2017年 · 第130卷第17期

Allergy, airway hyperreactivity (AHR), and allergic asthma are risk factors of chronic obstructive pulmonary disease (COPD), a heterogeneous disease presenting with various phenotypes. An allergic phenotype of COPD, characterized by more severe respiratory symptoms and higher risk of acute exacerbations, was described recently.^[1]Further investigations into the role of allergy in the pathogenesis and/or expressions of COPD may lead to new modalities targeting the allergic component, a potentially treatable feature of a progressive disease like COPD.

Screening on multidrug-resistant tuberculosis (MDR-TB) has been limited to the serious TB subpopulations excluding the new TB patients. This study aimed to examine MDR-TB burden among the new TB patients.

We conducted a study in Zhejiang Province during 2009-2013 to screen for MDR-TB patients among the low MDR-TB risk patients and five subpopulations of high MDR-TB risk patients. The number, prevalence, and trend of MDR-TB were compared while the logistic regression model was used to examine risk factors related to MDR-TB.

A total of 200 and 791 MDR-TB cases were, respectively, identified from the 9830 new TB cases and 2372 high-risk suspects who took MDR-TB screening from 2009 to 2013. The MDR-TB rates went down in both of the new TB patients and five MDR-TB high-risk groups over the study time, but the percentage of MDR-TB patients identified from the new TB patients in all diagnosed MDR-TB cases kept stable from 28.3% in 2011 to 27.0% in 2012 to 26.0% in 2013.

The study indicated that MDR-TB burden among new TB patients was high, thus screening for MDR-TB among the new TB patients should be recommended in China as well as in the similar situation worldwide.

Treatment of adrenal metastasis from lung carcinoma may prolong survival in the selected patients. However, not all patients can undergo surgery; thus, minimally invasive ablation procedures such as radiofrequency ablation (RFA) and microwave ablation (MWA) have gained acceptance as alternative treatment methods. This study summarized a 5-year single-center experience regarding the evaluation of safety and efficacy of computed tomography (CT)-guided thermal ablation in the management of adrenal metastasis originating from non-small cell lung cancer (NSCLC).

The data of NSCLC patients ablated for adrenal metastasis at the Department of Diagnostic Imaging and Interventional Radiology, General Hospital Sotiria, were retrospectively analyzed. Patients were divided into two groups: RFA group and MWA group according to the therapeutic approaches. Preprocedural blood tests included measurement of international normalized ratio, partial thromboplastin time, and platelet enumeration. A dual-phase contrast-enhanced spiral CT was performed immediately after the procedure to assess the immediate response after ablation and to screen for related complications. Follow-up was performed with CT or magnetic resonance imaging at 1, 3, 6 months and 1 year after ablation and every 6 months thereafter.

A total of 99 ablation sessions in 71 patients with adrenal metastasis originating from NSCLC were included in the final analysis. Self-limited, postablation syndrome occurred in 16/99 (16.1%) of ablation sessions. All procedures were technically successful. Immediate postablation imaging showed no contrast enhancement of the ablated tumor in all patients. Follow-up imaging at 3 months revealed local tumor progression in 8 (22.8%) patients of the RFA group and 7 (19.4%) patients of MWA group, all of them underwent a second session successfully. The 1-year assessment revealed local recurrence of the ablated tumor in six patients (17.1%) of RFA group and seven patients (19.4%) of MWA group. Among these 71 patients, those with tumor size >3.5 cm had a higher local recurrence rate (65.2%, 15/23) than those with tumors ≤3.5 cm (16.7%, 8/48; P = 0.012). There was no significant difference in the median survival time between RFA (14.0 months) and MWA (14.6 months) groups (P > 0.05).

RFA and MWA showed comparable efficacy and safety in adrenal metastasis treatment.

Increased proinflammatory cytokines and chemokines might contribute to infiltration of inflammatory cells and remodeling in airways of asthma. Although these molecules may be associated with asthma, there is lack of systemic evidence showing which and how important these events are in the disease. We aimed to analyze the concentrations of these molecules in the airways and relationships with disease severity and with airway infiltration of inflammatory cells in a large cohort of asthmatics (n = 70, including 37 mild and 33 moderate/severe asthmatics) compared with controls (n = 30).

