2021年 · 第134卷第20期

Pregnancy-associated breast cancer (PABC), including breast cancer during pregnancy (BCP) and postpartum breast cancer (PBC), has become a critical issue for clinicians in consideration of both maternal and offspring safety during diagnosis and treatment. The recommendations in this guideline are mainly based on currently available high-quality prospective studies, retrospective cohort studies, meta-analyses, and guidelines and consensus documents published by internationally recognized or national societies or associations. Clinicians should carefully analyze the potential benefits and risks of each treatment before recommending whether to terminate the pregnancy or lactation, balance the advantages and disadvantages of the treatments, and respect the wishes of patients.

Whether regional anesthesia may help to prevent disease recurrence in cancer patients is still controversial. The stage of cancer at the time of diagnosis is a key factor that defines prognosis and is one of the most important sources of heterogeneity for the treatment effect. We sought to update existing systematic reviews and clarify the effect of regional anesthesia on cancer recurrence in late-stage cancer patients.

Medline, Embase, and Cochrane Library were searched from inception to September 2020 to identify randomized controlled trials (RCTs) and cohort studies that assessed the effect of regional anesthesia on cancer recurrence and overall survival (OS) compared with general anesthesia. Late-stage cancer patients were primarily assessed according to the American Joint Committee on Cancer Cancer Staging Manual (eighth edition), and the combined hazard ratio (HR) from random-effects models was used to evaluate the effect of regional anesthesia.

A total of three RCTs and 34 cohort studies (including 64,691 patients) were identified through the literature search for inclusion in the analysis. The risk of bias was low in the RCTs and was moderate in the observational studies. The pooled HR for recurrence-free survival (RFS) or OS did not favor regional anesthesia when data from RCTs in patients with late-stage cancer were combined (RFS, HR= 1.12, 95% confidence interval [CI]: 0.58-2.18, P = 0.729, I² = 76%; OS, HR= 0.86, 95% CI: 0.63-1.18, P = 0.345, I² = 48%). Findings from observational studies showed that regional anesthesia may help to prevent disease recurrence (HR = 0.87, 95% CI: 0.78-0.96, P = 0.008, I² = 71%) and improve OS (HR = 0.88, 95% CI: 0.79-0.98, P = 0.022, I² = 79%).

RCTs reveal that OS and RFS were similar between regional and general anesthesia in late-stage cancers. The selection of anesthetic methods should still be based on clinical evaluation, and changes to current practice need more support from large, well-powered, and well-designed studies.

Once the sperm enters into the female reproductive tract, they undergo an important process called capacitation, which involves a series of physiological and biochemical changes that ensure fertilization. During capacitation, calcium ions (Ca²⁺) increase the bending amplitude of a sperm’s flagellum. This causes hyperactivation, which is manifested as the asymmetrical beating of the flagellum. Tyrosine phosphorylation is also a cause for human sperm hyperactivation; asthenospermia—that is, reduced sperm motility—occurs when the sperm are incapable of hyperactivation owing to impaired tyrosine phosphorylation.^[1]Hyperactivated motility enables the sperm to migrate and penetrate the cumulus cells and zona pellucida surrounding the oocyte, leading to fertilization. Therefore, the hyperactivated motility of sperm is critical for male reproductive ability, and the molecular mechanism underlying human sperm hyperactivation requires discussion.

Stroke is the second leading cause of death and the third leading contributor to the loss of disability-adjusted life-years. The fatality rate of all stroke patients ranges from 15% to 50% at 1 month to 5 years after stroke. Ischemic stroke is the most common type of stroke and accounts for 87% of all stroke cases.^[1]

Stroke has the characteristics of high rates of recurrence, disability, and mortality, and it has a heavy economic burden in China and around the world.^[1,2]The "Report on Nutrition and Chronic Disease Status of Chinese Residents (2020)" shows that deaths from chronic diseases accounted for 88.5% of the total deaths, and strokes, in particular, have been the first cause of death in China.^[3]The China lifetime risk of stroke from 25 years onward was 39.3%, whereas the global estimated risk was approximately 25%.^[4]

Empiric therapy for patients with unexplained recurrent pregnancy loss (URPL) is not precise. Some patients will ask for assisted reproductive technology due to secondary infertility or advanced maternal age. The clinical outcomes of URPL patients who have undergone in vitro fertilization-embryo transfer (IVF-ET) require elucidation. The IVF outcome and influencing factors of URPL patients need further study.

A retrospective cohort study was designed, and 312 infertile patients with URPL who had been treated during January 2012 to December 2015 in the Reproduction Center of Peking University Third Hospital were included. By comparing clinical outcomes between these patients and those with tubal factor infertility (TFI), the factors affecting the clinical outcomes of URPL patients were analyzed.

The clinical pregnancy rate (35.18% vs. 34.52% in fresh ET cycles, P = 0.877; 34.48% vs. 40.27% in frozen-thawed ET cycles, P = 0.283) and live birth rate (LBR) in fresh ET cycles (27.67% vs. 26.59%, P = 0.785) were not significantly different between URPL group and TFI group. URPL group had lower LBR in frozen-thawed ET cycles than that of TFI group (23.56% vs. 33.56%, P = 0.047), but the cumulative LBRs (34.69% vs. 38.26%, P = 0.368) were not significantly different between the two groups. The increased endometrial thickness (EMT) on the human chorionic gonadotropin day (odds ratio [OR]: 0.848, 95% confidence interval [CI]: 0.748-0.962, P = 0.010) and the increased number of eggs retrieved (OR: 0.928, 95% CI: 0.887-0.970, P = 0.001) were protective factors for clinical pregnancy in stimulated cycles. The increased number of eggs retrieved (OR: 0.875, 95% CI: 0.846-0.906, P < 0.001), the increased two-pronucleus rate (OR: 0.151, 95% CI: 0.052-0.437, P < 0.001), and increased EMT (OR: 0.876, 95% CI: 0.770-0.997, P = 0.045) in ET day were protective factors for the cumulative live birth outcome.

After matching ages, no significant differences in clinical outcomes were found between the patients with URPL and the patients with TFI. A thicker endometrium and more retrieved oocytes increase the probability of pregnancy in fresh transfer cycles, but a better normal fertilization potential will increase the possibility of a live birth.

Circulating tumor DNA (ctDNA) is a promising biomarker for non-invasive epidermal growth factor receptor mutations (EGFRm) detection in lung cancer patients, but existing methods have limitations in sensitivity and availability. In this study, we used the ΔCt value (mutant cycle threshold [Ct] value-internal control Ct value) generated during the polymerase chain reaction (PCR) assay to convert super-amplification-refractory mutation system (superARMS) from a qualitative method to a semi-quantitative method named reformed-superARMS (R-superARMS), and evaluated its performance in detecting EGFRm in plasma ctDNA in patients with advanced lung adenocarcinoma.

A total of 41 pairs of tissues and plasma samples were obtained from lung adenocarcinoma patients who had known EGFRm in tumor tissue and were previously untreated. EGFRm in ctDNA was identified by using superARMS. Through making use of ΔCt value generated during the detection process of superARMS, we indirectly transform this qualitative detection method into a semi-quantitative PCR detection method, named R-superARMS. Both qualitative and quantitative analyses of the data were performed. Kaplan-Meier analysis was performed to estimate the progression-free survival (PFS) and overall survival (OS). Fisher exact test was used for categorical variables.

