2019年 · 第132卷第06期

The comparative outcomes of subcutaneous implantable cardioverter-defibrillator (S-ICD) and transvenous ICD (T-ICD) have not been well studied. The aim of this study was to evaluate the safety and efficacy of currently available S-ICD and T-ICD.

The study included 86 patients who received an S-ICD and 1:1 matched to those who received single-chamber T-ICD by gender, age, diagnosis, left ventricular ejection fraction (LVEF), and implant year. The clinical outcomes and implant complications were compared between the two groups.

The mean age of the 172 patients was 45 years, and 129 (75%) were male. The most common cardiac condition was hypertrophic cardiomyopathy (HCM, 37.8%). The mean LVEF was 50%. At a mean follow-up of 23 months, the appropriate and inappropriate ICD therapy rate were 1.2% vs. 4.7% (χ² = 1.854, P = 0.368) and 9.3% vs. 3.5% (χ² = 2.428, P = 0.211) in S-ICD and T-ICD groups respectively. There were no significant differences in device-related major and minor complications between the two groups (7.0% vs. 3.5%, χ² = 1.055, P= 0.496). The S-ICD group had higher T-wave oversensing than T-ICD group (9.3% vs. 0%, χ²= 8.390, P= 0.007). Sixty-five patients had HCM (32 in S-ICD and 33 in T-ICD). The incidence of major complications was not significantly different between the two groups.

The efficacy of an S-ICD is comparable to that of T-ICD, especially in a dominantly HCM patient population. The S-ICD is associated with fewer major complications demanding reoperation.

Ciprofloxacin is usually used in the treatment of lower respiratory tract infections (LRTIs). Recent studies abroad have shown ciprofloxacin is inadequately dosed and might lead to worse outcomes. The aim of this study was to perform pharmacokinetic and pharmacodynamic analyses of ciprofloxacin in elderly Chinese patients with severe LRTIs caused by Gram-negative bacteria.

From September 2012 to June 2014, as many as 33 patients were empirically administered beta-lactam and ciprofloxacin combination therapy. Patients were infused with 200 or 400 mg of ciprofloxacin every 12 h, which was determined empirically by the attending physician based on the severity of the LRTI and the patient’s renal condition. Ciprofloxacin serum concentrations were determined by high-performance liquid chromatography. Bacterial culture was performed from sputum samples and/or endotracheal aspirates, and the minimum inhibitory concentrations (MICs) of ciprofloxacin were determined. The ratios of the area under the serum concentration-time curve to the MIC (AUC/MIC) and of the maximum serum concentration of the drug to the MIC (C_max/MIC) were calculated. The baseline data and pharmacokinetic parameters were compared between clinical success group and clinical failure group, bacteriologic success group and bacteriologic failure group.

Among the 33 patients enrolled in the study, 17 were infected with Pseudomonas aeruginosa, 14 were infected with Acinetobacter baumannii, and two were infected with Klebsiella pneumoniae. The mean age of the patients was 76.9 ± 6.7 years. Thirty-one patients (93.4%) did not reach the target AUC/MIC value of >125, and 29 patients (87.9%) did not reach the target C_max/MIC value of >8. The AUC/MIC and C_max/MIC ratios in the clinical success group were significantly higher than those in the clinical failure group (61.1 [31.7–214.9] vs. 10.4 [3.8–66.1], Z=－4.157; 9.6 [4.2–17.8] vs. 1.3 [0.4–4.7], Z=－4.018; both P < 0.001). The AUC/MIC and C_max/MIC ratios in the patients for whom the pathogens were eradicated were significantly higher than those in the patients without the pathogens eradicated (75.3 [31.7–214.9] vs. 10.5 [3.8–66.1], Z=－3.938; 11.4 [4.2–17.8] vs. 1.4 [0.4–5.4], Z =－3.793; P < 0.001 for both). Receiver operating characteristic curve analysis showed that the AUC/MIC and C_max/MIC values were closely associated with clinical and bacteriologic efficacies (P < 0.001 in both).

