2020年 · 第133卷第06期

Aberrant activation of the complement system plays an important role in the pathogenesis and development of immunoglobulin A nephropathy (IgAN). The relationship between serum complement and the clinical-histopathological features and outcomes of IgAN is controversial. This retrospective study aimed to examine the relationship between the complement 3/4 (C3/C4) ratio and the clinicopathologic changes and prognosis of patients with IgAN.

A total of 397 patients with primary IgAN from January 2007 to December 2012 at the Chinese People’s Liberation Army General Hospital were included in this study. The correlation test and Chi-square test or one-way analysis of variance test were performed to evaluate the relationship between the C3/C4 ratio and other clinical-pathological factors. Propensity score matching and a multivariate Cox regression model were used to calculate the risk factors of renal outcome.

The median follow-up period was 75 months. During the follow-up period, 62 patients (15.6%) developed into the end-stage renal disease (ESRD). The C3/C4 ratio at baseline was associated with the level of serum creatinine (SCr), 24 h urinary protein excretion (24 h Upre), global glomerular sclerosis, and tubulointerstitial lesion. The level of SCr and 24 h Upre and the degree of chronic kidney injury were statistically different among groups defined by different C3/C4 ratio levels. The survival rates of patients among groups with different C3/C4 ratio levels were different. After propensity score matching, eighty-eight pairs of patients were successfully matched, and the C3/C4 ratio was an influencing factor for the patients’ outcome (hazard ratio 0.587, 95% confidence interval 0.329-0.880). Patients with a C3/C4 ratio <3.6 had a poorer outcome compared with the others (P = 0.002).

IgAN patients with decreased C3/C4 ratio displayed significantly more severe clinical symptoms and chronic renal injury than patients with higher ratios. A low C3/C4 ratio could be a risk factor for patients developing to ESRD.

Cell salvage has recently been recommended for obstetric use in cases with a high risk of massive hemorrhage during cesarean section (CS). However, limited data are available to support the use of one suction device to collect lost blood. This study aimed to investigate the volume of red blood cells (RBCs) salvaged and the components of amniotic fluid (AF) in blood salvaged by one suction device or two devices during CS in patients with placenta previa and/or accrete.

Thirty patients with placenta previa and/or accrete undergoing elective CS in the Women’s Hospital of Zhejiang University School of Medicine were recruited for the present study from November 1, 2017 to December 1, 2018. The patients were randomly assigned to one of the two groups according to an Excel-generated random number sheet: Group 1 (n = 15), in which only one suction device was used to aspirate all blood and AF, and Group 2 (n = 15), in which a second suction device was mainly used to aspirate AF before the delivery of the placenta. Three samples of blood per patient (pre-wash, post-wash, and post-filtration) were collected to measure AF components. The salvaged RBC volumes were recorded. Continuous data of pre-wash, post-wash, and postfiltration samples were analyzed by using one-way analysis of variance with Tukey’s test for multiple comparisons, or Kruskal-Wallis test with Dunn test for multiple comparisons. Comparisons of continuous data between Group 1 and Group 2 were conducted using Student’s t test or Mann-Whitney U test.

The salvaged RBC volume was significantly higher in Group 1 than that in Group 2 (401.6 ± 77.2 mL vs. 330.1 ± 53.3 mL, t = 4.175, P < 0.001). In both groups, squamous cells, lamellar bodies, and fat were significantly reduced by washing (all P<0.001) and squamous cells were further reduced by filtering (P < 0.001). Squamous cells were found in six post-filtration samples (three from each group). Lamellar bodies and fat were completely removed by filtering. Insulin-like growth factor binding protein 1, alphafetoprotein, albumin, lactate dehydrogenase, and potassium were significantly reduced post-wash (all P < 0.05), with no further significant reduction after filtration in either group (all P > 0.05). The mean percentage of fetal RBCs post-filtration was (1.8 ± 0.8)% with a range of 1.0% to 3.5% and (1.9 ± 0.9)% with a range of 0.7% to 4.0% in Groups 1 and 2, respectively, showing no significant difference between the two groups (U= 188.5, P = 0.651).

Cell salvage performed by one suction device could result in higher volume of salvaged RBCs and can be used safely for CS in patients with placenta previa and/or accrete when massive hemorrhage occurs.

Clinically amyopathic dermatomyositis (CADM) is a unique sub-type of idiopathic inflammatory myopathies with a high prevalence of interstitial lung disease (ILD). Poor prognosis of the patients was strongly associated with rapid progressive ILD. The aim of this study was to identify risk factors for prediction of different types of ILD in CADM.

In this study, data of 108 inpatients with CADM were collected, including 87 with ILD. The baseline clinical data and laboratory parameters, including myositis-specific and associated antibodies and tumor-associated antigens were analyzed to identify risk factors for acute or subacute interstitial pneumonitis (A/SIP) and chronic interstitial pneumonitis (CIP).

In 87 patients with CADM-ILD, 39 (36.1%) were A/SIP, and 48 (44.4%) were CIP. There were 22 (20.4%) patients with asymptomatic ILD who were detected by routine high resolution computed tomography. Cytokeratin-19 fragment (CYFRA21-1) was significantly higher in CADM-ILD than that in CADM patients without ILD; carcinoembryonic antigen and neuron-specific enolase were significantly elevated in A/SIP than that in CIP. Patients with A/SIP had a higher positive rate of anti-melanoma differentiation-associated gene 5 (MDA5), while patients with CIP had a higher positive rate of anti PL-12 and anti-Ro-52. Logistic regression analysis indicated that elevation of CYFRA21-1 was a risk factor for ILD, higher titer of anti-MDA5 indicated increased likelihood for A/SIP, and higher titer of anti-Ro-52 was also clearly associated with CIP.

This study indicated that the prevalence of ILD was high in CADM. Asymptomatic ILD has been previously underestimated. Anti-MDA5 was a risk factor for the presence of A/SIP, and CYFRA21-1 was a risk factor for ILD.

Intravertebral and general anesthesia (GA) are two main anesthesia approaches but both have defects. This study was aimed to evaluate the effect of subarachnoid anesthesia combined with propofol target-controlled infusion (TCI) on blood loss and transfusion for total hip arthroplasty (THA) in elderly patients in comparison with combined spinal-epidural anesthesia (CSEA) or GA.

Totally, 240 patients (aged ≥65 years, American Society of Anesthesiologists [ASA] I-III) scheduled for posterior THA were enrolled from September 1st, 2017 to March 1st, 2018. All cases were randomly divided into three groups to receive CSEA (group C, n = 80), GA (group G, n = 80), or subarachnoid anesthesia and propofol TCI (group T, n= 80), respectively. Primary outcomes measured were intra-operative blood loss, autologous and allogeneic blood transfusion, mean arterial pressure at different time points, length of stay in post-anesthesia care unit (PACU), length of hospital stay, and patient satisfaction degree. Furthermore, post-operative pain scores and complications were also observed. The difference of quantitative index between groups were analyzed by one-way analysis of variance, repeated measurement generalized linear model, Student-Newman-Keuls test or rank-sum test, while ratio index was analyzed by Chi-square test or Fisher exact test.

