2020年 · 第133卷第14期

The efficacy of entecavir (ETV) add-on peg-interferon therapy compared with ETV monotherapy in treatment-naïve hepatitis B virus (HBV) patients remains controversial. We investigated whether adding peg-interferon to ongoing ETV treatment leads to a better curative effect or not.

All patients have been recruited between August 2013 and January 2015 from the Shanghai Public Health Clinical Center and Zhongshan Hospital (China). Eligible HBV patients (n = 144) were randomly divided (1:1) to receive either ETV monotherapy (n = 70) or peg-interferon add-on therapy from week 26 to 52 (n = 74). Patients were followed-up for at least 2 years. Indexes including hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) seroconversion rate, sustained virologic response, transient elastography value, and histological scores were evaluated every 3 months until the end of the study. The rate of patients with HBsAg loss was defined as the primary endpoint criteria.

At week 26, no patient achieved HBsAg seroconversion in either group. At week 52, one patient in the monotherapy group was HBsAg-negative but there was none in the combination therapy group. The monotherapy group showed significantly better liver function recovery results than the combination therapy group. At week 78, one patient in the combination group had HBsAg seroconverted. At week 104, only three patients in the combination therapy group were HBsAg-negative compared with one patient in monotherapy. The mean alanine aminotransferase and aspartate aminotransferase levels and transient elastography values decreased significantly compared with baseline. Both groups showed a favorable decrease in alpha-fetoprotein (monotherapy: 4.5 [2.8, 7.1] vs. 2.2 [1.8, 3.1] ng/mL, P < 0.001; combination therapy: 5.7 [3.0, 18.8] vs. 3.2 [2.0, 4.3] ng/mL, P < 0.001) and an improved result of liver biopsy examination scores. The combination group showed a better improvement in histology compared with the monotherapy group (mean transient elastography value 6.6 [4.9, 9.8] vs. 7.8 [5.4, 11.1] kPa, P = 0.028). But there was no significant difference in HBsAg conversion rate (1.8% [1/56] vs. 4.1% [3/73], P = 0.809) and HBeAg conversion rate (12.5% [7/56] vs. 11.0% [8/73], P = 0.787), as well as HBV-DNA, sustained virologic response (93.2% vs. 98.5%, P = 0.150) between the two groups.

Both therapies supported liver function recovery and histology improvement. Combination therapy did not show better anti-viral efficacy in HBsAg or HBeAg seroconversion compared with monotherapy. However, combination therapy played a more positive role in reversing hepatic fibrosis compared with monotherapy.

ClinicalTrials.gov: NCT02849132; https://clinicaltrials.gov/ct2/show/NCT02849132

Benign epilepsy with centrotemporal spikes (BECTS) is the most common type of childhood idiopathic focal epilepsy. BECTS is associated with pervasive cognitive deficits and behavior problems. While seizures can be easily controlled, it is crucial to select anti-epileptic drugs that do not impair cognition, do not cause psychosocial effects, and improve the quality of life. Previous studies showed effects of oxcarbazepine (OXC) monotherapy on the cognitive and psychosocial profiles of patients with BECTS. Here, we studied the effects of OXC monotherapy on the neuropsychologic profiles and quality of life in patients with BECTS in China.

Thirty-one patients aged 6 to 12 years newly diagnosed with BECTS were recruited. A psychometric assessment was performed before and during the follow-up of OXC monotherapy with Cognitive Computerized Task Battery, Depression Self-Rating Scale for children, Screen for Child Anxiety Related Emotional Disorders, and Quality of Life in Epilepsy-31 (QOLIE-31). The results of the assessments were compared to explore the effect of OXC monotherapy in patients with BECTS.

Thirty children with BECTS completed the study. Five of ten cognitive test scores improved after treatment via OXC monotherapy, including visual tracing (F = 14.480, P < 0.001), paired associated learning (language) (F = 6.292, P < 0.001), paired associated learning (number) (F= 9.721, P < 0.05), word semantic (F = 6.003, P < 0.05), and simple subtraction (F = 6.229, P < 0.05). Of the neuropsychology data concerning the quality of life, statistically significant improvements were observed in emotion (F = 4.946, P < 0.05), QOLIE-social (F = 5.912, P < 0.05), and QOLIE-total (F= 14.161, P < 0.001).