Ciprofloxacin is inadequately dosed against Gram-negative bacteria, especially for those with relatively high MIC values. Consequently, the target values, AUC/MIC > 125 and C_max/MIC > 8, cannot be reached.

Immunoglobulin A nephropathy (IgAN) is the most common pathological type of glomerular disease. Kidney biopsy, the gold standard for IgAN diagnosis, has not been routinely applied in hospitals worldwide due to its invasion nature. Thus, we aim to establish a non-invasive diagnostic model and determine markers to evaluate disease severity by analyzing the serological parameters and pathological stages of patients with IgAN.

A total of 272 biopsy-diagnosed IgAN inpatients and 518 non-IgA nephropathy inpatients from the Department of Nephrology of Chinese People’s Liberation Army General Hospital were recruited for this study. Routine blood examination, blood coagulation testing, immunoglobulin-complement testing, and clinical biochemistry testing were conducted and pathological stages were analyzed according to Lee grading system. The serological parameters and pathological stages were analyzed. The receiver operating characteristic (ROC) analysis was performed to estimate the diagnostic value of the clinical factors. Logistic regression was used to establish the diagnostic model.

There were 15 significantly different serological parameters between the IgAN and non-IgAN groups (all P < 0.05). The ROC analysis was performed to measure the diagnostic value for IgAN of these parameters and the results showed that the area under the ROC curve (AUC) of total protein (TP), total cholesterol (TC), fibrinogen (FIB), D-dimer (D2), immunoglobulin A (IgA), and immunoglobulin G (IgG) were more than 0.70. The AUC of the "TC+ FIB+ D2+ IgA+ age" combination was 0.86, with a sensitivity of 85.98% and a specificity of 73.85%. Pathological grades of I, II, III, IV, and V accounted for 2.21%, 17.65%, 62.50%, 11.76%, and 5.88%, respectively, with grade III being the most prevalent. The levels of urea nitrogen (UN) (13.57 ± 5.95 vs. 6.06 ± 3.63, 5.92 ± 2.97, 5.41 ± 1.73, and 8.41 ± 3.72 mmol/L, respectively) and creatinine (Cr) (292.19 ± 162.21 vs. 80.42 ± 24.75, 103.79 ± 72.72, 96.41 ± 33.79, and 163.04 ± 47.51 μmol/L, respectively) were significantly higher in grade V than in the other grades, and the levels of TP (64.45 ± 7.56, 67.16 ± 6.94, 63.22 ± 8.56, and 61.41 ± 10.86 vs. 37.47 ± 5.6 mg/d, respectively), direct bilirubin (DB) (2.34 ± 1.23, 2.58 ± 1.40, 1.91 ± 0.97, and 1.81 ± 1.44 vs. 0.74 ± 0.57 μmol/L, respectively), and IgA (310.35 ± 103.78, 318.48 ± 107.54, 292.58 ± 81.85, and 323.29 ± 181.67 vs. 227.17 ± 68.12 g/L, respectively) were significantly increased in grades II–V compared with grade I (all P < 0.05).

The established diagnostic model that combined multiple factors (TC, FIB, D2, IgA, and age) might be used for IgAN non-invasive diagnosis. TP, DB, IgA, Cr, and UN have the potential to be used to evaluate IgAN disease severity.

In China, upper airway cough syndrome (UACS) is only less frequent than cough-variant asthma and accounts for 24.71% of chronic cough. This study aimed to determine the pathogenetic constituents and factors affecting UACS in children of different age groups, and to identify clinical clues for diagnosing UACS and a method for curative effect evaluation.

A total of 103 children with UACS whose chief complaint was chronic cough were studied from January to November 2013 at Children’s Hospital, Capital Institute of Pediatrics. According to their age, children with UACS were divided into 3 groups: nursing children, pre-school children, and school-age children. We analyzed the differences in pathogenetic constituents and factors affecting UACS in children. The effect of UACS treatment was evaluated by the visual analog scale (VAS) and an objective examination. Chi-squared test and analysis of variance were performed with the SPSS 19.0 statistical software.

