Study on Fu-Fang-Jin-Qian-Cao Inhibiting Autophagy in Calcium Oxalate-induced Renal Injury by UHPLC/Q-TOF-MS-based Metabonomics and Network Pharmacology Approaches

INTRODUCTION

Fu-Fang-Jin-Qian-Cao is a Chinese herbal preparation used to treat urinary calculi. Fu-Fang-Jin-Qian-Cao can protect renal tubular epithelial cells from calcium oxalateinduced renal injury by inhibiting ROS-mediated autopathy. The mechanism still needs further exploration. Metabonomics is a new subject; the combination of metabolomics and network pharmacology can find pathways for drugs to act on targets more efficiently.

METHODS

Comprehensive metabolomics and network pharmacology to study the mechanism of Fu-Fang-Jin-Qian-Cao inhibiting autophagy in calcium oxalate-induced renal injury. Based on UHPLC-Q-TOF-MS, combined with biochemical analysis, a mice model of Calcium oxalateinduced renal injury was established to study the therapeutic effect of Fu-Fang-Jin-Qian-Cao. Based on the network pharmacology, the target signaling pathway and the protective effect of Fu- Fang-Jin-Qian-Cao on Calcium oxalate-induced renal injury by inhibiting autophagy were explored. Autophagy-related proteins LC3-II, BECN1, ATG5, and ATG7 were studied by immunohistochemistry.

RESULTS

Combining network pharmacology and metabolomics, 50 differential metabolites and 2482 targets related to these metabolites were found. Subsequently, the targets enriched in PI3KAkt, MAPK and Ras signaling pathways. LC3-II, BECN1, ATG5 and ATG7 were up-regulated in Calcium oxalate-induced renal injury. All of them could be reversed after the Fu-Fang-Jin-Qian- Cao treatment.

CONCLUSIONS

Fu-Fang-Jin-Qian-Cao can reverse ROS-induced activation of the MAPK signaling pathway and inhibition of the PI3K-Akt signaling pathway, thereby reducing autophagy damage of renal tubular epithelial cells in Calcium oxalate-induced renal injury.

[Clinical characteristics of patients with rheumatic diseases and abnormal liver function]

Objective: To investigate the clinical characteristics of patients with rheumatic diseases and abnormal liver function, as well as determine the proportion and severity of liver function abnormalities. Methods: Cross-sectional study. Data were collected from patients registered in the Chinese Rheumatism Date Center from 2011 to 2021. The rheumatic diseases analyzed in this study were rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Sjogren syndrome (SS), ankylosing spondylitis (AS), and gout. Patient data, including demographic characteristics [ such as age, sex, body mass index,(BMI), and smoking history], liver function test results [including alanine aminotransferase (ALT), aspartate aminotransferase, alkaline phosphatase(ALP), and total bilirubin], and use of anti-rheumatic immune drugs and liver-protective drugs, were collected and compared between groups with normal and abnormal liver functions. In addition, the proportions of abnormal liver function were compared between sex and age groups. Results: A total of 116 308 patients were included in this study, including 49 659 with RA, 17 597 with SLE, 9 039 with SS, 11 321 with AS, and 28 692 with gout. The lowest proportion of liver function abnormalities was observed in patients with RA[11.02% (5 470/49 659)], followed by those with SS[17.97% (1 624/9 039)] and AS [18.22% (2 063/11 321) ], whereas patients with SLE [21.14% (3 720/17 597) ] and gout [28.73% (8 242/28 692)] exhibited the highest proportion of these abnormalities. Elevated ALT, mostly classified as grade 1, was the most commonly noted liver function abnormality, whereas elevated ALP was the least common. Some patients who took liver-protective drugs had normal liver function, with the lowest percentage observed in patients with gout [7.45% (36/483) ] and ranging from 21.7% to 30.34% in patients with RA, SLE, SS, and AS. The proportion of liver function abnormalities was higher in males than in females for all disease types [RA: 13.8%(1 368/9 906) vs. 10.3%(4 102/39 753); SLE: 33.6% (479/1 424) vs. 20.0% (3 241/16 173); SS: 25.4%(111/437) vs. 17.6%(1 513/8 602); AS: 20.1%(1 629/8 119) vs. 13.6% (434/3 202); and gout: 29.3% (8 033/27 394) vs. 16.1% (209/1 298)]. In RA, SLE, and AS, the proportions of liver function abnormalities were similar across all age groups. In SS, the proportion of liver function abnormalities increased with age [<40 years: 14.9%(294/1 979); 40-59 years: 18.1%(858/4 741); ≥60 years: 20.4%(472/2 319)], whereas a reversal of this trend was observed in gout [<40 years: 34.9%(4 294/12 320); 40-59 years: 25.5%(2 905/11 398);≥60 years: 21.0%(1 042/4 971)]. Conclusions: The proportions of combined liver function abnormalities in patients with rheumatologic diseases were high, and the utilization rates of liver-protective drugs were low. It is necessary to pay more attention to monitoring patients' liver function, timely administer liver-protective drugs, and optimize liver-protective regimens during the treatment of rheumatic diseases.

[Clinical characteristics of 42 children with focal atrial tachycardia originated from the right atrial appendage]

Objective: To investigate the feature and treatment of atrial tachycardia (AT) originated from right atrial appendage (RAA) in children. Methods: The data of 42 children with AT originated from RAA, who were admitted the First Hospital of Tsinghua University from January 2010 to September 2022 were analyzed retrospectively.The clinical characteristics, treatment and efficacy were analyzed. The children were divided into tachycardia cardiomyopathy group and normal cardiac function group. The differences in the ablation age and the heart rate during AT between two groups were compared by independent sample t-test. Results: Among 42 children, there were 20 males and 22 females. The age of onset was 2.7 (0.6, 5.1) years. Their age at radiofrequency ablation was (6.5±3.6) years, and the weight was (23.4±10.0) kg. Thirty-two children (76%) had sustained AT. The incidence of tachycardia cardiomyopathy was 43% (18/42). Compared to that of the normal cardiac function group, the ablation age and the heart rate at atrial tachycardia of the tachycardia cardiomyopathy group were higher ((8.1±3.8) vs. (5.3±3.1) years, t=-2.63, P=0.012; (173±41) vs. (150±30) beats per minute, t=-2.05, P=0.047. Thirty-eight children (90%) responded poorly to two or more antiarrhythmic drugs. The immediate success rate of radiofrequency ablation (RFCA) was 57% (24/42), and the AT recurrence rate was 17% (4/24). Twenty-two children underwent RAA resection, and their AT were all converted to sinus rhythm after the surgery. During the RAA resection, 10 cases of right atrial appendage aneurysm were found, 9/18 of which failed the RFCA. Conclusions: The AT originated from the RAA in children tend to present with sustained AT, respond poorly to antiarrhythmic drugs, and has a low success rate of RFCA as well as high recurrence rate. Resection of the RAA is a safe and effective complementary treatment.

Corrigendum: Phyllanthus niruri L. exerts protective effects against the calcium oxalate-induced renal injury via ellgic acid

[This corrects the article DOI: 10.3389/fphar.2022.891788.].

Current status and temporal trend of disease burden of thyroid cancer in China from 1990 to 2019

OBJECTIVE

Thyroid cancer has been an increasingly high-profile public health issue. Comprehensive assessment for its disease burden seems particularly important for understanding health priorities and hinting high-risk populations.

METHODS

We estimated the age-sex-specific thyroid cancer burden and its temporal trend in China from 1990 to 2019 by following the general methods from the global burden of disease (GBDs) 2019 Study. And Joinpoint regression model, the Cox-Stuart trend test, and Cochran-Armitage test were applied for the analysis of temporal and age trend. The Mantel-Haenszel statistical method was used to compare the gender difference.

RESULTS

From 1990 to 2019, the age-standardized incidence rate of thyroid cancer in China has almost doubled to 2.05 per 100,000. Although the mortality rate and DALY rate kept leveling off, they presented a downtrend among females, while an upward trend in males. While the average annual percentage changes of those metrics all became deline since 2010 than the previous years. With age advancing, the rates of incidence, mortality, and DALYs for both sexes all presented linear fashion increases, which was particularly typical among males.

CONCLUSION

Given the serious trend and gender-age heterogeneity of Chinese thyroid cancer burden, male gender and advanced age may be related to poor prognosis of thyroid cancer, and strengthening primary prevention and exploring the underlying risk factors should be among the top priorities.

[Clinical characteristics of 37 antiphospholipid syndrome patients complicated by autoimmune hemolytic anemia]

Objective: We sought to investigate the clinical characteristics and risk factors of antiphospholipid syndrome (APS) complicated by autoimmune hemolytic anemia (AIHA). Methods: Retrospective anaysis.Three hundred fifteen consecutive patients with APS were enrolled at the Department of Rheumatology of Peking Union Medical College Hospital between May 2017 to May 2021, and their clinical manifestations[including initial symptoms, time interval between APS onset and diagnosis, systemic lupus erythematosus(SLE), thrombotic events, obstetric morbidity, and extra-criteria manifestations] and laboratory test results[including blood routine, antiphospholipid antibodies(aPLs), blood lipid profile, homocysteine, anti-nuclear antibody profile, immunoglobulin levels, and complement levels] were collected. Then, univariate and multivariate logistic regression analyses were performed. Clinical features and risk factors were analyzed using univariable and multivariable logistic regression analysis. Results: Among 315 APS patients, 37 cases (11.7%) were complicated by AIHA, and AIHA was the first manifestation or co-occurrence. The median time interval between APS onset and diagnosis was 12 months. The proportion of SLE in APS patients combined with AIHA was higher than that in APS patients without AIHA[62.2%(23/37) vs. 19.4%(54/278), P<0.001]. There was no significant difference in the proportions of thrombosis and pregnancy morbidity between the two groups. In terms of extra-criteria manifestations, APS patients with AIHA had a significantly (P<0.05) greater risk of thrombocytopenia (OR=6.19, 95%CI 2.81-13.65) and higher proportions of hypocomplementemia, a positive lupus anticoagulant (LA) result, double aPLs positivity[i.e., any two of the following antibodies were positive: LA, anticardilolipin antibody(aCL), and anti-β2 glycoprotein Ⅰ(β2GPⅠ)], and triple aPLs positivity (i.e., LA, aCL, and anti-β2GPⅠ antibodies were all positive). Multivariate logistic regression analysis showed that SLE (OR=3.46,95%CI 1.60-7.48), thrombocytopenia (OR=2.56,95%CI 1.15-5.67), and hypocomplementemia (OR=4.29,95%CI 2.03-9.04) were independent risk factors for the complication of APS. In the primary APS subgroup, multivariate logistic regression analysis showed that livedo reticularis (OR=10.51,95%CI 1.06-103.78), thrombocytopenia (OR=3.77, 95%CI 1.23-11.57), and hypocomplementemia (OR=5.92,95%CI 1.95-17.95) were independent risk factors for the complication of APS. Conclusions: AIHA is not rare in APS patients; moreover, it occurs more frequently in APS secondary to SLE and is more likely to present with a variety of extra-criteria manifestations. Patients with AIHA should be promptly tested for antiphospholipid antibody profiles and alerted to the possibility of thrombotic events.

[The analysis to data from Chinese Rheumatism Data Center external quality assurance program for autoantibodies in 2021]

To evaluate the data obtained from the external quality assurance program initiated by Chinese Rheumatism Data Center (CRDC-QAP) for autoantibodies detection in 2021, so as to assess the consensus and differences in cross-laboratory testing to autoantibodies in China. This is a retrospective study. After collecting data from the first half year (from May 15th to July 10th) and the second half year (from August 15th to November 19th) of CRDC-QAP program for autoantibody detection in 2021, it firstly analyzed the qualitative consensus of the cross-laboratory results. Secondly, it compared the positivity grade of numeric results according to the Sample to cut-off ratio (S/CO ratio) calculation. Finally, the mean and coefficient variation (CV) of numeric results from three major manufacturers were calculated. A total of 303 and 332 clinical labs voluntarily participated in the first half year and the second half year of CRDC-QAP program for autoantibody detection in 2021, respectively. Except for anti-β2 glycoprotein type I (aβ2-GPI) IgM, the cross-laboratory consensus of qualitative results for the other autoantibodies is greater than 96%. As for anti-cyclic citrullinated peptide antibody (anti-CCP) and anti mitochondrial antibody-M2 (AMA-M2), the numeric results from more than 90% laboratories showed the same positivity grade. More than 50% of laboratories used chemiluminescence immunoassay (CLIA) for quantitative evaluation of autoantibody. The CV of numeric results from different manufacturers showed certain differences(P<0.01) with the range from 0 to 238%. Although high consensus can be observed in term of qualitative result for autoantibody detection in cross-laboratory, there are still certain differences in numeric results in term of positivity grade and manufacturer-based CV.

[Recommendations for the diagnosis and treatment of connective tissue disease-associated interstitial lung disease in China]

Interstitial lung disease (ILD) is a frequent complication of patients with connective tissue disease (CTD) and significantly affects morbidity and mortality. Disease course may vary from stable or mildly progressive to more severe, with rapid loss of lung function. At present, there are great challenges and poor prognosis in the diagnosis and treatment of CTD-ILD. Based on the evidence and guidelines from China and other countries, experts from the Chinese Rheumatology Association developed standardization of diagnosis and treatment of CTD-ILD. The aim is to strengthen the early identification of, standardize the diagnosis and treatment of CTD-ILD, and delay the progress of the disease.

[The clinical characteristics of nuclear dense fine speckled pattern in 95 289 patients]

To investigate the distribution and clinical significance of nuclear dense fine speckled (DFS) pattern in various diseases. A total of 95 289 patients who received DFS tests at Peking Union Medical College Hospital from January 2019 to December 2020 were included in this study. The results of indirect immunofluorescence assay (IIF) for detection of antinuclear antibody (ANA) were evaluated. The positive rates of ANA and DFS were 39.60% (37 733/95 289) and 1.19% (1 139/95 289) respectively. The positive rate of DFS in ANA-positive patients was 3.02% (1 139/37 733). DFS and ANA positivity were significantly different among different age groups rather than gender. The positivity rate of DFS reached the peak (55.57%, 633/1 139) in young patients between 21-40 years, while positive ANA with negative DFS was mainly observed in patients between 41-60 years (37.26%, 13 636/36 594). Additionally, single ANA-positivity were mainly detected in rheumatology department (59.23%, 18 402/31 066), whereas positive DFS was more common in obstetrics and gynecology department (3.08%, 49/1 593). There were 82.88% (944/1 139) patients with positive DFS diagnosed with non-autoimmune disease (non-AID), and 19.49%(222/1 139) with dermatosis. Positive DFS with higher titer (≥1∶320) was detected more frequently in autoimmune disease (AID) patients (5.13%, 10/195) than in non-AID patients (1.69%, 16/944) (P<0.05). The DFS pattern is rare in ANA positive patients, which is mainly observed in women between 21-49 years. High titer of DFS is prevalent in AID patients, but positive DFS is detected more in non-AID patients, especially those with dermatosis.

[Effectiveness investigation on left bundle branch area pacing in 10 infants and toddlers]

Objective: To explore the feasibility, safety and effectiveness of left bundle branch area pacing (LBBAP) in children aged ≤3 years. Methods: A total of 10 children aged ≤3 years who were diagnosed with brady arrhythmia in the First Hospital of Tsinghua University from September 2020 to September 2021 were retrospectively analyzed. All the children met the indication of permanent pacemaker implantation and underwent LBBAP successfully. The intraoperative data (pacing parameters, electrocardiogram and radiographic imaging), cardiac ultrasound data and clinical data during regular postoperative follow-up were recorded. The preoperative and postoperative data were compared using matched samples t test. Results: Ten children (aged (1.6±0.7) years with weight of (10.3±2.5) kg) underwent LBBAP successfully. The QRS wave duration on the postoperative electrocardiogram was (100±9) ms, and the percentage of ventricular pacing was (97±7)%. The postoperative follow-up period was 6 (6, 12) months. At 1 week after operation, the left ventricular end-diastolic diameter Z scores in these children reduced significantly compared with those before operation (1.3±0.6 vs. 3.6±1.1, t=9.37, P<0.001). During the follow-up period, cardiac function was normal and the last left ventricular ejection fraction was (66±4)% in all children. At the last follow-up, the pacing threshold of the 10 children was smaller than 1.0 V and was acceptable. Compared with the intraoperative baseline values, the pacing threshold was slightly higher ((0.8±0.1) vs. (0.5±0.1) V, t=-5.27, P=0.001). However, no significant difference was found regarding sensing threshold ((16±5) vs. (14±4) mV, t=-0.83, P=0.426) and impedance ((584±88) vs. (652±86) Ω, t=2.26, P=0.050). During follow-up, no electrode related complications were recorded. Conclusions: LBBAP is safe and effective for infants and toddlers. Narrow QRS pacing with stable pacing parameters and normal cardiac function could be achieved postoperatively.

[The 498th case: rash, fever and hematuria]

A 50-year-old man was admitted to the Department of Rheumatology at Peking Union Medical College Hospital with rash for 6 months, and fever and hematuria for 5 months. The main clinical manifestations included fever, fatigue, purpura, hematuria and thrombocytopenia. He was positive for antinuclear antibody (ANA), anti-neutrophil cytoplasmic antibodies (ANCA) and rheumatoid factor (RF), and had low complement levels. Initial blood culture, echocardiography and chest CT showed no signs of infection. Diagnosis of connective tissue disease was made initially. His disease improved under treatment with glucocorticoids and immunosuppressive agents, but relapsed when glucocorticoids were tapered. After admission, the diagnosis was reconsidered, and infective endocarditis was finally diagnosed with repeated positive blood cultures and vegetations detected by transesophageal echocardiography. Amoxicillin and clavulanate potassium were initiated, and surgery was performed. His symptoms finally recovered gradually.

[Assessment of MS-Score and HScore in timeliness of diagnosis of macrophage activation syndrome associated with adult-onset Still's disease]

The data of 33 patients with adult-onset still's disease (AOSD)-associated macrophage activation syndrome (MAS) were retrospectively collected from January 2013 to December 2020 in Peking Union Medical College Hospital. Hemophagocytic lymphohistiocytosis (HLH)-2004 criteria, macrophage activation syndrome/juvenile idiopathic arthritis (MS-Score) and hemophagocytic syndrome diagnostic score (HScore) were used to diagnose AOSD-associated MAS, respectively. The time of diagnosis of AOSD-associated MAS by MS-Score was 19.0 (4.5, 31.0) days [M (Q₁,Q₃)] earlier than by HLH-2004 criteria, and 13.5 (0.5, 21.5) days earlier than by HScore (both P<0.05). The difference was not statistically significant between the time of diagnosis of AOSD-associated MAS by Hscore and by HLH-2004 criteria (P>0.05). There was significant difference among the three criteria (P<0.001). MS-Score can be used to diagnose AOSD-associated MAS earlier than HLH-2004 criteria, while the timeliness of HScore is not certain.

[Association of skin lesion severity with clinical features of psoriatic arthritis]

Objective: To investigate the relationship between psoriasis severity and clinical features in psoriatic arthritis (PsA). Methods: Patients were recruited from the Chinese REgistry of Psoriatic ARthritis (CREPAR) between December 2018 and June 2021, and data were collected including the baseline demographic characteristics, various clinical manifestations (including arthritis, nail disease, comorbidities), laboratory tests[including erythrocyte sedimentation rate(ESR), C-reactive protein (CRP)], health assessment questionnaire (HAQ). Body surface area (BSA) and psoriasis area and severity index (PASI) were selected for the tools of assessment of cutaneous psoriasis. Patients were divided to two groups, including the severe psoriasis group (BSA>10%) and the non-severe psoriasis group (BSA≤10%). Disease assessment included ankylosing spondylitis disease activity score (ASDAS), disease activity score 28 (DAS28) and disease activity in psoriatic arthritis (DAPSA). Results: 1 074 eligible patients with PsA were recruited, and 106 (9.9%) had severe psoriasis. Compared with non-severe psoriasis group, the severe psoriasis group had more peripheral joint involvement (including patients with ever or current peripheral arthritis, 94.3% vs. 85.6%), more polyarticular joint involvement (including patients with current peripheral arthritis, 74.0% vs. 58.2%), more axial joint involvement (51.4% vs. 39.9%), more nail disease (72.6% vs. 61.4%), more frequency of smoking (20.2% vs. 18.7%), and higher proportion of hypertension (23.4% vs. 14.4%). In addition, the severe psoriasis group had higher level of ESR [33(10, 70) mm/1h vs. 20(9, 38) mm/1h] and CRP [18.6(5.0, 60.8) mg/L vs. 7.0(2.4, 18.1) mg/L], higher values of DAS28-ESR (4.5±1.7 vs. 3.7±1.5), DAS28-CRP (4.2±1.5 vs. 3.4±1.4), ASDAS-ESR (3.5±1.4 vs. 2.6±1.2), and ASDAS-CRP(3.4±1.6 vs. 2.5±1.2), higher scores of HAQ [0.6(0.1, 1.0) vs. 0.3(0.0, 0.8)]. Conclusion: Patients with PsA with severe psoriasis bore a heavier disease burden. Therefore, clinicians were supposed to pay more attention to them. In addition to skin lesions, they should also focus on examination of other clinical manifestations, such as joints and nails.

Phyllanthus Niruri L. Exerts Protective Effects Against the Calcium Oxalate-Induced Renal Injury via Ellgic Acid

Background: Urolithiasis or kidney stones is a common and frequently occurring renal disease; calcium oxalate (CaOx) crystals are responsible for 80% of urolithiasis cases. Phyllanthus niruri L. (PN) has been used to treat urolithiasis. This study aimed to determine the potential protective effects and molecular mechanism of PN on calcium oxalate-induced renal injury.

Methods: Microarray data sets were generated from the calcium oxalate-induced renal injury model of HK-2 cells and potential disease-related targets were identified. Network pharmacology was employed to identify drug-related targets of PN and construct the active ingredient-target network. Finally, the putative therapeutic targets and active ingredients of PN were verified in vitro and in vivo.

Results: A total of 20 active ingredients in PN, 2,428 drug-related targets, and 127 disease-related targets were identified. According to network pharmacology analysis, HMGCS1, SQLE, and SCD were identified as predicted therapeutic target and ellagic acid (EA) was identified as the active ingredient by molecular docking analysis. The increased expression of SQLE, SCD, and HMGCS1 due to calcium oxalate-induced renal injury in HK-2 cells was found to be significantly inhibited by EA. Immunohistochemical in mice also showed that the levels of SQLE, SCD, and HMGCS1 were remarkably restored after EA treatment.

Conclusion: EA is the active ingredient in PN responsible for its protective effects against CaOx-induced renal injury. SQLE, SCD, and HMGCS1 are putative therapeutic targets of EA.

[Sex disparities in clinical characteristics of Chinese patients with systemic sclerosis]

Objective: To evaluate the differences in clinical characteristics between different genders of Chinese patients with systemic sclerosis(SSc). Methods: The data of SSc patients registered in Chinese Rheumatism Data Center between August 2008 and June 2020 were retrospectively analyzed. Results: A total of 1 844 patients with SSc were enrolled in the study. The ratio of males to females was 289 to 1 555. The onset age was (48.6±13.7) years in males and (45.5±13.1) years in females(P<0.001). Male patients represented shorter disease duration [2.0(0.0, 4.0)years vs.3.0(1.0, 7.0) years, P<0.001],higher proportion of diffuse cutaneous SSc (dcSSc) [63.0% (182/289)vs.44.2%(688/1 555), P<0.001]. Although more man patients experienced smoking [47.4%(137/289) vs. 1.7%(27/1 555), P<0.001] and exposure to harmful environments [7.6%(22/289) vs. 2.1%(33/1 555), P<0.001], there was no statistically significant difference in interstitial lung disease between male and female patients [69.3%(181/261) vs. 74.5%(1 085/1 457), P=0.084].Otherwise, Raynaud's phenomenon [87.7% (1 364/1 555) vs.75.4%(218/289), P<0.001], arthritis [11.1%(173/1 555) vs.6.9%(20/289), P=0.032], gastroesophageal reflux disease [22.0%(342/ 1 555) vs.13.1%(38/289), P=0.001], and leucopoenia [10.7(161/1 511)% vs. 6.1%(17/279), P=0.019] were more common in female patients, but finger ulcer was less common [22.5%(350/1 555) vs. 30.4%(88/289), P=0.004]. Antinuclear antibody(ANA) positivity rate [85.6%(1 310/1 531) vs. 78.6%(221/281), P=0.003], anti-RNP antibody positivity rate [23.1%(342/1 479) vs.14.0%(38/271), P=0.001], anti-SSA antibody positivity rate [28.2%(419/1 487) vs.13.9%(38/274), P<0.001] were higher in female patients. Physician's global assessment(PGA) scores [1.4 (1.0, 2.0) vs. 1.0 (0.3, 1.6), P<0.001] and modified Rodnan Skin Score(mRSS) [18.0 (9.5, 28.0) vs. 14.0 (5.0, 28.0), P=0.003] were higher in males. Conclusion: Even though male SSc patients account for a small proportion, more extensive skin involvement, finger ulcers and higher PGA are manifested in males. Physicians need pay attention to these clinical disparities between different genders in SSc.

Bioaugmentation with syntrophic volatile fatty acids-oxidizing consortia to alleviate the ammonia inhibition in continuously anaerobic digestion of municipal sludge

Ammonia inhibition easily affects the performance of anaerobic digestion (AD) for municipal sludge and the oxidization of volatile fatty acids (VFAs) is the rate-limiting step of this process. Bioaugmentation is considered to be an effective method to alleviate ammonia inhibition of AD, but most study used the hydrogenotrophic methanogens as the bioaugmentation culture. In this study, bioaugmentation of mesophilic AD (MAD) and thermophilic AD (TAD) under ammonia inhibition with syntrophic acetate and propionate oxidizing consortia was investigated. The results showed that the bioaugmented reactors recovered earlier than control reactors with 20 (MAD) and 8 (TAD) days, respectively. The high-throughput 16S rRNA gene sequencing indicated that the relative abundance of carbohydrates fermenter (Lentimicrobium), syntrophic VFAs-oxidizing bacteria (Rikenellaceae_DMER64, Smithella and Syntrophobacter) and acetoclastic and hydrogenotrophic methanogens (Methanosaeta, Methanolinea and Methanospirillum) increased in MAD after bioaugmentation. However, part of the bioaugmentation culture could not adapt to the high free ammonia (FAN) concentration in MAD and the effect was weakened. In TAD, proteolytic bacteria (Keratinibaculum and Tepidimicrobium), syntrophic VFAs-oxidizing bacteria (Syntrophomonas) and hydrogenotrophic methanogen (Methanosarcina) were strengthened. The effect of bioaugmentation in TAD was durable even at higher organic loading rate (OLR), due to its positive influence on microbial community. These results suggested that the different bioaugmentation mechanism occurred in MAD and TAD, which are derived from the synergetic effects of ammonia tolerance and microbial interactions. Our study revealed the VFAs-oxidizing consortia as bioaugmented culture could be the potential strategy to alleviate the ammonia stress of AD.

[Heritability of body mass index based on twin studies: a Meta-analysis]

Objective: To use Meta analysis to understand the prevalence of the heritability of body mass index (BMI) in twins. Methods: All studies on the heritability of the twins' BMI published before December 31, 2020 were retrieved through the China National Knowledge Network, Wanfang, VIP, PubMed and Web of Science databases. The literature quality was evaluated by using Joanna Briggs Institute Critical Appraisal tools. Stata 16.0 was used to perform subgroup analysis on the outcome indicators (heritability, 95%CI) to explore the source of heterogeneity. The local weighted regression method was used to fit the trend of heritability with age. The publication bias test and the sensitivity analysis of included literatures were also performed by using Stata 16.0. Results: A total of 10 articles meeting the inclusion and exclusion criteria were included with 79 twins' independent estimates of heritability for BMI. Meta-analysis showed that the combined value of BMI heritability was 0.69 (95%CI: 0.65-0.71), the combined value of BMI (0.68, 95%CI: 0.65-0.70) in males was lower than that (0.70, 95%CI: 0.68-0.72) in females. The heritability of BMI (0.72, 95%CI: 0.68-0.76) in childhood and adolescence was higher than that (0.68, 95%CI: 0.66-0.70) in adulthood. The gender specific difference in BMI heritability in twins ≤18 years old was even greater, which was lower in males (0.68, 95%CI: 0.61-0.76) than in females (0.75, 95%CI: 0.69-0.81). The heritability increased with age in childhood, reached peak at about 18 years old, and then slowly decreased with age. Conclusions: The heritability of BMI varied with population characteristics, especially age and gender. In view of the high estimated value of BMI heritability in female children and adolescents, more attention should be paid to the start time of health intervention.

[Value of IgA antiphospholipid antibodies in diagnosis of the antiphospholipid syndrome]

Objective: To examine the prevalence of multiple antiphospholipid antibodies (aPL) subtypes in healthy people and antiphospholipid syndrome (APS) patients, and to assess the value of IgA-aPL in the diagnosis of APS. Methods: According to the 2006 Sydney International APS Classification Criteria, a total of 218 APS patients who were admitted to Peking Union Medical College Hospital or West China Hospital of Sichuan University from July to December 2019 were enrolled. Among them, 66 were males, and 152 were females, aged (44.5±15.4) years, including 148 primary APS patients and 70 secondary APS patients. Age-and gender-matched controls were collected at the same period at the ratio of 1∶1 with the APS cases. IgA/IgG/IgM anticardiolipin antibodies (aCL) and anti-β₂ glycoprotein I antibodies (aβ₂GPI) were detected by chemiluminescent immunoassay. The differences of indicators between groups were analyzed, and the receiver operating characteristic (ROC) curve was used to evaluate the diagnostic value of IgA-aPL for APS. Results: The positivity of IgA-aCL and IgA-aβ₂GPI was 20.6% and 15.6% in the APS patients, while in the IgG/IgM-aCL or IgG/IgM-aβ₂GPI negative individuals, the isolated positivity of IgA-aCL and IgA-aβ₂GPI was only 2.3% and 0.9%, respectively. Accordingly, IgA-aCL and IgA-aβ₂GPI isolated positivity could be used to diagnose APS (P=0.216, 1, respectively). The area under the ROC curve (AUC) of IgG/IgM-aCL for APS diagnosis was 0.833, which was significantly better than that of IgG-aCL alone (AUC=0.776, P<0.001); while the AUC of IgA/IgG/IgM-aCL was 0.833, which could not further increase the diagnostic value for APS (P=0.287). As for aβ₂GPI, the diagnostic efficacy of combined IgG/IgM (AUC=0.875) or IgA/IgG/IgM (AUC=0.875) antibodies was not superior to IgG-aβ₂GPI used alone (AUC=0.869, both P>0.05). Besides, patients with IgA-aPL were more likely to have heart valve lesions and thrombocytopenia (both P<0.05). Conclusion: Based on the existing serological markers, such as lupus anticoagulant, IgG/IgM subtype of aCL and aβ₂GPI, testing IgA-aCL and IgA-aβ₂GPI cannot further improve the predictive value of APS. However, IgA-aPL is associated with clinical manifestations of APS, including heart valve lesions and thrombocytopenia.

[Trends of a burden on atherosclerotic cardiovascular disease and its related risk factors in China, 1990 to 2019]

Objective: To quantitatively analyze the effects of population aging and other risk factors on the burden of atherosclerosis cardiovascular disease (ASCVD) in China from 1990 to 2019. Methods: Disability adjusted life years (DALY) and age-standardized rates obtained from the Global Burden of Disease Study 2019 (GBD2019) were used to describe the temporal trend of a burden on ASCVD. And a decomposition method established by Gupta was applied to quantify the burden related to population growth, aging, age-specific prevalence, and the severity of the disease. Results: In 2019, 61.00% of the burden of cardiovascular disease in China was caused by ASCVD. The DALY of ischemic heart disease increased by 133.66% compared with that in 1990, with 29.57% of the increase attributed to population growth, 108.74% due to population aging, and 8.87% due to the rise of age-specific prevalence and -13.53% benefited from changes in disease severity. The DALY of ischemic stroke increased by 138.64% compared with 1990, and the proportions attributable to the above four parts were 30.95%, 123.38%, 55.80%, and -71.49%, respectively. Hypertension remained the leading risk factor for ASCVD in 2019, followed by high LDL cholesterol. The age-standardized DALY rate attributable to drinking had the most significant increase (486.01%) from 1990, with an average annual growth of 10.93%. Conclusions: Aging population seems responsible for the main reason for the considerable increase in the burden of ASCVD in China. Still, the adverse trends of other avoidable risk factors, especially metabolic risk factors, can not be ignored.

[Clinical characteristics and pregnancy outcomes of non-criteria obstetric antiphospholipid syndrome]

Objective: To study clinical characteristics and pregnancy outcomes under anti-coagulation therapy of non-criteria obstetric antiphospholipid syndrome. Methods: Patients suspected of obstetric antiphospholipid syndrome(OAPS) were recruited through Chinese Rheumatism Data Center from 2015 to 2019 consecutively. Patients fulfilling 2006 Sydney revised antiphospholipid syndrome criteria were classified as OAPS. Patients fulfilling definition of non-criteria OAPS(NCOAPS) by expert consensus on diagnosis and management of obstetric antiphospholipid syndrome of China were classified as NCOAPS. Clinical characteristics and laboratory results of two groups were compared. Live birth rates and pregnancy outcomes under anti-coagulation therapy were studied. Results: A total of 88 patients were enrolled, including 56 patients (63.6%) as OAPS, 32(36.4%) as NCOAPS. Live births were only reached in 16.1% (9/56) in OAPS patients and 12.5%(4/32) in NCOAPS. Fetal losses after 10 weeks of gestation and pre-eclampsia before 34 weeks were more common in OAPS group compared to NCOAPS group [78.6%(44/56) vs. 18.8%(6/32), P<0.001; 25.0%(14/56) vs. 3.1%(1/32), P=0.020, respectively]. After enrollment, 15 pregnancies were recorded in OAPS, 10 in NCOAPS, all of whom were treated with low-dose aspirin (LDA) combined with low-molecular weight heparin (LMWH). Live birth rates saw dramatic improvements compared to baseline levels in OAPS [16.1% (9/56) vs. 11/15] along with NCOAPS [12.5% (4/32) vs. 7/10]. Conclusion: Though NCOAPS and OAPS patients differ in antiphospholipid antibody spectrum and pattern of pregnancy morbidities, both groups benefit from LDA combined with LWMH treatment, as live birth rates improve. Non-criteria OAPS patients are recommended to receive anti-coagulation therapy during pregnancy.

Network Pharmacology-Based Approach to Investigate the Molecular Targets of Sinomenine for Treating Breast Cancer

Purpose

Sinomenine has been known to inhibit the proliferation of breast cancer cells. However, its targets have not been found yet. This study aimed to search for molecular targets of sinomenine for treating breast cancer via network pharmacology.

Methods

Potential targets of sinomenine or breast cancer were separately screened from indicated databases. The common targets of both sinomenine and breast cancer were considered as the targets of sinomenine for treating breast cancer. A sinomenine-target-pathway network was constructed based on the obtained results from Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis. The putative targets of sinomenine were further determined by using protein–protein interaction (PPI) analysis and molecular docking. Finally, the putative targets were verified in vitro and in vivo.

Results

Twenty predicted targets were identified through network pharmacological analysis. Gene Ontology (GO) and KEGG pathway enrichment indicated that these predicted targets enriched in the process of MAP kinase activity, VEGF signaling pathway, Relaxin signaling pathway, Growth hormone synthesis, secretion and action. MAPK1, NOS3, NR3C1, NOS1 and NOS2 were further identified as the putative targets by using PPI and molecular docking analysis. Expression of MAPK1, NR3C1, NOS1, NOS2 and NOS3 genes were significantly regulated by sinomenine in both MCF-7 cells and MDA-MB-231 cells. Furthermore, the expression of NR3C1 in human breast cancer specimens was lower than that in para-tumor normal tissues. Meanwhile, the expression of NR3C1 in xenograft tumors was up-regulated after sinomenine treatment.

Conclusion

MAPK1, NR3C1, NOS1, NOS2 and NOS3 were identified as the putative targets of sinomenine for treating breast cancer. NR3C1 was preliminarily confirmed as a target of sinomenine in two breast cancer cell lines, xenograft tumor models and human breast cancer specimens. These data indicated that the network pharmacology-based prediction of sinomenine targets for treating breast cancer could be reliable.

A combined approach using slightly acidic electrolyzed water and UV exposure to improve egg internal quality during storage

This study investigated the combined efficacy of slightly acidic electrolyzed water (SAEW) and UV light (UV) in improving egg internal quality (weight loss, Haugh unit, yolk index, albumen pH) over a 6-wk storage time at 25°C. Eggs were preserved after immersion for 4 min in SAEW (30 mg/L), irradiation for 4 min under a UV lamp, or a combination of SAEW and UV treatment for 4 min. The combination of SAEW and UV inhibited the deterioration of yolk index over the storage period, as well as reducing the extent of decrease in Haugh unit and of weight loss during storage at 25°C, and it was more effective than SAEW or UV alone in maintaining egg internal quality (P < 0.05). The results highlight the promising use of a SAEW and UV combination treatment to improve egg internal quality during storage.

[Clinical characteristics and radiofrequency ablation of focal atrial tachycardia in 125 children]

Objective: To investigate the clinical characteristics of focal atrial tachycardia (FAT) and the efficacy of radiofrequency catheter ablation (RFCA) in pediatric FAT. Methods: A total of 125 children with FAT who were treated with RFCA in the First Hospital of Tsinghua University from January 2010 to July 2018 were involved in the study. The clinical characteristics, origin of FAT, success rate of RFCA and recurrence rate and complications post RFCA were retrospectively analyzed, and the efficacy and X-ray radiation were compared between two-dimensional (2D) and 3D mapping system by t test or Chi-square analysis. Results: Among the 125 children, 57 were males and 68 females, age of (7.6±3.5) years old and body weight of (27.7±13.3) kg; and 62 (49.6%) had paroxysmal FAT, and 63 (50.4%) incessant FAT. Twenty-seven patients (21.6%) presented with tachycardia-induced cardiomyopathy (TIC), and 22 of whom (81.5%) were secondary to the incessant FATs. Most of the FATs originated from atrial auricle (46/125, 36.8%). Ablation was successful in 111 children (88.8%), and the recurrence rate was 25.2% (28/111). No complications were identified in the whole group. The efficacy and safety of 3D mapping system (87 cases) was better than that of the 2D mapping system (38 cases), according to the lower recurrence rate ((19.0% (15/79) vs. 40.6% (13/32), χ² = 3.849, P=0.049), shorter X-ray exposure time ((4.9±2.3) vs. (12.5±5.7) min, t=7.942, P<0.01) and lower radiation doses ((5.3±3.3) vs. (10.9±3.7) mGy, t=8.038, P<0.01). Conclusions: FAT in children is mainly originated from atrial auricle, and incessant FAT is prone to progress to tachycardia-induced cardiomyopathy. RFCA is safe and effective for drug-resistant or drug-intolerant FAT in children, and 3D mapping system should be preferred.

Characteristics of Chinese patients with primary Sjögren's syndrome: preliminary report of a multi-centre registration study

BACKGROUND

We established a multi-centre online registry for primary Sjögren's syndrome (pSS) in China, and compared Chinese patients with those from other countries.

METHODS

Data were from 87 rheumatology centres in 27 provinces. All 2986 patients had pSS according to the 2002 American-European Consensus Group or the 2016 American College of Rheumatology/European League Against Rheumatism. All centres used the same methods. Data on demographics, clinical parameters, laboratory results, disease activity and treatments were examined.

RESULTS

The female:male ratio was 22.9:1, and the mean age at onset was 46.31 years. A total of 332 (11.1%) patients had thyroid disease, including hyperthyroidism (1.2%), hypothyroidism (6.0%) and subacute thyroiditis (3.9%). Dry eye had a prevalence of 68.59% in Chinese patients, 93.7-96% in European patients and 97.3% in American patients. Dry mouth had a prevalence of 86.5% in Chinese patients, 93.2-96% in European patients and 97.9% in American patients. Fewer Chinese than European patients had arthritis (6.9% vs. 15-19.3%). ANA positivity was 90.7% in Chinese, 81.3% in European and 77.6% in American patients. Anti-SSA antibody positivity was 84.6% in Chinese, 71% in European and 68.2% in American patients. The most commonly used drugs in Chinese patients were hydroxychloroquine (n = 1818; 67.5%), glucocorticoids (n = 1720; 63.9%) and total glucosides of paeony (n = 1120; 41.7%).

CONCLUSIONS

This study provided information on the phenotypes of Chinese patients with pSS, and identified several differences with patients from other geographical regions.

[Clinical and prognostic analysis of accessory pathway-induced dilated cardiomyopathy after catheter ablation in children]

Objective: To investigate the clinical characteristics and prognostic factors after catheter ablation of accessory pathway (AP)-induced dilated cardiomyopathy (DCM) in children. Methods: Data were collected and analyzed on 147 consecutive pediatric patients (81males and 66 females), who hospitalized in our pediatric heart center between January 2009 and August 2018 and received catheter ablation for ventricular pre-excitation (right AP). Thirty-one children were diagnosed as AP-induced DCM and 116 children with normal cardiac function served as control. Data including clinical characteristics, electrocardiogram (ECG), echocardiography, electrophysiological examination (EPS), successful ablation and follow up were analyzed. Results: The median age at first examination was 3.07 (0.09, 5.83) years. The pre-hospital misdiagnosis rate was 87.1% (27/31). The incidence of the AP-induced DCM was 21.1% (31/147) and the rate of right anterior free wall accessory pathway (AP) was the highest (50.0%, 10/20). AP-induced DCM was more common in right free wall Aps (41.9%, 13/31) and right anterior free wall (32.3%, 10/31). 48.4% (15/31) cases had no supraventricular tachycardia (SVT). EPS showed that 29% (9/31) of the AP did not have retrograde conduction. The median follow-up time after successful catheter ablation was 8 (2, 36) months of AP-induced DCM group, LVDd was significantly decreased ((41.6±12.8)mm vs. (45.6±13.9)mm, P<0.01) and LVEF ((56.2±11.8)% vs. (40.8±12.5)%, P<0.01) was significantly increased after ablation. Cox regression analysis showed that LVEF was the predictor of the duration of cardiac function recovery (HR=1.08, 95%CI 1.01-1.15, P=0.03). Conclusions: Misdiagnosis rate is high for children with AP-induced DCM, leading to the delayed treatment. All of the AP-induced DCM occurred in right APs and right anterior free wall APs is the highest. Right free wall APs and right anterior free wall are most common in AP-induced DCM. Catheter ablation is a safe and effective treatment option for these patients. The lower the LVEF, the longer the cardiac function recovery.

[The neurological manifestations in 52 patients with primary Sjögren's syndrome]

Objective: To summarize the neurological manifestations in patients with primary Sjögren's syndrome (pSS). Methods: A total of 68 patients were diagnosed as pSS in neurology department of Peking Union Medical College Hospital from March 2014 to February 2018, among whom sixteen cases were excluded due to modified final diagnoses of primary neurological diseases. Therefore 52 pSS patients with neurological involvement were enrolled and retrospectively analyzed. They were divided into two groups as extensive group in which both central and peripheral nervous system were involved, non-extensive group in which either central or peripheral nervous system was involved. Results: Neurological manifestations were presented as primary symptoms in 98.1%(51/52) patients, while 35 had neurological involvement as their only extraglandular manifestations. Thirteen cases were in extensive group. The other 39 in non-extensive group including 22 cases with only peripheral nervous system involved and 17 cases with only single central nervous system involved. Compared to non-extensive group, the proportion of woman patients [13/13 vs.71.8% (28/39), P=0.047], serum IgG level [17.73(11.11,22.41)g/L vs. 11.49(9.58,13.40)g/L, P=0.017] and positive rates of oligoclonal band (OB) in cerebral spinal fluid (CSF) [7/13 vs. 22.6%(7/31), P=0.042)] were significantly higher in extensive involvement group. Conclusions: Neurological manifestations in pSS patients could be extensive, both central and peripheral nervous system might be associated. Female patients, high serum IgG level and positive OB in CSF are risk factors of extensive neurological involvement, suggesting that the immune system may be generally over-stimulated.

[Clinical characteristics and treatment of congenital long QT syndrome in 58 children]

Objective: To assess the clinical characteristics, pathogenic genes and therapeutic effects of congenital long QT syndrome (LQTS) in children. Methods: A retrospective analysis included 58 LQTS children (37 boys, 21 girls; age of diagnosis (8.0±4.1) years, range 0.1 to 16.0 years) at Division of Pediatric Cardiology, First Hospital of Tsinghua University from August 2013 to November 2017. Each patient was evaluated with a detailed medical history, 12-lead resting electrocardiogram, Doppler echocardiography, and molecular genetic analysis. Results: Forty-eight of the children (83%) had a delay to diagnosis (0.7 (0.1, 2.0)years) and initially received a misdiagnosis. QT prolongation of unknown origin was found in 10 cases (17%), complex arrhythmic conditions in 27 cases (47%), myocarditis in 3 cases (5%), syncope of unknown origin in 3 cases (5%), epilepsy in 2 cases (3%), myocardial infarction in 1 case (2%), cardiomyopathy in 1 case (2%), and vasovagal syncope in 1 case (2%). Nine children presented with the positive family history of LQTS and three children had congenital nervous deafness. Twenty-one (36%) children presented with recurrent syncope, and 14 cases of whom had symptoms during physical activity and/or emotional stress. The common arrhythmias were ventricular arrhythmia (26 cases), sinus node dysfunction (18 cases), atrioventricular block (AVB) (12 cases), and atrial arrhythmia (6 cases). LQTS-associated pathologic or possibly pathologic mutations were found in 41 children (71%). Thirty-three children (57%) were treated with propranolol (22 cases), permanent pacemaker (PM) combined with propranolol (5 cases), PM (4 cases), and implantable cardioverter defibrillator (ICD) combined with propranolol (2 cases). Eighteen children (55%) were asymptomatic, thirteen children (39%) reported infrequent syncope, and one case (2%) died. Conclusions: LQTS in children is potentially malignant and present as phenotypic diversity and complex arrhythmias. LQTS-related pathogenic or possibly pathogenic mutations are identified in most of the children. Beta-blockers therapy is effective in reducing the risk of malignant cardiac events. Some children with LQTS should receive PM or ICD therapy.

[Marrow megakaryocyte count as a response predictor of severe thrombocytopenia in patients with primary Sjögren syndrome]

Objective: To explore the predictive factors for determining the therapeutic response and prognosis of severe thrombocytopenia (TP) in patients with primary Sjögren syndrome(pSS). Method: Patients with pSS and severe TP (platelet count ≤ 50×10(9)/L) admitted between 2010 to 2016 at Peking Union Medical College Hospital were classified according to their therapeutic response and analyzed retrospectively. The response parameters and clinical data including bone marrow aspiration results and laboratory findings were collected. Result: Thirty patients were finally analyzed, including twenty with appreciable bone marrow aspiration results. Fourteen and 7 patients achieved a complete response (CR) and a partial response (PR) respectively, other 9 patients with no response (NR). The megakaryocyte counts in bone marrow (BM-MK) counts per slide in each group were 13.0 (9.2,23.5) in CR patients, 7.0 (7.0,20.0) in PR patients, and 5.0 (1.0,6.0) in NR patients. BM-MK counts in patients with clinical response (CR+PR) were significantly higher than those with NR (P=0.006). A receiver-operation characteristic analysis revealed a cutoff value of BM-MK counts at 6.5 per slide stratifying patients by different responses with a sensitivity of 13/14, a specificity of 6/7, and area under the curve of 0.879. Univariate analysis indicated a better prognosis as BM-MK counts>6.5 per slide. Conclusion: BM-MK count could be a predictive factor of response in patients with pSS and severe TP. Patients with BM-MK counts≤6.5 per slide represent worse platelet improvement..

[The clinical characteristics of antiphospholipid syndrome associated with chronic thromboembolic pulmonary hypertension]

Objective: To analyze the clinical characteristics of antiphospholipid syndrome (APS) patients with chronic thromboembolic pulmonary hypertension (CTEPH). Methods: A total of 22 APS patients with CTEPH were enrolled in our study, who were admitted in Peking Union Medical College Hospital from January 2012 to August 2018. Diagnoses were confirmed by computed tomographic pulmonary angiography (CTPA), or pulmonary angiography. Demographic characteristics, clinical manifestations, laboratory tests, therapy, World Health Organization (WHO) functional class were retrospectively collected. Results: There were 15 females and 7 males with a median age of 29-year-old. Chest pain (6 cases), dyspnea on exertion (22 cases), cough (6 cases) and hemoptysis (9 cases) were the most common clinical manifestations. Lupus anticoagulant (LA), anticardiolipin (ACL) antibodies and anti-beta 2 glycoprotein Ⅰ (anti-β(2) GPⅠ) antibodies were all positive in 12 patients, two of three antibodies positive in 5 patients, only one positive in 5 patients. The WHO functional classes were Ⅱ-Ⅳ before treatment. Anticoagulants were administrated in all patients. After multidisciplinary evaluation, 9 patients underwent pulmonary thromboendarterectomy (PTE), who all had a good outcome. Symptoms in eleven over thirteen patients with only anticoagulants improved. Three patients developed cardiac deterioration while other 3 patients died of right heart failure during follow-up. Conclusion: Pulmonary embolism is one of the most common thrombotic events in APS patients. It is important to recognize symptoms and signs related to pulmonary embolism and start anticoagulation as soon as possible. Standard anticoagulation improves symptoms but can't reverse the process of pulmonary hypertension. Some patients may benefit from PTE after anticoagulation and multidisciplinary evaluation.

[The 466th case:myasthenia,fever,blurred vision and pancytopenia]

A 45-year-old woman was admitted to the Department of Rheumatology and Immunology, Peking Union Medical College Hospital, due to weakness of the upper limbs, fever, and blurred vision. She was clinically diagnosed as systemic lupus erythematosus overlapped primary biliary cirrhosis, with renal, retinal, hematological and musculoskeletal involvement, combined with severe pulmonary infection and respiratory failure. Treated with glucocorticoids, ursodeoxycholic acid, antibiotics and respiratory support, the patient got better. A couple of days later, her fever recurred and platelets count dropped to 30×10(9)/L, hemoglobin to 78 g/L, fibrinogen to<1.5 g/L, ferritin to 1 640 ng/ml, natural killer (NK) cell count to 8/μl, the activity of NK cells 2% (reference value 9.5%-23.5%), considering the occurrence of hemophagocytic lymphohistiocytosis (HLH). Cytomegalovirus pp65 antigenemia test: 13 positive cells/2×10(5) WBC. Considered the possibility of HLH caused by cytomegalovirus infection and treated by 250 mg ganciclovir intravenous drip twice a day for a full course. The temperature of the patient was gradually reduced to 36.5 ℃, the count of platelets were increased to 229 ×10(9)/L, the hemoglobin was increased to 94 g/L, and the fibrinogen was increased to 3.26 g/L. When there were unexplained critical signs of the primary disease during systemic lupus erythematosus treatment, severe complications such as infection, HLH, thrombotic thrombocytopenic purpura should be taken into account.

[3D electronic anatomy mapping guided radiofrequency catheter ablation in 95 children with atrioventricular nodal reentrant tachycardia]

Objective: To investigate the clinical features and evaluate the efficacy of radiofrequency catheter ablation (RFCA) guided by 3D electronic-anatomy mapping system (CARTO3 System) in children with atrioventricular nodal reentrant tachycardia (AVNRT). Methods: This was a retrospective case-controlled study. Data were collected from 95 children with AVNRT who underwent RFCA using CARTO3 System in the first hospital of Tsinghua University from January 2014 to December 2017. The onset age, characteristic of electrophysiology and anatomy feature of Koch triangle were analyzed. The efficacy and safety of ablation and X-ray fluoroscopy were compared with control 135 children with AVNRT who underwent RFCA without using CARTO3 System. The t test or the chi-square test was used for group comparison. Linear regression equation was established for correlation analysis. Results: The onset age of the 95 children (male 55, female 40; the average age (8.0±3.6) years) with AVNRT was (0.2-17.0) years and 23(24.2%) children were less than 3 years old. Electrophysiologic study showed that 84.2% (80 cases) was AVNRT-slow fast (SF), 11.6% (11 cases) AVNRT-slowslow and 4.2%(4 cases) AVNRT-fast slow. The phenomena of atrio-Hisian(AH) jump occurred in 65.3% and the interval of AH jump was (73.0±10.6) ms. The height of Koch triangle (CSo-His) was (22.3±5.8) mm and related with the weight of children (Y=0.171X+ 16.660, r(2)=0.224, P<0.001).The distance between the successful ablation target and the lowest point of His zone (ABL-His) was (11.7±2.6) mm. And there was no relation with the body weight(Y=-0.005X + 11.650, r(2)=0.001, P=0.780) and CSo-His (Y=0.072X+9.914, r(2)=0.030, P=0.171). The acute success rate was 97.9% (93/95) and recurrent rate was 5.4% (5/93) during follow-up. No obvious complication was reported. Compared with control group, the fluoroscopy time ((3.3±2.5) vs. (10.7±5.8) min, t=13.190, P<0.05), radiation dose ((5.4±4.9) vs. (15.5±6.3) mGy, t=13.660, P<0.05), and dose area product (514±445) vs. (2 478±415) mGy·cm(2), t=33.850, P<0.05) were decreased significantly. Conclusions: AVNRT-SF was the most common type of AVNRT. AVNRT incidence in infant and toddlers is lower than that in elder children. CSo-His is correlated with the body weight. ABL-His is relatively fixed. There is no correlation between ABL-His and the body weight and also no correlation between ABL-His and CSo-His. RFCA of AVNRT in children using the CARTO3 system is safe, effective and minimizes X-ray fluoroscopy.

Evidence for weak collective pinning and δl pinning in topological superconductor Cu x Bi2Se3

We investigated the vortex pinning behavior in the single crystal topological superconductor Cu_0.10Bi₂Se₃ with a pronounced anisotropic peak effect. A weak collective pinning regime is clarified from the power-law behavior in [Formula: see text] and the small critical current density ratio of [Formula: see text] ~ 10^-5 ([Formula: see text] is the critical current density, [Formula: see text] is the depairing current density). The spatial variation of the charge-carrier mean free path induced pinning is evidenced and probably results from the well-defined atomic defects. Within the framework of collective pinning theory, we computed the values of the correlated length and volume at 1.8 K, which start declining prior to the onset field of the peak effect [Formula: see text], demonstrating the vortex lattices already suffered a preferential collapse ahead of the peak effect turns up. Thus, the peak effect can be understood by elastic moduli softening near the upper critical field [Formula: see text]. We suggest Cu _x Bi₂Se₃ is a prototype topological material for investigating the vortex pinning dynamics associated with the peak effect phenomenon.

Magnetotransport study of topological superconductor Cu0.10Bi2Se3 single crystal

We report a magnetotransport study of vortex-pinning in Cu_0.10Bi₂Se₃ single crystal. The sample is demonstrated to be in clean limit and absent of Pauli spin-limiting effect. Interestingly, the resistivity versus magnetic field shows an anomalously pronounced increase when approaching the superconducting-normal state boundary for both [Formula: see text] and [Formula: see text] configurations. We have investigated the flux-flowing behavior under various magnetic fields and temperatures, enabling us to establish its anisotropic vortex phase diagram. Our results suggest the Cu_0.10Bi₂Se₃ can be served as one unique material for exploring exotic surface vortex states in topological superconductors.

[Clinical challenges in the management of catecholaminergic polymorphic ventricular tachycardia in children]

Objective: Catecholaminergic polymorphic ventricular tachycardia (CPVT) accounts for up to 10%-15% sudden cardiac death (SCD) in the children and young population. This study aimed to assess the current situation and challenges in CPVT clinical diagnosis. Method: A retrospective review included 11 children (7 male patients) at the First Hospital of Tsinghua University clinically diagnosed with CPVT from June 2014 to July 2017. Each patient was evaluated with detailed history, physical examination, resting 12-lead electrocardiogram(ECG), 24-h Holter, exercise stress test, Doppler echocardiography and genetic test. Result: During physical activity and/or emotional stress, ten children presented with recurrent syncope and one child presented with palpitation and chest distress. The mean age of symptom onset was 8.4 (4.0-13.7) years with a delayed diagnosis of 2.4 (0.04-5.00) years. Two children had a familial history of syncope or sudden death. Nine children were initially misdiagnosed as complex arrhythmic conditions (n=4), syncope of unknown origin (n=3), and drug-resistant epilepsy (n=2) treated with antiepileptic medication for several years. Bidirectional VT and (or) polymorphic VT were detected using Holter recording or exercise test ECG in all patients. Genetic test revealed CPVT-associated pathologic or possible pathologic mutations in nine patients. All patients were treated with beta-blockers. Six patients were asymptomatic, four patients reported infrequent syncope, and one sudden death occurred during a mean follow-up of 0.97 years. Conclusion: CPVT mainly occurs in children and adolescents with recurrent syncope during physical activities and/or emotional stress. Early diagnosis of CPVT remains challenging due to delayed diagnosis or misdiagnosis. Detailed clinical history and exercise stress test improve the early diagnosis and intervention for CPVT patients.

[The 460th case: lower extremity edema, positive fecal occult blood]

An 61-year-old woman presenting deep vein thrombosis and persistent positive anticardiolipin antibodies was diagnosed as antiphospholipid syndrome and treated with low molecular weight heparin. Before and after anticoagulant therapy, continuous positive fecal occult-blood was found asymptomatically. Colonoscopy confirmed rectal cancer. Antiphospholipid autoantibodies are non-specially positive in some malignances, especially in elder onset patients. Thus, routine screening of malignancies is strongly suggested.

[Multicenter investigation of the correlation between supraventricular tachycardia and tachycardia-induced cardiomyopathy in children]

Objective: This study aimed to investigate the correlation between supraventricular tachycardia (SVT) and tachycardia-induced cardiomyopathy(TIC) in children and assess the risk factors for the development of TIC. Method: One hundred and eighty-three patients were recruited in four hospitals of Beijing diagnosed as SVT were divided into two groups depending on whether or not complicated with TIC. The age, gender, tachycardia type, ventricular rate during tachycardia, frequency of tachycardia episodes and duration of tachycardia were compared between the two groups and risk factors associated with TIC were analyzed. Statistical analyses were performed using t test, Mann-Whitney U and χ(2) test. Result: Totally 183 patients were included in this study (paroxysmal supraventricular tachycardia, PSVT, n=149; atrial tachycardia, AT, n=34). The incidence of TIC was 13.1%. There was significant difference regarding the incidence of TIC between children with AT and children with PSVT (26.5% vs. 10.1%, χ(2)=6.537, P=0.011). The percentage of AT in patients with TIC was significantly higher than patients without TIC (37.5% vs. 15.7%, χ(2)=6.537, P=0.011). Patients with TIC had a higher frequency of tachycardia episodes(2.5(1.0-4.8) beats/year vs 4.0(1.0-10.0) beats/year, Z=-2.223, P=0.026)and longer duration of tachycardia(11.0(1.1-36.0) h vs 2.5(1.0-12.0) h, Z=-2.154, P=0.031)compared with patients without TIC. Multivariate predictors of TIC was longer duration of tachycardia (OR=2.041, P=0.028). Conclusion: TIC occurs in 13.1% of children with SVT. The incidence of TIC in children with AT is higher than in children with PSVT. Risk factor for the development of TIC is longer duration of tachycardia.

[A clinical analysis on fever of unknown origin in in-patients with systemic lupus erythematosus]

To investigate the etiology and differential diagnoses of patients with systemic lupus erythematosus (SLE) and fever of unknown origin (FUO). From January 2012 to December 2014, a total of 928 SLE patients were admitted to Peking Union Medical College Hospital.Only 50 patients were combined with FUO (5.4%). The most common reason of fever was caused by infections(33 cases, 66.0%), including bacterial infection in 17 cases with 5 tuberculosis, viral infection in 11 cases, and fungal infection in 5 cases.The second reason offever was due to poor disease control or recurrence in 17 patients (34.0%). No fever was caused by malignant tumor.When clinical data was compared between 17 non-infected patients versus 33 infected patients, C reactive protein and procalcitonin in the infected group were significantly higher than those in the non-infected group.In SLE patients combined with FUO, infection is the most common etiology which is necessary to be paid attention to.

Retinal vasculopathy in patients with systemic lupus erythematosus

A retrospective case control study was conducted in the Peking Union Medical College Hospital. Medical records were reviewed for demographic data, clinical features, laboratory results, systemic lupus erythematosus (SLE) disease activity evaluations, and ophthalmic examinations to investigate the clinical characteristics and significance of retinal vasculopathy (RV) in Chinese patients with systemic lupus erythematosus. The prevalence of RV was approximately 0.66% (35/5298) in SLE patients. A total of 60 eyes were involved. The ocular presentations included decrease of visual acuity (48/60, 80%), visual field loss (7/60, 11.7%), and diplopia (3/60, 5%). Ophthalmic fundoscopic examination revealed cotton-wool spots (30/60, 50%), retinal vascular attenuation (31/60, 51.6%), and hemorrhages (41/60, 68.3%). Retinal angiogram showed that 72.7% (16/22) eyes had vaso-occlusion. The ophthalmic episodes could occur at any stage of SLE duration, with a median of 12 months (0-168 months) following SLE onset. Twenty-one (35%) eyes did not recover, or even worsened, during hospital stay. RV was found to be significantly associated with neuropsychiatric lesions (51.4% vs. 21.3%, p = .005) and hematological disturbance (62.9% vs. 34.3%, p = .005). SLE patients with RV had significantly higher SLE disease activity index scores than controls (19.9 ± 0.9 vs. 10.2 ± 0.7, p < .001). An inverse association of anti-SSA antibody with RV was detected (34.3% vs. 67.1%, p = .001). Nervous system disturbance (odds ratio (OR) = 4.340, 95% confidence interval (CI) 1.438, 13.094, p = .009) and leukocytopenia (OR = 6.385, 95% CI 1.916, 21.278, p = .003) were independent risk factors, while anti-SSA antibody positivity (OR = 0.249, 95% CI 0.087, 0.710, p = .009) was a protective factor for RV in SLE patients. In certain cases, RV is a threatening condition for SLE patients presenting with clinical ocular manifestations. Ophthalmo-fundoscopic detection is recommended as soon as SLE is diagnosed.

[The clinical manifestations and thrombotic risk factors in primary antiphospholipid syndrome]

OBJECTIVE

To investigate the clinical characteristics in patients with primary antiphospholipid syndrome (PAPS) and to identify potential predictors of thrombotic events.

METHODS

A total of 107 patients with PAPS were enrolled in our study, who were admitted in Peking Union Medical College Hospital from January 2004 to December 2014. Demographic data, age at onset, disease duration, past history of hypertension and regular cigarette smoking, clinical manifestations, imaging characteristics, management and prognosis were retrospectively collected. Bivariate statistical analysis and logistical regression test were performed to compare the discrepancy between patients with or without thromboembolic events.

RESULTS

In 107 patients, there were 65 female and 42 male patients, with mean age (39.8±15.8) years old, median disease duration 10.5 (2.0, 48.0) months. A total of 72(67.3%) patients reported episodes of thromboembolic events, including 72 venous thromboses and 29 arterial thromboses. The most frequent venous thromboses were deep vein thromboses (35.5%), pulmonary embolism the second common (29.9%), with cranial venous sinus thromboses the following (8.4%). In arterial thromboembolic events, the incidence of transient ischemic attack (TIA) and ischemic stoke was the highest(14.0%), embolism of lower extremities the second (6.5%), and 4 patients (3.7%) with acute myocardial infarction. Sixty seven patients(62.6%)had positive lupus anticoagulant, 60 patients(56.1%)with positive anticardiolipin antibody, 32 patients(29.9%, 32/74) with positive β2 glycoprotein Ⅰ(β2GPⅠ). Forty patients(37.4%)had double positive antibodies, while 19 cases(17.8%)with triple positive. In logistical regression, aging (per 10 years) and hypocomplementemia were significantly related to venous thrombosis (OR=1.421, 95%CI 1.066-1.894, P<0.05, and OR=6.435, 95%CI 1.374-30.130, P<0.05, respectively). Cigarette smoking and triple positive antibodies were independent risk factors of arterial thrombosis (OR=3.996, 95%CI 1.079-14.795, P<0.05 and OR=3.166, 95%CI 1.102-9.097, P<0.05, respectively).

CONCLUSION

APS is an autoimmune disorder characterized by recurrent arterial and venous thromboembolic events. Venous thromboembolism is more common than the arterial. Age and hypocomplementemia are predictors of venous thromboembolism; while smoking and triple positive antibodies are independent risk factors of arterial thromboembolism.