Volume 132 · Issue 12 · 2019

复杂高危和适应症患者（CHIPs）是指需要血运重建的严重冠状动脉疾病（CAD）患者。然而，这些患者接受该手术的风险增加。^[1]自Kirtane于2016年推出以来，CHIP人群在介入心脏病学领域引起了极大的兴趣等人,^[1]针对该人群的最佳治疗策略几乎在国内外每一个介入论坛上都得到了激烈的讨论。首先，必须进行全面的风险评估，根据临床表现、功能检查和解剖特征确定哪些CAD患者应该接受血运重建。当可以实现完全血运重建时，经皮冠状动脉介入治疗（PCI）可能是一种有益的选择，尤其是对于无法手术或手术风险较高的患者。^[2,3]为了安全有效地用PCI治疗这些高危患者，需要训练有素、具有技术和认知技能的介入医生。

Mental stress-induced myocardial ischemia (MSIMI) is closely associated with adverse cardiac events in patients with coronary artery disease (CAD) and we aimed to determine whether biomarkers and blood pressure could be potential predictors of MSIMI.

This study enrolled 82 patients with documented CAD between June 1, 2017 and November 9, 2017. Patient blood samples were obtained at resting period and at the end of mental arithmetic. Then, patients were assigned to MSIMI positive group and MSIMI negative group. The main statistical methods included linear regression, receiver operating characteristic (ROC) curves, and logistic regression.

Patients with CAD with MSIMI had significantly greater median resting N-terminal pro-brain natriuretic peptide (NT-proBNP, 141.02 [45.85–202.76] pg/mL vs. 57.95 [27.06–117.64] pg/mL; Z = -2.23, P = 0.03) and mean systolic blood pressure (SBP) (145.56 ± 16.87 mmHg vs. 134.92 ± 18.16 mmHg, Z = -2.13, P = 0.04) when compared with those without MSIMI. After 5-min mental stress task, those who developed MSIMI presented higher elevation of median post-stressor high sensitivity cardiac troponin I (hs-cTnI, 0.020 [0.009–0.100] ng/mL vs. 0.009 [0.009–0.010] ng/mL; Z = -2.45, P = 0.01), post-stressor NT-proBNP (138.96 [39.93–201.56] pg/mL vs. 61.55 [25.66–86.50] pg/mL; Z = -2.15, P = 0.03) compared with those without MSIMI. Using the ROC curves, and after the adjustment for basic characteristics, the multiple logistic regression analysis showed that patients presenting a post-stressor hs-cTnI ≥ 0.015 ng/mL had seven-fold increase in the risk of developing MSIMI (odds ratio [OR]: 7.09; 95% confidence interval [CI]: 1.65–30.48; P = 0.009), a rest NT-proBNP ≥ 80.51 pg/mL had nearly eight-fold increase (OR: 7.85; 95% CI: 1.51–40.82; P = 0.014), a post-stressor NT-proBNP ≥ 98.80 pg/mL had 35-fold increase (OR: 34.96; 95% CI: 3.72– 328.50; P = 0.002), a rest SBP ≥ 129.50 mmHg had 11-fold increase (OR: 11.42; 95% CI: 1.21–108.17; P = 0.034).

The present study shows that CAD patients with higher hs-cTnI level, and/or greater NT-proBNP and/or SBP are at higher risk of suffering from MSIMI when compared with those without MSIMI, indicating that hs-cTnI, NT-proBNP, SBP might be potential predictors of MSIMI.

Necroptosis plays an important role in human atherosclerosis and atheroma development. Since receptor interacting protein kinase-3 (RIP3) acts as a key mediator of necroptosis, this study aimed to explore its relationship between plasma RIP3 levels and coronary artery disease (CAD) and discover a potential new biomarker for screening CAD subtypes and severity.

A total of 318 patients with CAD who had coronary angiography and 166 controls in Peking Union Medical College Hospital from September 2017 to January 2018 were enrolled in this study. Patients with CAD were divided into three subgroups: patients with stable coronary artery disease (SCAD), patients with unstable angina (UA), and patients with myocardial infarction (MI). The severity of atherosclerosis was determined by Gensini score (GSS). Logistic regression was used to determine the relationship between plasma RIP3 levels and CAD. The correlation between plasma RIP3 and GSS was calculated using multiple linear regression models.

