Volume 104 · Issue 31 · 2024

The etiology of childhood arterial ischemic stroke is complex, and identifying the underlying cause is crucial for optimizing treatment and preventing recurrence. Currently, the classification methods for childhood arterial ischemic stroke are largely based on data from international studies, but a unified consensus have not yet been reached. This paper reviews the existing classification methods and their subtype definitions, and points out some doubts and ambiguities. On this basisi, combined with the data collected by Beijing Children′s Hospital on Chinese children with arterial ischemic stroke, a new classification method (COIST) was proposed according to the etiology and pathogenesis, namely: inflammation (I), abnormal vascular structure (S), thrombophilia (T), heart disease (C), other identifiable causes (O), and uncertain causes; and various subtypes are listed. It is hoped that this new classification method can attract the attention and discussion of domestic colleagues, with the aim of further refinement, in order to help clinicians better understand and quickly identify the etiologies of childhood ischemic stroke.

Vascular cognitive impairment (VCI) refers to cognitive impairment primarily mainly caused by cerebrovascular pathologies and their risk factors. It is the second leading cause of cognitive impairment in individuals aged 60 and above in China. Currently, there are no specific treatments for VCI, but early identification and prevention can help reduce the risk of onset and improve patients′ prognosis. To raise awareness and attention among clinicians towards VCI and provide guidance for its standardized management, the Chinese Stroke Association Vascular Cognitive Impairment Subcommittee updated and revised the clinical classification, diagnostic procedures, neuropsychological evaluation criteria and imaging evaluation criteria and etc.on the basis of the Guidelines for the Diagnosis and Treatment of Vascular Cognitive Impairment in China (2019). Through systematic literature reviews, including meta-analysis, systematic review, randomized controlled trials, retrospective studies, clinical case-control studies, etc, evidence and recommendation levels were formulated according to the evaluation and evaluation criteria of recommendation classification, and a total of 8 recommendations were formed on the etiology, clinical classification, clinical manifestations, diagnostic criteria, prevention and treatment of VCI. A standardized diagnostic process for VCI suitable for the clinical practice in China was proposed, aiming at providing guidance for the standardized diagnosis and accurate treatment of VCI.

Knee osteoarthritis (KOA) is common in middle-aged and elderly populations, with typical symptoms including knee joint pain, deformity, and restricted movement. The concept of early KOA (EKOA) is ambiguous, and clinical diagnosis and treatment are often overlooked. The diagnosis and effective prevention of EKOA can help delay the progression of the disease and reduce the incidence of mid-to-late stage KOA. To standardize the clinical diagnosis and treatment of EKOA, the Osteoarthrosis Committee of Chinese Aging Well Association has initiated the development of non-operative treatment guidelines for EKOA, selecting key clinical issues of concern to clinicians, including the definition, diagnosis, and non-operative treatment and strategies for EKOA. Ultimately, a total of 13 recommendations were formulated with the aim of raising the level and scientificity of EKOA diagnosis and treatment, thereby delaying the progression of EKOA in patients, improving their quality of life, and reducing the societal burden of the disease.

Bacterial extracellular vesicles (BEVs), considered to mediate interactions between bacteria, and bacteria-host interactions, play a crucial role in the development and progression of diseases. However, there is currently no unified standard for the nomenclature, isolation, and detection of BEVs. Consequently, inconsistencies are observed in the results of related research, preventing a more comprehensive and objective analysis of BEVs. Therefore, it is imperative to establish an expert consensus based on fundamental research methods for the nomenclature, isolation, and detection of BEVs to facilitate their clinical translation and applications. This consensus statement was written by a working group composed of experienced experts in the fields of medical diagnostics, microbiology, and materials biology. It provides an overview of commonly used techniques and basic methods for the isolation and detection of BEVs. The statement offers recommendations and considerations to improve the feasibility and reproducibility of BEVs research, emphasizing pivotal issues and challenges in the transition of BEVs towards clinical applications, with the aim of serving as a reference for subsequent studies.

To compare the postoperative analgesic effect of modified superior trunk block and traditional interscalene brachial plexus block in arthroscopic rotator cuff repair.

A total of 40 patients undergoing arthroscopic rotator cuff repair in the Second Affiliated Hospital of Wenzhou Medical University from October to November 2023 were prospectively included, whose American Society of Anesthesiologists (ASA) grade were Ⅰ-Ⅱ. They were divided into modified superior trunk block group (group S) and interscalene brachial plexus block group (group I) by random number table according to different nerve block methods, with 20 cases in each group. Local anesthetics was a mixture of 1.33% liposomal bupivacaine and 0.5% levobupivacaine hydrochloride injection in equal volume. Patients in group S were injected 5 ml mixture for ultrasound-guided modified superior trunk block, and patients in group I were injected with 15 ml mixture for ultrasound-guided traditional interscalene block respectively. Both groups underwent superficial cervical plexus block (5 ml mixture). Standardized general anesthesia and standardized postoperative analgesia were followed. The primary outcome measures included 48 h resting numerical rating scale (NRS) scores after surgery and the incidence of hemidiaphragmatic paralysis (HDP) at 30 min after block. The secondary outcome measures included resting NRS scores during the post anesthesia care unit (PACU), 12, 24, and 36 h after surgery, postoperative opioid consumption and satisfaction with analgesia, pulse oxygen saturation (SpO₂) at 30 min after block, sensory and motor block duration, and the incidence of perioperative adverse reactions. The non-inferiority cut-off value of resting NRS scores for patients in group S was set as"1 point"at each observation time point after surgery.

In group S, one patient was excluded because the target nerve was blocked by the subclavian vein and could not be blocked, nineteen patients [11 males and 8 females, aged (52.2±9.0) years] were eventually included. In group I, there were 7 males and 13 females, aged (55.0±5.1) years. Resting NRS scores of group S and Group I at 48 h after surgery were 0 (0, 0) and 0 (0, 0.8) point, respectively, with no statistical significance (P>0.05). The median difference was 0 (95%CI:0-0) point and the upper 95%CI was 0 point, which was lower than the preset non-inferiority cut-off value"1 point"(non-inferiority P<0.001). The incidence of HDP in group S and group I were 5% (1/19) and 75% (15/20), respectively, with statistically significant (P<0.001). There were no significant differences in resting NRS scores at PACU and 12, 24, 36 h after surgery, opioid dosage, satisfaction with analgesia, SpO₂ at 30 min after block, sensory and motor block duration between two groups (all P>0.05). No respiratory adverse events such as hypoxemia and airway spasm occurred in two groups after extubation. One patient in group I showed symptoms of breath shortness when entering PACU, and 3 patients felt uncomfortable due to prolonged numbness and weakness of the blockade limb (>2 days). No nerve block procedures and opioid drugs relative adverse reactions and no neurological complications happened in both groups.

Liposomal bupivacaine usage for modified superior trunk block can provide long-term postoperative analgesic effects which is noninferior to traditional interscalene brachial plexus block and causes less HDP in patients undergoing arthroscopic rotator cuff repair.

To compare the efficacy of remimazolam and propofol on hemodynamics and quality of early postoperative recovery in elderly patients with frailty undergoing endoscopic retrograde cholangiopancreatography (ERCP).

A total of 108 elderly patients with frailty (aged≥75 years) undergoing elective ERCP in the General Hospital of Northern Theater Command were prospectively enrolled from November 2022 to May 2023. According to the different anesthetic drugs used, the patients were divided into two groups by random number table method: remimazolam group (group R) and propofol group (group P). The group R was given remimazolam 0.15-0.20 mg/kg and alfentanil 5.0 μg/kg for anesthesia onset, and then was pumped remimazolam 0.4-0.8 mg·kg^-1·h^-1 and alfentanil 0.5 μg·kg^-1·min^-1 to maintain sedation. The group P was given propofol 1.0-1.5 mg/kg and alfentanil 5.0 μg/kg, and was pumped propofol 2.0-6.0 mg·kg^-1·h^-1 and alfentanil 0.5 μg·kg^-1·min^-1. The primary outcome was the incidence of intraoperative hypotension [mean arterial pressure (MAP)<65 mmHg (1 mmHg=0.133 kPa) or MAP>20% decrease from baseline value] and severe hypotension (MAP<55 mmHg) in both groups, and other outcomes included: MAP, heart rate, pulse oxygen saturation (SpO₂) and bispectral index (BIS) values of patients at each time of before anesthesia induction (T₀), 1 min after anesthesia induction (T₁), endoscope through the oropharynx (T₂), immediate lithotomy (T₃), endoscope withdrawal from the oropharynx (T₄), and patients awake (T₅); the use of vasoactive drug during operation; the incidence of bradycardia, hypoxemia and injection pain; and the postoperative 15-item Quality of Recovery (QoR-15) score.

Group R included 33 males and 20 females, aged (81.5±4.9) years. Group P included 26 males and 29 females, aged (82.3±6.0) years. The incidence of intraoperative hypotension in group R was 24.5% (13/53), which was lower than 43.6% (24/55) in group P (P=0.036), there was no significant difference of the incidence of severe hypotension which was 0 (0/53) and 5.5% (3/55) (P=0.225). Compared with T₀, MAP and BIS decreased at T₁-T₄ (both P<0.05); heart rate and SpO₂ decreased at T₁-T₂ in both groups (both P<0.05). Compared with group P, MAP increased at T₁-T₄; heart rate, SpO₂ and BIS increased in group R (all P<0.05). The use of intraoperative vasoactive drug in group R was (93.9±21.4) μg, lower than (123.3±29.7) μg in group P (P<0.001), and the incidence of bradycardia, hypoxemia and injection pain in group R was 5.7% (3/53), 13.2% (7/53), and 3.8% (2/53), lower than 18.2% (10/55), 30.9% (17/55), and 16.4% (9/55) in group P (all P<0.05). There was no significant difference in the incidence of bucking or involuntary body movement and hiccuping in both groups (both P>0.05). The awakening time in group R was (11.8±3.0) min, longer than (10.3±3.3) min in group P (P=0.016), and the incidence of emergence agitation was 3.8% (2/53), lower than 16.4% (9/55) (P=0.031). There was no significant difference in postanesthesia care unit (PACU) stay duration and the incidence of postoperative nausea and vomiting in both groups (all P>0.05). The postoperative QoR-15 scores at 1 d were (131.9±4.7) and (129.3±5.7) with statistically significant difference (P=0.010), and QoR-15 scores at 3 d were (134.8±3.3) and (133.6±5.0) with no significant difference (P=0.205).

Compared with propofol, remimazolam reduces the incidence of intraoperative hypotension, bradycardia, injection pain and the use of intraoperative vasoactive drug on elderly patients with frailty undergoing ERCP. Remimazolam has relatively stable hemodynamics, it prolongs the recovery time but does not significantly affect the quality of early postoperative recovery.

To estimate the impacts of different anesthetic protocols on the speed and quality of postoperative resuscitation in patients undergoing painless gastroscopy.

This was a prospectively designed randomized control study that included 150 patients who underwent painless gastroscopy in Hainan Cancer Hospital affiliated to Hainan Medical College between April and December of 2023. All the patients, classified as American Society of Aneshesiologists (ASA) Grade Ⅰ or Ⅱ, were randomly divided into three groups with different anesthetic protocols, including propofol group (group P), remimazolam group (group R) and remimazolam with flumazenil group (group RF). There were eventually 50 patients in each group. The three groups of patients were compared for their resuscitation time and the time that they stayed in the resuscitation room (addressed as"room time"below). At 10 min and 20 min after resuscitation, each patient was tested for recognition ability (orientation score), walking ability and fine motor skill (including reaction speed, quick-click ability and visual memory), respectively, with possible adverse reactions recorded spontaneously, such as hypotension, dizziness, nausea and vomitus.

There were 29 males and 21 females in group P with an average age of (34±6) years, 27 males and 23 females in group R with an average age of (36±8) years, and 26 males and 24 females in group RF with an average age of (33±7) years, respectively. All examinations for each patient were successfully completed with no interruptions. The resuscitation time and room time of group RF were (47±15) s and (26±5) min,respectively, which were both shorter than those in either group R [(489±92) s and (35±6) min] or group P [(196±61) s and (31±7) min] (all P<0.05). The orientation score of patients in group RF at 10 min after resuscitation was (79.0±10.5), which was significantly higher than that in group R (70.0±11.7) (P<0.05). The patients′ walking ability score of group RF at 10 min and 20 min after resuscitation were [(23.6±10.8), (48.0±4.5)], which were better than those in group R[(15.4±11.1), (47.6±4.8)] (both P<0.05). The patients′ reaction speed and quick-click scores of group RF were [(851.0±150.9), (547.0±114.0) ms] and [(758.0±73.2), (629.0±128.9) ms], which were better than those in either group R [(1 151.0±206.0), (732.0±135.1) ms], [(893.0±110.9), (765.8±125.8) ms] or group P [(985.0±225.3), (613.0±123.2) ms], [(831.0±87.7), (691.0±115.8) ms] (all P<0.05). The incidence rate of hypotension in group P was 18% (9/50), higher than that in either Group R [4% (2/50)] or group RF [2% (1/50)] (all P<0.05). The incidence rates of dizziness, nausea and vomitus were comparable among all the three groups with no statistical differences (all P>0.05).

In patients undergoing anesthesia with remazolam, the use of flumazenil can not only shorten the resuscitation time and the time that the patients need to stay in the resuscitation room, but also speed up the recovery of the patients′ recognition, walking and fine motor skill abilities.

The clinical data of 7 patients (3 males and 4 females) with functional pituitary neuroendocrine tumor treated by endoscopic transnasal resection of the cavernous sinus medial wall from May to October 2023 in the Department of Neurosurgery of the First Affiliated Hospital of University of Science and Technology of China were retrospectively analyzed. They ranged in age from 29 to 60, with an average age of 45. The clinical diagnosis was acromegaly in 5 cases and Cushing′s disease in 2 cases. There were 1 cases of microadenoma and 6 cases of macroadenoma. Knosp grade: Grade 1 adenoma in 3 cases, grade 2 adenoma in 3 cases and grade 3A adenoma in 1 case. Intraoperative resection of cavernous sinus medial wall was performed on the side of tumor. Five cases were determined to be invaded by tumor, and 2 cases were uncertain. No internal carotid artery injury occurred in all patients. The average intraoperative blood loss was 156 ml, and no patient was transfused. Postoperative endocrine remission was found in 6 cases, and tumor cells were found in 6 cases by pathological examination of the medial wall of cavernous sinus. No serious complications occurred in all patients. For Knosp grade 1-3 functional pituitary neuroendocrine tumor surgery, if there is no clear false envelope or normal pituitary between the tumor and the cavernous sinus medial wall during the operation, the cavernous sinus medial wall should be actively removed to improve the postoperative endocrine remission rate.

Autoimmune enteropathy (AIE) is a rare disease that presents as chronic watery diarrhea with malabsorption and weight loss. AIE-like clinical manifestations and pathological features are more rare in patients with ulcerative colitis (UC). This paper reports a case of a 66-year-old male patient who was diagnosed with UC due to blood in the stool. Combined with endoscopic findings and pathological findings, the initial treatment with mesalazine was effective, but the efficacy was not good in the later stage. The blood in the stool was repeated, and the chronic massive watery diarrhea appeared. The fasting test was ineffective. The diarrhea did not improve significantly after oral hormone and active anti-infective treatment. After admission, the patient's condition was recurrent, and laboratory tests showed ANA cytoplasmic type 1:80, and anti-neutrophil cytoplasmic antibody (ANCA) was positive; Perfect gastroscopy in the later stage showed that the posterior duodenal bulb and descending mucosa were rough and uneven, the small intestinal villi were shortened, and there were multiple white dotted changes in the descending segment. Biopsy pathology showed that the small intestinal mucosal villi were blunt and partially disappeared, the intraepithelial lymphocytes slightly increased, goblet cells decreased, Pan cells disappeared, apoptotic bodies were seen, plasma cells and scattered eosinophils were seen in the membrane propria. After excluding other diseases, UC combined with AIE with intestinal infection was diagnosed. Diarrhea was relieved after antiviral and intravenous methylprednisolone (30 mg/time, once/d) treatment, and tacrolimus was added during the subsequent hormone reduction. Maintenance therapy. At the follow-up in March 2024, the diarrhea was relieved, and the gastroscopic and pathological manifestations were improved compared with the previous ones.

Neuronavigation technology, as an advanced high-precision surgical positioning technology, has promoted the development of minimally invasive neurosurgery. With the improvement of neuroimaging technology and computer computing power, navigation systems have diversified functions, and are widely used in surgery of brain tumors, cerebral hemorrhage, cerebrovascular malformations and other diseases. The emergence of optical navigation has solved the traumatic problem of framed stereotactic and has become the mainstream neuronavigation system at present. The application of electromagnetic navigation has solved the problem of line-of-sight occlusion of optical navigation, but it can't completely replace optical navigation at present because of the instability of its magnetic field. Virtual navigation based on mixed reality technology brings immersive experience to clinicians and gets rid of the "hand-eye separation" problem of traditional navigation. 3D printing positioning guide technology has achieved good results in many clinical reports because of its low cost and simple operation. The emergence of neural navigation robots has led the development of intelligent navigation. However, how to reduce the R&D cost of navigation and simplify its clinical use process on the premise of ensuring navigation accuracy still needs further exploration.

The occurrence and development of multiple myeloma depend on its interactions with the bone marrow microenvironment and immune system, which are often mediated by key surface antigens. Regarding surface antigen molecules of myeloma cells, a large number of literatures have confirmed the biological activity and prognostic value of some commonly used antigens, and even targeted drugs developed based on certain surface antigens have been approved for use. This article reviews and summarizes some recent studies of myeloma surface markers, including CD319, CD229, GPRC5D, CD47, CD84, analyzes the biological activity of each antigen, the difference between its expression on normal and malignant plasma cells, and its impact on prognosis. Understanding the roles of these specific surface antigens can provide a new research direction for targeted therapy of multiple myeloma, and provide a reference for more individualized prognostic monitoring and treatment of patients with multiple myeloma.

There are currently many guidelines on the management of unexpected difficult airways, but few guidelines on expected difficult airways. It is also expected that difficult airways need to be paid attention to, especially the iatrogenic difficult airways caused by treatment devices such as cephalopelvic ring traction of patients with severe spinal deformity for secondary correction are challenging. Cephalopelvic ring traction is a rare iatrogenic difficult airway in patients with severe spinal deformity for secondary orthopedic surgery. Its characteristics include straightening and fixation of the cervical vertebra, complete inability of the head to tilt backward, obstruction of laryngoscope placement caused by the head ring and the front support rod, and the patient cannot lie flat normally, which makes it difficult to intubate through the cephalic trachea. This article reviews the research progress of cephalopelvic ring traction for airway management in patients with severe spinal deformity undergoing secondary orthopedic surgery, in order to provide a reference for clinical anesthesia management. The contents include airway assessment methods, airway management methods, etc. Adequate preoperative evaluation, reasonable selection of conscious tracheal intubation protocol, optimization of details, safe extubation, smooth communication with patients, and active cooperation of patients are the keys to successful airway management of patients with severe spinal deformity by cephalopelvic ring traction.

A 19-year-old male went to the emergency department of Lishui Central Hospital, Zhejiang Province for "repeated hemoptysis for more than 1 year and aggravated for 2 weeks", and invited interventional and vascular surgery consultation. In the past 1 year, the patient has repeated hemoptysis, 2~5 ml each time, bright red color, no fever and chills, no chest tightness and breathlessness, and no night sweats. In the past 2 weeks, the number of hemoptysis increased, and the total amount increased. The previous patients had no history of hypertension, heart disease, kidney disease, cerebrovascular disease, malignant tumor, etc., and no history of anticoagulant use. The parents are in good health, and the patient has 1 brother and 1 sister, all of whom have no relevant medical history. Emergency pulmonary CT angiography (CTA) showed that the thoracic aorta was communicated with the left lower pulmonary vein, and the left lower pulmonary vein was thickened; Minor alveolar bleeding in the lower lobe of the left lung; Multiple thickened and tortuous small vessel branches were seen in the brachiocephalic vein (Figures 1, 2). Consider descending aortic pulmonary venous fistula (DAPVF), which is very rare. There is congenital abnormal development of blood vessels between the descending aorta and the left inferior pulmonary vein, resulting in increased blood supply to the lungs, and then massive hemoptysis and other symptoms, which is a rare chest vascular malformation. At present, there is no clear cause of the disease. Combined with previous case reports, DAPVF can be treated radically according to the surgical method of congenital patent ductus arteriosus, and the effect is good. This patient had a history of repeated hemoptysis. Combined with the CTA image of the patient, the thoracic aorta-left inferior pulmonary vein fistula was finally diagnosed. After abnormal communicating vessel occlusion, the symptoms of the patient were significantly improved.