There was a high incidence of UACS in school-age children. Rhinitis with adenoid hypertrophy was the main cause of 103 suspected UACS cases. Adenoidal hypertrophy was the major cause of UACS in the pre-school children group, while rhinitis was the major reason in the nursing children and school-age children groups. Among the 103 children, there were 45 allergen-positive children, with no significant difference among different age groups. VAS scores in the different disease groups after treatment were lower than those before treatment (all P < 0.01). VAS scores in different disease groups showed significant differences, except for 12 vs. 24 weeks after treatment (P= 0.023). Different age groups had different secondary complaints.

There are different pathogeneses in different UACS age groups. Clinical treatment efficacy of children with UACS can be evaluated by the VAS combined with an objective examination. We recommend that the course of treatment should be 12 weeks.

Herpes virus is considered to be the pathogen of acute retinal necrosis (ARN) infection. Previous studies have found that patients with ARN caused by the varicella-zoster virus (VZV) are often older, and patients with herpes simplex virus (HSV) induced ARN are considerably younger. However, in our clinical work, we find that VZV is also a pathogen in younger ARN patients. We, therefore, aimed to analyze the common etiology of younger ARN patients.

A retrospective analysis was made of 20 eyes (18 patients) diagnosed as having ARN in the Department of Ophthalmology of Peking Union Medical College Hospital from 2014 to 2016. All patients were reviewed for demographic data, clinical course, clinical manifestations, time from onset to initial physician visit, duration of follow-up, visual acuity at both presentation and final visit, and treatment strategies. A paired t test was used to compare visual acuity between the presenting vision and those of final follow-up. Vitreous or aqueous specimens from 18 eyes of 18 patients were analyzed with multiplex polymerase chain reaction (mPCR)/quantitative PCR (qPCR) and xTAG-liquid chip technology (xTAG-LCT) to determine the causative virus of ARN.

Final best visual acuity (BCVA) improved significantly from 1.36 ± 0.95 (median 20/400) to 0.95 ± 0.82 (median 20/100) (t= 2.714, P= 0.015) after systemic and intravitreal antiviral treatment combined with or without pars plana vitrectomy. PCR and xTAG-LCT results showed four of the five samples in the younger group (32.2 ± 5.2 years) and 12 of the 13 samples in the senior group (53.6 ± 4.9 years) were positive for VZV, and two of the five samples in the younger group were positive for HSV-1.

This study demonstrates that VZV is also a common causative virus for ARN in younger patients. Considering this finding, a systemic antiviral treatment protocol should be immediately changed to intravenous ganciclovir when the patient does not respond to acyclovir before determining the causative virus, especially in younger patients.

Peritoneal fibrosis is the primary reason that patients with end-stage renal disease (ESRD) have to cease peritoneal dialysis. Peritonitis caused by Gram-negative bacteria such as Escherichia coli (E. coli) were on the rise. We had previously shown that matrine inhibited the formation of biofilm by E. coli. However, the role of matrine on the epithelial-mesenchymal transition (EMT) in peritoneal mesothelial cells under chronic inflammatory conditions is still unknown.

We cultured human peritoneal mesothelial cells (HPMCs) with lipopolysaccharide (LPS) to induce an environment that mimicked peritonitis and investigated whether matrine could inhibit LPS-induced EMT in these cells. In addition, we investigated the change in expression levels of the miR-29b and miR-129-5p.

We found that 10 μg/ml of LPS induced EMT in HPMCs. Matrine inhibited LPS-induced EMT in HPMCs in a dose-dependent manner. We observed that treatment with matrine increased the expression of E-cadherin (F= 50.993, P < 0.01), and decreased the expression of alpha-smooth muscle actin (F= 32.913, P < 0.01). Furthermore, we found that LPS reduced the expression levels of miR-29b and miR-129-5P in HPMCs, while matrine promoted the expression levels of miR-29b and miR-129-5P.

Matrine could inhibit LPS-induced EMT in HPMCs and reverse LPS inhibited expressions of miR-29 b and miR-129-5P in HPMCs, ultimately reduce peritoneal fibrosis. These findings provide a potential theoretical basis for using matrine in the prevention and treatment of peritoneal fibrosis.

