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Wen-Tung Hsu,1 Deng-Ho Yang,1– 4 Chun-Cheng Liao,3,5 Jia -Wen Chen,6 Wen-Hsiu Hsu,3,7 Chia-Wen Kuo,3,8 Hung-Chang Hsu,9 Sheng-Huang Chang,10 Li-Mien Chen2,3 1Division of Laboratory, Taichung Armed Force General Hospital, Taichung, Taiwan, Republic of China; 2Department of Internal Medicine, Taichung Armed Force General Hospital, Taichung, Taiwan, Republic of China; 3School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China; 4Department of Medical Laboratory Science and Biotechnology, Central Taiwan University of Science and Technology, Taichung, Taiwan, Republic of China; 5Department of Family Medicine, Taichung Armed Force General Hospital, Taichung, Taiwan, Republic of China; 6Medicine Laboratory, Ministry of Health and Welfare Feng Yuan Hospital, Taichung, Taiwan, Republic of China; 7Division of Gastroenterology, Taichung Armed Force General Hospital, Taichung, Taiwan, Republic of China; 8Division of Nephrology, Taichung Armed Force General Hospital, Taichung, Taiwan, Republic of China; 9Division of Laboratory, Ching Chyuan Hospital, Taichung, Taiwan, Republic of China; 10Tsaotun Psychiatric Center, Ministry of Health and Welfare, Nantou, Taiwan, Republic of ChinaCorrespondence: Li-Mien ChenDepartment of Internal Medicine, Taichung Armed Force General Hospital, No. 348, Sec. 2, Chung-Shan Road, Taiping, Taichung, Taiwan, Republic of ChinaEmail c332860@ms65.hinet.netPurpose: To evaluate the blood glucose and renal function, determine the prevalence of hyperglycemia/diabetes mellitus (DM) and renal disease (nephropathy), and investigate the association between hyperglycemia/DM and renal disease in patients with viral hepatitis (VH).Patients and Methods: A total of 491 subjects were included in the study. Patients with VH were further divided into the hepatitis B virus (HBV) infection, hepatitis C virus (HCV) infection, and HBV-HCV co-infection subgroups. Fasting blood glucose, glycated hemoglobin (HbA1c), glycated albumin (GA), glutamic oxaloacetic transaminase (GOT), creatinine (Cr), and cystatin C (Cys C) levels were measured. Urine microalbumin levels were also assessed. Formulas for estimated average glucose calculated using glycated albumin(eAG(GA)), estimated average glucose calculated using HbA1c (eAG(HbA1c)), and estimated glomerular filtration rate calculated using cystatin C (eGFRcys) were used to evaluate the average glucose and renal function.Results: The prevalence of hyperglycemia/DM and renal disease was significantly higher in the VH group, especially in the HCV subgroup. The prevalence of renal disease was significantly higher in patients with VH with eAG(GA) ≥ 200 mg/dL.Conclusion: Our study used multiple parameters to evaluate blood glucose and renal function in patients with VH and found that hyperglycemia/DM and renal disease are closely associated with VH, especially in subjects with HCV infection. Patients with VH, especially those with HCV infection and hyperglycemia/DM, were particularly vulnerable to renal disease.Keywords: viral hepatitis, hyperglycemia, diabetes mellitus, renal disease, nephropathy

Background Gouty arthritis (GA) is a chronic systemic disease with recurrent acute monoarthritis. In a previous study, a higher incidence of acute flares was observed during the initial marked decrease in serum urate level. Our study evaluated the effect of early urate-lowering therapy in patients with acute GA flares. Methods This study included 40 patients with acute GA; of them, 20 received colchicine 0.5 mg colchicine twice daily, while 20 received probenecid 500 mg and colchicine 0.5 mg twice daily. We evaluated GA severity and laboratory data for 2 weeks after the initial therapy. Medians and interquartile ranges (IQRs) were calculated to evaluate clinical presentations between these two groups. Results Rapidly decreasing median serum uric acid levels was found in the patients treated with probenecid and colchicine compared with the patients treated with colchicine alone on day 8 (− 1.9 [IQR, − 3.7 to 0] vs 0.8 [IQR, − 0.1–2.2]; P Conclusion No significant increase was noted in acute gout flare severity or duration among GA patients treated with early aggressive control of hyperuricemia using probenecid plus colchicine.

BACKGROUND Pedicle screw loosening (PSL) is a postsurgical complication of spinal fusion surgery that can result in morbidity. The aim of this study was to evaluate the efficacy and safety of percutaneous parapedicle screw vertebroplasty (PPSV) for pain reduction and motility improvement in patients with PSL. METHODS The postsurgical solid inter-body fusion with inter-body bone mass formation of 32 patients who underwent lumbar-sacrum spinal fusion surgery was confirmed with plain films and CT scans. Each patient had one or two screws with symptomatic PSL and was treated with PPSV. All the patients were then followed up for 12 to 24 months. The visual analog scale (VAS) and Roland-Morris Disability Questionnaire (RMDQ) were used to evaluate each patient before the operation, after the operation, and during the follow-up period. RESULTS A total of 32 patients with a total of 47 screws with PSL were treated with PPSV and experienced different results in terms of pain reduction (with the mean VAS score dropping from 7.97 ± 0.74 to 2.34 ± 1.59, p < 0.001) and motility improvement (with the mean RMDQ score dropping from 16.75 ± 1.84 to 7.21 ± 4.08, p < 0.001). The motility improvement was significantly correlated with pain reduction (r = 0.42, p = 0.018), with the mean follow-up period being 19.3 ± 6.2 months (range: 8-36 months). However, five patients who experienced moderate improvements had eventually received a revision operation after undergoing PPSV. CONCLUSION The PPSV procedure is effective and safe for the reduction of pain and improvement of life quality in patients with PSL. It can thus be considered as a possible option for the revision of spinal fusion surgery.

In Taiwan, the incidence and prevalence of psoriatic arthritis (PsA) have risen significantly in recent years. Moreover, data from the Taiwan National Health Insurance Research Database (NHIRD) show that more than 85% of PsA patients are treated with just non-steroidal anti-inflammatory drugs (NSAIDs) and/or conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs). Taiwanese clinicians have also expressed concerns regarding uncertainties in the diagnosis of PsA and the delayed, interrupted, and/or tapered use of biologics, as well as differences in therapeutic preferences between and within dermatologists and rheumatologists. To address these issues, the Taiwan Rheumatology Association and the Taiwanese Association for Psoriasis and Skin Immunology jointly convened a committee of 28 clinicians from the fields of rheumatology, dermatology, orthopedics, and rehabilitation, to develop evidence-based consensus recommendations for the practical management of PsA in Taiwan. A total of six overarching principles and 13 recommendations were developed and approved, as well as a treatment algorithm with four separate tracks for axial PsA, peripheral PsA, enthesitis, and dactylitis. Psoriasis (PsO) management was not discussed here, as the Taiwanese Dermatological Association has recently published a comprehensive consensus statement on the management of PsO. Together, these recommendations provide an up-to-date, evidence-based framework for PsA care in Taiwan.

Gout is a common systemic inflammatory disease with a male predominance. This study aimed to determine the relationship between serum total testosterone level and hyperuricemia. Data on 1899 men, collected from 2007 to 2017, were included in the analysis. Serum testosterone and urate (SU) were measured on enrolment. The primary endpoints were SU levels ≥ 7 mg/dL and ≥9 mg/dL. On enrolment, participants had a mean age of 45.6 years and mean total testosterone and SU levels of 510 ng/dL and 6.6 mg/dL, respectively. The mean total testosterone levels were 533 and 470 ng/dL in patients with SU levels < 7 mg/dL and ≥7 mg/dL, respectively (p < 0.001); and 515 and 425 ng/dL in patients with SU levels < 9 mg/dL and ≥9 mg/dL, respectively (p < 0.001). After adjusting for age, body mass index, creatinine, serum lipid, fasting blood glucose, systolic blood pressure, and diastolic blood pressure, low testosterone level (

This study processed the recent in vivo survey results for over a thousand patients and optimized their neck and head CT angiography triggered timing (CTA-TT) via the inverse problem algorithm, which ensured the maximal ratio of both left and right arterial to upper sinuses (LRA/US). These results are instrumental in examining the ischemic stroke syndromes along the neck and head. These 1001 patients were randomly categorized into test surveyed (802 patients) and verification group (199 patients), then a six factors semi-empirical formula was constructed by the STATISTICA program. The six factors were assigned a patient’s biological data and preset of the CTA facility; namely Age, mean arterial pressure (MAP), heart rate (HR), contrast media dose (CMD), Pre (injected pressure of CMD), and body surface area (BSA). Each factor was normalized into dimensionless values and incorporated into the dataset matrix [Formula: see text] to analyze the coefficient matrix [Formula: see text]. The derived semi-empirical formula closely correlated with experimental data, according to the loss function [Formula: see text], correlation coefficient [Formula: see text], and variance of 0.8965. The formula verification for 199 more patients (verification group) yielded a correlation coefficient [Formula: see text]. Thus, it can be used for the CTA-TT estimation of patients without their preliminary tests, avoiding unnecessary irradiation. The estimated LRA/US was [Formula: see text] for the verification group in this study. A simplified three-factor formula, featuring only age, MAP, and BSA, was also proposed.

Shang-Rong Zhong,1 Han-Hsuan Yang,1– 3 Cheng-Hsi Liao,4– 7 Deng-Ho Yang,5,6,8,9 Shih-Kai Tu,1,5 Chia-Lien Hung,6 Chun-Cheng Liao1,5,6 1Department of Family Medicine, Taichung Armed Forces General Hospital, Taichung, Taiwan; 2Department of Occupational Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; 3School of Professional Education and Continuing Studies, National Taiwan University, Taipei, Taiwan; 4Division of Urology, Department of Surgery, Taichung Armed Forces General Hospital, Taichung, Taiwan; 5School of Medicine, National Defense Medical Center, Taipei, Taiwan; 6Department of Medical Education and Research, Taichung Armed Forces General Hospital, Taichung, Taiwan; 7Graduate Institute of Biomedical Science, China Medical University, Taichung, Taiwan; 8Division of Rheumatology/Immunology/Allergy, Department of Internal Medicine, Taichung Armed Forces General Hospital, Taichung, Taiwan; 9Department of Medical Laboratory Science and Biotechnology, Central Taiwan University of Science and Technology, Taichung, TaiwanCorrespondence: Chun-Cheng Liao Email milkbottle97@yahoo.com.twPurpose: To assess the association between serum testosterone (T) and metabolic syndrome (MS) in different age groups in Taiwanese men.Materials and Methods: Male participants, regardless of age or any underlying disease, were identified from MJ Health Screening Center in Taiwan from 2007 to 2016 for this cross-sectional study. They were divided into three groups according to age, and further classified according to MS diagnosis. Basic patient characteristics with relevant parameters were obtained. One-way ANOVA of mean T values between different numbers of measures that exceeds the cut-off values of MS components was performed to assess the relationship of T and MS. Logistic regression analysis was also used to estimate the risk for MS with each increment in T, age, and BMI.Results: A total of 4,931 men were included. The MS group had significantly lower serum T levels compared to the non-MS group in each age group. The one-way ANOVA found the mean value of T was significantly higher in patients without MS component (6.19± 2.12 ng/mL) than those with 1– 5 MS components (with one MS component: 5.48± 2.13 ng/mL, two MS components: 4.93± 2.03 ng/mL, three MS components: 4.37± 1.60 ng/mL, four MS components: 4.13± 2.89 ng/mL, five MS components: 3.74± 1.27 ng/mL, and P< 0.001). There was no significant difference between the patients with three components and the patients with four or five components. Logistic regression models with age stratification showed T with lower odds ratio (OR) for MS after adjusting for BMI in those ≥ 65 years old (OR=0.693; 95% CI=0.559– 0.858; P< 0.001); 50– 64 years old (OR=0.868; 95% CI=0.802– 0.940; P< 0.001) and < 50 years old (OR=0.810; 95% CI=0.758– 0.865; P< 0.001).Conclusion: Lower serum T was strongly associated with MS, with the predictive value increasing with age in Taiwanese men.Keywords: testosterone, metabolic syndrome, hypogonadism, insulin resistance

Sj&ouml, gren&rsquo, s syndrome (SS) is a chronic systemic inflammation disease with clinical presentation of dry eye, dry mouth, and polyarthralgia. Active inflammation is associated with an increased risk of associated arterial stiffness or subclinical atherosclerosis-related cardiovascular events. We used the longitudinal health insurance database of Taiwan, which includes one million participants, to evaluate the relationship between the clinical medication of hydroxychloroquine (HCQ) and the development of coronary artery disease (CAD). In total, 1674 patients with SS receiving HCQ medication were included after exclusion for previous CAD. Altogether, 1142 SS patients were included for evaluation after follow-up for more than one year. After adjusting for age, gender, medications, and chronic comorbidities, a significantly decreased hazard ratio (HR) for developing CAD was found among SS patients with higher medication possession ratio (MPR) of HCQ (HR = 0.49, 95% confidence interval, CI: 0.26&ndash, 0.94) when compared with low MPR of HCQ. A low HR for CAD was observed in SS patients with a high cumulative dose of at least 100,267 mg of HCQ (HR = 0.25, 95% CI: 0.09&ndash, 0.66). Long-term HCQ therapy may decrease the HR of CAD in SS patients. The significant cardiovascular protective effect of HCQ therapy was observed in our study.

Systemic lupus erythematosus (SLE) is a chronic systemic inflammatory disease associated with a high prevalence of cardiovascular disease (CVD). Hydroxychloroquine (HCQ) is commonly used to control disease activity in patients with SLE. We evaluated its potential additional therapeutic effect for reducing CVD in SLE patients. We conducted a retrospective cohort study, in which one million participants were sampled from 23 million beneficiaries and data were collected from 2000 to 2013. In total, 826 SLE patients receiving HCQ medication were included after exclusion for previous CVD. The total number of SLE patients was 795 after follow-up for more than one year. After adjusting for chronic comorbidity, a significantly decreased hazard ratio (HR) for coronary artery disease (CAD) was found among SLE patients with a high usage of HCQ for at least 318 days (HR = 0.31, 95% confidence interval, CI: 0.12&ndash, 0.76). A low HR for CAD was observed in SLE patients with a high cumulative dose of at least 100,267 mg HCQ (HR = 0.25, 95% CI: 0.09&ndash, 0.66). However, there was no significant lowering of the HR for stroke. Long-term HCQ therapy decreases the HR of CVD in SLE patients. The cardiovascular protective effect of HCQ therapy was associated with decrease in CAD, but not stroke.

Background Osteoarthritis (OA) is a degenerative joint disease with damage to the articular cartilage. Active production of inflammatory cytokine/chemokine and matrix metalloproteinases may be found during the progression of OA. Isorhamnetin had the effects of anti-inflammatory, antioxidant, anti-ischemia, anti-atherosclerotic hepatoprotective and anticancer activities. Objectives Our study was focused on the effects of isorhamnetin treatment in OA. Methods We used monosodium iodoacetate (MIA)-induced OA rats to evaluate the effects of isorhamnetin related anti-inflammatory process. The rats in all groups were sacrificed on four weeks post-MIA injection. The measurements of knee joint swelling, histological analysis, serum inflammatory biomarkers and Western blot were evaluated. Results We found that isorhamnetin may reduce MIA-induced knee swelling by significantly reduction of articular cartilage damage in rats. The severity of OA lesion was graded using the modified Mankin scoring system, and we found that the overall modified Mankin’s scores were significantly decreased after isorhamnetin treatment compared with a MIA-treated group. The production of IL-1β, IL-6, and TNF-α decreased in isorhamnetin treatment group compared with MIA alone group. Isorhamnetin inhibited the production of NO and PGE2, and the expression of iNOS and COX-2. The production of COMP and CTX-II were also inhibited in MIA-induced OA rats. Conclusion Isorhamnetin may modulate the inflammatory progression of OA in MIA-induced OA rats. The prevention of cartilage damage was found in OA after adequate isorhamnetin treatment. Isorhamnetin may serve as a potential agent for the management of OA. References [1] Sellam J, Berenbaum F. The role of synovitis in pathophysiology and clinical symptoms of osteoarthritis. Nat Rev Rheumatol2010; 6: 625-635. [2] Manu KA, Shanmugam MK, Ramachandran L, et al. Isorhamnetin augments the anti-tumor effect of capeciatbine through the negative regulation of NF-kappaB signaling cascade in gastric cancer. Cancer Lett2015; 363: 28-36. [3] Chen TL, Zhu GL, Wang JA, et al. Protective effects of isorhamnetin on apoptosis and inflammation in TNF-alpha-induced HUVECs injury. Int J Clin Exp Pathol2015; 8: 2311-2320. Disclosure of Interests None declared

Osteoporosis is a systemic disease with progressive bone loss. The bone loss is associated with an imbalance between bone resorption via osteoclasts and bone formation via osteoblasts. Other cells including T cells, B cells, macrophages, and osteocytes are also involved in the pathogenesis of osteoporosis. Different cytokines from activated macrophages can regulate or stimulate the development of osteoclastogenesis-associated bone loss. The fusion of macrophages can form multinucleated osteoclasts and, thus, cause bone resorption via the expression of IL-4 and IL-13. Different cytokines, endocrines, and chemokines are also expressed that may affect the presentation of macrophages in osteoporosis. Macrophages have an effect on bone formation during fracture-associated bone repair. However, activated macrophages may secrete proinflammatory cytokines that induce bone loss by osteoclastogenesis, and are associated with the activation of bone resorption. Targeting activated macrophages at an appropriate stage may help inhibit or slow the progression of bone loss in patients with osteoporosis.

The objective of this study was to evaluate the potential therapeutic effects of betahistine dihydrochloride (betahistine) in a collagen-induced arthritis (CIA) mouse model. CIA was induced in DBA/1 male mice by primary immunization with 100μl of emulsion containing 2mg/ml chicken type II collagen (CII) mixed with complete Freund's adjuvant (CFA) in an 1:1 ratio, and booster immunization with 100μl of emulsion containing 2mg/ml CII mixed with incomplete Freund's adjuvant (IFA) in an 1:1 ratio. Immunization was performed subcutaneously at the base of the tail. After being boosted on day 21, betahistine (1 and 5mg/kg) was orally administered daily for 2weeks. The severity of CIA was determined by arthritic scores and assessment of histopathological joint destruction. Expression of cytokines in the paw and anti-CII antibodies in the serum was evaluated by ELISA. The proliferative response against CII in the lymph node cells was measured by (3)H-thymidine incorporation assay. The frequencies of different CII specific CD4(+) T cell subsets in the lymph node were determined by flow-cytometric analysis. Betahistine treatment attenuated the severity of arthritis and reduced the levels of pro-inflammatory cytokines, including TNF-α, IL-6, IL-23 and IL-17A, in the paw tissues of CIA mice. Lymph node cells from betahistine-treated mice showed a decrease in proliferation, as well as a lower frequency of Th17 cells. In vitro, betahistine suppressed CD4(+) T cell differentiation into Th17 cells. These results indicate that betahistine is effective in suppressing both inflammatory and Th17 responses in mouse CIA and that it may have therapeutic value as an adjunct treatment for rheumatoid arthritis.

The overall survival (OS) prediction for nonsmall cell lung carcinoma (NSCLC) patients of clinical IIIA-N2 stage undergone various treatments was investigated through a refined Taylor series expansion algorithm. The model was created according to a population-based study in Taiwan. The proposed prediction algorithm is based on the well-known hit and target model adopted for analyzing the cell death from the microscopic viewpoint. It also implies the application of the Taylor series expansion to the population-based survey dataset. In the proposed algorithm, the basic degradation of a patient’s health is represented via a specific function comprising a single exponential term exp([Formula: see text]). The refined algorithm successfully predicted NSCLC IIIA-N2 patients’ OS rate. A total of 127,301 patients were collected from 2010 to 2017. Then, 2655 patients were recognized as effective events and classified into eight classes according to various medical treatments, namely surgical operation, radiotherapy, and chemotherapy. For each class of patients, the average life was evaluated, according to Taylor’s expansion algorithm, and the average derived life range spread from 3.51 to 7.81 years. An index of life gain with specific treatment was defined according to the Taguchi optimization analysis. The life gains provided by the surgical operation, chemotherapy, and radiotherapy were 2.74, 1.18, and 0.48 years. The surgical operation was the most beneficial treatment, which is in concert with recommendations of European experts. A similar finding was also reflected in four out of eight classes, which included the surgical operation in the treatment plans of most Taiwanese hospitals.

Aim To establish guidelines for the clinical management of axial spondyloarthritis that take into account local issues and clinical practice concerns for Taiwan. Method Overarching principles and recommendations were established by consensus among a panel of rheumatology and rehabilitation experts, based on analysis of the most up‐to‐date clinical evidence and the clinical experience of panelists. All Overarching Principles and Recommendations were graded according to the standards developed by the Oxford Centre for Evidence Based Medicine, and further evaluated and modified using the Delphi method. Results The guidelines specifically address issues such as local medical considerations, National Health Insurance reimbursement, and management of extra‐articular manifestations. Conclusion It is hoped that this will help to optimize clinical management outcomes for axial spondyloarthritis in Taiwan.

Evans syndrome is a rare disorder with presentations of autoimmune hemolytic anemia and immune thrombocytopenia, in the absence of any underlying cause. Here, we reported a case with a history of Evans syndrome for seven years. A persistent scrotal ulcer with severe pain occurred for two weeks. He called at our emergency room because of a painful, necrolytic cutaneous ulcer over the scrotal region. A biopsy showed sterile dermal neutrophilia with lymphocytic vasculitis, and pyoderma gangrenosum was impressed. The patient received steroid treatment and recovery after one month.

Interleukin-6 (IL-6) is one of the pro-infl ammatory cytokines involved in pathogenesis of various autoimmune and chronic infl ammatory diseases. IL-6 through binding to its cellular receptor can transduce both classical- and trans-signaling pathways. Overproduction of circulating IL-6 can be detected in patients with different autoimmune diseases. Tocilizumab, a humanized monoclonal antibody against IL-6 receptor, can block IL-6-mediated signaling and has been approved for the treatment of rheumatoid arthritis and Castleman’s disease. Besides, expression of IL-6 may promote tumorigenesis and has been detected in various tumors, including multiple myeloma, colorectal cancer, breast cancer, lymphoma, breast cancer and lung cancer. Furthermore, increased levels of circulating IL-6 are associated with poor prognosis and cachexia in cancer patients. Monotherapy with IL-6 blockade or a combination therapy with both IL-6 blockade and conventional chemotherapy may reduce the progression of cancer and improve the status of cachexia in cancer patients. Finally, based upon the known biological effects of IL-6, diseases, other than autoimmune diseases and cancers, potentially to be anti-IL-6 candidates will be briefl y discussed.

Background: Advanced glycation end-products (AGEs) can accumulate in organs and tissues during ageing and diabetes. Increased levels of AGEs are found in the bone tissue of patients with osteoporosis. The purpose of this study was to evaluate circulating AGEs in patients with osteoporosis. Methods: We evaluated plasma AGEs, osteoporosis-related biomarkers, and bone mass in 82 menopausal women with osteoporosis or osteopenia, 16 young women with osteopenia, and 43 healthy women without osteoporosis or osteopenia. Results: Higher levels of serum AGEs were found in the osteoporosis or osteopenia group compared to healthy women (P < 0.0001). A negative correlation was observed between serum AGEs and lumbar spine bone density (BMD of lumbar spine, r = -0.249, P = 0.028; T-score of lumbar spine, r = -0.261, P = 0.021). Women with a increased level of serum AGEs (> 8.12 U/mL) had a 5.34-fold risk of osteopenia regarding lumbar spine T-score and a 3.31-fold risk of osteopenia regarding the hip T-score. Conclusion: Serum AGEs could be used to monitor the severity and progression of osteoporosis. An increased serum level of AGEs was associated with impaired bone formation and was a risk factor for the development of osteoporosis. Targeting AGEs may represent a novel therapeutic approach for primary or secondary osteoporosis.

Patients with psoriatic arthritis (PsA) are at increased risk of infection due to disease course or treatment-related immunodeficiency. We describe a patient with a 10-year history of PsA, with arthritis of the right knee and pain and edema in the right calf, treated with the TNFa inhibitor etanercept for 6 months. Ultrasound showed accumulation of hypoechoic fluid, which was aspirated and was positive for staphylococcus and aspergillus. The patient recovered after surgical drainage and four weeks of antibiotic and antifungal therapy.

Anti-cyclic citrullinated peptide (anti-CCP) antibody is highly specific for diagnosing rheumatoid arthritis (RA). Cigarette smoking is a lifestyle and environmental factor associated with anti-CCP production and is strongly associated with chronic obstructive pulmonary disease (COPD). This study assessed levels of anti-CCP antibodies and rheumatoid factor (RF) among patients with RA and COPD. The study sample comprised 63 patients with RA and 70 patients with COPD, all of whom underwent assessment of anti-CCP antibody and RF levels. Testing revealed that 54.2 % of RA patients and 0 % of COPD patients were positive for anti-CCP antibodies. Additionally, 82.5 % of RA patients and 42 % of COPD patients were positive for RF. Among RA patients, levels of anti-CCP antibodies were higher among smokers than among nonsmokers (242.7 ± 128.3 vs. 68.1 ± 112.1, P

Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) is an unusual inflammatory arthritis with unknown pathogenic mechanism, and is characterized by an acute onset of symmetrical synovitis with pitting edema of the hands or feet. Numerous diseases are associated with RS3PE, including neoplasia, infection, Parkinson's disease, and other rheumatic diseases. Neoplasia is the most common condition associated with RS3PE. We report a case of RS3PE that occurred following acute intracranial hemorrhage in an 80-year-old man with a 20-year history of hypertension.

Objective. SLE is an autoimmune disorder characterized by abnormal complement activation. Numerous new biomarkers have recently been used to diagnose or monitor disease activity in patients with SLE. We checked the levels of erythrocyte-bound C4d (E-C4d), an activationderived fragment of C4 that is deposited on the erythrocytes, under different conditions of SLE in order to correlate these levels with disease activity. Methods. We conducted a cross-sectional investigation of three groups of patients: (i) 63 patients with SLE; (ii) 43 patients with other diseases; and (iii) 26 healthy controls. Erythrocytes were analysed by flow cytometry to determine the levels of E-C4d. Results. We found a significant elevation in the mean levels of E-C4d in SLE patients compared with patients with other diseases or healthy controls. In SLE patients, the levels of E-C4d were correlated with the SLEDAI and inversely correlated with serum C3/C4 levels. In the subgroup of SLE patients with haemolytic anaemia (HA), a significantly higher level of E-C4d was observed than that in SLE patients without HA. However, in SLE patients with HA, there was no correlation between the levels of E-C4d and other markers of disease activity, including SLEDAI and levels of anti-dsDNA, C3 and C4. Conclusion. E-C4d levels are useful diagnostic markers for SLE and can serve as biomarkers of disease activity in patients with SLE. However, E-C4d is of limited value in monitoring disease activity in SLE patients with HA.

Objective.Fever in systemic lupus erythematosus (SLE) can be caused by infection or flare-up of the disease. This study aimed to determine whether the ratio of the level of erythrocyte-bound C4d to that of complement receptor 1 (C4d/CR1) can serve as a useful biomarker in the differentiation between infection and flare-up in febrile SLE patients.Methods.We enrolled febrile SLE patients and determined the ratio on the day of admission. The patients were divided into 2 groups according to the subsequent clinical course.Results.Among the febrile SLE patients, those with flare-up had higher ratios and lower C-reactive protein (CRP) levels than those with infection. Cut-off values of 4.67 for C4d/CR1 ratio and CRP, respectively, were 40.91% sensitive and 100.0% specific for the presence of infection in febrile SLE patients; similarly, cut-off values of >1.2447 and Conclusion.The C4d/CR1 ratio is a simple and quickly determinable biomarker that enables the differentiation between infection and flare-up in febrile SLE patients at initial evaluation. Further, when combined with the CRP level, it is useful to evaluate disease activity in SLE patients with infection.

Acute porphyrias are rare diseases with varying incidences worldwide. These diseases are disorders of heme biosynthesis characterized by acute attacks of neurological symptoms. Acute porphyria should be considered in patients with unexplained abdominal pain or neurological damage. Clinical manifestations of acute porphyria are nonspecific and are associated with multiple organ systems. This report examines a rare case of an uncommon type of acute porphyria in a patient with an initial presentation of abdominal pain and progressive polyneuropathy.

Streptococcus bovis is a Gram-positive coccus that can be found in the intestinal flora of healthy people; it is also associated with colon cancer and infective endocarditis. We report on a 79-year-old male who initially presented with acute-onset lower back pain. Streptococcus bovis was detected in repeated blood cultures, and magnetic resonance imaging of the lumbar spine revealed septic discitis of the L2-L3 intervertebral disc. Excision and debridement of the intervertebral disc was performed and a tissue culture tested positive for S. bovis. Repeat echocardiography and colonoscopy showed no signs of vegetation or tumor lesions, respectively. We diagnosed the patient with isolated septic discitis caused by S. bovis-induced bacteremia. The patient was discharged after six weeks of antibiotic therapy.

Objective: The expression of complement receptor type 1 on different cells is associated with autoimmunity. Erythrocyte-Complement Receptor Type 1 (E-CR1) is a candidate for early diagnosis of Systemic Lupus Erythematosus (SLE) and assessed the roles of disease activity. We evaluated the expression of E-CR1 in the patients with SLE and other autoimmune diseases. Methods: We conducted a cross-sectional investigation of 3 groups: (1) 36 patients with SLE; (2) 51 patients with other diseases including Rheumatoid Arthritis (RA), Sjogren’s syndrome, anti-phospholipid syndrome, Mixed Connective Tissue Disease (MCTD), Raynaud’s disease, ankylosing spondylitis, pulmonary Tuberculosis (TB); and (3) 26 healthy controls. Erythrocytes were analyzed by flow cytometry to determine levels of E-CR1. Results: We found a significant reduction in the mean levels of E-CR1 in SLE patients compared to patients with healthy controls (1.79 ± 0.16 versus 3.82 ± 0.32, P

Internal hernia is an unusual cause of intestinal obstruction, and the through sites of hernias may include the paraduodenum, transmesenteric region, foramen of Winslow, paracecum, the broad ligament of the uterus, and the transomental region. Transomental hernia is the rarest type of internal hernia and accounts for fewer than 1% of internal hernias. Transmesenteric and transomental hernias are different from the other types of internal hernia, and usually present acute intestinal obstruction with strangulation of the small bowel. We report a 74-year-old male with initial manifestation of peritonitis. Internal hernia-induced intestinal obstruction with strangulation was highly suspected from the image study. After an urgent exploratory laparotomy, transomental hernia was diagnosed.

Systemic lupus erythematosus (SLE) is a systemic autoimmune disorder with involvement of multiple organs. Various forms of serositis, including pleural effusion, pericardial effusion, and ascites, may be found during the course of SLE. Peritoneal involvement by ascites is common in the initial presentation of SLE. However, chylous ascites is uncommon in SLE patients. Here, we describe a 93-year-old female with initial presentation of chylous ascites during SLE flares. Marked distention and an ovoid shape of the abdomen were observed. Shifting dullness and central tympanic sounds were found on percussion. Rales were heard in bilateral breathing sounds, multiple oral ulcers appeared in the oral cavity, and chest images showed bilateral pleural effusion. Abdominal sonography revealed moderate ascites and pleural effusion. Neither organisms nor malignant cells were revealed in the culture or cytology of ascites and pleural effusion. The diagnosis of SLE was arrived at by positive antinuclear antibody (ANA), discoid rash, oral ulcers, serositis (pleural effusion and ascites), and proteinuria. The patient received intravenous methylprednisolone 250 mg/day for three days. The pleural effusion resolved dramatically after steroid therapy and abdominal distention related to ascites formation subsided obviously.

Purpose To distinguish lupus flare-up from infection in systemic lupus erythematosus (SLE), we analyze the expression of circulating CD27high plasma cells in SLE patients with and without infection, in comparison to non-SLE patients with infection. Materials and Methods The percentage of circulating CD27high plasma cells was measured by flow cytometry in the following four groups: 36 SLE patients without infection, 23 SLE patients with infection, eight non-SLE patients with infection, and 26 healthy controls. Results The frequency of CD27high plasma cells had a correlation with the SLE disease activity index (SLEDAI) (r = 0.866, p < 0.05), level of anti-dsDNA (r = 0.886, p < 0.05), C3 (r = - 0.392, p < 0.05), and C4 (r = - 0.337, p < 0.05) in SLE patients without infection, but there was no correlation with disease activity in SLE patients with infection. Among three groups in particular-SLE without infection, SLE with infection, and non-SLE with infection-the percentages of CD27high plasma cells were elevated. The percentage of CD27high plasma cells was higher in SLE patients with infection, when compared to SLE patients without infection. Conclusion The percentage of CD27high plasma cells is a biomarker for disease activity of SLE without infection, under correlation with SLEDAI, anti-dsDNA, and C3 and C4 level. However, when the SLE patients have an infection, the percentage of CD27high plasma cells is not an adequate biomarker for the survey of disease activity. The percentage of CD27high plasma cells may serve as a potential parameter to distinguish a lupus flare-up from infection.

Cecorectal intussusception, a variant form of intussusception, occurs when the cecum enters through the entire course of colon and reaches to the rectum. This condition is rare but often associated with a pathologic lead point. Here, we report a 13-year-old boy, featuring insidious abdominal discomfort and constipation for 1 month, who developed cecorectal intussusception. Before surgical intervention, multi-detector row computed tomography with reconstructed images demonstrated the route of cecorectal intussusception and identified a cecal fat-containing tumor as the lead point. The patient received surgical reduction with resection of the cecal tumor. Final pathological diagnosis was a hamartoma of the cecum. The relevant literature pertaining to this condition is reviewed, and the possible pathophysiology of the condition discussed.

Accumulation of advanced glycation end products (AGEs) is a hallmark in aged people. T cells play important roles in maintaining homeostasis of immune function. This study investigated the effects of AGEs-bovine serum albumin (AGEs) in human T cells. Incubation of Jurkat and several immortalized T cell lines with AGEs resulted in cell death dose-dependently. AGEs-induced cell death was partially but significantly blocked by neutralizing antibodies recognizing receptor of AGEs. In addition to detecting DNA nick, simultaneous stainings of annexin V with 7-amino-actinomycin D further confirmed the apoptotic nature of cell death. AGEs also caused apoptosis in purified T cells. Although AGEs-induced apoptosis could be blocked by the pan-caspase inhibitor, Ala-Asp-fluomethyl ketone (Z-VAD-fmk), there was no activation of caspase-3, -5, -8 and -9. AGEs caused mitochondrial outer membrane permeabilization and this process was prevented by an antioxidant or Z-VAD-fmk. Furthermore, AGEs treatment led to translocation of apoptosis inducing factor (AIF) from the mitochondria into the nucleus. Altogether, this report demonstrated that AGEs induced T cell apoptosis in an oxidative stress-associated and caspase-dependent manner with involvement of the mitochondrial pathway. It is likely that AGEs-induced T cell apoptosis may play a role in T cell homeostasis in ageing.

Adult onset Still’s disease (AOSD) is an uncommon disorder of unknown cause. The clinical symptoms of AOSD are a spiking fever, a typical rash, arthralgia or arthritis, sore throat, lymphadenopathy, and splenomegaly. Pleuropulmonary and cardiac involvement are rare. We report a patient with a two-year history of AOSD with myocarditis refractory to cyclosporine and glucocorticoid. Significant congestive heart failure due to left ventricle dysfunction and hyperferritinemia developed during the hospital course. After therapy with etanercept, the patient’s clinical manifestations recovered and she regained normal left ventricular systolic function.

A 60-year-old male presented, and was admitted, to our hospital with a 1-week history of intermittent chills and high fever. He has rheumatoid arthritis for 2 years with regular medication of hydroxychloroquine, methotrexate, sulfasalazine, and low-dose prednisolone (5 mg daily). The patient had a history of type 2 diabetes for which he was under regular medication. General malaise and dyspnea would occur during the episode of fever. On admission to our hospital, his blood pressure was 129/74 mm Hg, and his body temperature was 39 C. His heart sounds were normal with no murmur; the lungs were clear to auscultation. The abdomen was soft without palpable masses or tenderness; the liver and spleen were not palpable. The patient had mild back pain. A complete blood count revealed 9,000 leukocytes/lL and 221,000 platelets/uL, with mild anemia (hemoglobin: 9.4 g/dL). The C-reactive protein (CRP) level was 24.1 mg/dL (normal\0.5 mg/dL) and the erythrocyte sedimentation rate (ESR), 64 mm/h (normal \15 mm/h). Urine analysis and culture yielded negative results. Two blood cultures obtained before intravenous antibiotic administration tested positive for salmonella group D. No vegetations or signs of infective endocarditis were detected on transthoracic echocardiography. Computed tomography (CT) showed a saccular aneurysm arising from the abdominal aorta, with fatty stranding, free air-bubbles (arrow indicates air-bubbles and asterisk indicates aneurysm; Fig. 1) and periaortic fluid accumulation (Fig. 2). Mycotic aneurysm was confirmed. The patient received surgical management for debridement of abscess and intravenous ceftriaxone 2 gm daily continuously for 8 weeks. The patient had an excellent clinical response and was discharged 2 months later with no recurrence of fever. Mycotic aneurysms are uncommon of all aortic aneurysms, and the overall mortality is about 50 % after treatment. The common initial symptoms include pain over abdomen or back, fever, general discomfort, and hypovolaemic shock [1]. The most frequent site of mycotic aneurysms is abdominal aorta, followed by the thoracic and suprarenal abdominal aorta. High level of ESR and CRP can be found from the laboratory data. Abdominal CT can be used for early detection of mycotic aneurysms. Saccular, multilobulate, periaortic soft tissue stranding, and irregular peripheral enhancement of arterial walls can be found from the image study. The cultures from blood or the aneurismal content include Salmonella species, staphylococcus aureus, Streptococcus pneumoniae, and Mycobacterium tuberculosis [1]. Immunocompromised patients including HIV infection, patients with received immunosuppressive agent may develop fulminating bacteremia, which leads to the formation of infected aneurysms [2, 3]. Antimicrobial treatment alone usually results in poor prognosis; therefore, surgery may play a major role in reducing mortality. The combination of antimicrobial treatment and surgical debridement of surrounding necrotic tissue with revascularization is indicated in the patient with mycotic aneurysm. D.-H. Yang (&) Division of Rheumatology/Immunology/Allergy, Department of Internal Medicine, Taichung Armed Forces General Hospital, No 348, Sec. 2, Chung Shan Road, Taiping 411, Taichung, Taiwan, Republic of China e-mail: deng6263@ms71.hinet.net

During the course of chronic hepatitis C virus (HCV) infection, various extrahepatic manifestations of autoimmune disorders may occur, including arthralgia/arthritis, sicca complex, purpura, cutaneous ulcer, and thyroid dysfunction. In addition, the prevalence of circulating autoantibodies is high among patients with HCV infection. Commonly detected autoantibodies in HCV-infected patients include rheumatoid factor, antinuclear antibody, anti-SSA/anti-SSB antibody, cryoglobulin, antineutrophil cytoplasmic antibody, anti-smooth muscle antibody, anti-liver and anti-thyroid autoantibodies. These autoantibodies may be associated with underlying autoimmune disorders or liver inflammation in HCV infection. A possible reason for antibody production is overactivation and proliferation of B lymphocytes, via the interaction with the surface protein of HCV. Because immunotherapy can cause HCV flare-up or liver damage, overdiagnosis of HCV-related autoimmune symptoms as primary autoimmune disorders should be avoided. This review describes biomarkers that are useful in clinically evaluating autoimmune manifestations and disorders associated with HCV infection.