[Analyses of the risk factors for the progression of primary antiphospholipid syndrome to systemic lupus erythematosus]

Objectives: Analyze the clinical characteristics of patients with primary antiphospholipid syndrome (PAPS) progressing to systemic lupus erythematosus (SLE).Explore the risk factors for the progression from PAPS to SLE. Methods: The clinical data of 262 patients with PAPS enrolled in Peking Union Medical College Hospital from February 2005 to September 2021 were evaluated. Assessments included demographic data, clinical manifestations, laboratory tests (serum levels of complement, anti-nuclear antibodies, anti-double-stranded DNA antibodies), treatment, and outcomes. Kaplan-Meier analysis was used to calculate the prevalence of SLE in patients with PAPS. Univariate Cox regression analysis was employed to identify the risk factors for PAPS progressing to SLE. Results: Among 262 patients with PAPS, 249 had PAPS (PAPS group) and 13 progressed to SLE (5.0%) (PAPS-SLE group). Univariate Cox regression analysis indicated that cardiac valve disease (HR=6.360), positive anti-double-stranded DNA antibodies (HR=7.203), low level of complement C3 (HR=25.715), and low level of complement C4 (HR=10.466) were risk factors for the progression of PAPS to SLE, whereas arterial thrombotic events (HR=0.109) were protective factors (P<0.05 for all). Kaplan-Meier analysis showed that the prevalence of SLE in patients suffering from PAPS with a disease course>10 years was 9%-15%. Hydroxychloroquine treatment had no effect on the occurrence of SLE in patients with PAPS (HR=0.753, 95%CI 0.231-2.450, P=0.638). Patients with≥2 risk factors had a significantly higher prevalence of SLE compared with those with no or one risk factor (13-year cumulative prevalence of SLE 48.7% vs. 0 vs. 6.2%, P<0.001 for both). Conclusions: PAPS may progress to SLE in some patients. Early onset, cardiac-valve disease, positive anti-dsDNA antibody, and low levels of complement are risk factors for the progression of PAPS to SLE (especially in patients with≥2 risk factors). Whether application of hydroxychloroquine can delay this transition has yet to be demonstrated.

[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.

[Recommendations for diagnosis and treatment of systemic lupus erythematosus]

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease with complicated pathogenesis and diverse clinical manifestations. The current recommendations of the Chinese Rheumatology Association are based on a comprehensive investigation of evidence based medicine, domestic and international guidelines for SLE, and experts' proposals, and aim to provide a more scientific and authoritative reference for the diagnosis and management of SLE. The recommendations focus on four aspects; clinical manifestations, laboratory evaluation, diagnosis and disease assessment, and disease treatment and monitoring. The goal of the recommendations is to standardize the diagnosis and treatment of SLE in China so as to improve the prognosis of SLE patients.

[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.

[Analysis of differentially expressed microRNA and protein expression profiles carried by exosomes in the plasma of patients with Takayasu's arteritis]

