Bilateral Tubal Pregnancies Presenting 11 Days Apart: A Case Report.

INTRODUCTION: Ectopic pregnancy is the most common cause of maternal mortality in the first trimester. Bilateral tubal pregnancy is the rarest subset with an estimated incidence of one in 725 to 1,580 ectopic pregnancies. Of the cases of bilateral tubal pregnancy reported in the literature, most were associated with the use of assisted reproductive techniques. Here we present the case of a patient, without a prior history of reproductive technology use, who underwent treatment for a tubal pregnancy and was subsequently found to have a second, contralateral tubal pregnancy 11 days later. CASE REPORT: A 35-year-old female gravida eight para two with a history of left tubal pregnancy and salpingectomy 11 days prior, presented to the emergency department (ED) with two days of left lower and upper quadrant abdominal pain. The patient's last menstrual period had been several months prior. A physical examination revealed left lower quadrant abdominal tenderness, rebound, guarding, and left adnexal tenderness. Her vital signs were unremarkable, and her laboratory studies revealed normal white blood cell and hemoglobin values. Her human chorionic gonadotropin had tripled from her last presentation 11 days prior. Transvaginal ultrasound showed a possible ectopic pregnancy adjacent to the right ovary. She promptly underwent a right salpingectomy. Pathology findings confirmed a tubal pregnancy, and the patient's postoperative course was uneventful. CONCLUSION: This case highlights the importance of maintaining a high index of suspicion for ectopic pregnancy in all biologically female patients of reproductive age who present to the ED with abdominal pain.

Core Structure-Activity Relationship Studies of 5,7,20-O-Trimethylsilybins in Prostate Cancer Cell Models.

Silibinin, also known as silybin, is isolated from milk thistle (Silybum marianum). Silibinin has been demonstrated to be a good lead compound due to its potential to prevent and treat prostate cancer. Its moderate potency and poor pharmacokinetic profile hindered it from moving forward to therapeutic use. Our research group has been working on optimizing silibinin for the potential treatment of castration-resistant prostate cancer. Our previous studies established 5,7,20-O-trimethylsilybins as promising lead compounds as they can selectively suppress androgen receptor (AR)-positive LNCaP cell proliferation. Encouraged by the promising data, the present study aims to investigate the relationships between the core structure of 5,7,20-O-trimethylsilybin and their antiproliferative activities towards AR-positive (LNCaP) and AR-negative prostate cancer cell lines (PC-3 and DU145). The structure-activity relationships among the four different core structures (including flavanonol-type flavonolignan (silibinin), flavone-type flavonolignan (hydnocarpin D), chalcone-type flavonolignan, and taxifolin (a flavonolignan precursor) indicate that 5,7,20-O-trimethylsilybins are the most promising scaffold to selectively suppress AR-positive LNCaP prostate cancer cell proliferation. Further investigation on the antiproliferative potency of their optically enriched versions of the most promising 5,7,20-O-trimethylsilybins led to the conclusion that (10R,11R) derivatives (silybin A series) are more potent than (10S,11S) derivatives (silybin B series) in suppressing AR positive LNCaP cell proliferation.

Accuracy of Medical Student Measurements of CT Right-to-Left Ventricular Diameter in Patients with Acute Pulmonary Embolism.

Objectives: Acute pulmonary embolism (PE) is a common disease, necessitating risk stratification to determine management. A right ventricle (RV) to left ventricle (LV) diameter ratio ≥1.0 on computed tomography pulmonary angiography (CTPA) suggests RV strain, which may indicate a worse prognosis. Two prior studies showed that residents with brief training by a radiologist could accurately measure RV/LV ratio. We assessed whether medical students could accurately measure RV dilatation. Methods: We conducted a post hoc analysis of a retrospective cohort study of adults undergoing management for acute PE at 21 community emergency departments across Kaiser Permanente Northern California from 2013 to 2015. We created a sample, stratified to contain an equal number of patients from each of the 5 PE Severity Index classes. Four medical students measured RV and LV diameter on CTPA after training from an emergency medicine physician and an interventional radiologist. We used Cohen's kappa statistics, Bland-Altman plots, and Pearson correlation coefficients to assess interrater reliability. Results: Of the 108 CTPAs reviewed, 79 (73%) showed RV dilatation and 29 (27%) did not. The kappa statistic for the presence of RV dilatation of the medical students compared to the radiologist showed moderate agreement for 3 medical students (kappa (95% CI): 0.46 (0.21-0.70), 0.49 (0.31-0.68), 0.50 (0.32-0.68)) and fair agreement for 1 medical student (kappa (95% CI): 0.29 (0.10-0.47)). The average interrater differences in RV/LV ratio between a radiologist and each of the 4 medical students were -0.04, -0.05, 0.04, and 0.24. Pearson correlation coefficients were 0.87, 0.80, 0.74, and 0.78, respectively, indicating moderate correlation (P < .001 for all). Conclusion: Medical students were able to identify RV dilatation on CTPA in moderate agreement with that of a radiologist. Further study is needed to determine whether medical student accuracy could improve with additional training.