2019年 · 第132卷第07期

Sevoflurane is widely used to anesthetize children because of its rapid action with minimal irritation of the airways. However, there is a high risk of agitation after emergence from anesthesia. Strabismus surgery, in particular, can trigger agitation because patients have their eyes covered in the postoperative period. The aim of this study was to determine whether or not esmolol and lidocaine could decrease emergence agitation in children.

Eighty-four patients aged 3 to 9 years undergoing strabismus surgery were randomly assigned to a control group (saline only), a group that received intravenous lidocaine 1.5 mg/kg, and a group that received intravenous esmolol 0.5 mg/kg and lidocaine 1.5 mg/kg. Agitation was measured using the objective pain score, Cole 5-point score, and Richmond Agitation Sedation Scale score at the end of surgery, on arrival in the recovery room, and 10 and 30 min after arrival.

The group that received the combination of esmolol and lidocaine showed lower OPS and RASS scores than the other two groups when patients awoke from anesthesia (OPS = 0 (0-4), RASS = -4 [(-5)-1]) and were transferred to the recovery room (OPS = 0 (0-8), RASS = -1 [(-5)-3]) (P < 0.05). There was no significant difference in the severity of agitation among the three groups at other time points (P > 0.05).

When pediatric strabismus surgery is accompanied by sevoflurane anesthesia, an intravenous injection of esmolol and lidocaine could alleviate agitation until arrival in the recovery room.

Clinical Research Information Service, No. KCT0002925; https://cris.nih.go.kr/cris/en/search/search_re sult_st01.jsp?seq=11532

Helicobacter pylori (H. pylori) eradication has been widely used. The recurrence rate of H. pylori after eradication and its related factors are gaining more and more attention. Our study aimed to determine the recurrence rate of H. pylori infection after successful eradication, and analyze its influential factors.

We prospectively studied 1050 patients with upper gastrointestinal symptoms who were diagnosed as H. pylori infection by gastroscopy and underwent eradication therapies from April 2013 to January 2014. The ¹³C-urea breath test (UBT) or Warthin-Starry (WS) staining was done at 8 to 12 weeks after the therapy. Patients with successful eradication were followed by repeated UBT or gastroscopy at one year and 3 years after therapy, as well as, questionnaire surveys. Recurrence was considered if the UBTs or WS staining of biopsy were positive. One-year and 3-year recurrence rates were calculated, and analyzed the differences between recurred patients and others in basic data, sociological characteristics, lifestyle.

A total of 743 patients finished the 1-year follow-up, and the 1-year recurrence rate was 1.75%. Of the 607 patients who finished the 3-year follow-up, 28 patients recurred, and the 3-year recurrence rate was 4.61%. Analysis of variance showed that low-income, poor hygiene condition of dining out place, and receiving invasive diagnoses or treatments were significant risk factors for H. pylori infection recurrence. Logistic regression analysis demonstrated that the combination of invasive diagnoses or treatments, the level of income, and the hygiene standard of dining out place were significant and independent influential factors of the recurrence of H. pylori.

The 1-year and 3-year recurrence rates of H. pylori infection after eradication therapy are 1.75% and 4.61%. Low-income, poor hygiene condition of dining out place, and a combination of invasive diagnoses or treatments are independent risk factors of H. pylori recurrence.

Areal bone mineral density (aBMD) applied for osteoporosis diagnosis unavoidably results in the missingdiagnosis in patients with large bones and misdiagnosis in those with small bones. Therefore, we try to find a new adjusted index of bone mineral content (BMC) to make up shortcomings of aBMD in osteoporosis diagnosis.

In this multi-center epidemiological study, BMC and aBMD of lumbar spines (n = 5510) and proximal femurs (n = 4710) were measured with dual energy X-ray absorptiometry (DXA). We analyzed the correlation between the bone mass and body weight in all subjects including four age groups (<19 years, 20–39 years, 40–49 years, >50 years). And then the body weight was used for standardizing BMC (named wBMC) and applied for the epidemiological analysis of osteoporosis.

