Volume 134 · Issue 13 · 2021

Chronic obstructive pulmonary disease (COPD) is the most common chronic airway disease worldwide. Recent epidemiologic survey shown that as many as 100 million people have COPD in China, leading to heavy disease burden comparable to hypertension and diabetes.^[1]Therefore, COPD has been listed as one of the public health priorities in "Action Plan of Heathy China 2030" . It has been recognized worldwide that the goals of long-term treatment of COPD are optimization of symptom relief, prevention and treatment of exacerbations, prevention of disease progression and reduction of mortality.^[2]

Breast cancer is the most common female cancer around the world. Approximately 5% to 10% of breast cancer is associated with a hereditary predisposition from inherited germline mutations,^[1]with about 15% of mutations occurring in the breast cancer susceptibility genes (BRCA1/2).^[2,3,4]Individuals carryingBRCA1/2mutations may reduce their risk of breast cancer through screening and preventing managements.^[5,6]It is essential for breast oncologists to improve their ability of identifying individuals with high risk ofBRCA1/2mutations, providing reasonable genetic counselling guidance to high risk individuals. Chinese Society of Breast Surgery (CSBrS) evaluated the relevant evidences using the Grading of Recommendations Assessment, Development, and Evaluation system, and developed the Clinical Practice Guideline ofBRCA1/2Testing for Patients with Breast Cancer (Version 2021), with the aim of providing guidance to the clinical practices of breast surgeons in China.

Ductal carcinomain situ(DCIS), also known as intraductal carcinoma, is anin situcarcinoma limited to the mammary ducts. The gold-standard screening, diagnostic, and treatment options have long been controversial. The Chinese Society of Breast Surgery (CSBrS) has re-evaluated the quality of the clinical study evidence on DCIS. In order to standardize the diagnosis and treatment of DCIS and provide a reference for Chinese breast surgeons, the CSBrS has used the Grading of Recommendations Assessment, Development, and Evaluation handbook while referring to its feasibility in the actual clinical practice of Chinese breast surgeons to develop the CSBrS Clinical Practice Guideline for the Diagnosis and Treatment of Ductal CarcinomaIn Situ(2021).

Chronic obstructive pulmonary disease (COPD) has recently become the third leading cause of death following heart disease and cancer. Acute exacerbation of COPD (AECOPD) can be prevented by early detection of deterioration and timely treatment, which can effectively lower the severity of exacerbation and prevent hospitalization.^[1]

Auricular reconstruction is challenging for plastic surgeons because of its rarity and technical complications.^[1,2]During development over 60 years, many surgical techniques have been explored and have produced good effects; these techniques include the Tanzer method, Brent method, Nagata's two-stage method, and tissue expansion method.^[3]The key to successful auricular reconstruction is to replicate the elaborate ear framework and ensure sufficient soft tissues for coverage. However, auricular reconstruction is often associated with undesirable esthetic outcomes because of the postoperative complications, the patient's individual condition, and the surgeon's poor skills. In this report, we introduced several strategies in salvage procedures. Improvement of an unfavorably reconstructed ear usually involves correcting the position, increasing the height, remolding the contour, and blending the color tones. If the superior part of the reconstructed ear is pitched forward, the ear should be mobilized and rotated back into the correct position or a full-thickness skin graft should be added to the face anteriorly, if necessary.^[2]If the position of the reconstructed lobule is higher or lower than that of the opposite ear, an incision can be made in the upper pole of the cranioauricular sulcus to adjust the framework and fix the scaffold on the cranial periosteum.^[4]Patients who have previously undergone external auditory meatoplasty might exhibit an inferoposterior position deformity of the reconstructed ear with indirect separation of the auricle and canal orifice. Jiet al^[5]and Zhanget al^[6]described an ear-forward technique in which an inverted U-shaped purse was used to change the high anterior location of the external auditory canal orifice along with the use of rotation flaps to relocate the ear position.

Chronic obstructive pulmonary disease (COPD) is a common public health problem worldwide. Recent studies have reported that socioeconomic status (SES) is related to the incidence of COPD. This study aimed to investigate the association between SES and COPD among adults in Jiangsu province, China, and to determine the possible direct and indirect effects of SES on the morbidity of COPD.

A cross-sectional study was conducted among adults aged 40 years and above between May and December of 2015 in Jiangsu province, China. Participants were selected using a multistage sampling approach. COPD, the outcome variable, was diagnosed by physicians based on spirometry, respiratory symptoms, and risk factors. Education, occupation, and monthly family average income (FAI) were used to separately indicate SES as the explanatory variable. Mixed-effects logistic regression models were introduced to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for examining the SES-COPD relationship. A pathway analysis was conducted to further explore the pulmonary function impairment of patients with different SES.

The mean age of the 2421 participants was 56.63 ± 9.62 years. The prevalence of COPD was 11.8% (95% CI: 10.5%-13.1%) among the overall sample population. After adjustment for age, gender, residence, outdoor and indoor air pollution, body weight status, cigarette smoking, and potential study area-level clustering effects, educational attainment was negatively associated with COPD prevalence in men; white collars were at lower risk (OR: 0.60, 95% CI: 0.43-0.83) of experiencing COPD than blue collars; compared with those within the lower FAI subgroup, participants in the upper (OR: 0.68, 95% CI: 0.49-0.97) tertiles were less likely to experience COPD. Such negative associations between all these three SES indicators and COPD were significant among men only. Education, FAI, and occupation had direct or indirect effects on pulmonary function including post-bronchodilator forced expiratory volume in 1 s/forced vital capacity (FEV₁/FVC), FEV₁, FVC, and FEV₁ percentage of predicted. Education, FAI, and occupation had indirect effects on pulmonary function indices of all participants mainly through smoking status, indoor air pollution, and outdoor air pollution. We also found that occupation could affect post-bronchodilator FEV₁/FVC through body mass index.

Education, occupation, and FAI had an adverse relationship with COPD prevalence in Jiangsu province, China. SES has both direct and indirect associations with pulmonary function impairment. SES is of great significance for COPD morbidity. It is important that population-based COPD prevention strategies should be tailored for people with different SES.

Delivery room resuscitation assists preterm infants, especially extremely preterm infants (EPI) and extremely low birth weight infants (ELBWI), in breathing support, while it potentially exerts a negative impact on the lungs and outcomes of preterm infants. This study aimed to assess delivery room resuscitation and discharge outcomes of EPI and ELBWI in China.

The clinical data of EPI (gestational age [GA] <28 weeks) and ELBWI (birth weight [BW] <1000 g), admitted within 72 h of birth in 33 neonatal intensive care units from five provinces and cities in North China between 2017 and 2018, were analyzed. The primary outcomes were delivery room resuscitation and risk factors for delivery room intubation (DRI). The secondary outcomes were survival rates, incidence of bronchopulmonary dysplasia (BPD), and risk factors for BPD.

A cohort of 952 preterm infants were enrolled. The incidence of DRI, chest compressions, and administration of epinephrine was 55.9% (532/952), 12.5% (119/952), and 7.0% (67/952), respectively. Multivariate analysis revealed that the risk factors for DRI were GA <28 weeks (odds ratio [OR], 3.147; 95% confidence interval [CI], 2.082-4.755), BW <1000 g (OR, 2.240; 95% CI, 1.606-3.125), and antepartum infection (OR, 1.429; 95% CI, 1.044-1.956). The survival rate was 65.9% (627/952) and was dependent on GA. The rate of BPD was 29.3% (181/627). Multivariate analysis showed that the risk factors for BPD were male (OR, 1.603; 95% CI, 1.061-2.424), DRI (OR, 2.094; 95% CI, 1.328-3.303), respiratory distress syndrome exposed to ≥2 doses of pulmonary surfactants (PS; OR, 2.700; 95% CI, 1.679-4.343), and mechanical ventilation ≥7 days (OR, 4.358; 95% CI, 2.777-6.837). However, a larger BW (OR, 0.998; 95% CI, 0.996-0.999), antenatal steroid (OR, 0.577; 95% CI, 0.379-0.880), and PS use in the delivery room (OR, 0.273; 95% CI, 0.160-0.467) were preventive factors for BPD (all P < 0.05).

