Volume 132 · Issue 06 · 2019

The comparative outcomes of subcutaneous implantable cardioverter-defibrillator (S-ICD) and transvenous ICD (T-ICD) have not been well studied. The aim of this study was to evaluate the safety and efficacy of currently available S-ICD and T-ICD.

The study included 86 patients who received an S-ICD and 1:1 matched to those who received single-chamber T-ICD by gender, age, diagnosis, left ventricular ejection fraction (LVEF), and implant year. The clinical outcomes and implant complications were compared between the two groups.

The mean age of the 172 patients was 45 years, and 129 (75%) were male. The most common cardiac condition was hypertrophic cardiomyopathy (HCM, 37.8%). The mean LVEF was 50%. At a mean follow-up of 23 months, the appropriate and inappropriate ICD therapy rate were 1.2% vs. 4.7% (χ² = 1.854, P = 0.368) and 9.3% vs. 3.5% (χ² = 2.428, P = 0.211) in S-ICD and T-ICD groups respectively. There were no significant differences in device-related major and minor complications between the two groups (7.0% vs. 3.5%, χ² = 1.055, P= 0.496). The S-ICD group had higher T-wave oversensing than T-ICD group (9.3% vs. 0%, χ²= 8.390, P= 0.007). Sixty-five patients had HCM (32 in S-ICD and 33 in T-ICD). The incidence of major complications was not significantly different between the two groups.

The efficacy of an S-ICD is comparable to that of T-ICD, especially in a dominantly HCM patient population. The S-ICD is associated with fewer major complications demanding reoperation.

Ciprofloxacin is usually used in the treatment of lower respiratory tract infections (LRTIs). Recent studies abroad have shown ciprofloxacin is inadequately dosed and might lead to worse outcomes. The aim of this study was to perform pharmacokinetic and pharmacodynamic analyses of ciprofloxacin in elderly Chinese patients with severe LRTIs caused by Gram-negative bacteria.

From September 2012 to June 2014, as many as 33 patients were empirically administered beta-lactam and ciprofloxacin combination therapy. Patients were infused with 200 or 400 mg of ciprofloxacin every 12 h, which was determined empirically by the attending physician based on the severity of the LRTI and the patient’s renal condition. Ciprofloxacin serum concentrations were determined by high-performance liquid chromatography. Bacterial culture was performed from sputum samples and/or endotracheal aspirates, and the minimum inhibitory concentrations (MICs) of ciprofloxacin were determined. The ratios of the area under the serum concentration-time curve to the MIC (AUC/MIC) and of the maximum serum concentration of the drug to the MIC (C_max/MIC) were calculated. The baseline data and pharmacokinetic parameters were compared between clinical success group and clinical failure group, bacteriologic success group and bacteriologic failure group.

Among the 33 patients enrolled in the study, 17 were infected with Pseudomonas aeruginosa, 14 were infected with Acinetobacter baumannii, and two were infected with Klebsiella pneumoniae. The mean age of the patients was 76.9 ± 6.7 years. Thirty-one patients (93.4%) did not reach the target AUC/MIC value of >125, and 29 patients (87.9%) did not reach the target C_max/MIC value of >8. The AUC/MIC and C_max/MIC ratios in the clinical success group were significantly higher than those in the clinical failure group (61.1 [31.7–214.9] vs. 10.4 [3.8–66.1], Z=－4.157; 9.6 [4.2–17.8] vs. 1.3 [0.4–4.7], Z=－4.018; both P < 0.001). The AUC/MIC and C_max/MIC ratios in the patients for whom the pathogens were eradicated were significantly higher than those in the patients without the pathogens eradicated (75.3 [31.7–214.9] vs. 10.5 [3.8–66.1], Z=－3.938; 11.4 [4.2–17.8] vs. 1.4 [0.4–5.4], Z =－3.793; P < 0.001 for both). Receiver operating characteristic curve analysis showed that the AUC/MIC and C_max/MIC values were closely associated with clinical and bacteriologic efficacies (P < 0.001 in both).

Ciprofloxacin is inadequately dosed against Gram-negative bacteria, especially for those with relatively high MIC values. Consequently, the target values, AUC/MIC > 125 and C_max/MIC > 8, cannot be reached.

Immunoglobulin A nephropathy (IgAN) is the most common pathological type of glomerular disease. Kidney biopsy, the gold standard for IgAN diagnosis, has not been routinely applied in hospitals worldwide due to its invasion nature. Thus, we aim to establish a non-invasive diagnostic model and determine markers to evaluate disease severity by analyzing the serological parameters and pathological stages of patients with IgAN.

A total of 272 biopsy-diagnosed IgAN inpatients and 518 non-IgA nephropathy inpatients from the Department of Nephrology of Chinese People’s Liberation Army General Hospital were recruited for this study. Routine blood examination, blood coagulation testing, immunoglobulin-complement testing, and clinical biochemistry testing were conducted and pathological stages were analyzed according to Lee grading system. The serological parameters and pathological stages were analyzed. The receiver operating characteristic (ROC) analysis was performed to estimate the diagnostic value of the clinical factors. Logistic regression was used to establish the diagnostic model.

There were 15 significantly different serological parameters between the IgAN and non-IgAN groups (all P < 0.05). The ROC analysis was performed to measure the diagnostic value for IgAN of these parameters and the results showed that the area under the ROC curve (AUC) of total protein (TP), total cholesterol (TC), fibrinogen (FIB), D-dimer (D2), immunoglobulin A (IgA), and immunoglobulin G (IgG) were more than 0.70. The AUC of the "TC+ FIB+ D2+ IgA+ age" combination was 0.86, with a sensitivity of 85.98% and a specificity of 73.85%. Pathological grades of I, II, III, IV, and V accounted for 2.21%, 17.65%, 62.50%, 11.76%, and 5.88%, respectively, with grade III being the most prevalent. The levels of urea nitrogen (UN) (13.57 ± 5.95 vs. 6.06 ± 3.63, 5.92 ± 2.97, 5.41 ± 1.73, and 8.41 ± 3.72 mmol/L, respectively) and creatinine (Cr) (292.19 ± 162.21 vs. 80.42 ± 24.75, 103.79 ± 72.72, 96.41 ± 33.79, and 163.04 ± 47.51 μmol/L, respectively) were significantly higher in grade V than in the other grades, and the levels of TP (64.45 ± 7.56, 67.16 ± 6.94, 63.22 ± 8.56, and 61.41 ± 10.86 vs. 37.47 ± 5.6 mg/d, respectively), direct bilirubin (DB) (2.34 ± 1.23, 2.58 ± 1.40, 1.91 ± 0.97, and 1.81 ± 1.44 vs. 0.74 ± 0.57 μmol/L, respectively), and IgA (310.35 ± 103.78, 318.48 ± 107.54, 292.58 ± 81.85, and 323.29 ± 181.67 vs. 227.17 ± 68.12 g/L, respectively) were significantly increased in grades II–V compared with grade I (all P < 0.05).

The established diagnostic model that combined multiple factors (TC, FIB, D2, IgA, and age) might be used for IgAN non-invasive diagnosis. TP, DB, IgA, Cr, and UN have the potential to be used to evaluate IgAN disease severity.

In China, upper airway cough syndrome (UACS) is only less frequent than cough-variant asthma and accounts for 24.71% of chronic cough. This study aimed to determine the pathogenetic constituents and factors affecting UACS in children of different age groups, and to identify clinical clues for diagnosing UACS and a method for curative effect evaluation.

A total of 103 children with UACS whose chief complaint was chronic cough were studied from January to November 2013 at Children’s Hospital, Capital Institute of Pediatrics. According to their age, children with UACS were divided into 3 groups: nursing children, pre-school children, and school-age children. We analyzed the differences in pathogenetic constituents and factors affecting UACS in children. The effect of UACS treatment was evaluated by the visual analog scale (VAS) and an objective examination. Chi-squared test and analysis of variance were performed with the SPSS 19.0 statistical software.

There was a high incidence of UACS in school-age children. Rhinitis with adenoid hypertrophy was the main cause of 103 suspected UACS cases. Adenoidal hypertrophy was the major cause of UACS in the pre-school children group, while rhinitis was the major reason in the nursing children and school-age children groups. Among the 103 children, there were 45 allergen-positive children, with no significant difference among different age groups. VAS scores in the different disease groups after treatment were lower than those before treatment (all P < 0.01). VAS scores in different disease groups showed significant differences, except for 12 vs. 24 weeks after treatment (P= 0.023). Different age groups had different secondary complaints.

There are different pathogeneses in different UACS age groups. Clinical treatment efficacy of children with UACS can be evaluated by the VAS combined with an objective examination. We recommend that the course of treatment should be 12 weeks.

Herpes virus is considered to be the pathogen of acute retinal necrosis (ARN) infection. Previous studies have found that patients with ARN caused by the varicella-zoster virus (VZV) are often older, and patients with herpes simplex virus (HSV) induced ARN are considerably younger. However, in our clinical work, we find that VZV is also a pathogen in younger ARN patients. We, therefore, aimed to analyze the common etiology of younger ARN patients.

A retrospective analysis was made of 20 eyes (18 patients) diagnosed as having ARN in the Department of Ophthalmology of Peking Union Medical College Hospital from 2014 to 2016. All patients were reviewed for demographic data, clinical course, clinical manifestations, time from onset to initial physician visit, duration of follow-up, visual acuity at both presentation and final visit, and treatment strategies. A paired t test was used to compare visual acuity between the presenting vision and those of final follow-up. Vitreous or aqueous specimens from 18 eyes of 18 patients were analyzed with multiplex polymerase chain reaction (mPCR)/quantitative PCR (qPCR) and xTAG-liquid chip technology (xTAG-LCT) to determine the causative virus of ARN.

Final best visual acuity (BCVA) improved significantly from 1.36 ± 0.95 (median 20/400) to 0.95 ± 0.82 (median 20/100) (t= 2.714, P= 0.015) after systemic and intravitreal antiviral treatment combined with or without pars plana vitrectomy. PCR and xTAG-LCT results showed four of the five samples in the younger group (32.2 ± 5.2 years) and 12 of the 13 samples in the senior group (53.6 ± 4.9 years) were positive for VZV, and two of the five samples in the younger group were positive for HSV-1.

This study demonstrates that VZV is also a common causative virus for ARN in younger patients. Considering this finding, a systemic antiviral treatment protocol should be immediately changed to intravenous ganciclovir when the patient does not respond to acyclovir before determining the causative virus, especially in younger patients.

Peritoneal fibrosis is the primary reason that patients with end-stage renal disease (ESRD) have to cease peritoneal dialysis. Peritonitis caused by Gram-negative bacteria such as Escherichia coli (E. coli) were on the rise. We had previously shown that matrine inhibited the formation of biofilm by E. coli. However, the role of matrine on the epithelial-mesenchymal transition (EMT) in peritoneal mesothelial cells under chronic inflammatory conditions is still unknown.

We cultured human peritoneal mesothelial cells (HPMCs) with lipopolysaccharide (LPS) to induce an environment that mimicked peritonitis and investigated whether matrine could inhibit LPS-induced EMT in these cells. In addition, we investigated the change in expression levels of the miR-29b and miR-129-5p.

We found that 10 μg/ml of LPS induced EMT in HPMCs. Matrine inhibited LPS-induced EMT in HPMCs in a dose-dependent manner. We observed that treatment with matrine increased the expression of E-cadherin (F= 50.993, P < 0.01), and decreased the expression of alpha-smooth muscle actin (F= 32.913, P < 0.01). Furthermore, we found that LPS reduced the expression levels of miR-29b and miR-129-5P in HPMCs, while matrine promoted the expression levels of miR-29b and miR-129-5P.

Matrine could inhibit LPS-induced EMT in HPMCs and reverse LPS inhibited expressions of miR-29 b and miR-129-5P in HPMCs, ultimately reduce peritoneal fibrosis. These findings provide a potential theoretical basis for using matrine in the prevention and treatment of peritoneal fibrosis.

Fatty acid oxidation (FAO) disorder is involved in the pathogenesis of some cases of preeclampsia (PE). Several studies show that mammalian target of rapamycin (mTOR) signaling pathway is related to FAO. Pravastatin (Pra) can promote FAO in Nω-nitro-L-arginine methyl ester (L-NAME) PE-like mouse model in our previous study. This study aimed to investigate the effect of mTOR signaling pathway in PE-like model treated with Pra.

Pregnant mice were randomly injected with L-NAME as PE-like model group or saline as control group respectively, from gestational 7th to 18th day. Giving Pra (L-NAME + Pra, Control + Pra, n = 8) or normal saline (NS; L-NAME + NS, Control + NS, n = 8) from gestational 8th to 18th day, the mice were sacrificed on day 18 and their liver and placental tissues were collected. Then the activation of mTOR and its substrates in the liver and placenta were detected. And the association between mTOR activation and serum free fatty acid (FFA) levels and the expression of long-chain 3-hydroxyacyl-coenzyme A dehydrogenase (LCHAD) were evaluated using Pearson correlation test. Differences between groups were analyzed using independent t-test or one-way analysis of variance (ANOVA).

Both in the maternal liver and placenta, the activation of mTOR protein and its effect on substrates increased significantly in the L-NAME + NS group and decreased significantly in the L-NAME + Pra group. The p-mTOR/mTOR protein ratio decreased in the L-NAME + Pra group significantly than that in the L-NAME + NS group both in liver and placenta (liver: 0.74 ± 0.08 vs. 0.85 ± 0.06, t= 2.95, P < 0.05; placenta: 0.63 ± 0.06 vs. 0.77 ± 0.06, t= 4.64, P < 0.05). The activation of mTOR protein in the liver and placenta negatively correlated with the expression of LCHAD in the L-NAME+ NS group (liver: r= －0.745, P < 0.05; placenta: r= －0.833, P < 0.05) and that in the maternal liver negatively correlated with the expression of LCHAD (r= －0.733, P < 0.05) and positively with the serum FFA levels (r= 0.841, P < 0.05) in the L-NAME + Pra group.

The inhibition of mTOR signaling pathway might be involved in the regulation of FAO in mouse model treated with Pra.

Several patients experience persistent otorrhea after a flawless surgical procedure because of insufficient epithelial healing. Several efforts, such as autologous tissue allograft and xenograft, have been made to halt otorrhea. However, a stable technology to induce temporal epithelial repair is yet to be established. Therefore, this study aims to investigate whether implantation of seeding adipose-derived mesenchymal stem cell (ADMSC) aggregates on extracellular matrix (ECM; herein, ADMSC aggregate-ECM) into damaged skin wound promotes skin regeneration.

ADMSC aggregate-ECM was prepared using a previously described procedure that isolated ADMSCs from rabbits and applied to the auricle and auditory meatus wound beds of New Zealand white rabbits. Wound healing was assessed by general observation and hematoxylin and eosin (H&E) staining. Secretion of growth factor of the tissue was evaluated by western blotting. Two other groups, namely, ECM and control, were used. Comparisons of three groups were conducted by one-way analysis of variance analysis.

ADMSCs adhered tightly to the ECM and quickly formed cell sheets. At 2 weeks, general observation and H&E staining indicated that the wound healing rates in the ADMSC aggregate-ECM (69.02 ± 6.36%) and ECM (59.32 ± 4.10%) groups were higher than that in the control group (43.74 ± 12.15%; P= 0.005, P < 0.001, respectively) in ear auricle excisional wounds. At 7 weeks, The scar elevation index was evidently reduced in the ADMSC aggregate-ECM (2.08 ± 0.87) and ECM (2.31 ± 0.33) groups compared with the control group (4.06 ± 0.45; P < 0.001, P < 0.001, respectively). In addition, the scar elevation index of the ADMSC aggregate-ECM group reached the lowest rate 4 weeks in advance. In auditory meatus excisional wounds, the ADMSC aggregate-ECM group had the largest range of normal skin-like structure at 4 weeks. The ADMSC aggregate–ECM and ECM groups secreted increased amounts of growth factors that contributed to skin regeneration at weeks 1 and 2, respectively.

ADMSC aggregate-ECM and ECM are effective repair materials for wound healing, especially ADMSC aggregate-ECM. This approach will provide a meaningful experimental basis for mastoid epithelium repair in subsequent clinical trials.

As a potent pro-inflammatory cytokine of the interleukin (IL)-1 family, IL-18 was elevated in early active and progressive plaque-type psoriatic lesions and that serum or plasma levels of IL-18 correlated with the Psoriasis Area and Severity Index (PASI). Although results from previous studies have established that IL-18 may aggravate psoriatic inflammation, the mechanisms of this process remain unknown. In this study, IL-18 knock out (KO) mice and wild-type (WT) mice were used to investigate the effects of IL-18 within a mouse model of psoriasis.

WT and IL-18 KO mice were divided into four groups, including imiquimod (IMQ)-treated IL-18 KO group (n= 11) and WT group (n= 13) as well as their respectively gene-matched control mice (receiving vaseline; n= 12). PASI scores were used to evaluate psoriatic lesions in IMQ-treated mice. Pathological features and dermal cellular infiltration were investigated by hematoxylin and eosin staining. The levels of psoriasis-related cytokines including IL-23, IL-17, IL-12, IL-1β, IFNγ, IL-15, IL-27, and IL-4 were tested by real-time polymerase chain reaction (PCR). The protein level of IL-1β, IL-27, CXCL1, and Ly6 g were investigated by immunohistochemistry (IHC).

Acanthosis (98.46 ± 14.12 vs. 222.68 ± 71.10 μm, P < 0.01) and dermal cell infiltration (572.25 ± 47.45 vs. 762.47 ± 59.59 cells/field, P < 0.01) were significantly milder in IMQ-induced IL-18 KO mice compared with that in WT mice. IMQ-induced IL-18 KO mice manifested larger areas of Munro microabscesses (11,467.83 ± 5112.09 vs. 4093.19 ± 2591.88 μm², P < 0.01) and scales (100,935.24 ± 41,167.77 vs. 41,604.41 ± 14,184.10 μm², P < 0.01) as compared with WT mice. In skin lesions of IL-18 KO mice, the expressions of IL-1β, IL-4, and IL-27 were all significantly upregulated but IL-17 was decreased. Histologically, strong positive signals of Ly6g were observed within the epidermis of IL-18 KO mice but expressions of CXCL1 were decreased.

IL-18 may exacerbate prominent inflammation and influence pathological features in IMQ-induced mouse model of psoriasis. IL-18 may upregulate pro-inflammatory cytokines and reduce protective cytokines, thus aggravating psoriatic inflammation. In addition, IL-18 may be involved in the formation of Munro microabscesses and scales.

Spinal cord injury (SCI) is a worldwide medical concern. This study aimed to elucidate the mechanism underlying the protective effect of hyperbaric oxygen (HBO) against SCI-induced neurologic defects in rats via exploring the stromal cell-derived factor-1 (SDF-1)/CXC chemokine receptor 4 (CXCR4) axis and expression of brain-derived neurotrophic factor (BDNF).

An acute SCI rat model was established in Sprague-Dawley rats using the Allen method. Sixty rats were divided into four groups (n= 15 in each group): sham-operated, SCI, SCI treated with HBO (SCI+ HBO), and SCI treated with both HBO and AMD3100 (an antagonist of CXCR4; SCI+ HBO+ AMD) groups. The rats were treated with HBO twice a day for 3 days and thereafter once a day after the surgery for up to 28 days. Following the surgery, neurologic assessments were performed with the Basso-Bettie-Bresnahan (BBB) scoring system on postoperative day (POD) 7, 14, 21, and 28. Spinal cord tissues were harvested to assess the expression of SDF-1, CXCR4, and BDNF at mRNA and protein levels, using quantitative real-time polymerase chain reaction, Western blot analysis, and histopathologic analysis.

HBO treatment recovered SCI-induced descent of BBB scores on POD 14, (1.25 ± 0.75 vs. 1.03 ± 0.66, P < 0.05), 21 (5.27 ± 0.89 vs. 2.56 ± 1.24, P < 0.05), and 28 (11.35 ± 0.56 vs. 4.23 ± 1.20, P < 0.05) compared with the SCI group. Significant differences were found in the mRNA levels of SDF-1 (mRNA: day 21, SCI+ HBO vs. SCI+ HBO+ AMD, 2.89 ± 1.60 vs. 1.56 ± 0.98, P < 0.05), CXCR4 (mRNA: day 7, SCI+ HBO vs. SCI, 2.99 ± 1.60 vs.1.31 ± 0.98, P < 0.05; day 14, SCI+ HBO vs. SCI+ HBO+ AMD, 4.18 ± 1.60 vs. 0.80 ± 0.34, P < 0.05; day 21, SCI+ HBO vs. SCI, 2.10 ± 1.01 vs.1.15 ± 0.03, P < 0.05), and BDNF (mRNA: day 7, SCI+ HBO vs. SCI, 3.04 ± 0.41 vs. 2.75 ± 0.31, P < 0.05; day 14, SCI+ HBO vs. SCI, 3.88 ± 1.59 vs. 1.11 ± 0.40, P < 0.05), indicating the involvement of SDF-1/CXCR4 axis in the protective effect of HBO.

HBO might promote the recovery of neurologic function after SCI in rats via activating the SDF-1/CXCR4 axis and promoting BDNF expression.

To confirm that acupuncture applied to patients would improve the clinical curative effect and accelerate the patient’s recovery by introducing the application of acupuncture in pre-operation, during operation, and post-operation.

Literature cited in this review was retrieved from PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI) and was primarily published in English or Chinese from 2010 to 2018, with keywords of "acupuncture," "electroacupuncture," "perioperative period," "sedation," "analgesia," and "recovery." Relevant citations in the retrieved articles were also screened to include more data.

All retrieved literature was scrutinized, most typical articles related on perioperative acupuncture application in clinical study were reviewed.

Acupuncture could relieve anxiety and stress during the preoperative stage. It reduces the usage of narcotics and stress response, and maintains the respiratory stability and homeostasis during surgery. It also exerts a protective effect on vital organs, and during the postoperative stages, enhances the recovery while effectively alleviating the postoperative pain. This phenomenon prevents common postoperative discomforts such as nausea and vomiting. In addition, it might improve the patients’ long-term prognosis.

The novel concept "perioperative acupuncture medicine" is to focus on the optimal treatment in the perioperative period of surgical patients. The review reveals the important role of acupuncture in enhancing rapid recovery of patients during the perioperative period.

致编辑：线粒体脑肌病伴乳酸酸中毒和卒中样发作（MELAS）是最常见的多系统线粒体疾病之一，具有广泛的临床表现。^[1]它通常是由线粒体的点突变引起的MT-TL1基因，约占MELAS综合征个体突变的80%。^[2]致病性线粒体DNA（mtDNA）突变于1988年首次被描述^[3]并且m.14487T>C是已知的致病性mtDNA突变，^[4]在Leigh综合征、视神经病变、上睑下垂、肌张力障碍和脑肌病患者中已有报道。我们在此首次报告了一例具有m.14487T>C突变的迟发性MELAS综合征患者。

致编辑：运动神经元疾病(MND)的特征是上(UMN)或下(LMN)运动神经元体征和症状，^[1]其以各种组合形成MND分类的基础。在这方面，肌萎缩侧索硬化（ALS）是最常见的亚型。^[2]尽管在其他方面被认为是一种无法治疗的退行性疾病，但现在越来越多的证据表明其发病机制更加异质性，表明MND和副肿瘤综合征之间存在联系。^[3]

致编辑：急性基底动脉闭塞（BAO）是卒中的一种灾难性变异，约占所有卒中的1%。^[1]虽然罕见，但BAO与高发病率和死亡率相关。^[2]尽管可以治疗，但与BAO相关的死亡或致残率仍高达80%。^[2]溶栓或血管内血栓切除术的早期再通已被证明可显著改善BAO患者的预后。

致编辑：在新生儿中，食管闭锁（EA）和气管食管瘘（TEF）的发生率约为1/3000。^[1]一项大型人群研究显示，46%的TEF/EA患者至少有一种其他椎体、肛门、心脏、气管、食管、肾和肢体（VACTERL）畸形。^[2]十二指肠梗阻的发生率为1/7000活产，可由十二指肠闭锁（DA）或环状胰腺（AP）引起。^[3]AP是一种不常见的先天性异常，十二指肠梗阻最常见于患者的婴儿期或儿童早期。^[4]DA合并电针的发生率在3%~6%之间，^[5]DA联合EA通常与显著的发病率和死亡率相关。^[6]EA/TEF和十二指肠梗阻的联合存在总是会导致一些管理挑战，例如确定治疗顺序和治疗模式（一起或分阶段）。^[7]对于胸腹部不同部位合并消化道闭锁的复杂病例，尚无相关的手术策略或文献。这种异常组合的管理方案没有很好的定义和争议。大多数外科医生建议首先放置胃造口管进行胃减压和分期修复（理想情况下在几天、几周内）。^[8]

致编辑：先天性膈疝是一种先天性异常，成人少见。成人先天性膈疝的延迟表现可导致诊断困境。对于这些患者，建议立即腹腔镜修复。在这里，我们提出了一个18岁的男性主诉胸痛和腹部不适的病例。X线和计算机断层扫描(CT)显示右侧胸膜-腹膜裂孔疝，位于后外侧膈，也称为Bochdalek疝。

致编辑：患者男，68岁，出现持续1年的蛋白尿。腹部检查发现一个22cm × 18cm的巨大固定肿块。实验室检查显示重度蛋白尿（3.0 g/24 h）和重度低白蛋白血症29 g/L（正常范围：40-55 g/L）。患者主诉排出泡沫尿约1年，入院前20天症状似乎恶化。炎症和肿瘤标志物正常，但腹部对比增强计算机断层扫描[图1]显示一个巨大的囊性实体瘤从腹膜后右上象限延伸到骨盆。丰富的血管供应产生了肿瘤表面的强烈增强。肿瘤、蛋白尿和低白蛋白血症的存在促使手术切除腹部肿块。肿块的整块切除不仅具有挑战性，而且还会引发下腔静脉减压引起的短暂术中低血压和高血管化肿瘤包膜的少量出血。患者出现术后急性肾衰竭，血清肌酸升高，严重少尿，术后第1天手术切口部分坏死。血液透析1个月后肾功能完全恢复（每周三次，每次4 h）。局部应用前列地尔（一种血管扩张剂）2周后，坏死切口皮肤被健康皮肤取代。术后组织病理学评估证实了腹膜后副神经节瘤的诊断，这是一种来源于肾上腺外嗜铬细胞的神经内分泌肿瘤的不寻常位置。大多数产生神经肽（如儿茶酚胺），生长迅速，并伴有远处转移。^[1,2,3]手术切除是目前唯一的治疗方法，因为腹膜后副神经节瘤似乎对放化疗有耐药性。^[2,3]3个月随访时，蛋白尿已消退，血清白蛋白接近正常。这些发现证实了肿瘤相关蛋白尿和蛋白尿相关低白蛋白血症的最初解释。患者的正常血压与非功能性副神经节瘤一致。术后急性肾衰竭的发展表明，在腹部巨大肿块切除术中控制减压对于维持术中血流动力学稳定至关重要，但急性肾损伤的根本原因可能是术前蛋白尿。^[4]腹部切口周围皮肤术后缺血性坏死是一种极其罕见的手术并发症。血管扩张剂治疗的疗效间接提示了血液供应不足和皮肤坏死之间的因果关系。肿瘤的存在导致的皮肤张力增加严重损害了腹壁的血液供应，但建立了连接受压皮肤和肿瘤的异常血管。切除肿块导致术后皮肤血液循环急性减少。28个月时的最新随访发现，患者保持无病状态，对其健康状况非常满意。当时，他知情同意发表这份病例报告。

致编辑：尽管肺癌（LC）的病因和机制仍不清楚，但随着科学技术的进步和研究方法的进步，已经表明肿瘤细胞与血小板（PLTs）聚集并逃避免疫系统的识别。它们粘附在远处的血管内皮细胞上，并通过血液循环继续转移、侵袭和生长。^[1]因此，高凝状态和PLT功能的增强促进了肿瘤的生长、侵袭和转移。^[2,3]因此，PLT计数及其活性的有效降低有助于减少LC的进展和预后。我们进行这项研究是为了探索肿瘤对LC患者循环血小板的影响。

致编辑：由霍华德和休·海利兄弟首次发现的海利-海利病（HHD），^[1]是一种发生在摩擦间部位的遗传性皮肤病。突变ATP2C1在编码钙依赖性ATP酶的染色体2021年第三季度-2上引起角质形成细胞内的钙功能障碍，由于信号转导障碍导致棘层松解。^[2]有人认为，这种基因突变与频繁摩擦、寒冷和紫外线照射等刺激相结合会导致HHD的发展。^[3]

致编辑：非动脉炎性前部缺血性视神经病变(NAION)以突然发作的单侧无痛性视力丧失和视盘肿胀为特征，是50岁以上患者中最常见的急性视神经病变形式。^[1]NAION的发病机制仍不清楚，但大多数组织病理学研究支持睫状后短动脉区域血管病变闭塞的概念。^[2]功能性磁共振成像（fMRI）是测量大脑功能随时间变化的最广泛使用的非侵入性技术之一体内据我们所知，只有一项研究调查了刺激人类NAION视觉外区域受影响眼睛的影响。^[3]然而，这项先前的研究只检查了任务状态fMRI，缺乏静息状态fMRI（rs-fMRI）的测量。因此，尚不清楚局部自发性大脑变化是否仅限于视觉系统。

致编辑：法洛四联症(TOF)于1955年首次手术修复。使用经环右心室流出道补片进行初始TOF修复以缓解梗阻。然而，该手术导致长期肺动脉瓣反流和右心室（RV）容量增加，导致心律失常和猝死。^[1]因此，保留肺环成为TOF修复最普遍的手术策略，可能导致肺动脉狭窄和肺动脉瓣反流的混合。目前，临床医生在使用心脏磁共振成像（CMR）的长期随访期间关注RV功能下降，以预测瓣膜保留干预的适当时机。尽管CMR技术在过去二十年中已经发展成为评估RV体积和功能的参考标准，但常规监测修复的法洛四联症（rTOF）RV功能障碍的进展仍然很困难。超声心动图筛查工具可以帮助评估右心室功能，并协助临床医生确定CMR的理想时机。因为RV功能障碍是一个重要的临床结局指标，^[2]心室功能的早期检测至关重要。由于复杂的心室形状，超声心动图评估rTOF患者的右心室功能具有挑战性。散斑跟踪成像（STI）为量化心室功能提供了替代测量方法。评估右心室功能参数的STI超声心动图技术的发展可能会提供更灵敏的检测，尤其是在使用应变和应变率（SR）时。尽管STI可以在临床实践中评估左心室功能，但在病理条件下评估右心室功能的价值仍然值得怀疑。在这里，我们评估了TOF手术后儿童患者早期右心室变形参数的变化，并研究了STI值。