2017年 · 第130卷第16期

Atrial fibrillation (AF) is the most common type of cardiac arrhythmia which affects 33 million individuals worldwide.^[1]It is associated with many adverse outcomes, including stroke, dementia, heart failure (HF), and mortality.^[2]Based on a growing body of evidence illustrating its efficacy and safety, catheter ablation (CA) has become an important treatment strategy for symptomatic AF.^[3]Most centers have progressively moved from performing paroxysmal AF to more complex long-standing persistent AF or patients with more comorbidities.

The emergency department (ED) has a pivotal influence on the management of acute heart failure (AHF), but data concerning current ED management are scarce. This Beijing AHF Registry Study investigated the characteristics, ED management, and short- and long-term clinical outcomes of AHF.

This prospective, multicenter, observational study consecutively enrolled 3335 AHF patients who visited 14 EDs in Beijing from January 1, 2011, to September 23, 2012. Baseline data on characteristics and management were collected in the EDs. Follow-up data on death and readmissions were collected until November 31, 2013, with a response rate of 92.80%. The data were reported as median (interquartile range) for the continuous variables, or as number (percentage) for the categorical variables.

The median age of the enrolled patients was 71 (58–79) years, and 46.84% were women. In patients with AHF, coronary heart disease (43.27%) was the most common etiology, and myocardium ischemia (30.22%) was the main precipitant. Most of the patients in the ED received intravenous treatments, including diuretics (79.28%) and vasodilators (74.90%). Fewer patients in the ED received neurohormonal antagonists, and 25.94%, 31.12%, and 33.73% of patients received angiotensin converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, and spironolactone, respectively. The proportions of patients who were admitted, discharged, left against medical advice, and died were 55.53%, 33.58%, 7.08%, and 3.81%, respectively. All-cause mortalities at 30 days and 1 year were 15.30% and 32.27%, respectively.

Substantial details on characteristics and ED management of AHF were investigated. The clinical outcomes of AHF patients were dismal. Thus, further investigations of ED-based therapeutic approaches for AHF are needed.

The CHA2DS2-VASc score is used clinically for stroke risk stratification in patients with atrial fibrillation (AF). We sought to investigate whether the CHA2DS2-VASc score predicts stroke and death in Chinese patients with sick sinus syndrome (SSS) after pacemaker implantation and to evaluate whether the predictive power of the CHA2DS2-VASc score could be improved by combining it with left atrial diameter (LAD) and amino-terminal pro-brain natriuretic peptide (NT-proBNP).

A total of 481 consecutive patients with SSS who underwent pacemaker implantation from January 2004 to December 2014 in our department were included. The CHA2DS2-VASc scores were retrospectively calculated according to the hospital medical records before pacemaker implantation. The outcome data (stroke and death) were collected by pacemaker follow-up visits and telephonic follow-up until December 31, 2015.

During 2151 person-years of follow-up, 46 patients (9.6%) suffered stroke and 52 (10.8%) died. The CHA2DS2-VASc score showed a significant association with the development of stroke (hazard ratio [HR] 1.45, 95% confidence interval [CI] 1.20–1.75, P < 0.001) and death (HR 1.45, 95% CI 1.22–1.71, P < 0.001). The combination of increased LAD and the CHA2DS2-VASc score improved the predictive power for stroke (C-stat 0.69, 95% CI 0.61–0.77 vs. C-stat 0.66, 95% CI 0.57–0.74, P = 0.013), and the combination of increased NT-proBNP and the CHA2DS2-VASc score improved the predictive power for death (C-stat 0.70, 95% CI 0.64–0.77 vs. C-stat 0.67, 95% CI 0.60--0.75, P = 0.023).

CHA2DS2-VASc score is valuable for predicting stroke and death risk in patients with SSS after pacemaker implantation. The addition of LAD and NT-proBNP to the CHA2DS2-VASc score improved its predictive power for stroke and death, respectively, in this patient cohort. Future prospective studies are warranted to validate the benefit of adding LAD and NT-proBNP to the CHA2DS2-VASc score for predicting stroke and death risk in non-AF populations.

Aspirin is widely used for the prevention of cardiovascular and cerebrovascular diseases for the past few years. However, much attention has been paid to the adverse effects associated with aspirin such as gastrointestinal bleeding. How to weigh the benefits and hazards? The current study aimed to assess the feasibility of a cardiovascular/gastrointestinal risk calculator, AsaRiskCalculator, in predicting gastrointestinal events in Chinese patients with myocardial infarction (MI), determining unique risk factor(s) for gastrointestinal events to be considered in the calculator.

The MI patients who visited Shapingba District People’s Hospital between January 2012 and January 2016 were retrospectively reviewed. Based on gastroscopic data, the patients were divided into two groups: gastrointestinal and nongastrointestinal groups. Demographic and clinical data of the patients were then retrieved for statistical analysis. Univariate and multiple logistic regression analyses were used to identify independent risk factors for gastrointestinal events. The receiver operating characteristic (ROC) curves were used to assess the predictive value of AsaRiskCalculator for gastrointestinal events.

A total of 400 MI patients meeting the eligibility criteria were analyzed, including 94 and 306 in the gastrointestinal and nongastrointestinal groups, respectively. The data showed that age, male gender, predicted gastrointestinal events, and Helicobacter pylori (HP) infection were positively correlated with gastrointestinal events. In multiple logistic regression analysis, predicted gastrointestinal events and HP infection were identified as risk factors for actual gastrointestinal events. HP infection was highly predictive in Chinese patients; the ROC curve indicated an area under the curve of 0.822 (95% confidence interval: 0.774–0.870). The best diagnostic cutoff point of predicted gastrointestinal events was 68.0‰, yielding sensitivity and specificity of 60.6% and 93.1%, respectively, for predicting gastrointestinal events in Chinese patients with MI.

AsaRiskCalculator had a predictive value for gastrointestinal events in Chinese patients with MI. HP infection seemed to be an independent risk factor for gastrointestinal events caused by long-term aspirin treatment in Chinese patients with MI, and it should be included in the risk calculator adapted for Chinese patients.

Coronary intervention therapy is the main treatment for uremic patients with coronary heart disease. The studies on whether dialysis reduces the efficacy of dual antiplatelet drugs are limited. The aim of this study was to examine the effect of dialysis on antiplatelet drugs in uremic patients with coronary heart disease.

This study included 26 uremic patients who had undergone percutaneous coronary intervention in China-Japan Friendship Hospital from November 2015 to May 2017. We examined their thromboelastography results before and after hemodialysis. Self-paired t-tests were employed to analyze changes in the inhibition rate of platelet aggregation.

The mean inhibition rates of arachidonic acid-induced platelet aggregation before and after hemodialysis were 82.56 ± 2.79% and 86.42 ± 3.32%, respectively (t = −1.278, P = 0.213). The mean inhibition rates of adenosine diphosphate-induced platelet aggregation before and after hemodialysis were 67.87 ± 5.10% and 61.94 ± 5.90%, respectively (t = 1.425, P = 0.167). There was no significant difference in the inhibition rates of platelet aggregation before or after hemodialysis. These results also applied to patients with different sensitivity to aspirin and clopidogrel.

Dialysis did not affect the antiplatelet effects of aspirin and clopidogrel in uremic patients with coronary heart disease.

Transcatheter closure of congenital coronary artery fistulas (CCAFs) is an alternative therapy to surgery; however, data regarding transcatheter closure for CCAF with a giant coronary artery aneurysm (CAA) in pediatric patients are still limited due to the rarity of the disease. We aimed to evaluate the efficacy and safety of transcatheter closure for CCAF with a giant CAA in a pediatric population at a single center.

Medical records of pediatric patients (<18 years old) who underwent transcatheter closure of CCAF with a giant CAA between April 2007 and September 2016 at Guangdong Cardiovascular Institute (Guangdong, China) were reviewed.

Twelve patients (median age, 6.1 years; range, 1.9–11.0 years) underwent successful transcatheter closure procedures. One patient underwent closure at both the entry and exit points of the CAA, three patients underwent closure at the exit point of the CAA, and eight patients underwent closure at the entry point of the CAA. After a mean follow-up of 7.2 years (range, 0.5–9.8 years), one patient (with closure at the exit point of the CAA) underwent transcatheter re-intervention because of a significant residual shunt. She eventually underwent a surgical procedure due to aneurysm dilation after the second intervention. One patient experienced thrombus formation within the CAA after the procedure. Among those with closure at the entry point of the CAA, a mild-to-moderate residual shunt was detected in three patients.

Transcatheter closure appears to be a safe and effective alternative therapy for CCAF with a giant CAA in the pediatric population. Closure at the entry point of the CAA, and closure at both the entry and exit points when feasible, may reduce the risk of postinterventional complications.

The current pain assessment methods are strongly subjective and easily affected by outside influences, and there is an urgent need to develop a reliable objective and quantitative pain-monitoring indicator. The aim of this study was to evaluate the feasibility of using Pain index (Pi) to assess pain symptoms in pain patients.

Subjects were enrolled from patients seeking treatment at Pain Medicine Center of China Medical University Aviation General Hospital from October 2015 to December 2016, such as postherpetic neuralgia, spinal cord injury, femoral head necrosis, lumbar disc herniation, trigeminal neuralgia, complex regional pain syndrome, perineal pain, phantom limb pain, etc., (pain group, n = 111), as well as healthy volunteers without subjective pain (control group, n = 100). The subjective pain symptoms in pain patients were evaluated by Pi and visual analogue scale/numerical rating scales (VAS/NRS), respectively, and the relationship between them was analyzed using single factor correlation analysis and multiple factor regression analysis.

Pi levels in the pain group were significantly higher than those of the control group (t = 6.273, P < 0.001 ), the correlation analysis of Pi and VAS/NRS score in the pain group showed that the Pearson correlation coefficient was 0.797 (P < 0.001); After adjusted for types of pain, pain sites, medication, gender, and age, Pi was found to be independently correlated to VAS/NRS score (P < 0.001).

Pi significantly correlates with VAS/NRS score, might be used to evaluate the subjective pain symptoms in patients and has good research and application value as an objective pain assessment tool.

The endometriosis fertility index (EFI) has a predictive value for pregnancy after surgery. In vitro fertilization and embryo transfer (IVF-ET) is a good treatment to infertility. This study aimed to provide external validation of EFI, assess the factors affecting the ability of EFI to predict cumulative spontaneous pregnancy rates (PRs), and propose reasonable advice for treatment by evaluating the effect of infertility management combining surgery and IVF-ET.

This retrospective study enrolled 345 endometriosis-related infertile women after laparoscopic surgery from January 2012 to January 2016. Among them, 234 patients tried to conceive naturally and were divided into six groups according to their different EFI scores. Of the 345 patients, 307 with an EFI score ≥5 were divided into non-IVF-ET group (n = 209) and IVE-ET group (n = 98) to compare the cumulative PRs. Cumulative PRs’ curves were calculated using the Kaplan-Meier product limit estimate and the differences were evaluated by log-rank test. Independent predictive factors for pregnancy were assessed using the Cox regression model.

Significant differences in spontaneous PRs among different EFI scores were identified (χ² = 29.945, P < 0.05). The least function score was proved to be the most important factor for EFI (χ² = 6.931, P < 0.05) staging system. In patients with an EFI score ≥5 after 12 months from surgery, the cumulative PRs of those who received both surgery and IVF-ET were much higher than the spontaneous PRs of those who received surgery alone (χ² = 4.160, P = 0.041).

The EFI is a reliable staging system to predict the spontaneous PR of patients. The least function score was the most influential factor to predict the spontaneous PR. Patients with an EFI score ≥5 after 12 months from surgery are recommended to receive IVF-ET to achieve a higher PR.

Currently, treatment of symptomatic polycystic liver disease (PLD) is still a challenging problem, especially for these patients who are not feasible for surgery. Minimally invasive options such as laparoscopic fenestration and percutaneous cyst aspiration with sclerotherapy demonstrated disappointing results due to multiple lesions. Because the cysts in PLD are mostly supplied from hepatic arteries but not from portal veins, transcatheter arterial embolization (TAE) of the hepatic artery branches that supply the major hepatic cysts can lead to shrinkage of the cyst and liver size, relieve symptoms, and improve nutritional status. This study aimed to evaluate the effectiveness of TAE with a mixture of N-butyl-2-cyanoacrylate (NBCA) and iodized oil for patients with severe symptomatic PLD during a more than 2-year follow-up.

Institutional review board had approved this study. Written informed consent was obtained from all patients. From February 2007 to December 2014, twenty-three patients (20 women and 3 men; mean age, 49.0 ± 14.5 years) infeasible for surgical treatments underwent TAE. Changes in the abdominal circumferences, volumes of intrahepatic cysts, hepatic parenchyma volume, and whole liver, clinical symptoms, laboratory data, and complications were evaluated after TAE.

Technical success was achieved in all cases. No procedure-related major complications occurred. The median follow-up period after TAE was 48.5 months (interquartile range, 30.0–72.0 months). PLD-related severe symptoms were improved remarkably in 86% of the treated patients; TAE failed to benefit in four patients (four patients did not benefit from TAE). The mean maximum abdominal circumference decreased significantly from 106.0 ± 8.0 cm to 87.0 ± 15.0 cm (P = 0.021). The mean intrahepatic cystic volume reduction rates compared with pre-TAE were 36% at 12 months, 37% at 24 months, and 38% at 36 months after TAE (P < 0.05). The mean liver volume reduction rates were 32% at 12 months, 31% at 24 months, and 33% at 36 months (P < 0.05).

TAE with the mixture of NBCA and iodized oil appears to be a safe and effective treatment method for patients with symptomatic PLD, especially for those who are not good candidates for surgical treatments, to improve both hepatic volume and hepatic cysts volume.

Current understanding of tumor biology suggests that breast cancer is a group of diseases with different intrinsic molecular subtypes. Anatomic staging system alone is insufficient to provide future outcome information. The American Joint Committee on Cancer (AJCC) expert panel updated the 8^th edition of the staging manual with prognostic stage groups by incorporating biomarkers into the anatomic stage groups. In this study, we retrospectively analyzed the data from our center in China using the anatomic and prognostic staging system based on the AJCC 8^th edition staging manual.

We reviewed the data from January 2008 to December 2014 for cases with Luminal B Human Epidermal Growth Factor Receptor 2 (HER2)-negative breast cancer in our center. All cases were restaged using the AJCC 8^th edition anatomic and prognostic staging system. The Kaplan-Meier method and log-rank test were used to compare the survival differences between different subgroups. SPSS software version 19.0 (IBM Corp., Armonk, NY, USA) was used for the statistical analyses.

This study consisted of 796 patients with Luminal B HER-negative breast cancer. The 5-year disease-free survival (DFS) of 769 Stage I–III patients was 89.7%, and the 5-year overall survival (OS) of all 796 patients was 91.7%. Both 5-year DFS and 5-year OS were significantly different in the different anatomic and prognostic stage groups. There were 372 cases (46.7%) assigned to a different group. The prognostic Stage II and III patients restaged from anatomic Stage III had significant differences in 5-year DFS (χ² = 11.319, P = 0.001) and 5-year OS (χ² = 5.225, P = 0.022). In addition, cases restaged as prognostic Stage I, II, or III from the anatomic Stage II group had statistically significant differences in 5-year DFS (χ² = 6.510, P = 0.039) but no significant differences in 5-year OS (χ² = 5.087, P = 0.079). However, the restaged prognostic Stage I and II cases from anatomic Stage I had no statistically significant differences in either 5-year DFS (χ² = 0.440, P = 0.507) or 5-year OS (χ² = 1.530, P = 0.216).

The prognostic staging system proposed in the AJCC 8^th edition refines the anatomic stage group in Luminal B HER2-negative breast cancer and will lead to a more personalized approach to breast cancer treatment.

Whether cholinergic innervations and/or autophagy have a role in the etiopathology of benign prostatic hyperplasia (BPH) is still unknown. This study aimed to investigate the role of cholinergic innervation and autophagy in the etiopathology of BPH.

Male, 13-week-old spontaneous hypertension rats (spontaneous BPH animal model) were divided into three groups: an experimental group (EG, n = 24), a control group (CG, n = 24), and a normal control group (NC, n = 10). The EG animals were intragastrically injected with tolterodine (3.5 mg/kg, twice a day), CG animals were intragastrically injected with physiological saline, and the NC animals did not receive any treatment. Rats were sacrificed every 4 weeks, and the prostatic gross morphological changes, wet weight/body weight (ww/bw), dry weight/wet weight (dw/ww), histological changes, ultrastructural changes, and LC3 immunohistochemistry were continuously observed and compared.

The gross morphological and ww/bw changes in the three groups were similar at every stage. The dw/ww (mg/mg) values of the EG at week 17, 21, 25, and 29 were 0.1478 ± 0.0034, 0.1653 ± 0.0036, 0.1668 ± 0.0045, and 0.1755 ± 0.0034, respectively, and the CG values were 0.1511 ± 0.0029, 0.1734 ± 0.0020, 0.1837 ± 0.0052, and 0.1968 ± 0.0045, respectively. The difference between EG and CG for dw/ww showed statistical significance after 21 weeks of age (week 21: P = 0.016, week 25: P = 0.008, and week 29: P = 0.001). Both EG and CG, prostatic glandular epithelial cell proliferation, and secretory function improved with age, but in EG, these improvements were slower than those in CG, and all the differences were statistically significant after 21 weeks. An increasing number of autophagosomes in the prostatic glandular cell cytoplasm, attenuation of LC3-I immunohistochemical staining, enhancement of LC3-II staining, and the ratio of LC3-II/LC3-I staining were all progressive in both groups, but the rate of change in EG was faster than that in CG, and these differences gained statistical significance after 25 weeks. Comparisons with regard to the above indexes between CG and NC showed no statistical significance at any stage.

Cholinergic innervations and activation of autophagy appear to have important functions in the etiopathology of BPH. Drug-mediated blockade of cholinergic innervations could delay the physiopathology processes. Moreover, overactivation of autophagy may also play an important role in this delay.

Hypertension is an important risk factor of cardiovascular disease and increases mortality in the elderly. However, the available medical evidences are both inconsistent and insufficient regarding establishing credible and useful blood pressure (BP) targets in the hypertensive elderly. This review summarizes the existing evidences used for establishing optimal BP targets for this patient population and points out some data inconsistencies which have added to the uncertainty.

We conducted a search for the articles published in English in the PubMed database up to March 2017, with the keywords "hypertension," "elderly," "blood pressure," and "antihypertensive."

Articles that related to BP targeting in the hypertensive elderly were selected for this review.

The selected studies indicated that antihypertensive therapy can substantially reduce the risk of cardiovascular events and mortality, for a subset of the elderly (60 years or older) with systolic BP >160 mmHg. Studies regarding more strict targets yielded mixed findings. For the very old and frail patients (80 years or older), there is a lack of evidence that optimal BP targets and intensive antihypertensives are helpful but in fact may be harmful.

There are solid evidences that patients who are 60–80 years old and in good health have benefited from lowering their BP to below 150/90 mmHg. If well tolerated, the BP target can be further lowered to below 140/90 mmHg. However, for the very old and frail, individualized and careful assessment is crucial. Antihypertensive treatment should be cautious and the adverse effect of drugs requires close monitoring as such treatment can be counterproductive.

Primary central nervous system lymphoma (PCNSL) is a specific type of non-Hodgkin lymphoma with poor prognosis. The rare incidence of this disease and difficulty to obtain sufficient tissue material impede deep research into PCNSL. However, application of modern molecular techniques makes it possible to find biological characteristics exclusive to PCNSL. Therefore, we systematically reviewed the latest research progress on biological characteristics and pathogenesis of PCNSL.

The data analyzed in this review were from the articles listed in PubMed database.

Articles focusing on the biology of PCNSL at the cytogenetic or molecular level were reviewed, including clinical, basic research, and review articles.

With respect to histopathology, perivascular growth pattern and reactive perivascular T-cell infiltration are regarded as typical histopathological manifestations of tumor cells in PCNSL. Moreover, tumor cells of PCNSL predominantly express an activated B-cell-like phenotype, including CD10⁻ BCL-6⁺ MUM1⁺, CD10⁻ BCL-6⁻ MUM1⁺, and CD10⁻ BCL-6⁻ MUM1⁻. On the molecular level, some molecular and genetic alterations may contribute to malignant transformation, including mutations of proto-oncogenes and tumor suppressor genes, gains and losses of genetic material, as well as aberrant activation of some important signaling pathways, such as nuclear factor-κB and JAK/STAT pathway.

The integrated molecular mechanisms involved in pathogenesis of PCNSL are not well understood. The important biomarkers indicating prognosis are not identified. Multicenter studies should be carried out to elucidate pathogenesis of PCNSL to find novel and effective therapeutic strategies.

Homocysteine is a sulfur-containing amino acid with potential clinical significance. Abnormal homocysteine levels have been found in patients with psoriasis. This review summarizes the possible correlations among homocysteine, cardiovascular risk, and DNA methylation in psoriasis.

We retrieved the articles published in English from the PubMed database up to January 2017, using the keywords including "psoriasis," "homocysteine," "cardiovascular risk," "DNA methylation," "methylenetetrahydrofolate reductase," "MTHFR," and "MTHFR C677T."

Articles about the roles of homocysteine in the cardiovascular risk and DNA methylation in psoriasis were obtained and reviewed.

Observational studies consistently reported that elevated homocysteine is an independent risk factor for cardiovascular diseases. Several studies also consistently reported an association between psoriasis and increased cardiovascular risk. A substantial body of evidence also suggested that an elevated homocysteine level is related to the demethylation of DNA. Data from clinical trials also demonstrated that MTHFR C677T polymorphisms as well as DNA methylation aberrations are associated with psoriasis.

This review highlighted the relationships among homocysteine, cardiovascular risk, and DNA methylation, suggesting that homocysteine may be a biological link between cardiovascular risk and DNA methylation in psoriasis.

Microneurosurgery made its debut in the early 1960s. It became popular in the medical field and became a primary operation method in neurosurgery since it improved the efficacy of neurosurgery with a less surgery-related injury. Over the past five decades, the accumulation of experience of microsurgery, improvement of microsurgery techniques, refined micro-instruments, and advanced preoperative diagnostic imaging allowed the evolution of microneurosurgery techniques and further reduced surgery-related trauma. The advanced development has made it possible for a neurosurgeon to treat more sophisticated lesions with smaller craniotomy. Keyhole neurosurgery, the combination of modern microsurgical techniques, preoperative imaging, neuroendoscopy, and modern minimally invasive surgery concept, is one of the techniques representing the medical advancement from microneurosurgery to minimally invasive neurosurgery.

Secondary hyperparathyroidism (SHPT) is a common complication in chronic kidney disease (CKD) that is characterized by excessive synthesis of parathyroid hormone (PTH) and parathyroid hyperplasia.^[1]The prevalence of CKD is estimated to be 5–10%, and the burden of CKD-associated diseases is alarmingly high.^[2,3]Despite advances in medical therapy for SHPT, surgical parathyroidectomy remains the definitive therapy for refractory SHPT, which drastically decreases PTH levels and ameliorates symptoms related to severe SHPT.^[4]Total parathyroidectomy, subtotal parathyroidectomy, or total parathyroidectomy with autotransplantation represents the current surgical options in the treatment of SHPT.^[5]Total parathyroidectomy with autotransplantation may be preferable in patients who will require long-term hemodialysis after surgery, and total parathyroidectomy without autotransplantation should be prohibited in patients who have a better chance of receiving kidney transplantation because of the risks of iatrogenic hypoparathyroidism and hypocalcemia after kidney transplantation.^[4]

Difficult airway is a challenge frequently faced by anesthesiologists. For children recovering from burns with severe scarring contracture in the neck and chest wall, the best strategy is to maintain spontaneous breathing during the induction of anesthesia and to insert a laryngeal mask airway to secure the airway as early as possible.

Hepatic hydrothorax occurs in 4–12% of patients with liver cirrhosis.^[1]A part of patients with persisted hydrothorax resists conservative treatment, known as refractory hepatic hydrothorax (RHH). Portal vein thrombosis (PVT) is observed in about 2.1–16.2% patients with liver cirrhosis,^[2]which may aggravate portal hypertension. If RHH and PVT are combined in a cirrhotic patient, transjugular intrahepatic portosystemic shunt (TIPS) may be a reasonable intervention.^[3]However, no such successful case has been reported. We herein reported a case of cirrhotic patient complicated with both RHH and PVT, who underwent TIPS and achieved long-term survival.

To the Editor: A 35-year-old female was admitted with a 6-day history of fever and sore throat. On admission, she was feverish, with a temperature of 40.2°C by rectum. Her pulse was regular at 90 beats/min, and blood pressure was 93/69 mmHg. Other findings were vomiting, abdominal pain, and a macular rash across the upper trunk. She also had abdominal tenderness in the right upper quadrant and epigastrium without guarding.

To the Editor: Exercise-induced ST-segment elevation is an uncommon clinical scenario with a prevalence of 0.15%.^[1]ST-segment elevation during exercise is a marker of both transient and severe ischemia. Appropriate treatment is crucial because coronary vasospasm can result in acute coronary syndrome, syncope, life-threatening cardiac arrhythmias, and even out-of-hospital cardiac arrest.^[2]Here, we report on a patient with exercise-induced myocardial ischemia and life-threatening cardiac arrhythmias due to coronary vasospasm.

To the Editor: Persistent left superior vena cava (PLSVC) with the absence of right superior vena cava (RSVC) is a very rare congenital anomaly that can complicate the implantation of a permanent pacemaker lead. If the atrial lead is placed beyond the right atrial appendage during atrial fibrillation (AF), assessment of adequate lead fixation might be challenging. We present a case of PLSVC with the absence of RSVC and sick sinus syndrome with paroxysmal AF, in which a permanent pacemaker was successfully implanted.

To the Editor: A 38-year-old woman presented at our hospital with a complaint of hypermenorrhea lasting 2 months. No symptoms were found by bimanual examination, and vaginal ultrasound showed endometrial thickness of 4 mm. Diagnostic curettage strongly suggested clear-cell adenocarcinoma. Magnetic resonance imaging of the pelvis showed an intact endometrial binding zone with no extrauterine infiltration. Other laboratory examinations were normal; serum alpha-fetoprotein (AFP) level was not determined at admission. Exploratory laparoscopy was performed under general anesthesia. Radical surgery was performed involving total hysterectomy, bilateral salpingo-oophorectomy, pelvic and abdominal aortic lymphadenectomy, and omental resection. All surgical specimens were analyzed carefully. A tumor measuring 2.5 cm × 1.5 cm × 1.5 cm was found in the left corner of the posterior uterine cavity [Figure 1a]. Several metastatic nodules with a diameter of 1.0 cm were found in the omentum. No other metastases were found in the abdominal cavity. All pelvic and abdominal aortic lymph nodes were normal. Pelvic washes were negative for tumor cells.

To the Editor: Fructose 1,6-bisphosphatase (FBPase) deficiency is an autosomal recessive metabolic disease, which is characterized by episodic attacks of hypoglycemia, ketosis, and lactic acidosis triggered by long-term fasting or fever or plenty of a load of fructose.^[1]As we all know, mutations of the fructose-1,6-bisphosphatase 1 gene (FBP1) could lead to FBPase deficiency which will correspondingly cause an enzymatic block in the last steps of the gluconeogenesis.^[1]It is known to be often lethal during the neonatal period and infancy because of lack of storage of glycogen, however, there were also few reports of adult patients with this inherited disease. Here, we described a Chinese female adult with FBPase deficiency.

To the Editor: A 50-year-old man presented with recurrent episodes of bullae, erosions, and crust on sun-exposed areas for 1 year. Lesions healed with scarring and hyperpigmentation. The skin lesions were aggravated after sun exposure. The patient had a 30-year alcohol abuse (100–200 ml/day) history. Family heredity history was unremarkable. Physical examination revealed multiple erosions with erythema, hyperpigmentation, bullae, and crusting on his face, neck, and dorsum of the hands [Figure 1a]. Mild hypertrichosis located over the temple. Dean symptom was positive. The results of blood tests were as follows: aspartate aminotransferase, 91 U/L; alanine aminotransferase, 66 U/L; gamma-glutamyl transferase, 447 U/L; zinc-protoporphyrin levels, 3.3 µg/gHb; uroporphyrin levels were elevated. Viral and autoimmune screening was negative. Urine color was turbid and presented pink fluorescence under Wood’s lamp. No gene mutation was observed with uroporphyrinogen decarboxylase (UROD) gene analysis. Histopathological manifestation demonstrated crust and eosinophilic depositions around the blood vessels [Figure 1b]. Acid-fast staining showed cyclic blue-violet depositions around the blood vessels [Figure 1c]. A diagnosis of sporadic porphyria cutanea tarda (PCT) was established. After treatments of compound glycyrrhizin for liver protection, sunscreen, and alcohol discontinuation for 3 months, there was obvious improvement on the patient’s skin lesions. Laboratory analysis also showed an improvement; there was a reduction of zinc-protoporphyrin, 1.1 µg/gHb, alanine aminotransferase 46 U/L, and uroporphyrin became negative.

To the Editor: Elastosis perforans serpiginosa (EPS) is part of different kinds of perforating diseases that are dependent on factors such as idiopathic, reactive, or drug induced. We report here a case of a patient who presented with multiple reddish-brown keratinized papules coalescing to form serpiginous plaques in the anterior and posterior of the neck, which was found to be typical D-penicillamine-induced EPS.

To the Editor: Viral hepatitis is a major public health concern worldwide, and hepatitis B virus (HBV), with which two billion people infected globally, has been commonly reported to undergo reactivation during chemotherapy for malignancies.^[1,2]Some literatures have reported hepatitis C virus (HCV) reactivation in hematological malignancies.^[1,3]Breast cancer, the most common cancer in female, is increasing rapidly globally. Hence, oncologists would undoubtedly deal with breast cancer patients with asymptomatic HCV carrier who are prone to HCV reactivation.^[3]HCV reactivation is defined as a minimum 3-fold increase in alanine transaminase (ALT) level in a patient with the absence of liver metastasis with careful exclusion of HCV reactivation from other causes.^[1]An increase in HCV viral load of more than 1 × 10³U/L could be a sign of HCV reactivation.^[1]