Combined Immunosuppressive Treatment Research Articles

Successful full-term pregnancy after preterm event in a liver transplant patient: a case report

BackgroundPregnancy after liver transplantation poses a significant challenge to both the patient and the transplant team.Case presentationWe present the case of a 19-year-old European patient who underwent liver transplantation 5 years previously owing to autoimmune hepatitis. Poor compliance with immunosuppressive therapy and missed follow-up visits during the patient’s first pregnancy likely contributed to her liver function deterioration, hospitalization, and failed pregnancy. Owing to the patient’s complex medical history, combined immunosuppressive treatment, and risks to the fetus, her second pregnancy was high risk. However, close outpatient monitoring and adherence to treatment led to a successful, uneventful, full-term pregnancy and healthy delivery.ConclusionLiver transplant recipients who desire to become pregnant require careful planning and management to ensure optimal outcomes for both the mother and the fetus. A personalized strategy is necessary to balance the potential benefits of childbirth with the risks involved in pregnancy after liver transplantation.

Giant cell myositis and myocarditis revisited.

Giant cell myositis (GCMm) and giant cell myocarditis (GCMc) are two rare autoimmune conditions. Among these, GCMc is a life-threatening disease with a 1-year mortality rate of 70%. Lethal ventricular arrhythmias, rapid evolution to heart failure and sudden death risk makes GCMc an emergency condition. It is thought to be mediated by T-cells and characterized by the presence of myofiber necrosis and giant cells in biopsies. Most commonly co-manifesting conditions with GCMm and/or GCMc are thymoma, myasthenia gravis and orbital myositis, all of which are treatable. As suspicion is the key approach in diagnosis, the physician following patients with thymoma with or without myasthenia gravis and with orbital myositis should always be alert. The fatal nature of GCMc associated with these relatively benign diseases deserves a special emergency attention with prompt institution of combined immunosuppressive treatment and very early inclusion of heart failure teams.

Efficacy of plasma exchange in anti-MDA5-positive dermatomyositis with interstitial lung disease under combined immunosuppressive treatment.

Rapidly progressive interstitial lung disease (RP-ILD) with poor prognosis often accompanies anti-melanoma differentiation-associated gene 5 (MDA5)-positive DM. Combined immunosuppressive therapy, including glucocorticoids, calcineurin inhibitors and intravenous cyclophosphamide (IVCY) is reportedly effective in DM with RP-ILD, but some patients remain resistant to therapy. We examined the utility of plasma exchange (PE) in such intractable cases and investigated the prognostic factors of the disease. Thirty-eight anti-MDA5-positive DM-ILD patients who received the combined immunosuppressive therapy were retrospectively reviewed. Their serum cytokines were evaluated by multiplex assay before treatment. The patients were divided into two groups: those who achieved remission without exacerbation of respiratory dysfunction (n = 25, group A) and those who progressed to hypoxemia during the treatment (n = 13, group B). PE was carried out in eight group B patients, but none of group A. Five of the eight treated with PE survived, while the five untreated patients died (P=0.04). Higher neutrophil lymphocyte ratio, higher serum ferritin, hypoxemia, high-resolution computed tomography (HRCT) score before treatment and increase of Krebs von Lungen-6 (KL-6) in the first 4 weeks of the treatment were the prognostic factors for disease progression. Serum cytokines such as IL-1, IL-6, IL-8, IL-10, IL-12p70, IL-18 and sCD163 levels were higher in group B than group A. PE should be an effective adjuvant treatment in anti-MDA5-positive DM with RP-ILD. Assessment of basal laboratory tests or monocyte/macrophage-derived cytokines and the increase of KL-6, HRCT score and hypoxemia may help us to predict intractable cases and to make early treatment decisions regarding PE in anti-MDA5-positive DM.

