Multidisciplinary Treatment for Severe Secondary Raynaud's Phenomenon: A Case Report.

Raynaud's phenomenon is a symptom complex manifested as intermittent fingertip ischemia caused by cold or other sympathetic drivers. Secondary Raynaud's phenomenon is often more severe and could even lead to finger ulceration, making it particularly complicated to treat. We describe a case of severe Raynaud's phenomenon secondary to subclinical hypothyroidism lasting for more than 6 hours in a 65-year-old woman. The patient was also diagnosed with hypothyroidism, epilepsy, and secondary soft tissue infection of the right middle and ring fingers. After careful multidisciplinary consultation and discussion, the patient received vasodilation, anticoagulation, thyroxine supplementation, stellate ganglion block, hyperbaric oxygen therapy and debridement. The patient responded well to the medication, avoiding amputation or obviously dysfunction. Multidisciplinary team gathering the doctors from different departments proposes appropriate strategies for patients with severe Raynaud's phenomenon and could improve the prognosis and satisfaction of patient effectively.

Different effects of hydrogen-rich water intake and hydrogen gas inhalation on gut microbiome and plasma metabolites of rats in health status.

The potential for preventive and therapeutic applications of H2 have now been confirmed in various disease. However, the effects of H2 on health status have not been fully elucidated. Our previous study reported changes in the body weight and 13 serum biochemical parameters during the six-month hydrogen intervention. To obtain a more comprehensive understanding of the effects of long-term hydrogen consumption, the plasma metabolome and gut microbiota were investigated in this study. Compared with the control group, 14 and 10 differential metabolites (DMs) were identified in hydrogen-rich water (HRW) and hydrogen inhalation (HI) group, respectively. Pathway enrichment analysis showed that HRW intake mainly affected starch and sucrose metabolism, and DMs in HI group were mainly enriched in arginine biosynthesis. 16S rRNA gene sequencing showed that HRW intake induced significant changes in the structure of gut microbiota, while no marked bacterial community differences was observed in HI group. HRW intake mainly induced significant increase in the abundance of Lactobacillus, Ruminococcus, Clostridium XI, and decrease in Bacteroides. HI mainly induced decreased abundances of Blautia and Paraprevotella. The metabolic function was determined by metabolic cage analysis and showed that HI decreased the voluntary intake and excretions of rats, while HRW intake did not. The results of this study provide basic data for further research on hydrogen medicine. Determination of the effects of hydrogen intervention on microbiota profiles could also shed light on identification of mechanism underlying the biological effects of molecular hydrogen.

Multidisciplinary Treatment for Severe Secondary Raynaud's Phenomenon: A Case Report / 中国医学科学杂志(英文版)

Raynaud's phenomenon is a symptom complex manifested as intermittent fingertip ischemia caused by cold or other sympathetic drivers. Secondary Raynaud's phenomenon is often more severe and could even lead to finger ulceration, making it particularly complicated to treat. We describe a case of severe Raynaud's phenomenon secondary to subclinical hypothyroidism lasting for more than 6 hours in a 65-year-old woman. The patient was also diagnosed with hypothyroidism, epilepsy, and secondary soft tissue infection of the right middle and ring fingers. After careful multidisciplinary consultation and discussion, the patient received vasodilation, anticoagulation, thyroxine supplementation, stellate ganglion block, hyperbaric oxygen therapy and debridement. The patient responded well to the medication, avoiding amputation or obviously dysfunction. Multidisciplinary team gathering the doctors from different departments proposes appropriate strategies for patients with severe Raynaud's phenomenon and could improve the prognosis and satisfaction of patient effectively.

Plasma-Derived Extracellular Vesicles Circular RNAs Serve as Biomarkers for Breast Cancer Diagnosis.