Objective: To detect the microRNAs (miRNAs) and proteins carried by exosomes in the plasma of patients with newly diagnosed Takayasu's arteritis (TAK) and analyze their possible roles in the pathogenesis of TAK. Methods: Ten patients with newly diagnosed TAK from the Department of Rheumatology and Immunology, Peking Union Medical College Hospital were selected during June-November 2020. Five healthy controls were matched with five patients by age and sex. RNA sequencing and protein mass spectrometry were used to detect miRNAs and proteins, respectively, carried by exosomes in the plasma. Differentially expressed miRNAs (DE-miRNAs) and proteins (DEPs) were screened. Thereafter, hierarchical cluster analysis, function, signal pathway, and protein domain enrichment analysis of DE-miRNAs and DEPs were performed. Finally, miRNAs and proteins related to vasculitis and autoimmunity were identified. The possible roles of the miRNAs and proteins in the pathogenesis of TAK were explored. Enumeration data were compared using Fisher's exact probability test or Chi-square test, and a P-value<0.05 was considered significant. Results: Compared with the healthy controls, patients with TAK had 29 DE-miRNAs on their plasma exosomes. Among these DE-miRNAs, miR-101-3p, miR-122-5p, miR-143-3p, miR-185-3p, miR-192-5p, miR-194-5p, miR-19a-3p, miR-19b-3p, miR-20b-5p, miR-21-5p, miR-22-3p, miR-335-5p, miR-34a-5p, miR-3613-5p, miR-548ad-5p, miR-590-3p, and miR-7-5p were upregulated; whereas miR-1249-3p, miR-141-3p, miR-199a-5p, miR-199b-5p, miR-200a-3p, miR-200c-3p, miR-204-5p, miR-29c-5p, miR-335-3p, miR-381-3p, miR-4433b-5p, and miR-584-5p were downregulated. Finally, miR-34a-5p, miR-200c-3p, miR-143-3p, miR-22-3p, and miR-21-5p were identified. Among the 357 DEPs screened, 236 DEPs were upregulated, whereas 121 DEPs were downregulated. Finally, kallikrein B1 (KLKB1), kininogen 1 (KNG1), desmoplakin (DSP) were identified. Conclusion: MiR-34a-5p, miR-200c-3p, miR-143-3p, miR-22-3p, miR-21-5p, KLKB1, KNG1, and DSP carried by exosomes in plasma might participate in the pathogenesis of TAK by regulating vascular physiology, inflammation, autoimmunity, and other processes. They may be biomarkers and therapeutic targets of TAK.

[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 pulmonary arterial hypertension in China]

Pulmonary arterial hypertension (PAH) is a clinicopathological syndrome caused by the increase of pulmonary artery, and it is the most serious complication of connective tissue disease (CTD). In recent years, a lot of progress has been made in the diagnosis, treatment and evaluation of PAH. Chinese Rheumatology Association formulated this recommendation on the basis of current experience and guidelines, in order to promote early screening, early diagnosis and early intervention of CTD-PAH, as well as patient follow-up and management, to improve the prognosis of CTD-PAH patients.

[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.

[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.

[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.

[The 490th case: arthralgia, amenorrhea, aphasia]

A 25-year-old woman was admitted to Peking Union Medical Hospital presented with arthralgia for 5 years, amenorrhea for 16 months, and speech disorder for 3 months. This patient has been afflicted by intermittent pain in metacarpophalangeal and proximal interphalangeal joints of both hands for 5 years. Her menstruation has been irregular 1 year ago and rapidly progressed to amenorrhea. Laboratory tests revealed postmenopausal sex hormones levels (estradiol<5 ng/L, follicle-stimulating hormone 62.5 IU/L, luteinizing hormone 58.71 IU/L) and no antral follicles were seen in gynecologic ultrasound. She was diagnosed with premature ovarian failure and treated with hormone replacement therapy, still with no ovulation. Numbness and weakness of right arm has recurrently occurred to her 4 months ago, and persistent weakness of right limbs combined with motor speech disorder occurred 1 month later. Magnetic resonance angiography was suggestive of ischemic stroke. Hormone replacement therapy was discontinued. Comprehensive laboratory tests revealed positive anti-dsDNA, anti-SSA/SSB, anticardiolipin and anti-β₂GPⅠ antibodies. Systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS) was diagnosed. Since no drug with gonadal toxicity had been applied to the patient before, her amenorrhea was considered to be due to autoimmune oophoritis secondary to SLE. After treated with high-dose glucocorticoid, mycophenolate mofetil and hydroxychloroquine for 4 months, her menstruation recurred and regularly occurred till now. In some cases, amenorrhea in SLE patient might be resulted from autoimmune oophoritis associated with lupus flare, instead of use of drug with gonadal toxicity.

[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.

[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.

[The 487th case: prominent eyes, headache, blurred vision]

One 51 years old man was admitted to the rheumatology department with a history of prominent eyes, headache and blurred vision for half year. The main manifestations included retrobulbar inflammatory pseudotumor and retroperitoneal fibrosis. He was initially diagnosed as granulomatosis with polyangiitis. Prednisone and cyclophosphamide were administrated and effective. New mass of dura mater and osteosclerosis presented during follow up. Finally Erdheim Chester disease(ECD) was diagnosed by biopsy and pathological examination. Vemurafenib, a v-raf murine sarcoma viral oncogenes homolog B1 (BRAF) inhibitor, 480 mg was given twice a day. The patient's condition is stable and still in follow-up. Although ECD is a rare histiocytosis, clinicians should pay attention to its manifestations and differential diagnoses.

