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BACKGROUND: Upper tracheal surgery is used to treat patients who with tracheal tumors or tracheal stenosis. The non-intubated spontaneous ventilation anesthesia (NSVA) may have advantages over endotracheal intubation and surgical cross-field intubation in upper tracheal surgery. This study aimed to illustrate and assess the feasibility of NSVA strategy for upper tracheal surgery. METHODS: This is a retrospective case series study in which 51 patients (from May 2015 to August 2020) who met the criteria in NSVA strategy were analyzed. Anesthesia was performed using total intravenous anesthesia (TIVA) combined with bilateral superficial cervical plexus block (CPB) or thoracic epidural anesthesia (TEA). Patients received spontaneous ventilation through laryngeal mask airway (LMA) during the surgery. Anesthesia conversion technique was applied to patients who met the anesthesia conversion criteria. RESULTS: In total, 51 patients met the NSVA criteria and were included in this study. Forty-six out of 51 patients (90%) had TIVA + bilateral superficial CPB and five patients (10%) had TIVA + TEA + CPB. During the airway-opened period, 46 patients had stable spontaneous ventilation. Five patients need anesthesia conversion, two patients had high-frequency ventilation (HFV), and three patients required cross-field intubation. Postoperative complications occurred in seven (14%) patients, no reintubation was needed after surgery. The median postoperative hospital stay was 6.31±4.30 days. CONCLUSIONS: This NSVA strategy includes criteria for patient selection, preoperative assessment, surgical technique, airway management, criteria and technique for anesthesia conversion. The NSVA strategy is a feasible procedure in upper tracheal surgery.

General conditionals, if p then q, can be used to make assertions about sets of objects. Previous studies have generally found that people judge the probability of one these conditionals to be the conditional probability of q given p, P( q|p). Two experiments investigated the qualitative relation between the exhaustive possibilities, p & q, p & ¬q, ¬p & q, and ¬p & ¬q, and truth and possibility judgements about general conditionals. In Experiment 1, for truth judgements, people evaluated a general conditional as “true” in sets containing p & q cases but no p & ¬q, and “true” judgements depended only on P( q|p). In Experiment 2, for possibility judgements, people’s responses implied that only p & q cases have to be possible in a set for a general conditional to be true of the set. Our results add to earlier findings against representing a general conditional as the material conditional of extensional logic, and they provide novel disconfirmation of two recent proposals: the modal semantics of revised mental model theory and certain inferentialist accounts of conditionals. They supply new support for suppositional theories of conditionals.

Cadmium is a toxic heavy metal distributed broadly in the environment and manufactory industry. Long-term exposure to cadmium, considered as a risk for kidney injury, leads to chronic kidney disease eventually. Phospholipase D1 (PLD1) promotes cell proliferation and inhibits apoptosis, and might be involved in cadmium-induced kidney injury. In this study, we used miRNA microarray assays and bioinformatics analysis to identify miRNAs, which may regulate PLD1 expression and exert an impact on cadmium-induced kidney injury. MiR-122-5p and miR-326-3p，selected as candidates, were explored for their regulatory functions in kidney injury, using NRK-52E cells. Both of these two miRNAs exhibited higher expression in kidneys of SD rats after exposure to cadmium for 6 weeks. Cadmium treatment also increased miR-122-5p and miR-326-3p and decreased PLD1 in NRK-52E cells. Both of miR-122-5p and miR-326-3p could downregulate PLD1 expression through targeting its 3'UTR and enhance cadmium-induced apoptosis, while inhibiting either of these two miRNAs could reverse such effects. In conclusion, our results suggest that miR-122-5p and miR-326-3p might enhance cadmium-induced NRK-52E cell apoptosis through downregulating PLD1 expression.

Spontaneous ventilation video-assisted thoracic surgery (SV-VATS) is reported to have superior or equal efficacy on postoperative recovery to mechanical ventilation VATS (MV-VATS). However, perioperative safety of the SV-VATS blebectomy is not entirely demonstrated.We performed a noninferiority, randomized controlled trial (No. NCT03016858) for primary spontaneous pneumothorax patients aged 16 to 50 years undergoing a SV-VATS and the MV-VATS procedure. The trial was conducted at 10 centers in China from April 2017 to January 2019. The primary outcome was the comparison of intra- and postoperative complications between SV-VATS and MV-VATS procedures. Secondary outcomes included total analgesia dose, change of vital sign during surgery, procedural duration, recovery time, postoperative visual analog pain scores, and hospitalization length.In this study, 335 patients were included. There was no significant difference between the SV-VATS group and the MV-VATS group in the intra- and postoperative complication rates (17.90% vs 22.09%; relative risk, 0.81; 95% confidence interval, 0.52-1.26; P = .346). The SV-VATS group was associated with significantly decreased total dose of intraoperative opioid agents; that is, sufentanil (11.37 μg vs 20.92 μg; P .001) and remifentanil (269.78 μg vs 404.96 μg; P .001). The SV-VATS procedure was also associated with shorter extubation time (12.28 minutes vs 17.30 minutes; P .001), postanesthesia care unit recovery time (25.43 minutes vs 30.67 minutes; P = .02) and food intake time (346.07 minute vs 404.02 minutes; P = .002). Moreover, the SV-VATS procedure deceased the anesthesia cost compared with the MV-VATS ($297.81 vs $399.81; P .001).SV-VATS was shown to be noninferior to MV-VATS in term of complication rate and in selected patients undergoing blebectomy for primary spontaneous pneumothorax.

Background: Spontaneous breathing anesthesia (SBA) may have advantages over general anesthesia for cervical tracheal resection and reconstruction (TRR), avoiding the difficulties and complication caused by endotracheal intubation and surgical cross-field intubation. This prospective study evaluates SBA for cervical TRR. Methods: Date was obtained from 35 patients who had cervical TRR under SBA from May 2015 to March 2019. Intravenous sedation and ultrasound-guided bilateral superficial cervical plexus block (CPB) were applied to maintain effective analgesia and sedation. Results: Thirty-two patients with tracheal tumors and 3 patients with post-intubation tracheal stenosis underwent TRR. After the airway was opened, 29 patients resumed stable spontaneous breathing, 1 patient needed high-frequency jet ventilation, and 1 patient needed anesthesia conversion for surgical reasons. Conclusions: Spontaneous breathing anesthesia is feasible for the cervical TRR. It can be an alternative anesthetic technique for certain patients.

Cadmium is a severe environmental pollutant that mainly targets kidney and causes kidney disease in the end. However, the mechanism of cadmium-induced kidney disease is still unclear. In this study, we treated SD rats, kidney epithelial or fibroblast cells with cadmium, and examined the renal fibrosis process and underlying cellular and molecular mechanism. Rats received daily (Monday-Friday) subcutaneous injections of CdCl2, 0.6 mg/kg, for 6 weeks or 12 weeks, and NRK-52E cells were treated with CdCl2 of 8 μM for 24 h. Sirius red staining and immunohistochemistry assay showed that sub-chronic exposure to cadmium caused interstitial fibrosis in rat kidneys. Cell experiments showed that cadmium treatment in NRK-52E cells only changed levels of α-SMA, vimentin and E-cadherin, but not collagen1, indicating that cells other than EMT cells might be responsible for the extracellular matrix production. By contrast, co-culture of NRK-49F cells with cadmium-treated NRK-52E cells produced collagen1. Assays of supernatant of NRK-52E cell culture showed that the secreted Wnt1, Wnt4 were increased, while miR-503-5p was decreased by cadmium treatment. RT-QPCR assay found that miR-503-5p was downregulated in both kidney of rats and NRK-52E cells exposed to cadmium. miR-503-5p was further shown to be competent in hindering epithelial-mesenchymal transition and fibroblast activation. Given the well established involvement of Wnt/β-catenin pathway in fibrosis, this study suggested that dysregulations of Wnts and miR-503-5p coordinate in mediating cadmium-induced kidney fibrosis. Our findings might provide new insight in the cellular and molecular mechanisms of kidney interstitial fibrosis and novel therapeutic targets for cadmium-induced kidney disease.

Objectives To describe and assess the techniques of spontaneous-ventilation video-assisted thoracoscopic surgery (SV-VATS) for tracheal/carinal resections and compare the outcomes with the conventional thoracoscopic intubated method. Methods From May 2015 to November 2016, some 18 consecutive patients with malignant or benign diseases invading distal trachea and carina who met the criteria for SV were treated by SV-VATS resection. To evaluate the feasibility of this novel technique, they were compared with a control group consisting of 14 consecutive patients with the same diseases who underwent VATS resection using intubated general anesthesia from October 2014 to April 2015. Data were collected with a median follow-up of 10.2 months 75 (range: 1-27). Results The SV-VATS group consisted of 4 carinal resections and 14 tracheal resections. In the control group, 2 patients underwent carinal resection and 12 underwent tracheal resection. Median operative time was shorter in the SV-VATS group compared with the intubated group (162.5 minutes vs 260 minutes), as was the median time for tracheal end-to-end anastomosis (22.5 minutes vs 45 minutes) and carinal reconstruction (40 minutes vs 86 minutes). The lowest oxygen saturation during the procedure was 94.2% ± 4.9% in SV-VATS group and 93.9% ± 4.5% in the control group. The peak carbon dioxide level at the end of expiration was greater in the SV-VATS group (47.7 ± 4.2 mm Hg vs 39.1 ± 5.7 mm Hg). No conversion to tracheal intubation was needed in the SV-VATS group. Postoperative complications occurred in 6 patients in the SV-VATS group and 9 in the control group. Patients who underwent SV-VATS had a trend toward shorter postoperative hospital stays (11.5 ± 4.3 days vs 13.2 ± 6.3 days). One recurrence (SV-VATS group) and 2 deaths (one in each group) were observed during follow-up. Conclusions SV-VATS is a feasible procedure in tracheal and carinal resection and reconstruction in highly selected patients. It can be a valid alternative to conventional intubated VATS for airway surgery.

The objective of the study is to retrospectively analyze the cough status after double lumen tube (DLT) and spontaneous respiration thoracic anesthesia, to compare the degree of influence of anesthesia and surgical factors, and to investigate whether spontaneous respiration anesthesia can reduce the incidence of cough.Postoperative follow-ups were performed on 1,162 patients from July 2011 to December 2015 who meet the selected conditions, whose surgical approach is limited to VAST bullectomy, wedge resection, segmentectomy, or lobectomy. Patients' probability of cough in 1st day (T1), 2nd days (T2), 3rd days (T3), 1st month (T4), 3rd months (T5), 6th months (T6) and 12th months (T7) after thoracoscopic surgery were recorded, as well as the Leicester cough questionnaire (LCQ) survey results, visual cough score (VAS), and cough symptom scores. All cases were divided into double-lumen endotracheal tubes anesthesia group (group T, n=925 cases) and spontaneous respiratory anesthesia group (group S, n=456 cases), and group S was further divided into intravenous composite intercostal nerve block anesthesia group (group SB, n=157 cases) and intravenous combined epidural anesthesia group (group SE, n=299 cases).The probability of cough decreases with the increasing of postoperative time (P0.05). The probability of cough is similar between group SE and group SB (P0.05). The probability of cough in group T is significantly higher than other groups at any time point (P0.05). In group T, the symptom of cough is the most severe, the scores of physiological, psychological, and social parts of LCQ are the lowest, and the VAS score is the highest (P0.05), but all these are similar in group SE and group SB (P0.05). The duration of antibiotic application, the days of chest drainage tube indwelling, and the days of hospital stay are all lower in group S than in group T (P0.05).There is a correlation between pulmonary surgery and postoperative cough. The probability of postoperative cough is higher in the more invasive patients. The probability of coughing is approximately 27% to 36% at 3 months after surgery, and approximately 2.6% to 7.9% in one year after surgery. The combination of surgery and anesthesia methods increases the probability of cough from 48.9% to 65.1% at 3 months after surgery, and about 20.5% to 22.8% in 1 year after surgery. Spontaneous respiration anesthesia can significantly reduce the probability of cough, improve postoperative recovery, and improve postoperative quality of life.

Subglottic stenosis is an uncommon structural abnormality that can pose as a difficulty for patients undergoing surgery, and treatment is complex due to the special anatomical location. Pulmonary nodule resection in patients with subglottic stenosis is challenging and has not yet been reported. Here we present a case of pulmonary nodule resection in a patient with subglottic stenosis using uniportal thoracoscopy under spontaneous ventilation anesthesia (SVA). Compared with traditional double lumen endotracheal intubation, we believe this modified technique can significantly reduce airway trauma, and accelerate patient recovery.

