Volume 135 · Issue 06 · 2022

上腹部磁共振（MR）成像适用于身体成分分析。^[1]特别是对于肥胖个体，在临床评估过程中量化肝脏质子密度脂肪分数（PDFF）和腹部脂肪组织的数量以及对肥胖相关风险的研究具有重要价值。分析结果可用于确定外科手术的最佳选择和评估治疗结果。已经开发了多种人工智能(AI)算法和系统用于身体成分的自动测量。AI发展和应用的基础是要有统一的临床数据采集和管理标准。MR图像质量参差不齐是人工智能系统开发和分析结果的主要障碍之一。迫切需要MR扫描和临床数据管理的标准化流程。

Since the diagnostic value of aldosterone to renin ratio (ARR) calculated by plasma renin concentration (PRC) or plasma renin activity (PRA) is still inconclusive, we conducted a meta-analysis by systematically reviewing relevant literature to explore the difference in the diagnostic efficacy of ARR calculated by PRC or PRA, so as to provide guidance for clinical diagnosis.

We searched PubMed, Embase, and Cochrane Library from the establishment of the database to March 2021. We included studies that report the true positive, false positive, true negative, and false negative values for the diagnosis of primary aldosteronism, and we excluded duplicate publications, research without full text, incomplete information, or inability to conduct data extraction, animal experiments, reviews, and systematic reviews. STATA 15.1 was used to analyze the data.

The pooled results showed that ARR (plasma aldosterone concentration [PAC]/PRC) had a sensitivity of 0.82 (95% confidence interval [CI]: 0.78-0.86), a specificity of 0.94 (95% CI: 0.92-0.95), a positive-likelihood ratio (LR) of 12.77 (95% CI: 7.04-23.73), a negative LR of 0.11 (95% CI: 0.07-0.17), and symmetric area under the curve (SAUC) of 0.982, respectively. Furthermore, the diagnostic odds ratio (DOR) of ARR (PAC/PRC) was 180.21. Additionally, the pooled results showed that ARR (PAC/PRA) had a sensitivity of 0.91 (95% CI: 0.86-0.95), a specificity of 0.91 (95% CI: 0.90-0.93), a positive LR of 7.30 (95% CI: 2.99-17.99), a negative LR of 0.10 (95% CI: 0.04-0.26), and SAUC of 0.976, respectively. The DOR of ARR (PAC/PRA) was 155.52. Additionally, we conducted a subgroup analysis for the different thresholds (<35 or ≥35) of PAC/PRC. The results showed that the DOR of the cut-off ≥35 groups was higher than the cut-off <35 groups (DOR = 340.15, 95% CI: 38.32-3019.66; DOR= 116.40, 95% CI = 23.28-581.92).

The research results suggest that the determination of ARR (PAC/PRC) and ARR (PAC/PRA) was all effective screening tools for PA. The diagnostic accuracy and diagnostic value of ARR (PAC/PRC) are higher than ARR (PAC/PRA). In addition, within a certain range, the higher the threshold, the better the diagnostic value.

Few studies have assessed the relationship between multimorbidity patterns and mortality risk in the Chinese population. We aimed to identify multimorbidity patterns and examined the associations of multimorbidity patterns and the number of chronic diseases with the risk of mortality among Chinese middle-aged and older adults.

We used data from the China Kadoorie Biobank and included 512,723 participants aged 30 to 79 years. Multimorbidity was defined as the presence of two or more of the 15 chronic diseases collected by self-report or physical examination at baseline. Multimorbidity patterns were identified using hierarchical cluster analysis. Cox regression was used to estimate the associations of multimorbidity patterns and the number of chronic diseases with all-cause and cause-specific mortality.

Overall, 15.8% of participants had multimorbidity. The prevalence of multimorbidity increased with age and was higher in urban than rural participants. Four multimorbidity patterns were identified, including cardiometabolic multimorbidity (diabetes, coronary heart disease, stroke, and hypertension), respiratory multimorbidity (tuberculosis, asthma, and chronic obstructive pulmonary disease), gastrointestinal and hepatorenal multimorbidity (gallstone disease, chronic kidney disease, cirrhosis, peptic ulcer, and cancer), and mental and arthritis multimorbidity (neurasthenia, psychiatric disorder, and rheumatoid arthritis). During a median of 10.8 years of follow-up, 49,371 deaths occurred. Compared with participants without multimorbidity, cardiometabolic multimorbidity (hazard ratios [HR] = 2.20, 95% confidence intervals [CI]: 2.14-2.26) and respiratory multimorbidity (HR= 2.13, 95% CI:1.97-2.31) demonstrated relatively higher risks of mortality, followed by gastrointestinal and hepatorenal multimorbidity (HR= 1.33, 95% CI:1.22-1.46). The mortality risk increased by 36% (HR= 1.36, 95% CI: 1.35-1.37) with every additional disease.

