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Journal: Zhonghua nei ke za zhi

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To develop a new evidence-based diagnosis, treatment guideline for rheumatoid arthritis (RA) in China.A multidisciplinary guideline development group was established. The grading of recommendations assessment, development and evaluation (GRADE) system was used to rate the quality of evidence and the strength of recommendations. Recommendations were derived from evidence body, the balance of benefits and harmsand patient’s values and preferences.The guideline development group developed 10 recommendations for the diagnosis and treatment of RA. The guideline covered the classification criteria, disease activity monitoring and assessing, antirheumatic drugs (DMARDs) and glucocorticoids with treat-to-target approach of RA.This rheumatoid arthritis guideline was intended to serve as a tool for clinicians and patients for best decisions-making in China.

Concepts: Hospital, Rheumatoid arthritis, Rheumatology, China, Methotrexate, Disease-modifying antirheumatic drug, Hydroxychloroquine, Human Development Index

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Asthma exacerbations can do a lot of harm to the patients and consume large amounts of medical resources. This consensus is based on the domestic and foreign guidelines and literatures to standardize the evaluation and management of asthma exacerbations in China. Asthma exacerbations are characterized by a progressive increase in symptoms of shortness of breath, cough, wheezing or chest tightness and progressive decrease in lung function, and usually require modification of treatment. Recognizing risk factors and triggering factors of asthma exacerbations is helpful for the prevention and long-term management. Evaluation of asthma exacerbations is based on symptoms, lung function, and arterial blood gas. Management is stratified according to the severity of disease. Different regimens to treat asthma exacerbations are discussed in this consensus. Glucocorticoids should be used properly. Overuse of antibiotics should be avoided. Management of life-threatening asthma is discussed separately. Special attention should be paid in some special respects, such as asthma during peri-operation period, gestation period, and childhood. Diagnosis and management of complications are also of great significance and are discussed in details.

Concepts: Pulmonology, Asthma, Pneumonia, Heart, Chronic obstructive pulmonary disease, Arterial blood gas, Bronchitis, Respiratory therapy

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Objective: To explore the relationship between ulcerative colitis (UC) susceptibility and tumor necrosis factor superfamily member (TNFSF) 15 gene polymorphisms and haplotypes in Han nationality in Zhejiang province of China. Methods: A total of 408 UC patients and 574 healthy controls were recruited in this study. Three single nucleotide polymorphisms of TNFSF15 (rs3810936, rs4263839, rs4979462) were examined by improved multiple ligase detection reaction (iMLDR) technique. Analyses of linkage disequilibrium (LD) and haplotype were performed by Haploview 4.2 software in all study subjects. Results: The variant allele A and genotype (GA+AA) of rs4263839 were less frequent in UC patients than in controls (45.34% vs. 50.17%, P=0.035;68.38% vs. 76.66%, P=0.004). According to the severity and location of disease, UC patients were divided into different subgroups. After multiple comparison correction(α=0.012 5), the frequencies of variant allele A and genotype (GA+AA) of rs4263839 were lower in patients with severe UC than in the controls (37.69% vs. 50.17%, P=0.007; 60.00% vs. 76.66%, P=0.004). Similar findings were also drawn for patients with extensive colitis in contrast with the controls (42.22% vs. 50.17%, P=0.009; 63.33% vs. 76.66%, P<0.001). Furthermore, the haplotype analysis indicated that three SNPs above were in a strong LD. The frequency of haplotype TAC was lower in UC patients than in the controls(40.83% vs. 46.04%, P=0.023). Also it was less prevalent in patients with severe UC and patients with extensive colitis when compared with controls respectively (33.38% vs. 46.04%, P=0.005;37.22% vs. 46.04%, P=0.003). Conclusions: TNFSF15 (rs4263839) variation might not only reduce the risk of UC, but also affect the severity and lesion location of UC. The haplotype TAC formed by rs3810936, rs4263839 and rs4979462 might be related to a lower risk of UC, especially in patients with severe colitis or patients with extensive colitis.