Basic characteristics were comparable among the three groups. Intra-operative blood loss in group T (331.53 ± 64.33 mL) and group G (308.03 ± 64.90 mL) were significantly less than group C (455.40 ± 120.48 mL, F = 65.80, P < 0.001). Similarly, the autologous transfusion of group T (130.99 ± 30.36 mL) and group G (124.09 ± 24.34 mL) were also markedly less than group C (178.31 ± 48.68 mL, F= 52.99, P < 0.001). The allogenetic blood transfusion of group C (0 [0, 100.00]) was also significantly larger than group T (0) and group G (0) (Z = 2.47, P = 0.047). Except for the baseline, there were significant differences in mean arterial blood pressures before operation (F= 496.84, P < 0.001), 10-min after the beginning of operation (F = 351.43, P < 0.001), 30-min after the beginning of operation (F = 559.89, P < 0.001), 50-min after the beginning of operation (F = 374.74, P < 0.001), and at the end of operation (F= 26.14, P < 0.001) among the three groups. Length of stay in PACU of group T (9.41 ± 1.19 min) was comparable with group C (8.83 ± 1.26 min), and both were significantly shorter than group G (16.55 ± 3.10 min, F = 352.50, P < 0.001). There were no significant differences among the three groups in terms of length of hospitalization and post-operative visual analog scale scores. Patient satisfaction degree of group T (77/80) was significantly higher than group C (66/80, χ²= 7.96, P = 0.004) and G (69/80, χ² = 5.01, P = 0.025). One patient complained of post-dural puncture headache and two complained of low back pain in group C, while none in group T. Incidence of post-operative nausea and vomiting in group G (10/80) was significantly higher than group T (3/80, χ² = 4.10, P = 0.043) and group C (2/80, χ² = 5.76, P = 0.016). No deep vein thrombosis or delayed post-operative functional exercise was detected.

Single subarachnoid anesthesia combined with propofol TCI seems to perform better than CSEA and GA for posterior THA in elderly patients, with less blood loss and peri-operative transfusion, higher patient satisfaction degree and fewer complications.

Mallet fracture is avulsion of the terminal extensor tendon from the base of the distal phalangeal bone with a bony fragment. This study was performed to evaluate the anatomical characteristics of mallet fractures, investigate a new mallet fracture classification system using anatomical and imaging methods, and discuss the treatment schemes for different types of mallet fracture.

Sixty-four fresh cadaveric fingers were divided into four groups, and models of different types of mallet fracture with distal interphalangeal joint instability were established by dissecting 25%, 50%, 75%, and 100% of the bilateral collateral ligaments. The effect of mallet fractures on the stability of the distal interphalangeal joint was then observed. The lateral radiographs of mallet fractures in 168 patients were analyzed and classified according to the involvement of the joint surface in the fracture, the thickness of fracture, the untreated time after injury, and the complication of distal interphalangeal joint palmar subluxation. Forty-seven patients were surgically treated by reconstruction of extensor tendon insertion, the Ishiguro method, or single Kirschner wire fixation.

The established mallet fracture model showed that the distal interphalangeal joint was stable when the bilateral collateral ligaments were cut off by 25% (t= -0.415, P = 0.684) and significantly unstable when this range was ≥50% (50% transection: t= -6.363, P < 0.001; 75% transection: t= -17.036, P < 0.001; 100% transection: t = -30.977, P < 0.001, respectively). The mallet fractures were divided into Types I, II, and III (fracture involving <20%, 20%-50%, and >50% of the joint surface, respectively). Type II was further divided into Types IIa and IIb according to whether the course of injury was < or ≥2 weeks, respectively. The mean post-operative flexion of the distal interphalangeal joint was 63.4° ± 7.9°, and the mean extension lag was 6.7°± 4.6°.

The lateral collateral ligament is the main factor that maintains the stability of the distal interphalangeal joint. Classification that combines the involvement of the joint surface in the fracture, the thickness of the fracture, and the untreated time after injury is reasonable and will help to choose an appropriate operational method.

Proliferative diabetic retinopathy (PDR) is a progressive stage of diabetic retinopathy featured by the formation of neovascular and proliferative membrane. Vascular endothelial growth factor (VEGF) acts as a pivot factor in the development of neovascularization. This study was to investigate the changes of intravitreal VEGF concentrations of severe PDR after intravitreal injection of conbercept (IVC) and its potential advantages to the following vitrectomy.

