ObjectivePolygoni Multiflori Radix is a commonly used tonic traditional Chinese medicine （TCM） in clinical practice， but liver injury has often been reported in recent years. Some related preparations containing Polygoni Multiflori Radix have been reported by the National Medical Products Administration many times for the risk of liver injury. This has caused extensive discussion on the potential toxicity of TCM in China and abroad， which has limited the clinical use of Polygoni Multiflori Radix to some extent. To understand the adverse reactions of Polygoni Multiflori Radix， the safe and rational use of Polygoni Multiflori Radix in clinical practice was discussed. MethodsThe pharmacovigilance thought of modern Chinese medicine and the TCM pharmacovigilance system framework of ''identification of poison， use of poison， anti-poison， and detoxification'' were employed to mine the relevant toxicity records， usage and dosage， processing compatibility， and contraindication of taking Polygoni Multiflori Radix in ancient books. The drug safety information of Polygoni Multiflori Radix was summarized by comparing with modern reports. ResultsA total of 74 ancient books related to Polygoni Multiflori Radix were included， suggesting that the toxicity of Polygoni Multiflori Radix was recognized in ancient times. The main chemical components of Polygoni Multiflori Radix had both efficacy and toxicity， and the adverse reactions may be related to long-term use， excessive use， and individual differences. The results showed that the toxic components of Polygoni Multiflori Radix could be reduced by peeling， steaming with black beans， and processing without iron tools. The toxic effects of Polygoni Multiflori Radix could be reduced by the compatibility of Polygoni Multiflori Radix with Poria， Psoraleae Fructus， and Cistanches Herba. ConclusionReasonable dosage， standard processing， correct compatibility， and syndrome differentiation are the key points to standardize the use of Polygoni Multiflori Radix and reduce the incidence of adverse reactions. Clinically， the toxicity classification of TCM should be strengthened， and the susceptible population should be prioritized. The detection indicators and early warning mechanisms should be improved， and precise drug dosage and course of treatment should be guaranteed. These measures can ensure the safe use of Polygoni Multiflori Radix.

ObjectivePolygoni Multiflori Radix is a commonly used tonic traditional Chinese medicine （TCM） in clinical practice， but liver injury has often been reported in recent years. Some related preparations containing Polygoni Multiflori Radix have been reported by the National Medical Products Administration many times for the risk of liver injury. This has caused extensive discussion on the potential toxicity of TCM in China and abroad， which has limited the clinical use of Polygoni Multiflori Radix to some extent. To understand the adverse reactions of Polygoni Multiflori Radix， the safe and rational use of Polygoni Multiflori Radix in clinical practice was discussed. MethodsThe pharmacovigilance thought of modern Chinese medicine and the TCM pharmacovigilance system framework of ''identification of poison， use of poison， anti-poison， and detoxification'' were employed to mine the relevant toxicity records， usage and dosage， processing compatibility， and contraindication of taking Polygoni Multiflori Radix in ancient books. The drug safety information of Polygoni Multiflori Radix was summarized by comparing with modern reports. ResultsA total of 74 ancient books related to Polygoni Multiflori Radix were included， suggesting that the toxicity of Polygoni Multiflori Radix was recognized in ancient times. The main chemical components of Polygoni Multiflori Radix had both efficacy and toxicity， and the adverse reactions may be related to long-term use， excessive use， and individual differences. The results showed that the toxic components of Polygoni Multiflori Radix could be reduced by peeling， steaming with black beans， and processing without iron tools. The toxic effects of Polygoni Multiflori Radix could be reduced by the compatibility of Polygoni Multiflori Radix with Poria， Psoraleae Fructus， and Cistanches Herba. ConclusionReasonable dosage， standard processing， correct compatibility， and syndrome differentiation are the key points to standardize the use of Polygoni Multiflori Radix and reduce the incidence of adverse reactions. Clinically， the toxicity classification of TCM should be strengthened， and the susceptible population should be prioritized. The detection indicators and early warning mechanisms should be improved， and precise drug dosage and course of treatment should be guaranteed. These measures can ensure the safe use of Polygoni Multiflori Radix.

