2016年 · 第129卷第04期

Rapid eye movement (REM) sleep behavior disorder (RBD) may be a risk factor for cognitive impairment in patients with Parkinson’s disease (PD). However, little is known regarding the relation between the severity of RBD and the different domains of cognitive impairment. The aim of this study was: (1) to investigate the domains of cognitive impairment in patients with PD and RBD, and (2) to explore risk factors for PD-mild cognitive impairment (PD-MCI) and the relationship between RBD severity and impairment in different cognitive domains in PD.

The participants were grouped as follows: PD without RBD (PD-RBD; n = 42), PD with RBD (PD + RBD; n = 32), idiopathic RBD (iRBD; n = 15), and healthy controls (HCs; n = 36). All participants completed a battery of neuropsychological assessment of attention and working memory, executive function, language, memory, and visuospatial function. The information of basic demographics, diseases and medication history, and motor and nonmotor manifestations was obtained and compared between PD-RBD and PD + RBD groups. Particular attention was paid to the severity of RBD assessed by the RBD Questionnaire-Hong Kong (RBDQ-HK) and the RBD Screening Questionnaire (RBDSQ), then we further examined associations between the severity of RBD symptoms and cognitive levels via correlation analysis.

Compared to PD-RBD subjects, PD + RBD patients were more likely to have olfactory dysfunction and their Epworth Sleepiness Scale scores were higher (P < 0.05). During neuropsychological testing, PD + RBD patients performed worse than PD-RBD patients, including delayed memory function, especially. The MCI rates were 33%, 63%, 33%, and 8% for PD-RBD, PD + RBD, iRBD, and HC groups, respectively. RBD was an important factor for the PD-MCI variance (odds ratio = 5.204, P = 0.018). During correlation analysis, higher RBDSQ and RBDQ-HK scores were significantly associated with poorer performance on the Trail Making Test-B (errors) and Auditory Verbal Learning Test (delayed recall) and higher RBD-HK scores were also associated with Rey–Osterrieth complex figure (copy) results.

When PD-RBD and PD + RBD patients have equivalent motor symptoms, PD + RBD patients still have more olfactory dysfunction and worse daytime somnolence. RBD is an important risk factor for MCI, including delayed memory. Deficits in executive function, verbal delayed memory, and visuospatial function were consistently associated with more severe RBD symptoms.

The conventional method cannot guarantee the precise osteotomies required for a perfect realignment and a better prognosis after total knee arthroplasty (TKA). This study investigated a customized guide plate for osteotomy placement in TKAs with the aid of the statistical shape model technique using weight-bearing lower-extremity X-rays and computed tomography (CT) images of the knee.

From October 2014 to June 2015, 42 patients who underwent a TKA in Guizhou Provincial People’s Hospital were divided into a guide plate group (GPG, 21 cases) and a traditional surgery group (TSG, 21 cases) using a random number table method. In the GPG group, a guide plate was designed and printed using preoperative three-dimensional measurements to plan and digitally simulate the operation. TSG cases were treated with the conventional method. Outcomes were obtained from the postoperative image examination and short-term follow-up.

Operative time was 49.0 ± 10.5 min for GPG, and 62.0 ± 9.7 min in TSG. The coronal femoral angle, coronal tibial angle, posterior tibial slope, and the angle between the posterior condylar osteotomy surface and the surgical transepicondylar axis were 89.2 ± 1.7°, 89.0 ± 1.1°, 6.6 ± 1.4°, and 0.9 ± 0.3° in GPG, and 86.7 ± 2.9°, 87.6 ± 2.1°, 8.9 ± 2.8°, and 1.7 ± 0.8° in TSG, respectively. The Hospital for Special Surgery scores 3 months after surgery were 83.7 ± 18.4 in GPG and 71.5 ± 15.2 in TSG. Statistically significant differences were found between GPG and TSG in all measurements.

A customized guide plate to create an accurate osteotomy in TKAs may be created using lower-extremity X-ray and knee CT images. This allows for shorter operative times and better postoperative alignment than the traditional surgery. Application of the digital guide plate may also result in better short-term outcomes.

Chronic kidney disease (CKD) has become a public health problem. New interventions to slow or prevent disease progression are urgently needed. In this setting, cell therapies associated with regenerative effects are attracting increasing interest. We evaluated the effect of embryonic stem cells (ESCs) on the progression of CKD.

