2019年 · 第132卷第18期

Thyroid autoimmunity (TAI) is prevalent among women of reproductive age and associated with adverse pregnancy outcomes. This study aimed to investigate the association between iron nutritional status and the prevalence of TAI in women during the first trimester of pregnancy and in non-pregnant women of childbearing age.

Cross-sectional analysis of 7463 pregnant women during the first trimester of pregnancy and 2185 non-pregnant women of childbearing age nested within the sub-clinical hypothyroid in early pregnancy study, a prospective collection of pregnant and non-pregnant women’s data, was conducted in Liaoning province of China between 2012 and 2015. Serum thyrotropin, free thyroxine, thyroid peroxidase antibodies (TPOAbs), thyroglobulin antibodies (TgAbs), serum ferritin, and urinary iodine were measured. Iron deficiency (ID) was defined as serum ferritin <15 μg/L and iron overload (IO) was defined as ferritin >150 μg/L. TPOAb-positive was defined as >34 U/mL and TgAb-positive was defined as >115 U/mL. Multilevel logistic regression was conducted to examine the association between TAI and different iron nutritional status after adjusting for potential confounders.

The prevalence of isolated TPOAb-positive was markedly higher in women with ID than those without ID, in both pregnant and non-pregnant women (6.28% vs. 3.23%, χ² = 10.264, P = 0.002; 6.25% vs. 3.70%, χ² = 3,791, P = 0.044; respectively). After adjusting for confounders and the cluster effect of hospitals, ID remained associated with TPOAb-positive in pregnant and non-pregnant women (odds ratio [OR]: 2.111, 95% confidence interval [CI]: 1.241–3.591, P = 0.006; and OR: 1.822, 95% CI: 1.011–3.282, P = 0.046, respectively).

ID was associated with a higher prevalence of isolated TPOAbs-positive, but not with isolated TgAb-positive, in both pregnant women during the first trimester of pregnancy and non-pregnant women of childbearing age, while IO was not associated with either isolated TPOAb-positive or isolated TgAb-positive.

ChiCTR-TRC-13003805, http://www.chictr.org.cn/index.aspx.

The association between peripheral leukocyte count and bleeding events in nonvalvular atrial fibrillation (NVAF) patients treated with dabigatran remains unclear. This study aimed to explore the association between leukocyte count and bleeding events after excluding other confounders in NVAF patients taking dabigatran.

A total of 851 NVAF patients treated with dabigatran (110 mg bid) were recruited from 12 centers in China from February 2015 to December 2017. Follow-up was completed by May 2018. The exposure and outcome variables were leukocyte count measured at baseline and the number of bleeding events within the subsequent 6 months. Multivariate Cox proportional hazards models were constructed to analyze independent associations, and a Cox proportional hazards regression with cubic spline functions and smooth curve fitting (penalized spline method) was used to address nonlinearity between leukocyte count and bleeding. The inflection point was calculated using a recursive algorithm, and then a two-piecewise Cox proportional hazards model for both sides of the inflection point was constructed.

During 6-month follow-up, 87 participants occurred bleeding events. For every 1 × 10⁹/L increase in leukocyte count, the risk of bleeding increased by 11% (hazard ratio [HR]: 1.11, 95% confidence interval [CI]: 0.99–1.25). The smooth curve showed nonlinear relationship between leukocyte count and bleeding events. The inflection point of the leukocyte count was 6.75 × 10⁹/L. For leukocyte counts < 6.75 × 10⁹/L, the HR (95% CI) was 0.88 (0.69–1.13), and for leukocyte counts ≥ 6.75 × 10⁹/L, the HR (95% CI) was 1.28 (1.09–1.51).

This study found a J-shaped association between baseline leukocyte count and risk of bleeding in NVAF patients treated with dabigatran.

NCT02414035, https://clinicaltrials.gov.

Handan Eye Study (HES), a large population-based cohort study in rural area of northern China, was one of the few studies focusing on the major eye diseases of rural Chinese population. The aim of this study was to introduce the design, methodology and to assess the data quality of the follow-up phase of HES.

All participants were recruited in Yongnian county of Handan city between 2012 and 2013. Main outcomes were measured by visual quality scales and ocular examinations. We performed the Chi-square test to make comparison of categorical data among groups, One-way analysis of variance and Kruskal-Wallis test was applied to make comparison of continuous data among groups, a post-hoc test was done to make further pairwise comparison. Inter-class correlation coefficients (ICCs) and Kappa coefficients were used to evaluate the consistency between different operators. Logistic regression was used to explore the influence factors of death, odds ratio (OR) and 95% confidence interval (CI) were used to estimate the effect size of each influence factor.

