Adult vasovagal syncope with abdominal pain diagnosed by head-up tilt combined with transcranial doppler: a preliminary study.

BACKGROUND: Syncope is a common condition that increases the risk of injury and reduces the quality of life. Abdominal pain as a precursor to vasovagal syncope (VVS) in adults is rarely reported and is often misdiagnosed.​. METHODS: We present three adult patients with VVS and presyncopal abdominal pain diagnosed by synchronous multimodal detection (transcranial Doppler [TCD] with head-up tilt [HUT]) and discuss the relevant literature. RESULTS: Case 1: A 52-year-old man presented with recurrent decreased consciousness preceded by six months of abdominal pain. Physical examinations were unremarkable. Dynamic electrocardiography, echocardiography, head and neck computed tomography angiography, magnetic resonance imaging (MRI), and video electroencephalogram showed no abnormalities. Case 2: A 57-year-old woman presented with recurrent syncope for 30 + years, accompanied by abdominal pain. Physical examination, electroencephalography, and MRI showed no abnormalities. Echocardiography showed large right-to-left shunts. Case 3: A 30-year-old woman presented with recurrent syncope for 10 + years, with abdominal pain as a precursor. Physical examination, laboratory analysis, head computed tomography, electrocardiography, and echocardiography showed no abnormalities. Syncope secondary to abdominal pain was reproduced during HUT. Further, HUT revealed vasovagal syncope, and synchronous TCD showed decreased cerebral blood flow; the final diagnosis was VVS in all cases. CONCLUSIONS: Abdominal pain may be a precursor of VVS in adults, and our findings enrich the clinical phenotypic spectrum of VVS. Prompt recognition of syncopal precursors is important to prevent incidents and assist in treatment decision-making. Abdominal pain in VVS may be a sign of sympathetic overdrive. Synchronous multimodal detection can help in diagnosing VVS and understanding hemodynamic mechanisms.

Triptolide improves Alzheimer's disease by regulating the NF­κB signaling pathway through the lncRNA NEAT1/microRNA 361­3p/TRAF2 axis.

Alzheimer's disease (AD) is the most common type of dementia and is a serious social and medical problem threatening human health. The present study investigated the effect and underlying action mechanism of triptolide (Tri) on AD progression. Reverse transcription-quantitative PCR and western blotting analysis were used to determine the changes in RNA expression and levels of NF-κB signaling pathway proteins before and after lipopolysaccharide (LPS) induction. Nucleocytoplasmic separation experiments determined the intracellular localization of long non-coding RNA (lncRNA) nuclear paraspeckle assembly transcript 1 (NEAT1). A dual-luciferase assay was used to analyze the binding between NEAT1 and microRNA (miRNA/miR)-361 or tumor necrosis factor receptor-associated factor 2 (TRAF2) and miR-361-3p and RNA pull-down was used to analyze the binding between NEAT1 and miR-361-3p. Cell Counting Kit-8, flow cytometry and ELISA were used to detect the effects of interaction between Tri and NEAT1/miR-361-3p/TRAF2 on cell viability, apoptosis and inflammatory factor levels, respectively. The results showed that LPS-mediated human microglial clone 3 cell line (HMC3) viability decreased and apoptosis and inflammatory factors (IL-1ß, IL-6, IL-18 and TNF-α) increased. Tri inhibited LPS-mediated effects in a dose-dependent manner by downregulating NEAT1 expression. NEAT1 is highly expressed in the cytoplasm and reduces the transcription and translation of downstream TRAF2 by acting as a competitive endogenous RNA that adsorbs miR-361-3p. LPS-mediated HMC3 cell injury, inflammation and activation of NF-κB signaling were partially reversed in presence of Tri. The miR-361-3p mimic promoted the Tri effect and overexpression of (ov)-NEAT1 partially reversed the Tri-miR-361-3p combined effect. The effects of ov-NEAT1 were partially attenuated by small interfering (si)-TRAF2. Overall, Tri inhibited the LPS-induced decrease in viability, increase in apoptosis and inflammation and activation of NF-κB signaling in HMC3 cells. Tri regulation affected the NEAT1/miR-361-3p/TRAF2 axis. These findings suggested a potential therapeutic role for Tri in the clinical management of AD by modulating this molecular axis.