[Practice guideline for patients with osteoporosis]

In recent years, osteoporosis (OP) has become one of the main diseases affecting the health of middle-aged and elderly people in China, and the prevalence of OP has increased significantly. The clinical diagnosis and treatment guidelines for this disease are also constantly updated. The overall principles speciallyemphasise that doctors and patients need to work together to negotiate the details of the diagnosis and treatment guidelines, in order to improve the OP clinical diagnosis and treatment rate. Therefore, patients' knowledge of the disease, understanding of clinical guidelines, and cooperation with doctors to implement diagnosis and treatment plans are very important. In this study, from the most concerned issues of the patients, we established the OP patient practice guideline working group. 14 recommendations, as the OP patient practice guidelines, are proposed in accordance with the relevant principles of the "World Health Organization guidelines development manual" and the international normative process.

[The 482nd case: vomiting, paroxysmal dizziness and anhidrosis]

A 31-year-old woman was admitted to Peking Union Medical College Hospital presented with intermittent vomiting and abdominal pain for 2 years, and recurrence with paroxysmal dizziness for 1 month. This patient was diagnosed with systemic lupus erythematosus (SLE) 2 years ago with involvement of gastrointestinal and urinary tracts. One month ago, repeated vomiting and nausea recurred. No laboratory and imaging abnormalities were found in central nervous system and gastrointestinal evaluation. Orthostatic hypotension and fluctuation of blood pressure were recorded during hospitalization. Combined with sexual dysfunction, left adie pupil, anhidrosis and abnormal sympathetic skin response, autonomic nerve dysfunction related to SLE was diagnosed. After treated with pulse glucocorticoids and intravenous immunoglobulin, the patient's symptoms improved remarkably. Orthostatic hypotension in SLE patients may link to autonomic nerve dysfunction.

[Clinical and prognostic characteristics in patients with eosinophilic granulomatosis with polyangitis]

Objective: To analyze the clinical and prognostic characteristics in patients with eosinophilic granulomatosis with polyangitis (EGPA). Methods: The clinical data of 146 EGPA patients hospitalized in Peking Union Medical College Hospital from 2000 to 2019 were analyzed retrospectively, including clinical manifestations, laboratory results, treatment, complications and outcome at discharge. Birmingham Vasculitis activity score-V3 (BVAS-V3) was used to evaluate disease activity. Results: The ratio of male to female was 1.8∶1 with average age (41.7±16.1) year-old. The median time from disease onset to diagnosis was 18(6, 60) months (0.5~450). The most common clinical manifestations were lung [121(82.9%)] and nose/paranasal sinuses [119(81.5%)] involvement. The positive rate of anti-neutrophil cytoplasmic antibody (ANCA) was 24.7%, mainly peripheral (P)-ANCA/myeloperoxidase (MPO)-ANCA. Compared with ANCA-negative patients, the ANCA-positive patients had a higher incidence of renal involvement and nervous system involvement (66.7% vs. 20.9%, 80.6% vs. 51.8%, P<0.001), fever and optic neuropathy (66.7% vs. 40.9%,8.3% vs. 0, P<0.05), more active disease [median BVAS-V3 25(18,30)vs. 19(14,24),P=0.001] and more elevated erythrocyte sedimentation rate [40.5(20.5,82.8)mm/1h vs. 25.0(13.3,50.8)mm/1h,P=0.006] and C-reactive protein [37.1(11.8,72.9)mg/L vs.13.5(3.4,66.1)mg/L,P=0.036]. More ANCA-negative patients had pleural effusion (20.9% vs. 5.6%, P<0.04) compared with ANCA-negative patients. Pulmonary infection was the most common complication. A total of 12 EGPA patients (8.2%)achieved remission and 6 patients (4.1%)died or discharged themselves from the hospital. Conclusion: EGPA is a rare small vessel vasculitis. The clinical manifestations and outcomes are heterogenous. The mortality rate of EGPA is high.

[Recommendations of diagnosis and treatment of gout in China]

Gout is a crystal associated arthritis caused by monosodium urate (MSU) accumulating in joint, and it belongs to metabolic rheumatic disease. In China, gout is common but it is insufficient for education of standardized diagnosis and treatment for gout. Based on the evidence and guidelines from China and other countries, Chinese gout Collaborative Research Group developed standardization of diagnosis and treatment of gout in China. The purpose is to standardize the methods for diagnosis of gout, treatment opportunity and strategies in order to reduce misdiagnosis, missed diagnosis and irreversible damage.

[Recommendations of diagnosis and treatment of primary Sjögren's syndrome in China]

Sjögren's syndrome is a chronic systemic autoimmune disease characterized by lymphocyte proliferation and progressive exocrine gland damage. In China, standardized diagnosis and treatment for Sjögren's syndrome lags behind other common rheumatic diseases, such as rheumatoid arthritis and systemic lupus erythematosus. Based on the evidence and guidelines from China and other countries, Chinese Sjögren's Syndrome Collaborative Research Group together with stomatologist and ophthalmologist developed Standardization of diagnosis and treatment of primary Sjögren's syndrome. The purposes are: (1) to standardize the detection and interpretation of key indicators for the diagnosis of Sjögren's syndrome, including serum anti SSA antibody and labial gland pathology; (2) to suggest using widely accepted disease activity index in evaluation of the disease; (3) to standardize rational management for Sjögren's syndrome patients with topical and systemic diseases.

[Effects of titania nanotubes with different diameters on human gingival fibroblast]

Objective: To study the effects of titania nanotubes with three different diameters on human gingival fibroblast (HGF). Methods: Three groups of specimens were prepared. Titania nanotubes with diameters of 30, 100, and 200 nm were synthesized on titanium surfaces through electrochemical anodization at 10, 30, and 60 V, respectively. Specimens were assigned into the three groups according to the diameter of the titania nanotubes. Pure smooth titanium without any treatment was set as the control group. HGF were seeded on the surface of the samples. The cell morphology on the specimens was observed with immunofluorescence staining after 2 h, the cell adhesion after 2 d and cell proliferation after 1, 3, and 7 d were detected using methyl thiazolyl tetrazolium assay, and the secretion of type Ⅰ collagen after 7 d was determined using enzyme-linked immunosorbent assay (each group has three samples for each experiment). Results: HGF on the control group exhibited an oval shape without noticeable extensions. HGF on titania nanotubes with a diameter of 30 nm and titania nanotubes with a diameter of 100 nm elongated further and were arranged orderly. HGF on titania nanotubes with a diameter of 200 nm were sparsely distributed without noticeable extensions. Titania nanotubes with a diameter of 30 nm and titania nanotubes with a diameter of 100 nm could enhance the cell attachment (0.603±0.021 and 0.773±0.045), and secretion of type Ⅰ collagen [(36.5±9.5) and (47.7±4.5) μg/ml, respectively] compared with the control group whose cell attactment was 0.427±0.057, and secretion of type Ⅰ collagen was (22.2±5.9) μg/ml (P<0.05). Furthermore, titania nanotubes with a diameter of 100 nm showed more cell attchment than titania nanotubes with a diameter of 30 nm did (P<0.05). Ttania nanotubes with a diameter of 200 nm clearly impaired the cell adhesion (0.250±0.046) and secretion of type Ⅰ collagen [(10.1±3.7) μg/ml] compared with the control group (P<0.05). At each time point, titania nanotubes with a diameter of 100 nm showed the highest cell proliferation, and the amount of cell proliferation was significantly higher than that on the titania nanotubes with a diameter of 200 nm and the control group at each time point (P<0.05), and was also significantly higher than that on the titania nanotubes with a diameter of 30 nm at day three (P<0.05). At each time point, titania nanotubes with a diameter of 200 nm showed the lowest cell proliferation, which was significantly lower than that on the control group at each time point (P<0.05), except that there was no significant difference in the amount of cell proliferation between titania nanotubes with a diameter of 200 nm and the control group at day one (P>0.05). Conclusions: Titania nanotubes with a diameter of 100 nm can improve the HGF attachment, proliferation, and secretion of type Ⅰ collagen.