Overall, plasma RIP3 levels were significantly higher than serum RIP3 levels. Plasma RIP3 levels in patients with CAD were significantly higher than those in controls. Plasma RIP3 levels were strongly associated with CAD (odds ratio: 6.00, 95% confidence interval 3.04–11.81; P < 0.001). Plasma RIP3 levels increased linearly from controls to patients with SCAD, then patients with UA, and finally to patients with MI. We found a significantly positive correlation between proportion of cases of acute coronary syndrome in subjects and their plasma RIP3 level quartile. Plasma RIP3 levels were also associated with GSS (B 0.027; standard error 0.012; P < 0.05).

Plasma RIP3 levels were independently associated with CAD. Plasma RIP3 levels could potentially supplement clinical assessment to screen CAD and determine CAD severity.

The long-term predicted value of microvolt T-wave alternans (MTWA) for ventricular tachyarrhythmia in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) remains unclear. Our study explored the characteristics of MTWA and its prognostic value when combined with an electrophysiologic study (EPS) in patients with ARVC.

All patients underwent non-invasive MTWA examination with modified moving average (MMA) analysis and an EPS. A positive event was defined as the first occurrence of sudden cardiac death, documented sustained ventricular tachycardia (VT), ventricular fibrillation, or the administration of appropriate implantable cardioverter defibrillator therapy including shock or antitachycardia pacing.

Thirty-five patients with ARVC (age 38.6 ± 11.0 years; 28 males) with preserved left ventricular (LV) function were recruited. The maximal TWA value (MaxValt) was 17.0 (11.0–27.0) μV. Sustained VT was induced in 22 patients by the EPS. During a median follow-up of 99.9 ± 7.7 months, 15 patients had positive clinical events. When inducible VT was combined with the MaxValt, the area under the curve improved from 0.739 to 0.797. The receiver operating characteristic curve showed that a MaxValt of 23.5 μV was the optimal cutoff value to identify positive events. The multivariate Cox regression model for survival showed that MTWA (MaxValt, hazard ratio [HR], 1.06; 95% confidence interval [CI], 1.01–1.11; P = 0.01) and inducible VT (HR, 5.98; 95% CI, 1.33–26.8; P = 0.01) independently predicted positive events in patients with ARVC.

MTWA assessment with MMA analysis complemented by an EPS might provide improved prognostic ability in patients with ARVC with preserved LV function during long-term follow-up.

Perioperative and median-term follow-up outcomes have not been compared among procedures using radiofrequency ablation devices for permanent atrial fibrillation with concomitant rheumatic valve disease. We compared the sinus rhythm restoration efficacy of "non-irrigation" ablation forceps and an "irrigation" ablation device in patients with rheumatic valve disease undergoing a modified Cox maze radiofrequency ablation procedure due to permanent atrial fibrillation.

Data of 278 patients with rheumatic valve disease from the Cardiac Surgery Department of Sichuan Provincial People’s Hospital who underwent the modified Cox maze radiofrequency ablation procedure between May 2013 and May 2017 were reviewed. The procedure was performed using "non-irrigation" ablation forceps (AtriCure, group A) in 149 patients and an "irrigation" ablation device (Medtronic, group M) in 129 patients. Data were collected prospectively, and follow-up was documented and compared between the groups.

The radiofrequency procedure duration was 28.9 ± 3.8 min in group A and 29.5 ± 2.8 min in group M (t = 1.623, P = 0.106). The predicted radiofrequency time to the left atrium diameter was (Ya = 0.4964 X + 0.3762, R² = 0.74) in group A and (Ym = 0.4331 X + 4.3563, R² = 0.8435) in group M. The sinus rhythm (SR) conversion rate without use of anti-arrhythmic drugs was similarly good in groups A and M, with 75.2%, 72.5%, and 70.5% vs. 73.6%, 71.3%, and 69.8% at discharge, 6 and 12 months, respectively (F = 0.084, F = 0.046, F = 0.046, P > 0.05, respectively).

Two types of radiofrequency ablation devices characteristic of "non-irrigation" and "irrigation" bipolar ablation forceps were similarly efficient at SR restoration.

Youths are disproportionally affected by the human immunodeficiency virus (HIV) infection. We aimed to assess antiretroviral therapy (ART) initiation and viral suppression rates among student and non-student youths in Hangzhou, China.

Data were taken from the Chinese HIV/acquired immune deficiency syndrome Comprehensive Response Information Management System. Youths aged 15 to 24 years who were newly diagnosed with HIV between 2012 and 2016 and were living in Hangzhou were included in the study. Comparisons between student and non-student youths were made for ART initiation within 30 days, 90 days, and 12 months of HIV diagnosis, and the viral suppression rate at 12 months of HIV diagnosis and at 12 months of ART initiation.

A total of 707 cases met inclusion criteria, 29.6% of which were students and 70.4% were non-student youths. The student group had a higher proportion of ART initiation compared with the non-student group within 30 days of diagnosis (45.5% vs. 37.0%, P = 0.044), and a slightly higher but not statistically significant proportion at 90 days (67.0% vs. 62.7%), and 12 months (83.7% vs. 78.5%) of HIV diagnosis. ART initiation within 30 days improved from <15% in 2012 to over 65% in 2016 in both groups, and ART initiation within 90 days improved from <30% in 2012 to >90% in 2016. A smaller proportion of students experienced viral suppression compared with the non-student group (9.6% vs. 17.1%, P = 0.011) at 12 months after HIV diagnosis, but the suppression rate was similar at 12 months of ART initiation (69.9% vs. 71.1%, P = 0.743).

ART initiation in both student and non-student youths has significantly improved between 2012 and 2016. However, the viral suppression rate remained unacceptably low at 12 months of HIV diagnosis in both student and non-student groups. Specific intervention strategies must be taken to address this challenge.

Methicillin-resistant Staphylococcus aureus (MRSA) pneumonia is an important issue with significant morbidity and mortality in clinical practice, especially in diabetes mellitus (DM). Studies focusing on S. aureus pneumonia in DM is limited, we sought to make a relatively comprehensive exploration of clinical characteristics, antimicrobial resistance, and risk factors for mortality of S. aureus pneumonia in DM and non-diabetics mellitus (non-DM).

A retrospective study was conducted in Ruijin Hospital from 2014 to 2017. The characteristics of DM and non-DM patients were assessed, including demographics, comorbidities, using of invasive mechanical ventilation, Hemoglobin A1c (HbA1C), confusion, urea, respiratory rate, blood pressure, age ≥65 years (CURB-65) score, length of hospital stay, clinical outcomes, antimicrobial susceptibility. Independent risk factors for mortality were identified by univariate and multivariate logistic regression analysis.

A total of 365 patients with S. aureus pneumonia were included in our study, including 144 with DM and 221 non-DM. DM patients were more susceptible to MRSA infection (65.3% vs. 56.1%, P > 0.05), suffered from much severer pneumonia with a higher CURB-65 score, invasive mechanical ventilation rate (46.5% vs. 28.1%, P < 0.01) and mortality rates (30.6% vs. 23.1%, P > 0.05); almost all DM patients had higher antimicrobial resistance than non-DM patients, the DM group had a higher coinfection rate (47.2% vs. 45.7%, P > 0.05), and Acinetobacter baumannii was the most common bacterium in DM, while Klebsiella pneumoniae ranked first in patients with non-DM. Independent risk factors for pneumonia-related mortality were MRSA and CURB-65. Higher HbA1c levels were linked to a higher MRSA infection and co-infection rate and more severe pneumonia, leading to an increase in mortality.

DM patients with poor glucose control are more susceptible to MRSA infection. They suffer from higher antimicrobial resistance, a higher co-infection rate, and much severer pneumonia than non-DM. MRSA itself is an independent risk factor for mortality in all patients.

Previous studies have shown that endogenous T cells play an important role in the prolonged survival time of highgrade glioma (HGG) patients. Our objectives were to investigate the features of T-cell receptor (TCR) repertoires in HGG patients and to elucidate any potential therapeutic value.

During November 2011 and December 2018, tumor tissues and blood samples of 35 patients with HGG who underwent surgery at Beijing Tiantan Hospital or Beijing Shijitan Hospital were selected after surgery. After isolating DNA from samples, multiple rounds of PCR were performed to establish a DNA immune repertoire (IR). Then, the sequences and frequencies of the complementarity-determining 3 (CDR3) region in TCR beta chain (TRB) were identified by high-throughput sequencing and IR analysis. A survival follow-up was conducted monthly thereafter until December 2018. Finally, the t test and Mann-Whitney test were used to compare statistical differences between two sets of data.

The Shannon diversity index (SHDI) of TRB sequences of HGG patients was significantly lower than that of healthy individuals (7.34 vs. 8.45, P = 0.001). The SHDI of TRB sequences of glioblastoma (GBM) patients with more than 16 months survival time was much higher than that of GBM patients with shorter survival times in both tumor tissues (3.48 ± 0.31 vs. 6.21 ± 0.33, t = -5.49, P = 0.002) and blood cells (6.02 ± 0.66 vs. 7.44 ± 0.32, t = -2.20, P = 0.036). In addition, patients achieved a distinctly higher proportion compared to that of healthy individuals in the proportion of TRBV9 and TRBV5 functional regions (9.83% vs. 6.83%, P = 0.001). Surgical tissue from patients who survived more than 16 months yielded a much higher proportion of TRBV4 and TRBV9 regions (7.14% vs. 3.28%, t = 3.18, P = 0.019). In surgical tissues from two GBM patients who survived for longer than 46 months, we found a potentially therapeutic TCR sequence.

HGG patients have less species diversity of TCR repertoires compared with that of healthy individuals. TRBV9 regions in TCRs may be protective factors for long-term survival of GBM patients.

Diagnosis of heparin-induced thrombocytopenia (HIT) is challenging. This study aimed to compare the diagnostic performance of HIT expert probability (HEP) and 4T scores, and to evaluate the inter-observer reliability for the 4T score in a clinical setting.

This prospective study included HIT-suspected patients between 2016 and 2018. Three hematologists assessed the HEP and 4T scores. Correlations between scores and anti-platelet factor 4 (anti-PF4)/heparin antibodies were evaluated. Receiver operating characteristic curves and area under the curve (AUC) were used to assess the predictive accuracy of these two scoring models. The intraclass correlation coefficient (ICC) was used to assess the inter-observer agreement of 4T scores between residents and hematologists.

Of the 89 subjects included, 22 (24.7%) were positive for anti-PF4/heparin antibody. The correlations between antibody titer and either HEP or 4T scores were similar (r = 0.392, P < 0.01 for the HEP score; r = 0.444, P < 0.01 for the 4T score). No significant difference in the diagnostic performance was displayed between these two scores (AUC for the HEP score: 0.778 vs. AUC for the 4T score: 0.741, P = 0.357). Only 72 4T scores were collected from the residents, with a surprisingly low percentage of observers (43.1%) presenting the four individual item scores which made up their 4T score. The AUC of 4T score assessed by residents and hematologists was 0.657 (95% confidence interval [CI]: 536–0.765) and 0.780 (95% CI: 0.667–0.869, P < 0.05), respectively. The ICC of 4T score between residents and hematologists was 0.49 (95% CI: 0.29–0.65, P < 0.01), demonstrating a fair inter-observer agreement.

The HEP score does not display a better performance for predicting HIT than the 4T score. With the unsatisfactory completion rate, the inter-observer agreement of 4T score in a tertiary hospital is fair, underscoring the necessity for continuing education for physicians.

There is no absolute consensus for the best time for triggering. The aim of this study was to investigate the effect of different proportion of dominant follicles (PDF) on the human chorionic gonadotropin (HCG) day for the clinical outcomes in patients with polycystic ovary syndrome (PCOS) of different ovarian stimulation protocols.

A total of 371 cycles of the gonadotropin-releasing hormone (GnRH) agonist long protocol and 347 cycles of GnRH antagonist protocol from January 2014 to December 2016 were included in this retrospective study. Based on the PDF on the day of the HCG administration, the included patients were divided into three groups: Group A (low PDF), PDF <20%; Group B (medium PDF), 20%≤ PDF ≤40%; Group C (high PDF), PDF >40%. The measurements regarding ovarian stimulation characteristics, fertilization rate, top quality embryo rate, clinical pregnancy rate, and ovarian hyperstimualtion syndrome (OHSS) rate were compared in different PDF groups with different protocols.

In both the GnRH antagonist protocol and GnRH agonist long protocol, the characteristics such as mean age, anti-Mullerian hormone, antral follicle count (AFC), and body mass index were comparable between groups. The number of oocytes retrieved decreased statistically significantly as the PDF and rate of matured oocytes increased. In the GnRH agonist long protocol, the rate of normally fertilized oocytes was highest in Group A (59.74 ± 31.21 vs. 49.70 ± 37.95, 49.67 ± 36.62; F = 3.743, P = 0.025). There were no significant differences in the rate of top-quality embryos and the clinical pregnancy rate between the groups. The clinical pregnancy rate was similar in the three groups (63.6%, 62.5%, 67.5%, respectively, χ² = 0.989, P = 0.911). The moderate and severe OHSS rate increased statistically significantly when the PDF increased, which was highest in group C (1.4%, 3.1%, 6.7%, respectively, χ² = 12.014, P = 0.017). In the GnRH antagonist protocol, there were no significant differences in the rate of top-quality embryos, the rate of normally fertilized oocytes, the clinical pregnancy rate, and the moderate and severe OHSS rate between the groups. The clinical pregnancy rate in Group C was higher than that in Group A (57.9% vs. 46.6%, χ² = 10.850, P = 0.093).

In the GnRH antagonist protocol, PDF on the HCG day of less than 20% may be unfavorable to the clinical pregnancy rate in PCOS. In the GnRH agonist long protocol, delaying the HCG trigger timing has no good effect on clinical pregnancy and the risk of OHSS might increase in patients with PCOS.

This study was designed to evaluate the clinical and radiographic outcomes of patients with nutcracker syndrome (NCS) who were treated with three-dimensional printing (3DP) extravascular titanium stents (EVTSs). The 3DP EVTS was expected to release the hypertension of the left renal vein (LRV) produced by its compression between the superior mesenteric artery (SMA) and the aorta without causing any complications.

The pre-operative kidney model of each patient was printed out to enable surgical planning. After that, the EVTS was designed based on the LRV’s primitive physiologic structure using computer-aided design software, and each stent was printed out with a precision setting of 20 μm. Seventeen patients who had been suffering from NCS underwent laparoscopic 3DP EVTS placement. The surgical procedure was designed for the placement of EVTS, taking great care in positioning and fixing the stent. Surgical data, which included patient demographic characteristics as well as pre- and post-operative test results, were collected and analyzed.

The mean duration of surgery was 75 ± 9 min, and the mean blood loss was 20 ± 5 mL. Computed tomography examinations revealed that the pre- and post-operative angle between the SMA and the aorta ranged from 18.7° ± 4.3° to 48.0° ± 8.8° (P < 0.05); in patients with left varicocele, the mean diameter of the left spermatic vein ranged from 3.7 ± 0.5 to 1.3 ± 0.2 mm (P < 0.05). Moreover, Doppler ultrasound examinations showed that the peak velocity of blood flow at the hilar area ranged from 12.4 ± 3.3 to 18.5 ± 3.4 cm/s (P < 0.05). No side effects were observed in the 24 to 42 months following surgery.

The findings after 2 years of follow-up suggest that the 3DP EVTS is a safe and effective minimally invasive alternative for the treatment of NCS.

Low handgrip strength (HS) and declining gait speed (GS) are increasingly obvious with aging, requiring effective, and safe medication for treatment. Trimetazidine (TMZ) modified release tablets, a common anti-angina drug, has potential benefits for alleviating the condition, but this has not yet been fully studied and therefore is the aim of this study.

This is a prospective randomized controlled study. Fifty-eight eligible patients will be randomly assigned to one of two study groups: TMZ group or control group. For the TMZ group, a dose of 35 mg of oral TMZ will be administered with a meal twice a day for 3 months, in addition to any conventional treatments for angina. Only conventional treatments for angina will be administrated in the control group. The primary outcome will be the 6-min walking distance and the secondary outcomes will be: muscle strength (HS and pinch strength), GS, muscle endurance (five times sit-to-stand test), balance maintenance (tandem standing test), and the frequency of angina per week. Additionally, body mass index, circumferences (biceps, waist, hip, and calf), albumin levels, and the score on a five-question scale for sarcopenia will be obtained during the study.

This study aims to evaluate the usefulness of TMZ in a population with poor muscle function. The results may provide an effective and safe medical treatment to people with low muscle strength or physical performance.

Chinese Clinical Trial Registry, ChiCTR1800015000; www.chictr.org.cn/showproj.aspx?proj=25445.

The 3-N-butylphthalide (NBP) comprises one of the chemical constituents of celery oil. It has a series of pharmacologic mechanisms including reconstructing microcirculation, protecting mitochondrial function, inhibiting oxidative stress, inhibiting neuronal apoptosis, etc. Based on the complex multi-targets of pharmacologic mechanisms of NBP, the clinical application of NBP is increasing and more clinical researches and animal experiments are also focused on NBP. The aim of this review was to comprehensively and systematically summarize the application of NBP on neurologic diseases and briefly summarize its application to non-neurologic diseases. Moreover, recent progress in experimental models of NBP on animals was summarized.

Literature was collected from PubMed and Wangfang database until November 2018, using the search terms including "3-N-butylphthalide," "microcirculation," "mitochondria," "ischemic stroke," "Alzheimer disease," "vascular dementia," "Parkinson disease," "brain edema," "CO poisoning," "traumatic central nervous system injury," "autoimmune disease," "amyotrophic lateral sclerosis," "seizures," "diabetes," "diabetic cataract," and "atherosclerosis."

Literature was mainly derived from English articles or articles that could be obtained with English abstracts and partly derived from Chinese articles. Article type was not limited. References were also identified from the bibliographies of identified articles and the authors’ files.

NBP has become an important adjunct for ischemic stroke. In vascular dementia, the clinical application of NBP to treat severe cognitive dysfunction syndrome caused by the hypoperfusion of brain tissue during cerebrovascular disease is also increasing. Evidence also suggests that NBP has a therapeutic effect for neurodegenerative diseases. Many animal experiments have found that it can also improve symptoms in other neurologic diseases such as epilepsy, cerebral edema, and decreased cognitive function caused by severe acute carbon monoxide poisoning. Moreover, NBP has therapeutic effects for diabetes, diabetes-induced cataracts, and non-neurologic diseases such as atherosclerosis. Mechanistically, NBP mainly improves microcirculation and protects mitochondria. Its broad pharmacologic effects also include inhibiting oxidative stress, nerve cell apoptosis, inflammatory responses, and anti-platelet and anti-thrombotic effects.

The varied pharmacologic mechanisms of NBP involve many complex molecular mechanisms; however, there many unknown pharmacologic effects await further study.

致编辑：与经股动脉通路（TFA）相比，经桡动脉通路（TRA）用于经皮冠状动脉介入治疗（PCI）已被证明可显著降低30天死亡率、院内主要心脏和心血管不良事件（30天死亡率和院内心肌再梗死、靶血管血运重建和脑血管事件的复合）、大出血和通路部位并发症。^[1]TRA更容易压缩，最大限度地降低了血肿风险，并降低了与另一个通路的交叉率。患者可在手术后立即行走，住院时间可显著缩短。在一些中心，TRA患者可以在手术当天出院。它也优于使用闭合装置的TFA，成为近期PCI的首选入路部位。^[2]

致编辑：持续性第五主动脉弓（PFAA）是一种罕见的先天性心血管畸形，发生在胚胎期咽部第五主动脉弓未退化时。1969年的尸检标本中描述了第一例PFAA。^[1]1973年，首次报道了左第五主动脉弓的持续存在。^[2]此后，几份病例报告以不同的形式描述了PFAA。与主动脉弓A型中断（A型IAA）相关的PFAA狭窄在临床实践中最常见，需要手术干预。2013年至2018年六宗[表1和表2]使用超声心动图和计算机断层血管造影（CTA）进行诊断。5例手术治疗成功，并随访。本研究的目的是总结与A型IAA相关的PFAA狭窄的临床特征和诊断特征，以提高其诊断准确性，并允许完整的术前准备和适当的治疗。

致编辑：患者女，89岁，有吞咽困难和下颌抽搐3天病史。她有高血压、糖尿病、手术矫正的左肱骨近端骨折和右C5皮区带状疱疹后神经痛病史。下巴抽搐导致吞咽困难，无法喝液体。体格检查证实持续性下颌肌阵挛（补充视频；http://links.lww.com/CM9/A48）。患者完全清醒，其他肢体无抽搐或眼球震颤。神经系统检查和生化分析结果（包括全血谱、电解质水平、随机葡萄糖浓度、肾功能检查和肝功能检查）均在正常范围内。大脑的计算机断层扫描并不明显，脑电图显示没有癫痫发作的证据。对其处方药物的仔细审查揭示了以下情况：患者在大约3个月前主诉右侧C5皮区异常性疼痛，并被开了加巴喷丁。大约2个月前，加巴喷丁的剂量增加至300 mg总溶解固体（TDS）。肌酐水平正常，但根据Cockcroft-Gault方程估计，她的肾小球滤过率为36 mL/min。^[1]由于患者的亲属监督她的药物摄入，用药过量是不可能的。停用加巴喷丁，代之以普瑞巴林50 mg BD，并短暂给予患者安定2 mg TDS。下颌肌阵挛在第二天消退。在咨询语言治疗师后，患者恢复口服摄入，并保持对正常饮食的耐受性。1个月后复查时，患者仍无下颌肌阵挛。

致编辑：肌萎缩侧索硬化（ALS）是一种以上下运动神经元缺失为特征的异质性疾病，既没有明确的发病机制，也没有有效的治疗方法。因此，需要潜在的生物标志物来对疾病进行分类并找到新的药物靶标。先前的研究表明，在希腊和意大利ALS队列中约23%的患者中发现了针对低密度脂蛋白受体相关蛋白4（LRP4）的自身抗体，称为抗LRP4抗体，^[1]在10%的美国ALS人口中。^[2]抗LRP4抗体先前在最常见的神经肌肉接头(NMJ)疾病重症肌无力(MG)中被鉴定，并在动物研究中显示导致NMJ异常。^[3]在这里，我们研究了中国患者的抗LRP4抗体，并研究了抗LRP4抗体与ALS异常神经肌肉传递之间的相关性。

致编辑：阿尔茨海默病(AD)是最常见的神经退行性疾病，占痴呆病例的大多数。AD的全球患病率正在上升，对老年人及其家庭来说是一个越来越大的挑战。^[1]每10名AD患者中就有7名在家中接受非正式护理，依靠共同居住的家庭成员，尤其是配偶。^[2]然而，这种疾病的影响存在文化差异。例如，与西方社会痴呆症患者的照顾者相比，中国痴呆症患者的照顾者在抑郁和照顾者负担方面的得分更高。^[3]重要的是要考虑到AD不仅会影响患者，还会影响他们的护理人员，尤其是一半以上时间与患者在一起的配偶护理人员。^[4]随着AD的进展，患者越来越依赖护理人员。与此同时，照顾者的负担越来越重，其特征是照顾受损老年人的家庭成员经历的身体、心理或情感、社会和经济问题。^[5]此外，经常报道睡眠障碍症状与AD护理人员的健康后果相关。^[6]

致编辑：肺炎支原体是导致儿童呼吸道感染的常见病原体，常引起其他多个器官和组织的免疫相关损伤。据报道，5%至7%的患者累及中枢神经系统肺炎支原体感染。^[1]的临床表现肺炎支原体脑炎具有高度异质性，半数以上患者在急性期发作，严重者出现癫痫持续状态。^[2]

