Neurologic disease promoted by microbial pathogens, sterile injury, or neurodegeneration rapidly induces innate immunity in adjacent healthy tissue, which in turn contributes extensively to neurologic injury. With more recent focus on innate immune processes, it appears that necrotic, but not apoptotic, death mechanisms provoke inflammatory responses likely due to the release or production of endogenous ligands that activate resident immune cells of the central nervous system. These ligands comprise a diverse set of proteins, nucleic acids, and gly-cosaminoglycans, including heat shock proteins, HMGB1, RNA, DNA, hyaluronan, and heparin sulfate, that stimulate innate immune mechanisms largely through Toll-like receptors (TLRs). The blockade of interactions between endogenous ligands and TLRs may enable neuroprotective therapeutic strategies for a variety of neurologic diseases.

Objective: Postoperative pneumonia is one of the most common complications after cardiac surgery, entailing increased patient morbidity, mortality, and health care burden. The primary aim of this study was to assess whether preoperative chlorhexidine mouthwash is associated with reduced postoperative pneumonia after cardiac surgery.Methods: A comprehensive systematic search of NLM Pubmed, Embase, Scopus, and Cumulative Index of Nursing and Allied Health was executed to include the studies since inception to June 27, 2017, which assessed the effects of preoperative chlorhexidine gluconate mouthwash on postoperative pneumonia. Studies were identified by 2 independent reviewers, and data were extracted using a predefined protocol. Random effects models were run to obtain risk ratios with 95% confidence intervals. Quality of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation criteria. Postoperative pneumonia after cardiac surgery was the primary outcome of the study.Results: Five studies including a cumulative of 2284 patients were included. A total of 1125 patients received preoperative chlorhexidine. Use of chlorhexidine gluconate was associated with reduced risk of postoperative pneumonia compared with the patients who did not receive it (risk ratio, 0.52; 95% confidence interval, 0.39-0.70; P<.001). No adverse effects from chlorhexidine gluconate mouthwash were reported by any of these studies.Conclusions: Among the patients receiving preoperative chlorhexidine mouthwash, the risk of postoperative pneumonia is reduced by approximately onehalf; its adoption in preoperative protocols could help improve patient outcomes.

may be related to high-dose use of norepinephrine. 1 Acute ischemic hepatitis ("shock liver") has been identified as a potential risk factor for limb ischemic necrosis or symmetrical peripheral gangrene. 2 The previous study shows that abnormal coagulation results, especially markedly elevated D-dimer and fibrin degradation product, are common in deaths with COVID-19. 3 Therefore, the occurrence of limb ischemic necrosis in COVID-19 patients should be monitored closely.

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