The Need for a Coagulation Assay after Initiation of New Oral Anticoagulants in Patients with Renal Dysfunction: A Case Report

Background

Dabigatran etexilate, a new oral anticoagulant, was recently approved as an efficacious alternative to warfarin for the prevention of first and recurrent stroke in patients with nonvalvular atrial fibrillation. Limited data are available for dabigatran use in patients with a creatinine clearance rate (CrCL) of 15-30 mL/min. Furthermore, current guidelines do not recommend frequent blood monitoring after dabigatran use. We report herein a patient with severe renal dysfunction who exhibited profound coagulopathy after 2 days of dabigatran use.

Case Report

An 87-year-old woman was admitted for altered mental status and left-side weakness. She was diagnosed with right middle cerebral artery infarction. The baseline assessment revealed a serum creatinine concentration of 1.29 mg/dL and a CrCL of 27.2 mL/min. Dabigatran therapy was started 5 weeks after admission at a dosage of 110 mg twice daily. After 2 days of dabigatran use, the patient developed multiple bruises and evidence of upper-gastrointestinal bleeding. Laboratory tests demonstrated a severe coagulopathy, with a prothrombin time of 85.9 sec, an international normalized ratio of 11.36, an activated partial thromboplastin time of 119.2 sec, and a thrombin time of 230.8 sec. Serial assessment of the patient''s renal function revealed substantial fluctuation of the CrCL (range, 17.9-26.5 mL/min).

Conclusions

The present case emphasizes the need for frequent checking of renal function and assessment using coagulation assays after commencing dabigatran therapy in patients with moderate-to-severe renal impairment.     

Neural indicators of emotion regulation via acceptance vs reappraisal in remitted major depressive disorder

Mood disorders are characterized by impaired emotion regulation abilities, reflected in alterations in frontolimbic brain functioning during regulation. However, little is known about differences in brain function when comparing regulatory strategies. Reappraisal and emotional acceptance are effective in downregulating negative affect, and are components of effective depression psychotherapies. Investigating neural mechanisms of reappraisal vs emotional acceptance in remitted major depressive disorder (rMDD) may yield novel mechanistic insights into depression risk and prevention. Thirty-seven individuals (18 rMDD, 19 controls) were assessed during a functional magnetic resonance imaging task requiring reappraisal, emotional acceptance or no explicit regulation while viewing sad images. Lower negative affect was reported following reappraisal than acceptance, and was lower following acceptance than no explicit regulation. In controls, the acceptance > reappraisal contrast revealed greater activation in left insular cortex and right prefrontal gyrus, and less activation in several other prefrontal regions. Compared with controls, the rMDD group had greater paracingulate and right midfrontal gyrus (BA 8) activation during reappraisal relative to acceptance. Compared with reappraisal, acceptance is associated with activation in regions linked to somatic and emotion awareness, although this activation is associated with less reduction in negative affect. Additionally, a history of MDD moderated these effects.     

Posterior Cerebral Artery Insufficiency in Pediatric Moyamoya Disease

The majority of clinical studies on moyamoya disease (MMD) have focused on anterior circulation. The disease involvement of posterior circulation in MMD, mainly in the posterior cerebral artery (PCA), has been mentioned since the early 1980s, and it has been repeatedly emphasized as one of the most important factors related to poor prognosis in MMD. However, its clinical features and outcome have only been elucidated during the last few years. In this review, the angiographic definition of PCA stenosis is summarized. The clinical features are elucidated as being either early-onset or delayed-onset, according to the time of PCA stenosis diagnosis in reference to the anterior circulation revascularization surgeries. The surgical strategy and hypothesis on the mechanism of PCA stenosis is also briefly mentioned. It appears that some MMD patients may show PCA stenosis during the early or late course of the disease and that the presenting symptoms may vary. Because the hemodynamic compromise caused by PCA stenosis may respond well to surgical treatment, clinicians should be aware of the condition, especially during follow-up of MMD patients.     

Brain Activation Evoked by Sensory Stimulation in Patients with Spinal Cord Injury : Functional Magnetic Resonance Imaging Correlations with Clinical Features

Objective

The purpose of this study is to determine whether the changes of contralateral sensorimotor cortical activation on functional magnetic resonance imaging (fMRI) can predict the neurological outcome among spinal cord injury (SCI) patients when the great toes are stimulated without notice.

