AIM: To investigate the effects of rosiglitazone on fibroblast-like synoviocyte ( FLS )-induced osteoclastogenesis in rheumatoid arthritis ( RA) and the related mechanism.METHODS: RA-FLS were cocultured with peripheral blood monocytes from healthy volunteers in the presence of macrophage colony-stimulating factor ( M-CSF) and rosiglitazone.Osteoclasts were assayed by tartrate-resistant acid phosphatase ( TRAP) staining.Resorption lacunae area was identified by toluidine blue staining and quantified by image analysis software.The mRNA expression of RANKL and OPG was evaluated by real-time PCR, and the protein levels of RANKL, OPG, p-ERK, p-p38 and p-JNK were measured by Western blot.RESULTS:Compared with control group ( without rosiglitazone treatment) , rosiglitazone at concentration of 15 μmol/L significantly decreased the number of osteoclasts (P<0.01) and resorption lacunae area (P<0.05).The expression of RANKL at mRNA and protein levels was significantly down-regulated by rosiglitazone at concentration of 15μmol/L, while the mRNA and protein expression of OPG was up-regulated (P<0.01).Rosiglitazone (15 μmol/L) sig-nificantly decreased the protein level of p-ERK ( P<0.05 ) , but not the protein level of p-p38 or p-JNK ( P>0.05 ) . CONCLUSION:Rosiglitazone inhibits RA-FLS-induced osteoclast formation and its resorption activity by down-regulating RANKL expression and ERK phosphorylation, suggesting that rosiglitazone may inhibit RA osteoclastogenesis and bone re-sorption.

Objective To investigate the optimal technology of blind needle synovial biopsy.Methotis Blind needle synovial biopsy was performed on 81 knees with pain and swelling.Twenty patients with rheumatoid arthritis (RA) received uhrasonographic (US) examination before biopsies.Results Synovium were obtained in all patients and the successful rate was (71±21)%,while the area of synovium was (1.8±0.8)mm2.The time for accomplishing the procedure was (26±6) min and the depth of trocar insertion Was (3.1±0.7) cm.The successful rate in patients with RA (80±6)% was much higher than that in non-RA patients (54±10)%.The successful rate with US guidance (85±5)% was much higher than that without US guidance (78±6)%.The positive predictive value of synovium evaluation by naked eye Was 95.0%,while the negative predictive value was 81.1%.Conclusion Blind needle synovial biopsy should be spread because it is simple and safe to perfonn and it can obtain sufficient synovium for all purposes.

Objective:To analyze the clinical characteristics of patients with eosinophilic granulo-matosis with polyangiitis (EGPA) and improve the understanding of the disease.Methods:EGPA patients who fulfilled the 1990 American College of Rheumatology (ACR) classification criteria were recruited from Sun Yat-sen Memorial Hospital Sun Yat-sen University between December 2003 and April 2020. Their demographic characteristics, clinical manifestations, laboratory and auxiliary examinations were analyzed retrospectively. Mann-whitney U test and χ2 test were used for statistical analysis. Results:Among 52 EGPA patients, 34 (65.4%) were males and the median age at disease onset was 47(38-55) years. The median time from disease onset to diagnosis was 30(4-96) months. The most common initial symptoms were respiratory (61.5%) and nose/paranasal sinus (21.2%) involvement. The most common department for the first visit was respiratory medicine (53.8%), followed by rheumatology (11.5%). 44.2% EGPA patients were diagnosed by rheumatologists. The most common clinical manifestations were asthma (88.5%), nose/paranasal sinusitis (84.6%), pulmonary (76.9%) and nervous system (61.5%) in volvement. Eight(15.4%) patients were positive for antineutrophil cytoplasmic antibodies (ANCA). Patients with positive ANCA had lower incidence of asthma, but higher incidence of general symptoms especially arthralgia and renal involvement, elevated eosinophil count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Birmingham vasculitis activity score and vasculitis damage index than patients with negative ANCA (all P<0.05). 21.2%-34.6% EGPA patients had poor prognostic factors. Conclusion:Early diagnosis of EGPA is important. EGPA patients with positive ANCA may be more severe than patients with negative ANCA. The management should be a multi-disciplinary collaboration between rheumatologists and pulmonologists.