Cardiometabolic multimorbidity and respiratory multimorbidity posed the highest threat on mortality risk and deserved particular attention in Chinese adults.

Antiphospholipid syndrome (APS) is an autoimmune prothrombotic condition with significant morbidity. The objective of this study was to identify additional clinical and epidemiological risks of arterial thrombosis, venous thrombosis, and pregnancy morbidities in a large cohort of persistent antiphospholipid antibodies (aPLs)-positive carriers.

This was a cross-sectional cohort study of 453 consecutive patients with a documented positive aPL who attended Peking University People's Hospital. Among 453 patients screened, 297 patients had persistent positive aPL. We compared asymptomatic aPL carriers with thrombotic and obstetric APS patients. And the univariate analysis and multivariable logistic regression were used to evaluate the association between different risk factors and APS clinical manifestations. The levels of circulating markers of neutrophil extracellular traps (NETs) (cell-free DNA and citrullinated histone H3 [Cit-H3]) were assessed and compared among aPL-positive carriers with or without autoimmune disease and APS patients.

Additional risk factors associated with arterial thrombosis among aPL-positive carriers included: smoking (odds ratio [OR] = 6.137, 95% confidence interval [CI] = 2.408-15.637, P = 0.0001), hypertension (OR = 2.368, 95% CI = 1.249-4.491, P = 0.008), and the presence of underlying autoimmune disease (OR = 4.401, 95% CI = 2.387-8.113, P < 0.001). Additional risks associated with venous thrombosis among aPL carriers included: smoking (OR = 4.594, 95% CI = 1.681-12.553, P = 0.029) and the presence of underlying autoimmune disease (OR = 6.330, 95% CI = 3.355-11.940, P < 0.001). The presence of underlying autoimmune disease (OR = 3.301, 95% CI= 1.407-7.744, P = 0.006) is the additional risk, which demonstrated a significant association with APS pregnancy morbidity. Higher circulating levels of cell-free DNA and Cit-H3 were observed among APS patients and aPL patients with autoimmune diseases compared with those aPL carriers without underlying autoimmune diseases. Furthermore, control neutrophils that are conditioned with APS patients' sera have more pronounced NET release compared with those treated with aPL carriers' sera without underlying autoimmune diseases.

We identified several potential additional risk factors for APS clinical manifestations among a large cohort of Chinese aPL carriers. Our data may help physicians to risk stratify aPL-positive Asian patients.

Gestational diabetes mellitus (GDM) brings health issues for both mothers and offspring, and GDM prevention is as important as GDM management. It was shown that a history of GDM was significantly associated with a higher maternal risk for GDM recurrence. The incidence of GDM recurrence was unclear because of the incidence of second-child was low before 2016 in China. We aim to investigate the prevalence of GDM recurrence and its associated high-risk factors which may be useful for the prediction of GDM recurrence in China.

A retrospective study was conducted which enrolled participants who underwent regular prenatal examination and delivered twice in the same hospital of 18 research centers. All participants were enrolled from January 2018 to October 2018, where they delivered the second baby during this period. A total of 6204 women were enrolled in this study, and 1002 women with a history of GDM were analyzed further. All participants enrolled in the study had an oral glucose tolerance test (OGTT) result at 24 to 28 weeks and were diagnosed as GDM in the first pregnancy according to the OGTT value (when any one of the following values is met or exceeded to the 75-g OGTT: 0 h [fasting], ≥5.10 mmol/L; 1 h, ≥10.00 mmol/L; and 2 h, ≥8.50 mmol/L). The prevalence of GDM recurrence and development of type 2 diabetes mellitus were calculated, and its related risk factors were analyzed.

In 6204 participants, there are 1002 women (1002/6204, 16.15%) with a history of GDM and 5202 women (5202/6204, 83.85%) without a history of GDM. There are significant differences in age (32.43 ± 4.03 years vs. 33.00 ± 3.34 years vs. 32.19 ± 3.37 years, P < 0.001), pregnancy interval (4.06 ± 1.44 years vs. 3.52 ± 1.43 years vs. 3.38 ± 1.35 years, P = 0.004), prepregnancy body mass index (BMI) (27.40 ± 4.62 kg/m²vs. 23.50 ± 3.52 kg/m²vs. 22.55 ± 3.47 kg/m², P < 0.001), history of delivered macrosomia (22.7% vs. 11.0% vs. 6.2%, P < 0.001) among the development of diabetes mellitus (DM), recurrence of GDM, and normal women. Moreover, it seems so important in the degree of abnormal glucose metabolism in the first pregnancy to the recurrence of GDM and the development of DM. There are significant differences in OGTT levels of the first pregnancy such as area under the curve of OGTT value (18.31 ± 1.90 mmol/L vs. 16.27 ± 1.93 mmol/L vs. 15.55 ± 1.92 mmol/L, P < 0.001), OGTT fasting value (5.43 ± 0.48 mmol/L vs. 5.16 ± 0.49 mmol/L vs. 5.02 ± 0.47 mmol/L, P < 0.001), OGTT 1-hour value (10.93 ± 1.34 mmol/L vs. 9.69 ± 1.53 mmol/L vs. 9.15 ± 1.58 mmol/L, P < 0.001), OGTT 2-hour value (9.30 ± 1.66 mmol/L vs. 8.01 ± 1.32 mmol/L vs. 7.79 ± 1.38 mmol/L, P < 0.001), incidence of impaired fasting glucose (IFG) (fasting plasma glucose ≥5.6 mmol/L) (31.3% vs. 14.6% vs. 8.8%, P < 0.001), and incidence of two or more abnormal OGTT values (68.8% vs. 39.7% vs. 23.9%, P < 0.001) among the three groups. Using multivariate analysis, the factors, such as age (1.07 [1.02-1.12], P = 0.006), prepregnancy BMI (1.07 [1.02, 1.12], P = 0.003), and area under the curve of OGTT in the first pregnancy (1.14 [1.02, 1.26], P = 0.02), have an effect on maternal GDM recurrence; the factors, such as age (1.28 [1.01-1.61], P = 0.04), pre-pregnancy BMI (1.26 [1.04, 1.53], P = 0.02), and area under the curve of OGTT in the first pregnancy (1.65 [1.04, 2.62], P = 0.03), have an effect on maternal DM developed further.

The history of GDM was significantly associated with a higher maternal risk for GDM recurrence during follow-up after the first pregnancy. The associated risk factors for GDM recurrence or development of DM include age, high pre-pregnancy BMI, history of delivered macrosomia, the OGTT level in the first pregnancy, such as the high area under the curve of OGTT, IFG, and two or more abnormal OGTT values. To prevent GDM recurrence, women with a history of GDM should do the preconception counseling before preparing next pregnancy.

It is still unclear what the minimal infusion volume is to effectively predict fluid responsiveness. This study was designed to explore the minimal infusion volume to effectively predict fluid responsiveness in septic shock patients. Hemodynamic effects of fluid administration on arterial load were observed and added values of effective arterial elastance (Ea) in fluid resuscitation were assessed.

Intensive care unit septic shock patients with indwelling pulmonary artery catheter (PAC) received five sequential intravenous boluses of 100 mL 4% gelatin. Cardiac output (CO) was measured with PAC before and after each bolus. Fluid responsiveness was defined as an increase in CO >10% after 500 mL fluid infusion.

Forty-seven patients were included and 35 (74.5%) patients were fluid responders. CO increasing >5.2% after a 200 mL fluid challenge (FC) provided an improved detection of fluid responsiveness, with a specificity of 80.0% and a sensitivity of 91.7%. The area under the ROC curve (AUC) was 0.93 (95% CI: 0.84-1.00, P < 0.001). Fluid administration induced a decrease in Ea from 2.23 (1.46-2.78) mmHg/mL to 1.83 (1.34-2.44) mmHg/mL (P = 0.002), especially for fluid responders in whom arterial pressure did not increase. Notably, the baseline Ea was able to detect the fluid responsiveness with an AUC of 0.74 (95% CI: 0.59-0.86, P < 0.001), whereas Ea failed to predict the pressure response to FC with an AUC of 0.50 (95% CI: 0.33-0.67, P = 0.086).

