A missed diagnosis of sputum crust with fiberoptic bronchoscope causing extubation failure: a case report.

BACKGROUND: Fiberoptic bronchoscopy (FOB) and bronchoscopic biopsy are the established methods for diagnosing and treating sputum crust. However, sputum crust in concealed locations can sometimes be missed or undiagnosed, even with bronchoscopy. CASE PRESENTATION: We present the case of a 44-year-old female patient who experienced initial extubation failure and postoperative pulmonary complications (PPCs) due to the missed diagnosis of sputum crust by FOB and low-resolution bedside chest X-ray. The FOB examination showed no apparent abnormalities prior to the first extubation, and the patient underwent tracheal extubation 2 h after aortic valve replacement (AVR). However, she was reintubated 13 h after the first extubation due to a persistent irritating cough and severe hypoxemia, and a bedside chest radiograph revealed pneumonia and atelectasis. Upon performing a repeat FOB examination prior to the second extubation, we serendipitously discovered the presence of sputum crust at the end of the endotracheal tube. Subsequently, we found that the sputum crust was mainly located on the tracheal wall between the subglottis and the end of the endotracheal tube during the "Tracheobronchial Sputum Crust Removal" procedure, and most of the crust was obscured by the retained endotracheal tube. The patient was discharged on the 20th day following therapeutic FOB. CONCLUSION: FOB examination may miss specific areas in endotracheal intubation (ETI) patients, particularly the tracheal wall between the subglottis and distal end of the tracheal catheter, where sputum crust can be concealed. When diagnostic examinations with FOB are inconclusive, high-resolution chest CT can be helpful in identifying hidden sputum crust.

Rheumatoid arthritis characteristics and classification of heat and cold patterns-an observational study.

Introduction: Traditional Chinese medicine (TCM) has been proven to be an effective complementary therapy in treating rheumatoid arthritis (RA). The cold pattern and the heat pattern were the two main TCM patterns for RA, which is crucial for TCM treatment. The cold pattern is characterized by fear of cold and wind, joint pain with a thin white tongue coating which can be relieved by hot herbs. In contrast, heat pattern patients suffer from severe joint pain with a yellow coating, with red swelling of the skin and high skin temperature which can be relieved by cooling herbs. Objective: We aimed to classify the heat and cold patterns in RA patients with cluster analysis and factor analysis. Moreover, we aimed to explore the association of RA characteristics between these two patterns. Methods: and Design: A cross-sectional observational research method was used, and data was collected on 300 RA patients in Hangzhou in China. Signs and symptoms associated with RA were clustered using SPSS 22.0 software. In addition, factor analysis was also used for the classification. After classification of heat and cold patterns, characteristics and treatment of the RA participants between the two patterns were explored. Results: RA patients in the study were divided into two categories using cluster analysis. Twenty-two symptoms in the first category were included in the heat pattern of RA patients. After factor analysis, nine principal components were extracted to heat pattern. The component with the highest eigenvalue (2.530) were mainly contributed by shortness of breath, palpitation, heavy limbs, chest tightness and yellow greasy tongue with high factor loading values (0.765, 0.703, 0.504, 0.429 and 0.402, respectively). Ten symptoms in the second category were included in the cold pattern of RA patients. Four principal components were extracted to cold pattern. The component with the highest eigenvalue (2.089) were mainly contributed by joint distension and pain, joint stiffness, fatigue and upset with high factor loading values (0.597, 0.590, 0.491 and 0.481, respectively). Although there were no statistical differences between the levels of rheumatoid factor and anti-cyclic peptide containing citrulline (anti-CCP), the levels of C-reactive protein, platelet count and the disease activity score using 28 joint counts were significantly higher in the heat pattern RA patients compared to the ones in cold pattern. Moreover, heat pattern RA patients were more likely to be prescribed two more disease-modifying anti-rheumatic drugs (DMARDS) combined with Methotrexate (MTX) (70.59% versus 49.72%; P = 0.000). Conclusions: In conclusion, heat and cold patterns in RA patients could be classified well using cluster analysis and factor analysis. Most of RA patients with heat pattern were active and likely to be prescribed two more DMARDs combined with MTX.

Time Course of Metabolic Alterations Associated with the Progression of Systemic Lupus Erythematosus in MRL/lpr Mice Based on GC/MS.

Exploring the dynamic changes of metabolites and metabolic pathways during the development of the disease can help to further understand the etiology and pathogenesis of systemic lupus erythematosus (SLE). In this study, serum metabolomics based on gas chromatography/mass spectrometry (GC/MS) was employed to investigate the metabolic alterations at different stages of SLE using lupus-prone mice (MRL/lpr) of 9, 11, and 13 weeks of age. Multivariate statistical analysis was performed to view the alterations of metabolic profiles between MRL/lpr mice and age-matched C57BL/6 mice, and t-test and fold change criteria were used to identify differential metabolites at each stage. 11 changed metabolites were found in MRL/lpr mice at 9 weeks of age, which were mainly involved in the tricarboxylic acid (TCA) cycle, glycolysis, and butanoate metabolism; with the increase of week age, the TCA cycle was still disturbed, and the biosynthesis of fatty acids was significantly upregulated since 11 weeks of age; in addition, urea, urate, and indole-3-lactate were increased at 13 weeks of age. We found a time course of metabolic alterations in MRL/lpr mice, which may be related to the progression of SLE. These findings could provide a reference for studying the mechanism of SLE and judging the pathological stage and severity of the disease. The MS data have been deposited in Mendeley (https://www.mendeley.com/).

Goodpasture syndrome manifesting as nephrotic-range proteinuria with anti-glomerular basement membrane antibody seronegativity: A case report.

RATIONALE: The Goodpasture syndrome is an extremely rare disease, with renal and pulmonary manifestations, and is mediated by anti-glomerular basement membrane (anti-GBM) antibodies. Renal pathological changes are mainly characterized by glomerular crescent formation and linear immunofluorescent staining for immunoglobulin G on the GBM. There are few reports on the atypical course of the syndrome involving serum-negative anti-GBM antibodies. Therefore, we present a case of Goodpasture syndrome that presented with nephrotic-range proteinuria and was seronegative for anti-GBM antibodies. PATIENT CONCERNS: A 38-year-old Chinese man presented with a lung lesion that was discovered by physical examination a month prior to presentation. The chief concern was occasional hemoptysis without fever, cough, chest pain, and edema. DIAGNOSES: Laboratory testing revealed that the urinary protein level and urine erythrocyte count were 7.4 g/24 hours and 144/high-power field (HPF), respectively. Serological testing for anti-GBM antibodies was negative. Chest computed tomography revealed multiple exudative lesions in both lungs, indicating alveolar infiltration and hemorrhage. Electronic bronchoscopy and pathological examination of the alveolar lavage fluid indicated no abnormalities. However, kidney biopsy suggested cellular crescent formation and segmental necrosis of the globuli, with linear IgG and complement C3 deposition on the GBM. These findings were consistent with the diagnosis of anti-GBM antibody nephritis. INTERVENTIONS: The patient underwent 7 sessions of double filtration plasmapheresis. He was also administered with intravenous methylprednisolone and cyclophosphamide. After renal function stabilization, he was discharged under an immunosuppressive regimen comprising of glucocorticoids and cyclophosphamides. OUTCOMES: Three months later, follow-up examination revealed that the 24-hour urine protein had increased to 13 g. Furthermore, the urine erythrocyte count was 243/HPF. After a 6-month follow-up, the patient achieved partial remission, with a proteinuria level of 3.9 g/24 hours and a urine erythrocyte count of 187/HPF. LESSONS: This extremely rare case of Goodpasture syndrome manifested with seronegativity for anti-GBM antibodies and nephrotic-range proteinuria. Our findings emphasize the importance of renal biopsy for the clinical diagnosis of atypical cases. Furthermore, because renal involvement achieved only partial remission despite therapy, early detection and active treatment of the Goodpasture syndrome is necessary to improve the prognosis of patients.

Aging Mechanism and Properties of SBS Modified Bitumen under Complex Environmental Conditions.

Bitumen aging can lead to the deterioration of asphalt pavement performance, shortening the service life of road. In order to solve the problem that current studies on the ultraviolet (UV) aging of bitumen either ignore the effects of natural environmental conditions or only consider the effects of water. In this study, different aqueous media and UV coupled simulated aging tests were carried out on virgin bitumen and styrene butadiene styrene (SBS) modified bitumen in a UV environment chamber. The combination of macroscopic performance tests and microstructure tests was used to analyze the physical, rheological, and microstructure changes of virgin bitumen and SBS modified bitumen after The film oven test (TFOT) aging and UV aging in different environments (UV, UV + Water, UV + Acid, UV + Salt). Dynamic shear rheometer (DSR) results indicated that UV aging results in the increase of rutting factor and the improvement of rutting resistance at high temperature. The Fourier transform infrared spectrum (FTIR) results illustrated that the bitumen would be oxidized and SBS would be degraded under ultraviolet radiation. The four-component analysis test results showed that light component migrated to the heavy component during the aging process. Moreover, water will aggravate the UV aging of bitumen, and the presence of acid or salt worsens ultraviolet aging.

Indole compounds with N-ethyl morpholine moieties as CB2 receptor agonists for anti-inflammatory management of pain: synthesis and biological evaluation.