Objective To gain insights into the biological characteristics of different populations of Culex tritaeniorhynchus within and around the Yellow Sea wetland from the perspective of the occurrence of resistance, we investigated the levels of resistance to deltamethrin and kdr gene mutation in the wetland and its peripheral areas. Methods Specimens were collected from Cx. tritaeniorhynchus populations at two monitoring sites in the Rare Bird National Nature Reserve and Tiaozi Ni Wetland Scenic Area, and also from two populations in Yancheng City and the Liuhe District of Nanjing, and the resistance of these mosquitoes to deltamethrin was determined using the CDC biotest bottle method. For each concentration of deltamethrin assessed, a random subset of exposed specimens was selected for amplification of the kdr gene fragment, followed by Sanger sequencing to identify and analyze resistance-associated mutations. Results The LC50 levels of deltamethrin among mosquitoes from the four populations in Luhe, Yancheng, the Rare Bird National Nature Reserve and the Tiaozi Ni Wetland Scenic Area were 2.048 5, 7.798 2, 3.473 3, and 17.695 5 mg/mL, respectively, with corresponding concentrations of deltamethrin ranging from 0.005 to 5.000,0.050 to 50.000,0.050 to 25.000 and 0.050 to 50.000 mg/mL, respectively. Furthermore, the ranges of the KT50 values were 11.76-107.43, 67.05-216.30,29.77-107.43 and 28.40-329.51 min; the 1-h knockdown rates were 34.58%-99.15%, 9.52%-43.80%, 55.09%-73.01%, and 10.09%-68.07%; and the 24-h mortality rates were 12.15%-67.52%,9.52%-79.56%,13.17%-82.21%, and 11.01%-78.99%, respectively. With respect to kdr gene mutation, we assayed a total of 63,70,59, and 57 mosquitoes for the four populations, for which we detected L1014F mutation frequencies of 14.29%, 35.00%, 20.34%, and 31.58%, respectively, with a majority of these mutations being heterozygous for resistance. In addition, five adult mosquitoes were identified has having synonymous mutations at site 1011[i. e. , AAT(asparagine)mutation to AAC(asparagine)]. Conclusions Our findings revealed the clear resistance of Cx. tritaeniorhynchus to deltamethrin in the Yancheng region of the Yellow Sea wetland, and the resistance phenotype and kdr frequency of Cx. tritaeniorhynchus in the wetland environment were comparable to those of Cx. tritaeniorhynchus in the wetland environment, thereby indicating that the resistance of different populations of Cx. tritaeniorhynchus was homogeneous under the pressure of different insecticide selection within and around the wetland. However, the underlying mechanisms need to be further studied.

ObjectiveTo investigate the novel post-translational modifications (PTMs) of SnRK2.6, a central component in the abscisic acid (ABA) signaling pathway, such as SUMOylation, and to establish a foundation for revealing the physiological functions and molecular mechanisms of SnRK2.6 regulated by these new modifications. MethodsThe interaction between SnRK2.6 and the SUMO E3 ligase SIZ1, as well as members of the SUMO protease family, was examined using yeast two-hybrid and in vitro pull-down assays. An in vitro SUMOylation system in Escherichia coli was utilized to determine whether SnRK2.6 undergoes SUMOylation. Mass spectrometry, combined with site-directed mutagenesis of candidate lysine residues, was employed to identify potential SUMOylation sites on SnRK2.6. In vitro de-SUMOylation assays were performed to assess whether SUMO proteases interacting with SnRK2.6 could catalyze the removal of SUMO moieties from modified SnRK2.6. The protein stability of SnRK2.6 was assessed in a cell-free degradation assay using bacterial-purified SnRK2.6 incubated with total protein extracts from Col and siz1 mutant seedlings. To dissect the genetic relationship between SnRK2.6 and SIZ1, stomatal aperture assays were performed under ABA treatment using snrk2.6, siz1, and snrk2.6 siz1 double mutant plants. ResultsSnRK2.6 physically interacts with SIZ1 and the SUMO protease ESD4, with the binding domains localized to the C-terminal region of SIZ1 and the N-terminal region of ESD4, respectively. SnRK2.6 was found to be SUMOylated, exhibiting two distinct high-molecular-mass bands ranging from 70 to 100 ku, indicative of modified forms. Bioinformatics analysis predicted four putative SUMOylation sites on lysine residues K57, K63, K142, and K190. Mass spectrometry identified three SUMOylation sites on K63, K142, and K174. However, individual or combinatorial point mutations