In septic shock patients, a minimal volume of 200 mL 4% gelatin could reliably detect fluid responders. Fluid administration reduced Ea even when CO increased. The loss of arterial load might be the reason for patients who increased their CO without pressure responsiveness. Moreover, a high level of Ea before FC was able to predict fluid responsiveness rather than to detect the pressure responsiveness.

ClinicalTrials.gov, NCT04515511

At present, there is no consensus on the induction methods in term pregnancy with borderline oligohydramnios. This study aimed to compare the effectiveness and pregnancy outcomes of labor induction with dinoprostone or single-balloon catheter (SBC) in term nulliparous women with borderline oligohydramnios.

We conducted a retrospective cohort study from January 2016 to November 2018. During the study period, a total of 244 cases were enrolled. Of these, 103 cases were selected for induction using dinoprostone and 141 cases were selected for induction with SBC. The pregnancy outcomes between the two groups were compared. Primary outcomes were successful vaginal delivery rates. Secondary outcomes were maternal and neonatal adverse events. Multivariate logistic regression was used to assess the risk factors for vaginal delivery failure in the two groups.

The successful vaginal delivery rates were similar between the dinoprostone group and the SBC group (64.1% [66/103] vs. 59.6%, [84/141] P = 0.475), even after adjustment for potential confounding factors (adjusted odds ratio [aOR]: 1.07, 95% confidence interval [CI]: 0.57-2.00, P = 0.835). The incidence of intra-amniotic infection was lower in the dinoprostone group than in the SBC group (1.9% [2/103] vs. 7.8% [11/141], P < 0.001), but the presence of non-reassuring fetal heart rate was higher in the dinoprostone group than in the SBC group (12.6% [13/103] vs. 0.7%, [1/141] P < 0.001). Multivariate logistic regression showed that nuchal cord was a risk factor for vaginal delivery failure after induction with dinoprostone (aOR: 6.71, 95% CI: 1.96-22.95). There were three factors related to vaginal delivery failure after induction with SBC, namely gestational age (aOR: 1.51, 95% CI: 1.07-2.14), body mass index (BMI) >30 kg/m² (aOR: 2.98, 95% CI: 1.10-8.02), and fetal weight >3500 g (aOR: 2.49, 95% CI: 1.12-5.50).

Term nulliparous women with borderline oligohydramnios have similar successful vaginal delivery rates after induction with dinoprostone or SBC, with their advantages and disadvantages. In women with nuchal cord, the risk of vaginal delivery failure is increased if dinoprostone is used in the induction of labor. BMI >30 kg/m², large gestational age, and estimated fetal weight >3500 g are risk factors for vaginal delivery failure after induction with SBC.

Coronavirus disease 2019 (Covid-19) remains a serious health threat worldwide. We aimed to investigate whether low molecular weight heparin (LMWH) can promote organ function recovery in moderate Covid-19 pneumonia patients.

We initiated an LMWH protocol in Covid-19 patients with increased D-dimer, body mass index >30 kg/m² or a history of diabetes from January 18, 2020 at Shanghai Public Health Clinical Center. In this retrospective study, we assigned moderate Covid-19 pneumonia patients admitted between January 18th and April 18, 2020 receiving the LMWH protocol to the LMWH group. Moderate patients who met the inclusion criteria but did not receive LMWH protocol were included in the control group by 1:2 propensity score matching. General clinical information, indicators for renal function, arterial blood gas analyses, arterial blood lactic acid content (mmol/L), and coagulation indexes at 0 day, 3 days, 7 days, and 11 days after admission were recorded and compared between the two groups.

There were 41 patients in the LMWH group and 82 patients in the control group. General information in both groups were similar. Compared to the control group, the arterial blood lactic acid content (mmol/L) at day 11 (1.3 [1.1, 1.7] vs. 1.2 [0.9, 1.3], P = 0.016) was reduced in the LMWH group. The estimated glomerular filtration rate (eGFR) in the LMWH group was higher than that in the control group at day 7 (108.54 [89.11, 128.17] vs. 116.85 [103.39, 133.47], P= 0.039) and day 11 (113.74 [94.49, 126.34] vs. 128.31 [112.75, 144.12], P = 0.003). The serum creatinine levels (Scr) in the LMWH group were lower than that in the control group at day 7 (62.13 [51.47, 77.64] vs. 55.49 [49.50, 65.75], P= 0.038) and day 11 (63.35 [50.17, 75.73] vs. 51.62 [44.62, 61.24], P = 0.005).

