2018年 · 第131卷第21期

Innovation springs from practice, and its soul lies in practical thinking. All human wisdom is a product of practice and needs to be tested during the practice. With the rapid development of medicine, a clinician has to keep pace with the new era, grasp the pulse of the times and innovate. Only in this way, could he or she lead the trend of the new era. Clinical medicine is a practical science and implemented mainly by clinicians, requiring them to explore the truth and pursue technological innovation all the time. At the same time, as an academic leader, a clinician is encouraged to practice actively, to take risks to innovate, to pursue truth and test truth in the practice, discarding old ideas and correcting wrong theories and technologies. To summarize, a clinician has to push forward practice-based innovation of theory and technology to keep up with the pace of the times.

Few studies have investigated the differences in proximal femoral geometry and risk factors between patients with different types of hip fracture, especially in elderly Chinese. This study aimed to assess the differences in proximal femoral geometry parameters between patients with femoral neck fractures and patients with intertrochanteric fractures to provide guidance for individualized customized prosthesis and accurate reconstruction of proximal femurs in elderly Chinese patients.

We retrospectively studied the electronic medical records of 198 elderly patients over 65 years of age who were admitted to the orthopedic department with hip fractures between January 2017 and December 2017 in The Third Hospital, Hebei Medical University. Age, fracture site, gender, and proximal femoral geometry parameters (neck shaft angle [NSA], center edge angle [CEA], femoral head diameter [FHD], femoral neck diameter [FND], femoral neck axial length [FNAL], hip axial length [HAL], and femoral shaft diameter [FSD]) were recorded. Student’s t-test was used to compare the continuous variables, Chi-square test was used to analyze categorical variables, and multiple logistic stepwise regression analysis was used to evaluate the influencing factors of hip fracture type.

Statistically significant differences in NSA (137.63 ± 4.56° vs. 132.07 ± 4.17°, t = 1.598, P < 0.001), CEA (37.62 ± 6.77° vs. 43.11 ± 7.09°, t = 5.597, P < 0.001), FND (35.21 ± 3.25 mm vs. 34.09 ± 3.82 mm, t = 2.233, P = 0.027), and FNAL (99.30 ± 7.91 mm vs. 103.58 ± 8.39 mm, t = 3.715, P < 0.001) were found between the femoral neck fracture group and femoral intertrochanteric fracture group. FHD, FND, FSD, HAL, and FNAL were different between sexes (all P < 0.001). The greater NSA was the risk factor for femoral neck fractures (odds ratio [OR]: 0.70, P < 0.001), greater CEA and longer FNAL were risk factors for femoral intertrochanteric fractures (OR: 1.15, 1.17, all P < 0.001), and greater FND was a protective factor for femoral intertrochanteric fractures (OR: 0.74, P < 0.001).

We demonstrate differences in geometric morphological parameters of the proximal femur in different hip fracture types, as well as an effect of sex. These differences should be considered in the selection of prostheses for fracture internal fixation and hip replacements. These data could help guide the design of individualized customized prostheses and improve the accurate reconstruction of the proximal femur for elderly Chinese hip fracture patients.

Identification of the proper femoral intramedullary (IM) access point is an important determinant of final implant position in IM-guided total knee arthroplasty (TKA). The aim of this study was to identify the optimal entry point in Chinese participants using a new three-dimensional method.

A series of computed tomography scans of 44 femurs in Chinese participants from October 2014 to October 2015 were imported into Mimics 17.0 software to identify the optimal entry point. The apex of the intercondylar notch (AIN) was used as the reference bony anatomical landmark to identify the proper entry point to insert the IM rod. The statistical significance was calculated on the basis of a 5% level (P < 0.05) using the Student’s t-test.

