2018年 · 第131卷第20期

The quick Sequential Organ Failure Assessment (qSOFA) score emerged recently. We investigated its contribution to risk stratification in acute pulmonary embolism (PE) by combining with electrocardiography (ECG).

Acute PE patients diagnosed in Beijing Chao-Yang Hospital, Capital Medical University, from 2008 to 2018 were retrospectively studied and divided into high- and low-risk groups by imaging and biomarkers. The ECG scores consisted of tachycardia, McGinn-White sign (S₁Q₃T₃), right bundle branch block, and T-wave inversion of leads V₁–V₃. A new combination of qSOFA scores and ECG scores by logistic regression for predicting high-risk stratification patients with acute PE was evaluated by a receiver operating characteristic curve.

Totally 1318 patients were enrolled, including 271 in the high-risk group and 1047 in the low-risk group. A combination predictive scoring system named qSOFA-ECG = qSOFA score + ECG score was created. The optimal cutoff value for qSOFA-ECG was 2, and the sensitivity, specificity, positive predictive value, and negative predictive value were 81.5%, 72.3%, 43.2%, and 93.8%, respectively. For predicting high-risk stratification and reperfusion therapy, the qSOFA-ECG is superior to PE Severity Index (PESI) and simplified PESI.

The qSOFA score contributes to identify acute PE patients with potentially hemodynamic decompensation that need monitoring and possible reperfusion therapy at the emergency department arrival when used in combination with ECG score.

The influence of different right ventricular lead locations on ventricular arrhythmias (VTA) in patients with a cardiac resynchronization therapy (CRT) is not clear. This study aimed to evaluate the influence on VTA in patients with a CRT when right ventricular lead was positioned at the right ventricular middle septum (RVMS) and the right ventricular apical (RVA).

A total of 352 patients implanted with a CRT-defibrillator (CRT-D) between May 2012 and July 2016 in the Department of Cardiology of Anhui Provincial Hospital were included. Two-year clinical and pacemaker follow-up data were collected to evaluate the influence of the right ventricular lead location on VTA. Patients were divided into the RVMS group (n = 155) and the RVA group (n = 197) based on the right ventricular lead position. The VTA were compared between these two groups using a Kaplan-Meier curve and Cox multivariate analysis.

When the left ventricular lead location was not considered, RVMS and RVA locations did not affect VTA. However, the subgroup analysis results showed that when the left ventricular lead was positioned at the anterolateral cardiac vein (ALCV), the RVMS group had an increased risk of ventricular arrhythmias and appropriate defibrillation (hazard ratio [HR] = 3.29, P = 0.01 and HR = 4.33, P < 0.01, respectively); when the left ventricular lead was at the posterolateral cardiac vein (PLCV), these risks in the RVMS group decreased (HR = 0.45, P = 0.02 and HR = 0.33, P < 0.01, respectively), and when the left ventricular lead was at the lateral cardiac vein, there was no difference between the two groups. In regard to inappropriate defibrillation, there was no significant difference among all these groups.

When the left ventricular lead was positioned at ALCV or PLCV, the right ventricular lead location was associated with VTA and appropriate defibrillation after CRT. Greater distances between leads not only improved cardiac function but also may reduce the risk of VTA.

The diagnosis and treatment of small hepatocellular carcinoma (HCC) play a vital role in the prognosis of patients with HCC. The purpose of our study was to evaluate angio-computed tomography (angio-CT)-guided immediate lipiodol CT (a CT scan performed immediately after transarterial chemoembolization [TACE]) in the diagnosis of potential HCCs ≤1 cm in diameter.

This study retrospectively analyzed 31 patients diagnosed with HCCs after routine imaging (contrast-enhanced CT or magnetic resonance imaging) or pathologic examinations with undefined or undetermined tumor lesions (diameter ≤1 cm) from February 2016 to September 2016. After TACE guided by digital subtraction angiography of the angio-CT system, potential HCC lesions with a diameter ≤1 cm were diagnosed by immediate lipiodol CT. The number of well-demarcated lesions was recorded to calculate the true positive rate. The correlation between the number of small HCCs detected by immediate lipiodol CT and the size of HCC lesions (diameter >1 cm) diagnosed preoperatively was analyzed 1 month after TACE. A paired t-test was used to analyze differences in liver function. Pearson analysis was used to analyze correlation. Chi-square test was used to compare the rates.

Fifty-eight lesions were detected on preoperative routine imaging examinations in 31 patients including 15 lesions with a diameter ≤1 cm. Ninety-one lesions were detected on immediate lipiodol CT, of which 48 had a diameter ≤1 cm. After 1 month, CT showed that 45 lesions had lipiodol deposition and three lesions had lipiodol clearance. Correlation analysis showed that the number of small HCCs detected by lipiodol CT was positively correlated with the size of HCC lesions diagnosed by conventional imaging examination (R² = 0.54, P < 0.05).

Immediate lipiodol CT may be a useful tool in the diagnosis of potential HCC lesions with a diameter of ≤1 cm.

Unfractionated heparin (UFH), despite its limitations, has been used as the primary anticoagulant alternative during the percutaneous coronary intervention (PCI). Some studies indicated that intravenous enoxaparin could be an effective and safe option. Our team used enoxaparin alone at one time according to the guidelines (Class IIA) and found a little catheter thrombosis during PCI. We recommend a new anticoagulation strategy using enoxaparin in combination with UFH. Enoxaparin has a more predictable anticoagulant response with no need of repeatedly monitoring anticoagulation during PCI. This retrospective study aimed to evaluate the efficacy and safety of using enoxaparin in combination with UFH in PCI patients with complex coronary artery disease.

Between January 2015 and April 2017, 600 PCI patients who received intravenous UFH at an initial dose of 3000 U plus intravenous enoxaparin at a dose of 0.75 mg/kg (observation group) and 600 PCI patients who received UFH at a dose of 100 U/kg (control group) were consecutively included in this retrospective study. The endpoints were postoperative 48-h thrombolysis in myocardial infarction (TIMI) bleeding and transfusion and 30-day and 1-year major adverse cardio-cerebrovascular events (MACCE).

Baseline clinical, angiographic, and procedural characteristics were similar between groups, except there was less stent implantation per patient in the observation group (2.13 vs. 2.25 in the control group, P = 0.002). TIMI bleeding (3.3% vs. 4.7%) showed no significant difference between the observation group and control group. During the 30-day follow-up, the rate of MACCE was 0.9% in the observation group and 1.5% in the control group. There was no significant difference in the rates of MACCE, death, myocardial infarction, target vessel revascularization, cerebrovascular event, and angina within 30 days and 1 year after PCI between groups as well as in the subgroup analysis of transfemoral approach.

UFH with sequential enoxaparin has similar anticoagulant effect and safety as UFH in PCI of complex coronary artery disease.

The excess volume of contrast media (CM) is a marker of a more severe coronary culprit lesion and longer intervention duration in patients undergoing cardiac procedures. However, it is unclear whether the contrast volume is directly correlated with worse clinical outcomes. The aim of this study was to investigate the association between contrast dose and the incidence of 1-year major adverse cardiac and cerebrovascular events (MACCE) and all-cause bleeding events in patients undergoing cardiac catheterization and coronary angiography (CAG).

We prospectively enrolled 10,961 consecutive patients diagnosed with coronary heart disease expecting CAG from 2012 to 2013. The study population was pursued with a follow-up duration of 1 year. The predictive value of contrast volume, divided into quartiles, for the risk of MACCE and all-cause bleeding events was assessed using logistic regression analysis.

The cumulative incidence of 1-year MACCE was 8.65%, which was directly associated with increasing contrast volume. In particular, MACCE was observed in 7.16%, 7.89%, 9.31%, and 11.73% of cases in the contrast volume quartile Q1 (≤100 ml), Q2 (101–140 ml), Q3 (141–200 ml), and Q4 (>200 ml), respectively (P < 0.001). Moreover, the incidence of 1-year all-cause bleeding events was noted in 4.70%, 5.93%, 7.28%, and 8.21% of patients in Q1, Q2, Q3, and Q4, respectively (P < 0.001). The survival analysis showed that the 1-year MACCE rate was higher in patients using greater CM volume during the CAG. CM volume used >140 ml was associated with the occurrence of 1-year MACCE, and the incidence was dramatically elevated in patients exceeding a contrast volume of 200 ml (P = 0.007).