致编辑：患者女，24岁，主诉乏力和足底水肿。她在4年前被诊断为系统性红斑狼疮（SLE），因此无法追踪诊断标准。患者接受泼尼松龙、羟氯喹、环磷酰胺治疗2年，病情控制稳定。偶尔，下肢疼痛是她唯一的主诉，泼尼松龙可以缓解疼痛。入院前8个月出现进行性腹胀、下肢水肿。在当地医院腹部超声检查显示有腹水；于是给病人用利尿剂治疗，让她感觉好多了。但5个月后，患者向当地医院报告呼吸急促。胸部计算机断层扫描（CT）显示双侧胸腔积液。她再次服用利尿剂，但没有明显缓解。2017年3月，患者入住我科。体检时，她的体温和血压正常。她被诊断为呼吸音减弱、腹水和双腿水肿。她的脚踝又肿又痛。实验室检查结果如下：白细胞（WBC）为1340/mm³，但无贫血或血小板减少。C反应蛋白为14 mg/dL。抗核抗体滴度为1:32 0（颗粒型），而抗双链DNA抗体、抗Sm抗体、抗心磷脂抗体和狼疮抗凝剂均为阴性。补体C3为45.1 mg/dL（正常范围78.5-152.0 mg/dL），C4为4.84 mg/dL（正常范围14.5-36 mg/dL）。库姆斯试验呈阳性。蛋白尿定量为0.36 g/24h，肾功能正常。白蛋白为3.35 g/dL，铁蛋白为42.49 ng/mL。CA125为949 IU/mL（正常范围为0-35 IU/mL），而其他肿瘤标志物包括甲胎蛋白（AFP）、癌胚抗原（CEA）和CA199均正常。胸部CT显示胸膜心包积液，腹部超声显示大量腹水和脾肿大。

致编辑：蓝色橡胶泡痣综合征（BRBNS）是一种罕见的全身性血管疾病，以累及多个器官的多发性静脉畸形为特征。BRBNS可发生于各种器官，但最常受累的器官是皮肤和胃肠道。BRBNS的胃肠道病变可导致急性或慢性出血和贫血。^[1]在目前的数据库中只能找到几例BRBNS孕妇的病例报告，其中大多数合并胃肠道出血。我们报告了一例妊娠期BRBNS，患有严重肺栓塞（PE）并成功复苏。

致编辑：一名46岁女性（孕妇3，第1段）在华西第二医院就诊，主诉子宫占位性病变，2年前在华西第二医院被诊断为子宫囊肿。前一次B超检查发现盆腔左侧有分隔结构的囊性肿块（10.3 × 5.4 × 8.8 cm），腹腔镜探查发现子宫后壁有囊性肿块，根据速冻手术组织病理分析诊断为“平滑肌瘤伴囊性变性”。行腹腔镜“肌瘤切除术”，石蜡包埋组织病理分析证实“平滑肌瘤伴变性”。免疫组织化学显示病变caldesmon阳性，但CD10阴性。Ki67阳性率小于1%，提示良性病变。这位妇女手术后恢复得很好。术后3个月随访超声检查发现子宫囊性肿块3.0 × 2.5 × 1.7 cm。

致编辑：胰腺癌（PC）是一种致命的恶性肿瘤，总体5年生存率为5%至15%，尽管其发病率较低，但仍被列为全球癌症死亡的第七大原因。^[1,2]早期检测似乎是提高PC患者总生存率的最有效方法。然而，早期检测PC的困难在于缺乏特异性症状和可靠的生物标志物。目前，碳水化合物抗原19-9（CA 19-9）是广泛用于PC检测的血清生物标志物。然而，10%的PC患者不能产生CA 19-9，并且血清CA 19-9在早期癌症患者中经常不存在。此外，经常发现CA 19-9在良性病症或其他癌症中升高，使得其效用受到限制。因此，识别新的诊断生物标志物以改善PC检测是重要的。

我们很高兴读了张的文章等人^[1]关于一项对102例线粒体脑肌病、乳酸性酸中毒和卒中样发作（MELAS）癫痫患者的回顾性研究，其中评估了残疾和结局（中位随访：4年）。与其他抗癫痫药物（AED）相比，左乙拉西坦（LEV）给药与更好的结局相关。^[1]这项研究有几个缺点需要讨论。