LMWH treatment can reduce arterial blood lactic acid levels and improve eGFR in moderate Covid-19 pneumonia patients. Randomized controlled trials are warranted to further investigate this issue.

ChiCTR.org.cn, ChiCTR2000034796.

Breast cancer with low-positive human epidermal growth factor receptor 2 (HER2) expression has triggered further refinement of evaluation criteria for HER2 expression. We studied the clinicopathological features of early-stage breast cancer with low-positive HER2 expression in China and analyzed prognostic factors.

Clinical and pathological data and prognostic information of patients with early-stage breast cancer with low-positive HER2 expression treated by the member units of the Chinese Society of Breast Surgery and Chinese Society of Surgery of Chinese Medical Association, from January 2015 to December 2016 were collected. The prognostic factors of these patients were analyzed.

Twenty-nine hospitals provided valid cases. From 2015 to 2016, a total of 25,096 cases of early-stage breast cancer were treated, 7642 (30.5%) of which had low-positive HER2 expression and were included in the study. After ineligible cases were excluded, 6486 patients were included in the study. The median follow-up time was 57 months (4-76 months). The disease-free survival rate was 92.1% at 5 years, and the overall survival rate was 97.4% at 5 years. At the follow-up, 506 (7.8%) cases of metastasis and 167 (2.6%) deaths were noted. Multivariate Cox regression analysis showed that tumor stage, lymphvascular invasion, and the Ki67 index were related to recurrence and metastasis (P < 0.05). The recurrence risk prediction model was established using a machine learning model and showed that the area under the receiving operator characteristic curve was 0.815 (95% confidence interval: 0.750-0.880).

Early-stage breast cancer patients with low-positive HER2 expression account for 30.5% of all patients. Tumor stage, lymphvascular invasion, and the Ki67 index are factors affecting prognosis. The recurrence prediction model for breast cancer with low-positive HER2 expression based on a machine learning model had a good clinical reference value for predicting the recurrence risk at 5 years.

ChiCTR.org.cn, ChiCTR2100046766.

Tourette syndrome (TS) is a neuropsychiatric disorder with onset in childhood that warrants effective therapies. Gut microbiota can affect central physiology and function via the microbiota-gut-brain axis. Therefore, the gut microbiota plays an important role in some mental illnesses. A small clinical trial showed that fecal microbiota transplantation (FMT) may alleviate TS symptoms in children. Herein, FMT effects and mechanisms were explored in a TS mouse model.

TS mice model (TSMO) (n = 80) were established with 3,3^＇-iminodipropionitrile, and 80 mice were used as controls. Mice were grouped into eight groups and were subjected to FMT with feces from children or mice with or without TS, or were given probiotics. Fecal specimens were collected 3 weeks after FMT. 16S rRNA sequencing, behavioral observation, and serum serotonin (5-HT) assay were performed. Differences between groups were analyzed using Mann-Whitney U test and Kolmogorov-Smirnov (KS) tests.

A total of 18 discriminative microbial signatures (linear discriminant analysis score > 3) that varied significantly between TS and healthy mice (CONH) were identified. A significant increase in Turicibacteraceae and Ruminococcaceae in TSMO after FMT was observed (P < 0.05). Compared with non-transplanted TSMO, the symptoms of those transplanted with feces from CONH were alleviated (W = 336, P = 0.046). In the probiotic and FMT experiments, the serum 5-HT levels significantly increased in TSMO that received probiotics (KS = 1.423, P = 0.035) and in those transplanted with feces from CONH (W= 336.5, P = 0.046) compared with TSMO without transplantation.

This study suggests that FMT may ameliorate TS by promoting 5-HT secretion, and it provides new insights into the underlying mechanisms of FMT as a treatment for TS.

Circular RNAs (circRNAs) are considered to be important regulators in cancer biology. In this study, we focused on the effect of circRNA baculoviral inhibitor of apoptosis protein (IAP) repeat containing 6 (circBIRC6) on non-small cell lung cancer (NSCLC) progression.

The NSCLC and adjacent non-tumor tissues were collected at Shanghai Ninth People's Hospital. Quantitative real-time polymerase chain reaction was conducted for assessing the levels of circBIRC6, amyloid beta precursor protein binding protein 2 (APPBP2) messenger RNA (mRNA), baculoviral IAP repeat containing 6 mRNA (BIRC6), and microRNA-217 (miR-217). Western blot assay was adopted for measuring the protein levels of APPBP2, E-cadherin, N-cadherin, and vimentin. Colony formation assay, transwell assay, and flow cytometry analysis were utilized for evaluating cell colony formation, metastasis, and apoptosis. Dualluciferase reporter assay and RNA immunoprecipitation assay were carried out to determine the interaction between miR-217 and circBIRC6 and APPBP2 in NSCLC tissues. The murine xenograft model assay was used to investigate the function of circBIRC6 in tumor formation in vivo. Differences were analyzed via Student's t test or one-way analysis of variance. Pearson's correlation coefficient analysis was used to analyze linear correlation.

CircBIRC6 was overexpressed in NSCLC tissues and cells. Knockdown of circBIRC6 repressed the colony formation and metastasis and facilitated apoptosis of NSCLC cells in vitro and restrained tumorigenesis in vivo. Mechanically, circBIRC6 functioned as miR-217 sponge to promote APPBP2 expression in NSCLC cells. MiR-217 inhibition rescued circBIRC6 knockdown-mediated effects on NSCLC cell colony formation, metastasis, and apoptosis. Overexpression of miR-217 inhibited the malignant phenotypes of NSCLC cells, while the effects were abrogated by elevating APPBP2.

CircBIRC6 aggravated NSCLC cell progression by elevating APPBP2 via sponging miR-217, which might provide a fresh perspective on NSCLC therapy.

既往多项研究证实了经口内镜肌切开术（POEM）治疗贲门失弛缓症的有效性和安全性。然而，严重的层间粘连排除了粘膜下隧道的建立，然后导致POEM程序流产。为了应对这一挑战，我们在2014年推出了同时粘膜下和肌肉解剖的POEM（POEM-SSMD）。^[1]短期随访期间，患者症状明显改善。因此，对于食管夹层粘连患者，POEM的相对适应症可能会延长。然而，迄今为止，只有少数使用该技术且随访时间较短的病例报告已发表。因此，本研究旨在进一步报告POEM-SSMD治疗相对较大人群中伴有严重层间粘连的贲门失弛缓症的长期结果。

致编辑：Lisfranc损伤的机制很复杂，可能导致中足复合体不同模式的骨折或脱位。外展力损伤是一种特殊的损伤模式，可引起Lisfranc关节外侧柱，尤其是长方体的骨折或（和）脱位。^[1,2,3]然而，前外侧跟骨不太常见受累。由于跟骨立方体（CC）关节小平面的碎片太不明显，在X线平片上无法显示，并且外科医生总是更关注Lisfranc关节，所以跟骨前外侧压缩性骨折甚至Chopart关节损伤经常被忽视，这可能导致手术治疗延迟、慢性足部畸形和功能残疾。

致编辑：前蛋白转化酶枯草杆菌蛋白酶/kexin 9型（PCSK9）抑制剂evolocumab可与血浆中的PCSK9结合，减少PCSK9-低密度脂蛋白（LDL）受体复合物的降解，从而降低LDL水平。^[1]在临床实践中，PCSK9抑制剂可显著降低低密度脂蛋白胆固醇（LDL-c），降低甘油三酯（TG）约8%~17%。^[2]我们使用PCSK9抑制剂降低了3例严重高甘油三酯血症（HTG）患者的血脂，并进行了全外显子组测序（WES）来详细分析可能导致高脂血症的基因。我们已获得患者的同意书。我们发现，无论是否存在HTG突变，PCSK9抑制剂都能显著降低血脂水平。这些结果为使用PCSK9抑制剂治疗重度HTG患者提供了新的证据。

