Case series of patients with cholesterol crystal embolism syndrome that mimics systemic vasculitis / 中华风湿病学杂志

Objective:To improve the awareness of cholesterol crystal embolism syndrome (CCE) inrheumatologists.Methods:The clinical characteristics of 40 Chinese CCE patients admitted to our department (one case) were summarize and in the literature (thirty-nine cases) were reviewed.Results:Among these 40 patients, 87.5%(35/40) were male and the mean age was (68±6) years. All patients suffered from athero-sclerosis and 87.5%(35/40) of them had precipitating factors such as endovascular intervention, vascular surgery, anticoagulant, or thrombolytic therapy. The clinical manifestations included renal insufficiency (90.0%, 36/40), blue toe syndrome (82.5%, 33/40), ulceration or gangrene (25.0%, 10/40), and livedo reticularis (15%, 6/40). Acute phase reactant was tested in 25 cases, of whom 84.0%(21/25) showed elevated C-reactive protein (CRP) and 56.0%(14/25) showed elevated erythrocyte sedimentation rate (ESR).Conclusion:Rheumatologists should be alert that CCE is one of the differential diagnosis of systemic vasculitis, especially for patients with severe atherosclerosis.

Clinical characteristics and renal uric acid excretion in early-onset gout patients / 中华内科杂志

Objective To investigate clinical characteristics and renal uric acid excretion in early-onset gout patients.Methods Consecutive inpatients with primary gout were recruited between 2013 and 2017.The patients with gout onset younger than 30 were defined as early-onset group while the others were enrolled as control group.Clinical characteristics and uric acid (UA) indicators were compared between two groups.Results Among 202 recruited patients,the early-onset group included 36 patients (17.8％).Compared with control group,the early-onset group presented more patients with obesity [13 patients (36.1％) vs.22 patients (13.3％),P＜0.05],significantly higher serum UA level [(634± 124)μmol/L vs.(527± 169).μmol/L] and glomerular load of UA[(7.2±2.8)mg· min-1 · 1.73m-2 vs.(4.4±2.2)mg· min-1 · 1.73m-2] and estimated glomerular filtration rate (GFR) [(83±21)ml· min-1 · 1.73m-2 vs.(67±21)ml· min-1 · 1.73m-2] (all P＜ 0.05),lower fractional excretion of UA [4.4％ (3.4％,6.1％) vs.7.2％ (5.2％,9.6％),P＜0.05],whereas 24h urinary UA excretion was comparable [(2 788±882)l,μmol/1.73m2 vs.(2 645±1 140)μmol/1.73m2,P=0.274].Subgroup analysis of patients without chronic kidney disease showed significantly lower fractional excretion of UA in the early-onset group [4.5％(3.3％,6.1％) vs.6.7％ (5.1％,8.7％),P＜0.05].Logistic regression analysis showed that obesity (OR=3.25) and fractional excretion of UA less than 7％ (OR=9.01,all P＜0.05) were risk factors of gout early onset.Conclusion The gout patients with early-onset younger than 30 present high serum and glomerular load of uric acid which might be due to obesity and relative under-excretion of renal uric acid.

Rosiglitazone inhibits osteoclastogenesis in rheumatoid arthritis by down-regulating RANKL expression and suppressing ERK phosphorylation / 中国病理生理杂志

AIM: To investigate the effects of rosiglitazone on fibroblast-like synoviocyte ( FLS )-induced osteoclastogenesis in rheumatoid arthritis ( RA) and the related mechanism.METHODS: RA-FLS were cocultured with peripheral blood monocytes from healthy volunteers in the presence of macrophage colony-stimulating factor ( M-CSF) and rosiglitazone.Osteoclasts were assayed by tartrate-resistant acid phosphatase ( TRAP) staining.Resorption lacunae area was identified by toluidine blue staining and quantified by image analysis software.The mRNA expression of RANKL and OPG was evaluated by real-time PCR, and the protein levels of RANKL, OPG, p-ERK, p-p38 and p-JNK were measured by Western blot.RESULTS:Compared with control group ( without rosiglitazone treatment) , rosiglitazone at concentration of 15 μmol/L significantly decreased the number of osteoclasts (P0.05 ) . CONCLUSION:Rosiglitazone inhibits RA-FLS-induced osteoclast formation and its resorption activity by down-regulating RANKL expression and ERK phosphorylation, suggesting that rosiglitazone may inhibit RA osteoclastogenesis and bone re-sorption.

