Volume 132 · Issue 09 · 2019

Clinical remission is the treatment target in rheumatoid arthritis (RA). This study aimed to investigate clinical remission and related factors in a large cohort of patients with RA.

This study composed of 342 patients with RA. Data were collected by face-to-face interview of 1049 patients with RA who visited the Department of Rheumatology of three teaching hospitals from September 2015 to May 2016. The patients with RA were clinically assessed by rheumatologists and a four-page questionnaire was completed on site. Subsequently, patients fulfilled remission criteria were further analyzed. The practicability of different definitions of remission of RA was rated by a panel of rheumatologists. Sustained intensive disease modifying anti-rheumatic drug (DMARD) treatment was defined as a combination treatment with two or more DMARDs for at least 6 months.

In this cohort of 342 patients with RA, the proportions of patients achieving remission were 38.0%, 29.5%, 24.9%, 21.1%, 19.0%, 18.1%, and 17.0%, based on criteria of disease activity score in 28 joints (DAS28) using CRP (DAS28-CRP), DAS28 using ESR (DAS28-ESR), routine assessment of patient index data 3 (RAPID-3), Boolean, simplified disease activity index (SDAI), clinical disease activity index, and the newly described clinical deep remission (CliDR), respectively. Boolean and CliDR are the best in practicability scored by rheumatologists (7.5 and 8.0, respectively). Compared with the non-sustained intensive group, sustained intensive treatment with DMARDs yielded higher remission rates of 25.6%, 23.8%, and 21.3% in patients with RA based on Boolean (χ²=3.937, P=0.047), SDAI (χ²=4.666, P=0.031), and CliDR criteria (χ²=4.297, P=0.038). The most commonly prescribed conventional synthesized DMARDs (csDMARDs) in patients with RA was leflunomide, followed by methotrexate, and hydroxychloroquine. Compared with the non-remission group, patients achieving remission had a longer median duration of DMARDs (45.0 [22.8–72.3] months, Z=-2.295, P=0.022).

The findings in this study indicated that clinical deep remission is achievable in patients with RA. Sustained intensive DMARD treatment is needed to achieve a better outcome in RA.

Large-nerve fiber dysfunction, as assessed by vibration perception threshold (VPT) predicts risks of ulceration, amputation, and mortality in diabetes. Serum uric acid (UA) is closely associated with various metabolic disorders, especially diabetes. Thus, we sought to investigate the clinical relevance of UA to large-nerve fiber dysfunction, among patients with type 2 diabetes (T2D).

Medical records of consecutive patients with T2D who were admitted to Beijing Friendship Hospital Pinggu Campus between May 2014 and December 2016 were collected. Data for the 824 eligible patients included in the final analysis were extracted using a structured form. A VPT value ≥15 in either foot was defined as abnormal. We compared the clinical characteristics between patients with abnormal VPT and those with normal VPT (VPT value <15 in both feet) in the overall population and in gender subgroups. Logistic regression analysis was performed to explore the association of abnormal VPT with UA level. One-way analysis of variance was used to compare VPT values across four UA quartiles.

UA levels were significantly lower in T2D patients with abnormal VPT than in those with normal VPT (294.5 ± 84.0 vs. 314.9 ± 92.8 μmol/L, P < 0.01), especially among male patients (311.7 ± 85.2 vs. 336.9 ± 89.6 μmol/L, P < 0.01). From the logistic regression analysis, hyperuricemia (males >420 μmol/L; females >360 μmol/L) was associated with a reduced risk of abnormal VPT (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.39–0.91; P < 0.05). This association was robust in male patients (OR, 0.43; 95% CI, 0.24–0.76; P < 0.01) but not in female patients (OR, 0.92; 95% CI, 0.47–1.82; P = 0.816), even after adjustment for confounding factors. For the younger male subgroup (age <65 years), VPT values decreased as the UA level increased (P for trend = 0.002), but this trend was not significant in older male subgroup (age ≥65 years; P for trend = 0.400).

Low serum UA levels showed a significant association with an increased risk of large-nerve fiber dysfunction in male patients with T2D, but not in female patients with T2D. In addition, in only the younger subgroup of male patients (<65 years), lower levels of UA also correlated with higher VPT values.

It is important to determine prognostic factors for the outcome of amyotrophic lateral sclerosis (ALS) at an early stage. The time taken for symptoms to spread from spinal or bulbar regions to both (time to generalization; TTG) is considered a strong predictor of survival; however, this has rarely been studied in Asian populations. The aim of this retrospective study was to evaluate potential factors affecting prognosis in Chinese patients with sporadic ALS, with a focus on the association between TTG and overall survival.

Seventy-one patients with sporadic ALS who were hospitalized at Chinese PLA General Hospital from 2009 to 2016 were followed up until December 2017. Survival analysis was performed using univariate Kaplan-Meier log-rank and multivariate Cox proportional hazards models. The clinical data of the patients were recorded and analyzed. Variables studied were age at symptom onset, sex, site of symptom onset, diagnostic latency, TTG, diagnostic category, ALS Functional Rating Scale-revised score, percent predicted forced vital capacity (FVC%), and disease progression rate (DPR) at diagnosis.

The mean age at onset was 54 (SD = 10.2) years, and the median survival time from symptom onset was 41 months (95% confidence interval: 34–47). By univariate analysis, factors independently affecting survival were age at symptom onset (Log rank = 15.652, P < 0.0001), TTG (Log rank = 14.728, P < 0.0001), diagnostic latency (Log rank = 11.997, P = 0.001), and DPR (Log rank = 6.50, P = 0.011). In the Cox multivariate model, TTG had the strongest impact on survival time (hazard ratio = 0.926, P = 0.01).

TTG can be used as an effective indicator of prognosis in patients with sporadic ALS.

The mortality of cardiovascular disease is constantly rising, and novel biomarkers help us predict residual risk. This study aimed to evaluate the predictive value of serum homocysteine (HCY) levels on prognosis in patients with ST-segment elevation myocardial infarction (STEMI).

The 419 consecutive patients with STEMI, treated at one medical center, from March 2010 to December 2015 were retrospectively investigated. Peripheral blood samples were obtained within 24 h of admission and HCY concentrations were measured using an enzymatic cycling assay. The patients were divided into high HCY level (H-HCY) and low HCY level (L-HCY) groups. Short- and long-term outcomes were compared, as were age-based subgroups (patients aged 60 years and younger vs. those older than 60 years). Statistical analyses were mainly conducted by Student t-test, Chi-squared test, logistic regression, and Cox proportional-hazards regression.

The H-HCY group had more males (84.6% vs. 75.4%, P=0.018), and a lower prevalence of diabetes (20.2% vs. 35.5%, P < 0.001), compared with the L-HCY group. During hospitalization, there were seven mortalities in the L-HCY group and 10 in the H-HCY group (3.3% vs. 4.8%, P= 0.440). During the median follow-up period of 35.8 (26.9–46.1) months, 33 (16.2%) patients in the L-HCY group and 48 (24.2%) in the H-HCY group experienced major adverse cardiovascular and cerebrovascular events (MACCE) (P=0.120). History of hypertension (hazard ratio [HR]: 1.881, 95% confidence interval [CI]: 1.178–3.005, P=0.008) and higher Killip class (HR: 1.923, 95% CI: 1.419–2.607, P < 0.001), but not HCY levels (HR: 1.007, 95% CI: 0.987–1.027, P=0.507), were significantly associated with long-term outcomes. However, the subgroup analysis indicated that in older patients, HCY levels were significantly associated with long-term outcomes (HR: 1.036, 95% CI: 1.011–1.062, P=0.005).

Serum HCY levels did not independently predict in-hospital or long-term outcomes in patients with STEMI; however, among elderly patients with STEMI, this study revealed a risk profile for late outcomes that incorporated HCY level.

Cardiac rupture (CR) is a major lethal complication of acute myocardial infarction (AMI). However, no valid risk score model was found to predict CR after AMI in previous researches. This study aimed to establish a simple model to assess risk of CR after AMI, which could be easily used in a clinical environment.

This was a retrospective case-control study that included 53 consecutive patients with CR after AMI during a period from January 1, 2010 to December 31, 2017. The controls included 524 patients who were selected randomly from 7932 AMI patients without CR at a 1:10 ratio. Risk factors for CR were identified using univariate analysis and multivariate logistic regression. Risk score model was developed based on multiple regression coefficients. Performance of risk model was evaluated using receiveroperating characteristic (ROC) curves and internal validity was explored using bootstrap analysis.

Among all 7985 AMI patients, 53 (0.67%) had CR (free wall rupture, n=39; ventricular septal rupture, n=14). Hospital mortalities were 92.5% and 4.01% in patients with and without CR (P < 0.001). Independent variables associated with CR included: older age, female gender, higher heart rate at admission, body mass index (BMI) <25 kg/m², lower left ventricular ejection fraction (LVEF) and no primary percutaneous coronary intervention (pPCI) treatment. In ROC analysis, our CR risk assess model demonstrated a very good discriminate power (area under the curve [AUC]= 0.895, 95% confidence interval: 0.845–0.944, optimism-corrected AUC= 0.821, P < 0.001).

This study developed a novel risk score model to help predict CR after AMI, which had high accuracy and was very simple to use.

Depression and anxiety have been correlated with elevated risks for quality-of-life (QOL), adverse outcomes, and medical expenditure in patients with acute coronary syndrome (ACS). However, the relevant data are lacking for Chinese ACS populations, especially regarding different effects of major depression, anxiety, and comorbidity. The objective of this study was to evaluate the dynamic changes of depression and/or anxiety over 12 months and examine the effects of depression, anxiety, and comorbidity on QOL, adverse outcomes, and medical expenditure in Chinese patients with ACS.

For this prospective longitudinal study, a total of 647 patients with ACS were recruited from North China between January 2013 and June 2015. Among them, 531 patients (82.1%) completed 12-month follow-ups. Logistic regression model was utilized for analyzing the association of baseline major depression, anxiety, and comorbidity with 12-month all-cause mortality, cardiovascular events, QOL, and health expenditure.

During a follow-up period of 12 months, 7.3% experienced non-fatal myocardial infarction (MI) and 35.8% cardiac rehospitalization. Baseline comorbidity, rather than major depression/anxiety, strongly predicted poor 12-month QOL as measured by short-form health survey-12 (odds ratio [OR]: 1.77, 95% confidence interval [CI]: 1.22–2.52, P = 0.003). Regarding 12-month non-fatal MI and cardiac re-hospitalization, baseline anxiety (OR: 2.83, 95% CI: 1.33–5.89, P < 0.01; OR: 4.47, 95% CI: 1.50–13.00, P < 0.01), major depression (OR: 2.58, 95% CI: 1.02–6.15, P < 0.05; OR: 5.22, 95% CI: 1.42–17.57, P < 0.03), and comorbidity (OR: 6.33, 95% CI: 2.96–13.79, P < 0.0001, OR: 14.08, 95% CI: 4.99–41.66, P < 0.0001) were all independent predictors, and comorbidity had the highest predictive value. Number of re-hospitalization stay, admission frequency within 12 months and medical expenditure within 2 months were the highest in patients with ACS with comorbidity.

Major depression and anxiety may predict 12-month non-fatal MI and cardiac re-hospitalization. However, comorbidity has the highest predictive value with greater medical expenditure and worse QOL in Chinese patients with ACS. And depression with comorbid anxiety may be a new target of mood status in patients with ACS.

High on-treatment platelet reactivity (HTPR) has been suggested as a risk factor for patients with ischemic vascular disease. We explored a predictive model of platelet reactivity to clopidogrel and the relationship with clinical outcomes.

A total of 441 patients were included. Platelet reactivity was measured by light transmittance aggregometry after receiving dual antiplatelet therapy. HTPR was defined by the consensus cutoff of maximal platelet aggregation >46% by light transmittance aggregometry. CYP2C19 loss-of-function polymorphisms were identified by DNA microarray analysis. The data were compared by binary logistic regression to find the risk factors. The primary endpoint was major adverse clinical events (MACEs), and patients were followed for a median time of 29 months. Survival curves were constructed with Kaplan-Meier estimates and compared by logrank tests between the patients with HTPR and non-HTPR.

The rate of HTPR was 17.2%. Logistic regression identified the following predictors of HTPR: age, therapy regimen, body mass index, diabetes history, CYP2C19^*2, or CYP2C19^*3 variant. The area under the curve of receiver operating characteristic for the HTPR predictive model was 0.793 (95% confidence interval: 0.738–0.848). Kaplan-Meier analysis showed that patients with HTPR had a higher incidence of MACE than those with non-HTPR (21.1% vs. 9.9%; χ² = 7.572, P = 0.010).

Our results suggest that advanced age, higher body mass index, treatment with regular dual antiplatelet therapy, diabetes, and CYP2C19^*2 or CYP2C19^*3 carriers are significantly associated with HTPR to clopidogrel. The predictive model of HTPR has useful discrimination and good calibration and may predict long-term MACE.

Visual-spatial neglect (VSN) is a neuropsychological syndrome, and right-hemisphere stroke is the most common cause. The pathogenetic mechanism of VSN remains unclear. This study aimed to investigate the behavioral and event-related potential (ERP) changes in patients with or without VSN after right-hemisphere stroke.

Eleven patients with VSN with right-hemisphere stroke (VSN group) and 11 patients with non-VSN with righthemisphere stroke (non-VSN group) were recruited along with one control group of 11 age- and gender-matched healthy participants. The visual-spatial function was evaluated using behavioral tests, and ERP examinations were performed.

The response times in the VSN and non-VSN groups were both prolonged compared with those of normal controls (P < 0.001). In response to either valid or invalid cues in the left side, the accuracy in the VSN group was lower than that in the non-VSN group (P < 0.001), and the accuracy in the non-VSN group was lower than that in controls (P < 0.05). The P1 latency in the VSN group was significantly longer than that in the control group (F[2, 30] = 5.494, P = 0.009), and the N1 amplitude in the VSN group was significantly lower than that in the control group (F[2, 30] = 4.343, P = 0.022). When responding to right targets, the lefthemisphere P300 amplitude in the VSN group was significantly lower than that in the control group (F[2, 30] = 4.255, P = 0.025). With either left or right stimuli, the bilateral-hemisphere P300 latencies in the VSN and non-VSN groups were both significantly prolonged (all P < 0.05), while the P300 latency did not differ significantly between the VSN and non-VSN groups (all P > 0.05).

Visual-spatial attention function is impaired after right-hemisphere stroke, and clinicians should be aware of the subclinical VSN. Our findings provide neuroelectrophysiological evidence for the lateralization of VSN.

Colorectal cancer is the third most common cancer worldwide and still lack of effective therapy so far. Petasin, a natural product found in plants of the genus Petasites, has been reported to possess anticancer activity. The present study aimed to investigate the anticolon cancer activity of petasin both in vitro and in vivo. The molecular mechanism of petasin was also further explored.

Caco-2, LoVo, SW-620, and HT-29 cell lines were used to detect the inhibitory effect of petasin on colon cancer proliferation. Cell viability was determined using the MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide) assay. Cell apoptosis was analyzed by flow cytometry. Hoechst 33258 staining was used to visualize morphological changes. Cell migration was assessed using a wound-healing migration assay, and cell invasion was investigated using Transwell chambers. Western blotting assays were employed to evaluate the expression levels of proteins in the protein kinase B/mammalian target of rapamycin (Akt/mTOR) signaling pathway. Finally, in vivo activity of petasin was evaluated using the SW-620 subcutaneous tumor model established in Balb/c nude mice. Twelve rats were randomly divided into control group and 10 mg/kg petasin group. The tumor volume was calculated every 7 days for 28 days. Terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) assay was performed to assess the apoptotic effect of petasin. Differences between two groups were assessed by analysis of independent-sample t tests.

Petasin significantly inhibited the proliferation of human colon carcinoma cell lines, induced apoptosis, and suppressed migration and invasion in SW-620 cells. Western blotting results showed that petasin decreased the phosphorylation of Akt (1.01 ± 0.16 vs. 0.74 ± 0.06, P = 0.042), mTOR (0.71 ± 0.12 vs. 0.32 ± 0.11, P = 0.013), and P70S6K (1.23 ± 0.21 vs. 0.85 ± 0.14, P = 0.008), elevated the expression of caspase-3 (0.41 ± 0.09 vs. 0.74 ± 0.12, P = 0.018) and caspase-9 (1.10 ± 0.27 vs. 1.98 ± 0.22, P = 0.009), decreased the Bcl-2 protein (2.75 ± 0.47 vs. 1.51 ± 0.36, P = 0.008), downregulated the expression of matrix metalloproteinase (MMP)-3 (1.51 ± 0.31 vs. 0.82 ± 0.11, P = 0.021) and MMP-9 (1.56 ± 0.32 vs. 0.94 ± 0.15, P = 0.039) in SW-620 cell. In vivo, 10 mg/kg petasin inhibited tumor growth in Balb/c nude mice (924.18 ± 101.23 vs. 577.67 ± 75.12 mm³ at day 28, P = 0.001) and induced apoptosis (3.6 ± 0.7% vs. 36.0 ± 4.9%, P = 0.001) in tumor tissues.

Petasin inhibits the proliferation of colon cancer SW-620 cells via inactivating the Akt/mTOR pathway. Our findings suggest petasin as a potential candidate for colon cancer therapy.

Endothelial dysfunction, the initial pathogenic factor in atherosclerosis, can be alleviated via transient limb ischemia. We observed the effects of regular transient limb ischemia (RTLI) on atherosclerosis in hypercholesterolemic rabbits.

Twenty-eight rabbits were randomized to control, cholesterol, sham, ischemia groups (n=7 each) between October 2010 and March 2011. They were fed a normal diet in the control group and hypercholesterolemic diet in other groups for 12 weeks. Six cycles of RTLI were performed once per day on the ischemia group. Serum samples were prepared to measure the total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) before the experiment (W0), at the end of weeks 4, 8, 12 (W4, W8, W12). The whole aorta was harvested at W12 and stained using Sudan IV to identify the plaque. The plaque area was measured using Image J. Results were analyzed by analysis of variance or rank sum test.

Concentrations of TC in the cholesterol group were higher than those in the control group at W4 (29.60 [23.75, 39.30] vs. 1.00 [0.80, 1.55], Z = –2.745, P = 0.006), W8 (41.78 [28.08, 47.37] vs. 0.35 [0.10, 0.68], Z = –2.739, P = 0.006), W12 (48.32 [40.04, 48.95] vs. 0.61 [0.50, 0.86], Z = –2.739, P = 0.006). Similar results were obtained for HDL-C and LDL-C. Serum concentrations of TC, HDL-C, and LDL-C in the hypercholesterolemic groups had no differences (all P > 0.05). The percentage of plaque area in the cholesterol group was higher than that in the control group (47.22 ± 23.89% vs. 0, Z = –2.986, P = 0.003). Square root of the percentage of plaque area was smaller in the ischemia group than that in the cholesterol (0.44 ± 0.13 vs. 0.67 ± 0.18, P = 0.014) or sham groups (0.44 ± 0.13 vs. 0.61 ± 0.12, P = 0.049).

In hypercholesterolemic rabbits, RTLI might prevent atherosclerosis progression by reducing the percentage of plaque area.

Portosystemic shunts, including surgical portosystemic shunts and transjugular intra-hepatic portosystemic shunt (TIPS), may have benefit over endoscopic therapy (ET) for treatment of variceal bleeding in patients with cirrhotic portal hypertension; however, whether there being a survival benefit among them remains unclear. This study was to compare the effect of three above-mentioned therapies on the short-term and long-term survival in patient with cirrhosis.

Using the terms "variceal hemorrhage or variceal bleeding or variceal re-bleeding" OR "esophageal and gastric varices" OR "portal hypertension" and "liver cirrhosis," the Cochrane Central Register of Controlled Trials, PubMed, Embase, and the references of identified trials were searched for human randomized controlled trials (RCTs) published in any language with full texts or abstracts (last search June 2017). Risk ratio (RR) estimates with 95% confidence interval (CI) were calculated using random effects model by Review Manager. The quality of the included studies was evaluated using the Cochrane Collaboration’s tool for the assessment of the risk of bias.

Twenty-six publications comprising 28 RCTs were included in this analysis. These studies included a total of 2845 patients: 496 (4 RCTs) underwent either surgical portosystemic shunts or TIPS, 1244 (9 RCTs) underwent either surgical portosystemic shunts or ET, and 1105 (15 RCTs) underwent either TIPS or ET. There was no significant difference in overall mortality and 30-day or 6-week survival among three interventions. Compared with TIPS and ET, separately, surgical portosystemic shunts were both associated with a lower bleeding-related mortality (RR = 0.07, 95% CI = 0.01–0.32; P < 0.001; RR = 0.17, 95% CI = 0.06–0.51, P < 0.005) and rate of variceal re-bleeding (RR = 0.23, 95% CI = 0.10–0.51, P < 0.001; RR = 0.10, 95% CI = 0.04–0.24, P < 0.001), without a significant difference in the rate of postoperative hepatic encephalopathy (RR = 0.52, 95% CI = 0.25–1.00, P = 0.14; RR = 1.09, 95% CI = 0.59–2.01, P = 0.78). TIPS showed a trend toward lower variceal re-bleeding (RR = 0.46, 95% CI = 0.36–0.58, P < 0.001), but a higher incidence of hepatic encephalopathy than ET (RR = 1.78, 95% CI = 1.34–2.36, P < 0.001).

The overall analysis revealed that there seem to be no short-term and long-term survival advantage, but surgical portosystemic shunts are with the lowest bleeding-related mortality among the three therapies. Surgical portosystemic shunts may be the most effective without an increased risk of hepatic encephalopathy and TIPS is superior to ET but at the cost of a higher incidence of hepatic encephalopathy. However, some of findings should be interpreted with caution due to the lower level of evidence and the existence of significant heterogeneity.

当患者因白带异常等疾病就诊时，临床医生应考虑下生殖道感染的可能性，如外阴阴道念珠菌病(VVC)。此时，适当的是进一步评估感染的典型临床表现、诊断和常规管理。然而，有时，通过标准诊断技术根本不可能检测到任何病原体。在这种情况下，这些病人会怎么样？

致编辑：膀胱过度活动症（OAB）是排尿功能障碍的常见临床表现。OAB在18岁以上人群中的发病率为5.9%，并且已知随着年龄的增长而增加，在中国40岁以上人群中的发病率高达11.3%。OAB严重影响生活质量，给患者的工作和家庭生活带来极大不便，可导致各种生理、心理和社会问题。OAB的诊断主要依靠患者的主观临床症状，以及辅助检查包括有创性尿动力学检查、排尿日记、症状问卷等，可缺乏客观性和准确性。因此，近年来，人们对鉴定OAB的生物标志物感兴趣。迄今为止鉴定的OAB的潜在生物标志物包括神经生长因子(NGF)和脑源性神经营养因子(BDNF)。

致编辑：子宫内膜异位症是指发生在子宫腔的子宫内膜和子宫肌层以外的地方的具有生长功能的子宫内膜组织（间质和腺体）。它常导致疼痛、不孕、结节或肿块等症状和体征，从而给个人和社会带来沉重的负担。传统的血液逆流学说、免疫学说、炎症学说、激素学说等，不能完全阐明子宫内膜异位症的发病机制。最近的研究表明，子宫内膜异位症患者的在位内膜本身存在一定的特异性，使子宫内膜碎片有可能在宫腔外黏附、侵入和生长。^[1,2]在位内膜可能是子宫内膜异位症发生的关键因素之一。本研究拟利用全外显子组测序（WES）和基因芯片测序技术探讨卵巢子宫内膜异位症（OEM）患者在位内膜在子宫内膜异位症发病中的作用。

致编辑：炎性肌纤维母细胞瘤（IMT）是一种罕见的中间性肿瘤，具有恶性潜能，常影响儿童和年轻人。尽管IMT可以来自各种器官，但大多数起源于肺、腹部/骨盆或腹膜后。这些肿瘤被认为是通过良性炎症过程产生的，尽管一些肿瘤表现出恶性行为或经历恶性转化。IMT的临床管理没有统一的指南。^[1,2]目前，手术是治疗的首选，尽管当完全切除不可能时，可以考虑其他治疗方案。^[2,3]在本报告中，我们总结了2013年至2018年间我科病理诊断为IMT的16例≤18岁患者的临床资料，回顾文献并分享我们对该疾病的诊断和治疗经验。

致编辑：骨关节炎（OA）被定义为一种慢性退行性关节疾病，人们普遍认为遗传因素在OA发病中起重要作用。

致编辑：一名66岁女性出现严重咳嗽，于2014年4月入院。正电子发射断层扫描/计算机断层扫描（PET/CT）显示位于左肺下叶的2.0 cm × 2.0 cm结节，多纵隔淋巴结肿大和胸腔积液[图1A].PET扫描还发现她有多处脑部病变。行胸膜芯针活检，经病理证实为肺腺癌。对肿瘤组织进行直接基因测序，发现表皮生长因子受体（EGFR）外显子19缺失。埃克替尼（贝达，中国），第一代EGFR酪氨酸激酶抑制剂（EGFR TKI），口服剂量为125 mg，每日三次。她还接受了脑转移瘤调强放疗（IMRT），剂量为56GY/28f。根据实体瘤缓解评估标准1.1（RECIST 1.1），患者获得部分缓解（PR）。缓解30个月后，疾病进展，左肺肿瘤增大[图1B].从左肺病变进行再活检，通过扩增难治性突变系统聚合酶链反应（ARMS PCR）检查EGFR基因组，检测EGFR 19 del和EGFR T790 M突变。开始使用奥希替尼，患者在治疗3个月后达到PR[图1C].9个月后肺部肿瘤进展缓慢[图1D].用新的活检肺组织进行下一代测序（NGS），发现EGFR 19 del、T790 M、C797G和V834L突变；突变等位基因分数（MAFs）分别为85.5%、61.5%、36.6%和91.1%。EGFR T790 M和C797G位于cis给予埃克替尼和奥希替尼联合三线治疗。未发生腹泻、皮疹、肺炎或转氨酶炎。治疗2个月后，CT扫描显示疾病稳定[图1E].然而，患者在联合治疗4个月后出现严重的背痛。磁共振成像显示多发性椎体转移。NGS是用患者的血液进行的；结果表明，EGFR19 del/T790M/C797G/V834L突变和MAF分别为0.4%、0.3%、0.6%和0.8%。采用卡铂、培美曲塞联合贝伐单抗全身化疗，目前进行姑息性椎体成形术，然后进行椎体放疗。2018年4月10日末次随访时，患者病情稳定。

致编辑：来源于神经嵴的黑素细胞干细胞（MSCs）作为黑素细胞（MCs）的储存库发挥作用。目前多数学者认为MSCs主要存在于毛囊的隆起处。^[1]在胚胎末期，神经嵴细胞分化为黑素母细胞（MBs），其通过真皮迁移到表皮并进入发育中的毛囊。^[2]当MBs进入毛囊时，它们中的一些迁移到有毛的母亲区域并分化成成熟的MCs，产生色素并将其传递给角质形成细胞(KC)。其他的定居在卵泡中并成为MSCs，其负责MCs的再生。^[3]MSCs的标记标记包括配对盒基因3（PAX3)和多巴色素互变异构酶。^[4]PAX3作为一种重要的转录因子，属于配对盒（PAX）家族，在MB和MCs的分化、迁移和增殖中起着关键作用。^[5]有学者认为PAX3在维持MSCs未分化的分子遗传机制中起关键作用。^[6]所以PAX3可作为MSCs的标志物。除了MSC，在毛囊中也发现了另一种称为毛囊干细胞（HFSC）的干细胞。HFSCs来源于外胚层上皮，具有向多个方向分化的潜力；它们可以接受来自成熟MCs的黑色素并生成含有黑色素的毛干。^[7]HFSC具有各种分子标记，包括CK15、CK19、CD34等。^[8]CD34作为一种粘附分子，选择性地表达于人和其他哺乳动物的干细胞表面，并随着细胞的成熟而逐渐减少。^[9]2010年，有学者利用CD34的免疫组化染色标记毛囊皮肤组织，证明CD34在人毛囊隆起部有特异性良好的阳性表达。^[10]因此，在本研究中，CD34被用作HFSCs的标志物。

致编辑：一名70岁女性因严重胸闷住入呼吸重症监护室。她在7个月前确诊为肺腺鳞癌。由于表皮生长因子受体基因突变和间变性淋巴瘤激酶融合基因均为阴性，给予吉非替尼治疗3个月，随后给予程序性死亡-1药物治疗2个疗程。面部部水肿近1个月，电脑断层扫描显示出现上腔静脉综合征。给予伽玛刀放射外科10次。

致编辑：活体肝移植（LDLT）有效地扩大了供体库。然而，高达40%的活体供体患有术后并发症，这些并发症大多与右肋下剖腹手术伤口有关。^[1]自2013年以来，纯腹腔镜技术已用于活体供体右肝切除术。^[2,3]为了供体的安全，建议对解剖结构正常的选定供体进行纯腹腔镜活体供体右肝切除术（PLDRH）。为了克服肝静脉变异限制，我们报告了一例使用尸体髂动脉同种异体移植物重建肝中静脉（MHV）V段和VIII段支流的PLRDH病例。

致编辑：女性阴道是一个复杂的微生态系统。一般来说，健康女性的阴道微生物群以H为主₂O₂-生产乳酸菌，将阴道上皮细胞中的糖原分解为乳酸，维持阴道正常的酸性环境。^[1]以及主导地位的变化乳酸菌会引起各种阴道感染。阴道炎的常规治疗主要是通过抗生素杀灭病原微生物。同时，乳酸菌对头孢菌素类抗生素、青霉素、克林霉素等敏感。

致编辑：子宫内膜间质肉瘤（ESS）是一种组织学亚型，约占子宫肉瘤的38%。^[1]ESS的早期和完全手术切除是最初的治疗方法。^[2]然而，卵巢保留、淋巴结切除术和术后放疗的局部治疗方式的效果仍不清楚。国际妇产科联合会（FIGO）2009系统将伴有淋巴结转移的ESS患者归类为IIIC期，暗示淋巴结状态对患者预后有显著的不良影响。据全国肿瘤综合网消息，^[3]低级别ESS（LGESS）首选双侧输卵管卵巢切除术，但没有证据支持选择淋巴结切除术，育龄患者的卵巢管理可能个体化。超过80%的LGESS患者为雌激素受体阳性，^[4]对于II至IV期LGESS，建议术后雌激素阻断。^[5,6]对于II期疾病患者，建议将辅助放疗作为术后治疗，以降低局部复发率。然而，非转移性LGESS初次手术（全子宫切除术/双侧输卵管卵巢切除术）后淋巴结切除术的益处仍有争议。^[7]此外，很少有研究发现卵巢切除术和激素受体状态对总生存期（OS）和内分泌治疗没有影响。^[8]也有少数研究表明，术后盆腔放疗不能改善I期或II期子宫肉瘤的OS。^[9]由于这些研究因异质性和小样本量而产生偏差，^[3]我们回顾性回顾了监测、流行病学和最终结果(SEER)18注册数据库（1973-2015年，2017年11月提交）中LGESS患者的治疗，以评估淋巴结切除术、术后放疗和卵巢保留对LGESS患者生存结果（5年OS和5年病因特异性生存[CSS]）的影响。^[10]

在第132卷第6期第735-737页发表的题为“肺癌血液转移中血小板参数和活化标志物的分析”的文章中中华医学杂志,^[1]作者的隶属关系被错误地写成“中国人民解放军第96医院胸外科，中国山东济南250031”，而不是“中国人民解放军第960医院胸外科，中国山东济南250031。”