With the development of minimally invasive thoracoscopic and anesthesia control techniques, intravenous anesthesia with spontaneous ventilation video-assisted thoracic surgery (SV-VATS) has been increasingly employed in management of pleural effusion, bullectomy for pneumothorax, mediastinal biopsy, thymectomy and thymomectomy, wedge lung resections, anatomical lung resections for radical treatment of lung cancer and even more complex surgical procedures including tracheal resection and sleeve lobectomy (1-7) This changes in surgical strategies have been applied in the believe that SV-VATS can avoid adverse effects of mechanical ventilation and the residual effects of muscle relaxants, can achieve a faster recovery of respiratory muscle function and lower operative morbidity (7,8).

Background To compare the safety and feasibility of ultrasound-guided thoracic paravertebral blockade (TPVB) and internal intercostal nerve block (IINB) for non-intubated video-assisted thoracic surgery (NIVATS). Methods Thirty-four patients who underwent NIVATS from April 2016 to May 2017 were retrospectively reviewed and divided into two groups consecutively according to local analgesia treatment, of which 20 patients received TPVB (P group) and the remaining 14 received IINB (I group). A Propensity Score Matching (PSM) analysis was performed to control the selection bias due to nonrandom assignment. Results The procedure of propensity scores yielded 2 matched cohorts of 14 patients. There were no significant differences between the two groups regarding gender, age, BMI, and surgical types (P>0.05). Blood-gas analysis 15 minutes after opening the chest showed significantly lower PaCO2 in the P group compared to the I group (P=0.004). The consumption of propofol from anesthesia induction to 15 minutes after opening the chest was also lower in the P group compared with the I group (P=0.012). There were no significant differences in the duration of surgery and visual analogue scale (VAS) pain scores between the two groups (P>0.05). Conclusions Ultrasound-guided TPVB can provide safe and reliable local anesthesia for NIVATS.

Cadmium is a common environmental and occupational pollutant and can produce toxic effects in a range of organs, especially in kidneys, after long-term exposure. MicroRNAs are ideal candidate biomarkers for various types of disorders, including renal diseases. In this study, we profiled the global miRNA expressions in rat kidneys using miRNA microarrays and found a collection of differentially expressed miRNAs induced by cadmium exposure. Among all of the candidate miRNAs, we identified miR-122-5p and miR-326-3p as early biomarkers for cadmium-induced nephrotoxicity. The two-miRNA signature was validated by quantitative real-time PCR in HK-2 and NRK-52E cells, rat kidney, serum and urine samples, and serum of an occupational population. Our results indicate that miR-122-5p and miR-326-3p may be potential biomarkers for cadmium exposure.

Objectives At present, few data exist regarding the comparisons of perioperative outcomes and recurrence of spontaneous ventilation (SV) video-assisted thoracic surgery (VATS) bullectomy using total intravenous anaesthesia (TIVA) with local anaesthesia (LA) or thoracic epidural anaesthesia (TEA). We evaluated the feasibility and safety of TIVA with LA in the management of primary spontaneous pneumothorax (PSP). Methods We conducted a single-institution retrospective analysis of patients undergoing VATS bullectomy between July 2011 and May 2015; 240 patients were included for analysis. Preoperative, intraoperative and postoperative variables of patients undergoing VATS bullectomy using TIVA-TEA (n = 140) were compared with those using TIVA-LA (n = 100). Results Baseline demographics were similar between groups. No patients in either group required conversion to thoracotomy. Three patients (TIVA-TEA: 2; TIVA-LA: 1) required conversion to intubated general anaesthesia. Both groups had comparable surgical duration, estimated blood loss, peak EtCO2 and lowest intraoperative SpO2 level. Postoperatively, thoracic drainage volume, duration of chest tube drainage and hospitalization cost did not differ between groups. The incidence of postoperative complications between groups was not significant (2% for TIVA-TEA vs 2% for TIVA-LA, P = 1.00). Pneumothorax recurrence rate was 3% in TIVA-TEA cases (n = 4) and 2% in TIVA-LA cases (n = 2). Conclusions SV-VATS bullectomy using TIVA with LA or TEA is technically feasible and safe. Both groups have comparable short-term outcomes and recurrence rates; TIVA-LA seems a valid alternative to TIVA-TEA for the surgical management of PSP under SV.

