Challenges and Opportunities in Internal Medicine

Challenges and Opportunities in Internal Medicine

Chun-Man Chen

Yen-Ling Chen

Shu-Min Lin

Huang-Pin Wu

Jiun-Nong Lin

Kai-Huang Lin

Chin-Ming Chen

Kuang-Yao Yang

Shih-Chi Ku

Fu-Tsai Chung

Chih-His Kuo

Chien Tung Chiu

Chi-Kuei Hsu

Hsin-Hui Hsu

Chien-Ming Chu

Han-Chung Hu

Chung-Shu Lee

Shin-Hwar Wu

I-Chieh Mao

Ting-Yu Chao

Yi-Wen Chu

Du-Shieng Chien


The relationship between serum selenium levels and mortality was investigated in septic patients with severe selenium deficiency (baseline selenium ≤ 80 ng/mL). Eligible patients of sepsis or septic shock were randomized to receive Placebo or High-Dose Selenium (1,000 μg/day) via intravenous injection. Safety, serum selenium, mortality, SOFA, and Glasgow Coma Scale (GCS) scores were monitored. Among all 330 subjects, 27.9% subjects (n=92) had severe selenium deficiency (mean serum selenium = 66.5 ng/mL). Mortality of severe selenium deficiency patients was 27.2%, significantly higher than 17.9% of all subjects. In severe selenium deficiency Placebo group (n=45), 62% subjects showed gradual increase of selenium levels to ~110 ng/mL (mortality ~21.4%), while 38% subjects remained at low selenium ≤ 110 ng/mL throughout study (mortality ~41.2%). Mortality for Placebo subjects with normal baseline selenium ≥ 110 ng/mL was 13.6%. With High-Dose Selenium treatment, 91% of severe selenium deficiency subjects showed quick selenium increase to ~110 ng/mL (mortality 25.5%). Mortality was reduced to 8.6% for High-Dose Selenium subjects with baseline selenium ≥ 110 ng/mL. The odds ratio showed significantly greater survival of High-Dose Selenium subjects with baseline selenium ≥ 110 ng/mL (91.4%) than severe selenium deficiency Placebo subjects (74.1%). Mean baseline SOFA scores for severe selenium deficiency patients were 9.1–9.4, decrease of SOFA scores in High-Dose Selenium subjects was significantly greater than Placebo subjects, along with significant improvement of GCS scores. Repeated infusion of High-Dose Selenium in severe selenium deficiency patients for 14 days was safe and well-tolerated. Mortality for patients with sepsis was clearly affected by serum selenium concentrations. High mortality (41–50%) was observed in the sepsis patients constantly with low selenium £ 80 ng/mL; mortality was reduced to 21–23% if their serum selenium could be increased to ≥ 110 ng/mL. High-Dose Selenium resulted in rapid restoration of serum selenium and improved the survival of severe selenium deficiency septic patients. Low mortality (9–14%) was observed in the sepsis patients starting with baseline selenium ≥ 110 ng/mL. Overall this study demonstrates the significant impact of insufficient selenium levels on the mortality of septic patients. Treatment with high-dose selenium reduced the mortality of severe selenium deficiency septic subjects.

Wajid Ali Rafai

Ahmad Ussaid

Babar Riaz

Faisal Amin Baig

Sohail Anwar

Atif Masood

Rahma Fiaz

Khurram Saleem

Farrukh Iqbal


SARS-COV-2 emerged as pneumonia of unknown etiology and transforming into global pandemic leading mass casualties globally. It leads to serious complications with a wide range of symptoms and laboratory and radiological abnormalities.

Methodology: This retrospective study included 191 admitted patients was conducted between 15 April 2020 and 31 August 2020 at university of Lahore teaching hospital, Lahore, Pakistan. Baseline demographics, clinical, laboratory and radiological characteristics were compared amongst disease severity categories with One way ANOVA and comparison amongst recovered and non-recovered was carried out  by independent t test, Fisher’s exact and chi-square test respectively.  All data were analysed in SPSS 25 and p-value <0.05 was considered significant.

Results: Out of 191 patients enrolled in this study, majority were male and above 50 year age. Fever (68%) was the most common symptom though dyspnea was statistically significant (p-value<0.05) and diabetes (41.4%) being the most common comorbidity. A statistical significant downtrend in eosinophil counts were observed in critical and severe disease from non-severe disease and similar trend was observed in non-recovered (died) patients than recovered. A significant rise in neutrophil to lymphocyte ratio, crp, ferritin and d-dimer were observed amongst critical and severe disease and non-recovered patients (p-value<0.05). Patients with eosinopenia had low survival proportion at day 5 and 10 than those with relatively normal eosinophil counts.