OXC is safe and does not impair neuropsychologic functions, with no obvious mood burden on children with BECTS. Most importantly, OXC has positive impacts on children’s perception of quality of life, especially in terms of happiness and life satisfaction.

Early neurologic deterioration (END) may occur in patients with anterior circulation ischemic stroke (ACIS) after receiving endovascular treatment (EVT). Hemodynamic insufficiency, re-occlusion, and post-re-canalization hyper-perfusion are likely to play a critical role in END. We hypothesized that hemodynamic changes can predict END in patients with ACIS post-successful EVT using trans-cranial Doppler (TCD).

We utilized a prospectively maintained database of ACIS patients treated with EVT between September 2016 and June 2018 in the Xuanwu Hospital, Capital Medical University. TCD parameters including peak systolic velocity (PSV), bilateral mean flow velocity (MFV), and pulse index (PI) were determined via the middle cerebral arteries within 72 h post-EVT. A logistic regression model was applied to detect independent predictors for END.

Totally, 112 EVT patients were included in this study and 80/112 patients experienced successful re-canalization with <50% residual stenosis, while 17/80 (21.3%) patients suffered END, for which vasogenic cerebral edema (11/17) was considered as a leading role and followed by symptomatic intra-cranial hemorrhage (4/17) and ischemia progression (2/17). For the 80 patients, the PSV (median: 127 cm/s vs. 116 cm/s, P = 0.039), the ratio of ipsilateral-MFV/contra-lateral-MFV (iMFV/cMFV) (median: 1.29 vs. 1.02, P = 0.036) and iMFV/mean blood pressure (MBP) (median: 0.97 vs. 0.79, P = 0.008) in END patients were higher than those of non-END. Using the receiver-operating characteristic curve to obtain cut-off values for PSV, PI, iMFV/cMFV, and iMFV/MBP for END, we found that PI ≥0.85 (odds ratio: 11.03, 95% confidence interval: 1.92-63.46, P = 0.007) and iMFV/MBP ≥0.84 (odds ratio: 9.20, 95% confidence interval: 2.07-40.84, P = 0.004) were independent predictors of END in a multivariate logistic regression model, with a sensitivity of 82.4% and 76.5% and a specificity of 42.9% and 66.7%, respectively, and had the positive predictive values of 29.0% and 38.2%, and negative predictive values of 90.0% and 91.3%, with an area under the receiver-operating characteristic curve of 0.57 and 0.71, respectively.

TCD examination of EVT patients may be used as a real-time tool to detect END predictors, such as the higher PI and iMFV/MBP, allowing for better post-thrombectomy management in ACIS patients.

Angiopoietin-2 (Ang-2) is a type of endothelial growth factor involved in angiogenesis and vascular remodeling. Circulating Ang-2 levels are elevated in patients with obstructive coronary artery disease (CAD). This study aimed to evaluate the association between serum Ang-2 levels and coronary microvascular dysfunction in patients without obstructive CAD.

A total of 125 patients with angina in the absence of obstructive CAD were included in this cross-sectional study. Coronary flow reserve (CFR) was measured in the distal left anterior descending coronary artery by trans-thoracic Doppler echocardiography. The patients were divided into the following two sub-groups according to CFR: the impaired CFR group with CFR values <2.5 and the preserved CFR group with CFR values ≥2.5. Serum Ang-2 levels were determined using enzyme-linked immunosorbent assay. Independent predictors for impaired CFR were identified by binary logistic regression analysis. The receiver-operating characteristic curve was determined to evaluate the ability of serum Ang-2 in predicting impaired CFR.

We found that age, percentage of female sex, N-terminal pro-B-type natriuretic peptide levels, Ang-2 levels (763.3 ± 264.9 vs. 579.7 ± 169.3 pg/mL, P < 0.001), and the left atrial volume index were significantly higher in patients with impaired CFR than in patients with preserved CFR. Serum Ang-2 levels were negatively correlated with CFR (r = -0.386, P < 0.001). Binary logistic regression analysis showed that Ang-2 (odds ratio: 1.004, 95% confidence interval [CI]: 1.001-1.006, P = 0.003) and age (odds ratio: 1.088, 95% CI: 1.023-1.156, P = 0.007) were independently associated with impaired CFR. Furthermore, Ang-2 was a significant predictor of impaired CFR on the receiver-operating characteristic curve (P < 0.001). The area under the curve was 0.712 (95% CI: 0.612-0.813).

High serum Ang-2 levels are independently associated with impaired CFR in patients with angina in the absence of obstructive CAD.

Certain hemophilia patients are unable to cooperate with or afford magnetic resonance imaging (MRI) examinations. The purpose of our study was to explore the value of multislice spiral computed tomography (MSCT) in evaluating hemophilic arthropathy (HA).

Thirty-eight patients with 73 joints of HA were consecutively selected from January 2016 to May 2018 for this prospective study. All 73 joints were examined by X-ray, CT, and MRI within 2 days. The MRI scores of the joints were determined by the International Prophylaxis Study Group (IPSG) standard. The CT findings were quantified according to the IPSG standard, except for cartilage injury, which was quantified by joint space narrowing using the X-ray Pettersson score. The CT and MRI scores were compared by the paired Wilcoxon signed-rank test. The correlations between the CT score of joint space narrowing and MRI score of cartilage injury and the total CT and MRI scores were analyzed by Spearman rank correlation. The kappa test was used to compare the consistency of CT and MRI scores.

MRI was superior to CT based on the scores for small amount of effusion (P < 0.05), synovial hypertrophy and hemosiderin deposition in the mild groups (P < 0.05). The CT and MRI scores were not significantly different for moderate and massive effusion, synovial hypertrophy, and hemosiderin deposition in the moderate and severe groups, bone erosion or cystic changes (P > 0.05), and there was a high degree of consistency between the two scores (kappa > 0.81). The consistency between the Pettersson scores of joint space narrowing on CT and the IPSG scores of cartilage injury on MRI was high (kappa = 0. 774, P < 0.05).

The image scores of MSCT are generally consistent with MRI except for mild synovitis, which can be used as an alternative for the evaluation of HA.

Recently, adjustable-loop devices (ALDs) have been widely used, and their reliability has always been the focus of attention. This study compared loop length changes under pull stress caused by flexion and extension of the cadaver knee between ALDs and fixed-loop devices (FLDs) in terms of femoral fixation after anterior cruciate ligament (ACL) reconstruction.

ACL reconstruction in cadaveric knee joints was performed under arthroscopy with femoral suspension devices and tibial fixation by tying sutures on staples. The knee joint was repeatedly flexed and extended 30 times after fixation. According to the femoral fixation device used (Endobutton or Ultrabutton), the knee joints were divided into two groups: the ALD group (12 specimens) and the FLD group (ten specimens). The length of the loop before and after fixation was measured, and the loop length of the ALD group was re-measured 1 day after reconstruction.

There was no significant difference in the length of the loop between the two groups (t = 0.579, P = 0.569). One day later, the loop length of the ALDs retracted by 0.29 ± 0.33 (0-1.1) mm, and there was no retraction in three specimens.

There was no significant difference in the loop length under flexion and extension stress after ACL reconstruction between ALDs and FLDs.

The catheter-tissue contact force (CF) is one of the significant determinants of lesion size and thus has a considerable impact on the effectiveness of ablation procedures. This study aimed to evaluate the impact of CF on the lesion size during right ventricular outflow tract (RVOT) ablation in a swine model.

Twelve Guangxi Bama miniature male pigs weighing 40 to 50 kg were studied. After general anesthesia, a ThermoCool SmartTouch contact-sensing ablation catheter was introduced to the RVOT via the femoral vein under the guidance of the CARTO 3 system. The local ventricular voltage amplitude and impedance were measured using different CF levels. We randomly divided the animals into the following four groups according to the different CF levels: group A (3-9 g); group B (10-19 g); group C (20-29 g); and group D (30-39 g). Radiofrequency ablations were performed at three points in the free wall and septum of the RVOT in power control mode at 30 W for 30 s while maintaining the saline irrigation rate at 17 mL/min. At the end of the procedures, the maximum depth, surface diameter, and lesion volume were measured and recorded. A linear regression analysis was performed to determine the relationship between continuous variables.