The follow-up rate was 85.3%. Subjects were classified into three groups: the follow-up group (n = 5394), the loss to follow-up group (n = 929), and the dead group (n = 507), comparison of their baseline information was done. Compared with the other two groups, age of the dead group (66.52 ± 10.31 years) was the oldest (Z = 651.293, P < 0.001), male proportion was the highest (59.0%) (χ² = 42.351, P < 0.001), only 65.9% of the dead finished middle school education (Z = 205.354, P < 0.001). The marriage percentage, body mass index (BMI), best-corrected visual acuity (BCVA), and intra-ocular pressure of the dead group was the lowest either. Spherical equivalent error (SER) of the dead group was the highest. Besides, history of smoking, hypertension, diabetes, and heart disease were more common in the dead group. Multivariate analysis showed that age (OR = 1.901, 95% CI: 1.074–1.108), gender (OR = 0.317, 95% CI: 0.224–0.448), and BCVA (OR = 0.282, 95% CI: 0.158–0.503) were associated with death. While between the follow-up group and the loss to follow-up group, there was only difference on age, gender, BMI, systolic blood pressure and SER. The Cronbach coefficients of all scales used in the follow-up were ≥0.63 and the cumulative variances were ≥0.61, indicating good reliability and validity. The ICCs and Kappa coefficients between different operators were ≥0.69.

HES has a high follow-up rate and a low risk of loss to follow-up bias. Age, gender, and BCVA are influence factors of death. Specifically, male subjects are at a higher risk of death than female, age is a risk factor of death while BCVA is a protective factor for death.

Anastomotic leakage is a serious surgical complication in rectal cancer; however, effective evaluation methods for predicting anastomotic leakage individual risk in patients are not currently available. This study aimed to develop a method to evaluate the risk of leakage during surgery.

The 163 patients with rectal cancer, who had undergone anterior resection and low-ligation procedures for Doppler sonographic hemodynamic measurement from April 2011 to January 2015 in Peking University Cancer Hospital, were prospectively recruited. A predictive model was constructed based on the associations between anastomotic leakage and alterations in the anastomotic blood supply in the patients, using both univariate and multivariate statistical analyses, as well as diagnostic methodology evaluation, including Chi-square test, logistic regression model, and receiver operating characteristic curve.

The overall anastomotic leakage incidence was 9.2% (15/163). Doppler hemodynamic parameters whose reduction was significantly associated with anastomotic leakage were peak systolic velocity, pulsatility index, and resistance index. The areas under the receiver operating characteristic curve of residual rates of peak systolic velocity, pulsatility index, and resistance index in predicting anastomotic leakage were 0.703 (95% confidence interval [CI]: 0.552–0.854), 0.729 (95% CI: 0.579–0.879), and 0.689 (95% CI: 0.522–0.856), respectively. The predictive model revealed that the patients with severely reduced blood-flow signal exhibited a significantly higher incidence rate of anastomotic leakage than those with sufficient blood supply (19.6% vs. 3.7%, P = 0.003), particularly the patients with low rectal cancer (25.9% vs. 3.9%, P = 0.007) and those receiving neoadjuvant chemoradiotherapy (32.1% vs. 3.7%, P = 0.001), independent of prophylactic ileostoma. Multivariate analysis revealed that insufficient blood supply of the anastomotic bowel was an independent risk factor for anastomotic leakage (odds ratio: 10.37, 95% CI: 2.703–42.735, P = 0.001).

Based on this explorative study, Doppler sonographic hemodynamic measurement of the anastomotic bowel presented potential value in predicting anastomotic leakage.

The prognosis of acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) is very poor with a high mortality. The aim of this study was to describe the clinical features and survival of patients with AE-IPF with usual pulmonary fibrosis (UIP) and possible UIP (P-UIP) pattern on chest high resolution computed tomography (HRCT).

This retrospective study included 107 patients with AE-IPF admitted to Nanjing Drum Tower Hospital from January 2010 to December 2016. The subjects were divided into UIP (n = 86) and P-UIP group (n = 21) based on chest HRCT. Continuous variables were analyzed using Student’s t test or Mann-Whitney U test. Categorical variables were analyzed using χ² test. Log-rank test was used for the survival analysis. Cox proportional models evaluated the risk factors for AE occurrence and survival.

