Volume 132 · Issue 19 · 2019

Air pollutants and their pathogenic effects differ among regions and seasons. We aimed to explore the relationship between fine particulate matter (PM_2.5), sulfur dioxide (SO₂), and ozone-8 hours (O₃-8h) concentrations in heating and non-heating seasons and the associated death risk due to cardiovascular diseases (CDs), respiratory diseases (RDs), and malignant tumors.

Data were collected in Shenyang, China, from April 2013 to March 2016. We analyzed the correlation or lagged effect of atmospheric pollutant concentration, meteorological conditions, and death risk due to disorders of the circulatory system, respiratory system, and malignant tumor in heating and non-heating seasons. We also used multivariate models to analyze the association of air pollutants during holidays with the death risk due to the evaluated diseases while considering the presence or absence of meteorological factors.

An increase in the daily average SO₂ concentration by 10 μg/m³ increased the death risk by CDs, which reached a maximum of 2.0% (95% confidence interval [CI]: 1.3%–2.7%) on lagging day 4 during the non-heating season and 0.2% (95% CI: 0.1%-0.4%) on lagging day 3 during the heating season. The risk of death caused by RDs peaked on lagging day 1 by 0.8% (95% CI: 0.4%–1.2%) during the heating season. An increase in O₃-8h concentration by 10 μg/m³ increased the risk of RD-related death on lagging day 2 by 1.0% (95% CI: 0.4%–1.7%) during the non-heating season, which was significantly higher than the 0.1% (95% CI: 0–0.9%) increase during the heating season. Further, an increase in the daily average PM_2.5 concentration by 10 μg/m³ increased the risk of death caused by RDs by 0.3% and 0.8% during heating and non-heating seasons, respectively, which peaked on lagging day 0. However, air pollution was not significantly associated with the risk of death caused by malignant tumors.

Short-term exposure to PM_2.5, SO₂, and O₃ during the non-heating season resulted in higher risks of CD-related death, followed by RD-related death.

Clinical assessment and treatment guidance for heart failure depends on a variety of biomarkers. The objective of this study was to investigate the prognostic predictive value of growth differentiation factor-15 (GDF-15) and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) in assessing hospitalized patients with acute heart failure (AHF).

In total, 260 patients who were admitted for AHF in the First Affiliated Hospital of Nanjing Medical University were enrolled from April 2012 to May 2016. Medical history and blood samples were collected within 24 h after the admission. The primary endpoint was the all-cause mortality within 1 year. The patients were divided into survival group and death group based on the endpoint. With established mortality risk factors and serum GDF-15 level, receiver-operator characteristic (ROC) analyses were performed. Cox regression analyses were used to further analyze the combination values of NT-proBNP and GDF-15.

Baseline GDF-15 and NT-proBNP were significantly higher amongst deceased than those in survivors (P < 0.001). In ROC analyses, area under curve (AUC) for GDF-15 to predict 1-year mortality was 0.707 (95% confidence interval [CI]: 0.648–0.762, P < 0.001), and for NT-proBNP was 0.682 (95% CI: 0.622–0.738, P < 0.001). No statistically significant difference was found between the two markers (P = 0.650). Based on the optimal cut-offs (GDF-15: 4526.0 ng/L; NT-proBNP: 1978.0 ng/L), the combination of GDF-15 and NT-proBNP increased AUC for 1-year mortality prediction (AUC = 0.743, 95% CI: 0.685–0.795, P < 0.001).

GDF-15, as a prognostic marker in patients with AHF, is not inferior to NT-proBNP. Combining the two markers could provide an early recognition of high-risk patients and improve the prediction values of AHF long-term prognosis.

ChiCTR-ONC-12001944, http://www.chictr.org.cn.

Patients with ST-segment elevation myocardial infarction (STEMI) who present without typical chest pain are associated with a poor outcome. However, whether angiographic characteristics are related to a higher risk of mortality in this population is unclear. This study aimed to investigate whether the higher mortality risk in patients with STEMI without chest pain could be explained by their "high-risk" angiographic characteristics.

We used data of 12,145 patients with STEMI who was registered in China Acute Myocardial Infarction registry from January 2013 to September 2014. We compared the infarct-related artery (IRA), thrombolysis in myocardial infarction (TIMI) flow grade in the IRA, and other angiographic characteristics between patients without and those with chest pain. Multivariable logistic regression model was used to identify independent risk factor of in-hospital mortality.

The 2922 (24.1%) patients with STEMI presented without typical chest pain. These patients had a higher TIMI flow grade (mean TIMI flow grade: 1.00 vs. 0.94, P = 0.02) and a lower rate of IRA disease of the left anterior descending artery (44.6% vs. 51.2%, χ² = 35.63, P < 0.01) than did those with typical chest pain. Patients without chest pain were older, more likely to have diabetes, longer time to hospital and higher Killip classification, and less likely to receive optimal medication treatment and primary percutaneous coronary intervention and higher In-hospital mortality (3.3% vs. 2.2%, χ² = 10.57, P < 0.01). After adjusting for multi-variables, presentation without chest pain was still an independent predictor of in-hospital death among patients with STEMI (adjusted odds ratio: 1.36, 95% confidence interval: 1.02–1.83).

Presentation without chest pain is common and associated with a higher in-hospital mortality risk in patients with acute myocardial infarction. Our results indicate that their poor prognosis is associated with baseline patient characteristics and delayed treatment, but not angiographic lesion characteristics.

NCT01874691, https://clinicaltrials.gov.

The dose and time point for switching from clopidogrel to ticagrelor remain controversial, especially for Chinese acute coronary syndrome (ACS) patients with complicated coronary artery disease (CAD). Hence, the purpose of this study was to further explore the optimal dose and time point for the switching strategy to balance the increase in platelet inhibition and the decrease in adverse events in Chinese ACS patients with complicated CAD managed by percutaneous coronary intervention (PCI).

From July 2017 to December 2017, the prospective, randomized, open-label study (the SwitcHIng from clopidogrel to ticagrelor study) assigned the eligible Chinese ACS patients with complicated CAD managed by PCI (n = 102) for 90 mg of ticagrelor at 12 h (T-90 mg-12 h), 90 mg of ticagrelor at 24 h (T-90 mg-24h) or 180 mg ticagrelor at 24 h (T-180 mg-24 h) after the last dose of clopidogrel. The primary endpoint was the comparison of maximal platelet aggregation (MPA) values at 2 h after switching strategies among the three groups. In addition, the MPA values at baseline, 8 h and before discharge and the rates of high ontreatment platelet reactivity were evaluated, the incidences of bleeding episodes and dyspnea during hospitalization and at 30-day follow-up in our study were also recorded. The MPA was measured by light transmittance aggregometry in our study. A repeatedmeasures analysis of variance (ANOVA) model and one-way ANOVA were used to compare data for the primary endpoint.

The MPA values were significantly decreased in the T-180 mg-24 h group compared with the T-90 mg-12 h group (P = 0.017) and decreased numerically compared with the T-90 mg-24 h group (P = 0.072) at 2 h. In particular, the MPA values were markedly reduced in the T-90 mg-24 h group compared with the T-90 mg-12 h group at 8 h after switching treatment (P = 0.002). There was no significant difference among the three groups in all bleedings and dyspnea events.

The optimal treatment strategy recommended in this study for Chinese ACS patients with complicated CAD managed by PCI is 180 or 90 mg of ticagrelor at 24 h after the last dose of clopidogrel. In addition, a negative interaction was detected in this study between the overlap for clopidogrel and ticagrelor at 12 h after the last dose of clopidogrel.

ClinicalTrials.gov, NCT03577652; http://clinicaltrials.gov/ct2/show/NCT03577652.

Although the rehabilitation of aphasia has been extensively studied, the prediction of language outcome still has not received sufficient attention. The aim of this study was to predict the language outcome using mismatch negativity (MMN) in patients with large left-hemispheric infarction.

MMN was elicited by an oddball paradigm in which a standard tone (1000 Hz) and deviant tone (1500 Hz) were presented at 90% and 10% of the number of tones, respectively. The mean amplitudes and laterality indexes (LIs) of MMN were measured over the prefrontal, frontal, central, parietal, temporal, and perisylvian electrodes and both hemispheres during the first 7 days (session 1) and 10 to 20 days (session 2) post-onset. Mixed three-way analysis of variance (ANOVA) was used to investigate differences in these factors between two aphasia groups (the good recovery group and poor recovery group). The predictive value of the most significant LI was also compared with the score of National Institutes of Health Stroke Scale score and low-density volume on computed tomography.

A total of 18 patients were enrolled in this study. Mixed three-way ANOVA showed no interaction effect of session × region of interest (ROI) × group (F [3.59, 57.38] = 1.301, P = 0.282) and no interaction effect of ROI × group (F [1.81, 29.01] = 0.71, P= 0.487) and session × group (F [1.00, 16.00]= 0.084, P= 0.776) for MMN amplitude. No interaction effect of session × ROI × group (F [1.79, 28.58] = 0.62, P = 0.530), but an interaction effect of session × group (F [1.00, 16.00] = 5.21, P = 0.036) was found for LIs. In the poor recovery group, the LIs of MMN over all the ROIs, except the parietal area, became more negative at session 2 than those at session 1 (P < 0.05), but this effect was not observed in the good recovery group. Additionally, significant differences were observed in the LIs at session 2 between the two groups (P < 0.05). The LI over the perisylvian area at session 2 had the highest predictive value with an area under the curve of 0.963 (95% confidence interval: 0.884–1.000). An LI score >-0.36 over the perisylvian area suggested good recovery, but a score <-0.36 suggested poor recovery. The LI cut-off value of-0.36 had the highest sensitivity (90.0%) and specificity (87.5%) for predicting a good language outcome at 3 months post-stroke.

LIs of MMN amplitudes at approximately 2 weeks post left-hemisphere stroke serve as more sensitive predictors of language outcome, among which the LI over the perisylvian area exhibits the best predictive value.

Patients with Alzheimer disease (AD) and amnesic mild cognitive impairment (aMCI) have deficits in emotion recognition. However, it has not yet been determined whether patients with AD and aMCI also experience difficulty in recognizing the emotions conveyed by music. This study was conducted to investigate whether musical emotion recognition is impaired or retained in patients with AD and aMCI.

All patients were recruited from the First Affiliated Hospital of Anhui Medical University between March 1, 2015 and January 31, 2017. Using the musical emotion recognition test, patients with AD (n = 16), patients with aMCI (n = 19), and healthy controls (HCs, n = 16) were required to choose one of four emotional labels (happy, sad, peaceful, and fearful) that matched each musical excerpt. Emotion recognition scores in three groups were compared using one-way analysis of variance (ANOVA) test. We also investigated the relationship between the emotion recognition scores and Mini-Mental State Examination (MMSE) using Pearson’s correlation analysis test in patients with AD and aMCI.

Compared to the HC group, both of the patient groups showed deficits in the recognition of fearful musical emotions (HC: 7.88 ± 1.36; aMCI: 5.05 ± 2.34; AD: 3.69 ± 2.02), with results of a one-way ANOVA confirming a significant main effect of group (F_(2,50) = 18.70, P < 0.001). No significant differences were present among the three groups for the happy (F_(2,50)=2.57, P = 0.09), peaceful (F_(2,50) = 0.38, P = 0.09), or sad (F_(2,50) = 2.50, P = 0.09) musical emotions. The recognition of fearful musical emotion was positively associated with general cognition, which was evaluated by MMSE in patients with AD and aMCI (r = 0.578, P < 0.001). The correlations between the MMSE scores and recognition of the remaining emotions were not significant (happy, r = 0.228, P= 0.11; peaceful, r= 0.047, P= 0.74; sad, r= 0.207, P= 0.15).

This study showed that both patients with AD and aMCI had decreased ability to distinguish fearful emotions, which might be correlated with diminished cognitive function.

Nucleos(t)ide analog (NA) in combination with peginterferon (PegIFN) therapy in patients with hepatitis B e antigen (HBeAg)-positive chronic hepatitis B (CHB) shows better effectiveness than NA monotherapy in hepatitis B surface antigen loss, termed "functional cure," based on previous published studies. However, it is not known which strategy is more cost-effective on functional cure. The aim of this study was to analyze the cost-effectiveness of first-line monotherapies and combination strategies in HBeAg-positive CHB patients in China from a social perspective.