Single-nucleus RNA sequencing and mRNA hybridization indicate key bud events and LcFT1 and LcTFL1-2 mRNA transportability during floral transition in litchi.

In flowering plants, floral induction signals intersect at the shoot apex to modulate meristem determinacy and growth form. Here, we report a single-nucleus RNA sequence analysis of litchi apical buds at different developmental stages. A total of 41 641 nuclei expressing 21 402 genes were analyzed, revealing 35 cell clusters corresponding to 12 broad populations. We identify genes associated with floral transition and propose a model that profiles the key events associated with litchi floral meristem identity by analyzing 567 identified floral meristem cells at single cell resolution. Interestingly, single-nucleus RNA-sequencing data indicated that all putative FT and TFL1 genes were not expressed in bud nuclei, but significant expression was detected in bud samples by RT-PCR. Based on the expression patterns and gene silencing results, we highlight the critical role of LcTFL1-2 in inhibiting flowering and propose that the LcFT1/LcTFL1-2 expression ratio may determine the success of floral transition. In addition, the transport of LcFT1 and LcTFL1-2 mRNA from the leaf to the shoot apical meristem is proposed based on in situ and dot-blot hybridization results. These findings allow a more comprehensive understanding of the molecular events during the litchi floral transition, as well as the identification of new regulators.

Transcription factor LcNAC002 coregulates chlorophyll degradation and anthocyanin biosynthesis in litchi.

Chlorophyll degradation and anthocyanin biosynthesis, which often occur almost synchronously during fruit ripening, are crucial for vibrant coloration of fruits. However, the interlink point between their regulatory pathways remains largely unknown. Here, 2 litchi (Litchi chinensis Sonn.) cultivars with distinctively different coloration patterns during ripening, i.e. slow-reddening/stay-green "Feizixiao" (FZX) vs rapid-reddening/degreening "Nuomici" (NMC), were selected as the materials to study the key factors determining coloration. Litchi chinensis STAY-GREEN (LcSGR) was confirmed as the critical gene in pericarp chlorophyll loss and chloroplast breakdown during fruit ripening, as LcSGR directly interacted with pheophorbide a oxygenase (PAO), a key enzyme in chlorophyll degradation via the PAO pathway. Litchi chinensis no apical meristem (NAM), Arabidopsis transcription activation factor 1/2, and cup-shaped cotyledon 2 (LcNAC002) was identified as a positive regulator in the coloration of litchi pericarp. The expression of LcNAC002 was significantly higher in NMC than in FZX. Virus-induced gene silencing of LcNAC002 significantly decreased the expression of LcSGR as well as L. chinensis MYELOBLASTOSIS1 (LcMYB1), and inhibited chlorophyll loss and anthocyanin accumulation. A dual-luciferase reporter assay revealed that LcNAC002 significantly activates the expression of both LcSGR and LcMYB1. Furthermore, yeast-one-hybrid and electrophoretic mobility shift assay results showed that LcNAC002 directly binds to the promoters of LcSGR and LcMYB1. These findings suggest that LcNAC002 is an important ripening-related transcription factor that interlinks chlorophyll degradation and anthocyanin biosynthesis by coactivating the expression of both LcSGR and LcMYB1.

Metabotropic glutamate receptor 5-related autoimmune encephalitis with reversible splenial lesion syndrome following SARS-CoV-2 vaccination.