The male, older patients, previous N-acetylcysteine use, elevated white blood cell (WBC) counts, and microbiology infection were more common in the UIP group than the P-UIP group (χ²= 13.567, P < 0.001; z = -2.936, P = 0.003; χ² = 5.901, P = 0.015; t = 2.048, P = 0.043; χ² = 10.297, P = 0.036, respectively). The percentage of AE with UIP pattern in idiopathic interstitial pneumonia (IIP) was significantly higher than P-UIP pattern (χ² = 40.011, P < 0.001). Smoking was the risk factor for AE within 6 months after IPF diagnosis in the UIP group. The cumulative proportion survival of 30-days was significantly higher in the UIP group compared with the P-UIP group (χ² = 5.489, P = 0.019) despite of the similar overall survival in the two groups. Multivariate Cox regression analysis indicated WBC count, partial pressure of oxygen in artery (PaO₂)/fractional concentration of inspired oxygen (FiO₂), and computed tomography (CT) score were the independent predictors for survival in the UIP group (hazard ratio [HR]: 1.070, 95% confidential interval [CI]: 1.027-1.114, P = 0.001; HR: 0.992, 95% CI: 0.986–0.997, P = 0.002; and HR: 1.649, 95% CI: 1.253–2.171, P < 0.001, respectively).

AE occurrence of UIP patients in IIP was significantly more than P-UIP cases. The short-term survival was better in the UIP group despite of the similar overall survival in the two groups. WBC count, PaO₂/FiO₂, and CT score were the independent predictors for survival in UIP subjects.

Jaw thrust has been proven as a useful test determining adequate depth of anesthesia for successful insertion of supraglottic airway device (SAD) in normal adults and children receiving intra-venous or inhalational anesthesia induction. This prospective observational study aimed to determine the feasibility and validity of this test when using as an indicator assessing adequate depth of anesthesia for successful insertion of SAD in spontaneously breathing morbidly obese patients receiving sevoflurane inhalational induction.

Thirty morbidly obese patients with a body mass index 40 to 73 kg/m² undergoing bariatric surgery in Beijing Friendship Hospital from October 2018 to January 2019 were included in this study. After adequate pre-oxygenation, 5% sevoflurane was inhaled and inhalational concentration of sevoflurane was increased by 1% every 2 min. After motor responses to jaw thrust disappeared, a SAD was inserted and insertion conditions were graded. The anatomic position of SAD was assessed using a fiberoptic bronchoscope.

The SAD was successfully inserted at the first attempt in all patients. Insertion conditions of SAD were excellent in nine patients (30%) and good in 21 patients (70%), respectively. The fiberoptic views of SAD position were adequate in 28 patients (93%).

Jaw thrust test is a reliable indicator determining adequate anesthesia depth of sevoflurane inhalational induction for successful insertion of SAD in spontaneously breathing morbidly obese patients.

ChiCTR1800016868; http://www.chictr.org.cn/showproj.aspx?proj=28646.

Although the use of extra-corporeal membrane oxygenation (ECMO) has been rapidly increasing, the benefit of ECMO in patients with acute respiratory distress syndrome (ARDS) remains unclear. Our objective was to investigate the effect of venovenous ECMO (VV-ECMO) on adult patients with severe ARDS.

We conducted a multi-center, retrospective, cohort study in the intensive care units (ICUs) of six teaching hospitals between January 2013 and December 2018. Patients with severe ARDS who received VV-ECMO support were included. The detailed demographic data and physiologic data were used to match ARDS patients without ECMO. The primary endpoint was the 28-day mortality.

Ninety-nine patients with severe ARDS supported by VV-ECMO and 72 patients without ECMO were included in this study. The acute physiology and chronic health evaluation II score was 23.1 ± 6.3 in the ECMO group and 24.8 ± 8.5 in the control group (P = 0.1195). The sequential organ failure assessment score was 12.8 ± 3.4 in the ECMO group and 13.7 ± 3.5 in the control group (P = 0.0848). The 28-day mortality of patients with ECMO support was 39.4%, and that of the control group was 55.6%. The survival analysis curve showed that the 28-day mortality in the ECMO group was significantly lower than that in the control group (P = 0.0097). Multivariate Cox regression analysis showed that the independent predictors of the 28-day mortality were the requirement of vasopressors before ECMO (hazard ratio [HR]: 1.006; 95% confidence interval [CI]: 1.001–1.013; P = 0.030) and duration of mechanical ventilation before ECMO (HR: 3.299; 95% CI: 1.264–8.609; P = 0.034).