Adult male Sprague-Dawley rats were subjected to 5/6 nephrectomy. We used pedicled greater omentum flaps packing ESC-loaded gelatin microcryogels (GMs) on the 5/6 nephrectomized kidney. The viability of ESCs within the GMs was detected using in vitro two-photon fluorescence confocal imaging. Rats were sacrificed after 12 weeks. Renal injury was evaluated using serum creatinine, urea nitrogen, 24 h protein, renal pathology, and tubular injury score results. Structural damage was evaluated by periodic acid-Schiff and Masson trichrome staining.

In vitro, ESCs could be automatically loaded into the GMs. Uniform cell distribution, good cell attachment, and viability were achieved from day 1 to 7 in vitro. After 12 weeks, in the pedicled greater omentum flaps packing ESC-loaded GMs on 5/6 nephrectomized rats group, the plasma urea nitrogen levels were 26% lower than in the right nephrectomy group, glomerulosclerosis index was 62% lower and tubular injury index was 40% lower than in the 5/6 nephrectomized rats group without GMs.

In a rat model of established CKD, we demonstrated that the pedicled greater omentum flaps packing ESC-loaded GMs on the 5/6 nephrectomized kidney have a long-lasting therapeutic rescue function, as shown by the decreased progression of CKD and reduced glomerular injury.

Laparoscopic liver resection has become an accepted treatment for liver tumors or intrahepatic bile duct stones, but its application in patients with previous upper abdominal surgery is controversial. The aim of this study was to evaluate the feasibility and safety of laparoscopic hepatectomy in these patients.

Three hundred and thirty-six patients who underwent laparoscopic hepatectomy at our hospital from March 2012 to June 2015 were enrolled in the retrospective study. They were divided into two groups: Those with previous upper abdominal surgery (PS group, n = 42) and a control group with no previous upper abdominal surgery (NS group, n = 294). Short-term outcomes including operating time, blood loss, hospital stay, morbidity, and mortality were compared among the groups.

There was no significant difference in median operative duration between the PS group and the NS group (180 min vs. 160 min, P = 0.869). Median intraoperative blood loss was same between the PS group and the control group (200 ml vs. 200 ml, P = 0.907). The overall complication rate was significantly lower in the NS group than in the PS group (17.0% vs. 31.0%, P = 0.030). Mortality and other short-term outcomes did not differ significantly between groups.

Our study showed no significant difference between the PS group and NS group in term of short-term outcomes. Laparoscopic hepatectomy is a feasible and safe procedure for patients with previous upper abdominal surgery.

Lung cancer has become the leading cause of death in many regions. Carcinogenesis is caused by the stepwise accumulation of genetic and chromosomal changes. The aim of this study was to investigate the chromosome and gene alterations in the human lung adenocarcinoma cell line OM.

We used Giemsa banding and multiplex fluorescence in situ hybridization focusing on the human lung adenocarcinoma cell line OM to analyze its chromosome alterations. In addition, the gains and losses in the specific chromosome regions were identified by comparative genomic hybridization (CGH) and the amplifications of cancer-related genes were also detected by polymerase chain reaction (PCR).

We identified a large number of chromosomal numerical alterations on all chromosomes except chromosome X and 19. Chromosome 10 is the most frequently involved in translocations with six different interchromosomal translocations. CGH revealed the gains on chromosome regions of 3q25.3-28, 5p13, 12q22-23.24, and the losses on 3p25-26, 6p25, 6q26-27, 7q34-36, 8p22-23, 9p21-24, 10q25-26.3, 12p13.31-13.33 and 17p13.1-13.3. And PCR showed the amplification of genes: Membrane metalloendopeptidase (MME), sucrase-isomaltase (SI), butyrylcholinesterase (BCHE), and kininogen (KNG).

The lung adenocarcinoma cell line OM exhibited multiple complex karyotypes, and chromosome 10 was frequently involved in chromosomal translocation, which may play key roles in tumorigenesis. We speculated that the oncogenes may be located at 3q25.3-28, 5p13, 12q22-23.24, while tumor suppressor genes may exist in 3p25-26, 6p25, 6q26-27, 7q34-36, 8p22-23, 9p21-24, 10q25-26.3, 12p13.31-13.33, and 17p13.1-13.3. Moreover, at least four genes (MME, SI, BCHE, and KNG) may be involved in the human lung adenocarcinoma cell line OM.

Bispectral index (BIS) is considered very useful to guide anesthesia care in elderly patients, but its use is controversial for the evaluation of the adequacy of analgesia. This study compared the BIS changes in response to loss of consciousness (LOC) and loss of somatic response (LOS) to nociceptive stimuli between elderly and young patients receiving intravenous target-controlled infusion (TCI) of propofol and remifentanil.

This study was performed on 52 elderly patients (aged 65–78 years) and 52 young patients (aged 25–58 years), American Society of Anesthesiologists physical status I or II. Anesthesia was induced with propofol administered by TCI. A standardized noxious electrical stimulus (transcutaneous electrical nerve stimulation, [TENS]) was applied (50 Hz, 80 mA, 0.25 ms pulses for 4 s) to the ulnar nerve at increasing remifentanil predicted effective-site concentration (Ce) until patients lost somatic response to TENS. Changes in awake, prestimulus, poststimulus BIS, heart rate, mean arterial pressure, pulse oxygen saturation, predicted plasma concentration, Ce of propofol, and remifentanil at both LOC and LOS clinical points were investigated.

BIS_LOC in elderly group was higher than that in young patient group (65.4 ± 9.7 vs. 57.6 ± 12.3) (t = 21.58, P < 0.0001) after TCI propofol, and the propofol Ce at LOC was 1.6 ± 0.3 μg/ml in elderly patients, which was significantly lower than that in young patients (2.3 ± 0.5 μg/ml) (t = 7.474, P < 0.0001). As nociceptive stimulation induced BIS to increase, the mean of BIS maximum values after TENS was significantly higher than that before TENS in both age groups (t = 8.902 and t = 8.019, P < 0.0001). With increasing Ce of remifentanil until patients lost somatic response to TENS, BIS_LOS was the same as the BIS_LOC in elderly patients (65.6 ± 10.7 vs. 65.4 ± 9.7), and there were no marked differences between elderly and young patient groups in BIS_awake, BIS_LOS, and Ce of remifentanil required for LOS.

In elderly patients, BIS can be used as an indicator for hypnotic-analgesic balance and be helpful to guide the optimal administration of propofol and remifentanil individually.

CTRI Reg. No: ChiCTR-OOC-14005629; http://www.chictr.org.cn/showproj.aspx?proj=9875.

Both procalcitonin (PCT) and plasma endotoxin levels cannot be solely used for a definite diagnosis of bacteremia or sepsis, and there has been few study comparing the values of the two biomarkers for the diagnosis of bacteremia. The aim of this study was to identify bacteria causing bacteremia and evaluate the role of the two biomarkers in the diagnosis of bacteremia in Intensive Care Unit (ICU).

The medical records of 420 patients in ICU were retrospectively reviewed. Patients (n = 241) who met the inclusion criteria were subjected to blood culture (BC) for the analysis of the endotoxin or PCT levels. The exclusion criteria included the presence of infection with human immunodeficiency virus and/or AIDS, neutropenia without sepsis, pregnancy, treatment with immunosuppressive therapies, or blood diseases such as hematological tumors. Patients' BC episodes were divided into BC negative, Gram-negative (GN) bacteria, Gram-positive bacteria, and fungi groups. The PCT and plasma endotoxin levels were compared in the different groups.

A total of 241 patients with 505 episodes of BC were analyzed. The GN bacteria group showed higher levels of PCT and endotoxin than the BC negative, Gram-positive bacteria, and fungi groups. GN bacteremia was more prevalent than Gram-positive bacteremia. The GN bacteremia caused by non-Enterobacteriaceae infection presented higher endotoxin level than that by Enterobacteriaceae, but no significant difference in PCT levels was observed between the two groups. The plasma endotoxin significantly differed among different groups and was bacterial species dependent.

Plasma endotoxin was more related to GN than to Gram-positive bacteremia, and that endotoxin level was species dependent, but PCT level remained relatively more stable within the GN bacteria caused bacteremia. Both GN and positive bacteria caused bacteremia in the ICU patients in different regions of China. And PCT is a more valuable biomarker than endotoxin in the diagnosis of bacteremia.

MicroRNA-206 (miR-206) and connexin 43 (Cx43) are related with the distant metastasis of breast cancer. It remains unclear whether the regulatory effect of miR-206 on Cx43 is involved in metastasis of breast cancer.

Using quantitative real-time polymerase chain reaction and Western blot, the expressions of miR-206 and Cx43 were determined in breast cancer tissues, hepatic and pulmonary metastasis (PM), and cell lines (MCF-10A, MCF-7, and MDA-MB-231). MCF-7/MDA-M-231 cells were transfected with lentivirus-shRNA vectors to enhance/inhibit miR-206, and then Cx43 expression was observed. Cell counting kit-8 assay and Transwell method were used to detect their changes in proliferation, migration, and invasion activity. The mutant plasmids of Cx43-3’ untranslated region (3’UTR) at position 478–484 and position 1609–1615 were constructed. Luciferase reporter assay was performed to observe the effects of miR-206 on luciferase expression of different mutant plasmids and to confirm the potential binding sites of Cx43.

Cx43 protein expression in hepatic and PM was significantly higher than that in the primary tumor, while no significant difference was showed in messenger RNA (mRNA) expression. MiR-206 mRNA expression in hepatic and PM was significantly lower than that in the primary tumor. Cx43 mRNA and protein levels, as well as cell proliferation, migration, and invasion capabilities, were all significantly improved in MDA-MB-231 cells after reducing miR-206 expression but decreased in MCF-7 cells after elevating miR-206 expression, which demonstrated a significantly negative correlation between miR-206 and Cx43 expression (P = 0.03). MiR-206 can drastically decrease Cx43 expression of MCF-7 cells but exerts no effects on Cx43 expression in 293 cells transfected with the Cx43 coding region but the lack of Cx43-3’UTR, suggesting that Cx43-3’UTR may be the key in Cx43 regulated by miR-206. Luciferase expression showed that the inhibition efficiency was reduced by 46.80% in position 478–484 mutant, 16.72% in position 1609–1615 mutant; the inhibition was totally disappeared in double mutant (P = 0.02).

MiR-206 can regulate the expression of Cx43, the cytobiological activity, and the metastasis of breast cancer through binding to the two binding sites in Cx43-3’UTR: position 478–484 and position 1609–1615.

Clarifying the risk factors for postoperative complications and taking measures to minimize these complications will improve the outcomes in patients with ulcerative colitis (UC). This study aimed to systemically explore the risk factors for short-term postoperative complications in Chinese UC patients undergoing ileocolorectal surgery.

Forty-nine UC patients undergoing proctocolectomy or ileostomy were retrospectively enrolled. Univariate and multivariate logistic regression analyses were conducted to reveal the risk factors among the clinical, laboratory, and surgical variables as well as preoperative medications.

Twenty-two (44.9%) patients who suffered from at least one short-term postoperative event had more severe hypoalbuminemia (P = 0.007) and an increased prevalence of preoperative corticosteroid usage (prednisone more than 20 mg daily or equivalent) for more than 6 weeks (59.1% vs. 25.9%, P = 0.023) compared with patients without short-term postoperative complications. Based on the multivariate logistic regression analysis, the odds ratio (95% confidence interval) values of these two risk factors were 1.756 (0.889–3.470, P = 0.105) and 3.233 (0.916–11.406, P = 0.068), respectively. In 32 severe UC patients, prolonged preoperative hospital stay worsened the short-term postoperative outcomes.

Preoperative corticosteroids usage and hypoalbuminemia worsened the short-term outcomes following ileocolorectal surgery in Chinese UC patients.

Claudin-5, claudin-9, and claudin-11 are expressed in endothelial cells to constitute tight junctions, and their deficiency may lead to hyperpermeability, which is the initiating process and pathological basis of cardiovascular disease. Although tongxinluo (TXL) has satisfactory antianginal effects, whether and how it modulates claudin-5, claudin-9, and claudin-11 in hypoxia-stimulated human cardiac microvascular endothelial cells (HCMECs) have not been reported.

In this study, HCMECs were stimulated with CoCl₂ to mimic hypoxia and treated with TXL. First, the messenger RNA (mRNA) expression of claudin-5, claudin-9, and claudin-11 was confirmed. Then, the protein content and distribution of claudin-9, as well as cell morphological changes were evaluated after TXL treatment. Furthermore, the distribution and content histone H3K9 acetylation (H3K9ac) in the claudin-9 gene promoter, which guarantees transcriptional activation, were examined to explore the underlying mechanism, by which TXL up-regulates claudin-9 in hypoxia-stimulated HCMECs.