Fatty acid oxidation (FAO) disorder is involved in the pathogenesis of some cases of preeclampsia (PE). Several studies show that mammalian target of rapamycin (mTOR) signaling pathway is related to FAO. Pravastatin (Pra) can promote FAO in Nω-nitro-L-arginine methyl ester (L-NAME) PE-like mouse model in our previous study. This study aimed to investigate the effect of mTOR signaling pathway in PE-like model treated with Pra.

Pregnant mice were randomly injected with L-NAME as PE-like model group or saline as control group respectively, from gestational 7th to 18th day. Giving Pra (L-NAME + Pra, Control + Pra, n = 8) or normal saline (NS; L-NAME + NS, Control + NS, n = 8) from gestational 8th to 18th day, the mice were sacrificed on day 18 and their liver and placental tissues were collected. Then the activation of mTOR and its substrates in the liver and placenta were detected. And the association between mTOR activation and serum free fatty acid (FFA) levels and the expression of long-chain 3-hydroxyacyl-coenzyme A dehydrogenase (LCHAD) were evaluated using Pearson correlation test. Differences between groups were analyzed using independent t-test or one-way analysis of variance (ANOVA).

Both in the maternal liver and placenta, the activation of mTOR protein and its effect on substrates increased significantly in the L-NAME + NS group and decreased significantly in the L-NAME + Pra group. The p-mTOR/mTOR protein ratio decreased in the L-NAME + Pra group significantly than that in the L-NAME + NS group both in liver and placenta (liver: 0.74 ± 0.08 vs. 0.85 ± 0.06, t= 2.95, P < 0.05; placenta: 0.63 ± 0.06 vs. 0.77 ± 0.06, t= 4.64, P < 0.05). The activation of mTOR protein in the liver and placenta negatively correlated with the expression of LCHAD in the L-NAME+ NS group (liver: r= －0.745, P < 0.05; placenta: r= －0.833, P < 0.05) and that in the maternal liver negatively correlated with the expression of LCHAD (r= －0.733, P < 0.05) and positively with the serum FFA levels (r= 0.841, P < 0.05) in the L-NAME + Pra group.

The inhibition of mTOR signaling pathway might be involved in the regulation of FAO in mouse model treated with Pra.

Several patients experience persistent otorrhea after a flawless surgical procedure because of insufficient epithelial healing. Several efforts, such as autologous tissue allograft and xenograft, have been made to halt otorrhea. However, a stable technology to induce temporal epithelial repair is yet to be established. Therefore, this study aims to investigate whether implantation of seeding adipose-derived mesenchymal stem cell (ADMSC) aggregates on extracellular matrix (ECM; herein, ADMSC aggregate-ECM) into damaged skin wound promotes skin regeneration.

ADMSC aggregate-ECM was prepared using a previously described procedure that isolated ADMSCs from rabbits and applied to the auricle and auditory meatus wound beds of New Zealand white rabbits. Wound healing was assessed by general observation and hematoxylin and eosin (H&E) staining. Secretion of growth factor of the tissue was evaluated by western blotting. Two other groups, namely, ECM and control, were used. Comparisons of three groups were conducted by one-way analysis of variance analysis.

ADMSCs adhered tightly to the ECM and quickly formed cell sheets. At 2 weeks, general observation and H&E staining indicated that the wound healing rates in the ADMSC aggregate-ECM (69.02 ± 6.36%) and ECM (59.32 ± 4.10%) groups were higher than that in the control group (43.74 ± 12.15%; P= 0.005, P < 0.001, respectively) in ear auricle excisional wounds. At 7 weeks, The scar elevation index was evidently reduced in the ADMSC aggregate-ECM (2.08 ± 0.87) and ECM (2.31 ± 0.33) groups compared with the control group (4.06 ± 0.45; P < 0.001, P < 0.001, respectively). In addition, the scar elevation index of the ADMSC aggregate-ECM group reached the lowest rate 4 weeks in advance. In auditory meatus excisional wounds, the ADMSC aggregate-ECM group had the largest range of normal skin-like structure at 4 weeks. The ADMSC aggregate–ECM and ECM groups secreted increased amounts of growth factors that contributed to skin regeneration at weeks 1 and 2, respectively.