A total of 72 ablation lesions were created in the RVOT of the 12 Bama pigs. The maximum depth, surface diameter, and volume of the lesions measured were well correlated with the CF (free wall: β = 0.105, β = 0.162, β = 3.355, respectively, P < 0.001; septum: β = 0.093, β = 0.150, β = 3.712, respectively, P < 0.001). The regional ventricular bipolar voltage amplitude, unipolar voltage amplitude, and impedance were weakly positively associated with the CF (β = 0.065, β = 0.125, and β = 1.054, respectively, P < 0.001). There was a significant difference in the incidence of steam pops among groups A, B, C, and D (free wall: F = 7.3, P = 0.032; septum: F = 10.5, P = 0.009); and steam pops occurred only when the CF exceeded 20 g. Trans-mural lesions were observed when the CF exceeded 10 g in the free wall, while the lesions in the septum were non-trans-mural even though the CF reached 30 g.

CF seems to be a leading predictive factor for the size of formed lesions in RVOT ablation. Maintaining the CF value between 3 and 10 g may be reasonable and effective for creating the necessary lesion size and reducing the risk of complications, such as steam pops and perforations.

Zinc finger and BTB domain-containing protein 46 (Zbtb46) is a transcription factor identified in classical dendritic cells, and maintains dendritic cell quiescence in a steady state. Zbtb46 has been reported to be a negative indicator of acute myeloid leukemia (AML). We found that Zbtb46 was expressed at a relatively higher level in hematopoietic stem and progenitor cells (HSPCs) compared to mature cells, and higher in AML cells compared to normal bone marrow (BM) cells. However, the role of Zbtb46 in HSPCs and AML cells remains unclear. Therefore, we sought to elucidate the effect of Zbtb46 in normal hematopoiesis and AML cells.

We generated Zbtb46^fl/fl and Zbtb46^fl/flMx1-Cre mice. The deletion of Zbtb46 in Zbtb46^fl/flMx1-Cre mice was induced by intraperitoneal injection of double-stranded poly (I). poly (C) (poly(I:C)), and referred as Zbtb46 cKO. After confirming the deletion of Zbtb46, the frequency and numbers of HSPCs and mature blood cells were analyzed by flow cytometry. Serial intraperitoneal injection of 5-fluorouracil was administrated to determine the repopulation ability of HSCs from Zbtb46^fl/fl and Zbtb46 cKO mice. The correlation between Zbtb46 expression and prognosis was analyzed using the data from the Cancer Genome Atlas. To investigate the role of Zbtb46 in AML cells, we knocked down the expression of Zbtb46 in THP-1 cells using lentiviral vectors expressing small hairpin RNAs targeting Zbtb46. Cell proliferation rate was determined by cell count assay. Cell apoptosis and bromodeoxyuridine incorporation were determined by flow cytometry.

The percentages and absolute numbers of HSPCs and mature blood cells were comparable in Zbtb46 cKO mice and its Zbtb46^fl/fl littermates (Zbtb46^fl/flvs. Zbtb46 cKO, HPC: 801,310 ± 84,282 vs. 907,202 ± 97,403, t = 0.82, P = 0.46; LSK: 86,895 ± 7802 vs. 102,210 ± 5025, t = 1.65, P = 0.17; HSC: 19,753 ± 3116 vs. 17,608 ± 3508, t = 0.46, P = 0.67). The repopulation ability of HSCs from Zbtb46^fl/flMx1-Cre mice was similar to those from Zbtb46^fl/fl control (P = 0.26). Zbtb46 had elevated expression in AML cells compared to total BM cells from normal control. Knockdown of Zbtb46 in THP-1 cells led to a significant increase in cell apoptosis and reduced cell growth and proliferation.

Collectively, our data indicate that Zbtb46 is essential for survival and proliferation of AML cells, but dispensable for normal hematopoiesis.

Amniotic fluid embolism (AFE) is a rare but potentially lethal condition characterized by an abrupt onset, unpredictability, and high fatality rate. The Society for Maternal-Fetal Medicine (SMFM) published clinical guideline No. 9 "Amniotic fluid embolism: diagnosis and management" in 2016.^[1]Based on this guideline and other relevant studies, the Obstetrics Group of the Chinese Society of Obstetrics and Gynecology, Chinese Medical Association, developed a consensus on the diagnosis and treatment of AFE in December 2018, aiming to standardize its diagnosis and management, and to improve maternal and perinatal outcomes.^[2]

Hypertension is a significant contributor to cardiovascular diseases. When controlled ineffectively, hypertension can lead to heart diseases and stroke, which together constitutes the leading causes of global premature death and disability. According to a national cross-sectional survey in China, the prevalence of hypertension among adults aged ≥18 years was 23.2% in 2015.^[1]

To the Editor:A 43-year-old female patient was admitted to our department for a 6-month-history of paroxysmal cough in July 2013. She was diagnosed with right lower lung adenocarcinoma (cT2aN3M1b, stage IV, anaplastic lymphoma kinase [ALK]+) with bone metastasis in other hospital and came to participate a phase III trial of crizotinib (No. NCT01639001).