RATIONALE: Metabotropic glutamate receptor 5 (mGluR5)-related autoimmune encephalitis (AE) has been rarely reported; however, there are no reports on mGluR5-related AE with reversible splenial lesion syndrome following vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). PATIENT CONCERNS: A 29-year-old man was admitted with a history of headache and fever for 9 days and 6 days, respectively. DIAGNOSIS: He was initially diagnosed with an intracranial infection, however the final diagnosis was corrected as anti-mGluR5-related AE with reversible splenial lesion syndrome. INTERVENTIONS: He had received an inactivated SARS-CoV-2 vaccine 3 weeks prior to the examination and was initially diagnosed with an intracranial infection. Physical examination revealed bilateral horizontal nystagmus, ataxia, and neck rigidity. Antiinfective therapy was minimally helpful. An analysis of the cerebrospinal fluid did not reveal pathogens for sequencing. Magnetic resonance imaging displayed abnormal signals in the splenium of the corpus callosum. OUTCOMES: We identified mGluR5 antibodies in the cerebrospinal fluid and serum. Subsequently, intravenous methylprednisolone pulse and gamma-globulin pulse therapies were administered, which substantially improved the symptoms. Follow-up did not reveal abnormal neurological symptoms, and the lesion in the corpus callosum had resolved. LESSONS: AE with mGluR5 antibodies could arise from SARS-CoV-2 vaccination, which warrants the awareness of healthcare workers. Reversible splenial lesion syndrome may accompany mGluR5-related AE and mimic intracranial infection. Thus, early treatment can prevent serious residual signs and symptoms.

Function of a non-enzymatic hexokinase LcHXK1 as glucose sensor in regulating litchi fruit abscission.

Fruit abscission is a severe hindrance to commercial crop production, and a lack of carbohydrates causes fruit abscission to intensify in a variety of plant species. However, the precise mechanism by which carbohydrates affect fruit setting potential has yet to be determined. In the current study, we noticed negative correlation between hexose level and fruit setting by comparing different cultivars, bearing shoots of varying diameters, and girdling and defoliation treatments. The cumulative fruit-dropping rate was significantly reduced in response to exogenous glucose dipping. These results suggested that hexose, especially glucose, is the key player in lowering litchi fruit abscission. Moreover, five putative litchi hexokinase genes (LcHXKs) were isolated and the subcellular localization as well as activity of their expressed proteins in catalyzing hexose phosphorylation were investigated. LcHXK2 was only found in mitochondria and expressed catalytic protein, whereas the other four HXKs were found in both mitochondria and nuclei and had no activity in catalyzing hexose phosphorylation. LcHXK1 and LcHXK4 were found in the same cluster as previously reported hexose sensors AtHXK1 and MdHXK1. Furthermore, VIGS-mediated silencing assay confirms that LcHXK1 suppression increases fruit abscission. These findings revealed that LcHXK1 functions as hexose sensor, negatively regulating litchi fruit abscission.

Intermittent hypoxia-induced METTL3 downregulation facilitates MGLL-mediated lipolysis of adipocytes in OSAS.

Intermittent hypoxia (IH) is the core pathological feature of obstructive sleep apnea syndrome (OSAS), and insulin resistance (IR) is the most common metabolic complication of OSAS. Studies have shown that the levels of free fatty acids (FFAs), which are mainly released from adipocytes by lipolysis, are elevated in OSAS and play an important role in the development of IR. However, whether and how IH regulates adipocyte lipolysis in OSAS is not clear. Here, we revealed that the apnea hypopnea index was positively correlated with the serum levels of FFAs and FFA release from adipocytes in OSAS. In addition, IH facilitated lipolysis and FFA release from adipocytes by downregulating the level of METTL3. METTL3 downregulation impaired N6-methyladenosine (m6A) levels in MGLL mRNA and reduced MGLL expression, thereby promoting lipolysis. In addition, we identified YTHDF2 as the m6A reader that interacts with MGLL mRNA, accelerating its degradation. Furthermore, our data showed reduced levels of METTL3 and elevated levels of MGLL in the adipose tissues of OSAS patients and indicated an effect of METTL3 on lowering FFA levels and improving IR in rats with chronic IH. In conclusion, our study provides new insights into the development and treatment of IR in OSAS.

Foliar application of ethephon induces bud dormancy and affects gene expression of dormancy- and flowering-related genes in 'Mauritius' litchi (Litchi chinensis Sonn.).

