2019年 · 第132卷第16期

Community-acquired pneumonia (CAP) is a common respiratory disease and is considered to be the leading cause of mortality among various infectious diseases.^[1,2]A large population-based study showed that among hospitalized patients diagnosed with pneumonia, 21% of them required the intensive care unit (ICU) admission, 6% required invasive mechanical ventilation, and 2% died.^[3]Although therapeutic strategies have been significantly improved over recent years, the morbidity and mortality of CAP, especially severe CAP (SCAP), remain high. Mortality of SCAP has been reported to range from 17% to 49% by different multi-center cohort studies.^[4]The Infectious Diseases Society of America (IDSA), American Thoracic Society (ATS) and the Infectious Disease Assembly, Chinese Thoracic Society, have published consensus guidelines for CAP (IDSA/ATS 2007, CTS 2016), which clearly defined SCAP criteria.^[5]According to IDSA/ATS SCAP criteria, patients with SCAP requiring ICU admission should have at least one major criteria (invasive mechanical ventilation or septic shock with the need for vasopressors) or at least three minor criteria (respiratory rate ≥30 breaths/min, oxygenation index (PaO2/FiO2) ratio ≤250, multi-lobe infiltrates, hypothermia (core temperature <36℃), leukopenia (white blood cell count <4000 cells/mm³), thrombocytopenia (platelet count <100,000 cells/mm³), hypotension requiring aggressive fluid resuscitation, confusion/disorientation, and uremia (blood urea nitrogen (BUN) ≥20 mg/dL).^[5]

Extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (E. coli) and Klebsiella pneumoniae (K. pneumoniae) are the important pathogens causing pneumonia. This study aimed to investigate the clinical characteristics and molecular epidemiology of ESBL-producing E. coli and K. pneumoniae causing pneumonia at a large teaching hospital in China.

We collected patient’s clinical data and ESBL-producing E. coli and K. pneumoniae strains causing pneumonia (from December 2015 to June 2016) at a hospital in Wuhan. The susceptibilities, multi-locus sequence typing, homologous analysis, ESBL genes by polymerase chain reaction and sequencing were determined.

A total of 59 ESBL-producing strains (31 E. coli and 28 K. pneumoniae) isolated from patients with pneumonia were analyzed. The majority of strains were isolated from patients were with hospital-acquired pneumonia (37/59, 62.7%), followed by community-acquired pneumonia (13/59, 22.0%), and ventilator-related pneumonia (9/59, 15.3%). The E. coli ST131 (9 isolates, 29.0%) and K. pneumoniae ST11 (5 isolates, 17.9%) were the predominant sub-types. The most prevalent ESBL gene was CTX-M-14, followed by SHV-77, CTX-M-3, SHV-11, and CTX-M-27. At least 33 (55.9%) of the ESBL-producing strains carried two or more ESBL genes. The ISEcp1 and IS26 were found upstream of all blaCTX-M (CTX-Ms) and of most blaSHV (SHVs) (57.6%), respectively. Moreover, three ESBL-producing K. pneumoniae ST11 strains which were resistant to carbapenems carried the bla_NDM-1 and bla_KPC-2, two of which also bearing bla_OXA-48 were resistant to all antibiotics (including Tigecycline).

Hospital-acquired pneumonia is more likely correlated with ESBL-producing E. coli and K. pneumoniae. ESBL-producing E. coli ST131 and multi-drug resistance ESBL-producing, as well as New Delhi metallo-β-lactamase-1 (NDM-1) and Klebsiella pneumoniae carbapenemases-2 (KPC-2) bearing K. pneumoniae ST11 are spreading in patients with pneumonia in hospital.

Cross-sectional area (CSA) for small pulmonary vessels is considered a parameter of pulmonary vessel alterations in patients with chronic obstructive pulmonary disease. This study was to evaluate the correlation of CSA with airflow obstruction parameters in asthma. Furthermore, we aimed to measure the difference in vascular alteration between asthma phenotypes and evaluate its relation with cytokine levels.