Previous tracheal surgeries were performed under tracheal and cross-field intubation. However, the intubation would lead to bleeding if the tumors were large or hemorrhagic. Moreover, the tracheal intubation might interfere the surgical vision and anastomosis during the reconstruction process. Therefore, we performed a tracheal tumor resection and reconstruction via nonintubated spontaneous anesthesia. We describe the feasibility and safety of tracheal surgeries via such anesthesia.

Background: Spontaneous ventilation VATS (SV-VATS) is reported to be associated with faster recovery and fewer complications than mechanical ventilation video-assisted thoracic surgery (MV-VATS). This study aimed to evaluate the effect of SV-VATS for patients with spontaneous pneumothorax. Methods: We performed a randomized controlled trial at 10 medical centers by recruiting primary pneumothorax patients undergoing SV-VATS and MV-VATS. Participants were randomly assigned (1:1), to receive non-intubated spontaneous ventilation (SV-VATS) or intubated mechanical one lung ventilation (MV-VATS). The primary outcome was the intraoperative surgery/anesthesia related accident rate, which was assessed according to incedences of intraoperative hypoxia, conversion to open surgery, conversion to intubation and other intraoperative adverse events that could happen in both groups. Other study outcomes included changes of vital signs, total analgesic dose, recovery time, post-operative complication rates, cost-effectiveness evaluation, etc. Findings: The trial began on Apr 10, 2017, and ended on Jan 03, 2019. During this time, 355 patients were assessed. After evaluation and randomization, 325 eligible patients were assigned to receive an SV-VATS (n=162) or MV-VATS (n=163) procedure. In the intention-to-treat analysis, there was no difference between the intraoperative accident rate of the SV-VATS (1.23%) and MV-VATS (1.23%) group (P=0.995). The SV-VATS group was associated with significantly decreased total dosage of both sufentanil (11.37 μg vs 20.92 μg; p

Background: The current guidelines emphasize the significant role of video-assisted thoracic surgical lung biopsy (VATS-LB) for a definite diagnosis of interstitial lung diseases (ILD), but they also encourage physicians to maintain the balance between the surgical benefits as well as risks. Both spontaneous ventilation video-assisted thoracic surgery (VATS) and uniportal VATS have emerged as remarkable progresses in VATS. We combined these two types of VATS and refined them to uniportal spontaneous ventilation VATS without urinary catheterization and chest tube drainage [uniportal and tubeless VATS (UT-VATS)] to perform LB in selected patients with ILD. Methods: From January 2014 to May 2015, 43 patients were included in the study. The surgical data was retrospectively analyzed. Results: The mean diffusion capacity for carbon monoxide (DLCO) of patients was 57.6%±13.0%, forced vital capacity (FVC) was 73.1%±17.0%. There was no 30-day mortality. No patient required a switch to intubated anesthesia. The mean age was 49.6±10.7 years. The general median operative duration was 22±5 minutes, with 25±3 minutes for multiple specimens and 15±2 minutes for single specimen, respectively. Intra-operative conversion to 2-portal VATS followed by chest tube drainage and urinary catheterization occurred in 3 (7.0%) patients due to extensive pleural adhesion, and postoperative chest tube insertion was documented in 1 (2.3%) patient due to subcutaneous emphysema. No postoperative mechanical ventilation was noted. Precise histopathological diagnosis was achieved in 38 (88.4%) patients. Conclusions: Uniportal and tubeless thoracoscopic LB using spontaneous ventilation anesthesia can be considered a feasible and safe operation method for selected patients with ILD.

Immediate recovery from thoracic surgery, twenty years ago, this was only a dream of thoracic surgeons. However, in 2016 we have seen the development of techniques culminate to take what may have been a 5-day recovery 20 years ago (1), to immediate patient ambulation and oral intake post operatively and patient discharge within 24 hours (2).

Primary spontaneous pneumothorax (PSP) has an estimated incidence ranging from 17–24/100,000 and 1–6/100,000 among males and females, respectively (1,2). It usually occurs in tall thin individuals between 10–30 years of age, especially smokers (3).