Conclusion: Patients with advanced age, multiple comorbidities, elevated hematological, deranged coagulation markers presented with more severe disease and had poor outcome. In particular, eosinopenia can play key role in early diagnosis, disease severity recognition and disease surveillance as it is an independent risk factor for prognosis.

Preeti Malik, MD, MPH

Azka Zergham, MBBS

Neel Patel, MBBS

Yasameen Kerakhan, MBBS

Shamima Somi, MD

Nagaraj Sanchitha Honganur, MBBS

Aelia Akbar, MD, MPH

Aran Deol, MD

Richa Jaiswal, MD

Janice L. Gabrilove, MD, FACP

Urvish Patel, MD, MPH


Background and Objective: Few small observational studies have described various therapeutic interventions utilized in coronavirus disease 2019 (COVID-19) patients based on single/multi-center experiences across the globe. Understanding the utilization of available and possible treatments to curb the COVID-19 pandemic is paramount. We aimed to identify the prevalence and disease-associated utilization of specific therapeutic reagents in hospitalized COVID-19 patients as a function of severity status.

Methods: In systematic review and meta-analysis, extracted data on treatments utilized and severity of COVID-19 hospitalized patients from observational studies using PRISMA guidelines from December 1, 2019 to August 20, 2020. The pooled prevalence and odds of treatment utilization were obtained, and created forest plots using random‐effects models. 

Results: 29 studies with 8570 COVID-19-positive patients were included. Higher odds of the utilization of steroids (pooled OR:4.47; 95%CI:3.18–6.28; p<0.00001), antibiotics (3.1;1.81–5.30; p<0.0001), and IV Immunoglobulin (IVIG) (3.76;2.11–6.72; p<0.00001) was observed in patients with severe disease. No association of remdesivir (initially administered via clinical trials and subsequently FDA-approved during this study period), lopinavir/ritonavir, or hydroxychloroquine (HCQ) treatment with the severity of disease was observed.

Conclusion: Higher utilization of steroids, lopinavir/ritonavir, antibiotics, hydroxychloroquine (HCQ), and IV Immunoglobulin (IVIG) was observed in severe COVID-19 patients. Due to limited studies on remdesivir, its accurate utilization could not be delineated. Currently, no Level A evidence favoring single-drug treatment for COVID-19 exists, and trials are needed of combination therapy to evaluate efficacy on the survival outcome.

Ammouri W

Harmouche H

Khibri Hajar

Maamar Mouna

Mezalek Tazi Zoubida

Adnaoui Mohamed


Macrophage activation syndrome can be primary with a genetic etiology, or secondary, associated with malignancies, infections or systemic diseases. Its a severe and potentially life-threatening complication of autoimmune diseases. The incidence of MAS among patients with systemic lupus erythematosus is not well known, as most of the previous studies were limited to a small number of case series or case reports. In recent years it has been suggested that macrophage activation syndrome in systemic lupus erythemaosus may be underrecognized because it can mimic the clinical features of the underlying disease or be confused with an infectious complication. The diagnosis of macrophage activation sydrome in adults is supported by hyperferritinemia (higher than 2000 ng/ml), and/or splenomegaly, pronounced cytopenias, hypofibrinogenemia, characteristic cytokine profile and hypertriglyceridemia. In the case of systemic lupus erythematosus flare, hyerferritinemia is the strongest indicator to differentiate them from MAS. So far, no validated and universally embraced diagnostic criteria for macrophage activation syndrome in adult secondary to systemic lupus erythematosus are available. It is important to know the parameters that can guide the clinician towards the diagnosis of macrophage activation syndrome in adult with systemic lupus. Early diagnosis and intensive therapy are essential in improving clinical outcomes. Hence, we decided to write this mini- review to focus on the demographic data, on the pathophysiological mechanisms, clinical and laboratory manifestations, treatments, and outcomes of patients with systemic lupus erythematosus associated macrophage activation syndrome.