This was a prospective, interventional, randomized controlled study. Sixty eyes (60 patients) with severe PDR and 20 eyes from 20 patients with rhegmatogenous retinal detachment complicated with proliferative vitreoretinopathy were enrolled in this study. PDR eyes were randomly assigned to three groups by sortation randomization method with 20 eyes in each based on the interval of preoperative IVC (group A: 7 days, group B: 14 days, group C: non-IVC). Another 20 eyes without diabetes were enrolled as the non-diabetic control group (group D), receiving PPV directly. Vitreous specimens of all 80 patients were collected and evaluated afterwards. The intravitreal VEGF concentration of the four groups, and the total surgical time and the intraoperative bleeding rate of the PDR groups were recorded.

The mean intravitreal VEGF concentrations of groups A-D were 66.6 ± 43.3, 93.1 ± 52.3, 161.4 ± 106.1 and 1.8 ± 1.2 pg/mL, respectively. It increased significantly in PDR patients (groups A, B and C) (P = 0.002, <0.001, and <0.001, respectively). PDR patients with preoperative IVC (groups A and B) presented significantly lower VEGF concentrations (P < 0.001 and 0.001), intraoperative bleeding rates (P= 0.004) and total surgical time (P < 0.001, P= 0.003) compared with group C. No statistical differences were presented between groups A and B on the three parameters.

Seven days and 14 days of preoperative IVC are equally efficient and safe for the vitrectomy of severe PDR patients through decreasing vitreous VEGF concentrations, intraoperative bleeding rate and total surgical times.

In consideration of the difficulty in diagnosing high heterogeneous glioma, valuable prognostic markers are urgent to be investigated. This study aimed to verify that connective tissue growth factor (CTGF) is associated with the clinical prognosis of glioma, also to analyze the effect of CTGF on the biological function.

In this study, glioma and non-tumor tissue samples were obtained in 2012 to 2014 from the Department of Neurosurgery of Nanfang Hospital of Southern Medical University, Guangzhou, China. Based on messenger RNA (mRNA) data from the Cancer Genome Atlas (TCGA) and CCGA dataset, combined with related clinical information, we detected the expression of CTGF mRNA in glioma and assessed its effect on the prognosis of glioma patients. High expression of CTGF mRNA and protein in glioma were verified by reverse transcription-polymerase chain reaction, immunohistochemistry, and Western blotting. The role of CTGF in the proliferation, migration, and invasion of gliomas were respectively identified by methylthiazoletetrazolium assay, Transwell and Boyden assay in vitro. The effect on glioma cell circle was assessed by flow cytometry. For higher expression of CTGF in glioblastoma (GBM), the biological function of CTGF in GBM was investigated by gene ontology (GO) analysis.

In depth analysis of TCGA data revealed that CTGF mRNA was highly expressed in glioma (GBM, n= 163; lowly proliferative glioma [LGG], n = 518; non-tumor brain tissue, n = 207; LGG, t = 2.410, GBM, t = 2.364, P < 0.05). CTGF mRNA and protein expression in glioma (86%) was significantly higher than that in non-tumor tissues (18%) verified by collected samples. Glioma patients with higher expression of CTGF showed an obviously poorer overall survival (35.4 and 27.0 months compared to 63.3 and 55.1 months in TCGA and Chinese Glioma Genome Atlas (CGGA) databases separately, CGGA: χ² = 7.596, P = 0.0059; TCGA: χ² = 10.46, P = 0.0012). Inhibiting CTGF expression could significantly suppress the proliferation, migration, and invasion of gliomas. CTGF higher expression had been observed in GBM, and GO analysis demonstrated that the function of CTGF in GBM was mainly associated with metabolism and energy pathways (P < 0.001).

CTGF is highly expressed in glioma, especially GBM, as an unfavorable and independent prognostic marker for glioma patients and facilitates the progress of glioma.