To the Editor:A previously healthy 33-year-old Chinese man initially presented to local hospital with fever, upper abdominal pain, vomiting, and diarrhea over a period of 5 days. Laboratory findings of local medical center revealed liver and kidney function impairments. The patient was treated for suspected bacterial infection and anuria. On illness day 8, the patient became confused and disoriented. He was transferred to our emergency room. Initial investigations showed severe elevations of transaminases and moderate coagulopathy [Table 1]. Viral serologies for hepatitis A, B, C, and E were negative. Chest X-ray was normal. Computed tomography of brain and abdomen showed hepatomegaly and a small amount of ascites. On illness day 10, he developed status epilepticus and was intubated for airway protection. The relatives denied history of alcohol abuse, illicit drug use, and orolabial lesions. The patient was admitted to intensive care unit for further management on illness day 10.

To the Editor:Embryo development at the early cleavage stage is a complex and well-orchestrated biological process. Duringin vitrofertilization-embryo transfer (IVF-ET), embryos are routinely stratified according to morphological criteria and transferred on the morning of day 3 after fertilization. This stage of embryonic development is mainly regulated by maternal factors because the embryonic genome has not yet been fully activated.^[1]Day 3 is a key period for embryos to accomplish embryonic genome activation (EGA). Embryos with higher developmental potential initiate EGA for subsequent development and implantation, while non-viable embryos undergo arrest.^[2]However, it is difficult to precisely select embryos with EGA. Thus, implantation rates remain at 20% to 30% in IVF-ET.^[3]During IVF-ET treatment, we found that more than half of day 3 embryos continued developing during an extended culture (EC) of 7 to 8 h from 08:00-09:00 to 16:00, and live birth rates increased when these embryos were transferred. Then, this strategy was used to improve live birth rates during IVF-ET.

To the Editor:Myocardial electrical and structural remodeling are closely related to the pathogenic mechanisms of atrial fibrillation (AF), which mainly result from disordered Ca²⁺homeostasis in the atrium. Recent evidence showed that altered inositol 1,4,5-trisphosphate receptors (IP₃R) activity can affect conduction velocity and rhythm in the sinoatrial nodes. The disruption of Ca²⁺homeostasis mediated by IP₃Rs is closely associated with the special pathophysiology observed in AF, which involves atrial remodeling, inflammation, and oxidative stress (OS).

To the Editor:Human pathogens have evolved over a long time to become mesophiles to adapt to the typical 37°C temperature of the human body. Yeast and yeast-like fungi also grow very well at this temperature, while the optimal temperature for the growth of filamentous fungi is 25 to 28°C. Hainan Island in China has a tropical oceanic monsoon climate with indistinct seasons. The mean temperature at this place for many years has been 24.4°C, and the annual temperature variation is small; the precipitation is approximately 1718.6 mm, and the relative humidity is 82%. These unique weather characteristics provide a favorable growth environment for pathogens. Patients with hematologic malignancies have poor immunity and are susceptible to pathogens. This results in high nosocomial infection rates in patients with hematologic malignancies and frequent antibiotic use. Epidemiological surveys of different regions and hospitals can provide more guidance for clinical drug administration by hematologists in treating infections in patients with hematologic malignancies.

To the Editor:Chronic kidney disease (CKD) is rapidly becoming a major public disease burden, affecting approximately 11% to 13% of the general population.^[1]Its related treatments severely influence the physical, psychological, and social well-being of patients by restricting their daily activity. It has been shown that exercise may have multiple benefits for patients with CKD in terms of improving their physical activity, enhancing cardio-respiratory function, and promoting quality of life (QoL).^[2]Furthermore, some results regarding the effectiveness of exercise on QoL in patients with CKD were inconsistent. Several studies have demonstrated that exercise significantly improved QoL in patients with CKD, while others failed to detect a significant difference despite showing evidence that post-exercise QoL scores for pre-dialysis patients with CKD were greater than at baseline. Even in studies that had indicated the effectiveness of exercise on QoL, the components of improvement varied. Thus, a meta-analysis was performed to evaluate the effect of exercise on QoL in pre-dialysis patients with CKD.

To the Editor:Quantitative magnetic resonance imaging (MRI) objectively evaluates the degeneration of cartilage in knee osteoarthritis (KOA) patients by measuring changes in proteoglycans, collagen fibers, and water content, thereby facilitating early clinical diagnosis and treatment.^[1]Western Ontario and MacMaster Universities (WOMAC) osteoarthritis index score is used to evaluate the symptoms of KOA patients.^[2]Presently, few studies have evaluated the correlation between quantitative MRI findings and clinical symptoms (eg., study performed by Zarinset al^[3]). This study explored the relationship between quantitative MRI in T1rho and T2-mapping sequence and WOMAC osteoarthritis index scores of KOA patients.

To the Editor:Sleeve fracture of the patella is considered as a unique type of patellar injury to the pediatric population. It is a special type of avulsion fracture in which the avulsed fragment comprises of a small bony fragment from the patella, accompanied by a large portion of articular cartilage.^[1]It makes up approximately half of patellar fracture in children.^[2]However, the occurrence of this injury bilaterally is extremely rare and there has been only few reports regarding the treatment and prognosis to this injury during its chronic phase. Here we reported a case of chronic bilateral sleeve fracture of the patellae in a 13-year-old healthy boy, who got injured in a running competition. To the author’s best knowledge, this is the first case of chronic bilateral sleeve fracture of the patellae in current English literature.

To the Editor:A 52-year-old man presented with fever and a painful ulcer on the right thigh for 10 days. The patient had acute lymphoblastic leukemia for 2 years. Two months ago, the patient developed cough and expectoration. Blood and lung tissue cultures gave negative results but the serum 1,3-β-D-glucan assay was positive. Chest computed tomography (CT) showed new exudation in the right lung. A diagnosis of pulmonary fungal infection was made. Ten days ago, the patient began to suffer from fever, meanwhile a small erythema was noticed on the right thigh with severe pain. The lesion enlarged rapidly and became an ulcer in the center. Physical examination showed a 2 cm × 4 cm ulcer with surrounding erythema and induration on the right thigh, necrotic eschar can be seen on the ulcer without purulent secretion and exudation [Figure 1A]. Histopathology revealed hyperplasia of epidermis and dermal perivascular infiltration of lymphocytes, neutrophils, and plasma cells. Thrombosis of blood vessel was seen in the dermis [Figure 1B]. Hematoxylineosin and periodic acid-Schiff stain both revealed the similar broad non-septate hyphae with right-angle in thrombosis [Figure 1B and C]. The direct microscopy of the lesion and the polymerase chain reaction (PCR) assay for mucormycosis in formalin-fixed paraffin-embedded tissue were negative. Based on the history, clinical examination, and histopathology, the patient was diagnosed as disseminated mucormycosis. Intravenous liposomal amphotericin B 50 mg/d and posaconazole 800 mg/d was given for the treatment. Four weeks later, chest CT scan revealed great improvement and the skin ulcer healed with crusts on it [Figure 1D].

To the Editor:Human skin is not only a physical barrier that prevents the invasion of foreign substances, it is also a biological barrier that mounts immune responses to pathogenic microorganism, exogenous macromolecular substances, allograft, and so on.^[1]For exogenous skin graft, the immune system-recognized target is the exogenous cell-derived major histocompatibility complex (MHC) class-1 molecule, along with the peptide-MHC class 1 complex.^[2]All exogenous substances known to be rejected by skin are organic; it remains unclear whether human skin has a rejection to inorganic substances. The author noticed the phenomenon in his own experience that a metal particle residing under his foot skin was discharged by the skin. Notably, the skin was intact before eliminating the metal. Thus, the author further investigated this process.

In the article titled, "Follistatin-Like 1 Promotes Bleomycin-Induced Pulmonary Fibrosis Through the Transforming Growth Factor Beta 1/Mitogen-Activated Protein Kinase Signaling Pathway" published in pages 1917-1925, Issue 16, Vol. 131 ofChinese Medical Journal,^[1]the upper panel ofFigure 4Ccontains identical images incorrectly(the image of FSTL1/DMSO and TGF-β1/U0126), the updated and correctFigure 4is as followed: