2021年 · 第134卷第18期

Breast-conserving surgery (BCS) with radiotherapy is the primarily agreed surgical choice for eligible patients with an early diagnosis of breast cancer. In 2019, the panel of Chinese experts assembled by the Chinese Society for Breast Surgery (CSBrS) developed a Chinese experts' consensus on BCS for early-stage breast cancer (Version 2019) with the aim of standardizing BCS in China. Subsequently, the CSBrS conducted a review of published reports and discussions between experts to determine the key clinical questions for the Clinical Practice Guideline for BCS in Patients with Early-Stage Breast Cancer. The group evaluated the relevant evidence using the grading of recommendations assessment, development, and evaluation system, and developed a Clinical Practice Guideline for BCS in Patients with Early-Stage Breast Cancer (Version 2021), with the aim of providing guidance on clinical practice to breast surgeons in China.

Breast cancer is the most common cancer in women in China. Since Halsted introduced radical mastectomy, surgery has remained the cornerstone of breast cancer treatment. Before performing such surgery, a comprehensive and standardized evaluation should be undertaken. This should include identification of factors that could increase the risk of surgery or prejudice recovery, as well as factors that may affect the subsequent course of the disease. The Chinese Society of Breast Surgery (CSBrS) has conducted a literature review and experts have discussed key clinical issues related to standardizing pre-operative evaluation of patients with breast cancer; evaluated the relevant evidence with reference to the grading of recommendations assessment, development, and evaluation system; combined the accessibility under China’s national conditions; and formulated the following written Clinical Practice Guidelines for Pre-operative Evaluation of Breast Cancer (2021 Edition) with the aim of providing a reference for Chinese breast surgeons.

Acute pancreatitis (AP) is a complex abdominal disease with high morbidity and mortality that involves a strong local and systemic inflammatory response. When AP develops into severe acute pancreatitis (SAP), it easily leads to multiple organ dysfunction syndrome, which is also one of the main reasons for death in SAP patients.^[1]In the past decade, we have made substantial progress in our understanding of the pathophysiological mechanism of AP. The mechanism of calcium-mediated acinar cell damage and death has been elucidated. The cytoprotective effects of the unfolded protein response and autophagy in preventing continuous endoplasmic reticulum stress, apoptosis, and necrosis has been shown. The central role of unsaturated fatty acids in causing pancreatic organ failure has also been confirmed. In contrast, we know very little about the mechanism of parenchymal cell death.^[2]Early and effective regulation of pancreatic acinar cell death may be an effective treatment for AP. In recent years, a new type of cell death called pyroptosis has become an important research topic in the field of inflammation and immune diseases. Recent studies have shown that pyroptosis is involved in the pathogenesis of pancreatic parenchymal cell death. Inhibiting pyroptosis can reduce pancreatic damage and has an important impact on the progression of AP.^[3,4]This article reviews the research progress on pyroptosis in AP, with a focus on understanding the pathogenesis of AP and providing references for the identification of new therapeutic targets [Supplementary Figure 1, http://links.lww.com/CM9/A630].

A clinical trial is a systematic investigation or study in or on one or more human subjects, undertaken to assess the safety, clinical performance, and/or effectiveness of a medical device.^[1]In this paper, "overseas clinical trial data" refers to data generated from a clinical trial(s) conducted in a foreign country or jurisdiction and proposed to be used as clinical evidence for a pre-market registration application in China.

The effectiveness of bronchial thermoplasty (BT) has been reported in patients with severe asthma. This study compared the effects of BT and cryoballoon ablation (CBA) therapy on the airway smooth muscle (ASM).

Eight healthy male beagle dogs were included in this experiment. In the preliminary experiment, one dog received BT treatment for both lower lobe bronchus, another dog received CBA treatment for 7 s on the upper and lower lobe of right bronchus, and 30 s on the left upper and lower lobe. The treatments were performed twice at an interval of 1 month. In subsequent experiments, the right lower lobe bronchus was treated with BT, and the left lower lobe bronchus was treated with CBA. The effects of treatment were observed after 1 (n = 3) month and 6 months (n = 3). Hematoxylin-eosin staining, Masson trichrome staining, and immunohistochemical staining were used to compare the effects of BT and CBA therapy on the ASM thickness, collagen fibers synthesis, and M3 receptor expression after treatment. One-way analysis of variance with Dunnett post hoc test was used to analyze the differences among groups.

In the preliminary experiment, the ASM ablation effect of 30-s CBA was equivalent to that of 7-s CBA (ASM thickness: 30.52 ± 7.75 μm vs. 17.57 ± 15.20 μm, P = 0.128), but the bronchial mucociliary epithelium did not recover, and large numbers of inflammatory cells had infiltrated the mucosal epithelium at 1-month post-CBA with 30-s freezing. Therefore, we chose 7 s as the CBA treatment time in our follow-up experiments. Compared with the control group (35.81 ± 11.02 μm), BT group and CBA group (13.41 ± 4.40 μm and 4.81 ± 4.44 μm, respectively) had significantly decreased ASM thickness after 1 month (P < 0.001). Furthermore, the ASM thickness was significantly lower in the 1-month post-CBA group than in the 1-month post-BT group (P = 0.015). There was no significant difference in ASM thickness between the BT and CBA groups after six months (9.92 ± 4.42 μm vs. 7.41 ± 7.20 μm, P = 0.540). Compared with the control group (0.161 ± 0.013), the average optical density of the ASM M3 receptor was significantly decreased in 6-month post-BT, 1-month post-CBA, and 6-month post-CBA groups (0.070 ± 0.022, 0.072 ± 0.012, 0.074 ± 0.008, respectively; all P < 0.001). There was no significant difference in the average optical density of ASM M3 receptor between the BT and CBA therapy groups after six months (P = 0.613).

CBA therapy effectively ablates the ASM, and its ablation effect is equivalent to that of BT with a shorter onset time. A neural mechanism is involved in both BT and CBA therapy.

Macrophages are involved in the pathogenesis of idiopathic pulmonary fibrosis, partially by activating lung fibroblasts. However, how macrophages communicate with lung fibroblasts is largely unexplored. Exosomes can mediate intercellular communication, whereas its role in lung fibrogenesis is unclear. Here we aim to investigate whether exosomes can mediate the crosstalk between macrophages and lung fibroblasts and subsequently induce fibrosis.

In vivo, bleomycin (BLM)-induced lung fibrosis model was established and macrophages infiltration was examined. The effects of GW4869, an exosomes inhibitor, on lung fibrosis were assessed. Moreover, macrophage exosomes were injected into mice to observe its pro-fibrotic effects. In vitro, exosomes derived from angiotensin II (Ang II)-stimulated macrophages were collected. Then, lung fibroblasts were treated with the exosomes. Twenty-four hours later, protein levels of α-collagen I, angiotensin II type 1 receptor (AT1R), transforming growth factor-β (TGF-β), and phospho-Smad2/3 (p-Smad2/3) in lung fibroblasts were examined. The Student’s t test or analysis of variance were used for statistical analysis.

In vivo, BLM-treated mice showed enhanced infiltration of macrophages, increased fibrotic alterations, and higher levels of Ang II and AT1R. GW4869 attenuated BLM-induced pulmonary fibrosis. Mice with exosomes injection showed fibrotic features with higher levels of Ang II and AT1R, which was reversed by irbesartan. In vitro, we found that macrophages secreted a great number of exosomes. The exosomes were taken by fibroblasts and resulted in higher levels of AT1R (0.22 ± 0.02 vs. 0.07 ± 0.02, t = 8.66, P = 0.001), TGF-β (0.54 ± 0.05 vs. 0.09 ± 0.06, t= 10.00, P < 0.001), p-Smad2/3 (0.58 ± 0.06 vs. 0.07 ± 0.03, t= 12.86, P < 0.001) and α-collagen I (0.27 ± 0.02 vs. 0.16 ± 0.01, t = 7.01, P = 0.002), and increased Ang II secretion (62.27 ± 7.32 vs. 9.56 ± 1.68, t= 12.16, P < 0.001). Interestingly, Ang II increased the number of macrophage exosomes, and the protein levels of Alix (1.45 ± 0.15 vs. 1.00 ± 0.10, t = 4.32, P = 0.012), AT1R (4.05 ± 0.64 vs. 1.00 ± 0.09, t = 8.17, P = 0.001), and glyceraldehyde-3-phosphate dehydrogenase (2.13 ± 0.36 vs. 1.00 ± 0.10, t = 5.28, P = 0.006) were increased in exosomes secreted by the same number of macrophages, indicating a positive loop between Ang II and exosomes production.

Exosomes mediate intercellular communication between macrophages and fibroblasts plays an important role in BLM-induced pulmonary fibrosis.

Pregnancy-associated breast cancer (PABC) is a special type of breast cancer that occurs during pregnancy and within 1 year after childbirth. With the rapid social development and the adjustment of reproductive policies in China, the average age of females at first childbirth is increasing, which is expected to lead to an increase in the incidence of PABC. This study aimed to accumulate clinical experience and to investigate and summarize the prevalence, diagnosis, and treatment of PABC based on large multicenter samples in China.

According to the Chinese Society of Breast Surgery, a total of 164 patients with PABC in 27 hospitals from January 2016 to December 2018 were identified. The pregnancy status, clinicopathological features, comprehensive treatment methods, and outcomes were retrospectively analyzed. Survival curves were plotted using the Kaplan-Meier method.

A total of 164 patients of PABC accounted for 0.30% of the total number of cases in the same period; of which, 83 patients were diagnosed during pregnancy and 81 patients during lactation. The median age of PABC was 33 years (24-47 years). Stage I patients accounted for 9.1% (15/164), stage II 54.9% (90/164), stage III 24.4% (40/164), and stage IV 2.4% (4/164). About 9.1% (15/164) of patients were luminal A. Luminal B patients accounted the most (43.3% [71/164]). About 15.2% (25/164) of patients were human epidermal growth factor receptor 2 (Her-2) overexpression and 18.9% (31/164) of patients were triple-negative breast cancer. For pregnancy breast cancer, 36.1% (30/83) of patients received direct surgery and 20.5% (17/83) received chemotherapy during pregnancy. About 31.3% (26/83) chose abortion or induction of labor. The median follow-up time was 36 months (3-59 months); 11.0% (18/164) patients had local recurrence or distant metastasis and 3.0% (5/164) died.

It is safe and feasible to standardize surgery and chemotherapy for PABC.

Previous studies have demonstrated different predominant sites of distant metastasis between patients with and without neoadjuvant chemoradiotherapy (NCRT). This study aimed to explore whether NCRT could influence the metastasis pattern of rectal cancer through a propensity score-matched analysis.

In total, 1296 patients with NCRT or post-operative chemoradiotherapy (PCRT) were enrolled in this study between January 2008 and December 2015. Propensity score matching was used to correct for differences in baseline characteristics between the two groups. After propensity score matching, the metastasis pattern, including metastasis sites and timing, was compared and analyzed.

After propensity score matching, there were 408 patients in the PCRT group and 245 patients in the NCRT group. NCRT significantly reduced local recurrence (4.1% vs. 10.3%, P = 0.004), but not distant metastases (28.2% vs. 27.9%, P= 0.924) compared with PCRT. In both the NCRT and PCRT groups, the most common metastasis site was the lung, followed by the liver. The NCRT group developed local recurrence and distant metastases later than the PCRT group (median time: 29.2 [18.8, 52.0] months vs. 18.7 [13.3, 30.0] months, Z=-2.342, P= 0.019; and 21.2 [12.2, 33.8] vs. 16.4 [9.3, 27.9] months, Z=-1.765, P = 0.035, respectively). The distant metastases occurred mainly in the 2nd year after surgery in both the PCRT group (39/114, 34.2%) and NCRT group (21/69, 30.4%). However, 20.3% (14/69) of the distant metastases appeared in the 3rd year in the NCRT group, while this number was only 13.2% (15/114) in the PCRT group.

The predominant site of distant metastases was the lung, followed by the liver, for both the NCRT group and PCRT group. NCRT did not influence the predominant site of distant metastases, but the NCRT group developed local recurrence and distant metastases later than the PCRT group. The follow-up strategy for patients with NCRT should be adjusted and a longer intensive follow-up is needed.

Hyperbaric oxygen treatment (HBOT) has been demonstrated to influence the keloid recurrence rate after surgery and to relieve keloid symptoms and other pathological processes in keloids. To explore the mechanism of the effect of HBOT on keloids, tumor immune gene expression and immune cell infiltration were studied in this work.

From February 2021 to April 2021, HBOT was carried out on keloid patients four times before surgery. Keloid tissue samples were collected and divided into an HBOT group (keloid with HBOT before surgery [HK] group, n = 6) and a non-HBOT group (K group, n = 6). Tumor gene expression was analyzed with an Oncomine Immune Response Research Assay kit. Data were mined with R package. The differentially expressed genes between the groups were compared. Hub genes between the groups were determined and verified with Quantitative Real-time PCR. Immune cell infiltration was analyzed based on CIBERSORT deconvolution algorithm analysis of gene expression and verified with immunohistochemistry (IHC).

Inflammatory cell infiltration was reduced in the HK group. There were 178 upregulated genes and 217 downregulated genes. Ten hub genes were identified, including Integrin Subunit Alpha M (ITGAM), interleukin (IL)-4, IL-6, IL-2, Protein Tyrosine Phosphatase Receptor Type C (PTPRC), CD86, transforming growth factor (TGF), CD80, CTLA4, and IL-10. CD80, ITGAM, IL-4, and PTPRC with significantly downregulated expression were identified. IL-10 and IL-2 were upregulated in the HK group but without a significant difference. Infiltration differences of CD8 lymphocyte T cells, CD4 lymphocyte T-activated memory cells, and dendritic resting cells were identified with gene CIBERSORT deconvolution algorithm analysis. Infiltration levels of CD4 lymphocyte T cell in the HK group were significantly higher than those of the K group in IHC verification.

HBOT affected tumor gene expression and immune cell infiltration in keloids. CD4 lymphocyte T cell, especially activated memory CD4⁺T, might be the key regulatory immune cell, and its related gene expression needs further study.

Accumulating evidence suggests that lithium influences mesenchymal stem cell (MSC) proliferation and osteogenic differentiation. As decreased bone formation in femoral heads is induced by glucocorticoids (GCs), we hypothesized that lithium has a protective effect on GC-induced osteonecrosis of femoral heads (ONFH).

A rat ONFH model was induced by methylprednisolone (MP) and the effect of lithium chloride on the models was evaluated. Micro-computed tomography (CT)-based angiography and bone scanning were performed to analyze the vessels and bone structure in the femoral heads. Hematoxylin and eosin and immunohistochemical staining were performed to evaluate the trabecular structure and osteocalcin (OCN) expression, respectively. Bone marrow-derived MSCs were isolated from the models, and their proliferative and osteogenic ability was evaluated. Western blotting and quantitative real-time polymerase chain reaction were performed to detect osteogenic-related proteins including Runx2, alkaline phosphatase, and Collagen I.

Micro-CT analysis showed a high degree of osteonecrotic changes in the rats that received only MP injection. Treatment with lithium reduced this significantly in rats that received lithium (MP + Li group); while 18/20 of the femoral heads in the MP showed severe osteonecrosis, only 5/20 in the MP + Li showed mild osteonecrotic changes. The MP + Li group also displayed a higher vessel volume than the MP group (0.2193 mm³vs. 0.0811 mm³, P < 0.05), shown by micro-CT-based angiography. Furthermore, histological analysis showed better trabecular structures and more OCN expression in the femoral heads of the MP + Li group compared with the MP group. The ex vivo investigation indicated higher proliferative and osteogenic ability and upregulated osteogenic-related proteins in MSCs extracted from rats in the MP + Li group than that in the MP group.

We concluded that lithium chloride has a significant protective effect on GC-induced ONFH in rats and that lithium also enhances MSC proliferation and osteogenic differentiation in rats after GC administration.

Although congenital hypothyroidism (CH) has been widely studied in Western countries, CH incidence at different administrative levels in China during the past decade remains unknown. This study aimed to update the incidence and revealed the spatial pattern of CH incidence in the mainland of China, which could be helpful in the planning and implementation of preventative measures.

The data used in our study were derived from 245 newborns screening centers that cover 30 provinces of the Chinese Newborn Screening Information System. Spatial auto-correlation was analyzed by Global Moran I and Getis-Ord Gi statistics at the provincial level. Kriging interpolation methods were applied to estimate a further detailed spatial distribution of CH incidence at city level throughout the mainland of China, and Kulldorff space scanning statistical methods were used to identify the spatial clusters of CH cases at the city level.

A total of 91,921,334 neonates were screened from 2013 to 2018 and 42,861 cases of primary CH were identified, yielding an incidence of 4.66 per 10,000 newborns screened (95% confidence interval [CI]: 4.62-4.71). Neonates in central (risk ratio [RR] = 0.84, 95% CI: 0.82-0.85) and western districts (RR = 0.71, 95% CI: 0.69-0.73) had lower probability of CH cases compared with the eastern region. The CH incidence indicated a moderate positive global spatial autocorrelation (Global Moran I value = 0.394, P < 0.05), and the CH cases were significantly clustered in spatial distribution. A most likely city-cluster (log-likelihood ratio [LLR]= 588.82, RR = 2.36, P < 0.01) and 25 secondary city-clusters of high incidence were scanned. The incidence of each province and each city in the mainland of China was estimated by kriging interpolation, revealing the most affected province and city to be Zhejiang Province and Hangzhou city, respectively.

This study offers an insight into the space clustering of CH incidence at provincial and city scales. Future work on environmental factors need to focus on the effects of CH occurrence.

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disorder associated with loss of motor neurons. Our objective was to explore the epidemiology, clinical features, and survival factors of 1809 patients with ALS.

We analyzed 1809 ALS patients, who were recruited from the Peking University Third Hospital from January 2005 to December 2015. Demographic data and disease-related parameters were collected. Kaplan-Meier curves were used to compare survival time. Cox proportional hazards function and the hazard ratio were used to identify adjusted prognostic predictors.

The results showed that the average annual incidence in Beijing alone was 0.38 cases/100,000 person-years and the mean age of onset was 48.88 ± 11.35 (95% confidence interval [CI]: 48.17-49.85) years. The median survival time from onset to death/tracheostomy was 58.89 ± 33.03 (95% CI: 51.46-63.84) months. In the adjusted Cox proportional hazard model, age of onset, diagnosis delay, rate of disease progression (Amyotrophic Lateral Sclerosis Functional Rating Scale Revised decline [points/month]), and body mass index all had an independent effect on survival in ALS.

Our study provides information on epidemiology, clinical features, and survival factors of patients with ALS in China. These results can be helpful in clinical practice, clinical trial design, and validation of new tools to predict disease progression.

To the Editor:Obstructive sleep apnea (OSA) is a common sleep-disordered breathing. Previous studies reported that the incidence of daytime hypercapnia in patients with OSA was 26.2% in China^[1]and 14% in Japan.^[2]However, Weitzenblumet al^[3]demonstrated that daytime hypercapnia in patients with OSA might not be secondary to sleep apneas/hypopneas, but might due to the comorbidities, such as chronic obstructive pulmonary disease or severe obesity. Obesity hypoventilation syndrome (OHS) is defined as a conjunction of obesity (body mass index [BMI] ≥30 kg/m²), daytime hypercapnia (partial pressure of carbon dioxide in arterial blood [PaCO₂] ≥45 mmHg) and sleep disordered breathing, after excluding other causes for alveolar hypoventilation.^[4]Since patients with OHS were not completely excluded in previous studies,^[1,2]we assumed that the incidence of daytime hypercapnia in Chinese patients with OSA might be low.

To the Editor: Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a common sleep-disordered breathing disease with a range of harmful sequelae. As a syndrome related to multiple systems,^[1]the clinical presentation of OSAHS is characterized by a large heterogeneity. At the World Sleep 2019 conference, a series of cluster analyses on the Icelandic sleep apnea cohort^[2]were introduced in detail. However, data from China are missing due to less relevant studies. Furthermore, although the relationship between OSAHS and cognitive impairment was confirmed in the 1980s, all variables assessing cognitive function have not yet been explored.

To the Editor: Type 2 diabetes (T2D) is a metabolic disease characterized by hyperglycemia caused by multiple etiologies.^[1]Long-term hyperglycemia causes microvascular and macrovascular damage and lipid metabolism disorders in T2D patients, which can lead to atherosclerosis.^[1]About two-thirds of patients with T2D die of cardiovascular complications, mainly atherosclerotic cardiovascular disease.^[2]The overall prevalence of macrovascular complications in T2D is approximately 32%.^[3]There are no clinical indicators that can accurately predict the cardiovascular complications of T2D. The early detection of biomarkers for atherogenic dyslipidemia in patients with T2D can realize the early identification of diabetic macrovascular disease, which is of great significance for early intervention, improvement of clinical prognosis, and reduction of disability mortality and economic burden. Fibroblast growth factor 19 (FGF19) is a hormone secreted by the distal small intestine which regulates lipid and glucose metabolism. However, it is unclear whether FGF19 functions in the progression of T2D to atherogenic dyslipidemia. In humans, some studies have investigated the relationship between circulating FGF19 and the presence of coronary artery disease (CAD), and have also proved the association between FGF19 and the development of major cardiovascular adverse events in stable CAD.^[4,5]Our previous studies also showed that FGF19 could predict the progression of subclinical atherosclerosis in men with T2D.^[6]In this study, we aimed to investigate the relationship between FGF19 and the risk of atherogenic dyslipidemia in patients with T2D and to explore whether FGF19 can be a biomarker for early diagnosis of atherogenic dyslipidemia in patients with T2D.

To the editor:The diabetes epidemic has increasingly become a major public health concern worldwide. In 2014, there were 102.9 million diabetic adults in China, representing 24.4% of the world’s diabetic population, even though China only comprised 18.7% of the global population at the time.^[1]Furthermore, the estimated overall prevalence of diabetes and prediabetes was 10.9% and 35.7%, respectively, indicating China as one of the countries with the highest prevalence of diabetes in the world.^[2]Although factors, including sedentary lifestyles and energy-dense diets, drive the diabetes epidemic, genetic architecture may also contribute to the susceptibility of an individual’s response to environmental challenges. Aldehyde dehydrogenase (ALDH)2 is a key enzyme that eliminates toxic aldehydes by catalyzing their oxidation to non-reactive acids. Emerging evidence has suggested that individuals withALDH2deficiency have an increased risk of cardiovascular and metabolic diseases, in addition to alcohol intolerance, nitroglycerin tolerance, and carcinoma.^[3]Notably, a uniqueALDH2loss-of-function allele,ALDH2*2, is found in approximately 50% of the East Asian and 8% of the global populations. It has been reported that thisALDH2mutation is associated with a higher prevalence of diabetes in coronary artery disease (CAD) patients, accompanied with increased C-reactive protein (CRP) levels.^[4]ALDH2mutation is also related to various diabetes risk factors, but the direct correlation remains elusive. Herein, we have explored the potential pathogenicity and mechanisms ofALDH2deficiency in the development of type 2 diabetes in both laboratory and clinical settings.

To the Editor:Pre-eclampsia is a leading cause of maternal morbidity and mortality. Although the etiology and progression of pre-eclampsia are not fully understood, it has been demonstrated that delivery is the definitive treatment. The clinician is then faced with the decision of when, and how, to proceed with the delivery. According to the guidelines, pre-eclampsia is not an indication of cesarean section, as expected with some serious complications. This means that pregnant women with pre-eclampsia can have a vaginal trial. However, most pregnant women with pre-eclampsia select to have a direct cesarean section at present. Whether having a cesarean section after trialing a vaginal delivery affects the outcomes of mother and child, and its related risk factors, are still unclear. The purpose of this study was to investigate the risk factors and maternal-neonatal outcomes in severe pre-eclampsia patients who underwent a transfer-cesarean section during vaginal labor.

To the Editor: Membranous nephropathy (MN) is an autoimmune disease and accounts for the most common cause of nephrotic syndrome in adults. In China, the incidence of MN is estimated at approximately 12/million per year, with a mean age between 50 and 60 years and a 2:1 male predominance. MN (29.1%) was the most common pathological disease in a 10-year renal biopsy analysis.^[1]

To the Editor: Liver fibrosis is the critical stage leading to hepatic dysfunction and might be important in the progress to portal hypertension, biliary cirrhosis, and hepatocellular carcinoma. Therefore, the accurate assessment of liver fibrosis remains a clinical concern for physicians. In recent researches, liver biopsy has been considered the golden standard for the diagnostic and assessment of liver fibrosis for many years. However, due to its invasive practice, sampling variability, and inter- and intra-assessor variability of pathological interpretations, liver biopsy is not well received in the patients and clinical physicians in many circumstances. As a result, multiple non-invasive detections of hepatic fibrosis assessment have been developed as an alternative strategy for liver biopsy as they could offer a convenient operation and acceptable diagnostic accuracy through medical imaging information. Early detection of hepatic fibrosis through clinical imaging could reduce liver failure and prevent its progression. The interpretation and analysis of medical imaging information are usually performed by clinical experts. Benefit from the rapid development of computer-aided diagnosis, especially the improved algorithm of deep learning in artificial intelligence, physicians could extract more accurate assessment for clinical decisions for diagnosis and treatment.^[1]

To the Editor: In sepsis, bacterial endotoxins play a central role by inducing a dysregulated and exaggerated release of inflammatory mediators and cytokines, often described as the "cytokine storm" or "cytokinemia."^[1]Both endotoxins and cytokines have been implicated in the development of organ dysfunction, including acute kidney injury (AKI).^[2]Removing circulating endotoxins and excess cytokines from the circulation restores chemotactic gradients, localizing the immune response to the principal site of infection and re-establishing a regulated immune response.^[1,3]Therefore, using hemofilters with enhanced endotoxin and cytokine adsorptive properties may bring about additional therapeutic benefits compared with conventional continuous renal replacement therapy (CRRT) filters.

To the Editor:Traumatic brain injury (TBI) indicates the disruption of normal function after a head or body blow or a concussion. In accordance with the criteria of the Glasgow Coma Scale, the severity of a TBI is classified into mild, moderate, and severe, based on patients’ motor and verbal responses and eye opening.^[1]Recently, studies have shown that 10% to 30% of individuals who tolerate head injuries may experience delayed symptoms and impairments from months to years later.^[2]

To the Editor: Identifying the increase in intracranial pressure (ICP) is very important in the management of neurosurgical and neurological disorders, because raised ICP is associated with poor outcomes such as brain herniation and death. Although the intraparenchymal or intraventricular invasive methods remain the gold standard for ICP measurement, they cannot be routinely employed because of the lack of an adequate number of neurosurgeons. In addition, because of contraindications (eg, blood coagulation disorders and severe platelet disorders) and complications (eg, infection and hemorrhage), the invasive approach is not always possible.^[1]Therefore, accurate non-invasive methods are needed to estimate ICP in clinical practice. A large number of studies have shown that the optic nerve sheath diameter (ONSD) is an indirect marker of ICP, and that there is a linear relationship between the two parameters.^[1,2]Therefore, ONSD and its accurate measurement methods are getting more and more attention from scholars.

To the Editor: A supraglottic airway device (SAD) can be used instead of an endotracheal tube (ET) in emergency situations. There are two types of SAD, cuffed and non-cuffed, the ease of use and success rates of which are similar. Compared to ET insertion, SAD insertion is quick and simple, while providing comparable ventilation. The 2019 American Heart Association guideline recommends SAD insertion in emergency situations, such as out-of-hospital cardiac arrest.^[1,2]However, the success of SAD insertion is not easily ascertained. According to one study, when a SAD was used in an emergency medical service (EMS) setting, airway failure was not recognized in 13.8% of patients.^[3]Incorrect positioning of a SAD is evidenced by bite block malalignment with the incisors and ineffective gas exchange (characterized by thoracic and "front of neck" excursions, inadequate tidal volume, low arterial oxygen saturation [SpO₂], poor capnograph trace, high airway pressure, and air leak).^[1,4]Failure to insert a SAD to the proper depth typically results from the resistance of structures around the hypopharynx.^[5]In this study, we introduce the thyroid cartilage elevation (TCE) maneuver, a simple and novel method that facilitates correct insertion of a SAD.