Volume 132 · Issue 16 · 2019

社区获得性肺炎（CAP）是一种常见的呼吸系统疾病，被认为是各种传染病中导致死亡的主要原因。^[1,2]一项基于大型人群的研究显示，在诊断为肺炎的住院患者中，21%的患者需要入住重症监护室（ICU），6%需要有创机械通气，2%死亡。^[3]尽管近年来治疗策略有了显著改善，但CAP，尤其是重度CAP（SCAP）的发病率和死亡率仍然很高。不同的多中心队列研究报告了SCAP的死亡率在17%至49%之间。^[4]美国传染病学会（IDSA）、美国胸科学会（ATS）和中国胸科学会传染病大会发布了CAP共识指南（IDSA/ATS 2007，CTS 2016），明确定义了SCAP标准。^[5]根据IDSA/ATS SCAP标准，需要入住ICU的SCAP患者应至少具备一项主要标准（有创机械通气或需要血管加压药的感染性休克）或至少三项次要标准（呼吸频率≥30次/min、氧合指数(PaO2/FiO2)比值≤250、多叶浸润、体温过低（核心温度<36℃）、白细胞减少（白细胞计数<4000个细胞/mm³）、血小板减少症（血小板计数<100,000个细胞/mm³）、需要积极液体复苏的低血压、意识模糊/定向障碍和尿毒症（血尿素氮（BUN）≥20 mg/dL）。^[5]

Extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (E. coli) and Klebsiella pneumoniae (K. pneumoniae) are the important pathogens causing pneumonia. This study aimed to investigate the clinical characteristics and molecular epidemiology of ESBL-producing E. coli and K. pneumoniae causing pneumonia at a large teaching hospital in China.

We collected patient’s clinical data and ESBL-producing E. coli and K. pneumoniae strains causing pneumonia (from December 2015 to June 2016) at a hospital in Wuhan. The susceptibilities, multi-locus sequence typing, homologous analysis, ESBL genes by polymerase chain reaction and sequencing were determined.

A total of 59 ESBL-producing strains (31 E. coli and 28 K. pneumoniae) isolated from patients with pneumonia were analyzed. The majority of strains were isolated from patients were with hospital-acquired pneumonia (37/59, 62.7%), followed by community-acquired pneumonia (13/59, 22.0%), and ventilator-related pneumonia (9/59, 15.3%). The E. coli ST131 (9 isolates, 29.0%) and K. pneumoniae ST11 (5 isolates, 17.9%) were the predominant sub-types. The most prevalent ESBL gene was CTX-M-14, followed by SHV-77, CTX-M-3, SHV-11, and CTX-M-27. At least 33 (55.9%) of the ESBL-producing strains carried two or more ESBL genes. The ISEcp1 and IS26 were found upstream of all blaCTX-M (CTX-Ms) and of most blaSHV (SHVs) (57.6%), respectively. Moreover, three ESBL-producing K. pneumoniae ST11 strains which were resistant to carbapenems carried the bla_NDM-1 and bla_KPC-2, two of which also bearing bla_OXA-48 were resistant to all antibiotics (including Tigecycline).

Hospital-acquired pneumonia is more likely correlated with ESBL-producing E. coli and K. pneumoniae. ESBL-producing E. coli ST131 and multi-drug resistance ESBL-producing, as well as New Delhi metallo-β-lactamase-1 (NDM-1) and Klebsiella pneumoniae carbapenemases-2 (KPC-2) bearing K. pneumoniae ST11 are spreading in patients with pneumonia in hospital.

Cross-sectional area (CSA) for small pulmonary vessels is considered a parameter of pulmonary vessel alterations in patients with chronic obstructive pulmonary disease. This study was to evaluate the correlation of CSA with airflow obstruction parameters in asthma. Furthermore, we aimed to measure the difference in vascular alteration between asthma phenotypes and evaluate its relation with cytokine levels.

We consecutively enrolled 20 adult asthmatic patients (13 women: age range, 26–80 years) and 20 healthy controls (8 women: age range, 23–61 years) from Peking University Third Hospital. Total CSA <5 mm² (CSA<5) was measured with 64-slice spiral computed tomography, and the percentage CSA <5 for the lung area (%CSA<5) was calculated. Data were corrected for body surface area to obtain sixth-generation airway luminal diameter (LD_cor), luminal area (Ai_cor), and airway wall thickness, and airway wall area percentage (WA%) was calculated. Enzyme-linked immunosorbent assay was used to detect the expression of leptin, total immunoglobulin E, periostin, and transforming growth factor β1 in serum and matrix metalloproteinase 9 in induced sputum supernatant of asthmatic patients. The differences in %CSA<5 between subgroups were assessed by independent samples Student’s t test, and Spearman correlation analysis was used to analyze the correlation of %CSA<5 with clinical indexes and inflammatory cytokine levels.

Patients with asthma and controls did not differ in %CSA<5. In asthma patients, %CSA<5 was lower with initial onset age ≤12 years old, airflow restriction and uncontrolled Global Initiative for Asthma classification (all P < 0.05). Moreover, it was positively correlated with forced vital capacity ratio in 1 s (FEV₁)/forced expiratory volume ratio, FEV₁%, LD_cor, Ai_cor, and serum leptin level (all P < 0.05) and negatively with total lung WA% (P = 0.007).

%CSA<5 of pulmonary small vessels was well correlated with airflow limitation indexes and sixth-generation airway parameters. It has certain significance in predicting the clinical control of asthma.

Little study has investigated the differences between Talatomyces marneffei (T. marneffei) respiratory infection and tuberculosis and the prognostic factors of such infection. This study investigated the characteristics and prognostic factors of T. marneffei infections with respiratory lesions and the causes of misdiagnosis.

Clinical characteristics and prognoses of patients with T. marneffei infections with respiratory system lesion were investigated. T. marneffei diagnosis followed isolation from clinical specimens using standard culture, cytology, and histopathology. Survival curves were estimated by using Kaplan-Meier analysis, with log-rank test to compare differences in survival rates between groups. Univariate and multivariate Cox regression analyses were also performed to assess significant differences in clinical characteristics of overall survival.

Of 126 patients diagnosed with T. marneffei infections, 63 (50.0%) had T. marneffei respiratory system infections; 38.1% (24/63) were misdiagnosed as having tuberculosis. Human immunodeficiency virus (HIV) infection, CD4/CD8 < 0.5, percentage of CD4⁺ T cells <42.8%, and length of time from onset to confirmation of diagnosis >105 days were potential risk factors for poor prognoses. Length of time from onset to confirmation of diagnosis persisted as an independent predictor of all-cause mortality in multivariate analysis (odds ratio: 0.083, 95.0% confidence interval: 0.021–0.326, P < 0.001). However, the size of the lung lesions, dyspnea, thoracalgia, mediastinal lymphadenopathy, and pleural effusion did not significantly predict overall survival. There was no significant difference in prognosis according to the type of treatment.

T. marneffei infections involving the respiratory system are common. The critical determinants of prognosis are HIV infection, CD4/CD8, percentage of CD4⁺ T cells, type of treatment, and the time range from onset to confirmation of diagnosis. Rapid and accurate diagnosis is crucial for improving prognosis.

Differential diagnosis of idiopathic Parkinson disease (IPD) and multiple system atrophy-Parkinson type (MSA-P) is challenging since they share clinical features with parkinsonism and autonomic dysfunction. To distinguish MSA-P from IPD when the symptoms are relatively mild, we investigated the usefulness of the quantitative fractionalized autonomic indexes and evaluated the correlations of autonomic test indexes and functional status.

Thirty-six patients with parkinsonism (22 with IPD and 14 with MSA-P) in Soonchunhyang University Bucheon Hospital from February 2014 to June 2015 were prospectively enrolled in the study. We compared fractionalized autonomic indexes and composite autonomic scoring scale between patients with IPD and MSA-P with Hoehn and Yahr (H&Y) score ≤3. Parasympathetic indexes included expiratory/inspiratory ratio during deep breathing, Valsalva ratio (VR), and regression slope of systolic blood pressure (BP) in early phase II (vagal baroreflex sensitivity) during Valsalva maneuver. Sympathetic adrenergic indexes were pressure recovery time (PRT) and adrenergic baroreflex sensitivity (BRSa) (BP decrement associated with phase 3 divided by the PRT), sympathetic index 1, sympathetic index 3, early phase II mean BP drop, and pulse pressure reduction rate. Additionally, we compared the unified multiple system atrophy rating scale (UMSARS) and H&Y scores and the autonomic indexes in all patients.