We consecutively enrolled 20 adult asthmatic patients (13 women: age range, 26–80 years) and 20 healthy controls (8 women: age range, 23–61 years) from Peking University Third Hospital. Total CSA <5 mm² (CSA<5) was measured with 64-slice spiral computed tomography, and the percentage CSA <5 for the lung area (%CSA<5) was calculated. Data were corrected for body surface area to obtain sixth-generation airway luminal diameter (LD_cor), luminal area (Ai_cor), and airway wall thickness, and airway wall area percentage (WA%) was calculated. Enzyme-linked immunosorbent assay was used to detect the expression of leptin, total immunoglobulin E, periostin, and transforming growth factor β1 in serum and matrix metalloproteinase 9 in induced sputum supernatant of asthmatic patients. The differences in %CSA<5 between subgroups were assessed by independent samples Student’s t test, and Spearman correlation analysis was used to analyze the correlation of %CSA<5 with clinical indexes and inflammatory cytokine levels.

Patients with asthma and controls did not differ in %CSA<5. In asthma patients, %CSA<5 was lower with initial onset age ≤12 years old, airflow restriction and uncontrolled Global Initiative for Asthma classification (all P < 0.05). Moreover, it was positively correlated with forced vital capacity ratio in 1 s (FEV₁)/forced expiratory volume ratio, FEV₁%, LD_cor, Ai_cor, and serum leptin level (all P < 0.05) and negatively with total lung WA% (P = 0.007).

%CSA<5 of pulmonary small vessels was well correlated with airflow limitation indexes and sixth-generation airway parameters. It has certain significance in predicting the clinical control of asthma.

Little study has investigated the differences between Talatomyces marneffei (T. marneffei) respiratory infection and tuberculosis and the prognostic factors of such infection. This study investigated the characteristics and prognostic factors of T. marneffei infections with respiratory lesions and the causes of misdiagnosis.

Clinical characteristics and prognoses of patients with T. marneffei infections with respiratory system lesion were investigated. T. marneffei diagnosis followed isolation from clinical specimens using standard culture, cytology, and histopathology. Survival curves were estimated by using Kaplan-Meier analysis, with log-rank test to compare differences in survival rates between groups. Univariate and multivariate Cox regression analyses were also performed to assess significant differences in clinical characteristics of overall survival.

Of 126 patients diagnosed with T. marneffei infections, 63 (50.0%) had T. marneffei respiratory system infections; 38.1% (24/63) were misdiagnosed as having tuberculosis. Human immunodeficiency virus (HIV) infection, CD4/CD8 < 0.5, percentage of CD4⁺ T cells <42.8%, and length of time from onset to confirmation of diagnosis >105 days were potential risk factors for poor prognoses. Length of time from onset to confirmation of diagnosis persisted as an independent predictor of all-cause mortality in multivariate analysis (odds ratio: 0.083, 95.0% confidence interval: 0.021–0.326, P < 0.001). However, the size of the lung lesions, dyspnea, thoracalgia, mediastinal lymphadenopathy, and pleural effusion did not significantly predict overall survival. There was no significant difference in prognosis according to the type of treatment.

T. marneffei infections involving the respiratory system are common. The critical determinants of prognosis are HIV infection, CD4/CD8, percentage of CD4⁺ T cells, type of treatment, and the time range from onset to confirmation of diagnosis. Rapid and accurate diagnosis is crucial for improving prognosis.

Differential diagnosis of idiopathic Parkinson disease (IPD) and multiple system atrophy-Parkinson type (MSA-P) is challenging since they share clinical features with parkinsonism and autonomic dysfunction. To distinguish MSA-P from IPD when the symptoms are relatively mild, we investigated the usefulness of the quantitative fractionalized autonomic indexes and evaluated the correlations of autonomic test indexes and functional status.

Thirty-six patients with parkinsonism (22 with IPD and 14 with MSA-P) in Soonchunhyang University Bucheon Hospital from February 2014 to June 2015 were prospectively enrolled in the study. We compared fractionalized autonomic indexes and composite autonomic scoring scale between patients with IPD and MSA-P with Hoehn and Yahr (H&Y) score ≤3. Parasympathetic indexes included expiratory/inspiratory ratio during deep breathing, Valsalva ratio (VR), and regression slope of systolic blood pressure (BP) in early phase II (vagal baroreflex sensitivity) during Valsalva maneuver. Sympathetic adrenergic indexes were pressure recovery time (PRT) and adrenergic baroreflex sensitivity (BRSa) (BP decrement associated with phase 3 divided by the PRT), sympathetic index 1, sympathetic index 3, early phase II mean BP drop, and pulse pressure reduction rate. Additionally, we compared the unified multiple system atrophy rating scale (UMSARS) and H&Y scores and the autonomic indexes in all patients.