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Objective: To analyze the outcome and the prognostic factors of hepatic veno-occlusive disease (HVOD) after hematopoietic stem cell transplantation (HSCT). Methods: A total of 797 patients receiving HSCT were analyzed retrospectively. The prophylaxis regimen of HVOD in the First Affiliated Hospital of Guangxi Medical University consisted of low molecular weight heparin and lipoprostaglandin E1 (PGE1). Results: Fifty-nine patients (7.4%) developed HVOD at 3-49 days after HSCT (median 12 days). Age younger than 15 years at transplant(HR= 6.47, P<0.001), busulphan conditioning (HR=6.40, P<0.001), thalassemia major (HR=6.35, P<0.001), allogeneic transplantation (HR=7.74, P=0.005) were univariate risk factors for HVOD. Multivariate analyses suggested that thalassemia major and busulphan conditioning were independently correlated with the development of HVOD. Conclusion: Thalassemia major and busulphan conditioning are independent risk factors for HVOD after HSCT.

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Objective: To investigate the clinical and pathological characteristics of chronic active Epstein-Barr virus associated enteritis (CAEAE) . Methods: The clinical data of 6 CAEAE patients in Peking Union Medical College Hospital were retrospectively analyzed from January 2010 to November 2017, including clinical manifestations, endoscopic, pathological features, medications and clinical outcome. Results: The male∶female ratio was 4∶2 and the average age was 34 years old. All patients did not have personal and family history of immunodeficiency. The common symptoms consisted of fever (6/6), abdominal pain (6/6), hematochezia (6/6) and diarrhea (5/6). The most frequently affected sites were colorectum (5/6), followed by small intestine (3/6). Further serologic tests revealed a high load of serum Epstein-Barr virus(EBV) DNA. The main manifestations under endoscopy were multifocal or diffuse irregular ulcers. There was inflammation in the ulcer bases and surrounding areas, where EBV-encoded small RNA (EBER) was positive by in situ hybridization (6/6). The common complications were massive hemorrhage (3/6) and intestinal perforation (2/6). None of treatment agents including glucocorticoid, ganciclovir, foscarnet sodium and cytotoxic drugs was effective. All patients died within 0.5 to 13 months after diagnosis. Conclusions: CAEAE in immunocompetent individuals is a rare disorder with poor prognosis. It is difficult to differentiate CAEAE from inflammatory bowel disease due to similar clinical and endoscopic manifestations.

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Objectives: Exploring the association between depression/anxiety and mental stress-induced myocardial ischemia (MSIMI) in patients with stable coronary artery disease (CAD). Methods: A total of 178 subjects was enrolled according to the inclusion and exclusion criterion with 88 men and 90 women at age of (54±12)years. The subjects were divided into four groups including CAD with depression/anxiety, CAD without depression/anxiety, depression/anxiety without CAD, and control group based on the state of coronary artery, the scores of Patient Health Questionnaire 9-item (PHQ-9) and Generalized Anxiety Disorder 7-item (GAD-7) . MSIMI was diagnosed by echocardiography. Data were analyzed by SPSS19.0. Results: The incidence of MSIMI in all CAD patients was 17.24%. Within each group, 35.00% patients were MSIMI in CAD with depression/anxiety, 2.13% were in CAD without depression/anxiety, 14.29% were in depression/anxiety without CAD, and 2.38% were in control group. The risks of MSIMI in depression/anxiety without CAD and with CAD groups were 6.83 (P>0.05) and 22.08 times (P<0.05) higher than that in control group, respectively. Logistic regression showed that a 1-point increment in the GAD-7 score, but not PHQ-9 score [OR=0.95, 95% CI (0.77-1.17), P=0.63], was associated with 1.22-fold increase in the likehood of MSIMI [95% CI (1.07-1.38), P=0.00]. Conclusions: The MSIMI rate is much higher in patients with CAD comorbid depression/anxiety compared with CAD without depression/anxiety. Anxiety, but not depression, is an independent risk factor of MSIMI in CAD patients.

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Objective: To investigate the prevalence and risk factors of diabetes and prediabetes in Jingyuan County in Ningxia. Methods: A cross-sectional survey including 10 639 participants (18-88 years of age) with a multistage sampling was conducted in Jingyuan County between January, 2014 and April, 2015. Questionnaires, physical examinations, and laboratory tests were included in the survey. Results: Among all the subjects, 10 491 participants (men: 4 826, women: 5 665) with complete data were included in the analysis. The standardized prevalence of diabetes and prediabetes was 4.2% (men: 3.9%, women: 4.5%) and 8.8% (men: 7.6%, women 10.3%), respectively, in which the standardized prevalence of diabetes was higher in Hui (4.5%) than that in Han (3.5%) (P< 0.05). Logistic regression analyses showed that age, family history of diabetes, overweight/obesity, hypertriglyceridemia and hypertension were positively associated with prediabetes and diabetes with the odds ratios being 1.60 and 2.14 (age, P< 0.001), 1.40 and 3.32 (family history, P< 0.05), 1.47 and 1.57 (overweight/obesity, P< 0.001), 1.88 and 2.55 (hypertriglyceridemia, P< 0.001), 1.44 and 1.89 (hypertension, P< 0.001), respectively. Conclusions: The prevalence of diabetes was relatively low in the rural area in Ningxia. However, it is still essential to take active interventions in people at high risk of diabetes in order to prevent the incident diabetes.

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Objective: Pancreatic enzymes may spread into the injured intestine, bloodstream,and cause the cascade of inflammatory reactions.Our objective was to explore trypsin expression in serum and vital organs in septic rats. Methods: Trypsin levels in serum,heart,lung and jejunum were tested and compared between Escherichia coli endotoxin injected rats(SS), SS treated with a protease inhibitor(ulinastatin) and control group(SHAM).The correlations between serum trypsin,intestinal proteins and inflammation indices were assessed.Two components of mucosal barrier, i.e. mucin-2 and E-cadherin,were measured to evaluate the intestinal mucosal barrier function.The levels of tumor necrosis factor alpha (TNFα),interleukin-6(IL-6) and neutrophil elastase(NE) were measured to determine the inflammation indices. Results: Compared to SHAM group, trypsin levels in serum[(73.71±9.14) ng/ml vs. (12.12±2.36) ng/ml],heart[(51.60±15.06) ng/ml vs. (6.39±3.53) ng/ml],lung [(54.73±5.57) ng/ml vs. (5.24±3.08) ng/ml] and jejunum(1.19±0.48 vs. 0.40±0.12) were significantly higher in SS group (all P<0.05). The level of serum trypsin had negative correlation with mucin-2 and E-cadherin, and positive correlation with TNFα, IL-6 and NE (all P<0.05). In rats treated with ulinastatin, trypsin levels were significantly decreased compared with those in SS group including in serum [(65.79±4.88)ng/ml]], heart [(26.33±12.03)ng/ml], lung [(28.73±14.46) ng/ml] and jejunum (0.80±0.20) (all P<0.05).Serum TNFα[(247.34±16.97)ng/L vs. (178.78±40.81)ng/L] revealed similar changes in ulinastatin and SS group,whereas mucin-2 (0.58±0.14 vs. 0.89±0.17) and E-cadherin (0.11±0.04 vs. 0.23±0.06) were both significantly elevated after administration of ulinastatin (both P<0.05) . Conclusion: Serum and tissue trypsin is elevated in septic rats. Protease inhibitor ulinastatin protects intestinal function by reducing inflammatory reaction.

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Clinical data of 19 patients with congenital pyruvate kinase deficiency were analyzed. Insufficient pyruvate kinase confirmed the diagnosis. Laboratory parameters of hemolysis were summarized. In cases of neonatal hyperbilirubinemia and unexplained hemolytic anemia, pyruvate kinase activity and next generation sequencing test may help the early diagnosis.

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To analyze the clinical features of deep venous thrombosis(DVT) in hospitalized patients and evaluate the effectiveness of Padua risk assessment model.The clinical data of DVT patients were retrospectively analyzed in Beijing Shijitan Hospital from April 1 2017 to June 30, 2017.Padua risk assessment scale was used to evaluate the risk score of DVT in the departments of internal medicine and surgery. Effectiveness of predicting DVT was analyzed by receiver operating characteristic curve (ROC).Logistic regression analysis was used to evaluate the related factors of DVT.In DVT group, age (OR=0.96),acute infection(OR=8.23),prothrombin time(OR=0.76),D dimer(OR=1.00),erythrocyte sedimentation rate(OR=1.02) and platelet count(OR=1.01) were significantly associated with thrombosis(all P<0.05).The specificity of Padua model to predict DVT in internal medical patients was better than the sensitivity(80.7% vs. 50%,P<0.05).Surgical patients reported similar findings with specificity to sensitivity of 87.5% vs. 67.5%(P<0.05).The area under curve of ROC in internal medical patients was more than that in surgical patients[0.62 (95%CI 0.59-0.67) vs.0.61(95%CI 0.56-0.66), P<0.05].Padua model is more specific than sensitive to predict DVT in hospitalized patients.It has better predictive value of DVT in internal medical patients than surgical patients.