2021年 · 第134卷第12期

Psoriatic arthritis (PsA) is a special subtype of psoriasis, which severely influences the quality of life of the affected people. Clinical manifestations of PsA are diverse. In addition to skin lesions, PsA patients often have musculoskeletal symptoms, nail changes, and ophthalmological features that simultaneously or successively occur with the skin lesions.^[1]Therefore, the diagnosis and treatment of PsA are challenging because of its various symptoms. In recent years, multidisciplinary management of PsA is gradually being valued, because early screening, diagnosis, and treatment can effectively control signs and symptoms of PsA, improve patients’ quality of life, and slow down the disease progression to a larger extent.^[1]

Ultrasound-guided vacuum-assisted breast biopsy (VABB) is a common technique in breast surgery. To standardize this technique, the Chinese Society of Breast Surgery (CSBrS) re-evaluated the quality of evidence for clinical studies of VABB, referring to the grading of recommendations assessment, development, and evaluation, and developed the Clinical Practice Guidelines for Ultrasound-guided vacuum-assisted breast biopsy: CSBrS Practice Guidelines 2021, in accordance with the Expert Consensus and Operation Guidelines for Ultrasound-guided Vacuum-assisted Breast Biopsy Surgery (2017) combined with data from clinical practice in breast surgery in China, providing a reference for breast surgeons in China.

With the maturation and advances of image-guided puncture biopsy technology, the proportion of open breast biopsy has gradually decreased. Ultrasound-guided biopsy is convenient in practice and supports real-time visualization. In order to standardize the practice of ultrasound-guided breast and regional lymph node biopsy, and provide a reference for Chinese breast surgeons, based on the version of Consensus statements and operation guidelines on breast lesions and lymph nodes biopsy guided by ultrasound (2019),^[1]the Chinese Society of Breast Surgery (CSBrS) has re-evaluated the quality of the evidence of relevant clinical studies referring to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) handbook and considered domestic medical condition to develop the Clinical Practice Guidelines for Ultrasound-guided Breast Lesions and Lymph Nodes Biopsy: CSBrS Practice Guidelines 2021.

Atherosclerotic renal artery stenosis (ARAS) is a common form of renal vascular disease and progressive disease. It could lead to resistant hypertension and renal insufficiency. It is almost associated with ischemic nephropathy with progressive decline in renal function and cardiac complications including flash pulmonary edema. The presence of ARAS is also associated with an increased risk of cardiovascular death. Common therapeutic strategies for ARAS include medical therapy and angioplasty with stenting.

More and more scholars have called for the cumulative live birth rate (CLBR) of a complete ovarian stimulation cycle as a key indicator for assisted reproductive technology. This research aims to study the CLBR of the first ovarian hyperstimulation cycles and analyze the related prognosis factors that might affect the CLBR.

Our retrospective study included first in vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI) cycles performed between January 2013 to December 2014. A total of 17,978 couples of first ovarian hyperstimulation IVF/ICSI cycles were included. The study was followed up for 4 years to observe the CLBR. The multivariable logistic regression model was used to analyze the prognosis factor, P value of <0.05 was considered statistically significant.

The cumulative pregnancy rate was 58.14% (10,452/17,978), and the CLBR was 49.66% (8928/17,978). The female age was younger in the live birth group when compared with the non-live birth group (30.81 ± 4.05 vs. 33.09 ± 5.13, P < 0.001). The average duration of infertility was shorter than the non-live birth cohort (4.22 ± 3.11 vs. 5.06 ± 4.08, P < 0.001). The preliminary gonadotropin used and the total number of gonadotropin used were lower in the live birth group when compared with the non-live birth group (both P < 0.001). Meanwhile, the number of oocytes retrieved and transferrable embryos were both significantly higher in the live birth group (15.35 ± 7.98 vs. 11.35 ± 7.60, P < 0.001; 6.66 ± 5.19 vs. 3.62 ± 3.51, P < 0.001, respectively).

The women’s age, body mass index, duration of infertility years, infertility factors, controlled ovarian hyperstimulation protocol, the number of acquired oocytes, and number of transferrable embryos are the prognosis factors that significantly affected the CLBR.