PRT was significantly different between the IPD and MSA-P groups (P = 0.004) despite the similar BP drop during tilt. Cutoff value of PRT was 5.5 s (sensitivity, 71.4%; specificity, 72.7%). VR (r = -0.455, P = 0.009) and BRSa (r = -0.356, P = 0.036) demonstrated a significant correlation with UMSARS and H&Y scores.

Among the cardiovascular autonomic indexes, PRT can be a useful parameter in differentiating the early stage of MSAP from that of IPD. Moreover, VR, and BRSa may be the optimal indexes in determining functional symptom severity.

The development of auditory and speech perception ability of children with hearing loss is affected by many factors after they undergo cochlear implantation (CI). Age at CI (CI age) appears to play an important role among these factors. This study aimed to evaluate the development of auditory and speech perception ability and explore the impact of CI age on children with prelingual deafness present before 3 years of age.

Two hundred and seventy-eight children with pre-lingual deafness (176 boys and 102 girls) were included in this study, and the CI age ranged from 6 to 36 months (mean age, 19 months). Categorical auditory performance (CAP) was assessed to evaluate auditory ability, and the speech intelligibility rating was used to evaluate speech intelligibility. The evaluations were performed before CI and 1, 3, 6, 12, 18, 24, 36, 48, and 60 months after CI.

The auditory ability of the pre-lingually hearing-impaired children showed the fastest development within 6 months after CI (k = 0.524, t = 30.992, P < 0.05); then, the progress started to decelerate (k = 0.14, t = 3.704, P < 0.05) and entered a plateau at the 24th month (k = 0.03, t = 1.908, P < 0.05). Speech intelligibility showed the fastest improvement between the 12th and 24th months after CI (k = 0.138, t = 5.365, P < 0.05); then, the progress started to decelerate (k = 0.026, t = 1.465, P < 0.05) and entered a plateau at the 48th month (k = 0.012, t = 1.542, P < 0.05). The CI age had no statistical significant effect on the auditory and speech abilities starting at 2 years after CI (P < 0.05). The optimal cutoff age for CI was 15 months.

Within 5 years after CI, the auditory and speech ability of young hearing-impaired children continuously improved, although speech development lagged behind that of hearing. An earlier CI age is recommended; the optimal cutoff age for CI is at 15 months.

There are only very few reports on clinical outcomes using multi-channel applicators (MCA) for patients with endometrial cancer (EC) in China. We aimed to evaluate the clinical experience of treating intermediate-risk (IR) to high-risk (HR) stage I EC using in-house made multi-channel applicators (IH-MCA) in a single institution.

Three hundred and ninety patients with stage I IR to HR EC were treated with hysterectomy and adjuvant radiotherapy from 2003 to 2015. All patients received post-operative vaginal cuff brachytherapy (VBT) alone or as a boost after external beam radiotherapy (EBRT). The prescriptions were 500 cGy per fraction for a total of 5 to 6 fractions with brachytherapy alone or 400 to 600 cGy per fraction for 2 to 3 fractions if it was combined with EBRT. Two types of applicators including a traditional rigid IH-MCA and a recent model custom-made with 3 dimension printing technology were used for treatment. The Kaplan-Meier method was used to calculate survival rate.

Follow-up rate was 92.8% and the median follow-up time was 48 months (range 4–172 months). The 5-year overall survival (OS), progression-free survival, local recurrence, and distant metastasis rates for all patients were 96.3%, 92.1%, 2.9%, and 4.8% respectively. Two patients had isolated relapse in vagina outside the irradiated volume. The univariate and multivariate analysis showed that age and grade were the prognostic factors correlated with OS (hazard ratio: 0.368, 95% confidence interval [CI]: 0.131–1.035, P = 0.048; hazard ratio: 0.576, 95% CI: 0.347–0.958, P = 0.026,).

For patients with IR to HR stage I EC, adjuvant VBT alone or in combination with EBRT using IH-MCA led to excellent survival and recurrence rates. Age and grade were the prognostic factors correlated with OS.

Henoch-Schonlein purpura nephritis (HSPN) is a very common secondary kidney disease of childhood. Its pathogenesis and the treatment mechanism of glucocorticoid have not been fully elucidated. The aim of this study was to determine the relationship between p300 and the pathogenesis, glucocorticoid therapy in mice with HSPN, respectively.

Forty-eight C57BL/6N male mice, weighing 18 to 20 g, were selected (3–4 weeks old, n = 8 per group). The mice in the normal control group (Group I) were given normal solvent and the HSPN model group (Group II) were given sensitizing drugs. The mice in Group III were injected intraperitoneally with dexamethasone after being given sensitizing drugs. Meanwhile, mice in Groups IV, V and VI with conditional knockout of p300 were also given normal solvent, sensitizing drugs and dexamethasone. The levels of serum IgA, creatinine, and circulating immune complex (CIC) concentrations, 24 h urinary protein and urinary erythrocyte in C57 wild mice, and p300 conditional knockout mice in each group were measured. The expression of p300 in renal tissues and the expression of glucocorticoid receptor (GR) α and β, transforming growth factor (TGF)-β1, and activator protein (AP)-1 after dexamethasone treatment were determined by real-time polymerase chain reaction and Western blotting.

Compared with the normal solvent control group (Group I), the expression of p300 mRNA in the model group (Group II) was significantly up-regulated. Western blotting further confirmed the result. Urinary erythrocyte count, 24 h urinary protein quantification, serum IgA, CIC, and renal pathologic score in Group V were distinctly decreased compared with non-knockout mice in Group II (9.7 ± 3.8 per high-power field [/HP] vs. 18.7 ± 6.2/HP, t = 1.828, P = 0.043; 0.18 ± 0.06 g/24 h vs. 0.36 ± 0.08 g/24 h, t = 1.837, P = 0.042; 18.78 ± 0.85 mg/mL vs. 38.46 ± 0.46 mg/mL, t = 1.925, P = 0.038; 0.80 ± 0.27 μg/mL vs. 1.64 ± 0.47 μg/mL, t = 1.892, P = 0.041; 7.0 ± 0.5 vs. 18.0 ± 0.5, t = 1.908, P = 0.039). Compared with non-knockout mice (Group III), the level of urinary erythrocyte count and serum IgA in knockout mice (Group VI) increased significantly after treatment with dexamethasone (3.7 ± 0.6/HP vs. 9.2 ± 3.5/HP, t = 2.186, P = 0.024; 12.38 ± 0.26 mg/mL vs. 27.85 ± 0.65 mg/mL, t = 1.852, P = 0.041). The expression level of GRα was considerably increased in the knockout group after dexamethasone treatment compared with non-knockout mice in mRNA and protein level (t = 2.085, P = 0.026; t = 1.928, P = 0.035), but there was no statistically significant difference in the expression level of GRβ between condition knockout and non-knockout mice (t = 0.059, P = 0.087; t = 0.038, P = 1.12). Furthermore, the expression levels of glucocorticoid resistance genes (AP-1 and TGF-β1) were notably increased after p300 knockout compared with non-knockout mice in mRNA and protein level (TGF-β1: t = 1.945, P = 0.034; t = 1.902, P = 0.039; AP-1: t = 1.914, P = 0.038; t = 1.802, P = 0.041).

p300 plays a crucial role in the pathogenesis of HSPN. p300 can down-regulate the expression of resistance genes (AP-1 and TGF-β1) by binding with GRα to prevent further renal injury and glucocorticoid resistance. Therefore, p300 is a promising new target in glucocorticoid therapy in HSPN.

The effect and mechanism of Saccharomyces boulardii (Sb) in inflammatory bowel disease are unclear. The objective of the study was to evaluate the impact of Sb on intestinal mucosal barrier and intestinal flora in a colitis mouse model.

Forty C57BL/6J male mice were randomly assigned to five groups: normal control group (A), pathologic control group (B), Sb treatment group (C), mesalazine treatment group (D), and Sb combined with mesalazine treatment group (E). Colitis was induced by the addition of 2.5% (wt/vol) dextran sodium sulfate (DSS) in the drinking water ad libitum for 7 days. The general condition, weight change, stool property, and bloody stool level of mice were observed to evaluate the disease activity index. The expression of zona occludens-1 (ZO-1) and occludin in intestinal tissue were measured by immunohistochemistry. The level of tumor necrosis factor-α (TNF-α) and interleukin (IL)-8 in plasma was measured by enzyme linked immunosorbent assay. Inter-cellular tight junctions were observed by transmission electron microscopy. The feces and intestinal contents were collected sterilely, and intestinal flora was analyzed by 16S rRNA sequencing.

Compared with group B, Sb reduced the disease activity index and histological score of group C (disease activity index: group B 2.708 ± 0.628, group C 1.542 ± 0.616, P_BC = 0.005; histological score: group B 9.875 ± 3.271, group C 4.750 ± 1.832, P_BC = 0.005) in DSS-induced colitis in mice. Sb exerted a protect effect on the expression of ZO-1 (group B 2.075 ± 1.176, group C 4.225 ± 1.316, P_BC = 0.019) and occludin (group B 2.200 ± 0.968, group C 3.525 ± 1.047, P_BC = 0.023). Compared with group B, Sb decreased the level of TNF-α and IL-8 of group C (TNF-α: group B 716.323 ± 44.691 ng/L, group C 521.740 ± 90.121 ng/L, P_BC = 0.001; IL-8: group B 128.992 ± 11.475 pg/mL, group C 106.283 ± 15.906 pg/mL, P_BC = 0.012). Treatment with Sb preserved the tight junctions and ameliorated microvilli and inter-cellular space. Treatment with Sb also showed its own characteristics: a higher percentage of Bacteroidetes and a lower percentage of Firmicutes, with significant differences or a significant trend. The proportion of the S24-7 family was increased significantly in the Sb treatment group.

Sb shows an anti-inflammatory effect and has a protective effect on the intestinal mucosal mechanical barrier. Sb may up-regulate the abundance of family S24-7 specifically, and maybe a mechanism underlying its function.

Nickel-induced allergic contact dermatitis (Ni-ACD) is a global health problem. More detailed knowledge on the skin uptake of haptens is required. This study aimed to investigate the penetration process and distribution of nickel in skin tissues with late phase and early phase of Ni-ACD to understand the mechanisms of metal allergy.

Forty Hartley guinea pigs were divided into four groups according to the NiSO₄ sensitizing concentration and the NiSO₄ challenged concentration: the 5% NiSO₄-group, 5% to 10% (sensitization-challenge; late phase group); 10% NiSO₄-group, 10% to 10% (sensitization-challenge; early-phase group); and the positive and negative controls. Pathological biopsies were performed on each group. The depth profile of nickel element concentration in the skin of guinea pigs was detected by synchrotron radiation micro X-ray fluorescence spectroscopy (SR-μ-XRF) and micro X-ray absorption near-edge spectroscopy (μ-XANES).

In each section, the nickel element concentration in both the 5% NiSO₄-group and 10% NiSO₄-group was significantly higher than that in the negative control group. In the upper 300-μm section of skin for the early phase group, the nickel element concentration was significantly higher than that in the lower section of skin. In deeper sections (<200 μm) of skin, the concentration of nickel in the early phase group was approximately equal to that in the late phase group. The curve of the late phase group was flat, which means that the nickel element concentration was distributed uniformly by SR-μ-XRF. According to the XANES data for the 10% NiSO₄ metal salt solution, structural changes occurred in the skin model sample, indicating that nickel was not present in the Ni²⁺ aqueous ionic state but in the nickel-binding protein.

This study showed that the distribution of the nickel element concentration in ACD skin tissue was different between the early phase and late phase groups. The nickel element was not present in the Ni²⁺ aqueous ionic state but bound with certain proteins to form a complex in the stratum corneum in ACD model tissue.

Recent studies have shown the important influence of various micro factors on the general biological activity and function of endothelial cells (ECs). Vascular endothelial growth factor (VEGF) and angiogenin (ANG) are classic micro factors that promote proliferation, differentiation, and migration of ECs. The underlying pathophysiological mechanisms and related pathways of these micro factors remain the focus of current research.

An extensive search was undertaken in the PubMed database by using keywords including "micro factors" and "endothelial cell." This search covered relevant research articles published between January 1, 2007 and December 31, 2018.

Original articles, reviews, and other articles were searched and reviewed for content on micro factors of ECs. Results: VEGF and ANG have critical functions in the occurrence, development, and status of the physiological pathology of ECs. Other EC-associated micro factors include interleukin 10, tumor protein P53, nuclear factor kappa B subunit, interleukin 6, and tumor necrosis factor. The results of Gene Ontology analysis revealed that variations were mainly enriched in positive regulation of transcription by the RNA polymerase II promoter, cellular response to lipopolysaccharides, negative regulation of apoptotic processes, external side of the plasma membrane, cytoplasm, extracellular regions, cytokine activity, growth factor activity, and identical protein binding. The results of the Kyoto Encyclopedia of Genes and Genomes analysis revealed that micro factors were predominantly enriched in inflammatory diseases.

In summary, the main mediators, factors, or genes associated with ECs include VEGF and ANG. The effect of micro factors on ECs is complex and multifaceted. This review summarizes the correlation between ECs and several micro factors.

Ultrasound imaging is well known to play an important role in the detection of thyroid disease, but the management of thyroid ultrasound remains inconsistent. Both standardized diagnostic criteria and new ultrasound technologies are essential for improving the accuracy of thyroid ultrasound. This study reviewed the global guidelines of thyroid ultrasound and analyzed their common characteristics for basic clinical screening. Advances in the application of a combination of thyroid ultrasound and artificial intelligence (AI) were also presented.

An extensive search of the PubMed database was undertaken, focusing on research published after 2001 with keywords including thyroid ultrasound, guideline, AI, segmentation, image classification, and deep learning.

Several types of articles, including original studies and literature reviews, were identified and reviewed to summarize the importance of standardization and new technology in thyroid ultrasound diagnosis.

Ultrasound has become an important diagnostic technique in thyroid nodules. Both standardized diagnostic criteria and new ultrasound technologies are essential for improving the accuracy of thyroid ultrasound. In the standardization, since there are no global consensus exists, common characteristics such as a multi-feature diagnosis, the performance of lymph nodes, explicit indications of fine needle aspiration, and the diagnosis of special populations should be focused on. Besides, evidence suggests that AI technique has a good effect on the unavoidable limitations of traditional ultrasound, and the combination of diagnostic criteria and AI may lead to a great promotion in thyroid diagnosis.

Standardization and development of novel techniques are key factors to improving thyroid ultrasound, and both should be considered in normal clinical use.

To review the application of radiomics in gastric cancer and its challenges as well as future prospects.

A research for relevant studies were performed in PubMed with the terms of "radiomics," "texture analysis," and "gastric cancer." The search was updated until February 28^th, 2019.

All original articles regarding the investigation of texture analysis or radiomics in gastric cancer were retrieved. Only papers written in English were included.

A total of 17 original articles were selected in final. It is shown that radiomics has yielded moderate to excellent performance in a spectrum of respects including differential diagnosis, assessment of histological differential degree, evaluation of tumor stage, prediction of response to therapy, and prognosis in gastric cancer. Yet, a number of challenges are facing both radiomics itself and its application in gastric cancer.

Radiomics holds great potential in facilitating decision-making in gastric cancer. With the standardization of work-flow and advancement of machine learning methods, radiomics is expected to make great breakthroughs in precision medicine of gastric cancer.

自1999年以来，来自各种动物模型的大量证据表明，生命早期的麻醉暴露与随后的神经发育障碍之间存在联系^[1];即，几乎所有常用的静脉和吸入麻醉剂，包括γ-氨基丁酸激动剂和N-甲基-D-天冬氨酸拮抗剂，均可诱导剂量和年龄依赖性神经元凋亡和死亡体外此外，从线虫到灵长类动物的大量数据已经显示了幼年动物麻醉暴露的各种解剖学和神经发育后遗症。^[2,3]在啮齿动物中，麻醉诱导的发育神经毒性（AIDN）的最突出表现通常在出生后第7天观察到，这是突触发生的高峰期。在动物模型中，单次和多次麻醉暴露均可影响神经发育。此外，麻醉暴露的持续时间和时机是AIDN的重要影响因素。^[4]令人担忧的是，新生儿暴露于麻醉的这些神经毒性作用可能导致儿童后期或成年期的长期有害功能结果，如记忆、学习、注意力和运动功能的缺陷。^[2]

冠状动脉疾病（CAD）患者在首次经皮冠状动脉介入治疗（PCI）后，由于罪魁祸首或非罪魁祸首病变中的斑块进展，通常需要重复计划外的经皮血运重建，包括靶病变血运重建（TLR）、靶血管血运重建（TVR）和其他血管血运重建（OVR）。^[1]低密度脂蛋白胆固醇（LDL-C）水平是可控的，其降低对于减少PCI后主要不良心脏事件是不可或缺的。在这项研究中，积极的降脂治疗在冠状动脉支架置入术后早期受到广泛赞赏，显示LDL-C水平最初下降，而随着时间的推移，其重视和认可度减弱，由于LDL-C水平较高，血运重建的风险增加。本研究是根据赫尔辛基宣言并经大连医科大学附属医院伦理委员会批准。2013年1月至2017年1月，共有621例首次入院时成功接受支架植入PCI的患者因“疑似/明确心肌缺血”接受了第二次冠状动脉造影检查。记录首次PCI和疑似心肌缺血入院之间的间隔时间。为了进一步探讨PCI后计划外血运重建中LDL-C的变化，排除了111例因任何原因再次住院的患者，包括出院后6个月内的分期血运重建。共选择510例患者，包括101例无再一次冠状动脉病变（对照组）和409例重复计划外经皮血运重建术患者（重复PCI组）。在计划外重复手术的患者中，10%（n=41）因ST段抬高型心肌梗死接受治疗，90%（n=368)用于非ST段抬高型急性冠状动脉综合征。这些患者中共有183例接受了TLR治疗，272例接受了TVR/OVR治疗，其中46例同时接受了两种治疗。

致编辑：自2013年3月中国上海首次发现甲型H7N9禽流感以来，共发生5次疫情。截至2017年9月，这些病例已达1564例实验室确诊病例，死亡率约为40%。^[1]在第五波中，4.09%的病例（31/758）感染了高致病性禽流感（HPAI）A（H7N9）。这表明A（H7N9）的致病型已从低致病性禽流感（LPAI）转变为HPAI。

致编辑：与计算机断层扫描相比，磁共振成像（MRI）是一种更敏感的横断面成像方式，用于检测髌骨脱位相关的包膜、韧带、软骨和骨损伤。^[1,2]

致编辑：弥漫性大B细胞淋巴瘤(DLBCL)是原发性肺淋巴瘤(PPL)的主要类型。DLBCL往往预后不良，5年生存率为0%至60%。但在本病例报告中，一位老年男性病理诊断为肺性DLBCL，肺部无症状性肺炎样影像学表现不变11年，提醒我们要重视病程惰性的肺性DLBCL。

致编辑：我们报告一位27岁女性，有2个月月经间不规则子宫出血病史。患者在2个月大时注意到头部起泡，青春期时颈部和背部逐渐出现红色斑丘疹性病变，暴露于物理摩擦后瘙痒。入院时，体格检查发现主要位于颈部和背部的弥漫性微弱斑丘疹[图1].盆腔检查显示宫颈上有一光滑的红色肿块（5厘米）。全血细胞计数未检出异常。后切除宫颈肿块，经仔细病理检查证实为成熟肥大细胞（MCs）浸润。此外，皮肤结节活检还显示大量MCs聚集，骨髓（BM）活检显示大量圆形MCs，具有丰富的细胞质颗粒。MCs约占抽吸涂片中所有细胞的22.5%。对BM的流式细胞术免疫表型分析表明，异常MC群体占总分析细胞的10%，其对CD117、CD33和CD9呈阳性，对CD2和CD68部分呈阳性，对CD25呈阴性。通过受体酪氨酸激酶全外显子组测序进行遗传检测（成套工具）基因显示K509I突变。