Vasculo-Behcet's Disease: Profile and Management - Single Center Experience

Background Behçet's disease (BD) is a multisystem vasculitis characterized by exacerbations and remissions with unknown etiology. Males are more affected than females with the usual onset in the third decade. Vascular involvement can occur in up to 40% of cases of BD. BD is unique among the vasculitides that it may involve all sizes and types of vessels. Objectives 1. To study the pattern of vascular involvement of Behçet's disease (BD) in the Saudi population; use of anticoagulation and its duration, thromboembolic, and major bleeding complications during anticoagulant therapy. 2. The effect of combined immunosuppression and anticoagulation treatment approach in reducing the risk of venous and arterial thromboembolism. 3. The role of vascular surgery for peripheral arterial and abdominal aortic aneurysms (AAA), and the role of immunosuppression in the treatment of pulmonary artery aneurysm (PAA) without the need for surgical intervention. Methods Twenty-three patients with confirmed vasculo-BD attending the thrombosis clinics at our tertiary care center between 2010 and 2015 were studied retrospectively and analyzed through descriptive statistics SPSS version 22. Results Demographics and pattern of vascular involvement are shown in tables 1 and 2. HLA-typing was performed for 13 patients, and HLA- B51 was positive in 7 (54%) patients tested. The acute phase reactants (ESR and CRP) were high in all 23 (100%). Hereditary and acquired thrombophilia workup was performed for all patients and only 1 (4.3%) was positive for antiphospholipid antibodies. Oral ulcers were present in all the patients, genital ulcers in 12 (52%), ocular involvement in 8 (35%), skin manifestations in 3 (13%), and arthritis in 1 (4.3%). Lower extremity vein thrombosis is the most frequent manifestation of Vasculo-BD in Saudi Arabia, followed by CVT, PAI, SVT/Budd-Chiari syndrome, IVC thrombosis, peripheral artery aneurysms, and AAA. Peripheral arterial and abdominal aortic aneurysms in 3 (13.6%), all of whom had successful vascular surgery for aneurysm repair. Inferior vena cava filter was inserted in 3 (13.6%). One patient was admitted to the intensive care unit with fulminant hepatic failure due to bilateral hepatic vein thrombosis and subsequently died. The vascular thrombosis recurrence was in 11 patients (48%, all venous) despite adherence to the prescribed anticoagulant therapy and lack of any provocation. These patients were initially treated with anticoagulant monotherapy. After combining immunosuppressive therapy to the pre-existing anticoagulant therapy, none had thrombosis recurrence. There was a complete resolution of the two patients with PAA with mono-immunosuppressant therapy and no surgical intervention. The most commonly prescribed initiation anticoagulant therapy was low molecular weight heparin (87%). Conclusion BD with vascular involvement continues to pose a major diagnostic and therapeutic challenge to physicians due to the heterogeneity of the clinical presentation and lack of the diagnostic laboratory test. Therefore, we must have a low threshold for BD in any patient with vascular thrombosis or aneurysm. Combined immunosuppressive therapy is essential in suppressing and preventing the venous and arterial recurrence attacks. Disclosures No relevant conflicts of interest to declare.

Recurrent and hemorrhagic posterior reversible encephalopathy syndrome: Does it a really benign and reversible clinical condition?

PRES defined as a variable combination of acute clinico-radiological symptoms secondary to several etiological factors. The overall incidence of hemorrhage in PRES had been reported in 15.2%, recurrence of PRES 6% and death up to 15% of patients. Data about risk factors for recurrent PRES still limited. To present a case with recurrent PRES associated with microbleeds and to discuss various contributing risk factors. We are presenting 18 years old female who known to have longstanding SLE, associated with lupus nephritis, CKD on regular hemodialysis (HD), HTN, severe osteoporosis, and growth hormone deficiency. She was on combined immunosuppression treatment including Rituximab and she was admitted after second dose of its administration with clinical and radiological sign of PRES (Fig. 1, D, E, F) which completely resolved after several weeks. Two years later she had been hospitalized again with recurrent PRES associated with micro-hemorrhages in both cerebellar hemispheres, occipital, parietal and posterior frontal regions (Fig. 2, A, B, C, D, E, F). Neuroimaging follow up after two months (Fig. 2, I, M, N, P) showed residual hemosiderin intra-parenchymal deposition, with complete resolution of vasogenic edema. Patients with SLE who are on combined immunosuppressive treatment, longstanding chronic renal failure on regular HD and uncontrolled hypertension seems have a higher risk of recurrent PRES which may be complicated by microbleeds and/or intracerebral hemorrhage. Clinical prognosis in such cases also still good if PRES recognized and managed in time.

Regressed coronary ostial stenosis in a young female with Takayasu arteritis: a case report

BackgroundTakayasu arteritis is a rare systemic vasculitis, which affects the aorta and its major branches, especially in young females. Diagnosis and treatment for Takayasu arteritis with coronary stenosis are important to prevent fatal complications. Immunosuppressive treatment such as corticosteroid is a common treatment for this condition. However, the effects of immunosuppressive treatment on inflammatory coronary stenosis caused by Takayasu arteritis remains unknown.Case presentationAn 18-year-old female had chest oppression on effort and was referred to our hospital due to ST-segment depression in I, aVL, and V2–4 on electrocardiogram. Coronary angiography showed severe stenosis in the ostium of both the left main trunk and the right coronary artery. 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography showed isolated inflammation of the aortic root. She was diagnosed with Takayasu arteritis and treated with combined immunosuppressive treatment with corticosteroid and tocilizumab, which decreased the FDG uptake in the aortic root. Four months after initiation of the immunosuppressive treatment, coronary angiography showed regression of the coronary ostial stenosis. Coronary artery bypass surgery was considered, but the patient rejected invasive revascularization for coronary artery disease. She did not have chest oppression or ST-segment depression after the immunosuppressive treatment. She had no cardiac events for 6 months after discharge.ConclusionsWe described regressed coronary ostial stenosis in a young female patient with Takayasu arteritis. Immunosuppressive treatment might have a favorable effect on coronary ostial stenosis in Takayasu arteritis.

Analysis of factors relevant to primary non-response to infliximab treatment in patients with Crohn's disease

Objective: To evaluate factors relevant to primary non-response in patients with Crohn's disease undergoing infliximab (IFX) treatment at week 14. Methods: Patients with Crohn's disease in the Third Hospital of Peking University who were subject to IFX treatment more than 3 times and followed-up for more than 14 weeks from October 2015 to October 2018 were reviewed. The response was defined by a decrease of ≥100 points from baseline in the Crohn's Disease Activity Index. The clinical data and laboratory examinations of the two groups were compared, and the treatment outcomes of non-responders were also followed up. Results: A total of 41 patients were enrolled, among which 27(65.9%) were male. The median age at treatment was 25 years, and 8 patients lost primary response (19.5%). There was no significant difference in the sex, age at diagnosis or treatment, Montreal disease type and laboratory examinations [C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), hemoglobin, albumin] in the response group and non-response group at baseline phase (P>0.05). Baseline CRP decreased from 17.7 (26.2) mg/L to 2.2 (3.6) mg/L in the response group, but increased from 11.7 (9.5) mg/L to 31.6 (28.4) mg/L in the non-response group at week 14 (P=0.024). The trend of ESR change in the response group [from 23.0 (28.5) mm/h to 7.0 (8.5) mm/h] and the non-response group [from 24.5 (22.5) mm/h to 35.0 (26.5) mm/h] was similar with that of CRP (P=0.036). Hemoglobin and albumin were significantly elevated in the response group, but not in the non-response group at week 14 (P=0.593, P=0.255). Among the non-response patients, 5 were converted to responsive after the treatment protocols had been adjusted. The combined immunosuppressant treatment all obtained clinical response. Conclusions: The elevated CRP and/or ESR may serve as indicators of primary non-response (at week 14) to IFX treatment among Crohn's disease patients, and the combination of immunosuppressive agents may be one of the effective treatments after excluding infection and other causes.

Combined immunosuppressive treatment (CIST) in lupus nephritis: a multicenter, randomized controlled study.

The standard strategy for treating lupus nephritis comprises glucocorticoids together with either intravenous cyclophosphamide or oral mycophenolate mofetil, but the low remission rate is still a challenge in practice. This study was aimed to seek higher remission rate of lupus nephritis using a combined strategy. A 24-week trial was conducted in 17 rheumatology or nephrology centers in China. A total of 191 lupus nephritis patients were randomized to follow a combined immunosuppressive treatment (CIST) with intravenous cyclophosphamide, an oral immunosuppressive agent, namely mycophenolate mofetil, azathioprine or leflunomide, and hydroxychloroquine (n = 95), or receive intravenous cyclophosphamide alone (n = 96) for 24weeks. Glucocorticoid was given to both groups. The primary end point was a complete remission with a most stringent standard as proteinuria < 150mg per 24h, normal urinary sediment, serum albumin, and renal function at 24weeks. The secondary end point was treatment failure at 24weeks. At week 24, both the rate of complete remission (39.5%) and total response (87.2%) was higher in the combined group, compared with CYC group (20.8% and 68.8%, p< 0.05). The cumulative probability of complete remission was also higher in the combined group (p= 0.013). In addition, the combined treatment was superior to routine CYC with less treatment failure (12.8% vs.31.2%, p< 0.001). No difference was found between the incidences of severe adverse events in the two arms: 3.2% (3/95 combined group) vs.4.2% (4/96 CYC group). Treatment with a combined immunosuppressive agent is superior to routine CYC only therapy in lupus nephritis.

Step-down steroid-sparing therapy in active thyroid eyedisease.

Intravenous steroid therapy in thyroid eye disease has limitations and is potentially harmful at high doses. A steroid-sparing approach is a reasonable option, but combination therapy must be tested in randomized clinical trials designed to establish the efficacy and the potentially increased risk of adverse effects of combined immunosuppressive treatment.

Combined Immunosuppressive Treatment May Improve Short-Term Renal Outcomes in Chinese Patients with Advanced IgA Nephropathy

Background/Aims: Treatment of advanced Immunoglobulin A nephropathy (IgAN) patients with estimated glomerular filtration rate (eGFR) below 45 mL/min per 1.73 m2 remains inconsistent. The aim of this study is to compare the effects of corticosteroid and immunosuppressant therapies among these patients. Methods: A total of 201 adult patients with advanced IgAN (eGFR < 45 mL/min/1.73 m2 and proteinuria > 1 g/24h at biopsy) grouped into supportive care (SC), steroids alone (CS), and steroids plus immunosuppressant (IT) groups, were investigated between 30th December 2002 and 30th June 2016. The primary endpoint was the combined endpoint of a 50% decline in eGFR and/or end stage renal disease (ESRD: eGFR < 15 mL/min/1.73 m2 or maintenance renal replacement treatment). Responses to therapy included complete remission (CR: urinary protein excretion < 0.5 g/24h, with eGFR decrease less than 10% baseline), partial remission (PR: proteinuria decrease by > 50% baseline, with eGFR decrease less than 10% baseline), no response (NR: proteinuria decrease < 50% baseline, or eGFR decrease > 10% baseline) and ESRD. Kaplan–Meier and Cox proportional hazards analyses were performed. Results: During the follow-up period (37.2 ± 22.7 months), 6.8% patients in SC group, 25.0% in CS group, and 38.0% in IT group achieved CR or PR, while 78.4%, 62.5% and 49.3% patients in these 3 groups reached primary endpoint respectively (p < 0.001). Three-year renal survival rates in SC and combined immunosuppressive treatment groups (CS and IT groups) were 33.8% vs 51.2% (p = 0.02), and 5-year renal survival rates were 12.2% vs 21.3% (p = 0.1) respectively. Multivariate Cox regression analysis showed that hypertension (HR = 2.44, 95% CI 1.51–3.95; p < 0.001), Scr (HR = 1.01, 95% CI 1.00-1.01; p < 0.001), T1-T2 lesion (HR = 1.99, 95% CI 1.35–2.93; p = 0.001) were independent indicators of poor renal outcome. Conclusion: Immunosuppressive treatment (CS and IT therapy) may improve short-term renal outcome compared with supportive treatment in advanced IgAN patients.

Risk factors for extraophthalmic involvement and treatment outcomes in patients with IgG4-related ophthalmic disease

Background/aimTo analyse the clinical risk factors for extraophthalmic involvement and treatment outcomes in patients with IgG4-related ophthalmic disease (IgG4-ROD) in Korea.MethodsWe retrospectively reviewed medical records of 42 patients diagnosed with...

The predictive role of enhanced CURB score in patients with pneumonia during combined immunosuppression treatment

Objective To explore the predictive value of enhanced CURB score in the prognosis of patients with community-acquired pneumonia (CAP) in the setting of immunosuppressive therapy. Methods Retrospective study of 156 CAP patients with diseases treated with immunosuppressive agents admitted from January 2012 to July 2016 was carried out. The patients were divided into survival group and death group, and comparisons of demographics of patients and clinical sitting between two groups were performed. The receiver operator characteristic(ROC) curve was used for the calculations of enhanced CURB score, CURB-65 score and qSOFA score measured to predict the 28-day outcome of patients as the clinical observation endpoint. The predictive value of three scoring systems was compared in the prognosis of CAP patients under immunosuppressive treatment using the area under the curve (AUC). Results Of 156 patients, there were 134 patients in survival group and 22 patients in death group. The statistically significant differences in measured results of three scoring systems between two groups were as follows: enhanced CURB score [8(6, 10) vs. 12(9, 13)], CURB-65 score [1(0, 2) vs. 2(2, 3)], and sSOFA score [0(0, 1) vs. 1(0, 1)] (P<0.05 in 3 scoring systems). According to ROC, the AUC of enhanced CURB score was 0.815, with sensitivity 50%, specificity 97.01%, the optimal cut-off value 11 (P<0.01); the AUC of CURB-65 score was 0.816, with sensitivity 81.82%, specificity 65.67%, the best cut-off value 1 (P<0.01); the AUC of qSOFA score was 0.642, with sensitivity 54.5%, specificity 73.1%, the best cut-off value 0 (P<0.01). There was a significant difference in score between qSOFA score and CURB-65 score, between qSOFA score and enhanced CURB score, but no significant difference between enhanced CURB score and CURB-65 score. Conclusions The enhanced CURB score has preferable predictive value in evaluating the prognosis of CAP patients during immunosuppressive treatment. Though its sensitivity is low, its specificity is superior to CURB-65 score and qSOFA score. Key words: Community-acquired pneumonia; Immunosuppression; CURB-65; Enhanced CURB; qSOFA

Baseline Wall Thickness Is Lower in Mucosa-Healed Segments 1 Year After Infliximab in Pediatric Crohn Disease Patients.

We aimed to quantitatively investigate the therapeutic response to combined immunosuppression treatment by magnetic resonance enterography (MRE) in active luminal Crohn disease (CD) in the pediatric population. Pediatric patients with moderate-to-severe luminal CD, who received scheduled infliximab and azathioprine, were included in this preliminary study. Ileocolonoscopy and MRE were performed at baseline and at 1 year, and Simple Endoscopic Score for Crohn's Disease (SES-CD) and Magnetic Resonance Index of Activity (MaRIA) scores were calculated. The correlation between SES-CD and MaRIA scores were investigated with analysis per person and per segment. A total of 167 segments from 17 patients were evaluated by both Ileocolonoscopy and MRE. SES-CD and MaRIA scores showed significant correlations on both per-person analysis (ρ = 0.699, P < 0.001) and per-segment analysis (ρ = 0.596, P < 0.001). Analysis according to ileocolonic location of each segment revealed that the correlation strength was strongest in the right colon (ρ = 0.653, P < 0.001), whereas the correlation in the rectum was statistically insignificant (ρ = 0.29, P = 0.096). A comparative analysis of MaRIA components revealed a significantly thinner bowel wall thickness at baseline in endoscopically healed segments (50/65) compared with unhealed segments (15/65) (median 4.3 vs 7.2 mm, P = 0.036). Therapeutic response to combined immunosuppression at 1 year assessed by MRE correlates with ileocolonoscopy in pediatric patients with CD. Bowel wall thickness of the involved segments at baseline may affect treatment response to combined immunosuppression.

