2022年 · 第135卷第19期

World Health Organization recommends that influenza vaccines should benefit as much of the population as possible, especially where resources are limited. Corona virus disease 2019 (COVID-19) has become one of the greatest threats to health systems worldwide. The present study aimed to extend the evidence of the association between influenza vaccination and COVID-19 to promote the former.

In this systematic review, four electronic databases, including the Cochrane Library, PubMed, Embase, and Web of Science, were searched for related studies published up to May 2022. All odds ratios (ORs) with 95% confidence intervals (CIs) were pooled by meta-analysis.

A total of 36 studies, encompassing 55,996,841 subjects, were included in this study. The meta-analysis for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection provided an OR of 0.80 (95% CI: 0.73–0.87). The statistically significant estimates for clinical outcomes were 0.83 (95% CI: 0.72–0.96) for intensive care unit admission, 0.69 (95% CI: 0.57–0.84) for ventilator support, and 0.69 (95% CI: 0.52–0.93) for fatal infection, while no effect seen in hospitalization with an OR of 0.87 (95% CI: 0.68–1.10).

Influenza vaccination helps limit SARS-CoV-2 infection and severe outcomes, but further studies are needed.

PROSPERO, CRD42022333747.

Current practice uses the latest measure of glycated hemoglobin (HbAlc) to facilitate clinical decision-making. Studies have demonstrated that HbAlc variability links the risk of death and complications of diabetes. However, the role of HbAlc variability is unclear in clinical practice. This systematic review summarized the evidence of visit-to-visit HbAlc variability regarding different metrics in micro- and macro-vascular complications and death in people with type 2 diabetes.

We searched PubMed, EMBASE (via OVID), and Cochrane Central Register (CENTRAL, via OVID) for studies investigating the association between HbAlc variability and adverse outcomes in patients with type 2 diabetes and performed random-effects meta-analysis stratified by HbAlc variability metrics in terms of standard deviation (SD), coefficient of variation (CV), and HbAlc variability score (HVS).

In people with type 2 diabetes, the highest quantile of all three HbAlc variability metrics (HbAlc-standard deviation [HbAlc-SD], HbAlc-coefficient of variance [HbAlc-CV], and HVS) is associated with increased risks of all-cause mortality, cardiovascular events, progression to chronic kidney disease, amputation, and peripheral neuropathy. For example, the hazard ratio of HbAlc-SD on all-cause mortality was 1.89 with 95% confidence interval (95% CI) 1.46–2.45 (HbAlc-CV 1.47, 95% CI 1.26-1.72; HVS 1.67, 95% CI 1.34–2.09).

High HbAlc variability leads to micro- and macro-vascular complications of type 2 diabetes and related death. People with type 2 diabetes and high HbAlc variability need additional attention and care for the potential adverse outcomes.

Hypertensive intracerebral hemorrhage (HICH) refers to the sudden onset of hemorrhage within cerebral parenchyma or ventricles of patients with a history of hypertension. Secondary intracerebral hemorrhage (ICH) with an underlying causative pathology, such as trauma, structural blood vessel abnormalities, coagulation or hematological disorder(s), systemic diseases, or neoplasms, should be excluded to make the diagnosis of HICH. HICH is characterized by high incidence, disability, mortality, and recurrence rates. In 2015, experts from the Chinese Medical Association branch of Neurosurgery, Chinese Medical Doctor Association branch of the Emergency Physician and Stroke Screening, and Prevention and Treatment Committee of the National Health Commission of the People’s Republic of China gathered to formulate and draft the Chinese Multidisciplinary Experts Consensus on the Management of Spontaneous Intracerebral Hemorrhage.^[1]This consensus has played an important role in guiding and standardizing the management of spontaneous ICH in China. With significant progress in multidisciplinary research and the publication of new evidence in this field within the past 5 years, upgrading the former consensus statement to a guideline would facilitate better decision-making during clinical practice at all levels in medical institutions in China. The present guideline mainly addresses HICH, which is the most common type of spontaneous ICH.^[2,3]

By the end of 1980, Japanese groups had started programs with ABO-incompatible kidney transplantation as a consequence of the very limited supply of cadaveric organs for transplantation. Since then, they have done successful transplantations across the blood type barrier in combination with plasmapheresis and splenectomy. In Japan, the strategy for ABO-incompatible transplantation has changed with the development of the tacrolimus (FK)/mycophenolate mofetil (MMF) combination in 2000 and rituximab in 2005.^[1]In addition, preoperative 1-week administration of FK/MMF produced much more excellent results. Current graft survival (2005–2013) was almost over 90% in both ABO-incompatible at 9-year follow-up, which was comparable to ABO-compatible kidney trans-plantations.^[1]Many researchers from other countries such as Sweden, the USA, as well as the UK also reported uncountable articles relating to ABO-incompatible kidney/liver transplantations. Unfortunately, the common obser-vations from their reports are a high risk of hyperacute antibody-mediated rejection leading to graft loss, and a high incidence rate of postoperative complications like an infectious disease, probably due to the thymoglobulin regimen.^[2]So, the future direction of ABO-incompatible transplantation in some countries is likely to go straight forward to a donor exchange program rather than a heavy immunosuppressive program at the time of ABO and/or human leukocyte antigen incompatible transplantation.^[3]

Although ABO-incompatible (ABOi) kidney transplantation (KT) has been performed successfully, a standard preconditioning regimen has not been established. Based on the initial antidonor ABO antibody titers, an individualized preconditioning regimen is developed, and this study explored the efficacy and safety of the regimen.

From September 1, 2014, to September 1, 2020, we performed 1668 consecutive living-donor KTs, including 100 ABOi and 1568 ABO-compatible (ABOc) KTs. ABOi KT recipients (KTRs) with a lower antibody titer (≤1:8) were administered oral immunosuppressive drugs (OIs) before KT, while patients with a medium titer (1:16) received OIs plus antibody-removal therapy (plasma exchange/double-filtration plasmapheresis), patients with a higher titer (≥1:32) were in addition received rituximab (Rit). Competing risk analyses were conducted to estimate the cumulative incidence of infection, acute rejection (AR), graft loss, and patient death.

After propensity score analyses, 100 ABOi KTRs and 200 matched ABOc KTRs were selected. There were no significant differences in graft and patient survival between the ABOi and ABOc groups (P = 0.787, P= 0.386, respectively). After using the individualized preconditioning regimen, ABOi KTRs showed a similar cumulative incidence of AR (10.0% vs. 10.5%, P= 0.346). Among the ABOi KTRs, the Rit-free group had a similar cumulative incidence of AR (P = 0.714) compared to that of the Rittreated group. Multivariate competing risk analyses revealed that a Rit-free regimen reduced the risk of infection (HR: 0.31; 95% CI: 0.12–0.78, P = 0.013). Notably, antibody titer rebound was more common in ABOi KTRs receiving a Rit-free preconditioning regimen (P = 0.013) than those receiving Rit. ABOi KTRs with antibody titer rebound had a 2.72-fold risk of AR (HR: 2.72, 95% CI: 1.01–7.31, P = 0.048). ABOi KTRs had similar serum creatinine and estimated glomerular filtration rate compared to those of ABOc KTRs after the first year.

An individualized preconditioning regimen can achieve comparable graft and patient survival rates in ABOi KT with ABOc KT. Rit-free preconditioning effectively prevented AR without increasing the risk of infectious events in those with lower initial titers; however, antibody titer rebound should be monitored.

Pertuzumab has been approved for application in China by the National Medical Products Administration, and both national and international guidelines make recommendations for the use of neoadjuvant treatment with trastuzumab or trastuzumab + pertuzumab plus chemotherapy regimens for patients with indications. The goal of this study was to investigate the short-term clinical efficacy of the neoadjuvant therapies trastuzumab and trastuzumab+pertuzumab for patients with early human epidermal growth factor receptor 2 (HER2)-positive breast cancer in China.

A real-world study was conducted using the clinicopathological data of patients with early HER2-positive breast cancer who were admitted to the member hospitals of the Chinese Society of Breast Surgery, Chinese Surgical Society of Chinese Medical Association between March 2019 and December 2020. This study analyzed the efficacy and tolerance of trastuzumab+chemotherapy and trastuzumab+pertuzumab+chemotherapy in patients with early HER2-positive breast cancer. The Response Evaluation Criteria in Solid Tumors 1.1 was adopted to evaluate clinical efficacy. The pathological efficacy was evaluated using the MillerPayne grade. The Common Terminology Criteria for Adverse Events (version 5.0) was adopted to evaluate adverse events (AEs). The propensity scores were subjected to propensity score matching using the R language (1:1 matching with a maximum allowable difference of 0.05 between the two groups). Efficacy was compared using the chi-square test, and correlation analysis was performed using linear regression.

A total of 1032 patients with early HER2-positive breast cancer met the enrollment criteria and were included in this study. Among these patients, 472 received neoadjuvant trastuzumab+chemotherapy (the trastuzumab group), and 560 received neoadjuvant trastuzumab+pertuzumab+chemotherapy (the trastuzumab+pertuzumab group). The overall pathologic complete response (pCR) rate was 47.2% (487/1032), while the pCR rates of the trastuzumab and trastuzumab+pertuzumab groups were 34.5% (163/472) and 57.9% (324/560), respectively, and the difference was significant (P < 0.001). The incidence of grade 4 AEs was 24/321 (7.5%) in the trastuzumab+pertuzumab group, and there were no cases in which the left ventricular ejection fraction decreased by more than 10%.

Patients in the trastuzumab+pertuzumab group had a higher pCR rate than those in the trastuzumab group, and the toxic side effects were tolerable.

Endoscopic retrograde cholangiopancreatography (ERCP) is the endoscopic modality of choice for the treatment of biliary and pancreatic diseases. However, patients with cirrhosis, particularly those with decompensated cirrhosis, are believed to be at increased risk for complications associated with ERCP. There is a paucity of literature describing the outcomes of ERCP for patients with cirrhosis. This study aimed to investigate the outcomes of ERCP for cirrhosis patients, especially adverse events, and evaluated its safety and efficacy.

We performed a multicenter, retrospective study of all patients at Beijing Friendship Hospital affiliated to Capital Medical University, Xijing Hospital affiliated to Air Force Military Medical University, Beijing Youan Hospital affiliated to Capital Medical University, and the Fifth Medical Center of the People’s Liberation Army General Hospital from June 2003 to August 2019. The adverse events of inpatient ERCP for patients with (n = 182) and without liver cirrhosis (controls; n = 385) were compared.

A total of 567 patients underwent ERCP between January 2003 and December 2019 were enrolled in this study. Compared to patients without cirrhosis, patients with cirrhosis were at higher risk for postoperative complications (odds ratio [OR], 4.172; 95% confidence interval [CI], 1.232–7.031; P < 0.001) such as postoperative pancreatitis (OR, 2.026; 95% CI, 1.002–4.378; P= 0.001) and cholangitis (OR, 3.903; 95% CI, 1.001–10.038; P= 0.036). The main indications for ERCP for patients with cirrhosis in this study included choledocholithiasis (101 cases; 55.5%), benign bile duct strictures (46 cases; 25.3%), and malignant bile duct strictures (28 cases; 15.4%). Among them, 23 patients (12.6%) underwent balloon dilation and 79 patients (43.4%) underwent sphincterotomy. Of the patients with cirrhosis, delayed bleeding occurred in ten patients (5.5%), postoperative pancreatitis occurred in 80 patients (44.0%), and postoperative cholangitis occurred in 25 patients (13.7%). An additional multivariate analysis showed that the total bilirubin (TBIL) level (OR, 4.58; 95% CI, 2.37–6.70) and Child-Pugh score of C (OR, 3.11; 95% CI, 1.04–5.37) were risk factors for postoperative complications in patients with cirrhosis.

Compared with the general population of patients undergoing ERCP, patients with cirrhosis were more prone to postoperative pancreatitis and cholangitis. TBIL levels and Child-Pugh scores were risk factors for postoperative complications in patients with cirrhosis.

Cell competition is an important feature in pancreatic cancer (PC) progression, but the underlying mechanism remains elusive. This study aims to explore the role of exosomes derived from normal pancreatic ductal epithelial cells involved in PC progression.

PC cells and pancreatic stellate cells (PSCs) were treated with exosomes isolated from pancreatic ductal epithelial cells. Cell proliferation was assessed by CCK8 assays. Cell migration and invasion were assessed by Transwell assays. PC and matched adjacent non-tumor tissue specimens were obtained from 46 patients pathologically diagnosed with PC at Peking University First Hospital from 2013 to 2017. Tissue miR-485-3p and p21-activated kinase-1 (PAK1) expression was examined by real-time polymerase chain reaction (RT-PCR), and the relationship of the two was analyzed using Pearman’s product-moment correlation. The clinical significance of miR-485-3p was analyzed using the Chi-square test, Wilcoxon rank-sum test, and Fisher exact probability, respectively. The binding of miR-485-3p to PAK1 5^＇-untranslated region (5^＇-UTR) was examined by luciferase assay. PC cells were xenografted into nude mice as a PC metastasis model.

Exosomes from pancreatic ductal epithelial cells suppressed PC cell migration and invasion as well as the secretion and migration of PSCs. MiR-485-3p was enriched in the exosomes of pancreatic ductal epithelial cells but deficient in those of PC cells and PSCs, in accordance with the lower level in PSCs and PC cells than that in pancreatic ductal cells. And the mature miR-485-3p could be delivered into these cells by the exosomes secreted by normal pancreatic duct cells, to inhibit PC cell migration and invasion. Clinical data analysis showed that miR-485-3p was significantly decreased in PC tissues (P < 0.05) and was negatively associated with lymphovascular invasion (P = 0.044). As a direct target of miR-485-3p, PAK1 was found to exert an inhibitory effect on PC cells, and there was a significantly negative correlation between the expression levels of miR-485-3p and PAK1 (r = -0.6525, P < 0.0001) in PC tissues. Moreover, miR-485-3p could suppress PC metastasis in vivo by targeting p21-activated kinase-1.

Exosomal miR-485-3p delivered by normal pancreatic ductal epithelial cells into PC cells inhibits PC metastasis by directly targeting PAK1. The restoration of miR-485-3p by exosomes or some other vehicle might be a novel approach for PC treatment.

Chemotherapy is a common treatment for advanced hepatocellular carcinoma, but the effect is not satisfactory. The study aimed to retrospectively evaluate the effects of adding all-trans-retinoic acid (ATRA) to infusional fluorouracil, leucovorin, and oxaliplatin (FOLFOX4) for advanced hepatocellular carcinoma (HCC).

We extracted the data of patients with advanced HCC who underwent systemic chemotherapy using FOLFOX4 or ATRA plus FOLFOX4 at the Eastern Hepatobiliary Surgery Hospital, First Hospital of Jilin University, and Zhejiang Sian International Hospital and retrospectively compared for overall survival. The Cox proportional hazards model was used to calculate the hazard ratios for overall survival and disease progression after controlling for age, sex, and disease stage.

From July 2013 to July 2018, 111 patients with HCC were included in this study. The median survival duration was 14.8 months in the ATRA plus FOLFOX4 group and 8.2 months in the FOLFOX4 only group (P < 0.001). The ATRA plus FOLFOX4 group had a significantly longer median time to progression compared with the FOLFOX4 group (3.6 months vs. 1.8 months, P < 0.001). Hazard ratios for overall survival and disease progression were 0.465 (95% confidence interval: 0.298–0.726; P = 0.001) and 0.474 (0.314–0.717; P < 0.001) after adjusting for potential confounders, respectively.

ATRA plus FOLFOX4 significantly improves the overall survival and time to disease progression in patients with advanced HCC.

Recombinant human thrombopoietin (rh-TPO) and eltrombopag are two distinct TPO receptor agonists (TPO-RAs) with different mechanisms. During the pandemic, when immunosuppressive medications are controversial, switching to another TPO-RA may be worth exploring in patients who do not benefit from their first TPO-RA. We investigated the outcomes of switching from rh-TPO to eltrombopag or vice versa in immune thrombocytopenia (ITP) patients.

This prospective, open-label, observational investigation included 96 adult ITP patients who needed to switch between rh-TPO and eltrombopag between January 2020 and January 2021 at Peking University People’s Hospital in China. The study evaluated response rates and platelet counts at different time points after the switch, bleeding events, time to response, duration of response, and adverse events.

At 6 weeks after switching, response was observed in 21/49 patients (43%) who switched for inefficacy and 34/47 patients (72%) who switched for non-efficacy-related issues. In the inefficacy group, 9/27 patients (33%) responded to eltrombopag, and 12/22 patients (55%) responded to rh-TPO. In the non-efficacy-related group, 21/26 (81%) and 13/21 (62%) patients in the eltrombopag and rh-TPO groups maintained their response rates at 6 weeks after switching, respectively. Response at 6 months was achieved in 24/49 patients (49%) switching for inefficacy and 37/47 patients (79%) switching for non-efficacy issues. In the inefficacy group, 13/27 patients (48%) responded to eltrombopag, and 11/22 patients (50%) responded to rh-TPO. In the non-efficacy-related group, 22/26 patients (85%) and 15/21 patients (71%) in the eltrombopag and rh-TPO groups maintained their response rates at 6 months after switching, respectively. Both eltrombopag and rh-TPO were well tolerated.

Our study confirmed the safety and effectiveness of switching between rh-TPO and eltrombopag for ITP patients who had no response to or experienced adverse events with their first TPO-RA. When the switch was motivated by other reasons, including patient preference and platelet count fluctuations, the probability of response was high.

ClinicalTrials.gov, NCT04214951.

According to current guidelines, patients with chronic hepatitis B virus (HBV) infection whose HBV DNA is positive but whose alanine aminotransferase (ALT) levels are normal do not currently need antiviral treatment.^[1]However, studies have found that even chronic HBV infection patients with normal ALT may progress to cirrhosis or hepatocellular carcinoma (HCC). Furthermore, almost half of patients with normal ALT levels were found to have moderate to severe inflammation and/or significant fibrosis.^[2]Currently there were only a few studies on the treatment of chronic HBV patients with normal ALT levels, and the factors that affect their virological response (VR) are still unclear. An increasing number of studies have proven that serum HBV RNA can be used as a non-invasive indicator to predict a VR.^[3]In this study, we explored the predictive value of HBV RNA in anticipating a VR in normal ALT chronic HBV patients.

To the Editor:Tranexamic acid (TXA) has recently become popular for use in orthopedic surgeries owing to its efficacy in reducing blood loss, transfusion rates, and mortality without increasing the risk of deep venous thrombosis.^[1]Although the ideal dosage and route for TXA administration remain unclear, it has become one of the most important parts of the perioperative blood conservation strategy. However, it remains controversial to prescribe TXA to patients with cardiovascular diseases, because of prothrombotic and proconvulsant effects, which potentially increases cardiovascular risk. Atrial fibrillation (AF), being the most common sustained cardiac arrhythmia, affects over 33 million individuals worldwide and is associated with a fivefold increase in the risk of stroke.^[2]Oral anticoagulants are administered to these patients toward preventing stroke and systemic embolism, and anticoagulant therapy would increase the perioperative blood loss during total joint arthroplasty. Although a previous study demonstrated no detrimental effect of TXA on the risk of cardiovascular events and death following total hip arthroplasty, the population investigated in that study included patients without cardiovascular diseases, which might cover up the real incidence of postoperative cardiovascular complication in these patients and thereby lead to statistical bias.^[1]Therefore, the retrospective cohort study aimed to assess the effects of perioperative TXA administration on cardiovascular occlusive events, perioperative resuscitation in patients with AF undergoing total joint arthroplasty.

