Volume 131 · Issue 20 · 2018

The quick Sequential Organ Failure Assessment (qSOFA) score emerged recently. We investigated its contribution to risk stratification in acute pulmonary embolism (PE) by combining with electrocardiography (ECG).

Acute PE patients diagnosed in Beijing Chao-Yang Hospital, Capital Medical University, from 2008 to 2018 were retrospectively studied and divided into high- and low-risk groups by imaging and biomarkers. The ECG scores consisted of tachycardia, McGinn-White sign (S₁Q₃T₃), right bundle branch block, and T-wave inversion of leads V₁–V₃. A new combination of qSOFA scores and ECG scores by logistic regression for predicting high-risk stratification patients with acute PE was evaluated by a receiver operating characteristic curve.

Totally 1318 patients were enrolled, including 271 in the high-risk group and 1047 in the low-risk group. A combination predictive scoring system named qSOFA-ECG = qSOFA score + ECG score was created. The optimal cutoff value for qSOFA-ECG was 2, and the sensitivity, specificity, positive predictive value, and negative predictive value were 81.5%, 72.3%, 43.2%, and 93.8%, respectively. For predicting high-risk stratification and reperfusion therapy, the qSOFA-ECG is superior to PE Severity Index (PESI) and simplified PESI.

The qSOFA score contributes to identify acute PE patients with potentially hemodynamic decompensation that need monitoring and possible reperfusion therapy at the emergency department arrival when used in combination with ECG score.

The influence of different right ventricular lead locations on ventricular arrhythmias (VTA) in patients with a cardiac resynchronization therapy (CRT) is not clear. This study aimed to evaluate the influence on VTA in patients with a CRT when right ventricular lead was positioned at the right ventricular middle septum (RVMS) and the right ventricular apical (RVA).

A total of 352 patients implanted with a CRT-defibrillator (CRT-D) between May 2012 and July 2016 in the Department of Cardiology of Anhui Provincial Hospital were included. Two-year clinical and pacemaker follow-up data were collected to evaluate the influence of the right ventricular lead location on VTA. Patients were divided into the RVMS group (n = 155) and the RVA group (n = 197) based on the right ventricular lead position. The VTA were compared between these two groups using a Kaplan-Meier curve and Cox multivariate analysis.

When the left ventricular lead location was not considered, RVMS and RVA locations did not affect VTA. However, the subgroup analysis results showed that when the left ventricular lead was positioned at the anterolateral cardiac vein (ALCV), the RVMS group had an increased risk of ventricular arrhythmias and appropriate defibrillation (hazard ratio [HR] = 3.29, P = 0.01 and HR = 4.33, P < 0.01, respectively); when the left ventricular lead was at the posterolateral cardiac vein (PLCV), these risks in the RVMS group decreased (HR = 0.45, P = 0.02 and HR = 0.33, P < 0.01, respectively), and when the left ventricular lead was at the lateral cardiac vein, there was no difference between the two groups. In regard to inappropriate defibrillation, there was no significant difference among all these groups.

When the left ventricular lead was positioned at ALCV or PLCV, the right ventricular lead location was associated with VTA and appropriate defibrillation after CRT. Greater distances between leads not only improved cardiac function but also may reduce the risk of VTA.

The diagnosis and treatment of small hepatocellular carcinoma (HCC) play a vital role in the prognosis of patients with HCC. The purpose of our study was to evaluate angio-computed tomography (angio-CT)-guided immediate lipiodol CT (a CT scan performed immediately after transarterial chemoembolization [TACE]) in the diagnosis of potential HCCs ≤1 cm in diameter.

This study retrospectively analyzed 31 patients diagnosed with HCCs after routine imaging (contrast-enhanced CT or magnetic resonance imaging) or pathologic examinations with undefined or undetermined tumor lesions (diameter ≤1 cm) from February 2016 to September 2016. After TACE guided by digital subtraction angiography of the angio-CT system, potential HCC lesions with a diameter ≤1 cm were diagnosed by immediate lipiodol CT. The number of well-demarcated lesions was recorded to calculate the true positive rate. The correlation between the number of small HCCs detected by immediate lipiodol CT and the size of HCC lesions (diameter >1 cm) diagnosed preoperatively was analyzed 1 month after TACE. A paired t-test was used to analyze differences in liver function. Pearson analysis was used to analyze correlation. Chi-square test was used to compare the rates.

Fifty-eight lesions were detected on preoperative routine imaging examinations in 31 patients including 15 lesions with a diameter ≤1 cm. Ninety-one lesions were detected on immediate lipiodol CT, of which 48 had a diameter ≤1 cm. After 1 month, CT showed that 45 lesions had lipiodol deposition and three lesions had lipiodol clearance. Correlation analysis showed that the number of small HCCs detected by lipiodol CT was positively correlated with the size of HCC lesions diagnosed by conventional imaging examination (R² = 0.54, P < 0.05).

Immediate lipiodol CT may be a useful tool in the diagnosis of potential HCC lesions with a diameter of ≤1 cm.

Unfractionated heparin (UFH), despite its limitations, has been used as the primary anticoagulant alternative during the percutaneous coronary intervention (PCI). Some studies indicated that intravenous enoxaparin could be an effective and safe option. Our team used enoxaparin alone at one time according to the guidelines (Class IIA) and found a little catheter thrombosis during PCI. We recommend a new anticoagulation strategy using enoxaparin in combination with UFH. Enoxaparin has a more predictable anticoagulant response with no need of repeatedly monitoring anticoagulation during PCI. This retrospective study aimed to evaluate the efficacy and safety of using enoxaparin in combination with UFH in PCI patients with complex coronary artery disease.

Between January 2015 and April 2017, 600 PCI patients who received intravenous UFH at an initial dose of 3000 U plus intravenous enoxaparin at a dose of 0.75 mg/kg (observation group) and 600 PCI patients who received UFH at a dose of 100 U/kg (control group) were consecutively included in this retrospective study. The endpoints were postoperative 48-h thrombolysis in myocardial infarction (TIMI) bleeding and transfusion and 30-day and 1-year major adverse cardio-cerebrovascular events (MACCE).

Baseline clinical, angiographic, and procedural characteristics were similar between groups, except there was less stent implantation per patient in the observation group (2.13 vs. 2.25 in the control group, P = 0.002). TIMI bleeding (3.3% vs. 4.7%) showed no significant difference between the observation group and control group. During the 30-day follow-up, the rate of MACCE was 0.9% in the observation group and 1.5% in the control group. There was no significant difference in the rates of MACCE, death, myocardial infarction, target vessel revascularization, cerebrovascular event, and angina within 30 days and 1 year after PCI between groups as well as in the subgroup analysis of transfemoral approach.

UFH with sequential enoxaparin has similar anticoagulant effect and safety as UFH in PCI of complex coronary artery disease.

The excess volume of contrast media (CM) is a marker of a more severe coronary culprit lesion and longer intervention duration in patients undergoing cardiac procedures. However, it is unclear whether the contrast volume is directly correlated with worse clinical outcomes. The aim of this study was to investigate the association between contrast dose and the incidence of 1-year major adverse cardiac and cerebrovascular events (MACCE) and all-cause bleeding events in patients undergoing cardiac catheterization and coronary angiography (CAG).

We prospectively enrolled 10,961 consecutive patients diagnosed with coronary heart disease expecting CAG from 2012 to 2013. The study population was pursued with a follow-up duration of 1 year. The predictive value of contrast volume, divided into quartiles, for the risk of MACCE and all-cause bleeding events was assessed using logistic regression analysis.

The cumulative incidence of 1-year MACCE was 8.65%, which was directly associated with increasing contrast volume. In particular, MACCE was observed in 7.16%, 7.89%, 9.31%, and 11.73% of cases in the contrast volume quartile Q1 (≤100 ml), Q2 (101–140 ml), Q3 (141–200 ml), and Q4 (>200 ml), respectively (P < 0.001). Moreover, the incidence of 1-year all-cause bleeding events was noted in 4.70%, 5.93%, 7.28%, and 8.21% of patients in Q1, Q2, Q3, and Q4, respectively (P < 0.001). The survival analysis showed that the 1-year MACCE rate was higher in patients using greater CM volume during the CAG. CM volume used >140 ml was associated with the occurrence of 1-year MACCE, and the incidence was dramatically elevated in patients exceeding a contrast volume of 200 ml (P = 0.007).

Our data suggested that higher contrast volume was significantly correlated with an increased risk of MACCE and all-cause bleeding events in patients undergoing cardiac catheterization.

ClinicalTrials.gov, NCT01735305; https://clinicaltrials.gov/ct2/show/NCT01735305?id=NCT017353057rank=1.

Treatment of myoclonic seizures in myoclonic epilepsy with ragged-red fibers (MERRFs) has been empirical and ineffective. Guideline on this disease is not available. Additional trials must be conducted to find more suitable treatments for it. In this study, the antimyoclonic effects of monotherapies, including levetiracetam (LEV), clonazepam (CZP), valproic acid (VPA), and topiramate (TPM) compared to combination therapy group with LEV and CZP on MERRF, were evaluated to find a more advantageous approach on the treatment of myoclonic seizures.

Treatments of myoclonic seizures with VPA, LEV, CZP, and TPM were reported as monotherapies in 17 MERRF patients from Qilu Hospital between 2003 and 2016, who were diagnosed through clinical data and genetic testing. After 1–4 months of follow-up (mean: 82.9 ± 28.1 days), 12 patients that exhibited poor responses to monotherapy were given a combined treatment consisting of LEV and CZP subsequently. The follow-up period was 4–144 months (mean: 66.3 ± 45.3 months), the effective rates of monotherapy group (17 patients) and combination therapy group (12 patients) were analyzed by Chi-square test.

The m.8344 A>G mutation was detected in all patients. There were four patients with partial response (4/17, two in the CZP group and two in the LEV group), ten patients with stable disease (10/17, six in the CZP group, three in the LEV group, and one in the TPM group), and three patients with progressive disease (3/18, two in the VPA group and one in the TPM group). Twelve of the patients with LEV combined with CZP showed a positive effect and good tolerance (12/12), eight of them demonstrated improved cognition and coordination. There was a significant difference between the monotherapy group and combination therapy group in the efficacy of antimyoclonic seizures (χ² = 13.7, P < 0.001).

LEV in combination with CZP is an efficient and safe treatment for myoclonic seizures in patients with this disease exhibiting the m.8344A>G mutation.

Standard automated perimetry does not sufficiently detect early open-angle glaucoma (OAG) in the clinic. New visual function tests for early glaucoma damage are therefore needed. The present study evaluated whether an isolated-check visual evoked potential (icVEP) could be used to detect visual function abnormalities in early-stage OAG and to explore potential related factors.

This was a cross-sectional study. Thirty-seven OAG patients with early-stage visual field loss (mean deviation ≥ −6.00 dB) detected by the Humphrey Field Analyzer (30-2 SITA program) and 26 controls were included in this study. Optical coherence tomography (OCT) was used to detect retinal nerve fiber layer (RNFL) defects. The icVEP preferentially evaluates the magnocellular-ON pathway. VEPs were recorded and signal-to-noise ratios (SNRs) were derived based on multivariate analysis. Eyes that yielded an SNR ≤1 were considered abnormal. Receiver operating characteristic (ROC) curve analysis was used to estimate the accuracy of group classification. Correlations between SNRs and related factors were analyzed.

Based on an SNR criterion of 1, the icVEP had a sensitivity of 62.2% and a specificity of 92.3% for diagnosing early-stage OAG with 74.6% classification accuracy. The ROC curve analysis, however, suggested that an SNR criterion of 0.93 would produce the highest classification accuracy (77.3%). Both RNFL thinning in the temporal superior quadrant on OCT and number of abnormal test points in the central 11° visual field (pattern deviation, P < 0.5%) significantly correlated with the SNR (P < 0.05).

The icVEP detected visual function abnormalities in approximately 3/5 of eyes with early-stage OAG with greater than 90% specificity. SNR correlated with both a decrease in RNFL thickness and severity of central visual field loss.

The increasing frequency of explosive injuries has increased interest in blast-induced traumatic brain injury (bTBI). Various shock tube models have been used to study bTBI. Mild-to-moderate explosions are often overlooked because of the slow onset or mildness of the symptoms. However, heavy gas cylinders and large volume chambers in the model may increase the complexity and danger. This study sought to design a modified model to explore the effect of moderate explosion on brain injury in mice.

Pathology scoring system (PSS) was used to distinguish the graded intensity by the modified model. A total of 160 mice were randomly divided into control, sham, and bTBI groups with different time points. The clinical features, imaging features, neurobehavior, and neuropathology were detected after moderate explosion. One-way analysis of variance followed by Fisher’s least significant difference posttest or Dunnett’s t 3-test was performed for data analyses.

PSS of mild, moderate, and severe explosion was 13.4 ± 2.2, 32.6 ± 2.7 (t = 13.92, P < 0.001; vs. mild group), and 56.6 ± 2.8 (t = 31.37, P < 0.001; vs. mild group), respectively. After moderate explosion, mice showed varied symptoms of malaise, anorexia, incontinence, apnea, or seizure. After bTBI, brain edema reached the highest peak at day 3 (82.5% ± 2.1% vs. 73.8% ± 0.6%, t = 7.76, P < 0.001), while the most serious neurological outcomes occurred at day 1 (Y-maze: 8.25 ± 2.36 vs. 20.00 ± 4.55, t = −4.59, P = 0.048; 29.58% ± 2.84% vs. 49.09% ± 11.63%, t = −3.08, P = 0.008; neurologic severity score: 2.50 ± 0.58 vs. 0.00 ± 0.00, t = 8.65, P = 0.016). We also found that apoptotic neurons (52.76% ± 1.99% vs. 1.30% ± 0.11%, t = 57.20, P < 0.001) and gliosis (2.98 ± 0.24 vs. 1.00 ± 0.00, t = 14.42, P = 0.021) in the frontal were significantly higher at day 3 post-bTBI than sham bTBI.

We provide a reliable, reproducible bTBI model in mice that can produce a graded explosive waveform similar to the free-field shock wave in a controlled laboratory environment. Moderate explosion can trigger mild-to-moderate blast damage of the brain.

Fine particulate matter (PM_2.5) exacerbates airway inflammation and hyperreactivity in patients with asthma, but the mechanism remains unclear. The aim of this study was to observe the effects of prolonged exposure to high concentrations of PM_2.5 on the pathology and airway hyperresponsiveness (AHR) of BALB/c mice undergoing sensitization and challenge with ovalbumin (OVA) and to observe the effects of apoptosis and T-cell immunoglobulin and mucin domain 1 (TIM-1) in this process.

Forty female BALB/c mice were divided into four groups: control group, OVA group, OVA/PM group, and PM group (n = 10 in each group). Mice in the control group were exposed to filtered clean air. Mice in the OVA group were sensitized and challenged with OVA. Mice in the OVA/PM group were sensitized and challenged as in the OVA group and then exposed to PM_2.5 for 4 h per day and 5 days per week for a total of 8 weeks using a nose-only "PM_2.5 online enrichment system" in The Second Hospital of Hebei Medical University. Mice in the PM group were exposed to the PM_2.5 online enrichment system only. AHR was detected. Bronchoalveolar lavage fluid (BALF) was collected for cell classification. The levels of interleukin-4 (IL-4), IL-5, and IL-33 in BALF were measured using enzyme-linked immunosorbent assay. Changes in histological structures were examined by light microscopy, and changes in ultramicrostructures were detected by electron microscopy. Apoptosis was determined by terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) assay in the lung tissues. Western blotting and immunohistochemistry were utilized to analyze the expression of Bcl-2, Bax, and TIM-1 in the lungs.

The results showed that AHR in the OVA/PM group was significantly more severe than that in the OVA and PM groups (P < 0.05). AHR in the PM group was also considerably more severe than that in the control group (P < 0.05). The BALF of OVA/PM group (28.00 ± 6.08 vs. 12.33 ± 4.51, t = 4.631, P = 0.002) and PM group (29.00 ± 3.00 vs. 12.33 ± 4.51, t = 4.927, P = 0.001) had more lymphocytes than the BALF of the control group. The number of neutrophils in the BALF of the OVA/PM group (6.67 ± 1.53 vs. 3.33 ± 1.53, t = 2.886, P = 0.020) and PM group (6.67 ± 1.53 vs. 3.33 ± 1.53, t = 2.886, P = 0.020) was much higher than those in the BALF of OVA group (P < 0.05). TUNEL assays showed that the number of apoptotic cells in the OVA/PM group was significantly higher than that in the OVA group (Tunel immunohistochemical scores [IHS%], 1.20 ± 0.18 vs. 0.51 ± 0.03, t = 8.094, P < 0.001) and PM group (Tunel IHS%, 1.20 ± 0.18 vs. 0.51 ± 0.09, t = 8.094, P < 0.001), and that the number of apoptotic cells in the PM group was significantly higher than that in the control group (Tunel IHS%, 0.51 ± 0.09 vs. 0.26 ± 0.03, t = 2.894, P = 0.020). The concentrations of IL-4 (77.44 ± 11.19 vs. 48.02 ± 10.02 pg/ml, t = 4.595, P = 0.002) and IL-5 (15.65 ± 1.19 vs. 12.35 ± 0.95 pg/ml, t = 3.806, P = 0.005) and the Bax/Bcl-2 ratio (1.51 ± 0.18 vs. 0.48 ± 0.10, t = 9.654, P < 0.001) and TIM-1/β-actin ratio (0.78 ± 0.11 vs. 0.40 ± 0.06, t = 6.818, P < 0.001) in the OVA/PM group were increased compared to those in the OVA group. The concentrations of IL-4 (77.44 ± 11.19 vs. 41.47 ± 3.40 pg/ml, t = 5.617, P = 0.001) and IL-5 (15.65 ± 1.19 vs. 10.99 ± 1.40 pg/ml, t = 5.374, P = 0.001) and the Bax/Bcl-2 ratio (1.51 ± 0.18 vs. 0.97 ± 0.16, t = 5.000, P = 0.001) and TIM-1/β-actin ratio (0.78 ± 0.11 vs. 0.31 ± 0.06, t = 8.545, P < 0.001) in the OVA/PM group were increased compared to those in the PM group. The concentration of IL-4 (41.47 ± 3.40 vs. 25.46 ± 2.98 pg/ml, t = 2.501, P = 0.037) and the Bax/Bcl-2 ratio (0.97 ± 0.16 vs. 0.18 ± 0.03, t = 7.439, P < 0.001) and TIM-1/β-actin ratio (0.31 ± 0.06 vs. 0.02 ± 0.01, t = 5.109, P = 0.001) in the PM group were also higher than those in the control group.

Exacerbated AHR associated with allergic asthma caused by PM_2.5 is related to increased apoptosis and TIM-1 activation. These data might provide insights into therapeutic targets for the treatment of acute exacerbations of asthma induced by PM_2.5.

子宫内粘连（IUA）是一种由于子宫内膜的基底层被各种因素破坏而导致子宫肌壁彼此粘连，从而导致子宫腔部分或完全闭塞的疾病形式。^[1]近年来，随着宫腔手术的增多，其发病率不断上升，严重影响妇女的生殖功能、月经生理以及身心健康。宫腔镜检查是诊断IUAs的金标准。因此，宫腔镜图像的识别在确定诊断、同时治疗的选择和预后评估中具有至关重要的意义。在本文中，我们描述了两例成功治疗罕见宫腔镜发现的IUAs病例。IUAs的诊断和分类基于1988年美国生育协会（AFS）分类系统。^[2]

致编辑：维生素B12（钴胺素，Cbl）对人类的正常生长和发育至关重要。它可以转化为两种重要的活性辅酶，即腺苷钴胺素（AdoCbl）和甲基钴胺素（MeCbl），它们分别在线粒体和细胞质中起着至关重要的作用。以常染色体隐性方式遗传的细胞内钴胺素代谢障碍是由来源于维生素B12的AdoCB1和MeCB1的合成缺陷引起的；病症的类型包括：cblA、cblB、cblC、cblD等。，取决于致病基因。^[1,2]由突变引起的cblD疾病（MIM#277410）MMADHC基因包含三种亚型：cblD分离的甲基丙二酸血症（MMA）、cblD分离的同型胱氨酸尿症（HC）和cblD-MMA/HC（MMA和HC组合）。^[1]我们在此报告了一例中国患者的cblD疾病归因于一种新的MMADHC与翻译重启相关的突变。

致编者：脑静脉血栓形成（CVT）是指主窦/窦或皮质静脉闭塞，导致血管充血和神经系统病变。^[1]患有唐氏综合征（DS）的青少年更容易发生血栓形成。^[2]然而，血栓形成和DS之间的关系尚未广泛报道。

致编者：在中国和邻国，人们越来越关注源自中国甘肃走廊和蒙古地区的沙尘暴细颗粒物（PM）的健康问题。^[1]PM是各种颗粒的混合物，包括地壳物质、金属和生物气溶胶。据报道，环境PM水平升高也与心肺发病率和死亡率增加有关。^[2]世界卫生组织最近的一份报告表明，2012年，暴露于细颗粒物空气污染和其他污染物导致全球约700万人死亡，而全球疾病负担研究表明，2013年，颗粒物暴露导致290万人死亡和6970万人残疾调整生命年。^[2]最后，研究表明，PM浓度降低与死亡风险降低相关。

致编者：退行性二尖瓣疾病是一种常见疾病，影响2-3%的普通人群，其中近一半是老年人。^[1]大量研究证实，对于退行性瓣膜疾病，二尖瓣修复术比二尖瓣置换术有更好的结果。^[2]为了说明退行性瓣膜疾病的病因、病理、瓣膜功能障碍、手术策略和二尖瓣修复中期持久性之间的关系，我们回顾性分析了单个中心的数据。在连续队列中，所有手术均由熟练的外科医生（G.D.）根据100%修复标准进行。

致编者：动静脉畸形（AVM），又称环状动脉瘤、动静脉动脉瘤、动静脉瘘和海绵状血管瘤，可发生于身体任何器官。子宫AVM是一种罕见的实体，分为先天性或获得性。先天性子宫AVM被认为是由胚胎分化期间导致异常血管连接的缺陷发展而来，而获得性子宫AVM已被报道是由于先前的子宫创伤（如刮宫或剖宫产）而发生的，或与肿瘤性疾病（包括妊娠滋养细胞疾病（GTD）和子宫内膜腺癌）有关。^[1]

致编者：单绒毛膜三胞胎妊娠非常罕见，占所有三胞胎妊娠的3.5-4.0%，发生在所有分娩的0.001-0.004%。^[1]它们与围产期发病率和死亡率的高风险相关。连体双胞胎是单绒毛膜妊娠的一种独特而罕见的并发症，当两个相同的个体通过他们的解剖部分融合时就会发生；这种罕见事件的发生率为100,000-200,000例活产中的一例。^[2]虽然单绒毛膜三胞胎中连体双胞胎的存在非常罕见，但它对产科咨询和管理都提出了巨大的挑战。

致编者：子宫腺肌病（AM）是由于子宫肌层内膜腺体和间质异位生长，伴有周围平滑肌细胞增生肥大，导致子宫弥漫性增大。AM虽然是一种常见的妇科良性疾病，但可引起严重的痛经、月经过多、子宫增大、不孕等，对患者的健康和生活质量产生负面影响。到目前为止，缺乏高质量的数据来让临床医生全面了解AM的临床表现和病理特征。本报告介绍了AM合并或不合并子宫内膜异位症（EM）的临床和病理特征，以帮助临床医生和患者在未来对此类疾病进行早期诊断和干预。我们希望上述特征能改善患者的生育能力和生活质量。

致小编：瓣膜狭窄和反流会导致一系列症状，包括胸闷和呼吸困难。瓣膜置换术是一种有效的外科手术，提高了患者的生活质量和寿命，在二尖瓣疾病的治疗中发挥了越来越重要的作用。既往研究报道了二尖瓣置换术（MVR）和/或主动脉瓣置换术（AVR）患者死亡率增加的不同危险因素和独立预测因素。^[1,2,3]本研究回顾性回顾了接受瓣膜手术患者的数据，以确定该患者人群中短期死亡率的危险因素和预测因素。

编者：胆囊癌（GBC）是一种预后不良的罕见疾病，通常在胆囊切除术中或术后偶然发现。^[1]它倾向于通过淋巴、腹膜、胆管内和血行途径早期传播。患者通常表现为转移性疾病。如果胆囊切除术中怀疑GBC，在术中冰冻活检证实癌症后，考虑转为开放手术进行根治性切除。当胆囊切除术后诊断为GBC时，根据癌症浸润深度（T期）再次手术进行根治性切除是不可避免的。^[1]然而，并非所有患者都进行根治性手术的再次手术，原因包括拒绝接受根治性手术、医疗条件差或癌症进展提示不可切除。

编者：磁共振（MR）成像在直肠癌（RC）治疗决策中起着重要作用。^[1]对于RC的MR成像过程中是否有必要使用直肠造影剂存在争议。^[2,3,4]直肠内粪便和气体可能影响病灶的显示，诱发伪影，尤其是在弥散加权像（DWI）上。^[5]因此，一些研究者认为直肠填充是必要的。常规方法是输注超声凝胶或口服钆喷酸双葡甲胺和聚乙二醇填充直肠。直肠充盈引起的肠腔可能改变肿瘤与手术平面之间的距离，从而影响分期的准确性。用超声凝胶填充直肠还有其他局限性，包括在MR检查期间插入灌肠管不方便以及患者在大量试剂排便后感到不舒服。钆喷酸葡胺和聚乙二醇溶液在T1加权图像上显示高信号，并在增强图像和DWI上引入磁化率伪影。前者在静脉注射造影剂后可掩盖病变及其增强。为了克服磁共振成像期间直肠充盈的这些限制，我们开发了一种新的磁共振直肠造影方案。我们的方案如下：（1）在检查前晚上口服500毫升20%甘露醇作为泻药，以清除结肠直肠，然后停止所有口服；（2）考试安排在上午。检查前90~120 min内连续饮用等渗甘露醇溶液约1500 ml；（3）MR直肠造影时，患者有排便冲动时，说明药剂已到达直肠。为了确保检查的完整性，允许患者在检查开始前进行两到三次排便。

弥漫性大B细胞淋巴瘤（DLBCL）是成人中最常见的淋巴肿瘤。几十年来，由于利妥昔单抗的引入，利妥昔单抗、环磷酰胺、多柔比星、泼尼松和长春新碱（R-CHOP）治疗显著改善了临床结局。即便如此，仍有约30-40%的患者最终复发或进展，这变得难以控制。一项研究表明，原发性难治性DLBCL或含利妥昔单抗治疗后早期复发的患者预后非常差，^[1]这使得将新药引入DLBCL方案无疑是一个迫切的需求。

“你最近读过报纸或博客，翻阅过杂志，或者使用过社交媒体；你可能会遇到信息图表——那些自成一体的画报，一眼就能告诉你故事或概念的要点”。^[1]

在题为“香烟烟雾提取物对培养细胞中脂多糖激活的丝裂原激活蛋白激酶信号转导途径的影响”的文章中，发表在第120卷第12期第1075-1081页中华医学杂志,^[1]两项应更正如下：

在题为“低密度脂蛋白胆固醇/高密度脂蛋白胆固醇比值作为年轻男性首次急性心肌梗死和干预后主要不良心血管事件的预测因素”的文章中，发表于第131卷第18期第2239-2241页中华医学杂志,^[1]作者单位和通讯地址“首都医科大学”应写成“首都医科大学”，“肺血管疾病”应写成“肺血管疾病”。

我们饶有兴趣地阅读了Ban的病例报告等人.^[1]关于一名17岁男性肌阵挛性癫痫伴参差不齐的红色纤维（MERRF）综合征归因于线粒体tRNA谷氨酸（tRNA[Glu])变体线粒体14709T>C。作者声称，这种变异是零星发生的，到目前为止还没有报道与MERRF表型相关。^[1]我们有以下意见和关切。

感谢您对我们学习的关注和兴趣，^[1]也感谢您的问题和意见。