The correlation of body weight and BMC is 0.839 to 0.931 of lumbar vertebra 1–4 (L_1–4), and 0.71 to 0.95 of femoral neck in different age groups. When aBMD was applied for diagnosing osteoporosis, the prevalence was 7.55%, 16.39%, and 25.83% in patients with a high, intermediate, and low body weight respectively. However, the prevalence was 21.8%, 18.03%, and 11.64% by wBMC applied for diagnosing osteoporosis. Moreover, the prevalence of osteoporosis increased by 3.76% by wBMC with the body weight increased by 5 kg. The prevalence decreased by 1.94% when the body weight decreased by 5 kg.

wBMC can reduce the missed diagnosis in patients with large body weight and reduce misdiagnosis in those with small body weight. Including children, wBMC may be feasible for osteoporosis diagnosis individuals at any age.

Gastric intestinal metaplasia (GIM) is generally considered to be the main mucosal background for the development of gastric adenocarcinomas. Using linked color imaging (LCI), we noticed that the color pattern in areas of GIM was purple mixed with white on the epithelium with signs of mist that were detected by the non-magnifying LCI observation. We have termed this endoscopic finding "Purple in Mist" (PIM). The aim of this study was to investigate whether PIM could be a useful optical sign for predicting GIM.

We prospectively evaluated consecutive patients undergoing endoscopy for various indications. The endoscopist used the LCI system to carefully observe the gastric antrum, body and angulus. When a PIM was identified in the surface layer, targeted biopsies were subsequently taken from this part. If the suspected area had no PIM on the surface, targeted biopsies were also taken.

Sixty-three consecutive patients were included in this study. The prevalence of intestinal metaplasia (IM) was 29/63 (46%). In PIM-positive patients, the prevalence of IM was 23/26 (89%). Of these patients, 146 biopsy specimens were included in this study. For the diagnosis of IM, compared to histological assessment, the LCI finding had an accuracy of 91.1% (95%CI: 86.5%–95.7%), a sensitivity of 89.8% (95%CI: 81.3%–98.3%), a specificity of 91.8% (95%CI: 86.3%–97.2%), a positive predictive value of 84.6% (95%CI: 74.8%–94.4%), and a negative predictive value of 94.7% (95%CI: 90.1%–99.2%).

A positive PIM finding in a suspicious lesion on LCI would complement LCI diagnosis of possible IM because of the positive predictive value of PIM. PIM could be a novel endoscopic marker for IM.

ClinicalTrials.gov, No. NCT03092414; https://clinicaltrials.gov/ct2/show/NCT03092414?id=NCT03092414&rank=1

Growing industrialization of China exposes its labor population to the risk of musculoskeletal disorders (MSDs). This study aimed to investigate the prevalence and risk factors of MSDs in a modern industrial region of Beijing.

A cross-sectional study included 1415 employees in six industrial companies was conducted between January 2018 and May 2018 in Fangshan district, Beijng, China. Nordic Musculoskeletal Questionnaire (NMQ) was used to collect the information about MSDs. Demographic factors, lifestyle factors, health and medical factors, and work-related factors were collected as independent variables. Descriptive statistics, the chi-squared (χ²) test, and binary logistic regression analysis were used to analyze data.

Among 1415 participants, 498 reported MSDs. The regions involved were the neck (25.16%), shoulders (17.17%), and upper back (13.29%). There was a significant statistical difference between frontline industrial workers and other staff in the prevalence of self-reported symptoms involving the shoulders (χ² = 4.33, P= 0.037), wrists and hands (χ² = 8.90, P= 0.003), and ankles and feet (χ²= 12.88, P < 0.001). Increased age (P= 0.005, OR= 1.63; P= 0.001, OR = 2.33), a high or a low salary (P < 0.001, OR = 0.49; P < 0.001, OR = 0.30), night-shift (P= 0.027, OR = 1.46), two-week-history of illness and treatment (P= 0.004, OR= 5.60; P= 0.013, OR= 4.19), concurrent chronic diseases (P= 0.001, OR= 3.45; P= 0.092, OR= 7.81), limited access to health information (P= 0.004, OR= 0.49), and negative attitude towards seeking healthcare (P= 0.010, OR= 1.77; P= 0.009, OR= 2.75) were associated with MSDs in frontline workers. Female gender (P < 0.001, OR= 2.30), high education (P= 0.001, OR= 1.96), no exercises (P= 0.027, OR= 0.59), night-shift (P= 0.017, OR= 1.98), concurrent chronic diseases (P= 0.002, OR= 3.73; P= 0.020, OR= 13.42), limited access to health information (P= 0.013, OR= 0.53), far distance to medical institution (P= 0.009, OR = 1.83), and negative propensity (P= 0.009, OR = 1.94; P = 0.014, OR = 2.74) were associated with MSDs in other staffs.

The prevalence of MSDs among industrial employees has changed. Frontline workers had different prevalence and risk factors for MSDs compared with other employees. Negative propensity to healthcare, limited ways to obtain health knowledge, and concomitant chronic diseases were associated with MSDs. Surprisingly, highly educated and high-income employees had a higher risk of MSDs.

The endoscopic transnasal approach has been proven to have advantages on the removal of the tumors in pterygopalatine fossa (PPF) and infratemporal fossa (ITF). Herein, this study aimed to describe a modified approach for resection of the tumors in these areas, both in cadaveric specimen and clinical patients.

The 20 adult cadaveric specimens and five patients with tumors in PPF and ITF were enrolled in this study. For the cadaveric specimens, ten were simulated anterior transmaxillary approach and ten were performed modified endoscopic transnasal transmaxillary approach. The exposure areas were compared between two groups and main anatomic structure were measured. Surgery was operated in the five patients with tumors of PPF and ITF to verify the experience from the anatomy. Perioperative management, intraoperative findings and postoperative complications were recorded and analyzed.

The modified endoscopic transnasal transmaxillary approach provided as enough surgical exposure and high operability to the PPF and ITF as the anterior transmaxillary approach did. The diameter of maxillary artery in the PPF was 3.77 ± 0.78 mm (range: 2.06–4.82 mm), the diameter of middle meningeal artery in the ITF was 2.79 ± 0.61 mm (range: 1.54–3.78 mm). Four patients who suffered schwannoma got total removal and one of adenocystic carcinoma got subtotal removal. The main complications were facial numbness and pericoronitis of the wisdom tooth. No permanent complication was found.

With the widespread use of neuroendoscopy, the modified endoscopic transnasal transmaxillary approach is feasible and effective for the resection of tumors located in PPF and ITF, which has significant advantages on less trauma and complications to the patients.

Abnormally activated mechanistic target of rapamycin (mTOR) pathway has been reported in several model animals with inherited metabolic myopathies (IMMs). However, the profiles of mTOR pathway in skeletal muscles from patients are still unknown. This study aimed to analyze the activity of mTOR pathway in IMMs muscles.

We collected muscle samples from 25 patients with mitochondrial myopathy (MM), lipid storage disease (LSD) or Pompe disease (PD). To evaluate the activity of mTOR pathway in muscle specimens, phosphorylation of S6 ribosomal protein (p-S6) and p70S6 kinase (p-p70S6K) were analyzed by Western blotting and immunohistochemistry.

