2018年 · 第131卷第07期

It is known that there is a definite association between platelet distribution width (PDW) and poor prognosis in patients with coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM). However, there are no data available regarding the prognostic significance of PDW for in-stent restenosis (ISR) in patients with CAD and T2DM. We aimed to determine the value of PDW on admission that predicted ISR in patients with CAD and T2DM.

Between January 2012 and December 2013, a total of 5232 consecutive patients diagnosed with CAD and T2DM undergoing percutaneous coronary intervention were admitted. Three years of retrospective follow-up was undertaken. A total of 438 patients with second angiography operations were included. ISR was defined as ≥50% luminal stenosis of the stent or peri-stent segments. Continuous data were presented as the mean ± standard deviation or median (P₂₅, P₇₅) and were compared by one-way analysis of variance or Kruskal-Wallis H-test. Categorical variables were presented as percentages and were compared by Chi-square test or Fisher’s exact test. The association between PDW and ISR was calculated by logistic regression analysis. A two-sided value of P < 0.05 was considered statistically significant. Statistical analyses were performed by SPSS version 22.0 for windows.

Fifty-nine patients with ISR, accounting for 13.5% of the total, were included. ISR was significantly more frequent in patients with higher PDW quartiles compared with lower quartiles. We observed that PDW had a strong relationship with mean platelet volume (r = 0.647, 95% confidence interval [CI]: 0.535–0.750, P < 0.0001). The receiver-operating characteristic curves showed that the PDW cutoff value for predicting ISR rate was 13.65 fl with sensitivity of 59.3% and specificity of 72.4% (area under curve [AUC] = 0.701, 95% CI: 0.625–0.777, P < 0.001). Multivariate analysis showed that the risk of ISR increased approximately 30% when PDW increased one unit (odds ratio [OR]: 1.289, 95% CI: 1.110–1.498, P = 0.001). Patients with higher PDW, defined as more than 13.65 fl, had a 4-fold higher risk of ISR compared with lower PDW (OR: 4.241, 95% CI: 1.879–9.572, P = 0.001). Furthermore, when patients were divided by PDW quartiles values, PDW was able to predict ISR (Q2: OR = 0.762, 95% CI: 0.189–3.062, P = 0.762; Q3: OR = 2.782, 95% CI: 0.865–8.954, P = 0.086; and Q4: OR = 3.849, 95% CI: 1.225–12.097, P = 0.021, respectively; P for trend <0.0001).

PDW is an independent predictor of ISR in patients with CAD and T2DM.

Despite its limitations, unfractionated heparin (UFH) has been the standard anticoagulant used during percutaneous coronary intervention (PCI). This study compared the safety of low-dose UFH with sequential enoxaparin with that of UFH in patients with diabetes mellitus (DM) and complex coronary artery disease receiving elective PCI.

In this retrospective study, 514 consecutive patients with atherosclerotic cardiovascular diseases and type 2 DM were admitted to the hospital and received selective PCI, from January 2013 to December 2015. All patients with PCI received low-dose UFH with enoxaparin (intraductal 50 U/kg UFH and 0.75 mg/kg enoxaparin, n = 254; UFH-Enox group) or UFH only (intraductal 100 U/kg UFH, n = 260; UFH group). The study endpoints were major adverse cardiac events (MACEs), namely death, myocardial infarction (MI), stroke, target-vessel immediate revascularization (TVR), and thrombolysis in MI (TIMI) major bleeding, within 30 days and 1 year after PCI. Any catheter thrombosis during the procedure was recorded.

Only one patient had an intraductal thrombus in the UFH group. At the 30-day follow-up, no MACE occurred in any group; seven and five cases of recurrent angina and/or rehospitalization were reported in the UFH-Enox and UFH groups, respectively; there was no significant difference between the two groups (χ² = 0.11, P = 0.77). There was no TIMI major bleeding in the groups. With respect to the 1-year endpoint, two cases of recurrent MI and two of TVRs were reported in the UFH-Enox group, whereas in the UFH group, one case of recurrent MI and three of TVRs were reported; no significant difference existed between the two groups (χ² = 0, P = 0.99). There were 30 and 25 recurrent angina and/or rehospitalizations in the UFH-Enox and UFH groups, respectively; there was no significant difference between the two groups (χ²= 0.37, P = 0.57).