Meso scale discovery system and commercial ELISA kits were used to measure the concentrations of proinflammatory cytokines interleukin (IL)-1β; tumor necrosis factor-alpha (TNF-α); IL-6; and IL-17 and CC and CXC chemokines CCL2, CCL4, CCL11, CCL13, CCL17, CCL22, and CCL26 and CXCL8, CXCL9, CXCL10, and CXCL11 in bronchoalveolar lavage fluid of asthmatics and controls.

The concentrations of IL-1, TNF-α, IL-6, CXCL8 and CXCL10, and CCL4, CCL11, CCL17, and CCL22 were significantly elevated in asthmatics compared with controls (P < 0.05). The concentrations of TNF-α and CXCL8, but not others, were negatively correlated with severity of disease (lung function forced expiratory volume in 1 s) (TNF-α vs. total: r= −0.359, P = 0.002 vs. moderate/severe: r= −0.541, P = 0.001; CXCL8 vs. total: r= −0.327, P = 0.006 vs. moderate/severe: r= −0.625, P = 0.0001, respectively). In addition, concentrations of these two molecules were also correlated with the absolute numbers of infiltrating eosinophils and neutrophils in asthmatic airways.

Increased concentrations of TNF-α and CXCL8 are associated with pathogenesis of asthma. Targeting these molecules might provide an alternative therapeutic for this disease.

The Space Glucose Control (SGC) system is a computer-assisted device combining infusion pumps with the enhanced Model Predictive Control algorithm to achieve the target blood glucose (BG) level safely. The objective of this study was to evaluate the efficacy and safety of glycemic control by SGC with customized BG target range of 5.8–8.9 mmol/L in the critically ill patients.

It is a randomized controlled trial of seventy critically ill patients with mechanical ventilation and hyperglycemia (BG ≥ 9.0 mmol/L). Thirty-six patients in the SGC group and 34 in the routine glucose management group were observed for three consecutive days. Target BG for both groups was 5.8–8.9 mmol/L. The primary outcome was the percentage time in the target range.

The percentage time within BG target range in the SGC group (69±15%) was significantly higher than in the routine management group (52±24%; P < 0.01). No measurement was ≤2.2 mmol/L, and there was only one episode of hypoglycemia (2.3–3.3 mmol/L) in each group. The average BG was significantly lower in the SGC group (7.8±0.7 mmol/L) than in the routine management group (9.1±1.6 mmol/L, P < 0.001). Target BG level was reached earlier in the SGC group than routine management group (2.5±2.9 vs. 12.1±15.3 h, P = 0.001). However, the SGC group performed worse for daily insulin requirement (59.8±39.3 vs. 28.4±36.7 U, P = 0.001) and sampling interval (2.0±0.5 vs. 3.7±0.5 h, P < 0.001) than the routine management group did. Multiple linear regression showed that the intervention group remained a significant individual predictor (P < 0.001) of the percentage time in target range.

The SGC system, with a BG target of 5.8–8.9 mmol/L, resulted in effective and reliable glycemic control with few hypoglycemic episodes in critically ill patients with mechanical ventilation and hyperglycemia. However, the workload was increased.

http://www.clinicaltrials.gov, NCT 02491346; https://www.clinicaltrials.gov/ct2/show/NCT02491346?term=NCT0 2491346&cond=Hyperglycemia&cntry1=ES%3ACN&rank=1.

Antimicrobial resistance is a serious problem that compromises the empirical treatment of infections, resulting in a lack of effective antibiotics and high medical expenses. Here, we aimed to monitor the trends in antimicrobial resistance among Enterobacteriaceae isolated from blood samples in mainland China.

A total of 2240 Enterobacteriaceae isolates from blood were collected from hospitalized patients at 19 tertiary hospitals between October 2004 and June 2014. The minimum inhibitory concentrations of all isolates were determined using the agar dilution method according to the Clinical and Laboratory Standards Institute 2016 guidelines.

The most commonly isolated bacteria were Escherichia coli, compromising 47.0% (1053/2240) of the total isolates, followed by Klebsiella spp. (26.3%), Salmonella spp. (10.4%), and Enterobacter spp. (9.2%). The detection rates of extended-spectrum β-lactamases (ESBLs) among E. coli were 68.9% (2004-2005), 73.2% (2007–2008), 67.9% (2009-2010), 72.6% (2011-2012), and 58.4% (2013-2014), whereas those in ESBL-producing Klebsiella pneumoniae were slightly decreased (75.9%, 50.0%, 41.4%, 40.2%, and 43.0%, respectively). Carbapenems were the most potent agents against the Enterobacteriaceae isolates, followed by moxalactam, tigecycline, and amikacin. However, there was a decrease in the susceptibility rates for carbapenems in all species, particularly K. pneumoniae (decreased by 10.6% for imipenem) and Enterobacter aerogenes (decreased by 21.1% for imipenem). Reviving antibiotics (tigecycline and polymyxins) showed good in vitro activity against Enterobacteriaceae.

The activity of antibiotics against Enterobacteriaceae isolated from blood was decreased overall. Large proportions of ESBL-producing isolates were identified among E. coli and Klebsiella spp. Carbapenem-resistant isolates have become a major challenge in the treatment of infections.

A higher frequency of spontaneous miscarriage has been observed in infertile couples, and there is a higher prevalence of infertility among patients with a history of recurrent spontaneous miscarriages (RSMs; ≥2 miscarriages). This study aimed to determine the proportion of infertile patients with RSM and examine risk factors associated in patients with RSM being treated with assisted reproductive technologies.

This cross-sectional observational study was conducted at six reproductive medicine centers in three cities of China. Data of 751 patients with at least one spontaneous miscarriage were analyzed. Demographic data and etiological factors associated with infertility were compiled and compared between patients with a single spontaneous miscarriage (SSM) and those with RSM.

Two hundred (26.6%, 95% confidence interval [CI]: 23.50-29.95%) patients experienced RSMs and 551 (73.4%) had a single miscarriage. The odds of RSM increased with increasing age (odds ratio [OR] = 1.06), uterine disorders (OR = 2.09), endocrine disorders (OR = 2.48), and immune disorders (OR = 2.98). Higher education level, masters or above, and a pelvic cavity disorder were associated with lower risk of RSM (OR = 0.27 and 0.46, respectively). Late spontaneous miscarriages were more frequent in patients with RSM than in those with a SSM (31.5% vs. 14.2%, respectively, P < 0.001) and were associated with a history of uterine cavity procedures (OR = 2.095) and cervical factors related to infertility (OR = 4.136, 95% CI: 1.012–16.90).

Compared to patients with only a SSM, the conditions of patients with RSM are more complicated. To increase the success rate of assisted reproductive technology, factors including uterus cavity adhesion, cervical relaxation, endocrine disorders, and immune disorders should be treated before assisted reproduction is initiated. These data may provide treatment guidance for infertile patients with a history of RSM.

The pretreatment neutrophil-to-lymphocyte ratio (NLR) has been reported to be a prognostic factor in various types of carcinomas. The aim of this study was to investigate the prognostic value of pretreatment NLR in a large cohort of Chinese patients with upper tract urothelial carcinoma (UTUC).

We retrospectively analyzed the medical data of 656 UTUC patients who underwent radical nephroureterectomy (RNU) from 2001 to 2011 at Peking University First Hospital. Receiver operating characteristic (ROC) curve analysis was performed to calculate the optimal cutoff point of pretreatment NLR. Uni- and multi-variate analyses were used to identify the prognostic factors for cancer-specific survival (CSS) and intravesical recurrence-free survival (IVRFS).

The optimal cutoff point of pretreatment NLR was 2.40 by ROC curves, by which patients with high NLR (NLR ≥2.40) and low NLR (NLR <2.40) accounted for 314 (47.9%) and 342 (52.1%) patients, respectively. Patients with a high pretreatment NLR tended to have high tumor grades (χ² = 15.725, P < 0.001), high tumor stages (χ² = 25.416, P < 0.001), tumor sizes >5 cm (χ² = 8.213, P = 0.005), ipsilateral hydronephrosis (χ² = 4.624, P = 0.033), and concomitant carcinoma in situ (CIS) (χ² = 9.517, P = 0.003). A high pretreatment NLR (hazard ratio [HR] = 1.820, P = 0.001), main tumor diameter >5 cm (HR = 1.789, P = 0.009), lymph node metastasis (HR = 1.863, P = 0.024), and high tumor stage (HR = 1.745, P < 0.001) independently predicted poor CSS after surgery, while only concomitant carcinoma in situ (CIS) (HR = 2.164, P = 0.034), ureteroscopy before surgery (HR = 1.701, P = 0.015), and high tumor grade (HR = 1.645, P = 0.018) were independent predictors of IVRFS after RNU.