This study showed that ECMO improved the survival of patients with severe ARDS. The duration of mechanical ventilation and the requirement of vasopressors before ECMO might be associated with an increased risk of death.

Few studies have reported brain function differences in drug-naïve first-episode schizophrenia patients who had auditory verbal hallucinations (AVH) with insight vs. those without insight. This study aimed to investigate brain function differences between drug-naïve first-episode AVH-schizophrenia patients with and without insight.

Forty first-episode drug-naïve AVH-schizophrenia patients with or without insight and 40 healthy controls between December 2016 and December 2018 were recruited in this study. The auditory hallucinations rating scale (AHRS) was used to assess AVH severity, while the insight and treatment attitudes questionnaire was used to distinguish insight. The global functional connectivity density (gFCD) between different groups was compared using a voxel-wise one-way analysis of covariance. The relationship between gFCD and AHRS total scores were analyzed using voxel-wise multiple regression.

Finally, 13 first-episode drug-naïve AVH-schizophrenia patients with insight, 15 AVH-schizophrenia patients without insight, and 20 healthy controls were included for analysis. Except for global assessment of functioning scores, there were no significant differences in sociodemographic information between the AVH-schizophrenia and healthy groups (P > 0.05). Compared to the healthy controls, AVH-schizophrenia patients with insight demonstrated a decreased gFCD in the supramarginal gyrus within the primary auditory cortex, while those without insight demonstrated an increased gFCD in the inferior frontal gyrus and superior temporal gyrus and decreased gFCD in the supplemental motor area. Compared to the AVH-schizophrenia patients with insight, those without insight demonstrated an increased gFCD in the supra-marginal gyrus and posterior superior temporal lobule and a decreased gFCD in the frontal lobe. No significant correlation between gFCD and AVH severity (AHRS total score: r = 0.23, P = 0.590; and frequency: r = 0.42, P = 0.820) was found in both AVH-schizophrenia groups.

The gFCD-aberrant brain regions in the AVH-schizophrenia patients without insight were wider compared to those with insight, although the AHRS scores were not significantly different. The AVH-schizophrenia patients without insight had wide functional impairment in the frontal lobule, which may underlie the lack of insight and the abnormal hyperactivity in the inferior frontal gurus and temporal lobe related to the AVH symptoms.

Whether the time course of post-stroke depression (PSD) can be used to predict the quality of life (QoL) of patients with late-stage stroke remains unclear, this study investigated whether persistent depression at 1 year after stroke predicts QoL at 5 years following stroke.

We analyzed the demographic and clinical data of patients with stroke in 56 hospitals across China that participated in the Prospective Cohort Study on the Incidence and Outcome of Patients with PSD in China Study. Follow-up assessments were performed at the following time points after stroke: in person, 2 weeks, 3 months, 6 months, and 1 year; by telephone, 5 years. National Institutes of Health Stroke Scale (NIHSS) score on admission, recurrence, disability, depression, QoL, and chronic complications were recorded. Depression was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders. QoL was measured using short form-12 (SF-12). Multivariable ordinal logistic regression analysis was used to identify factors that independently affected the physical component summary (PCS) and mental component summary (MCS) scores of the SF-12.

Of the 801 patients evaluated in this study, 80 had persistent depression. The multivariable regression analysis of data obtained at 5 years showed that persistent depression at 1 year (odds ratio [OR]: 0.48; 95% confidence interval [CI]: 0.29–0.81) and disability at 5 years (OR: 0.34; 95% CI: 0.23–0.49) were associated with poor MCS scores at 5 years. Old age, a high NIHSS score on admission, disability at 5 years, and stroke recurrence within 5 years were associated with poor PCS scores at the 5-year follow-up.

Persistent depression at the 1-year follow-up could predict poor MCS scores at the 5-year follow-up. The development of interventional strategies targeting post-stroke patients with persistent depression is warranted.

MicroRNAs (miRNAs) have played important roles in the regulation of gene expression in many cancers, but their roles in esophageal squamous cell carcinoma (ESCC) are still unclear. The aim of this study was to determine the potential ESCC-specific key miRNAs from a large sample dataset in The Cancer Genome Atlas (TCGA).

Integrative bioinformatics analysis was used to identify key ESCC-specific miRNAs related to the ESCC patients’ tumor histological grade and lymphatic metastasis from TCGA. Next, these key miRNA potential gene regulatory functions and relationships with ESCC patients’ clinical characteristics and overall survival were analyzed. Finally, three key miRNAs were selected randomly and quantificational real-time polymerase chain reaction (qRT-PCR) was used to validate in 51 newly diagnosed ESCC patients’ tissues samples (collected from Nov. 2017 to Feb. 2019, in Wuwei, China) whether the bioinformatics analyses results were reliable and valid. Two-tailed Student’s t test, Pearson Chi-squared test and Kaplan-Meier survival analysis were used in this study.

Thirty-five ESCC-specific miRNAs from TCGA database were investigated (fold-change > 2.0, P < 0.05), and 28 participated in the miRNAs-mRNAs co-expression network construction, while 17 were related with ESCC patients’ tumor histological grade, TNM stage, and lymphatic metastasis (P < 0.05). Meanwhile, six miRNAs (including miR-200b-3p, miR-31-5p, miR-15b-5p, miR-141-3p, miR-135b-5p, and miR-195-5p) were correlated with overall survival of ESCC patients (log-rank, P < 0.05). MiR-135b-5p, miR-15b-5p, and miR-195-5p were selected for verification of the expression levels in 51 ESCC patients’ tissue samples by using qRT-PCR. We found that the fold-changes between qRT-PCR and TCGA were completely consistent. The results also suggested that miR-135b-5p, miR-15b-5p, and miR-195-5p were significantly correlated with tumor differentiation degrees (P < 0.05), miR-195-5p was significantly correlated with tumor TNM stage (P < 0.05), and miR-135b-5p was significantly correlated with lymph-node metastasis (P < 0.05). MiR-135b-5p, miR-15b-5p, and miR-195-5p expression levels, ESCC patient clinical features association analysis results and the aforementioned TCGA bioinformatics analyses were similar.

This study identified key ESCC-related miRNAs. The key miRNAs are worthy of further investigation as potential novel biomarkers for diagnosis, classification, and prognosis of ESCC.

Autologous fat grafting has gained popularity in breast augmentation. Various methods can be used to estimate the volume retention rate. This systematic review aimed to establish whether the type of method used for measuring breast volume is a factor that influences the reported volume retention rate.

Studies were identified using the electronic databases PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science from inception of the database up to February 2019. Articles describing autologous fat grafting for breast augmentation were selected based on pre-determined inclusion and exclusion criteria. The characteristics of the included studies were summarized, and the reported volume retention rate from the studies was compared. A quality assessment of all included articles was performed using the methodological index for non-randomized studies criteria.

A total of 618 articles were identified, of which 12 studies, with a total of 1337 cases, were eligible. The retention rate of injected adipose tissue varied when the method of fat grafting and volume analysis used were both the same, as well as when the method of fat grafting was the same but the method of volumetric evaluation used was different.

Currently, the tools available for estimating the volume retention rate come with limitations. In order to objectively evaluate the percentage of graft retention, a standard protocol that applies to the different methods should be established in the future.

Anabolic-androgenic steroids (AAS) represents a group of synthetic testosterone derivatives that play an important role in clinical treatment. These drugs are widely abused among the general public to increase lean weight and improve athletic performance. It has been reported that AAS use can produce many adverse effects, especially the occurrence of cardiovascular risk. Although there are many related studies, there has been no consensus on AAS use and cardiovascular risk. The present study was to review the effect of AAS on the cardiovascular system.

The data in this review were obtained from articles included in PubMed and the National Center for Biotechnology Information database.

Original articles, case reports, and systematic reviews about AAS were selected for the article.

The use/abuse of AAS is correlated with higher cardiovascular risks, and many AAS users/abusers had cardiovascular diseases. However, there are many confounding factors in the studies that explored the causality between AAS intake and disease development, and additional studies are required to determine AAS toxicity.

AAS produces toxic effects on the cardiovascular system, and it is necessary to ensure that more people know this about AAS, including medical personnel.

Chronic rhinosinusitis (CRS) involves inflammation of the nasal and para-nasal mucosa. Due to its heterogeneous nature, unknown pathogenesis, and high recurrence rate, effective treatment is difficult. Nasal cytology is presently not a part of the routine diagnosis or treatment decision for CRS.

A literature search was performed for published papers in English between January 1990 and June 2019 using MEDLINE.

Terms used were chronic rhinosinusitis, eosinophils, etiology, immunopathology, inflammation, mast cells, nasal cytology, polyps, and treatment. Both reviews and original articles were collected and studied.

There is no standard nasal fluid, mucus sampling, or staining techniques for identifying inflammatory cell types. Results were divergent from different countries. Moreover, the main focus of these papers on the cells in nasal washings was eosinophils, with infrequent mentioning of other cell types that may imply different etiology and pathology. The heterogeneous cell profile of CRS and the role of mast cells have been unappreciated due to the lack of specific immunohistochemical technique or study of its unique mediators.

Nasal cytology could help distinguish the type and the activation state of inflammatory cells. Thus it can help in providing a clearer picture of CRS pathogenesis, identifying different patient groups, and developing effective treatments.

Surgical treatment of aortic arch lesions is a challenge for cardiac surgeons because of the complexity of the technique. For high-risk patients who are not suitable to undergo traditional open arch replacement, debranching thoracic endovascular aortic repair (d-TEVAR) is often a good choice. Retrograde type A aortic dissection (RTAD) is a common and fatal complication after d-TEVAR,^[1]and thus d-TEVAR is contraindicated in low-risk patients. Herein, we describe a modification of d-TEVAR with an aortoplasty of the ascending aorta using artificial blood vessels and the subsequent use as an anchoring zone to minimize the occurrence of RTAD.

Undifferentiated embryonal sarcoma of the liver (UESL) very rarely presents clinically. Approximately 1% to 4% of all solid tumors in children are malignant liver tumors, and UESL accounts for 9% to 15% of the liver tumor. The onset of UESL usually occurs at 6 to 10 years of age and there is no obvious difference based on sex.^[1]The first symptoms of UESL are abdominal distention and abdominal pain without jaundice, while a physical examination commonly reveals no positive vital signs except the palpable liver tumor.^[1]The serum alphafetoprotein (AFP) test is not sensitive for UESL.^[2]Preoperative diagnosis of UESL is very difficult. A definitive diagnosis depends on histopathologic examinations including immunohistochemical analysis. Patients with UESL usually have positive for vimentin, antitrypsin (AAT), desmin, and smooth muscle actin and have foci positive for cytokeratin (CK8/18) but negative for AFP and S-100 protein.^[3]Complete tumor resection is still a key factor that affects the prognosis of UESL.^[2]UESL is an aggressive liver tumor with a poor prognosis. The previously reported long-term disease-free survival rate of UESL was less than 37%.^[1]In recent years, the prognosis of UESL has improved as treatment has changed to the use of surgery combined with chemotherapy. A recent article reported that the total 5-year survival rate was as high as 92% to 100%.^[2,4]However, the recurrence rate of UESL is high, and the overall prognosis is still not optimistic. Because of its low incidence, the recurrence features and high-risk factors affecting prognosis are seldom reported upon. Therefore, in this report we summarize the characteristics of recurrence and the risk factors affecting prognosis of UESL.

To the Editor:Sudden cardiac death is a major public health issue across the world.^[1]Timely cardiopulmonary resuscitation (CPR) and defibrillation helps improve prognosis and avert the neurological sequelae of ventricular fibrillation.^[2]However, there is low availability and utilization of defibrillators in China.^[3]Hence, we investigated the availability and utilization of defibrillators during two consecutive years (before and after an administrative intervention) at all primary (public and private) hospitals in Suzhou city (Jiangsu province, China) to assess the effect of administrative intervention.

To the Editor:Meningiomas are the most common central nervous system neoplasms.^[1]The World Health Organization (WHO) 2016 classification system classifies meningiomas into three grades: grade I (benign), grade II (atypical), and grade III (anaplastic/malignant) meningioma.^[1]Benign meningiomas are usually associated with favorable prognosis; however, higher grade (WHO grades II and III) menigiomas are more aggressive, resulting in less favorable outcome.^[1]

To the Editor:POU domain class 3 transcription factor 4 orBRN-4(POU3F4) is a causative gene of non-syndromic X-linked hearing loss (HL), which is characterized by inner ear anomalies. To date, six X-linked non-syndromic HL loci (DFNX1-6) have been mapped to chromosome X and five of these genes have been identified: phosphoribosyl pyrophosphate synthetase 1 (PRPS1) (DFNX1, OMIM: 304500),POU3F4(DFNX2, OMIM: 304400),^[1]small muscle protein, X-linked (SMPX) (DFNX4, OMIM: 300066), apoptosis-inducing factor, mitochondria-associated, 1 (AIFM1) (DFNX5, OMIM: 300614), and collagen, type IV alpha-6 (COL4A6) (DFNX6, OMIM; 300914).POU3F4mutation accounts for nearly 50% of all cases of DFNX.^[2,3]The humanPOU3F4gene is located in the Xq21.1 region with only one exon, encoding 361 amino acids.POU3F4belongs to a superfamily of POU domain transcription factors, comprised of a POU-specific domain (75 amino acids) and a POU-homeodomain (63 amino acids), both of which influence DNA binding and specificity. The POU3F4 protein is involved in the development of the middle ear and inner ear, as well as some areas of the brain before birth.^[4]However, HL is the only clinical phenotype observed in DFNX2 patients. So far, 72 different mutations in the coding region (57 mutations) and the putative regulatory element region (15 mutations) of thePOU3F4gene have been reported to be associated with non-syndromic HL in families with DFNX2. In this study, a new non-sense mutation inPOU3F4was analyzed and found to be associated with non-syndromic X-linked inheritance HL in a Chinese Han family.

To the Editor:The mucopolysaccharidosis (MPS) disorders are a group of rare, inherited lysosomal storage disorders in which progressive cellular accumulation of glycosaminoglycans (GAGs) caused by lysosomal enzyme deficiency, leads to multi-organ dysfunction. Each kind of MPS disorder (I–IX) is caused by deficiency of a specific lysosomal enzyme and subsequent degraded GAGs fragments increase in urine, blood, and cerebral spinal fluid. MPS II, also called Hunter Syndrome (OMIM 309900), is a recessive X-linked lysosomal storage disorder caused by deficiency of iduronate-2-sulfatase (IDS). TheIDSgene is located on Xq28, contains nine exons and encodes a precursor protein of 550 amino acids.^[1]More than 500IDSmutations have been identified that cause MPS II in the Human Gene Mutation Database. This deficiency leads to accumulation of GAGs, including dermatan sulfate and heparan sulfate in lysosomes of the liver, spleen, connective tissue, and brain, with excretion in the urine.^[2]MPS II was traditionally divided into two sub-types according to clinical severity. Individuals with the mild form may have attenuated somatic complications, short stature, survive to adulthood, and often exhibit no mental retardation. In contrast, severely affected individuals are characterized by early somatic abnormalities including progressive neurological damage, hepatosplenomegaly, progressive cardiopulmonary deterioration, skeletal deformities, and usually die of obstructive airway disease or cardiac failure before the age of 15 years.^[3]Here, we describe the clinical and genetic findings of a Tibetan boy with MPS II carrying a novel variation in heparan-N-sulfatase (SGSH, sulfamidase). Our report also explains the impact ofIDSmutations on enzyme activity.

To the Editor:Rosai-Dorfman disease (RDD), also named sinus histiocytosis with massive lymphadenopathy (SHML), was first reported by Rosai and Dorfman in 1969.^[1]Nodal RDD is usually characterized by massive lymphadenopathy; however, extranodal RDD is uncommon, its more severe fibrosis and fewer histiocytes in the lesion make it more difficult to diagnose than nodal RDD.^[2]We herein describe a patient with both extranodal RDD in the hypopharynx, larynx, and cervical lymph nodes and a long history of half body stabbing pain that disappeared after surgical excision.

To The Editor:Bariatric surgery, as an effective treatment for patients with morbid obesity and its related metabolic diseases, is gaining increasing popularity. Non-alcoholic fatty liver disease (NAFLD) is a common comorbidity associated with morbid obesity. Growing evidence suggests that patients with non-alcoholic steatohepatitis are at high-risk of adverse outcomes such as cirrhosis and liver-related mortality. Liver function failure caused by NAFLD is predicted to become the most common reason for liver transplantation (LT) in the United States by 2025.^[1]The estimated prevalence of obesity is 20% to 30% in LT recipients in the United States.^[2]LT is the only radical treatment for end-stage liver disease. If patients with end-stage liver disease and morbid obesity cannot effectively control their body weight after LT, the donor liver will be at high-risk of NAFLD again. Simultaneous LT and sleeve gastrectomy (SG) may be performed for effectively controlling post-operative body weight and metabolic disorders in these patients. We present a case of simultaneous LT and SG for a patient with end-stage liver disease and morbid obesity.

To the Editor:A 27-year-old man without psychiatric history presented with a 2-month history of apathy, decreased responsiveness, and malaise. The onset of these new behavioral changes was preceded by fatigue and insomnia. On physical examination, the patient’s limbs had normal muscle tone and strength and no pathological reflexes were detected. Four years earlier, the patient underwent an operation for spinal meningioma resection. Before the operation, some analogous symptoms, like apathy and reduced responsiveness, appeared; the symptoms lasted for a month and remitted after the operation. Four days later, the patient developed mutism and irresponsiveness. He was diagnosed with organic psychosis and was admitted to a psychiatric unit. The patient began regular anti-psychotic treatment, including olanzapine, escitalopram, sertraline, and oxazepam, but there was no improvement in his mutism and irresponsiveness.

To the Editor:A 57-year-old man was diagnosed with bladder cancer and underwent bladder tumor transurethral resection to treat a high-grade T1 urothlial carcinoma. Intravesical bacillus Calmette-Guérin (BCG) (BCG for Therapeutic Use, CDIBP, China) immunotherapy was performed once per week for 6 weeks at a concentration of 120 mg in 50 mL saline. The patient had no history of tuberculosis. After 6 weeks of treatment, the patient complained of perineal discomfort. A digital rectal examination (DRE) showed tenderness, thus resulting in suspicion of infection in the left lobe of the prostate. Microscopic urinalysis showed few red blood cells. The level of total prostate-specific antigen (PSA) was 2.61 ng/mL, and the free PSA was 0.23 ng/mL. A magnetic resonance (MR) scan was performed to evaluate prostate infection and revealed an approximately 2.1 × 1.2 cm hypo-intense lesion on T2-weighted imaging (T2WI) and hyper-intensity on diffusion-weighted imaging in the peripheral zone of the left prostate gland [Figure 1AandFigure 1B]. For differential diagnosis of the prostatic hypo-intense lesion on T2WI, a prostate biopsy was performed. Subsequent histology showed granulomatous prostatitis [Figure 1C] positive for tuberculosis according to polymerase chain reaction. There was no evidence of tuberculosis elsewhere. On the basis of these findings, tuberculous prostatic abscess was confirmed. The patient was treated with a 9-month antituberculous regime of isoniazid (300 mg/day), rifampicin (450 mg/day), and ethambutol (750 mg/day). The symptoms were relieved after 1 month of anti-tuberculous therapy. After completion of the 9-month regimen of antituberculous therapy, a follow-up MR scan was performed, which indicated disappearance of the prostatic abscess. The most recent cystoscopy showed no evidence of tumor recurrence and no inflammation of the prostate.

To the Editor:Posterior reversible encephalopathy syndrome (PRES) is a rare condition of the central nervous system (CNS). Clinically, it can present with headache, blurred vision, seizures, or coma. The diagnosis of PRES is based on the classic radiologic imaging studies at occipital and parietal lobes in the subcortical white matter, and sometimes in the cortex. Hypertensive encephalopathy, eclampsia, immunosuppressive agents, and cytotoxic drugs can cause PRES. A patient with PRES may recover without sequela after removal of the causative factors. Notably, uncertainty in diagnosis and delay in treatment would have probably aggravated CNS injuries or death. However, the underlying mechanism of the disease remains unclear and controversial.

The Chinese Medical Association (CMA) is the largest national-level medical and academic organization in China. Established in 1915, as a non-profit and academic organization voluntarily formed by Chinese science and technology medical professionals, the CMA is an important social force in the development of medical science and technology and healthcare courses in China. After 100 years of development, the CMA now has 88 specialty societies, 677,000 members and 478 professional subsociety groups. The CMA has joined 42 international or regional medical organizations, and keeps close cooperation with medical associations of every province, autonomous region, municipality, and deputy-provincial level city. The CMA publishes 186 paper and electronic medical journals, and hosts nearly 200 international and national high-level medical academic conferences every year.

In the article titled "ATrichophyton Rubruminfection model based on the reconstructed human epidermis - Episkin^®", published onChinese Medical Journal,^[1]the "Financial Support and Sponsorship" section should be corrected as "This study was supported by the grant from Natural Science Foundation of Guangdong Province (No. 2015A030313137).