A Markov model was developed with functional cure and other five states including CHB, compensated cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, and death to assess the cost-effectiveness of seven representative treatment strategies. Entecavir (ETV) monotherapy and tenofovir disoproxil fumarate (TDF) monotherapy served as comparators, respectively.

In the two base-case analysis, compared with ETV, ETV generated the highest costs with $44,210 and the highest quality-adjusted life-years (QALYs) with 16.78 years. Compared with TDF, treating CHB patients with ETV and NA - PegIFN strategies increased costs by $7639 and $6129, respectively, gaining incremental QALYs by 2.20 years and 1.66 years, respectively. The incremental cost-effectiveness ratios were $3472/QALY and $3692/QALY, respectively, which were less than one-time gross domestic product per capita. One-way sensitivity analysis and probabilistic sensitivity analyses showed the robustness of the results.

Among seven treatment strategies, first-line NA monotherapy may be more cost-effective than combination strategies in HBeAg-positive CHB patients in China.

The aortic arch replacement and cardiopulmonary bypass (CPB) are both associated with the early mortality after cardiothoracic surgery. This study aimed to investigate the relationship between CPB time and 90-day post-operative mortality in patients undergoing aortic arch surgery using the frozen elephant trunk (FET) technique with selective ante-grade cerebral perfusion (SACP).

We retrospectively reviewed data of 377 adult patients undergoing aortic arch surgery via FET with SACP from July 1, 2017 to December 31, 2018 at Beijing Anzhen Hospital. The baseline characteristics, intra-operative data, and post-operative data were collected. Univariate and multivariate Cox regression analyses were used to determine independent predictors of 90-day postoperative mortality.

The 90-day post-operative mortality was 13.53%. The 78.51% of patients were men. There were 318 (84.35%) type A aortic dissections and 28 (7.43%) aortic aneurysms. Among those, 264 (70.03%) were emergency operations. Median CPB time was 202.0 (176.0, 227.0) min. Multivariate Cox regression analysis revealed that CPB time was independently associated with 90-day post-operative mortality after adjusting confounding factors (hazard ratio: 1.21/10 min increase in CPB time, 95% confidence interval: 1.15–1.27, P < 0.001). Kaplan-Meier analysis based on CPB time tertiles revealed that the top tertile (median 236.0 min) was associated with reduced survival rate compared with middle and bottom tertiles (P < 0.001). Each sub-group analysis based on the complexity of the underlying disease process showed similar associations between CPB time and 90-day post-operative mortality.

CPB time remains a significant factor in determining 90-day post-operative mortality in patients undergoing aortic arch surgery using FET with SACP. Surgeons should be aware of the relationship between CPB time and 90-day post-operative mortality during operative procedures and avoid extended CPB time as far as possible.

Very few studies have been conducted regarding the optimal time interval between hysteroscopic adhesiolysis and the embryo transfer (ET). Investigation of this optimal time may be helpful for assisted reproductive technology. Therefore, we investigated effects of the interval between hysteroscopic adhesiolysis and ET upon in vitro fertilization (IVF) cycle outcomes.

Patients were recruited between January 2014 and September 2017 at the Reproductive Hospital Affiliated to Shandong University. Patients who were diagnosed with intra-uterine adhesion (IUA) and underwent hysteroscopic adhesiolysis before fresh IVF-ET or intra-cytoplasmic sperm injection cycles were classified into three groups according to the interval between hysteroscopic adhesiolysis and ET: less than 90 days (Group 1), 90 to 180 days (Group 2), and greater than 180 days (Group 3). Baseline characteristics, controlled ovarian stimulation (COS) response, and pregnancy outcomes after ET were compared. Analysis of variance or non-parametric tests were used to test numerical data. The Pearson’s Chi-squared test was used to test categorical data.

A total of 312 patients were recruited as follows: 112 in Group 1, 137 in Group 2, and 63 in Group 3. There were no differences in baseline and COS characteristics among the three groups. The live-birth rate in Group 2 (40.1%) was significantly higher than that in Group 1 (17.9%; χ² = 14.545, P < 0.001). There were no significant differences in the rates of biochemical, ongoing, and clinical pregnancy, and biochemical and clinical pregnancy abortion, as well as stillbirth among the groups. In the mild IUA patients, the live-birth rate was significantly higher in Group 2 (42.6%) compared with Group 1 (22%; χ² = 8.413, P = 0.004). In the moderate IUA patients, Group 2 (35.7%) had a higher frequency of live births than Group 1 (6.7%; χ² = 8.187, P = 0.004).

The optimal waiting period for fresh ET after hysteroscopic adhesiolysis was 90 to 180 days in the current study.

Studies have reported mitophagy activation in renal tubular epithelial cells (RTECs) in acute kidney injury (AKI). Phosphatase and tensin homolog-induced putative kinase 1 (PINK1) and E3 ubiquitin-protein ligase Parkin are involved in mitophagy regulation; however, little is known about the role of PINK1-Parkin mitophagy in septic AKI. Here we investigated whether the PINK1-Parkin mitophagy pathway is involved in septic AKI and its effects on cell apoptosis in vitro and on renal functions in vivo.

Mitophagy-related gene expression was determined using Western blot assay in human RTEC cell line HK-2 stimulated with bacterial lipopolysaccharide (LPS) and in RTECs from septic AKI rats induced by cecal ligation and perforation (CLP). Autophagy-related ultrastructural features in rat RTECs were observed using electron microscopy. Gain- and loss-of-function approaches were performed to investigate the role of the PINK1-Parkin pathway in HK-2 cell mitophagy. Autophagy activators and inhibitors were used to assess the effects of mitophagy modulation on cell apoptosis in vitro and on renal functions in vivo.

LPS stimulation could significantly induce LC3-II and BECN-1 protein expression (LC3-II: 1.72 ± 0.05 vs. 1.00 ± 0.05, P < 0.05; BECN-1: 5.33 ± 0.57 vs. 1.00 ± 0.14, P < 0.05) at 4 h in vitro. Similarly, LC3-II, and BECN-1 protein levels were significantly increased and peaked at 2 h after CLP (LC3-II: 3.33 ± 0.12 vs. 1.03 ± 0.15, P < 0.05; BECN-1: 1.57 ± 0.26 vs. 1.02 ± 0.11, P < 0.05) in vivo compared with those after sham operation. Mitochondrial deformation and mitolysosome-mediated mitochondria clearance were observed in RTECs from septic rats. PINK1 knockdown significantly attenuated LC3-II protein expression (1.35 ± 0.21 vs. 2.38 ± 0.22, P < 0.05), whereas PINK1 overexpression markedly enhanced LC3-II protein expression (2.07 ± 0.21 vs. 1.29 ± 0.19, P < 0.05) compared with LPS-stimulated HK-2 cells. LPS-induced proapoptotic protein expression remained unchanged in autophagy activator-treated HK-2 cells and was significantly attenuated in PINK1-overexpressing cells, but was remarkably upregulated in autophagy inhibitor-treated and in PINK1-depleted cells. Consistent results were observed in flow cytometric apoptosis assay and in renal function indicators in rats.

PINK1-Parkin-mediated mitophagy might play a protective role in septic AKI, serving as a potential therapeutic target for septic AKI.

Premature ejaculation (PE) is regarded as one of the most common male sexual dysfunctions. This review introduced several pharmaceutical and surgical methods for the management of PE. The definition, etiology, behavioral, and psychological therapy of PE were also discussed.

"Premature," "ejaculation," or "sexual dysfuction" were used as the medical subject headings (MeSH) to obtain relevant articles before June 2019 on Pubmed, Google Scholar and CNKI. Most articles used were written in English and several Chinese articles were also cited.

Full-text articles of retrospective/prospective/randomized controlled trials were analyzed. Animal experiments and letters were excluded.

There are four PE sub-types: lifelong PE, acquired PE, natural variable PE, and subjective PE. Behavioral therapy, psychotherapy, medication, topical anesthetics, and surgery are currently used for the treatment of PE. However, all the above treatments have limitations. Therefore, novel ways should be investigated to more efficiently control PE.

The pharmaceutical therapy that is currently being used in clinical practice for the management of PE is still the main choice globally due to its good efficacy. Surgery may be a choice for patients who are resistant to medication. However, it should be performed cautiously.

慢性阻塞性肺疾病（COPD）是一种常见的慢性呼吸系统疾病。到2020年，慢阻肺将成为第三大死亡原因。嗜酸性粒细胞是T辅助细胞2介导的免疫的组成部分，具有抗菌防御的武库。炎症后大量嗜酸性粒细胞从骨髓释放到血液循环中，它们将通过趋化因子介导的趋化性募集到气道和其他组织，以启动和上调免疫反应[图1].^[1]

致编辑：我们报告一位46岁男性，左下肢进行性疼痛超过5年。体格检查显示身材矮小，下肢呈“O”型弯曲，“企鹅”步态。先证者的家谱见图1A他头骨的X光片显示在图1BX光检查发现他脊柱骨量增加[图1C]、左股骨骨折伴骨折边缘硬化[图1D和图1E].2018年测量的双能X射线吸收仪（DEXA）扫描显示，他的脊柱骨量增加【补充表1，http://links.lww.com/CM9/A96】。值得注意的是，2019年7月进行的第二次DEXA扫描显示，他脊柱的骨量减少，股骨颈的骨量增加。他的母亲（I-2）、兄弟（II-2）和一个姐妹（II-5）也出现身材矮小、下肢形状和步态异常。II-2和II-5的X射线见补充图1，http://links.lww.com/CM9/A96.II-2的DEXA扫描还发现他脊柱的骨量增加，而股骨颈的骨量减少；II-5脊柱骨量正常，股骨颈骨量呈下降趋势；先证者(II-7)、III-3和III-9患有低磷血症和甲状旁腺激素水平升高[补充表1，http://links.lww.com/CM9/A96]。他们的血清钙水平在正常范围的下限。II-2和II-5的血清磷酸盐水平不可用。II-2、II-5、II-7、III-3和III-9中成纤维细胞生长因子23（FGF23）的血清水平升高。II-7和III-3具有较低的每肾小球滤过率磷酸盐的肾小管最大重吸收阈值【补充表1，http：//links.lww.com/CM9/A96】。

致编辑：淋巴管平滑肌瘤病（LAM）是一种罕见的多系统疾病，主要影响女性，与囊性肺破坏、乳糜液积聚和腹部肿瘤有关。^[1]LAM患者的肺功能下降的速度比典型的年龄相关下降快两到四倍或更多倍。尽管哺乳动物雷帕霉素靶标（mTOR）抑制剂对LAM患者显示出一定的益处，但治疗选择仍然有限。^[2]滑膜炎、痤疮、脓疱病、骨质增生和骨炎(SAPHO)综合征是一系列以骨关节和皮肤病学表现为特征的异质性疾病。非甾体抗炎药（NSAIDs）、缓解疾病的抗风湿药、双膦酸盐和关节内类固醇经常被处方，但通常不足以控制疾病进展。可在难治性病例中施用的生物制剂最近显示出有希望的临床效用。Janus激酶（JAK）和下游效应物激活信号转导（STAT）蛋白是I型和II型细胞因子的重要细胞内信号分子，最近的证据表明JAK抑制剂在治疗自身免疫性疾病中的功效。^[3]而且，小分子选择性JAK抑制剂tofacitinib在治疗难治性SAPHO综合征方面表现出良好的疗效。^[4]在此，我们报告了一例SAPHO综合征合并LAM的患者，其关节痛和肺功能在托法替尼治疗后均有所改善。

致编辑：肿瘤诱导骨软化症(TIO)是一种极其罕见的副肿瘤综合征，以低磷血症和高磷尿症为特征。^[1]自1947年首次描述TIO以来，全球已报告500多例。^[2,3]TIO是一种获得性低磷血症性骨软化症，由肾小管磷重吸收减少和肾磷排泄增加引起。TIO的临床表现多样，无特异性；最常见的表现是进行性骨痛、骨折、骨骼畸形和运动功能障碍。^[1,2,3]迄今为止，很少有报道的TIO病例出现由磷酸尿间充质肿瘤引起的邻近骨质破坏。因此，临床医生缺乏及时诊断和合理治疗这种罕见疾病的知识和经验。在此，我们介绍了一例伴有大量骨质破坏的TIO病例，该病例通过手术成功治疗[图1].

