2021年 · 第134卷第14期

Human serum albumin (HSA) is a non-glycosylated, negatively charged, single-chain polypeptide composed of 585 amino acid residues with a relative molecular mass of 66.438 kD. It is synthesized by the liver at a rate of approximately 200 mg·kg^-1·day^-1, with a half-life of 21 days, and subjected to catabolism in the muscles, liver, and kidneys at a rate of 4% per day.^[1]

Breast cancer is the most common malignancy among women in China. Approximately 304,000 new cases of breast cancer were diagnosed during 2015 in China, which ranked first in cancer diagnosis and accounted for 17.1% of all new cancers among women.^[1,2]Both the US Preventive Services Task Force (USPSTF)^[3]and National Comprehensive Cancer Network (NCCN) clinical practice guidelines^[4]have made recommendations regarding risk assessment, to identify women with increased risk for breast cancer, in whom risk-based cancer screening and/or risk-reducing medication use should be provided so as to lower the individual breast cancer risk.

Intraductal papilloma of the breast is relatively common, accounting for 5.3% of all benign breast diseases.^[1]However, relapse readily occurs with pathological changes such as atypical ductal hyperplasia (ADH) and canceration, and the rate of underestimation of biopsy diagnosis is high.^[2,3]Therefore, specific considerations are required for the diagnosis and treatment methods of intraductal papilloma, and some clinical problems with these methods remain controversial. To standardize the diagnosis and treatment of intraductal papilloma of the breast and provide a reference for the clinical work of breast specialists, Chinese Society of Breast Surgery has determined the key clinical issues of the clinical practice guidelines for intraductal papilloma of the breast through a literature search and expert discussion. The relevant evidence was evaluated with reference to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system, and theClinical Practice Guidelines for Intraductal Papilloma: Chinese Society of Breast Surgery (CSBrS) practice guidelines 2021was formulated to provide a reference for the clinical work of breast surgeons in China .

The neoadjuvant chemotherapy is increasingly used in advanced gastric cancer, but the effects on safety and survival are still controversial. The objective of this meta-analysis was to compare the overall survival and short-term surgical outcomes between neoadjuvant chemotherapy followed by surgery (NACS) and surgery alone (SA) for locally advanced gastric cancer.

Databases (PubMed, Embase, Web of Science, Cochrane Library, and Google Scholar) were explored for relative studies from January 2000 to January 2021. The quality of randomized controlled trials and cohort studies was evaluated using the modified Jadad scoring system and the Newcastle-Ottawa scale, respectively. The Review Manager software (version 5.3) was used to perform this meta-analysis. The overall survival was evaluated as the primary outcome, while perioperative indicators and post-operative complications were evaluated as the secondary outcomes.

Twenty studies, including 1420 NACS cases and 1942 SA cases, were enrolled. The results showed that there were no significant differences in overall survival (P = 0.240), harvested lymph nodes (P = 0.200), total complications (P = 0.080), and 30-day post-operative mortality (P = 0.490) between the NACS and SA groups. However, the NACS group was associated with a longer operation time (P < 0.0001), a higher R0 resection rate (P = 0.003), less reoperation (P = 0.030), and less anastomotic leakage (P = 0.007) compared with SA group.

Compared with SA, NACS was considered safe and feasible for improved R0 resection rate as well as decreased reoperation and anastomotic leakage. While unbenefited overall survival indicated a less important effect of NACS on long-term oncological outcomes.

Spinal cord injury (SCI) is a common traumatic disease of the central nervous system; it causes serious physical and psychological harm to patients and a huge economic burden on the entire society.^[1]The tough situation of SCI treatment requires further exploration of the mechanism and obtaining a new therapeutic strategy.

The term "Big Data" originated at the 11th Electronic Materials Conference World Annual Conference, which originally referred to the large amount of data generated by the application of technology.^[1]Medical big data includes not only the medical history and examination data accumulated during patient hospitalization, but also patient-related follow-up data, prognostic data from outpatient, emergency, and medical insurance settlement departments as well as clinical experiment centers. So far, it has profound applications in the various specialties of medicine.^[2,3,4]However, intensive care medicine (ICU) is different from other medical fields. In comparison with clinical practice data, medical data in ICU have the following characteristics: large scale, rapid production, diverse dimensions, inaccuracies, heterogeneity, incompleteness, complexity, and privacy concerns.^[5]In fact, in the process of constructing major ICU databases in China and worldwide, these databases have been optimized at great length. Taking heterogeneity as an example, the possible formats for medical data include text type, digital type, and image type. Text-based data include demographic characteristics, drug use, medical history, and symptoms. Digital data include various laboratory test results, vital signs, and monitoring instrument data. Image-type data include various imaging evaluations, such as type-B ultrasound, computerized tomography, magnetic resonance imaging, X-ray, and other examinations. In the formation of a database, standardized formats for text-type data are required. For digital data, the time of the collection is emphasized, and trends in treatment methods and various indicators are considered. For image data, in addition to conventional imaging reports, an artificial intelligence image reading model could be established by combining diagnoses and image characteristics. So far, China has not yet reached an industrystandard consensus in the field of critical care medicine. The Critical Care Medicine Branch of the China Health Information and Health Care Big Data Society was established in March 2019 and aims to establish and promote critical care big data applications. After a comprehensive investigation, it was found that quantity and quality of ICU database construction were limited. More effort should be made to improve this situation. We fully believe that the development of China’s critical care databases will make utmost of big data platform, which could provide patients with better diagnosis and treatment processes, provide management decision-makers with accurate and objective diagnosis and provide medical researchers with a higher-quality data.

Computed tomography images are easy to misjudge because of their complexity, especially images of solitary pulmonary nodules, of which diagnosis as benign or malignant is extremely important in lung cancer treatment. Therefore, there is an urgent need for a more effective strategy in lung cancer diagnosis. In our study, we aimed to externally validate and revise the Mayo model, and a new model was established.

A total of 1450 patients from three centers with solitary pulmonary nodules who underwent surgery were included in the study and were divided into training, internal validation, and external validation sets (n = 849, 365, and 236, respectively). External verification and recalibration of the Mayo model and establishment of new logistic regression model were performed on the training set. Overall performance of each model was evaluated using area under receiver operating characteristic curve (AUC). Finally, the model validation was completed on the validation data set.

The AUC of the Mayo model on the training set was 0.653 (95% confidence interval [CI]: 0.613-0.694). After re-estimation of the coefficients of all covariates included in the original Mayo model, the revised Mayo model achieved an AUC of 0.671 (95% CI: 0.635-0.706). We then developed a new model that achieved a higher AUC of 0.891 (95% CI: 0.865-0.917). It had an AUC of 0.888 (95% CI: 0.842-0.934) on the internal validation set, which was significantly higher than that of the revised Mayo model (AUC: 0.577, 95% CI: 0.509-0.646) and the Mayo model (AUC: 0.609, 95% CI, 0.544-0.675) (P < 0.001). The AUC of the new model was 0.876 (95% CI: 0.831-0.920) on the external verification set, which was higher than the corresponding value of the Mayo model (AUC: 0.705, 95% CI: 0.639-0.772) and revised Mayo model (AUC: 0.706, 95% CI: 0.640-0.772) (P < 0.001). Then the prediction model was presented as a nomogram, which is easier to generalize.

After external verification and recalibration of the Mayo model, the results show that they are not suitable for the prediction of malignant pulmonary nodules in the Chinese population. Therefore, a new model was established by a backward stepwise process. The new model was constructed to rapidly discriminate benign from malignant pulmonary nodules, which could achieve accurate diagnosis of potential patients with lung cancer.

Glucose control is an important aspect in managing critically ill patients. The goal of this study was to compare the effects of sequential feeding (SF) and continuous feeding (CF) on the blood glucose of critically ill patients.

A non-inferiority randomized controlled trial was adopted in this study. A total of 62 patients who were fed enteral nutritional suspension through gastric tubes were enrolled. After achieving 80% of the nutrition target calories (25 kcal·kg^-1·day^-1) through CF, the patients were then randomly assigned into SF and CF groups. In the SF group, the feeding/fasting time was reasonably determined according to the circadian rhythm of the human body as laid out in traditional Chinese medicine theory. The total daily dosage of the enteral nutritional suspension was equally distributed among three time periods of 7 to 9 o’clock, 11 to 13 o’clock, and 17 to 19 o’clock. The enteral nutritional suspension in each time period was pumped at a uniform rate within 2 h by an enteral feeding pump. In the CF group, patients received CF at a constant velocity by an enteral feeding pump throughout the study. Blood glucose values at five points (6:00/11:00/15:00/21:00/1:00) were monitored and recorded for seven consecutive days after randomization. Enteral feeding intolerance was also recorded. Non-inferiority testing was adopted in this study, the chi-square test or Fisher test was used for qualitative data, and the Mann-Whitney U test was used for quantitative data to determine differences between groups. In particular, a repeated measure one-way analysis of variance was used to identify whether changes in glucose value variables across the time points were different between the two groups.

There were no significant demographic or physiological differences between the SF and CF groups (P > 0.050). The average glucose level in SF was not higher than that in CF (8.8 [7.3-10.3] vs. 10.7 [9.1-12.1] mmol/L, Z = -2.079, P for non-inferiority = 0.019). Hyperglycemia incidence of each patient was more common in the CF group than that in the SF group (38.4 [19.1-63.7]% vs. 11.8 [3.0-36.7]%, Z = -2.213, P = 0.027). Hypoglycemia was not found in either group. Moreover, there was no significant difference during the 7 days in the incidence of feeding intolerance (P > 0.050).

In this non-inferiority study, the average blood glucose in SF was not inferior to that in CF. The feeding intolerance in SF was similar to that in CF. SF may be as safe as CF for critically ill patients.

ClinicalTrials.gov, NCT03439618; https://clinicaltrials.gov/ct2/show/record/NCT03439618

The basis of individualized treatment should be individualized mortality risk predictive information. The present study aimed to develop an online individual mortality risk predictive tool for acute-on-chronic liver failure (ACLF) patients based on a random survival forest (RSF) algorithm.

The current study retrospectively enrolled ACLF patients from the Department of Infectious Diseases of The First People’s Hospital of Foshan, Shunde Hospital of Southern Medical University, and Jiangmen Central Hospital. Two hundred seventy-six consecutive ACLF patients were included in the present study as a model cohort (n = 276). Then the current study constructed a validation cohort by drawing patients from the model dataset based on the resampling method (n = 276). The RSF algorithm was used to develop an individual prognostic model for ACLF patients. The Brier score was used to evaluate the diagnostic accuracy of prognostic models. The weighted mean rank estimation method was used to compare the differences between the areas under the time-dependent ROC curves (AUROCs) of prognostic models.

Multivariate Cox regression identified hepatic encephalopathy (HE), age, serum sodium level, acute kidney injury (AKI), red cell distribution width (RDW), and international normalization index (INR) as independent risk factors for ACLF patients. A simplified RSF model was developed based on these previous risk factors. The AUROCs for predicting 3-, 6-, and 12-month mortality were 0.916, 0.916, and 0.905 for the RSF model and 0.872, 0.866, and 0.848 for the Cox model in the model cohort, respectively. The Brier scores were 0.119, 0.119, and 0.128 for the RSF model and 0.138, 0.146, and 0.156 for the Cox model, respectively. The nonparametric comparison suggested that the RSF model was superior to the Cox model for predicting the prognosis of ACLF patients.

The current study developed a novel online individual mortality risk predictive tool that could predict individual mortality risk predictive curves for individual patients. Additionally, the current online individual mortality risk predictive tool could further provide predicted mortality percentages and 95% confidence intervals at user-defined time points.

According to the amyloid, tau, neurodegeneration research framework classification, amyloid and tau positive (A+T+) mild cognitive impairment (MCI) individuals are defined as prodromal Alzheimer disease. This study was designed to compare the clinical and biomarker features between A+T+MCI individuals who progressed to progressive MCI (pMCI) and those who remained stable MCI (sMCI), and to identify relevant baseline clinical biomarker and features that could be used to predict progression to dementia within 2 years.

We stratified 197 A+T+MCI individuals into pMCI (n = 64) and sMCI (n = 133) over 2 years. Demographics and cognitive assessment scores, cerebrospinal fluid (CSF), and neuroimaging biomarkers (¹⁸F-florbetapir positron emission tomography mean standardized uptake value ratios [SUVR] and structural magnetic resonance imaging [MRI]) were compared between pMCI and sMCI at baseline, 12- and 24-month follow-up. Logistic regression models then were used to evaluate clinical baseline and biomarker features that predicted dementia progression in A+T+MCI.

pMCI individuals had higher mean ¹⁸F-florbetapir SUVR, CSF total-tau (t-tau), and p-tau_181P than those in sMCI individuals. pMCI individuals performed poorer in cognitive assessments, both global and domain specific (memory, executive, language, attention, and visuospatial skills) than sMCI. At baseline, there were significant differences in regions of interest of structural MRI between the two groups, including bilateral amygdala, hippocampus and entorhinal, bilateral inferior lateral ventricle, left superior and middle temporal, left posterior and caudal anterior cingulate (P < 0.05). Baseline CSF t-tau levels and cognitive scores of Montreal cognitive assessment, functional assessment questionnaire, and everyday cognition by the patient’s study partner language domain could predict progression to dementia in A+T+MCI within 2 years.

In future clinical trials, specific CSF and cognitive measures that predict dementia progression in A+T+MCI might be useful risk factors for assessing the risk of dementia progression.

Geriatric hip fracture patients receiving clopidogrel are a surgical challenge. In China, most of these patients undergo delayed surgical treatment after clopidogrel withdrawal for at least 5 to 7 days. However, delayed surgery is associated with increased complications and mortality in the older adults. This retrospective paralleled comparison study investigated the safety of early surgery for geriatric hip fracture patients within 5 days of clopidogrel withdrawal.

Acute hip fracture patients (≥65 years) who were hospitalized in the orthogeriatric co-management ward of Beijing Jishuitan Hospital between November 2016 and April 2018 were retrospectively reviewed. Sixty patients taking clopidogrel before injury and discontinued <5 days before surgery constituted the clopidogrel group. The control group constituted 60 patients not taking antiplatelet or anticoagulant drugs and matched 1:1 with the clopidogrel group for sex, fracture type, operative procedure, and time from injury to operation (±10 h). The primary outcome was perioperative blood loss and the secondary outcomes were transfusion requirement, complications, and mortality. The Student’s t test or Wilcoxon signed rank sum test was used for continuous variables and the Chi-square test was used for categorical variables.

Age, body mass index, American Society of Anesthesiologists score, and percentage undergoing general anesthesia were comparable between the groups (P > 0.050). The percentages of patients with coronary heart disease (61.7% vs. 18.3%; P < 0.001) and cerebrovascular disease (45.0% vs. 15.0%; P < 0.010) were significantly higher in the clopidogrel vs. control groups, respectively. The median clopidogrel discontinuation time before operation was 73.0 (range: 3.0-120.0) h. There was no significant difference in the estimated perioperative blood loss between the clopidogrel group (median: 745 mL) and control group (median: 772 mL) (P = 0.866). The intra-operative transfusion rate was higher in the clopidogrel group (22/60, 36.7%) than that in the control group (12/60, 20.0%) (P < 0.050). However, there was no significant difference in the blood transfusion rate during the entire perioperative period (26/60, 43.3% vs. 20/60, 33.3%; clopidogrel group vs. control group, respectively; P > 0.050). There was no significant difference in perioperative complications, and 30-day and 1-year mortality rates between the groups.

Early hip fracture surgery is safe for elderly patients within 5 days of clopidogrel withdrawal, without increased perioperative blood loss, transfusion requirement, complications, and mortality compared with patients not taking antiplatelet drugs.

Reports evaluating the efficacy of transcranial sonography (TCS) for the differential diagnosis of Parkinson disease (PD) and other movement disorders in China are scarce. Therefore, this study aimed to assess the application of TCS for the differential diagnosis of PD, multiple system atrophy (MSA), progressive supranuclear palsy (PSP), and essential tremor (ET) in Chinese individuals.

From 2017 to 2019, 500 inpatients treated at the Department of Dyskinesia, Beijing Tiantan Hospital, Capital Medical University underwent routine transcranial ultrasound examination. The cross-sections at the midbrain and thalamus levels were scanned, and the incidence rates of substantia nigra (SN) positivity and the incidence rates of lenticular hyperechoic area were recorded. The echo of the SN was manually measured.

Of the 500 patients, 125 were excluded due to poor signal in temporal window sound transmission. Among the 375 individuals with good temporal window sound transmission, 200 were diagnosed with PD, 90 with ET, 50 with MSA, and 35 with PSP. The incidence rates of SN positivity differed significantly among the four patient groups (χ² = 121.061, P < 0.001). Between-group comparisons were performed, and the PD group showed a higher SN positivity rate than the ET (χ² = 94.898, P < 0.017), MSA (χ² = 57.619, P < 0.017), and PSP (χ² = 37.687, P < 0.017) groups. SN positivity showed a good diagnostic value for differentiating PD from the other three movement diseases, collectively or individually. The incidences of lenticular hyperechoic area significantly differed among the four patient groups (χ² = 38.904, P < 0.001). Next, between-group comparisons were performed. The lenticular hyperechoic area was higher in the PD group than in the ET (χ² = 6.714, P < 0.017) and MSA (χ²= 18.680, P < 0.017) groups but lower than that in the PSP group (χ² = 0.679, P > 0.017).

SN positivity could effectively differentiate PD from ET, PSP, and MSA in a Chinese population.

Sepsis involves the early activation of both pro- and anti-inflammatory responses, but is also accompanied by major changes in nonimmunologic pathways.^[1]Autophagy is the lysosome-dependent process of removing damaged proteins and organelles.^[2]Accumulating evidence fromin vitroandin vivostudies reveals that autophagy may have a protective effect on sepsis, and the late-stage suppression of autophagy is associated with a poor outcome.^[3]Thus, reversal of late-stage autophagy may be a good therapeutic strategy for sepsis. Accordingly, the identification of biomarker, which could inform the clinical diagnosis of autophagic impairment, will be essential for guiding the management of septic patients. Microtubule-associated protein light chain 3 type II (LC3β) is a key protein for autophagy.^[2]A previous study demonstrated that patients with sepsis-induced myocardial dysfunction (SIMD) had significantly lower serum levels of LC3β than patients without SIMD,^[4]suggesting the potential use of this molecule as a pathophysiological biomarker in the course of sepsis. In light of these prior findings, the present study aimed to investigate the potential role of LC3β protein as an autophagy-related biomarker in a cohort of septic patients stratified according to disease progression. Moreover, in the same patient sample, serum levels of interleukin 1 β (IL-1β) and interleukin 18 (IL-18) were measured as indicators of proinflammatory cytokines.

The global spread of carbapenem-resistantKlebsiella pneumoniae(CRKP) has become a major healthcare burden because of the limited therapeutic options and poor prognosis, and this situation gets worse among patients admitted to intensive care unit (ICU).^[1]CRKP can cause a range of infections, including pneumonia, urinary tract infection (UTI), and bloodstream infection (BSI). BSI is one of the most serious infections caused by CRKP and associated with high mortality ranging from 39% to 82%.^[2]BSI due to CRKP could be primary infection or secondary infection that originated from primary infections in the lungs or bladder, and 50% of CRKP-BSIs originated from primary infections in the lungs.^[3]Although previous studies have explored several risk factors for CRKP infections, the association between CRKP pneumonia and the development of secondary CRKP-BSI was not fully revealed thus far. The aim of this study was to predict risk factors of 28-day mortality and the development of secondary CRKP-BSI in ICU-acquired pneumonia caused by CRKP.

Rhabdomyolysis is a severe clinical syndrome that occurs when damaged striated muscles break down and intracellular muscle components leak into the blood. Acute kidney injury (AKI) is the most common complication of rhabdomyolysis. Rhabdomyolysis patients with AKI have been shown to exhibit a higher mortality rate than those without AKI. Moreover, AKI has been reported to be an independent predictor of mortality in rhabdomyolysis.^[1]Therefore, early identification of rhabdomyolysis patients with AKI or those at a high risk of developing AKI is necessary to initiate aggressive therapeutic interventions.

Human leukocyte antigen (HLA) is the major histocompatibility complex for humans. Previous studies have shown that high-resolution HLA matching can reduce graftvs. host disease and improve the outcome of hematopoietic stem cell transplantation (HSCT). Unrelated donor HSCT is very-important when patients have no HLA-identical sibling donors. However, the chance of finding an available unrelated donor is not equal for every patient. Previous studies in Western countries have found that the HLA haplotype frequency (HF) could help to predict the probability of identifying HLA allele-matched unrelated donors.^[1]However, the HLA system shows ethnic diversity and regional disparity. Therefore, if we want to use the HLA haplotype tool in China, a reliable HLA haplotype database for the Chinese population needs to be established.

To the Editor:Anemia is a common finding among patients admitted to intensive care units (ICUs), nearly 60% of ICU patients had serum hemoglobin levels <12 g/dL at baseline, 30% of whom had serum hemoglobin levels <9 g/dL, over 95% of critically ill patients were anemic within 3 days of ICU admission.^[1]Moreover, anemia may be aggravated or newly developed in critically ill patients during their ICU stay.

To the Editor:In the past decades, there were at least 31.5 million sepsis patients worldwide. Of these patients, 5.3 million sepsis patients face death every year.^[1]Studies have shown the mortality from sepsis can be reduced by compliance with the surviving sepsis campaign guidelines (C_ssc).^[2]Compliance with guidelines depends on the execution of the medical team. We assume that the medical quality of the intensive care unit (Q_ICU) will have an important impact on the C_ssc.

To the Editor: Retroperitoneal hemorrhage is an acute abdominal complication commonly caused by trauma, iatrogenic operation injury, and rupture of tumor or solid organs such as kidney.^[1]Spontaneous retroperitoneal hemorrhage (SRH), namely, the spontaneous rupture of retroperitoneal vessels, is characterized by the low diagnostic rate and high mortality. Patients who undergo therapeutic anticoagulation and dialysis and have renal cell carcinoma have an SRH incidence of 0.6% to 6.6%, 0.9%, and 0.3% to 1.4%, respectively. However, SRH is very rare in individuals without these conditions.^[1]This study aimed to report a case of SRH accompanied by renal failure and acute left heart failure.

To the Editor:Cerebral small vessel disease (CSVD) refers to a wide spectrum of pathological processes, which affects the small arteries, arterioles, venous, and capillaries in the brain. This disease causes cognitive, psychological, and physical disabilities and is responsible for up to 45% of vascular dementia in the elderly. With the prolongation of human life expectancy, the medical expense and family burden of cognitive disorders in the elderly increasingly aggravate, and the early identification and effective treatment of CSVD are receiving increasing attention.

To the Editor: Cervical cancer (CC) is one of the leading causes of cancer deaths in women around the world.^[1]In clinical practice, screening methods such as human papillomavirus testing and cytology-based detection have the disadvantages of having a high false rate, being hysteretic or ineffective.^[2]Novel non-invasive biomarkers that can help diagnose CC with higher specificity and sensitivity are in great demand. MicroRNA (miRNA) is a type of non-coding small RNA of 18 to 25 nucleotides in length. Circulating miRNAs show the great potential of being cancer biomarkers for the stable existence in peripheral serum or plasma.^[3]In this study, we performed a four-stage experiment using a total of 108 CC and 108 normal control (NC) serum samples to explore the diagnostic potential of serum miRNAs in CC. The schematic diagram of the experimental procedure was shown in Supplementary Figure 1, http://links.lww.com/CM9/A429.

To the Editor:Medically unexplained physical symptoms (MUPS) and related disorders are especially common in healthcare-seeking populations. A recent meta-analysis revealed the prevalence of somatoform disorders of 34.8 % (by International Classification of Diseases) and 26.2% (by Diagnostic and Statistical Manual of Mental Disorders [DSM]) in primary care patients. Further, at least one medically unexplained symptom was detected among 40% to 49% of primary care patients using questionnaires.^[1]

To the Editor: Eighty-four 6-week-old male Wistar rats, weighing from 120 to 180 g, were categorized into three groups: normal control (NC) group, diethylnitrosamin (DEN) group, and multi-stress group. In the NC group, rats were maintained at room temperature with a relative humidity of 60% to 80% and fed with a normal diet and drinking water. In the DEN group, the rats were maintained the same as the NC group, but fed with sterile drinking water supplemented with 0.1 mg/mL DEN daily for 20 weeks. In the multi-stress group, the rats were maintained at 5 to 7°C with a relative humidity of 25% to 32.8%. Then, the rats were exposed to electrical stimulation daily through the food pads (30 min at 35 V for the first week, 35 min at 40 V for the second week, and 45 min at 45 V for the third week). They were also forced to swim in the water at 15 to 25°C for 5 min once a week to establish multi-stress models. The rats were treated with 0.1 mg/mL DEN daily through drinking water for 20 weeks to induce liver cancer. Until the end of the experiment, 22 rats survived in the NC group, 16 rats survived in the DEN group, and ten rats survived in the multi-stress group. The rats were sacrificed by cervical dislocation under anesthetization at 20 weeks after treatment with DEN. This study was approved by the Animal Ethics Committee of the First Affiliated Hospital of Xinjiang Medical University (No. IACUC-20150225-128). The liver tissues were excised and fixed in 10% formaldehyde solution followed by imaging [Supplementary Figure 1, http://links.lww.com/CM9/A544] and staining with hematoxylin and eosin (H&E). Anatomy of the liver and H&E staining demonstrated that the livers of rats in the NC group did not exhibit the cancer symptoms [Figure 1A, upper panels], whereas the rats in the DEN group showed irregular organization, or necrosis of liver cells, distinctive pseudo hepatic lobules, and liver fibrosis [Figure 1A, middle panels]. Interestingly, the rats in the multi-stress group appeared significantly a high incidence of liver cancer compared with NC and DEN groups. All rats (N= 10) in the multi-stress group developed hepatocellular carcinoma or bile duct epithelial cancer, which indicated cancer cells and liver tissues were partially transformed into fibrosis.

In the article "A single-operator technique in ultrasound-guided regional anesthesia" which appeared in vol. 134, issue 6, page 735 ofChinese Medical Journal,^[1]the work was supported by "the Fundamental Research Funds for the Central Universities (No. 3331019031)" , which should be corrected as "the Fundamental Research Funds for the Central Universities (No. 3332019031)" .