A systemic lupus erythematosus patient with thunderclap headache: reversible cerebral vasoconstriction syndrome

Headaches are common in patients with systemic lupus erythematosus (SLE). It is important to identify the exact cause of headaches in SLE to avoid unnecessary steroid or immunosuppressive therapy like in neuropsychiatric SLE. A 35-year-old woman with SLE suddenly developed severe headache. Magnetic resonance angiography showed multifocal segmental narrowing of cerebral arteries, suggestive of central nervous system vasculitis. However, lack of abnormal enhancement in vessel wall imaging indicated reversible cerebral vasoconstriction syndrome (RCVS) rather than central nervous system vasculitis. The patient was treated with oral nimodipine and she recovered over a period of two months. Following magnetic resonance angiography on day 90 was normal. Herein we report a case of reversible cerebral vasoconstriction syndrome in an SLE patient with literature review.

Reduction of chronic hepatitis B-related hepatocellular carcinoma with anti-viral therapy, including low risk patients

BACKGROUND

Anti-viral therapy in chronic hepatitis B (CHB) is associated with a reduced risk of hepatocellular carcinoma (HCC) primary described in patients with cirrhosis.

AIM

To examine the effects of treatment on HCC incidence in CHB with and without cirrhosis, after adjustment for background risks.

METHODS

A total of 2255 CHB patients from a US cohort (973 received anti-viral therapy) and 3653 patients from the community-based Taiwanese REVEAL-HBV study, none of whom received treatment. We used Cox proportional hazard models to calculate the risk of developing HCC after adjustment with the previously validated REACH-B risk score.

RESULTS

We found 273 incident cases of HCC. After adjustment, therapy lowered the risk of HCC development in the US treated cohort when compared to the US untreated cohort (HR 0.31; 95% CI: 0.15-0.66; P = 0.002). HCC risk reduction was also confirmed when compared to the REVEAL cohort (HR 0.22; 95% CI: 0.12-0.40; P < 0.001). Each REACH-B point was associated with a 53% increased risk of HCC (HR 1.53; 95% CI 1.46-1.59; P < 0.001). We found a significant statistical reduction in HCC incidence with therapy regardless of gender, age, cirrhosis status, HBeAg serology, alanine aminotransferase level, REACH-B score or treatment medication. Therapy was beneficial to those with mildly- to moderately elevated HBV DNA levels (>2000 IU/mL) and of even greater benefit to those with levels >200 000 IU/mL.

CONCLUSION

After adjustment for background risk, anti-viral therapy was associated with a significant reduction in HCC incidence in both community and real-life clinical cohorts, including in those patients previously thought to be at low risk.

Inflammatory Bowel Disease Patients' Participation, Attitude and Preferences Toward Exercise

The purpose of the study was to investigate the level of exercise participation in patients with inflammatory bowel disease (IBD) and to investigate their intention, attitude and preference toward exercise. The data of 158 IBD patients that participated in a self-administered survey at Severance Hospital between March 2013 and November 2013 were included in this cross sectional and descriptive analysis. Questionnaires included 3 sections to determine the IBD patient's current exercise participation, attitude toward exercise, and exercise preferences. This study investigated IBD patients both collectively, and according to their specific disease: Crohn's disease (CD) (n=62), Ulcerative colitis (UC) (n=73) and intestinal Behçet's disease (BD) (n=23). IBD patients currently participate in 103 min/week of exercise including mild, moderate and strenuous intensity, with BD patients being the least active, followed by CD, and UC being most active. The majority of IBD patients found exercise to be pleasant (57.7%), beneficial (80.5%), sensible (71.8%), uplifting (61%) and good (70.5%), and 44.4% found exercise to be enjoyable. This study shows the IBD patients' participation, attitude and preferences toward exercise and provides much needed information for the development of evidence based exercise programs that are specific to IBD.

Updated thresholds for serum alanine aminotransferase level in a large-scale population study composed of 34 346 subjects

BACKGROUND

The sensitivity of current upper limit of normal (ULN) of serum alanine aminotransferase (ALT) levels for detecting chronic liver disease has been challenged recently.

AIM

To identify modulating factors for serum ALT levels and to refine its ULN threshold.

METHODS

We enrolled 34 346 consecutive subjects who completed the health check-up at Taipei Veterans General Hospital from 2002 to 2009. ULN was set for healthy ALT level to the 95th percentile of the reference healthy population.

