2017年 · 第130卷第15期

Amyotrophic lateral sclerosis (ALS) is characterized by the progressive degeneration of upper and lower motor neurons. Typical clinical features of ALS are limb paralysis, muscle atrophy, dysphagia, dysarthria, shortness of breath, and respiratory failure. Approximately 90% of ALS cases are classified as sporadic ALS, the remaining 10% are classified as familial.^[1,2]Researchers have found that the survival of ALS patients is related to several factors, including clinical phenotype, age at onset, sex, early presence of respiratory failure, and treatment with riluzole. We recently found that there is a potential linear relationship in ALS between serum lactate and motor deterioration, and that slower lactate elimination rate might be associated with faster disease progression.^[3]In addition, several studies have reported that nutritional status is closely related to the survival time of ALS patients, and there exists a U-shaped association between patients’ body mass index (BMI) and mortality.^[1,4]The main cause of malnutrition (BMI ≤18.5 kg/m²) in ALS patients is an imbalance between intake and consumption, and some symptoms, such as dysphagia, can lead to insufficient energy intake. More importantly, recent studies have shown that ALS patients are in states of hypermetabolism.^[5,6]

Progressive bulbar palsy (PBP) is a classic phenotype of bulbar onset amyotrophic lateral sclerosis (ALS) with more rapid progression and worse prognosis. However, as an often under-understood variant of ALS, isolated bulbar palsy (IBP) appears to progress more slowly and has a relatively benign prognosis. This study aimed to investigate the natural course and clinical features of IBP in Chinese population and to compare them with those of PBP.

The clinical data of patients with bulbar onset ALS were collected from January 2009 to December 2013. Revised ALS Functional Rating Scale (ALSFRS-R), forced vital capacity (FVC), and follow-up evaluation were performed, and the differences in basic clinical features, ALSFRS-R, FVC, and primary outcome measures between IBP and PBP were analyzed. The independent t-test, Chi-square test, Mann-Whitney U-test, and Kaplan-Meier analysis were used.

Totally 154 patients with bulbar onset ALS were categorized into two groups, 33 with IBP and 121 with PBP. In the IBP group, the male to female ratio was 0.7 to 1.0, and the mean onset age was 58.5 years. The mean duration from the onset was 16.0 months, and the mean ALSFRS-R score was 43.4 at patients’ first visit to our hospital. In 14 IBP patients performing FVC examination, the mean FVC value was 90.5% and there were only two cases with abnormal FVC. In 26 IBP patients completing follow-up, 15 (58%) suffered death or tracheotomy and the mean survival time was 40.5 months. Significant differences were noted in sex ratio, onset age, ALSFRS-R score, upper motor neuron limb signs, pure lower motor neuron (LMN) bulbar signs, FVC, and survival time between IBP and PBP.

IBP was evidently different from PBP, which was characterized with the predominance of female, pure LMN bulbar signs, an older onset age, a relative preservation of respiratory function, and a better prognosis.

The 9-hole peg test (9-HPT) and 10-meter walk test (10-MWT) are commonly used to test finger motor function and walking ability. The aim of this present study was to investigate the efficacy of these tests for evaluating functional loss in Chinese Charcot-Marie-Tooth (CMT) disease.

Thirty-four Chinese CMT patients (CMT group) from August 2015 to December 2016 were evaluated with 9-HPT, 10-MWT, CMT disease examination score, overall neuropathy limitation scale (ONLS), functional disability score, and Berg Balance Scale (BBS). Thirty-five age- and gender-matched healthy controls (control group) were also included in the study. Student’s nonpaired or paired t-test were performed to compare data between two independent or related groups, respectively. The Pearson test was used to examine the correlations between recorded parameters.

The mean 9-HPT completion time in the dominant hand of CMT patients was significantly slower than that in the healthy controls (29.60 ± 11.89 s vs. 19.58 ± 3.45 s; t = −4.728, P < 0.001). Women with CMT completed the 9-HPT significantly faster than men with CMT (dominant hand: 24.74 ± 7.93 s vs. 33.01 ± 13.14 s, t = 2.097, P = 0.044). The gait speed of the average self-selected velocity and the average fast-velocity assessed using 10-MWT for CMT patients were significantly slower than those in the control group (1.03 ± 0.18 m/s vs. 1.44 ± 0.17 m/s, t = 9.333, P < 0.001; 1.31 ± 0.30 m/s vs. 1.91 ± 0.25 m/s, t = 8.853, P < 0.001, respectively). There was no difference in gait speed between men and women. Both 9-HPT and 10-MWT were significantly correlated with the ONLS, functional disability score, and BBS (P < 0.05 for all).

The 9-HPT and 10-MWT might be useful for functional assessment in Chinese patients with CMT.

Charcot-Marie-Tooth disease (CMT) is the most common inherited peripheral neuropathy. A great number of causative genes have been described in CMT, and among them, the heterozygous duplication of peripheral myelin protein-22 (PMP22) is the major cause. Although the missense mutation in PMP22 is rarely reported, it has been demonstrated to be associated with CMT. This study described a novel missense mutation of PMP22 in a Chinese family with CMT phenotype.

Targeted next-generation sequencing (NGS) was used to screen the causative genes in a family featured with an autosomal dominant demyelinating form of CMT. The potential variants identified by targeted NGS were verified by Sanger sequencing and classified according to the American College of Medical Genetics and Genomics standards and guidelines. Further cell transfection studies were performed to characterize the function of the novel variant.

Using targeted NGS, a novel heterozygous missense variant in PMP22 (c.320G>A, p.G107D) was identified. In vitro cell functional studies revealed that mutant PMP22 protein carrying p.G107D mutation lost the ability to reach the plasma membrane, was mainly retained in the endoplasmic reticulum, and induced cell apoptosis.

This study supported the notion that missense mutations in PMP22 give rise to a CMT phenotype, possibly through a toxic gain-of-function mechanism.

Some esophageal cancer patients complicated with depression exhibit cognitive impairments. Frontal electroencephalogram (EEG) may be used as a reliable biomarker for prefrontal-mediated cognitive functions. This study was to investigate alterations of EEG and frontal cognitive impairment in esophageal cancer patients complicated with depression and to assess their correlation.

Sixty-five esophageal cancer patients with depression (study group) and 62 healthy controls (control group) were included in this study. The study group were assigned into psychotic depressed (PD, n= 32) and nonpsychotic depressed (NPD, n= 33) subgroups based on complication with psychotic symptoms (Brief Psychiatric Rating Scale [BPRS] >35). EEG examination, Beck self-rating depression scale, and BPRS were used to assess clinical symptoms. Chi-square test, two independent sample t-test, one-way analysis of variance, and Kruskal-Wallis test were utilized to compare the variables between two groups. EEG abnormalities and scores of frontal cognitive function test were analyzed by partial correlation analysis in the PD and NPD subgroups.

Compared with control group, the study group displayed greater scores either in the Stroop test (19.89 ± 2.05 vs. 24.12 ± 2.19, P = 0.006) or Color Trails Test (CTT; 11.92 ± 1.01 vs. 15.02 ± 1.63, P = 0.008), and reduced score (35.05 ± 2.01 vs. 32.11 ± 2.38, P = 0.007) in the verbal fluency test (VFT). Compared to NPD subgroup, PD subgroup exhibited increased scores in Stroop test (22.89 ± 2.07 vs. 25.38 ± 2.32, P= 0.009) and CTT (13.16 ± 1.71 vs. 15.82 ± 1.13, P = 0.008). Moreover, increased scores in Stroop test and CTT as well as scores in VFT were associated with the severity of depression. The study group had an abnormal frontal EEG, such as α forward, α asymmetry, α moderation, and increased θ activity relative to control group. Similarly, compared with NPD subgroup, PD subgroup displayed α forward, α asymmetry, and α moderation. The correlation test revealed that α forward and α asymmetry were negatively associated with VFT score, but positively correlated with the scores of CTT and the Stroop test in PD subgroup. In addition, α asymmetry in NPD subgroup was positively related to CTT scores.

This study indicated that frontal cognitive impairment in esophageal cancer patients complicated with depression is associated with EEG alterations.

Inflammatory demyelinating disease of central nervous system (CNS) is an inflammatory disease characterized by a high childbearing female predominance. Labor-related alterations for postpartum demyelinating attacks are not entirely clear. This study aimed to summarize clinical features of female patients of reproductive age with initial CNS inflammatory demyelinating attacks during puerperium.

Fourteen female patients with initial demyelinating events during puerperium between January 2013 and December 2016 were retrospectively studied. Records of clinical features, neuroimaging, serum antibodies, cerebrospinal fluid (CSF) findings, annualized relapse rate (ARR), and treatment were analyzed.

Among 14 patients, 5 patients were diagnosed with multiple sclerosis (MS), four as neuromyelitis optica (NMO), two as longitudinal extensive transverse myelitis, two as clinical isolated syndrome (CIS), and one as acute brainstem syndrome. All the 14 puerperal female patients presented with more than one manifestation of hemiplegia, paraplegia, uroschesis, visual loss or dysarthria, and with mild to moderate abnormalities of CSF. Attacks occurred during the first trimester postpartum and cesarean section was the main delivery way (n = 10). Median Expanded Disability Status Scale (EDSS) scores were 5.0 (range: 2.0–9.0) at the onset and 2.5 (range: 0–7.0) at the end of follow-ups. Patients with MS and CIS had a significantly lower EDSS scores than patients with NMO spectrum disorders (P < 0.05). Median ARR was 0.46 (range: 0–1.16); all patients had a low ARR (0.49 ± 0.34, 95% confidence interval: 0.29–0.69) with standardized treatments.

Labor-related alterations in the mother’s immune system might result in newly-onset demyelinating diseases of central nervous system.

Glehnia littoralis, as a traditional herbal medicine to heal various health ailments in EastAsia, displays various therapeutic properties including antioxidant effects. However, neuroprotective effects of G. littoralis against cerebral ischemic insults have not yet been addressed. Therefore, in this study, we first examined its neuroprotective effects in the hippocampus using a gerbil model of transient global cerebral ischemia (TGCI).

Gerbils were subjected to TGCI for 5 min. G. littoralis extract (GLE; 100 and 200 mg/kg) was administrated orally once daily for 7 days before ischemic surgery. Neuroprotection was examined by neuronal nuclear antigen immunohistochemistry and Fluoro-Jade B histofluorescence staining. Gliosis was observed by immunohistochemistry for glial fibrillary acidic protein and ionized calcium-binding adapter molecule 1. For neuroprotective mechanisms, immunohistochemistry for superoxide dismutase (SOD) 1 and brain-derived neurotrophic factor (BDNF) was done.

Pretreatment with 200 mg/kg of GLE protected pyramidal neurons in the cornu ammonis 1 (CA1) area from ischemic insult area (F = 29.770, P < 0.05) and significantly inhibited activations of astrocytes (F = 22.959, P < 0.05) and microglia (F = 44.135, P < 0.05) in the ischemic CA1 area. In addition, pretreatment with GLE significantly increased expressions of SOD1 (F = 28.561, P < 0.05) and BDNF (F = 55.298, P < 0.05) in CA1 pyramidal neurons of the sham- and ischemia-operated groups.

Our findings indicate that pretreatment with GLE can protect neurons from ischemic insults, and we suggest that its neuroprotective mechanism may be closely associated with increases of SOD1 and BDNF expressions as well as attenuation of glial activation.

Galectin-3 (Gal-3) plays a role in the mechanisms underlying ocular venous malformation. We conducted this study to investigate the effect of pingyangmycin pretreatment on the Gal-3 expressions and biological behavior of ocular venous malformation.

Tissue samples were collected from 136 patients with ocular venous malformation. Patients were randomly divided into pingyangmycin (n = 69) and nonpingyangmycin group (n = 67). Patients in the pingyangmycin group received a local injection of 0.02% pingyangmycin once every 2 days for 2 weeks (7 doses) before removal surgery, whereas patients in the nonpingyangmycin group underwent removal surgery without local injection. The protein and messenger RNA (mRNA) expression of Gal-3 were detected by using immunohistochemistry and in situ hybridization.

Gal-3 protein was expressed in 35 (52%) of 67 samples in the nonpingyangmycin group and in 19 (28%) of 69 samples in the pingyangmycin group (P < 0.05). Gal-3 mRNA expression was detected in 39 (58%) of 67 samples in the nonpingyangmycin group and 22 (32%) of 69 samples in the pingyangmycin group (P < 0.05). The higher Gal-3 expressions were detected in samples with deeper invasiveness than those with superficial invasiveness before (χ² = 12.720 and 13.369, respectively, both P < 0.05) and after pingyangmycin treatment (χ² = 8.429 and 4.590, respectively, both P < 0.05). It was more frequently detected in mesh-like lesions with unclear boundary than round lesions with clear boundary before (χ² = 30.291 and 41.466, respectively, both P < 0.05) and after pingyangmycin treatment (χ² = 14.619 and 15.130, respectively, both P < 0.05). Pingyangmycin treatment led to a significant difference in Gal-3 expressions at both protein and mRNA levels (χ² = 8.664 and 9.524, respectively, both P < 0.05).

Gal-3 expression may be involved in the development and invasiveness of ocular venous malformation, and pingyangmycin can inhibit Gal-3 expression, indicating a role of pingyangmycin treatment before the removal of ocular venous malformation.

Hepatitis B is an immune response-mediated disease. The aim of this study was to explore the differences of ratios of T-helper (Th) 2 cells to Th1 cells and cytokine levels in acute hepatitis B (AHB) patients and chronic hepatitis B virus (HBV)-infected patients in immune-tolerance and immune-active phases.

Thirty chronic HBV-infected patients in the immune-tolerant phase (IT group) and 50 chronic hepatitis B patients in the immuneactive (clearance) phase (IC group), 32 AHB patients (AHB group), and 13 healthy individuals (HI group) were enrolled in the study. Th cell proportions in peripheral blood, cytokine levels in plasma, and serum levels of HBV DNA, hepatitis B surface antigen, and hepatitis B e antigen were detected.

The Th1 cell percentage and Th2/Th1 ratio in the HBV infection group (including IT, IC, and AHB groups) were significantly different from those in HI group (24.10% ± 8.66% and 1.72 ± 0.61 vs. 15.16% ± 4.34% and 2.40 ± 0.74, respectively; all P < 0.001). However, there were no differences in the Th1 cell percentages and Th2/Th1 ratios among the IT, IC, and AHB groups. In HBV infection group, the median levels of Flt3 ligand (Flt3L), interferon (IFN)-γ, and interleukin (IL)-17A were significantly lower than those in HI group (29.26 pg/ml, 33.72 pg/ml, and 12.27 pg/ml vs. 108.54 pg/ml, 66.48 pg/ml, and 35.96 pg/ml, respectively; all P < 0.05). IFN-α2, IL-10, and transforming growth factor (TGF)-β2 median levels in hepatitis group (including patients in AHB and IC groups) were significantly higher than those in IT group (40.14 pg/ml, 13.58 pg/ml, and 557.41 pg/ml vs. 16.74 pg/ml, 6.80 pg/ml, and 419.01 pg/ml, respectively; all P < 0.05), while patients in hepatitis group had significant lower Flt3L level than IT patients (30.77 vs. 59.96 pg/ml, P = 0.021). Compared with IC group, patients in AHB group had significant higher median levels of IL-10, TGF-β1, and TGF-β2 (22.77 pg/ml, 10,447.00 pg/ml, and 782.28 pg/ml vs. 8.66 pg/ml, 3755.50 pg/ml, and 482.87 pg/ml, respectively; all P < 0.05).

Compared with chronic HBV-infected patients in immune-tolerance phase, chronic HBV-infected patients in immune-active phase and AHB patients had similar Th2/Th1 ratios, significantly higher levels of IFN-α2, IL-10, and TGF-β. AHB patients had significantly higher IL-10 and TGF-β levels than chronic HBV-infected patients in immune-active phase.

Foreign bodies within the sinuses, orbit, and skull base (FBSOS) are rare; hence, diagnosis and management guidelines are lacking. Endoscopic sinus surgery (ESS) removal is preferred because of the less invasiveness and minimal morbidity. This study was designed to summarize clinical experience with ESS management of FBSOS.

We retrospectively reviewed clinical manifestations, imaging findings, treatment, and outcomes in consecutive patients with ESS removal of FBSOS between 2004 and 2015 at a tertiary academic medical center. The Chi-square test was performed to compare the infection rate between wooden and nonwooden FBSOS.

There were 23 male and five female patients, with median age of 11 years. FBSOS were located within the sinuses (86%), orbit (75%), and skull base/intracranial region (46%). Wooden FBSOS had a significantly higher risk of infection (78%) compared with nonwooden FBSOS (5%, P < 0.05). Contrast-enhanced computed tomography (CT) plus three-dimensional reconstruction was sensitive in all cases. Twenty-seven (96%) FBSOS were removed by ESS alone, while 1 (4%) FBSOS was removed using the combined ESS and lateral cervical approach. Four of the nine intracranial penetrating FBSOS patients had intraoperative cerebrospinal fluid (CSF) leak and received endoscopic CSF leak repair. Twelve (43%) patients suffered complications (meningitis, diplopia, and vision loss).

ESS is a minimally invasive, safe, and promising surgical approach for FBSOS removal. Contrast-enhanced CT is effective in preoperative diagnosis and intraoperative guidance. Wooden FBSOS had higher risk of infection, thus antibiotics are recommended.

Nuclear mitotic apparatus protein 1 (NuMA1) had been reported to produce three groups of isoforms categorized as long, middle, and short groups, of which short NuMA displayed distinct localization patterns compared to long and middle isoforms. However, the function of short NuMA was not clear in the progress of cancer formation. This study aimed to unveil the role of short NuMA in cancer pathogenesis.

The expression levels of short isoforms were explored in paired gastric carcinoma (GC) samples and different cell lines. Furthermore, the short isoform behaved as a putative tumor suppressor based on cell proliferation and cell colony formation assays. Pull-down assay and whole-genome gene expression analysis were carried out to search candidate interaction partners of short NuMA.

The expression of short NuMA was highly expressed in S and G2 phases of the cell cycle; compared with nontumor tissues, short NuMA downregulated in nine GCs (GC1 [0.131, P = 5 × 10⁻⁴]; GC2 [0.316, P = 3 × 10⁻⁵]; GC3 [0.111, P = 6 × 10⁻⁴]; GC4 [0.456, P = 0.011]; GC5 [0.474, P = 0.001]; GC6 [0.311, P = 0.004]; GC7 [0.28, P = 3 × 10⁻⁵]; GC8 [0.298, P = 0.007]; and GC9 [0.344, P = 0.002]). Besides, high expression of short NuMA significantly inhibits cell growth (2.43 × 10⁵ vs. 2.97 × 10⁵, P = 0.0029) and cell clone information in vitro (70 vs. 2, P = 1.67 × 10⁻⁴⁵). Short NuMA could bind with alpha–actinin-4 (ACTN4), a putative tumor promoting gene. Overexpression of short NuMA could tremendously decrease the expression of MYB proto-oncogene like 2 (MYBL2) of about 92-fold, which played an important role in the cell cycles.

Short isoform of NuMA might be functioned as a putative role of tumor suppressor. Further studies should be made to illuminate the relationship between ACTN4, MYBL2, and tumor progression.

Tumefactive demyelinating lesions (TDLs),^[1,2,3]previously named as tumor-like inflammatory demyelinating disease^[4,5]or demyelinating pseudotumor,^[6]are relatively special type of immune-mediated inflammatory demyelinating lesions in the central nervous system (CNS),^[7]which mainly occur within cerebrum, but rarely in spinal cord. TDLs are so named because it mimics brain tumors with such characteristics as less severe symptoms, large lesions with perilesional edema, mass effect and/or enhancement on neuroimaging, and easily misdiagnosed as brain tumors.^[8,9]

Since the 1950s, electroencephalography (EEG) has been used extensively in Neurocritical Care Units (NCUs). At the beginning of this century, China’s NCUs underwent rapid development. According to an incomplete statistical report,^[1]76 NCUs had achieved the construction standard in 2010. Therefore, the establishment of EEG monitoring stations and the development of national competency skill standards is imperative. In response to this urgent need, the Neurocritical Care Committee (NCC) of the Chinese Society of Neurology presents this document to set the national criteria to evaluate competencies for performing studies associated with EEG monitoring in NCUs. The NCC organized a writing committee to evaluate the literature and develop an evidence- and expert-based (neurocritical care and neurophysiological experts) consensus for practice recommendations. Literature searches were conducted using the PubMed database (from 1995 to 2013). Studies meeting the criteria established by the writing committee were evaluated. Recommendations were developed based on the literature using grading standards and level-of-evidence confirmation from the 2011 edition of the Oxford-based medicine center.^[2]Expert opinions were gathered to improve the recommended level when sufficient data were lacking. The NCC aims to provide help and references for physicians in NCUs, Intensive Care Units (ICUs), and Emergency Medicine Departments.

The aim of this study was to summarize recent studies on nondopaminergic options for the treatment of motor symptoms in Parkinson’s disease (PD).

Papers in English published in PubMed, Cochrane, and Ovid Nursing databases between January 1988 and November 2016 were searched using the following keywords: PD, nondopaminergic therapy, adenosine, glutamatergic, adrenergic, serotoninergic, histaminic, and iron chelator. We also reviewed the ongoing clinical trials in the website of clinicaltrials.gov.

Articles related to the nondopaminergic treatment of motor symptoms in PD were selected for this review.

PD is conventionally treated with dopamine replacement strategies, which are effective in the early stages of PD. Long-term use of levodopa could result in motor complications. Recent studies revealed that nondopaminergic systems such as adenosine, glutamatergic, adrenergic, serotoninergic, histaminic, and iron chelator pathways could include potential therapeutic targets for motor symptoms, including motor fluctuations, levodopa-induced dyskinesia, and gait disorders. Some nondopaminergic drugs, such as istradefylline and amantadine, are currently used clinically, while most such drugs are in preclinical testing stages. Transitioning of these agents into clinically beneficial strategies requires reliable evaluation since several agents have failed to show consistent results despite positive findings at the preclinical level.

Targeting nondopaminergic transmission could improve some motor symptoms in PD, especially the discomfort of dyskinesia. Although nondopaminergic treatments show great potential in PD treatment as an adjunct therapy to levodopa, further investigation is required to ensure their success.

UEscope is a new angulated videolaryngoscope (VL). This review aimed to describe the features of UEscope and provide clinical evidences regarding the efficacy and safety of this video device in adult tracheal intubation and its roles in airway management teaching.

The Wan Fang Data, CNKI, PubMed, Embase, Cochrane Library, and Google Scholar were searched for relevant English and Chinese articles published up to January 15, 2017, using the following keywords: "HC video laryngoscope" , "UE videolaryngoscope" , "video laryngoscope" , and "videolaryngoscopy" .

Human case reports, case series, observable studies, and randomized controlled clinical trials were included in our search. The results of these studies and their reference lists were cross-referenced to identify a common theme.

UEscope features the low-profile portable design, intermediate blade curvatures, all-angle adjustable monitor, effective anti-fog mechanisms, and built-in video recording function. During the past 5 years, there have been a number of clinical studies assessing the application and roles of UEscope in airway management and education. As compared with direct laryngoscope, UEscope improves laryngeal visualization, decreases intubation time (IT), and increases intubation success rate in adult patients with normal and difficult airways. These findings are somewhat different from the previous results regarding the other angulated VLs; they can provide an improved laryngeal view, but no conclusive benefits with regard to IT and intubation success rate. Furthermore, UEscope has extensively been used for intubation teaching and shown a number of advantages.

UEscope can be used as a primary intubation tool and may provide more benefits than other VLs in patients with normal and difficult airways. However, more studies with large sample are still needed to address some open questions about clinical performance of this new VL.

Recently, the survival rate of head and neck cancer patients has increased with the improvement of radiotherapy (RT) technology and comprehensive treatment. Cancer survivors after RT are at increased risk for cerebrovascular events.^[1]Radiation-induced cervical artery stenosis (RICAS) has its own characteristics compared with those lesions without a history of RT.

For aged patients, the treatment of type A aortic dissection (TAAD) with the primary entry tear at the inner curve of the ascending aorta is a great challenge. Conventional surgical repair with cardiopulmonary bypass and deep hypothermic circulatory arrest is associated with high risk of mortality.^[1]Thoracic endovascular aortic repair (TEVAR) with associated techniques to reconstruct all supra-aortic branches is still controversial.^[2,3]Herein, we reported a new endovascular method.

With the popularity of urine flow dynamic monitoring and indwelling catheter technologies in animal experiments, the urethral catheterization has become a common technique in scientific research. The miniature pig is considered as one of the major animal species used in scientific research and is increasingly being used as an alternative to a dog or monkey as the nonrodent species of choice in the preclinical toxicological testing of pharmaceuticals.^[1]Since there are three acute angles bending in the urethra of the male miniature pig, and the end of the penis head is cork-screw shaped, it is difficult to implement routine urethral catheterization in male miniature pigs. Currently, researchers usually implement bladder colostomies or dissections in male miniature pigs, while transurethral urethral catheterization can be implemented in female miniature pigs.According to the existing reports, implementing transurethral urethral catheterization in female miniature pigs is seldom seen.^[2]We chose 3-month-old female Bama miniature pigs in our experiments and employ the following methods: first, use a "V" -shaped platform with an angle of about 30° to the horizontal plane; second, utilize a pediatric laryngoscope for deep lighting; third, bend the lower limbs and press down to the ventral side. Satisfactory results through transurethral urethral catheterization were achieved in the end.

To the Editor: In June 2013, a 17-year-old patient was admitted to our hospital for a pelvic mass and primary amenorrhea. The patient’s cousin had a similar clinical presentation without a definite diagnosis. Physical examination revealed a phenotypic female with a slender body, poor mammary gland development, an infantile vulva, no pubic hair, and a normal-appearing vaginal orifice and vestibule. A hard and solid abdominal mass, approximately 12 cm in diameter, was found. The vagina was approximately 3.0 cm in length with a blind end measured by cotton swabs. The human chorionic gonadotropin (HCG) (40.64 mU/ml) and lactate dehydrogenase (LDH) (431 U/ml) levels were elevated. The follicle-stimulating hormone (111 mU/ml) and leutinizing hormone (27.8 mU/ml) levels were also elevated, while the E2, T, and A levels were below the reference values. The diurnal cortisol and adrenocorticotropic hormone (ACTH) levels were normal. Chromosome karyotype analysis was then done and revealed a result of 46XY. Pelvic computed tomography scan revealed multiple masses posterior to the uterus and involving the retroperitoneal abdominal aorta to the level of the left renal veins.

To the Editor: Intraorbital electroacupuncture (IEA) therapy is highly effective in treating ocular motility disorders, but it has only rarely been used to treat thyroid-associated ophthalmopathy (TAO). Herein, we report one successful case.

To the Editor: Health-care redesign seems to be a buzzword in the USA. However, the President Trump recently objected to some parts of Obamacare. No one doubts the importance of the initiatives of "shooting for the moon" and precision medicine in cancer treatment. All-round health care has had a major beneficial impact through state-of-the-art technology, such as big data, internet medical care services, smart medical devices, and minimally invasive techniques. As a result, health care is entering a new, third era; a collision between emerging technology and old notions of care redesign. This new era has also aroused broader interest from global leading experts to the general public.

To the Editor: Pretibial myxedema (PTM), a localized thyroid-associated dermopathy, is characterized by local thickening and remodeling of the skin − it is often associated with a group of autoimmune thyroid diseases (ATDs).^[1]PTM is most frequently located across the lower legs, especially the pretibial areas or the dorsum of the foot. Rarely, the fingers and hands, elbows, arms, or face are affected. Here, we report an unusual case of PTM and vitiligo, involving buttocks and face.

To the Editor: We read with great interest the article entitled, "A Case of Acute Myocardial Infarction Induced by Selective Cyclooxygenase-2 Inhibitor" by Seoet al.^[1]The authors have shown a correlation of aceclofenac intake with the myocardial infarction. This is really important information to be noted as aceclofenac or any nonsteroidal anti-inflammatory drugs (NSAIDS) of this group were prescribed more frequently worldwide. There are a number of studies and analysis supporting and warning regarding the cardiac risk factor with diclofenac, as aceclofenac is its analogs.^[2,3]

On behalf of the authors of the article titled, "A Case of Acute Myocardial Infarction Induced by Selective Cyclooxygenase-2 Inhibitor," I would like to thank the reader for the comment.