Comparison of the effects of deep and moderate neuromuscular block on respiratory system compliance and surgical space conditions during robot-assisted laparoscopic radical prostatectomy: a randomized clinical study.

OBJECTIVE: Robot-assisted radical prostatectomy (RARP) requires pneumoperitoneum (Pnp) and a steep head-down position that may disturb respiratory system compliance (Crs) during surgery. Our aim was to compare the effects of different degrees of neuromuscular block (NMB) on Crs with the same Pnp pressure during RARP. METHODS: One hundred patients who underwent RARP were enrolled and randomly allocated to a deep or moderate NMB group with 50 patients in each group. Rocuronium was administered to both groups: in the moderate NMB group to maintain 1-2 responses to train-of-four (TOF) stimulation; and in the deep NMB group to maintain no response to TOF stimulation and 1-2 responses in the post-tetanic count. Pnp pressure in both groups was 10 mmHg (1 mmHg=133.3 Pa). Peak inspiratory pressure (Ppeak), mean pressure (Pmean), Crs, and airway resistance (Raw) were recorded after anesthesia induction and at 0, 30, 60, and 90 min of Pnp and post-Pnp. Surgical space conditions were evaluated after the procedure on a 4-point scale. RESULTS: Immediately after the Pnp, Ppeak, Pmean, and Raw significantly increased, while Crs decreased and persisted during Pnp in both groups. The results did not significantly differ between the two groups at any of the time points. There was no difference in surgical space conditions between groups. Body movements occurred in 14 cases in the moderate NMB group and in one case in the deep NMB group, and all occurred during obturator lymphadenectomy. A significant difference between the two groups was observed. CONCLUSIONS: Under the same Pnp pressure in RARP, deep and moderate NMBs resulted in similar changes in Crs, and in other respiratory mechanics and surgical space conditions. However, deep NMB significantly reduced body movements during surgery.

Intraoperative management and early post-operative outcomes of patients with coronary artery disease who underwent orthotopic liver transplantation.

BACKGROUND: Coronary artery disease (CAD) is frequently observed in aging end-stage liver disease (ESLD) patients who require orthotopic liver transplantation (OLT). This situation is challenging for both the patients and the medical staff. METHODS: We retrospectively studied the case records of 26 ESLD patients with CAD who underwent OLT with total clamping of the inferior vena cava between 2014 and 2018. We analyzed the details of the pre-operative evaluation, intraoperative anesthetic management and post-operative prognosis of these patients. RESULTS: All patients tolerated the anhepatic stage well. Post-reperfusion syndrome (PRS) was observed in 13 patients (50%) and 2 of them were severe but corrected well. ST-segment depression was frequently observed during the anhepatic stage and reperfusion stage. No mortality due to cardiac-related events occurred among the patients during hospitalization. OLT with the modified piggyback technique could successfully be performed in ESLD patients with mild and moderate CAD. CONCLUSIONS: A thorough evaluation and optimization of recipients, strict monitoring and optimized management of circulation, knowledge of the complicated changes during OLT procedures, and strategies to ameliorate post-reperfusion syndrome favorite the outcomes.

Anaesthetic management in endovascular total aortic arch repair via needle-based in situ fenestration: a case series of 14 patients.

OBJECTIVE: Endovascular total aortic arch repair (ETAAR) via needle-based in situ fenestration (ISF) is a major challenge for anaesthesiologists because of haemodynamic instability and the risk of cerebral hypoxia. We herein summarise our experience with anaesthetic management of patients who underwent this procedure. METHODS: Fourteen patients who underwent ETAAR via ISF for arch pathologies involving the major supra-arch branches were included. Regional cerebral oxygen saturation was measured to monitor cerebral perfusion. Partial extracorporeal circulation (EC) support from the right common femoral vein to the right axillary artery was introduced to provide cerebral perfusion. RESULTS: During ISF, vessel rupture occurred in three patients and ventricular fibrillation occurred in one patient. The regional cerebral oxygen saturation significantly decreased during the potential risk period for cerebral ischaemia. Establishment of EC effectively prevented cerebral ischaemia. CONCLUSIONS: During ETAAR, the risks of haemodynamic instability caused by the procedure and vessel rupture during ISF need to be overcome. Partial EC ensured good cerebral protection in our study, and regional cerebral oxygen saturation monitoring may help to reduce the rate of desaturation.