In elective PCI, low-dose UFH with sequential enoxaparin has similar effects and safety to the UFH-only method.

Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are common X-linked recessive neuromuscular disorders caused by mutations in dystrophin gene. Multiplex polymerase chain reaction (multiplex PCR) and multiplex ligation-dependent probe amplification (MLPA) are the most common methods for detecting dystrophin gene mutations. This study aimed to contrast the two methods and discern the genetic characterization of patients with DMD/BMD in Eastern China.

We collected 121 probands, 64 mothers of probands, and 15 fetuses in our study. The dystrophin gene was detected by multiplex PCR primarily in 28 probands, and MLPA was used in multiplex PCR-negative cases subsequently. The dystrophin gene of the remaining 93 probands and 62 female potential carriers was tested by MLPA directly. In fetuses, multiplex PCR and MLPA were performed on 4 fetuses and 10 fetuses, respectively. In addition, sequencing was also performed in 4 probands with negative MLPA.

We found that 61.98% of the subjects had genetic mutations including deletions (50.41%) and duplications (11.57%). There were 43.75% of mothers as carriers of the mutation. In 15 fetuses, 2 out of 7 male fetuses were found to be unhealthy and 2 out of 8 female fetuses were found to be carriers. Exons 3–26 and 45–52 have the maximum frequency in mutation regions. In the frequency of exons individually, exon 47 and exon 50 were the most common in deleted regions and exons 5, 6, and 7 were found most frequently in duplicated regions.

MLPA has better productivity and sensitivity than multiplex PCR. Prenatal diagnosis should be applied in DMD high-risk fetuses to reduce the disease incidence. Furthermore, it is the responsibility of physicians to inform female carriers the importance of prenatal diagnosis.

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening clinical syndrome. Central nervous system (CNS) involvement is a severe complication, which can lead to rapid disease development and higher morality. However, this has not been given enough attention in adult HLH. Therefore, we carried out this study to analyze the clinical features, laboratory findings, treatment outcomes, and other characteristics of adult HLH with CNS involvement.

A retrospective analysis of 96 adult patients with HLH combined with CNS involvement between June 2003 and December 2016 was conducted. Clinical features, cerebrospinal fluid (CSF) features, image changes, and therapeutic outcomes were analyzed.

Among the 96 patients, 86 had various CNS symptoms and 33 (38.4%) had already presented symptoms before the HLH diagnosis was confirmed. A total of 59 patients received CSF examinations and showed abnormalities in 23 patients (39.0%). Seventy patients received imaging examinations and the results showed fifty patients with imaging changes (71.4%). Fifty-seven patients received multiple rounds of repeated intrathecal injection therapy and 35 patients improved (61.4%). As for the multiple analyses of effective factors on survival time, the results showed that the effects of combined Epstein–Barr virus (EBV) infection (P = 0.026, Exp(B) = 2.309, 95% confidence interval [CI] [1.108, 4.823) and intrathecal injection therapy (P = 0.013, Exp(B) = 0.422, 95% CI [0.214, 0.831]) on the survival time of the CNS-HLH patients were significant.

Complication with EBV infection is a risk factor, and intrathecal injection is a protective factor. CNS involvement in HLH is not rare, which can result in a poor prognosis. Multiple rounds of repeated intrathecal injection therapy can improve the prognosis of CNS-HLH patients.

Robot-assisted/laparoscopic intracorporeal ileal conduit (ICIC) has been reported in many experienced centers. Whether laparoscopic ICIC is superior to extracorporeal ileal conduit (ECIC) and whether laparoscopic ICIC should be promoted is still controversial. The aim of the study was to compare surgical and early oncological outcomes between patients undergoing laparoscopic radical cystectomy (LRC) with ICIC and ECIC.

From January 2011 to June 2016, a total of 45 patients with bladder cancer underwent LRC with ileal conduit at our department, of whom 20 patients underwent LRC with ECIC and 25 patients underwent LRC with ICIC. Data of each patient’s characteristics, surgical outcomes, and short-term oncological outcomes were collected and analyzed.

LRC with ileal conduit was performed successfully on all 45 patients. There were no significant differences in patients' characteristics, mean total operative time, and mean estimated blood loss between the ICIC and ECIC groups. Median time of flatus and oral intake was shorter in the ICIC group compared with the ECIC group (3 vs. 5 days, P = 0.035; 4 vs. 5 days, P = 0.002). The complications rates did not show significant difference between the two groups within the first 90 days postoperatively (P = 0.538). Cancer staging showed 45% of patients in the ECIC group and 36% in the ICIC group had a pathologic stage of T3 or T4, and 50% of patients in the ECIC group and 44% in the ICIC group had a pathologic stage of N1 or N1+. Kaplan–Meier analysis showed no significant difference in overall survival at 24 months (60% vs. 62%, P = 0.857) between the ECIC and ICIC groups.

ICIC after LRC may be successful with the benefits of faster recovery time. No significant difference was found in complications and oncological outcomes between ICIC and ECIC. However, larger series with longer follow-up are needed to validate this procedure.

Studies of haploidentical-related donor (HRD) stem cell transplantation using a combination of peripheral blood stem cells (PBSCs) and bone marrow as the graft have reported encouraging results for patients with hematological diseases. However, few studies specifically reported transplantation of only PBSCs from HRDs among patients with relapsed or refractory acute myeloid leukemia (AML). Here, the long-term outcomes and side effects of unmanipulated HRD PBSC transplantation (HRD-PBSCT) for relapsed/refractory AML were analyzed.

We performed a retrospective analysis of the outcomes in relapsed/refractory AML patients who underwent PBSCT from HRDs (n = 36).

Thirty-one (86.1%) patients in the HRD-PBSCT group achieved platelet recovery. The cumulative incidence of acute graft-versus-host disease (aGVHD) in the HRD-PBSCT group was 40.00%, and the cumulative incidence of grades 2–4 aGVHD in this group was 13.33%. A total of 13 patients in the HRD-PBSCT group had recurrent disease at a median of 183 days after transplantation (range: 10–1700 days), reaching cumulative incidences of relapse of 50.28% at 5 years. On multivariate analysis, donor age and patient age >40 years were independent risk factors for inferior disease-free survival or overall survival (P < 0.05). The results of the present study demonstrate rapid and complete neutrophil engraftment, a low incidence of grade 2–4 aGVHD, and promising survival rates in patients after HRD-PBSCT. Thus, granulocyte colony-stimulating factor- primed PBSCs may be a reliable graft source in unmanipulated HRD-HSCT under myeloablative conditioning when no matched sibling donor is available.

Our results support the feasibility, effectiveness, and tolerability of PBSCs as a graft source in unmanipulated HRD transplantation under myeloablative conditioning in patients with leukemia.

Idiopathic basal ganglia calcification (IBGC) is a genetic disorder characterized by bilateral basal ganglia calcification and neural degeneration. In this study, we reported a new SLC2OA2 mutation of IBGC and reviewed relevant literature to explore the association between phenotypes and genotypes in Chinese IBGC patients.

Clinical information of the proband and her relatives were collected comprehensively. Blood samples of both the patient and her father were obtained, and genetic screening related to IBGC was performed using second generation sequencing with their consent. Findings were confirmed by Sanger sequencing. Polyphen-2 was used to predict the potential association between mutations and disease. Then, we retrieved literatures of Chinese IBGC patients and explored the association between phenotype and genotype.

A novel mutation was identified through genetic testing, and it is suggested to be a damage mutation predicted by Polyphen-2. Through literature review, we found that SLC20A2 mutation is the most common cause for IBGC in China. Its hot spot regions are mainly on the 1^st and 8^th exons; the second common one is PDGFB where the hot spot covered a length of 220–230 bp localized on the 2^nd exon; moreover, Chinese IBGC patients featured early-onset, more severe movement disorder and relatively mild cognitive impairment compared with those in other countries.

There is significant heterogeneity both in phenotype and genotype in Chinese IBGC patients. Further research of pathogenic mechanism of IBGC is required to eventually develop precise treatment for individuals who suffered this disease.

Ventilator-induced lung injury (VILI) is commonly associated with barrier dysfunction and inflammation reaction. Glutamine could ameliorate VILI, but its role has not been fully elucidated. This study examined the relationship between inflammatory cytokines (interleukin [IL]-6, tumor necrosis factor [TNF]-α, and IL-10) and adherens junctions (E-cadherin, p120-catenin), which were ameliorated by glutamine in VILI, both in vitro and in vivo.