Efficacy of tocilizumab on disease activity and psychological state in patients with refractory rheumatoid arthritis / 中华风湿病学杂志

Objective To observe the efficacy and safety of tocilizumab on patients with refractory rheumatoid arthritis (RA).Methods Eighteen RA patients who were refractory to disease-modifying antirheumatic drugs (DMARDs) or tumor necrosis factor-α (TNF-α) antagonist were treated with tocilizumab were included into this study.Their clinical disease activity indices,Hospital Anxiety and Depression Scale (HADS)and safety were evaluated regularly.Statistical analysis was conducted with Mann-Whitney U test and x2 test.Results According to clinical disease activity index,44％(8/18) of patients reached treatment target 2 weeks after the first infusion of tocilizumab,and 78％ (14/18) reached treatment target after three infusions of tocilizumab.Fifty-six percent (10/18) of patients had anxiety and 22％ (4/18) had depressive symptoms at baseline.After three infusions of tocilizumab,6％(1/18) had anxiety symptoms and 11％(2/18) had depressive symptoms.The adverse effects included upper respiratory tract infection,aminotransferase elevation and neutropenia (3 patients,respectively).Conclusion Tocilizumab can rapidly and significantly improve the disease activity and psychological state with good tolerance and safety,which can be applied to Chinese refractory RA patients who failed with DMARDs or TNF-α antagonist.

Dynamic expression and significance of Bcl6 in fibroblast-like synoviocytes induced osteoclast differentiation and activation in rheumatoid arthritis / 中华风湿病学杂志

Objective To investigate the dynamic expression and significance of B cell lymphoma (Bcl) 6 in fibroblast-like synoviocytes (FLS) induced osteoclast differentiation and activation in rheumatoid arthritis (RA) patients.Methods RA-FLS were co-cultured with peripheral blood monocytes (PBMCs) from healthy volunteers in the medium containing M-CSF.Bcl6 protein and mRNA in osteoclasts and their precursors were determined by immunofluorescence and Real-time PCR at day 0,7,14 and 21,respectively.Osteoclasts were identified by tartrate-resistant acid phosphatase (TRAP) staining.Bone resorption activity of osteoclasts was determined by bone slices stained with toluidine blue.Kruskal-Wallis H and Bonferroni were used for statistical analysis.Results ① Immunofluorescence staining and TRAP staining showed that Bcl6 protein was mainly expressed in the nuclei of PBMCs.After co-cultured with RA-FLS for 7 days,some PBMCs differentiated into macrophages and a few differentiated to TRAP-positive multinucleated osteoclasts,and the total Bcl6 protein expression in osteoclasts and their precursors were increased.At day 14,the total Bcl6 protein expression was increased further.At day 21,the Bcl6 protein expression in nuclei of osteoclasts was decreased while PBMCs were differentiated into osteoclasts,and total Bcl6 protein expression was decreased.②Real-time PCR showed that Bcl6 mRNA expression in osteoclasts and their precursors at day 7 tended to increase than that at day 0 (x2=3.429,P＞0.05).At day 14 after co-cultured with RA-FLS,Bcl6 mRNA expression in osteoclasts and their precursors was significantly higher than that at day 0 (x2=5.333,P=0.045).At day 21,the expression of Bcl6 mRNA was significantly lower than that at day 14 (x2=6.023,P=0.038).Conclusion Bcl6 may be involved in osteoclast differentiation and activation,and may play a role in the inflammatory status in the process of differentiation from PBMCs to macrophages.Further studies are needed to establish the mechanisms.