PRT was significantly different between the IPD and MSA-P groups (P = 0.004) despite the similar BP drop during tilt. Cutoff value of PRT was 5.5 s (sensitivity, 71.4%; specificity, 72.7%). VR (r = -0.455, P = 0.009) and BRSa (r = -0.356, P = 0.036) demonstrated a significant correlation with UMSARS and H&Y scores.

Among the cardiovascular autonomic indexes, PRT can be a useful parameter in differentiating the early stage of MSAP from that of IPD. Moreover, VR, and BRSa may be the optimal indexes in determining functional symptom severity.

The development of auditory and speech perception ability of children with hearing loss is affected by many factors after they undergo cochlear implantation (CI). Age at CI (CI age) appears to play an important role among these factors. This study aimed to evaluate the development of auditory and speech perception ability and explore the impact of CI age on children with prelingual deafness present before 3 years of age.

Two hundred and seventy-eight children with pre-lingual deafness (176 boys and 102 girls) were included in this study, and the CI age ranged from 6 to 36 months (mean age, 19 months). Categorical auditory performance (CAP) was assessed to evaluate auditory ability, and the speech intelligibility rating was used to evaluate speech intelligibility. The evaluations were performed before CI and 1, 3, 6, 12, 18, 24, 36, 48, and 60 months after CI.

The auditory ability of the pre-lingually hearing-impaired children showed the fastest development within 6 months after CI (k = 0.524, t = 30.992, P < 0.05); then, the progress started to decelerate (k = 0.14, t = 3.704, P < 0.05) and entered a plateau at the 24th month (k = 0.03, t = 1.908, P < 0.05). Speech intelligibility showed the fastest improvement between the 12th and 24th months after CI (k = 0.138, t = 5.365, P < 0.05); then, the progress started to decelerate (k = 0.026, t = 1.465, P < 0.05) and entered a plateau at the 48th month (k = 0.012, t = 1.542, P < 0.05). The CI age had no statistical significant effect on the auditory and speech abilities starting at 2 years after CI (P < 0.05). The optimal cutoff age for CI was 15 months.

Within 5 years after CI, the auditory and speech ability of young hearing-impaired children continuously improved, although speech development lagged behind that of hearing. An earlier CI age is recommended; the optimal cutoff age for CI is at 15 months.

There are only very few reports on clinical outcomes using multi-channel applicators (MCA) for patients with endometrial cancer (EC) in China. We aimed to evaluate the clinical experience of treating intermediate-risk (IR) to high-risk (HR) stage I EC using in-house made multi-channel applicators (IH-MCA) in a single institution.

Three hundred and ninety patients with stage I IR to HR EC were treated with hysterectomy and adjuvant radiotherapy from 2003 to 2015. All patients received post-operative vaginal cuff brachytherapy (VBT) alone or as a boost after external beam radiotherapy (EBRT). The prescriptions were 500 cGy per fraction for a total of 5 to 6 fractions with brachytherapy alone or 400 to 600 cGy per fraction for 2 to 3 fractions if it was combined with EBRT. Two types of applicators including a traditional rigid IH-MCA and a recent model custom-made with 3 dimension printing technology were used for treatment. The Kaplan-Meier method was used to calculate survival rate.

Follow-up rate was 92.8% and the median follow-up time was 48 months (range 4–172 months). The 5-year overall survival (OS), progression-free survival, local recurrence, and distant metastasis rates for all patients were 96.3%, 92.1%, 2.9%, and 4.8% respectively. Two patients had isolated relapse in vagina outside the irradiated volume. The univariate and multivariate analysis showed that age and grade were the prognostic factors correlated with OS (hazard ratio: 0.368, 95% confidence interval [CI]: 0.131–1.035, P = 0.048; hazard ratio: 0.576, 95% CI: 0.347–0.958, P = 0.026,).

For patients with IR to HR stage I EC, adjuvant VBT alone or in combination with EBRT using IH-MCA led to excellent survival and recurrence rates. Age and grade were the prognostic factors correlated with OS.

Henoch-Schonlein purpura nephritis (HSPN) is a very common secondary kidney disease of childhood. Its pathogenesis and the treatment mechanism of glucocorticoid have not been fully elucidated. The aim of this study was to determine the relationship between p300 and the pathogenesis, glucocorticoid therapy in mice with HSPN, respectively.

