2017年 · 第130卷第22期

It has been more than 100 years since ulcerative colitis (UC) was first described in the mid-1800s,^[1]and nearly 90 years from 1932 when Crohn’s disease (CD) was first reported.^[2]Based on the explorations of disease pathogenesis, epidemiology, and emerging new targets of treatment, the goal of therapy has now shifted from symptom control to altering the natural history in order to prevent bowel damage and disability. In Asian countries, an increasing incidence and prevalence of inflammatory bowel disease (IBD) have been witnessed during the past decades.^[3,4]Our team has reported the age-adjusted incidence for IBD as 1.77 per 100,000 population in northern region of China in 2013.^[5]Although it is lower compared with that of the Western countries, the incidence and prevalence are rapidly increasing and following the steps of which Western countries had undergone 50 years ago. Therefore, there are more and more gastroenterologists dedicating in IBD subspecialty in Asia. Although guidelines and knowledge are on hands and regularly renewed, there remain to be unanswered questions and unmet needs in IBD management in Asia.

For Chinese patients with hepatocellular carcinoma (HCC), surgical resection is the most important treatment to achieve long-term survival for patients with an early-stage tumor, and yet the prognosis after surgery is diverse. We aimed to construct a scoring system (Shanghai Score) for individualized prognosis estimation and adjuvant treatment evaluation.

A multivariate Cox proportional hazards model was constructed based on 4166 HCC patients undergoing resection during 2001–2008 at Zhongshan Hospital. Age, hepatitis B surface antigen, hepatitis B e antigen, partial thromboplastin time, total bilirubin, alkaline phosphatase, γ-glutamyltransferase, α-fetoprotein, tumor size, cirrhosis, vascular invasion, differentiation, encapsulation, and tumor number were finally retained by a backward step-down selection process with the Akaike information criterion. The Harrell’s concordance index (C-index) was used to measure model performance. Shanghai Score is calculated by summing the products of the 14 variable values times each variable’s corresponding regression coefficient. Totally 1978 patients from Zhongshan Hospital undergoing resection during 2009–2012, 808 patients from Eastern Hepatobiliary Surgery Hospital during 2008–2010, and 244 patients from Tianjin Medical University Cancer Hospital during 2010–2011 were enrolled as external validation cohorts. Shanghai Score was also implied in evaluating adjuvant treatment choices based on propensity score matching analysis.

Shanghai Score showed good calibration and discrimination in postsurgical HCC patients . The bootstrap-corrected C-index (confidence interval [CI]) was 0.74 for overall survival (OS) and 0.68 for recurrence-free survival (RFS) in derivation cohort (4166 patients), and in the three independent validation cohorts, the CIs for OS ranged 0.70–0.72 and that for RFS ranged 0.63–0.68. Furthermore, Shanghai Score provided evaluation for adjuvant treatment choices (transcatheter arterial chemoembolization or interferon-α). The identified subset of patients at low risk could be ideal candidates for curative surgery, and subsets of patients at moderate or high risk could be recommended with possible adjuvant therapies after surgery. Finally, a web server with individualized outcome prediction and treatment recommendation was constructed.

Based on the largest cohort up to date, we established Shanghai Score – an individualized outcome prediction system specifically designed for Chinese HCC patients after surgery. The Shanghai Score web server provides an easily accessible tool to stratify the prognosis of patients undergoing liver resection for HCC.

The Food and Drug Administration recently announced that the use of morcellation may cause fibroids or pelvic dissemination and metastasis of uterine sarcoma; therefore, the use of morcellation is limited in the USA. A large sample study is necessary to assess the proportion of uterine malignant tumors found in patients with laparoscopic myomectomy.

A national multicenter study was performed in China. From 2002 to 2014, 33,723 cases were retrospectively selected. We calculated the prevalence and recorded the clinical characteristics of the patients with malignancy after morcellation application. A total of 62 cases were finally pathologically confirmed as malignant postoperatively. Additionally, the medical records of the 62 patients were analyzed in details.

The proportion of postoperative malignancy after morcellation application was 0.18% (62/33,723) for patients who underwent laparoscopic myomectomy. Nearly 62.9% (39/62) of patients had demonstrated blood flow signals in the uterine fibroids before surgery. And, 23 (37.1%) patients showed rapid growth at the final preoperative ultrasound. With respect to the pathological types, 38 (61.3%) patients had detectable endometrial stromal sarcoma, 13 (21.0%) had detectable uterine leiomyosarcoma, only 3 (3.2%) had detectable carcinosarcoma, and 5 (8.1%) patients with leiomyoma had an undetermined malignant potential.