Methods

This study enrolled a total of 49 patients with SCI and investigated each patient''s preoperative fMRI, postoperative fMRI, American Spinal Injury Association (ASIA) score, and neuropathic pain occurrence. Patients were classified into 3 groups according to the change of blood oxygenation level dependent (BOLD) response on perioperative fMRI during proprioceptive stimulation with repetitive passive toe movements : 1) patients with a response of contralateral sensorimotor cortical activation in fMRI were categorized; 2) patients with a response in other regions; and 3) patients with no response. Correlation between the result of fMRI and each parameter was analyzed.

Results

In fMRI data, ASIA score was likely to show greater improvement in patients in group A compared to those belonging to group B or C (p<0.001). No statistical significance was observed between the result of fMRI and neuropathic pain (p=0.709). However, increase in neuropathic pain in response to the signal change of the ipsilateral frontal lobe on fMRI was statistically significant (p=0.030).

Conclusion

When there was change of BOLD response at the contralateral sensorimotor cortex on perioperative fMRI after surgery, relief of neurological symptoms was highly likely for traumatic SCI patients. In addition, development of neuropathic pain was likely to occur when there was change of BOLD response at ipsilateral frontal lobe.     

应用加权秩和比法综合评价浦东新区社区护理相关政策的落实效果

目的采用加权秩和比法评价浦东新区44所社区卫生中心社区护理相关政策的落实情况。方法采用德尔菲法确定"十二五"规划中提出的社区卫生护理工作相关的6个政策维度,即"护理内涵拓展(六位一体)"、"家庭责任制实行"、"人员素质能力提升"、"培训教育增加"、"专科技术和学科建设"、"考核和薪酬合理",确定了各政策评价指标的计分标准及权重。通过对浦东新区44家社区卫生服务中心分批进行焦点小组访谈和后续补充收集数据。数据采用加权秩和比法进行统计分析。结果根据行为、价值/导向性、效率、可行性/可操作性四方面进行评价。结果显示,6个维度间存在差异(F=42.423,P0.01),两两比较,"家庭责任制实行"相关政策落实情况最好,2项"护理内涵拓展"次之,"专科技术和学科建设"及"考核和薪酬合理"2项相关政策落实最差。结论浦东新区社区卫生服务中心对社区护理相关政策的落实情况存在差异,应对社区普遍落实不良的具体政策应该进行更深入的探讨和分析,以便能够为社区护理工作的改善提供科学建议。     

微小隐孢子虫cDNA文库的构建及P23、CP15/60基因的克隆

目的　微小隐孢子虫地方株cDNA文库构建及P2 3、CP15 60基因的克隆。　方法　提取微小隐孢子虫总RNA、mRNA ,逆转录合成cDNA。将cDNA与 pUC18DNA连接 ,导入DH5α宿主细胞中生成cDNA文库。根据文献分别设计并合成两对PCR引物 ,从上述文库中筛选保护性基因 ,对PCR产物克隆、测序。　结果　文库容量为 1.9× 10 6个重组子 ,文库中cDNA插入片段大小介于 0 .4× 10 3～ 6.5× 10 3bp。从该文库中克隆出编码 2 3kDa、15 60kDa子孢子表面蛋白的核苷酸序列。　结论　成功地用 pUC18质粒载体构建了C .parvumcDNA文库。     

培哚普利对肾血管性高血压大鼠心肌钙调神经磷酸酶及丝裂原活化蛋白激酶的影响

目的研究两肾一夹高血压大鼠心肌肥厚过程中钙调神经磷酸酶(CaN)和丝裂原活化蛋白激酶(MAPK，包括胞外信号调节激酶、c-Jun NH2-末端激酶、p38丝裂原活化蛋白激酶)的变化，探讨血管紧张素转换酶抑制剂培哚普利对心肌肥厚和CaN、MAPK的影响。方法制作两肾一夹高血压大鼠模型；以左心室重、左心室重与体重比值、心肌细胞横截面积、左心室后壁和室间隔厚度作为大鼠心肌肥厚指标；应用RT-PCR法测定大鼠心肌CaN和MAPK mRNA表达，采用免疫印迹法检测CaN蛋白表达，以对硝基苯磷酸作底物测定CaN活性。结果两肾一夹术后2个月大鼠已发生心肌肥厚，术后3个月心肌肥厚进一步加重；手术组大鼠左心室心肌CaN mRNA、蛋白表达和CaN活性以及c-Jun NH2-末端激酶mRNA表达均高于同龄假手术组。培哚普利治疗可逆转大鼠心肌肥厚和CaN、c-Jun NH2-末端激酶的变化。结论培哚普利可通过抑制胞内CaN和c-Jun NH2-末端激酶信号通路逆转两肾一夹高血压大鼠心肌肥厚。