Fibroblast-like synoviocytes (FLSs), resident mesenchymal cells of synovial joints, play an important role in the pathogenesis of rheumatoid arthritis (RA). Dickkopf-1 (DKK-1) has been proposed to be a master regulator of bone remodeling in inflammatory arthritis. Here, potential impairation on the activity of FLSs derived from RA to small interfering RNAs (siRNAs) targeting DKK-1 was investigated.

siRNAs targeting DKK-1 were transfected into FLSs of patients with RA. Interleukin (IL)-1β, IL-6, IL-8, matrix metalloproteinase (MMP) 2, MMP3, MMP9, transforming growth factor (TGF)-β1, TGF-β2 and monocyte chemoattractant protein (MCP)-1 levels in the cell culture supernatant were detected by enzyme-linked immunosorbent assay (ELISA). Invasion assay and ³H incorporation assay were utilized to investigate the effects of siRNAs targeting DKK-1 on FLSs invasion and cell proliferation, respectively. Western blotting was performed to analyze the expression of nuclear factor (NF)-κB, interleukin-1 receptor-associated kinase (IRAK)1, extracellular regulated protein kinases (ERK)1, Jun N-terminal kinase (JNK) and β-catenin in FLSs.

DKK-1 targeting siRNAs inhibited the expression of DKK-1 in FLSs (P < 0.01). siRNAs induced a significant reduction of the levels of IL-6, IL-8, MMP2, MMP3 and MMP9 in FLSs compared to the control group (P < 0.05). DKK-1 targeting siRNAs inhibited the proliferation and invasion of FLSs (P < 0.05). Important molecules of pro-inflammatory signaling in FLSs, including IRAK1 and ERK1, were decreased by the inhibition of DKK-1 in FLSs. In contrast, β-catenin, a pivotal downstream molecule of the Wnt signaling pathway was increased.

By inhibiting DKK-1, we were able to inhibit the proliferation, invasion and pro-inflammatory cytokine secretion of FLSs derived from RA, which was mediated by the ERK or the IRAK-1 signaling pathway. These data indicate the application of DKK-1 silencing could be a potential therapeutic approach to RA.

Machine learning shows enormous potential in facilitating decision-making regarding kidney diseases. With the development of data preservation and processing, as well as the advancement of machine learning algorithms, machine learning is expected to make remarkable breakthroughs in nephrology. Machine learning models have yielded many preliminaries to moderate and several excellent achievements in the fields, including analysis of renal pathological images, diagnosis and prognosis of chronic kidney diseases and acute kidney injury, as well as management of dialysis treatments. However, it is just scratching the surface of the field; at the same time, machine learning and its applications in renal diseases are facing a number of challenges. In this review, we discuss the application status, challenges and future prospects of machine learning in nephrology to help people further understand and improve the capacity for prediction, detection, and care quality in kidney diseases.

Epigenetic regulation includes changes of DNA methylation and modifications of histone proteins and is essential for normal physiologic functions, especially for controlling gene expression. Epigenetic dysregulation plays a key role in disease pathogenesis and progression of some malignancies, including acute myeloid leukemia (AML). Epigenetic therapies, including hypomethylating agents (HMAs) and histone deacetylase (HDAC) inhibitors, were developed to reprogram the epigenetic abnormalities in AML. However, the molecular mechanisms and therapeutic effects of the two agents alone or their combination remain unknown. An overview of these epigenetic therapies is given here. A literature search was conducted through PubMed database, looking for important biological or clinical studies related to the epigenetic regimens in the treatment of AML until October 15th, 2019. Various types of articles, including original research and reviews, were assessed, identified, and eventually summarized as a collection of data pertaining the mechanisms and clinical effects of HMAs and HDAC inhibitors in AML patients. We provided here an overview of the current understanding of the mechanisms and clinical therapeutic effects involved in the treatment with HMAs and HDAC inhibitors alone, the combination of epigenetic therapies with intensive chemotherapy, and the combination of both types of epigenetic therapies. Relevant clinical trials were also discussed. Generally speaking, the large number of studies and their varied outcomes demonstrate that effects of epigenetic therapies are heterogeneous, and that HMAs combination regimens probably contribute to significant response rates. However, more research is needed to explore therapeutic effects of HDAC inhibitors and various combinations of HMAs and HDAC inhibitors.