Application of the modified team-based learning in internal medicine practice teaching for eight-year clinical students / 中华医学教育探索杂志

Targeting to improve clinical thinking and practice skill of interns, modified Team-based learning (TBL) based on seeing real patient was performed for interns from eight-year clinical medicine program. Teachers prepared the corresponding case material before the teaching and made teaching aids. And interns were mobilized and guided to preview and self-study in teams. During modi-fied TBL, in-class application of seeing real patient was performed to assess the effect of self-study in teams, besides individual test and team test deriving from traditional TBL. All teams were assigned one task of seeing real patient by drawing lots, and then finished the task, answered teachers' questions. And the students' performance was given comments and comprehensive scores by the judges. After the completion of teaching, the teaching effectiveness of the modified TBL was assessed from students' performance, their scores and their teaching evaluation. Practice shows that the modified TBL can not only attract students to engage in it, but also elevate their abilities of clinical thinking and practical skill. It can also cultivate their interpersonal ability.

Application of team-based learning in practice teaching of internal medicine / 中华医学教育探索杂志

Objective To explore the feasibility of team-based learning (TBL) for practice teaching of internal medicine.Methods TBL was carried out in 40 interns from clinical medical students of eight-year program.Every team included 4 ～ 5 members.The course of rheumatoid arthritis was chosen according to the course syllabus.Results The students discussed enthusiastically in the team test and in-class application exercises.More than 80％ of the students expressed that TBL was helpful to understand the course content better,to learn the disease better,to elevate personal study ability and to know others' thought processes.76％ of the students supported to carrry out TBL again.Conclusions TBL is helpful for senior medical students to elevate their ability of applying course concepts to solve practical problems through a series of team activities.Improvement of teaching idea and skill is the key to perform TBL successfully.

Rosiglitazone inhibits receptor activator of NF-κB ligand expression in rheumatoid synovial fibroblasts through p-ERK pathway / 中华风湿病学杂志

ObjectiveTo investigate the effect of rosiglitazone (RSG), a high-affinity synthetic agonist for PPAR-γ, on the expression of receptor activator of NF-κB ligand (RANKL) and osteoprotegerin (OPG)in rheumatoid arthritis fibroblast-like synoviocyte (RA-FLS) and the underlying mechanisms. MethodsRAFLS were incubated with different concentrations of RSG(0, 5, 10, 15, and 20 μmol/L) for 3 days, RAFLS proliferation was detected by Cell Counting Kit-8 assay, and then the expression of RANKL and OPG was examined by real-time PCR and Western blot. The expression of phosphorylated ERK, p38 and JNK was also detected after RA-FLS was incubated with RSG(0, 15, and 20 μmol/L) for 3 days. One-way ANOVA and Bonferroni were used for statistical analysis. ResultsRSG (5, 10, 15, and 20 μmol/L) had significantly inhibited the expression of RANKL mRNA(0.503±0.005, 0.438±0.031, 0.161±0.042, 0.050±0.018) and protein (1.72±0.09, 1.58x±0.05, 1.46±0.11, 1.22x±0.14) in RA-FLS (F=200.820, F=13.602, P＜0.01 ), while the expression of OPG mRNA (2.8 ±0.5, 7.0 ±3.2, 8.4 ±2.3, 25.7 ±5.1 ) and protein ( 1.21 ±0.11, 1.52 ±0.16, 1.63±0.11, 1.91 ±0.03) increased significantly (F=26.531, F=24.872, P＜0.01), both in a dose dependent manner. The ratio of RANKL/OPG mRNA and protein significantly reduced (F=453.425, P＜0.01 ;F=4.173, P＜0.05 ). RSG (15, 20 μ mol/L) significantly inhibited the expression of p-ERK-1/2 protein (0.55±0.06, 0.45±0.06, F=6.991, P＜0.05). ConclusionRSG can inhibit RANKL expression in RA-FLS through p-ERK pathway.