Our data suggested that higher contrast volume was significantly correlated with an increased risk of MACCE and all-cause bleeding events in patients undergoing cardiac catheterization.

ClinicalTrials.gov, NCT01735305; https://clinicaltrials.gov/ct2/show/NCT01735305?id=NCT017353057rank=1.

Treatment of myoclonic seizures in myoclonic epilepsy with ragged-red fibers (MERRFs) has been empirical and ineffective. Guideline on this disease is not available. Additional trials must be conducted to find more suitable treatments for it. In this study, the antimyoclonic effects of monotherapies, including levetiracetam (LEV), clonazepam (CZP), valproic acid (VPA), and topiramate (TPM) compared to combination therapy group with LEV and CZP on MERRF, were evaluated to find a more advantageous approach on the treatment of myoclonic seizures.

Treatments of myoclonic seizures with VPA, LEV, CZP, and TPM were reported as monotherapies in 17 MERRF patients from Qilu Hospital between 2003 and 2016, who were diagnosed through clinical data and genetic testing. After 1–4 months of follow-up (mean: 82.9 ± 28.1 days), 12 patients that exhibited poor responses to monotherapy were given a combined treatment consisting of LEV and CZP subsequently. The follow-up period was 4–144 months (mean: 66.3 ± 45.3 months), the effective rates of monotherapy group (17 patients) and combination therapy group (12 patients) were analyzed by Chi-square test.

The m.8344 A>G mutation was detected in all patients. There were four patients with partial response (4/17, two in the CZP group and two in the LEV group), ten patients with stable disease (10/17, six in the CZP group, three in the LEV group, and one in the TPM group), and three patients with progressive disease (3/18, two in the VPA group and one in the TPM group). Twelve of the patients with LEV combined with CZP showed a positive effect and good tolerance (12/12), eight of them demonstrated improved cognition and coordination. There was a significant difference between the monotherapy group and combination therapy group in the efficacy of antimyoclonic seizures (χ² = 13.7, P < 0.001).

LEV in combination with CZP is an efficient and safe treatment for myoclonic seizures in patients with this disease exhibiting the m.8344A>G mutation.

Standard automated perimetry does not sufficiently detect early open-angle glaucoma (OAG) in the clinic. New visual function tests for early glaucoma damage are therefore needed. The present study evaluated whether an isolated-check visual evoked potential (icVEP) could be used to detect visual function abnormalities in early-stage OAG and to explore potential related factors.

This was a cross-sectional study. Thirty-seven OAG patients with early-stage visual field loss (mean deviation ≥ −6.00 dB) detected by the Humphrey Field Analyzer (30-2 SITA program) and 26 controls were included in this study. Optical coherence tomography (OCT) was used to detect retinal nerve fiber layer (RNFL) defects. The icVEP preferentially evaluates the magnocellular-ON pathway. VEPs were recorded and signal-to-noise ratios (SNRs) were derived based on multivariate analysis. Eyes that yielded an SNR ≤1 were considered abnormal. Receiver operating characteristic (ROC) curve analysis was used to estimate the accuracy of group classification. Correlations between SNRs and related factors were analyzed.

Based on an SNR criterion of 1, the icVEP had a sensitivity of 62.2% and a specificity of 92.3% for diagnosing early-stage OAG with 74.6% classification accuracy. The ROC curve analysis, however, suggested that an SNR criterion of 0.93 would produce the highest classification accuracy (77.3%). Both RNFL thinning in the temporal superior quadrant on OCT and number of abnormal test points in the central 11° visual field (pattern deviation, P < 0.5%) significantly correlated with the SNR (P < 0.05).

The icVEP detected visual function abnormalities in approximately 3/5 of eyes with early-stage OAG with greater than 90% specificity. SNR correlated with both a decrease in RNFL thickness and severity of central visual field loss.

The increasing frequency of explosive injuries has increased interest in blast-induced traumatic brain injury (bTBI). Various shock tube models have been used to study bTBI. Mild-to-moderate explosions are often overlooked because of the slow onset or mildness of the symptoms. However, heavy gas cylinders and large volume chambers in the model may increase the complexity and danger. This study sought to design a modified model to explore the effect of moderate explosion on brain injury in mice.

Pathology scoring system (PSS) was used to distinguish the graded intensity by the modified model. A total of 160 mice were randomly divided into control, sham, and bTBI groups with different time points. The clinical features, imaging features, neurobehavior, and neuropathology were detected after moderate explosion. One-way analysis of variance followed by Fisher’s least significant difference posttest or Dunnett’s t 3-test was performed for data analyses.

PSS of mild, moderate, and severe explosion was 13.4 ± 2.2, 32.6 ± 2.7 (t = 13.92, P < 0.001; vs. mild group), and 56.6 ± 2.8 (t = 31.37, P < 0.001; vs. mild group), respectively. After moderate explosion, mice showed varied symptoms of malaise, anorexia, incontinence, apnea, or seizure. After bTBI, brain edema reached the highest peak at day 3 (82.5% ± 2.1% vs. 73.8% ± 0.6%, t = 7.76, P < 0.001), while the most serious neurological outcomes occurred at day 1 (Y-maze: 8.25 ± 2.36 vs. 20.00 ± 4.55, t = −4.59, P = 0.048; 29.58% ± 2.84% vs. 49.09% ± 11.63%, t = −3.08, P = 0.008; neurologic severity score: 2.50 ± 0.58 vs. 0.00 ± 0.00, t = 8.65, P = 0.016). We also found that apoptotic neurons (52.76% ± 1.99% vs. 1.30% ± 0.11%, t = 57.20, P < 0.001) and gliosis (2.98 ± 0.24 vs. 1.00 ± 0.00, t = 14.42, P = 0.021) in the frontal were significantly higher at day 3 post-bTBI than sham bTBI.

We provide a reliable, reproducible bTBI model in mice that can produce a graded explosive waveform similar to the free-field shock wave in a controlled laboratory environment. Moderate explosion can trigger mild-to-moderate blast damage of the brain.

Fine particulate matter (PM_2.5) exacerbates airway inflammation and hyperreactivity in patients with asthma, but the mechanism remains unclear. The aim of this study was to observe the effects of prolonged exposure to high concentrations of PM_2.5 on the pathology and airway hyperresponsiveness (AHR) of BALB/c mice undergoing sensitization and challenge with ovalbumin (OVA) and to observe the effects of apoptosis and T-cell immunoglobulin and mucin domain 1 (TIM-1) in this process.

Forty female BALB/c mice were divided into four groups: control group, OVA group, OVA/PM group, and PM group (n = 10 in each group). Mice in the control group were exposed to filtered clean air. Mice in the OVA group were sensitized and challenged with OVA. Mice in the OVA/PM group were sensitized and challenged as in the OVA group and then exposed to PM_2.5 for 4 h per day and 5 days per week for a total of 8 weeks using a nose-only "PM_2.5 online enrichment system" in The Second Hospital of Hebei Medical University. Mice in the PM group were exposed to the PM_2.5 online enrichment system only. AHR was detected. Bronchoalveolar lavage fluid (BALF) was collected for cell classification. The levels of interleukin-4 (IL-4), IL-5, and IL-33 in BALF were measured using enzyme-linked immunosorbent assay. Changes in histological structures were examined by light microscopy, and changes in ultramicrostructures were detected by electron microscopy. Apoptosis was determined by terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) assay in the lung tissues. Western blotting and immunohistochemistry were utilized to analyze the expression of Bcl-2, Bax, and TIM-1 in the lungs.

