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Problem: The novel coronavirus disease 2019 (COVID-19) pandemic adversely affected the preparation of Malaysia’s National Health and Morbidity Survey for 2020 because conducting it would expose data collectors and participants to an increased risk of infection. Context: The survey is nationally representative and community based and is conducted by the Institute for Public Health, part of the National Institutes of Health, to generate health-related evidence and to support the Malaysian Ministry of Health in policymaking. Its planned scope for 2020 was the seroprevalence of communicable diseases such as hepatitis B and C. Action: Additional components were added to the survey to increase its usefulness, including COVID-19 seroprevalence and facial anthropometric studies to ensure respirator fit. The survey’s scale was reduced, and data collection was changed from including only face-to-face interviews to mainly self-administered and telephone interviews. The transmission risk to participants was reduced by screening data collectors before the survey and fortnightly thereafter, using standard droplet and contact precautions, ensuring proper training and monitoring of data collectors, and implementing other administrative infection prevention measures. Outcome: Data were collected from 7 August to 11 October 2020, with 5957 participants recruited. Only 4 out of 12 components of the survey were conducted via face-to-face interview. No COVID-19 cases were reported among data collectors and participants. All participants were given their hepatitis and COVID-19 laboratory test results; 73 participants with hepatitis B and 14 with hepatitis C who had been previously undiagnosed were referred for further case management. Discussion: Preparing and conducting the National Health and Morbidity Survey during the COVID-19 pandemic required careful consideration of the risks and benefits, multiple infection prevention measures, strong leadership and strong stakeholder support to ensure there were no adverse events.

Objective: Bacterial co-infections in cases of coronavirus disease 2019 (COVID-19) can lead to less favourable outcomes. The aim of this study was to determine the prevalence of primary bacterial co-infections among patients with COVID-19 in Brunei Darussalam. Methods: Seventy-one of 180 patients admitted to the National Isolation Centre between 9 March 2020 and 4 February 2021 were screened for primary bacterial co-infection (infection occurring

Lupus erythematosus is an autoimmune disease that causes damage to multiple organs ranging from skin lesions to systemic manifestations. Cutaneous lupus erythematosus (CLE) is a common type of lupus erythematosus (LE), but its molecular mechanisms are currently unknown. The study aimed to explore changes in the gene expression profiles and identify key genes involved in CLE, hoping to uncover its molecular mechanism and identify new targets for CLE.We analyzed the microarray dataset (GSE109248) derived from the Gene Expression Omnibus (GEO) database, which was a transcriptome profiling of CLE cutaneous lesions. The differentially expressed genes (DEGs) were identified, and the functional annotation of DEGs was performed with Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses. Protein-protein interaction (PPI) network was also constructed to identify hub genes involved in CLE.A total of 755 up-regulated DEGs and 405 down-regulated DEGs were identified. GO enrichment analysis showed that defense response to virus, immune response, and type I interferon signaling pathway were the most significant enrichment items in DEGs. The KEGG pathway analysis identified 51 significant enrichment pathways, which mainly included systemic lupus erythematosus, osteoclast differentiation, cytokine-cytokine receptor interaction, and primary immunodeficiency. Based on the PPI network, the study identified the top 10 hub genes involved in CLE, which were CXCL10, CCR7, FPR3, PPARGC1A, MMP9, IRF7, IL2RG, SOCS1, ISG15, and GSTM3. By comparison between subtypes, the results showed that ACLE had the least DEGs, while CCLE showed the most gene and functional changes.The identified hub genes and functional pathways found in this study may expand our understanding on the underlying pathogenesis of CLE and provide new insights into potential biomarkers or targets for the diagnosis and treatment of CLE. Key Points • The bioinformatics analysis based on CLE patients and healthy controls was performed and 1160 DEGs were identified • The 1160 DEGs were mainly enriched in biological processes related to immune responses, including innate immune response, type I interferon signaling pathway, interferon-γ-mediated signaling pathway, positive regulation of T cell proliferation, regulation of immune response, antigen processing, and presentation via MHC class Ib and so on • KEGG pathway enrichment analysis indicated that DEGs were mainly enriched in several immune-related diseases and virus infection, including systemic lupus erythematosus, primary immunodeficiency, herpes simplex infection, measles, influenza A, and so on • The hub genes such as CXCL10, IRF7, MMP9, CCR7, and SOCS1 may become new markers or targets for the diagnosis and treatment of CLE.

IL‐38 is a newly identified cytokine that belongs to the IL‐1 family. In our previous study, we found elevated plasma levels of IL‐38 in patients with systemic lupus erythematosus (SLE). However, the clear relationship of IL‐38 expression in plasma, peripheral blood mononuclear cells (PBMCs) and clinical and laboratory features needs elucidation. Additionally, we evaluated the possible role of IL‐38 in regulating production of inflammatory cytokines in PBMCs in vitro. A pristane‐induced murine lupus model was used to further demonstrate the effects of IL‐38 on cytokines in vivo and discuss the significance of IL‐38 in lupus development. The results showed that mRNA expression of IL‐38 in PBMCs of patients with SLE was elevated compared with volunteers, and expression of IL‐38 in both plasma and PBMCs was strongly related to clinical features, such as haematuria and proteinuria, and correlated with a SLEDAI score. Plasma levels of TNF‐α, IL‐1β, IL‐6 and IL‐23 were elevated in patients with SLE and were related to plasma levels of IL‐38. In vitro, PBMCs of patients with SLE stimulated with IL‐38 showed a decreased expression of the four inflammatory cytokines compared with PBMCs of patients without treatment. Interestingly, IL‐38 administration in lupus mice significantly reduced the development of lupus, such as reduced proteinuria, improved histological examinations of the kidneys and down‐regulated inflammatory cytokines. In conclusion, IL‐38 may suppress synthesis of pro‐inflammatory cytokines and therefore regulate lupus pathogenesis.

