[Postpartum fatal pulmonary embolism with F5 gene mutation: a case report]

Pulmonary embolism (PE) is one of the leading causes of maternal death. Various clinical and environmental risk factors can cause PE. Here, we reported an uncommon PE case with multiple etiological causes, including caesarean section, overweight, anti-cardiolipin antibody positive, and factor 5 gene mutation. The patient was a 25-year-old woman who developed cardiac asystole and apnea one day after cesarean delivery due to pulmonary embolism. After cardiopulmonary resuscitation and thrombolytic therapy, high doses of epinephrine were still needed to maintain blood pressure and heart rate, so we treated her with venoarterial extracorporeal membrane oxygenation (ECMO) to maintain systemic circulation. She progressively improved and was discharged on oral warfarin treatment. Comprehensive laboratory tests revealed a positive anticardiolipin antibody. Through whole exon gene sequencing, we identified a novel mutation (A2032➝G) in the F5 gene. This mutation was predicted to result in the replacement of lysine with glutamate at position 678, close to one of the APC cleavage sites. P.Lys678Glu was found to be a detrimental mutation by SIFT software and suspected detrimental by Polyphen-2 software. Attention should be paid to the etiological screening of young patients with pulmonary embolism, which is helpful in guiding the anticoagulant scheme and anticoagulant duration, and is of great significance in preventing thrombosis recurrence and complications.

The Optimal Age to Stop Endoscopic Surveillance of Patients With Barrett's Esophagus Based on Sex and Comorbidity: A Comparative Cost-Effectiveness Analysis

BACKGROUND AND AIMS

Current guidelines recommend surveillance for patients with nondysplastic Barrett's esophagus (NDBE) but do not include a recommended age for discontinuing surveillance. This study aimed to determine the optimal age for last surveillance of NDBE patients stratified by sex and level of comorbidity.

METHODS

We used 3 independently developed models to simulate patients diagnosed with NDBE, varying in age, sex, and comorbidity level (no, mild, moderate, and severe). All patients had received regular surveillance until their current age. We calculated incremental costs and quality-adjusted life-years (QALYs) gained from 1 additional endoscopic surveillance at the current age versus not performing surveillance at that age. We determined the optimal age to end surveillance as the age at which incremental cost-effectiveness ratio of 1 more surveillance was just less than the willingness-to-pay threshold of $100,000/QALY.

RESULTS

The benefit of having 1 more surveillance endoscopy strongly depended on age, sex, and comorbidity. For men with NDBE and severe comorbidity, 1 additional surveillance at age 80 years provided 4 more QALYs per 1000 patients with BE at an additional cost of $1.2 million, whereas for women with severe comorbidity the benefit at that age was 7 QALYs at a cost of $1.3 million. For men with no, mild, moderate, and severe comorbidity, the optimal ages of last surveillance were 81, 80, 77, and 73 years, respectively. For women, these ages were younger: 75, 73, 73, and 69 years, respectively.

CONCLUSIONS

Our comparative modeling analysis illustrates the importance of considering comorbidity status and sex when deciding on the age to discontinue surveillance in patients with NDBE.

Optimizing Management of Patients With Barrett's Esophagus and Low-Grade or No Dysplasia Based on Comparative Modeling

BACKGROUND & AIMS

Endoscopic treatment is recommended for patients with Barrett's esophagus (BE) with high-grade dysplasia, yet clinical management recommendations are inconsistent for patients with BE without dysplasia (NDBE) or with low-grade dysplasia (LGD). We used a comparative modeling analysis to identify optimal management strategies for these patients.

METHODS

We used 3 independent population-based models to simulate cohorts of 60-year-old individuals with BE in the United States. We followed up each cohort until death without surveillance and treatment (natural disease progression), compared with 78 different strategies of management for patients with NDBE or LGD. We determined the optimal strategy using cost-effectiveness analyses, at a willingness-to-pay threshold of $100,000 per quality-adjusted life-year (QALY).

RESULTS

In the 3 models, the average cumulative incidence of esophageal adenocarcinoma was 111 cases, with costs totaling $5.7 million per 1000 men with BE. Surveillance and treatment of men with BE prevented 23% to 75% of cases of esophageal adenocarcinoma, but increased costs to $6.2 to $17.3 million per 1000 men with BE. The optimal strategy was surveillance every 3 years for men with NDBE and treatment of LGD after confirmation by repeat endoscopy (incremental cost-effectiveness ratio, $53,044/QALY). The average results for women were consistent with the results for men for LGD management, but the optimal surveillance interval for women with NDBE was 5 years (incremental cost-effectiveness ratio, $36,045/QALY).

CONCLUSIONS

Based on analyses from 3 population-based models, the optimal management strategy for patient with BE and LGD is endoscopic eradication, but only after LGD is confirmed by a repeat endoscopy. The optimal strategy for patients with NDBE is endoscopic surveillance, using a 3-year interval for men and a 5-year interval for women.

[Effects of maslinic acid on isoproterenol-induced myocardial fibrosis in mice]

Objective: To investigate the effect of maslinic acid (MA) on isoproterenol (ISO)-induced myocardial fibrosis in mice. Methods: ISO was used to induce myocardial fibrosis in adult male C57BL/6 mice, and MA was administered for two weeks to detect the effects of MA on cardiac function and fibrosis. Molecular changes of fibrosis markers and signaling pathways were detected by RT-PCR and western blotting. Phosphate buffer saline (PBS), PBS+SB203580 (p38 MAPK inhibitor), PBS+MA, ISO, ISO+SB203580, ISO+MA were added to the primary cultured rat fibroblasts. Cells were collected after 48 h for subsequent detection. Results: In this study, the mouse model of myocardial fibrosis was successfully established. The left ventricular faction shortening (FS) and maximum rate of rise and maximum rate of fall of pressure in left ventricular chamber (±dp/dt) of the ISO+MA group were significantly higher than those of the ISO group ((35.1±1.8)% vs (28.5±2.6)%, (7 256±153) mmHg/s vs (6 402±240) mmHg/s, (7 156±163) mmHg/s vs (6 319±219) mmHg/s, all P<0.05). The levels of interstitial and perivascular collagen deposition in the ISO+MA group were higher than those in the ISO group (P<0.05), the relative mRNA levels of COL-1, COL-3 and TGF-β in the ISO+MA group were significantly lower than those in the ISO group, with the relative expression levels of 1.70±0.24 vs 3.69±0.34, 1.72±0.56 vs 4.84±0.82, 1.52±0.19 vs 2.64±0.29, respectively (all P<0.05). The phosphorylation levels of p38 MAPK, Smad3 and protein expression level of TGF-β1 in ISO+MA group were lower than those in ISO group (relative expression levels were 1.67±0.35 vs 2.61±0.58, 1.68±0.23 vs 2.52±0.19,1.56±0.15 vs 2.48±0.26, respectively, all P<0.05). The results of in vitro cell experiments showed that the mRNA levels of COL-1, COL-3 and TGF-β in the SB203580 and MA groups were significantly lower than those in the ISO group (relative expression levels were 2.25±0.51, 2.16±0.48 vs 5.29±1.21; 1.58±0.34, 1.69±0.29 vs 4.97±1.32; 1.41±0.31, 1.55±0.38 vs 3.53±0.56, respectively, all P<0.05). The phosphorylation levels of p38 MAPK and Smad3 in the SB203580 MA groups was significantly lower than those in the ISO group, and the protein expression level of TGF-β1 was lower than that in the ISO group (1.81±0.18, 1.77±0.16 vs 2.56±0.32; 1.85±0.21, 1.81±0.17 vs 2.48±0.37; 1.84±0.24, 1.72±0.17 vs 2.52±0.29, all P<0.05). Conclusion: Maslinic acid can inhibit the phosphorylation of p38 MAPK, thereby preventing the canonical TGF-β1/Smads fibrosis signaling pathway to achieve an anti-fibrosis role.

Portal venous gas as a radiological sign in a sigmoid diverticular abscess and its non-surgical management: a case report

A 62-year old man who presented unwell with no specific symptoms or signs was found to have portal venous circulation gas complicating a small diverticular abscess. He was successfully managed with a course of antibiotics and had full resolution of symptoms, therefore avoiding the need for surgical intervention. While most commonly associated with bowel ischaemia and therefore often warranting emergency laparotomy, portal venous gas within the context of other underlying pathology often presents opportunities for delayed surgery or more conservative management options.

