Volume 4, Issue 2

Neuraxial anesthesia is often challenging in patients with obesity, spinal deformity, prior spinal surgery, ankylosing spondylitis, or of advanced age, as conventional landmark-based techniques frequently fail in this population. Ultrasound guidance has improved puncture accuracy; however, commonly used approaches may still be limited by patient positioning and the side from which the operator prefers to work. We report five cases of extremely difficult neuraxial anesthesia in which the procedure was successfully performed using an ultrasound-guided paramedian sagittal long-axis out-of-plane approach. This technique allows continuous visualization of the lamina and the anterior–posterior complex, providing a short and direct puncture path with real-time guidance. All procedures were completed successfully on the first attempt, with short puncture times and no anesthesia-related complications. These cases suggest that the ultrasound-guided long-axis out-of-plane approach is a safe, effective, and flexible option for managing difficult neuraxial anesthesia.

Objectives: This study aimed to identify acupoint selection patterns for breast cancer-related pain using the Knowledge Discovery in Databases (KDD) method, construct a data-informed candidate acupoint prescription, and preliminarily evaluate its clinical efficacy when combined with the World Health Organization three-step analgesic ladder. Methods: Databases including China National Knowledge Infrastructure, VIP Information, WanFang, PubMed, and Web of Science were searched from inception to May 2024. An Excel-based dataset was developed to analyze acupoint frequency and meridian attribution. Acupuncture prescriptions for cancer pain without specifying cancer type were retained as potentially informative references for breast cancer-related pain. Sixty eligible patients were randomized into two groups. The control group received standard three-step analgesics, including celecoxib, tramadol sustained-release, or oxycodone sustained-release according to pain severity. The intervention group received the same regimen plus a KDD-derived acupuncture prescription consisting of bilateral Hegu (LI4), Zusanli (ST36), Neiguan (PC6), Taichong (LR3), Sanyinjiao (SP6), and Ashi points. Needles were retained for 30 minutes using balanced stimulation, five sessions per week for three weeks. Outcomes included pain intensity, breakthrough pain frequency, duration of pain relief, Karnofsky Performance Status, sleep quality, depressive symptoms, analgesic efficacy, quality of life, and safety. Results: The KDD-derived candidate prescription was associated with a higher overall response rate than analgesics alone. Patients receiving adjunctive acupuncture showed greater reductions in pain intensity and breakthrough pain episodes, as well as improvements in functional status, sleep quality, and depressive symptoms. Fewer adverse events were reported in the acupuncture group. Conclusions: This study proposes a potential acupoint combination for relieving breast cancer-related pain based on distal meridian points and local tender points. Combined acupuncture and conventional pharmacotherapy may improve analgesic outcomes, quality of life, and psychological status, with a favorable safety profile.

Sepsis is a systemic inflammatory response syndrome triggered by infection. It presents with simultaneous overactive immune activation and immune paralysis, leading to a cytokine storm, tissue injury, and multiple organ failure. The molecular mechanisms and pathological characteristics of the septic cytokine storm are comprehensively interpreted from multiple perspectives, including immune regulation, signaling pathways, cellular interactions, metabolic state reprogramming, and microcirculatory dysfunction. The cross-activation of signaling pathways, including NF-κB, JAK/STAT, mitogen-activated protein kinase (MAPK), and NLRP3 inflammasome, underlies the core mechanism for the enhancement of the inflammatory response via continued release of proinflammatory cytokines and also is involved in maintaining immune balance. In the latestage immunosuppressive phase, Treg cells, myeloid-derived suppressor cells (MDSCs) and regulatory macrophages play pivotal roles in reestablishing host homeostasis through negative feedback, and their dysfunction is closely associated with secondary infections and high mortality. This review consolidates the latest developments in precision medicine and multidimensional biomarkers, emphasizing the prospective value of several markers such as lactate and CD64, pentraxin 3 (PTX3), and BMP9 for early diagnosis and rognosis evaluation. Moreover, it reviews novel immunomodulators, for instance, bee venom peptides, GDF15, N-(1,3,4-oxadiazol-2-yl) guanidine (NWG), 4-octyl itaconate  (4-OI), and nanoparticle drug delivery systems that inhibit inflammatory signaling cascades, restore energy metabolism, and provide organ protection. Taken together, the pathogenic mechanisms of sepsis are non-linear and dynamic, which may render single-target therapy insufficient for successful management. Personalized interventions targeting multi-target network regulation based on omics and AI models may accomplish precision monitoring and stratified treatment of inflammatory responses, also providing new theoretical and clinical strategies to reduce sepsis-related mortality.

Perioperative pain management remains challenging, as inadequate analgesia may delay recovery and increase opioid exposure. Multidisciplinary pain management (MPM) emphasizes multimodal and collaborative strategies, creating opportunities for integrating non-pharmacological interventions. Acupuncture anesthesia (AA), derived from traditional Chinese medicine, has re-emerged as a potential adjunct in perioperative care through modulation of nociceptive transmission, stress responses, and opioid requirements. This review summarizes the historical development, proposed neuroimmune mechanisms, and current clinical applications of AA in modern perioperative settings. Evidence from randomized controlled trials and meta-analyses suggests that AA may reduce postoperative pain scores, opioid consumption, and postoperative nausea and vomiting, and facilitate recovery in selected procedures. Moderate-level evidence supports its adjunctive role in gastrointestinal, orthopedic, and gynecological surgeries, whereas evidence in thoracic, cardiac, and highly invasive procedures remains limited and inconsistent. Critically, current evidence is constrained by small sample sizes, heterogeneous acupuncture protocols, inadequate blinding, regional concentration of studies, and insufficient long-term outcome reporting. These limitations reduce external validity and hinder guideline-level recommendations. Overall, AA shows promise as part of MPM pathways, particularly in enhanced recovery protocols, but standardized intervention protocols and large multicenter high-quality trials are needed before broader implementation in perioperative anesthesia practice.

Sepsis is typically initiated by bacterial infection and the associated immune dysregulation displays a complex, dynamic biphasic immune response characterized by hyperinflammation followed by immunosuppression. In the initial period, pathogens activate the innate immune system through receptors such as Toll-like receptors (TLRs) and NOD-like receptors (NLRs), resulting in the massive release of cytokines, including IL-1β, IL-6, and IFN-γ, thereby initiating a "cytokine storm" that leads to vascular endothelial damage, complement activation, and the induction of abnormal cellular aggregation. Sustained activation of inflammatory signals initiates inflammasome-mediated cell death, including pyroptosis-apoptosis-necroptosis (PANoptosis), leading to systemic inflammation and organ dysfunction. Later, the host develops an immunosuppressive phase characterized by increased anti-inflammatory mediators (e.g., IL-10 and TGF-β), exhaustion of B, T, and NK cells, and immune checkpoint-mediated immune paralysis. The stepwise progression of these two stages suggests that sepsis is not simply a consequence of uncontrolled inflammation but rather reflects immune system reprogramming. A better understanding of the molecular basis of inflammation and immunosuppression, particularly the crosstalk among cell death pathways, metabolic reprogramming, and immune regulation, may facilitate timely precision interventions and the restoration of host immune homeostasis in sepsis.