Forty-eight C57BL/6N male mice, weighing 18 to 20 g, were selected (3–4 weeks old, n = 8 per group). The mice in the normal control group (Group I) were given normal solvent and the HSPN model group (Group II) were given sensitizing drugs. The mice in Group III were injected intraperitoneally with dexamethasone after being given sensitizing drugs. Meanwhile, mice in Groups IV, V and VI with conditional knockout of p300 were also given normal solvent, sensitizing drugs and dexamethasone. The levels of serum IgA, creatinine, and circulating immune complex (CIC) concentrations, 24 h urinary protein and urinary erythrocyte in C57 wild mice, and p300 conditional knockout mice in each group were measured. The expression of p300 in renal tissues and the expression of glucocorticoid receptor (GR) α and β, transforming growth factor (TGF)-β1, and activator protein (AP)-1 after dexamethasone treatment were determined by real-time polymerase chain reaction and Western blotting.

Compared with the normal solvent control group (Group I), the expression of p300 mRNA in the model group (Group II) was significantly up-regulated. Western blotting further confirmed the result. Urinary erythrocyte count, 24 h urinary protein quantification, serum IgA, CIC, and renal pathologic score in Group V were distinctly decreased compared with non-knockout mice in Group II (9.7 ± 3.8 per high-power field [/HP] vs. 18.7 ± 6.2/HP, t = 1.828, P = 0.043; 0.18 ± 0.06 g/24 h vs. 0.36 ± 0.08 g/24 h, t = 1.837, P = 0.042; 18.78 ± 0.85 mg/mL vs. 38.46 ± 0.46 mg/mL, t = 1.925, P = 0.038; 0.80 ± 0.27 μg/mL vs. 1.64 ± 0.47 μg/mL, t = 1.892, P = 0.041; 7.0 ± 0.5 vs. 18.0 ± 0.5, t = 1.908, P = 0.039). Compared with non-knockout mice (Group III), the level of urinary erythrocyte count and serum IgA in knockout mice (Group VI) increased significantly after treatment with dexamethasone (3.7 ± 0.6/HP vs. 9.2 ± 3.5/HP, t = 2.186, P = 0.024; 12.38 ± 0.26 mg/mL vs. 27.85 ± 0.65 mg/mL, t = 1.852, P = 0.041). The expression level of GRα was considerably increased in the knockout group after dexamethasone treatment compared with non-knockout mice in mRNA and protein level (t = 2.085, P = 0.026; t = 1.928, P = 0.035), but there was no statistically significant difference in the expression level of GRβ between condition knockout and non-knockout mice (t = 0.059, P = 0.087; t = 0.038, P = 1.12). Furthermore, the expression levels of glucocorticoid resistance genes (AP-1 and TGF-β1) were notably increased after p300 knockout compared with non-knockout mice in mRNA and protein level (TGF-β1: t = 1.945, P = 0.034; t = 1.902, P = 0.039; AP-1: t = 1.914, P = 0.038; t = 1.802, P = 0.041).

p300 plays a crucial role in the pathogenesis of HSPN. p300 can down-regulate the expression of resistance genes (AP-1 and TGF-β1) by binding with GRα to prevent further renal injury and glucocorticoid resistance. Therefore, p300 is a promising new target in glucocorticoid therapy in HSPN.

The effect and mechanism of Saccharomyces boulardii (Sb) in inflammatory bowel disease are unclear. The objective of the study was to evaluate the impact of Sb on intestinal mucosal barrier and intestinal flora in a colitis mouse model.

Forty C57BL/6J male mice were randomly assigned to five groups: normal control group (A), pathologic control group (B), Sb treatment group (C), mesalazine treatment group (D), and Sb combined with mesalazine treatment group (E). Colitis was induced by the addition of 2.5% (wt/vol) dextran sodium sulfate (DSS) in the drinking water ad libitum for 7 days. The general condition, weight change, stool property, and bloody stool level of mice were observed to evaluate the disease activity index. The expression of zona occludens-1 (ZO-1) and occludin in intestinal tissue were measured by immunohistochemistry. The level of tumor necrosis factor-α (TNF-α) and interleukin (IL)-8 in plasma was measured by enzyme linked immunosorbent assay. Inter-cellular tight junctions were observed by transmission electron microscopy. The feces and intestinal contents were collected sterilely, and intestinal flora was analyzed by 16S rRNA sequencing.