For the males, the average ideal entry point was 1.49 mm medial and 13.39 mm anterior to the AIN. The values were 1.77 mm medial and 15.29 mm anterior to the AIN in females. A significant difference was present between males and females (13.39 ± 2.46 mm vs. 15.29 ± 3.44 mm, t = 2.124, P= 0.040). When using the recommended location as the entry point for the IM rod, the mean potential error differed significantly from the femoral trochlear groove (the potential error of IM in males in coronal plane: 0.93°± 0.24° vs. 1.27°± 0.32°, t= −4.166, P < 0.001; the potential error of IM in males in sagittal plane: 1.40°± 0.42° vs. 2.79°± 0.70°, t= −7.155, P < 0.001; the potential error of IM in females in coronal plane: 0.73°± 0.28° vs. 1.15°± 0.35°, t = −3.940, P < 0.001; and the potential error of IM in females in sagittal plane: 1.48°± 0.47° vs. 2.76°± 0.83°, t= −5.574, P< 0.001). A significant difference was present between the recommended point and the point 10 mm anterior to the origin of the posterior cruciate ligament (the potential error of IM in males in coronal plane: 0.93°± 0.24° vs. 1.53°± 0.43°, t= −5.948, P < 0.001; the potential error of IM in males in sagittal plane: 1.40°± 0.42° vs. 2.15°± 0.75°, t= −3.152, P= 0.003; the potential error of IM in females in coronal plane: 0.73°± 0.28° vs. 1.28°± 0.42°, t= −4.632, P < 0.001; and the potential error of IM in females in sagittal plane: 1.48°± 0.47° vs. 2.40°± 0.93°, t= −3.763, P= 0.001).

The technique described here is an innovative method for swift, easy, and accurate access to the medullary canal during TKA, and it can optimize the position and orientation of the prosthetic components in knee arthroplasty.

Many clinical studies over the past decade have indicated positive outcomes for patients treated with Dynesys dynamic stabilization for lumbar degenerative disease. However, long-term outcomes of Dynesys for lumbar spinal stenosis are rarely reported. The aim of this study was to analyze the long-term clinical and radiologic outcomes for patients with lumbar spinal stenosis treated with Dynesys stabilization.

Thirty-eight patients with lumbar spinal stenosis were treated with Dynesys stabilization from July 2008 to March 2010. The minimal duration of follow-up was 72 months. The patients were divided into stenosis and spondylolisthesis groups according to degenerative spondylolisthesis. Clinical outcomes were evaluated using the Oswestry Disability Index (ODI) and visual analog scale (VAS). Radiographic evaluations included range of motion (ROM) and the disc heights of stabilized segments and the upper adjacent segments. We also evaluated the occurrence of radiographic and symptomatic adjacent segment degeneration (ASD).

There were 23 patients in stenosis group and 15 patients in spondylolisthesis group. The ODI scores were significantly improved at the final follow-up evaluation, as compared to the baseline values (16.1 ± 5.7 vs. 57. 2 ± 14.2, t = 61.41, P< 0.01). The VAS scores for back and leg pain were significantly improved from 4.82 ± 0.89 and 4.04 ± 0.82 preoperatively to 0.93 ± 0.61 and 0.54 ± 0.51 postoperatively (t = 6.59, P< 0.01, and t = 5.91, P< 0.01, respectively). There were no differences between the two groups with respect to VAS and ODI scores. The ROM of stabilized segments decreased significantly from 7.8°± 2.4° to 4.5°± 1.5° (t = 7.18, P< 0.05 ), while the upper adjacent segments increased significantly from 8.3°± 2.4° to 10.4°± 2.4° (t = 2.87, P= 0.01). The change in disc height of stabilized segments was not significant (11.9 ± 2.1 preoperatively vs. 12.5 ± 1.5 postoperatively, t = 1.43, P= 0.15), whereas the decrease in disc height of the upper adjacent segments was significant (12.5 ± 2.0 preoperatively vs. 11.0 ± 1.7 postoperatively, t = 2.94, P= 0.01). The occurrence of radiographic and symptomatic ASD was 16% (6/38) and 3% (1/38), respectively.

Decompression and Dynesys stabilization for lumbar stenosis with or without spondylolisthesis showed good long-term clinical and radiographic results. Lumbar stenosis with or without Grade I spondylolisthesis, particularly in patients <60 years of age with mild-to-moderate lumbar disc degeneration, would be one of the main indications for the Dynesys system.

In a small proportion of cases, spontaneous osteonecrosis of the knee (SONK) involves the medial tibial plateau (MT). Here, we introduced the clinical characteristics of spontaneous osteonecrosis of the MT and unicompartmental knee arthroplasty (UKA) as the favorable treatment for this situation based on a retrospective case study.

Patients with spontaneous osteonecrosis of the MT, confirmed by magnetic resonance imaging (MRI) at Guangdong Provincial Hospital of Chinese Medicine (China) from March 2015 to June 2016, were included as a case serial and analyzed retrospectively. All patients underwent Oxford Medial UKA. The characteristics of their lesions, corresponding treatment, and results of follow-up were presented. The lesion scores and grade were determined according to the criteria of Ficat and Arlet.