致编辑：输尿管结石是泌尿外科常见病。近年来，主要的治疗方法之一是输尿管镜配合钬激光碎石术。然而，随着钬激光碎石术的广泛应用，术后输尿管狭窄甚至闭塞的发生率越来越高，引起了临床医生对其病因的重视。术中钬激光热效应的问题也逐渐得到重视。钬激光是一种长波长脉冲激光，它通过光机/光声机制以及光热机制来粉碎结石，并且它主要基于光热机制。^[1]目前，多个体外世界范围内的研究证实，钬激光确实提高了工作区域的水温。然而，这些研究仅模拟了钬激光的碎石过程体外这并没有完全反映钬激光器在实际操作过程中的热效应。因此，本研究监测输尿管镜下钬激光碎石实际过程中术野灌洗液的温度变化，旨在为输尿管镜下钬激光碎石术后输尿管狭窄的病因研究提供更多信息。

致编辑：一名19岁男性因“皮肤和巩膜黄色染色18年，伴有生长迟缓”入院。患者在4月龄时出现巩膜发黄，当时诊断为Wilson病（WD），对症保肝治疗。9岁时，患者出现甲床苍白、手指和脚趾杵状指，并伴有生长迟缓。16岁时发生右上肢和左耻骨自发性骨折。17岁时，患者出现神经精神症状，包括疲劳、性格改变、智力低下、麻木、癫痫发作和便秘。他每天需要甘油来帮助排便。入院前5个月，存在明显的胸骨畸形和胸骨前突。家族史显示，他的父母是近亲（表兄妹关系），患者的堂兄在12岁时死于WD。患者的弟弟3岁，也有WD病史。

致编辑：眼皮肤白化病（OCA）是一种常染色体隐性疾病，由一组与黑色素合成和黑素体生物发生调节相关的突变引起。OCA的全球患病率约为1/17,000。^[1]除了对症治疗，白化病没有有效的治疗方法。由于临床表型的变异性，很难简单地通过临床特征进行亚型分类；因此，分子和遗传分析是确诊、携带者筛查和产前诊断最可靠的方法。

致编辑：智能手机也改变了人眼暴露在光线下的方式。由于智能手机的所有光谱峰都非常类似于短波长蓝色可见光，^[1]智能手机对眼睛的伤害引起了公众的关注，这并不奇怪。在本文中，我们描述了一名因过度使用智能手机而疑似黄斑光损伤的患者。

致编辑：2018年3月9日，一名31岁女性在甲状腺癌手术后出现肝功能障碍。她身体健康；没有慢性疾病，如高血压和糖尿病；无肝炎、肺结核等传染病史；无药物、食物过敏、吸烟和饮酒史；病程中无明显主诉。3年前体检B超显示“左侧甲状腺占位”。2018年2月5日，她已在我院接受手术。2018年2月6日实验室检查：白细胞（WBC）9.06 × 10⁹/L（3.50-9.50 × 10⁹/L)；中性粒细胞（NEs）5.66 × 10⁹/L（1.80-6.30 × 10⁹/L)；三碘甲状腺原氨酸(T3)0.94(0.80-2.00)ng/mL；甲状腺素(T4)6.4(5.1-14.1)μ g/dL；游离T3(FT3)3.95(3.10-6.80)pmol/L；游离T4(FT4)15.57(12.00-22.00)pmol/L；促甲状腺激素（TSH）2.56（0.27-4.20）μ/L；甲状腺过氧化物酶抗体(TPOAb)8.2(0-34.0)IU/mL；甲状腺球蛋白抗体<10(≤115)IU/mL；总胆红素（T-BIL）21.5（5.0-22.0）μ mol/L；直接胆红素（D-BIL）6.3（0-10.2）μ mol/L；丙氨酸转氨酶(ALT)27.5(7.0-40.0)U/L；天冬氨酸转氨酶(AST)22.7(13.0-35.0)U/L；和碱性磷酸酶(ALP)，48.9(35.0-100.0)U/L。丙肝抗体、乙肝表面抗原、乙肝核心抗体免疫球蛋白M检测阴性。2018.2.7左甲状腺切除术术中病理提示微乳头状癌。2018年2月11日出院，给予左旋甲状腺素片A（LTA；Merck KGaA，Darmstadt，Germany）100 μ g和碳酸钙D3片（CC-D3；Pfizer，China）600 mg每日一次。