OBJECTIVE:To compare the effects of general anesthesia (GA) and regional anesthesia (RA) on postoperative anxiety and/or depression (PAD) in patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR), and explore potential mediation by salivary cortisol (SC) or alpha-amylase (sAA). METHODS:This prospective, randomized trial compared GA versus RA in 82 patients undergoing ACL reconstruction. Primary outcomes were incidences of PAD, SC, sAA, and blood glucose levels. Secondary outcomes were knee swelling, skin temperature, postoperative opioid consumption, Numeric Rating Scale (NRS) pain scores, hospital stay, and hospitalization costs. Assessments were conducted at 1d preoperatively (T0), surgery day (T1), postoperative 2 h (T2), 1d (T3), 2d (T4), and 5d (T5). RESULTS:After adjusting for all confounding factors combined (anesthesia preference, preoperative NRS pain scores, and baseline HADS scores), the incidence of postoperative anxiety was significantly higher in the RA group than in the GA group at T3 ( P < 0.000), T4 ( P = 0.001), and T5 ( P = 0.001). In contrast, SC levels were significantly higher in the GA group than in the RA group at T2 ( P < 0.001), T3 ( P = 0.010), and T4 ( P = 0.012). Mediation analysis revealed a non-significant indirect effect of SC on the relationship between anesthesia technique and postoperative anxiety. No significant differences were observed in postoperative depression, sAA activity, or blood glucose levels between groups. CONCLUSIONS:GA exhibits lower postoperative anxiety in ACLR patients, whereas RA shows superior perioperative SC suppression. SC did not mediate the relationship between anesthesia technique and postoperative anxiety. These findings suggest GA may benefit anxiety-prone individuals, while RA appears advantageous for stress-sensitive cases.

Nerve injury-induced gene dysregulation in the dorsal root ganglion (DRG) is considered a key molecular basis for neuropathic pain genesis. Circular RNA is emerging as a critical regulator of gene expression. Here, we reported a novel circular RNA circNrip1 formed by back-splicing from exon 3 to exon 2 of the Nrip1 pre-RNA. Peripheral nerve injury upregulates circNrip1, but not Nrip1 mRNA, in injured DRG neurons, at least in part due to increased binding of the RNA-binding protein FUS to Nrip1 pre-RNA, thereby promoting circNrip1 formation. Blocking this upregulation attenuates nerve injury-induced increases in toll-like receptor 2 (Tlr2) mRNA and TLR2 protein levels in injured DRG, as well as nerve injury-induced nociceptive hypersensitivity. Conversely, mimicking this upregulation elevates DRG Tlr2 mRNA and TLR2 protein expression and produces neuropathic pain-like symptoms in naïve mice. Mechanistically, upregulated circNrip1 enhances its binding to the 3'- untranslated region (UTR) of Tlr2 mRNA and to the RNA-binding protein SYNCRIP, thereby recruiting more SYNCRIP to the Tlr2 mRNA 3'-UTR and stabilizing Tlr2 mRNA in injured DRG neurons. Thus, circNrip1 contributes to neuropathic pain by promoting SYNCRIP-triggered stabilization of TLR2 in DRG neurons and represents a promising therapeutic target for intervention.

ABSTRACT:Nerve trauma-induced alternations of gene expression in the neurons of dorsal root ganglion (DRG) participate in nerve trauma-caused nociceptive hypersensitivity. Transcription factors regulate gene expression. Whether the transcription factor E74-like factor 1 (ELF1) in the DRG contributes to neuropathic pain is unknown. We report here that peripheral nerve trauma caused by chronic constriction injury (CCI) of unilateral sciatic nerve or unilateral fourth lumbar spinal nerve ligation led to the time-dependent increases in the levels of Elf1 mRNA and ELF1 protein in injured DRG, but not in the spinal cord. Preventing this increase through DRG microinjection of adeno-associated virus 5 expressing Elf1 shRNA attenuated the CCI-induced upregulation of matrix metallopeptidase 9 (MMP9) in injured DRG and induction and maintenance of nociceptive hypersensitivities, without changing locomotor functions and basal responses to acute mechanical, heat, and cold stimuli. Mimicking this increase through DRG microinjection of AAV5 expressing full-length Elf1 upregulated DRG MMP9 and produced enhanced responses to mechanical, heat, and cold stimuli in naive mice. Mechanistically, more ELF1 directly bond to and activated Mmp9 promoter in injured DRG neurons after CCI. Our data indicate that ELF1 participates in nerve trauma-caused nociceptive hypersensitivity likely through upregulating MMP9 in injured DRG. E74-like factor 1 may be a new target for management of neuropathic pain.

Objective To evaluate the analgesic effectiveness of two novel regional nerve blocks in paediatric patients with developmental dysplasia of the hip (DDH) after open reduction surgeries. Design Prospective, double-blinded, randomised controlled trial. Setting 2 tertiary teaching hospitals in China between August 2017 and July 2018. Participants 110 paediatric patients aged 2–10 years with DDH undergoing open reduction surgeries were recruited, 95 were randomised and 90 were included in the final analysis. Interventions Random assignment to quadratus lumborum block III (QLB III) group, transversalis fascia plane block (TFPB) group and the control (no region nerve block) group. Primary and secondary outcome measures The primary outcome was the Face, Legs, Activity, Cry and Consolability (FLACC) Scale Scores. Secondary outcomes included perioperative opioid consumption, the time until first press of nurse-controlled analgesia/patient-controlled analgesia (NCA/PCA) pump and the total counts number of pressing, length of postanaesthesia care unit (PACU) stay, length of hospital stay, parental satisfaction with pain management and adverse events. Results Mean FLACC Scores were significantly lower in QLB III group and TFPB group while in the PACU and for 48 hours postoperatively, compared with control group (p<0.0001, p<0.0001, respectively). No differences were found for FLACC Scores between QLB III group and TFPB group, neither at rest (p=0.0402) nor while posture changing (p=0.0306). TFPB prolonged the first-time request for NCA/PCA analgesia, and decreased the total number of pressing counts, compared with QLB III (22.5 (16.2 to 28.7) vs 11.7 (6.6 to 16.8), p<0.0001; 2.4 (1.3 to 3.6) vs 3.8 (2.8 to 4.8), p=0.0111, respectively). No patient experienced any adverse events. Conclusions We suggested that both ultrasound-guided QLB III and TFPB should be considered as an option for perioperative analgesia in children with DDH undergoing open reduction surgeries. TFPB was superior to the QLB III because it prolonged the first-time request for NCA/PCA analgesia and decreased the total counts number of pressing. Trial registration number NCT03189966 /2017.

Objective. To explore whether better teaching effect can be achieved by applying the online and offline interactive teaching method to clinical anesthesiology teaching. Methods. Sixty-three students in grade three majoring in anesthesiology of Wenzhou Medical University were selected as research objects and randomly divided into 2 groups. The experimental group (32 students) adopted the online and offline interactive teaching method. The control group (31 students) adopted the traditional teaching method. The teaching effect was evaluated by the theoretical test results of the two groups and the survey of students in the experimental group. Results. The score of the theoretical test of students in the experimental group (79.31 ± 4.54) was higher than that of students in the control group (75.61 ± 4.88), and the difference achieved statistical significance p<0.05. 81.3% of the students think that the interactive teaching method enhances the interest of learning. 90.6% (29/32) of the students in the experimental group hold positive attitude towards the fact that the overall learning effect can be improved by the online and offline interactive teaching method. Conclusions. The online and offline interactive teaching method can not only improve students’ theoretical test results but also help to improve students’ learning participation. Students have given a high score for the evaluation of the online and offline interactive teaching method; good teaching effect has been achieved.

Objective To determine the risk factors for postoperative hyperactive-type delirium (PHTD) in elderly patients undergoing orthopedic surgery.Methods A total of 7 171 elderly patients of both sexes,aged more than or equal to 65 yr,of American Society of Anesthesiologists physical status Ⅰ-Ⅳ,who underwent orthopedic surgery from January 2008 to December 2012 in Second Affiliated Hospital of Wenzhou Medical University,were retrospectively analyzed.Data such as gender,age,preoperative electrolytes,blood glucose,hemoglobin,albumin,senile dementia and use of benzodiazepines,type of operation,anesthesia methods,operation time,intraoperative use of anticholinergic agents and benzodiazepines and hypotension (decrease more than 20％ of the baseline),and postoperative electrolyte,hemoglobin,albumin and hypotension were collected.The patients were divided into postoperative PHTD group (group PHTD) and postoperative non-PHTD group (group non-PHTD) according to whether PHTD developed within 7 days after operation.The risk factors of which P values were less than 0.05 would enter the multivariate logistic regression to stratify the risk factors for postoperative PHTD.Results Ninety-nine patients developed PHTD,and the incidence was 1.38％.The results of logistic regression analysis showed that age more than or equal to 80 yr,hip surgery and preoperative anemia were independent risk factors for postoperative PHTD (P＜0.05).Conclusion Age more than or equal to 80 yr,hip surgery and preoperative anemia are independent risk factors for postoperative PHTD in elderly patients undergoing orthopedic surgery.

Objective To evaluate the effect of dexmedetomidine on postoperative outcomes in ped?iatric patients undergoing open reduction and internal fixation following upper limb fracture performed under sevoflurane anesthesia combined with brachial plexus block. Methods Sixty American Society of Anesthe?siologists physical status Ⅰ pediatric patients of both sexes, aged 6-12 yr, with body mass index <24 kg∕m2, scheduled for elective open reduction and internal fixation following upper limb fracture, were ran?domly divided into ropivacaine group(group R)and dexmedetomidine mixed with ropivacaine group (group DR), with 30 cases in each group. Interscalene brachial plexus block was performed under ultra?sound guidance after sevoflurane anesthesia, 0.25% ropivacaine plus 1 μg∕kg dexmedetomidine(0.3 ml∕kg)was given in group DR, and 0.25% ropivacaine 0.3 ml∕kg was given in group R. The emergence time was recorded, and the development of agitation was observed immediately after emergence from anes?thesia. Sensory block duration, motor block duration, consumption of sedatives and analgesics during post?anesthesia care unit(PACU), consumption of rescue analgesics within 24 h after operation, length of stay in PACU and adverse reactions in the perioperative period were observed and recorded. Results Compared with group R, the incidence of agitation immediately after emergence from anesthesia was significantly de?creased, sensory block duration was prolonged, the consumption of sedatives and analgesics during PACU and rescue analgesics within 24 h after operation was reduced, and the emergence time and length of stay in PACU were prolonged in group DR(P<0.05). There was no significant difference in the incidence of bradycardia between the two groups(P>0.05). No adverse reactions were found in the perioperative period in the two groups. Conclusion Dexmedetomidine can promote postoperative outcomes in pediatric patients undergoing open reduction and internal fixation following upper limb fracture performed under sevoflurane anesthesia combined with brachial plexus block.

Objective: To evaluate the safety of dexmedetomidine on pediatric patients undergoing removal of airway foreign body. Methods: Randomized controlled trials (RCTs) about the pediatric patients un-dergoning removal of airway foreign body receiving intravenous infusion of dexmedetomidine were searched in The Cochrane Library, Medline, CNKI, VIP, CBM up to March 2016. The methodological quality of the included literatures were evaluated, and meta-analyses were performed with The Cochrane Collaboration's RevMan 5.0 software. Results: A total of 4 RCTs involving 227 pediatric patients were included. The results of meta-analyses showed: ①Dexmedetomidine significantly reduced the coughing ratio (OR=0.44, 95%CI: 0.21-0.92, P<0.05); ②Dexmedetomidine significantly reduced the airway-spasm ratio (OR=0.21, 95%CI: 0.05-0.86, P<0.05); ③Dexmedetomidine did not significantly reduce the breath holding ratio (OR=0.50, 95%CI: 0.22-1.14, P>0.05); ④Dexmedetomidine significantly reduced the airway-spasm ratio (OR=0.44, 95%CI: 0.21-0.92, P<0.05). Conclusion: Dexmedetomidine is a safe anesthestic for airway foreign body removal in children from general anesthesia, decreasing the perioperative respiratory adverse events (coughing, airway-spasm, hypox-emia). However, because of the limited quality of the included researchs, further verification with more high quality RCTs are needed.

目的 观察右美托咪定联合罗哌卡因在小儿肌间沟臂丛鞘内注射对感觉神经及运动神经阻滞的影响.方法 选择2014年7月～2015年3月间在我院择期行上肢桡侧切复内固定手术的60例患儿(6～12岁),随机分为右美托咪定组(Dex组,n=30)和对照组(C组,n=30).Dex组采用0.25％罗哌卡因(0.3 mL/kg)联合1μg/kg右美托咪定在超声引导下行肌间沟臂丛神经阻滞;C组采用0.25％罗哌卡因(0.3 mL/kg).记录术后不同时间点CHIPPS评分(判断疼痛程度)和改良Bromage分级(判断运动阻滞程度);观察臂丛神经感觉阻滞和运动阻滞的持续时间,并记录不良反应.结果 与C组比较,Dex组患儿术后8h、12h的CHIPPS评分及改良Bromage评分均降低,差异均有统计学意义(P＜0.05);Dex组感觉神经阻滞时间[(750.2±206.0)min]较C组[(591.6±182.1)mini显著延长(P=0.0060);两组运动神经阻滞时间比较,差异无统计学意义[(594.1± 180.6)min vs(524.3±171.9)min,P=0.1766)].结论 右美托咪定1 μg/kg联合0.25％罗哌卡因用于小儿肌间沟臂丛神经阻滞时可以增强感觉神经及运动神经的阻滞效果并延长感觉神经阻滞时间,改善术后镇痛效果,且无明显不良反应.

目的 探讨非心脏手术患儿围术期死亡的危险因素,建立预测死亡的风险评分系统.方法 选择2008年1月至2013年12月0～14岁非心脏手术围术期死亡患儿(57例)及非死亡患儿(1 14例)的临床资料,对其年龄、BMI、ASA分级、是否早产、手术方式、手术类别、体温、血氧饱和度(SpO2)、是否饱胃、手术时间、手术次数、WBC、是否贫血、是否低白蛋白、是否凝血功能异常及是否血电解质异常共17项可能的风险因素进行多因素和单因素分析,确定死亡危险因素,建立预测评分系统.结果 多因素回归确定非心脏手术患儿围术期死亡的危险因素为:年龄＞1岁,BMI＜ 15kg/cm2、ASA≥3级、SPO2＜96％、饱胃、凝血功能异常(均P＜0.05).非心脏手术患儿围术期死亡发生的风险评分系统如下:年龄＜1岁(14分),BMI＜ 15 kg/cm2(17分),ASA≥3级(30分),SpO2＜96％(22分),饱胃(16分),凝血异常(27分)(P＜0.05或0.01).根据方程绘制ROC曲线,所对应的非心脏手术患儿发生死亡的风险得分为30.5分,灵敏度为98.2％,特异度为89.5％.如患儿得分＞30.5分,则围术期死亡的发生率大大增加.结论 非心脏手术患儿围术期死亡的预警评分系统简单易行,结果可靠,可为围术期死亡的早期发现和干预提供帮助.

Background: Although some studies have investigated the potential predictors of perioperative mortality, there are few specifically for pediatrics.Objective: The aim of the retrospective study was to analyze potential preoperative risk factors and to develop a pediatric preoperative risk prediction score (PRPS), and to predict postoperative ICU admission and the incidence of perioperative death in pediatric patients.Methods: Patients who postoperatively admitted to ICU or died (occurred within 30 days after the surgery) from 263 607 pediatric surgical patients with age from 1 day to 14 years old in eight centers in China from October 2010 to September 2013 were retrospectively analyzed. About 5500 non-ICU admission and death patients were randomly selected from those 263 607 patients as controls for analysis comparison. Independent risk factors and a risk model were derived from these analyses, and were further assessed with the likelihood ratio test and the area under the receiver operating characteristic (ROC) curve.Results: There were 1812 ICU admission or death patients but 187 patients' records are incomplete. There were 487 patients with incomplete records among 5500 controls. Collectively, data from 6626 patients were enrolled in final analyses. With multiple logistic regression analysis, age, ASA physical status, SpO(2), prematurity, and unfasted status were found to be independent predictors for critical patients. The AUC value of 0.905 indicated excellent predictive performance between critical and noncritical predictors.Conclusions: Our study revealed that age, ASA physical status, SpO(2), prematurity, and unfasted status are risk factors to predict postoperative ICU admission and death in pediatric patients.

目的 分析小儿肠道手术死亡病例的临床特点,为治疗管理策略提供依据.方法 检索并统计2010年1月～2013年12月本院37例小儿肠道手术死亡病例(包括自动出院病例).结果 37例死亡病例中1～31 d年龄段死亡人数占总死亡病例的83.8％;体重指数(BMI)处于异常低值,BMI的P50为12.5;同时81％的病例以不同程度的肠梗阻/腹膜炎为首要和主要的临床表现.可获得死亡结论的14例病例中,患儿死亡前均有不同程度的多脏器功能衰竭(MODS),以脓毒症休克或感染性休克为主的MODS占57.1％,以血液系统功能异常为主的MODS占21.4％,心肺骤停占21.4％.结论 小儿肠道术后死亡的危险因素可能为新生儿、早产、低出生体重、急诊,但需要多中心大样本病例的回归建模来确定其危险因素.先天性肠道疾病是其主要病因.重症感染、循环衰竭、呼吸衰竭、血液系统功能异常是小儿肠道疾病术后死亡前全身衰竭的标志.

目的 系统评价分析氨茶碱用于全麻术后催醒的有效性及可行性.方法 计算机检索Cochrane图书馆、MEDLINE、CNKI、VIP及CBM(从建库至2015年6月),收集所有氨茶碱用于全麻术后催醒的随机对照试验(RCT),使用Cochrane系统评价方法对纳入研究进行质量评价后,采用RevMan 5.0软件进行Meta分析.结果 共纳入14个RCT,包括1055例患者.Meta分析结果显示:①苏醒时间:氨茶碱与空白对照组比较能明显缩短全麻术后睁眼时间、拔管时间和听从指令时间[分别为WMD=-1.85,95％CI(-2.59,-1.12),P＜0.01;WMD=-1.98,95％CI(-2.34,-1.62),P＜0.01;WMD=-3.06,95％CI(-3.80,-2.32),P＜0.01],效果与多沙普仑相当[分别为WMD=1.59,95％CI(-0.33,3.60),P＞0.05;WMD=0.72,95％CI(-0.53,1.96),P＞0.05;WMD=1.09,95％CI(-1.02,3.20),P＞0.05],听从指令时间优于毒扁豆碱[WMD=-6.91,95％CI(-10.17,-3.65),P＜0.01];②BIS值:氨茶碱与空白对照组比较能明显提高全麻苏醒期BIS值(P＜0.05),与多沙普仑相当(P＞0.05);③不良事件:与空白对照组比较,氨茶碱不增加术后寒战、烦躁、恶心、呕吐、心律失常发生率(P＞0.05),术后躁动发生率少于毒扁豆碱组及纳洛酮组[RR=6.0,95％CI(1.94,18.55),P＜0.05;RR =0.09,95％CI(0.01,0.68),P＜0.05].结论 现有研究表明,氨茶碱能有效缩短全麻术后苏醒时间,不增加术后不良事件发生,是一种安全有效的全麻催醒药物.但限于纳入研究方法学质量上的局限性,本系统评价结果尚需更多高质量的RCT进一步验证.