We found that hypoxia-suppressed claudin-9 gene expression in HCMECs (F= 7.244; P = 0.011) and the hypoxia-suppressed claudin-9 could be reversed by TXL (F= 61.911; P = 0.000), which was verified by its protein content changes (F= 29.142; P = 0.000). Moreover, high-dose TXL promoted the cytomembrane localization of claudin-9 in hypoxia-stimulated HCMECs, with attenuation of cell injury. Furthermore, high-dose TXL elevated the hypoxia-inhibited H3K9ac in the claudin-9 gene promoter (F= 37.766; P = 0.000), activating claudin-9 transcription.

The results manifested that TXL reversed the hypoxia-suppressed claudin-9 by elevating H3K9ac in its gene promoter, playing protective roles in HCMECs.

This review focuses on the current knowledge on the implication and significance of beta 2 microglobulin (β2M), a conservative immune molecule in vertebrate.

The data used in this review were obtained from PubMed up to October 2015. Terms of β2M, immune response, and infection were used in the search.

Articles related to β2M were retrieved and reviewed. Articles focusing on the characteristic and function of β2M were selected. The exclusion criteria of articles were that the studies on β2M-related molecules.

β2M is critical for the immune surveillance and modulation in vertebrate animals. The dysregulation of β2M is associated with multiple diseases, including endogenous and infectious diseases. β2M could directly participate in the development of cancer cells, and the level of β2M is deemed as a prognostic marker for several malignancies. It also involves in forming major histocompatibility complex (MHC class I or MHC I) or like heterodimers, covering from antigen presentation to immune homeostasis.

Based on the characteristic of β2M, it or its signaling pathway has been targeted as biomedical or therapeutic tools. Moreover, β2M is highly conserved among different species, and overall structures are virtually identical, implying the versatility of β2M on applications.

5-Fluorouracil (5-FU)-based combination therapies are standard treatments for gastrointestinal cancer, where the modulation of autophagy is becoming increasingly important in offering effective treatment for patients in clinical practice. This review focuses on the role of autophagy in 5-FU-induced tumor suppression and cancer therapy in the digestive system.

All articles published in English from 1996 to date those assess the synergistic effect of autophagy and 5-FU in gastrointestinal cancer therapy were identified through a systematic online search by use of PubMed. The search terms were "autophagy" and "5-FU" and ( "colorectal cancer" or "hepatocellular carcinoma" or "pancreatic adenocarcinoma" or "esophageal cancer" or "gallbladder carcinoma" or "gastric cancer" ).

Critical reviews on relevant aspects and original articles reporting in vitro and/or in vivo results regarding the efficiency of autophagy and 5-FU in gastrointestinal cancer therapy were reviewed, analyzed, and summarized. The exclusion criteria for the articles were as follows: (1) new materials (e.g., nanomaterial)-induced autophagy; (2) clinical and experimental studies on diagnostic and/or prognostic biomarkers in digestive system cancers; and (3) immunogenic cell death for anticancer chemotherapy.

Most cell and animal experiments showed inhibition of autophagy by either pharmacological approaches or via genetic silencing of autophagy regulatory gene, resulting in a promotion of 5-FU-induced cancer cells death. Meanwhile, autophagy also plays a pro-death role and may mediate cell death in certain cancer cells where apoptosis is defective or difficult to induce. The dual role of autophagy complicates the use of autophagy inhibitor or inducer in cancer chemotherapy and generates inconsistency to an extent in clinic trials.

Autophagy might be a therapeutic target that sensitizes the 5-FU treatment in gastrointestinal cancer.

To summary the recent advances in molecular research of glioblastoma (GBM) and current trends in personalized therapy of this disease.

Data cited in this review were obtained mainly from PubMed in English up to 2015, with keywords "molecular", "genetics", "GBM", "isocitrate dehydrogenase", "telomerase reverse transcriptase", "epidermal growth factor receptor", "PTPRZ1-MET", and "clinical treatment".

Articles regarding the morphological pathology of GBM, the epidemiology of GBM, genetic alteration of GBM, and the development of treatment for GBM patients were identified, retrieved, and reviewed.

There is a large amount of data supporting the view that these recurrent genetic aberrations occur in a specific context of cellular origin, co-oncogenic hits and are present in distinct patient populations. Primary and secondary GBMs are distinct disease entities that affect different age groups of patients and develop through distinct genetic aberrations. These differences are important, especially because they may affect sensitivity to radio- and chemo-therapy and should thus be considered in the identification of targets for novel therapeutic approaches.

This review highlights the molecular and genetic alterations of GBM, indicating that they are of potential value in the diagnosis and treatment for patients with GBM.

While airway management is a fundamental skill set for many healthcare professionals, the difficult airway management has long been recognized as one of the most challenging tasks facing healthcare providers. As yet, failure to properly manage airway conditions remains a significant source of patients’ morbidity and mortality.^[1]To avoid or reduce medical errors and improve patient safety and outcomes, training for healthcare providers for airway management skills is essential.

Fahr’s disease, or idiopathic basal ganglia calcification (IBGC), is a rare neurological syndrome characterized by abnormal calcified deposits located mostly in bilateral basal ganglia and dentate nucleus, and also in cerebral cortex, thalamus, hippocampus, cerebellar, and subcortical white matter. Clinically, it presents various symptoms, including parkinsonism (presented in 57% of the patients), chorea (19%), tremors (8%), dystonia (8%), athetosis (5%), and orofacial dyskinesia (3%).^[1]

Reversible posterior leukoencephalopathy syndrome (RPLS) was first described by Hincheyet al.^[1]in 1996 as a clinical radiologic syndrome consisting of reversible cortical neurologic dysfunction and brain imaging findings involving the posterior circulation, especially the occipital lobes.

An intrauterine device (IUD) is a safe, effective, simple, and reversible method for birth control, but some women with IUD may still become pregnant. Induced abortion is the main method for termination of pregnancy. If induced abortion is not well-managed in these patients, it may result in serious vaginal bleeding and uterine rupture. We report a case of uterine artery rupture after induced abortion combined with extraction of an IUD. This case highlights the necessity of a standard operation for complicated induced abortion, and the value of interventional therapy, such as uterine artery embolization (UAE), for controlling serious vaginal bleeding.

Myotonic dystrophy type 1 (DM1) is the most common disease causing muscle weakness and atrophy in adults.^[1]The prevalence of DM1 in China is not clear. DM1 is an autosomal dominant genetic disorder associated with the cytosine-thymine-guanine (CTG) repeat expansion in 3’untranslated region in dystrophia myotonica-protein kinase (DMPK) gene on chromosome 19q13.3. In DM1, CTG pathological repeat numbers are more than 50. The size of CTG repeat expansion is associated with the time of clinical phenotypes onset and severity.^[1,2,3]The coexistence of DM1 and syringomyelia is rare. Here, we report DM1 coexisting with syringomyelia in a Chinese male patient.

To the Editor: A frail 74-year-old woman visited the emergency department with a chief complaint of "intermittent abdominal pain for 6 days and vomiting for 2 days". She described her symptoms as a colicky lower abdominal pain that occurred 6 days ago, recurred several times, and resolved spontaneously, but progressed to severe and sustained pain with vomiting 2 days before visiting the hospital. The lower abdominal pain also radiated down to the right medial thigh. Physical examination of the abdomen revealed distention, with intestinal pattern and positive bowel sounds. Tenderness on the lower abdomen was identified, which radiated to the right medial thigh. There was no palpable mass in the abdominal or groin area.

To the Editor: With the increase of human noncommunicable disease (NCD) and the release of Big Health Data in China in March 2015, people need to call for more effective action to address the challenges posed by NCD. For example, according to the latest evidence in the Global Burden of Disease Study 2013, for most countries, NCD remains a leading cause of death. In general, people accept the preventive, predictive, personalized, and participation,^[1]or "4P" medical model from treatment to prevention as an effective strategy. For example, exceptional responders can help scientists predict the responses of many patients with cancer. Therefore, the authors propose adding another "P", that is, "Platform" to the medical model. Constructing new platform that may help people tackle the increase of NCD in China, and globally, is a further challenge.