Western blotting results showed that p-p70S6K/p70S6K in muscles from LSD and MM was up-regulated when compared with normal controls (NC) (NC vs. LSD, U= 2.000, P= 0.024; NC vs. MM: U= 6.000, P= 0.043). Likewise, p-S6/S6 was also upregulated in muscles from all three subgroups of IMMs (NC vs. LSD, U= 0.000, P= 0.006; NC vs. PD, U= 0.000, P= 0.006; NC vs. MM, U= 1.000, P = 0.007). Immunohistochemical study revealed that p-S6 was mainly expressed in fibers with metabolic defect. In MM muscles, most p-S6 positive fibers showed cytochrome C oxidase (COX) deficiency (U= 5.000, P= 0.001). In LSD and PD muscles, p-S6 was mainly overexpressed in fibers with intramuscular vacuoles containing lipid droplets (U= 0.000, P = 0.002) or basophilic materials (U= 0.000, P= 0.002).

The mTOR pathway might be activated in myofibers with various metabolic defects, which might provide evidence for mTOR inhibition therapy in human IMMs.

Pulmonary artery hypertension associated with congenital heart disease (PAH-CHD) occurs predominantly among patients with uncorrected CHD. Treatment of severe pediatric PAH-CHD remains a major intractability. This study evaluated the predictors and prognoses of children with PAH-CHD who underwent surgical correction.

The data for 59 children with severe PAH-CHD who underwent surgical correction, with or without postoperative medication, between May 2011 and June 2015 at the Guangdong Provincial People’s Hospital were analyzed retrospectively. A regression analysis, receiver-operating characteristic (ROC) curves, and Kaplan-Meier curves were used for survival analysis.

Fifty-nine children with severe PAH-CHD underwent heart catheterization and correction, with or without specific anti-PAH drugs postoperatively, were included in this study. The pulmonary pressure, heart function, and ending events were observed and median observation period was 49 ± 20 months. Twenty-eight patients (50%) received at least one additional anti-PAH drug after correction. The survival rate after 2 years was 91.5% (54/59); two patients were in a critical condition, and three were lost to follow-up. Twelve patients (29%) still received over one additional PAH-specific therapy at follow-up, whereas 42 (75%) had successfully stopped drug treatment. Two patients (3.5%) died and one underwent a second thoracotomy to remove the ventricular septal defect patch. Acute vasoreactivity test (AVT) criteria had limited efficacy in predicting pediatric PAH-CHD, whereas pulmonary vascular resistance (PVR) ≤ 6.65 Wood units (WU)/m² or PVR/systemic vascular resistance (SVR) ≤ 0.39 during AVT indicated a good prognosis after surgical correction with an AUC of 98.3% (95% confidence interval [CI]: 96.0–100%), 98.4% (95% CI: 96.0–100%) sensitivity of 100%, 100% and specificity of 82.1%, 92.9%, respectively.

Although the criteria for positive AVT currently used are unsuitable for pediatric patients with PAH-CHD, PVR and PVR/SVR during AVT are excellent predictors of outcome in pediatric PAH-CHD. Surgery aided by anti-PAH drugs is an effective strategy and should be recommended for severe pediatric PAH-CHD with PVR ≤ 6.65 WU/m² and PVR/SVR ≤ 0.39 after iloprost aerosol inhalation.

The early identification of heart failure (HF) risk may favorably affect outcomes, and the combination of multiple biomarkers may provide a more comprehensive and valuable means for improving the risk of stratification. This study was conducted to assess the importance of individual cardiac biomarkers creatine kinase MB isoenzyme (CK-MB), B-type natriuretic peptide (BNP), galectin-3 (Gal-3) and soluble suppression of tumorigenicity-2 (sST2) for HF diagnosis, and the predictive performance of the combination of these four biomarkers was analyzed using random forest algorithms.

A total of 193 participants (80 patients with HF and 113 age- and gender-matched healthy controls) were included from June 2017 to December 2017. The correlation and regression analysis were conducted between cardiac biomarkers and echocardiographic parameters. The accuracy and importance of these predictor variables were assessed using random forest algorithms.

Patients with HF exhibited significantly higher levels of CK-MB, BNP, Gal-3, and sST2. BNP exhibited a good independent predictive capacity for HF (AUC 0.956). However, CK-MB, sST2, and Gal-3 exhibited a modest diagnostic performance for HF, with an AUC of 0.709, 0.711, and 0.777, respectively. BNP was the most important variable, with a remarkably higher mean decrease accuracy and Gini. Furthermore, there was a general increase in predictive performance using the multi-marker model, and the sensitivity, specificity was 91.5% and 96.7%, respectively.

The random forest algorithm provides a robust method to assess the accuracy and importance of predictor variables. The combination of CK-MB, BNP, Gal-3, and sST2 achieves improvement in prediction accuracy for HF.

Heterotopic ossification (HO) is a known complication of hip arthroscopy. We investigated incidence of HO after hip arthroscopy and determined whether revision for HO improved outcome.

A retrospective study was conducted on 242 patients (140 men and 102 women, mean age: 36.2 ± 9.5 years) who underwent hip arthroscopy for femoroacetabular impingement (FAI) between January 2016 and January 2018. The average follow-up period was 22.88 ± 11.74 months (range: 11–34 months). Thirteen (5.37%) cases of HO (six men and seven women, five left hips and eight right hips; mean age: 37.5 ± 4.7 years) were observed. Among them, four cases with HO with obvious pain symptoms and persistent non-remission underwent revision surgery to remove HO. Monthly follow-up was conducted. Visual analog scale (VAS), modified Harris Hip Score (mHHS), and non-Arthritis Hip Score (NAHS) were evaluated and compared between HO and non-HO patients. Independent sample t test, Mann-Whitney U test and the Chi-square test were used for inter-group comparisons. HO degree was evaluated using Brooker classification. Symptoms and function were evaluated before and after revision.

A total of 242 patients were involved in this study. Thirteen cases (5.4%) had imaging evidence of HO. Nine (9/13) were classified as Brooker stage I, three (3/13) Brooker stage II, and one (1/13) Brooker stage III. HO was detected by ultrasonography as early as 3 weeks after operation. After primary surgery, the mHHS of the HO group and non-HO group increased by 13.00 (8.50, 25.50) and 24.00 (14.00, 34.50) points (Z=－1.80, P= 0.08), NAHS increased by 18.00 (9.50, 31.50) and 26.00 (13.50, 36.00) points (Z=－1.34, P= 0.18), and VAS decreased by 3.00 (2.00, 4.00) and 4.00 (3.00, 4.50) points (Z=－1.55, P= 0.12). Average follow-up time after revision was 9.00 ± 2.94 months; mHHS increased by 34.75 points (t=－55.23, P < 0.01) and NAHS by 28.75 points (t=－6.03, P < 0.01), and VAS decreased by 4 points (t= 9.80, P < 0.01). HO and non-HO patients were similar for demographic and surgical data, and clinical and functional scores.

HO incidence after arthroscopic treatment of FAI is similar to that found in previous studies. Most HO have no effect on clinical symptoms. Patients who undergo revision HO resection show improvement in pain and joint function.

Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by a broad spectrum of clinical manifestations. Although great progress has been made in understanding the contribution of genetic and environmental factors in SLE pathogenesis, as there are over 20,000 published studies evaluating related cellular dysfunction,^[1]the exact mechanisms that underline this process are still unknown. Over the past 10 years, novel insights have mainly originated from genome-wide association (GWAS) and gene expression studies.

To the Editor:Neonatal diabetes mellitus (NDM) is defined as diabetes diagnosed within 6 months after birth and occurs in approximately one in every 90,000 to 160,000 live births, with an 80% yield due to a known genetic diagnosis. NDM can be classified as transient (TNDM), permanent (PNDM), or syndromic, in which TNDM accounts for approximately 45% of all cases of NDM. Overexpression of genes on chromosome 6q24 is the most common cause of TNDM (OMIM_601410), which accounts for approximately 70% of all cases and occurs by one of three mechanisms: (1) paternal uniparental disomy (41%), (2) duplication of paternal alleles (33%), or (3) hypomethylation of the maternal allele (26%).^[1]TNDM can be characterized as small for gestational age and yield a "Diabetes-Remission-Relapse" natural history, where insulin is deemed to be the original treatment.^[2]However, there is no standard treatment for relapsed patients. Hence, we report a Chinese male patient with a history of 6q24-related TNDM (hypomethylation of the maternal allele) who relapsed at 14 years old and was successfully treated with a low dose of glimepiride.

To the Editor:Regeneration is a common phenomenon among many animals including; starfish, salamander, zebrafish and flatworms. These creatures have a natural ability to regrow their accidentally lost body parts, for example flatworms can regenerate their lost head.^[1]But not all organisms can regenerate their whole body organs. However, this natural phenomena is akin with the modern day advancement in stem cell biology and developmental biology, which has enabled scientists to not only study organsin vitrobut also achieve new frontiers in regenerative medicine.^[2]

To the Editor:Chloroma is a rare solid tumor that was formed sometimes from malignant myeloid blast cells outside the hematopoietic system; these are known as chloroma or granulocytic sarcoma.^[1]Chloroma can be diagnosed anywhere outside of the hematopoietic system, such as the head and neck, skeletal system, breast, uterus, and central nervous system.^[2]This tumor is common in leukemic patients.^[3]Chloroma presents as an epidural mass resulting in spinal cord compression with neurologic symptoms.^[4]Spinal lesions occur most frequently at the thoracic level; however, the most common primary symptoms are low back pain and radiating pain in the legs.^[5]

To the Editor:Distal myopathy is a heterogenetic disorder characterized by early distal lower limb involvement, which has been linked to 18 disease-causing genes. The gene responsible for Laing distal myopathy (LDM, also called distal myopathy 1; OMIM 160500) was determined to be the myosin heavy chain 7 gene (MYH7) located on chromosome 14q11.^[1]MYH7encodes the myosin heavy chain beta isoform (MyHC-β) and is expressed predominantly in the cardiac ventricle and in type 1 skeletal muscle fibers. The mutant MyHC-β protein is also linked to familial hypertrophic cardiomyopathy (OMIM 192600), dilated cardiomyopathy (OMIM 115200), left ventricular non-compaction and myosin storage myopathy (OMIM 608358). Only deletion or missense mutations in exon 32 to 36 of theMYH7gene are linked to LDM; missense mutations of exon 37 to 40 are linked to myosin storage myopathy.^[2]The mutations of theMYH7gene exhibit complete penetrance.

To the Editor:Leukemia is a malignant proliferative disease that has become the most common malignancy in children, accounting for 40.5% of malignant cancers children.^[1]Although chemotherapy can effectively treat children, some patients with high-risk and relapsed acute lymphoblastic leukemia (ALL) and acute myelocytic leukemia (AML) failed to achieve long-term relief. For these patients, allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the best choice. However, many factors may impact the efficacy of allo-HSCT. We retrospectively analyzed the clinical data of 71 children with leukemia treated using allo-HSCT to observe the clinical efficacy and analyze the possible influencing factors.

To the Editor: Mutations in mitochondrial DNA (mtDNA) cause mitochondrial diseases with multisystem involvement and variable clinical phenotypes. Myoclonic epilepsy with ragged red fiber (MERRF) syndrome is characterized by myoclonus, generalized epilepsy, cerebellar ataxia, and mitochondrial myopathy with ragged red fibers (RRFs). Other features include hearing impairment, psychiatric disorders, and dysarthria.^[1]More than 20 heteroplasmic point mutations have been identified as responsible for MERRF, indicating the genetic heterogeneity of mitochondrial diseases. The m.8344A>G mutation in the mitochondrial tRNA^Lys(MT-TK) gene is the most common mutation and is responsible for approximately 80% of MERRF cases. Other MERRF-related mutations are relatively rare, but up to 10% of MERRF patients have no identifiable mutations. The m.5703G>A mutation in the mitochondrial tRNA^Asn(MT-TN) gene has previously been reported to cause mitochondrial myopathy (MM).^[2,3]To the best of our knowledge, no association has been reported between MERRF syndrome and the m.5703G>A mutation. The present report describes a patient with typical MERRF syndrome carrying a heteroplastic m.5703G>A mutation and expands not only the genotypic spectrum of MERRF but also the phenotypic spectrum of the m.5703G>A mutation.