The pretreatment NLR was related to some adverse clinicopathological features and was an independent predictor of CSS, although not IVRFS, in Chinese UTUC patients.

It remains controversial whether patients with Stage II colorectal cancer would benefit from adjuvant chemotherapy after radical resection. The aim of this study was to establish two mathematical models to identify the suitable patients for adjuvant chemotherapy.

The current study comprised of two steps. In the first step, 353 patients with Stage II colorectal cancer who underwent surgical procedures at the Third Affiliated Hospital of Sun Yat-sen University between June 2006 and December 2015 were entered and followed up for 6–120 months. Their clinical data were collected and enrolled into the database. We established two mathematical models by univariate and multivariate Cox regression analysis to identify the target patients; in the second step, 230 patients under the same standard between January 2012 and December 2016 were entered and followed up for 3-62 months to verify the two models’ validation.

In the first step, totally 340 surgical patients with Stage II colorectal cancer were finally enrolled in this study. Statistical analysis showed that tumor differentiation (TD) (P < 0.001), lymphovascular invasion (LVI) (P < 0.001), uncertain or positive margins (UPM) (P < 0.001), and fewer lymph nodes (LNs) (<12) retrieved (P < 0.001) were correlated with the overall survival (OS) and disease free survival (DFS). We obtained two models: (1) OS risk score = 1.116 × TD + 2.202 × LVI + 3.676 × UPM + 1.438 × LN−0.493; (2) DFS risk score = 0.789 × TD + 2.074 × LVI + 3.183 × UPM + 1.329 × LN−0.432. According to the models and cutoff points [(0.07, 1.33) and (−0.04, 1.30), respectively], patients can be divided into three groups: low-risk, moderate-risk, and high-risk. Moreover, the high-risk group patients could benefit from adjuvant chemotherapy. In the second step, totally 221 patients were finally used to verify the models’ validation. The results proved that the models were accurate and feasible (P < 0.05).

According to the predictive models, patients with Stage II colorectal cancer in the high-risk group are strongly recommended for adjuvant chemotherapy, thus facilitating the individualized and precise treatment.

Acute leukemia is the most common pediatric hematological malignancy. Bloodstream infections (BSIs) are severe complications in these patients during chemotherapy. This study aimed to explore the clinical presentation and etiology of BSI, as well as the common sites of infection, and to provide a basis for the rational regarding antibiotic use.

We performed a retrospective chart review of all pediatric patients who had acute leukemia accompanied by a BSI in our hospital from December 2011 to September 2015. All patients were selected based on clinical presentation and had to have at least one positive blood culture for inclusion. The basic clinical characteristics, blood culture results, and antimicrobial susceptibilities were analyzed.

All 231 patients had a fever; of them, 12 patients continued to have a fever. Twenty-five patients had nonremitting (NR) leukemia, and 206 patients achieved complete remission (CR). Differences in the duration of fever between the NR and CR groups were significant (9.6 ± 7.9 vs. 5.1 ± 3.8 days, P = 0.016). One hundred and eighty patients had agranulocytosis. Differences in fever duration between the agranulocytosis and nonagranulocytosis groups were significant (6.2 ± 5.1 vs. 4.1 ± 2.6 days, P = 0.001). The other sites of infection in these 231 patients were the lung, mouth, digestive tract, and rectum. Blood culture comprised 2635 samples. There were 619 samples, which were positive. Of the 619 positive blood culture samples, 59.9% had Gram-negative bacteria, 39.3% had Gram-positive bacteria, and 0.8% had fungus. The primary pathogens were Pseudomonas aeruginosa, Enterobactercloacae, Escherichia coli, and Klebsiella pneumoniae. Of these 231 patients, 217 patients were cured. The effective treatment ratio was 94%.

Gram-negative bacteria were the main pathogenic bacteria in patients with acute leukemia in our center. NR primary illness, agranulocytosis, and drug-resistant pathogenic bacteria were all risk factors for poor prognosis.

There has been no a specific scale to measure quality of life (QOL) for prostate cancer patients receiving androgen deprivation therapy (ADT) to date. This study aimed to develop and initially validate the scale to evaluate QOL for prostate cancer patients receiving ADT.

The scale was developed following international recommendations. Moreover, the items were all generated through literature review and referenced questionnaires. After being reviewed by expert panelists, the revised scale was formed and then completed by a convenience sample of 200 prostate cancer patients from our hospital. Explore factor analysis (EFA) was applied to test the construct validity, then split-half reliability, Cronbach’s alpha, and test-retest reliability were applied to assess the reliability and stability of the scale.

The revised scale contained 22 items and a total of 200 participants had completed the scale. One hundred participants were randomly selected from the total 200 participants to perform EFA with varimax rotation on the revised scale, and "hot flashes" item was deleted for low factor loading. We selected only 3 items from each factor, then, the final scale was formed with 18-items. We selected another 100 participants to perform the EFA again on the final scale. It was demonstrated that the structure with 6 factors explained 72.5% of total variance and factor loading value was above 0.40 in all items of the factors. Moreover, the split-half reliability coefficient, Cronbach’s alpha, and test-retest reliability coefficient were calculated to be 0.74, 0.63, and 0.89, respectively, exhibiting good reliability on the whole.

The scale was identified to be a valid and reliable instrument to measure QOL for prostate cancer patients receiving ADT. Moreover, further research is needed to overcome the potential drawbacks.

The development of culture-independent techniques for microbiological analysis shows that bronchial tree is not sterile in either healthy or chronic obstructive pulmonary disease (COPD) individuals. With the advance of sequencing technologies, lung microbiome has become a new frontier for pulmonary disease research, and such advance has led to better understanding of the lung microbiome in COPD. This review aimed to summarize the recent advances in lung microbiome, its relationships with COPD, and the possible mechanisms that microbiome contributed to COPD pathogenesis.

Literature search was conducted using PubMed to collect all available studies concerning lung microbiome in COPD. The search terms were "microbiome" and "chronic obstructive pulmonary disease" , or "microbiome" and "lung/pulmonary" .

The papers in English about lung microbiome or lung microbiome in COPD were selected, and the type of articles was not limited.

The lung is a complex microbial ecosystem; the microbiome in lung is a collection of viable and nonviable microbiota (bacteria, viruses, and fungi) residing in the bronchial tree and parenchymal tissues, which is important for health. The following types of respiratory samples are often used to detect the lung microbiome: sputum, bronchial aspirate, bronchoalveolar lavage, and bronchial mucosa. Disordered bacterial microbiome is participated in pathogenesis of COPD; there are also dynamic changes in microbiota during COPD exacerbations. Lung microbiome may contribute to the pathogenesis of COPD by manipulating inflammatory and/or immune process.

Normal lung microbiome could be useful for prophylactic or therapeutic management in COPD, and the changes of lung microbiome could also serve as biomarkers for the evaluation of COPD.

Epinephrine is the primary drug administered during cardiopulmonary resuscitation (CPR) to reverse cardiac arrest. The evidence for the use of adrenaline in out-of-hospital cardiac arrest (OHCA) and in-hospital resuscitation is inconclusive. We conducted a systematic review on the clinical efficacy of adrenaline in adult OHCA patients to evaluate whether epinephrine provides any overall benefit for patients.

The EMBASE and PubMed databases were searched with the key words "epinephrine," "cardiac arrest," and variations of these terms.

Data from clinical randomized trials, meta-analyses, guidelines, and recent reviews were selected for review.

Sudden cardiac arrest causes 544,000 deaths in China each year, with survival occurring in <1% of cases (compared with 12% in the United States). The American Heart Association recommends the use of epinephrine in patients with cardiac arrest, as part of advanced cardiac life support. There is a clear evidence of an association between epinephrine and increased return of spontaneous circulation (ROSC). However, there are conflicting results regarding long-term survival and functional recovery, particularly neurological outcome, after CPR. There is currently insufficient evidence to support or reject epinephrine administration during resuscitation. We believe that epinephrine may have a role in resuscitation, as administration of epinephrine during CPR increases the probability of restoring cardiac activity with pulses, which is an essential intermediate step toward long-term survival.

The administration of adrenaline was associated with improved short-term survival (ROSC). However, it appears that the use of adrenaline is associated with no benefit on survival to hospital discharge or survival with favorable neurological outcome after OHCA, and it may have a harmful effect. Larger placebo-controlled, double-blind, randomized control trials are required to definitively establish the effect of epinephrine.

Fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) is widely applied in non-small cell lung cancer (NSCLC). The standardized uptake value (SUV), a semi-quantitative index, plays an essential role in NSCLC for diagnosis, staging, and efficacy evaluation. It has been proposed that the SUV_maxof tumors may correlate with the presence or absence of chemotherapy resistance-associated biomarkers based on studies that have displayed a close correlation between SUV_maxand the expression levels of excision repair cross-complementary Group 1 (ERCC1)^[1]and Tp53-induced glycolysis and apoptosis regulator.^[2]FDG avidity of NSCLC and ERCC1 and ribonucleotide reductase subunit M1 (RRM1) levels have not been as extensively investigated. Based on these findings, we looked for correlations among metabolic parameters (SUV_max, metabolic tumor volume [MTV], and total lesion glycolysis [TLG]) andERCC1andRRM1expression in patients with NSCLC, to investigate whether FDG uptake reflects the presence or absence of chemoresistance proteins (ERCC1 and RRM1) within tumor cells.

Airway gastric fistula (AGF) is a rare but dangerous complication following esophagectomy for esophageal cancer, with an incidence rate of 0.3–1.9%.^[1]For AGF, the primary goal is closure of the fistula between the digestive and respiratory tracts to avert ongoing soilage of the airway. Although surgical repair remains the definitive treatment, it is associated with a mortality rate of 32%.^[2]With the development of interventional therapy, airway stenting has become an effective palliative treatment for AGF. Dumon™ (Novatech, France) stents have been successfully used to treat AGF for years.^[3]We conducted this retrospective study to explore the value of these devices to treat AGF.

Accidental exposure to the laser may result in visual impairment from retinal injury. Laser-induced damages to the macula include outer retinal disruption, foveal hemorrhage, macular edema, epiretinal membrane, full thickness macular hole, etc.^[1,2]There are some case reports of visual improvement following the use of oral corticosteroids, but till date, there is no known effective treatment for this condition.^[3,4]We report a case series of laser-induced maculopathy treated with standard doses of oral corticosteroids.

Primary cardiac lymphoma (PCL) is an extremely rare entity that accounts for only 0.5% of extranodal lymphomas and 1.0% of cardiac tumors.^[1]Because the tumor is clinically aggressive and fatal, it is of great significant to diagnose this disease and treat it promptly. Nevertheless, The diagnosis of PCL is very difficult due to its nonspecific clinical manifestations.^[1]Herein, we report the imaging findings in two cases of PCL.

Castleman’s disease (CD) is a rare lymphoproliferative syndrome typically involving a mediastinal mass. CD in the pararenal area should be distinguished from lymphoma diseases. We analyzed the clinical features of ten CD patients in the pararenal retroperitoneum that mimics other tumors to summarize some of our experiences and conduct a literature review.

Pulmonary nocardiosis is an opportunistic infection, especially in immunocompromised patients. Hemophagocytic lymphohistiocytosis (HLH) is a rare but potentially fatal disease. We report a case of pulmonary nocardiosis with secondary HLH.

Inflammatory fibroid polyp (IFP) is a group of rare benign mesenchymal tumors throughout the gastrointestinal tract. The most involved sites are stomach and large intestines, followed by small intestines, esophagus, and anal canal. However, even in the stomach, its incidence is only 0.1% of all gastric polyps.^[1]We here reported an IFP located in the cecum.

To the Editor: A 54-year-old man developed painful ulcers on the neck one month ago, followed by periorbital edema. The ulcers then spread to his trunk, back, and upper arms. He had muscle weakness, mild muscle soreness with activity, and dysphagia for foods for the past three weeks. He was diagnosed as drug eruption in a local hospital and received irregular corticosteroids therapy for two weeks. Thereafter, the ulcers started to heal. He had a 40 years’ history of smoking. The patient was emaciation, and physical examination revealed heliotrope sign, poikiloderma involving the face, "V" sign of the chest, and the upper arm, nail fold telangiectasia, and large well-defined ulcers on the abdomen, back, and upper arms, there was no Gottron sign [Figure 1]. It was hard for him to raise his arms and squat. The triceps and quadriceps were tender to palpation. Investigation revealed elevated levels of antinuclear antibodies (1:40; normal range, <1:40), creatin kinase (382 U/L; normal range, 56–244 U/L), lactic dehydrogenase (254 U/L; normal range, 109-245 U/L), white blood cell (19.71 × 10⁹/L, normal range, 3.5–9.5 × 10⁹/L), erythrocyte sedimentation rate (78 mm/h; normal range, 0–15 mm/h), C-reactive protein (117.52 mg/L; normal range, <8 mg/L), neurospecific enolase (25.03 ng/ml; normal range, 0–16.30 ng/ml), and electromyography showed muscle damage. Chest computed tomography plain and enhanced scan suggested possible malignant tumor in left upper lobe [Figure 1]. The biopsy of axillary lymph node showed "small cell lung cancer" . Histopathology of ulcer edge revealed ulceration of the epidermis with a dense neutrophils infiltration. There was no organisms or vasculitis [Figure 1].

To the Editor: A 48-year-old woman presented with a plaque on her left helix that had persisted for 20 years, erythemas and scales on both earlobes present for 9 months, and papules on both thighs present for 6 months. Neither she nor her family had any special history. Physical examination revealed a well-circumscribed, dark-red plaque on her left helix, and red erythema on both her earlobes, with adherent scales and red papules symmetrically distributed on both thighs with crust and scale [Figure 1a]. Routine examinations showed no abnormal findings. Pathological examination of the left helix showed that the epidermis was thin, with flattening of the rete ridges and many epithelioid granulomas with local caseous necrosis, accompanied by infiltration of lymphocytes into the dermis, multinucleated giant cells were not remarkable [Figure 1b]. In addition, acid-fast staining yielded negative results. The earlobe biopsy showed epidermal hyperkeratosis and parakeratosis, liquefaction degeneration of the basal cells, and follicular keratotic plugging, and the blood vessels and skin appendages surrounded by lymphocytes in the dermis [Figure 1c]. The thigh biopsy showed epidermal hyperkeratosis and local parakeratosis, and palisading granuloma in the dermis, accompanied by progressive necrosis of the central collagen with mucin deposition [Figure 1d]. A tuberculin (purified protein derivative [PPD]) test performed on the forearm was strongly positive. Polymerase chain reaction forMycobacterium tuberculosisin both the left helix plaque and the thigh papule was negative. Therefore, a diagnosis of lupus vulgaris was made for the left helix; both earlobes were diagnosed with discoid lupus erythematosus, and both thighs with papulonecrotic tuberculid.

To the Editor: Atrial premature contractions (APCs) or atrial tachycardia (AT) is a common form of supraventricular (SV) arrhythmias. Arising from the right atrial appendage (RAA), it usually responds well to radiofrequency (RF) ablation; however, successful ablation in this anatomic region can be challenging. Herein, we report a successful treatment of a case.

To the Editor: Early primary gastrointestinal non-Hodgkin’s lymphoma represents a diagnostic challenge and may be easily misdiagnosed as Crohn’s disease or intestinal tuberculosis.^[1]Here, we describe a 58-year-old man who was admitted due to recurrent colic in the middle and upper abdomen with intermittent vomiting for 10 months. The colic was paroxysmal lasting from a few minutes to several hours without obvious triggers. His medical history was otherwise unremarkable. In November 2013, gastrointestinal endoscopy revealed gastroenteritis, and abdominal computed tomography (CT) showed jejunal wall edema and thickening. His symptoms did not improve after 1-month treatment for suspected gastroenteritis.

Idiopathic pulmonary fibrosis (IPF) is a specific type of chronic progressive fibrosing interstitial pneumonia associated with a histopathologic pattern of usual interstitial pneumonia. IPF is typically considered to be a lung-limited disorder. Although the primary manifestations of IPF are pulmonary in nature, IPF is increasingly recognized as a systemic disease due to its strong association with comorbidities and complications.

Penget al.^[1]reported that the MDR-TB burden among the new tuberculosis (TB) patients accounted for more than 1/4^thof all multidrug-resistant TB (MDR-TB) cases in the past 5 years in Zhejiang province, although the identified rate of MDR-TB among 9830 new TB cases was only 2.0%. Drug-resistant TB, especially MDR-TB, is a major threat to the control of TB worldwide. However, due to high cost and limited budget, screening on MDR-TB has not been implemented among all TB cases by now.