on these sites had minimal impact on the pattern or intensity of SUMOylation signals, suggesting that these residues may not be responsible for the SUMOylation on SnRK2.6. Instead, such mutations only weaken the protein stability or accelerate the protein mobility of SnRK2.6. Therefore, the exact SUMOylation sites on SnRK2.6 remain unidentified. In de-SUMOylation experiments, incubation of GST-ESD4 with SUMOylated SnRK2.6 for 1-2 h led to the near-complete disappearance of both SUMOylated bands. In contrast, neither the GST control nor the catalytically inactive mutant GST-ESD4^C448S exhibited any de-SUMOylation activity. In protein turnover experiments, SnRK2.6 exhibited markedly enhanced half-life in siz1 compared with Col, indicating that SIZ1-dependent SUMOylation promotes SnRK2.6 turnover. Phenotypically, snrk2.6 mutants were completely insensitive to ABA-induced stomatal closure; siz1 mutants displayed pronounced hypersensitivity; and the snrk2.6 siz1 double mutant phenocopied snrk2.6—showing no significant response to ABA beyond that of the snrk2.6 mutant. These data indicate that SIZ1 acts as a negative regulator of ABA-triggered stomatal closure and SnRK2.6 functions as a positive regulator, and the inhibitory activity of SIZ1 is strictly dependent on SnRK2.6, placing SnRK2.6 genetically upstream of SIZ1 in the ABA signaling pathway. ConclusionSnRK2.6 undergoes SUMOylation, although the specific SUMOylation sites have not been defined. SnRK2.6 is dynamically regulated by reversible SUMOylation—catalyzed by SIZ1 and reversed by ESD4—which controls its protein stability. SUMOylation acts as a destabilizing signal for SnRK2.6, and SIZ1 exerts its negative effect on ABA-triggered stomatal closure probably through promoting SnRK2.6 degradation via SUMOylation. These findings uncover SUMOylation as a critical regulatory layer fine-tuning SnRK2.6 abundance in ABA signaling.

Neurocritical care involves complex pathophysiological mechanisms, and its incidence is higher, injuries are more severe, and treatment is more challenging in high-altitude environments. This consensus, based on the latest domestic and international evidence-based medical data, establishes a standardized, goal-oriented framework for neurocritical care management applicable in high-altitude regions and nationwide. The consensus was developed following international standards for evidence quality assessment and underwent two rounds of Delphi expert consultation, resulting in 32 recommendation statements covering three parts: management systems, monitoring and assessment, and core strategies. Key updates include: advocating for the establishment of independent neurocritical care units and implementing precise tiered diagnosis and treatment based on the "Five Differences in Critical Care" concept; constructing a "trinity" multimodal brain monitoring system centered on cerebral blood flow, cerebral oxygenation, and brain function, emphasizing routine bedside transcranial Doppler ultrasound, cerebral oximetry, and continuous electroencephalography monitoring; shifting management strategies from mild hypothermia therapy to targeted temperature management, and defining the "446" target management pathway for the supercritical stage; emphasizing the assessment of static and dynamic cerebrovascular autoregulation functions through multimodal methods to achieve individualized optimal mean arterial pressure management; elevating cerebrospinal fluid management goals to the level of "glymphatic system" function maintenance; implementing a multidisciplinary collaborative, whole-process management model focusing on patients' long-term neurological functional outcomes; de-escalation criteria include multidimensional indicators such as recovery of brain structure, restoration of cerebrovascular autoregulation, improvement in cerebrospinal fluid dynamics, and reduction in biomarker levels; and integrating cutting-edge technologies like artificial intelligence into post-critical care management and rehabilitation planning. This consensus systematically integrates the entire process of neurocritical care management, reflecting the modern connotation of goal-oriented, dynamic, and multimodal integration in neurocritical care medicine. It aims to adapt to new trends such as deepening understanding of pathophysiological mechanisms, the integration of medicine and engineering, and the empowerment of artificial intelligence, thereby further advancing the discipline of critical care medicine.