The concordance rate of EGFRm in tumor tissues and matched plasma samples was 68.3% (28/41). At baseline, EGFRm-positive patients were divided into two groups according to the cut-off ΔCt value of EGFRm set at 8.11. A significant difference in the median OS (mOS) between the two groups was observed (EGFRm ΔCt ≤8.11 vs. >8.11: not reached vs. 11.0 months; log-rank P = 0.024). Patients were divided into mutation clearance (MC) group and mutation incomplete clearance (MIC) group according to whether the ΔCt value of EGFRm test turned negative after 1 month of treatment. We found that there was also a significant difference in mOS (not reached vs. 10.4 months; log-rank P = 0.021) between MC group and MIC group. Although there was no significant difference in PFS between the two groups, the two curves were separated and the PFS of MC group tended to be higher than the MIC group (not reached vs. 27.5 months; log-rank P = 0.088). Furthermore, EGFRm-positive patients were divided into two groups according to the cut-off of the changes in ΔCt value of EGFRm after 1 month of treatment, which was set at 4.89. A significant difference in the mOS between the two groups was observed (change value of ΔCt >4.89 vs. ≤4.89: not reached vs. 11.0 months; log-rank P = 0.014).

Detecting EGFRm in ctDNA using R-superARMS can identify patients who are more likely sensitive to targeted therapy, reflect the molecular load of patients, and predict the therapeutic efficacy and clinical outcomes of patients.

Since the outbreak of coronavirus disease 2019 (COVID-19), human mobility restriction measures have raised controversies, partly because of the inconsistent findings. An empirical study is promptly needed to reliably assess the causal effects of the mobility restriction. The purpose of this study was to quantify the causal effects of human mobility restriction on the spread of COVID-19.

Our study applied the difference-in-difference (DID) model to assess the declines of population mobility at the city level, and used the log-log regression model to examine the effects of population mobility declines on the disease spread measured by cumulative or new cases of COVID-19 over time after adjusting for confounders.

The DID model showed that a continual expansion of the relative declines over time in 2020. After 4 weeks, population mobility declined by -54.81% (interquartile range, -65.50% to -43.56%). The accrued population mobility declines were associated with the significant reduction of cumulative COVID-19 cases throughout 6 weeks (ie, 1% decline of population mobility was associated with 0.72% [95% CI: 0.50%-0.93%] reduction of cumulative cases for 1 week, 1.42% 2 weeks, 1.69% 3 weeks, 1.72% 4 weeks, 1.64% 5 weeks, and 1.52% 6 weeks). The impact on the weekly new cases seemed greater in the first 4 weeks but faded thereafter. The effects on cumulative cases differed by cities of different population sizes, with greater effects seen in larger cities.

Persistent population mobility restrictions are well deserved. Implementation of mobility restrictions in major cities with large population sizes may be even more important.

Postoperative pneumonia (POP) is one of the most common infections following heart valve surgery (HVS) and is associated with a significant increase in morbidity, mortality, and health care costs. This study aimed to identify the major risk factors associated with the occurrence of POP following HVS and to derive and validate a clinical risk score.

Adults undergoing open HVS between January 2016 and December 2019 at a single institution were enrolled in this study. Patients were randomly assigned to the derivation and validation sets at 1:1 ratio. A prediction model was developed with multivariable logistic regression analysis in the derivation set. Points were assigned to independent risk factors based on their regression coefficients.

POP occurred in 316 of the 3853 patients (8.2%). Multivariable analysis identified ten significant predictors for POP in the derivation set, including older age, smoking history, chronic obstructive pulmonary disease, diabetes mellitus, renal insufficiency, poor cardiac function, heart surgery history, longer cardiopulmonary bypass, blood transfusion, and concomitant coronary and/or aortic surgery. A 22-point risk score based on the multivariable model was then generated, demonstrating good discrimination (C-statistic: 0.81), and calibration (Hosmer-Lemeshow χ² = 8.234, P = 0.312). The prediction rule also showed adequate discriminative power (C-statistic: 0.83) and calibration (Hosmer-Lemeshow χ² = 5.606, P = 0.691) in the validation set. Three risk intervals were defined as low-, medium-, and high-risk groups.

We derived and validated a 22-point risk score for POP following HVS, which may be useful in preventive interventions and risk management.

Chictr.org, ChiCTR1900028127; http://www.chictr.org.cn/showproj.aspx?proj=46932

Investigations of the pathogenic mechanisms in motor neurons (MNs) derived from amyotrophic lateral sclerosis (ALS) disease-specific induced pluripotent stem (iPS) cell lines could improve understanding of the issues affecting MNs. Therefore, in this study we explored mutant superoxide dismutase 1 (SOD1) protein expression in MNs derived from the iPS cell lines of ALS patients carrying different SOD1 mutations.

We generated induced pluripotent stem cell (iPSC) lines from two familial ALS (FALS) patients with SOD1-V14M and SOD1-C111Y mutations, and then differentiated them into MNs. We investigated levels of the SOD1 protein in iPSCs and MNs, the intracellular Ca²⁺ levels in MNs, and the lactate dehydrogenase (LDH) activity in the process of differentiation into the MNs derived from the controls and ALS patients’ iPSCs.

The iPSCs from the two FALS patients were capable of differentiation into MNs carrying different SOD1 mutations and differentially expressed MN markers. We detected high SOD1 protein expression and high intracellular calcium levels in both the MN and iPSCs that were derived from the two SOD1 mutant patients. However, at no time did we observe stronger LDH activity in the patient lines compared with the control lines.

MNs derived from patient-specific iPSC lines can recapitulate key aspects of ALS pathogenesis, providing a cell-based disease model to further elucidate disease pathogenesis and explore gene repair coupled with cell-replacement therapy. Incremental mutant expressions of SOD1 in MNs may have disrupted MN function, either causing or contributing to the intracellular calcium disturbances, which could lead to the occurrence and development of the disease.

Ubiquitin-conjugating enzyme E2C (UBE2C) has been shown to be associated with the occurrence of various cancers and involved in many tumorigenic processes. This study aimed to investigate the specific molecular mechanism through which UBE2C affects breast cancer (BC) proliferation.

BC-related datasets were screened according to filter criteria in the Gene Expression Omnibus (GEO) database and The Cancer Genome Atlas (TCGA) database. Then differentially expressed genes (DEGs) were identified using Venn diagram analysis. By using DEGs, we conducted the following analyses including Gene ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), protein-protein interaction (PPI), and survival analysis, and then validated the function of the hub gene UBE2C using quantitative reverse transcription-polymerase chain reaction (RT-qPCR), cell counting kit-8 (CCK-8) assay, transwell assay, and Western blot assay.

In total, 151 DEGs were identified from the GEO and TCGA databases. The results of GO analysis demonstrated that the DEGs were significantly enriched with mitotic nuclear division, lipid droplet, and organic acid-binding. KEGG analysis showed that the peroxisome proliferators-activated receptor (PPAR) signaling pathway, regulation of lipolysis in adipocytes, and proximal tubule bicarbonate reclamation were significantly enriched in the signal transduction pathway category. The top three hub genes that resulted from the PPI network were FOXM1, UBE2C, and CDKN3. The results of survival analysis showed a close relationship between UBE2C and BC. The results of CCK-8 and transwell assays suggested that the proliferation and invasion of UBE2C knockdown cells were significantly inhibited (P < 0.050). The results of Western blot assay showed that the level of phosphorylated phosphatase and tensin homology deleted on chromosome 10 (p-PTEN) was obviously increased (P < 0.050), whereas the levels of phosphorylated protein kinase B (p-AKT), phosphorylated mammalian target of rapamycin (p-mTOR), and hypoxia-inducible factor-1 alpha (HIF-1α) were dramatically decreased (P < 0.050) in the UBE2C knockdown cell.

UBE2C can promote BC proliferation by activating the AKT/mTOR signaling pathway.

There is growing evidence that 5-fluorouracil (5-FU) combined with therapeutic trauma can effectively induce skin repigmentation in vitiligo patients who are unresponsive to conventional treatments. Previous studies have mainly focused on identifying the antimitotic activity of 5-FU for the treatment of skin cancer, but few studies have investigated its extra-genotoxic actions favoring melanocyte recruitment.