[The 476th case: skin rash, edema, thrombocytopenia and anemia]

The 21-year-old male patient was admitted to the Department of Rheumatology and Immunology at Peking Union Medical College Hospital with chief complaints of "skin rash for 1 year and edema for 2 months". He was diagnosed with systemic lupus erythematosus (SLE) with renal, cardiac and hematological involvement. Remission was not achieved after glucocorticoid pulse treatment. The patient experienced oliguria, malignant hypertension, accompanied by thrombocytopenia and low serum complements, and elevated lactate dehydrogenase and serum creatinine. Schistocytes were seen in the peripheral blood smear. Thrombotic microangiopathy (TMA) secondary to SLE was diagnosed. Though plasma exchange was partially effective, TMA could not be controlled yet. The activity of serum von Willebrand factor -cleaving protease (ADAMTS 13) was 100%, and ADAMTS 13 inhibitor was negative. Finally, remission of the disease was achieved after second glucocorticoid pulse therapy and rituximab treatment. At the 3-month follow-up, the patient's condition was stable with mild anemia and normal platelet count. Patients with TMA secondary to SLE are heterogenous, while normal ADAMT 13 activity indicates poor prognosis. Early and aggressive treatment is important for disease control, and plasma exchange is helpful as a supportive care.

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 outcomes and predictive relapse factors of IgG4-related disease following treatment: a long-term cohort study

OBJECTIVES

The aim of this study was to investigate the predictive factors for relapse of IgG4-related disease (IgG4-RD) and observe the long-term clinical outcomes in patients with IgG4-RD.

METHODS

We included in the present analysis 122 patients who were newly diagnosed with IgG4-RD, treated with glucocorticoid (GC) monotherapy or GC and immunosuppressant combination therapy, and followed for at least 3 years. Clinical relapse, response and side effects were recorded.

RESULTS

The cumulative relapse rates of patients in this study were 10.66%, 22.95% and 27.87% at 12, 24 and 36 months, respectively. Complete drug withdrawal was an independent risk factor for disease relapse. Higher serum IgG4 concentrations, involvement of more organs, higher IgG4 RI scores and elevation of eosinophils at baseline were closely associated with disease relapse. Re-elevation of serum IgG4 concentrations and low GC maintenance dosage during the follow-up period were significantly associated with clinical relapse. The GC dosage should be more than 6.25 mg day^-1 as monotherapy during the maintenance stage; moreover, combining with immunosuppressants can reduce the GC dosage. Adding GC or immunosuppressants for patients with re-elevation of serum IgG4 levels could prevent later disease relapse. No serious complications were noted during long-term follow-up.

CONCLUSIONS

The combination of GC with immunosuppressants was more effective than GC monotherapy during the steroid tapering and maintenance stages. Higher serum IgG4 levels, involvement of more organs, higher IgG4 RI scores, history of allergy, eosinophil elevation at baseline, re-elevation of serum IgG4 levels and lower GC maintenance dosage at follow-up might be predictive of relapse.

[Clinical characteristics of 57 patients with polyarteritis nodosa and renal involvement]

Objective: To investigate the clinical characteristics of polyarteritis nodosa (PAN) patients with renal involvement. Methods: PAN patients admitted to the department of rheumatology, department of pediatrics, department of nephrology, general internal medicine department and department of vascular surgery at Peking Union Medical College Hospital from June 2012 to August 2018 were enrolled in this study and were divided into two groups according to renal involvement or not. The clinical characteristics were analyzed. Results: A total of 94 PAN patients were finally enrolled and 57 (60.64%) presented kidney manifestation. The mean age of onset was (37.76±17.40) years old and the interval from onset to diagnosis was 10 (0 to 240) months. Forty patients were misdiagnosed once or more times. In patients with renal involvement, 9 cases suffered from renal ischemia or infarction, 31 with microscopic haematuria, 26 with proteinuria, renal artery or its branch involved in 17 cases, renal vein thrombosis in 1 case, 4 cases with pyeloureterectasis, one case with renal fascia thickening, 33 cases with impaired renal function (serum creatinine>84 μmol/L) including creatinine>140 μmol/L in 10 patients. Renal artery branch stenosis was the most common presentation [9 cases (52.94%)] of renal vascular involvement, other abnormalities including nodular dilatation [4 cases (23.53%)], occlusion [3 cases (17.65%)]. There were significant differences (P<0.05) in the PAN patients with and without renal involvement in the following: age of onset [(33.72±16.13) years vs. (43.97±17.66) years, t(2)=2.901, P=0.005], weight loss(≥4kg since PAN onset) [25(43.86%) vs. 7(18.92%), χ(2)=6.216, P=0.013], elevation of diastolic blood pressure [22(38.60%) vs. 7(18.92%), χ(2)=4.072, P=0.044], acromegaly gangrene [18(31.58%) vs. 21(56.76%), χ(2)=5.859, P=0.015], and gastrointestinal artery involvement [20(35.09%) vs. 6(1.22%), χ(2)=3.993, P=0.046]. Laboratory parameters and the application of glucocorticoid and cyclophosphamide therapies were similar in two groups (all P>0.05). Conclusion: Young PAN patients are more likely to be associated with renal involvement, especially gastrointestinal arteries.

[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.

[The 469th case: multiple cutaneous abscesses, pelvic mass, and lung cavities]

A 28-year-old woman with multiple abscesses for 2 month and fever for 1 month was admitted in Peking Union Medical College Hospital. The skin abscesses gradually developed at skull, face, abdominal wall and pelvis. Laboratory examinations related to inflammatory reactions were strongly high including erythrocyte sedimentation rate 99 mm/1 h,C-reactive protein160.28 mg/L and ferritin 1 584 μg/L. Multiple nodules and cavities were detected in lungs. And vesico-cervical fistula was found during exploratory laparotomy. The pathological tests of abdominal tissues demonstrated necrosis and granuloma. Evidence of infectious diseases was not definite. Positive anti-proteinase 3 (PR3) antibody confirmed the diagnosis of granulomatosis with polyangiitis. After treated with glucocorticoid and immunosuppressants, the patient's symptoms improved remarkably. This case suggested that systemic vasculitis should be considered as a differential diagnosis of multiple abscesses which are not explained by infections.

[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.

[Research Progress of Traffic Accident Reconstruction Technology Based on PC-Crash Software]

With the development of the computer simulation technology and the digital simulation technology, the traditional calculation method has been gradually replaced by the digital method to deal the road traffic accident scene and analyse the process. The PC-Crash software simulation system can reconstruct the traffic accidents within 32 vehicles, and the accuracy of reconstruction has been fully verified, which is widely used by the transport police department and the accreditation agency. In this paper, the research of road traffic accident reconstruction using PC-Crash software is reviewed, and the application of road traffic accident reconstruction technology based on PC-Crash software and some existing problems in forensic practice are discussed, which provides reference for the research and identification of road traffic accident simulation and reconstruction and theoretical basis for accident treatment.

Dietary supplemented antimicrobial peptide microcin J25 improves the growth performance, apparent total tract digestibility, fecal microbiota, and intestinal barrier function of weaned pigs

Microcin J25 (MccJ25) is an antimicrobial peptide produced by a fecal strain of Escherichia coli containing 21 AA. This study was performed primarily to evaluate the effects of MccJ25 as a potential substitute for antibiotics (AB) on growth performance, nutrient digestibility, fecal microbiota, and intestinal barrier function in weaned pigs. In the present study, 180 weaned pigs (7.98 ± 0.29 kg initial BW) were randomly assigned to 1 of 5 treatments, including a basal diet (CON) and CON supplemented with AB (20 mg/kg colistin sulfate; ABD) or 0.5, 1.0, and 2.0 mg/kg MccJ25. On d 0 to 14, dietary supplementation with MccJ25 and ABD had positive effects on ADG, ADFI, diarrhea incidence, and G:F ( < 0.05). Pigs fed the 2.0 mg/kg MccJ25 diet had greater ADG ( < 0.05) and marginally greater G:F ( < 0.10) compared with pigs fed the ABD diet. Compared with the CON diet, the 2.0 mg/kg MccJ25 diet sharply improved ( < 0.05) ADG and G:F and decreased ( < 0.05) diarrhea incidence (d 15 to 28 and d 0 to 28). Apparent digestibility of nutrients in pigs fed 1.0 and 2.0 mg/kg MccJ25 was improved ( < 0.05) compared with that of pigs fed CON and ABD. The serum cytokines IL-6 and IL-1β and tumor necrosis factor-α levels in pigs fed MccJ25 were greater than in pigs fed CON ( < 0.05). Additionally, the IL-10 concentration in pigs fed MccJ25 was sharply increased ( < 0.05) compared with that of pigs fed CON. Pigs fed 1.0 and 2.0 mg/kg MccJ25 diets had remarkably decreased lactate, diamine oxidase, and endotoxin concentrations and fecal numbers ( < 0.05) and improved fecal and numbers ( < 0.05). Compared with the ABD diet, the diet containing 2.0 mg/kg MccJ25 did not increase lactate, diamine oxidase, and endotoxin (d 14) concentrations ( < 0.05) or decrease the and (d 28) numbers ( < 0.05). The diets containing 1.0 and 2.0 mg/kg MccJ25 and ABD (d 28) improved lactate concentration and short-chain fatty acid concentrations, including acetate, propionate, and butyrate, in feces ( < 0.05). Moreover, the pigs fed 2.0 mg/kg MccJ25 had greater lactate, butyrate (d 14), and propionate concentrations than the pigs fed the ABD diet ( < 0.05). In conclusion, dietary supplemented MccJ25 effectively improved performance, attenuated diarrhea and systematic inflammation, enhanced intestinal barrier function, and improved fecal microbiota composition of weaned pigs. Therefore, MccJ25 could be a potential effective alternative to AB for weaned pigs.

Modulation of broilers' caecal microflora and metabolites in response to a potential probiotic Bacillus amyloliquefaciens

Studies have found that a dietary supplement of Bacillus amyloliquefaciens improved the growth performance, increased the nutrient digestibility of hosts and modulated the intestinal microflora. A total of 360 1-day-old Ross broilers were randomly divided into three treatments: a control group with a basal diet, an antibiotic group with a basal diet and added colistin sulphate, and a probiotics group with a basal diet and added Bacillus amyloliquefaciens. The HiSeq high-throughput sequencing analysis of 16S rRNA was used to investigate the differences in birds' caecal microflora, and metabolomics was used to analyse changes in caecal metabolites. Results showed that the supplementation of Bacillus amyloliquefaciens significantly improved the BW and ADG compared with the control birds. Results of sequencing indicated that (i) 645, 670, 596 unique operational taxonomic units (OTUs) were found in birds supplemented with Bacillus amyloliquefaciens on day 7, 21 and 42, separately, (ii) due to the diversity and relative abundance of the birds' caecal microflora, the OTUs of the caecal microflora clustered according to age and treatment, except on day 42, (iii) among the six predominate families (Ruminococcaceae, Lachnospiraceae, Enterobacteriaceae, Erysipelotrichaceae, Lactobacillaceae and Rikenellaceae), the supplementation of Bacillus amyloliquefaciens significantly increased Enterobacteriaceae on day 42, (iv) Bacillus amyloliquefaciens increased the relative abundance of Faecalibacterium and Ruminococcus on day 21, increased the Faecalibacterium and Blautia and decreased the Ruminococcus on day 42. The metabolomics of caecal metabolites showed that the dietary Bacillus amyloliquefaciens changed the caecal metabolites involved of amino acid metabolism and glyceride metabolism, and the antibiotics changed the caecal metabolites that were related to carbohydrates and amino acid metabolism on day 21.