For the in vivo study, 30 healthy C57BL/6 mice weighing 25–30 g were randomly divided into five groups with random number table (n = 6 in each group): control (Group C); low tidal volume (Group L); low tidal volume + glutamine (Group L + G); high tidal volume (Group H); and high tidal volume + glutamine (Group H + G). Mice in all groups, except Group C, underwent mechanical ventilation for 4 h. For the in vitro study, mouse lung epithelial 12 (MLE-12) cells pretreated with glutamine underwent cyclic stretching at 20% for 4 h. Cell lysate and lung tissue were obtained to detect the junction proteins, inflammatory cytokines, and lung pathological changes by the Western blotting, cytokine assay, hematoxylin and eosin staining, and immunofluorescence.

In vivo, compared with Group C, total cell counts (t = −28.182, P < 0.01), the percentage of neutrophils (t = −28.095, P < 0.01), IL-6 (t = −28.296, P < 0.01), and TNF-α (t = −19.812, P < 0.01) in bronchoalveolar lavage (BAL) fluid, lung injury scores (t = −6.708, P < 0.01), and the wet-to-dry ratio (t= −15.595, P < 0.01) were increased in Group H; IL-10 in BAL fluid (t = 9.093, P < 0.01) and the expression of E-cadherin (t = 10.044, P < 0.01) and p120-catenin (t = 13.218, P < 0.01) were decreased in Group H. Compared with Group H, total cell counts (t = 14.844, P < 0.01), the percentage of neutrophils (t = 18.077, P < 0.01), IL-6 (t = 18.007, P < 0.01), and TNF-α (t = 10.171, P < 0.01) in BAL fluid were decreased in Group H + G; IL-10 in BAL fluid (t = −7.531, P < 0.01) and the expression of E-cadherin (t = −14.814, P < 0.01) and p120-catenin (t= −9.114, P < 0.01) were increased in Group H + G. In vitro, compared with the nonstretching group, the levels of IL-6 (t = −21.111, P < 0.01) and TNF-α (t = −15.270, P < 0.01) were increased in the 20% cyclic stretching group; the levels of IL-10 (t = 5.450, P < 0.01) and the expression of E-cadherin (t = 17.736, P < 0.01) and p120-catenin (t = 16.136, P < 0.01) were decreased in the 20% cyclic stretching group. Compared with the stretching group, the levels of IL-6 (t = 11.818, P < 0.01) and TNF-α (t = 8.631, P < 0.01) decreased in the glutamine group; the levels of IL-10 (t = −3.203, P < 0.05) and the expression of E-cadherin (t = −13.567, P < 0.01) and p120-catenin (t = −10.013, P < 0.01) were increased in the glutamine group.

High tidal volume mechanical ventilation and 20% cyclic stretching could cause VILI. Glutamine regulates VILI by improving cytokines and increasing the adherens junctions, protein E-cadherin and p120-catenin, to enhance the epithelial barrier function.

Recent research indicates that nerve growth factor (NGF) promotes cardiac repair following myocardial infarction by promoting angiogenesis and cardiomyocyte survival. The purpose of this study was to investigate the effects of NGF on cardiac fibroblasts (CFs) proliferation, cell cycle, migration, and myofibroblast transformation in vitro.

CFs were obtained from ventricles of neonatal Sprague-Dawley rats and incubated with various concentrations of NGF (0, 0.01, 0.1, 1, 10, and 100 ng/ml; 0 ng/ml was designated as the control group). Cell proliferation and cell cycle of the CFs were measured by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay and flow cytometry (FCM), respectively. A cell scratch wound model and transwell were carried out to observe effects of NGF on migration of CFs after 24 h of culture. Real-time polymerase chain reaction (RT-PCR) and Western blotting were used to measure α-smooth muscle actin (α-SMA) at mRNA and protein levels after CFs were incubated with various concentrations of NGF.

Expression of α-SMA measured by RT-PCR and Western blotting significantly increased in the 1 and 10 ng/ml NGF groups (P < 0.05). Absorbance values of CFs showed that NGF did not influence the proliferation of CFs (The A₄₉₀ values were 0.178 ± 0.038, 0.182 ± 0.011, 0.189 ± 0.005, 0.178 ± 0.010, 0.185 ± 0.025, and 0.177 ± 0.033, respectively, in the 0, 0.01, 0.1, 1, 10, and 100 ng/ml NGF groups [P = 0.800, 0.428, 0.981, 0.596, and 0.913, respectively, compared with control group]), and FCM analysis showed that the percentage of CFs in G0/G1, S, and G2/M phases was not changed (P > 0.05). The cell scratch wound model and transwell showed that CFs migration was not significantly different (P > 0.05).

NGF induces myofibroblast transformation but does not influence proliferation, cell cycle, or migration of CFs in vitro.

Mineral and bone disorder is one of the severe complications in kidney transplant recipients (KTRs). Previous studies showed that bisphosphonates had favorable effects on bone mineral density (BMD). We sought to compare different bisphosphonate regimens and rank their strategies.

We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) up to April 01, 2017, for randomized controlled trials (RCTs) comparing bisphosphonate treatments in adult KTRs. The primary outcome was BMD change. We executed the tool recommended by the Cochrane Collaboration to evaluate the risk of bias. We performed pairwise meta-analyses using random effects models and network meta-analysis (NMA) using Bayesian models and assessed the quality of evidence.

A total of 21 RCTs (1332 participants) comparing 6 bisphosphonate regimens were included. All bisphosphonates showed a significantly increased percentage change in BMD at the lumbar spine compared to calcium except clodronate. Pamidronate with calcium and Vitamin D analogs showed improved BMD in comparison to clodronate with calcium (mean difference [MD], 9.84; 95% credibility interval [CrI], 1.06–19.70). The combination of calcium and Vitamin D analogs had a significantly lower influence than adding either pamidronate or alendronate (MD, 6.34; 95% CrI, 2.59–11.01 and MD, 6.16; 95% CrI, 0.54–13.24, respectively). In terms of percentage BMD change at the femoral neck, both pamidronate and ibandronate combined with calcium demonstrated a remarkable gain compared with calcium (MD, 7.02; 95% CrI, 0.30–13.29 and MD, 7.30; 95% CrI, 0.32–14.22, respectively). The combination of ibandronate with calcium displayed a significant increase in absolute BMD compared to any other treatments and was ranked best.

Our NMA suggested that new-generation bisphosphonates such as ibandronate were more favorable in KTRs to improve BMD. However, the conclusion should be treated with caution due to indirect comparisons.

Several studies have reported that mindfulness meditation has a potential effect in controlling headaches, such as migraine and tension-type headache; however, its role remains controversial. This review assessed the evidence regarding the effects of mindfulness meditation for primary headache pain.

Only English databases (PubMed, Cochrane Central Register of Controlled Trials [the Cochrane Library], PsycINFO, Psychology and behavioral science collection, PsyArticles, Web of Science, and Scopus) were searched from their inception to November 2016 with the keywords ( "meditation" or "mindfulness" or "vipassana" or "dzogchen" or "zen" or "integrative body-mind training" or "IBMT" or "mindfulness-based stress reduction" or "MBSR" or "mindfulness-based cognitive therapy" or "MBCT" and "Headache" or "Head pain" or "Cephalodynia" or "Cephalalgia" or "Hemicrania" or "Migraine" ). Titles, abstracts, and full-text articles were screened against study inclusion criteria: controlled trials of structured meditation programs for adult patients with primary headache pain. The quality of studies included in the meta-analysis was assessed with the Yates Quality Rating Scale. The meta-analysis was conducted with Revman 5.3.

Ten randomized controlled trials and one controlled clinical trial with a combined study population of 315 patients were included in the study. When compared to control group data, mindfulness meditation induced significant improvement in pain intensity (standardized mean difference, −0.89; 95% confidence interval, −1.63 to −0.15; P = 0.02) and headache frequency (−0.67; −1.24 to −0.10; P = 0.02). In a subgroup analysis of different meditation forms, mindfulness-based stress reduction displayed a significant positive influence on pain intensity (P < 0.000). Moreover, 8-week intervention had a significant positive effect (P < 0.000).

Mindfulness meditation may reduce pain intensity and is a promising treatment option for patients. Clinicians may consider mindfulness meditation as a viable complementary and alternative medical option for primary headache.

Hydrogen sulfide (H₂S), a gaseous signal molecule, plays a crucial role in many pathophysiologic processes in the cardiovascular system. Autophagy has been shown to participate in the occurrence of many cardiac diseases. Increasing evidences indicated that H₂S regulates myocardial structure and function in association with the altered autophagy and plays a "switcher" role in the autophagy of myocardial diseases. The aim of this review was to summarize these insights and provide the experimental evidence that H₂S targets cardiomyocyte autophagy to regulate cardiovascular function.

This review was based on data in articles published in the PubMed databases up to October 30, 2017, with the following keywords: "hydrogen sulfide," "autophagy," and "cardiovascular diseases."

Original articles and critical reviews on H₂S and autophagy were selected for this review.

When autophagy plays an adaptive role in the pathogenesis of diseases, H₂S restores autophagy; otherwise, when autophagy plays a detrimental role, H₂S downregulates autophagy to exert a cardioprotective function. For example, H₂S has beneficial effects by regulating autophagy in myocardial ischemia/reperfusion and plays a protective role by inhibiting autophagy during the operation of cardioplegia and cardiopulmonary bypass. H₂S postpones cardiac aging associated with the upregulation of autophagy but improves the left ventricular function of smoking rats by lowering autophagy.

H₂S exerts cardiovascular protection by regulating autophagy. Cardiovascular autophagy would likely become a potential target of H₂S therapy for cardiovascular diseases.

The objective of the study was to summarize the role of DNA methylation in the development and metastasis of uveal melanoma (UM).

The relevant studies in MEDLINE were searched.

In this review, we performed a comprehensive literature search in MEDLINE using "uveal melanoma" AND ( "DNA methylation" OR "epigenetics" ) for original research/review articles published before February 2018 on the relationship between DNA methylation and UM. References of the retrieved studies were also examined to search for potentially relevant papers.

Previous studies on the relationship between DNA methylation and UM covered many genes including tumor suppressor genes (TSGs), cyclin-dependent kinase genes, and other genes. Among them, the TSG genes such as RASSF1A and p16INK4a, which encodes a cyclin-dependent kinase inhibitor, are relatively well-studied genes. Specifically, a high percentage of promoter methylation of RASSF1A was observed in UM cell lines and/or patients with UM. Promoter methylation of RASSF1A was also associated with the development of metastasis. Similarly, a high percentage of promoter hypermethylation of p16INK4a was found in UM cell lines. DNA promoter methylation can control the expression of p16INK4a, which affect cell growth, migration, and invasion in UM. Many other genes might also be involved in the pathogenesis of UM such as the Ras and EF-hand domain containing (RASEF) gene, RAB31, hTERT, embryonal fyn-associated substrate, and deleted in split-hand/split-foot 1.

Our review reveals the complex mechanisms underlying the tumorigenesis of UM and highlights the great needs of future studies to discover more genes/5’-C-phosphate-G-3’ sites contributing to the development/metastasis of UM and explore the mechanisms through which epigenetic changes exert their function in UM.

Since the advent of induced pluripotent stem cell (iPSC) technology a decade ago, enormous progress has been made in stem cell biology and regenerative medicine. Human iPSCs have been widely used for disease modeling, drug discovery, and cell therapy development. In this review, we discuss the progress in applications of iPSC technology that are particularly relevant to drug discovery and regenerative medicine, and consider the remaining challenges and the emerging opportunities in the field.

Articles in this review were searched from PubMed database from January 2014 to December 2017.

Original articles about iPSCs and cardiovascular diseases were included and analyzed.

iPSC holds great promises for human disease modeling, drug discovery, and stem cell-based therapy, and this potential is only beginning to be realized. However, several important issues remain to be addressed.

The recent availability of human cardiomyocytes derived from iPSCs opens new opportunities to build in vitro models of cardiac disease, screening for new drugs and patient-specific cardiac therapy.

To the Editor: Painless intubation is extremely important to avoid perforation during colonoscopy. Ultrathin colonoscopes and standard gastroscopes (9.2–9.8 mm) can increase the proportion of patients with painless intubation, but there remain approximately 10% patients who suffer from moderate or severe abdominal pain.^[1]Sedation and anesthesia during colonoscopy could alleviate patient’s suffering and improve the success rate of colonoscopy, but warning effect of abdominal pain disappears and the risk of perforation is increasing.^[2]In this paper, a transnasal gastroscope (5.9 mm) was used to simulate the ultrathin colonoscope for examination. The authors hypothesized that none of the patients would have severe abdominal pain in this study, demonstrating good safety of transnasal gastroscope on colon examination.

To the Editor: In the clinic, atrial fibrillation (AF) is one of the most common types of arrhythmia encountered, and its burden and prevalence on the health-care system are still on the rise. Over the past 50 years,AF incidence has increased by roughly 350.0%.^[1]In a review from the Global Burden of Disease study, it was estimated that the worldwide prevalence ofAF is 596.2 or 373.1/100,000 men or women. The Incidence ofAF significantly increased with age.^[2]Approximately 1% of AF patients are <60 years old, up to 12% of AF patients are in the 75–84 years age range and the AF prevalence is even higher in patients that are 80 years or older. Dementia is a disabling disease of the brain that characterized by impairments in memory and other cognitive functions. It can seriously affect human life. Worldwide, an estimated 33 million elderly individuals suffer from dementia, and this number is expected to reach 81.1 million by 2040. It is obvious that cognitive function deteriorates naturally with the aging of the body, butAF could accelerate the pace. According to some systematic reviews and meta-analysis, AF can increase the risk of dementia by 40%. For the elder individuals, who are more than 75 years old, their dementia usually resulting from cerebrovascular lesions and neurodegeneration. While for the middle age individuals who are 40–59 years old, the advent of dementia is derived from cardiovascular disease. AF increases the risk of stroke, heart failure, and mortality. However,AF may also increase the risk of dementia, given the mutual vascular risk factors, such as smoking, hypertension, high cholesterol, diabetes mellitus, advancing age, chronic kidney disease, vascular disease, heart failure, inactivity/low activity, genetics, sleep apnea, and alcohol consumption.^[3,4]The term "cardiogenic dementia" was first introduced more than 40 years ago to support a possible link between AF and cognitive impairment. It was not until recently that demonstratedAF is an independent risk factor of cognitive impairment and may increase the risk of dementia through several mechanisms, including cerebral hypoperfusion, thromboembolism (including both stroke and subclinical cerebral infarcts), inflammation, anticoagulation cerebral micro-bleeds, and neuronal function impairment. Therefore, strategies that control the development of AF and promote cardiovascular health may help delay the onset of dementia. TraditionalAF treatment involves anticoagulation, rhythm, and rate control. Thus, by understanding the potential relationship between AF and dementia, novel approaches may be proposed for future AF management.

To the Editor: Male steroid hormones are synthesized in the adrenal cortex and testis, and pediatric reference intervals for normal steroid hormone levels are essential for the diagnosis of adrenal and gonadal disorders. Importantly, steroid hormone profiles vary with age and pubertal development, and to date, only very limited data have been published concerning normal steroid hormone ranges in terms of age and pubertal development. The absence of such data has been primarily due to the lack of a sufficiently sensitive and specific method for determining appropriate reference intervals for steroid concentrations.

To the Editor: A 48-year-old Chinese woman complained of chest tightness, shortness of breath, and palpitations for 8 months. These symptoms were gradually increasing and the edema on both lower limbs appeared 1 month ago. She had a history of uterine fibroids. Sound of tumor fluttering was heard at the 3/4^thintercostal space of the left libs; at the same time, systolic murmur was heard at the apical area. Cardiac ultrasound of another hospital indicated a mass of right atrium which was diagnosed as myxoma. Cardiac ultrasound imaging showed that inferior vena cava and right heart cavity were occupied by a mass [Figure 1a]. Computed tomography angiography (CTA) of the abdomen and heart demonstrated that there were multiple irregular soft-tissue masses in uterus, which entered the inferior vena cava through the right ovarian vein and finally reached the right atrium [Figure 1b,Figure 1c]. Radiologists considered the disease as uterine leiomyomatosis (UL) and proposed to check through magnetic resonance imaging (MRI). According to MRI of the abdomen [Figure 1d,Figure 1e] and heart [Figure 1f], as well as diffusion-weighted imaging (DWI) [Figure 1g], the disease was diagnosed as UL. Such diagnosis was confirmed by surgery and pathology [Figure 1h]. The above symptoms were significantly alleviated after operation, and edema of both lower limbs disappeared 10 days after operation.

To the Editor: Gastric submucosal lesions are easily misdiagnosed as submucosal tumors (SMTs) or oppression, and these patients may go through endoscopic resection or surgeries. For submucosal lesions in the gastric fundus, with echotexture same as the spleen and extragastric under endoscopic ultrasound (EUS) examination, especially in patients with the history of splenectomy, accessory spleen should be suspected. It is a challenge for EUS operators. This report presented two cases diagnosed as accessary spleen by EUS and CT for the purpose of avoiding unnecessary treatment.

To the Editor: Thyroid surgeries are the most frequently performed endocrine procedures worldwide. One of the most serious complications of thyroid surgery is injury to the recurrent laryngeal nerve (RLN), which varies from 0.5% to 14.0%, depending on the type of disease, the type of surgery, the extent of resection, and the surgical technique.^[1,2,3]Currently, there are three approaches used to identify the nerve: the superior, lateral, and inferior approaches.^[4]Each of these has advantages and disadvantages; however, the common component of all three techniques is that the RLN is identified from the lateral side of the thyroid. Yet, in some special cases when the lateral side of the thyroid is difficult to divide, it is not possible to use any of the three techniques to identify the RLN. Therefore, we introduce a new approach to help identify the RLN in special cases.

To the Editor: Elephantiasis results from chronic lymphedema and is characterized by gross enlargement of the arms, legs, or genitalia. It occurs due to various obstructive diseases of the lymphatic system. The most common form of lymphedema is secondary lymphedema involving resection or ablation of the regional lymph nodes by surgery, radiation, tumor invasion, direct trauma, or an infection.^[1,2]We present an unusual case of bilateral lower limb and abdominal elephantiasis due to extensive lymph node destruction by erysipelas.

To the Editor: Retrievable inferior vena cava (IVC) filter placement has been on the rise over the years, but only a small percentage of retrievable IVC filters have been removed, ranging between 10.1% and 38.9%.^[1,2]Laparoscopic retrieval of IVC filter case report was available since 2015,^[3]the filter hook in the case report was seen clearly protruding from the anterior wall of the cava, and there was no need for vena cavotomy and reconstruction. In this case, the IVC filter tip was embedded in the posterior wall and cavotomy was required. Very few studies have reported the laparoscopic IVC filter retrieval through vena cavotomy and reconstruction.

To the Editor: A 12-year-old boy born in Guizhou Province, China, presented with a history of generalized raised nodular lesions developing over the course of 2 months on the face and limbs. The patient’s first symptom was the appearance of small nodules on the face, unaccompanied by sensations of itching, pain, or burning. The number of lesions increased over the course of a week, and also appeared on his limbs, with no report of fever, joint pain, or swelling of joints. A preliminary biopsy suggested histiocytic proliferative disease, and other tests were normal, so the patient was treated with traditional Chinese medications. However, the lesions continued to increase, and the patient was brought to our clinic. Physical examination revealed diffuse small tawny nodules on the face and limbs, sparse eyebrows, and scars from ulcers on the face. His vital signs and laboratory tests were normal. The biopsy of new lesions on the right forearm showed the granulomatous infiltrate in the superficial and deep dermis and hypodermis, composed of a mixture of foamy and epithelioid histiocytes and including scattered lymphocytes. Moreover, a Fite-Faraco stain showed numerous acid-fast bacilli [Figure 1]. A diagnosis of multibacillary leprosy as defined by the World Health Organization (WHO) was made. The patients, without a clear history of exposure to infectious diseases, were subsequently treated with multidrug therapy, consisting of monthly doses of rifampicin 450 mg and clofazimine 200 mg, plus daily doses of dapsone 50 mg and clofazimine 50 mg, resulting in partial remission of the cutaneous lesions within 2 months.

To the Editor: In the last 10 years, mounting evidence has confirmed that schizophrenia is associated with white matter (WM) impairment; this impairment exists even before the occurrence of an episode of schizophrenic symptoms. Widespread WM fiber tracts were affected in patients, especially in certain key brain regions, such as the arcuate fasciculus, fasciculi longitudinalis superior, and corpus callosum. A previous study reported that although there was no more than 1% WM impairments in schizophrenic patients, it is nonetheless a stable and specific aberrant pathological feature of schizophrenia.^[1]