Immunosuppressive Treatment Alters Secretion of Ileal Antimicrobial Peptides and Gut Microbiota, and Favors Subsequent Colonization by Uropathogenic Escherichia coli

Transplant recipients are treated with immunosuppressive (IS) therapies, which impact host-microbial interactions. We examined the impact of IS drugs on gut microbiota and on the expression of ileal antimicrobial peptides. Mice were treated for 14 days with prednisolone, mycophenolate mofetil, tacrolimus, a combination of these 3 drugs, everolimus, or water. Feces were collected before and after treatment initiation. Ileal samples were collected after sacrifice. Fecal and ileal microbiota were analyzed by pyrosequencing of 16S rRNA genes and enumeration of selected bacteria by culture, and C-type lectins were assessed in ileal tissues by reverse transcriptase-quantitative polymerase chain reaction. Prednisolone disrupted fecal microbiota community structure, decreased Bacteroidetes, and increased Firmicutes in the feces. Prednisolone, tacrolimus, and mycophenolate mofetil modified fecal microbiota at the family level in each experimental replicate, but changes were not consistent between the replicates. In ileal samples, the genus Clostridium sensu stricto was dramatically reduced in the prednisolone and combined IS drug groups. These modifications corresponded to an altered ileal expression of C-type lectins Reg3γ and Reg3β, and of interleukin 22. Interestingly, the combined IS treatment enabled a commensal Escherichia coli to flourish, and dramatically increased colonization by uropathogenic E. coli strain 536. IS treatment alters innate antimicrobial defenses and disrupts the gut microbiota, which leads to overgrowth of indigenous E. coli and facilitates colonization by opportunistic pathogens.

144 Evaluation of the Use of Combined Immunosuppression Treatment Regimens in the Sheffield Adult Uveitis/Scleritis Service

144 Evaluation of the Use of Combined Immunosuppression Treatment Regimens in the Sheffield Adult Uveitis/Scleritis Service

237 Evaluation of the Use of Combined Immunosuppression Treatment Regimens in the Sheffield Paediatric Uveitis Service

237 Evaluation of the Use of Combined Immunosuppression Treatment Regimens in the Sheffield Paediatric Uveitis Service

Two-year outcome of thymectomy with or without immunosuppressive treatment in nonthymomatous myasthenia gravis and its effect on regulatory T cells

BackgroundMyasthenia gravis (MG) is the autoimmune disorder in which the thymus is considered the pathogenic organ. Thymectomy (TE) is a therapeutic option for MG and often ameliorates clinical symptoms. MethodsWe evaluated clinical features and outcomes after TE in patients without thymoma and the influence of TE with or without concomitant immunotherapy on the CD4+CD25+ regulatory T cell subpopulation of lymphocytes in peripheral blood in defined followed groups of nonthymomatous MG patients. ResultsA total of 46 patients with generalized MG who underwent transsternal TE were identified. Neurologic outcomes after TE were favorable for the majority of patients mainly from the group treated with corticosteroids or combined immunosuppressive treatment. TEs with immunosuppressive treatment in MG patients were associated with increased percentages of CD4+CD25+ cells (p<0.001). No significant change in the postoperative levels of CD4+CD25+ cells was observed in thymectomized patients who preoperatively only received pyridostigmine. Also their clinical response to TE after 2years of follow-up was worst of all followed groups. ConclusionsThe exact mechanism by which TE ameliorates symptoms of MG is yet not clear. These observations indicate that increased percentages of CD4+CD25+ T cells in MG may be related to disease stability and that TE and synergistic effect with concomitant, continuing immunotherapy augmented the proportion of CD4+CD25+ T cells. On the basis of our observations TE alone is not enough to increase the number of circulating CD4+CD25+ regulatory T cells and to establish complete stable remission.

Polyarteritis nodosa complicating multiple myeloma – a case report and review of the literature

Polyarteritis nodosa (PAN) is a necrotizing vasculitis of small to-medium-sized vessels, rarely associated with hematologic neoplasms. We report a 44-year-old man with a history of monoclonal gammopathy of undetermined significance (MGUS) who presented with rapidly progressing sensorimotor peripheral neuropathy. Two weeks after onset the patient developed severe acute acral and retinal ischemia. MR-angiography and nerve biopsy revealed a systemic necrotizing vasculitis (PAN type). At this time, bone marrow biopsy identified a smoldering multiple myeloma. Immediate immunosuppressive and anti-neoplastic treatment (steroids, immunoglobulins, bortezomib combined with cyclophosphamide followed by lenalidomide maintenance) resulted in a favorable clinical outcome. After 4 years, the patient is in good clinical condition with sustained partial remission from myeloma and without evidence of relapse of PAN. This is a remarkable case of a histologically confirmed peripheral neuropathy due to polyarteritis nodosa associated with progression of MGUS to multiple myeloma. Immediate diagnosis and combined immunosuppressive and anti-neoplastic treatment may improve the outcome of this potentially life-threatening clinical condition.

Addition of immunosuppressive treatment to hemoperfusion is associated with improved survival after paraquat poisoning: a nationwide study.

Paraquat poisoning associates very high mortality rate. Early treatment with hemoperfusion is strongly suggested by animal and human studies. Although the survival benefit of additional immunosuppressive treatment (IST) in combination with hemoperfusion is also reported since 1971, the large-scale randomized control trials to confirm the effects of IST is difficult to be executed. Therefore, we designed this nationwide large-scale population-based retrospective cohort study to investigate the outcome of paraquat poisoning with hemoperfusion and the additional effects of IST combined with hemoperfusion. This nationwide retrospective cohort study utilized data retrieved from the National Health Insurance Research Database (NHIRD) of Taiwan. A total of 1811 hospitalized patients with a diagnosis of paraquat poisoning who received hemoperfusion between 1997 and 2009 were enrolled. The mean age of all 1811 study subjects was 47.3 years. 70% was male. The overall survival rate was only 26.4%. Respiratory failure and renal failure were diagnosed in 56.2% and 36% patients. The average frequency of hemoperfusion was twice. IST was added in 42.2% patients. IST significantly increases survival rate (from 24.3% to 29.3%, P<0.001). The combined IST with methylprednisolone, cyclophosphamide and dexamethasone associates with the highest survival rate (48%, P<0.001). Moreover, patients younger than 45 years of age in the IST group had the best survival (41.0% vs. 33.7%, p<0.001). Our results support the use of IST with hemoperfusion for paraquat-poisoned patients. The best survival effect of IST is the combination of methylprednisolone, cyclophosphamide and daily dexamethasone, especially in patients with younger age.

Epidemiology of pemphigus vulgaris in the Northeast China: A 10‐year retrospective study

The aim of the present study was to evaluate the incidence, epidemiological, clinical and therapeutic features of patients with pemphigus vulgaris in China. We retrospectively investigated a total of 221 patients with pemphigus vulgaris. The parameters including age at diagnosis/onset, sex, diagnostic methods, hospitalizations, side-effects with different treatments, pemphigus vulgaris-associated diseases, the therapeutic features and duration of follow up were evaluated. The male:female ratio was 1:1.40. The incidence rate was obviously higher in two age groups, 31-40years and 41-50years. The mean age at onset was 44.19±21.45years. The majority of patients (56.56%) presented the mucocutaneous type. In addition, we found that various doses of corticosteroids (including the mean initial dose, maximum control dose, total dose before reducing and hospitalized total dose) exhibited statistical differences between only corticosteroids and corticosteroids-immunosuppressant groups in mild, moderate and severe pemphigus vulgaris (P<0.05). Our survey suggested that pemphigus vulgaris most frequently occurred in the 41-50-year age group in China and the majority of patients manifested mucocutaneous lesions. Importantly, the incidence rate in females was higher than in males. The patients who needed combined immunosuppressant treatment, usually needed higher doses of corticosteroids initially, to control the disease and over the total course of treatment.