目的 探讨腹部手术患儿围术期死亡的术前相关危险因素.方法 回顾性分析58例围术期死亡的腹部手术患儿病例资料,并选择同期住院的小儿腹部手术未死亡患儿58例作为对照组,对数据进行单因素分析,并选取有意义的危险因素进行logistic回归分析.结果 单因素分析筛选出7个可能与腹部手术患儿术后死亡相关的危险因素,包括年龄、低BMI、ASA分级、早产、急诊、凝血功能异常、饱胃.logistic回归分析结果显示:年龄＜0.1岁(0R=303.501,95％Cl 20.553～4481.738,P=0.000)、低BMI(OR=17.870,95％Cl 1.514～210.976,P=0.022)、ASA≥Ⅲ级(OR=53.509,95％Cl 4.005～714.919,P=0.003)、凝血功能异常(OR=72.222,95％Cl 3.154～1653.967,P=0.007)为腹部手术患儿围术期死亡的术前独立危险因素.结论 腹部手术患儿合并年龄＜0.1岁、BMl＜ 15kg/m2、ASA≥Ⅲ级、凝血功能异常时应警惕发生死亡的可能性.

Objective To investigate effect of dexmedetomidine on postoperative analgesia pump dose and effect.Methods 50 cases of patients with abdominal surgery under general anesthesia were selected.According to the postoperative analgesic drugs were divided into control group and experimental group, 25 cases in each group were given corresponding drug treatment.After treatment, the visual analogue scale, comfort score, adverse reaction rate and dosage of analgesic drugs were detected and compared.Results Compared with the control group,the VAS score were lower(P <0.05),the BCS score were higher(P<0.05),the adverse reaction rate were lower(P<0.05),the dosage of analgesic pump were lower(P<0.05). Conclusion Dexmedetomidine can significantly reduce postoperative pain degree of patients, reduce the incidence of adverse reaction, reduce analgesic dosage of the drug pump.

目的 研究右美托咪定对内毒素诱导感染性休克大鼠细胞免疫的作用.方法 选取12周龄雄性Walse大鼠18只,采用数字表法随机分为空白组(S组)、内毒素组(E组)和右美托咪定治疗组(D组),每组6只.S组静脉推注1.0 mL/kg 0.9％生理盐水后,持续泵入同浓度的生理盐水,E组、D组均采用静脉注射内毒素(LPS)建立感染性休克大鼠模型,D组在注射内毒素后持续微泵右美托咪定.持续监测心率(HR)、呼吸、有创动脉血压(ABP)及平均动脉压(MAP),用药后0.5、1、2、3、4、6h检测血清中IL-4(白介素-4)、IL-10、IFN-γ(γ干扰素)和IL-2的浓度,6h后处死大鼠,检测大鼠脾脏及胸腺caspase-3、caspase-8、caspase-9活性,测定淋巴细胞凋亡情况及Th1/Th2.结果 ①与S组相比,E组、D组大鼠血清的抗炎因子IL-4、IL-10和促炎因子IFN-γ、IL-2均显著提高,其差异均有统计学意义(P＜0.05).随着治疗时间延长,E组的IL-4、IL-10水平降低,IFN-γ、IL-2水平升高;D组IL-4、IL-10水平升高,IFN-γ、IL-2水平降低;两组比较差异有统计学意义(P＜0.05).②与E组相比,D组大鼠脾脏及胸腺caspase-3、caspase-8、caspase-9表达及淋巴细胞凋亡的阳性细胞数均显著减少,差异有统计学意义(P＜0.05).③D组大鼠脾脏及胸腺Th1/Th2比率均显著高于E组,差异有统计学意义(P＜0.05).结论 右美托咪定对感染性休克大鼠具有减轻炎症反应和改善免疫功能的作用,有利于改善预后.