The proportion of malignancy is low after using morcellation in patients who undergo laparoscopic myomectomy. Patients with fast-growing uterine fibroids and abnormal ultrasonic tumor blood flow should be considered for malignant potential, and morcellation should be avoided.

Currently, the treatment of large hepatocellular carcinoma (HCC) is still a challenging problem. Transcatheter arterial chemoembolization (TACE) is the main treatment for intermediate end-stage HCC, while it is only a palliative and not a curative treatment due to the existence of residual tumors, and radiofrequency ablation (RFA) has limitations in complete ablation of large HCC. We hypothesized that TACE combined with simultaneous RFA (herein referred to as TACE + RFA) could improve the efficacy and survival of large HCC. This study aimed to investigate the feasibility, efficacy, and safety of TACE + RFA on single large HCC.

A total of 66 patients with single large HCC (≥5 cm in diameter) were recruited between February 2010 and June 2016. TACE was first performed and computed tomography was performed immediately after TACE, and the lesions with poor lipiodol deposition were subjected to simultaneous RFA. The success rate, technique-related complications, liver and kidney functions, serum alpha-fetoprotein (AFP) levels, progression-free survival (PFS), median survival time (MST), focal control rate, and long-term survival rate were evaluated.

TACE + RFA were performed smoothly in all the patients with the success rate of 100%. Intra- and post-operative severe complications were not observed. There were no marked differences in mean alanine transaminase or aspartate transaminase before TACE + RFA compared with 7 days after TACE+ RFA (all P > 0.05). In 57 AFP-positive patients, the levels of serum AFP were reduced by 100.0%, 100.0%, and 94.7% at 1, 3, and 6 months after TACE + RFA, respectively; the tumor control rates (complete remission+ partial remission) were 100.0% (66/66), 92.4% (61/66), 87.9% (58/66), and 70.1% (39/55) at 1, 3, 6, and 12 months after TACE + RFA, respectively. Patients were followed up for 7–82 months after TACE + RFA. The MST was 18.3 months, PFS was 14.2 ± 6.2 months, and the 1-, 3-, and 5-year survival rates were 93.2% (55/59), 42.5% (17/40), and 27.2% (9/33), respectively.

TACE + RFA is safe, feasible, and effective in enhancing the focal control rate and survival rate of patients with large HCC.

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that is highly associated with inflammatory bowel disease (IBD). Certain PG patients with no systemic disorders have been diagnosed with idiopathic PG. This study sought to clarify the difference between PG with IBD and idiopathic PG based on clinical features, laboratory tests, and medications.

Twelve patients with PG and IBD and 24 patients with idiopathic PG, who were hospitalized in Peking Union Medical College Hospital from 2000 to 2017, were retrospectively categorized into the IBD group and control group, respectively. Data of clinical features, laboratory tests, and medications were collected and compared between the two groups.

Both groups were similar with respect to their clinical features. However, the IBD group had an increased occurrence of arthralgia or arthritis (58.3% vs. 12.5%, P = 0.007), anemia (83.3% and 29.2%, P = 0.004), and an increased percentage of antineutrophilic cytoplasmic antibody (ANCA)-positive patients (85.7% and 0.0%, P < 0.001), compared to the control group.

PG patients with IBD had increased occurrence rates of arthralgia or arthritis, anemia, and ANCA-positive status compared to idiopathic PG patients.

Whether Helicobacter pylori infection is associated with diabetic gastroparesis (DGP) is unclear. This study aimed to investigate the potential correlation between H. pylori infection and DGP.

In this study, 163 patients with type 2 diabetes mellitus and 175 nondiabetic patients who were treated in our department were divided into DGP, simple diabetes, non-DGP (NDG), and normal groups based on their conditions. The H. pylori infection rate in each group was calculated. H. pylori eradication therapy was performed for patients with H. pylori infection in each group. The eradication rates were compared between the groups, and the improvements in gastroparesis-associated symptoms were compared before and after treatment in patients with DGP.

The H. pylori infection rate was 74.6% in the DGP group, which was significantly higher than that in the simple diabetes (51.1%, P < 0.01), NDG (57.7%, P < 0.05), and normal groups (48.0%, P < 0.01). With increased disease course, the incidence of DGP and the H. pylori infection rate gradually increased (P < 0.05). In the DGP group, the incidences of upper abdominal pain and distention, early satiety, and anorexia were 75.5%, 66.0%, and 67.9%, respectively, before eradication treatment; and 43.4%, 35.8%, and 39.6%, respectively, after eradication treatment, and the difference was statistically significant (P < 0.01). In patients with DGP with successful H. pylori eradication, the number of barium strips discharged after eradication was 5.9 ± 1.0, which was significantly larger than that before treatment (4.1 ± 0.7, P < 0.01). In addition, the number of barium strips discharged was significantly larger in patients with DGP with successful H. pylori eradication than those with failed H. pylori eradication (P < 0.01).

DGP development might be associated with H. pylori infection. H. pylori eradication can effectively improve dyspepsia-associated symptoms and delayed gastric emptying in patients with DGP.

Overexpression and constitutive activation of signal transducer and activator of transcription (STAT) 3 have been suggested in the tumorigenesis of many human cancers, including multiple carcinomas, melanoma, and lymphoma. The diagnosis of hepatocellular carcinoma (HCC) in lobectomy specimens is usually straightforward, but distinguishing cirrhosis from well-differentiated HCC can be challenging in core biopsies. Our aims were to investigate the expression level of STAT3 and phosphorylated STAT3 (pSTAT3) in HCC and cirrhosis, and the application of STAT3 in the differential diagnosis of HCC and cirrhosis.

Sixty cases were divided into three groups: patients with HCC only (Group 1), HCC and cirrhosis (Group 2), and cirrhosis only (Group 3). Formalin-fixed and paraffin-embedded tissue sections were stained immunohistochemically for STAT3, pSTAT3, and CD163. The values obtained from the tissue sections of each group were compared in statistical analysis.

STAT3 showed a high level in HCC and was a significant marker for differentiating HCC from cirrhosis (P < 0.0001). The odds ratio between HCC and cirrhosis increased 34.4 times when the intensity of STAT3 increased by 1 level. Spearman’s correlation and Chi-square tests also demonstrated that expression level of STAT3 did not correlate with age, gender, or the presence of a cirrhotic background.

STAT3 staining differs significantly in HCC and cirrhosis. The findings reinforce the role of STAT3 in the tumorigenesis of HCC and provide a useful marker to differentiate HCC from cirrhosis in challenging liver biopsies.

Major abdominal surgery, including colorectal cancer (CRC) surgery, leads to systemic inflammatory response syndrome that can be detected and monitored with inflammatory markers testing. The aims of the study were to evaluate the usefulness of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1), interleukin-6 (IL-6), procalcitonin (PCT), and C-reactive protein (CRP) in following the inflammatory response in CRC surgery and postoperative period, as well as to determine if duration of the surgery and the time that the colon has been opened during the surgery (open colon time [OCT]) reflect a larger surgical stress through inflammatory markers rise.

The study included 20 patients who underwent CRC surgery and 19 healthy volunteers from June 2011 to September 2012. We determined inflammatory markers 1 day before surgery (T0), 24 h (T1), 48 h (T2), and 7 days after the surgery (T3). All statistical analyses were calculated using MedCalc Statistical Software version 14.8.1 (MedCalc Software bvba, Ostend, Belgium).

Concentrations of CRP, PCT, and IL-6 in all measurement times were statistically different and sTREM-1 did not yield statistical significance. A weak positive correlation was found between IL-6 in T1 and T2 with the duration of the surgery (T1: r = 0.4060, P < 0.0001; T2: r = 0.3430, P < 0.0001) and OCT (T1: r = 0.3640, P < 0.0001, T2: r = 0.3430, P < 0.0001). A weak positive correlation between CRP in T2 and OCT (r = 0.4210, P < 0.0001) was also found. The interconnectivity of tested parameters showed a weak positive correlation between CRP and IL-6 in T1 (r= 0.3680; P < 0.0001), moderate positive correlation in T2 (r = 0.6770; P < 0.0001), and a strong positive correlation in T3 (r = 0.8651; P < 0.0001).