A previous study showed that foliar application of ethephon to litchi trees with mature shoots and dormant terminal buds during autumn successfully inhibited new vegetative shoot growth prior to floral induction thereby promoting carbohydrate accumulation and flowering. However, the functional mechanisms of ethylene, the breakdown product of ethephon, in the leaves and terminal buds of litchi and its involvement in the flowering process is largely unknown. Therefore, this study aimed to investigate the phenological, physiological and molecular changes underlying ethephon application and its associations with bud dormancy and flowering in litchi. Ethephon was applied as a single full canopy spray at a concentration of 1000 mg⋅L-1 to 'Mauritius' litchi trees with mature vegetative shoots and dormant terminal buds during late autumn of 2018 (mid-April; Southern Hemisphere). Untreated trees served as a control. Phenological characteristics, such as bud dormancy and panicle development, leaf chlorophyll (as an indicator of shoot maturity), ethylene evolution, gene expression levels of flowering- (LcFT2, LcFLC and LcAP1), dormancy- (LcSVP1 and LcSVP2) and ethylene pathway-related (LcEIN3) genes and non-structural carbohydrates were determined in terminal buds, leaves and/or shoots. Ethephon application induced bud dormancy, significantly delayed panicle emergence and promoted pure floral panicle development under more favorable inductive conditions. Ethylene evolution increased sharply 2 h after application in both leaves and terminal buds, but decreased rapidly thereafter in the leaves, while remaining high in terminal buds for seven days before gradually declining. Ethephon application significantly increased relative expression of LcEIN3 and LcFLC in terminal buds one day after application, while LcFT2 expression in leaves and LcAP1 expression in terminal buds were significantly increased at the bud break stage. Significant treatments differences were also observed for various carbohydrate metabolites in leaves and shoots at the bud break or floral initiation stage. Our study provided evidence that ethephon application plays an important role in the physiological and molecular regulation of bud dormancy of litchi. By influencing the time of bud break, ethephon application can be a useful tool to manage panicle emergence under less inductive conditions.

The correlation of atherosclerosis and triglyceride glucose index: a secondary analysis of a national cross-sectional study of Japanese.

BACKGROUND: Few studies examined the relationship between triglyceride/glucose index (TyG index) and atherosclerosis in Japanese adults. Therefore, this study evaluated their relationship, as measured based on the brachial-ankle pulse wave velocity (baPWV) in Japanese adults. METHODS: A total of 912 participants was selected from the NAGALA (NAFLD in Gifu Area, Longitudinal Analysis) study conducted from 2004 to 2012. The relationship between the TyG index and baPWV was estimated through a logistic model. Subgroup analyses by sex, age, body mass index (BMI), total cholesterol, low-density lipoprotein cholesterol, estimated glomerular filtration rate (eGFR), and fatty liver was performed. The formula for TyG index was ln (½fasting triglyceride level [mg/dL] × fasting plasma glucose level [mg/dL]). RESULTS: A linear relationship between TyG and baPWV was discovered after adjusting for underlying confounders. An increased risk of baPWV was observed after adjusting for sex, age, BMI, systolic blood pressure, diastolic blood pressure, high-density lipoprotein cholesterol, fatty liver, eGFR, and TyG as a continuous variable (adjusted odds ratio [adj OR], 1.57; 95% confidence interval [95% CI], 1.14-2.18). Compared with the TyG index in the first tertile, the probabilities of subjects in the third tertile that developed to baPWV were 1.78-fold higher (adj OR 1.78, 95% CI 1.08-2.95: P for trend 0.024). Moreover, stable associations were observed between the TyG index and baPWV in different variables through subgroup analyses. CONCLUSIONS: The highest tertile (above 8.57) of the TyG index was positively and linearly related to subclinical atherosclerosis in Japanese adults and may be valuable as a predicted marker.

PSMG3-AS1 enhances glioma resistance to temozolomide via stabilizing c-Myc in the nucleus.