ObjectiveTo investigate the effects and underlying mechanisms of Modified Yupingfeng Nasal Spray （玉屏风加味鼻喷剂， MYNS） on nasal mucosal tissue remodeling in allergic rhinitis （AR） model rats based on the Janus kinase 2 （JAK2）/ signal transducer and activator of transcription 3 （STAT3） signaling pathway. MethodsThe chemical constituents of MYNS were identified and analyzed using liquid chromatography-tandem mass spectrometry （LC-MS/MS）. Network pharmacology and molecular docking were integrated to identify the potential targets and signaling pathways of MYNS in the treatment of AR， and to verify the crucial role of the JAK2/STAT3 pathway. Forty rats were randomly divided into blank group， model group， MYNS group， and mometasone furoate nasal spray group， with 10 rats per group. Except for the blank group， the AR rat model was established by ovalbumin （OVA） induction. After successful modeling， rats in the MYNS group received an intranasal instillation of 50 μl of MYNS at concentration of 1.05 g·ml^-¹ in each nostril， while the mometasone furoate nasal spray group received 50 μl of corresponding spray per nostril， and the model group received 50 μl of normal saline per nostril. Treatments were administered once daily. After 14 consecutive days of intervention， the frequencies of nosal scratching and sneezing in rats within 15 minutes were recorded. Hematoxylin-eosin （HE） staining was used to assess morphological changes in the nasal mucosa and perform pathological scoring. Masson staining was used to evaluate collagen fiber deposition in nasal mucosal tissue and calculate the collagen volume fraction （CVF）. Terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling （TUNEL） staining was performed to detect apoptosis in nasal mucosal cells and record the number of apoptotic cells. Immunofluorescence assay was used to detect the expression of E-cadherin （E-Cad） in the nasal mucosa. Enzyme-linked immunosorbent assay （ELISA） was used to determine the serum levels of interleukin-4 （IL-4）， interferon-γ （IFN-γ）， histamine （HIS）， immunoglobulin E （IgE）， superoxide dismutase （SOD）， and malondialdehyde （MDA）. Transmission electron microscopy was used to observe the ultrastructure of mitochondria in nasal mucosal epithelial cells. Flow cytometry was used to measure mitochondrial membrane potential （MMP） and reactive oxygen species （ROS） levels. Western Blot was used to determine the protein expression levels of collagen Ⅲ （Collagen Ⅲ）， α-smooth muscle actin （α-SMA）， Bcl-2-associated X protein （Bax）， Caspase-3， JAK2， phosphorylated JAK2 （p-JAK2）， STAT3， and phosphorylated signal transducer and activator of transcription 3 （p-STAT3）. ResultsA total of 626 chemical constituents were identified by LC-MS/MS. Network pharmacology screening identified 450 active ingredients. Nine intersecting components and 39 drug-AR intersecting targets were obtained. KEGG enrichment analysis indicated the involvement of signaling pathways including JAK2/STAT3. The animal experimental results showed that， compared with the blank group， rats in the model group exhibited significantly increased frequencies of nasal scratching and sneezing， as well as elevated CVF and the number of apoptotic cells， while the levels of E-Cad， MMP， and serum IFN-γ and SOD significantly decreased； meanwhile， the serum levels of IL-4， IgE， HIS， ROS， and MDA， along with the protein expression levels of Collagen Ⅲ， α-SMA， Bax， Caspase-3， p-JAK2， and p-STAT3 in the nasal mucosa， significantly increased （P＜0.05）， accompanied by aggravated pathological damage in the nasal mucosa， increased collagen fiber deposition， and abnormal mitochondrial morphology. Compared to the model group， rats in the MYNS group showed improvements in all the aforementioned indicators except for HIS （P＜0.05）， and those in the mometasone furoate nasal spray group showed improvements in all indicators except for IL-4， IgE， and SOD levels （P＜0.05）. ConclusionThe mechanism of MYNS in treating AR may be related to inhibiting the activation of the JAK2/STAT3 signaling pathway， reducing inflammatory responsesand oxidative stress， ameliorating mitochondrial damage， and suppressing nasal mucosal cell apoptosis， thereby improving nasal mucosal tissue pathological remodeling.

ObjectiveTo investigate the effects and underlying mechanisms of Modified Yupingfeng Nasal Spray （玉屏风加味鼻喷剂， MYNS） on nasal mucosal tissue remodeling in allergic rhinitis （AR） model rats based on the Janus kinase 2 （JAK2）/ signal transducer and activator of transcription 3 （STAT3） signaling pathway. MethodsThe chemical constituents of MYNS were identified and analyzed using liquid chromatography-tandem mass spectrometry （LC-MS/MS）. Network pharmacology and molecular docking were integrated to identify the potential targets and signaling pathways of MYNS in the treatment of AR， and to verify the crucial role of the JAK2/STAT3 pathway. Forty rats were randomly divided into blank group， model group， MYNS group， and mometasone furoate nasal spray group， with 10 rats per group. Except for the blank group， the AR rat model was established by ovalbumin （OVA） induction. After successful modeling， rats in the MYNS group received an intranasal instillation of 50 μl of MYNS at concentration of 1.05 g·ml^-¹ in each nostril， while the mometasone furoate nasal spray group received 50 μl of corresponding spray per nostril， and the model group received 50 μl of normal saline per nostril. Treatments were administered once daily. After 14 consecutive days of intervention， the frequencies of nosal scratching and sneezing in rats within 15 minutes were recorded. Hematoxylin-eosin （HE） staining was used to assess morphological changes in the nasal mucosa and perform pathological scoring. Masson staining was used to evaluate collagen fiber deposition in nasal mucosal tissue and calculate the collagen volume fraction （CVF）. Terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling （TUNEL） staining was performed to detect apoptosis in nasal mucosal cells and record the number of apoptotic cells. Immunofluorescence assay was used to detect the expression of E-cadherin （E-Cad） in the nasal mucosa. Enzyme-linked immunosorbent assay （ELISA） was used to determine the serum levels of interleukin-4 （IL-4）， interferon-γ （IFN-γ）， histamine （HIS）， immunoglobulin E （IgE）， superoxide dismutase （SOD）， and malondialdehyde （MDA）. Transmission electron microscopy was used to observe the ultrastructure of mitochondria in nasal mucosal epithelial cells. Flow cytometry was used to measure mitochondrial membrane potential （MMP） and reactive oxygen species （ROS） levels. Western Blot was used to determine the protein expression levels of collagen Ⅲ （Collagen Ⅲ）， α-smooth muscle actin （α-SMA）， Bcl-2-associated X protein （Bax）， Caspase-3， JAK2， phosphorylated JAK2 （p-JAK2）， STAT3， and phosphorylated signal transducer and activator of transcription 3 （p-STAT3）. ResultsA total of 626 chemical constituents were identified by LC-MS/MS. Network pharmacology screening identified 450 active ingredients. Nine intersecting components and 39 drug-AR intersecting targets were obtained. KEGG enrichment analysis indicated the involvement of signaling pathways including JAK2/STAT3. The animal experimental results showed that， compared with the blank group， rats in the model group exhibited significantly increased frequencies of nasal scratching and sneezing， as well as elevated CVF and the number of apoptotic cells， while the levels of E-Cad， MMP， and serum IFN-γ and SOD significantly decreased； meanwhile， the serum levels of IL-4， IgE， HIS， ROS， and MDA， along with the protein expression levels of Collagen Ⅲ， α-SMA， Bax， Caspase-3， p-JAK2， and p-STAT3 in the nasal mucosa， significantly increased （P＜0.05）， accompanied by aggravated pathological damage in the nasal mucosa， increased collagen fiber deposition， and abnormal mitochondrial morphology. Compared to the model group， rats in the MYNS group showed improvements in all the aforementioned indicators except for HIS （P＜0.05）， and those in the mometasone furoate nasal spray group showed improvements in all indicators except for IL-4， IgE， and SOD levels （P＜0.05）. ConclusionThe mechanism of MYNS in treating AR may be related to inhibiting the activation of the JAK2/STAT3 signaling pathway， reducing inflammatory responsesand oxidative stress， ameliorating mitochondrial damage， and suppressing nasal mucosal cell apoptosis， thereby improving nasal mucosal tissue pathological remodeling.

Objective The aim of the study is to reveal the polymorphisms of Eustrongylides spp.in Monopterus albus.Methods A total of five Eustrongylides spp.collected from five M.albus in the Yongzhou area were sampled to amplify ribosomal ITS sequence by PCR in vitro,then sequenced after extracting the DNA templates of Eustrongylides.The phylogenetic tree based on the ITS sequence was also constructed to explore the evolutionary history of Eustrongylides.Results The length of the ITS sequence of the five Eustrongylides spp.is approximately 933 bp,and the genetic differences between the isolates are 0.00％-0.90％and the genetic inheritance differences with other nematodes are 15.5％-18.20％,maintaining a certain genetic distance from other families.Conclusions The ITS sequence of Eustrongylides spp.in M.albus will be used as a genetic marker for the molecular identification of Eustrongylides spp.and will provide a basis for the prevention and control of Eustrongylides spp.in the future.

OBJECTIVES: To investigate the role and mechanism of Brahma-related gene 1 (Brg1) in regulating the Wnt/β-catenin signaling pathway in a bronchopulmonary dysplasia (BPD) model. METHODS: Wild-type C57BL/6 and Brg1^f1/f1 mice were randomly divided into four groups: wild-type control, wild-type BPD, Brg1^f1/f1 control, and Brg1^f1/f1 BPD (n=5 each). Immortalized mouse pulmonary alveolar type 2 cells (imPAC2) were cultured, and Brg1 gene was knocked down using lentivirus transfection technology. Cells were divided into three groups: control, empty vector, and Brg1 knockdown. Hematoxylin and eosin staining and immunofluorescence were used to detect pathological changes in mouse lung tissue. Western blot and real-time fluorescent quantitative PCR were used to measure Brg1 protein and mRNA expression levels in mouse lung tissue. Western blot and immunofluorescence were used to detect the expression of homeodomain-containing protein homeobox (HOPX), surfactant protein C (SPC), and Wnt/β-catenin signaling pathway proteins in mouse lung tissue and imPAC2 cells. The CCK8 assay was used to assess the proliferation of imPAC2 cells, and co-immunoprecipitation was performed to verify the interaction between Brg1 and β-catenin proteins in imPAC2 cells. RESULTS: Compared to the Brg1^f1/f1 control group and wild-type BPD group, the Brg1^f1/f1 BPD group showed increased alveolar diameter and SPC protein expression, and decreased relative density of pulmonary vasculature and HOPX protein expression (P<0.05). Compared to the control group, the Brg1 knockdown group showed increased cell proliferation ability, protein expression levels of SPC, Wnt5a and β-catenin, and β-catenin protein fluorescence intensity, along with decreased HOPX protein expression (P<0.05). An interaction between Brg1 and β-catenin proteins was confirmed. CONCLUSIONS The Brg1 gene may promote the proliferation of alveolar type 2 epithelial cells by regulating the Wnt/β-catenin signaling pathway, thus influencing the occurrence and development of BPD.
Animals ; DNA Helicases/genetics* ; Transcription Factors/genetics* ; Wnt Signaling Pathway/physiology* ; Nuclear Proteins/genetics* ; Mice ; Bronchopulmonary Dysplasia/etiology* ; Mice, Inbred C57BL ; beta Catenin/physiology* ; Disease Models, Animal ; Cell Proliferation ; Lung/pathology* ; Male

Objective To investigate the factors influencing international normalized ratio (INR)>3.0 in patients undergoing warfarin anticoagulation therapy after mechanical heart valve replacement. Methods A retrospective analysis was performed on the clinical data of patients who underwent mechanical heart valve replacement surgery and received warfarin anticoagulation therapy at West China Hospital of Sichuan University from January 1, 2011 to June 30, 2022. Based on the discharge INR values, patients were divided into two groups: an INR≤3.0 group and an INR>3.0 group. The factors associated with INR>3.0 at the time of discharge were analyzed. Results A total of 8901 patients were enrolled, including 3409 males and 5492 females, with a median age of 49.3 (43.5, 55.6) years. The gender, body mass index (BMI), New York Heart Association (NYHA) cardiac function grading, INR, glutamic oxaloacetic transaminase, and preoperative prothrombin time (PT) were statistically different between the two groups (P<0.05). Multivariate logistic regression analysis revealed that lower BMI, preoperative PT>15 s, and mitral valve replacement were independent risk factors for INR>3.0 at discharge (P<0.05). Conclusion BMI, preoperative PT, and surgical site are factors influencing INR>3.0 at discharge in patients undergoing warfarin anticoagulation therapy after mechanical heart valve replacement. Special attention should be given to patients with lower BMI, longer preoperative PT, and mitral valve replacement to avoid excessive anticoagulation therapy.