To the Editor: Letrozole, a third-generation aromatase inhibitor (AI), is a relatively newer class of endocrine agents used in hormone-receptor-positive breast cancer.^[1]Vascular thrombotic events, such as acute myocardial infarction and acute cerebral infarction, in patients with breast cancer after initiation of letrozole therapy have been documented in the literature.^[2,3]However, the impact of this adjuvant endocrine therapy on increasing the risk of developing vascular thrombotic events has been a controversial issue. Here, we report a rare case of a woman with breast cancer developing unilateral internal carotid artery (ICA) occlusion after letrozole treatment.

To the Editor: Carotid body tumor (CBT) is a highly vascular neoplasm of neural crest origin arising in paraganglial cells of the carotid bifurcation. Branches from external carotid artery or glomic artery arising at the bifurcation of common carotid artery dominate in the blood supply mode. Only very few cases with supplementary blood supply from an internal carotid artery (ICA) have been reported in literature, but were still short of imaging proof.^[1,2]Here, we report an extremely rare case of CBT with blood supply from ICA, which had been performed 4 times of unaccomplished surgical explorations before the tumor was excised during the 5^thtime of surgery. She also presented carotid sinus syndrome that was also extremely rare among CBT patients.

To the Editor: A 54-year-old woman with no significant history of a headache or hypertension underwent epidural oxygen-ozone injection at a concentration of 30 µg/ml (3 ml) for cervical disc herniation at cervical vertebra (C6–C7) level. Throughout the procedure, the routine monitorings of blood pressure, heart rate, and blood oxygen saturation were performed. One minute following the end of the injection, the patient developed a high-intensity headache mimicking symptoms of a ruptured cerebral aneurysm. The patient described the location of a headache as present in the frontoparietal and occipital areas accompanied by nausea and vomiting. The presumptive diagnosis of inadvertent epidural puncture was made. The patient was immediately treated oxygen therapy and bed rest. Monitoring showed vital signs of blood pressure (149/83 mmHg), heart rate (86 beats/min), pulse oxygen saturation (SpO₂, 96%), blood sugar (6.3 mmol/L), and body temperature (36.6°C). Subsequently, metoclopramide 10 mg and midazolam 1 mg were injected intravenously. Thirty minutes later, the severe headache symptom significantly improved. An immediate brain computed tomography (CT) scan revealed a large air collection in the frontal horns of the lateral ventricles, and a smaller one in the third ventricle region [Figure 1a]. The patient was discharged from the pain treatment clinic after 4 h of observation with a blood pressure of 130/80 mmHg. There were no further symptoms in the following 2 months, and the brain CT scan revealed no significant abnormalities 1 month later [Figure 1b].

To the Editor: In the very important report published in Chinese Medical Journal,^[1]a 50-year-old male patient, stented with a bare metal stent followed by 3 overlapping drug-eluting stents, developed anaphylactic reaction following a bee sting that was treated with intravenous 0.1 mg epinephrine at a 1:100,000 together with intravenous methylprednisolone, chlorpheniramine maleate, and ranitidine. He developed, immediately after, an anterior wall myocardial infarction, and subsequent coronary arteriography revealed total occlusion in the proximal left anterior descending stent and 90% stenosis with tissue growth in the mid-stent. The authors concluded that the acute myocardial infarction occurred due to acute stent thrombosis caused by exogenous epinephrine administration. This report, however, raises important questions related to the cause and pathophysiology of these events.

To the Editor: In a single-center, prospective, randomized double-blind clinical study comparing dexmedetomidine-midazolam and sufentanil-midazolam sedation regimens for awake fiberoptic intubation (AFOI) in 50 patients with difficult airways due to limited mouth opening, Liet al.^[1]show that both dexmedetomidine and sufentanil are effective as an adjuvant for AFOI under airway topical anesthesia combined with midazolam sedation, but respiratory depression is a potential risk in the sufentanil-midazolam regimen. Given that AFOI has been established as the gold standard for difficult airway management,^[2]their findings have potentially clinical implications. In our view, however, there are several aspects of this study that need to be clarified and discussed.

We appreciate Prof. Xueet al. for their thoughtful comments on our study.^[1]We agree with them that history of smoking and respiratory comorbidities can increase airway reactivity to airway irritation, resulting in an increased severity of cough. In our study, patients with a history of smoking and respiratory comorbidities were excluded and the demographic data of patients were comparable between the groups.