致编辑：不孕症是现代社会的公共卫生问题。少弱精子症（OA）是男性不育的主要原因之一，影响着全球约5%的育龄夫妇。OA的病因和发病机制仍然知之甚少。OA的特征包括总数减少（<33 × 10⁶每次射精或<12 × 10⁶/mL）或精子浓度，以及低或无精子活力（<32%).^[1]传统中医（TCM）通过使用来自天然来源的药物治疗男性不育有着悠久的历史，例如草药或动物组织来源的材料。龟甲胶（TSG）是一种经典中药，主要用作多种健康状况的药物或补充剂，以补充“气”，在中医理论中，气被认为是人体的能量来源。线粒体是细胞的“发电站”，对细胞信号传导至关重要，其作用类似于中医中的“气”。精子的中间部分充满了线粒体；因此，线粒体功能障碍可能在精子活力不足和男性不育中起重要的致病作用。^[2]线粒体不仅为精子提供成功受精所需的能量，而且通过线粒体通透性转换孔(mPTP)调节通透性与精子的活力密切相关，^[3]一种位于线粒体内膜的跨膜蛋白。正常情况下，它保持关闭，但mPTP的开放允许大分子通过线粒体膜。mPTP的功能障碍导致细胞凋亡，并且在OA的情况下，它导致精子数量和流动性降低。^[3]在目前的研究中，我们旨在评估TSG对精子发生和生殖激素的治疗作用，并研究TSG对线粒体功能的潜在保护作用。

致编辑：自身免疫性肝炎（AIH）是一类由肝细胞自身免疫反应介导的肝实质炎症。AIH以前被认为是一种慢性肝病，但最近的观察者证实AIH患者可以急性发作甚至肝功能衰竭（AIH-LF）。^[1]AIH-LF的发病率也有所增加。一旦发生LF，90天内的死亡率可达40%以上。^[2]因此，LF的发生对AIH的预后有重大影响。尽管AIH-LF发病率低，死亡率高，但部分病例仍可通过治疗治愈。可能影响AIH-LF患者预后的临床特征尚不清楚。为阐明影响AIH-LF预后的因素，我们比较了两组预后不同的AIH-LF患者的临床特点。

致编辑：原发性阴道癌是一种罕见的恶性疾病，仅占女性生殖器恶性肿瘤的约1%至2%。阴道腺病定义为阴道壁内存在化生宫颈或子宫内膜上皮，并且与阴道癌的高风险相关。在产前暴露于己烯雌酚（DES）的妇女中，高达90%的人可能出现阴道腺病，这些通常与阴道透明细胞腺癌有关。^[1]DES是一种口服活性非甾体雌激素。食品和药物管理局于1943年开始临床试验，并得出结论，DES给药有利于预防早产和流产。^[2]除原发性阴道透明细胞癌（PVCCC）外，子宫内暴露于DES也可导致T形子宫异常。^[3]在中国人群中，PVCCC是一种不常见的恶性肿瘤，目前尚无PVCCC与DES暴露关系的报道。^[4]鉴于PVCCC的罕见性，对相关病例进行分析具有重要意义，为今后的临床和基础研究提供一些有价值的信息。因此，本研究描述了10例PVCCC，并总结了这些患者的诊断、治疗和预后特征。

致编辑：中国是人口最多的国家，老龄化速度比世界上几乎任何其他国家都要快。根据Worldometer的数据，^[1]截至2020年，中国人口规模约为14亿，2017年60岁及以上人口比例为17.30%，预计2050年将达到35%。年龄较大往往与多病密切相关。沃德和席勒^[2]报告称，2010年，美国65岁以上的65%男性和72%女性至少患有两种慢性病。因此，患有多种慢性疾病的老年人往往在出院后再次入院，进一步导致支出增加和医疗资源的更多利用。许多研究报告了老年患者更高的阅读任务率。然而，以前的研究侧重于调查影响单一疾病阅读任务的因素，而不是调查中国老年人首次住院时的慢性合并症以及这些疾病从首次住院到阅读任务的变化。此外，大多数研究集中在白人患者身上，并且是在美国进行的。由于缺乏大规模数据，对中国患者知之甚少。确定老年人中常见的慢性共病以及这些疾病从首次住院到阅读任务的变化非常重要，因为这将有助于了解导致可避免的阅读任务的慢性疾病，并有助于制定减少阅读任务的有效干预策略。

致编辑：角膜碱烧伤（CABs）长期以来一直是临床治疗的难题。严重者出现失明；因此，研究角膜损伤的修复机制对于确定潜在的治疗靶点尤为重要。碱诱导的角膜损伤通常会引发侵袭性无菌性炎症反应，这是自身免疫反应的关键。^[1]然而，Nod样受体蛋白3（NLRP3）炎症小体在无菌性炎症中起着重要作用。^[2]在刺激下，如感染或应激，活化的NLRP3炎性小体不仅将胱天蛋白酶原-1加工成成熟的胱天蛋白酶-1，还进一步促进白细胞介素(IL)-1 β和IL-18的成熟和释放。^[3]牛磺酸（Tau）广泛分布于眼部结构中，是一种免疫调节剂。Tau可以通过抗氧化作用维持角膜上皮的稳定性，提高角膜上皮细胞的存活率。^[4]本研究的目的是研究Tau滴眼液对CAB的影响，并阐明角膜炎症反应的潜在机制。

致编辑：根据西方国家和中国的指南，低胆固醇摄入量的饮食模式已被广泛推荐以维持理想的脂质水平。鸡蛋作为优质蛋白质和膳食胆固醇的主要来源之一，一直是饮食方面的焦点。尽管随机对照试验（RCT）已经揭示了高鸡蛋摄入诱导的脂质水平增加，但由于超过7个鸡蛋/周或甚至14个鸡蛋/周的高剂量鸡蛋摄入，它们可能不足以反映习惯性鸡蛋摄入的影响。此外，RCT通常具有约3个月的较短干预期，由于人类胆固醇代谢的稳态，这可能不会观察到稳定的关联。^[1,2]到目前为止，只有三个队列评估了鸡蛋摄入量与血脂水平或血脂异常的关系，研究结果仍有争议。最近的一项队列研究报告了较高的鸡蛋摄入量（≥7vs.1个鸡蛋/周）和血脂谱。另一方面，另一个来自西班牙的队列发现，与<1个鸡蛋/周，>4个鸡蛋/周对总胆固醇（TC）和甘油三酯（TG）无显著影响，但显著降低高密度脂蛋白胆固醇（HDL-C）水平。^[4]然而，这些队列都不是来自发展中国家，适度鸡蛋摄入量和血脂水平之间的联系还没有得到很好的说明。作为发展中国家代表的中国鸡蛋消费量相对较高，或许可以更好地探索鸡蛋摄入的适宜范围。

致编辑：增强的肾清除率(ARC)是指肾脏以统计学上高于正常水平的速率增强对循环溶质(包括药物)的消除。在重症监护室（ICU）入院的第一天，ARC的发生可能预示肌酐清除率（CrCl）持续升高1天至数周。^[1]ARC对肾清除抗生素的药代动力学/药效学有显著的不良影响。治疗失败或更差的结局在ARC患者中更为常见。因此，在ARC患者中采用“一刀切”的药物给药方法是不合适的；剂量需要调整一些变量。

致编辑：目前，从病理学角度来看，用核黄素进行角膜胶原交联（CXL）是控制圆锥角膜进展的唯一新疗法。核黄素作为一种光敏剂，在紫外线照射角膜后可被激活，防止其损伤眼内组织。因此，在治疗过程中，角膜基质中核黄素的浓度必须维持在足够的水平。^[1]核黄素是一种水溶性大分子，对透过角膜上皮屏障有抵抗力。因此，常规采用去上皮滴眼液，具有不可避免的疼痛、恢复时间长、感染的潜在风险等并发症；经上皮角膜CXL正日益成为研究热点。因此，改善核黄素的经上皮渗透至关重要。虽然有离子电渗疗法的报道，但其效果略高，没有明确的机制分析。^[2,3,4]角膜上皮具有亲脂性和疏水性，亲水性药物通过细胞间途径进入角膜基质。在本研究中，比较了不同溶剂中核黄素通过离子导入进入角膜的渗透效应，并分析角膜上皮细胞层组织的变化，以检查最有利于离子导入的溶剂成分，并调查渗透效应的潜在机制。

在《中华医学杂志》第134卷第22期2700-2709页发表的《胸腺素α 1作为免疫调节疗法对非小细胞肺癌患者R0切除术后长期生存的影响：倾向评分匹配分析》一文中，^[1]中的风险比(HR)值图3A应更正为“HR（12-24个月vs小于12个月）：0.463（95%CI：0.341-0.683，P=0.0001);HR（超过24个月vs小于12个月）：0.284（95%CI：0.197-0.409，P<0.0001);HR（12-24个月vs超过24个月）：1.632（95%CI：1.056-2.522，P=0.0275)."人力资源值图3B应更正为“HR（12-24个月vs小于12个月）：0.357（95%CI：0.216-0.588，P<0.0001);HR（超过24个月vs小于12个月）：0.171（95%CI：0.107-0.272，P<0.0001);HR（12-24个月vs超过24个月）：2.090（95%CI：1.175-3.717，P=0.0121)."原来的结果和结论不受影响。图3更正如下。