2016年 · 第129卷第02期

The International Committee of Medical Journal Editors (ICMJE) believes that there is an ethical obligation to responsibly share data generated by interventional clinical trials because participants have put themselves at risk. In a growing consensus, many funders around the world - foundations, government agencies, and industry - now mandate data sharing. Here, we outline ICMJE’s proposed requirements to help meet this obligation. We encourage feedback on the proposed requirements. Anyone can provide feedback at www.icmje.org by April 18, 2016.

Fatigue is a common symptom both in diseases status and in healthy subjects. Various supplements and nutraceuticals for relieving of fatigue have been used. However, there are a few studies to evaluate the efficacy and the safety of the drug for fatigue alleviation, we conducted using URSA Complex to evaluate the efficacy on physical fatigue via score changes in the checklist individual strength (CIS).　

The study was designed as a multicenter, randomized, double-blind, placebo-controlled trial, with subjects randomized to one of the two arms, receiving either placebo or URSA Complex administered as identical capsules. The primary efficacy endpoints of this clinical trials are the ratio of improving CIS scores < 76 points in patients at the end (4 weeks). Secondary efficacy variables are as follows one is an improvement of fatigue and the other is an improvement of the liver enzyme.　

The fatigue recovery rate in who had improved CIS scores of < 76 points were 70.0%, 50.9% in the therapy group and placebo group, respectively (P = 0.019). The fatigue recovery rate in CIS score was higher in URSA Complex therapy group than placebo group. The difference between therapy group and placebo group was statistically significant at 4 weeks later, but not 2 weeks.　

Our results provided that the URSA Complex was effective in alleviating physical fatigue. The adverse event frequency in the therapy groups was similar to that in the placebo group.

Coronary computed tomographic angiography (CCTA) has been widely used in patients who are at intermediate risk for having stable coronary artery disease (SCAD), and 2013 European Society of Cardiology Guidelines on the Management of SCAD (2013G) recommended the appropriate application of CCTA. However, 2013G has not been subjected to systematic analyses for subsequent impact on clinical practice.　

A total of 5320 patients suspected with SCAD were enrolled and scheduled for CCTA from March 2013 to September 2014. For each patient, pretest probability of SCAD was calculated according to updated Diamond-Forrester model (UDFM). Appropriate CCTA or appropriate stress test was determined as described in the 2013G. A generalized estimating equation model was used to determine the trends in the half-monthly rate of appropriate CCTA.　

Overall, only 61.37% of patients received appropriate CCTA, and there was insignificant change over time (P = 0.8701). The application of CCTA in patients who should have had a stress test accounted for most of the inappropriate CCTA before (22.29%) or after (19.98%) the publication of the 2013G. In all patients or any subgroup, no significant change in the adjusted half-monthly rate of appropriate CCTA was found after the publication of the 2013G (odds ratio, 1.002; 95% confidence interval, 0.982–1.021; P = 0.8678).　

These findings suggest that the 2013G have not, to date, been fully incorporated into clinical practice, and the clinical utilization of CCTA remains unreasonable to some extent.

Late-onset multiple acyl-CoA dehydrogenase deficiency (MADD) is the most common type of lipid storage myopathies in China. Most patients with late-onset MADD are well responsive to riboflavin. Up to now, these patients are often treated with glucocorticoids as the first-line drug because they are misdiagnosed as polymyositis without muscle biopsy or gene analysis. Although glucocorticoids seem to improve the fatty acid metabolism of late-onset MADD, the objective evaluation of their rationalization on this disorder and comparison with riboflavin treatment are unknown.　

We performed a historical cohort study on the efficacy of the two drugs among 45 patients with late-onset MADD, who were divided into glucocorticoids group and riboflavin group. Detailed clinical information of baseline and 1-month follow-up were collected.　

After 1-month treatment, a dramatic improvement of muscle strength was found in riboflavin group (P < 0.05). There was no significant difference in muscle enzymes between the two groups. Significantly, the number of patients with full recovery in glucocorticoids group was less than the number in riboflavin group (P < 0.05). On the other hand, almost half of the patients in riboflavin group still presented high-level muscle enzymes and weak muscle strength after 1-month riboflavin treatment, meaning that 1-month treatment duration maybe insufficient and patients should keep on riboflavin supplement for a longer time.　

Our results provide credible evidences that the overall efficacy of riboflavin is superior to glucocorticoids, and a longer duration of riboflavin treatment is necessary for patients with late-onset MADD.

The supraspinatus tendon is the most commonly affected tendon in rotator cuff tears. Early detection of a supraspinatus tear using an accurate physical examination is, therefore, important. However, the currently used physical tests for detecting supraspinatus tears are poor diagnostic indicators and involve a wide range of sensitivity and specificity values. Therefore, the aim of this study was to establish a new physical test for the diagnosis of supraspinatus tears and evaluate its accuracy in comparison with conventional tests.　

Between November 2012 and January 2014, 200 consecutive patients undergoing shoulder arthroscopy were prospectively evaluated preoperatively. The hug-up test, empty can (EC) test, full can (FC) test, Neer impingement sign, and Hawkins-Kennedy impingement sign were used and compared statistically for their accuracy in terms of supraspinatus tears, with arthroscopic findings as the gold standard. Muscle strength was precisely quantified using an electronic digital tensiometer.　

The prevalence of supraspinatus tears was 76.5%. The hug-up test demonstrated the highest sensitivity (94.1%), with a low negative likelihood ratio (NLR, 0.08) and comparable specificity (76.6%) compared with the other four tests. The area under the receiver operating characteristic curve for the hug-up test was 0.854, with no statistical difference compared with the EC test (z = 1.438, P = 0.075) or the FC test (z = 1.498, P = 0.067). The hug-up test showed no statistical difference in terms of detecting different tear patterns according to the position (χ² = 0.578, P = 0.898) and size (Fisher’s exact test, P > 0.999) compared with the arthroscopic examination. The interobserver reproducibility of the hug-up test was high, with a kappa coefficient of 0.823.　

The hug-up test can accurately detect supraspinatus tears with a high sensitivity, comparable specificity, and low NLR compared with the conventional clinical tests and could, therefore, improve the diagnosis of supraspinatus tears in clinical settings.

To determine the influence of right ventricular function in patients with constrictive pericarditis (CP) undergoing surgery and to compare the outcomes of patients who received surgery with those managed medically.　

Patients with the diagnosis of CP and healthy volunteers were recruited from January 2006 to November 2011. Patients with CP chose to either receive pericardiectomy or medical management. Echocardiographic measurements were performed to evaluate heart function, and survival was recorded.　

A total of 58 patients with CP (36 received pericardiectomy, 22 managed medically), and 43 healthy volunteers were included. CP patients who received surgery had a higher survival rate than those managed medically (P = 0.003), and higher survival was also seen in the subgroup of CP patients with severely impaired right systolic function. Albumin level, left ventricular end-diastolic dimension, and tricuspid regurgitation velocity were associated with survival in CP patients who received surgery.　

Preoperative right heart function does not affect surgical outcomes. Patients with severely impaired preoperative right systolic function obtain a greater survival advantage with surgery than with medical treatment.

Resection of sacral chordomas is challenging. The anatomy is complex, and there are often no bony landmarks to guide the resection. Achieving adequate surgical margins is, therefore, difficult, and the recurrence rate is high. Use of computer navigation may allow optimal preoperative planning and improve precision in tumor resection. The purpose of this study was to evaluate the safety and feasibility of computer navigation-aided resection of sacral chordomas.　

Between 2007 and 2013, a total of 26 patients with sacral chordoma underwent computer navigation-aided surgery were included and followed for a minimum of 18 months. There were 21 primary cases and 5 recurrent cases, with a mean age of 55.8 years old (range: 35–84 years old). Tumors were located above the level of the S3 neural foramen in 23 patients and below the level of the S3 neural foramen in 3 patients. Three-dimensional images were reconstructed with a computed tomography-based navigation system combined with the magnetic resonance images using the navigation software. Tumors were resected via a posterior approach assisted by the computer navigation. Mean follow-up was 38.6 months (range: 18–84 months).　

Mean operative time was 307 min. Mean intraoperative blood loss was 3065 ml. For computer navigation, the mean registration deviation during surgery was 1.7 mm. There were 18 wide resections, 4 marginal resections, and 4 intralesional resections. All patients were alive at the final follow-up, with 2 (7.7%) exhibiting tumor recurrence. The other 24 patients were tumor-free. The mean Musculoskeletal Tumor Society Score was 27.3 (range: 19–30).　

Computer-assisted navigation can be safely applied to the resection of the sacral chordomas, allowing execution of preoperative plans, and achieving good oncological outcomes. Nevertheless, this needs to be accomplished by surgeons with adequate experience and skill.

The clinical behavior and management of poorly differentiated thyroid carcinoma (PDTC) are very different from papillary thyroid carcinoma (PTC). By comparing the clinical and ultrasonographic features between the two tumors, we proposed to provide more possibilities for recognizing PDTC before treatment.　

The data of 13 PDTCs and 39 age- and gender-matched PTCs in Peking Union Medical College Hospital between December 2003 and September 2013 were retrospectively reviewed. The clinical and ultrasonic features between the two groups were compared.　

The frequencies of family history of carcinoma, complication with other thyroid lesions, lymph node metastases, recurrent laryngeal nerve injuries, and distant metastases were higher in PDTCs (30.8%, 61.6%, 69.2%, 23.1%, and 46.2%, respectively) than those in PTCs (2.6%, 23.1%, 25.6%, 2.6%, and 2.6%, respectively) (P < 0.05). The mortality rate of PDTCs was greatly higher than PTCs (P < 0.01). Conventional ultrasound showed that the size of PDTCs was larger than that of PTCs (3.1 ± 1.9 cm vs. 1.7 ± 1.0 cm). Clear margins and rich and/or irregular blood flow were found in 92.3% of PDTCs, which differed substantially from PTCs (51.7% and 53.8%, respectively) (P < 0.05).　

PDTC is more aggressive and its mortality rate is higher than PTCs. Accordingly, more attention should be given to suspicious thyroid cancer nodules that show large size, regular shape, and rich blood flow signals on ultrasound to exclude the possibility of PDTCs.

Current knowledge about clinical and genetic risk factors for aspirin-induced gastric mucosal injury is not sufficient to prevent these gastric mucosal lesions.　

We recruited aspirin takers as the exposed group and healthy volunteers as the control group. The exposed group was categorized into two subgroups such as subgroup A as gastric mucosal injury diagnosed by gastroscopy, including erosion, ulcer or bleeding of the esophagus, stomach, or duodenum; subgroup B as no injury of the gastric mucosa was detected by gastroscopy. Clinical information was collected, and 53 single nucleotide polymorphisms were evaluated.　

Among 385 participants, 234 were in the aspirin-exposed group. According to gastroscopy, 82 belonged to subgroup A, 91 belonged to subgroup B, and gastroscopic results of 61 participants were not available. Using the Chi-square test and logistic regression, we found that peptic ulcer history (odds ratio [OR] = 5.924, 95% confidence intervals [CI]: 2.115–16.592), dual anti-platelet medication (OR = 3.443, 95% CI: 1.154–10.271), current Helicobacter pylori infection (OR = 2.242, 95% CI: 1.032–4.870), male gender (OR = 2.211, 95% CI: 1.027–4.760), GG genotype of rs2243086 (OR = 4.516, 95% CI: 1.180–17.278), and AA genotype of rs1330344 (OR = 2.178, 95% CI: 1.016–4.669) were more frequent in subgroup A than subgroup B. In aspirin users who suffered from upper gastrointestinal bleeding, the frequency of the TT genotype of rs2238631 and TT genotype of rs2243100 was higher than in those without upper gastrointestinal bleeding.　

Peptic ulcer history, dual anti-platelet medication, H. pylori current infection, and male gender were possible clinical risk factors for aspirin-induced gastric mucosal injury. GG genotype of rs2243086 and AA genotype of rs1330344 were possible genetic risk factors. TT genotype of rs2238631 and TT genotype of rs2243100 may be risk factors for upper gastrointestinal bleeding in aspirin users.

It is important to achieve the definitive pathogen identification in hospital-acquired pneumonia (HAP), but the traditional culture results always delay the target antibiotic therapy. We assessed the method called quantitative loop-mediated isothermal amplification (qLAMP) as a new implement for steering of the antibiotic decision-making in HAP.　

Totally, 76 respiratory tract aspiration samples were prospectively collected from 60 HAP patients. DNA was isolated from these samples. Specific DNA fragments for identifying 11 pneumonia-related bacteria were amplified by qLAMP assay. Culture results of these patients were compared with the qLAMP results. Clinical data and treatment strategies were analyzed to evaluate the effects of qLAMP results on clinical data. McNemar test and Fisher’s exact test were used for statistical analysis.　

The detection of Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumonia, Stenotrophomonas maltophilia, Streptococcus pneumonia, and Acinetobacter baumannii by qLAMP was consistent with sputum culture (P > 0.05). The qLAMP results of 4 samples for Haemophilus influenzae, Legionella pneumophila, or Mycoplasma pneumonia (MP) were inconsistent with culture results; however, clinical data revealed that the qLAMP results were all reliable except 1 MP positive sample due to the lack of specific species identified in the final diagnosis. The improvement of clinical condition was more significant (P < 0.001) in patients with pathogen target-driven therapy based on qLAMP results than those with empirical therapy.　

qLAMP is a more promising method for detection of pathogens in an early, rapid, sensitive, and specific manner than culture.

Smoking and body mass index (BMI) are the key risk factors for chronic obstructive pulmonary disease (COPD). Adiponectin with both anti-inflammatory and pro-inflammatory properties is a vital modulator of inflammatory processes, which is expressed in epithelial cells in the airway in COPD-emphysema. The aim of this study was to examine the effects of adiponectin on tobacco smoke-induced emphysema in rats, which were fed different diets.　

Seventy-six adult (6–8 weeks old) male Sprague-Dawley rats (average weight 220 ± 20 g) were exposed to smoke or smoke-free room atmosphere and fed different diets (regular, high-fat, or low-fat diets) for 6 months. The rats were randomly divided into six groups. They are nonsmoke-exposed regular diet (n = 10), nonsmoke-exposed high-fat diet (n = 14), nonsmoke-exposed low-fat diet (n = 14), smoke-exposed regular diet (n = 10), smoke-exposed high-fat diet (n = 14), and smoke-exposed low-fat diet groups (n = 14). A full 2³ factorial design was used to evaluate the effect of independent variables on smoke exposure and different rearing methods. Serum adiponectin and inflammatory cytokines were measured by the enzyme-linked immunosorbent assay (ELISA).　

Serum adiponectin levels in rats fed low-fat and regular diets exposed to smoke exposure were remarkably higher than that of rats exposed to room air while serum adiponectin levels of fat-rich diet rats exposed to tobacco smoke were lower than that of rats exposed to room air. Compared with regular diet or low-fat diet group, serum adiponectin levels in high-fat diet rats exposed to tobacco smoke were lower (t = 6.932, 11.026; all P < 0.001). BMI was inversely correlated with serum adiponectin levels (r = −0.751, P = 0.012). Serum interleukin 6 (IL-6), tumor necrosis factor-α (TNF-α), and 4-hydroxy 2-nonenal (HNE) levels in rats exposed to low-fat or fat-rich diets were remarkably higher than that of rats exposed to normal diets (IL-6, t = 4.196, 3.480; P < 0.01, P = 0.001; TNF-α, t = 4.286, 3.521; P < 0.01, P = 0.001; 4-HNE, t = 4.298, 4.316; all P < 0.001). In nonhigh-fat diet rats exposed to tobacco smoke, serum adiponectin levels correlated positively with serum IL-6, TNF-α, and 4-HNE, bronchoalveolar lavage cell count, and mean linear intercept. In contrast, in high-fat diet rats, serum adiponectin levels correlated inversely with these parameters.　

In smoke-induced emphysema and fat-rich diet rat model, serum adiponectin level was decreased, and the anti-inflammatory effect was attenuated. By contrast, nonhigh-fat diet elevated serum adiponectin and enhanced the role of pro-inflammatory.

This paper aimed to review the current literature on the surface modification of intraocular lenses (IOLs).　

All articles about surface modification of IOLs published up to 2015 were identified through a literature search on both PubMed and ScienceDirect.　

The articles on the surface modification of IOLs were included, but those on design modification and surface coating were excluded.　

Technology of surface modification included plasma, ion beam, layer-by-layer self-assembly, ultraviolet radiation, and ozone. The main molecules introduced into IOLs surface were poly (ethylene glycol), polyhedral oligomeric silsesquioxane, 2-methacryloyloxyethyl phosphorylcholine, TiO₂, heparin, F-heparin, titanium, titanium nitride, vinyl pyrrolidone, and inhibitors of cytokines. The surface modification either resulted in a more hydrophobic lens, a more hydrophilic lens, or a lens with a hydrophilic anterior and hydrophobic posterior surface. Advances in research regarding surface modification of IOLs had led to a better biocompatibility in both in vitro and animal experiments.　

The surface modification is an efficient, convenient, economic and promising method to improve the biocompatibility of IOLs.

Cardiovascular disease (CVD) is the leading cause of death worldwide and contributes considerably to morbidity.^[1,2,3]The underlying cause is atherosclerosis.^[4]The development of new preventive therapies is one of the steps to control the CVD epidemic. It is increasingly demanded that promising therapies be evaluated in trials using cardiovascular (CV) morbidity and mortality (M and M) as a primary outcome.^[5]M and M trials, however, are very costly, often multicenter studies requiring thousands of participants, and with a long follow-up period. There is great interest in alternative endpoints that can be used as a valid alternative or proxy for CV M and M alternative endpoints (surrogate endpoints) allow for the evaluation of novel therapies in randomized controlled trials within a shorter timeframe, fewer participants, at lower costs, and with a shorter time to availability of trial results when compared to an M and M trial. These studies may show a direct effect on atherosclerosis progression and in the same time may serve to direct or exclude subsequent large M and M trials. A measure of atherosclerosis is intuitively a suitable alternative endpoint for CVD events as atherosclerosis is the disease between exposure to risk factors and the majority of CV events. Atherosclerosis can be noninvasively assessed from early to late stages of the disease process using different imaging techniques.^[6,7,8,9]

Central venous catheters (CVCs) are commonly utilized to gain vascular access for varied clinical indications. These include administering drugs, renal replacement therapy, total parenteral nutrition, poor peripheral venous access, cardiac catheterization, and transvenous cardiac pacing.^[1]Central venous access involves a large bore catheter inserted in internal jugular, subclavian or femoral vein in the neck, and upper chest or groin (femoral) area.^[1]The preferred vein for CVCs is the right internal jugular vein (IJV) for its straight course to the right heart and the lowest risk of the venous stenosis and thrombosis.^[2,3,4]Successful catheter placement requires not only technical expertise but also awareness of the potential complications.^[5]Malposition of the catheter is a relatively common complication (5.01%), which results in the malfunction of catheters.^[6,7]Misplacement of the superior vena cava (SVC) can lead to the perforation of the cava or the right atrium, which are associated with serious sequelae.^[4,5]Multiple literatures are in the form of isolated case reports or small series, which are cumbersome or time-consuming to access and do not provide pragmatic guidance or solutions to the problem. This article outlines the normal and abnormal anatomy of the central veins in relation to CVCs, mainly for the IJV, similar advantages applying at all sites. In addition, it presents illustrated cases of the malposition and discusses practical management issues, avoiding the misplacement and following complications.

An intestinal duplication cyst is a very rare congenital anomaly, with symptoms including abdominal pain, abdominal distention, intestinal bleeding, and hematochezia. Hematochezia can be caused by ectopic gastric mucosa, although there are other causes of infantile hematochezia; hence, an intestinal duplication cyst can be misdiagnosed as bowel intussusception or Meckel’s diverticulum. Here, a case of an intestinal duplication cyst that was misdiagnosed as Meckel’s diverticulum is reported.

Ebola virus disease (EVD) is an acute hemorrhagic infectious disease caused by virus species of the genusE. virus. Gastrointestinal symptoms such as abdominal pain, vomiting, and diarrhea may occur in EVD. The fatality rate of the disease ranges from 30% to 90%.^[1,2]It has been reported thatE. virusis transmitted to a human index case via contact with body fluid or discharge from an infected person or animals. On March 21, 2014, EVD outbreak in Guinea was officially notified by WHO.^[3]Until July 2, 2014, the Ministry of Health of Guinea had reported a cumulative total of 412 clinical cases of EVD and 305 deaths in five provinces and the capital Conakry.^[4]

Coronary computed tomographic angiography (CCTA) as a noninvasive diagnostic technique for the evaluation of coronary anatomy is widely used clinically. Its advantages include high sensitivity and specificity for the diagnosis of present of coronary artery lesions and lesion characteristics, short scan time, low patient radiation exposure, and acceptable to patients. The sensitivity and specificity of CCTA for diagnosing coronary artery disease are 83%–100% and 70%–80% at patient level or 83%–97% and 93%–100% at vessel level. It can be proceeded in out-patient clinic for the most of the candidates. In high patient volume hospitals and most county hospitals, even more multi-slice computed tomography scanners are used for screening the coronary artery disease (CAD), but there is no stress testing equipment for functional evaluation of CAD before CCTA. The rule of CCTA in management of patients with symptoms suspicious for CAD comparing to well-established other noninvasive stress techniques including stress exercise electrocardiogram (ECG), single photon emission computed tomography (SPECT), and stress cardiac echocardiography is still not well-studied in different patients population. Assessment of patients with typical of stable or atypical angina generally follows the guidelines and established stepwise approach which based on evidence of clinical studies.^[1,2,3]The first step for the approach of CAD includes careful history taking, basic physical examination, routine ECG, and risk factors assessment to define the likelihood of CAD. Depending on the risk factors, patients are classified into subgroups of low, intermediate, and high pretest likelihood probability, and further noninvasive and invasive evaluation methods are referred. Patients with positive result of most common used stress ECG are only 41% likely to have obstructive coronary heart disease defined by invasive coronary angiography.^[4]This is why stress testing is less referred compared to CCTA for the initial test. Some of the exercise ECG results are not interpretable.

To the Editor: Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) syndrome is a rare disease. It is diagnosed in childhood (usually at 3–4 years of age). It affects endocrine, respiratory, and autonomic nervous systems. It shows different symptoms at different ages. Rapid weight gain, obesity, alveolar hypoventilation, hypernatremia, cardiopulmonary arrest, hyperprolactinemia, diabetes insipidus, excessive sweating, increase pain perception, obstructive sleep apnea, cold hands/feet, and digestive dysmotility can be seen. Alveolar hypoventilation is essential for the diagnosis.^[1]Behavioral problems, mental retardation, personality changes, and mood disorders may accompany. There is no any special diagnostic test. Its treatment is symptomatic.^[2]This study is intended to inform clinicians about psychiatric symptoms of a girl with ROHHAD syndrome.

To the Editor: The increased rate of leukemia in several Iraqi cities has been linked to exposure to depleted uranium, which was used during the consequent wars in Iraq from 1990 to 2010.^[1,2,3,4]Here, we investigated leukemia occurrence in the Sulaymaniyah Governorate (SG), which has been exposed to wars and crises at the same level as the rest of Iraq.^[5]To the best of our knowledge, this study is the first population-based study on leukemia in SG.

To the Editor: A 29-year-old woman arrived via ambulance to the emergency department with hematochezia 1 h after sustaining blunt abdominal trauma as a passenger in a traffic accident. The patient also had Crohn’s disease (CD) and, on arrival, complained of abdominal pain and ongoing hematochezia. On physical examination, she was pale and distressed with a systolic blood pressure of 90 mmHg and a heart rate of 126 beats/min. Routine blood tests showed a hemoglobin level of 86 g/L. Her systolic blood pressure initially responded to a 1.0-L intravenous crystalloid challenge but dropped to 70 mmHg within 30 min, coinciding with further large, bright red per rectal blood loss. Hematochezia also increased (likely fresh blood), and hemoglobin levels dropped to 68 g/L. The patient underwent abdominal computed tomography (CT) with intravenous contrast medium injection. The CT scan showed a suspicious wall defect in the transverse colon as well as free air densities and pericolic fat infiltration [Figure 1a]. Moreover, the presence of active bleeding and increased mucosal enhancement in the transverse colon were notable [Figure 1b]. Diffuse wall thickening and stricture of the terminal ileum, as well as mild wall thickening of the entire colon, were present (typical features of CD). Therefore, the patient was referred to the surgery department and underwent a laparoscopic total colectomy with a diverting ileostomy. On postsurgery, recovery was good, and the patient was discharged to home 30 days later.

To the Editor: Rasmussen’s encephalitis (RE) is a rare but devastating unihemispheric brain disorder, usually affecting children and characterized by intractable seizures and progressive neurological deficits.^[1]Characteristic magnetic resonance imaging (MRI) finding of RE is progressive unihemispheric focal cortical atrophy. Bilateral RE is very uncommon. Here, we report an RE patient with faciobrachial dystonic attacks and bilateral brain atrophy but without seizures.

To the Editor: A 32-year-old man was referred to First Affiliated Hospital of Zhengzhou University with a right kidney tumor which was found in his annual medical examination. His blood pressure was found high more than half a year ago, and it was 138/102 mmHg on admission. He had no family history of hypertension. His serum potassium level was normal. We failed to test his plasma renin activity.

To the Editor: Xieet al. analyzed warfarin doses in pulmonary embolism (PE) and its adverse effects in patients with obstructive sleep apnea hypopnea syndrome (OSAHS). The key findings were that OSAHS patients required a significantly higher dose of warfarin than their non-OSAHS counterparts (4.73 mg vs. 3.61 mg,P< 0.001) and that PE recurrence was higher in OSAHS than in non-OSAHS groups after withdrawal of warfarin (21.43% vs. 6.78%,P= 0.047). They conclude that OSAHS patients may present with hypercoagulation and relatively high risk of recurrence of PE after cessation of 6-month warfarin treatment. We have read this with great interest.^[1]

Thanks for your reading and priceless comments to our recent publication.^[1]The major concern is that whether OSAHS is an independent risk factor of PE, or just a companion of other diseases which may lead to thrombotic lesions, such as diabetes, hypertension, smoking, obesity, etc. Actually the independent relationship between OSAHS and PE has already been revealed,^[2,3,4]although the pathophysiological mechanism is far from being determined. As to the repeated PE, yet no literature is available pertaining to its association with OSAHS. Independent prognostic value of OSAHS cannot be concluded from current study because of the limited cases of recurrent PE (n= 10) and thus the statistical irrationality of adjusting for the traditional risk factors mentioned in the above letter as confounding variables in Cox proportional hazards model. Given the high prevalence of OSAHS and the high morbidity and mortality associated with PE, large-scale studies are warranted.