Glioblastoma (GBM) is the main form of primary brain malignancies with a dismal prognosis partly due to its invasive growth and rapid relapse. GBM frequently developed resistance to current standard-of-care therapeutic modalities, including surgery, radiation and chemotherapy, of which temozolomide (TMZ) is the most widely used first-line anti-GBM drug. Despite the intense efforts of the past decades, the underlying mechanisms of GBM resistance to TMZ remain largely unclear. Here we show that the long noncoding RNA (lncRNA) PSMG3-AS1 is significantly upregulated in GBM and its expression correlates with the grade of glioma, with the highest level observed in GBM (Grade IV glioma). We also demonstrated that PSMG3-AS1 mediates the resistance of GBM to TMZ, as knockdown of PSMG3-AS1 remarkably increased the sensitivity whereas overexpression of PSMG3-AS1 in sensitive GBM cell line induced a resistance phenotype to TMZ. Mechanistically, PSMG3-AS1 directly binds to c-Myc and thus stabilizes c-Myc in the nucleus to promote the survival of GBM cells under treatment of TMZ. Our data demonstrated an unreported role of PSMG3-AS1 in TMZ resistance and provide a potential novel target to tackle TMZ resistance in GBM.

Residue Analysis and the Effect of Preharvest Forchlorfenuron (CPPU) Application on On-Tree Quality Maintenance of Ripe Fruit in "Feizixiao" Litchi (Litchi chinensis Sonn.).

Litchi is a highly perishable fruit. Ripe litchi fruit loses quality quickly as they hang on tree, giving a very short hanging life and thus harvest period. This study attempted to explore the roles of cytokinin in regulating fruit ripening and senescence of litchi and examine the possibility of applying cytokinin in "on-tree storage" of the fruit. Exogenous cytokinin, forchlorfenuron (CPPU), was applied at 20 mg L-1 7 weeks after full bloom on litchi (Litchi chinensis cv. Feizixiao) fruit clusters. Color parameters, chlorophylls, anthocyanins, fruit and fruit part weights, total soluble solutes (TSSs), soluble sugars, organic acids, non-anthocyanin flavonoids, ethanol, and also CPPU residue in fruit were traced. CPPU residue was higher but decreased faster in the pericarp than in the aril, where it maintained < 10 µg kg-1. CPPU had no significant effect on fruit weight but tended to increase pericarp weight. The treatment suppressed chlorophyll loss and anthocyanin accumulation in the pericarp, increased non-anthocyanin flavonoids in the aril, but had no significant effects on non-anthocyanin flavonoids in the pericarp and total sugar and organic acids in the aril. As the commercially ripe fruit hanged on tree, TSSs, total sugar, and sucrose decreased with ethanol and acetic acid accumulation in the aril. CPPU significantly suppressed the loss of sucrose and total sugar and the accumulation of ethanol and acetic acid in the aril and inhibited malondialdehyde accumulation in the pericarp of the overripe fruit. Soluble invertase, alcohol dehydrogenase, and pyruvate decarboxylase (PDC) activity and gene expression in the aril were downregulated by CPPU. The results suggest that cytokinin partially suppresses the ripening process in litchi and is effective to slow quality loss in the overripe fruit on tree.

Endoscopic clipping for the secondary prophylaxis of bleeding gastric varices in a patient with cirrhosis: A case report.

BACKGROUND: Bleeding from gastroesophageal varices (GOV) is a serious complication in patients with liver cirrhosis, carrying a very high mortality rate. For secondary prophylaxis against initial and recurrent bleeding, endoscopic therapy is a critical intervention. Endoscopic variceal clipping for secondary prophylaxis in adult GOV has not been reported. CASE SUMMARY: A 66-year-old man with cirrhosis was admitted to our hospital complaining of asthenia and hematochezia for 1 wk. His hemoglobin level and red blood cell counts were significantly decreased, and his fecal occult blood test was positive. An enhanced computed tomography of the abdomen showed GOV. The patient was diagnosed with hepatitis B cirrhosis-related GOV bleeding. A series of palliative treatments were administered, resulting in significant clinical improvement. Subsequently, an endoscopic examination revealed severe gastric fundal varices, prompting endoscopic variceal clipping. There were no further episodes of gastrointestinal bleeding. The GOV improved significantly on follow-up imaging and was confirmed as improved on endoscopy at the 5th postoperative month. CONCLUSION: Our results suggest that endoscopic clipping is an inexpensive, safe, easy, effective, and tolerable method for the secondary prophylaxis of bleeding from gastric type 2 GOV. However, additional research is indicated to confirm its long-term safety and efficacy.

Characterizing the development of photosynthetic capacity in relation to chloroplast structure and mineral nutrition in leaves of three woody fruit species.

Plants have evolved different developmental patterns of photosynthetic capacity to better adapt to changing environmental conditions. Natural variation in photosynthetic development offers great potential for improving crop productivity. In this study, leaf developmental patterns were characterized in three woody fruit tree species with distinct photosynthetic capacity and growth habits. Changes in the photosynthetic rate, photosystem II (PSII) efficiency, chloroplast ultrastructure, activities of photosynthetic enzymes, and contents of carbohydrates and mineral nutrients were examined at five developmental stages to explore the interspecific variation in photosynthetic development. Rapid development of photosynthetic machinery and high photosynthetic capacity were found in Indian jujube (Ziziphus mauritiana) and apple (Malus domestica), whose net CO2 assimilation rate (A) peaked at full leaf expansion (FLE). Litchi (Litchi chinensis), a delayed-greening species, showed slow development of photosynthetic competence, with A peaked after FLE. The low photosynthetic capacity of litchi during early leaf expansion was associated with its delayed chloroplast development, low accumulation of starch, and low activities of ribulose-1,5-bisphosphate carboxylase/oxygenase and NADP-glyceraldehyde-3-phosphate dehydrogenase. Correlations between mineral contents and A across leaf stages and species identified manganese as the rate-limiting nutrients in photosynthetic development in new leaves. Foliar spray of MnSO4 solution (1 g l-1) induced a short-term increase in photosynthesis in young leaves of litchi. These findings suggest that a better understanding of interspecific variation in photosynthetic development facilitates the development of new strategies for improving the photosynthetic efficiency of woody fruit trees.

Two divergent haplotypes from a highly heterozygous lychee genome suggest independent domestication events for early and late-maturing cultivars.

Lychee is an exotic tropical fruit with a distinct flavor. The genome of cultivar 'Feizixiao' was assembled into 15 pseudochromosomes, totaling ~470 Mb. High heterozygosity (2.27%) resulted in two complete haplotypic assemblies. A total of 13,517 allelic genes (42.4%) were differentially expressed in diverse tissues. Analyses of 72 resequenced lychee accessions revealed two independent domestication events. The extremely early maturing cultivars preferentially aligned to one haplotype were domesticated from a wild population in Yunnan, whereas the late-maturing cultivars that mapped mostly to the second haplotype were domesticated independently from a wild population in Hainan. Early maturing cultivars were probably developed in Guangdong via hybridization between extremely early maturing cultivar and late-maturing cultivar individuals. Variable deletions of a 3.7 kb region encompassed by a pair of CONSTANS-like genes probably regulate fruit maturation differences among lychee cultivars. These genomic resources provide insights into the natural history of lychee domestication and will accelerate the improvement of lychee and related crops.

Relevance of small right-to-left shunt in contrast-enhanced transcranial Doppler in young and middle-aged patients with cryptogenic stroke: a report of two cases and literature review.

AIM: The clinical relevance of small right-to-left shunt (RLS) in young patients with cryptogenic stroke is unknown. We aimed to analyze and understand the relationship between cryptogenic stroke and small RLS by studying specific cases. MATERIALS AND METHODS: Clinical data from two cases of small RLS-related cryptogenic stroke in young patients were collected prospectively and analyzed. We followed up the patients for >1 year after discharge. RESULTS: Case 1. A 50-year-old man was admitted for slurred speech and right hemiplegia and was diagnosed with acute cerebral infarction. Contrast-enhanced transcranial Doppler (c-TCD) and contrast-enhanced transthoracic echocardiography (c-TTE) revealed a microbubble and 20-30 microbubbles per section, respectively, in the resting state. Three months later, he was readmitted for stroke recurrence. Transesophageal echocardiography (TEE) confirmed a patent foramen ovale (PFO), and he underwent transcatheter closure of the PFO. Case 2. A 48-year-old man was admitted for right hemiplegia with slurred speech. Brain magnetic resonance imaging showed acute cerebral infarction. c-TCD and contrast-enhanced TEE (c-TEE) revealed <10 microbubbles and approximately 20 microbubbles per section, respectively. These findings suggested a PFO. Two months later, he was readmitted for stroke recurrence. He underwent transcatheter closure of the PFO. Follow-up of cases 1 and 2 at >1 and >1.5 years after discharge, respectively, showed no stroke recurrence. CONCLUSION: We suspected that a small RLS may cause cryptogenic stroke. A small RLS in c-TCD in stroke patients may not be actually small, and c-TEE/c-TTE may be valuable in finding larger RLSs.