Compared with group B, Sb reduced the disease activity index and histological score of group C (disease activity index: group B 2.708 ± 0.628, group C 1.542 ± 0.616, P_BC = 0.005; histological score: group B 9.875 ± 3.271, group C 4.750 ± 1.832, P_BC = 0.005) in DSS-induced colitis in mice. Sb exerted a protect effect on the expression of ZO-1 (group B 2.075 ± 1.176, group C 4.225 ± 1.316, P_BC = 0.019) and occludin (group B 2.200 ± 0.968, group C 3.525 ± 1.047, P_BC = 0.023). Compared with group B, Sb decreased the level of TNF-α and IL-8 of group C (TNF-α: group B 716.323 ± 44.691 ng/L, group C 521.740 ± 90.121 ng/L, P_BC = 0.001; IL-8: group B 128.992 ± 11.475 pg/mL, group C 106.283 ± 15.906 pg/mL, P_BC = 0.012). Treatment with Sb preserved the tight junctions and ameliorated microvilli and inter-cellular space. Treatment with Sb also showed its own characteristics: a higher percentage of Bacteroidetes and a lower percentage of Firmicutes, with significant differences or a significant trend. The proportion of the S24-7 family was increased significantly in the Sb treatment group.

Sb shows an anti-inflammatory effect and has a protective effect on the intestinal mucosal mechanical barrier. Sb may up-regulate the abundance of family S24-7 specifically, and maybe a mechanism underlying its function.

Nickel-induced allergic contact dermatitis (Ni-ACD) is a global health problem. More detailed knowledge on the skin uptake of haptens is required. This study aimed to investigate the penetration process and distribution of nickel in skin tissues with late phase and early phase of Ni-ACD to understand the mechanisms of metal allergy.

Forty Hartley guinea pigs were divided into four groups according to the NiSO₄ sensitizing concentration and the NiSO₄ challenged concentration: the 5% NiSO₄-group, 5% to 10% (sensitization-challenge; late phase group); 10% NiSO₄-group, 10% to 10% (sensitization-challenge; early-phase group); and the positive and negative controls. Pathological biopsies were performed on each group. The depth profile of nickel element concentration in the skin of guinea pigs was detected by synchrotron radiation micro X-ray fluorescence spectroscopy (SR-μ-XRF) and micro X-ray absorption near-edge spectroscopy (μ-XANES).

In each section, the nickel element concentration in both the 5% NiSO₄-group and 10% NiSO₄-group was significantly higher than that in the negative control group. In the upper 300-μm section of skin for the early phase group, the nickel element concentration was significantly higher than that in the lower section of skin. In deeper sections (<200 μm) of skin, the concentration of nickel in the early phase group was approximately equal to that in the late phase group. The curve of the late phase group was flat, which means that the nickel element concentration was distributed uniformly by SR-μ-XRF. According to the XANES data for the 10% NiSO₄ metal salt solution, structural changes occurred in the skin model sample, indicating that nickel was not present in the Ni²⁺ aqueous ionic state but in the nickel-binding protein.

This study showed that the distribution of the nickel element concentration in ACD skin tissue was different between the early phase and late phase groups. The nickel element was not present in the Ni²⁺ aqueous ionic state but bound with certain proteins to form a complex in the stratum corneum in ACD model tissue.

Recent studies have shown the important influence of various micro factors on the general biological activity and function of endothelial cells (ECs). Vascular endothelial growth factor (VEGF) and angiogenin (ANG) are classic micro factors that promote proliferation, differentiation, and migration of ECs. The underlying pathophysiological mechanisms and related pathways of these micro factors remain the focus of current research.

An extensive search was undertaken in the PubMed database by using keywords including "micro factors" and "endothelial cell." This search covered relevant research articles published between January 1, 2007 and December 31, 2018.

Original articles, reviews, and other articles were searched and reviewed for content on micro factors of ECs. Results: VEGF and ANG have critical functions in the occurrence, development, and status of the physiological pathology of ECs. Other EC-associated micro factors include interleukin 10, tumor protein P53, nuclear factor kappa B subunit, interleukin 6, and tumor necrosis factor. The results of Gene Ontology analysis revealed that variations were mainly enriched in positive regulation of transcription by the RNA polymerase II promoter, cellular response to lipopolysaccharides, negative regulation of apoptotic processes, external side of the plasma membrane, cytoplasm, extracellular regions, cytokine activity, growth factor activity, and identical protein binding. The results of the Kyoto Encyclopedia of Genes and Genomes analysis revealed that micro factors were predominantly enriched in inflammatory diseases.