In total, 22 patients (5 men, 17 women; mean age, 64.1 years) with spontaneous osteonecrosis of the MT were analyzed. The lesion stages assessment showed that 3 (14%) were Stage II, 10 (45%) were Stage III, 7 (32%) were Stage IV, and 2 (9%) were Stage V. In the sagittal plane, 7 (32%) were in the anterior region (MTa) and 15 (68%) were central (MTc). The lesion volume averaged 2.24 ± 0.79 cm³ (range: 1.57–3.08 cm³). Seventeen patients (77%) had Level III posterior medial meniscus root tears (MMRTs). All the patients underwent UKA. Average follow-up was 30.0 ± 6.4 months with a range of 23.0–38.0 months. The visual analog scale score was 7.78 ± 0.67 before surgery while decreased to 2.22 ± 1.09 at the final follow-up (P < 0.001). The Hospital for Special Surgery scores of pre-／post-surgery were 65.67 ± 5.45 and 84.10 ± 4.20, respectively (P < 0.001).

SONK often occurs in the anterior and central tibial plateau due to abnormal stresses. Most of the patients had Level III posterior medial meniscus root tears. MRI is recommended for suspected cases to identify SONK at an early stage. The use of the Oxford Medial UKA for SONK of the MT is reliable both immediately and at follow-up.

In treatment of ankle fracture, intraoperative stress tests are used to assess the syndesmotic injury and instability. However, the optimized timing of the strees test should be applied whether in pre- or post-bony fixation during operation is seldom be reported in previous studies. The different strategies on stress test timing would exhibit opposite results within a type of pronation-external rotation (PER) fractures with supracollicular medial malleolar (SMM) fractures. This study was designed to assess the 3-year functional outcomes of the special PER fractures with or without a syndesmotic transfixation based on the results of two different intraoperative stress test strategies.

This retrospective cohort study included 61 PER injury-Weber C ankle fractures combined with SMM fractures who were treated in Beijing Jishuitan Hospital between 2013 and 2014 and followed up for 3 years. Stress test was performed twice intraoperatively. A positive intraoperative stress test before bony fixation and a negative intraoperative stress test after bony fixation were found in these included patients. Twenty-nine patients (Group 1) were treated without a supplemental syndesmotic screw fixation, according to the negative intraoperative stress test after bony fixation, while 32 patients (Group 2) were treated with an additional syndesmotic screw fixation based on the positive intraoperative stress test before bony fixation. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and Visual Analog Scale (VAS) for pain scores were the main measurements of outcome. The statistical index of demographic data, fracture morphologic data, time interval of follow-up, AOFAS and VAS were recorded and assessed by SPSS 21.0 software through Fisher exact tests and one- way analysis of variance . The associations between the main outcomes and influential factors were evaluated by linear regression models.

We observed no difference in the distribution of age, sex, presence of associated posterior malleolus (PM), fracture dislocation, and fixation of associated PM between two treatment groups. With the numbers available, no statistically significant association could be detected with regard to the AOFAS (Group 1 vs. Group 2, 96.72 ± 6.20 vs. 94.63 ± 8.26, F = 1.24, P= 0.27) and VAS (Group 1 vs. Group 2, 1.47 ± 2.14 vs. 0.72 ± 1.49, F = 2.44, P= 0.12) in association with two strategies.

The present study indicates no difference to the use of the syndesmotic screw in terms of the functional outcome between syndesmosis transfixation and no-fixation patients among PER-Weber C ankle fracture patients with SMM fracture after 3-year follow-up. More attention should be paid to pre- and post-bony-fixation intraoperative stress tests and the morphology of medial malleoli fractures in ankle fractures.

Estrogen, as an important hormone in human physiological process, is closely related to bone metabolism. The aim of this study was to investigate the mechanism of estrogen on osteoblasts metabolism in MC3T3-E1 cells.

We treated the MC3T3-E1 cells with different concentrations of β-estradiol (0.01, 0.1, 1, and 10 nmol/L), observed the morphological changes of the cells, and detected the cell’s proliferation and apoptosis of MC3T3-E1 cells. Two transcriptome libraries were constructed and sequenced. Quantitative real-time polymerase chain reaction (qRT-PCR) was performed to confirm the differentially expressed genes (DEGs), and then treated the MC3T3-E1 cells with estrogen receptor (ER) inhibitors α and β, respectively, and then examined the expression of Tgfbr1 and Bmpr1a genes. The promoter of Tgfbr1 and Bmpr1a gene was analyzed, and the ER response elements were identified. Finally, ChIP was used to verify the binding of ER to Tgfbr1 and Bmpr1a promoter.

In the high-concentration β-estradiol treatment group (1 nmol/L and 10 nmol/L), there was no significant difference in the morphology of the cells under the microscope, 1 nmol/L and 10 nmol/L treated group appeared statistically significant difference in cell apoptosis and proliferation (P < 0.05 and P < 0.01, respectively). We found 460 DEGs compared with the control group. Among the DEGs, there were 66 upregulated genes and 394 downregulated genes. Gene ontology classification and Kyoto Encyclopedia of Genes and Genomes pathway analysis revealed that many bone metabolism-related biological processes and cell signaling pathways were disordered. The qRT-PCR verification showed that the expressions of Tgfbr1- and Bmpr1a-related genes in bone metabolism pathway in the 10 nmol/L treatment group were significantly decreased (P < 0.05). ER β was involved in the inhibitory effect of Tgfbr1 and Bmpr1a genes. The bioinformatics of the promoter found that there were three ER response elements in the promoter of Tgfbr1 , and there were two ER response elements in Bmpr1a promoter regions. ChIP experiments showed that estrogen could enhance the binding of ERs to Tgfbr1 and Bmpr1a genes.

Estrogen can promote the apoptosis and proliferation of osteoblasts simultaneously, and the mechanism may be the joint action of transforming growth factor-beta, Wnt, mitogen-activated protein kinase, and nuclear factor-kappaB bone metabolism-related signaling pathway. Estrogen inhibits the expression of Tgfbr1 and Bmpr1a genes through ER β and affects the metabolism of MC3T3-E1 osteoblasts.

The effect of maternal weights on the risk of iron deficiency anemia (IDA) during pregnancy remains unclear. The study aimed to investigate the association between maternal weight indicators and IDA during pregnancy.

We conducted a cohort study to examine the association between maternal weight indicators, including prepregnancy body mass index and the rate of gestational weight gain (GWG), and the risk of IDA among Chinese pregnant women. Data about new-onset IDA at different trimesters from a national cross-sectional survey were collected; information regarding baseline variables and rate of GWG from women participating in the survey were retrospectively collected. Tested IDA and reported IDA were documented. Multilevel logistic regression to examine the association between maternal weight indicators and the risk of IDA after adjusting for potential confounders was conducted.

This study enrolled 11,782 pregnant women from 24 hospitals from September 19, 2016, to November 20, 2016. Among those, 1515 (12.9%) IDA events were diagnosed through test (test IDA); 3915 (33.3%) were identified through test and patient reporting (composite IDA). After adjusting for confounders and cluster effect of hospitals, underweight pregnant women, compared with normal women, were associated with higher risk of test IDA (adjusted odds ratio [aOR]: 1.35, 95% confidence interval [CI]: 1.17–1.57 and composite IDA (aOR: 1.35, 95% CI: 1.21–1.51); on the contrary, overweight and obese women had lower risk of test IDA (aOR: 0.68, 95% CI: 0.54–0.86 overweight; aOR: 0.30, 95% CI: 0.13- 0.69 obese) and composite IDA (aOR: 0.77, 95% CI: 0.67- 0.90 overweight; aOR: 0.34, 95% CI: 0.21- 0.55 obese). The higher rate of GWG was associated with higher risk of IDA (test aOR: 1.86 95% CI: 1.26- 2.76; composite aOR: 1.54, 95% CI: 1.16–2.03).

Pregnant women who are underweight before pregnancy and who have faster GWG are more likely to develop IDA. Enforced weight control during pregnancy and use of iron supplements, particularly among underweight women, may be warranted.

Dendritic cells (DCs) play an important role in host defense against pathogen infection. DC-specific intercellular adhesion molecule-3-grabbing nonintegrin (SIGN) is a group II C-type lectin receptor and specifically expressed on the surface of DCs. This study aimed to determine whether DC-SIGN affects intracellular signaling activation, Th1/Th2 imbalance and aspergillus immune evasion in aspergillus infection, and explore the application of DC-SIGN-modified DCs in immunotherapy.

DCs were first obtained from the mononuclear cells of peripheral blood. The interferon (IFN)-γ and dexamethasone (Dex) were used to stimulate DCs. The expression of DC-SIGN, Th1 and Th2 cytokines, and the capacity of DCs in stimulating T cells proliferation and phagocytosis, and nuclear factor (NF)-κB activation were analyzed. In addition, adenovirus expression vector Ad-DC-SIGN was generated to transfect DCs. Mannan was used to block DC-SIGN signaling for confirming the involvement of DC-SIGN function in Aspergillus fumigatus (Af)-induced DCs maturation. The unpaired, two-tailed Student's t-test was used in the comparisons between two groups.

Exogenous IFN-γ could activate Af-induced DCs and promote the Th0 cells toward Th1 profile (interleukin [IL]-12 in IFN-γ/Af group: 50.96 ± 4.38 pg/ml; control/Af group: 29.70 ± 2.00 pg/ml, t = 10.815, P < 0.001). On the other hand, Dex inhibited the secretion of Th2 cytokines (IL-10 in Dex/Af group: 5.27 ± 0.85 pg/ml; control/Af group: 15.14 ± 1.40 pg/ml, t = 14.761, P < 0.001)), and successfully caused immunosuppression. After transfection with Ad-DC-SIGN, DCs have improved phagocytosis (phagocytosis rates in Ad-DC-SIGN group: 74.0% ± 3.4%; control group: 64.7% ± 6.8%, t = 3.104, P = 0.013). There was more Th1 cytokine secreted in the Af-induced DC-SIGN modified DCs (IL-12 in Ad-DC-SIGN/Af group: 471.98 ± 166.31 pg/ml; control/Af group: 33.35 ± 5.98 pg/ml, t = 6.456, P = 0.001), correlated to the enhanced NF-κB activation.

Overexpressing DC-SIGN in DCs had a protective function on aspergillosis.

Sublingual immunotherapy (SLIT) has been proven to be effective against house dust mite-induced allergic rhinitis. However, the efficacy in adults with allergic rhinitis has never been reported on SLIT tablets. The current meta-analysis aimed to illustrate the differentiated efficacy of SLIT tablets on allergic rhinitis.

Our systematic review and meta-analysis were performed on allergic rhinitis patients and aimed to summarize those randomized controlled studies (RCTs). PubMed, EMBASE, Cochrane library, and MEDLINE were screened for associated articles. We included RCTs on allergic rhinitis patients undergoing SLIT therapy and reporting outcomes on symptom relief and serum-specific IgE levels. The effect of SLIT tablets on the Rhinitis Quality Life Questionnaire Score (RQLQ), Rhinitis Total Symptom Score (RTSS), and serum-specific IgE levels was evaluated using RevMan 5.3.

Seven studies were included, with 2723 patients identified. All of the studies were RCT. The included seven studies were all conducted on adults. Among the included seven articles, five researches administered patients with SLIT tablets and were eligible for meta-analysis of RTSS, consisting of 1490 patients. Overall, RTSS was significantly reduced in the SLIT tablet group compared with that in the placebo group (standard mean difference= −0.33, 95% confidence interval [−0.54, −0.13], P < 0.01). There was no significant difference in specific IgE levels between SLIT and placebo patients.

SLIT tablets effectively relieve rhinitis symptoms in adults with allergic rhinitis. Nevertheless, the current evidence may be limited due to sample size and the heterogeneity between studies. Large sample size and multiple center RCTs on the efficacy of different formulations of SLIT drugs are still needed to provide further evidence and a more precise recommendation.

To propose a new definition of the pericollapse stage of osteonecrosis of the femoral head (ONFH) and review its significance in disease diagnosis and treatment selection.

A search for eligible studies was conducted in three electronic databases including PubMed, Cochrane Library, and Embase up to August 10, 2018, using the following keywords: "osteonecrosis" , "prognosis" , and "treatment" .

Investigations appraising the clinical signs, symptoms, and imaging manifestations in different stages of ONFH were included. Articles evaluating the prognosis of various joint-preserving procedures were also reviewed.

The pericollapse stage refers to a continuous period in the development of ONFH from the occurrence of subchondral fracture to early collapse (<2 mm), possessing specific imaging features that mainly consist of bone marrow edema and joint effusion on magnetic resonance imaging (MRI), crescent signs on X-ray films, and clinical manifestations such as the sudden worsening of hip pain. Accumulating evidence has indicated that these findings may be secondary to the changes after subchondral fractures. Of note, computed tomography provides more information for identifying possible subchondral fractures than does MRI and serves as the most sensitive tool for grading the pericollapse lesion stage. The pericollapse stage may indicate a high possibility of progressive disease but also demonstrates satisfactory long- and medium-term outcomes for joint-preserving techniques. In fact, if the articular surface subsides more than 2 mm, total hip arthroplasty is preferable.

The pericollapse stage with distinct clinical and imaging characteristics provides a last good opportunity for the use of joint-preserving techniques. It is necessary to separate the pericollapse stage as an independent state in evaluating the natural progression of ONFH and selecting an appropriate treatment regimen.

Combining artificial scaffolds with stimulatory factors to reconstruct lost bone tissues is one of the hottest research directions. The purpose of this review was to conduct a retrospective survey on the latest reports on artificial bone fabrication with functional cytokines.

The status of related scientific research from the year 2005 to 2018 was analyzed through the mode of literature retrieval in PubMed and VIP Database. The retrieval words are as follows: "bone tissue engineering," "angiogenesis," "cytokines," "osteogenesis," "biomimetic bone marrow," "sol-gel," "delivery system," and the corresponding Chinese words.

After reading through the title and abstract for early screening, the full text of relevant studies was evaluated and those not related with this review had been ruled out.

According to the literature retrospective survey, there were three key points for the successful construction of functional artificial bones: (1) the continuous supply of relatively low concentration of cytokines during the required period; (2) the delivery of two or more cytokines essential to the process and ensure the relatively spatial independence to reduce the unnecessary interference; and (3) supporting the early-stage angiogenesis and late-stage osteogenesis, respectively, regulating and balancing the crosslinking of both to avoid the surface ossification that would probably block the osteogenesis inside.

The synergistic effect of both angiogenic factors and osteogenic factors applied in bone regeneration is a key point in the combined functional artificial bone. Through analysis, comparison, and summary of the current strategies, we proposed that the most promising one is to mimic the natural bone marrow function to facilitate the regeneration process and ensure the efficient repair of large weight-bearing bone defect.

To the Editor: Percutaneous endoscopic lumbar discectomy (PELD) becomes increasingly popular among spine surgeries in recent years. PELD is one of the minimally invasive spine surgeries with significant advantages including small incision, less muscle stripping, and enhanced postoperative recovery.^[1]

To the Editor: Instable elbow results from overuse and trauma. It brings pain and weakness to patients.^[1]There are three major considerations in treating this disease: central bone stability, lateral ligament stability, and medial ligament stability.^[2]The medial ligament includes the anterior, posterior, and transverse bundles.^[3]Its injury usually results from a valgus force and leads to medial instability, heterotopic ossification (HO) formation, and reduced elbow performance score, especially in elbow stiffness.^[4]Worse still, the persistent instable state eventually causes ulnar nerve irritation and irreversible motor and sensory loss.^[5]Therefore, it is very important and urgent to restore normal medial collateral ligament (MCL) structure and elbow stability. There is no consensus as to the standard protocol for elbow stability reconstruction, especially for the medial ligament. For acute ligament injury and ligament rupture, impaired ligaments can be reattached using either anchor or transosseous sutures.^[6]For chronic ligament injury and large ligament defects, either tendon graft or flexor-pronator fascia patch has been proven to be effective for providing sufficient elbow stability.^[7]These solutions have their own deficits. Direct suture or anchor suture may lead to secondary rupture due to high tension. Tendon graft causes damage to the donor site. Fascia patch cannot provide enough mechanical strength and may compromise muscle power. Therefore, this study proposed a new technique using cubital tunnel retinaculum (CTR) with suture anchor to rebuild normal MCL architecture in elbow stiffness patients.

To the Editor: Surgery for fractures is a major risk factor for pulmonary embolism (PE). Massive PE (MPE) remains an important clinical challenge with a high mortality rate. The potential for sudden and fatal hemodynamic deterioration highlights the need for prompt and appropriate interventions.^[1]The optimal treatment approaches for MPE are typically restricted to patients who are critically ill. Some case reports have demonstrated the use of extracorporeal membrane oxygenation (ECMO) as a potentially lifesaving therapeutic option that could provide clinical stability to allow definitive treatment. Here, we reported the successful use of ECMO alone without definitive therapy in a 52-year-old man who developed an MPE after surgery for tibiofibular fractures and presented with hemodynamic instability and severe hypoxemia. Because of the patient’s unstable hemodynamic status and the high risk of bleeding, thrombolysis and embolectomy were not administered. ECMO alone was successfully used as salvage therapy for the MPE, and the patient experienced a good recovery.

To the Editor: Pheochromocytomas are rare neuroendocrine tumors that originate from the chromaffin cells in the adrenal glands or associated sympathetic ganglia.^[1]To the best of our knowledge, malignant pheochromocytoma is extraordinarily rare, with a frequency of 0.2- 0.9 case per 1,000,000 individuals per year, and there is obvious shortage of clinical reports on metastatic pheochromocytoma to the spine. Thus, it can be difficult to diagnose and may result in devastating consequences upon mismanagement.^[2]

To the Editor: The "Parotid Gland" , out of all the salivary glands, is the one most frequently affected by neoplasms, accounting for approximately 75% in all cases.^[1]These neoplasms are generally benign, with only 25% of them being malignant forms.^[1]The percentage of distant metastases from salivary gland is relatively low, with their occurrence being associated with high-grade tumors. The "Adenoid Cystic Carcinoma" (ACC) is a tumor of exocrine glands originating primarily from the minor salivary glands of the upper respiratory gland, the major salivary glands, lacrimal gland, bronchus, breast, and intestinal and genital tracts.^[2]Its key characteristic is that it grows slowly; however, peritumoral invasion and perineural infiltration occur in the process. To date, the spinal metastasis from ACC of the parotid gland is exceedingly rare in literature, with only a few cases presenting spinal metastasis of the parotid gland have been documented, thus resulting in consequence of lacking imaging proof. Herein, we described a case of spinal metastases of parotid carcinoma treated with surgical treatment.

To the Editor: Heterotopic ossification (HO) is a formation of bone outside of the skeletal system. It usually occurs in the following five broad clinical settings: genetic, posttraumatic, neurogenic, postsurgical and as distinctive reactive lesions most often seen in the hands and feet.^[1]Although there is an increased tendency to bleed in soft tissue, HO has rarely been reported in hemophilia. At present, a few cases reported the location relationship between ectopic osteogenesis and the pelvis, and only two cases presented pelvi-femoral bone bridge-like progression of this phenomenon.^[2,3]More precisely, it was situated in the posterior area of the hip joint. Here, we describe a rare case of HO bridging from the anterior superior spine to the lesser trochanter of the femur in hemophilia. The orthopedic clinic was presented with an 18-year-old male with left hip pain, flexion deformity, and restricted walking. These symptoms had developed during the previous 4 years after falling off of a horse. He was diagnosed hemophilia A when he was 2 years old and almost never treated by factor VIII (FVIII).

To the Editor: Previous studies showed that the rate of retears after repair of rotator cuff injury was 38–94%, owing to the low healing capability of tendon–bone and the long duration.^[1]Adipose-derived mesenchymal stem cells (ADSCs) have been adopted to repair the tendon and ligament tears, which acquired effective repair improvement.^[2]Although ADSCs could effectively promote the healing of degenerative rotator cuff injury, the poor self-renewal ability and uncertain safety still disturb patients with rotator cuff tears. Therefore, a new or substitute treatment method remains to be investigated. Several studies demonstrated that the adipose stromal vascular fraction (SVF) treatment, which contained adipose stem cells, showed better therapy potential than adipose stem cell treatment in promoting healing of connective tissue injury in animal models.^[3]

To the Editor: Peripheral nerve injury has been a common clinical disease, and delayed treatment may ultimately lead to long-term physical dysfunction. The repair of peripheral nerve injury has become a major challenge in clinical practice. Different from the central nervous system, the peripheral nervous system has the capacity to regenerate after injury. However, the peripheral nerve regeneration after injury is a slow process, and more than 3 months is usually needed for the axons regenerating to the distal target organs or tissues, when the distal nerve stump and skeletal muscle usually become atrophy and the regenerated axons lost the ability to remodel in next few months. Therefore, accelerating the recovery of the peripheral nerve and the connection between central nervous system and distal nerves after injury is important for the improvement of postinjury nerve recovery. Available studies have revealed that the Wallerian degeneration occurs at the lesioned site after peripheral nerve injury. The proximal stump can sprout to connect the distal stump. The proliferation of the Schwann cells is critical for the repair and regeneration of peripheral nerves after injury. In recent years, increasing studies focus on the role of various signaling pathways in the peripheral nerve regeneration, one of which is the Wnt signaling pathway.

To the Editor: A 33-year-old Chinese male, with a 5-year history of recurrent oral and genital ulcers, was admitted to our hospital for chest tightness, fever, and tiredness from 2 weeks. The patient had been diagnosed with Behcet’s disease (BD) 3 years before admission to our hospital, suffered from deep venous thrombosis related to BD, and was being treated with prednisolone. Physical examination revealed multiple varisized lesions occurred in the skin of periorbital and lower extremities. Electrocardiogram and chest X-ray were negative, and laboratory data, including creatine kinase-MB and cardiac troponin, were within normal limits. The patient persisted with shortness of breath and thoracic oppression; therefore, a conventional contrast-enhanced coronary computed tomography angiography (CTA) was performed and showed a mass lesion of mixed density (46 mm × 40 mm × 65 mm) arising from the left circumflex coronary artery and compressing the left principal bronchus and left auricle [Figure 1]. In addition, CTA demonstrated an aneurysm measuring approximately 7 mm in diameter in the left anterior descending coronary artery. Based on CTA finding and preventing fatal complications due to this rapidly expanding pseudoaneurysm, urgent surgery was deemed necessary. No pericarditis or pericardial effusion was found preoperatively. The pseudoaneurysm sac was opened, and the thrombus was evacuated before restored blood flow with a bypass had been rapidly elected for controlling the pseudoaneurysm and revascularization. Moreover, basic treatment with prednisolone and cyclophosphamide was also adopted postoperatively. The patient was discharged 8 days later. At his 6-month follow-up, he was asymptomatic and had recovered full activity with no dyspnea or angina. However, we regret that the patient refused to receive coronary CTA review because of his good feeling and high expense of CTA examination.

To the Editor: A 67-year-old man presented with recurrent diarrhea and abdominal pain of increasing severity for 7 months in May 2016. He had mucopurulent stool for about 4- 6 times a day, with bellyache, tenesmus, and weight loss. He took a colonoscopy, which showed universal colitis, and a biopsy revealed crypt abscesses and inflammatory cell infiltration and he was diagnosed with ulcerative colitis (UC). 5-Aminosalicylic acid (mesalazine) was administered, with symptoms remitted after 3 months. Not long, he presented with diarrhea again. He passed 7–8 liquid motions daily, containing blood and mucus, with fever and weakness. After admission, a repeated colonoscopy revealed continuous edema and erosions across the hyperemic colorectal mucosa, and a biopsy showed crypt abscesses and inflammatory cell infiltrations [Figure 1aandFigure 1b]. Laboratory studies revealed hemoglobin of 107 g/L, and the white blood cell was 8.73 × 10⁹/L, with 77.6% neutrophils. The total serum protein was 70 g/L and the globulin was 38 g/L. The serum folate, serum vitamin B12, serum iron, and total iron-binding capacity were normal. The erythrocyte sedimentation rate ranged from 31 to 45 mm/h (reference value, 0–15 mm/h), and the C-reactive protein was 92.5 mg/L (reference value <8.0 mg/L). His serum immunoglobulin G (IgG) level increased to 24.90 g/L (reference value, 7.51–15.60 g/L）. M-protein (IgG-λ type) was found by routine examination of serum protein electrophoresis, which revealed an increase in γ globulin, accounting for 28.6% (reference value, 9.2–18.2%). Considering the possibility of plasma diseases, bone marrow aspiration was performed. The percentage of plasma cells in bone marrow was 8.5% accompanied by abnormal plasma cells with large binuclei, and a biopsy showed plasma cells scattered in the bone marrow [Figure 1candFigure 1d]. Red blood cell rouleaux could be seen. Flow cytometry findings were also compatible with plasma cell disease. After a comprehensive assessment, the patient was considered with recurrent UC and was recommended glucocorticoid therapy, but he refused. He was treated with mesalazine enema and bloody stool was under remission. Then, he was discharged from the hospital, with maintenance treatment of mesalazine 4 g/day accompanied by probiotics.

As the development of early detection and therapies advances in cancer patients, mortality rates attributed to cancer have declined. In the United States, there are approximately 15.5 million cancer survivors, and the number will grow to more than 20 million by 2026 (http://www.cancer.org/cancer/news/news/report-number-of-cancer-survivors-continues-to-grow). Unfortunately, the improved survival in cancer patients from cancer therapy is achieved at the expense of treatment-induced adverse effects with CVD being one of the most frequent side effects [Supplementary Table 1].^[1]This may result from the direct cardiotoxicity of anticancer treatment or from the accelerated preexisting CVD or cardiovascular risk factors. CVD is now the second leading cause of long-term morbidity and mortality among cancer survivors.^{[2,3,4,5,6,7]}

The median follow-up of the malignant glioma patients who received surgical resection combined with radiochemotherapy is 16 months. The recurrence of malignant glioma is unavoidable. Although the patient with recurrent glioblastoma has multiple choices of therapy, the 5-year survival rate is still less than 5%, and the average survival time is less than 12 months.^[1]Currently, there is no single second-line drug can have survival benefits.