We utilized the full thickness excisional skin wound model in Dct-LacZ transgenic mice to dynamically assess the migration of melanocytes in the margins of wounds treated with or without 5-FU. The in-situ expression of CXCL12 was examined in the wound beds using immunofluorescence staining. Quantitative real-time polymerase chain reaction and Western blotting analyses were performed to detect the expression levels of CXCL12 mRNA and protein in primary mouse dermal fibroblasts treated with or without 5-FU. Transwell assays and fluorescein isothiocyanate (FITC)-phalloidin staining were used to observe cell migration and filamentous actin (F-actin) changes of melan-a murine melanocytes.

Whole mount and cryosection X-gal staining showed that the cell numbers of LacZ-positive melanocytes were much higher in the margins of dorsal and tail skin wounds treated with 5-FU compared with the controls. Meanwhile, CXCL12 immunostaining was significantly increased in the dermal compartment of wounds treated with 5-FU (control vs. 5-FU, 22.47 ± 8.85 vs. 44.69 ± 5.97, P < 0.05). Moreover, 5-FU significantly upregulated the expression levels of CXCL12 mRNA (control vs. 5-FU, 1.00 ± 0.08 vs. 1.54 ± 0.06, P < 0.05) and protein (control vs. 5-FU, 1.00 ± 0.06 vs. 2.93 ± 0.10, P < 0.05) in cultured fibroblasts. Inhibition of the CXCL12/CXCR4 axis suppressed melanocyte migration in vitro using a CXCL12 small interfering RNA (siRNA) or a CXCR4 antagonist (AMD3100).

5-FU possesses a pro-pigmentary activity through activation of the CXCL12/CXCR4 axis to drive the chemotactic migration of melanocytes.

Extramammary Paget disease (EMPD) is an uncommon intraepithelial adenocarcinoma that tends to occur in regions with an abundance of apocrine glands. EMPD typically affects older individuals aged 50 to 80 years. The most commonly affected area of EMPD is the vulva; it accounts for 1% to 2% of vulvar malignancies.^[1]The most common symptoms are chronic itching, vulvar pain, and erythema. However, symptoms can vary, and patients can remain asymptomatic for years. The typical feature of vulvar Paget’s disease (VPD) is an "icing cake effect" on the skin.^[2]This disease is often misdiagnosed as eczema. Treatment delay is usually more than 2 years, and treatment can sometimes result in failure with a high recurrence rate.^[3]

Since 2019, an epidemic of pneumonia of unknown cause occurred around the world.^[1]The analysis of respiratory tract samples led to the identification of a novel coronavirus, which was named 2019 novel coronavirus (2019-nCoV). Epidemiological data showed that 2019-nCoV could spread rapidly from person to person and cause coronavirus disease-19 (COVID-19). The high infectivity of COVID-19 has led to a rapid increase in the number of cases and caused a global pandemic. To date, 2019-nCoV has infected millions of people and caused hundreds of thousands of deaths worldwide. These numbers are updated every day and are expected to increase further at a great rate. COVID-19 has now become a serious threat to public health worldwide.

To the Editor:Left ventricular (LV) hypertrophy and diastolic dysfunction are prevalent in patients with type 2 diabetes mellitus (T2DM)^[1]and contribute to an increased rate of cardiovascular events. The multifactorial pathological state may be linked to overweight and obesity. However, the definitions of obesity based on body mass index (BMI) resulted in discrepancies in the impact on cardiometabolic risk in different studies. Thus, the exact association between overweight/obesity and diabetic cardiomyopathy is yet controversial. Sarcopenia, age-related decline in muscle mass and strength, also showed an association with cardiovascular disease.^[2]Moreover, individuals with high BMI but low muscle mass may not be noticeable but need to be considered. Studies have demonstrated that sarcopenic overweight and obesity are associated with variable cardiometabolic diseases. Diabetes may coexist with sarcopenia or obesity. However, research on the association between sarcopenia and LV diastolic function, LV remodeling, and the association with sarcopenic overweight and obesity is lacking. This study sought to investigate whether sarcopenia and sarcopenic overweight and obesity are independently related to preclinical LV diastolic dysfunction and LV remodeling in patients with T2DM.

To the Editor: A 7-year-old boy underwent surgery at the West China Hospital in Chengdu, China, because of developing a mass in the left distal forearm over 1 month. A biopsy from the surgery resulted in a diagnosis of histiocytosis, with suspected yellow granulomas. The patient also suffered from poor wound healing with purulent secretions. Two months post-operation, the patient was re-admitted to the hospital due to suffer a painful swelling in the left ankle over 10 days. Color Doppler ultrasound examination revealed a left ankle joint synovitis and a left posterior tibialis fasciitis. The patient had a history of recurrent respiratory infections since infancy, for which he had received anti-tuberculosis therapy. However, there was no record of acid-fast bacilli being isolated from the patient. There was also no family history of a similar illness among his siblings or parents. In addition to the respiratory infections, the patient also underwent open drainage of abscesses in the posterior ears and posterior cervical lymph nodes at the age of 5 and the perianus at the age of 6. He was frequently prescribed two- or three-fold antibiotics, such as oxycefazid, vancomycin, and imipenem, because of his recurring multi-site infectious lesions.

To the Editor: The literature has registered a considerable interest among Western surgeons in the role of extended lymph node dissection in right hemicolectomy. There are a lot of voices of dissent regarding the harvest of nodes lying dorsally to the superior mesenteric vein (SMV) and superior mesenteric artery (SMA).^[1]

To the Editor:Primary hepatic myopericytoma (MPC) is a rare soft tumor, and the concept of myopericyte was first proposed by Dictor in 1992.^[1]In 1998, Granter adopted the name myopericytoma for this form of tumor.^[2]Most MPCs arise from the skin and superficial soft tissues of distal extremities,^[3]but rarely described in the liver.^[4]MPC observed by¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) has rarely been reported. Surgical resection of myopericytomas has a good curative effect, and occasionally there is recurrence or metastasis.^[5]Castleman disease (CD) was first described in 1954.^[6]About 70% of CD cases are in the chest, and it can also occur in other areas such as the pelvis, neck, retroperitoneum, and muscles.¹⁸F-FDG PET/CT is effective diagnostic imaging for the diagnosis of CD. Here we report a rare case of coexistence of MPC and mediastinal CD on¹⁸F-FDG PET/CT.

To the Editor: Percutaneous nephrolithotomy (PNL) constitutes the first-line of treatment for complex and staghorn stones. Performing PNL in morbidly obese patients is challenging because of potential risks and higher morbidity rates.^[1]Previous literature has confirmed the safety and feasibility of the surgery under fluoroscopy. However, the efficiency of total ultrasound (US)-guided access established procedures in morbidly obese patients has not been proved before, with the traditional view holding that obesity is a risk factor that increases the difficulty of accessing the renal collecting system under US. US is sometimes used to reduce radiation exposure in some Western countries, whereas the spread of X-ray-free technique for PNL in China has been lasting for >10 years. This study aims to investigate the feasibility and safety of total US-guided PNL in morbidly obese patients and to highlight the difficulties and problems, which can be encountered and effectively resolved.

To the Editor: During radiofrequency catheter ablation (RFCA), acute cardiac tamponade is a common but life-threatening occurrence in which rapid blood accumulation in the pericardium cavity compresses the heart and causes the systemic circulation to deteriorate. Emergency percutaneous pericardiocentesis and immediate autologous blood transfusion are necessary. The administration of protamine for incessant bleeding is controversial, for pericardial blood clots may form spontaneously despite the neutralizing effects of heparin and may even necessitate thoracotomy. Our aim is to discuss the necessity and optimum time of protamine administration and to explore the means to prevent blood clot formation.

To the Editor: Asthma is a common chronic respiratory disease. It is estimated that 300 million individuals worldwide suffer from asthma, and at least 50% of both adults and children do not take control medication as prescribed.^[1]Asthma control is closely related to treatment adherence, and poor adherence is a contributing factor for poorly controlled symptoms, exacerbations, and hospitalizations. Understanding the factors affecting adherence and improving it are important measures in achieving good asthma control. Systematic analysis of asthma treatment adherence shows significant differences in adherence rates and related factors across studies.^[2]The aim of this study was to investigate adherence to medication and factors influencing that among asthma patients in Shanghai, one of the most developed metropolises in China, to suggest further interventions to improve adult asthma control.

To the Editor: The current coronavirus disease 2019 (COVID-19) pandemic has resulted in an unprecedented worldwide health crisis. The Chinese government incorporated the syndrome into the B class of infectious diseases stipulated in the Law of China on the Prevention and Treatment of Infectious Diseases, with prevention and control measures implemented according to A class infectious diseases. On February 11, 2020, the World Health Organization named the syndrome COVID-19. Subsequently,the International Committee on Taxonomy of Viruses (ICTV)named the causative virus 2019 novel coronavirus (2019-nCoV). As we have been achieving a deeper understanding of COVID-19, its potential effects on the genitourinary system have gradually gained the public’s attention. The virus itself may have an impact on the male reproductive system, but the impacts of drugs, environmental factors, psychological factors, and other aspects on reproduction during the epidemic period should not be ignored.

To the Editor: Patients who undergo emergency general surgery (EGS) procedures are up to eight times more likely to die than those undergoing the same procedure electively.^[1]The development of an appropriate EGS risk stratification tool could facilitate accurate triage of high-risk patients, thereby supporting surgical decision-making, informed consent, and identification of EGS patients for transfer to a higher level of care.^[2]However, the ideal EGS risk stratification tool does not exist yet. In 2016, a uniform system [American Association for the Surgery of Trauma (AAST) grade] for measuring anatomic severity of 16 common EGS diseases has been reported by the AAST Patient Assessment Committee. Simultaneously, the committee pointed out that this system is not intended to serve alone as a predictor of outcome. Other important factors of the outcome, such as physiological status, comorbidities, age, and complexity of operation procedures, should be integrated into the system for risk stratification.^[3]In our EGS center, the spectrum of diseases is mainly abdominal related diseases among the 16 diseases including acute appendicitis, acute cholecystitis, acute diverticulitis of the colon, hernias, infectious colitis, intestinal obstruction, acute pancreatitis, pelvic inflammatory disease, perirectal abscess, and perforated peptic ulcer. We have identified abdominal related EGS diseases complicated with sepsis to be a major cause of morbidity and mortality in our EGS center. We assumed that the integration of anatomical severity of EGS diseases plus physiological severity and other parameters (eg, intra-operative variables, age, and comorbidities) together could work better. Thus, this study aimed to develop and validate a nomogram for predicting post-operative in-hospital outcome in abdominal related EGS diseases complicated with sepsis.

To the Editor:Continuous monitoring of hemodynamic status can be used to detect early abnormal circulation and is very helpful for the management of the critically ill. Today, different minimally invasive and non-invasive monitoring systems can measure functional hemodynamic parameters to guide treatment planning and improve patient care. Among them, the thoracic electrical bioimpedance (TEB) technique is widely available and is accurate for most patients, especially after open-heart surgery. However, there are ethnicity-related differences among hemodynamic characteristics and the hemodynamic response to the same cardiovascular disease differs among racial groups. Currently, no nationwide hemodynamic parameter reference ranges can be used for healthy Chinese Han adults. A large-scale, forward-looking research investigation of the hemodynamic state markers in China has not been wholly reported. Therefore, it is necessary to establish ethnicity-specific hemodynamic reference ranges for the Chinese Han population and evaluate the relationship between these parameters and age/sex, in order to promote efficient and accurate judgment in clinical practice. From July 2012 to September 2017, a prospective, nationwide study led by the Ministry of Science and Technology of the People’s Republic of China was designed, organized, and performed to establish normal reference ranges of hemodynamic parameters for the Chinese Han population and to confirm the impacts of age and sex on these parameters.