The CB2 receptor plays a crucial role in analgesia and anti-inflammation. To develop novel CB2 agonists with high efficacy and selectivity, a series of indole derivatives with N-ethyl morpholine moieties (compounds 1-56) were designed, synthesized and biologically evaluated. Compounds 1, 2, 3, 46 and 53 exhibited high CB2 receptor affinity at low nanomolar concentrations and good receptor selectivity (EC50(CB1)/EC50(CB2) greater than 1000). The most active compound, compound 2, was more potent than the standard drug GW405833 for in vitro agonistic action on the CB2 receptor. More importantly, in a rat model for CFA-induced inflammatory hyperalgesia, compound 2 had a potent anti-inflammatory pain effect within 12 hours after administration. At the 1 h time point, compound 2 had a dose-dependent reversal for hyperalgesia with an estimated ED50 value of 1.097 mg kg-1. Moreover, compound 2 significantly suppressed the pro-inflammatory cytokines (IL-1ß, IL-6 and TNF-α) in CFA-induced lesions. These protective effects of compound 2 on inflammatory pain were superior to those of GW405833, suggesting that compound 2 may be a promising therapeutic drug that needs further validation.

The clinical and laboratory characteristics of Sjögren's syndrome that progresses to systemic lupus erythematosus: a retrospective case-control study.

OBJECTIVE: We investigated the clinical and laboratory characteristics of Sjögren's syndrome-onset systemic lupus erythematosus (SS/SLE), focusing on the possible risk factors of SS that allow development to SLE. METHODS: The experimental group included 55 SS/SLE patients, and the control group included 55 primary SS (pSS) patients recruited from our department between 1997 and 2012. RESULTS: Compared with the control group, SS/SLE patients showed a younger age of onset of SS (31 ± 12 vs. 39 ± 11 years, P = 0.001). In clinical characteristics, SS/SLE patients showed a lower frequency of xerostomia (78.2% vs. 96.4%, P = 0.016) and interstitial lung disease (27.3% vs. 54.5%, P = 0.004), and a higher frequency of arthritis (74.5% vs. 40.0%, P = 0.000). In laboratory characteristics, SS/SLE patients showed a higher frequency of leukopenia (56.4% vs. 29.1%, P = 0.004), proteinuria (27.3% vs. 7.3%, P = 0.009), and low complement levels (CH50 : 30.9% vs. 1.8%; C3 : 54.5% vs. 12.7%; C4: 41.8% vs. 7.3%, P = 0.000). The multivariate analysis using logistic regression revealed that age of onset, low levels of C3 and C4 were the independent risk factors of SS/SLE (age of onset: RR = 0.919, P = 0.000; low C3 levels: RR = 9.659, P = 0.000; low C4 levels: RR = 6.035, P = 0.007). CONCLUSION: The SS/SLE patients had an earlier age of onset, higher incidences of arthritis, leucopenia, proteinuria and low complement levels, and lower incidences of xerostomia and interstitial lung disease compared with pSS patients. These results suggest that we should be vigilant with the pSS patients who have all these mentioned clinical and laboratory characteristics, and are more likely to develop SS/SLE.

Differentially expressed proteins of MCF-7 human breast cancer cells affected by Zilongjin, a complementary Chinese herbal medicine.

PURPOSE: Zilongjin, a complementary Chinese herbal medicine, has been used to alleviate the adverse effects of chemotherapeutic drugs in cancer therapy. However, the mechanisms of anti-cancer activity of Zilongjin are still largely unkonwn. EXPERIMENTAL DESIGN: First, the proteomic approach of combined 2-DE and ESI-MS/MS was used to investigate the effect of Zilongjin on the protein expression in MCF-7 cells. Then, the differential expression of some proteins was confirmed by Western blot, cytoimmunofluoresecnce, and quantitative real-time RT-PCR analysis. RESULTS: The identified proteins with differential expression, involved in such events as protein translation, cellular signal transduction, cytoskeleton formation and transportation, include seven downregulating proteins, such as Eukaryotic translation initiation factor 3 subunit I, Eukaryotic translation initiation factor 1A Y-chromosomal, Ran-specific GTPase-activating protein, Ubiquitin-conjugating enzyme E2 N, Tropomodulin-3, Macrophage-capping protein, and Tumor protein D52, as well as two upregulating proteins, HSP ß-1 and keratin18. Moreover, the differential expression of three proteins was confirmed. CONCLUSIONS AND CLINICAL RELEVANCE: (i) These results provide a new insight into the molecular mechanisms of Zilongjin on therapy for breast cancer. (ii) The application of the proteomic approaches will result in the more extended appreciation of Chinese medicine than those known at present.