Successful intravenous thrombolysis for acute ischemic stroke caused by aortic dissection with severe hypofibrinogenemia: a case report and literature review.

BACKGROUND: Intravenous thrombolysis (IVT) for acute brain infarctions caused by aortic dissection (AD) may lead to fatal outcomes; thus, it should be ruled out, especially if hypofibrinogenemia occurs after IVT. Successful management of AD-related acute brain infarction with hypofibrinogenemia after IVT has not been reported previously. CASE REPORT: An 84-year-old woman developed sudden left limb weakness and aphasia for almost 4 h. Alteplase was administered intravenously immediately after cerebral hemorrhage was ruled out by emergent head computed tomography (CT). An anomaly suspected to be AD was detected during subsequent routine chest CT, which was confirmed by CT angiography to be a thoracoabdominal aortic dissecting aneurysm (DeBakey type I). Severe hypofibrinogenemia was also noted. After effective blood pressure control, intramuscular injection of vitamin K, and rehydration therapy, her brain cell metabolism improved, hemiplegia improved slightly, and hypofibrinogenemia recovered gradually. The patient's cerebral hemorrhage did not progress, there was no chest pain or no aggravation of hemiplegia, and the fibrinogen level gradually returned to normal. The condition was stable during hospitalization. At 1.5 months after discharge, the patient showed minimal change in condition. CONCLUSION: The symptoms of AD may be nonspecific and latent. IVT may be allowed to perform for some patients with AD related ischemical stroke, And IVT can improve the neural symptoms of AD-related ischemic stroke, but close monitoring is needed to avoid aneurysm rupture. Fibrinogen levels should also be monitored periodically after IVT for early detection of hypofibrinogenemia.

Rehabilitation effect of rTMS combined with cognitive training on cognitive impairment after traumatic brain injury.

OBJECTIVE: To innvestigate the rehabilitation effects of repetitive transcranial magnetic stimulation (rTMS) combined with cognitive training on cognitive impairment in patients with traumatic brain injury (TBI) by using multimodal magnetic resonance imaging. METHODS: Clinical data of 166 patients with cognitive impairment after TBI were retrospectively analyzed. The patients were assigned into an observation group and a control group according to different treatment methods, with 83 cases in each group. The observation group was given rTMS + cognitive training, and the control group was given cognitive training only. The changes in GCS score, the Cho/Cr, Cho/NAA and NAA/Cr ratios examined by MRSI, the score of cognitive impairment, the grading of cognitive impairment, and the changes in modified Barthel index were observed and compared between the two groups. RESULTS: The GCS score, and the ratios of Cho/Cr, Cho/NAA and NAA/Cr after treatment were better than those before treatment in both groups and were lower in the observation group compared with the control group (all P<0.05). The score and grading of cognitive impairment as well as modified Barthel index after treatment were all significantly better in the observation group than in the control group (all P<0.05). CONCLUSION: rTMS can improve the rehabilitation effect on cognitive impairment in patients after TBI and is recommended for clinical use.

Gerstmann-Sträussler-Scheinker syndrome misdiagnosed as cervical spondylotic myelopathy: A case report with 5-year follow-up.

RATIONALE: Gerstmann-Sträussler-Scheinker syndrome (GSS) is a rare autosomal dominant disease caused by a mutation in the prion protein gene (PRNP) that is not well known among neurologists and is therefore easily misdiagnosed. PATIENT CONCERNS: : A 49-year-old man was admitted for the first time because of an unsteady walk with mogilalia for 1 year. He underwent a cervical discectomy and a plate-screw fixation 6 months prior, although postoperative gait instability did not improve. DIAGNOSIS: Whole exome sequencing identified a pathogenic and heterozygous mutation in the PRNP 4 years after onset. The patient was eventually diagnosed with GSS. INTERVENTIONS: Symptomatic treatment to improve cerebrocirculation and cerebrometabolism was provided. OUTCOMES: The neurological decline continued. The Mini-Mental State Examination and modified Rankin Scale scores changed from 19 to 11 and 2 to 5, respectively. Progressive cerebral and cerebellar atrophy on magnetic resonance imaging was observed. LESSONS: Cerebral and cerebellar atrophy are neuroimaging features symptomatic of GSS that become more apparent as the disease progresses. This atrophy is positively correlated with the severity of symptoms and reduced quality of life. Neurologists treating middle-aged patients with progressive ataxia, cognitive impairment or dysarthria, and brain atrophy need to consider the possibility of GSS.

Rare severe hypofibrinogenemia induced by tissue plasminogen activator in stroke patients: Case report.

RATIONALE: Severe hypofibrinogenemia after intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rt-PA) is rare and easily overlooked, but hypofibrinogenemia increases the risk of major bleeding. However, it is unclear when hypofibrinogenemia reaches the peak and when hypofibrinogenemia is resolved. PATIENT CONCERNS: Case 1 was of a 66-year-old man who was hospitalized due to sudden onset of vague speech and right hemiplegia for 4 hours. Case 2 was of an 84-year-old woman who was hospitalized for sudden onset of left hemiplegia and vague speech for 4 hours. In case 1, fibrinogen levels decreased from normal values to <0.25 g/L within 4.5 hours after commencing IVT and returned to normal at 35 hours later. In case 2, fibrinogen levels decreased from 1.1 to <0.25 g/L within 2 hours after commencing IVT and normalized 36.5 hours later. DIAGNOSES: Both patients were diagnosed with rt-PA-related hypofibrinogenemia. INTERVENTIONS: No antiplatelet or symptomatic treatment was administered during the period of hypofibrinogenemia. OUTCOMES: Fibrinogen levels gradually recovered. In case 1, the patient did not experience cerebral hemorrhage during hypofibrinogenemia. His symptoms improved significantly within 1 week. In case 2, repeat computed tomography revealed minor cerebral hemorrhage, but no deterioration in her condition was noted until she was discharged. LESSONS: Rapid, severe, and prolonged hypofibrinogenemia may occur after IVT with rt-PA, which may increase the risk of massive hemorrhage and affect the related therapy. Prompt diagnosis of hypofibrinogenemia is important for preventing complications. We recommend checking the fibrinogen levels routinely after IVT. Fibrinogen replacement therapy and platelet transfusion are the main management routes for rt-PA-related symptomatic intracranial hemorrhage.

LcERF2 modulates cell wall metabolism by directly targeting a UDP-glucose-4-epimerase gene to regulate pedicel development and fruit abscission of litchi.

Elucidating the biochemical and molecular basis of premature abscission in fruit crops should help develop strategies to enhance fruit set and yield. Here, we report that LcERF2 contributes to differential abscission rates and responses to ethylene in Litchi chinensis (litchi). Reduced LcERF2 expression in litchi was observed to reduce fruit abscission, concurrent with enhanced pedicel growth and increased levels of hexoses, particularly galactose, as well as pectin abundance in the cell wall. Ecoptic expression of LcERF2 in Arabidopsis thaliana caused enhanced petal abscission, together with retarded plant growth and reduced pedicel galactose and pectin contents. Transcriptome analysis indicated that LcERF2 modulates the expression of genes involved in cell wall modification. Yeast one-hybrid, dual-luciferase reporter and electrophoretic mobility shift assays all demonstrated that a UDP-glucose-4-epimerase gene (LcUGE) was the direct downstream target of LcERF2. This result was further supported by a significant reduction in the expression of the A. thaliana homolog AtUGE2-4 in response to LcERF2 overexpression. Significantly reduced pedicel diameter and enhanced litchi fruit abscission were observed in response to LcUGE silencing. We conclude that LcERF2 mediates fruit abscission by orchestrating cell wall metabolism, and thus pedicel growth, in part by repressing the expression of LcUGE.