Volume 132 · Issue 03 · 2019

Enhanced recovery after surgery (ERAS) protocols are a series of perioperative care to optimize preoperative preparation, prevent postoperative complications, minimize stress, and speed up recovery. This study aimed to assess the impact of ERAS protocols for functional endoscopic sinus surgery (FESS) in patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

One hundred and two patients with CRSwNP undergoing FESS were randomly divided into the ERAS group and the control group. The outcomes of the Self-Rating Anxiety Scale (SAS), Visual Analogue Scale (VAS), Medical Outcomes Study Sleep Scale (MOS-SS) and Kolcaba Comfort Scale Questionnaire (GCQ) were determined in both groups. The serum levels of C-reactive protein (CRP) were compared preoperatively and 24 hours postoperatively.

The ERAS group had a significantly better SAS scores than did the control group (28 [24, 35] vs. 43 [42, 47], Z=5.968, P<0.001). The rhinalgia and headache scores at 2, 24 and 48 hours postoperatively were lower in the ERAS group than that in the control group (all P < 0.001). The outcomes of the MOS-SS (43 [42, 39] vs. 28 [22, 35], Z= 7.071, P < 0.001) and GCQ (76 [68, 87] vs. 64 [50, 75], Z= 4.806, P < 0.001) were significantly different between the two groups. No significant difference was found in the preoperative CRP levels between the two groups (1.3 [0.6, 2.8] vs. 0.5 [0.5, 1.2], Z = 3.049, P > 0.05); However, the CRP level in 24 hours postoperatively was significantly lower in the ERAS group than that in the control group (2.5 [1.4, 3.9] vs. 6.6 [3.8, 9.0], Z = 5.027, P < 0.001). The incidence rates of complications, such as nausea/emesis (χ²=0.343, P>0.05), hemorrhage, aspiration and tumble, were not increased in the ERAS group compared with those in the control group. The ERAS group had a significantly shorter length of hospital stay (5 [4, 5] days vs. 8 [8,9] days, Z=8.939, P<0.001) and hospitalization expenses ($ 2670 [2375, 2740] vs. $3129 [3116, 3456], Z=8.514, P<0.001).

ERAS protocols might optimize FESS for patients with CRSwNP by reducing psychological and physical stress, shortening the length of hospital stay and lowering hospitalization expenses without increasing postoperative complications.

Chinese Clinical Trial Registry, No. ChiCTR1800015791; http://www.chictr.org.cn/showproj.aspx?proj=26872

This study used the National Emergency Department Information System (NEDIS) data to analyze the flow of emergency and critical emergency patients and to identify the patterns of emergency medical service usage in Korea.

The relevance index (RI) and commitment index (CI) were calculated from the 2016 NEDIS data. In this study, the number of clusters was determined using NbClust, and cluster analysis was used to analyze the usage patterns of emergency and critical emergency patients.

The RI and CI were calculated using 8,389,766 cases of 214 districts. The results of the RI and CI suggested that there were 3 types of clusters among the emergency patients. In Cluster 1, 54 districts (25.2%) had low RI and high CI, and it was of outflow type. Cluster 2 was categorized as the influx-type in 58 districts (27.1%) irrespective of RI and low CI. Cluster 3 was categorized as the self-sufficient type found in 102 districts (47.7%), with high RI and high CI. The cluster analysis of the critical emergency patients was divided into 2 types. Cluster 1 was categorized as outflow type with high CI found in 129 districts (60.3%), while Cluster 2 was categorized as inflow type with low CI found in 85 districts (39.7%).

This study elucidates the regional status of usage patterns of emergency and critical emergency patients in Korea. This study might serve as a basis for the establishment and selection of emergency medical service areas and vulnerable emergency medical service areas.

Studies on the relationship between antiepileptic drug (AED) administration and clinical outcomes in patients with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) remain scarce. Levetiracetam (LEV) is an AED that is neuroprotective in various neurologic disorders. This study aimed to determine the impact of LEV on the outcome of MELAS.

A retrospective, single-center study was performed based on a large cohort of patients with MELAS with a history of seizures (n=102). Decisions on antiepileptic therapies were made empirically. Patients were followed up for 1 to 8 years (median, 4 years) and divided into 2 groups based on whether LEV was administered (LEV or non-LEV). The modified Rankin scale (mRS) scores and mortality risks were analyzed in all patients.

LEV, carbamazepine, benzodiazepines, topiramate, oxcarbazepine, valproate, and lamotrigine were administered in 48, 37, 18, 13, 11, 9, and 9 patients, singly or in combination, respectively. The mean mRS score of the LEV group (n=48) was lower than that of the non-LEV group (n=54; mean±standard deviation, 2.79±1.47 vs. 3.83±1.93, P=0.006) up to the end of the study. Nevertheless, there was no difference in the proportion of subjects without disability (mRS ranging 0–1) between the groups (P=0.37). The multivariate regressions revealed that LEV treatment was associated with lower mRS scores (odds ratio 0.32, 95% confidence interval [CI] 0.15–0.68, P=0.003) and mortality rates (hazard ratio 0.24, 95% CI 0.08–0.74, P=0.013). There was a significant difference in the Kaplan-Meier survival curves between the groups (χ²=4.29, P=0.04).

The LEV administration is associated with lower mortality in patients with MELAS in this retrospective study. Further laboratory research and prospective cohort studies are needed to confirm whether LEV has neuroprotective effects on patients with mitochondrial diseases.

Late-onset multiple acyl-coA dehydrogenase deficiency (MADD) is an autosomal recessive inherited metabolic disorder. It is still unclear about the muscle magnetic resonance image (MRI) pattern of the distal lower limb pre- and post-treatment in patients with late-onset MADD. This study described the clinical and genetic findings in a cohort of patients with late-onset MADD, and aimed to characterize the MRI pattern of the lower limbs.

Clinical data were retrospectively collected from clinic centers of Peking University People’s Hospital between February 2014 and February 2018. Muscle biopsy, blood acylcarnitines, and urine organic acids profiles, and genetic analysis were conducted to establish the diagnosis of MADD in 25 patients. Muscle MRI of the thigh and leg were performed in all patients before treatment. Eight patients received MRI re-examinations after treatment.

All patients presented with muscle weakness or exercise intolerance associated with variants in the electron transfer flavoprotein dehydrogenase gene. Muscle MRI showed a sign of both edema-like change and fat infiltration selectively involving in the soleus (SO) but sparing of the gastrocnemius (GA) in the leg. Similar sign of selective involvement of the biceps femoris longus (BFL) but sparing of the semitendinosus (ST) was observed in the thigh. The sensitivity and specificity of the combination of either "SO+/GA–" sign or "BFL+/ST–" sign for the diagnosis of late-onset MADD were 80.0% and 83.5%, respectively. Logistic regression model supported the findings. The edema-like change in the SO and BFL muscles were quickly recovered at 1 month after treatment, and the clinical symptom was also relieved.

This study expands the clinical and genetic spectrums of late-onset MADD. Muscle MRI shows a distinct pattern in the lower limb of patients with late-onset MADD. The dynamic change of edema-like change in the affected muscles might be a potential biomarker of treatment response.

Pulmonary vein (PV) occlusion generally depends on repetitive contrast agent injection when cryoballoon ablation for atrial fibrillation (AF). The present study was to compare the effect of cryoballoon ablation for AF guided by transesophageal echocardiography (TEE) vs. contrast agent injection.

Eighty patients with paroxysmal AF (PAF) were enrolled in the study. About 40 patients underwent cryoballoon ablation without TEE (non-TEE group) and the other 40 underwent cryoballoon ablation with TEE for PV occlusion (TEE group). In the TEE group during the procedure, PVs were displayed in 3-dimensional images to guide the balloon to achieve PV occlusion. The patients were followed up at regularly scheduled visits every 2 months.

No differences were identified between the groups in regard to the procedure time and cryoablation time for each PV. The fluoroscopy time (6.7±4.2 min vs. 17.9±5.9 min, P<0.05) and the amount of contrast agent (3.0±5.1 mL vs.18.1±3.4 mL, P<0.05) in the TEE group were both less than the non-TEE group. At a mean of 13.0±3.3 mon follow-up, success rates were similar between the TEE group and non-TEE group (77.5% vs. 80.0%, P=0.88).

Cryoballoon ablation with TEE for occlusion of the PV is both safe and effective. Less fluoroscopy time and a lower contrast agent load can be achieved with the help of TEE for PV occlusion during procedure.

Non-Hodgkin T/NK cell lymphoma is a rare and widely variable type of lymphoma with the most dismal prognosis. This study aimed to investigate varied impact of the clinical indicators to the overall survival (OS).

We conducted a retrospective study to identify the non-invasive clinical features of T cell lymphoma that can predict prognosis with an innovative analysis method using quantile regression. A total of 183 patients who visited a top-tier hospital in Beijing, China, were enrolled from January 2006 to December 2015. Demographic information and main clinical indicators were collected including age, erythrocyte sedimentation rate (ESR), survival status, and international prognostic index (IPI) score.

The median age of the patients at diagnosis was 45 years. Approximately 80% of patients were at an advanced stage, and the median survival time after diagnosis was 5.1 months. Multivariable analysis of the prognostic factors for inferior OS associated with advanced clinical staging [HR=3.16, 95%CI (1.39–7.2)], lower platelet count [HR=2.57, 95%CI (1.57–4.19), P<0.001] and higher IPI score [HR=1.29, 95%CI (1.01–1.66), P=0.043]. Meanwhile, T cell lymphoblastic lymphoma [HR=0.40, 95%CI (0.20–0.80), P=0.010], higher white blood cell counts [HR=0.57, 95%CI (0.34–0.96), P=0.033], higher serum albumin level [HR=0.6, 95%CI (0.37–0.97), P=0.039], and higher ESR [HR=0.53, 95%CI (0.33–0.87), P=0.011] were protective factors for OS when stratified by hemophagocytic lymphohistiocytosis (HLH). Multivariable quantile regression between the OS rate and each predictor at quartiles 0.25, 0.5, 0.75, and 0.95 showed that the coefficients of serum β2-microglobulin level and serum ESR were statistically significant in the middle of the coefficient curve (quartile 0.25–0.75). The coefficient of IPI was negatively associated with OS. The coefficients of hematopoietic stem cell transplantation (HSCT) and no clinical symptoms were higher at the middle of the quartile level curve but were not statistically significant.

The IPI score is a comparatively robust indicator of prognosis at 3 quartiles, and serum ESR is stable at the middle 2 quartiles section when adjusted for HLH. Quantile regression can be used to observe detailed impacts of the predictors on OS.

Six epidemic waves of human infection with avian influenza A (H7N9) virus have emerged in China with high mortality. However, study on quantitative relationship between clinical indices in ill persons and H7N9 outcome (fatal and nonfatal) is still unclear. A retrospective cohort study was conducted to collect laboratory-confirmed cases with H7N9 viral infection from 2013 to 2015 in 23 hospitals across 13 cities in Guangdong Province, China.

Multivariable logistic regression model and classification tree model analyses were used to detect the threshold of selected clinical indices and risk factors for H7N9 death. The receiver operating characteristic curve (ROC) and analyses were used to compare survival and death distributions and differences between indices. A total of 143 cases with 90 survivors and 53 deaths were investigated.

Average age (Odds Ratio (OR)=1.036, 95% Confidence Interval (CI)=1.016–1.057), interval days between dates of onset and confirmation (OR=1.078, 95% CI=1.004–1.157), interval days between onset and oseltamivir treatment (OR=5.923, 95% CI=1.877–18.687), body temperature (BT) (OR=3.612, 95% CI=1.914–6.815), white blood cell count (WBC) (OR=1.212, 95% CI=1.092–1.346) were significantly associated with H7N9 death after adjusting for confounders. The chance of death from H7N9 infection was 80.0% if BT was over 38.1 °C, and chance of death is 67.4% if WBC count was higher than 9.5 (10⁹/L). Only 27.1% of patients who began oseltamivir treatment less than 9.5 days after disease onset died, compared to 68.8% of those who started treatment more than 15.5 days after onset.

The intervals between date of onset and confirmation of diagnosis, between date of onset to oseltamivir treatment, age, BT and WBC are found to be the best predictors of H7N9 mortality.

The clinical trials emerged centromere protein E inhibitor GSK923295 as a promising anticancer drug, but its function in hepatocellular carcinoma (HCC) remain needs to be fully elucidated, especially as chemotherapy after hepatectomy for liver tumors. We aimed to describe anti-HCC activities of GSK923295 and compare its antiproliferative effects on liver regeneration after partial hepatectomy (PH).

All subjects were randomized to treatment with either vehicle or GSK923295. Antitumor activity of GSK923295 was assessed by xenograft growth assays. The C57BL/6 mice were subjected to 70% PH and the proliferation was calculated by liver coefficient, further confirmed by immunohistochemistry. The proliferation and cell cycle analysis of liver cell AML12 and HCC cells LM3, HUH7, and HepG2 were investigated using the cell counting kit-8 assay and Flow Cytometry. The chromosome misalignment and segregation in AML12 cells were visualized by immunofluorescence.

Treatment with GSK923295 induced antiproliferation in HCC cell lines. It also caused delay on HCC tumor growth instead of regression both in a HCC cell line xenograft model and patient-derived tumor xenograft model. With microarray analysis, CENtromere Protein E was gradually increased in mouse liver after PH. Exposure of liver cells to GSK923295 resulted in delay on a cell cycle in mitosis with a phenotype of misaligned chromosomes and chromosomes clustered. In 70% PH mouse model, GSK923295 treatment also remarkably reduced liver regeneration in later stage, in parallel with the mitotic marker phospho-histone H3 elevation.

The anticancer drug GSK923295 causes a significant delay on HCC tumor growth and liver regeneration after PH in later stage.

Eucommia ulmoides Oliv. is a medicinal plant native to China, with its bark (Eucommiae Cortex) traditionally being used for medicinal purposes. Previous research has shown that Eucommia male flowers can exert anti-inflammatory, analgesic, antibacterial, and other pharmacological effects, including immune regulation. This study explored the anti-inflammatory effects of the 70% ethanol extract of male flowers (EF) of E. ulmoides in lipopolysaccharide (LPS)-stimulated RAW 264.7 cells and LPS-administered mice.

Cytotoxicity of EF for RAW 264.7 cells was investigated using Cell Counting Kit-8. The production of proinflammatory mediators, nitric oxide (NO), tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6 was determined using enzyme-linked immunosorbent assays. IL-17, IL-23, and IL-10 mRNA levels were determined using quantitative real-time polymerase chain reaction. Activation of the nuclear factor (NF)-κB pathway in RAW 264.7 cells was investigated via Western blotting. In vivo antiinflammatory effects of EF were studied in an LPS-induced acute inflammation mouse model by analyzing lung tissue histopathology, serum TNF-α and IL-6 levels, and myeloperoxidase (MPO) activity in lung tissue.

EF showed no significant cytotoxicity at concentrations from 10 to 60 μg/mL (cell viability > 80%) in the CCK-8 cell viability assay. EF inhibited the RAW 264.7 cell proliferation (EF 60 μg/mL, 120 μg/mL, and 250 μg/mL vs. negative control: 87.31±2.39% vs. 100.00±2.50%, P=0.001; 79.01±2.56 vs. 100.00±2.50%, P<0.001; and 64.83±2.50 vs. 100.00±2.50%, P<0.001), suppressed NO (EF 20 μg/mL and 30 μg/mL vs. LPS only, 288.81±38.01 vs. 447.68±19.07 μmol/L, P=0.004; and 158.80±45.14 vs. 447.68±19.07 μmol/L, P<0.001), TNF-α (LPS+EF vs. LPS only, 210.20±13.85 vs. 577.70±5.35 pg/mL, P<0.001), IL-1β (LPS+EF vs. LPS only, 193.30±10.80 vs. 411.03±42.28 pg/mL, P<0.001), and IL-6 (LPS+EF vs. LPS only, 149.67±11.60 vs. 524.80±6.24 pg/mL, P<0.001) secretion, and downregulated the mRNA expression of IL-17 (LPS+EF vs. LPS only, 0.23±0.02 vs. 0.43±0.12, P<0.001), IL-23 (LPS+EF vs. LPS only, 0.29±0.01 vs. 0.42±0.06, P=0.002), and IL-10 (LPS+EF vs. LPS only, 0.30±0.01 vs. 0.47±0.01, P=0.008) in LPS-stimulated RAW 264.7 cells. EF inhibited the LPS-induced NF-κB p65 (LPS+EF 20 μg/mL and 30 μg/mL vs. LPS only: 0.78±0.06 vs. 1.17±0.08, P<0.001; and 0.90±0.06 vs. 1.17±0.08, P=0.002) and inhibitor of kappa B (IκBα) phosphorylation (LPS+EF 20 μg/mL and 30 μg/mL vs. LPS only: 0.25±0.01 vs. 0.63±0.03, P<0.001; and 0.31±0.01 vs. 0.63±0.03, P<0.001), LPS+EF 30 μg/mL inhibited IκB kinase (IKKα/β) phosphorylation (LPS+EF 30 μg/mL vs. LPS only, 1.12±0.14 vs. 1.71±0.25, P=0.002) in RAW 264.7 cells. Furthermore, EF 10 mg/kg and EF 20 mg/kg inhibited lung tissue inflammation in vivo and suppressed the serum TNF-α (LPS+EF 10 mg/kg and 20 mg/kg vs. LPS only, 199.99±186.49 vs. 527.90±263.93 pg/mL, P=0.001; and 260.56±175.83 vs. 527.90±263.93 pg/mL, P=0.005), and IL-6 (LPS+EF 10 mg/kg and 20 mg/kg vs. LPS only, 41.26±30.42 vs. 79.45±14.16 pg/ml, P=0.011; and 42.01±26.26 vs. 79.45±14.16 pg/mL, P=0.012) levels and MPO (LPS+EF 10 mg/kg and 20 mg/kg vs. LPS only, 3.19±1.78 vs. 5.39±1.51 U/g, P=0.004; and 3.32±1.57 vs. 5.39±1.51 U/g, P=0.006) activity in lung tissue.

EF could effectively inhibit the expression of inflammatory factors and overactivation of neutrophils. Further investigation is needed to evaluate its potential for anti-inflammation therapy.

声明：2013年，我们在《中华医学杂志》（Chin Med J 2013, 126：4786-4790）上发表了《成人脑死亡判定标准与实用指南（BQCC版）》。从此，我国有了脑死亡的判定标准。为进一步推动脑死亡相关工作，国家卫生健康委员会脑损伤评估质量控制中心（BQCC）旨在修订更新《成人脑死亡判定标准与实用指南》。本次2018年新版基于脑死亡判定5年临床实践、脑死亡病例BQCC质控分析以及BQCC专家委员会、技术委员会和咨询委员会的意见和建议。我们希望脑死亡判定在中国的发展更加规范有序。

致编辑：人星状病毒（HAstVs）是世界范围内病毒性胃肠炎的重要病原体，^[1,2]尤其是在≤5岁的儿科患者中。^[3]然而，关于中学HAstV爆发的报告仍然有限。在这里，我们报告了中国一所中学的HAstV疫情。临床和环境样品对HAstV检测呈阳性，显示衣壳蛋白基因的348-bp区域100%核苷酸同一性。

致编辑：脓毒症和脓毒性休克是重症监护室（ICU）入院的主要原因，并导致显著的发病率和死亡率。^[1,2]早期给予安抚性抗生素与脓毒症和脓毒性休克的生存率提高显著相关^[3,4]这是国际准则所建议的。^[5]然而，脓毒症方案的依从性仍然很低。^[6]护士在执行医嘱中起着至关重要的作用，很可能与经验性抗生素给药的依从性有关。普阿等人^[7]表明护士作为医生抗生素决策的中间人占据着重要和有意识的地位。此外，其他研究也表明，护士主导的方案是在疑似发热性中性粒细胞减少症患者中实现早期抗生素给药的有效、安全和可持续的方法。^[8]因此，我们进行了一项回顾性队列研究，以证实护理人员能力对脓毒性休克患者护士经验性抗生素治疗依从性的影响。

致编辑：良性阵发性位置性眩晕（BPPV）是眩晕最常见的病因之一。最近，BPPV的诊断和治疗已经成为人们越来越感兴趣的领域。因此，临床诊断和治疗水平有了很大提高。虽然已经在世界范围内进行了研究来检查BPPV的发病机制和病理生理学，但很少有人关注BPPV的诊断和治疗成本。因此，本研究旨在根据BPPV患者的有效筛查和眩晕分类，分析BPPV不同治疗策略的效果和支出。

致编辑：肠易激综合征（IBS）是一种常见的功能性胃肠疾病，表现为腹痛伴排便习惯改变。IBS的病理生理学机制尚不清楚，尽管已经提出了许多假说，包括内脏超敏反应、胃肠运动障碍、肠粘膜低度炎症和脑-肠相互作用功能障碍。脑干相互作用的功能障碍被认为与IBS有关，因为相当大比例的IBS患者具有某种形式的心理共病，如抑郁或焦虑。此外，精神和心理问题会增加IBS的风险和IBS的症状严重程度。最近，肠道微生物群的变化也被认为有助于IBS和抑郁症。我们之前的研究表明，腹泻型IBS（IBS-D）和抑郁症患者的肠道微生物群谱显著改变。^[1]

致编辑：虚弱被定义为一种脆弱状态，使老年人面临更大的不良健康结果风险，并可以解释健康状况的实质性异质性。先前的研究已经证明了虚弱表型量表和虚弱指数（FI）在识别中国虚弱老年人中的效用。^[1]近年来，使用上述方法发表了几项关于虚弱的实验和临床研究，但尚未确定区分中国老年人虚弱水平的影响因素。阐明这一问题非常重要，因为早期发现虚弱相关因素和随后的干预对于保障老年人的功能和预防不良后果的发生至关重要。

致编辑：感染是白血病患儿化疗后死亡的原因之一。约20%~30%的急性淋巴细胞白血病（ALL）患者化疗后死于感染。^[1]免疫缺陷、化疗或接受免疫抑制剂治疗的患者更容易感染人巨细胞病毒（HCMV），导致严重的系统性疾病。^[2]巨细胞病毒性视网膜炎（CMVR）是一种主要的视力威胁疾病，主要发生在免疫缺陷患者中，如果延误治疗会导致失明。CD4+T细胞的减少与艾滋病等免疫缺陷综合征中的CMVR有关。^[3]然而，在所有接受化疗的患者中，具有不同标志物的T细胞水平与CMVR发作之间的关系知之甚少。因此，本研究旨在探讨不同标志物T细胞对ALL患者化疗后巨细胞病毒性视网膜炎的诊断价值。

致编辑：Posner-Schlossmann综合征（PSS）也称为青光眼睫状体危象，其特征是急性、单侧、复发性高眼压发作、轻度非肉芽肿性前葡萄膜炎（AU）和自发恢复。然而，这种疾病的病因尚不清楚。已经提出了许多机制，包括病毒感染、自身免疫、自主神经失调、过敏性病症和血管内皮功能障碍。^[1]通常开局部抗高血压药和抗炎药来对抗这种疾病。反复发作可能导致首次发作后5-10年内的长期青光眼视神经损伤。由于病理生理学尚未完全了解，复发的治疗和预防已被证明是困难的。

致编辑：社区获得性甲氧西林耐药的发生率金黄色葡萄球菌（CA-MRSA）感染和CA-MRSA感染的报告每年都在增加。但社区获得性椎管内甲氧西林耐药金黄色葡萄球菌（MRSA）感染从未报告过。我们描述了一例由于CA-MRSA感染引起的椎管内脓肿。

致编辑：胆固醇晶体栓塞（CCE）是由胆固醇晶体栓塞导致多种器官小动脉闭塞而引起的全身性疾病。它可能自发发生，或更经常发生在血管内手术（如冠状动脉造影和颈动脉支架植入术）、心血管手术（如冠状动脉旁路移植术或主动脉瘤手术）后。^[1]先前报道肾脏是CCE最常见的靶器官，在大约50%的CCE患者的临床病程中发现了肾脏CCE。^[2]

致编辑：双极半关节成形术是老年不稳定性股骨颈骨折的治疗选择之一。髋关节置换术后髋关节脱位是常见并发症，但双极假体分离是罕见且更严重的并发症，总是需要切开复位和翻修。一些作者报道了双极半髋关节置换术后的分离。本研究报告了四例原发性双极半关节置换术后因不同原因导致的拆卸病例，并解释了其机制。这将有利于遇到同样情况的外科医生。

脑死亡的概念在20世纪60年代首次引入，为医疗实践提供了一个重要的概念变化，^[1]其诊断基于证明脑干功能完全、不可逆的停止。尽管医学进步，器官移植仍然是终末期器官衰竭患者生存的唯一希望，脑死亡后的捐献仍然是器官的主要来源。已故器官捐赠者的缺乏是移植的最大障碍之一，在中国人口中仍然是一个特殊的问题。2016年中国内地器官捐献者比例为每百万人口3人（pmp），2017年中国香港死亡捐献者数量为6人pmp，两者相对较低。^[2]更积极的神经外科干预以及更好的创伤和重症监护管理也有助于潜在器官捐献者数量的大幅减少。与此同时，移植技术更加成熟，现在向一群过去被认为不适合接受者的“年龄较大、病情较重”的患者提供移植。每天，中国大陆约有30万人和中国香港有2000多名患者等待器官移植。多项研究试图通过调查对器官获取的潜在影响来检验持续的供需失衡，包括个人文化信仰、对政府政策的信仰以及对医疗保健系统的信仰。^[3,4,5]我们报告了一项试点横断面研究，调查了2014年至2016年当地重症监护室（ICU）的520名来访者，并调查了他们对这3个方面的看法。18岁以下的游客被排除在外。伦理批准由相关研究伦理委员会授予。

从1997年7月到2017年4月，在10360例冠状动脉旁路移植术（CABG）中，有IMA收获记录到286例内乳动脉（IMA）损伤，发生率高达2.7%，相对较高。这种高发病率的主要原因可能是外科医生的经验和学习曲线。虽然所有这些手术都是由一名外科医生（Huang FJ）进行的，但这些病例是在许多不同的医院进行的，200多名年轻且缺乏经验的外科助理获得了IMA。因此，我们在此为年轻外科医生提供一些提示：