Breast cancer is the second cause of cancer-associated death among women and seriously endangers women's health. Therefore, early identification of breast cancer would be beneficial to women's health. At present, circular RNA (circRNA) not only exists in the extracellular vesicles (EVs) in plasma, but also presents distinct patterns under different physiological and pathological conditions. Therefore, we assume that circRNA could be used for early diagnosis of breast cancer. Here, we developed classifiers for breast cancer diagnosis that relied on 259 samples, including 144 breast cancer patients and 115 controls. In the discovery stage, we compared the genome-wide long RNA profiles of EVs in patients with breast cancer (n=14) and benign breast (n=6). To further verify its potential in early diagnosis of breast cancer, we prospectively collected plasma samples from 259 individuals before treatment, including 144 breast cancer patients and 115 controls. Finally, we developed and verified the predictive classifies based on their circRNA expression profiles of plasma EVs by using multiple machine learning models. By comparing their circRNA profiles, we found 439 circRNAs with significantly different levels between cancer patients and controls. Considering the cost and practicability of the test, we selected 20 candidate circRNAs with elevated levels and detected their levels by quantitative real-time polymerase chain reaction. In the training cohort, we found that BCExoC, a nine-circRNA combined classifier with SVM model, achieved the largest AUC of 0.83 [95% CI 0.77-0.88]. In the validation cohort, the predictive efficacy of the classifier achieved 0.80 [0.71-0.89]. Our work reveals the application prospect of circRNAs in plasma EVs as non-invasive liquid biopsies in the diagnosis and management of breast cancer.

[Multimodal Analgesia of Enhanced Recovery after Surgery Management in Lobectomy by Video-assisted Thoracoscopic Surgery].

Video-assisted thoracoscopic surgery(VATS)has become the main method of lobectomy.Multimodal analgesia is one of the core contents of enhanced recovery after surgery(ERAS)management in VATS lobectomy,which aims to control perioperative pain,reduce stress response,and achieve rapid recovery after surgery.In recent years,multimodal analgesia has developed rapidly,emphasizing the comprehensive implementation of a variety of analgesic methods and the synergistic application of analgesics with different mechanisms.This article reviews the new progress in the implementation of multimodal analgesia in VATS lobectomy and addresses the current problems and challenges,aiming to help develop more effective and practical analgesic strategies of ERAS.

[Clinical Utility of Revised Cardiac Risk Index to Predict Perioperative Cardiac Events in Elderly Patients with Coronary Heart Disease Undergoing Non-cardiac Surgery].

Objective To explore the predictive ability of the revised cardiac risk index(RCRI)in elderly patients with coronary heart disease(CHD)undergoing non-cardiac surgery. Methods We performed a retrospective study including a total of 2100 patients,aged≥65 with a history of CHD who underwent non-cardiac surgery form January 2013 to September 2019.The preoperative,intraoperative and postoperative clinical data were extracted from an electronic database.The RCRI and reconstructed-RCRI(R-RCRI)score of each patient were calculated.The primary end point was defined as an occurrence of perioperative MACE.Multivariate logistic regression analysis was performed to evaluate the risk factors of perioperative MACE.The area under the receiver operating characteristic(ROC)curve was used to compare the predictive value of RCRI,R-RCRI,and the new risk scoring system of the study for perioperative MACE. Results The incidence of perioperative MACE in elderly patients with CHD was 5.4%.Six independent risk factors of perioperative MACE for this population were identified:age≥80 years;female;history of heart failure;insulin-depended diabetes mellitus;preoperative ST segment abnormality;American Society of Anesthesiologists grade≥Ⅲ,and the risk index was 2,2,2,2,2 and 3 respectively.The area under ROC curve of RCRI,R-RCRI and risk scoring system in this study were 0.586,0.552 and 0.741. Conclusion The correlation between RCRI score and perioperative MACE was poor in elderly patients with CHD undergoing non-cardiac surgery,and a better cardiac risk assessment method should be established for this population.

[Effects of Continuous Intravenous Intraoperative Lidocaine Infusion on Opioids Consumption and Postoperative Recovery in Patients Undergoing Video-assisted Thoracoscopic Lobectomy].

Objective To investigate whether continuous intravenous intraoperative lidocaine infusion can reduce the opioids dosage and improve postoperative recovery in patients undergoing video-assisted thoracoscopic(VATS) lobectomy. Methods Totally 60 patients undergoing VATS lobectomy were enrolled in this single-center randomized controlled study.The patients were equally randomized into lidocaine continuous pumping group(lidocaine group) and control group by computer-based random numbers.The patients had double-lumen catheter intubation,and total intravenous anesthesia was administrated intraoperatively.In the lidocaine group,patients continuously received intravenous pumping of lidocaine [2 mg/(kgdh) ] after a loading doses(1 mg/kg) until the end of the operation.We recorded the basic characteristics,preoperative examination,intraoperative medications,and postoperative recovery of both groups.Results The basic characteristics and preoperative examination findings were comparable between these two groups(all P>0.05).Compared with the control group,the intraoperative sufentanil consumption significantly decreased in the lidocaine group [(32.3±7.5) µg vs.(40.9±10.2) µg,P<0.001].Significantly more patients were given esmolol intraoperatively in the control group to lower heart rate(P=0.010).The incidence of postoperative nausea within 24 hours was significantly lower in the lidocaine group(P=0.045).There was no significant difference between the two groups in postoperative recovery(all P>0.05).Conclusion Intravenous continuous pumping of lidocaine during operation can reduce opioids consumption and lower the incidence of postoperative nausea without extra adverse or toxic reaction in patients undergoing VATS lobectomy.

Comparison of learning performance of 2 intubating laryngeal mask airways in novice: A randomized crossover manikin study.

BACKGROUND: Intubating laryngeal mask airways (LMAs) such as i-gel and Aura-i could serve as rescue devices in resuscitation and further ensure the airway by facilitating trachea intubation without ventilation interruption. But data regarding intubating LMAs in novice are limited and skill degeneration without regular training has not been evaluated. So we designed this prospective randomized crossover manikin study to compare the learning performance of 2 intubating LMAs (i-gel and Aura-i). METHODS: In total, 46 novice doctors participated in this study. After standardized training and finishing 3 consecutive successful intubations with both LMAs on manikin, each participant applied intubation with both LMAs in random order for initial evaluation. To evaluate skill retention, participants were reassessed 90 days later on the same manikin without retraining between times. Primary outcome was time to successful ventilation (TTV). RESULTS: The TTV for i-gel was significantly shorter than Aura-i (initial evaluation 11.8 ±â€Š2.9 seconds vs 22.4 ±â€Š5.2 seconds, 90-days reevaluation 14.9 ±â€Š3.6 seconds vs 28.9 ±â€Š10.0 seconds, initial evaluation, P = .001; second evaluation, P < .001); during re-evaluation, TTV taken for i-gel and Aura-i were both significantly longer (initial evaluation, P = .001; second evaluation, P < .001) and ease score of insertion both increased profoundly (i-gel P = .025; Aura-i P < .001). In both assessments, participants preferred i-gel as easier alternative (initial evaluation, P = .001; second evaluation, P < .001). There was no difference in successful intubation rate, first attempt success rate, bronchoscopy assessment, and insertion score for 2 LMAs. CONCLUSION: Compared with Aura-i, i-gel showed a faster and easier intubation by novice doctors in this manikin study; the skill retention of intubation performance after 3 months was acceptable for both intubating LMAs, but TTV prolonged significantly.

Application of Cardiopulmonary Exercise Testing in Enhanced Recovery after Surgery.

Enhanced recovery after surgery (ERAS) is a new perioperative concept that aims to reduce perioperative stress response and accelerate rehabilitation of patients through a variety of optimized management. With the wider application of this concept,the effective implementation of ERAS program has become a new challenge. Cardiopulmonary exercise testing (CPET) has shown promising value in the preoperative assessment,perioperative optimization,and postoperative rehabilitation of ERAS. This article reviews the application of CPET in ERAS,with an attempt to provide evidence for more detailed and comprehensive ERAS program.

Anesthesia Strategies and Perioperative Optimization for Patients with Ankylosing Spondylitis Undergoing Total Hip Replacement Surgery.

Objective To identify the characteristics of anesthesia and perioperative management for ankylosing spondylitis (AS) patients undergoing total hip arthroplasty (THA). Methods Totally 63 patients scheduled for single THA in PUMC Hospital from January 1st 2013 to June 1st 2015 were included in this retrospective analysis,among whom 21 patients were diagnosed of AS. The perioperative clinical data included:demographic data,American Society of Anesthesiologists (ASA) classification,medical history,airway assessment,preoperative laboratory examinations,electrocardiogram,pulmonary function tests,intubation information,operation time,intraoperative intake and output volume,postoperative hospital stay,and postoperative complications. Results Significantly fewer AS patients undergoing THA were evaluated as ASA classification I than non-AS patients (9.5% vs. 33.3%,P=0.041). AS patients had significantly higher level of preoperative high-sensitivity C-reactive protein [(17.0±14.8)mg/L vs.(4.3±7.1)mg/L,P<0.001],platelets [(275.0±71.3)×10(9)/L vs. (237.7±68.0)×10(9)/L,P=0.048] and neutrophils [(4.7±1.7)×10(9)/L vs. (3.9±1.4)×10(9)/L,P=0.044] and higher incidence of pulmonary function abnormality (42.9% vs.16.7%,P=0.024).More AS patients were induced with scoline (14.3% vs.0,P=0.012). More AS patients underwent THA with Mallampati classification 3 (28.6% vs.7.1%,P=0.022),reduced neck extension(47.6% vs.2.4%,P<0.001),Cormack-Lehane classification2(56.3% vs.15.4%,P=0.002)and 3 (18.8% vs.0,P=0.005),while much fewer AS patients had Cormack-Lehane classification1 (25.0% vs.84.6%,P<0.001).A variety of difficult airway tools were used in intubation (AS group:Macintosh laryngoscope:14%,Macintosh laryngoscope with stylet:38%,visualization laryngoscope:24%,visualization stylet:10% and fiber bronchoscope:14%;non-AS group:57%,24%,12%,5% and 2%,respectively). The use of intraoperative autologous blood transfusion (33.3% vs.11.9%,P=0.041) and postoperative 24 h drainage (61.9% vs.31.0%,P=0.019) were more common in AS group. However,no statistical difference existed in the success rate of first intubation,postoperative hemoglobin,postoperative hematocrit,and postoperative hospitalization(all P>0.05). Conclusions AS patients undergoing THA have elevated preoperative inflammatory markers,with high incidence of pulmonary function abnormality and difficult airway. In consideration of high risk of surgery and anesthesia,adequate airway evaluation and optimization of perioperative management are needed to ensure the patients' safety.

Comparison of McGrath Series 3 and Macintosh Laryngoscopes for Tracheal Intubation in Patients With Normal Airway by Inexperienced Anesthetists: A Randomized Study.

Difficult and failed intubations account for the major causes of morbidity and mortality in current anesthetic practice. Several devices including McGrath Series 3 videolaryngoscope are available which may facilitate tracheal intubation by improving view of the larynx compared with Macintosh blade laryngoscopy. But no studies demonstrate whether McGrath Series 3 performs better than Macintosh laryngoscope in normal airway intubations by inexperienced anesthetists so far. We therefore designed this randomized controlled study to compare McGrath with Macintosh in routine tracheal intubation performed by inexperienced anesthetists.In total, 180 adult patients with normal-appearing airways requiring orotracheal intubation for elective surgery were randomly allocated to be intubated by 9 inexperienced anesthetists with McGrath or Macintosh. The primary outcome was time to intubation. Ease of intubation was assessed by a 5-point ordinal scale. Intubation attempts/failures, best laryngoscopy view using the Cormack-Lehane grade, associated complications and hemodynamic changes during intubation were recorded.We found that there was no significant difference between McGrath and Macintosh in the median time to intubation (P = 0.46); the Cormack-Lehane views attained using McGrath were superior (P < 0.001); the difference of ease of intubation was statistically significant (P = 0.01). No serious trauma occurred in both groups. And there was statistically significant difference in the systolic blood pressure changes between 2 groups (P < 0.05).We demonstrated that in orotracheal intubation in patients with normal airway by inexperienced anesthetists, McGrath compared with the Macintosh allows superior glottis views, greater ease of intubation, less complications, and hemodynamic changes with noninferior intubation time. And it remained a potential selection for inexperienced anesthetists in uncomplicated intubation.

[Risk Factors of Perioperative Cardiac Events in Elderly Patients with Coronary Heart Disease Undergoing Non-cardiac Surgery].

OBJECTIVE: To identify the incidence and risk factors of perioperative major adverse cardiac events (MACE) in elderly patients with coronary heart disease (CHD) undergoing non-cardiac surgery. METHODS: We prospectively analyzed the clinical data of 360 CHD patients who aged 75 years or older undergoing elective intermediate-to high-risk surgery in five medical centers across China from January 2008 to January 2010. The clinical variables included the 12-lead ECG and Troponin I levels after surgery. The combined outcome was defined as all the perioperative MACE in hospital. The risk factors of MACE and their indexes were analyzed with univariate analysis and multivariable logistic regression in SPSS software,together with a risk scoring and stratification system established. RESULTS: Perioperative MACE occurred in 11.94% of elderly CHD patients undergoing non-cardiac surgery. Seven independent risk factors of perioperative MACE for this population were identified,which included angina within 6 months (P=0.001), hypertension(P=0.014), preoperative haematocrit (HCT) <40% (P=0.050), serum creatinine (Scr)>150 mmol/L (P=0.014), ejection fraction(EF) <50% (P=0.019), intraoperative hyoxemia (P=0.019), and operative time>150 min (P=0.001). The risk indexes of these factors were 4,3,3,6,4,5, and 4, respectively. The rate of perioperative MACE increased significantly as the level of risk stratification elevated. CONCLUSIONS: Elderly CHD patients undergoing non-cardiac surgery are at high risk of perioperative MACE. Angina within 6 months,hypertension, preoperative HCT<40%, Scr>150 mmol/L, EF<50%, intraoperative hyoxemia, and operative time>150 min can increase the risk of MACE. The risk scoring and stratification system based on the risk factor index can be a valuable parameter for assessing the perioperative cardiac risk of noncardiac surgery for elderly CHD patients.

[Anesthesia Update in Enhanced Recovery after Surgery].

Enhanced recovery after surgery (ERAS) is a series of clinical programs on base of evidence-based perioperative optimization management,focusing on clinical multidisciplinary cooperation,with an attempt to improve patient's outcomes, reduce complications, and shorten postoperative hospitalization. Anesthesia plays an important role in many aspects of ERAS, including patient education,preoperative evaluation and optimization, anesthesia choice and medication,fluid therapy, temperature monitoring, and postoperative analgesia. This review explores new understandings and points on clinical anesthesia in ERAS management.

Risk factors for perioperative major cardiac events in Chinese elderly patients with coronary heart disease undergoing noncardiac surgery.

BACKGROUND: Few studies have investigated perioperative major adverse cardiac events (MACEs) in elderly Chinese patients with coronary heart disease (CHD) undergoing noncardiac surgery. This study examined the incidence and risk factors for perioperative MACE in elderly patients who underwent noncardiac surgery, and established a risk stratification system. METHODS: This retrospective observational clinical study included 482 patients aged ≥60 years with CHD who underwent elective major noncardiac surgery at the Peking Union Medical College Hospital. The primary outcome was MACE within 30 days after surgery. Risk factors were evaluated using multivariate Logistic regression analysis. RESULTS: Perioperative MACE occurred in 61(12.66%) of the study patients. Five independent risk factors for perioperative MACE were identified: history of heart failure, preoperative arrhythmia, preoperative diastolic blood pressure ≤75 mmHg, American Society of Anesthesiologists grade 3 or higher, and intraoperative blood transfusion. The area under the receiver operating characteristic curve for the risk-index score was 0.710±0.037. Analysis of the risk stratification system showed that the incidence of perioperative MACE increased significantly with increasing levels of risk. CONCLUSIONS: Elderly Chinese patients with CHD who undergo noncardiac surgery have a high risk of perioperative MACE. Five independent risk factors for perioperative MACE were identified. Our risk stratification system may be useful for assessing perioperative cardiac risk in elderly patients undergoing noncardiac surgery.

Transcriptomic analysis of phenotypic changes in birch (Betula platyphylla) autotetraploids.

Plant breeders have focused much attention on polyploid trees because of their importance to forestry. To evaluate the impact of intraspecies genome duplication on the transcriptome, a series of Betula platyphylla autotetraploids and diploids were generated from four full-sib families. The phenotypes and transcriptomes of these autotetraploid individuals were compared with those of diploid trees. Autotetraploids were generally superior in breast-height diameter, volume, leaf, fruit and stoma and were generally inferior in height compared to diploids. Transcriptome data revealed numerous changes in gene expression attributable to autotetraploidization, which resulted in the upregulation of 7052 unigenes and the downregulation of 3658 unigenes. Pathway analysis revealed that the biosynthesis and signal transduction of indoleacetate (IAA) and ethylene were altered after genome duplication, which may have contributed to phenotypic changes. These results shed light on variations in birch autotetraploidization and help identify important genes for the genetic engineering of birch trees.