CRP, IL-6, and PCT were shown to be reliable for postoperative monitoring. Simultaneous determination of CRP and IL-6 might not be useful as they follow similar kinetics. sTREM-1 might not be useful in CRC postoperative monitoring.

www.ClinicalTrials.gov, NCT01244022;https://www.clinicaltrials.gov/ct2/show/NCT01244022?term=01244022&rank=1.

Estimating the grades of liver inflammation is critical in the determination of antiviral therapy in patients chronically infected with hepatitis B virus (HBV). The aim of this study was to investigate the correlation of serum levels of hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) with the liver inflammation grades in treatment-naïve patients with chronic HBV infection.

We retrospectively enrolled 584 treatment-naïve HBeAg-positive patients who underwent liver biopsy in Ditan Hospital from January 2008 to January 2016. Based on the severity of liver inflammation, the patients were divided into minimal, mild, and moderate groups. SPSS software was used for statistical analysis of all relevant data.

The liver histological examinations showed that 324, 194, and 66 patients had minimal, mild, and moderate liver inflammation, respectively. The median age of the three groups was 30, 33, and 38 years, respectively (χ² = 26.00, P < 0.001). The median HBsAg levels in minimal, mild, and moderate inflammation groups were 4.40, 4.16, and 3.67 log U/ml, respectively, and the median HBeAg levels in the three groups were 3.12, 2.99, and 1.86 log sample/cutoff, respectively; both antigens tended to decrease as the grade of inflammation increased (χ² = 99.68 and χ² = 99.23, respectively; both P < 0.001). The cutoff values of receiver operating characteristic curve in the age, HBsAg and HBeAg levels were 36 years, 4.31 log U/ml, and 2.86 log S/CO, respectively, 1 to distinguish minimal grade and other grades of treatment-naïve HBeAg-positive patients with chronic HBV infection.

Serum HBsAg and HBeAg quantitation might gradually decrease with aggravated liver inflammation and the corresponding cutoff values might help us to distinguish minimal grades and other grades and detect those who do not need antiviral therapy in treatment-naïve HBeAg-positive patients with chronic HBV infection.

Halo nevus (HN) has been shown to be associated with vitiligo, but no standard signs are currently available to identify HN patients at risk of vitiligo, and the relevant data obtained in previous studies are somewhat conflicting. This study aimed to identify factors affecting the presence of vitiligo in HN patients.

We performed a retrospective study on consecutive patients with HN at the First Affiliated Hospital of Sun Yat-sen University between January 2011 and December 2016. Detailed demographic and clinical data were collected to identify the factors associated with the presence of vitiligo in this cohort of patients using uni- and multi-variate logistic regression analyses.

A total of 212 HN patients were included, 101 of whom had vitiligo-associated HN (HNV). Univariate analysis indicated that a personal history of thyroid diseases was positively associated with HNV (odds ratio [OR] = 10.761, P = 0.025), while the onset age of HN was negatively associated with HNV (OR = 0.537, P = 0.026). Multivariate analysis demonstrated that the Koebner phenomenon (KP; OR = 10.632, P < 0.0001), multiple HN (OR = 3.918, P < 0.0001), and a familial history of vitiligo (OR = 3.222, P = 0.014) were independent factors associated with HNV.

HN without vitiligo has clinical features distinct from HN associated with vitiligo. HN patients with KP, multiple lesions, or familial history of vitiligo are more likely to develop vitiligo and therefore should be monitored for clinical signs of such accompanied conditions.

Leber congenital amaurosis (LCA) is a visual disease which is caused by RPE65 mutations and results in retinal degeneration and severe vision loss in early infancy. According to previous researches, mutations of the RPE65 gene account for 16% of all cases of LCA. This study aimed to identify RPE65 gene mutations in Chinese patients with LCA.

We recruited 52 sporadic patients from Peking University Third Hospital in 2016 and applied Sanger sequencing to identify variants among exons responsible for the disease. The genomic DNAs from blood leukocytes of these patients were isolated, and the entire coding region of the RPE65 gene was amplified by polymerase chain reaction. We then determined the sequence of RPE65 using ABI 3100 Genetic Analyzer.

Our study identified that only 1 out of the 52 patients with LCA carried the previously unreported homozygosis missense mutation c1174A>C (T392P) of the RPE65 gene. However, the mutation was associated with the disease phenotype and not detected in 100 normal controls.

Though we identified a novel missense mutation in the RPE65 gene that causes LCA, our result indicates that RPE65 mutations may not play a major role in the LCA patients in China since only 1 out of the 52 patients carried mutation in the RPE65 gene.

Intrauterine adhesion (IUA) is a major health problem that causes infertility, menstrual irregularities, and recurrent pregnancy losses in women. Unfortunately, treatments for IUA are limited, and there are currently no effective strategies for preventing IUA recurrence. In this review, we introduced the role of Hippo signaling in the normal endometrium and IUA and described the mechanisms by which the Hippo pathway integrates with the Wnt and transforming growth factor-β (TGF-β) signaling pathways to form an intricate network governing the development of fibrosis.

Original research articles in English that were published until July 2017 were collected from the PubMed database.

Literature search was conducted using the search terms "endometrial fibrosis OR fibrosis AND or OR intrauterine adhesion OR Asherman syndrome OR IUA," "Hippo AND or OR Hippo/TAZ," "TGF-β," and "Wnt." Related original research articles were included in the comprehensive analysis.

Endometrial fibrosis is recognized as a key pathological event in the development of IUA, which is characterized by epithelial/fibroblast–myofibroblast transition. Myofibroblasts play crucial roles in the pathogenesis of fibrous scarring, and myofibroblast differentiation can be triggered by multiple signaling pathways. Hippo signaling is a critical regulator of the epithelial/fibroblast–myofibroblast transition and α-smooth muscle actin, which exhibits a specific spatiotemporal expression in the endometrium.

Hippo signaling plays a critical role in fibrous diseases and participates in cross talks with Wnt and TGF-β signaling. Our findings not only contributed to knowledge on the pathogenesis of endometrial fibrosis, but can also serve as a useful resource for developing specific molecular inhibitors for IUA treatment and prevention.

The population of elderly patients and the amount of geriatric anesthesia have been growing rapidly in China. Thus, understanding the morbidity and mortality associated with geriatric anesthesia in China is critical to the improvement of anesthesia quality and outcome. The aim of the review was to discuss the geriatric anesthesia-related morbidity and mortality in China, as well as to point out the future trend.

Articles in this review were all searched from Wanfang, China National Knowledge Infrastructure (CNKI), VIP, PubMed, and Web of Science databases, based on the reports originated in China from January 2011 to December 2016.

A total of 57 studies were selected for further study, including 12 retrospective studies, 35 prospective studies, 3 meta-analyses, 4 reviews, 1 viewpoint, and 2 case reports. Of the total studies, 42 studies were in Chinese while 15 were in English.

The mortality and morbidity associated with geriatric anesthesia in China are not yet completely reported. Some factors have been recognized, while some are yet to be identified and confirmed. Several studies addressed postoperative cognitive dysfunction and postoperative delirium, whereas only a few studies can be found on renal complications. Thus, a nationwide registry is essential for geriatric anesthesia-associated adverse outcomes. The mortality associated with geriatric anesthesia in China should be reported promptly. In the future, the perspective of geriatric anesthesia needs to be expanded into perioperative geriatric medicine to improve the perioperative management strategy based on the postoperative outcome-directed concept transformation.

Anesthesiologists should evaluate the physiological and medical status and focus on the prevention of potential complications in the perioperative setting with the goal to enhance elderly patients’ long-term well-being and survival quality.

It is estimated that 130–150 million people are chronically infected with hepatitis C virus (HCV) worldwide. During the late 1980s and early 1990s, illegal commercial plasma or blood donation practices were common in selected rural areas of China, which caused a rapid spread of HCV infection. Cross-sectional studies have showed that the prevalence rates of HCV infection in former paid plasma or blood donors varied from 9.6% to 72.8%. Chronic HCV infection can cause cirrhosis, liver failure, and hepatocellular carcinoma (HCC), and is a major global health problem. Eradicating HCV can prevent decompensation of cirrhosis, HCC, and death.^[1]The availability of direct-acting antiviral agents (DAAs) has significantly increased sustained virological response rates and decreased the complexity and adverse effects of HCV treatment. Much of the current debate on HCV treatment focuses on the high cost of these drugs, but even if the cost of HCV drugs is affordable, treatment would only benefit infected persons who have been diagnosed, have access to care, and wish to be treated. Despite the availability of effective treatments for HCV, globally no more than 15% of those infected are aware of their status and no more than 20% of those diagnosed have been treated.

The first documented journal club was organized in 1875 by William Osler at McGill University, to keep staff informed of medical science in a cost-effective manner.^[1]Nowadays, journal club has already become a common form of interactive education in hope to keep medical practitioners up-to-date of current literature, understand research design and statistics, and expand critical appraisal skills. A considerable amount of literatures describing journal clubs in different forms have been published; most were to enhance students' critical thinking, research competency, and evidence-based clinical practice. However, there is no gold standard to evaluate their effectiveness.^[2]Some appraised the results according to the senior consultants’ assessment^[3]while the others evaluate the journal clubs according to an attendee’s self-report survey.^[1,4]The form of journal club varies; and a well-accepted assessment system has yet been established.

A 75-year-old Han Chinese man presented with a 1-day history of acute shortness of breath. His medical history included lung adenocarcinoma, hepatitis B virus (carrier), hypertension, previous deep vein thrombosis (DVT), smoking for 45 years, and drinking for 35 years. He underwent dissection of his right upper and middle lobes and mediastinal lymph nodes 5 years previously and developed pleural and multiple pulmonary metastasis 3 months postoperatively. Molecular tests for epidermal growth factor receptor, KRAS, and anaplastic lymphoma kinase rearrangement were negative. He received 33 cycles of chemotherapy and 2 sessions of radiotherapy for lung metastases. However, he still developed bilateral lung metastases and multiple thoracic and lumbar vertebral metastases. Six weeks before the current presentation, he received nivolumab (3 mg/kg every 2 weeks, three cycles).

Wernicke encephalopathy (WE) is an acute or subacute neurological syndrome caused by thiamine (Vitamin B1) deficiency and is usually underestimated in clinical practice. WE is suspected in merely about 6% of non-alcoholic patients and one-third of alcoholic patients.^[1]Non-alcoholic causes include gastrointestinal surgery and disease, malnutrition, cancer and chemotherapeutic treatments, and long-term parenteral nutrition.^[2]However, few cases were reported about WE in patients with tuberculosis. Early diagnosis and medication are vital for the prognosis of this disease.

Mucosa-associated lymphoid tissue (MALT) lymphoma has previously been diagnosed only by a histological examination of gastric specimens, which made the diagnosis of MALT lymphoma very difficult. Endoscopic findings of gastric MALT lymphoma are variable, and current conventional white-light endoscopy cannot distinguish the cancerous tissue of MALT lymphoma from inflammation due to its histomorphological similarities. A new endoscopic modality known as linked color imaging (LCI) has been developed that may help in the diagnosis of gastric MALT lymphoma. Here, we reported a case of MALT lymphoma diagnosed by LCI. A 66-year-old male underwent upper gastrointestinal endoscopy at the Affiliated Hospital of Academy of Military Medical Sciences. The results revealed a longitudinal, hypertrophic gastric fold approximately 15 mm in size in the greater curvature of the gastric body with a normal white-light imaging [WLI;Figure 1a]. Compared with the WLI, the lesion was more easily recognizable on the LCI, on which it appeared as a bright reddish area [Figure 1b]. Additionally, a flat lesion, approximately 2 cm in diameter, was observed in the greater curvature of the gastric body in LCI [Figure 1c]. The demarcation of the lesion was easily visualized due to the striking color contrast between the lesion and the normal mucosa, which accentuated the distinction between the flat and the marginal elevation. The lesion appeared slightly erythematous in LCI compared to WLI, and was more clearly and easily recognizable [Figure 1d]. A target biopsy of the reddish area performed during LCI produced a specimen that was immunohistochemically positive for CD20(+) and negative for CyclinD1(-) and CD5(-), resulting in a pathological diagnosis of gastric MALT lymphoma [Figure 2a-Figure 2d].

Spinal lipomas are benign tumors that are usually divided into extradural and intradural types. In all, 60% are located intradurally and 40% are located extradurally. The most common spinal lipomas are known to be associated with dysraphism in the lumbosacral region.^[1]We present a rare case of a posterior mediastinal, intraspinal, intradural, intramedullary lipoma through a Kovalevsky canal combined with the failure of multiple segments from T3 to T6 in the thoracic spine.

To the Editor: Multiple primary lung cancer (MPLC) refers to the synchronous or metachronous appearance of more than one primary lung cancer in a single patient. The diagnosis of MPLC is complicated and it is often difficult to differentiate MPLC from metastatic lung cancers based on radiologic and histopathologic criteria alone. Moreover, the therapeutic regimens and prognosis for early MPLC and metastatic lung cancers are quite different.

To the Editor: Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a severe autoimmune disease. Dalmau identified anti-hippocampal and prefrontal nerve cell membrane NMDAR antibodies in this patient population and first named this syndrome.^[1]Here, we describe a case of one patient with anti-NMDAR encephalitis accompanied by ovarian teratoma.

To the Editor: Charcot-Marie-Tooth disease (CMT) is a clinically and genetically heterogeneous inherited neuropathy, with Type 1A being the most common. CMT 1A is characterized by progressive weakness and atrophy of the distal limb muscles beginning in the peroneal group, mild distal sensory loss, diminished tendon reflexes, and slow nerve conduction velocity.^[1]Spinal nerve root hypertrophy is a distinct sign of CMT 1A.^[2]This sign can be detected on magnetic resonance images (MRI), but it is often overlooked. Instead, diagnosis of this disease is often made basing on biopsy and genetic testing.

To the Editor: Henna tattoo has become popular and is increasingly reported as a cause of allergic skin reactions. Three cases of contact dermatitis caused by henna tattoos in China have been described.

To the Editor: We present a Chinese case of cystic fibrosis (CF) with Pseudo-Bartter syndrome (PBS) in a 6-month-old female infant. She started to have recurrent cough and wheezing after "a common cold" at 3-month-old and had been hospitalized several times for "pneumonia" . She received oral antibiotics and nebulized bronchodilators which resulted in no improvement. In addition, she developed hypokalemia (2.5 mmol/L) and metabolic alkalosis. She was transferred to our hospital for ongoing care. She had an uncomplicated birth history. She was the fourth child born to consanguineous parents. Her elder brother died of severe pneumonia and bronchiectasis at 13 years of age. Her elder sister was diagnosed as asthma at 6 years old which is well controlled. Physical examination showed moderate dehydration, failure to thrive (3^rdpercentile), and diffuse rhonchi on auscultation. A computed tomography (CT) scans illustrated scattered infiltrates and mild consolidation in the right lung [Figure 1a]. Six months later, a repeat CT scan demonstrated mild bilateral bronchiectasis [Figure 1b]. Genetic analysis revealed she had homozygous mutation c.532G>A (exon 5) inCFTR. His mutation was also found in both of her parents. There were no evidences of congenital pulmonary/heart disorders, tuberculosis, gastroesophageal reflux, primary immunodeficiency diseases, primary ciliary dyskinesia, and Bartter syndrome. Finally, she was diagnosed as CF with PBS. With antibiotics, fluid therapy, respiratory supportive treatment, and nutrition supplement, she improved significantly. CF is the most frequent monogenic disease in Caucasians but is rare in Asian. Few patients with CF can have hyponatremia, hypokalemia, and metabolic alkalosis that mimic Bartter syndrome, which called PBS.^[1,2]PBS as a rare phenotype of CF with the prevalence of 16.8%. Indeed, it can be an initial presentation of CF, especially in infants. PBS is well recognized and has been reported in the literature in patents of Caucasian origin. It is frequently missed as simple dehydration or Bartter syndrome. It is reported that about 30% of patients present initially in the nephrology clinics and are diagnosed as Bartter syndrome.^[3]In China mainland, just 53 cases with CF have been reported from 1974 till now.^[4,5]Moreover, the main phenotypic characteristics of these cases were bronchiectasis, sinusitis, and recurrent pneumonia. The phenotypic features differed that described in Caucasian patients.^[4,5]The final diagnosis is often delayed in China because of lack of newborn screening, atypical phenotype, and low frequency in the population. In addition, PBS has rarely been reported in Chinese origin. Therefore, the patients with atypical features of CF are likely to be greatly underdiagnosed in China. This case expands the phenotypic spectrum of CF patients in Chinese origin. Pediatricians should keep CF with PBS in the differential diagnosis of infants presenting with recurrent pulmonary infection, failure to thrive and electrolytes disturbance, especially in those with dehydration, hypokalemia, and metabolic alkalosis who are usually suspected to have Bartter syndrome. With the development of molecular diagnostic technique, CF is not as infrequent as once thought in the Chinese population.