ADMSC aggregate-ECM and ECM are effective repair materials for wound healing, especially ADMSC aggregate-ECM. This approach will provide a meaningful experimental basis for mastoid epithelium repair in subsequent clinical trials.

As a potent pro-inflammatory cytokine of the interleukin (IL)-1 family, IL-18 was elevated in early active and progressive plaque-type psoriatic lesions and that serum or plasma levels of IL-18 correlated with the Psoriasis Area and Severity Index (PASI). Although results from previous studies have established that IL-18 may aggravate psoriatic inflammation, the mechanisms of this process remain unknown. In this study, IL-18 knock out (KO) mice and wild-type (WT) mice were used to investigate the effects of IL-18 within a mouse model of psoriasis.

WT and IL-18 KO mice were divided into four groups, including imiquimod (IMQ)-treated IL-18 KO group (n= 11) and WT group (n= 13) as well as their respectively gene-matched control mice (receiving vaseline; n= 12). PASI scores were used to evaluate psoriatic lesions in IMQ-treated mice. Pathological features and dermal cellular infiltration were investigated by hematoxylin and eosin staining. The levels of psoriasis-related cytokines including IL-23, IL-17, IL-12, IL-1β, IFNγ, IL-15, IL-27, and IL-4 were tested by real-time polymerase chain reaction (PCR). The protein level of IL-1β, IL-27, CXCL1, and Ly6 g were investigated by immunohistochemistry (IHC).

Acanthosis (98.46 ± 14.12 vs. 222.68 ± 71.10 μm, P < 0.01) and dermal cell infiltration (572.25 ± 47.45 vs. 762.47 ± 59.59 cells/field, P < 0.01) were significantly milder in IMQ-induced IL-18 KO mice compared with that in WT mice. IMQ-induced IL-18 KO mice manifested larger areas of Munro microabscesses (11,467.83 ± 5112.09 vs. 4093.19 ± 2591.88 μm², P < 0.01) and scales (100,935.24 ± 41,167.77 vs. 41,604.41 ± 14,184.10 μm², P < 0.01) as compared with WT mice. In skin lesions of IL-18 KO mice, the expressions of IL-1β, IL-4, and IL-27 were all significantly upregulated but IL-17 was decreased. Histologically, strong positive signals of Ly6g were observed within the epidermis of IL-18 KO mice but expressions of CXCL1 were decreased.

IL-18 may exacerbate prominent inflammation and influence pathological features in IMQ-induced mouse model of psoriasis. IL-18 may upregulate pro-inflammatory cytokines and reduce protective cytokines, thus aggravating psoriatic inflammation. In addition, IL-18 may be involved in the formation of Munro microabscesses and scales.

Spinal cord injury (SCI) is a worldwide medical concern. This study aimed to elucidate the mechanism underlying the protective effect of hyperbaric oxygen (HBO) against SCI-induced neurologic defects in rats via exploring the stromal cell-derived factor-1 (SDF-1)/CXC chemokine receptor 4 (CXCR4) axis and expression of brain-derived neurotrophic factor (BDNF).

An acute SCI rat model was established in Sprague-Dawley rats using the Allen method. Sixty rats were divided into four groups (n= 15 in each group): sham-operated, SCI, SCI treated with HBO (SCI+ HBO), and SCI treated with both HBO and AMD3100 (an antagonist of CXCR4; SCI+ HBO+ AMD) groups. The rats were treated with HBO twice a day for 3 days and thereafter once a day after the surgery for up to 28 days. Following the surgery, neurologic assessments were performed with the Basso-Bettie-Bresnahan (BBB) scoring system on postoperative day (POD) 7, 14, 21, and 28. Spinal cord tissues were harvested to assess the expression of SDF-1, CXCR4, and BDNF at mRNA and protein levels, using quantitative real-time polymerase chain reaction, Western blot analysis, and histopathologic analysis.