One inevitable shortcoming of non-invasive prenatal screening (NIPS)/cell-free DNA (cfDNA) sequencing is the uninterpretable ( "no-call" ) result, which is mainly caused by an insufficient fetal fraction. This study was performed to investigate the factors associated with a successful second NIPS in these cases and determine the optimal management for women with initial no-call results.

We retrospectively analyzed the data of women who underwent NIPS with initial no-call results due to an insufficient fetal fraction from 2017 to 2019 in our center. We compared these women’s maternal and pregnancy information with the data of women who had attained a successful second NIPS result and women who had received no-call results for a second time.

Among the 33,684 women who underwent NIPS, 137 with a no-call result underwent a retest. Comparison between the 87 (63.50%) women with a successful retest and the other 50 (36.50%) women showed a significant difference in both the initial fetal fraction and maternal body mass index (BMI), whereas the other factors showed no significant differences. In addition, with an initial fetal fraction of < 2.00%, the retest success rate was very limited.

We identified two major factors associated with a successful NIPS retest: the initial fetal fraction and the maternal BMI. These findings suggest the need for specialized management for this subset of women and would be instructional for the counseling for these women.

Functional dyspepsia (FD) has rarely been investigated in areas with a high prevalence of esophageal squamous cell carcinoma (ESCC). This study aims to reveal the epidemiological and clinical features of FD and organic dyspepsia (OD) in such a population.

A middle-aged and elderly population-based study was conducted in a region with a high incidence of ESCC. All participants completed the Gastroesophageal Reflux Disease Questionnaire and Functional Gastrointestinal Disease Rome III Diagnostic Questionnaire, and they underwent gastroscopy. After exclusion of gastroesophageal reflux disease, uninvestigated dyspepsia (UID) was divided into OD and FD for further analyses.

A total of 2916 participants were enrolled from July 2013 to March 2014 in China. We detected 166 UID cases with questionnaires, in which 17 patients with OD and 149 with FD were diagnosed via gastroscopy. OD cases presented as reflux esophagitis (RE), ESCC, and duodenal ulcer. Heartburn (52.94%) and reflux (29.41%) were common in OD, but no symptomatic differences were found between FD and OD. Male sex, low education level, and liquid food were the risk factors for OD, while frequent fresh vegetable consumption was a protective factor. FD included 56 (37.58%) cases of postprandial distress syndrome (PDS), 52 (34.89%) of epigastric pain syndrome (EPS), nine (6.04%) of PDS + EPS, and 32 (21.48%) of FD + functional esophageal disorders. The Helicobacter pylori infection rate in FD patients was not higher than that in the control group (34.23% vs. 42.26%, P = 0.240). Frequent spicy food consumption was associated with PDS (odds ratio [OR]: 2.088, 95% confidence interval [CI]: 1.028-4.243), while consumption of deep well water was protective for PDS (OR: 0.431, 95% CI: 0.251-0.741).

The prevalence of FD was 5.11% in the studied population. Gastroscopy should be prescribed for dyspepsia patients in case that ESCC and RE would be missed in UID cases diagnosed solely by the Rome III questionnaire.

ClinicalTrials.gov, NCT01688908; https://clinicaltrials.gov/ct2/show/record/NCT01688908.

The impacts of previous cardio-cerebrovascular disease (pre-CCVD) on the outcomes of hematopoietic cell transplantation (HCT) are not well described. Patients with pre-CCVD may often be poor candidates for HCT. This study aimed to investigate the impact of pre-CCVD on transplant outcomes.

A retrospective study was conducted between patients with and without pre-CCVD who consecutively received allogeneic or autologous HCT between November 2013 and January 2020 with a matching of age and disease status. The cardiovascular complications and HCT outcomes of the two groups were evaluated and compared. The primary endpoints were post-transplant cardio-cerebrovascular disease (post-CCVD) and non-relapse mortality (NRM). We used a multivariable Cox proportional hazard model and the Fine-Gray competing risk regressions for analyses to estimate the hazard ratios (HRs).

The outcomes of 23 HCT recipients with pre-CCVD were compared with those of 107 patients in the control group. No significant differences were noted in terms of engraftment, overall survival (OS) (67.00% vs. 67.90%, P = 0.983), or relapse (29.78% vs. 28.26%, P = 0.561) between the pre-CCVD group and the control group. The cumulative incidences of 2-year NRM were similar between patients with pre-CCVD and the controls (14.68% vs. 17.08%, P = 0.670). However, pre-CCVD was associated with an increased incidence of post-CCVD (HR: 12.50, 95% confidence interval [CI]: 3.88-40.30, P < 0.001), which was an independent risk factor for increased NRM (HR: 10.29, 95% CI: 3.84-27.62, P < 0.001) and inferior OS (HR: 10.29, 95% CI: 3.84-27.62, P < 0.001).

These findings suggest that the existence of pre-CCVD before transplantation might not result in increased mortality directly but superpose the toxicity of the transplantation procedure, leading to a risk of post-CCVD. Post-CCVD was a powerful predictor for high NRM and inferior OS. Further risk stratification of pre-CCVD is needed to reduce NRM in various transplantation settings.

Andersson lesions (ALs) are not uncommon in ankylosing spondylitis (AS). Plain radiography (PR) is widely used for the diagnosis of ALs. However, in our practice, there were some ALs in AS patients that could not be detected on plain radiographs. This study aimed to propose the concept of occult ALs and evaluate the prevalence and radiographic characteristics of the occult ALs in AS patients.

A total of 496 consecutive AS patients were admitted in the Affiliated Drum Tower Hospital, Medical School of Nanjing University between April 2003 and November 2019 and they were retrospectively reviewed. The AS patients with ALs who met the following criteria were included for the investigation of occult ALs: (1) with pre-operative plain radiographs of the whole-spine and (2) availability of pre-operative computed tomography (CT) and/or magnetic resonance imaging (MRI) of the whole-spine. The occult ALs were defined as the ALs which were undetectable on plain radiographs but could be detected by CT and/or MRI. The extensive ALs involved the whole discovertebral junction or manifested as destructive lesions throughout the vertebral body. Independent-samples t test was used to compare the age between the patients with only occult ALs and those with only detectable ALs. Chi-square or Fisher exact test was applied to compare the types, distribution, and radiographic characteristics between detectable and occult ALs as appropriate.

Ninety-two AS patients with a mean age of 44.4 ± 10.1 years were included for the investigation of occult ALs. Twenty-three patients had occult ALs and the incidence was 25% (23/92). Fifteen extensive ALs were occult, and the proportion of extensive ALs was significantly higher in detectable ALs (97% vs. 44%, χ² = 43.66, P < 0.001). As assessed by PR, the proportions of osteolytic destruction with reactive sclerosis (0 vs. 100%, χ² = 111.00, P < 0.001), angular kyphosis of the affected discovertebral units or vertebral body (0 vs. 22%, χ² = 8.86, P = 0.003), formation of an osseous bridge at the intervertebral space adjacent to ALs caused by the ossification of the anterior longitudinal ligament (38% vs. 86%, χ² = 25.91, P < 0.001), and an abnormal height of the affected intervertebral space were all significantly lower in occult ALs (9% vs. 84%, χ² = 60.41, P < 0.001).

Occult ALs presented with more subtle radiographic changes. Occult ALs should not be neglected, especially in the case of extensive occult ALs, because the stability of the spine might be severely impaired by these lesions.

Drug-coated balloons (DCBs) have emerged as potential alternatives to drug-eluting stents in specific lesion subsets for de novo coronary lesions. Quantitative flow ratio (QFR) is a method based on the three-dimensional quantitative coronary angiography and contrast flow velocity during coronary angiography (CAG), obviating the need for an invasive fractional flow reserve procedural. This study aimed to assess the serial angiographic changes of de novo lesions post-DCB therapy and further explore the cut-off values of lesion and vessel QFR, which predict vessel restenosis (diameter stenosis [DS] ≥50%) at mid-term follow-up.

The data of patients who underwent DCB therapy between January 2014 and December 2019 from the multicenter hospital were retrospectively collected for QFR analysis. From their QFR performances, which were analyzed by CAG images at follow-up, we divided them into two groups: group A, showing target vessel DS ≥50%, and group B, showing target vessel DS <50%. The median follow-up time was 287 days in group A and 227 days in group B. We compared the clinical characteristics, parameters during DCB therapy, and QFR performances, which were analyzed by CAG images between the two groups, in need to explore the cut-off value of lesion/vessel QFR which can predict vessel restenosis. Student’s t test was used for the comparison of normally distributed continuous data, Mann-Whitney U test for the comparison of non-normally distributed continuous data, and receiver operating characteristic (ROC) curves for the evaluation of QFR performance which can predict vessel restenosis (DS ≥50%) at mid-term follow-up using the area under the curve (AUC).

A total of 112 patients with 112 target vessels were enrolled in this study. Group A had 41 patients, while group B had 71. Vessel QFR and lesion QFR were lower in group A than in group B post-DCB therapy, and the cut-off values of lesion QFR and vessel QFR in the ROC analysis to predict target vessel DS ≥50% post-DCB therapy were 0.905 (AUC, 0.741 [95% confidence interval, CI: 0.645, 0.837]; sensitivity, 0.817; specificity, 0.561; P < 0.001) and 0.890 (AUC, 0.796 [95% CI: 0.709, 0.882]; sensitivity, 0.746; specificity, 0.780; P < 0.001).

The cut-off values of lesion QFR and vessel QFR can assist in predicting the angiographic changes post-DCB therapy. When lesion/vessel QFR values are <0.905/0.890 post-DCB therapy, a higher risk of vessel restenosis is potentially predicted at follow-up.

Clinical observational studies revealed that ⁹⁹Tc-methylene diphosphonate (⁹⁹Tc-MDP) could reduce joint pain and swollenness in rheumatoid arthritis (RA) patients. This multicenter, randomized, double-blind, double-dummy study aimed to evaluate the effects of ⁹⁹Tc-MDP plus methotrexate (MTX) vs. MTX alone or ⁹⁹Tc-MDP alone on disease activity and structural damage in MTX-naïve Chinese patients with moderate to severe RA.

Eligible patients with moderate to severely active RA were randomized to receive ⁹⁹Tc-MDP plus MTX (n = 59) vs. MTX (n = 59) alone or ⁹⁹Tc-MDP (n = 59) alone for 48 weeks from six study sites across four provinces in China. The primary outcomes were the American College of Rheumatology 20% improvement (ACR20) response rates at week 24 and changes in modified total Sharp score at week 48.

At week 24, the proportion of participants achieving ACR20 was significantly higher in the MTX+ ⁹⁹Tc-MDP combination group (69.5%) than that in the MTX group (50.8%) or ⁹⁹Tc-MDP group (47.5%) (P = 0.03 for MTX+ ⁹⁹Tc-MDP vs. MTX, and MTX+ ⁹⁹Tc-MDP vs.⁹⁹Tc-MDP, respectively). The participants in the MTX+ ⁹⁹Tc-MDP group and the ⁹⁹Tc-MDP group had significantly less important radiographic progression than the participants in the MTX group over the 48 weeks (MTX + ⁹⁹Tc-MDP vs. MTX: P = 0.03, ⁹⁹Tc-MDP vs. MTX: P = 0.03, respectively). There was no significant difference in terms of adverse events (AEs) among the groups. No serious AEs were observed.

This study demonstrated that the combination of ⁹⁹Tc-MDP with MTX inhibited structural damage and improved disease activity in RA patients compared with MTX and ⁹⁹Tc-MDP monotherapies, without increasing the rate of AEs. Additional clinical studies of ⁹⁹Tc-MDP therapy in patients with RA are warranted.

Chictr.org, ChiCTR-IPR-14005684; http://www.chictr.org.cn/showproj.aspx?proj=10088.

Disease activity indices (DAIs) including disease activity score 28 (DAS28), simplified disease activity index (SDAI), and clinical disease activity index (CDAI) have been widely used in clinical practice and research studies of rheumatoid arthritis (RA). The objective of our study was to evaluate the correlation and concordance among different DAIs in Chinese patients with RA.

A cross-sectional study, including patients enrolled in the Chinese registry of rheumatoid arthritis from November 2016 to August 2018, was conducted. The correlations were evaluated using Spearman correlation coefficient and concordance with Bland-Altman plots, quadratic weighted kappa, and discordance rates in the crosstab. For other indices, the optimal cutoff points corresponding to SDAI remission were explored through receiver operating characteristic curve analysis.

A total of 30,501 patients were included, of whom 80.46% were women. Most individuals were with moderate disease activity or high disease activity. High correlations among DAS28-erythrocyte sedimentation rate (ESR) and DAS28-C-reactive protein (CRP), SDAI and CDAI were observed. Similarly, the weighted kappa value among the indices was high. In Bland-Altman plots, a positive difference between DAS28-ESR and DAS28-CRP was observed, with an absolute difference of >1.2 in 3079 (10.09%) patients. In crosstab, approximately 30% of the patients were classified into different groups. Concordance values between SDAI remission and the optimal cutoff points of DAS28-ESR, DAS28-CRP, and CDAI were 3.06, 2.37, and 3.20, respectively.

Although DAIs had high correlations and weighted kappa values, the discordance between DAIs was significant in Chinese patients with RA. The four DAIs are not interchangeable.

Taxanes are an essential class of antineoplastic agents used to treat various cancers and are a fundamental cause of hypersensitivity reactions. In addition, other adverse events, such as bone marrow toxicity and peripheral neuropathy, can lead to chemotherapy discontinuation. This study aimed to evaluate the safety of taxanes in the real world.

Taxane-associated adverse events were identified by the Medical Dictionary for Regulatory Activities Preferred Terms and analyzed and compared by mining the US Food and Drug Administration Adverse Event Reporting System pharmacovigilance database from January 2004 to December 2019. Reported adverse events, such as hypersensitivity reaction, bone marrow toxicity, and peripheral neuropathy, were analyzed with the following signal detection algorithms: reporting odds ratio (ROR), proportional reporting ratio (PRR), multi-item gamma Poisson shrinker (MGPS), Bayesian confidence propagation neural network (BCPNN), and logistic regression methods. Adverse outcome events and death outcome rates were compared between different taxane groups using Pearson’s χ² test, whereas significance was determined at P < 0.05 with a 95% confidence interval (CI).

A total of 966 reports of hypersensitivity reactions, 1109 reports of bone marrow toxicity, and 1374 reports of peripheral neuropathy were analyzed. Compared with paclitaxel and docetaxel, bone marrow toxicity following the use of nab-paclitaxel had the highest ROR of 6.45 (95% two-sided CI, 6.05-6.88), PRR of 5.66, (χ² = 4342.98), information component of 2.50 (95% one-sided CI = 2.34), and empirical Bayes geometric mean of 5.64 (95% one-sided CI = 5.34). Peripheral neuropathy following the use of nab-paclitaxel showed a higher ROR of 12.78 (95% two-sided CI, 11.55-14.14), PRR of 12.16 (χ² = 4060.88), information component of 3.59 (95% one-sided CI = 3.25), and empirical Bayes geometric mean of 12.07 (95% one-sided CI = 11.09).

The results showed that bone marrow toxicity and peripheral neuropathy were the major adverse events induced by taxanes. Nab-paclitaxel exhibited the highest potential for taxane-associated adverse events. Further research in the future is warranted to explain taxane-associated adverse effects in real-world circumstances.

Tumor suppressor geneP53(TP53) is a critical tumor suppressor gene. The mutant p53 protein enhances the activity, invasion and metastasis of tumor cells. Acute myeloid leukemia (AML) patients withTP53mutations respond poorly to conventional chemotherapy and have poor clinical outcomes. We previously conducted a multi-center phase II clinical trial (No. ChiCTRONC-11001700) in elderly AML patients with decitabine, low-dose cytarabine, aclarubicin, and granulocyte colony-stimulating factor (G-CSF) (DCAG regimen), which showed an overall response rate (ORR) of 82.4% and a complete remission (CR) rate of 64.7%.^[1]Given this satisfactory effect of DCAG regimen, the present study has been designed to compare the efficacy and safety of DCAG regimen with standard therapy in AML patients withTP53mutations.

Hemorrhagic cystitis (HC), which is characterized by a congested vasculature and extensive hemorrhage in the bladder lamina propria, is often secondary to chemotherapy, external radiation therapy, allogeneic hematopoietic stem cell transplantation (Allo-HSCT), and/or opportunistic infection.^[1]The incidence of HC after Allo-HSCT has been reported to range between 1.3% and 20%.^[2]The severity of HC may vary from bladder irritation symptoms with mild hematuria, which is observed in most cases and is resolved with conservative management, such as adequate hydration and bladder irrigation, to transfusion-dependent hemorrhage and/or a lower urinary tract obstruction post renal failure. Other strategies, including bladder irrigation with intravesical alum, formalin, aminocaproic acid, or prostaglandin and hyperbaric oxygen therapy, have been reported, with the resolution of bleeding in the majority of cases.^[3]However, for patients in whom these measures fail and the lower urinary tract becomes obstructed by numerous blood clots, further surgery, including internal iliac angioembolization, cystoscopy with control of bladder hemorrhage and cystectomy, should be considered.^[4]

Alpha-dystroglycanopathy (α-DGP) is a subtype of congenital muscular dystrophies (CMDs) with autosomal recessive inheritance. Its main pathogenesis is the defect of post-translational O-glycosylation in α-dystroglycan (α-DG). α-DGP presents a wide clinical spectrum that ranges from the most severe CMDs such as Walker-Warburg syndrome (WWS), muscle-eye-brain disease (MEB), and Fukuyama congenital muscular dystrophy to the mildest limb-girdle muscular dystrophy. TheB3GALNT2(NM 152490) is one of the pathogenic genes of α-DGP. It encodes an enzyme that produces a unique carbohydrate structure, nitroacetylgalactosamine-β-1,3-nitroacetylglucosamine (GalNAc-β-1-3GlcNAc), which is essential for O-glycosylation of α-DG.^[1]Most patients withB3GALNT2mutations in previous studies presented with the most severe WWS or less severe MEB^[2]and those with WWS generally had a very short lifespan. They universally exhibited severe muscle weakness, ocular anomalies, including congenital cataract, glaucoma, severe myopia, and optic nerve atrophy. Their brain imaging showed cobblestone lissencephaly or polymicrogyria, cerebellum cysts, and dysplasia.

Stellate ganglion block (SGB) is highly beneficial when used for treating pain syndromes, including acute herpes zoster of the face, postherpetic neuralgia, and sympathetically mediated pain of the head. Horner’s syndrome is not reliable as a traditional indicator of successful SGB because of ambiguous and subjective judgment.^[1]Cutaneous temperature change was reported to be a simple and objective method for assessing successful SGB.^[2]However, temperature increase was only observed at least 10 min after successful SGB, demonstrating that the assessment of skin temperature cannot predict the efficacy of SGB in the early stage.^[3]Laser speckle contrast imaging (LSCI) provides a powerful tool for quantitative assessment of flow dynamics for microcirculation over large areas with high spatiotemporal resolution.^[4,5]According to our knowledge, LSCI has not been studied as an indicator of successful SGB.

Physician-modified fenestrated stent-graft for thoracic endovascular aortic repair (TEVAR) has economic advantages and can be used in acute situations for aortic dissection and aneurysm involving aortic arch.^[1]However, accurate alignment of fenestrations and branch arteries of the aortic arch is challenging, especially for multi-fenestration.^[2]Once misaligned, complications such as branch occlusion or cerebral ischemia will occur. Details about how to align fenestrations with branch arteries of the aortic arch in TEVAR with physician-modified triple fenestrated stent-graft are elaborated in this article.

Asymmetric superior oblique palsy (SOP) is a complicated, non-comitant type of strabismus. Patients usually present with small-angle hypertropia in the affected eyes, accompanied by inferior oblique muscle overaction (IOOA).^[1]Compensatory head posture and asymmetric development of the face are typically observed in congenital SOP, while diplopia is more common in an acquired SOP.^[2]Prism glasses can improve diplopia and vertical deviation in the primary position, but they are not so successful at correcting non-comitant paralytic strabismus. In addition, vertical strabismus and compensatory head posture will return after the prism glasses are removed, wearing prism glasses will lower the vision of children prominently. Surgery like an inferior oblique muscle (IO) weakening procedure is often required eventually in those patients. However, conventional procedures for IO weakening may cause overcorrection and/or secondary A pattern in patients who have mild to moderate IOOA together with small-angle asymmetric SOP, posing a risk to its safety.^[3]In the study by Caldeira,^[4]21% of the patients with mild to moderate IOOA developed A pattern following the surgery. Therefore, it remains a clinical challenge to select the most appropriate type of surgery for the treatment of small-angle asymmetric SOP. Inferior oblique muscle belly transposition (IOMBT),^[5]a new IO weakening procedure introduced to our practice lately, has shown positive results in treating small-angle asymmetric SOP as well as a lower risk of complications such as overcorrection and secondary A pattern. In this study, we evaluated the efficacy and safety of the IOMBT procedure for the treatment of small-angle asymmetric SOP.

A 16-year-old male adolescent was hospitalized complaining of intermittent dizziness, drowsiness, and fatigue for approximately 2 years. The patient had an episode of fever and pharyngalgia lasting nearly 2 weeks and had undergone appendectomy because of acute appendicitis before the presentation of the above symptoms. He suffered from severe dizziness mostly after switching from a supine to an upright posture when he was getting up in the morning. The symptom of dizziness usually persisted for minutes to hours and could be partially alleviated by recumbency. In addition, he felt drowsy and fatigued all day despite a total sleep duration of 14 to 15 h per day. All the symptoms could be partially mitigated by complete bed rest for 1 or 2 weeks, but he relapsed after taking part in normal school life again. Additionally, the feeling of fatigue was obviously aggravated after exertion or infection. He was unable to focus on his studies and had to withdraw from school for a long time. As a result, there was a decline in academic performance after the onset of illness. He used to benefit from taking carnitine and folate; however, the improvement was limited in enabling him to take part in normal social and school life. He was physically and mentally healthy before the presentation and did not feel disgusted with learning in the past. No family history of cardiovascular or nervous system disease was evident. The study was approved by the Ethics Committee of Peking University First Hospital (No. 2020-415).

To the Editor: Currently, there is no standardized treatment protocol for the pediatric anti-N-methyl-D-aspartate receptor (NMDAR). There are two surveys by Kahnet al^[1]and Bartoliniet al^[2]that aimed at determining the treatment strategies that are used for pediatric NMDAR encephalitis in other parts of the world rather than China. Bartoliniet al^[2]performed a worldwide survey involving 199 participants: 61 adult neurologists, 86 pediatric neurologists, and 52 pediatric rheumatologists. Their survey investigated the differences in anti-NMDAR encephalitis treatment strategies, according to medical specialty, years in practice, and geographical location.^[2]The survey of Kahnet al^[1]involved 151 pediatric neurologists and focused on identifying the indications for the initiation of immunotherapy, type of the used immunotherapy, length of the first-line immunotherapy, time for the initiation of the second-line immunotherapy, and the preferable options for the second-line immunotherapy. Additionally, they investigated the indications and time for adding a disease-modifying therapy, and how long should patients continue with the immunotherapy once returned to their neurologic base-line.^[1]Both surveys did not sufficiently focus on identifying the utility of the modified Rankin Scale (mRS), dosages and duration of the treatments (including the duration of oral prednisone), the utility of Cluster of Differentiation 19 positive (CD19⁺) B cells in adjusting the dosages of rituximab, the necessity of long-term immunosuppressive treatment (for relapse prevention), and the indications for stopping the immunotherapy.

To the Editor: Sleep-disordered breathing (SDB) is a health problem affecting approximately 12% of children in China,^[1]characterized by habitual loud snoring and increased respiratory effort. Increased upper airway resistance related to enlarged adenoids has been identified as the most common cause in children with obstructive SDB, and adenoidectomy is the standard treatment for the disorder. Similar to lymphoid tissues, adenoids show a unique natural growth pattern, which incorporates both overgrowth and involution. However, the development patterns of adenoids have not been clearly elucidated. Since the adenoids are located in the nasopharynx roof, direct evaluation of their size and proportion to the upper airway area is difficult. Thus, radiological methods have been employed widely for such purposes, including traditional plain cranial radiographs, computed tomography (CT), cone-beam CT, and magnetic resonance imaging (MRI). MRI can reveal the accurate size of adenoids by differentiating them from other soft tissue structures without any ionizing radiation; therefore, it can effectively study the adenoids’ developmental pattern in normal children. Previous studies have evaluated age-associated changes in adenoid size by MRI. Arenset al^[2]indicated that adenoids grow proportionally to the skeletal structures in children aged 1 to 11 years. Papaioannouet al^[3]reported that head MRI examinations demonstrated increased adenoid size during the first 7-8 years of life and then decreased gradually in children without snoring signs. Variabilities of the above-reported adenoids’ development pattern exist due to the limitations associated with the small sample size. Furthermore, none of the above-mentioned studies on normal children used a strict method to exclude SDB. Additionally, for adenoid hypertrophy, the adenoid/nasopharyngeal (A/N) ratio was found to be a useful, tolerable, and confident diagnostic method in pediatric patients, with emphasis on the correlation of the adenoid size and upper airway lumen to variable degrees. Therefore, the A/N ratio can be considered a useful objective tool in evaluating adenoid development in children. We aimed to investigate the growth and involution patterns of adenoids in consecutive age groups from birth to 16 years in Chinese children without SDB using MRI data, which may benefit the study of diseases associated with the development of adenoids.

To the Editor:Papular elastorrhexis (PE) is a rare acquired elastic tissue disease. Its etiology and pathogenesis remain unknown. PE is predisposed to the trunk and limbs and clinically presented as multiple asymptomatic, 3- to 5-mm non-follicular flesh-colored papules on children and adolescents, mainly in women. It presents only cutaneous involvement, and most of the patients are asymptomatic and often misdiagnosed and untreated. Herein, we present a case of PE and describe its dermoscopic features that have not been previously reported.

To the Editor: Desmoid tumors (DTs) show local aggressiveness to surrounding structures and exhibit a propensity to recur, leading to a high local recurrence rate and significant functional impairments and morbidity.^[1]It has been shown that DTs located in the abdominal wall and abdominal cavity are relatively minimally invasive and have a relatively low recurrence rate,^[2]which indicated abdominal desmoid tumors (ADTs) may have different biological make-ups and genes. This study was aimed to delineate the clinicopathological features and determine the prognostic factors for recurrence-free survival (RFS) in ADTs after macroscopic complete surgical resection.

To the Editor:Focal acantholytic dyskeratosis (FAD) is used to describe a group of diseases with diverse clinical manifestations but characteristic histological structures. In 1984, the first case of "papular acantholytic dyskeratosis (PAD) of the vulvocrural area" was reported in a 23-year-old female with pathological manifestations of FAD and the researchers believed that it might be a new independent disease.^[1]Recently, the relationship between PAD and Hailey-Hailey disease (HHD) as well as Darier disease (DD) is receiving increasing attention from scholars. We performed gene mutation screening in two patients with sporadic PAD and explored the nature of PAD.

To the Editor: Colonic diverticulosis is a common colon disorder worldwide and is mostly observed in the right colon in Asian patients, unlike in western patients. Inverted colonic diverticula (ICD) are less common and are observed in about 0.7% of colonoscopy procedures. Because ICD often resemble colon polyps, they are difficult to distinguish by colonoscopy. Thus, bowel perforation after biopsy or endoscopic resection may be a serious complication. The colonoscopy maneuvers described to help diagnose ICD include radiating pillow sign, the use of air insufflation and water jet, and reversion of the ICD with forceps. Aurora rings, most recently described as concentric pale rings surrounding the lesion, also can help to diagnose ICD without the need for maneuvers. The present report describes the cases that underwent endoscopic maneuvers by submucosal saline injection. The results of this clinical trial may help to distinguish ICD from colon polyps.