2021年 · 第134卷第02期

Radiation therapy is widely used to treat various thoracic tumors. However, X-rays inevitably cause damage to normal lung tissues while killing tumor cells, leading to the occurrence of radiation-induced lung injury (RILI). Recent data showed that lung cancer has the highest incidence of RILI (5-25%), followed by mediastinal lymphoma (5-10%), and breast cancer (1-5%).^[1]With the progress in research, our understanding of the mechanism of RILI has changed from the traditional hypothesis of "target cell death" to "a continuous process involving multiple cells," which is dynamic and evolving [Figure 1]. In the present review, we summarize the current knowledge of RILI, and discuss the potential limitations of combined radio-immunotherapy.

Aspirin has demonstrated safety and efficacy for venous thromboembolism (VTE) prophylaxis following total hip arthroplasty (THA); however, inconsistent dose regimens have been reported in the literature. This study aimed to evaluate and compare the safety and efficacy of 100 mg aspirin twice daily with rivaroxaban in VTE prophylaxis following THA.

Patients undergoing elective unilateral primary THA between January 2019 and January 2020 were prospectively enrolled in the study and randomly allocated to receive 5 weeks of VTE prophylaxis with either oral enteric-coated aspirin (100 mg twice daily) or rivaroxaban (10 mg once daily). Medication safety and efficacy were comprehensively evaluated through symptomatic VTE incidence, deep vein thrombosis (DVT) on Doppler ultrasonography, total blood loss (TBL), laboratory bloodwork, Harris hip score (HHS), post-operative recovery, and the incidence of other complications.

We included 70 patients in this study; 34 and 36 were allocated to receive aspirin and rivaroxaban prophylaxis, respectively. No cases of symptomatic VTE occurred in this study. The DVT rate on Doppler ultrasonography in the aspirin group was not significantly different from that in the rivaroxaban group (8.8% vs. 8.3%, χ² = 0.01, P = 0.91), confirming the non-inferiority of aspirin for DVT prophylaxis (χ² = 2.29, P = 0.01). The calculated TBL in the aspirin group (944.9 mL [658.5-1137.8 mL]) was similar to that in the rivaroxaban group (978.3 mL [747.4-1740.6mL]) (χ² = 1.55, P = 0.12). However, there were no significant inter-group differences in HHS at post-operative day (POD) 30 (Aspirin: 81.0 [78.8-83.0], Rivaroxaban: 81.0 [79.3-83.0], χ² = 0.43, P = 0.67) and POD 90 (Aspirin: 90.0 [89.0-92.0], Rivaroxaban: 91.5 [88.3-92.8], χ² = 0.77, P = 0.44), the incidence of bleeding events (2.9% vs. 8.3%, χ² = 0.96, P = 0.33), or gastrointestinal complications (2.9% vs. 5.6%, χ² = 1.13, P = 0.29).

In terms of safety and efficacy, the prophylactic use of 100 mg aspirin twice daily was not statistically different from that of rivaroxaban in preventing VTE and reducing the risk of blood loss following elective primary THA. This supports the use of aspirin chemoprophylaxis following THA as a less expensive and more widely available option for future THAs.

Chictr.org, ChiCTR18000202894; http://www.chictr.org.cn/showproj.aspx?proj=33284

Recent studies suggest that a healthy diet helps to prevent the development of Alzheimer disease (AD). This study aimed to investigate whether spicy food consumption is associated with cognition and cerebrospinal fluid (CSF) biomarkers of AD in the Chinese population.

We enrolled 55 AD patients and 55 age- and gender-matched cognitively normal (CN) subjects in a case-control study, as well as a cohort of 131 participants without subjective cognitive decline (non-AD) in a cross-sectional study. Spicy food consumption was assessed using the Food Frequency Questionnaire (FFQ). Associations of FFQ scores with cognition and CSF biomarkers of AD were analyzed.

In the case-control study, spicy food consumption was lower in AD patients than that in CNs (4.0 [4.0-8.0] vs. 8.0 [4.5-10.0], P < 0.001); FFQ scores were positively associated with Mini-Mental Status Examination scores in the total sample (r = 0.218, P = 0.014). In the cross-sectional study, the association between spicy food consumption and cognition levels was verified in non-AD subjects (r = 0.264, P = 0.0023). Moreover, higher FFQ scores were significantly associated with higher β-Amyloid (1-42) (Aβ₄2) levels and lower phospho-tau/Aβ₄₂ and total tau/Aβ₄₂ ratios in the CSF of non-AD subjects (P < 0.05).

Spicy food consumption is closely related to higher cognition levels and reversed AD biomarkers in the CSF, suggesting that a capsaicin-rich diet might have the potential to modify the cognitive status and cerebral pathologies associated with AD.

Homozygous or compound heterozygous mutations in high temperature requirement serine peptidase A1 (HTRA1) gene are responsible for cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL). Recently, increasing evidence has shown that heterozygous HTRA1 mutations are also associated with cerebral small vessel disease (CSVD) with an autosomal dominant pattern of inheritance. This study was aimed to analyze the genetic and clinical characteristics of HTRA1-related autosomal dominant CSVD.

We presented three new Chinese cases of familial CSVD with heterozygous HTRA1 mutations and reviewed all clinical case reports and articles on HTRA1-related autosomal dominant CSVD included in PUBMED by the end of March 1, 2020. CARASIL probands with genetic diagnosis reported to date were also reviewed. The genetic and clinical characteristics of HTRA1-related autosomal dominant CSVD were summarized and analyzed by comparing with CARASIL.

Forty-four HTRA1-related autosomal dominant CSVD probands and 22 CARASIL probands were included. Compared with typical CARASIL, HTRA1-related autosomal dominant probands has a higher proportion of vascular risk factors (P < 0.001), a later onset age (P < 0.001), and a relatively slower clinical progression. Alopecia and spondylosis can be observed, but less than those in the typical CARASIL. Thirty-five heterozygous mutations in HTRA1 were reported, most of which were missense mutations. Amino acids located close to amino acids 250-300 were most frequently affected, followed by these located near 150∼200. While amino acids 250∼300 were also the most frequently affected region in CARASIL patients, fewer mutations precede the 200th amino acids were detected, especially in the Kazal-type serine protease domain.

HTRA1-related autosomal dominant CSVD is present as a mild phenotype of CARASIL. The trend of regional concentration of mutation sites may be related to the concentration of key sites in these regions which are responsible for pathogenesis of HTRA1-related autosomal dominant CSVD.

The Shexiang Baoxin Pill (MUSKARDIA) has been used for treating coronary artery disease (CAD) and angina for more than 30 years in China. Nevertheless, methodologically sound trials on the use of MUSKARDIA in CAD patients are scarce. The aim of the study is to determine the effects of MUSKARDIA as an add-on to optimal medical therapy (OMT) in patients with stable CAD.

A total of 2674 participants with stable CAD from 97 hospitals in China were randomized 1:1 to a MUSKARDIA or placebo group for 24 months. Both groups received OMT according to local tertiary hospital protocols. The primary outcome was the occurrence of a major adverse cardiovascular event (MACE), defined as a composite of cardiovascular death, non-fatal myocardial infarction (MI), or non-fatal stroke. Secondary outcomes included all-cause mortality, non-fatal MI, non-fatal stroke, hospitalization for unstable angina or heart failure, peripheral revascularization, angina stability and angina frequency.

In all, 99.7% of the patients were treated with aspirin and 93.0% with statin. After 2 years of treatment, the occurrence of MACEs was reduced by 26.9% in the MUSKARDIA group (MUSKARDIA: 1.9% vs. placebo: 2.6%; odds ratio = 0.80; 95% confidence interval: 0.45-1.07; P = 0.2869). Angina frequency was significantly reduced in the MUSKARDIA group at 18 months (P = 0.0362). Other secondary endpoints were similar between the two groups. The rates of adverse events were also similar between the two groups (MUSKARDIA: 17.7% vs. placebo: 17.4%, P = 0.8785).

As an add-on to OMT, MUSKARDIA is safe and significantly reduces angina frequency in patients with stable CAD. Moreover, the use of MUSKARDIA is associated with a trend toward reduced MACEs in patients with stable CAD. The results suggest that MUSKARDIA can be used to manage patients with CAD.

chictr.org.cn, No. ChiCTR-TRC-12003513

Endometrial cancer is one of the most common malignancies of the reproductive system. Effective and cost-effective screening method for populations at high risk is not available. This study aimed to investigate specimen adequacy and the influencing factors in microscale endometrial sampling biopsy and to evaluate the diagnostic accuracy and medical cost of biopsy in endometrial cancer and atypical hyperplasia screenings in comparison with hysteroscopic endometrial biopsy.

A total of 1551 patients at high risk for endometrial lesions who required hysteroscopic endometrial biopsy from November 2017 to August 2018 were included. Microscale endometrial sampling biopsy was performed, followed by hysteroscopic endometrial biopsy. We evaluated the specimen adequacy and influencing factors of microscale endometrial sampling. Diagnostic consistency between microscale endometrial sampling biopsy and hysteroscopic endometrial biopsy was evaluated. The sensitivity, specificity, positive predictive value, and negative predictive value of microscale endometrial sampling biopsy in screening for endometrial cancer and atypical hyperplasia were analyzed, and the medical costs of the two procedures were compared.

The specimen adequacy was 81.2%. Patient age, menopausal status, endometrial thickness, and endometrial lesion type were correlated with specimen adequacy. There was good consistency in distinguishing benign and malignant endometrial diseases between microscale endometrial sampling biopsy and hysteroscopic biopsy (kappa 0.950, 95% CI 0.925-0.975). The sensitivity, specificity, positive predictive value, and negative predictive value of microscale endometrial sampling biopsy were 91.7%, 100.0%, 100.0%, and 99.3% for endometrial cancer screening, respectively, and 82.0%, 100.0%, 100.0%, and 99.4% for atypical hyperplasia screening. The medical cost of endometrial sampling biopsy was only 22.1% of the cost of hysteroscopic biopsy.

Microscale endometrial sampling biopsy is a minimally invasive alternative technique for obtaining adequate endometrial specimens for histopathological examination. It has the potential to be used in detecting endometrial cancer and atypical hyperplasia with high efficiency and low cost.

It has been a global trend that increasing complications related to pelvic floor surgeries have been reported over time. The current study aimed to outline the development of Chinese pelvic floor surgeries related to pelvic organ prolapse (POP) over the past 14 years and investigate the potential influence of enhanced monitoring conducted by the Chinese Association of Urogynecology since 2011.

A total of 44,594 women with POP who underwent pelvic floor surgeries between October 1, 2004 and September 30, 2018 were included from 22 tertiary academic medical centers. The data were reported voluntarily and obtained from a database. We compared the proportion of each procedure in the 7 years before and 7 years after September 30, 2011. The data were analyzed by performing Z test (one-sided).

The number of different procedures during October 1, 2011-September 30, 2018 was more than twice that during October 1, 2004-September 30, 2011. Regarding pelvic floor surgeries related to POP, the rate of synthetic mesh procedures increased from 38.1% (5298/13,906) during October 1, 2004-September 30, 2011 to 46.0% (14,107/30,688) during October 1, 2011-September 30, 2018, whereas the rate of non-mesh procedures decreased from 61.9% (8608/13,906) to 54.0% (16,581/30,688) (Z = 15.53, P < 0.001). Regarding synthetic mesh surgeries related to POP, the rates of transvaginal placement of surgical mesh (TVM) procedures decreased from 94.1% (4983/5298) to 82.2% (11,603/14,107) (Z = 20.79, P < 0.001), but the rate of laparoscopic sacrocolpopexy (LSC) procedures increased from 5.9% (315/5298) to 17.8% (2504/14,107).

The rate of synthetic mesh procedures increased while that of non-mesh procedures decreased significantly. The rate of TVM procedures decreased while the rate of LSC procedures increased significantly.

NCT03620565, https://register.clinicaltrials.gov.

Minimal change nephropathy (MCD) is a common pathological type of nephrotic syndrome and is often associated with acute kidney injury (AKI). This study aimed to investigate the clinical characteristics and related factors of AKI in patients with MCD and nephrotic syndrome.

Patients from Chinese People’s Liberation Army General Hospital who were diagnosed with pathological renal MCD with clinical manifestations of nephrotic syndrome were included from January 1, 2013 to December 31, 2017. Patients diagnosed with membranous nephropathy (MN) by renal biopsy from January 1, 2013 to December 31, 2017 are included as a control population. We retrospectively analyzed the clinical and pathological characteristics of patients as well as the percentages and clinical characteristics of AKI in different age groups. We assessed the correlation of pathological characteristics with serum creatinine using multivariate linear regression analysis.

A total of 367 patients with MCD were included in the analysis, with a sex ratio of 1.46: 1 (male: female) and an age range of 6 to 77 years. Among all the patients, 109 developed AKI (29.7%), and of these patients, 85 were male (78.0%). In the 586 patients with MN, 27 (4.6%) patients developed AKI. The percentage of AKI in MCD patients was significantly higher than that in MN patients (χ² = 41.063, P < 0.001). The percentage of AKI increased with age in the MCD patients. The percentage of AKI in patients aged 50 years or older was 52.9% (46/87), which was significantly higher than that [22.5% (63/280)] in patients under 50 years (χ² = 6.347, P = 0.013). We observed statistically significant differences in age (43 [27, 59] years vs. 28 [20, 44] years, Z = 5.487, P < 0.001), male (78.0% vs. 51.4%, χ² = 22.470, P < 0.001), serum albumin (19.9 ± 6.1 g/L vs. 21.5 ± 5.7 g/L, t = 2.376, P = 0.018), serum creatinine (129.5 [105.7, 171.1] μmol/L vs. 69.7 [57.7, 81.9] μmol/L, Z = 14.190, P < 0.001), serum urea (10.1 [6.2, 15.8] mmol/L vs. 4.7 [3.6, 6.4] mmol/L, Z = 10.545, P < 0.001), IgE (266.0 [86.7, 963.0] IU/ml vs. 142.0 [35.3, 516.5] IU/ml, Z = 2.742, P = 0.007), history of diabetes (6.4% vs. 1.2%, P = 0.009), and history of hypertension (23.9% vs. 5.1%, χ² = 28.238, P < 0.001) between the AKI group and the non-AKI group. According to multivariate linear regression analysis, among the renal pathological features analyzed, renal tubular epithelial cell damage (β = 178.010, 95% CI: 147.888-208.132, P < 0.001) and renal interstitial edema (β = 28.833, 95% CI: 11.966-45.700, P = 0.001) correlated with serum creatinine values.

The percentage of AKI in MCD patients is significantly higher than that in MN patients. Patients over 50 years old are more likely to develop AKI. Renal tubular epithelial cell injury and renal interstitial edema may be the main pathological lesions that are associated with elevated serum creatinine in patients with MCD.

Previous studies have reported that mitochondrial dysfunction participates in the pathological process of osteoarthritis (OA). However, studies that improve mitochondrial function are rare in OA. Mitochondrial transfer from mesenchymal stem cells (MSCs) to OA chondrocytes might be a cell-based therapy for the improvement of mitochondrial function to prevent cartilage degeneration. This study aimed to determine whether MSCs can donate mitochondria and protect the mitochondrial function and therefore reduce cartilage degeneration.

Bone-marrow-derived mesenchymal stromal cells (BM-MSCs) were harvested from the marrow cavities of femurs and tibia in young rats. OA chondrocytes were gathered from the femoral and tibial plateau in old OA model rats. BM-MSCs and OA chondrocytes were co-cultured and mitochondrial transfer from BM-MSCs to chondrocytes was identified. Chondrocytes with mitochondria transferred from BM-MSCs were selected by fluorescence-activated cell sorting. Mitochondrial function of these cells, including mitochondrial membrane potential (Δψm), the activity of mitochondrial respiratory chain (MRC) enzymes, and adenosine triphosphate (ATP) content were quantified and compared to OA chondrocytes without mitochondrial transfer. Chondrocytes proliferation, apoptosis, and secretion ability were also analyzed between the two groups.

Mitochondrial transfer was found from BM-MSCs to OA chondrocytes. Chondrocytes with mitochondrial from MSCs (MSCs + OA group) showed increased mitochondrial membrane potential compared with OA chondrocytes without mitochondria transfer (OA group) (1.79 ± 0.19 vs. 0.71 ± 0.12, t = 10.42, P < 0.0001). The activity of MRC enzymes, including MRC complex I, II, III, and citrate synthase was also improved (P < 0.05). The content of ATP in MSCs + OA group was significantly higher than that in OA group (161.90 ± 13.49 vs. 87.62 ± 11.07 nmol/mg, t = 8.515, P < 0.0001). Meanwhile, we observed decreased cell apoptosis (7.09% ± 0.68% vs.15.89% ± 1.30%, t = 13.39, P < 0.0001) and increased relative secretion of type II collagen (2.01 ± 0.14 vs.1.06 ± 0.11, t = 9.141, P = 0.0008) and proteoglycan protein (2.08 ± 0.20 vs. 0.97 ± 0.12, t = 8.227, P = 0.0012) in MSCs + OA group, contrasted with OA group.

Mitochondrial transfer from BM-MSCs provided protection for OA chondrocytes against mitochondrial dysfunction and degeneration through improving mitochondrial function, cell proliferation, and inhibiting apoptosis in chondrocytes. This finding may offer a new therapeutic direction for OA.

The standard protocol to maximize cerebral protection during open aortic arch surgery in acute type A aortic dissection (ATAAD) generally involves a combination of two perioperative strategies including hypothermic circulatory arrest (HCA) and cerebral perfusion in conjunction with pharmacologic agents (eg,barbiturates) as adjuncts for additional cerebral protection.^[1,2,3]Pharmacologic agents are routinely used as an adjunct intraoperatively in a majority of cases despite minimal evidence supporting their use for incremental neurological protection.^[1,3,4]Our study aims to evaluate the cerebral protection that intraoperative administration of adjunctive sedatives provides in aortic arch surgery with HCA and antegrade cerebral perfusion (ACP) in ATAAD. We hypothesize that adjunctive sedatives would not provide additional cerebral protection in aortic arch surgery with HCA and ACP, but would prolong patients’ wake-up and intubation time due to its sedative effect.

To the Editor:Organ donation after the citizen’s death program was fully launched in China in 2015. According to the allocation regulations of donated organs, all donated lungs must be allocated through the China Organ Transplant Response System (COTRS, www.cot.org. cn).^[1]To fully optimize the implementation of organ transportation sharing policy and coordinate multiple government departments and social groups involved in the process, the "Green Channel of Human Organ Transport (GCHOT)" was established on May 6th, 2016 in China [Supplementary Figure 1, http://links.lww.com/CM9/A431].^[2]In this study, we reviewed and compared the status of lung transportation between the pre- and post-GCHOT periods based on data collected from the largest lung transplantation (LT) center in Wuxi, Jiangsu, China, with the aim of introducing the detailed process and implementation of GCHOT in China.

After the advent of antibiotic treatment, tertiary syphilis is rarely observed over the last several decades, and its cardiovascular manifestations are particularly rare. Syphilitic aortitis typically involves the tubular portion of the ascending aorta, aortic arch and descending thoracic aorta, sparing the sinuses of Valsalva.^[1]Although exceptional cases of treatment of syphilitic thoracic aortic aneurysm have been reported,^[2,3,4]the optimal technique for treatment is not established. Total arch replacement combined with stented elephant trunk technique was proven to be feasible in patients with type A aortic dissection. Herein, we described our experience of total arch replacement with stented elephant trunk technique in three patients presenting with syphilitic thoracic aortic aneurysm involving the aortic arch and proximal descending aorta.

Laparoscopic partial nephrectomy (LPN) as a minimally invasive nephron-sparing surgery is gradually becoming the preferred surgical treatment for T1a renal carcinoma since it yields faster post-operative recovery and equivalent oncological outcomes to radical nephrectomy.^[1]However, it is difficult to perform LPN for complex renal tumors, resulting in a longer warm ischemic time (WIT), which consequently affects the recovery of post-operative renal function.^[2]With the development of laparoscopic instruments and techniques and the accumulating experience of surgeons, the WIT during LPN may be shortened using anatomy-based early unclamping (EUC)^[1]after the placement of one or two running sutures on the tumor bed. In this study, we improved the closure techniques for LPN using EUC in patients with complex renal tumors and assessed their effectiveness.

The surgical spectrum for radical prostatectomy (RP) has evolved from open surgery to novel minimally invasive approaches during the past few decades, with roboticassisted radical prostatectomy (RARP) being collectively reckoned as an increasingly popular option for prostate cancer (PCa). A previous study has demonstrated the safety and effectiveness of radical-assisted Laparoscopic radical Prostatectomy (RALP).^[1]While the transperitoneal route is the most popular surgical access option, alternative propositions include extraperitoneal, perineal, or transvesical access. Since the advent of the next-generation da Vinci Xi and single-port (SP) platforms, robotic laparoendoscopic single-site surgery (R-LESS) has emerged as an intriguing concept in various general or gynecological procedures and in partial nephrectomy. The first single-port robotic-assisted radical prostatectomy (spRARP) was reported in 2008,^[2]but has not seen much improvement in surgical techniques and popularity thereafter, with less than 60 total cases reported globally.^[3]A previous report^[4]demonstrated that the adoption of transumbilical incision in spRARP surgery may cause reduced flexibility, limited working space, and frequent instrument clashing, potentially leading to longer surgeries and increased difficulty. Extraperitoneal RARP has been widely reported in the literature with similar trifecta outcomes and shows more rapid recovery and reduced peri-operative complication rates.^[5]The current study aims to investigate the feasibility of extraperitoneal single-port RARP (espRARP) with the use of the da Vinci Si HD model.

As an important barrier, the pulmonary alveolar epithelium plays an important role in lung gas exchange and host defense. The alveolar epithelium is mainly comprised of alveolar type I (AT1) and type II (AT2) cells that are tightly connected to maintain the integrity of the alveolar epithelium. There are several kinds of stem/progenitor cells capable of repairing the adult alveolar epithelium in response to various injuries. Kim and colleagues identified bronchioalveolar stem cells (BASCs) that are capable of differentiating into alveolar cells and airway cells.^[1]In addition, a subset of alveolar cells expressing the laminin receptor α6β4 but not surfactant protein C (SPC) was able to regenerate into AT2 cells upon bleomycin-induced lung injury.^[2]Rare keratin 5-positive basal cells give rise to alveolar epithelial lineages after influenza infection.^[3,4]Sex-determining region Y-box 2 (Sox2) is a transcription factor that maintains and regulates self-renewal and pluripotency in embryonic stem cells.^[5]The functional roles of Sox2 in the repair of alveolar epithelium injuries remain unknown. This study aimed to investigate whether the alveolar cells expressing Sox2 are involved in alveolar epithelial repair.

To the Editor:Hepatoid adenocarcinoma of the lung (HAL) is a rare malignant tumor, which can be defined as alph-fetoprotein (AFP)-producing primary lung cancer. Most hepatoid adenocarcinomas (HAC) have high AFP expression. HAL lacks effective treatment and has poor prognosis, but early diagnosis and timely treatment can improve long-term survival rate.

To the Editor:A 27-year-old man was admitted to the Peking Union Medical College Hospital for wheezing, accompanied by coughing; white phlegm; dyspnea; sneezing; a runny, stuffy, and itchy nose; red itchy eyes; wheals on both arms; abdominal pain and dizziness. His symptoms started 10 min after he bathed and dried his guinea pig. Cetirizine and steroids partially alleviated the symptoms that day and completely alleviated them by the next morning. The patient’s history included allergic rhinitis and eczema, and he had no food or drug allergies. His father was allergic to cheese and eggs. He had kept a cat for 20 years, a dog for 5 years, and a guinea pig for 2 years. Physical examination on admission revealed maculopapules, scratches, and scabs scattered around both legs, his nasal mucosa was pale and edematous, and his lung breath sounds were clear. He was diagnosed with anaphylaxis, allergic rhinitis, and eczema. Allergen testing was performed. The skin test was positive for dust mites (++), dust (+), and cats (++). His total IgE was 200 kU/L. Serumspecific IgE (sIgE) results showed the following: Phadiatop, 11.4 pharmacia arbitrary unit/L (grade 3); guinea pig (e6), 22.7 kU allergen (A)/L (grade 4);Dermatophagoides pteronyssinus(d1), 10.6 kU(A)/L (grade 3);Dermatophagoides farinae(d2), 11.4 kU(A)/L (grade 3); hx2 (h2, d1, d2, i6), 12.7 kU(A)/L (grade 3); and cat dander (e1), 0.89 kU(A)/L (grade 2). The sIgE values for hamster (e84), rat (e87), mouse (e88), dog dander (e5),Aspergillus fumigatus(m3), andAlternaria alternata(m6) were all <0.35 kU(A)/L (Immuno-CAP, Thermo Fisher Scientific, San Jose, CA, USA). Lung function tests were forced expiratory volume in 1 s (FEV1), 88%; FEV1/forced volume vital capacity, 114%; and fraction of exhaled nitric oxide, 98 ppb.

To the Editor:Coronavirus disease 2019 (COVID-19), a result of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, is highly infectious.^[1]As COVID-19 spreads rapidly, and the majority of the patients develop mild to moderate form of the disease, we aimed to study the clinical characteristics of these patients admitted to Jianghan Fangcang shelter hospital, the largest Fangcang shelter hospital in Wuhan, China.

To the Editor:With interest, we read the article by Xuet al^[1]about a 54-year old man with a multisystem mitochondrial disorder (MID) affecting the brain, ears, and muscle. Clinical manifestations were attributed to the variant m.8363G>A intRNA(Lys).^[1]We have the following comments and concerns.

To the Editor:An 82-year-old man with symptomatic severe calcific aortic valve stenosis (peak velocity: 5.19 m/s; mean gradient: 78.0 mmHg; aortic valve area: 0.48 cm²) underwent transfemoral transcatheter aortic valve replacement. During the procedure, a 0.035-inch straight-tip glide wire (Terumo, Somerset, NJ, USA) supported by a 6 Fr Judkins Right 4 (JR4) coronary catheter (Medtronic, Minneapolis, MN, USA) were used to cross the severely stenotic aortic valve. However, the JR4 catheter could not pass the aortic valve because the wire crossed the aortic valve in the left/right coronary commissure creating an unfavorable angle and limited pushability for the catheter. Instead of switching to a differently shaped catheter (eg, an Amplatz left 1 catheter), we advanced the glide wire and therefore the more supportive portion of the wire further through the aortic valve. Subsequently, both wire and JR4 catheter dropped into the non/left coronary commissure, allowing the JR4 catheter to cross the valve easily. Eventually, a 34 mm self-expanding Evolut R valve (Medtronic) was implanted, and the patient was discharged uneventfully (Figure 1A-Eand Supplementary Video 1, http://links.lww.com/CM9/A353 [ "Commissural drop" wiring technique.]).

To the Editor: Ventriculitis, also known as ependymitis, ventricular empyema, pyocephalus, or pyogenic ventriculitis, is the inflammation of the ependymal lining of the cerebral ventricles. The inflammation of the ventricular drainage system is usually secondary to bacterial infection of the cerebrospinal fluid. The morbidity associated with ventriculitis has been reported in up to 45% of patients.^[1]Generally, neurosurgical patients or patients with head trauma are particularly at risk of developing ventriculitis, when these patients are treated with cerebrospinal fluid shunts or drains, implantation of intrathecal infusion pumps, or implantation of deep brain stimulation hardware.^[2]Clinically, most patients with ventriculitis present with fever, deterioration of the conscious level, and dysneuria.^[3]Delayed in the diagnosis and treatment will lead to severe intracranial infection, serious neurological impairment, and death. Most cases of ventriculitis have been reported in the newborns and infants, with bacteria being the most common pathogens, although several cases of ventriculitis secondary toaspergillus fumigatusinfection have been described.

To the Editor:Freezing of gait (FOG) is a common disabling movement disorder in Parkinson disease (PD), affecting approximately 50% to 80% of PD patients in their late state. FOG can cause the patients to fall easily, seriously affects their quality of life and exerts both economic and emotional burdens. Unlike the common motor symptoms of PD (such as bradykinesia, tremor, or rigidity), FOG is seldom improved by dopaminergic medication therapy or deep brain stimulation. Moreover, FOG may be resistant to (or even worsened by) levodopa.^[1]However, cognitive training has showed it can reduce the severity of FOG.^[2]These findings imply that FOG may be caused not only by motor impairment but also by cognitive impairment. It is reasonable to hypothesize that FOG+ patients have impaired cognitive function and that the diffusion indices of the cerebral territories’ microstructures associated with cognition are altered. To test this hypothesis, we applied whole-brain voxel-based analysis (VBA), a fully automated whole-brain analysis that uses voxel-wise statistics on diffusion metrics, to investigate the diffusion indices of brain microstructures changes in FOG+ patients, PD patients without FOG (FOG-patients), and healthy controls (HCs).

To the Editor:The author found a suspected congenital hepatic diaphragmatic hernia in a middle-aged male specimen about 170 cm in height. The specific report is as follows. The specimen was laid flat and the thoracic cavity and abdominal cavity were opened with conventional anatomical method. Then it was surprisingly found that most of the right lobe of the liver passed through the aortic hiatus in the diaphragm and passed through the oblique fissure hernia of the right lung into the thoracic cavity, causing the lower lobe of the right lung severely squeezed and deformed, followed by dysplasia. Gallbladder and dark green bile was also visible around it, and the left lobe of the liver was still in the abdominal cavity [Figure 1]. The project followed the principle of respecting life and voluntariness, and it had passed the review of the Ethics Committee (Approval No. JZFY201620).