HBO treatment recovered SCI-induced descent of BBB scores on POD 14, (1.25 ± 0.75 vs. 1.03 ± 0.66, P < 0.05), 21 (5.27 ± 0.89 vs. 2.56 ± 1.24, P < 0.05), and 28 (11.35 ± 0.56 vs. 4.23 ± 1.20, P < 0.05) compared with the SCI group. Significant differences were found in the mRNA levels of SDF-1 (mRNA: day 21, SCI+ HBO vs. SCI+ HBO+ AMD, 2.89 ± 1.60 vs. 1.56 ± 0.98, P < 0.05), CXCR4 (mRNA: day 7, SCI+ HBO vs. SCI, 2.99 ± 1.60 vs.1.31 ± 0.98, P < 0.05; day 14, SCI+ HBO vs. SCI+ HBO+ AMD, 4.18 ± 1.60 vs. 0.80 ± 0.34, P < 0.05; day 21, SCI+ HBO vs. SCI, 2.10 ± 1.01 vs.1.15 ± 0.03, P < 0.05), and BDNF (mRNA: day 7, SCI+ HBO vs. SCI, 3.04 ± 0.41 vs. 2.75 ± 0.31, P < 0.05; day 14, SCI+ HBO vs. SCI, 3.88 ± 1.59 vs. 1.11 ± 0.40, P < 0.05), indicating the involvement of SDF-1/CXCR4 axis in the protective effect of HBO.

HBO might promote the recovery of neurologic function after SCI in rats via activating the SDF-1/CXCR4 axis and promoting BDNF expression.

To confirm that acupuncture applied to patients would improve the clinical curative effect and accelerate the patient’s recovery by introducing the application of acupuncture in pre-operation, during operation, and post-operation.

Literature cited in this review was retrieved from PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI) and was primarily published in English or Chinese from 2010 to 2018, with keywords of "acupuncture," "electroacupuncture," "perioperative period," "sedation," "analgesia," and "recovery." Relevant citations in the retrieved articles were also screened to include more data.

All retrieved literature was scrutinized, most typical articles related on perioperative acupuncture application in clinical study were reviewed.

Acupuncture could relieve anxiety and stress during the preoperative stage. It reduces the usage of narcotics and stress response, and maintains the respiratory stability and homeostasis during surgery. It also exerts a protective effect on vital organs, and during the postoperative stages, enhances the recovery while effectively alleviating the postoperative pain. This phenomenon prevents common postoperative discomforts such as nausea and vomiting. In addition, it might improve the patients’ long-term prognosis.

The novel concept "perioperative acupuncture medicine" is to focus on the optimal treatment in the perioperative period of surgical patients. The review reveals the important role of acupuncture in enhancing rapid recovery of patients during the perioperative period.

To the Editor: Mitochondrial encephalomyopathy with lactate acidosis and stroke-like episodes (MELAS) is one of the most common multisystem mitochondrial disorders with broad clinical manifestations.^[1]It is usually caused by point mutations in the mitochondrialMT-TL1gene, which accounts for approximately 80% of mutations in individuals with MELAS syndrome.^[2]Pathogenic mitochondrial DNA (mtDNA) mutations were first described in 1988^[3]and m.14487T>C is a known pathogenic mtDNA mutation,^[4]which has been reported in patients with Leigh syndrome, optic neuropathy, ptosis, dystonia, and encephalomyopathy. We herein report a patient with late-onset MELAS syndrome with the m.14487T>C mutation for the first time.

To the Editor:Motor neuron disease (MND) is marked by upper (UMN) or lower (LMN) motor neuron signs and symptoms,^[1]which in various combinations form the basis for MND classification. In this regard, amyotrophic lateral sclerosis (ALS) is the most common subtype.^[2]Although otherwise deemed an untreatable degenerative disease, there is now increasing evidence of more heterogeneous pathogenesis, signaling a link between MND and paraneoplastic syndromes.^[3]

To the Editor:Acute basilar artery occlusion (BAO) is a catastrophic variant of stroke, which accounts for about 1% of all strokes.^[1]Though rare, BAOs are associated with high morbidity and mortality rates.^[2]Although treatable, the rate of death or disability associated with BAO is still as high as 80%.^[2]Early recanalization either with thrombolysis or intravascular thrombectomy was shown to significantly improve the outcome of patients with BAO.