In summary, the main mediators, factors, or genes associated with ECs include VEGF and ANG. The effect of micro factors on ECs is complex and multifaceted. This review summarizes the correlation between ECs and several micro factors.

Ultrasound imaging is well known to play an important role in the detection of thyroid disease, but the management of thyroid ultrasound remains inconsistent. Both standardized diagnostic criteria and new ultrasound technologies are essential for improving the accuracy of thyroid ultrasound. This study reviewed the global guidelines of thyroid ultrasound and analyzed their common characteristics for basic clinical screening. Advances in the application of a combination of thyroid ultrasound and artificial intelligence (AI) were also presented.

An extensive search of the PubMed database was undertaken, focusing on research published after 2001 with keywords including thyroid ultrasound, guideline, AI, segmentation, image classification, and deep learning.

Several types of articles, including original studies and literature reviews, were identified and reviewed to summarize the importance of standardization and new technology in thyroid ultrasound diagnosis.

Ultrasound has become an important diagnostic technique in thyroid nodules. Both standardized diagnostic criteria and new ultrasound technologies are essential for improving the accuracy of thyroid ultrasound. In the standardization, since there are no global consensus exists, common characteristics such as a multi-feature diagnosis, the performance of lymph nodes, explicit indications of fine needle aspiration, and the diagnosis of special populations should be focused on. Besides, evidence suggests that AI technique has a good effect on the unavoidable limitations of traditional ultrasound, and the combination of diagnostic criteria and AI may lead to a great promotion in thyroid diagnosis.

Standardization and development of novel techniques are key factors to improving thyroid ultrasound, and both should be considered in normal clinical use.

To review the application of radiomics in gastric cancer and its challenges as well as future prospects.

A research for relevant studies were performed in PubMed with the terms of "radiomics," "texture analysis," and "gastric cancer." The search was updated until February 28^th, 2019.

All original articles regarding the investigation of texture analysis or radiomics in gastric cancer were retrieved. Only papers written in English were included.

A total of 17 original articles were selected in final. It is shown that radiomics has yielded moderate to excellent performance in a spectrum of respects including differential diagnosis, assessment of histological differential degree, evaluation of tumor stage, prediction of response to therapy, and prognosis in gastric cancer. Yet, a number of challenges are facing both radiomics itself and its application in gastric cancer.

Radiomics holds great potential in facilitating decision-making in gastric cancer. With the standardization of work-flow and advancement of machine learning methods, radiomics is expected to make great breakthroughs in precision medicine of gastric cancer.

Since 1999, a large body of evidence from various animal models indicates a link between anesthesia exposure in early stage of life and subsequent neurodevelopmental impairments^[1]; namely, almost all commonly used intravenous and inhalational anesthetics, including gamma-aminobutyric acid agonists and N-methyl-D-aspartate antagonists, can induce dose- and age-dependent neuronal apoptosis and deathin vitro. Moreover, abundant data from nematodes to primate animals have shown a variety of anatomic and neurodevelopmental sequelae from anesthesia exposure in young animals.^[2,3]In the rodents, the most prominent manifestations of anesthesia-induced developmental neurotoxicity (AIDN) are often observed at post-natal day 7, which is the peak period for synaptogenesis. In animal models, both single and multiple anesthesia exposures can affect neurodevelopment. Also, the duration and timing of anesthesia exposure are the important influencing factors of AIDN.^[4]Alarmingly, these neurotoxic effects by neonatal exposure to anesthesia may result in the long-term detrimental functional outcomes in later childhood or adulthood, such as deficits in memory, learning, attention, and motor function.^[2]