Objective We sought to compare clinical outcomes in patients with acute type A aortic dissection that undergone surgical repair during in-hours (IH) versus out-of-hours (OOH). Methods An electronic literature search was done till March 2020 to include studies with comparative cohorts of IH versus OOH. Primary outcomes were 30-day mortality, stroke, and reoperation for bleeding; secondary outcomes were acute kidney injury, total hospital stay, and intensive care unit stay. Results Six articles with a total of 3744 patients met the inclusion criteria. Mean age was similar, 60 ± 12 versus 60 ± 13 in IH versus OOH (p = .25). Aortic root and total arch replacement were similar in both cohorts, 22% in IH versus 25% in OOH (risk ratio [RR], 1.10; 95% confidence interval [CI: 0.78, 1.55]; p = .58) and 29% in IH versus 32% in OOH (RR, 0.96; 95% CI [0.89, 1.04], p = .37) respectively. Reoperation for bleeding and stroke rate were similar, with 18% in IH versus 23% in OOH (RR, 0.89; 95% CI [0.73, 1.08]; p = .24), and 12% in IH versus 13% in OOH (RR, 0.83; 95% CI [0.66, 1.03]; p = .09) respectively. Thirty-day mortality was significantly lower in IH (RR, 0.81; 95% CI [0.72, 0.90]; p = .0001). Conclusion There was higher 30-day mortality rate during OOH surgery, yet this difference diminished following sensitivity analysis. There were no significant differences in major postoperative outcomes. Therefore, operating on such cases should be decided on clinical priority without delay.

Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disorder. MASP2 is a mediator that plays an important role in complement system. As dysregulation of the complement system has been demonstrated to correlate with SLE pathogenesis, the role of MASP2 in lupus has not been widely discussed. In the present study, serum levels of MASP2 were evaluated in 61 lupus patients and 98 healthy controls by training cohort, and then a validation cohort including 100 lupus, 100 rheumatoid arthritis, 100 osteoarthritis, 100 gout, 44 Sjogren's syndrome, 41 ankylosing spondylitis patients confirmed the findings. Receiver operating characteristic (ROC) curve analysis determined the discriminatory capacity for serum MASP2. PCR methods tested the association of MASP2 gene polymorphisms (rs7548659, rs17409276, rs2273346, rs1782455 and rs6695096) and SLE risk. Impact of polymorphism on MASP2 serum levels was evaluated as well. Results showed that serum levels of MASP2 were significantly higher in lupus patients and correlated with some clinical, laboratory characteristics in the training cohort, and were much higher as compared to that in different rheumatic diseases patients in the validation cohort. Serum MASP2 showed a good diagnostic ability for lupus. Genotype frequencies and allele frequency of polymorphisms rs7548659, rs2273346 were strongly related to SLE risk, and genotypes of rs17409276, rs1782455, rs76695096 were significantly correlated with lupus genetic susceptibility. Interestingly, patients carrying GA genotype of rs17409276, TT, TC genotype of rs6695096 showed higher levels of serum MASP2. The findings suggested that MASP2 may be a potential disease marker for lupus, and correlate with SLE pathogenesis.

Novel coronavirus disease (COVID-19) is a highly contagious disease caused by severe acute respiratory distress syndrome coronavirus-2 that has resulted in the current global pandemic. Currently, there is no available treatment proven to be effective against COVID-19, but multiple medications, including hydroxychloroquine (HCQ), are used off label. We report the case of a 60-year-old woman without any cardiac history who developed right bundle brunch block and critically prolonged corrected electrocardiographic QT interval (QTc 631 ms) after treatment for 3 days with HCQ, which resolved on discontinuation of the medication. This case highlights a significant and potentially life-threatening complication of HCQ use.

This study estimated the prevalence of undetected, untreated and uncontrolled hypertension in Brunei Darussalam and the associations with socio-demographic and non-communicable diseases (NCDs) risk factors. Participants were aged 18–69 years old from the national NCDs and risk factors survey in Brunei Darussalam, conducted from August 2015 to April 2016. Multiple logistic regression was applied to estimate the associations of undetected, untreated and uncontrolled hypertension with socio-demographic and NCDs risk factors. The crude prevalence of hypertension was estimated to be 40.4% [95% confidence interval (CI) = 37.2–43.6] in men and 32.3% (95% CI = 29.6–35.0) in women. Multivariable adjustment using logistic regression found that those who were currently married [odds ratio (OR) = 0.34, p

This paper aims to investigate different routing protocols and compares network protocols, including IGRP, RIP, BGP, etc. on key metrics and identified predominant routing protocols. In order to implement the comparison of different routing protocols for smart green systems (RPSGSs), a network has been deployed with a Cisco packet tracer. Furthermore, the commands related to respective routing protocols are selected and used in CLI mode to configure the network. Cisco packet tracer is used since it provides a user-friendly interface on which users can drag and drop many devices to connect together to perform the configuration. The comparative analysis results suggest that EIGRP is a suitable routing protocol for the network that uses Cisco devices and OSPF is the most efficient routing protocol that can be used to transfer the packet from source to destination. RPSGSs allow datagrams to travel in the shortest path throughout the network.

Objective The benefit of Se supplementation in rheumatoid arthritis (RA) has been tested in clinical trials, but results remain inconclusive. The objective of this study was to specifically investigate the potential benefit of supranutritional Se by examining human samples from an area with supranutritional Se intake and testing a mouse model of RA. Methods Peripheral blood mononuclear cells (PBMCs) from RA patients (N = 57) and healthy controls (HC, N = 71) from an area of supranutritional Se intake (Enshi, Hubei, China) were analysed by flow cytometry. Serum cytokine and Se levels were measured by cytometric beads array (CBA) and inductively coupled plasma mass spectrometry (ICP‐MS), respectively. With sufficient or supranutritional selenium intake, mice were induced with collagen‐induced arthritis (CIA) and examined for disease activity and immunopathology. The influence of Se supplementation in the generation of RANKL‐expressing osteoclastogenic CD4+ T cells was investigated by in vitro assays. Results In Enshi city, HC showed the above‐normal concentrations of serum Se concentrations while RA patients were enriched in the normal range (70–150 ng mL−1) or below. RA patients with higher Se levels demonstrated milder disease and lower levels of C‐reactive protein, IL‐6, RANKL and Th17 cells. In the mouse CIA model, supranutritional Se supplementation delayed disease onset, ameliorated joint pathology and reduced CD4+CD44+RANKL+ T cells. Se supplementation could suppress RANKL expression in cultured mouse Th17 cells. Conclusion Supranutritional Se suppresses RANKL‐expressing osteoclastogenic CD4+ T cells and could be beneficial to RA, which warrants formal testing in randomised clinical trials., In this study, we found that supranutritional selenium (Se) was associated with improved disease activities in patients with rheumatoid arthritis and also ameliorated collagen‐induced arthritis in mice. Se attenuated the production of reactive oxygen species (ROS) and thus suppressed ROS‐mediated induction of RANKL expression in activated CD4+ T cells.