The regeneration capacity of cardiomyocytes (CMs) is retained in neonatal mouse hearts but is limited in adult mouse hearts. Myocardial infarction (MI) in adult hearts usually leads to the loss of large amounts of cardiac tissue, and then accelerates the process of cardiac remodeling and heart failure. Therefore, it is necessary to explore the potential mechanisms of CM regeneration in the neonates and develop potential therapies aimed at promoting CM regeneration and cardiac repair in adults. Currently, studies indicate that a number of mechanisms are involved in neonatal endogenous myocardial regeneration, including cell cycle regulators, transcription factors, non-coding RNA, signaling pathways, acute inflammation, hypoxia, protein kinases, and others. Understanding the mechanisms of regeneration in neonatal CMs after MI provides theoretical support for the studies related to the promotion of heart repair after MI in adult mammals. However, several difficulties in the study of CM regeneration still need to be overcome. This article reviews the potential mechanisms of endogenous CM regeneration in neonatal mouse hearts and discusses possible therapeutic targets and future research directions.

Acute barium poisoning is uncommon in clinical practice. It occurs primarily due to the ingestion of soluble barium compounds such as BaCl₂that causes gastroenteritis (vomiting, diarrhea, and abdominal pain), hypokalemia, hypertension, cardiac arrhythmia, and skeletal muscle paralysis. Recently, several related cases of barium poisoning due to food contamination occurred in the vicinity of our hospital. We present the data for these cases and describe a representative case that we managed.

Major depressive disorder (MDD) is a prevalent, often chronic, and highly disabling multidimensional psychiatric illness.^[1]Moreover, co-occurring anxiety symptoms are extremely common among patients with MDD; up to 90% of patients present with anxiety symptoms.^[2]Notably, high levels of anxiety symptoms may predict worse clinical outcomes because of poor response to pharmacotherapy for MDD.^[3]So use of augmentation or combination strategies during early course of treatment could be necessary, but ensuring the accurate and timely change is difficult because of the lack of consensus to assess the early improvement of initial treatment. To date, replicated evidence indicates that the lack of early improvement (eg, <20% reduction in a depression scale score) in 2 weeks can be an accurate predictor to identify eventual non-responders.^[4]This study aimed to evaluate the early onset of antidepressant action and clinical outcomes in patients with MDD and high anxiety, and to explore the potential influencing factors of early onset improvement.

Celiac disease (CeD) is an autoimmune enteropathy triggered by gluten in genetically susceptible individuals.^[1]CeD may present with typical gastrointestinal symptoms, such as chronic diarrhea, abdominal distention, and poor weight gain triggered by gluten in the diet. Some children may have short stature (SS) as the sole manifestation of CeD.^[2]Transient dysfunction of the endocrine growth axis has been reported in CeD.^[3]This apparent growth hormone deficiency (GHD) is generally normalized with the introduction of a gluten-free diet (GFD).

Percutaneous nephrolithotomy (PCNL) has achieved remarkable acceptance during the past decade. The minimization of the instruments used and flexible scope improvements helped lead to its popularity. A previous literature proved that the tract size was positively correlated with the rate of bleeding and renal injuries.^[1]On the basis of this conception, we devised a new PCNL technique, called "needle-perc" as the needle was even thinner than the micro-perc technique. In this study, we present our initial experience of using the needle-perc method to deal with small renal stones and to assess its feasibility and safety as new instrumentation in the field of minimally invasive endourology.

To the Editor:A 42-year-old Chinese man presented with head trauma caused by a brief loss of consciousness and fell after a bee sting on his nasal root while cycling outdoors. After being rushed to the emergency room, he developed sweats, dizziness, headaches, bosom frowsty, shortness of breath, and urinary incontinence. Blood pressure was 74/47 mmHg, blood oxygen saturation was 81%, and pulse rate was 149 beats/min. Physical examination revealed mental confusion, bilateral pupil diameter at 3 mm, slightly pupil insensitivity to light reflection, and rigid abdomen. 25 mg promethazine and 10 mg dexamethasone were administered immediately. The patient had no previous history of cardiovascular disease or related risk factors. However, he had a history of bee stings with no obvious abnormalities observed before. The electrocardiogram (ECG) showed sinus tachycardia (152 beats/min), ST-segment depression in II-III, and ST-segment elevation in aVR [Figure 1A]. Echocardiography and chest X-ray showed no abnormalities. Laboratory tests revealed the white blood cell count of 17.06 × 10⁹/L (normal range: 3.5-9.5 × 10⁹/L), eosinophil count of 0.73 × 10⁹/L (normal range: 0.02-0.52 × 10⁹/L), creatine kinase-MB (CK-MB) level of 29.5 ng/L (normal range: 0-5 ng/L), cardiac troponin I level of <0.5 ng/mL (normal range: 0-1 ng/mL), and myoglobin level of 249.1 ng/mL (normal range: 0-70 ng/mL); no other indicators showed obvious abnormalities. The patient underwent coronary angiography, but there were no significant abnormalities. A dermatologist performed specific immunoglobulin E (S-IgE) tests after consultation [Figure 1B], which revealed that S-IgE for tree combination (willow/poplar/elm) was 11.4 kU/L (normal range: 0-0.35 kU/L). After anti-allergy medications were administered and fluid infusion, the patient’s condition improved, and the ECG and myocardial enzyme abnormalities were normalized. The doctor recommended the patient to avoid exposure to allergens. After follow-up for 1 year, the patient did not have any similar episodes.

To the Editor:Autosomal dominant polycystic kidney disease (ADPKD) is a common inherited kidney disease with an estimated incidence of 1 in 400 to 1 in 1000.^[1]It is a late-onset systemic disorder characterized by the development and progressive enlargement of cysts in the kidney, eventually leading to end-stage renal disease.^[2]Previous studies have shown that ADPKD is a heterogeneous monogenic disorder resulting from mutations in two genes:PKD1andPKD2. Clinical data showed thatPKD1andPKD2mutations account for 85% and 15% of ADPKD cases, respectively.^[3]Compared toPKD2mutations,PKD1mutations usually indicate more severe disease, earlier onset, and poorer prognosis.^[4]There are no mutation hotspots forPKD1andPKD2, suggesting that mutations are not only unique to a single family but also high variable. In the present study, a novel nonsense mutation, c.6491C>A (p.Ser2164Ter), and a known frameshift mutation, c.12608_12635del (p.Arg4203Profs*146), in thePKD1gene were identified by targeted next generation sequencing in two Chinese ADPKD families.

To the Editor:Aesthetic medicine aims to provide assistance to patients seeking aesthetic beauty by aiding the maintenance, modification, and reshaping of their bodily appearance and beauty. Aesthetic medicine includes aesthetic surgery, aesthetic dermatology, aesthetic dentistry, aesthetic traditional Chinese medicine, aesthetic medical technology, aesthetic healthcare technology, aesthetic clinical psychology, medical aesthetic techniques, etc.^[1]All branches of aesthetic medicine originate from their parent discipline and share related objectives and aims. Aesthetic surgery originated from plastic, maxillofacial, eye, ear, nose, and throat, and orthopedic surgeries, including microsurgery, etc. Similarly, aesthetic dermatology originated from dermatology and aesthetic dentistry from stomatology.^[2]

To the Editor:Horseshoes crab is an ancient ocean creature, belonging to Arthropoda. There are three genera,Limulus,Tachypleus, andCarcinoscorpius.^[1]Amoebocyte lysate is a lyophilized product extracted from amoebocyte of horseshoes crab and known asLimulusamebocyte lysate (LAL) andTachypleusamebocyte lysate (TAL),which is widely used in endotoxin detection. As a result of occupational exposure, people working with endotoxin assessments have a risk of LAL or TAL allergy. Herein we describe a case of occupational allergy to TAL.

To the Editor: Acute-on-chronic liver failure (ACLF) is a syndrome in patients with chronic liver disease/cirrhosis, characterized by acute deterioration of liver function with one or more extra hepatic organ failures.^[1]ACLF may lead to an increased 28-day mortality rate, ranging from 23% to 74%.^[2]The common precipitant injuries that influence the course of ACLF include viruses, drugs, alcohol, infection/sepsis, gastrointestinal hemorrhage, ischemia, surgery, and idiopathic insults.^[1]There are few case reports on thyrotoxicosis triggered by iodinated contrast media (ICM) exposure that promotes ACLF. Here we report one such case.

To the Editor:Hepatocellular carcinoma (HCC) is the third most lethal malignancy globally.^[1]Besides sorafenib, lenvatinib is currently the second approved targeted agent for the first-line treatment of HCC in 2018. Lenvatinib is an oral multikinase inhibitor that targets vascular endothelial growth factor (VEGF) receptors 1 to 3, fibroblast growth factor receptors 1 to 4, platelet-derived growth factor receptor α, RET, and KIT.^[2]Patients who received lenvatinib experienced diarrhoea, and alopecia, and more instances of hypertension, proteinuria, and hypothyroidism. Here, we report two patients that developed irreversible pancreatic atrophy as a novel adverse event of lenvatinib.

To the Editor: Spider angiomas are benign vascular lesions mostly associated with decompensated liver cirrhosis. Here, we report multiple spider angiomas in a patient with chronic hepatic graft-versus-host disease (GVHD).

To the Editor:Esophageal cancer is the sixth most common cancer globally according to the World Health Organization.^[1]Due to rapid clinical progression and extremely poor prognosis, the 5-year survival rate of esophageal squamous cell carcinomas (ESCC) remains less than 20%;^[2]therefore, further developments in this field are needed. Human papillomavirus (HPV) is a small circular non-enveloped double-stranded DNA virus that primarily infects mucosa and cutaneous keratinocytes^[3]and its infection rates in ESCC range from 11.7% to 38.9% worldwide.^[4]P16 which is encoded by theCDKN2Agene and known as cyclin-dependent kinase inhibitor 2A, is a widely used immunohistochemical marker in squamous cell carcinomas and associated with high-risk HPV.^[5]

To the Editor:Many diseases present with chorea, such as cerebrovascular disease, diabetes mellitus, and systemic autoimmune disorder. The differential diagnosis for chorea is complicated, with many other rarer causes of chorea. Hemichorea is a type of chorea with unilateral involuntary movements. Hemichorea associated with nonketotic hyperglycemia and high-signal-intensity lesions on T1-weighted brain magnetic resonance imaging (MRI) is recognized as diabetic striatopathy (DS).^[1]The movement disorder and imaging abnormalities typically resolve with the treatment of hyperglycemia. Therefore, the disease is now easy to diagnose with the typical characteristics. However, hemichorea with anti-phospholipid syndrome (APS) has rarely been reported and presents with more highly variable clinical characteristics and imaging findings compared with DS.

To the Editor: In an era where publications in science citation index (SCI) journals speak louder to employers and the government than patients’ gratitude, "How’s your paper doing" has become the new "Hello" amongst young Chinese doctors.^[1]Although the pressure to publish means that doctors remain abreast of medical advances and also stimulates critical thinking,^[2]this is a means, not an end. I’ve noticed the extents that colleagues are prepared to go to have their articles published, including conducting meaningless experiments, analyzing irrelevant data, and writing redundant reviews. This is especially evident amongst medical graduate students in China who are expected to complete their studies with at least one publication; however, because they have only just begun their clinical work, they actually have little insight into their eventual specialty. The significance of publishing something outweighs the content.