Objective To investigate doctor's screening practice for hepatitis B virus (HBV) infection before immunosuppressive therapy for rheumatoid arthritis (RA) patients and clinical management of RA patients with positive surface antigen of HBV (HBsAg).Methods One hundred fifty doctors who treated RA patients in daily clinic were survied with a modified American College of Rheumatology (ACR) questionnaire which was composed of demographic data and 10 multiple-choice questions.Step-forward logistic regression analysis was performed to find out the influencing factors,then receiver operator characteristic curve analysis and area under the curve were performed to confirm the influencing factors.Results One hundred and thirtytwo effective questionnaires were collected.Before immunosuppressive therapy,HBV screening rate in outpatients with RA was significandy lower than that in hospitalized patients (68.7％ vs 94.6％,x2=31.5,P＜0.01).Only 23.7％(31/131) of doctors considered antiviral treatment for all RA patients with positive HBsAg.One hundred and thirteen doctors had clinical experience of antiviral treatment,but only 30.1％(34/113) and 23.9％ (27/113) of these doctors chose entecavir or adefovir as the antiviral drug respectively,59.3％ (67/113) prescribed antiviral drug before or together with immunosuppressive therapy compared with 40.7％(46/113) after HBV reactivation.Only 20.4％(23/113) of doctors would sustain antiviral treatment until the termination of steroid or disease modifying antirheumatic drugs (DMARDs).During immunosuppressive therapy for HBsAg(+) RA patients,11.4％(15/132) and 30.3％(40/132) of doctors reported no regular monitoring of aminotransferase or HBV DNA respectively.Conclusion Our survey shows that HBV screening rate in outpatients with RA is low and low awareness of antiviral treatment for all RA patients with positive HBsAg,and lack of awareness of indication,choosing of antiviral drugs,initiation,monitoring and duration of antiviral treatment during immunosuppressive therapy.Further medical education on the associated information and importance to collaborate with hepatologists should be emphasized.

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

ObjectivesTo examine the validity of high-frequency Doppler ultrasound in identifying knees synovitis in patients with rheumatoid arthritis(RA).MethodsNinety-five consecutive patients with active RA were examined withhigh-frequency Doppler ultrasound to examine synovitis signals in knees.Synovial tissue samples of 51 patients were obtained by closed needle biopsy from knees after ultrasound examination.Serial synovial tissue sections were stained with H&E and immunohistochemical staining,and the histopathological synovitis scores were evaluated.The relationship among clinical, histopathological and ultrasound synovitis indexes was analyzed by Spearman's rank order correlation test and receiver operating characteristic curve analysis.ResultsAmong 95 RA patients,the median thickness of synovial membrane in ultrasound was 2.8 mm,the median depth of effusion was 2.7 mm; Doppler signals of synovial blood flow were detected in 82％(78/95 ) of patients and the median semiquantitive grading of synovial blood flow was 1.0.The thickness of synovial membrane and synovial blood flow at Doppler ultrasound correlated positively with histological synovitis score,hyperplasia of the lining layer,and inflammatory infiltration in sublining area (the thickness of synovial membrane:r=0.438,0.424,0.368,respectively; synovial blood flow:r=0.357,0.377,0.347,respectively; all P＜0.05).Although there was no significant difference in clinical synovitis indexes between patients with histologically low-grade and high-grade synovitis,the thickness of synovial membrane and synovial blood flow in ultrasound in patients with histologically high-grade synovitis was significantly higher than those with low-grade synovitis(P=0.001,0.036,respectively).When the thickness of synovial membrane in ultrasound was ≥ 3.9 mm,the specificity of diagnosing the high-grade synovitis was 96.7％ and the sensitivity was 61.9％.ConclusionSynovitis signals at high-frequency Doppler ultrasound correlate with histopathological synovitis,and it might be helpful in evaluating the severity of histopathological synovitis.

Objective To investigate the effect of tumor necrosis factor (TNF)-α antagonists on liver function and reactivation of hepatitis B virus ( HBV ) in patients with inflammatory arthropathy with concurrent chronic HBV infection.Methods Patients with active rheumatoid arthritis (RA) and ankylosing spondylitis (AS) who were grouped according to serum HBV biomarkers were treated with TNF-α antagonist.The liver function and reactivation of HBV were monitored before and after anti-TNF-α therapy.Kruskal-Wallis one-way analysis of variance on ranks of continuous variables and x2 test or Fisher's exact test for categorical variables among 3 or more groups.Results Fifty patients were enrolled with 3 to 23 months of follow-up visit.The level of transaminases in chronic HBV infection group [n=11,AST (36±18) U/L,ALT (44±46) U/L] were significantly higher than that in past HBV exposure group [n=16,AST (22±6) U/L,ALT (17±9) U/L] or free of HBV infection group [n=23,AST (19±6) U/L,ALT (15±9) U/L](AST:x2=11.161,P＜0.01,ALT:x2=8.038,P＜0.01).One patient with elevated baseline HBV-DNA load was treated concomitantly with lamivudine and anti-TNF-α therapy,and the HBV-DNA load reduced about to normal 4 months later.Among the other 10 patients with normal baseline HBV-DNA load in chronic HBV infection group,one patient showed reactivation of HBV with elevated transaminases after anti-TNF-α therapy; another patient had only elevated transaminases without reactivation of HBV,and the transaminases returned to normal after withdrawal of antiTNF-α therapy,which suggested drug-induced liver injury.All patients in both past HBV exposure group and free of HBV infection group remained HBsAg negative after the therapy.Conclusion Patients with inflammatory arthropathy should be screened for HBV infection and check liver function before anti-TNF-α therapy,and carefully monitor the reactivation of HBV and liver function during treatment.Patients with concurrent chronic HBV infection should be treated conco-mitantly with anti-virus and anti-TNF-α therapy if they have elevated baseline HBV-DNA load (＞105 copies/ml,in particular) and good economic situation.

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

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

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