Difficulties in tracheal extubation due to phrenic nerve injury during massive mediastinal tumor resection: A case report.

RATIONALE: Massive mediastinal tumors present a major challenge for surgery and anesthesia management due to possible perioperative circulation and respiratory dysfunction. PATIENT CONCERNS: A 36-year-old female underwent difficulty with tracheal extubation and required mechanical ventilation for 3 months after resection of a massive mediastinal tumor. DIAGNOSES: Postoperative B-ultrasound examination of diaphragmatic motor weakness and electrophysiological examination indicated respiratory failure due to phrenic nerve injury. INTERVENTIONS: The patient failed tracheal extubation several times after the operation and finally a tracheotomy was performed. Mechanical ventilation, anti-infective treatment, and systemic supportive treatment were provided. OUTCOMES: The patient recovered well after tracheotomy and approximately 3 months of ventilation support. LESSONS: Weaning difficulty caused by phrenic nerve injury seriously affected patient postoperative rehabilitation. To reduce the occurrence of similar problems, intraoperative phrenic nerve electrophysiological monitoring should be conducted.

Relationship between genetic variation in the α2A-adrenergic receptor and the cardiovascular effects of dexmedetomidine in the Chinese Han population.

There are differences in individual cardiovascular responses to the administration of dexmedetomidine, a highly selective α2A-adrenergic receptor (ADRA2A) agonist. The aim of this study was to investigate ADRA2A gene polymorphisms in the Chinese Han population and their association with the cardiovascular response to intravenous dexmedetomidine infusion. Sixty elective surgery patients of Chinese Han nationality were administered 1 µg/kg dexmedetomidine intravenously over 10 min as a premedication. ADRA2A C-1291G and A1780G polymorphism status was determined in these patients, and their relationships to changes in blood pressure and heart rate after dexmedetomidine administration were analyzed. There were neither significant differences in systolic or diastolic blood pressure changes in individuals with different A1780G and C-1291G genotypes after dexmedetomidine administration, nor in heart rates among the different A1780G genotypes. However, there were significant differences in changes in heart rates in patients with different C-1291G genotypes. There were no significant differences in the sedative effects of dexmedetomidine among different A1780G and C-1291G genotypes. Logistic regression revealed that the C-1291G polymorphism was associated with differential decreases in heart rate after intravenous infusion of dexmedetomidine. These findings indicate that the ADRA2A C-1291G polymorphism can affect heart rate changes in patients after intravenous infusion of dexmedetomidine.

Diffuse alveolar hemorrhage in a patient with ANCA-associated vasculitis after thyroidectomy: A case report.

RATIONALE: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is an autoimmune disease that mainly affects the lungs and kidneys. Limited reports of perioperative management of such patients were primarily concerned with airway stenosis. Here, we report a patient with AAV who developed diffuse alveolar hemorrhage (DAH) early after radical thyroidectomy. PATIENT CONCERNS: A 57-year-old female developed wheezing and dyspnea approximately 30 minutes after radical thyroidectomy, with hemoptysis occurring the following day. The patient had a history of AAV and DAH and was maintained with prednisone. DIAGNOSIS: A diagnosis of DAH was made on the basis of the history of AAV, dyspnea, hemoptysis, and chest computed tomography scan results that showed diffuse high-density shadows in the lungs. INTERVENTIONS: The patient was administered high-dose glucocorticoids and cyclophosphamide immunosuppressive therapy. Non-invasive ventilation was needed for 2 days postoperatively due to dysfunction of oxygenation. OUTCOMES: After high-dose glucocorticoids and cyclophosphamide immunosuppressive therapy, DAH improved approximately 2 weeks after the surgery, during which time kidney function was not significantly impaired. LESSONS: Patients with AAV may develop DAH in the early postoperative period and this may be confused with surgical complications and general anesthetic residues. Therefore, it needs to be identified in an appropriate timeframe.

Cutaneous and Subcutaneous Metastases From Atypical Laryngeal Carcinoids: Case Report and Review of the Literature.

The incidence of cutaneous and subcutaneous metastases from atypical laryngeal carcinoids is approximately 20%. However, the pathogenesis and natural history of, and prognostic factors for, the condition remain poorly understood. We reported a 54-year-old female presented with cutaneous and subcutaneous metastases from atypical laryngeal carcinoid. Laryngoscopy revealed a 0.5 × 1.5-cm reddish mass on the laryngeal surface of the epiglottis. Under general anesthesia, a biopsy sample was obtained via suspension laryngoscopy. Routine pathology revealed atypical laryngeal carcinoid. Immunohistochemical staining of the sections of primary tumor was positive for cytokeratin, chromogranin A, synaptophysin, hypoxia-inducible factor-1α, P53, and CD56. GLUT-1, p-Akt, and PI3K were negative. The Ki-67 index was 15%. Supraglottic laryngectomy and selective right-neck dissection were performed. After 6 months, the patient complained of pain in the right wall of the chest; multiple cutaneous and subcutaneous nodules were evident at that site and in the abdomen. An abdominal nodule was biopsied and pathology revealed that the atypical metastatic carcinoid had metastasized to both cutaneous and subcutaneous areas of the abdomen. Chemotherapy was then prescribed. Currently, the intrathecal drug delivery system remains in place. No local recurrence has been detected. Furthermore, we systematically reviewed clinical manifestations of the disease, pathogenesis, prognostic factors, and treatment. The metastasis rate (cutaneous and subcutaneous) was approximately 12.2%. Thirty patients (62.5%) with cutaneous and subcutaneous metastases exhibited contemporaneous lymph node invasion. The 3-, 5-, and 10-year survival rates were 44.0%, 22.0%, and 13.0%, respectively. The prognosis of patients with atypical laryngeal carcinoids was poor. Relevant prognostic factors included the level of p53, human papilloma virus status, certain hypoxic markers, and distant metastasis. No optimal treatment for such metastases has yet been defined.

Expression of hypoxia-related markers in inflammatory myofibroblastic tumors of the head and neck.

BACKGROUND: The etiology of inflammatory myofibroblastic tumors (IMTs) is controversial and the prognosis is unpredictable. Previous studies have not investigated the expression of hypoxia-related markers in IMTs. METHODS: Between 2002 and 2012, 12 consecutive patients with histologically proven IMTs were enrolled in the study. Immunohistochemistry was used to detect GLUT-1, HIF-1α, PI3K, and p-Akt expression in paraffin-embedded tumor specimens. Associations among GLUT-1, HIF-1α, PI3K, and p-Akt protein expression and clinical parameters were investigated. RESULTS: The mean duration of follow-up was 52.1 months (range, 11 to 132 months). Six patients had local recurrence. GLUT-1, HIF-1α, PI3K, and p-Akt expression were detected in 41.7%, 50.0%, 33.3%, and 41.7% of patients, respectively. Fisher's exact test revealed significant correlations between recurrence of IMT and PI3K expression (P = 0.01) and p-Akt expression (P = 0.015). Univariate analyses revealed significant correlations between survival and GLUT-1 expression (P = 0.028), PI3K expression (P = 0.006), and p-Akt expression (P = 0.028). Multivariate analysis did not show a significant relationship between survival and GLUT-1, HIF-1α, PI3K, or p-Akt. Spearman rank correlation analysis showed significant correlations between HIF-1α and PI3K expression (r = 0.707, P = 0.01) and between p-Akt and PI3K expression (r = 0.837, P = 0.001). CONCLUSIONS: Although our results are inconclusive owing to the small sample size, they suggest that PI3K and p-Akt expression may play a role in the recurrence of IMTs of the head and neck.

Halomonas socia sp. nov., isolated from high salt culture of Dunaliella salina.

A moderately halophilic bacteria designed strain NY-011(T) was isolated from the high salt culture of Dunaliella salina in Chengdu of Sichuan Province, China. The isolate was Gram-negative, nonmotile, rod-shaped and 12.5-21.6 µm in length. Colonies on solid media are circular, wet, smooth and cream. The strain grew optimally at 37 °C, pH 7.0 and in the presence of 8 % NaCl. Acid was produced from glycerol, D-arabinose, glucose, trehalose, inositol, mannose, mannitol, sucrose, maltose and sorbitol. Catalase is produced but not oxidase. The major fatty acids are C18: 1ω7c (37.59 %), C19: 0 cyclo ω8c (18.29 %), C16: 0 (16.05 %) and C6: 0 (12.43 %). The predominant respiratory lipoquinone found in strain NY-011(T) is ubiquinone with nine isoprene units (Q-9). The genomic DNA G + C content of strain NY-011(T) was 62.7 mol%. Phylogenetic analysis based on 16S rRNA gene sequences revealed that strain NY-011(T) belonged to the genus Halomonas. The highest levels of 16S rRNA gene sequence similarity were found between the strain NY-011(T) and H. pantelleriensis (sequence similarity 98.43 %). However, the levels of DNA-DNA relatedness between them were only 23.1 %. In addition, the strain NY-011(T) had a phenotypic profile that readily distinguished it from H. pantelleriensis. The strain NY-011(T) therefore represents a new species of the genus Halomonas, for which the name Halomonas socia sp. nov. is proposed, with NY-011(T) (=CCTCC AB 2011033(T) = KCTC 23671(T)) as the type strain.

[Tramadol inhibits c-fos expression in spinal cord dorsal horn and serum IL-6 levels induced by plantar incision in rats].

OBJECTIVE: To investigate effect of tramadol on c-fos expression in spinal cord dorsal horn and serum IL-6 levels induced by plantar incision in rats. METHODS: The Brennan pain model was induced by incision on the planter surface of left hind paw in rats. Forty-eight rats were randomly divided into six groups: Sham group (Group C), control group (Group I,pretreatment with saline 5 ml), three tramadol pretreatment groups (Group T1, T10 and T20,pretreated with 1 mg/kg, 10 mg/kg and 20 mg/kg tramadol, respectively) and one tramadol treatment group (Group PT10, treated with tramadol 10 mg/kg immediately after operation). Pain behavior was assessed by withdrawal threshold to von Frey filament stimulation intensity, response latency of the hind paw to radiant thermal and a cumulative pain score 2 h after incision. Fos-positive neurons in spinal cord were identified by the immunohistochemical technique. Serum IL-6 levels were measured by enzyme-linked immunosorbent assay (ELISA). RESULTS: WithdrawIal threshold to von Frey filament stimulation intensity and response latency of the hind paw to radiant thermal in Group I were significantly lower than those in Group C (P<0.01). Cumulative pain score in Group I was significantly higher than that in Group C (P<0.01). In Groups of T10 and T20, withdrawal threshold to von Frey filament stimulation intensity and response latency of the hind paw to radiant thermal were significantly higher than those in Group I (P<0.01), cumulative pain score was significantly lower than that in Group I in a dose-dependent manner (P<0.01), and were also those in Group PT10. The greatest density of Fos-positive neurons was located in lamine I-II in Group I. Serum IL-6 levels were significantly elevated in Group I. Pretreatment with tramadol showed a dose-depended inhibitory effect on c-fos expression and serum IL-6 production,but not in Group T1. Administration of tramadol postoperatively also suppressed the c-fos expression and serum IL-6 production as showed in PT10 but were weaker than those in Group T10. CONCLUSION: Pretreatment with tramadol can produce dose-dependent inhibitory effect on c-fos expression in spinal cord dorsal horn and then suppress the inflammatory response to the trauma.

Effect of tramadol on immune responses and nociceptive thresholds in a rat model of incisional pain.

OBJECTIVE: To evaluate the effects of tramadol on the proinflammatory responses in a rat model of incisional pain by investigating its effects on nociceptive thresholds and serum interleukin-6 (IL-6) and IL-2 levels. METHODS: Forty-two male Sprague-Dawley (SD) rats scheduled for plantar incision were randomly divided into 7 groups (n=6 in each group). Rats in Group 1 receiving general anesthesia with no incision were served as control; At 30 min before skin incision, Groups 2 to approximately 5 were given 5 ml normal saline or 1, 10, and 20 mg/kg tramadol, respectively, intraperitoneally (i.p.); Group 6 received 10 mg/kg tramadol after operation; Group 7 received 10 mg/kg tramadol before incision, followed by 200 microg/kg naloxone after operation. Mechanical allodynia was measured by electronic von Frey filament to evaluate the nociceptive thresholds 1 h before incision, and 1 h and 2 h after operation. Serum IL-6 and IL-2 levels were measured by enzyme-linked immunosorbent assay (ELISA) 2 h after operation. RESULTS: Mechanical thresholds decreased significantly and serum IL-6 level increased significantly after operation in Group 2 compared with control (P<0.01), and these changes were reversed respectively by tramadol in a dose-dependent manner (P<0.05 and P<0.01, respectively). IL-2 level remained unchanged after operation in Group 2, but decreased in Group 3 (P<0.05), then gradually returned to the normal level in Groups 4 and 5. The intraperitoneally injected tramadol (10 and 20 mg/kg) produced a potent and dose-dependent antinocicptive effect on the lesioned paw. The antinocicptive effects of tramadol were partially antagonized by naloxone (200 microg/kg), suggesting an additional non-opioid mechanism. CONCLUSION: The results suggest that tramadol could be a good choice for the treatment of pain under the conditions that immunosuppression may be particularly contraindicated.

RFX1 mediates the serum-induced immediate early response of Id2 gene expression.

Id2, a negative regulator of basic helix-loop-helix transcription factors, is involved in regulating cell differentiation and proliferation. To obtain insight into the role of Id2 in cell cycle control, we investigated the mechanisms underlying the immediate early response of Id2 expression to serum stimulation in NIH3T3 cells. Luciferase reporter analysis with deletion and point mutants demonstrated the serum response element of Id2 (Id2-SRE) to be a consensus binding site for RFX1 (regulatory factor for X-box 1) present 3.0 kb upstream of the transcription initiation site of Id2. Gel shift and chromatin immunoprecipitation assays confirmed the binding of RFX1 to Id2-SRE in vitro and in vivo, respectively. In both assays, RFX1 binding was observed not only in serum-stimulated cells, but also in serum-starved cells. Knockdown of RFX1 by RNA interference disturbed the immediate early response of Id2 expression in cells and abrogated the Id2-SRE-mediated induction of luciferase activity by serum. These alterations were rescued by the introduction of RNA interference-resistant RFX1 into cells. On the other hand, in the Id2-SRE-mediated reporter assay, RFX1 with an N-terminal deletion abrogated the serum response, whereas RFX1 with a C-terminal deletion enhanced the reporter activity in serum-starved cells. Furthermore, HDAC1 was recruited to Id2-SRE in serum-starved cells. These results demonstrate that RFX1 mediates the immediate early response of the Id2 gene by serum stimulation and suggest that the function of RFX1 is regulated intramolecularly in its suppression in growth-arrested cells. Our results unveil a novel transcriptional control of immediate early gene expression.