To the Editor:Diabetic kidney disease (DKD) is one of the major causes of end-stage renal failure. Progressive mesangial expansion in the glomerulus is widely recognized. More and more evidence shows that tubulointerstitial fibrosis is also regarded as a prominent feature of DKD, in which tubular epithelial-mesenchymal transition (EMT) may play an important role.^[1]During EMT, tubular epithelial cells lose their characteristic and produce high levels of myofibroblast makers such as α-smooth actin (α-SMA) which is the signature protein of EMT.^[2]However, renal fibrogenesis is a complicated process in which the contribution of DKD is unknown.

To the Editor: MalasseziaandStaphylococcus epidermidis(S. epidermidis) are commensal organisms found on human skin, and both display an imbalance of colonization in individuals with seborrheic dermatitis/dandruff (SD/D).^[1,2,3]Malasseziahave been implicated in SD/D pathogenesis, as evidenced by an imbalance in the numbers ofMalasseziathat colonize the skin lesions of people with SD/D, and the fact that antifungal treatment exerts a modifying effect.^[4]AmongMalasseziaspecies,Malassezia furfur(M. furfur) is the predominant in Chinese seborrheic dermatitis (SD) patients.^[5]Recently, large numbers ofS. epidermidishave been found in the lesions of individuals with acquired immunodeficiency syndrome (AIDS)-related SD, classical SD, and dandruff.^[1,2]A topical antibiotic cream such as fusidic acid cream can often improve the symptoms of SD, suggesting a pathological role forS. epidermidisin SD.^[1]Whether co-colonization ofMalasseziaandS. epidermidisin the skin lesions of SD/D suggests their biological interactions is an interesting topic to investigate.

To the Editor:Nowadays, most infants with tetralogy of Fallot (TOF) survive the initial surgical repair; however, they continue to experience residual hemodynamic and physiologic abnormalities in the follow-up.^[1]Pulmonary regurgitation (PR) is still recognized as the most common complication that determines late outcomes. PR may result in right ventricular (RV) dilatation and, ultimately, cardiac dysfunction. Indicators of deterioration of clinical status such as impaired exercise tolerance, ventricular arrhythmia, and sudden cardiac death have all been associated with chronic PR. The degree of PR is one of the most important factors determining RV dysfunction; thus, pulmonary valve replacement becomes necessary to retain lower RV volumes, increase the RV systolic function, and lower the mortality rates.^[2]Cardiac magnetic resonance (CMR) imaging is now recommended as the optimal method to use in the follow-up of patients with TOF.^[3]It has been proven to be more accurate than transthoracic echocardiography for the evaluation of RV function due to the irregular RV cavity.^[4,5]Indexed PR volume (PRVi) and PR fraction (PRF) are the two main markers to be measured; however, the optimal method for PR quantification remains controversial. Previous studies have recommended the use of PRVi and hypothesized that this marker is better than PRF in reflecting RV preload. However, PRVi is not widely used in clinical practice and has not been the diagnostic standard for PR classification. Accordingly, our study aimed to discover the optimal index for the assessment of the degree of PR.

To the Editor:The prevalence of obesity, defined as body mass index (BMI) ≥30 kg/m², is increasing worldwide and has been identified that obesity is a risk factor for several kinds of chronic diseases.^[1]According to the severity of obesity, associated coexisting chronic diseases, and functional limitations, therapies for obesity include lifestyle intervention (eg, diet and exercise), pharmacotherapy, endoscopic bariatric therapies, bariatric surgery, and bariatric embolization (BAE).