Patients with coronary artery disease (CAD), after first percutaneous coronary intervention (PCI), often need repeat unplanned percutaneous revascularization due to plaque progression in culprit or non-culprit lesions, including target lesion revascularization (TLR), target vessel revascularization (TVR), and other vessel revascularization (OVR).^[1]Low-density lipoprotein cholesterol (LDL-C) levels are controllable and its reduction is integral to reducing major adverse cardiac events after PCI. In this study, active lipid-lowering therapy was widely appreciated early after coronary stenting, showing an initial decline in levels of LDL-C, while its emphasis and recognition was attenuated over time with an increased risk of revascularization due to higher levels of LDL-C. The study was conducted in accordance with theDeclaration of Helsinkiand was approved by the Ethics Committee of the Affiliated Hospital of Dalian Medical University. From January 2013 to January 2017, a total of 621 consecutive patients who survived successful PCI with stent implantation on initial admission to our institution, received a second coronary angiography examination due to "suspected/defined myocardial ischemia." Interval time was recorded between the first PCI and admission for suspected myocardial ischemia. To further explore LDL-C changes in unplanned revascularization following PCI, 111 patients, rehospitalized for any cause, including staged revascularization within 6 months after hospital discharge, were excluded. A total of 510 patients were selected, comprising 101 patients withoutde novocoronary artery lesions (control group) and 409 patients with repeat unplanned percutaneous revascularization (repeat PCI group). Of the patients with unplanned repeat procedures, 10% (n= 41) were treated for ST-elevation myocardial infarction and 90% (n= 368) for non-ST-segment elevation acute coronary syndromes. A total of 183 of these patients were treated with TLR and 272 with TVR/OVR, of whom 46 were treated with both.

To the Editor:Since avian influenza A(H7N9) was first identified in Shanghai, China, in March 2013, there have been a total of five epidemics. These have amounted to 1564 laboratory-confirmed cases up to September 2017, with a fatality rate of about 40%.^[1]In the fifth wave, 4.09% of cases (31/758) were infected with the highly pathogenic avian influenza (HPAI) A(H7N9). This indicated that the pathotype of the A(H7N9) had switched from low pathogenic avian influenza (LPAI) to HPAI.

To the Editor:Compared with the computed tomography, the magnetic resonance imaging (MRI) is a much more sensitive cross-sectional imaging modality for the detection of patellar dislocation-associated capsular, ligamentous, cartilaginous, and bone injuries.^[1,2]

To the Editor:Diffuse large B cell lymphoma (DLBCL) is the major type of primary pulmonary lymphoma (PPL). DLBCL tends to have a poor prognosis, with 5-year survival rates ranging from 0% to 60%. But in this case report, an old male was pathologically diagnosed as pulmonary DLBCL with unchanged asymptomatic pneumonia-like imaging manifestations in lung for 11 years, which reminds us to pay attention to pulmonary DLBCL with an indolent course.

To the Editor:We report a 27-year-old woman with a 2-month history of irregular uterine bleeding between periods. Blistering on the head was noted in the patient at the age of 2 months, and she gradually developed red maculopapular lesions over her neck and back during puberty, which were itchy after exposure to physical friction. On admission, physical examination had revealed diffuse faint maculopapular rash mainly on the neck and back [Figure 1]. Pelvic examination showed a smooth red lump (5 cm) on the cervix. No abnormality was detected in the complete blood count. Afterwards, the cervical lump was resected and confirmed to be the infiltration of mature mast cells (MCs) after careful pathological investigation. Additionally, a skin nodule biopsy also indicated mass aggregation of MCs, and a bone marrow (BM) biopsy showed a mass of round MCs with abundant cytoplasmic granules. The MCs accounted for about 22.5% of all cells in the aspirate smears. Flow cytometry immunophenotypic analysis on BM suggested that an aberrant MC population had represented 10% of the total analyzed cells, which was positive for CD117, CD33, and CD9, partially positive for CD2 and CD68, and negative for CD25. Genetic test through exome-wide sequencing for the receptor tyrosine kinase (KIT) gene had revealed K509I mutation.

To the Editor:Ureteral calculus is a common urological disease. In recent years, one of the main treatment methods is ureteroscopy with holmium laser lithotripsy. However, with the extensive application of holmium laser lithotripsy, the increasing incidence of postoperative ureteral stricture or even occlusion has attracted the attention of clinicians to its etiology. The issue of the intraoperative holmium laser thermal effect has also gradually gained attention. The holmium laser is a long-wavelength pulsed laser, which crushes calculi by an optomechanical/photoacoustic mechanism as well as a photothermal mechanism, and it is mainly based on the photothermal mechanism.^[1]Currently, multiplein vitrostudies worldwide have confirmed that the holmium laser did increase the water temperature in the working area. However, these studies only simulated the lithotripsy process of the holmium laserin vitro, which did not completely reflect the thermal effect of the holmium laser during an actual operation. Accordingly, this study monitored the temperature changes of the lavage fluid in the operative field during the actual holmium laser lithotripsy process under an ureteroscope, with the aim of providing more information for the etiology study of ureteral stricture after ureteroscopy with holmium laser lithotripsy.

To the Editor:A 19-year-old man was admitted to the hospital presenting with "skin and sclera yellow staining for 18 years, accompanied by growth retardation." The patient developed scleral yellowing at 4 months of age, at which time he was diagnosed as having Wilson’s disease (WD) and received symptomatic treatment for liver protection. At 9 years of age the patient developed a pale nail bed, clubbing of the fingers and toes, and accompanying growth retardation. A spontaneous fracture of the right upper limb and left pubic bone occurred at 16 years of age. At 17 years of age the patient developed neuropsychiatric symptoms consisting of fatigue, personality changes, mental retardation, numbness, epileptic seizures, and constipation. He required daily glycerin to assist with defecation. At 5 months prior to admission, obvious sternal malformations and anterior sternal processes were present. Family history revealed that his parents were close relatives (cousin-sister relationship) and the patient’s cousin died as a result of WD at age of 12 years. The patient’s younger brother was 3 years old and also had a history of WD.

To the Editor:Oculocutaneous albinism (OCA) is an autosomal recessive disorder caused by a group of mutations related to the regulation of melanin synthesis and melanosome biogenesis. The prevalence of OCA worldwide is approximately 1 in 17,000.^[1]Other than symptomatic treatment, there is no effective treatment for albinism. Due to the variability in clinical phenotypes, it is difficult to classify sub-types simply by clinical features; therefore, molecular and genetic analyses are the most reliable methods for confirming diagnosis, carrier screening, and pre-natal diagnosis.

To the Editor:Smartphones have also changed the exposure of human eyes to light. As all the spectral peaks for smartphones are very similar to short-wavelength blue visible light,^[1]it is not surprising that eye damage with smartphones has raised public concerns. In this article, we describe one patient with suspected macular light damage caused by the excessive use of a smartphone.

To the Editor:On March 9, 2018, a 31-year-old woman presented with liver dysfunction after thyroid cancer surgery. She was physically healthy; had no chronic diseases, such as hypertension and diabetes; had no history of infectious diseases, such as hepatitis and tuberculosis; had no history of drugs, food allergies, smoking, and alcohol consumption; and presented no obvious complaints during the disease course. B-ultrasound in the physical examination 3 years prior showed "left thyroid-occupying position." On February 5, 2018, she had undergone surgery at our hospital. Laboratory findings on February 6, 2018 revealed white blood cells (WBCs) 9.06 × 10⁹/L (3.50–9.50 × 10⁹/L); neutrophils (NEs) 5.66 × 10⁹/L (1.80–6.30 × 10⁹/L); triiodothyronine (T3) 0.94 (0.80–2.00) ng/mL; thyroxine (T4) 6.4 (5.1–14.1) μg/dL; free T3 (FT3) 3.95 (3.10–6.80) pmol/L; free T4 (FT4) 15.57 (12.00–22.00) pmol/L; thyroid-stimulating hormone (TSH) 2.56 (0.27–4.20) mU/L; thyroid peroxidase antibody (TPOAb) 8.2 (0–34.0) IU/mL; thyroglobulin antibody (TgAb) <10 (≤115) IU/mL; total bilirubin (T-BIL) 21.5 (5.0–22.0) μmol/L; direct bilirubin (D-BIL) 6.3 (0–10.2) μmol/L; alanine transaminase (ALT) 27.5 (7.0-40.0) U/L; aspartate transaminase (AST) 22.7 (13.0–35.0) U/L; and alkaline phosphatase (ALP), 48.9 (35.0–100.0) U/L. Hepatitis C antibody, hepatitis B surface antigen, and hepatitis B core antibody immunoglobulin M tested negative. On February 7, 2018, intra-operative pathology during left thyroidectomy indicated micro-papillary carcinoma. On February 11, 2018, she was discharged and prescribed levothyroxine tablets A (LTA; Merck KGaA, Darmstadt, Germany) 100 μg and calcium carbonate D3 tablets (CC-D3; Pfizer, China) 600 mg once daily.