The results showed that AHR in the OVA/PM group was significantly more severe than that in the OVA and PM groups (P < 0.05). AHR in the PM group was also considerably more severe than that in the control group (P < 0.05). The BALF of OVA/PM group (28.00 ± 6.08 vs. 12.33 ± 4.51, t = 4.631, P = 0.002) and PM group (29.00 ± 3.00 vs. 12.33 ± 4.51, t = 4.927, P = 0.001) had more lymphocytes than the BALF of the control group. The number of neutrophils in the BALF of the OVA/PM group (6.67 ± 1.53 vs. 3.33 ± 1.53, t = 2.886, P = 0.020) and PM group (6.67 ± 1.53 vs. 3.33 ± 1.53, t = 2.886, P = 0.020) was much higher than those in the BALF of OVA group (P < 0.05). TUNEL assays showed that the number of apoptotic cells in the OVA/PM group was significantly higher than that in the OVA group (Tunel immunohistochemical scores [IHS%], 1.20 ± 0.18 vs. 0.51 ± 0.03, t = 8.094, P < 0.001) and PM group (Tunel IHS%, 1.20 ± 0.18 vs. 0.51 ± 0.09, t = 8.094, P < 0.001), and that the number of apoptotic cells in the PM group was significantly higher than that in the control group (Tunel IHS%, 0.51 ± 0.09 vs. 0.26 ± 0.03, t = 2.894, P = 0.020). The concentrations of IL-4 (77.44 ± 11.19 vs. 48.02 ± 10.02 pg/ml, t = 4.595, P = 0.002) and IL-5 (15.65 ± 1.19 vs. 12.35 ± 0.95 pg/ml, t = 3.806, P = 0.005) and the Bax/Bcl-2 ratio (1.51 ± 0.18 vs. 0.48 ± 0.10, t = 9.654, P < 0.001) and TIM-1/β-actin ratio (0.78 ± 0.11 vs. 0.40 ± 0.06, t = 6.818, P < 0.001) in the OVA/PM group were increased compared to those in the OVA group. The concentrations of IL-4 (77.44 ± 11.19 vs. 41.47 ± 3.40 pg/ml, t = 5.617, P = 0.001) and IL-5 (15.65 ± 1.19 vs. 10.99 ± 1.40 pg/ml, t = 5.374, P = 0.001) and the Bax/Bcl-2 ratio (1.51 ± 0.18 vs. 0.97 ± 0.16, t = 5.000, P = 0.001) and TIM-1/β-actin ratio (0.78 ± 0.11 vs. 0.31 ± 0.06, t = 8.545, P < 0.001) in the OVA/PM group were increased compared to those in the PM group. The concentration of IL-4 (41.47 ± 3.40 vs. 25.46 ± 2.98 pg/ml, t = 2.501, P = 0.037) and the Bax/Bcl-2 ratio (0.97 ± 0.16 vs. 0.18 ± 0.03, t = 7.439, P < 0.001) and TIM-1/β-actin ratio (0.31 ± 0.06 vs. 0.02 ± 0.01, t = 5.109, P = 0.001) in the PM group were also higher than those in the control group.

Exacerbated AHR associated with allergic asthma caused by PM_2.5 is related to increased apoptosis and TIM-1 activation. These data might provide insights into therapeutic targets for the treatment of acute exacerbations of asthma induced by PM_2.5.

An intrauterine adhesion (IUA) is a form of disease that causes the uterine muscle walls to become adhered to each other due to the basal layers of the endometrium being damaged by various factors, thus resulting in partial or complete occlusion of the uterine cavity.^[1]In recent years, with the increase of uterine cavity surgery, its incidence has been increasing, seriously affecting women’s reproductive function, menstrual physiology, and physical and mental health. Hysteroscopy represents the gold standard for the diagnosis of IUAs. Hence, recognition of hysteroscopic images is of paramount significance in determining the diagnosis, the choice of concurrent treatment, and prognostic evaluation. In this paper, we describe two cases of IUAs that were successfully treated with rare hysteroscopic findings. The diagnosis and classification of IUAs were based on the American Fertility Society (AFS) classification system of 1988.^[2]

To the Editor: Vitamin B12 (cobalamin, Cbl) is essential for normal growth and development in humans. It can be converted into two important active coenzymes, namely adenosyl cobalamin (AdoCbl) and methyl cobalamin (MeCbl), which play crucial roles in mitochondria and cytoplasm, respectively. The disorders of intracellular cobalamin metabolism that are inherited in an autosomal recessive manner result from the deficient synthesis of AdoCbl and MeCbl derived from Vitamin B12; the types of disorders includes: cblA, cblB, cblC, cblD, etc., depending on the pathogenic genes.^[1,2]The cblD disease (MIM# 277410) caused by mutations in theMMADHCgene contains three subtypes: cblD-isolated methylmalonic acidemia (MMA), cblD-isolated homocystinuria (HC) and cblD-MMA/HC (combined MMA and HC).^[1]We herein reported the Chinese patient with cblD disease attributable to a novelMMADHCmutation related to translation reinitiation.

To the Editor: Cerebral venous thrombosis (CVT) indicates occlusion of the main sinus/sinuses or cortical veins, resulting in vascular congestion and neurological lesions.^[1]Juveniles with Down syndrome (DS) are more likely to develop thrombosis.^[2]However, the association between thrombosis and DS has not been reported widely.

To the Editor: In China and neighboring countries, there is increasing health concern over the dust storm fine particulate matter (PM) originating in the Gansu Corridor and Mongolian regions of China.^[1]PM is a mixture of various particles including crustal material, metals, and bioaerosols. Elevated levels of ambient PM were also reported to be associated with increased cardiopulmonary morbidity and mortality.^[2]A recent World Health Organization report indicated that exposure to fine PM air pollution and other pollutants caused approximately seven million deaths in 2012 worldwide, while the Global Burden of Disease Study showed that PM exposure was responsible for 2.9 million deaths and 69.7 million disability-adjusted life-years in 2013.^[2]Finally, studies showed that reduced PM concentrations were associated with reduced mortality risk.

To the Editor: Degenerative mitral valve disease is a common disorder afflicting 2–3% of the general population and nearly half of them are elderly.^[1]Plenty of studies have confirmed that mitral repair would result in better outcomes than mitral replacement for degenerative valve disease.^[2]In order to illustrate the relation of etiology, pathology, valvular dysfunction, surgical strategy, and midterm durability of mitral valve repair for degenerative valve disease, we retrospectively analyzed the data of a single center. In the consecutive cohort, all of operations were performed by a skillful surgeon (G. D.) based on 100% repair criteria.

To the Editor: Arteriovenous malformations (AVM), also referred to as cirsoid aneurysm, arteriovenous aneurysm, arteriovenous fistula, and cavernous hemangioma, can occur in any organ in the body. Uterine AVM is a rare entity that is classified as either congenital or acquired. Congenital uterine AVM is thought to develop from a defect during embryologic differentiation leading to abnormal vascular connections, whereas acquired uterine AVM has been reported to occur due to a previous uterine trauma, such as curettage or cesarean delivery, or to be associated with neoplastic disorders, including gestational trophoblastic disease (GTD) and endometrial adenocarcinoma.^[1]

To the Editor: Monochorionic triplet pregnancies are very rare, accounting for 3.5–4.0% of all triplet gestations and occurring in 0.001–0.004% of all deliveries.^[1]They are associated with higher risks of perinatal morbidity and mortality. Conjoined twins are a unique and rare complication of monochorionic pregnancies and occur when two identical individuals are fused through parts of their anatomy; this rare event occurs with an incidence of one in 100,000-200,000 live births.^[2]Although the presence of conjoined twins in a monochorionic triplet is exceptionally rare, it poses great challenges regarding both obstetric counseling and management.

To the Editor: Uterine adenomyosis (AM) is caused by the ectopic growth of endometrial glands and stroma in the myometrium of the uterus, accompanied by hyperplasia and hypertrophy of the surrounding smooth muscle cells, leading to a diffuse enlargement of the uterus. Although AM is a common benign gynecological disease, it may cause severe dysmenorrhea, menorrhagia, enlarged uterus, and infertility, which have negative impacts on patients' health and quality of life. Thus far, there is a lack of high-quality data to give clinicians a comprehensive understanding of AM with regard to its clinical manifestations and pathological characteristics. This report presented clinical and pathological features of AM with or without coexisting endometriosis (EM) to assist clinicians and patients to make early diagnosis and intervention for such a disease in the future. We hoped that the above features would improve patients’ fertility and their quality of life.

To the Editor: Valve stenosis and regurgitation can lead to a series of symptoms, including chest distress and dyspnea. Valve replacement is an effective surgical procedure that improves patients’ quality of life and life span and has played an increasingly important role in treating mitral valve diseases. Previous studies have reported different risk factors and independent predictors of increased mortality in patients with mitral valve replacement (MVR) and/or aortic valve replacement (AVR).^[1,2,3]This study retrospectively reviewed data on patients undergoing valve surgery to determine the risk factors and predictors of short-term mortality in this patient population.

To the Editor: Gallbladder cancer (GBC), a rare entity with poor prognosis, is often discovered incidentally during or after cholecystectomy.^[1]It tends to disseminate early through lymphatic, peritoneal, endobiliary, and hematogenous pathways. Patients usually present with metastatic diseases. If GBC is suspected during cholecystectomy, conversion to open surgery to perform radical resection after confirmation of cancer by intraoperative frozen biopsy is considered. When GBC is diagnosed after cholecystectomy, reoperation for radical resection according to depth of invasion of cancer (T stage) is inevitable.^[1]However, reoperation with radical surgery is not performed in all patients for several reasons including refusal to undergo radical surgery, poor medical condition, or cancer progression suggesting unresectability.

To the Editor: Magnetic resonance (MR) imaging plays an important role in rectal cancer (RC) treatment decision-making.^[1]There is controversy about whether it is necessary to use rectal contrast materials during MR imaging for RC.^[2,3,4]Feces and gas in the rectum may affect the display of lesions and induce artifacts, especially on diffusion-weighted image (DWI).^[5]Therefore, some investigators thought that rectal filling is necessary. The conventional method is to infuse ultrasound gel or oral gadopentetate dimeglumine and polyethylene glycol to fill the rectum. The intestinal lumen caused by rectal filling may alter the distance between the tumor and surgical plane, which may affect the accuracy of staging. There are other limitations of rectal filling with ultrasound gel including inconvenience for inserting the enema tube during MR examination and patients' comfortlessness after large amount of agent to defecate. Gadopentetate dimeglumine and polyethylene glycol solution show hyperintense on T1-weighted images and introduce the susceptibility artifacts on both enhanced images and DWI. The former could obscure lesions and their enhancement after intravenous injection of contrast agent. To overcome these limitations of rectal filling during MR imaging, we developed a novel MR rectographic regimen. Our protocol is the following: (1) taking 500 ml 20% mannitol administered orally as the laxative at night before the examination to clear the colorectum and then withhold all oral taken; (2) the examinations were scheduled in the morning. About 1500 ml of isotonic mannitol solution was drunk continuously within 90–120 min before examination; (3) during MR rectography, when the patient has an impulse to defecate, it means that the agent has reached the rectum. To ensure the completeness of the examination, the patients were permitted to have two or three bowel movements before the beginning of examination.

Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoid neoplasms in adults. Through the decades, rituximab, cyclophosphamide, doxorubicin, prednisone, and vincristine (R-CHOP) therapy has dramatically improved the clinical outcome due to the introduction of rituximab. Even so, still about 30–40% of patients ultimately relapse or progress, which become difficult to manage. A study has shown that patients with primary refractory DLBCL or early relapse after rituximab-containing therapy have a very poor prognosis,^[1]which makes the introduction of novel drugs to DLBCL regimen definitely an urge demand.

"You have read a newspaper or blog, flipped through a magazine, or used social media recently; you have likely come across infographics - those self - contained pictorials that tell you about the gist of the story or concept at a glance" .^[1]

In the article titled, "Effect of cigarette smoke extract on lipopolysaccharide-activated mitogen-activated protein kinase signal transduction pathway in cultured cells", published on pages 1075-1081, Issue 12, Vol 120 ofChinese Medical Journal,^[1]two items should be corrected as following:

In the article titled "Low-density Lipoprotein Cholesterol/High-density Lipoprotein Cholesterol Ratio as Predictor of First Acute Myocardial Infarction and Major Adverse Cardiovascular Event after Intervention in Young Males" , published on page 2239- 2241, Issue 18, Volume 131 ofChinese Medical Journal,^[1]the affiliation of authors and address for correspondence "Capital University of Medical Sciences" should be written as "Capital Medical University" , and "Lung and Blood Vessel Disease" should be written as "Lung and Blood Vessel Diseases" .

We read with interest the case report by Banet al.^[1]about a 17-year-old male with myoclonic epilepsy with ragged red fibers (MERRF) syndrome being attributed to the mitochondrial tRNA glutamic acid (tRNA [Glu]) variant mitochondrial 14709T>C. The authors claimed that the variant occurred sporadically and has not been reported in association with a MERRF phenotype so far.^[1]We have the following comments and concerns.

Thank you for your attention and interest for our study,^[1]and thank you for your questions and opinions as well.