致编辑：一位63岁的中国女性，主诉眼口干40年，反复鼻出血2年，到华西医院就诊。她9年前被诊断为缺铁性贫血（IDA），3年前被诊断为原发性干燥综合征（pSS）和原发性胆汁性肝硬化（PBC）。近3年来因重症IDA在华西医院诊治。重复红细胞悬液和补充蔗糖铁未见效果。2年前接受胃镜检查，发现胃窦毛细血管扩张。因此，给出了两次氩等离子体凝固(APC)。她没有异常家族史。入院体检发现舌毛细血管扩张，眼口干[图1A].口腔中可以看到龋齿。皮肤和眼睑结膜苍白。全血细胞计数显示小细胞性低色素性贫血。检测碱性磷酸酶、可溶性转铁蛋白受体和总铁结合力的升高。同时，观察到血清铁、转铁蛋白饱和度和铁蛋白的降低。大便潜血阳性。抗核抗体滴度为1:10 00。抗SS相关抗原A（SSA）抗体和抗线粒体2型抗体（AMA-M2）阳性。Schirmer试验显示左眼和右眼分别为每5分钟3 mm和4 mm。尿常规、葡萄糖-6-磷酸脱氢酶、Coombs试验、红细胞孵育渗透脆性试验均正常。腹部彩色多普勒超声显示肝硬化、脾肿大、腹水、肝静脉异常及肝外门静脉增厚。胆道彩超未见胆道狭窄。骨髓穿刺和活检提示红系增生活跃，而铁染色消失。因此，她在接受红细胞悬液和蔗糖铁后接受了胃肠内镜和双气囊小肠镜检查，显示胃窦、空肠和结肠直肠多发性毛细血管扩张[图1B].因此，严重贫血的原因是遗传性出血性毛细血管扩张症（HHT）。给予小剂量沙利度胺（每晚50 mg）。她没有出现明显的副作用。在随访期间，贫血症状和实验室检查显著改善，铁补充量减少。

致编辑：肾癌是最常遇到的泌尿系恶性肿瘤之一，占所有成人恶性肿瘤的2%~3%；死亡率超过40%。^[1]随着近年来医学技术的发展，肾癌的手术和辅助治疗有了很大的提高。曾经被认为是高危人群的肾癌和下腔静脉癌栓患者现在可以接受理想的治疗。

致编辑：患者男，66岁，主诉突然头晕，伴有恶心呕吐，转诊至兰州大学第一医院。病史显示重度吸烟40年，未查到其他相关信息。

致编辑：鳃源性癌是一种罕见的疾病。当它发生时，它经常被误诊为未知原发灶的转移。由于该实体疾病发病率较低，一直缺乏相关研究资料。^[1,2]在此，我们报告一例极其罕见的腮腺分支癌病例，以扩大对本病的认识。

致编辑：患者女，53岁，因疼痛，计算机断层扫描（CT）怀疑右髂骨转移而入住复旦大学附属中山医院。8年前，她接受了右侧甲状腺肺叶切除术，但病理未发现癌变。近1年来，患者出现甲状腺功能亢进，但因甲巯咪唑导致白细胞耗竭而未给予治疗。她有典型的甲状腺功能亢进症状，并得到以下实验室检查结果的支持：游离三碘甲状腺原氨酸12.3 pmol/L（参考2.8-7.1 pmol/L）；游离四碘甲状腺原氨酸，46.7 pmol/L(参考12.0-22.0 pmol/L)；甲状腺球蛋白(Tg)>5000.0 ng/mL(参考1.4-78.0 pmol/L)；促甲状腺激素、<0.005 μ IU/mL(参比0.270-4.200 μ IU/mL)；抗Tg抗体，163.2 IU/mL（参比<115.0 IU/mL)；和甲状腺过氧化物酶抗体，15.5 IU/mL（参比<34.0 IU/mL)。超声检查发现甲状腺左叶多发性结节，怀疑为腺瘤。甲状腺疾病家族史被否认。

致编辑：在过去的十年中，越来越多的放射学和超声检查结果报告认为，特发性颈动脉痛很可能是一种独特的疾病实体，其特征是单侧颈部疼痛、颈动脉周围的造影剂增强信号或颈动脉壁增厚，以及对非甾体抗炎药或类固醇治疗的良好反应。^[1,2,3,4]在此，我们报告了一例影像学证实的颈动脉痛，除了单侧颈部疼痛和头痛外，还有声音嘶哑、吞咽困难和晕厥等罕见临床表现。