The early shortage of novel coronavirus disease (COVID-19) tests in the United States led many hospitals to first screen for common respiratory pathogens, and only if this screen was negative to proceed with COVID-19 testing. We report a case of a 56-year-old woman with severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) coinfection with group A Streptococcus. The initial testing strategy resulted in delays in both diagnosis and implementation of appropriate precautions. Underlined is the importance of testing for both SARS-CoV-2 and other common respiratory pathogens during the current pandemic.

Purpose In this digitalization age, smart technologies are on the cusp of changing all business sector including retailing. Today’s consumers desire to shop in a smart store where the physical products on display are connected to the internet world. This study aims to propose a model for investigating Generation Z (Gen-Z) consumers’ expectations towards the smart retail technology (SRT) in the Malaysian context through the application of the stimulus-organism-response framework. Design/methodology/approach By using a purposive sampling technique, a self-administered questionnaire was conducted. A total of 220 usable responses were collected from Gen-Z consumers who had experience in using SRT. The data were analysed using partial least square structural equation modelling (PLS-SEM). Findings This study underscores the role of perceived usefulness, perceived enjoyment and perceived value on Gen-Z consumers’ attitude and word-of-mouth (WOM). Expectations on usefulness, enjoyment and value provide some ideas on Gen-Z consumers’ value who put a high emphasis on functional value, fun value and value for money when adopting the SRT. On the other hand, the result also demonstrates the mediating role of consumers’ attitude in connecting perceived value and perceived enjoyment on WOM towards SRT. Practical implications The findings of this study provide beneficial insights for a retailer who desire to pursue a smart-related acquisition strategy. Retailers are recommended to embrace on the following three key features: innovative solution (high usefulness), reliable benefits (high perceived value) and fun experience (high enjoyment) to provide Gen-Z consumers with compelling experiences. Additionally, retailers are suggested to acknowledge the importance of managing consumers’ attitude in driving positive WOM evaluations. Originality/value This paper responds to Ting et al.’s (2018) call in uncovering values and lifestyles of generation in details. In Malaysia, retailers ought to incorporate of the high level of usefulness, value and enjoyment when designing their SRT to constitute the Gen-Z consumers’ expectations. Moreover, similar to Ting’s conclusion, this cohort members are very much into technologies and they tend to embrace SRT in their lifestyles.

Interleukin‐29 (IL‐29) is a newly discovered member of type III interferon. It mediates signal transduction via binding to its receptor complex and activates downstream signalling pathways, and therefore induces the generation of inflammatory components. Recent studies reported that expression of IL‐29 is dysregulated in inflammatory autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus, osteoarthritis, Sjögren's syndrome, psoriasis and systemic sclerosis. Furthermore, functional analysis revealed that IL‐29 may involve in the pathogenesis of the inflammatory autoimmune disorders. In this review, we will systematically review the current knowledge about IL‐29. The information collected revealed the regulatory role of IL‐29 and may give important implications for its potential in clinical treatment.

This study evaluated expression of circRNA in primary Sjögren's syndrome (pSS) patients so as to find novel biomarkers for pSS screening and discussed possible role of circRNA in pSS. We also evaluated expression profile of circRNA in systemic lupus erythematosus (SLE) patients.Microarray analysis detected circRNA expression in PBMCs from five paired pSS, SLE patients, and controls. Then, differentially expressed circRNAs were validated in 30 pSS patients as compared to 30 SLE patients, healthy controls. CircRNAs interacting with miRNAs were discussed by Arraystar's homemade miRNA target prediction software. ROC analysis assessed the diagnostic value.We identified 234 differentially expressed circRNAs in pSS patients and verified five selected circRNAs (including hsa_circRNA_001264, hsa_circRNA_104121, hsa_circRNA_045355, hsa_circRNA_103461, hsa_circRNA_105034). Expression of hsa_circRNA_001264, hsa_circRNA_104121, and hsa_circRNA_045355 was strongly related to some clinical, laboratory parameters, and disease activity index in pSS patients. ROC analysis indicated potential diagnostic ability for the three circRNAs in pSS patients. One hundred and forty-eight circRNAs were differently expressed between lupus patients and controls.This study provides evidence that hsa_circRNA_001264, hsa_circRNA_104121, and hsa_circRNA_045355 might be biomarkers for pSS, correlate with pSS etiology.Key Points• Many circRNAs were dysregulated in pSS patients.• Differentially expressed circRNAs correlated with pSS clinical, laboratory features.• CircRNAs may be biomarkers for pSS.

Interleukin-34 (IL-34) shares a common receptor with macrophage colony-stimulating factor (M-CSF), and can bind to CSF-1R, induces lymphocytes differentiation, proliferation, and regulates the synthesis of inflammatory components. Recent findings reported aberrant expression of IL-34 in several autoimmune disorders, such as lupus, arthritis, systemic sclerosis, inflammatory bowel diseases. The functional analysis further demonstrated that IL-34 may perform significantly in these inflammatory autoimmune disorders. IL-34 might consider as a biomarker for these diseases. I hope this collection of the findings in this review will improve knowledge of the role of IL-34, and targeting IL-34 may give the potential for these autoimmune diseases.

Systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) are complex autoimmune diseases. CD40 participates in inflammatory response, and promotes fibroblast proliferation, leading to occurrence and progression of SLE, RA. This study explores CD40 gene polymorphisms in SLE and RA patients from a Chinese Han population. Two hundred SLE patients, 340 RA patients, and 900 healthy controls were enrolled. Genomic DNA was extracted from peripheral blood, and six polymorphisms of CD40 gene (rs3765456, rs1569723, rs73115010, rs13040307, rs1883832, and rs4810485) were detected by KASP method. Frequencies of rs1569723 genotypes AA, AC, AA+AC were significantly higher in RA patients as compared to those in healthy controls (P = 0.049, P = 0.024, P = 0.022). Frequencies of genotypes CT, CC+CT of rs1883832, and GT, GG+GT of rs4810485 were significantly higher in RA patients as compared to those in healthy controls (P = 0.012, P = 0.018, P = 0.009, P = 0.015). RA patients carrying rs13040307 C allele and rs73115010 T allele showed increased number of swollen joints. Moreover, frequency of allele T of rs13040307 was lower in SLE patients with positive anti-dsDNA and hematuria as compared to that in patients without these parameters (P = 0.038, P = 0.045). There were increased frequencies of genotype TT, allele T for rs13040307 and lower frequencies of genotype TT, allele T for rs73115010 in lupus patients with myositis (all P

Dengue is a major threat to public health globally. While point-of-care diagnosis of acute/recent dengue is available to reduce its mortality, a lack of rapid and accurate testing for the detection of previous dengue remains a hurdle in expanding dengue seroepidemiological surveys to inform its prevention, especially vaccination, to reduce dengue morbidity. This study evaluated ViroTrack Dengue Serostate, a biosensors-based semi-quantitative anti-dengue IgG (immunoglobulin G) immuno-magnetic agglutination assay for the diagnosis of previous and recent dengue in a single test. Blood samples were obtained from 484 healthy participants recruited randomly from two communities in Petaling district, Selangor, Malaysia. The reference tests were Panbio Dengue IgG indirect and capture enzyme-linked immunosorbent assays, in-house hemagglutination inhibition assay, and focus reduction neutralization test. Dengue Serostate had a sensitivity and specificity of 91.1% (95%CI 87.8–93.8) and 91.1% (95%CI 83.8–95.8) for the diagnosis of previous dengue, and 90.2% (95%CI 76.9–97.3) and 93.2% (95%CI 90.5–95.4) for the diagnosis of recent dengue, respectively. Its positive predictive value of 97.5% (95%CI 95.3–98.8) would prevent most dengue-naïve individuals from being vaccinated. ViroTrack Dengue Serostate’s good point-of-care diagnostic accuracy can ease the conduct of dengue serosurveys to inform dengue vaccination strategy and facilitate pre-vaccination screening to ensure safety.

Background Non-alcoholic fatty liver disease (NAFLD) is associated with increased cardiovascular risk irrespective of conventional risk factors. The role of gut-liver interaction is implicated in its development. We investigated the effects of VSL#3® probiotic supplementation on biomarkers of cardiovascular risk and liver injury in patients with NAFLD. Methods A randomised, double-blinded, placebo-controlled, proof-of-concept study was undertaken. Patients with NAFLD were randomly allocated to take 2 sachets VSL#3® probiotic or placebo twice daily for 10 weeks. Measurements of endothelial function (digital photoplethysmography, sVCAM-1 and cGMP), oxidative stress (glutathione ratio and LHP), inflammation (hsCRP), insulin resistance (HOMA-IR) and liver injury [transaminases, fibrosis risk score and acoustic structure quantification (ASQ)] were undertaken before and after intervention. Difference in baseline characteristics between the treatment groups was analysed using independent t-test or Mann Whitney U test for non-parametric data. Independent t-test was used to compare the outcomes at the end of the study between the two treatment groups. Wilcoxon Signed Rank test was used to determine the difference in fibrosis risk scores before and after treatment. Spearman’s correlation was used to determine any association between cardiovascular and hepatic markers at baseline. Results Thirty-five patients completed the study (28 males and 7 females) with a mean age of 57 ± 8 years, body mass index of 32.6 ± 5.0 kg/m2 and a relatively short duration of NAFLD (median duration 0.3 IQR 2.0 years). No significant difference was observed in biomarkers of cardiovascular risk and liver injury following VSL#3® supplementation. Significant correlations were noted between sVCAM-1 and hsCRP (rho = 0.392, p = 0.01), and HOMA-IR and AST (rho = 0.489, p Conclusions This is the first study to evaluate the effect of VSL#3® on ASQ in patients with NAFLD. VSL#3® did not significantly improve markers of cardiovascular risk and liver injury in patients with NAFLD. However, the study supports an association between endothelial dysfunction and inflammation in patients with NAFLD and suggests that NAFLD is linked with insulin resistance. Trial registration: ISRCTN05474560 (https://doi.org/10.1186/ISRCTN05474560) Registered 9 August 2012 (retrospectively registered).

In view of the urgent and complex demand of the surface ship's air-defense, this paper presents a CGF air-defense decision-making method based on the theory of fuzzy mathematics and the technology of behavior tree of single ships. According to the characteristics of different nodes in the behavior tree, the CGF behavior tree model framework is constructed according to the logical sequence of single ship air-defense action flow in the actual battlefield. Aiming at the requirement of intelligence of conditional nodes, the judgment algorithm constituted by the theory of fuzzy mathematics is applied to fill the conditional nodes of behavior tree, and verified by simulation experiment, so as to construct the CGF decision model of single ship's air-defense with intelligence.

The authors have requested that this preprint be removed from Research Square.

Interleukin (IL)-35 is the newest member of the IL-12 family. It is expressed in many immune cells and has been recognized as a novel inflammatory cytokine that may have bifunctional properties. Recent findings have indicated that the expression of IL-35 is abnormal in rheumatoid arthritis (RA) patients. However, the results were inconsistent. In this study, 400 RA patients were recruited to evaluate serum levels of IL-35 in a Chinese Han population by enzyme-linked immunosorbent assay. The association of IL-35 gene polymorphisms and RA genetic susceptibility was investigated in 400 RA patients and 612 healthy controls. The results showed that serum levels of IL-35 were elevated in 100 RA patients compared to 51 healthy controls, relating to disease activity and synovial fluid IL-35 expression in the training cohort. Another independent 300 RA patients and 369 other rheumatic disease patients (98 lupus, 95 osteoarthritis, 95 gout, 42 Sjogren's syndrome and 39 ankylosing spondylitis patients) confirmed that serum levels of IL-35 were elevated in RA patients, and serum IL-35 has good diagnostic ability for differentiating RA from the other rheumatic diseases. The genotyping of 10 IL-35 polymorphisms, including rs2227314, rs2243115, rs2243123, rs2243131, rs568408, rs583911, rs428253, rs4740, rs9807813 and rs4905, revealed that rs2227314, rs2243131, rs9807813, and rs583911 were correlated with RA risk. Different genotypes (rs2227314, rs583911, and rs9807813) exhibited different expression of IL-35. These findings demonstrate that serum levels of IL-35 are increased in RA patients and that IL-35 polymorphisms are correlated with RA risk.

Following the demonstration of the efficacy of hydroxychloroquine against severe acute respiratory syndrome coronavirus 2 in vitro, many trials started to evaluate its efficacy in clinical settings. However, no systematic review and meta‐analysis have addressed the issue of the safety and efficacy of hydroxychloroquine (HCQ) in coronavirus disease 2019. We conducted a systematic review and meta‐analysis with the objectives of evaluation of safety and efficacy of HCQ alone or in combination in terms of “time to clinical cure,” “virological cure,” “death or clinical worsening of disease,” “radiological progression,” and safety. RevMan was used for meta‐analysis. We searched 16 literature databases out of which seven studies (n = 1358) were included in the systematic review. In terms of clinical cure, two studies reported possible benefit in “time to body temperature normalization” and one study reported less “cough days” in the HCQ arm. Treatment with HCQ resulted in less number of cases showing the radiological progression of lung disease (odds ratio [OR], 0.31, 95% confidence interval [CI], 0.11‐0.9). No difference was observed in virological cure (OR, 2.37, 95% CI, 0.13‐44.53), death or clinical worsening of disease (OR, 1.37, 95% CI, 1.37‐21.97), and safety (OR, 2.19, 95% CI, 0.59‐8.18), when compared with the control/conventional treatment. Five studies reported either the safety or efficacy of HCQ + azithromycin. Although seems safe and effective, more data are required for a definitive conclusion. HCQ seems to be promising in terms of less number of cases with radiological progression with a comparable safety profile to control/conventional treatment. We need more data to come to a definite conclusion., Research Highlights Following the demonstration of the efficacy of hydroxychloroquine (HCQ) against severe acute respiratory syndrome coronavirus 2 in vitro, many trials were started to evaluate its efficacy in clinical settings.However, no systematic review and meta‐analysis have addressed the issue to the safety and efficacy of HCQ in coronavirus disease 2019 (COVID‐19).We searched 16 literature databases finally seven articles were identified, which evaluated the therapeutic efficacy of HCQ either alone or in combination with azithromycin in COVID‐19.RevMan was used for meta‐analysis. For continuous outcome, mean difference and for a dichotomous outcome, odds ratio with 95% confidence interval was calculated. Model selection (fixed effect or random effect) was done on the basis of heterogeneity among different studies.Three studies reported the safety and efficacy of HCQ vs control/conventional treatment in terms of safety and efficacy in COVID‐19.Treatment with HCQ resulted in benefit in terms of less number of cases with radiological progression with no increase in adverse events when compared with control/conventional/standard treatment.We can also expect a benefit in terms of a number of days to body temperature normalization and number of cough days.However, at this current point of time, no difference was seen in terms of virological cure on day 6 to 7 postinitiation of therapy and composite death or worsening of the disease.Four studies reported efficacy and five studies reported safety of the HCQ + azithromycin combination (out of which three studies from the same group).Although the combination of HCQ + azithromycin seems to be effective and safe, we need more controlled studies to come to an effective conclusion. However, electrocardiographic monitoring is essential while using this combination due to the risk of QT prolongation.

Background: Non-alcoholic fatty liver disease (NAFLD) can be ameliorated by weight loss although difficult to maintain. Emerging evidence indicates that prebiotics and antibiotics improve NAFLD. Aim: To determine whether inulin supplementation after brief metronidazole therapy is effective in reducing alanine aminotransferase (ALT) and maintaining weight loss achieved through a very-low-calorie diet (VLCD) among people with NAFLD. Methods: Sixty-two people with NAFLD commenced 4-week VLCD using Optifast meal replacements (600 kcal/day). Sixty were then randomised into a 12-week double-blind, placebo-controlled, parallel three-arm trial: (1) 400 mg metronidazole twice daily in Week 1 then inulin 4 g twice daily OR (2) placebo twice daily in week one then inulin OR (3) placebo-placebo. Main outcomes were ALT and body weight at 12 weeks. Fecal microbiota changes were also evaluated. Results: Mean body mass index (BMI) and ALT reduced after VLCD by 2.4 kg/m2 and 11 U/L, respectively. ALT further decreased after metronidazole-inulin compared to after placebo-placebo (mean ALT change &minus, 19.6 vs. &minus, 0.2 U/L, respectively, p = 0.026), however, weight loss maintenance did not differ. VLCD treatment decreased the ratio of Firmicutes/Bacteroidetes (p = 0.002). Conclusion: Brief metronidazole followed by inulin supplementation can reduce ALT beyond that achieved after VLCD in patients with NAFLD.

Interleukin 35 (IL-35) is the recently identified member of the IL-12 family of cytokines and provides the possibility to be a target for new therapies for autoimmune, inflammatory diseases. It is composed of an α chain (p35) and a β chain (EBI3). IL-35 mediates signaling by binding to its receptors, activates subsequent signaling pathways, and therefore, regulates the differentiation, function of T, B cells, macrophages, dendritic cells. Recent findings have shown abnormal expression of IL-35 in inflammatory autoimmune diseases, such as systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, multiple sclerosis, type 1 diabetes, psoriasis, multiple sclerosis, autoimmune hepatitis, experimental autoimmune uveitis. In addition, functional analysis suggested that IL-35 is critical in the onset and development of these diseases. Therefore, the present study will systematically review what had been occurred regarding IL-35 in inflammatory autoimmune disease. The information collected will help to understand the biologic role of IL-35 in immune cells, and give information about the therapeutic potential of IL-35 in these diseases.

In this study, a three-dimensional hybrid solar chimney with an integrated external thermal source is developed to complements the solar energy for uninterruptible power generation using flue gas channels as a supply source in the collector. The hybrid system is examined numerically using ANSYS Fluent software including a solar air collector with a diameter of 6 m, a 6.65-meter-long chimney, and four thermal channels. The timetable is set for different hours, namely for two modes, i.e. without flue gas during daytime (1st Case), with flue gas during daytime (Case 2-A), and with flue gas during night (Case 2-B). Moreover, the turbine effect in different day hours and with different heat sources during night are applied. The numerical method is validated by comparing its results with previous works based on different chimney heights. The present results show that the hybrid approach increases system performance significantly. Simulation is done in thermal channel with 0.0015 kg/s in chimney temperature of 116 °C. The results indicate that mass flow rate and power increased by 7.63% and 11.48%, respectively, compared to the mode with no flue gas. This study proved that the proposed method can eliminate the night defect and allow the operation of solar chimney power plants at night.

Background Interleukin-2 inducible T-cell kinase (ITK) is expressed in T cells, and plays an important role in autoimmune inflammatory diseases through regulating the balance of Th17/Treg. However, its role in human systemic lupus erythematosus (SLE) remains unclear. The present study aims to measure the activation status of ITK in T cells from SLE patients and healthy controls, and identify its possible correlation to disease severity. We also discuss the serum levels of Th17, Treg related cytokines including IL-17, IL-21, IL-22, IL-10, analyzing correlation between ITK and Th17/Treg related cytokines. Methods Peripheral blood samples were drawn from 42 patients with SLE and 43 healthy blood donors, and the phosphorylation of ITK protein was studied in T cells using flow cytometry. In addition, serum levels of Th17/Treg related cytokines were studied with enzyme-linked immunosorbent assay (ELISA). Results Percentages of CD4 + pITK + T cells, CD8 + pITK + T cells were higher in SLE patients compared with controls, and were positively related to disease activity, some clinical and laboratory parameters. Percentages of CD4 + pITK + T cells, CD8 + pITK + T cells were more prominent in active SLE patients compared with less active patients. Serum levels of Th17 and Treg related cytokines were higher in patients compared with controls. CD4 + pITK + T cells were related to levels of IL-17, IL-21. Conclusion These data indicate that increased ITK expression could act as a disease activity marker and as a risk factor for involvement in SLE, but it still needs further study to confirm.

In traditional vulnerability assessments, a synthetic index method is usually used to select all types of social and economic indexes so that more aspects can be covered; however, the requisite social and economic data are not always available or are not highly relevant to the studied geographical space, which makes it difficult to conduct quantitative calculations. In this paper, a spatial value density assessment method was developed to improve the hazard of place model. First, a three-dimensional (3D) model of a coastal city was obtained using oblique airborne photogrammetry and image-based 3D reconstruction and then, architecture footprints were employed to extract the geometric information of each individual building. Additionally, a vulnerability assessment system was established to quantitatively account for the aggregate economic value of a selected set of urban surface features. Using geographic information system (GIS) techniques, the aggregate value of these urban features within each g...

Environmental factors play an important role in the development of rheumatoid arthritis (RA). Among these factors, smoking is generally considered to be an established risk factor for RA. Data regarding the impact of diet on risk of RA development is limited. This study assessed the impact of dietary patterns on RA susceptibility in Chinese populations. This was a large scale, case-control study composed of 968 patients with RA and 1037 matched healthy controls. Subjects were recruited from 18 teaching hospitals. Socio-demographic characteristics and dietary intakes 5 years prior to the onset of RA were reported by a self-administered questionnaire. Differences in quantity of consumption between cases and controls were analyzed by Student’s t test. Multiple logistic regression analysis was applied to identify independent dietary risk factor(s) responsible for RA susceptibility. Compared to healthy individuals, RA patients had decreased consumption of mushrooms (P = 0.000), beans (P = 0.006), citrus (P = 0.000), poultry (P = 0.000), fish (P = 0.000), edible viscera (P = 0.018), and dairy products (P = 0.005). Multivariate analyses revealed that several dietary items may have protective effects on RA development, such as mushrooms (aOR = 0.669; 95%CI = 0.518–0.864, P = 0.002), citrus fruits (aOR = 0.990; 95%CI = 0.981–0.999, P = 0.04), and dairy products (aOR = 0.921; 95%CI 0.867–0.977, P = 0.006). Several dietary factors had independent effects on RA susceptibility. Dietary interventions may reduce the risk of RA.

Mesenchymal stem cell (MSC) infusion has become a novel therapeutic strategy for complex autoimmune diseases; however, few detailed studies have been performed to investigate the benefit and mechanism of MSC treatment on systemic sclerosis (SSc). The present study aimed to evaluate the therapeutic effect of human umbilical cord derived-MSCs (UC-MSCs) on bleomycin-induced SSc in mice and explore the potential underlying mechanism. The murine SSc model was established by daily subcutaneous injection of bleomycin for 4 weeks, followed with two UC-MSC infusions every 7 days. Skin fibrosis was assessed by H&E and Masson staining. Flow cytometry was used to determine IL-17A, IFN-γ, tumor necrosis factor-β, IL-10 and IL-12 levels in serum samples and T cell subsets in murine spleen. Additionally, gene expression levels of cytokines and fibrosis markers in skin samples were measured by reverse transcription-quantitative PCR. Immunofluorescence staining was performed to track UC-MSC localization and lymphocyte cell infiltration in vivo. UC-MSC treatment exerted an anti-fibrotic role in bleomycin-induced SSc mice, as confirmed by histological improvement, decreased collagen synthesis, and reduced collagen-1α1, collagen-1α2, fibronectin-1 and α-smooth muscle actin gene expression levels. The results indicated that UC-MSC treatment only had a limited systematic effect on cytokine production in serum samples and T cell activation in the spleen. By contrast, T helper (Th)17 cell infiltration and activation in skin were efficiently inhibited after UC-MSC infusion, as evidenced by the decreased IL-17A and retinoic acid-related orphan receptor γt gene expression as well as IL-17A production. UC-MSC administration significantly ameliorated bleomycin-induced skin fibrosis and collagen formation primarily by eliminating local inflammation and Th17 cell activation in the skin; however, the systemic inhibitory effect of UM-MSCs on cytokines was less profound.

BACKGROUND This study aimed to discuss the relationship between interferon regulatory factor (IRF)5 gene rs2004640 T/G polymorphism and systemic lupus erythematosus (SLE) susceptibility. METHODS A meta-analysis was calculated on the association between rs2004640 polymorphism and SLE by allelic contrast (T vs G), additive model (TT vs GG), recessive model (TT vs TG + GG) and dominant model (TT + TG vs GG). RESULTS A total of 28 comparisons were identified, including 11 228 SLE cases and 14 374 controls. Meta-analysis revealed a significant association between allele T and SLE in overall populations (odds ratio [OR] = 1.393, 95% CI: 1.276-1.522, P

AIM This study aims to discuss plasma and messenger RNA (mRNA) levels of interleukin (IL)-37 in rheumatoid arthritis (RA) patients and evaluate the potential of plasma IL-37 as a biomarker for RA. METHOD Plasma IL-37 levels and IL-37 mRNA relative concentrations were measured by enzyme-linked immunosorbent assay (ELISA) and quantitative reverse transcriptase-polymerase chain reaction (RT-PCR). We discussed the association of IL-37 levels and clinical, laboratory parameters in RA patients in a training cohort. Plasma IL-37 levels were tested for discriminatory capacity by receiver operating characteristic (ROC) curve analysis. We then validated plasma IL-37 expression in a cohort of 598 patients (230 RA, 107 systemic lupus erythematosus [SLE], 100 osteoarthritis [OA], 62 gout, 51 primary Sjogren's syndrome [pSS], 48 ankylosing spondylitis [AS]). RESULTS Both plasma levels of IL-37 and mRNA levels of IL-37 were elevated in RA patients compared to those in healthy controls in the training cohort, and there was a good diagnostic ability to predict RA (area under the curve [AUC] = 0.97). Plasma IL-37 levels were significantly related to Disease Activity Score of 28 joints - erythrocyte sedimentation rate (DAS28-ESR) (rs = 0.459, P

Previous studies have indicated that interleukin-38 (IL-38) is involved in rheumatoid arthritis (RA). The present study aims to assess plasma levels of IL-38 in RA and discuss the potential of IL-38 as a biomarker for RA. Protein concentrations of IL-38 were examined by enzyme-linked immunosorbent assay, and the mRNA level of IL-38 was tested by quantitative real-time polymerase chain reaction. Plasma IL-38 was first compared in a training cohort, including 130 RA patients and 53 healthy controls, given the optimal cutoff. Then, we validated the levels of IL-38 in a further cohort of 519 patients, including 250 with RA, 63 systemic lupus erythematosus, 62 primary Sjogren's syndrome, 51 gout, 63 osteoarthritis, and 30 psoriatic arthritis, as well as 60 healthy controls. To further discuss the changes in IL-38 after treatment and the relationship with disease activity, we tested IL-38 expression in RA patients from the training cohort under follow-up. In the training cohort, plasma levels of IL-38 were higher in RA patients compared with healthy controls (681.00 [234.45-826.47] versus 152.04 [70.06-246.80] pg/mL, P < 0.001). The IL-38 mRNA level was elevated in RA patients as compared with healthy controls (P < 0.001). Expression of IL-38 was significantly higher in RA patients compared with that in non-RA patients in the validation cohort (all P < 0.001). Treatment significantly reduced IL-38 expression. IL-38 expression was related to parameters of inflammation both at baseline and in the follow-up studies. The area under the curve (AUC) of the receiver-operating characteristic curve showed that IL-38 may be a potential biomarker for RA. At the optimal cutoff value of 341.90 pg/mL, the sensitivity, specificity, and AUC were 72.30%, 90.60%, and 0.840, respectively, in the training cohort. Similar results were noted in the validation cohort. In conclusion, IL-38 expression correlated with RA disease activity, and plasma IL-38 might be a promising diagnostic biomarker for RA.

The gut microbiome is established in the newborn period and is recognised to interact with the host to influence metabolism. Different environmental factors that are encountered during this critical period may influence the gut microbial composition, potentially impacting upon later disease risk, such as asthma, metabolic disorder, and inflammatory bowel disease. The sterility dogma of the foetus in utero is challenged by studies that identified bacteria, bacterial DNA, or bacterial products in meconium, amniotic fluid, and the placenta; indicating the initiation of maternal-to-offspring microbial colonisation in utero. This narrative review aims to provide a better understanding of factors that affect the development of the gastrointestinal (GI) microbiome during prenatal, perinatal to postnatal life, and their reciprocal relationship with GI tract development in neonates.

The H19 (rs2839698, rs3741219) and HOTAIR (rs920778) polymorphisms were related to many kinds of cancers. However, these polymorphisms have been scarcely explored in different autoimmune diseases. Here, we aimed to examine the association of the polymorphisms with susceptibility to or protection against systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and primary Sjogren’s syndrome (pSS) among Chinese Han patients. We conducted a case-control study including 800 patients (300 with SLE, 350 with RA, and 150 with pSS) and 350 healthy control individuals. The polymorphisms were specified from genomic DNA using TaqMan genotyping assay on a 7300 real-time reverse transcription polymerase chain reaction system. H19 rs2839698 was not associated with SLE susceptibility and was not associated with RA and pSS, respectively (P > 0.05). Similarly, we did not find significant differences of allele or genotype frequencies between SLE, RA, and pSS patients and healthy controls for H19 gene rs3741219 polymorphism (P > 0.05). In addition, no significant evidence was detected for the relationship of HOTAIR rs920778 polymorphism with risk of these diseases. Our results suggested that H19 rs2839698, rs3741219, and HOTAIR rs920778 polymorphisms may not be involved in the genetic background of SLE, RA, and pSS in Chinese.

TL1A is a member of the TNF superfamily. It performs significantly in the pathogenesis of rheumatic and autoimmune diseases partly through regulating the Th17 pathway. The clinical implication of circulating TL1A in patients with systemic sclerosis (SSc) remains unclear, and correlation between TL1A and Th17-related cytokines in the pathogenesis of SSc needs to be discussed. We measured serum levels of TL1A and Th17-related cytokines by ELISA in 47 patients with SSc, 56 patients with SLE, and 53 healthy subjects, and investigated association of these cytokines with clinical manifestations and laboratory variables. TL1A in relation to Th17-related cytokines were examined. In addition, the transcript level of TL1A in peripheral blood mononuclear cells (PBMCs) was determined by real-time reverse transcription polymerase chain reaction (real-time PCR). Serum TL1A levels were higher in patients with SSc than in healthy controls (P = 0.001), but were lower compared with SLE patients (P = 0.004). Diffuse cutaneous SSc or limited cutaneous SSc patients reported elevated expression of TL1A than those in healthy controls (P = 0.002, P = 0.007). Patients with active disease showed significantly higher expression of TL1A when compared with less active disease (P = 0.014). SSc patients with arthritis, elevated IgG titer, ESR >30 mm/h, and CRP >5 mg/l displayed elevated expression of TL1A, respectively. Serum levels of IL-17 and IL-21 were increased in SSc patients compared with healthy controls and positively related to TL1A levels (r s = 0.373, P = 0.010; r s = 0.370, P = 0.011, respectively). Moreover, TL1A mRNA expression in PBMCs was significantly higher in patients with SSc compared with healthy controls (P < 0.001). TL1A may play a role in the development of SSc.

In this paper, we presented an equipment fault diagnosis method based on multi-sensor data fusion, in order to solve the problems such as uncertainty, imprecision and low reliability caused by using a single sensor to diagnose the equipment faults. We used a variety of sensors to collect the data for diagnosed objects and fused the data by using D-S evidence theory, according to the change of confidence and uncertainty, diagnosed whether the faults happened. Experimental results show that, the D-S evidence theory algorithm can reduce the uncertainty of the results of fault diagnosis, improved diagnostic accuracy and reliability, and compared with the fault diagnosis using a single sensor, this method has a better effect.

For the status quo that monitoring system for mechanical equipment has limited ability to integrate information and make decision, designed the model of wireless monitoring system for mechanical equipment based on multi-Agent technology, discussed means to exchange information and communication principle among each Agent, proposed method to adjust performance parameters and task data for inference results of decision-making-Agent based on BP neural network control algorithm, realized automatic and intelligent monitoring for mechanical equipment performance.

Four models of the tunnel bedding structure were analyzed under the impact loads of the train by simulating the infrastructure under the track. In this study, we examined the relationship between the vertical dynamic coefficient and the train velocity, and also analyzed the damage sustained by the bedding structure under the static and dynamic loads. It is suggested that the damage in the concrete bedding is detected in the longitudinal direction, immediately below the two rails, and that this damage is likely to occur not from attaining an elastic limit under static loads but more likely from damage accumulation in fatigue due to repeated loadings. It is not advisable to improve the tunnel bedding structure by simply increasing the thickness of the concrete bedding board; however, the bending resistance of the tunnel bedding structure can be enhanced by adopting compact reinforced concrete structure.

A 47-year-old white man was admitted to the hos ith dysuria, generalized weakness, and volume depleti hree days before admission, he was treated with amox in for a urinary tract infection caused by Escherichia coli, hich was believed to be the precipitating cause of his llness. He reported a 2-year history of polyuria and pol ia. There was no history of problems with blood pressu ther medical conditions. He had 8 siblings with no si ant medical history, in addition to twins who were still e had attended a special-needs school as a child. On physical examination, he was clinically volume leted with a pulse rate of 120 beats/min and supine sy lood pressure of 70 mm Hg. He was in acute renal ith a urea level of 84 mg/dL (30.1 mmol/L) and crea evel of 3.3 mg/dL (293 mol/L). He had severe hypokal ic alkalosis with a potassium level of 1.4 mE 1.4 mmol/L) and bicarbonate level of 41.1 mEq/L ( mol/L). He was also hyponatremic, with a sodium lev 25 mEq/L (125 mmol/L), and hypomagnesemic, with m esium level of 1.1 mg/dL (0.47 mmol/L), but serum ium level was normal. Urine dipstick results showed protein of and a trac f blood. A 24-hour urine sample showed nephrotic-ra

In recognition that children are the key to securing a prosperous future for Australia, the health andwellbeing of Australia’s children has been placed at the centre of health related policy-making.Schools are identified by the health sector as ideal sites to promote health and wellbeing to childrenand thus some of the responsibility of children’s health and wellbeing has been assumed by schoolsin addition to the obligations of the health and physical education (HPE) curriculum.Notwithstanding the importance that government and society have afforded schooling as a primarymechanism through which Australians can enhance and maintain positive health and wellbeing,there is little research exploring the extent to which primary physical education (PE) specialists inQueensland currently undertake health work both overt and hidden.This ethnographic research adopted a grounded theory approach in exploring the phenomenon thatwas prominent in the work of PE specialists. It encompasses a detailed qualitative analysis of thehealth work that PE specialists assume, providing accountability on the implicit and explicit healtharea given their role as PE specialists. Furthermore, it reveals the implicit health education (HE)work executed within the health work done in schools. Three PE specialists from schools of varyingsocioeconomic status in metropolitan Queensland participated in this study. Each school andteacher was visited continuously for three weeks, which culminated in a lengthy semi-structuredinterview.The data analysis reveals that the work done by the specialists, in order of work responsibilityrequirements. The work can be categorised according to four key themes: curriculum work, policywork, curriculum related work and health related caring teaching the former two being, mandatorywhilst the latter two are informal and are executed to enhance the delivery of mandatory work.Informal curriculum related work and health related caring teaching are of paramount importance tothe specialists’ work and inevitably demand a large percentage of their time despite being beyondthe official job description of a PE specialist.This thesis aims to provide an insight into the informal curriculum related work and health relatedcaring teaching the teachers perform on a day-to-day basis. Noddings ethics of care will be utilisedto analyse the health work and HE work undertaken by the PE specialists. It provides PE specialistswith an understanding about their role as health workers and to gain recognition within the schoolsector regarding this role they have undertaken to reduce the burden schools are placed in the area of health work. Furthermore, there could be an increased status of PE specialists as HPE teachersundertaking this aspect of health work.

This paper examines accounting harmonisation and determinants explaining accounting measurement policy choice decisions by Asia‐Pacific listed manufacturing companies. Using Thomas' (1991) theoretical framework, four contingent variables (country of reporting, company size, profitability and debt leverage) are examined as possible determinants of firms' accounting choices concerning non‐current asset valuation measurement base, goodwill and depreciation. 130 listed manufacturing companies' annual reports were examined from Australia, Hong Kong, Indonesia, Malaysia, and Singapore. This study involves two phases. The first phase evaluates accounting harmonisation measurement indices in comparison with the extant literature. An important innovation is the operationalisation of Archer et. al. (1995) between‐country and within‐country C indices. Computed comparability indices indicated variations in the level of harmony across the five countries for all three accounting measurement practices. The second phase employed logistic regression to examine possible determinants of accounting policy choice decisions. Such a combined research approach should lead to a better understanding of de facto accounting harmonisation and practices.

We present a 46-year-old Caucasian lady with symptomatic hypocalcaemia. Investigations revealed markedly raised parathyroid hormone (PTH) levels with vitamin D deficiency. A number of conditions causing secondary hyperparathyroidism were ruled out from her medical history and initial investigations. The main differential diagnoses were vitamin D deficiency and PTH resistance (pseudohypoparathyroidism, PHP). With high-normal serum phosphate and normal alkaline phosphatase, and a lack of symptoms associated with osteomalacia, vitamin D deficiency alone was unlikely to be the cause of hypocalcaemia. Given a normal physical appearance, genetic testing was arranged and confirmed the diagnosis of PHP type Ib. She is currently taking activated vitamin D to maintain calcium homeostasis. PTH resistance is the hallmark of PHP, a rare complex genetic disorder, which can be easily missed resulting in potentially serious consequences.