Panagiota Xaplanteri Zoitopoulos

Vasiliki Diamanti

Athanasia Moutafidi

Panagiota Masoura

Charalampos Potsios

Konstantina Filioti

Angeliki Rapanou

Christina-Panagiota Koutsouri

Zoi Grammenidou

Aimilios Tzoudas

Chara Sakarelou

Tatiana Beqo Rokaj

Katerina Ntzinia

Elsa Kampos Martinez

Georgios Papachristopoulos

Constantinos A Letsas


Background: Since December 2019 mankind is agonized over the deadly coronavirus disease 2019 (COVID-19) which is due to the novel coronavirus (2019-nCoV) or Severe Acute Respiratory Syndrome Coronavirus-2 (Sars-cov-2).

Methods: In this retrospective study, laboratory findings and demographic features form all confirmed COVID-19 patients who attended the Emergency Department of both branches of our hospital during the first semester of 2021 were collected and analyzed. The working hypothesis was that initial laboratory data at the time the patients seeked medical assistant for the first time, regardless of comorbidities and day of onset of symptoms, can help predict patients’ outcomes. Demographic data and laboratory tests were compared between hospitalized and non-hospitalized patients.

Results: Data of 270 patients were collected and analyzed retrospectively. 31 blood measurement parameters performed in both hospital branches were compared between hospitalized and non-hospitalized patients. Of those, WBC count (p=0.016), neutrophil percentage (p<0.001), lymphocyte percentage (p<0.001), platelet count (p=0.041), glucose (p<0.001), urea (p<0.001), creatinine (p<0.001), SGOT (p=0.024), CK (p<0.053), LDH (p<0.001), GGT (p<0.001), sodium (p<0.001), calcium (p<0.001), high sensitivity Troponin I (p<0.001), and ferritin levels (p<0.001), proved statistically significant. Regarding demographic data, age was significantly linked to patients’ survival.

Conclusion: Our data suggest that common initial laboratory findings of COVID-19 patients who seek for the first-time medical assistant regardless of comorbidities and time from onset of symptoms can give clues to the patient outcome. Age is also important for patients’ survival. Especially in a Primary Health Care Setting, common blood parameters like WBC count, neutrophil and lymphocyte percentage, platelet count, glucose, urea, creatinine, SGOT, CK, LDH, GGT, sodium, calcium, high sensitivity Troponin I, and ferritin levels, could be really helpful to predict disease severity.

Richard Z Cheng, MD, PhD

Michael Passwater

Tievi Yang, MD


For over 3 years, the Covid-19 pandemic felt like a world war and has taken close to 7 million lives, disabled many more people, and caused innumerable economic losses around the globe. What can we learn from this tragedy? Are we ready for another Covid-19-like pandemic? Studies show that the majority of people with SARS-Cov-2 infection either show no symptoms or only mild to moderate clinical manifestations; only a small percentage develop severe Covid-19 disease, indicating that the clinical severity of Covid-19 disease is not determined only by the SARS-Cov-2 virus, but more importantly by how the host responds to the viral infection, what is known as natural immunity. Research of what enhances or weakens the natural immunity against viral infections and the practical application thereof is an important lesson one can learn from the pandemic. Research of natural immunity enhancing factors is summarized in this paper. One key characteristic of natural immunity against viral diseases is its non-specificity. The importance of this non-specificity helping to prevent and treat other infections of known or unknown viruses is also discussed. Calls for the clinical application of safe and inexpensive nutrients such as vitamin C in the prevention and treatment of Covid-19 have met significant resistance and objection from the medical authorities and the media since the pandemic outbreak. The main objection is the perceived lack of research and the absence of regulatory approvals. This raises a fundamental philosophical question: what is the primary goal of the medical profession? Facing a new viral pandemic like Covid-19 with no prior research, let alone any approved treatments, why is there opposition to known safe, inexpensive, widely available and often effective nutrients like vitamin C? Why are case reports and case series discounted or ignored rather than explored further to try to help more people? Is such objection protecting consumers or harming the public? Statistics show that viral epidemics and pandemics are occurring more frequently, with a recent review of epidemics and pandemics since 1600 concluding “ the yearly probability of occurrence of extreme epidemics can increase up to threefold in the coming decades.”1. When the next Covid-19-like pandemic of a new virus hits us, are we going to repeat the Covid-19 tragedy? Can improved emphasis on nutritional interventions to prepare for and respond to disease outbreaks mitigate future pandemics?

Aaron I. Vinik, M.D., Ph.D.

Etta J. Vinik, MEd.

Ying-Chuen Lai, M.D.

Steven Morrison, Ph.D.

Sheri R. Colberg, Ph.D.

Serina Neumann, Ph.D.

Joshua Edwards, MS.

Scott Gerwe, M.D

Carolina Casellini, M.D.

Henri Parson, Ph.D.


Aims To explore the impact of the autonomic nervous system function in “disease-free” people for testing and appropriate therapies in different age-groups.

Methods Seventy-five disease-free volunteers who participated in a previous study were randomly selected from five age-groups (30-79 years) for a cross/sectional study to assess the impact of fatigue on cardiac/autonomic function by analysis of heart rate variability (HRV) and measures of cognitive and physical fatigue on quality-of-life-fatigue (QOLF) scores. Written informed consent was obtained and protocol approved. To induce fatigue, three 5-minute walking trials were performed on an instrumental treadmill, increasing the incline in increments of 2°/min to measure perceived exertion (RPE) at the beginning and end of each trial. Polar monitors measured heart rate (HR); a modified Borg 10-point scale measured RPE. Cardiac autonomic reflex tests (CART) with time/frequency domains analyzed HRV. QOLF scores were measured and analyzed for correlation with sympathetic/parasympathetic function on the Norfolk QOL-F fatigue scale.

Results QOL-F scores were not significantly different among 5 age groups, likely due to wide standard deviations and small subject numbers. Significant correlations between overall fatigue severity and several indices of HRV were found, independent of age, gender, and body mass index (p<0.05). Self-rated physical fatigue and compromised activities of daily living (ADLs) were related to sympathetic hyperactivity and autonomic imbalance (p=0.04). Participants in the (70–79-year-olds) category had impaired scores.

Conclusions The study identifies a relationship between autonomic nervous system function and cognitive and physical fatigue even in “disease-free” people in different age- groups and suggests that fatigue is impacted by somatic and autonomic nerve function. Higher self-ratings of perceived fatigue were associated with sympathovagal hyperactivity. Impaired HR response to exercise in older people corresponding with vagal over-activity, and paradoxically, best self-rated QOL-F, mandates clinical autonomic dysfunction testing and lifestyle therapies to prevent catastrophic events.

Mohammed Shaban

Franklin Sosa

Jose Lopez

Gustavo J. Duarte

Justin D. Mark

Asma Khizar

Swati Jain

Rishabh Mishra

Miguel Rodriguez Guerra

Timothy J Vittorio


SARS-CoV-2 is a highly contagious viral illness that started the COVID-19 pandemic in March 2020. Accumulating evidence suggests that the cardiovascular system is primarily affected by SARS-CoV-2. Cardiovascular complications such as myocarditis, acute coronary syndrome, heart failure, arrhythmias, and venous thromboembolism have been reported. The role of cardiac biomarkers in diagnosing and monitoring COVID-19 patients is becoming of particular interest, as it may provide insights into the underlying mechanisms of cardiovascular injury and inform clinical decision-making.

Troponins, specifically troponin I, have been widely studied and was proven to be elevated in COVID-19 patients with myocardial injury, indicating a negative prognostic indicator and association with poorer outcomes. Elevated levels of Natriuretic peptides, such as B-type natriuretic peptide (BNP), have been noted in severe COVID-19 cases and are associated with higher mortality rates. However, it is essential to consider that elevated natriuretic peptide levels in COVID-19 patients may also be influenced by factors other than heart failure. CK-MB, a subtype of creatine kinase, has been found to have significantly higher concentrations in COVID-19 patients with high disease severity or non-survivor status, suggesting its potential as a biomarker for risk stratification in this population. Myoglobin and lactate dehydrogenase (LDH) are additional cardiac markers that can indicate heart muscle damage, but their specificity in COVID-19 patients may be limited.

The widely used cardiac markers provide valuable diagnostic and prognostic information about cardiac injury and function in COVID-19 patients. Still, their performance characteristics and interpretation should be considered in the context of the individual patient and conjunction with other clinical assessments.

Wen Liu

Mark Gonn

Susanna von Holst

Jessada Thutkawkorapin

Xiang Jiao

Jan Björk2

Ann-Sofie Backman

Kristina Lagerstedt-Robinson

Annika Lindblom


Colorectal cancer (CRC) is a multifactorial disease, where both the environment and genetics play a role. It is estimated that approximately 35% of CRCs have a potentially identifiable genetic cause. Well-known and highly penetrant genetic causes make up less than 5% of all CRC, and leave many families not explained by known predisposing genes/mutations. Low penetrant alleles have also been thought to modify the risk of CRC. Linkage studies have been successful in discovering and localizing highly penetrant genes in CRC and risk loci has become possible to discover performing genome wide association studies (GWAS).

In this study we have analyzed families with CRC where individuals with CRC as well as individuals with premalignant lesions, adenomas, were codes as affected. In total 600 individuals in 121 families were included in the study.

In total three genomic regions were found with suggestive linkage located at 4p16.3, 6p24.3 and 10p14. These regions were further studied using sequencing analysis and association studies using haplotypes.

Amy J. Armstrong

Carolyn E. Hawley

Ya Su

Anat Marmor

Sigal Sviri

Isabella Schwartz

Shimon Siri

Zeev Meiner


While COVID-19 has had a detrimental impact on most of the world’s population, it has especially affected health care workers (HCWs) who are on the front lines fighting the virusHow HCWs cope with the pandemic have recently been explored. Differences across cultural and health care system settings related to fear of COVID 19 and measures of wellbeing may provide further insight to the coping mechanisms and experiences of HCWs during this worldwide pandemic. The overall subjective well-being and meaning in life scores are noticeably higher for the American participants whereas the fear of COVID and resilience scores are close in both studies, with slightly higher resilience and lower fear in the Israeli HCWs. Age, ethnicity and lower resilience were found to be significantly associated with higher fear of COVID-19 in both cohorts. In the Israeli participants, education level and life satisfaction were also associated with lower fear of COVID19 whereas in the American cohort, gender and relationship were also associated. These results suggest that albeit the cultural differences, similar mechanisms namely age and resilience, are important in coping with fear of the COVID-19 pandemic among both cohorts of HCWs. Therefore, it is important to enhance resilience in order to reduce the psychological burden of the pandemic among HCWs. This study was conducted prior to the availability of a vaccine.

Ali Hamdan

Amir Omar

Rayane Salameh

Pierre Hani


Cholangiocarcinoma, an adenocarcinoma arising from the epithelium of biliary ducts, is considered the second most common hepatic malignancy after hepatocellular carcinoma with increasing incidence over the past 3 decades. Many imaging modalities with correlation to clinical presentation are used for the diagnosis and staging of cholangiocarcinoma. However, the diagnosis of cholangiocarcinoma is still challenging due to the presence of some benign and malignant conditions that mimic the clinical presentation and radiological findings of this disease. One of those mimics is the condition of intrabiliary hydatid cyst rupture which can cause biliary obstructive symptoms over weeks with radiological findings that may be indistinguishable from those of cholangiocarcinoma and specifically klatskin tumor when found at the bifurcation of the common hepatic duct. In such a confusing situation, the correct preoperative diagnosis and potential treatment of the disease could both be made possible using Endoscopic Retrograde Cholangiopancreatography avoiding unrequired surgical interventions.

Survival Benefit of High Dose Versus Usual Dose of Baricitinib in Hospitalized Patients with COVID-19: A Systematic Review

Shihan Mahmud Redwanul Huq, Dr

Raziuddin Ahmed, Dr

Md Mahiuddin Ahmed, Dr Raihan Rabbani, Dr

Md Jahidul Hasan

Ahmad Mursel Anam, Dr


Baricitinib is an oral selective Janus kinase 1 and 2 inhibitor with known anti-inflammatory and anti-viral properties. In patients hospitalized for coronavirus disease 2019 (COVID-19), baricitinib has shown to reduce the risk of death in line with dexamethasone and tocilizumab. However, the most effective and safe dose or optimal dose of baricitinib in severe COVID-19 was not addressed.

We conducted this systematic review to assess whether higher than usual dose could further improve survival as primary outcome. The need of ICU (Intensive care Unit) and Invasive or non-invasive positive pressure ventilation, time to wean from oxygen, length of stay at hospital and adverse events were analyzed as secondary outcome.

We included 10,032 patients in 5 studies (2 randomised control trials and 3 high quality clinical trials). Among them,5,071 patients received baricitinib at different dosage (4909 patients received 4 mg once daily and 162 patients got more than 4 mg daily) and 4961 received standard of care. Baseline characteristics including mean age, sex, co-morbidities, inflammatory marker (C-reactive protein/CRP) were similar across the intervention and standard care groups.

4 out of 5 trials showed significant survival benefit in baricitinib group usual to higher dose (4 to 8 mg daily). Use of higher dose in 3 controlled trials was associated with significant reduction in admission to ICU and requirement of invasive or non-invasive ventilation support, shortening of hospital stay and earlier stabilization of oxygen status which was not evident in two randomized control trials using usual dose (4 mg daily). There was no significant difference in any serious adverse events or opportunistic infections between higher dose versus usual dose group.

Therefore, baricitinib in higher dose could be a potent, highly effective and safe immunomodulatory drug in hospitalized patients with severe COVID-19.

Gustavo Alexis Lemus-Barrios

Jesus Beltrán España

Luisa Fernanda Rincón Benavides

Edward Andrés Cáceres Méndez

Angel Alberto García Peña


Extended dual antithrombotic therapy, which entails the concurrent administration of acetylsalicylic acid and a P2Y12 inhibitor or anticoagulant beyond the initial 12 months of presenting with acute coronary syndrome, has been the subject of considerable research in recent years. The objective of this study was to evaluate the impact of dual antithrombotic therapy in stable coronary artery disease. We conducted a registered (PROSPERO CRD42023394771) assessing the safety and efficacy of antithrombotic therapy published over the past 20 years up to May 2021 in four databases (PubMed, EMBASE, BVSalud /LILACS, Cochrane Reviews). Using the RoB2 tool, we evaluated the risk of bias. We performed a literature search using keywords and identified 95 eligible articles, of which 23 were excluded as duplicates. After applying the inclusion and exclusion criteria, we found 29 articles for a detailed review and assessment of bias by applying the ROB2 toll, and we found that five articles had a low risk of bias. Our analysis found that extended dual antithrombotic therapy reduces ischemic cardiovascular outcomes, but it comes at the cost of an increased risk of bleeding when compared with acetylsalicylic acid monotherapy.

Neglected Tropical Diseases key aspects for the rheumatologist

Anouk Le Goueff

David Jayne

Charlotte Martin

Eric Hachulla

Frédéric Vandergheynst

Nicky Longley


Neglected tropical diseases (NTDs) are a group of 20 infectious diseases that are no longer restricted to tropical regions and that will be increasingly encountered by physicians of the Northern hemisphere.

In this article, we review key aspects of tropical medicine relevant for rheumatologists or doctors working with autoimmune diseases or immunosuppressive drugs in order to be aware of NTDs, look out for them and prevent their complications.

The article addresses four main topics:

    • eosinophilia workup,
    • rheumatic presentations of NTDs, such as myositis or arthritis
    • lupus, granulomatosis with polyangiitis or vasculitis mimickers, such Leishmaniasis, Leprosy or Human African Trypanosomiasis and
    • screening before starting immunosuppression, including Strongyloidiasis and Chagas disease

With this review, we intend to raise awareness for NTDs amongst rheumatologists and internists working in the Northern hemisphere. NTDs should be considered and excluded in patients with relevant travelhistory or exposure in following situations:

    1. during the differential diagnosis of a suspected new autoimmune condition,
    1. in case of poor response or flare of symptoms on initiating immunosuppressive therapy,
  1. during systematic screening prior to starting immunosuppressive medication, along with blood born viruses and tuberculosis.

Amorn Sankhaanuruk, M.D.

Nuntana Kasitanon, M.D.

Worawit Louthrenoo, M.D.


Background: Nowadays, we have standard treatment guidelines for lupus nephritis (LN), a substantial proportion of patients have LN flare. The aims here to determine the incidence of LN flare in patients who had renal complete remission (CR) after receiving induction therapy (IT) and to identify factors associated with renal flare after CR in clinical practice.

Methods: Retrospective analysis in a tertiary-level center for the clinical outcomes of patients who had first LN episode, achieved CR (24hr urine protein <0.5 gm/day with normal renal function) within 12 months after received IT and received the maintenance therapy (MT).

Results: Eighty-seven out of 548 patients (96.6% female with mean age 29.5±10.8 years) met the inclusion criteria. During 6.1±3.4 years of observation after CR, 42 (48.3%) patients had LN flare. The incidence ratio of LN flare was 10.9/100 patient-years. The mean time from CR to flare was 3.1 years. Using Cox-regression analysis, induction to remission therapy ≥6 months (OR=0.33, p=0.006), and using statins ≥9 months after reached CR (OR=0.44, p=0.032) had a lower incidence of LN flare, while age at onset of disease ≤20 years had a higher incidence of LN flare.

Conclusion: Despite achieving CR with standard treatment, almost half of the patients had an LN flare within a few years. Young SLE patients had an increased incidence of LN flare, the long period of induction therapy and using statins may retard a flare of the disease.

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