To the Editor:Increasing attention is being paid to preventing ulcerative colitis (UC)-associated carcinogenesis. The intestinal microbiota plays an important role in maintaining the intestinal barrier and immune function. Probiotic mixture VSL#3, that was bought from Sigma-Tau pharmaceuticals (De Simone Formulation) in May 2015, is a mixture ofLactobacillus casei, L. plantarum, L. acidophilus, L. delbrueckii subsp. bulgaricus, Bifidobacterium longum, B. breve, B. infantis and Streptococcus salivariusand contains 4.5 billion live bacterial colonies.^[1]Previous studies have shown that VSL#3 can help induce and maintain UC remission. The effects of probiotics on UC-associated carcinogenesis are difficult to observe clinically; therefore, mouse models are often used to study this disease. Previous studies have shown that azoxymethane (AOM) combined with dextran sulfate sodium (DSS) can quickly induce a UC-associated carcinogenesis model. Studies using mouse models have demonstrated that VSL#3 inhibits UC-associated carcinogenesis, but the conclusions remain controversial. The exact mechanism by which VSL#3 prevents UC-associated carcinogenesis remains unclear. Therefore, we used a mouse model of AOM/DSS-induced UC-associated carcinogenesis to verify the effect of VSL#3 in preventing UC-associated carcinogenesis and explored the specific mechanism of action. Considering the differences between mice and humans, we further explored how probiotics influence the Wnt/β-catenin pathway at the human cellular level. Since cultivating multiple probiotics simultaneously is challenging, we usedBifidobacteriumto explore the effects and mechanisms of VSL#3 on UC-associated carcinogenesis in mice and cells.

To the Editor:Gastric cancer (GC) poses a great threat to human health worldwide. N6-methyladenosine (m6A) RNA methylation, the most abundant post-transcriptional RNA modification, plays a crucial role in RNA splicing, export, processing, translation, and decay.^[1]The tumor microenvironment (TME), an aggregation of tumor cells and surrounding tumor-related non-tumor cells, innately modulates tumor progression.^[2]However, the prognostic value of m6A regulator-related genes and their relationship with the TME have not been largely explored in GC. The aim of our study was to screen prognostic genes related to m6A modification in GC patients in The Cancer Genome Atlas (TCGA) database, establish an m6A regulator-associated signature for predicting clinical outcome, and validate the performance in TCGA and Gene Expression Omnibus (GEO) cohorts. The relationship between m6A and immune infiltration was also assessed in GC. With the underlying mechanism uncovered, m6A-related genes could become predictive biomarkers for GC and provide deeper insights into the TME and immunotherapy.

To the Editor:Hypothermia is described as a state in which the core temperature of a patient is decreased to equal to or <36°, which is a common and severe complication among patients undergoing elective surgery.^[1]Studies reported that hypothermia is associated with an increased risk of several adverse events including postoperative shivering, surgical site infection, increased blood loss, and a longer length of hospitalization.^[2]Active warming for >30 min during the surgical procedure has been found to reduce the risk of perioperative hypothermia. Thus, more and more attention has been paid to how effectively prevent perioperative hypothermia, and many intraoperative active warming strategies have therefore been applied in clinical practice, such as forced-air warming technology, prewarming technology before anesthesia, resistive-polymer system, circulating water mattresses, and self-warming blanket.

To the Editor:Coronary computed tomography angiography (CCTA) has been increasingly widely performed for diagnosing coronary artery disease.^[1]Anatomical diagnosis, that is, stenosis grading, is still the main diagnostic index provided by most CCTA tests. Post-processing and interpretation of stenosis are 2 essential steps that need to be performed by cardiovascular imaging professionals from scan completion to diagnosis conclusion, which is repetitive and time-consuming, taking an average of 30 minutes each case in China and becoming the bottleneck and gradually creating an imbalance between supply and demand. In line with the rapid development of artificial intelligence (AI) technology in recent years, it has been expected to solve these specific problems. We developed an AI system for automating post-processing and diagnostic reporting of CCTA data using deep learning algorithms to establish a new 1-click workflow for everyday use, namely, CCTA-AI (Figure 1). To further assess its capabilities, this study intends to answer 2 following questions: To what extent can it improve the efficiency of post-processing? To what extent can CCTA-AI detect and calculate coronary artery stenosis due to each atherosclerotic plaque?

To the Editor:Permanent vascular access is a life-sustaining measure for hemodialysis-dependent patients. Generally, tunneled cuffed catheters (TCCs) are regarded as a bridge access to arteriovenous fistula (AVF) or arteriovenous graft (AVG), and the guidelines discourage TCCs from being the first choice of permanent vascular access because of the higher risk of complications and shorter expected service life.^[1]However, notably, a subset (<10%) of hemodialysis patients require permanent access through a TCC because they have exhausted other arteriovenous access options.^[2]

To the Editor:Non-alcoholic fatty liver disease (NAFLD) comes to prevail in Asia and the prevalence in China is reported to be 24% to 36%.^[1]The prevalence of NAFLD and its associated medical burden might be underestimated. The diagnosis of NAFLD led to the exclusion of other chronic liver diseases including "excess" alcohols, thus the population with alcoholic consumptions or other liver diseases might be neglected. In March 2020, the international expert consensus proposed a new concept, "metabolic associated fatty liver disease (MAFLD)," and replaced the earlier term of "NAFLD."^[2]As the most prevalent female malignancy, breast cancer (BC) shares similar risk factors to MAFLD. Higher levels of obesity and physical inactivity are closely correlated to BC and are significant drive for the increasing trends in the prevalence of BC. Some BC survivors may receive chemotherapy and endocrine therapy, both of which are reported to increase the risk of hepatic steatosis (HS), which is the fundamental criteria of the diagnosis of MAFLD.^[2]The prevalence of HS among breast cancer survivors (BCS) is routinely ignored by oncologists and HS is usually diagnosed by conventional liver ultrasonography (US), while liver ultrasound elastography (USE) is increasingly used due to its higher sensitivity and specificity compared to US.^[3]Therefore, USE was used in our study to investigate the accurate prevalence of HS and MAFLD among BCS.

To the Editor:Cerebellar–facial–dental syndrome (CFDS) is a rare and autosomal recessive (AR) neurodevelopmental disease, characterized by cerebellar hypoplasia and intellectual disability, facial dysmorphisms, short stature, microcephaly, and dental anomalies.^[1]In 2015, Borck et observed three pairs of siblings with a previously undescribed pattern of abnormalities and established CFDS as a clinical entity. To date, a total of six CFDS families have been reported.^[1,2,3,4]The age of the reported patients ranges from infancy to early adulthood. Since the rarity of CFDS, more study is required for evaluating its natural history and clinical characteristics. This paper would like to report a novel homozygousBRF1gene mutation in two middleaged CFDS patients from Chinese, and to summarize its clinical and genetic characteristics, reinforcing the pathogenicity ofBRF1gene mutations and expanding the manifestation spectrum of CFDS.

To the Editor:Peripheral nerve injury (PNI) refers to the injury of the peripheral nerve plexus, nerve trunk, or its branches under the action of external forces. Skeletal muscle-derived cells serve a strong secretory function while they can differentiate into Schwann cell-like cells or other cell types, so that it can effectively promote regeneration of peripheral nerves.^[1]Using some specific acupuncture points with mild mechanical stimulation on the surface can have a positive effect on nerve repair.^[2]Tuina helps relieve symptoms such as muscle spasms and pain caused by nerve damage. There are three points belonging to the Bladder meridian of foot Taiyang (BL) and the Gallbladder meridian of foot Shaoyang (GB), which usually are selected to carry out Tuina. According to the anatomical nerve position, Yinmen (BL37) is on the sciatic nerve trunk, Chengshan (BL57) is on the tibial nerve, and Yanglingquan (GB34) is on the common peroneal nerve; meanwhile, the three points are on the sciatic nerve or its branches. The three points are on the biceps femoris, gastrocnemius, and tibial anterior muscles. Tuina can promote recovery of pain perception and fine movement of hind limbs in sciatic nerve injury (SNI) rats, and it is related to genetic changes of dorsal root ganglion and nerve injury points; meanwhile, the differentially expressed genes (DEGs) were enriched in the biological processes related to the regulation of myocytes.^[3]This study explored the effects of Tuina on the recovery of SNI rats’ changes of hind limb muscle strength and the genetic changes of gastrocnemius muscle.

To the Editor:Vascular dementia (VD) is a clinical disease characterized by cognitive dysfunction and intellectual decline caused by various cerebrovascular factors. The high incidence of VD in middle-aged and elderly people has become a major medical and social problem worldwide.^[1]Since its specific pathogenesis has not been fully elucidated, clinical practice is still focused on improving cognition and symptomatic treatment, such as piracetam and donepezil.^[2]Alternatively, with high effectiveness and few side effects, traditional Chinese medicine has drawn medical attention and become a hotspot in the medical research field.