2019年 · 第132卷第01期

According to the latest edition of Diabetes Atlas, the prevalence of diabetes is increasing globally, but the situation is particularly alarming in Asia and in China.^[1,2,3]It was estimated that, for the same body mass index (BMI), Asian population had a higher prevalence of diabetes than the non-Asian counterparts,^[4]because of the lower BMIs reported in Asian diabetes population. Based on the physiologic and pathologic background, it was believed that compared to non-Asian patients with type 2 diabetes, Asian patients might have a different pattern as more defect in β-cell function than decreased insulin sensitivity.^[5,6,7]Moreover, given the different genetic and pharma-cogenetics ethnic background,^[8,9]it was deduced that the treatment response in terms of glucose control and body weight control between the two ethnicities might be different. Is there any similarity or difference in the treatment response between Asian and non-Asian patients with type 2 diabetes? Asian diabetes, do it really exist? There is a need to better understand this question.

Owing to the multifactorial nature of the pathogenesis of diabetic peripheral neuropathy (DPN), conventional drug therapies have not been effective. The application of stem cells transplantation may be useful for the treatment of DPN. This study was designed to assess the safety and therapeutic effects of autologous bone marrow mononuclear cells (BMMNCs) transplantation on the treatment of refractory DPN.

One hundred and sixty-eight patients with refractory DPN were recruited and enrolled in the study. They received intramuscular injection of BMMNCs and followed at 1, 3, 6, 12, 18, 24, and 36 months after the transplantation. Clinical data, Toronto Clinical Scoring System (TCSS), and nerve conduction studies (NCSs) were compared before and after the transplantation.

The signs and symptoms of neuropathy were significantly improved after BMMNCs transplantation. The values of the TCSS scores at 1 month (9.68 ± 2.49 vs. 12.55 ± 2.19, P < 0.001) and 3 months (8.47 ± 2.39 vs. 12.55 ± 2.19, P < 0.001) after the treatment reduced significantly compared with the baseline value. This decrement remained persistent until the end of the study. The conduction velocity and action potential and sensory nerves were significantly improved after transplantation (3 and 12 months after the treatment vs. the baseline: motor nerve conduction velocity, 40.24 ± 2.80 and 41.00 ± 2.22 m/s vs. 38.21 ± 2.28 m/s, P < 0.001; sensory nerve conduction velocity, 36.96 ± 2.26 and 39.15 ± 2.61 m/s vs. 40.41 ± 2.22 m/s, P < 0.001; compound muscle action potential, 4.67 ± 1.05 and 5.50 ± 1.20 μV vs. 5.68 ± 1.08 μV, P < 0.001; sensory nerve action potential, 4.29 ± 0.99 and 5.14 ± 1.26 μV vs. 5.41 ± 1.14 μV, P < 0.001). No adverse event associated with the treatment was observed during the follow-up period.

Autologous transplantation of BMMNCs may be an effective and promising therapeutic strategy for the treatment of refractory DPN.

Little is known about the risk factors for sudden cardiac death (SCD) in the overall hospitalized cardiac department population. This study was conducted to investigate the risk factors and develop a predictive model for SCD in a hospitalized cardiac department population.

We conducted a retrospective study of patients admitted to the cardiac department of the First Affiliated Hospital of Xinjiang Medical University from June 2015 to February 2017. We collected the clinical data from medical records. Multiple stepwise logistic regression analysis was carried out to confirm the risk factors for SCD and develop a predictive risk model. The risk score was assessed by the area under receiver operating characteristic (AUROC) curve and the Hosmer-Lemeshow goodness-of-fit test.

A total of 262 patients with SCD and 4485 controls were enrolled in our study. Logistic regression modeling identified eight significant risk factors for in-hospital SCD: age, main admitting diagnosis, diabetes, corrected QT interval, QRS duration, ventricular premature beat burden, left ventricular ejection fraction, and estimated glomerular filtration rate. A predictive risk score including these variables showed an AUROC curve of 0.774 (95% confidence interval: 0.744–0.805). The Hosmer-Lemeshow goodness-of-fit test showed the chi-square value was 2.527 (P = 0.640). The incidence of in-hospital SCD was 1.3%, 4.1%, and 18.6% for scores of 0 to 2, 3 to 5 and ≥6, respectively (P < 0.001).

Age, main admitting diagnosis, diabetes, QTc interval, QRS duration, ventricular premature beat burden, left ventricular ejection fraction, and estimated glomerular filtration rate are factors related to in-hospital SCD in a hospitalized cardiac department population. We developed a predictive risk score including these factors that could identify patients who are predisposed to in-hospital SCD.

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is associated with a higher prevalence of osteoporosis. However, the underlying mechanisms linking OSAHS with bone loss are still unclear. The aim of this study was to investigate the changes of receptor activator of nuclear factor-κB ligand (RANKL, an osteoclastogenesis-promoting factor) and osteoprotegerin (OPG, the decoy receptor for RANKL), oxidative stress and bone metabolism markers in OSAHS, in order to understand the potential mechanisms underlying bone loss in OSAHS patients.

Forty-eight male patients with OSAHS, confirmed by polysomnography (PSG) study, were enrolled. Twenty male subjects who were confirmed as not having OSAHS served as the controls. The subjects’ bone mineral density (BMD) was assessed in lumbar spine and femoral neck using dual-energy X-ray absorptiometry (DXA). Blood samples were collected from all subjects for measurement of RANKL, OPG, the bone formation marker bone-specific alkaline phosphatase (BAP), the bone resorption marker tartrate-resistant acid phosphatase 5b (TRAP-5b), and total antioxidant capacity (TAOC).

The BMD and the T-score of the femoral neck and the lumbar spine were significantly lower in OSAHS patients as compared to the control group (P < 0.05). The serum level of BAP was significantly decreased in the OSAHS group (15.62 ± 5.20 μg/L) as compared to the control group (18.83 ± 5.50 μg/L, t= －2.235, P < 0.05), while the levels of TRAP-5b did not differ between the two groups (t= －1.447, P > 0.05). The serum level of OPG and the OPG/RANKL ratio were lower in the OSAHS group compared to the control group (both P < 0.05). TAOC level was also decreased significantly in the OSAHS group (P < 0.05). Correlation analysis showed that the TAOC level was positively correlated with BAP in the OSAHS group (r= 0.248, P = 0.04), but there were no correlations between TAOC and the BMD or the T-scores. The correlations between the level of OPG (or the OPG/RANKL ratio) and BMD or TAOC did not reach significance.

In OSAHS patients, lower levels of TAOC were associated with decreased bone formation, suggesting a role of oxidative stress in bone loss, while the role of OPG/RANKL imbalance in bone metabolism in OSAHS needs further evaluation .

The Global Registry of Acute Coronary Events (GRACE) score is recommended by current ST-elevation myocardial infarction (STEMI) guidelines. But it has inherent defects. The present study aimed to investigate the more compatible risk stratification for Chinese patients with STEMI and to determine whether the addition of biomarkers to the Korea Acute Myocardial Infarction Registry (KAMIR) score could enhance its predictive value for long-term outcomes.

A total of 1093 consecutive STEMI patients were included and followed up 48.2 months. Homocysteine, hypersensitive C-reactive protein (hs-CRP), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were detected. The KAMIR score and the GRACE score were calculated. The performance between the KAMIR and the GRACE was compared. The predictive power of the KAMIR alone and combined with biomarkers were assessed by the receiver-operating characteristic (ROC) curve.

The KAMIR demonstrated a better risk stratification and predictive ability than the GRACE (death: AUC = 0.802 vs. 0.721, P < 0.001; major adverse cardiovascular events (MACE): AUC = 0.683 vs. 0.656, P < 0.001). It showed that the biomarkers could independently predict death [homocysteine: HR= 1.019 (1.015–1.024), P < 0.001; hs-CRP: HR= 1.052 (1.000–1.104), P= 0.018; NT-pro BNP: HR= 1.142 (1.004–1.280), P= 0.021] and MACE [homocysteine: HR= 1.019 (1.015–1.024), P < 0.001; hs-CRP: HR= 1.012 (1.003–1.021), P= 0.020; NT-pro BNP: HR= 1.136 (1.104–1.168), P= 0.006]. When they were used in combination with the KAMIR, the area under the ROC curve (AUC) significantly increased for death [homocysteine: AUC = 0.802 vs. 0.890, Z = 5.982, P < 0.001; hs-CRP: AUC = 0.802 vs. 0.873, Z= 3.721, P < 0.001; NT-pro BNP: AUC= 0.802 vs. 0.871, Z = 2.187, P= 0.047; homocysteine, hs-CRP and NT-pro BNP: AUC = 0.802 vs. 0.940, Z = 6.177, P < 0.001] and MACE [homocysteine: AUC = 0.683 vs. 0.771, Z= 6.818, P < 0.001; hs-CRP: AUC= 0.683 vs. 0.712, Z= 2.022, P= 0.031; NT-pro BNP: AUC= 0.683 vs. 0.720, Z= 2.974, P= 0.003; homocysteine, hs-CRP and NT-pro BNP: AUC= 0.683 vs. 0.789, Z= 6.900, P < 0.001].

The KAMIR is better than the GRACE in risk stratification and prognosis prediction in Chinese STEMI patients. A combination of above-mentioned biomarkers can develop a more predominant prediction for long-term outcomes.

The Shanghai growth standards are higher than World Health Organization (WHO) growth standards, which may influence the feeding practices of the caregivers and increase the risk of overweight in these infants. This study aimed to compare the effects of different growth standards on childhood obesity in Shanghai metropolitan area.

This was a cluster-randomized controlled trial conducted in 2 downtown areas with 19 community health service centers in Shanghai from November 2013 to December 2015. Randomization was done at the level of the community. Infants (health newborns) were assessed and monitored by the Shanghai growth standards (S-group) and the 2006 WHO growth standards (W-group), respectively. Measurements were taken at 1.0, 2.0, 4.0, 6.0, 9.0 and 12.0 months of age during follow-up period. Based on the values of length and weight measurements, according to the group’s growth standards, doctors provided the caregivers with corresponding clinical consultation. Changes in weight-for-age z-score (WAZ), length-for-age z-score (LAZ), and weight-for length z-score (WLZ) between 2 groups were assessed using mixed regression models. Overweight was compared between 2 group at all follow-up measurements.

A total of 6509 infants (52.1% were boys) were in the W-group, and 8510 infants (51.4% were boys) were in the S-group. The overweight ratios between two groups were distinct at 9 months of age (3.4% in W-group and 4.3% in S-group) and 12 months of age (2.2% in W-group and 3.8% in S-group), and the differences were statistically significant (P= 0.020 and P< 0.001, respectively). Compared to W-group, the increase in WAZ (coefficient= 0.04, P= 0.004) and WLZ (coefficient= 0.09, P < 0.001) were significantly greater, and the LAZ was lower (coefficient = －0.04, P = 0.047) in S-group (W-group values were used as reference in mixed regression models).

Compared to the Shanghai growth standards, the adoption of WHO 2006 growth standards would reduce the risk of infant overweight in Shanghai metropolitan area up to 1 year of age.

ChiCTR1800015371, http://www.chictr.org.cn/Chinese Clinical Trial Registry.

Necroptosis is a new form of cell death that has been identified as a third pathway causing cell death. In this study, necrostatin-1 (Nec-1) was used to determine whether necroptosis exists in a rat ischaemia/reperfusion injury flap model.

In this study, twenty male Sprague-Dawley rats were divided randomly into two groups: a control group (CTL group) and a Nec-1 group. Each abdominal skin flap underwent 3 h of ischaemia and then reperfusion. Fifteen minutes before and after reperfusion, phosphate buffer saline (PBS) was administered intraperitoneally to the CTL group, while Nec-1 was administered intraperitoneally to the Nec-1 group. Twenty-four hours after reperfusion, the whole flap was divided equally into 54 sections. Flap blood perfusion was measured. One sample was taken randomly from each row. Morphological changes, apoptosis, receptor-interacting protein-1 (RIP-1) expression and caspase-3 activity were observed and detected. The measurements between the two groups were compared with the independent t-test, and a P value of <0.05 was considered statistically significant.

Compared to flaps in the CTL group, flaps in the Nec-1 group showed longer survival rates, better blood perfusion and less inflammatory infiltration. The total flap area considered to have survived was 70.88 ± 10.28% in the CTL group, whereas 80.56 ± 5.40% of the area was found to be living in the Nec-1 group (Nec-1 vs. CTL, t= –2.624, P < 0.05). For some rows, there were significant differences in cell apoptosis between the two groups, the apoptosis index (AI) in rows "9 cm", "7 cm", "6 cm" and "5 cm" was significantly lower in the Nec-1 group than that in the CTL group (Nec-1 vs. CTL, P < 0.05). RIP-1 expression was much lower in the Nec-1 group than that in the CTL group in rows "5 cm" to "9 cm" (Nec-1 vs. CTL, P < 0.05). No significant differences in caspase-3 activity were found.

According to the results, necroptosis was present in a rat abdominal ischaemia/reperfusion injury flap model.

Some porous materials have been developed to enhance biologic fusion of the implants to bone in spine fusion surgeries. However, there are several inherent limitations. In this study, a novel biomedical porous tantalum was applied to in vitro and in vivo experiments to test its biocompatibility and osteocompatibility.

Bone marrow-derived mesenchymal stem cells (BMSCs) were cultured on porous tantalum implant. Scanning electron microscope (SEM) and Cell Counting Kit-8 assay were used to evaluate the cell toxicity and biocompatibility. Twenty-four rabbits were performed discectomy only (control group), discectomy with autologous bone implanted (autograft group), and discectomy with porous tantalum implanted (tantalum group) at 3 levels: L3–L4, L4–L5, and L5–L6 in random order. All the 24 rabbits were randomly sacrificed at the different post-operative times (2, 4, 6, and 12 months; n = 6 at each time point). Histologic examination and micro-computed tomography scans were done to evaluate the fusion process. Comparison of fusion index scores between groups was analyzed using one-way analysis of variance. Other comparisons of numerical variables between groups were made by Student t test.

All rabbits survived and recovered without any symptoms of nerve injury. Radiographic fusion index scores at 12 months post-operatively between autograft and tantalum groups showed no significant difference (2.89 ± 0.32 vs. 2.83 ± 0.38, F = 244.60, P = 0.709). Cell Counting Kit-8 assay showed no significant difference of absorbance values between the leaching liquor group and control group (1.25 ± 0.06 vs. 1.23 ± 0.04, t = –0.644, P = 0.545), which indicated the BMSC proliferation without toxicity. SEM images showed that these cells had irregular shapes with long spindles adhered to the surface of tantalum implant. No implant degradation, wear debris, or osteolysis was observed. Histologic results showed solid fusion in the porous tantalum and autologous bone implanted intervertebral spaces.

This novel porous tantalum implant showed a good biocompatibility and osteocompatibility, which could be a valid biomaterial for interbody fusion cages.

Renal artery stenosis (RAS) is always associated with abnormalities in renal microvascular perfusion (RMP). However, few imaging methods can simultaneously evaluate the degree of luminal stenosis and RMP. Thus, this study will aim to evaluate the feasibility of using contrast-enhanced ultrasound (CEUS) for assessing both RAS and RMP to achieve a one-stop assessment of patients with suspected renovascular hypertension.

This will be a single-center diagnostic study with a sample size of 440. Patients with chronic kidney disease (CKD) and suspected of having resistant hypertension will be eligible. Patients with Stages 1–3 CKD will undergo CEUS and computed tomography (CT) angiography (CTA). Values obtained by CEUS and CTA for diagnosing low-grade (lumen reduced by <60%) and high-grade (lumen reduced by ≥60%) RAS will be compared. Moreover, all patients will also undergo radionuclide imaging. The diagnostic value for RAS will be assessed by the receiver operating characteristic curve, including the accuracy, sensitivity, specificity, positive predictive values, negative predictive values, and area under the ROC. Pearson correlation analysis will be performed to assess the association between CEUS findings for RMP and glomerular filtration rate measured by a radionuclide imaging method.

The data gathered from this study will be used to evaluate the feasibility of expanding clinical applications of CEUS for evaluation of patients with suspected renovascular hypertension.

Chinese Clinical Trial Registry, ChiCTR1800016252; https://www.chictr.org.cn.

How to increase the long-term retention rate of autologous fat grafting has been widely discussed. This study aimed to evaluate long-term fat graft retention rates for the most widely used fat processing methods in the area of facial esthetic surgery, including centrifugation, filtration, and sedimentation, using three-dimensional (3D) imaging.

PubMed, Embase, Wiley/Cochrane Library, and Web of Science databases were comprehensively searched from inception to July 2018 according to the guidelines of the American Society of Plastic Surgeons Fat Graft Task Force Assessment Methodology.

Articles were screened using predetermined inclusion and exclusion criteria. Data collected included patient characteristics, follow-up devices, fat grafting techniques, and clinical outcomes. Patient cohorts were pooled, and fat graft retention rates were calculated. Complications were summarized according to different clinical characteristics.

Of 77 articles, 10 clinical studies met the inclusion criteria and reported quantified measurement outcomes with 3D imaging which provide precise volumetric data with approximately 2% standard deviation compared to real volumes. Data of 515 patients were included. Fat grafting retention varied from 21% to 82%. We found filtration and centrifugation techniques could result in better retention outcomes. However, retention varied within each processing technique, with no significant difference among the 3 techniques. Twenty-two complications were reported among 515 patients, including donor-site hematoma (1 case), mild postoperative erythema (2 cases), mild volumetric asymmetries (2 cases), chronic edema (2 cases), overcorrection (2 cases), skin irregularity (6 cases), and headache or dysesthesia (7 cases).

Filtration and centrifugation techniques may result in better fat grafting retention outcomes than gravity sedimentation; however, more accurate statistical evidence is needed. Controversies continue to exist with respect to the performance of the different fat-processing techniques in fat graft retention.

Type 2 diabetes mellitus (T2DM)^[1]is a type of metabolic disease caused by metabolic disorders in the endocrine system and characterized by hyperglycemia. Insufficient insulin secretion and insulin resistance are the basic pathologic characteristics of T2DM. According to the International Diabetes Federation (IDF),^[2]the prevalence of diabetes among adults aged 20–79 in 2017 was 8.8% from a total population of 425 million, which will reach 629 million by 2045. Additionally, it is estimated that approximately half of all adult patients worldwide have not been diagnosed as of 2017. In 2017, approximately 4 million adults died of diabetes, and 46.1% of patients died before reaching the age of 60 years. These data show that the number of patients with diabetes is increasing at an alarming rate and have come to represent a challenge for human health. In addition, T2DM accounts for approximately 95% of the total population of diabetes, which leads to significant losses for human and economic health.^[3]T2DM is a chronic disease that can cause a series of complications that can lead to death.^[4]Therefore, preventing or delaying the occurrence of complications is the main purpose of treating T2DM, and the key link for those suffering from diabetes is to maintain blood glucose levels within the normal range.^[5]At present, the treatment of T2DM mainly depends on lifestyle intervention^[6](such as nutrition therapy and physical activity), oral medication^[7](such as biguanides, sulfonylureas, and α-glucoside inhibitors), injected drugs^[8](such as insulin and glucagonlike peptide-1 [7-36] amide [GLP-1] agonists), surgical treatment,^[9]and complementary and alternative treatment.^[10]

To the Editor:Drug-induced immune hemolytic anemia (DIIHA) is a rare but severe condition. Ceftriaxone, a third-generation cephalosporin with a wide antibacterial spectrum and effective antibacterial action, is one of the most common drugs causing DIIHA.^[1]Ceftriaxone-induced immune hemolytic anemia (CIIHA) is a potentially fatal complication.^[2]Most of the patients were children. The reported fatality rate of CIIHA was as high as 40%.^[3]Acute renal failure and cardiovascular decompensation are the most lethal complications in pediatric patients with CIIHA.^[2]Early diagnosis is difficult but extremely important to the outcome. Clinical treatment consists of immediate drug discontinuation and supportive care, including blood transfusion wherever appropriate.

To the Editor:Tuberous sclerosis complex (TSC), with the birth incidence of 1:6000,^[1]is an autosomal dominant inherited, multi-system disorder characterized by cellular hyperplasia and tissue dysplasia, among which, renal angiomyolipoma (AML) is one common comorbidity. However, malignancy of renal AML is rare. Herein, we shared a case of malignancy of renal AML from TSC in a young man.

To the Editor:The estrogen level of females plays an important role in the maintenance of auditory integrity.^[1]In laboratory studies, a worsened auditory function was reported on the ovariectomized rats relative to the result on the ovary-intact animals.^[2]However, contradictory findings were also presented.^[3]Therefore, the direct impact of estrogen level on the auditory function is still uncertain. Meanwhile, estrogen therapy in the ovariectomized rats has been used to restore the changes in auditory function due to estrogen deficiency.^[2]Nonetheless, conflicting findings on the benefits of estrogen replacement were also reported.^[4]In fact, the impact of estrogen deficiency on the auditory function can be increased by various added factors such as the administration of cisplatin, an anticancer drug.^[5]This finding may suggest that females with estrogen deficiency (eg, ovariectomy, menopause, ovarian failure) can experience a noticeable change in their auditory function when they are treated with an ototoxic drug such as cisplatin. Since many studies have docu-mented the clinical benefits of Astragalus (also known as Huangqi in the traditional Chinese medicine), including the reduction of side effects due to chemotherapy for cancer patients,^[6]we report on the protective capability of Astragalus on the auditory function of the ovariectomized rats when they were treated with cisplatin. In addition, the performance with estrogen therapy (Estradiol alone) was also obtained with the same procedures as applied to the study of Astragalus. Thus, the benefits between Astragalus and estrogen therapies in protecting the auditory function could be compared.

To the Editor:Systemic lupus erythematosus (SLE) is an autoimmune-mediated systemic inflammatory disease which involves nearly all organs of the body, and it is associated with premature atherosclerosis, vasculitis, and coagulopathy.^[1]Cases of subarachnoid hemorrhage (SAH) due to cerebral aneurysm associated with SLE are being reported more frequently. However, SAH due to SLE associated with multiple cerebral artery aneurysms that rapidly develop within only 2 months is rare, and the causal relations between cerebral aneurysm and SLE are not clearly understood. Herein, we reported a case of multiple cerebral artery aneurysms due to SLE, with enough evidence to confirm that the cerebral artery aneurysms were solely due to SLE.

To the Editor:We read with great interest regarding the article on "Acute Pancreatitis Associated with Valproate Treatment. " By Quanet al^[1]published in your esteemed journal.

To the Editor: Erythrokeratodermia variabilis (EKV; MIM 133200) is characterized by the coexistence of transient, figurate, erythematous patches, and localized keratotic hyperkeratosis. EKV shows marked phenotypic heterogeneity, even within kindreds bearing the same diseasecausing mutation.^[1]The term EKV et progressiva (EKVP) is a severe variant of EKV and has been proposed to encompass the diversity of phenotypes, ranging from limited hyperkeratotic plaques and erythematous patches to severe progressive symmetric erythrokeratodermia which can feature more generalized cutaneous involvement.^[2]

To the Editor:A 63-year-old male patient was referred from a local clinic for diffuse abdominal pain for 1 day and ruptured abdominal aortic aneurysm (rAAA) in computed tomography (CT). He denied any medical history of hypertension, diabetes mellitus, hepatitis or pneumonia. The patient’s blood pressure was 100/70 mmHg with a pulse rate of 105 beats/min and a body temperature of 37.1 °C. The Abdomen was mildly distended with diffuse pain and tenderness. A 5 cm × 5 cm-sized pulsatile mass could be palpated in mid-abdomen. Laboratory findings included a white blood cell (WBC) count of 10,600/μL, hemoglobin (Hb) of 92 g/L, hematocrit of 26.7%, serum creatinine (Cr) of 0.9 mg/dl, and C-reactive protein (CRP) of 10.24 mg/L. On initial chest radiography, there was no pathological lung lesion. Abdominal CT showed the 5 cm × 5 cm-sized ruptured infrarenal abdominal aortic pseudoaneurysm with focally enhanced bulging contour [Figure 1AandFigure 1B]. A decision was made to undergo emergency surgery. Under general anesthesia, we approached the retroperitoneal rAAA and hematoma via midline skin incision. After clamping the infrarenal aorta and both iliac arteries, we found a significant amount of infectious substances in the perianeurysmal area and the aneurysmal wall [Figure 1C]. We performed culture tests for various microorganisms in the perianeurysmal area tissue, thrombus, and aneurysmal wall. Subsequently, we did careful extensive local debridement and resection of the perianeurysmal area tissue and aneurysmal sac, along with massive irrigation [Figure 1D]. We completed an aortobiiliac artery interposition with bifurcated polytetrafluoroethylene (PTFE) graft with omental flap [Figure 1E]. According to our rAAA management protocol, we had administered the third generation cephalosporin as preoperative and postoperative preventive antibiotics until causative microorganisms and sensitivity to antibiotics were identified. We added metronidazole for the first 5 postoperative days. Culture tests of perianeurysmal area tissue, thrombus, and aneurysmal wall showed a heavy growth ofKlebsiella pneumoniaealone, and showed sensitivity to most antibiotics except ampicillin. The result of tissue-Gram stain (the Brown-Brenn stain) of the aorta wall was negative [Figure 1F]. Also, serologic and tissue tests for species ofSalmonellawere negative. We continued daily injection of a third generation cephalosporin intravenously for 4 weeks. At 3 weeks postoperatively, we performed a serologic culture test which was negative. At 4 weeks postoperatively, the patient was discharged without complications with a prescription for an oral third generation cephalosporin for 2 weeks. Subsequent clinical course has been uneventful. At 6 months postoperatively, CT showed that PTFE was patent and there was no recurrence of infection [Figure 1GandFigure 1H].

To the Editor:Congenital hemolytic anemia (CHA) can be caused by the defect of any component in red blood cell (RBC), including hemoglobinopathies, membrane and cytoskeleton defects, and metabolic enzymopathies etc. And it is characterized by early present normocytic/macrocytic anemia, reticulocytosis, and elevated unconju-gated bilirubin.

To the Editor: Autonomic dysfunction is an important factor in the pathogenesis of unstable angina pectoris (UAP). It affects coronary artery systolic function, induces coronary spasm, aggravates myocardial ischemia, reduces ventricular fibrillation threshold, and increases the incidence of sudden cardiac death in UAP.^[1]Oxidative stress, which is defined as an excessive production of reactive oxygenated species (ROS) that cannot be counteracted by the action of antioxidants, has been proposed as an underlying mechanism that contributes to the initiation and progression of cardiovascular diseases.^[2]Although the cause-and-effect relationship between autonomic dysfunction and oxidative stress has not been determined, it has been suggested that oxidative stress is one of the most crucial mechanisms that contributes to the onset and progression of neurodegenerative diseases by causing excitotoxicity, neuronal loss, axonal impairment.^[3]Studies have reported that serum levels of homocysteine (Hcy), uric acid, albumin, and bilirubin are simple laboratory parameters that reflect natural oxidativeantioxidant status. Furthermore, previous study showed that increased oxidative stress predicted autonomic dysfunction in diabetes. Heart rate variability (HRV) has considerable potential to evaluate the role of autonomic nervous system fluctuations in healthy individuals and in patients with various cardiovascular disorders.^[4]It is reported that suppressed HRV was associated with increased oxidative stress in both essential hypertensive and prehypertensive patients.^[5]Nevertheless, whether HRV is associated with endogenous oxidative-antioxidant substances in circulation has not been investigated. Therefore, we performed a cross-sectional study to investigate the correlation between HRV and circulating natural oxidativeantioxidant substances in patients with unstable angina.

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, which is clinical problem often faced by intensive care units (ICU) doctors. Without positive treatment, the incidence and mortality of sepsis are high.^[1]As hospital infection control plays an essential role in treating the nosocomial infections in the ICU, and according to the clinical presentation of critically ill patients, the biological characteristics of pathogenic microorganisms and the ICU environment, this article put forward a strategy for the nosocomial infections in the ICU.