A Nomogram Model for Prediction of Mortality Risk of Patients with Dangerous Upper Gastrointestinal Bleeding: A Two-center Retrospective Study

OBJECTIVE

This study aimed to establish a nomogram model to predict the mortality risk of patients with dangerous upper gastrointestinal bleeding (DUGIB), and identify high-risk patients who require emergent therapy.

METHODS

From January 2020 to April 2022, the clinical data of 256 DUGIB patients who received treatments in the intensive care unit (ICU) were retrospectively collected from Renmin Hospital of Wuhan University (n=179) and the Eastern Campus of Renmin Hospital of Wuhan University (n=77). The 179 patients were treated as the training cohort, and 77 patients as the validation cohort. Logistic regression analysis was used to calculate the independent risk factors, and R packages were used to construct the nomogram model. The prediction accuracy and identification ability were evaluated by the receiver operating characteristic (ROC) curve, C index and calibration curve. The nomogram model was also simultaneously externally validated. Decision curve analysis (DCA) was then used to demonstrate the clinical value of the model.

RESULTS

Logistic regression analysis showed that hematemesis, urea nitrogen level, emergency endoscopy, AIMS65, Glasgow Blatchford score and Rockall score were all independent risk factors for DUGIB. The ROC curve analysis indicated the area under curve (AUC) of the training cohort was 0.980 (95%CI: 0.962-0.997), while the AUC of the validation cohort was 0.790 (95%CI:0.685-0.895). The calibration curves were tested for Hosmer-Lemeshow goodness of fit for both training and validation cohorts (P=0.778, P=0.516).

CONCLUSION

The developed nomogram is an effective tool for risk stratification, early identification and intervention for DUGIB patients.

Intravenous Administration of Hypertonic Glucose Solution to Prevent Dizziness in Patients Undergoing Gastrointestinal Endoscopy Under General Anesthesia: A Randomized Clinical Trial

Background and Objectiv: Dizziness is a common complication of gastrointestinal endoscopy under general anesthesia. Dizziness is primarily caused by a lack of energy and blood volume following fasting and water deprivation. Hypertonic glucose solution (HGS) is an intravenous energy replenishment, that increases blood volume due to its hyperosmotic characteristics and can be directly absorbed from blood circulation. This study aimed to HGS can prevent dizziness after gastrointestinal endoscopy.

METHODS

This was a double-blind, randomized, controlled study. Eligible patients were randomly allocated into two groups based on the intravenous agent administered before gastrointestinal endoscopy: Group A, saline (0.9%; 20 mL); and group B, HGS (50%; 20 mL). Overall, 840 patients were included in the statistical analysis. The scores and incidence of dizziness were assessed.

RESULTS

The dizziness score were higher in group A than in group B (1.92 ± 0.08 vs. 0.92 ± 0.06; p < 0.01). The incidence of mild dizziness and moderate-to-severe dizziness was significantly lower in group B than in group A (40.10% vs. 51.78% and 3.10% vs. 19.72%, respectively; p < 0.01). The incidence and score of dizziness were significantly lower in males than in females (30.81% vs 51.82% and 0.64 ± 0.08 vs 1.12 ± 0.08, respectively; p < 0.01) after pretreatment with HGS.

CONCLUSION

Pretreatment with HGS effectively prevents dizziness after gastrointestinal endoscopy under general anesthesia. The mechanism of action is unclear but might be related to body energy replacement and an increase in blood volume following HGS administration.

[The importance of intranasal trigeminal event-related potentials test for patients with olfactory dysfunction]

Objective: To analyze the characteristics of trigeminal event-related potentials (tERPs) in different kinds of olfactory disorders (OD), and to evaluate the importance of tERPs for the patients with olfactory dysfunction. Methods: Clinical data of 314 patients with olfactory dysfunction from the Smell and Taste Clinics in Beijing Anzhen Hospital from 2015 to 2021 were retrospectively reviewed, including 158 males and 156 females, aging from 6 to 78 years. The control group consisted of healthy people from medical examination center, who were gender and age matched. The clinical characteristics of OD were analyzed using Sniffin' Sticks test, olfactory event-related potentials (oERPs), tERPs and acoustic rhinometry test. SPSS 17.0 software was used to compare the difference of tERPs between the two groups, and to analyze the related factors affecting trigeminal function. Results: The ratio of tERPs presence was different in OD caused by different reasons: head traumatic OD (54.9%), post-virus infection OD (63.6%), sinonasal inflammatory OD (68.4%) and OD due to other causes (56.9%). Compared with controls, tERPs signals in OD patients showed a significant lower amplitude in the N₁ wave (all P<0.001), and lower amplitude in the P₂ wave in most OD patients (head trauma t=-4.11, P<0.001; sinonasal inflammation t=-2.04, P=0.046; others t=-2.40, P=0.020) except in OD by post-virus infection (t=-1.98, P=0.052). tERPs signals in OD patients by sinonasal inflammation showed longer latency in the N₁ wave (t=2.15, P=0.036), but this difference was not observed in other OD patients (all P>0.05). tERPs signals were significantly correlated with the Sniffin' Sticks score, deficiency of oERPs and nasal minimum cross-sectional area (all P<0.05). Conclusions: OD patients show neurophysiologic deficits in trigeminal function. The absence of tERPs or lower amplitude in N₁ waves are the important characteristics of patients with OD.

A Nomogram Model for Predicting Type-2 Myocardial Infarction Induced by Acute Upper Gastrointestinal Bleeding

OBJECTIVE

To examine the independent risk factors of type-2 myocardial infarction (T2MI) elicited by acute upper gastrointestinal bleeding (AUGIB), and to establish a nomogram model for the prediction of AUGIB-induced T2MI.

METHODS

A nomogram model was established on the basis of a retrospective study that involved 533 patients who suffered from AUGIB in the Department of Critical Care Medicine (CCM) or Emergency Intensive Care Unit (EICU) of Renmin Hospital of Wuhan University, Wuhan, China, from January 2017 to December 2020. The predictive accuracy and discriminative power of the nomogram were initially evaluated by internal validation, which involved drawing the receiver operating characteristic (ROC) curve, calculating the area under the curve (AUC), plotting the calibration curve derived from 1000 resampled bootstrap data sets, and computing the root mean square error (RMSE). The predictive ability of the nomogram was further validated through the prospective and multicenter study conducted by the investigators, which enrolled 240 AUGIB patients [including 88 cases from Renmin Hospital of Wuhan University, 73 cases from Qilu Hospital of Shandong University (Qingdao), and 79 cases from Northern Jiangsu People's Hospital)], who were admitted to the Department of CCM or EICU, from February 2021 to July 2021.

RESULTS

Among the 533 patients in the training cohort, 78 (14.6%) patients were assigned to the T2MI group and 455 (85.4%) patients were assigned to the non-T2MI group. The multivariate analysis revealed that age >65, hemorrhagic shock, cerebral stroke, heart failure, chronic kidney disease, increased blood urea nitrogen, decreased hematocrit, and elevated D-Dimer were independent risk factors for AUGIB-induced T2MI. All these factors were incorporated into the nomogram model. The AUC for the nomogram for predicting T2MI was 0.829 (95% CI, 0.783-0.875) in the internal validation cohort and 0.848 (95% CI, 0.794-0.902) in the external validation cohort. The calibration curve for the risk of T2MI exhibited good consistency between the prediction by the nomogram and the actual clinical observation in both the internal validation (RMSE=0.016) and external validation (RMSE=0.020).

CONCLUSION

The nomogram was proven to be a useful tool for the risk stratification of T2MI in AUGIB patients, and is helpful for the early identification of AUGIB patients who are prone to T2MI for early intervention, especially in emergency departments and intensive care units.

Parasternal Intercostal Block Complementation Contributes to Postoperative Pain Relief in Modified Radical Mastectomy Employing Pectoral Nerve Block I and Serratus-Intercostal Block: A Randomized Trial

Purpose

Pectoral nerve block I (PECS I) and serratus-intercostal plane block (SIPB) can anesthetize the majority mammary region, while parasternal intercostal block (PSI) targets the internal area during breast resection surgery. The aim of this study was to determine whether including PSI with PECS I and SIPB is more effective compared to PECS I and SIPB alone.

Patients and Methods

Sixty-two adult females undergoing unilateral modified radical mastectomy (MRM) were randomly assigned to receive either PECS I and SIPB (PS group, n=31) or a combination of PECS I, SIPB, and PSI (PSP group, n=31). The outcomes were measured with a numerical rating scale (NRS) score, and in terms of opioid consumption and anesthesia-related complications within 48 h after surgery.

Results

Although there were no differences in the NRS scores between the two groups during the inactive periods, the combination of three nerve blocks significantly reduced the NRS scores during movement. In addition, morphine equivalent consumption was lower in the PSP group compared to the PS group. Postoperative adverse events were similar in both groups in terms of regional anesthesia-related complications.

Conclusion

The combination of PECS I block, SIPB, and PSI block provides superior pain relief and postoperative recovery for patients undergoing MRM.

Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection

BACKGROUND

The outbreak of 2019 novel coronavirus disease (COVID-19) in Wuhan, China, has spread rapidly worldwide. In the early stage, we encountered a small but meaningful number of patients who were unintentionally scheduled for elective surgeries during the incubation period of COVID-19. We intended to describe their clinical characteristics and outcomes.

METHODS

We retrospectively analyzed the clinical data of 34 patients underwent elective surgeries during the incubation period of COVID-19 at Renmin Hospital, Zhongnan Hospital, Tongji Hospital and Central Hospital in Wuhan, from January 1 to February 5, 2020.

FINDINGS

Of the 34 operative patients, the median age was 55 years (IQR, 43-63), and 20 (58·8%) patients were women. All patients developed COVID-19 pneumonia shortly after surgery with abnormal findings on chest computed tomographic scans. Common symptoms included fever (31 [91·2%]), fatigue (25 [73·5%]) and dry cough (18 [52·9%]). 15 (44·1%) patients required admission to intensive care unit (ICU) during disease progression, and 7 patients (20·5%) died after admission to ICU. Compared with non-ICU patients, ICU patients were older, were more likely to have underlying comorbidities, underwent more difficult surgeries, as well as more severe laboratory abnormalities (eg, hyperleukocytemia, lymphopenia). The most common complications in non-survivors included ARDS, shock, arrhythmia and acute cardiac injury.

INTERPRETATION

In this retrospective cohort study of 34 operative patients with confirmed COVID-19, 15 (44·1%) patients needed ICU care, and the mortality rate was 20·5%.

FUNDING

National Natural Science Foundation of China.

Exendin-4 attenuates pain-induced cognitive impairment by alleviating hippocampal neuroinflammation in a rat model of spinal nerve ligation

Glucagon-like peptide-1 receptor has anti-apoptotic, anti-inflammatory, and neuroprotective effects. It is now recognized that the occurrence and development of chronic pain are strongly associated with anti-inflammatory responses; however, it is not clear whether glucagon-like peptide-1 receptor regulates chronic pain via anti-inflammatory mechanisms. We explored the effects of glucagon-like peptide-1 receptor on nociception, cognition, and neuroinflammation in chronic pain. A rat model of chronic pain was established using left L5 spinal nerve ligation. The glucagon-like peptide-1 receptor agonist exendin-4 was intrathecally injected into rats from 10 to 21 days after spinal nerve ligation. Electrophysiological examinations showed that, after treatment with exendin-4, paw withdrawal frequency of the left limb was significantly reduced, and pain was relieved. In addition, in the Morris water maze test, escape latency increased and the time to reach the platform decreased following exendin-4 treatment. Immunohistochemical staining and western blot assays revealed an increase in the numbers of activated microglia and astrocytes in the dentate gyrus of rat hippocampus, as well as an increase in the expression of tumor necrosis factor alpha, interleukin 1 beta, and interleukin 6. All of these effects could be reversed by exendin-4 treatment. These findings suggest that exendin-4 can alleviate pain-induced neuroinflammatory responses and promote the recovery of cognitive function via the glucagon-like peptide-1 receptor pathway. All experimental procedures and protocols were approved by the Experimental Animal Ethics Committee of Renmin Hospital of Wuhan University of China (approval No. WDRM 20171214) on September 22, 2017.

Overexpression of miR-381 relieves neuropathic pain development via targeting HMGB1 and CXCR4

MicroRNA are significant regulators of neuropathic pain development. Neuroinflammation contributes a lot to the progression of neuropathic pain. miR-381 is involved in various pathological processes. However, the role of miR-381 in neuropathic pain development remains barely understood. Therefore, in our study, we aimed to investigate the effects of miR-381 on the process of neuropathic pain progression by establishing a rat model using chronic sciatic nerve injury (CCI). Here, we observed that miR-381 was dramatically decreased in CCI rats. Up-regulation of miR-381 strongly reduced neuropathic pain behaviors including mechanical and thermal hyperalgesia. In addition, inflammatory cytokine expression, including IL-6, IL-10 and TNF-α were significantly repressed by overexpression of miR-381. High mobility group box 1 protein (HMGB1) and Chemokine CXC receptor 4 (CXCR4) participate in neuropathic pain development. In our present study, HMGB1 and CXCR4 were predicted as direct targets of miR-381 by employing bioinformatics analysis. Overexpression of miR-381 was able to restrain the expression of HMGB1 and CXCR4 greatly. The direct correlation between HMGB1 and CXCR4 and miR-381 was confirmed in our research. Furthermore, we found that HMGB1 and CXCR4 were increased in CCI rats time-dependently. Moreover, it was demonstrated that silence of HMGB1 and CXCR4 in CCI rats depressed neuropathic pain progression greatly. In conclusion, it was indicated that miR-381could inhibit neuropathic pain development through targeting HMGB1 and CXCR4.

Penehyclidine hydrochloride inhibits TLR4 signaling and inflammation, and attenuates blunt chest trauma and hemorrhagic shock-induced acute lung injury in rats

Blunt chest trauma with hemorrhagic shock (THS) frequently induces pulmonary inflammation that leads to acute lung injury (ALI). Penehyclidine hydrochloride (PHC) possesses anti‑inflammatory properties that may attenuate the systemic inflammatory response. The present study aimed to evaluate the molecular mechanism of PHC in modifying THS‑induced ALI in rats. Rats underwent either THS or a sham procedure. At 6 h subsequent to blunt chest trauma, arterial blood was drawn for blood gas and pro‑inflammatory factors analyses, and lung tissue samples were collected to examine pulmonary histopathological alterations, the wet/dry weight ratio, myeloperoxidase activity, and the protein expression levels of Toll-like receptor 4 (TLR4), phosphorylated (p‑)p38 mitogen‑activated protein kinase (MAPK), nuclear factor (NF)‑κB and activator protein‑1 (AP‑1). THS caused significant reductions in heart rate and mean arterial blood pressure, and was associated with significant increases in tumor necrosis factor‑α, interleukin (IL)‑6, IL‑1β, p‑p38MAPK, NF‑κB and AP‑1 activation, in addition to TLR4 expression, in the lung. PHC effectively attenuated THS‑induced ALI, and inhibited TLR4 expression, reduced the activation of p‑p38MAPK, NF‑κB and AP‑1, and downregulated the expression of pro‑inflammatory mediators. In conclusion, the results of the present study demonstrated that PHC may exert an anti‑inflammatory effect and attenuate THS‑induced ALI by inhibiting the TLR4 signaling pathway. These preclinical findings may offer a novel therapeutic strategy to restrict TLR4 overactivation in ALI.

[Dexmedetomidine preconditioning protects against lipopolysaccharides-induced injury in the human alveolar epithelial cells]

BACKGROUND AND OBJECTIVES

Dexmedetomidine (DEX) has demonstrated the preconditioning effect and shown protective effects against organize injury. In this study, using A549 (human alveolar epithelial cell) cell lines, we investigated whether DEX preconditioning protected against acute lung injury (ALI) in vitro.

METHODS

A549 were randomly divided into four groups (n=5): control group, DEX group, lipopolysaccharides (LPS) group, and D-LPS (DEX+LPS) group. Phosphate buffer saline (PBS) or DEX were administered. After 2h preconditioning, the medium was refreshed and the cells were challenged with LPS for 24h on the LPS and D-LPS group. Then the malondialdehyde (MDA), superoxide dismutase (SOD), Bcl-2, Bax, caspase-3 and the cytochrome c in the A549 were tested. The apoptosis was also evaluated in the cells.

RESULTS

Compare with LPS group, DEX preconditioning reduced the apoptosis (26.43%±1.05% vs. 33.58%±1.16%, p<0.05) in the A549, which is correlated with decreased MDA (12.84±1.05 vs. 19.16±1.89nmol.mg^-1 protein, p<0.05) and increased SOD activity (30.28±2.38 vs. 20.86±2.19U.mg^-1 protein, p<0.05). DEX preconditioning also increased the Bcl-2 level (0.53±0.03 vs. 0.32±0.04, p<0.05) and decreased the level of Bax (0.49±0.04 vs. 0.65±0.04, p<0.05), caspase-3 (0.54±0.04 vs. 0.76±0.04, p<0.05) and cytochrome c.

CONCLUSION

DEX preconditioning has a protective effect against ALI in vitro. The potential mechanisms involved are the inhibition of cell death and improvement of antioxidation.

[Overexpression of Axin inhibits lymphoma cell invasion and metastasis in vitro by down-regulating β-catenin and MMP7/MMP9]

OBJECTIVE

To investigate that the role of Axin in regulating the invasion and migration ability of lymphoma cells and explore the molecular mechanisms.

METHODS

The expressions of Axin, β-catenin, MMP7, and MMP9 were detected in different lymphoma cell lines by RT-PCR and Western blotting. A lymphoma cell line with low Axin expressions was transiently transfected with pCMV5-HA-Axin and pcDNA5-His-β-catenin plasmid, and the expressions of β-catenin, MMP7, and MMP9 mRNA and protein were observed. A lymphoma cell model stably overexpressing Axin was transfected with AXIN-shRNA and β-catenin-shRNA, and the changes in β-catenin, MMP7, and MMP9 cexpressions were observed. The changes in the invasion and migration abilities of this cell model were assessed following Axin knockdown.

RESULTS

In the lymphoma cell lines tested, the Axin expression showed a negative correlation with β-catenin, MMP7, and MMP9 expressions. In Raji cells with a low Axin expression, overexpression of Axin resulted in decreased expressions of β-catenin, MMP7, and MMP9 at the protein levels but not the mRNA levels, and overexpression of β-catenin obviously increased MMP7 and MMP9 mRNA and protein expressions. In the cells with stable Axin overexpression, Axin knockdown caused increased expressions of β-catenin, MMP7, and MMP9 at the protein levels but not the mRNA levels, while β-catenin knockdown caused lowered expressions of MMP7 and MMP9 and suppressed cell invasion and migration.

CONCLUSION

In lymphoma cells, Axin overexpression can decrease the expression of β-catenin, which in turn decreases the expressions of MMP7 and MMP9 to inhibit the cell invasion and migration.

Study of the expression of GABA(A) receptor in rats during acute lung injury caused by endotoxin

The objective of the present study was to investigate the role of γ-aminobutyric acid type A receptor (GABA(A)R) in lipopolysaccharide (LPS)-induced acute lung injury (ALI) in rats. Thirty-two male wistar rats were randomly divided into four groups. Rats in the GABA group were pretreated with LPS and GABA, while those in the bicuculline (BIC) group were pretreated with LPS and bicuculline. We assessed the arterial blood gas, dry/wet ratio, and the level of tumor necrosis factor-α (TNF-α), IL-6, malondialdehyde, and superoxide dismutase 6 h after the immunization. Paraffin sections of samples were detected using the steptavidin-peroxidase method. Protein expression was detected using sodium dodecyl sulfate-polyacrylamide gel electrophoresis and western blotting. PaO2 in the LPS group was significantly lower than that in the control rats. Activation of GABA-mediated signaling by GABA increased the expression of GABA(A)R in airway bronchial and alveolar epithelial cells. Blockade of the GABA(A)R by bicuculline limited the expression of this receptor. The GABA group rats had higher levels of tissue TNF-α and IL-6 than in ALI rats and control rats. The BIC group rats demonstrated an opposite expression level compared to the GABA group rats. Our results suggest that the GABA(A)R could aggravate the inflammatory response syndrome and oxidative stress in the lungs and play an essential role in LPS-induced acute lung injury. It provides a novel method to study the incidence and mortality of ALI during the peroperative period.

Effects of penehyclidine hydrochloride on pulmonary contusion from blunt chest trauma in rats

BACKGROUND AND OBJECTIVE

Toll-like receptor 4 (TLR4) is widely recognised as a pattern recognition receptor (PRR) in the triggering of innate immunity. Lung inflammation and systemic innate immune responses are dependent on TLR4 activation undergoing pulmonary contusion. Therefore, the author investigated the effects of penehyclidine hydrochloride (PHC) on the expression of TLR4 and inflammatory responses of blunt chest trauma-induced pulmonary contusion.

MATERIALS AND METHODS

Male Sprague-Dawley (SD) rats were randomly assigned into three groups: normal control (NC) group, pulmonary contusion (PC) group and penehyclidine hydrochloride treatment (PHC) group. Pulmonary contusion was induced in anesthetised rats at fixed chest impact energy of 2.45J. Lung injury was assessed by the histopathology changes, arterial blood gas and myeloperoxidase (MPO) activity of lung. The serum tumour necrosis factor-α (TNF-α) and interleukin-6 (IL-6) levels were measured using enzyme-linked immunosorbent assays (ELISA). The expression of TLR4 was determined by immunohistochemistry.

RESULTS

Blunt chest trauma produced leucocytosis in the interstitial capillaries, hypoxemia, and increased MPO activity. The expressions of TNF-α, IL-6 and TLR4 in the lung were significantly enhanced during pulmonary contusion. PHC treatments effectively attenuated pulmonary inflammation responses, as shown by improved pulmonary oxygenation, histopathology damage, decreased the MPO activity, the expressions of TNF-α, IL-6, and TLR4 after lung injury.

CONCLUSION

It might be concluded that PHC exhibit anti-inflammatory and protective effects in traumatic lung injury via the inhibition of the TLR4 pathway.