RESULTS

A group of 21 282 subjects were used as a training set to define an ULN with the highest sensitivity; afterwards, this ULN was validated in another set of 13 064 subjects. A reference healthy population was selected from the training set after excluding subjects with any abnormalities in independent risk factors associated with elevated serum ALT level (>40 IU/L) by multivariate analysis like body mass index, waist circumference, glucose, cholesterol, high-density lipoprotein-cholesterol, triglyceride, hepatitis B virus surface antigen, anti-hepatitis C virus antibody and fatty liver. The new ULN of serum ALT level defined as the 95% percentile in the healthy population were 21 IU/L and 17 IU/L for men and women respectively. These cut-off values had the highest Youden's index and areas under the corresponding receiver operating curves among four widely applied thresholds in both the training and validation sets.

CONCLUSIONS

The suggested threshold of upper limit of normal provides better discrimination between healthy and unhealthy status. Viral hepatitis, metabolic syndrome and fatty liver are the major risk factors of elevated serum alanine aminotransferase levels.

Association between obesity, hypertriglyceridemia and low hepatitis B viral load

OBJECTIVE

This study aimed to investigate the metabolic risk factors of high hepatitis B viral load.

DESIGN

Large-scale, community-based cross-sectional study.

SUBJECTS

A total of 3587 hepatitis B virus (HBV)-infected participants without liver cirrhosis at study entry were investigated. High HBV viral load was defined as a serum level 10(4) copies per ml for hepatitis B e antigen (HBeAg) seronegatives or 10(8) copies per ml for HBeAg seropositives.

RESULTS

Among HBeAg seropositives (n=545), high HBV viral load was reversely associated with extreme obesity (odds ratio (OR), 0.30; 95% confidence interval (CI), 0.13-0.68; P=0.004) or central obesity (OR, 0.53; 95% CI, 0.34-0.82; P=0.004) after adjustment for gender, hypertriglyceridemia, hyperuricemia and history of hypertension. High HBV viral load remained significantly inversely associated with extreme obesity (OR, 0.17; 95% CI, 0.05-0.63; P=0.008) and central obesity (OR, 0.44; 95% CI, 0.25-0.78; P=0.005) in male HBeAg-seropositive participants in stratification analyses by gender. Among HBeAg seronegatives (n=3042), however, high HBV viral load was inversely associated with hypertriglyceridemia (OR, 0.74; 95% CI, 0.61-0.89, P=0.002) after adjustment for age, gender, high serum alanine aminotransferase level, and extreme obesity or central obesity. High HBV viral load was still inversely associated with hypertriglyceridemia in both female (OR, 0.70; 95% CI, 0.50-0.97; P=0.041) and male (OR, 0.75; 95% CI, 0.60-0.94; P=0.011) HBeAg-seronegative participants.

CONCLUSION

Extreme obesity and central obesity were associated with a low prevalence of high HBV viral load in HBeAg seropositives, especially in men; while hypertriglyceridemia was associated with a low prevalence of high viral load in HBeAg seronegatives in both women and men.

Optimized THP-1 differentiation is required for the detection of responses to weak stimuli

OBJECTIVES

The differentiation of THP-1 monocytes into macrophages is mainly conducted at a phorbol 12-myristate 13-acetate (PMA) concentration of 10-400 ng/ml. However, this concentration might be high enough to upregulate the expressions of some genes in differentiated macrophages, which could overwhelm gene expression increases induced by other stimuli. The present study was performed to optimize the PMA concentration required to differentiate monocytes whilst minimizing gene upregulation.

METHODS

THP-1 cells were treated with 2.5-100 ng/ml PMA and analyzed for the extent of cell adherence, the surface marker of macrophages, and stable differentiation without undesirable gene upregulation. The stably differentiated THP-1 cells at the minimum PMA concentration were treated with 10 ng/ml LPS or 125 nM amyloid beta (Abeta(1-42)).

RESULTS

The treatment of THP-1 with 5 ng/ml PMA was found to be sufficient to induce stable differentiation without undesirable gene upregulation. These macrophages differentiated at 5 ng/ml responded well to secondary weak stimuli like 10 ng/ml LPS or 125 nM of amyloid beta (Abeta(1-42)).

CONCLUSIONS

This finding suggests that THP-1 cells are well differentiated by 5 ng/ml PMA, and that the resulting differentiated macrophages respond well to secondary weak stimuli without being overwhelmed by undesirable gene upregulation induced by PMA.

Serologic markers of Epstein-Barr virus infection and nasopharyngeal carcinoma in Taiwanese men

BACKGROUND

It is probable but unproven that Epstein-Barr virus (EBV) has a role in nasopharyngeal carcinoma. We determined whether antibodies against EBV are present before the development of nasopharyngeal carcinoma.

METHODS

A total of 9699 men were enrolled between 1984 and 1986. Blood samples were examined for IgA antibodies against EBV capsid antigen and neutralizing antibodies against EBV-specific DNase. During 131,981 person-years of follow-up, 22 pathologically confirmed new cases of nasopharyngeal carcinoma that were diagnosed more than one year after recruitment were ascertained through linkage with the National Cancer Registry of Taiwan.

RESULTS

The cumulative risk of nasopharyngeal carcinoma per 100,000 person-years was 11.2 for subjects who tested positive for neither serologic marker, 45.0 for those who had one marker, and 371.0 for those who had both markers. After adjustment for age and the presence or absence of a family history of nasopharyngeal carcinoma, the relative risk of nasopharyngeal carcinoma was 32.8 for subjects with both markers (95 percent confidence interval, 7.3 to 147.2; P<0.001) and 4.0 for subjects with one marker (95 percent confidence interval, 1.6 to 10.2; P=0.003), as compared with subjects with neither marker. The longer the duration of follow-up, the greater the difference in the cumulative incidence of nasopharyngeal carcinoma between seropositive and seronegative subjects.

CONCLUSIONS

IgA antibodies against EBV capsid antigen and neutralizing antibodies against EBV DNase are predictive of nasopharyngeal carcinoma.

The impact of HLA-DRB1*0405 on disease severity in Korean patients with seropositive rheumatoid arthritis

Many reports have described HLA-DRB1 genes as having an influence on disease severity and susceptibility in rheumatoid arthritis (RA). Studies were undertaken to define the effect of RA-associated alleles on disease severity in Korean patients with seropositive RA. The results indicate that the most common RA susceptibility allele, HLA-DRB1*0405, is significantly associated with bony erosion, joint deformity and extra-articular manifestations. However, RA-associated alleles in Koreans have less effect on nodular disease than in Caucasians. This suggests that the presence of RA-associated alleles, especially HLA-DRB1*0405, seems to be a prognostic marker for severe erosive disease in Koreans.

Protein losing enteropathy associated with Henoch-Schönlein purpura in a patient with rheumatoid arthritis

Protein losing enteropathy is rarely associated with Henoch-Schönlein purpura. Moreover, the disease association of Henoch-Schönlein purpura and rheumatoid arthritis is also rare. We report a case of a 46 year old patient with rheumatoid arthritis presenting with Henoch-Schönlein purpura associated with protein losing enteropathy.

A case of Budd-Chiari syndrome with high antiphospholipid antibody in a patient with systemic lupus erythematosus

Antiphospholipid syndrome is characterized by recurrent episodes of arterial and venous thrombosis, spontaneous fetal losses, thrombocytopenia and persistently elevated levels of antiphospholipid antibodies. We experienced a case of Budd-Chiari syndrome in a 32-year old female lupus patient who was presented with left leg edema, ascites and esophageal varix. The clinical and laboratory findings were compatible with the cirteria for systemic lupus erythematosus (SLE) and she was found to have anticardiolipin antibody, thrombocytopenia and prolonged partial thromboplastin time. Initially, she was treated with intravenous heparin and uroki nase and she was followed up with warfarin, baby aspirin and steroids.

TNFB gene polymorphism in patients with systemic lupus erythematosus in Korean

OBJECTIVES

To elucidate the gene frequency of TNFB Ncol polymorphism and its association with HLA class II antigen in patients with systemic lupus erythematosus(SLE) in Korea.

METHODS

We investigated the gene frequency of the TNFB alleles using DNA obtained from peripheral mononuclar cells in 141 healthy controls and in 58 patients with SLE. The polymorphisms of TNFB gene (735 bp) were studied by Ncol PCR-RELP. A portion of TNFB gene(735 bp) was amplified by PCR and its products were digested with Ncol restriction enzyme. The digested samples of amplified DNA were analyzed by agarose gel electrophoresis. TNFB*1 and TNFB*2 alleles were identified according to polymorphic fragments on Ncol restriction site in the first intron of the TNFB gene. The generic types of HLA-DRBI were also determined by PCR with sequence specific primers(SSP) using genomic DNA from the same subjects.

RESULTS

The genotypic frequency of TNFB*2 homozygote was significantly increased in patients with SLE compared with controls(RR = 2.36, P = 0.011). The frequency of HLA-DRBI*15 was also significantly increased in patients (RR = 2.27, P = 0.029). However, the increased frequency of TNFB*2 homozygote was apparently increased in nephritis group (RR = 2.79, P = 0.035), whereas the significance of TNFB*2 homozygote was weakend in non-nephritis group.

CONCLUSIONS

Our results suggest that genetic predisposition of TNFB*2 homozygote is another risk factor in Korean SLE, especially in DR2 negative patients. In addition, TNFB*2 homozygote could have a tendency for the development of nephritis in patients with SLE.