To the Editor:The incidence of esophageal atresia (EA) along with tracheoesophageal fistula (TEF) is approximately 1/3000 in newborns.^[1]A large population study revealed that 46% of patients with TEF/EA had at least one of the other vertebral, anal, cardiac, tracheal, esophageal, renal, and limb (VACTERL) malformations.^[2]Duodenal obstruction has an incidence of 1/7000 live births and can be caused by duodenal atresia (DA) or annular pancreas (AP).^[3]AP is an uncommon congenital anomaly, and duodenal obstruction most commonly presents in the infancy or early childhood of patients.^[4]The incidence of DA combined with EA varies between 3% and 6%,^[5]and DA combined with EA is often associated with significant morbidity and mortality.^[6]Combined presence of EA/TEF and duodenal obstruction always lead to several management challenges, such as determination of the treatment order and the treatment pattern (together or staged).^[7]There is no relevant surgical strategy or literature for the complicated cases of combined digestive tract atresia in different parts of the chest and abdomen. The management protocol for this combination of anomalies is not well defined and controversial. A gastrostomy tube placed first for gastric decompression and staged repair (ideally within days, weeks) have been suggested by most surgeons.^[8]

To the Editor:Congenital diaphragmatic hernia is a congenital anomaly, rarely found in adults. Delayed presentation of congenital diaphragmatic hernia in adults can cause diagnostic dilemma. Immediate laparoscopic repair is recommended for these patients. Here, we presented a case of an 18-year-old man with complaints of chest pain and abdominal discomfort. X-ray and computed tomography (CT) scan revealed a right-sided pleuro-peritoneal hiatus hernia, which is located at postero-lateral diaphragm, also known as Bochdalek hernia.

To the Editor:A 68-year-old man presented with proteinuria of 1-year duration. A giant 22 cm × 18 cm fixed mass was found upon abdominal examination. Laboratory testing revealed severe proteinuria (3.0 g/24 h) and severe hypoalbuminemia 29 g/L (normal range: 40–55 g/L). The patient complained of passing foamy urine for a period of approximately 1 year and that the symptom seemed to worsen in the 20 days before hospital admission. Inflammatory and tumor markers were normal, but contrast-enhanced computed tomography of the abdomen [Figure 1] revealed a giant cystic solid neoplasm extending from the right upper quadrant of the retroperitoneum to the pelvis. A rich supply of blood vessels produced strong enhancement of the tumor surface. The presence of a tumor, proteinuria, and hypoalbuminemia prompted surgical removal of the abdominal mass. Enbloc resection of the mass was not only challenging, but also triggered transient intraoperative hypotension from decompression of the inferior vena cava and minor bleeding from the hypervascularized tumor capsule. The patient experienced postoperative acute kidney failure with increased serum creatine and severe oliguria and partial necrosis of the surgical incision on postoperative day 1. Kidney function completely recovered after 1 month of hemodialysis (three times weekly for 4 h). The necrotic incision skin was replaced by healthy skin following 2 weeks of topical alprostadil, a vasodilation agent. Postoperative histopathological evaluation confirmed a diagnosis of retroperitoneal paraganglioma, an unusual location of this neuroendocrine neoplasm that derives from extra-adrenal chromaffin cells. Most produce neuropeptides (e.g., catecholamines), grow rapidly, and progress with distant metastasis.^[1,2,3]Surgical excision is currently the only curative treatment as retroperitoneal paragangliomas appear to be resistant to radiochemotherapy.^[2,3]At the 3-month follow-up visit, the proteinuria had resolved and the serum albumin was nearly normal. The findings confirmed the initial interpretation of tumor-related proteinuria and proteinuria-related hypoalbuminemia. The patient’s normal blood pressure was consistent with a nonfunctional paraganglioma. The development of postoperative acute kidney failure indicates that control of decompression during resection of a giant abdominal mass is essential for maintaining stable intraoperative hemodynamics, but the root cause of the acute kidney injury might have been the preoperative proteinuria.^[4]Postoperative ischemic necrosis of the skin surrounding an abdominal incision is an extremely rare surgical complication. The efficacy of vasodilator treatment indirectly suggests a cause-effect relationship of insufficient blood supply and the skin necrosis. Increased skin tension resulting from the presence of the tumor seriously compromised the blood supply of the abdominal wall, but aberrant vessels connecting the compressed skin and the tumor were established. Removal of the mass resulted in acute postoperative reduction of the blood circulation in the skin. The latest follow-up at 28 months, found that the patient remained disease-free and was very satisfied with his health status. At that time, he gave informed consent to publish this case report.

To the Editor:Although the causes and mechanisms of lung cancer (LC) are still not clear, with the advances in science and technology and the progress in research methods, it has been shown that tumor cells aggregate with platelets (PLTs) and escape being recognized by the immune system. They adhere to distant vascular endothelial cells and continue to metastasize, invade and grow through the blood circulation.^[1]Therefore, the hypercoagulable state and enhancement of PLT functions promote tumor growth, invasion, and metastasis.^[2,3]Therefore, the effective reduction in PLT counts and their activities can help reduce the progression and prognosis of LC. We conducted this research to explore the effect of the tumor on circulating platelets in patients with LC.

To the Editor:Hailey-Hailey disease (HHD), first discovered by the brothers Howard and Hugh Hailey,^[1]is a genodermatosis at intertriginous sites. Mutation ofATP2C1on chromosome 3q21-2 coding a calcium-dependent ATPase gives rise to calcium dysfunction within keratinocytes, resulting in acantholysis due to a signal transduction disorder.^[2]It has been suggested that this gene mutation combined with irritation such as frequent friction, cold, and ultraviolet exposure leads to the development of HHD.^[3]

To the Editor:Non-arteritic anterior ischemic optic neuropathy (NAION), characterized by a sudden onset of unilateral painless visual loss and a swollen optic disc, is the most common form of acute optic neuropathy in patients over 50 years of age.^[1]The pathogenesis of NAION remains unclear, but most histopathological studies support the concept of vasculopathic occlusion in the region of the short posterior ciliary arteries.^[2]Functional magnetic resonance imaging (fMRI) is one of the most widely used non-invasive techniques for measuring brain function over timein vivo. To the best of our knowledge, only one study has investigated the effects of stimulating the affected eye in the extra-visual areas in NAION in humans.^[3]However, this previous study only examined task-state fMRI, and lacked a measure of resting-state fMRI (rs-fMRI). Thus, it remains unclear whether regional spontaneous brain changes are limited to the visual system.

To the Editor:Tetralogy of Fallot (TOF) was first surgically repaired in 1955. Initial TOF repairs were performed using a trans-annular right ventricular outflow tract patch to relieve the obstruction. However, this procedure resulted in long-standing pulmonary valve regurgitation and increased right ventricular (RV) volume, causing arrhythmias and sudden death.^[1]Thus, pulmonary annulus preservation became the most prevalent surgical strategy for TOF repair, possibly causing a mix of pulmonary stenosis and pulmonary valve regurgitation. Currently, clinicians concerned with RV function decrease during the long-term follow-up use of cardiac magnetic resonance imaging (CMR) to predict the appropriate timing of interventions for valve sparing. Although CMR techniques have evolved as the reference standard for assessing RV volumes and function during the last two decades, routinely monitoring the progression of repaired tetralogy of Fallot (rTOF) RV dysfunction remains difficult. Echocardiographic screening tools can help in estimating RV function and assist clinicians in determining the ideal timing of CMR. Because RV dysfunction is an important clinical outcome indicators,^[2]early detection of ventricular function is essential. Echocardiographic evaluation of RV function in rTOF patients is challenging because of the complex ventricle shape. Speckle tracking imaging (STI) provides alternative measurements for quantifying ventricular function. Developments in echocardiography techniques with STI that assess RV functional parameters may provide more sensitive detection, especially when using strain and strain rate (SR). Although STI can evaluate left ventricular function in clinical practice, the value of evaluating RV function in pathologic conditions remains questionable. Here, we evaluated the change of RV deformation parameters during the early phase in pediatric patients after TOF surgery and investigated STI value.