 (25.3%) patients developed postoperative infections. An increased storage time of transfused red blood cells was not associated with increased odds of postoperative infections in either transfusion episode-level analysis [odds ratio (OR) 1.03 per five days, 95% confidence interval (CI) 0.95 to 1.11] or patient-level analysis (mean: OR 1.02, 95% CI 0.95 to 1.10; weighted mean: OR 1.02, 95% CI 0.95 to 1.10; maximum: OR 1.06, 95% CI 0.98 to 1.14; Scalar Age of Blood Index: OR 0.99, 95% CI 0.96 to 1.03), after adjusting 17 confounders. CONCLUSIONS: Prolonged storage time of transfused red blood cells was not associated with increased risks of infections after clean-contaminated surgery.

Temporal trends and geographic variations in perioperative red blood cell transfusion in major surgical procedures from 2013 to 2018 in China.

BACKGROUND AND OBJECTIVES: Transfusion-related guidelines promote restrictive blood transfusion. However, whether these guidelines have been successfully translated into clinical practice in China is unknown. This study aimed to provide updated information about the temporal trends in the prevalence of perioperative red blood cell (RBC) transfusion in China. MATERIALS AND METHODS: We analysed data from the Hospital Quality Monitoring System database (2013-2018) to investigate the prevalence of perioperative RBC transfusion in patients undergoing craniotomy for cerebral aneurysms or arteriovenous malformations, sternotomy for mitral valve replacement, open thoracotomy lobectomy, open gastrectomy and hip arthroplasty. Mixed-effects logistic regression models quantified the likelihood of RBC transfusions. RESULTS: The study included 438,183 patients, with 44,697 (10.20%) receiving perioperative RBC transfusions. Introducing transfusion-related guidelines in China markedly decreased the prevalence of RBC transfusion among patients who underwent major surgical procedures in the following years. The prevalence of RBC transfusion for hip arthroplasty was 17.34% in 2013 and 7.03% in 2018. After adjusting for patient risk factors, the odds ratio of RBC transfusion for hip arthroplasty was significantly lower in 2018 (0.74, 95% confidence intervals [CI] 0.53-1.02) than in 2013 (1.84, 95% CI 1.37-2.48). CONCLUSION: The prevalence of perioperative RBC transfusion decreased from 2013 to 2018 in China, supporting the potential beneficial effects of transfusion-related guidelines. Considering the geographic variations in RBC transfusion, reducing heterogeneity may impact public health by improving surgical outcomes.

Occupational Factors Associated With Time to Breastfeeding Discontinuation After Return to Work Among Female Anesthesiologists in China: A Nationwide Survey.

BACKGROUND: Breast milk is of great benefit to both infants and mothers. Due to occupational barriers, female physicians are at high risk of unintentionally discontinuing breastfeeding. However, evidence among anesthesiologists was limited. The purpose of this study was to investigate occupational factors associated with time to breastfeeding discontinuation among female anesthesiologists following maternity leave in China. METHODS: We conducted a nationwide survey of female anesthesiologists who had given birth since January 1, 2015. A 60-item anonymous questionnaire was developed to collect information regarding breastfeeding practices and related factors. The questionnaire was revised based on the recommendations of 15 experts and feedback from the pilot survey. The survey was distributed by the Chinese Society of Anesthesiology. RESULTS: The completion rate was 57.9%. In total, 1364 responders were analyzed from all 31 provinces of Mainland China. In total, 1311 (96.1%) responders reported a reduction in breast milk supply on returning to work. Among the 1161 responders who discontinued breastfeeding, 836 (72.0%) did not achieve desired goals due to occupational factors. The median [interquartile range] of maternity leave length and breastfeeding duration were 5 [4-6] months and 10 [7-12] months, respectively. The following occupational factors were associated with longer time to breastfeeding discontinuation after adjusting for confounding effects of personal factors: length of maternity leave (hazard ratio [HR] per month 0.44; 95% confidence interval [CI], 0.36-0.54; P < .001), pumping breast milk during work time (HR, 0.04; 95% CI, 0.02-0.08; P < .001), support from colleagues (HR, 0.92; 95% CI, 0.86-0.99; P = .032), and additional nonclinical activities (HR, 0.87; 95% CI, 0.77-0.98; P = .022). Trainees under supervision (HR, 1.20; 95% CI, 1.06-1.43; P = .005) and the need to remain in the operating room during cases (HR, 2.59; 95% CI, 1.09-6.12; P = .031) were associated with shorter time to breastfeeding discontinuation. Approximately 899 (65.9%) responders pumped breast milk during work time. Among them, reduction in pumping frequency (HR, 1.17; 95% CI, 1.00-1.36; P = .049) and difficulty in finding opportunities for pumping (HR, 2.34; 95% CI, 1.36-4.03; P = .002) were associated with shorter time to breastfeeding discontinuation. CONCLUSIONS: We identified modifiable occupational factors associated with time to breastfeeding discontinuation. These findings underscored the necessity of facilitating breastfeeding in the workplace, including encouraging longer maternity leave and breastfeeding breaks, considering the feasibility of pumping in daily case assignments, establishing supportive culture, providing lactation rooms, and offering nonclinical activities.

Generating real-world evidence compatible with evidence from randomized controlled trials: a novel observational study design applicable to surgical transfusion research.

BACKGROUND: Numerous observational studies have revealed an increased risk of death and complications with transfusion, but this observation has not been confirmed in randomized controlled trials (RCTs). The "transfusion kills patients" paradox persists in real-world observational studies despite application of analytic methods such as propensity-score matching. We propose a new design to address this long-term existing issue, which if left unresolved, will be deleterious to the healthy generation of evidence that supports optimized transfusion practice. METHODS: In the new design, we stress three aspects for reconciling observational studies and RCTs on transfusion safety: (1) re-definition of the study population according to a stable hemoglobin range (gray zone of transfusion decision; 7.5-9.5 g/dL in this study); (2) selection of comparison groups according to a trigger value (last hemoglobin measurement before transfusion; nadir during hospital stay for control); (3) dealing with patient heterogeneity according to standardized mean difference (SMD) values. We applied the new design to hospitalized older patients (aged ≥60 years) undergoing general surgery at four academic/teaching hospitals. Four datasets were analyzed: a base population before (Base Match-) and after (Base Match+) propensity-score matching to simulate previous observational studies; a study population before (Study Match-) and after (Study Match+) propensity-score matching to demonstrate effects of our design. RESULTS: Of 6141 older patients, 662 (10.78%) were transfused and showed high heterogeneity compared with those not receiving transfusion, particularly regarding preoperative hemoglobin (mean: 11.0 vs. 13.5 g/dL) and intraoperative bleeding (≥500 mL: 37.9% vs. 2.1%). Patient heterogeneity was reduced with the new design; SMD of the two variables was reduced from approximately 100% (Base Match-) to 0% (Study Match+). Transfusion was related to a higher risk of death and complications in Base Match- (odds ratio [OR], 95% confidence interval [CI]: 2.68, 1.86-3.86) and Base Match+ (2.24, 1.43-3.49), but not in Study Match- (0.77, 0.32-1.86) or Study Match+ (0.66, 0.23-1.89). CONCLUSIONS: We show how choice of study population and analysis could affect real-world study findings. Our results following the new design are in accordance with relevant RCTs, highlighting its value in accelerating the pace of transfusion evidence generation and generalization.

Risk factors of postoperative pulmonary complications after primary posterior fusion and hemivertebra resection in congenital scoliosis patients younger than 10 years old: a retrospective study.

BACKGROUND: Postoperative pulmonary complications are common and associated with morbidity and mortality. Congenital scoliosis is a failure of vertebral formation and/or segmentation arising from abnormal vertebral development. Posterior fusion and osteotomy are necessary for these patients to prevent deterioration of spine deformity. The incidence of postoperative pulmonary complications in this specific group of patients, especially young children were unknown. METHODS: A retrospective study was conducted and electronic medical records of early-onset scoliosis patients who had primary posterior fusion and hemivertebra resection at our institution from January 2014 to September 2019 were reviewed. The demographic characteristics, the intraoperative and postoperative parameters were collected to identify the predictors of postoperative pulmonary complications. RESULTS: A total of 174 patients (57.5% boys) with a median age of 3 years old were included for analysis. Eighteen patients (10.3%) developed perioperative pulmonary complications and pneumonia (n=13) was the most common. History of recent upper respiratory infection was not related to postoperative pulmonary complications. Multifactorial regression analysis showed thoracoplasty was the only predictive risk factor of postoperative pulmonary complications. CONCLUSIONS: For congenital scoliosis patients younger than 10 years old, thoracoplasty determine the occurrence of postoperative pulmonary complications. Both surgeons and anesthesiologists should pay attention to patients undergoing thoracoplasty and preventive measures are necessary.

Obesity paradox among patients undergoing total knee arthroplasty: a retrospective cohort study.

BACKGROUND: Obesity has been recognized as the risk factor for postoperative complication for surgical patients. However, recent studies have showed protective effect of obesity in surgical and non-surgical patients. Our study is to examine the association of body mass index(BMI) with early postoperative complications in patients undergoing total knee arthroplasty. MATERIALS AND METHODS: All patients who had primary total knee arthroplasty between January 2014 and December 2019 were included. Medical records were retrospectively reviewed and BMI was categorized as underweight(BMI < 18.5), normal weight(18.5 < BMI < 24.9), overweight I(25 < BMI < 27.4), overweight II(27.5 < BMI < 29.9), obese I(30 < BMI < 34.9) and obese II(BMI ≥ 35). The association between BMI and occurrence of early postoperative complications was examined and logistic regression was used to calculate relationship between BMI and early postoperative complications. RESULTS: A total of 2969 patients were included in our analysis. The overall complication rate in patients undergoing total knee arthroplasty was 14.8%, with the highest complication being 22.2% in the underweight group, the second highest in the normal weight group(17.5%), the lowest in the overweight I(13.8%) and obese I(12.0%) group and then higher again in obese II group(16.7%). In multivariable analyses, overweight I (OR 0.737, 95% CI 0.559-0.972, P = 0.031) and obese I (OR 0.631, 95% CI 0.449-0.885, P = 0.008) were associated with lower risk of early postoperative complications after total knee arthroplasty. CONCLUSION: In this retrospective study, overweight and obese patients had a lower risk of early postoperative complications after total knee arthroplasty. Further studies are necessary to confirm and investigate the mechanism of obesity paradox in this surgical population. TRIAL REGISTRATION: This study had been registrated in www.chictr.org.cn on 25/10/2021 and the registration ID was ChiCTR2100052408.

Possible Risk Factors for Severe Complications Occurring after Primary Total Knee Arthroplasty.

Objective Total knee arthroplasty is one of the most common orthopedic surgeries. Readmission due to severe complications after total knee arthroplasty is a grave concern to surgeons. In this study, we evaluated the risk factors for severe complications after primary total knee arthroplasty. Methods We retrospectively collected clinical data of 2,974 patients who underwent primary total knee arthroplasty from July 2013 to June 2019 in our hospital. Postoperative complication ≥ grade Ⅲ was defined as severe complication according to Clavien-Dindo classification system. Binary logistic regression was used to identify the predictive risk factors for severe complications. Results The complication rate after primary total knee arthroplasty was 6.8% and severe complication rate was 2.5%. Male (OR = 2.178, 95%CI: 1.324-3.585, P= 0.002), individuals above 75 years old (OR = 1.936, 95%CI: 1.155-3.244, P= 0.012), arrhythmia (OR = 2.913, 95%CI: 1.350-6.285, P= 0.006) and cerebrovascular disease (OR = 2.804, 95%CI: 1.432-5.489, P= 0.003) were predictive risk factors for severe complications after primary total knee arthroplasty. Conclusion Advanced age, male, arrhythmia, and cerebrovascular disease might be patients-related risk factors for postoperative severe complications after primary total knee arthroplasty. Special attention should be paid to patients with risk factors.

[Association of Perioperative Allogeneic Red Blood Cell Transfusion with Postoperative Infections].

Allogeneic red blood cell transfusion can induce transfusion-related immunomodulation while correcting anemia and improving oxygenation,and thus may be associated with the increased risk of postoperative infections.However,the available studies have conflicting conclusions.Preclinical studies demonstrate transfusion-related immunomodulation is associated with transfusion amounts.Stored red blood cells can cause more significant immunosuppression than fresh blood products,while leukoreduction alleviates the negative effect on immune system.However,clinical studies do not reach agreements on these issues.Recently,accumulating multi-center,large-sample-size,real-world studies have reported significant associations of all ogeneic red blood cell transfusion in cardiac,orthopedic,hepatic,pancreatic,gastrointestinal,and vesical surgeries with postoperative infections.Considering the limitations of previous studies,future research should focus on multiple operations,prolong the time interval between transfusion and surgery,include different infections into outcomes,and define the postoperative infections accurately in the premise of adequate samples.High-quality clinical evidence could help to optimize the utilization of blood products and improve the postoperative outcomes.

Association between perioperative allogeneic red blood cell transfusion and infection after clean-contaminated surgery: a retrospective cohort study.

BACKGROUND: Allogeneic red blood cell (RBC) transfusion can induce immunosuppression, which can then increase the susceptibility to postoperative infection. However, studies in different types of surgery show conflicting results regarding this effect. METHODS: In this retrospective cohort study conducted in a tertiary referral centre, we included adult patients undergoing clean-contaminated surgery from 2014 to 2018. Patients who received allogeneic RBC transfusion from preoperative Day 30 to postoperative Day 30 were included into the transfusion group. The control group was matched for the type of surgery in a 1:1 ratio. The primary outcome was infection within 30 days after surgery, which was defined by healthcare-associated infection, and identified mainly based on antibiotic regimens, microbiology tests, and medical notes. RESULTS: Among the 8098 included patients, 1525 (18.8%) developed 1904 episodes of postoperative infection. Perioperative RBC transfusion was associated with an increased risk of postoperative infection after controlling for 27 confounders by multivariable regression analysis (odds ratio [OR]: 1.60; 95% confidence interval [CI]: 1.39-1.84; P<0.001) and propensity score weighing (OR: 1.64; 95% CI: 1.45-1.85; P<0.001) and matching (OR: 1.70; 95% CI: 1.43-2.01; P<0.001), and a dose-response relationship was observed. The transfusion group also showed higher risks of surgical site infection, pneumonia, bloodstream infection, multiple infections, intensive care admission, unplanned reoperation, prolonged postoperative length of hospital stay, and all-cause death. CONCLUSIONS: Perioperative allogeneic RBC transfusion is associated with an increased risk of infection after clean-contaminated surgery in a dose-response manner. Close monitoring of infections and enhanced prophylactic strategies should be considered after transfusion.

An animal model of transfusion-related acute lung injury and the role of soluble CD40 ligand.

BACKGROUND AND OBJECTIVES: Transfusion-related acute lung injury (TRALI) is a life-threatening complication of transfusion and is one of leading causes of transfusion-associated fatalities. However, the pathogenesis of TRALI is still unclear. Soluble CD40 ligand (sCD40L) is a proinflammatory cytokine that accumulates during blood component storage and is involved in transfusion reactions. The objective of this study was to establish a clinically relevant TRALI animal model and to evaluate the role of sCD40L in TRALI. MATERIALS AND METHODS: Rats' red-blood-cell (RBC) suspensions were prepared, and the quality of RBC was evaluated. A trauma-haemorrhage-transfusion strategy was applied to build the animal model. Lung oedema was evaluated by histopathology examination, total bronchoalveolar lavage fluid (BALF) protein concentration, Evans blue dye (EBD) leakage and inflammatory cytokines. The sCD40L concentrations were measured. RESULTS: Storage lesions of RBCs gradually increased over time. Obvious histological evidence of lung injury of rats transfused with a 35-day RBC was observed. The total BALF protein concentration, EBD leakage, inflammatory cytokines concentration were increased significantly in the Day 35 group. The sCD40L concentration increased significantly in the storage RBC suspension over time but was slightly elevated in rat plasma. CONCLUSIONS: These findings indicated successful establishment of a TRALI animal model with trauma-haemorrhage-transfusion, in which sCD40L may play a minor role in the development of TRALI.

[Nutritional analysis of eight kinds of prefabricated beef steaks].

OBJECTIVE: A investigate on the nutritional quality of the prefabricated beef steak in the market was conducted, aiming to provide scientific basis for consumers in the consumption of prefabricated beef steaks. METHODS: The basic nutriments, amino acids, fatty acids, vitamins and mineral elements of 8 kinds of prefabricated beef steaks were analyzed and evaluated. RESULTS: It was showed that the contents of crude ash(1. 3-2. 4 g/100 g edible) and crude fat(1. 3-10. 0 g/100 g edible) in the 8 kinds of prefabricated beef steaks were higher than those of raw beef, while the contents of protein(11. 4-17. 2 g/100 g edible) was lower than those of raw beef. All the 8 kinds of prefabricated beef steaks had 18 kinds of amino acids and the content of histidine in children's steak(0. 57 g/100 g edible) was the highest. With the exception of snowflake steak and bulk steak, the first limiting amino acid of other 6 kinds of prefabricated beef steaks was valine. The essential amino acid composition of the 8 kinds of prefabricated steaks was close to that of FAO/WHO standard protein. This meant they were all high quality protein sources. The proportion of saturated fatty acids(48. 0%-62. 0%) was the highest, followed by monounsaturated fatty acids(32. 2%-46. 6%) and polyunsaturated fatty acids(0. 7%-7. 6%). All the 8 kinds of prepared beef steak didn't meet the S∶M∶P standard recommended by American Heart Association. There were differences in the content of vitamins among 8 kinds of prefabricated beef steaks. In terms of mineral elements, the content of Na(344-689 mg/100 g edible), Ca(6-15 mg/100 g edible), Fe(1. 0-1. 9 mg/100 g edible), Cu(0. 029-0. 050 mg/100 g edible), Mn(0. 056-0. 183 mg/100 g edible) in prefabricated steak was higher than that in raw beef. CONCLUSION: There were interspecific differences in the nutritional element content and quality among different kinds of prefabricated steaks. Compared with the raw beef, the fat content was higher and protein content was lower, the composition of fatty acids was less reasonable than fish and pork.

Scalable Total Synthesis of (-)-Vinigrol.

Vinigrol is a structurally and stereochemically complex natural product that displays various potent pharmacological activities, including the capability to modulate TNF-α. A new and efficient synthetic route toward this natural product has been developed to complete the asymmetric synthesis of (-)-vinigrol and provide over 600 mg of material, manifesting the power of macrocyclic stereocontrol and transannular Diels-Alder reaction.

Preoperative moderate thrombocytopenia is not associated with increased blood loss for low-risk cesarean section: a retrospective cohort study.

BACKGROUND: The occurrence of thrombocytopenia is as high as 7-12% in pregnancy, yet minimum platelet count safe for cesarean section remains unknown. METHODS: In this retrospective noninferior cohort study, we consecutively included patients undergoing cesarean section for a period of 6 years in a tertiary hospital and excluded patients at very high risk for excessive hemorrhage. The included patients with preoperative platelet count of 50-100 × 109/L were defined as the thrombocytopenic group. The control group were eligible patients with preoperative platelet count>150 × 109/L, matched to the thrombocytopenic group by age and operation timing in a 1:2 ratio. Mixed effect model was used to analyze the effect of thrombocytopenia based on a noninferiority assumption. The predefined noninferiority delta of bleeding was 50 mL. RESULTS: There was no significant difference of the calculated blood loss between the thrombocytopenic and the control group (mean difference = 8.94, 95% CI - 28.34 mL to 46.09 mL). No statistical difference was observed in the requirement for blood transfusion, visually estimated blood loss, or the incidence of adverse events between groups. Although there were more patients admitted to intensive care unit (odds ratio = 12, 95% CI 2.69-53.62, p = 0.001) in the thrombocytopenic group, most of them required critical care for reasons other than hemorrhage. The thrombocytopenic group had longer length of hospital stay (mean difference = 0.40 days, 95% CI 0.09-0.71, p = 0.011), but the difference was considered as clinically insignificant. CONCLUSIONS: Preoperative moderate thrombocytopenia is not associated with increased blood loss, blood transfusion, or occurrence of adverse events in patients undergoing cesarean section in absence of additional bleeding risk.

Continuous noninvasive hemoglobin monitoring estimates timing for detecting anemia better than clinicians: a randomized controlled trial.

BACKGROUND: Hemoglobin measurement is important for transfusion decision-making. Pulse CO-Oximetry provides real-time continuous hemoglobin (SpHb) monitoring. The triage role of SpHb trends based on hemoglobin measurements was investigated. METHODS: In this diagnostic randomized controlled trial, 69 patients undergoing spine or cytoreductive surgery were randomly enrolled into SpHb-monitoring and standard-care groups. Diagnostic blood samples were drawn for CO-oximetry Hb (CoOxHb) when the SpHb decreased by 1 g/dl or at the clinician's discretion in the standard-care group. The positive predictive value (PPV) was defined as the ability to detect a decrease in CoOxHb > 1 g/dl or a CoOxHb < 10 g/dl; the PPVs were compared using Fisher's exact test. The SpHb and trend accuracies were calculated. The transfusion units and postoperative hemoglobin levels were compared. RESULTS: The PPV of a decrease in CoOxHb > 1 g/dl was 93.3% in the SpHb group vs 54.5% without SpHb monitoring (p = 0.002). The PPV of CoOxHb < 10 g/dl was 86.7% vs. 50.0% for these groups (p = 0.015). The CoOxHb was never < 7 g/dl with SpHb monitoring. Sixty SpHb-CoOxHb data pairs and 28 delta pairs (ΔSpHb-ΔCoOxHb) were collected. The bias, precision and limits of agreement were - 0.29, 1.03 and - 2.30 to 1.72 g/dl, respectively. When ΔSpHb and ΔCoOxHb were > 1 g/dl, the concordance rate for changes in hemoglobin reached 100%. The delta pairs revealed a positive correlation [ΔSpHb = 0.49 * ΔCoOxHb - 0.13; r = 0.69, 95% confidence interval (0.53, 0.82)]. No significant differences were found in the transfusion volume or postoperative anemia state. CONCLUSIONS: The SpHb trend tracked changes in hemoglobin satisfactorily during surgery and more accurately estimated the appropriate timing for invasive hemoglobin measurements than the clinicians. TRIAL REGISTRATION: ChiCTR1800016290 (Prospective registered). Initial registration date was 24/05/2018.

Predictors for blood loss in pediatric patients younger than 10 years old undergoing primary posterior hemivertebra resection: a retrospective study.

BACKGROUND: Blood loss during hemivertebra resection may be substantial. Few studies have examined the risk factors of blood loss undergoing hemivertebra resection, especially those in patients under 10 years old. METHODS: Patients under 10 years old diagnosed with congenital scoliosis and hemivertebra were retrospectively included from January 2014 to October 2017. They all had primary posterior hemivertebra resection at Peking Union Medical College Hospital. Perioperative information was collected and multivariable linear logistic regression was performed to determine the independent risk factors of blood loss. RESULTS: One hundred three patients were included. The mean total blood loss was 346 + 178 ml. The percentage of total blood loss to the EBV was 27.0 + 13.3%. Multivariable linear logistic regression indicated that preoperative total Cobb angle (P = 0.046) and the number of fused levels (P < 0.001) were independent risk factors of total blood loss. Preoperative platelet count and preoperative coagulation function were not associated with blood loss in patients undergoing hemivertebra resection. CONCLUSIONS: Preoperative total Cobb angle and the number of fused levels determined the blood loss for patients undergoing hemivertebra resection.

A Survey of Surgical Patient's Perception about Anesthesiologist in a Large Scale Comprehensive Hospital in China.

Objectives This study aim to evaluate patient's perception about anesthesiologists' job roles and investigate their expectations for anesthesia care.Methods We designed a self-administered questionnaire for this cross-sectional survey study and delivered questionnaire forms to adult in-patients who were scheduled for elective surgery before pre-operative anesthetic visit the day before surgery. We collected information of respondents' demographic data, education background, health literacy and previous experience of anesthesia, perception of anesthesiologist's job, the expectation on anesthesia care. Descriptive analyses, χ [2] test and multiple linear regression analysis were used for data analysis. Results Of 550 participants, 521（94.7%）completed the questionnaire. In these respondents, 335 (64.3%) considered anesthesiology as an independent medical discipline, 225 (43.2%) believed that anesthesiology department was an independent clinical department, and 243 (46.6%) recognized anesthesiologists as qualified doctors. Only 21.5% of them knew that anesthesiologists also work in the intensive care unit and 26.9% of them knew that anesthesiologists also work in pain clinic as well. Younger patients (ß=-0.044, P<0.001), those with higher education (ß=1.200, P<0.001), or with better health literacy (ß=0.781, P=0.005) had significant more knowledge about the job roles of anesthesiologists. Most patients demanded pre-anesthetic visit (80.5%), expected availability of preoperative anesthetic clinic (74.1%), wished to receive more information about anesthesia (91.3%) and anesthesiologist (77.4%).Conclusions Patients' perception about anesthesiologists might be limited. Efforts should be made on education about anesthesia, especially for elderly patients and those under-educated patients. Preoperative anesthetic clinic is expected by most in-patients.

Prediction of Hidden Blood Loss During Posterior Spinal Surgery.

Objective Identification of the risk factors for extraordinary hidden blood loss (HBL) could clarify the underlying causes and provide more appropriate management. This study aims to identify the predictors of HBL in spinal surgery.Methods Medical records were retrospectively retrieved to collect the data of patients who undergoing posterior thoracic and lumbar fusion surgery or scoliosis surgery. Demographic information, perioperative visible blood loss volume, as well as laboratory results were recorded. The patients receiving fusion surgery or scoliosis surgery were further divided into the HBL positive subgroup and the HBL negative subgroup. Differences in the variables between the groups were then analyzed. Binary logistic regression analysis was performed to determine independent risk factors associated with HBL.Results For patients undergoing posterior spinal surgery, the independent risk factors associated with HBL were autologous transfusion (for fusion surgery P=0.011, OR: 2.627, 95%CI: 1.574-2.782; for scoliosis surgery P<0.001, OR: 2.268, 95%CI: 2.143-2.504) and allogeneic transfusion (for fusion surgeryP<0.001, OR: 6.487, 95%CI: 2.349-17.915; for scoliosis surgery P<0.001, OR: 3.636, 95%CI: 2.389-5.231).Conclusions Intraoperative blood transfusion might be an early-warning indicator for perioperative HBL.