A novel tumor-based epithelial-to-mesenchymal transition score that associates with prognosis and metastasis in patients with Stage II/III colorectal cancer

It is increasingly appreciated that host factors within the tumor center and microenvironment play a key role in dictating colorectal cancer (CRC) outcomes. As a result, the metastatic process has now been defined as a result of epithelial-mesenchymal transition (EMT). Establishment of the role of EMT within the tumor center and its effect on the tumor microenvironment would be beneficial for prognosis and therapeutic intervention in CRC. The present study assessed five immunohistochemical EMT markers within the tumor center on a 185 Stage II/III CRC patient tissue microarray. In 185 patients with CRC, cytoplasmic snail (HR 1.94 95% confidence interval [CI] 1.15-3.29, p = 0.012) and a novel combined EMT score (HR 3.86 95% CI 2.17-6.86, p < 0.001) were associated with decreased cancer-specific survival. The combined EMT score was also associated with increased tumor budding (p = 0.046), and systemic inflammation (p = 0.007), as well as decreased memory T-cells within the stroma (p = 0.030) and at the invasive margin (p = 0.035). Furthermore, the combined EMT score was associated with cancer-specific survival independent of TNM-stage (HR 4.12 95% CI 2.30-7.39, p < 0.001). In conclusion, a novel combined EMT score stratifies patient's survival in Stage II/III CRC and associates with key factors of tumor metastasis. Therefore, the combined EMT score could be used to identify patients at risk of micrometastases and who may benefit from standard adjuvant therapy, potentially in combination with EMT blockade.

The use of the somatostatin analogue octreotide for the conservative management of symptomatic cholecystocolonic fistula: a case report

An 84-year-old woman presented with acute worsening of diarrhoea for a few weeks, with a background of chronic diarrhoea over the past 12 months accompanied by weight loss. Computed tomography during this admission revealed air in the biliary tree and resolution of gallstones in keeping with a cholecystocolonic fistula. Owing to her comorbidities, surgical management was deemed not to be the best option. She was trialled on octreotide, a somatostatin analogue, which effectively resolved her symptoms. This case presents an effective and novel method of managing cholecystocolonic fistulas conservatively in a patient where medical therapy is the ceiling of care.

A prospective evaluation of hemodynamic management in acute spinal cord injury patients

STUDY DESIGN

Prospective observational study of acute spinal cord-injured (SCI) patients.

OBJECTIVES

To determine how effectively mean arterial blood pressure (MAP) and spinal cord perfusion pressure (SCPP) are maintained at target levels in acute SCI patients.

SETTING

Single-institution study at a Canadian level-one trauma center.

METHODS

Twenty-one individuals with cervical or thoracic SCI were enrolled within 48 h of injury. A lumbar intrathecal drain was inserted for monitoring intrathecal cerebrospinal fluid pressure (ITP). The MAP was monitored concurrently with ITP, and the SCPP was calculated. Data was recorded hourly from the time of first assessment until at least the end of the 5th day post injury.

RESULTS

All subjects had at least one recorded episode with a MAP below 80 mm Hg, and 81% had at least one episode with a MAP below 70 mm Hg. On average, subjects with cervical injuries had 18.4% of their pressure recordings below 80 mm Hg. Subjects with thoracic cord injuries had on average 35.9% of their MAP recordings <80 mm Hg.

CONCLUSION

It is common practice to establish MAP targets for optimizing cord perfusion in acute SCI. This study suggests that even in an acute SCI referral center, when prospectively scrutinized, the actual MAP may frequently fall below the intended targets. Such results raise awareness of the vigilance that must be kept in the hemodynamic management of these patients, and the potential discrepancy between routinely setting target MAP according to 'practice guidelines' and actually achieving them.

A Computer Method for Validating Traditional Chinese Medicine Herbal Prescriptions

Traditional Chinese medicine (TCM) has been widely practiced and is considered as an alternative to conventional medicine. TCM herbal prescriptions contain a mixture of herbs that collectively exert therapeutic actions and modulating effects. Traditionally defined herbal properties, related to the pharmacodynamic, pharmacokinetic and toxicological, as well as physicochemical properties of their principal ingredients, have been used as the basis for formulating TCM multi-herb prescriptions. These properties are used in this work to develop a computer program for predicting whether a multi-herb recipe is a valid TCM prescription. This program is based on a statistical learning method, support vector machine (SVM), and it is trained by using 575 well-known TCM prescriptions and 1961 non-TCM recipes generated by random combination of TCM herbs. Testing results by using 72 well-known TCM prescriptions and 5039 non-TCM recipes showed that 73.6% of the TCM prescriptions and 99.9% of non-TCM recipes are correctly classified by this system. A further test by using 48 TCM prescriptions published in recent years found that 68.7% of these are correctly classified. These accuracies are comparable to those of SVM classification of other biological systems. Our study indicates the potential of SVM for facilitating the analysis of TCM prescriptions.

Usefulness of traditionally defined herbal properties for distinguishing prescriptions of traditional Chinese medicine from non-prescription recipes

Traditional Chinese medicine (TCM) has been widely practiced and is considered as an attractive to conventional medicine. Multi-herb recipes have been routinely used in TCM. These have been formulated by using TCM-defined herbal properties (TCM-HPs), the scientific basis of which is unclear. The usefulness of TCM-HPs was evaluated by analyzing the distribution pattern of TCM-HPs of the constituent herbs in 1161 classical TCM prescriptions, which shows patterns of multi-herb correlation. Two artificial intelligence (AI) methods were used to examine whether TCM-HPs are capable of distinguishing TCM prescriptions from non-TCM recipes. Two AI systems were trained and tested by using 1161 TCM prescriptions, 11,202 non-TCM recipes, and two separate evaluation methods. These systems correctly classified 83.1-97.3% of the TCM prescriptions, 90.8-92.3% of the non-TCM recipes. These results suggest that TCM-HPs are capable of separating TCM prescriptions from non-TCM recipes, which are useful for formulating TCM prescriptions and consistent with the expected correlation between TCM-HPs and the physicochemical properties of herbal ingredients responsible for producing the collective pharmacological and other effects of specific TCM prescriptions.

Polymer translocation through a nanopore. II. Excluded volume effect

Following our previous study of a Gaussian chain translocation, we have investigated the transport of a self-avoiding chain from one sphere to another sphere through a narrow pore, using the self-consistent field theory formalism. The free energy landscape for polymer translocation is significantly modified by excluded volume interactions among monomers. The free energy barrier for the placement of one of the chain ends at the pore depends on the chain length N nonmonotonically, in contrast to the N-independence for Gaussian chains. This results in a nonmonotonic dependence of the average arrival time [tau0] on N for self-avoiding chains. When the polymer chain is partitioned between the donor and recipient spheres, a local free energy minimum develops, depending on the strength w of the excluded volume interaction and the relative sizes of the donor and recipient spheres. If the sizes of spheres are comparable, the average translocation time tau (the average time taken by the polymer, after the arrival at the pore, to convert from the donor to the recipient) increases with an increase in w for a fixed N value. On the other hand, for the highly asymmetric sizes of the donor and recipient spheres, tau decreases with an increase in w. As in the case of Gaussian chains, tau depends nonmonotonically on the pore length.

Simulation of polymer translocation through protein channels

A modeling algorithm is presented to compute simultaneously polymer conformations and ionic current, as single polymer molecules undergo translocation through protein channels. The method is based on a combination of Langevin dynamics for coarse-grained models of polymers and the Poisson-Nernst-Planck formalism for ionic current. For the illustrative example of ssDNA passing through the alpha-hemolysin pore, vivid details of conformational fluctuations of the polymer inside the vestibule and beta-barrel compartments of the protein pore, and their consequent effects on the translocation time and extent of blocked ionic current are presented. In addition to yielding insights into several experimentally reported puzzles, our simulations offer experimental strategies to sequence polymers more efficiently.

An evaluation of the significance of mouth and hand contamination for lead absorption in lead-acid battery workers

The present study was conducted to evaluate the role of ingestion through hand and mouth contamination in the absorption of lead in 25 lead-acid battery workers. Levels of personal exposure to airborne lead ranged from 0.004 to 2.58 mg/m3 [geometric mean 0.098, with 25% of samples exceeding threshold limit values (ACGIH) of 0.15 mg/m3]; the mean (SD) blood lead level was 48.9 (10.8) micrograms/dl. Mean hand lead contents increased 33-fold from preshift levels on Monday mornings (33.5 micrograms/500 ml) to midshift levels on Thursday afternoons (1121 micrograms/500 ml). Mouth lead contents increased 16-fold from 0.021 micrograms/50 ml on Mondays to 0.345 micrograms/50 ml on Thursdays. The typical Malay racial habit of feeding with bare hands and fingers without utensils (closely associated with mouth and hand lead levels on Mondays) explained the bulk of the variance in blood lead levels (40%), with mouth lead on Thursdays (closely associated with poor personal hygiene) explaining a further 10%. Air lead was not a significant explanatory variable. The implementation of a programme of reinforcing hand-washing and mouth-rinsing practices resulted in a reduction of the blood lead level by 11.5% 6 months later. These results indicate that parenteral intake from hand and mouth contamination is an important cause of lead absorption in lead-exposed workers.