Improving delivery room resuscitation and management of respiratory complications are imperative during early management of the health of EPI and ELBWI.

Although de novo stage IV breast cancer is so far incurable, it has entered an era of individualized treatment and chronic disease management. Based on systemic treatment, whether the surgical resection of primary or metastatic foci of de novo stage IV breast cancer can bring survival benefits is currently controversial. We aimed to explore the clinicopathological factors and current status of the management of de novo stage IV breast cancer in China to provide a reference for clinical decisions.

Based on the assistance of Chinese Society of Breast Surgery, a retrospective study was conducted to analyze the clinical data of patients with de novo stage IV breast cancer in 33 centers from January 2017 to December 2018. The relationship between basic characteristic (age, menstrual status, family history, reproductive history, pathological type, estrogen receptor [ER] status, progesterone receptor [PR] status, human epidermal growth factor receptor 2 [HER2] status, Ki-67 percentage, and molecular subtype), and metastasis sites (lung metastasis, liver metastasis, and bone metastasis) was examined by Pearson Chi-square tests.

A total of 468 patients with de novo stage IV breast cancer were enrolled. The median age of the enrolled patients was 51.5 years. The most common pathological type of primary lesion was invasive carcinoma (97.1%). Luminal A, luminal B, HER2 overexpressing, and triple-negative subtypes accounted for 14.3%, 51.8%, 22.1%, and 11.8% of all cases, respectively. Age, PR status, and HER2 status were correlated with lung metastasis (χ²= 6.576, 4.117, and 8.643 and P = 0.037, 0.043, and 0.003, respectively). Pathological type, ER status, PR status, and molecular subtype were correlated with bone metastasis (χ² = 5.117, 37.511, 5.224, and 11.603 and P = 0.024, <0.001, 0.022, and 0.009, respectively). Age, PR status, HER2 status, Ki-67 percentage, and molecular subtype were correlated with liver metastasis (χ²= 11.153, 13.378, 10.692, 21.206, and 17.684 and P= 0.004, <0.001, 0.001, <0.001, and 0.001, respectively). Combined treatment with paclitaxel and anthracycline was the most common first-line chemotherapy regimen for patients with de novo stage IV breast cancer (51.7%). Overall, 91.5% of patients used paclitaxel-containing regimens. Moreover, 59.3% of hormone receptor-positive patients underwent endocrine therapy.

In 2018, 1.07% of patients from all studied centers were diagnosed with de novo stage IV breast cancer. This study indicated that 95.1% of patients received systemic therapy and 54.2% of patients underwent surgical removal of the primary lesion in China.

Various prediction tools have been developed to predict biochemical recurrence (BCR) after radical prostatectomy (RP); however, few of the previous prediction tools used serum prostate-specific antigen (PSA) nadir after RP and maximum tumor diameter (MTD) at the same time. In this study, a nomogram incorporating MTD and PSA nadir was developed to predict BCR-free survival (BCRFS).

A total of 337 patients who underwent RP between January 2010 and March 2017 were retrospectively enrolled in this study. The maximum diameter of the index lesion was measured on magnetic resonance imaging (MRI). Cox regression analysis was performed to evaluate independent predictors of BCR. A nomogram was subsequently developed for the prediction of BCRFS at 3 and 5 years after RP. Time-dependent receiver operating characteristic (ROC) curve and decision curve analyses were performed to identify the advantage of the new nomogram in comparison with the cancer of the prostate risk assessment post-surgical (CAPRA-S) score.

A novel nomogram was developed to predict BCR by including PSA nadir, MTD, Gleason score, surgical margin (SM), and seminal vesicle invasion (SVI), considering these variables were significantly associated with BCR in both univariate and multivariate analyses (P < 0.05). In addition, a basic model including Gleason score, SM, and SVI was developed and used as a control to assess the incremental predictive power of the new model. The concordance index of our model was slightly higher than CAPRA-S model (0.76 vs. 0.70, P = 0.02) and it was significantly higher than that of the basic model (0.76 vs. 0.66, P = 0.001). Time-dependent ROC curve and decision curve analyses also demonstrated the advantages of the new nomogram.

PSA nadir after RP and MTD based on MRI before surgery are independent predictors of BCR. By incorporating PSA nadir and MTD into the conventional predictive model, our newly developed nomogram significantly improved the accuracy in predicting BCRFS after RP.

There were few studies on real-world data about autologous hematopoietic stem cell transplantation (auto-HSCT) or allogeneic HSCT (allo-HSCT) in peripheral T-cell lymphoma (PTCL). This study aimed to investigate the clinical outcomes of patients who received auto-HSCT or allo-HSCT in China.

From July 2007 to June 2017, a total of 128 patients who received auto-HSCT (n = 72) or allo-HSCT (n = 56) at eight medical centers across China were included in this study. We retrospectively collected their demographic and clinical data and compared the clinical outcomes between groups.

Patients receiving allo-HSCT were more likely to be diagnosed with stage III or IV disease (95% vs. 82%, P = 0.027), bone marrow involvement (42% vs. 15%, P= 0.001), chemotherapy-resistant disease (41% vs. 8%, P= 0.001), and progression disease (32% vs. 4%, P < 0.001) at transplantation than those receiving auto-HSCT. With a median follow-up of 30 (2-143) months, 3-year overall survival (OS) and progression-free survival (PFS) in the auto-HSCT group were 70%(48/63) and 59%(42/63), respectively. Three-year OS and PFS for allo-HSCT recipients were 46%(27/54) and 44%(29/54), respectively. There was no difference in relapse rate (34%[17/63] in auto-HSCT vs. 29%[15/54] in allo-HSCT, P = 0.840). Three-year non-relapse mortality rate in auto-HSCT recipients was 6%(4/63) compared with 27%(14/54) for allo-HSCT recipients (P = 0.004). Subanalyses showed that patients with lower prognostic index scores for PTCL (PIT) who received auto-HSCT in an upfront setting had a better outcome than patients with higher PIT scores (3-year OS: 85% vs. 40%, P = 0.003). Patients with complete remission (CR) undergoing auto-HSCT had better survival (3-year OS: 88% vs. 48% in allo-HSCT, P = 0.008). For patients beyond CR, the outcome of patients who received allo-HSCT was similar to that in the atuo-HSCT group (3-year OS: 51% vs. 46%, P = 0.300).

Our study provided real-world data about auto-HSCT and allo-HSCT in China. Auto-HSCT seemed to be associated with better survival for patients in good condition (lower PIT score and/or better disease control). For patients possessing unfavorable characteristics, the survival of patients receiving allo-HSCT group was similar to that in the auto-HSCT group.

Non-communicable chronic diseases have become the leading causes of disease burden worldwide. The trends and burden of "metabolic associated fatty liver disease" (MAFLD) are unknown. We aimed to investigate the cardiovascular and renal burdens in adults with MAFLD and non-alcoholic fatty liver disease (NAFLD).

Nationally representative data were analyzed including data from 19,617 non-pregnant adults aged ≥20 years from the cross-sectional US National Health and Nutrition Examination Survey periods, 1999 to 2002, 2003 to 2006, 2007 to 2010, and 2011 to 2016. MAFLD was defined by the presence of hepatic steatosis plus general overweight/obesity, type 2 diabetes mellitus, or evidence of metabolic dysregulation.

The prevalence of MAFLD increased from 28.4% (95% confidence interval 26.3-30.6) in 1999 to 2002 to 35.8% (33.8-37.9) in 2011 to 2016. In 2011 to 2016, among adults with MAFLD, 49.0% (45.8-52.2) had hypertension, 57.8% (55.2-60.4) had dyslipidemia, 26.4% (23.9-28.9) had diabetes mellitus, 88.7% (87.0-80.1) had central obesity, and 18.5% (16.3-20.8) were current smokers. The 10-year cardiovascular risk ranged from 10.5% to 13.1%; 19.7% (17.6-21.9) had chronic kidney diseases (CKDs). Through the four periods, adults with MAFLD showed an increase in obesity; increase in treatment to lower blood pressure (BP), lipids, and hemoglobin A1c; and increase in goal achievements for BP and lipids but not in goal achievement for glycemic control in diabetes mellitus. Patients showed a decreasing 10-year cardiovascular risk over time but no change in the prevalence of CKDs, myocardial infarction, or stroke. Generally, although participants with NAFLD and those with MAFLD had a comparable prevalence of cardiovascular disease and CKD, the prevalence of MAFLD was significantly higher than that of NAFLD.

From 1999 to 2016, cardiovascular and renal risks and diseases have become highly prevalent in adults with MAFLD. The absolute cardiorenal burden may be greater for MAFLD than for NAFLD. These data call for early identification and risk stratification of MAFLD and close collaboration between endocrinologists and hepatologists.

Hypertension is considered an important risk factor for the coronavirus disease 2019 (COVID-19). The commonly anti-hypertensive drugs are the renin-angiotensin-aldosterone system (RAAS) inhibitors, calcium channel blockers (CCBs), and beta-blockers. The association between commonly used anti-hypertensive medications and the clinical outcome of COVID-19 patients with hypertension has not been well studied.

We conducted a retrospective cohort study that included all patients admitted with COVID-19 to Huo Shen Shan Hospital and Guanggu District of the Maternal and Child Health Hospital of Hubei Province, Wuhan, China. Clinical and laboratory characteristics were extracted from electronic medical records. Hypertension and anti-hypertensive treatment were confirmed by medical history and clinical records. The primary clinical endpoint was all-cause mortality. Secondary endpoints included the rates of patients in common wards transferred to the intensive care unit and hospital stay duration. Logistic regression was used to explore the risk factors associated with mortality and prognosis. Propensity score matching was used to balance the confounders between different anti-hypertensive treatments. Kaplan-Meier curves were used to compare the cumulative recovery rate. Log-rank tests were performed to test for differences in Kaplan-Meier curves between different groups.

Among 4569 hospitalized patients with COVID-19, 31.7% (1449/4569) had a history of hypertension. There were significant differences in mortality rates between hypertensive patients with CCBs (7/359) and those without (21/359) (1.95% vs. 5.85%, risk ratio [RR]: 0.32, 95% confidence interval [CI]: 0.13-0.76, χ² = 7.61, P = 0.0058). After matching for confounders, the mortality rates were similar between the RAAS inhibitor (4/236) and non-RAAS inhibitor (9/236) cohorts (1.69% vs. 3.81%, RR: 0.43, 95% CI: 0.13-1.43, χ² = 1.98, P = 0.1596). Hypertensive patients with beta-blockers (13/340) showed no statistical difference in mortality compared with those without (11/340) (3.82% vs. 3.24%, RR: 1.19, 95% CI: 0.53-2.69, χ²= 0.17, P= 0.6777).

In our study, we did not find any positive or negative effects of RAAS inhibitors or beta-blockers in COVID-19 patients with hypertension, while CCBs could improve prognosis.

Perioperative neurocognitive disorders (PND) are a series of severe complications in the perioperative and anesthetic periods with a decline in memory, execution ability, and information processing speed as the primary clinical manifestation. This study aimed to evaluate the impact of edaravone (EDA) on PND and peripheral blood C-X-C motif chemokine ligand 13 (CXCL13) levels in elderly patients with hip replacement.

A total of 160 elderly patients undergoing hip arthroplasty in Affiliated Dongguan People’s Hospital of Southern Medical University (from March 2016 to March 2018) were randomly and double-blindly categorized into an EDA group and a control group (CON). Group EDA was administered intravenously EDA 30 min before surgery, and group CON was administered intravenously saline. The cognitive function of the two groups was evaluated 1-day before the operation and at 1 and 12 months after surgery, and the incidence of post-operative delirium was tested on days 1, 3, and 7 after surgery using the Chinese version of the confusion assessment method. Serum CXCL13 and interleukin (IL)-6 concentrations were measured before anesthesia, during surgery (30 min after skin incision), and on days 1, 3, and 7 after surgery. The continuous variables in accordance with normal distribution were tested using the Student’s t test, the continuous variables without normal distribution using the Mann-Whitney U test, and categorical variables by the χ² test or Fisher exact test.

The incidence of post-operative delirium within 7 days after surgery was significantly higher in group CON than that in group EDA (31.3% vs. 15.0%, t=-5.6, P < 0.001). The modified telephone interview for cognitive status and activities of daily life scores were significantly higher in the group EDA than those in the group CON at 1 month (39.63 ± 4.35 vs. 33.63 ± 5.81, t = -2.13, P < 0.05 and 74.3 ± 12.6 vs. 61.2 ± 13.1, t = -1.69, P < 0.05) and 12 months (40.13 ± 5.93 vs. 34.13 ± 5.36, t = -3.37, P < 0.05 and 79.6 ± 11.7 vs. 65.6 ± 16.6, t= -2.08, P < 0.05) after surgery; and the incidence of neurocognitive dysfunction was significantly lower in the group EDA than that in the group CON (P < 0.05). Serum CXCL13 and IL-6 concentrations were significantly lower in the group EDA than those in the group CON during and after surgery (P < 0.05).

EDA can significantly reduce the serum concentrations of CXCL13 and IL-6 and improve the PND of patients.

Exposure to airborne particulate matters (fine particulate matter [PM2.5] and inhalable particulate matter [PM10]) causes acute exacerbation of chronic respiratory diseases and even death in some patients.^[1,2]Here, we studied the association between airborne pollutants (PM2.5, PM10, ozone [O₃]), weather conditions (mean air temperature, wind force), and outpatient and inpatient visits for chronic respiratory diseases (bronchitis, emphysema and chronic obstructive pulmonary disease [COPD], bronchiectasis) in Xiamen, China.

Developmental dysplasia of the hip (DDH) is one of the most common limb deformities in pediatric orthopedics. Patients who cannot achieve closed reduction, or cannot maintain concomitant reduction, suffer from repeated dislocation or delay in diagnosis, treatment and need to undergo open reduction (OR) therapy. However, since researchers have demonstrated that patients treated by OR are prone to continue to experience acetabular dysplasia and dislocation,^[1]it is recommended that OR and pelvic osteotomy should be performed at the same time in order to correct dysplasia, reduce the incidence of residual acetabular dysplasia and the rate of long-term reoperation. By performing pelvic osteotomy, acetabular coverage can be increased and the occurrence of hip instability can be avoided in the long run.^[2]In recent years, Dega osteotomy has been widely applied in clinical practice because of its wide indications, simplicity of operation, low trauma, and lack of necessity to take the history of hip surgery into account.

To the Editor: Obstructive sleep apnea syndrome (OSAS) is characterized by repetitive episodes of upper airway obstruction (partial or complete) during sleep, which leads to recurrent arterial hypoxemia and sleep fragmentation. Untreated OSAS in middle-aged patients cause impairments in attention, vigilance, some aspects of memory, and executive function.^[1]Transient ischemic attack (TIA) is characterized by a transient episode of neurological dysfunction caused by focal brain ischemia. By definition, TIA should not bring persistent deficits but it does increase the risk of long-term cognitive impairment.^[2]OSAS is an independent risk factor for TIA. However, transient or persistent cognitive impairment after TIA in OSAS patients remains unclear. Therefore, we conducted a prospective cohort study on cognitive function after TIA to provide insight into the characteristics and influence factors of cognitive function in OSAS patients within 2 years.

To the Editor:A 20-year-old man who developed hemophagocytic lymphohistiocytosis (HLH) was treated with methylprednisolone combined with etoposide (VP-16) for 24 weeks. One month after treatment completion, HLH recurred. The patient visited the Hematology Department of the Beijing Friendship Hospital and was diagnosed with primary HLH withPRF1fusion gene mutation. Subsequently, he was treated with a regimen of liposomal doxorubicin, VP-16, and methylprednisolone (DEP) and achieved complete remission. Later, in July 2014, the patient underwent an allogeneic hematopoietic stem cell transplant (allo-HSCT) from an allele human leukocyte antigen (HLA)-5-/10-matched, bone marrow donor. A conditioning protocol of total-body irradiation/cyclophosphamide/VP-16 (TBI/CY/VP-16) was used before the transplant. Additionally, the patient was administered cyclosporine, methotrexate, and mycophenolate mofetil as prophylaxis for graft-versus-host disease (GVHD). However, the patient developed chronic GVHD (cGVHD) in the liver 2 years later and received anti-GVHD treatment with methylprednisolone and tacrolimus (FK506). Despite treatment, 26 months after the HSCT, the patient was re-admitted due to progressive dyspnea. Prior to the HSCT, the patient’s forced expiratory volume in 1 s (FEV1) was 115.2% of the predicted value, and the FEV1/forced vital capacity (FVC) was 87.5%. However, after the HSCT, a pulmonary function test (PFT) demonstrated a reduced FEV1 of 31.7% and a FEV1/FVC of 36.6%. Computerized tomography (CT) examination of the chest revealed multiple bronchiectasis in a columnar shape and air-trapping in both lungs. No evidence was found which suggested lung or other organ infections. Based on these findings, a diagnosis of bronchiolitis obliterans syndrome (BOS) after HSCT was determined, and the patient received treatment with methylprednisolone (8 mg bid) and FK506 (3 mg bid). After 3 months of treatment, the dyspnea symptoms did not improve and the patient achieved no significant FEV1 improvement. Following the methylprednisolone and FK506 administration, the patient received intermittent treatment with mesenchymal stem cells (MSCs) (100 mL × 5, number of cells 5 × 10⁷/100 mL). Nevertheless, the patient’s dyspnea symptoms did not improve, and the FEV1 steadily decreased to 24.6% (the lowest recorded value). Subsequently, ruxolitinib treatment (10 mg bid) was initiated and the MSCs treatment was discontinued. After 3 months of ruxolitinib treatment, the patient achieved some degree of stability and improvement of BOS symptoms with an FEV1 of 35.1% [Figure 1]. Shortly after the initiation of the ruxolitinib treatment, the daily methylprednisolone dose was reduced to 2 mg bid and the ruxolitinib was continued for a total of 7 months. However, chest CT examination revealed that multiple bronchiectasis still remained after completion of the ruxolitinib treatment. The patient is still alive and was able to attend a 3.5-year follow-up visit.

To the Editor: Phenylketonuria (PKU) is an autosomal recessive genetic disease caused by pathogenic variants in thephenylalanine hydroxylase(PAH) gene encoding phenylalanine hydroxylase, a key enzyme in the metabolism of phenylalanine. Early low-phenylalanine diet improves most of the neuropsychological disorders, but it is difficult to be maintained for a long period of time.^[1]To date, 1184 variants inPAHgene, including missense, splicing, nonsense, insertion and deletion variants, have been identified. The distribution of the variants is quite variable in ethnic groups. Genetic testing and prenatal diagnosis are effective to prevent PKU families from transmitting the pathogenicPAHalleles to their progeny. However, only a few reports about the prenatal diagnosis of PKU from north China have been found in the literature. Here we summarized the results of variant detection in 157 probands and their parents, and prenatal diagnosis of 103 fetuses from 95 PKU families.

To the Editor: Previous studies paid less attention on the reasons of anemia in schoolchildren, particularly in a relatively well-off area, which might hamper policy design for anemia control. Thus, the present study would explore the reasons for anemia in schoolchildren aged 5 to 11 years in Beijing based on personal data including dietary intake and serum biomarkers of nutrients.

To the Editor: Prurigo pigmentosa is a rare inflammatory dermatosis first reported in Japan in 1971. Typical lesions of prurigo pigmentosa are erythematous papules with a reticular arrangement that quickly resolve leaving pigmentation. As a rare manifestation, bullous prurigo pigmentosa has been reported in cases^[1,2]and case series.^[3]We herein describe a case of prurigo pigmentosa with vesiculobullous formation following a ketogenic diet.

Following the original article’s publication,^[1]the authors informed us of the following errors:^[1]The Figure 2 is submitted incorrectly, while correct Figure 2 should submit as following: