2019年 · 第132卷第03期

Enhanced recovery after surgery (ERAS) protocols are a series of perioperative care to optimize preoperative preparation, prevent postoperative complications, minimize stress, and speed up recovery. This study aimed to assess the impact of ERAS protocols for functional endoscopic sinus surgery (FESS) in patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

One hundred and two patients with CRSwNP undergoing FESS were randomly divided into the ERAS group and the control group. The outcomes of the Self-Rating Anxiety Scale (SAS), Visual Analogue Scale (VAS), Medical Outcomes Study Sleep Scale (MOS-SS) and Kolcaba Comfort Scale Questionnaire (GCQ) were determined in both groups. The serum levels of C-reactive protein (CRP) were compared preoperatively and 24 hours postoperatively.

The ERAS group had a significantly better SAS scores than did the control group (28 [24, 35] vs. 43 [42, 47], Z=5.968, P<0.001). The rhinalgia and headache scores at 2, 24 and 48 hours postoperatively were lower in the ERAS group than that in the control group (all P < 0.001). The outcomes of the MOS-SS (43 [42, 39] vs. 28 [22, 35], Z= 7.071, P < 0.001) and GCQ (76 [68, 87] vs. 64 [50, 75], Z= 4.806, P < 0.001) were significantly different between the two groups. No significant difference was found in the preoperative CRP levels between the two groups (1.3 [0.6, 2.8] vs. 0.5 [0.5, 1.2], Z = 3.049, P > 0.05); However, the CRP level in 24 hours postoperatively was significantly lower in the ERAS group than that in the control group (2.5 [1.4, 3.9] vs. 6.6 [3.8, 9.0], Z = 5.027, P < 0.001). The incidence rates of complications, such as nausea/emesis (χ²=0.343, P>0.05), hemorrhage, aspiration and tumble, were not increased in the ERAS group compared with those in the control group. The ERAS group had a significantly shorter length of hospital stay (5 [4, 5] days vs. 8 [8,9] days, Z=8.939, P<0.001) and hospitalization expenses ($ 2670 [2375, 2740] vs. $3129 [3116, 3456], Z=8.514, P<0.001).

ERAS protocols might optimize FESS for patients with CRSwNP by reducing psychological and physical stress, shortening the length of hospital stay and lowering hospitalization expenses without increasing postoperative complications.

Chinese Clinical Trial Registry, No. ChiCTR1800015791; http://www.chictr.org.cn/showproj.aspx?proj=26872

This study used the National Emergency Department Information System (NEDIS) data to analyze the flow of emergency and critical emergency patients and to identify the patterns of emergency medical service usage in Korea.

The relevance index (RI) and commitment index (CI) were calculated from the 2016 NEDIS data. In this study, the number of clusters was determined using NbClust, and cluster analysis was used to analyze the usage patterns of emergency and critical emergency patients.

The RI and CI were calculated using 8,389,766 cases of 214 districts. The results of the RI and CI suggested that there were 3 types of clusters among the emergency patients. In Cluster 1, 54 districts (25.2%) had low RI and high CI, and it was of outflow type. Cluster 2 was categorized as the influx-type in 58 districts (27.1%) irrespective of RI and low CI. Cluster 3 was categorized as the self-sufficient type found in 102 districts (47.7%), with high RI and high CI. The cluster analysis of the critical emergency patients was divided into 2 types. Cluster 1 was categorized as outflow type with high CI found in 129 districts (60.3%), while Cluster 2 was categorized as inflow type with low CI found in 85 districts (39.7%).

This study elucidates the regional status of usage patterns of emergency and critical emergency patients in Korea. This study might serve as a basis for the establishment and selection of emergency medical service areas and vulnerable emergency medical service areas.

Studies on the relationship between antiepileptic drug (AED) administration and clinical outcomes in patients with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) remain scarce. Levetiracetam (LEV) is an AED that is neuroprotective in various neurologic disorders. This study aimed to determine the impact of LEV on the outcome of MELAS.

A retrospective, single-center study was performed based on a large cohort of patients with MELAS with a history of seizures (n=102). Decisions on antiepileptic therapies were made empirically. Patients were followed up for 1 to 8 years (median, 4 years) and divided into 2 groups based on whether LEV was administered (LEV or non-LEV). The modified Rankin scale (mRS) scores and mortality risks were analyzed in all patients.

LEV, carbamazepine, benzodiazepines, topiramate, oxcarbazepine, valproate, and lamotrigine were administered in 48, 37, 18, 13, 11, 9, and 9 patients, singly or in combination, respectively. The mean mRS score of the LEV group (n=48) was lower than that of the non-LEV group (n=54; mean±standard deviation, 2.79±1.47 vs. 3.83±1.93, P=0.006) up to the end of the study. Nevertheless, there was no difference in the proportion of subjects without disability (mRS ranging 0–1) between the groups (P=0.37). The multivariate regressions revealed that LEV treatment was associated with lower mRS scores (odds ratio 0.32, 95% confidence interval [CI] 0.15–0.68, P=0.003) and mortality rates (hazard ratio 0.24, 95% CI 0.08–0.74, P=0.013). There was a significant difference in the Kaplan-Meier survival curves between the groups (χ²=4.29, P=0.04).

The LEV administration is associated with lower mortality in patients with MELAS in this retrospective study. Further laboratory research and prospective cohort studies are needed to confirm whether LEV has neuroprotective effects on patients with mitochondrial diseases.

Late-onset multiple acyl-coA dehydrogenase deficiency (MADD) is an autosomal recessive inherited metabolic disorder. It is still unclear about the muscle magnetic resonance image (MRI) pattern of the distal lower limb pre- and post-treatment in patients with late-onset MADD. This study described the clinical and genetic findings in a cohort of patients with late-onset MADD, and aimed to characterize the MRI pattern of the lower limbs.

Clinical data were retrospectively collected from clinic centers of Peking University People’s Hospital between February 2014 and February 2018. Muscle biopsy, blood acylcarnitines, and urine organic acids profiles, and genetic analysis were conducted to establish the diagnosis of MADD in 25 patients. Muscle MRI of the thigh and leg were performed in all patients before treatment. Eight patients received MRI re-examinations after treatment.

All patients presented with muscle weakness or exercise intolerance associated with variants in the electron transfer flavoprotein dehydrogenase gene. Muscle MRI showed a sign of both edema-like change and fat infiltration selectively involving in the soleus (SO) but sparing of the gastrocnemius (GA) in the leg. Similar sign of selective involvement of the biceps femoris longus (BFL) but sparing of the semitendinosus (ST) was observed in the thigh. The sensitivity and specificity of the combination of either "SO+/GA–" sign or "BFL+/ST–" sign for the diagnosis of late-onset MADD were 80.0% and 83.5%, respectively. Logistic regression model supported the findings. The edema-like change in the SO and BFL muscles were quickly recovered at 1 month after treatment, and the clinical symptom was also relieved.

This study expands the clinical and genetic spectrums of late-onset MADD. Muscle MRI shows a distinct pattern in the lower limb of patients with late-onset MADD. The dynamic change of edema-like change in the affected muscles might be a potential biomarker of treatment response.

Pulmonary vein (PV) occlusion generally depends on repetitive contrast agent injection when cryoballoon ablation for atrial fibrillation (AF). The present study was to compare the effect of cryoballoon ablation for AF guided by transesophageal echocardiography (TEE) vs. contrast agent injection.

Eighty patients with paroxysmal AF (PAF) were enrolled in the study. About 40 patients underwent cryoballoon ablation without TEE (non-TEE group) and the other 40 underwent cryoballoon ablation with TEE for PV occlusion (TEE group). In the TEE group during the procedure, PVs were displayed in 3-dimensional images to guide the balloon to achieve PV occlusion. The patients were followed up at regularly scheduled visits every 2 months.

No differences were identified between the groups in regard to the procedure time and cryoablation time for each PV. The fluoroscopy time (6.7±4.2 min vs. 17.9±5.9 min, P<0.05) and the amount of contrast agent (3.0±5.1 mL vs.18.1±3.4 mL, P<0.05) in the TEE group were both less than the non-TEE group. At a mean of 13.0±3.3 mon follow-up, success rates were similar between the TEE group and non-TEE group (77.5% vs. 80.0%, P=0.88).

Cryoballoon ablation with TEE for occlusion of the PV is both safe and effective. Less fluoroscopy time and a lower contrast agent load can be achieved with the help of TEE for PV occlusion during procedure.

Non-Hodgkin T/NK cell lymphoma is a rare and widely variable type of lymphoma with the most dismal prognosis. This study aimed to investigate varied impact of the clinical indicators to the overall survival (OS).

We conducted a retrospective study to identify the non-invasive clinical features of T cell lymphoma that can predict prognosis with an innovative analysis method using quantile regression. A total of 183 patients who visited a top-tier hospital in Beijing, China, were enrolled from January 2006 to December 2015. Demographic information and main clinical indicators were collected including age, erythrocyte sedimentation rate (ESR), survival status, and international prognostic index (IPI) score.

The median age of the patients at diagnosis was 45 years. Approximately 80% of patients were at an advanced stage, and the median survival time after diagnosis was 5.1 months. Multivariable analysis of the prognostic factors for inferior OS associated with advanced clinical staging [HR=3.16, 95%CI (1.39–7.2)], lower platelet count [HR=2.57, 95%CI (1.57–4.19), P<0.001] and higher IPI score [HR=1.29, 95%CI (1.01–1.66), P=0.043]. Meanwhile, T cell lymphoblastic lymphoma [HR=0.40, 95%CI (0.20–0.80), P=0.010], higher white blood cell counts [HR=0.57, 95%CI (0.34–0.96), P=0.033], higher serum albumin level [HR=0.6, 95%CI (0.37–0.97), P=0.039], and higher ESR [HR=0.53, 95%CI (0.33–0.87), P=0.011] were protective factors for OS when stratified by hemophagocytic lymphohistiocytosis (HLH). Multivariable quantile regression between the OS rate and each predictor at quartiles 0.25, 0.5, 0.75, and 0.95 showed that the coefficients of serum β2-microglobulin level and serum ESR were statistically significant in the middle of the coefficient curve (quartile 0.25–0.75). The coefficient of IPI was negatively associated with OS. The coefficients of hematopoietic stem cell transplantation (HSCT) and no clinical symptoms were higher at the middle of the quartile level curve but were not statistically significant.

The IPI score is a comparatively robust indicator of prognosis at 3 quartiles, and serum ESR is stable at the middle 2 quartiles section when adjusted for HLH. Quantile regression can be used to observe detailed impacts of the predictors on OS.

Six epidemic waves of human infection with avian influenza A (H7N9) virus have emerged in China with high mortality. However, study on quantitative relationship between clinical indices in ill persons and H7N9 outcome (fatal and nonfatal) is still unclear. A retrospective cohort study was conducted to collect laboratory-confirmed cases with H7N9 viral infection from 2013 to 2015 in 23 hospitals across 13 cities in Guangdong Province, China.

Multivariable logistic regression model and classification tree model analyses were used to detect the threshold of selected clinical indices and risk factors for H7N9 death. The receiver operating characteristic curve (ROC) and analyses were used to compare survival and death distributions and differences between indices. A total of 143 cases with 90 survivors and 53 deaths were investigated.

Average age (Odds Ratio (OR)=1.036, 95% Confidence Interval (CI)=1.016–1.057), interval days between dates of onset and confirmation (OR=1.078, 95% CI=1.004–1.157), interval days between onset and oseltamivir treatment (OR=5.923, 95% CI=1.877–18.687), body temperature (BT) (OR=3.612, 95% CI=1.914–6.815), white blood cell count (WBC) (OR=1.212, 95% CI=1.092–1.346) were significantly associated with H7N9 death after adjusting for confounders. The chance of death from H7N9 infection was 80.0% if BT was over 38.1 °C, and chance of death is 67.4% if WBC count was higher than 9.5 (10⁹/L). Only 27.1% of patients who began oseltamivir treatment less than 9.5 days after disease onset died, compared to 68.8% of those who started treatment more than 15.5 days after onset.

The intervals between date of onset and confirmation of diagnosis, between date of onset to oseltamivir treatment, age, BT and WBC are found to be the best predictors of H7N9 mortality.

The clinical trials emerged centromere protein E inhibitor GSK923295 as a promising anticancer drug, but its function in hepatocellular carcinoma (HCC) remain needs to be fully elucidated, especially as chemotherapy after hepatectomy for liver tumors. We aimed to describe anti-HCC activities of GSK923295 and compare its antiproliferative effects on liver regeneration after partial hepatectomy (PH).

All subjects were randomized to treatment with either vehicle or GSK923295. Antitumor activity of GSK923295 was assessed by xenograft growth assays. The C57BL/6 mice were subjected to 70% PH and the proliferation was calculated by liver coefficient, further confirmed by immunohistochemistry. The proliferation and cell cycle analysis of liver cell AML12 and HCC cells LM3, HUH7, and HepG2 were investigated using the cell counting kit-8 assay and Flow Cytometry. The chromosome misalignment and segregation in AML12 cells were visualized by immunofluorescence.

Treatment with GSK923295 induced antiproliferation in HCC cell lines. It also caused delay on HCC tumor growth instead of regression both in a HCC cell line xenograft model and patient-derived tumor xenograft model. With microarray analysis, CENtromere Protein E was gradually increased in mouse liver after PH. Exposure of liver cells to GSK923295 resulted in delay on a cell cycle in mitosis with a phenotype of misaligned chromosomes and chromosomes clustered. In 70% PH mouse model, GSK923295 treatment also remarkably reduced liver regeneration in later stage, in parallel with the mitotic marker phospho-histone H3 elevation.

The anticancer drug GSK923295 causes a significant delay on HCC tumor growth and liver regeneration after PH in later stage.

Eucommia ulmoides Oliv. is a medicinal plant native to China, with its bark (Eucommiae Cortex) traditionally being used for medicinal purposes. Previous research has shown that Eucommia male flowers can exert anti-inflammatory, analgesic, antibacterial, and other pharmacological effects, including immune regulation. This study explored the anti-inflammatory effects of the 70% ethanol extract of male flowers (EF) of E. ulmoides in lipopolysaccharide (LPS)-stimulated RAW 264.7 cells and LPS-administered mice.

Cytotoxicity of EF for RAW 264.7 cells was investigated using Cell Counting Kit-8. The production of proinflammatory mediators, nitric oxide (NO), tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6 was determined using enzyme-linked immunosorbent assays. IL-17, IL-23, and IL-10 mRNA levels were determined using quantitative real-time polymerase chain reaction. Activation of the nuclear factor (NF)-κB pathway in RAW 264.7 cells was investigated via Western blotting. In vivo antiinflammatory effects of EF were studied in an LPS-induced acute inflammation mouse model by analyzing lung tissue histopathology, serum TNF-α and IL-6 levels, and myeloperoxidase (MPO) activity in lung tissue.

EF showed no significant cytotoxicity at concentrations from 10 to 60 μg/mL (cell viability > 80%) in the CCK-8 cell viability assay. EF inhibited the RAW 264.7 cell proliferation (EF 60 μg/mL, 120 μg/mL, and 250 μg/mL vs. negative control: 87.31±2.39% vs. 100.00±2.50%, P=0.001; 79.01±2.56 vs. 100.00±2.50%, P<0.001; and 64.83±2.50 vs. 100.00±2.50%, P<0.001), suppressed NO (EF 20 μg/mL and 30 μg/mL vs. LPS only, 288.81±38.01 vs. 447.68±19.07 μmol/L, P=0.004; and 158.80±45.14 vs. 447.68±19.07 μmol/L, P<0.001), TNF-α (LPS+EF vs. LPS only, 210.20±13.85 vs. 577.70±5.35 pg/mL, P<0.001), IL-1β (LPS+EF vs. LPS only, 193.30±10.80 vs. 411.03±42.28 pg/mL, P<0.001), and IL-6 (LPS+EF vs. LPS only, 149.67±11.60 vs. 524.80±6.24 pg/mL, P<0.001) secretion, and downregulated the mRNA expression of IL-17 (LPS+EF vs. LPS only, 0.23±0.02 vs. 0.43±0.12, P<0.001), IL-23 (LPS+EF vs. LPS only, 0.29±0.01 vs. 0.42±0.06, P=0.002), and IL-10 (LPS+EF vs. LPS only, 0.30±0.01 vs. 0.47±0.01, P=0.008) in LPS-stimulated RAW 264.7 cells. EF inhibited the LPS-induced NF-κB p65 (LPS+EF 20 μg/mL and 30 μg/mL vs. LPS only: 0.78±0.06 vs. 1.17±0.08, P<0.001; and 0.90±0.06 vs. 1.17±0.08, P=0.002) and inhibitor of kappa B (IκBα) phosphorylation (LPS+EF 20 μg/mL and 30 μg/mL vs. LPS only: 0.25±0.01 vs. 0.63±0.03, P<0.001; and 0.31±0.01 vs. 0.63±0.03, P<0.001), LPS+EF 30 μg/mL inhibited IκB kinase (IKKα/β) phosphorylation (LPS+EF 30 μg/mL vs. LPS only, 1.12±0.14 vs. 1.71±0.25, P=0.002) in RAW 264.7 cells. Furthermore, EF 10 mg/kg and EF 20 mg/kg inhibited lung tissue inflammation in vivo and suppressed the serum TNF-α (LPS+EF 10 mg/kg and 20 mg/kg vs. LPS only, 199.99±186.49 vs. 527.90±263.93 pg/mL, P=0.001; and 260.56±175.83 vs. 527.90±263.93 pg/mL, P=0.005), and IL-6 (LPS+EF 10 mg/kg and 20 mg/kg vs. LPS only, 41.26±30.42 vs. 79.45±14.16 pg/ml, P=0.011; and 42.01±26.26 vs. 79.45±14.16 pg/mL, P=0.012) levels and MPO (LPS+EF 10 mg/kg and 20 mg/kg vs. LPS only, 3.19±1.78 vs. 5.39±1.51 U/g, P=0.004; and 3.32±1.57 vs. 5.39±1.51 U/g, P=0.006) activity in lung tissue.

EF could effectively inhibit the expression of inflammatory factors and overactivation of neutrophils. Further investigation is needed to evaluate its potential for anti-inflammation therapy.

Statement:In 2013, we published "Criteria and practical guidance for determination of brain death in adults (BQCC version)" in Chinese Medical Journal (Chin Med J 2013, 126:4786–4790). Since then, China has the standard for the determination of brain death. In order to further promote the brain death related work, Brain Injury Evaluation Quality Control Center of National Health Commission (BQCC) aimed to revise and update "Criteria and practical guidance for determination of brain death in adults". This 2018 new edition was based on the 5-year clinical practice of brain death determination, BQCC quality control analysis of brain death cases, and the opinions and suggestions of BQCC expert committees, technical committees and advisory committees. We hope that the development of brain death determination will be more standardized and orderly in China.

To the Editor:Human astroviruses (HAstVs) are important etiologic agents of viral gastroenteritis worldwide,^[1,2]especially in pediatric patients aged ≤5 years.^[3]However, reports on HAstV outbreaks in middle schools remain limited. Here, we report a HAstV outbreak in a middle school in China. Clinical and environmental samples tested positive for HAstV, showing a 100% nucleotide identity of the 348-bp region of the capsid protein gene.

To the Editor:Sepsis and septic shock are a leading cause of intensive care unit (ICU) admissions and induce significant morbidity and mortality.^[1,2]Early propitiate antibiotics administration is significantly associated with improved survival in sepsis and septic shock^[3,4]which is recommended by the international guidelines.^[5]However, the compliance to sepsis protocols remains very low.^[6]Nurses, who play a vital role in carrying out physician orders, are likely associated with the compliance to empiric antibiotic administration. Phuaet al^[7]showed that nurses occupy an essential and conscious position as brokers of doctors’ antibiotic decisions. In addition, other studies also demonstrated that nurse-led protocols were an effective, safe, and sustainable method for achieving early antibiotic administration in patients with suspected febrile neutropenia.^[8]Therefore, we performed a retrospective cohort study to confirm the effect of nursing staff capacity on the compliance of nurses to empiric antibiotic treatment in patients with septic shock.

To the Editor:Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo. Recently, the diagnosis and treatment of BPPV have become areas of increased interest. As such, the levels of clinical diagnosis and treatment have greatly improved. While studies have been conducted worldwide examining the pathogenesis and pathophysiology of BPPV, very few have focused on the cost of diagnosis and treatment of BPPV. Therefore, the current study was designed to analyze the effects and expenditure of the different treatment strategies for BPPV, according to the effective screening of BPPV patients, and vertigo classification.

To the Editor:Irritable bowel syndrome (IBS) is a prevalent functional gastrointestinal disorder that presents as abdominal pain with altered bowel habits. The pathophysiologic mechanism of IBS is not well understood, although many hypotheses have been proposed, including visceral hypersensitivity, gastrointestinal dysmotility, lowgrade inflammation of the intestinal mucosa, and dysfunction of the brain-gut interaction. Dysfunction of the braingut interaction is thought to be involved in IBS because a considerable proportion of patients with IBS have some form of psychologic comorbidity, such as depression or anxiety. In addition, mental and psychologic problems increase the risk for IBS and the symptom severity of IBS. Recently, changes in the gut microbiota have also been suggested to contribute to both IBS and depression. Our previous study demonstrated significant altered gut microbiota profiles in patients with diarrhea-predominant IBS (IBS-D) and depression.^[1]

To the Editor:Frailty is defined as a vulnerable state that places older adults at increased risk for adverse health outcomes, and can explain substantial heterogeneity of health status. Previous studies have demonstrated the utility of the frailty phenotype scale and frailty index (FI) in identifying frail older people in China.^[1]Several experimental and clinical studies on frailty have been published using the above methods in recent years, but influential factors for discriminating frailty levels in Chinese older adults have not yet been determined. Elucidating this issue is of importance, because early detection of frailty-related factors and subsequent intervention are essential for safeguarding functionality and preventing the occurrence of adverse consequences among older people.

To the Editor:Infection is one of the causes of death after chemotherapy in children with leukemia. About 20% to 30% acute lymphocytic leukemia (ALL) patients die from infection after chemotherapy.^[1]Patients with immune deficiency, under chemotherapy, or treated with immunosuppressor are more inclined to be infected with human cytomegalovirus (HCMV) which leads to severe systematic disorders.^[2]Cytomegalvirus retinitis (CMVR) is a major sight threatening disease which mainly occurs in patients with immune deficiency and results in blindness if treatment is delayed. The decrease of CD4+ T cells has been related to CMVR in immune deficiency syndrome like AIDS.^[3]However, little is known about the relation between the level of T cells with different markers and the onset of CMVR in ALL patients under chemotherapy. Therefore, this study was designed to investigate the diagnostic value of T cells with different markers for cytomegalovirus retinitis after chemotherapy in patients with ALL.

To the Editor:Posner-Schlossmann syndrome (PSS), also known as glaucomatocyclitic crisis, is characterized by acute, unilateral, recurrent attacks of ocular hypertension, mild non-granulomatous anterior uveitis (AU), and spontaneous recovery. However, the etiology of this disease is unknown. Many mechanisms have been proposed including viral infection, autoimmune, autonomic dysregulation, allergic conditions and vascular endothelial dysfunction.^[1]Topical anti-hypertensives and anti-inflammatory medications are typically prescribed to combat this disease. Repeated attacks may lead to longterm glaucomatous optic nerve damage over 5–10 years after the first episode. Because the pathophysiology is not completely understood, treatment and prevention of recurrences has proven to be difficult.

To the Editor:The incidence of community acquired methicillin-resistantStaphylococcus aureus(CA-MRSA) infection and reports of CA-MRSA infection have been increasing yearly. But community-acquired intraspinal methicillin-resistantStaphylococcus aureus(MRSA) infection has never been reported. We describe a case of intraspinal abscess due to CA-MRSA infection.

To the Editor:Cholesterol crystal embolism (CCE) is a systemic disease caused by cholesterol crystal embolization leading to the occlusion of small arteries in a variety of organs. It may occur spontaneously, or more often, after intravascular procedures such as coronary angiography and carotid artery stenting, cardiovascular surgery such as coronary artery bypass grafting or aortic aneurysm surgery.^[1]The kidneys were previously reported to be the most frequent target organ for CCE, and renal CCE was found during the course of clinical illness in approximately 50% of patients with CCE.^[2]

To the Editor:Bipolar hemiarthroplasty is one of the treatment options for unstable femoral neck fracture in the elderly. Hip dislocation after hip replacement is a common complication but dissociation of a bipolar prosthesis is rare and more serious complication, which always requires open reduction and revision. Some authors have reported dissociation after bipolar hemiarthroplasty of the hip. The present study reported four cases of disassembly after the primary bipolar hemiarthroplasty due to different causes and explained the mechanism. It will beneficial for surgeons who encounter the same situation.

The concept of brain death was 1st introduced in the 1960s, providing an essential conceptual change to medical practice,^[1]and its diagnosis is based on demonstrating the complete, irreversible cessation of brainstem function. Despite medical advancement, organ transplantation remains the only hope for patients with end-stage organ failure to survive, and donation after brain death remains a main source of organs. A lack of deceased organ donors is one of the greatest obstacles to transplantation, and it remains a particular problem in the Chinese population. In 2016, the proportion of organ donors in mainland China is 3 per million population (pmp), and the number of deceased donors in Hong Kong, China in 2017 is 6 donors pmp, which are relatively low.^[2]More aggressive neurosurgical intervention and better trauma and critical care management have also contributed to a substantial reduction in the number of potential organ donors. At the same time, transplant techniques are more mature, and transplantations are now offered to a group of "older and sicker" patients who were considered unsuitable recipients in the past. Every day, around 300,000 people across mainland China and more than 2000 patients in Hong Kong, China are waiting for organ transplants. Multiple studies have attempted to examine the continuing supply-demand imbalance by investigating potential influences on organ procurement, including individual cultural beliefs, beliefs about government policy, and beliefs about the health care system.^[3,4,5]We reported a pilot cross-sectional study surveying 520 visitors at local intensive care units (ICUs) from 2014 to 2016, and their views toward the 3 aspects were investigated. Visitors under the age of 18 years were excluded. Ethics approval was granted by the relevant Research Ethics Committees.

From July 1997 to April 2017, 286 cases of internal mammary artery (IMA) damage were recorded out of the 10,360 coronary artery bypass graft (CABG) operations with IMA harvest, with an incidence up to 2.7%, which is relatively high. The main reason for such high incidence might be the surgeons’ experience and the learning curve. Although one surgeon (Huang FJ) performed all these operations, the cases were operated in many different hospitals, and more than 200 surgical assistants who were young and inexperienced harvested the IMA. Therefore, we provide here some tips for young surgeons: