Transcranial direct current electrical stimulation in combination with aerobic exercise: A pilot study in post-COVID-19 systemic autoimmune rheumatic patients

BACKGROUND

Systemic autoimmune rheumatic diseases (SARDs) are a group of diseases with multiorgan involvement and a high prevalence of chronic pain and fatigue. Patients with SARDs and post-coronavirus disease 2019 (COVID-19) syndrome experience aggravation of symptoms. In this context, it is essential to establish strategies to reduce chronic pain and fatigue and improve quality of life.

AIM

To assess the efficacy of transcranial direct current stimulation (tDCS) for the treatment of fatigue and pain-associated post-COVID-19 syndrome in patients with SARDs.

METHODS

This study included nine patients with different types of SARDs. All patients had reverse transcription-polymerase chain reaction (RT-PCR) test confirmed COVID-19 as well as significant, persistent fatigue and pain that began to worsen after infection. Anodal tDCS was administered in five daily sessions (2mA, 20 min). Concomitantly, patients were involved in aerobic exercise program. All participants were evaluated using specific questionnaires and strength assessment by handgrip and physical function by timed-up-and-go test and sit-to-stand test at baseline (within one week before tDCS protocol), and one week after tDCS protocol. During all procedures, the patients’ treatments remained unchanged.

RESULTS

The sample comprised eight women and one man with a mean age of 48.7 ± 9.6 years. After the tDCS protocol, pain and fatigue significantly improved on the visual analog scale (P < 0.05). The physical function also improved 9.5 ± 2.7 vs 6.8 ± 0.8 (P = 0.001) for timed-up-go-test and 10.3 ± 3.7 vs 15.1 ± 4.0 (P = 0.037) for sit-to-stand test. None of the patients experienced any adverse events.

CONCLUSION

The present study showed that tDCS in combination with aerobic exercise was effective in improving physical function, and reducing fatigue/pain in SARDs patients with post-COVID-19 syndrome.

Greater awareness of biosimilars and shared decision-making among patients attending rheumatology practices in Colorado, United States: Real-world data

BACKGROUND

There is a lack of studies and educational programs focused on biosimilars and shared decision-making among patients diagnosed with various rheumatic diseases.

AIM

To improve knowledge and awareness of biosimilars and shared decision-making among patients attending rheumatology practices in Colorado as well as to assess a rheumatology patient’s interest in discussing biosimilars as well as shared decision-making with others (e.g., medical professionals, family members, friends).

METHODS

Our goal was to work with 80 rheumatology teams in Colorado.  We developed and distributed 2000 multi-page brochures to each participating office and later conducted an online anonymous survey.

RESULTS

There were a total of 49 (2.5%) rheumatology patients who responded to our survey. After reading our educational booklet, many survey respondents identified the correct answer in most questions focused on biosimilars or shared decision-making. Our survey results suggest that patients attending rheumatology practices in Colorado are generally not involved in discussions with their providers regarding treatment plans or options. The improvement in scores after reading our educational materials was statistically significant for biosimilars and shared decision-making.

CONCLUSION

Overall, the level of knowledge and awareness of biosimilars and shared decision-making among patients attending rheumatology practices in Colorado was low. More educational programs as well as follow up trainings to measure changes in knowledge and awareness regarding biosimilars and shared decision-making among patients attending rheumatology practices are recommended.

Association between sarcopenia and rheumatological diseases

Sarcopenia (“sarx” for muscle, “penia” for loss) is an important problem in the elderly. Although muscle loss is a part of natural aging, excessive loss that limits physical activity is considered pathological. Sarcopenia is associated with age, malnutrition, physical inactivity, inflammatory stress and hormonal changes. Although relationships between sarcopenia and various chronic inflammatory diseases have been shown, the role of rheumatologic disease in sarcopenia development is currently unknown. Our aim in this mini-review was to increase the awareness of clinicians to sarcopenia, and to evaluate studies in which the relationship between sarcopenia and rheumatologic diseases was investigated. We also aimed to determine whether the available literature was sufficient to confirm a strong relationship between these conditions. Although our findings showed that diseases such as rheumatoid arthritis, osteoarthritis and systemic sclerosis may have a role in sarcopenia development and progress, the methodologies and results of the majority of studies were insufficient in determining direct causal relationships. We believe future studies would benefit from focusing on the factors and causes of sarcopenia, with a goal of determining the factors associated with rheumatologic disease that are most effective in sarcopenia development.

Maligned non-steroidal anti-inflammatory drugs: Misunderstanding of their safety profile in patients with renal insufficiency

Non-steroidal anti-inflammatory drugs have a fundamental and pivotal position in management of many of the disorders managed by rheumatologists. Promulgation of a false perspective of their toxicity has compromised our ability to advise our patients and participate in the management of their disorders. The literature sources, from which the false perspective derives, do not accurately reflect safety and fail to address the value of appropriate drug use monitoring. We, as rheumatologists, must stand up and proactively address engrained misconceptions-if we are to be able to continue to provide safe, effective care for our patients.

Physicians’ knowledge and attitude regarding bisphosphonates-related adverse events: An observational study

AIM

To assess the knowledge and attitude of Lebanese physicians regarding bisphosphonates (BPs)-related complications.

METHODS

An observational cross-sectional study was conducted at a major tertiary teaching hospital in Beirut city, and its affiliated primary health care center. Data were collected through a new self-administered questionnaire distributed via a delegated secretary to physicians expected to regularly prescribe BPs (n = 215). It assessed participants’ knowledge, fear and experience regarding BPs-reported complications.

RESULTS

One hundred and fifty-seven physicians fulfilled the questionnaire (response rate: 73.0%): 77.7% and 75.2% considered that gastrointestinal intolerance and osteonecrosis of the jaw are linked to BPs, respectively. Conversely, the least recognised complications are ocular inflammation (7.6%) and severe musculoskeletal pain (37.6%). The association of BPs with oesophageal cancer, atrial fibrillation and hepatotoxicity was reported by 11.5%, 13.4% and 24.8% of respondents, respectively. The multivariate analysis showed a significant association between level of knowledge and physicians’ department affiliation (P-value = 0.043), their gender (P-value = 0.044), whether or not they prescribe a BP (P-value = 0.012), and the number of BP prescriptions delivered monthly (P-value = 0.012). Physicians are mainly concerned about osteonecrosis of the jaw and nephrotoxicity when prescribing a BP. Yet, the complications commonly met in their practice are gastrointestinal intolerance (44.6%) and acute phase reactions (26.7%).

CONCLUSION

This study revealed the presence of a deficient knowledge regarding BPs-related adverse events among our physicians. Professional training proposals are needed to increase their knowledge and improve their practices. Pharmaceutical industries should reconsider the instructions they provide to physicians regarding the complications of medications they promote. Moreover, they must actively collaborate with education providers and institutions in educational interventions.

Exercise reduces depressive symptoms in adults with arthritis: Evidential value

AIM: To determine whether evidential value exists that exercise reduces depression in adults with arthritis and other rheumatic conditions.

METHODS: Utilizing data derived from a prior meta-analysis of 29 randomized controlled trials comprising 2449 participants (1470 exercise, 979 control) with fibromyalgia, osteoarthritis, rheumatoid arthritis or systemic lupus erythematosus, a new method, P-curve, was utilized to assess for evidentiary worth as well as dismiss the possibility of discriminating reporting of statistically significant results regarding exercise and depression in adults with arthritis and other rheumatic conditions. Using the method of Stouffer, Z-scores were calculated to examine selective-reporting bias. An alpha (P) value < 0.05 was deemed statistically significant. In addition, average power of the tests included in P-curve, adjusted for publication bias, was calculated.

RESULTS: Fifteen of 29 studies (51.7%) with exercise and depression results were statistically significant (P < 0.05) while none of the results were statistically significant with respect to exercise increasing depression in adults with arthritis and other rheumatic conditions. Right-skew to dismiss selective reporting was identified (Z = -5.28, P < 0.0001). In addition, the included studies did not lack evidential value (Z = 2.39, P = 0.99), nor did they lack evidential value and were P-hacked (Z = 5.28, P > 0.99). The relative frequencies of P-values were 66.7% at 0.01, 6.7% each at 0.02 and 0.03, 13.3% at 0.04 and 6.7% at 0.05. The average power of the tests included in P-curve, corrected for publication bias, was 69%. Diagnostic plot results revealed that the observed power estimate was a better fit than the alternatives.

CONCLUSION: Evidential value results provide additional support that exercise reduces depression in adults with arthritis and other rheumatic conditions.

Role of leptin in the progression of psoriatic, rheumatoid and osteoarthritis

Leptin, an adipokine responsible for body weight regulation, may be involved in pathological processes related to inflammation in joint disorders including rheumatoid arthritis (RA), osteoarthritis, and psoriatic arthritis (PsA). These arthropathies have been associated with a wide range of systemic and inflammatory conditions including cardiovascular disease, obesity, and metabolic syndrome. As a potent mediator of immune responses, leptin has been found in some studies to play a role in these disorders. Furthermore, current potent biologic treatments effectively used in PsA including ustekinumab (an interleukin 12/23 blocker) and adalimumab (a tumor necrosis factor-alpha blocker also used in RA) have been found to increase leptin receptor expression in human macrophages. This literature review aims to further investigate the role leptin may play in the disease activity of these arthropathies.

Roles of plasmablasts in IgG4-related disease and various immune-based diseases

IgG4-related disease (IgG4-RD) is a systemic fibro-inflammatory disease with multiple organ disorders. Recently, in IgG4-RD, increased circulating plasmablasts have been found. The subsets of plasmablasts are negative for RP105 (CD180). A large population of B cells lacking RP105 (RP105-negative B cells) are found in patients with active with systemic lupus erythematosus and other systemic autoimmune diseases, including dermatomyositis, and Sjögren’s syndrome. In other conditions, such as neuromyelitis optica, Kawasaki’s disease, primary biliary cirrhosis and aging, RP105 expression on B cells and monocytes also alters. We review the basic science and clinical significance of RP105-negative B cells including plasmablasts in various immune-based diseases. RP105-negative B cells, especially plasmablasts, play crucial roles in both systemic and organ-specific autoimmune and inflammatory disorders.

Return to clinical in contrast to serologically-based diagnoses

The future of rheumatology is predicated upon a return to basics. The advent and facile availability of laboratory testing led to reduction of emphasis on clinical skills. Recognition that immunologic abnormalities are not limited to individuals who clearly have related pathology provides new motivation for reorientation of training programs to assure that graduates have appropriate information gathering, diagnostic and procedural skills. Inadequate accessibility to rheumatologic care requires innovative approaches and especially training and educating those individuals who provide primary care. While the rheumatologist can elicit the patient’s history remotely, telerheumatology will be feasible only when the individual interacting physically with the patient has confidence in their examination skills and when those skills have been validated. Named syndromes or diseases will be modified to avoid impugning the individual or compromising their future access to health, disability and life insurance. Interventions will be pursued in a more cost-effective, evidence-based manner. The future of rheumatology is dependent upon the rheumatologist’s ability to amortize the inadequate reimbursement for direct patient interaction, depending on skills of interpretation of standard X-rays, ultrasound performance and results.

Scleroderma: Not an orphan disease any more

Scleroderma (or systemic sclerosis) is a rare disease associated with significant morbidity and mortality. Although previously thought to have a uniformly poor prognosis, the outlook has changed in recent years. We review recent insights into the pathogenesis, clinical features, assessment and management of scleroderma.

Complementary medicine use in rheumatology: A review

Complementary and alternative medicine (CAM) use is increasing worldwide; specifically it appears that these treatment modalities are popular among rheumatology patients. The most commonly reported CAM therapies are herbal medicines, homeopathy, chiropractic, acupuncture and reflexology. Despite high reported rates of CAM use, the number of patients disclosing use to their rheumatologists remains low. This review highlights rates of current CAM use in rheumatology in studies performed worldwide, and discusses potential reasons for nondisclosure of CAM use to clinicians.

Epigenetic targets of rheumatoid arthritis

Rheumatoid arthritis (RA) is a systemic, inflammatory and autoimmune disorder, characterized by chronic arthritis with progressive joint destruction. It has a multifactorial aetiology involving both genetic and environmental factors. Epigenetics can be defined as modifications of DNA that result in altered gene expression. The two main epigenetic mechanisms are post translational modifications to histone tails and DNA methylation. Recent evidence has suggested that epigenetic mechanisms may be an important contributor to RA susceptibility. The aim of this editorial is to present evidence for the role of epigenetic mechanisms in the pathogenesis of RA and the potential to therapeutic target. Several studies targeting histone modification and DNA methylation in animal models of inflammatory arthritis will be reviewed and alterations in the epigenetic signature of genes of key RA related pathways such as pro-inflammatory cytokines, proteases and regulators of cellular proliferation.

Current review of trapeziometacarpal osteoarthritis (rhizarthrosis)

Trapeziometacarpal (TMC) joint is the secondly affected joint for osteoarthritis in the hand. TMC joint arthritis affects most commonly postmenopausal women after the fifth decade of life, due to hormonal and structural factors. Rhizarthrosis may lead to a clinical spectrum from subtle symptoms to advanced symptoms such as; severe pain, limitation of range of motion, muscular weakness, bony deformities, and end up ultimately with disability. Regardless of the etiopathogenesis; a variety of non-surgical and surgical methods have been used for the treatment of rhizarthrosis, depending on the age of the patient, symptomatology and the stage of the disease. The main goals of the treatments are as follows; relief of pain, conservation or restoration the stability and mobility of the TMC joint with the optimal preservation of the strength of surrounding musculature. In this article, the current methods, which have been used for the treatment of TMC joint osteoarthritis, will be mainly reviewed, together with concise up-to-date information on both its diagnosis and the anatomy of the TMC joint.

Use of biologic agents for rheumatic diseases in pregnancy

Biologic agents have ushered a new era in the treatment of inflammatory rheumatic diseases. In recent years, several biologic agents have been approved by food and drug administration and have significantly improved outcomes for patients with immune mediated inflammatory disorders including rheumatic and inflammatory bowel diseases. The most common used biologic therapeutic agents are tumor necrosis factor inhibitors (etanercept, infliximab, adalimumab, certolizumab pegol, and golimumab), an interleukin (IL)-6 inhibitor (tocilizumab), an IL-1 receptor antagonist (anakinra), an anti-CD-20 antibody (rituximab), and a T cell co-stimulation modulator (abatacept). Their use during pregnancy has been controversial because of absence of controlled studies which have enrolled pregnant women. This brief overview provides published data on use of biologic agents for the treatment of rheumatic diseases in pregnancy.

What is the best biological treatment for rheumatoid arthritis? A systematic review of effectiveness

AIM: To evaluate the effectiveness of the biological disease-modifying antirheumatic drugs (bDMARD) in the treatment of rheumatoid arthritis through a systematic review of observational studies.

METHODS: The studies were searched in the PubMed, EMBASE, Cochrane Controlled Trials Register and LILACS databases (until August 2014), in the grey literature and conducted a manual search. The assessed criteria of effectiveness included the EULAR, the disease activity score (DAS), the Clinical Disease Activity Index, the Simplified Disease Activity Index, the American College of Rheumatology and the Health Assessment Questionnaire. The meta-analysis was performed with Review Manager^® 5.2 software using a random effects model. A total of 35 studies were included in this review.

RESULTS: The participants anti-tumor necrosis factor inhibitors (TNF) naïve, who used adalimumab (P = 0.0002) and etanercept (P = 0.0006) exhibited greater good EULAR response compared to the participants who used infliximab. No difference was detected between adalimumab and etanercept (P = 0.05). The participants who used etanercept exhibited greater remission according to DAS28 compared to the participants who used infliximab (P = 0.01). No differences were detected between adalimumab and infliximab (P = 0.12) or etanercept (P = 0.79). Better results were obtained with bDMARD associated with methotrexate than with bDMARD alone. The good EULAR response and DAS 28 was better for combination with methotrexate than bDMARD monotherapy (P = 0.03 e P < 0.00001). In cases of therapeutic failure, the participants who used rituximab exhibited greater DAS28 reduction compared to those who used anti-TNF agents (P = 0.0002). The participants who used etanercept achieved greater good EULAR response compared to those who did not use that drug (P = 0.007). Studies that assessed reduction of the CDAI score indicated the superiority of abatacept over rituximab (12.4 vs +1.7) and anti-TNF agents (7.6 vs 8.3). The present systematic review with meta-analysis found that relative to anti-TNF treatment-naïve patients, adalimumab and etanercept were more effective when combined with methotrexate than when used alone. Furthermore, in case of therapeutic failure with anti-TNF agents; rituximab and abatacept (non anti-TNF) and etanercept (as second anti-TNF) were more effective. However, more studies of effectiveness were found for the rituximab.

CONCLUSION: The best treatment for treatment-naïve patients is adalimumab or etanercept combined with methotrexate. For anti-TNF therapeutic failure, the best choice is rituximab, abatacept or etanercept.

Radiographic assessment of leg alignment and grading of knee osteoarthritis: A critical review

Knee osteoarthritis (OA) is a progressive joint disease hallmarked by cartilage and bone breakdown and associated with changes to all of the tissues in the joint, ultimately causing pain, stiffness, deformity and disability in many people. Radiographs are commonly used for the clinical assessment of knee OA incidence and progression, and to assess for risk factors. One risk factor for the incidence and progression of knee OA is malalignment of the lower extremities (LE). The hip-knee-ankle (HKA) angle, assessed from a full-length LE radiograph, is ideally used to assess LE alignment. Careful attention to LE positioning is necessary to obtain the most accurate measurement of the HKA angle. Since full-length LE radiographs are not always available, the femoral shaft - tibial shaft (FS-TS) angle may be calculated from a knee radiograph instead. However, the FS-TS angle is more variable than the HKA angle and it should be used with caution. Knee radiographs are used to assess the severity of knee OA and its progression. There are three types of ordinal grading scales for knee OA: global, composite and individual feature scales. Each grade on a global scale describes one or more features of knee OA. The entire description must be met for a specific grade to be assigned. The Kellgren-Lawrence scale is the most commonly-used global scale. Composite scales grade several features of knee OA individually and sum the grades to create a total score. One example is the compartmental grading scale for knee OA. Composite scales can respond to change in a variety of presentations of knee OA. Individual feature scales assess one or more OA features individually and do not calculate a total score. They are most often used to monitor change in one OA feature, commonly joint space narrowing. The most commonly-used individual feature scale is the OA Research Society International atlas. Each type of scale has its advantages; however, composite scales may offer greater content validity. Responsiveness to change is unknown for most scales and deserves further evaluation.

Ins and outs of Helicobacter pylori association with autoimmune rheumatic diseases

Helicobacter pylori (H. pylori) infection is widely prevalent throughout worldwide. H. pylori manage a long-term survival in hostile environment of human stomach leading to peptic ulcer diseases and gastric cancer. But mostly infected person remains asymptomatic. Its chronic interaction with immune system makes H. pylori as an attractive candidate for the researchers to study its association with autoimmune diseases. This article presents a review of the literature on the association of H. pylori infection in selective autoimmune rheumatic diseases (RD). The authors used MeSH terms “Helicobacter pylori” with “rheumatoid arthritis,”“systemic lupus erythematosus,” or “fibromyalgia” to search PubMed database. All relevant studies identified were included. Despite extensive medical advancement many questions on role of H. pylori infection in autoimmune RD still remain unanswered. Further studies are therefore needed to address the role of H. pylori in pathogenesis of RD.

Safety of biologic therapies during pregnancy in women with rheumatic disease

Inflammatory rheumatic diseases frequently affect women of childbearing age. Biologic therapy during pregnancy is an important topic that is yet unresolved. The majority of documented experiences are in case series, case reports, or registries. Tumor necrosis factor (TNF) inhibitors are now better known. Some evidence suggests that it is possible that differences between drugs regarding safety are associated with the structure and capacity to cross the placenta, but we are not aware of any study that supports unequivocally this statement. Most of the monoclonal antibodies are actively transferred to fetal circulation using the neonatal Fc receptor. Although this transfer does not appear to be associated with the risk of miscarriage, stillbirth, or congenital abnormality, the rate of premature births and lower birth weight may be increased. During fetal development, the neonatal period, and childhood, the immune system is constantly maturing. The ability to produce cytokines in response to infectious stimulus remains low for years, but is similar to that of an adult around the age of 3 years owing to the adaptive nature of the newborn’s immune system as a result of exposure to microbes. Therefore, exposure to TNF inhibitors may have serious consequences on the newborn, such as severe infections or allergic reactions. Regarding the former, an anecdotal case report described a fatal case of disseminated bacillus Calmette-Guérin (BCG) infection in an infant born to a mother taking infliximab for Crohn’s disease. Although the baby was born and progressed well initially, he died at 4.5 mo after he was vaccinated with BCG. Fortunately, serious infections do not appear to be frequent in newborns exposed to in utero biologic therapy. However, very limited short-term experiences are available regarding complications in an exposed fetus, and no data are available about long-term implications on the child’s developing immune system. Therefore, we must be aware of potential complications in later years. Although the clinical data to date are promising, no firm conclusions can be drawn about the safety of biologic drugs during pregnancy, and, without further evidence, guidelines that suggest these drugs should be avoided at the time of conception cannot yet be changed.

Pyoderma gangrenosum: An important dermatologic condition occasionally associated with rheumatic diseases

Pyoderma gangrenosum (PG) presents with refractory, sterile, deep ulcers most often on the lower legs. Clinically, PG exhibits four types, i.e., ulcerative, bullous, pustular, and vegetative types. PG may be triggered by surgical operation or even by minor iatrogenic procedures such as needle prick or catheter insertion, which is well-known as pathergy. PG is sometimes seen in association with several systemic diseases including rheumatoid arthritis (RA), inflammatory bowel disease, hematologic malignancy, and Takayasu’s arteritis. In particular, various cutaneous manifestations are induced in association with RA by virtue of the activation of inflammatory cells (neutrophils, lymphocytes, macrophages), vasculopathy, vasculitis, drugs, and so on. Clinical appearances of ulcerative PG mimic rheumatoid vasculitis or leg ulcers due to impaired circulation in patients with RA. In addition, patients with PG sometimes develop joint manifestations as well. Therefore, it is necessary for not only dermatologists but also rheumatologists to understand PG.

Pathogenetic mechanisms of antiphospholipid antibody production in antiphospholipid syndrome

Antiphospholiipid syndrome (APS) is an autoimmune disease characterized by the pathological action of antiphospholipid antibodies (aPL), that leads to recurrent pregnancy loss and thrombosis. Despite limited evidence, it is clear that there are both inherited and acquired components of the ontogeny of these antibodies. Animal genetic studies and human familial and population studies highlight the influence of genetic factors in APS, particularly human leukocyte antigen associations. Similarly, both animal and human studies have reported the importance of acquired factors in APS development and infectious agents in particular have a great impact on aPL production. Bacterial and viral agents have been implicated in the induction of autoimmune responses by various mechanisms including molecular mimicry, cryptic autoantigens exposure and apoptosis. In this review we highlight the latest updates with regards to inherited and acquired factors leading to the manufacturing of pathogenic antibodies and APS.

Interstitial lung disease in rheumatoid arthritis: Current concepts in pathogenesis, diagnosis and therapeutics

Rheumatoid arthritis (RA) is the most common chronic autoimmune inflammatory joint disease. RA-associated interstitial lung disease (RA-ILD) is a major extra-articular complication and causes symptoms that lead to a deterioration in the quality of life, high utilization of health resources, and an increased risk of earlier mortality. Early in the course of RA-ILD, symptoms are highly variable, making the diagnosis difficult. Therefore, a rational diagnostic strategy that combines an adequate clinical assessment with the appropriate use of clinical tests, including pulmonary function tests and high-resolution computed tomography, should be used. In special cases, lung biopsy or bronchioalveolar lavage should be performed to achieve an early diagnosis. Several distinct histopathological subtypes of RA-ILD are currently recognized. These subtypes also have different clinical presentations, which vary in therapeutic response and prognosis. This article reviews current evidence about the epidemiology of RA-ILD and discusses the varying prevalence rates observed in different studies. Additionally, aspects of RA-ILD pathogenesis, including the role of cytokines and other molecules such as autoantibodies, as well as the evidence linking several drugs used to treat RA with lung damage will be discussed. Some aspects of the clinical characteristics of RA-ILD are noted, and diagnostic strategies are reviewed. Finally, this article analyzes current treatments for RA-ILD, including immunosuppressive therapies and biologic agents, as well as other therapeutic modalities. The prognosis of this severe complication of RA is discussed. Additionally, this paper examines updated evidence from studies identifying an association between drugs used for the treatment of RA and the development of ILD.

Classification, diagnosis and treatment of ANCA-associated vasculitis

Diagnosis of anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis is usually not difficult in patient with systemic disease, including lung and kidneys involvement, and laboratory signs of inflammation. The presence of ANCA and the results of histological investigation confirm diagnosis of ANCA-associated vasculitis. Cyclophosphamide/azathioprine in combination with high dose steroids are used to induce and maintain remission of systemic vasculitis. The clinical trials also showed efficacy of rituximab that induces depletion of B-cells. Our understanding and management of ANCA-associated vasculitis improved significantly over the last decades but there is still a lot of debate over its classification, diagnostic criteria, assessment of activity and optimum treatment.

Orofacial pain and fibromyalgia pain: Being aware of comorbid conditions

Orofacial pain originating from myofascial pain of temporomandibular disorders is the second most common source of pain, after tooth pain. However, diagnosis of myofascial pain is challenging due to its characteristic referral pattern. Furthermore, pain arising from structures in the orofacial region may be a presentation of fibromyalgia and treatment directed at temporomandibular disorders fails to alleviate the pain. Similarly, patients with fibromyalgia may present with pain in the orofacial region. The physician in this case should be aware of temporomandibular disorders, its characteristic findings and treatment approaches that might be included in the treatment plan.

Osteoporosis in rheumatic diseases

Rheumatic diseases, characterized by chronic inflammation and damage to various organs and systems, include systemic lupus erythematosus, rheumatoid arthritis, ankylosing spondylitis and other connective tissue diseases. Bone is a target in many inflammatory rheumatic diseases. In recent years, the survival of patients with rheumatic diseases has increased markedly and the relationship between rheumatic diseases and osteoporosis (OP) has become more prominent. OP and related fragility fractures increase the morbidity and mortality of rheumatic disease. The cause of OP in rheumatic diseases is complex. The pathogenesis of OP in rheumatic diseases is multifactorial, including disease and treatment-related factors. Osteoimmunology, a crosstalk between inflammatory and bone cells, provides some insight into the pathogenesis of bone loss in systematic inflammatory diseases. The aim of this article is to review different risk factors in rheumatic diseases. Several factors play a role, such as chronic inflammation, immunological factors, traditional factors, metabolism and drug factors. Chronic inflammation is the most important risk factor and drug treatment is complex in patients with OP and rheumatic disease. Attention should be paid to bone loss in rheumatic disease. Optimal treatment of the underlying rheumatic disease is the first step towards prevention of OP and fractures. Apart from that, a healthy lifestyle is important as well as calcium and vitamin D supplementation. Bisphosphonates or denosumab might be necessary for patients with a low T score.

Muscle wasting in rheumatoid arthritis: The role of oxidative stress

Rheumatoid arthritis (RA), the commonest inflammatory arthritis, is a debilitating disease leading to functional and social disability. In addition to the joints, RA affects several other tissues of the body including the muscle. RA patients have significantly less muscle mass compared to the general population. Several theories have been proposed to explain this. High grade inflammation, a central component in the pathophysiology of the disease, has long been proposed as the key driver of muscle wasting. More recent findings however, indicate that inflammation on its own cannot fully explain the high prevalence of muscle wasting in RA. Thus, the contribution of other potential confounders, such as nutrition and physical activity, has also been studied. Results indicate that they play a significant role in muscle wasting in RA, but again neither of these factors seems to be able to fully explain the condition. Oxidative stress is one of the major mechanisms thought to contribute to the development and progression of RA but its potential contribution to muscle wasting in these patients has received limited attention. Oxidative stress has been shown to promote muscle wasting in healthy populations and people with several chronic conditions. Moreover, all of the aforementioned potential contributors to muscle wasting in RA (i.e., inflammation, nutrition, and physical activity) may promote pro- or anti-oxidative mechanisms. This review aims to highlight the importance of oxidative stress as a driving mechanism for muscle wasting in RA and discusses potential interventions that may promote muscle regeneration via reduction in oxidative stress.

Oral creatine supplementation: A potential adjunct therapy for rheumatoid arthritis patients

Creatine is one of the most popular forms of protein supplements and is known to improve performance in healthy athletic populations via enhanced muscle mass and adenosine triphosphate energy regeneration. Clinical use of creatine may similarly benefit patients with rheumatoid arthritis (RA), an inflammatory condition characterised by generalised muscle loss termed “rheumatoid cachexia”. The adverse consequences of rheumatoid cachexia include reduced strength, physical function and, as a consequence, quality of life. Whilst regular high-intensity exercise training has been shown to increase muscle mass and restore function in RA patients, this form of therapy has very low uptake amongst RA patients. Thus, acceptable alternatives are required. The aim of this review is to consider the potential efficacy of creatine as an anabolic and ergonomic therapy for RA patients. To date, only one study has supplemented RA patients with creatine, and the findings from this investigation were inconclusive. However, trials in populations with similar losses of muscle mass and function as RA, including older adults and those with other muscle wasting conditions, indicate that creatine is an efficacious way of improving muscle mass, strength and physical function, and may offer an easy, safe and cheap means of treating rheumatoid cachexia and its consequences.

Diagnosis and pharmacologic management of neuropathic pain among patients with chronic low back pain

Chronic low back pain consists of both nociceptive and neuropathic mechanisms and can be classified as a mixed pain syndrome. Neuropathic component of chronic low back pain has often been under-recognized and under-treated by the physicians. Recent studies have demonstrated that approximately 20%-55% of chronic low back pain patients have neuropathic pain symptoms. An altered peripheral, spinal, and supraspinal processing of pain arising as a result of a lesion affecting the nerves system are the major contributor to neuropathic low back pain. The clinical evaluation is still the gold standard for assessment and diagnosis of neuropathic low back pain. Although diagnosis can be difficult due to the lack of reliable gold standard diagnostic test for neuropathic low back pain, screening tools may help non-specialists, in particular, to identify potential patients with neuropathic low back pain who require further diagnostic evaluation and pain management. Several screening tools for neuropathic pain have been developed and tested with different patient populations. Among the screening tools, the painDETECT questionnaire and the Standardized Evaluation of Pain are validated in patients with low back pain. The Standardized Evaluation of Pain may lead to more effective in discriminating between neuropathic and nociceptive pain in patients with low back pain according to the higher rate of sensitivity and its validity in patients with low back pain. However, the most appropriate approach is still to combine findings on physical and neurologic examinations and patient’s report in distinguishing neuropathic pain from nociceptive pain. The clinical examination including bedside sensory tests is still the best available tool for assessment and diagnosis neuropathic pain among patients with chronic low back pain. Due to the fact that chronic low back pain consists of both nociceptive and neuropathic mechanisms, a multimodal treatment approach is more rational in the management of patients with chronic low back pain. Therefore, combination therapy including drugs with different mechanisms of action should be given to the patients with chronic low back pain.

Gender differences in axial spondyloarthritis

Within the concept of axial spondyloarthritis (axSpA), relevant differences between men and women have been described for patients with the radiographic disease form [ankylosing spondylitis (AS)]. The subjective perception of disease activity (spinal and peripheral pain, fatigue, morning stiffness) has been shown to be higher in female than in male patients. Moreover, women experience more functional limitations and a lower quality of life, despite lower degrees of radiographic spinal damage. Peripheral clinical involvement (arthritis and enthesitis) is, additionally, more predominant in women. On the other hand, a higher level of objective signs of inflammation (C-reactive protein, erythrocyte sedimentation rate, magnetic resonance imaging of sacroiliac joints and spine) has been reported in men. Whether these differences might explain the better response to treatment with anti-tumor necrosis factor agents observed in male patients remains unclear. The underlying causes of the discrepancies are still unknown and genetic, environmental, cultural and/or societal factors may be involved. While AS is still more prevalent in men in a ratio of 2-3:1, the prevalence of males and females in patients with axSpA without radiographic sacroiliac damage is similar. Gender differences in this subgroup of patients have not been adequately addressed, and are particularly needed to further validate the Assessment of SpondyloArthritis international Society classification criteria.

Quantifying synovial inflammation: Emerging imaging techniques

Imaging techniques to assess synovial inflammation includes radiography, ultrasound, computed tomography, magnetic resonance imaging (MRI) and recently positron emission tomography. The ideal objective of imaging approaches are to quantify synovial inflammation by capturing features such as synovial hyperplasia, neo-angiogenesis and infiltration of immune cells in the synovium. This may enable clinicians to estimate response to therapy by measuring the improvement in the inflammatory signals at the level of synovium. Ultrasound can provide information regarding thickening of the synovial membrane and can reveal increased synovial blood flow using power Doppler technique. Bone marrow edema and synovial membrane thickness on MRI scan may serve as indicators for arthritis progression. Enhancement of the synovium on dynamic contrast MRI may closely mirror the inflammatory activity in the synovium. Diffusion tensor imaging is an advance MRI approach that evaluates the inflammation related to cell infiltration or aggregation in an inflamed synovium. In this review, we summarize the newer imaging techniques and their developments to evaluate synovial inflammation.

Gout: A clinical overview and its association with cardiovascular diseases

Gout is a common disease caused by the deposition of monosodium urate (MSU) crystals in patients with hyperuricemia, and characterized by very painful recurrent acute attacks of arthritis. The gold standard for diagnosing gout is the identification of MSU crystals in synovial fluid by polarization light microscopy. Arthritis attacks can be treated with anti-inflammatory medications, such as non-steroidal anti-inflammatory drugs, colchicine, oral prednisone, or intra-articular or intramuscular glucocorticoids. To prevent gout uric acid lowering therapy with for example allopurinol can be prescribed. When gout is adequately treated, the prognosis is good. Unfortunately, the management of gout patients is often insufficient. Gout is associated with dietary factors, the use of diuretics, and several genetic factors. Comorbidities as hypertension, chronic kidney disease, cardiovascular diseases, the metabolic syndrome, diabetes, obesity, hyperlipidemia, and early menopause are associated with a higher prevalence of gout. Xanthine oxidase and chronic systemic inflammation seem to play an important role in the pathophysiology of the association between gout and cardiovascular diseases. To prevent cardiovascular diseases gout patients must be early screened for cardiovascular risk factors.

Does a biological link exist between periodontitis and rheumatoid arthritis?

Periodontitis or Periodontal disease (PD) and Rheumatoid arthritis (RA) are two the most common chronic inflammatory diseases. Periodontitis is a biofilm associated destructive inflammatory disease of the periodontium caused by specific microorganisms. Rheumatoid arthritis is an autoimmune condition and is identified by elevated serum autoantibody titre directed against citrullinated peptides or rheumatoid factor. Periodontitis may involve some elements of autoimmunity. Recent studies have established that PD and RA show a common pathway and could be closely associated through a common dysregulation and dysfunction in inflammatory mechanism. The enzyme peptidyl arginine deiminase (PAD), expressed by Porphyromonas gingivalis (P. gingivalis) is responsible for the enzymatic deimination of arginine residuals to citrulline resulting in protein citrullination and its increased accumulation in RA. Citrullination by PAD may act as a putative biologic link between PD and RA. Association of Human leukocytic antigen-DR4 antigen has been established both with RA and PD. Several interleukins and inflammatory mediators (ILs) and Nuclear factor kappa beta ligand are linked to these common chronic inflammatory diseases. Antibodies directed against heat shock protein (hsp 70 ab) of P. gingivalis, P. melanogenicus and P. intermedia are raised in PD as well as RA. Both the conditions share many pathological and immunological similarities. Bacterial infection, genetic susceptibility, altered immune reaction and inflammatory mediators considered responsible for RA are also associated with PD. So it is plausible that a biological link may exist between PD and RA. Therapies aimed at modifying the expression and effect of inflammatory mediators and effector molecules such as matrix metalloproteinases, proinflammatory cytokines and autoantibodies of structural proteins may probably reduce the severity of both RA and PD.

Functional assessment measures in rheumatologic disorders

Rheumatologic disorders cause functional impairment and significantly affect health-related quality of life. Functional assessment and health-related quality of life scales are increasingly being used as outcome measures to assess the influence of the diseases and health outcome in clinical studies of patients with rheumatologic diseases. In this article, we review the functional assessment and health-related quality of life measures which have been commonly used as outcome measures in rheumatologic disorders. These measures are Short form-36 (SF-36), SF-12, Nottingham Health Profile, Sickness Impact Profile, EuroQol, SF-6D, Health Utilities Index mark 2 and 3, Stanford Health Assessment Questionnaire, Rheumatoid Arthritis Quality of Life Questionnaire, Arthritis Impact Measurement Scales, McMaster Toronto Arthritis Patient Preference Disability Questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index, Lequesne Index, Knee Disability and Osteoarthritis Outcome Score, Knee Disability and Osteoarthritis Outcome Score-Physical Function Short-form, Hip Disability and Osteoarthritis Outcome Score, Hip Disability and Osteoarthritis Outcome Score-Physical Function SF, Fibromyalgia Impact Questionnaire, Psoriatic Arthritis Quality of Life Scale, Gout Assessment Questionnaires, Dougados Functional Index, Bath Ankylosing Spondylitis Functional Index, and Ankylosing Spondylitis Quality of Life Scale.

Monitoring osteoporosis therapy: Can FRAX help assessing success or failure in achieving treatment goals?

AIM: To assess: (1) Whether the World Health Organization fracture risk assessment tool (FRAX) can be used for monitoring osteoporosis patients receiving treatment as well as its clinical implications; and (2) The relation between fracture incidence and post-treatment FRAX.

METHODS: Five hundred and seventy-nine osteoporotic women known to be adherent to the prescribed osteoporosis medication, had dual-energy X-ray absorptiometry scan and fracture probability calculated at baseline, 2 and 5-year of osteoporosis treatment. Those patients who responded to treatment and did not sustain a new low trauma fracture during the first 2 years, continued their treatment and were re-assessed 3-year later. The patient subgroup who did not achieve an improvement in their bone mineral density (BMD) or sustain any fracture within the first 2-year, had their osteoporosis treatment changed. Outcome measures included BMD and FRAX assessment calculated 3-year after commencing new osteoporosis treatment.

RESULTS: There was a significant negative correlation between 10-year probability of major osteoporotic and hip fractures and BMD at the total proximal femur at 2-year of treatment (R = -0.449 and -0.479 respectively), and at 5-year (R = -0.489 and -0.594 respectively). At both 2 years and 5 years of treatment, the 10-year fracture probability showed significant correlation with the incidence of fracture (P < 0.01). On comparing fracture probability, there was a significant difference (P < 0.05) between the responders and non-responders to osteoporosis treatment.

CONCLUSION: In women currently or previously treated for osteoporosis, the FRAX tool can be used to predict fracture probability. Osteoporosis treatment does not annul prediction of fractures. FRAX tool may be of value in guiding clinicians towards the need for continuation or withdrawal of treatment.

TNF-α inhibitors and tocilizumab do not influence hepatic steatosis in patients with rheumatoid arthritis

AIM: To investigate the influence, if any, of tumor necrosis factor (TNF)-α inihibitors and Tocilizumab, on hepatic steatosis (HS) in rheumatoid arthritis (RA) patients in the light of the known role of TNF-α and interleukin-6, which are key-cytokines in the pathogenesis of RA, in inducing HS in general population.

METHODS: We retrospectively reviewed the clinical charts of 36 RA patients, out of whom 12 had been treated with Methotrexate (MTX), 12 with TNF inhibitors ± MTX and 12 with Tocilizumab ± MTX. The 3 subgroups of patients matched each other for sex, age, body mass index, metabolic syndrome (MS) and other risk factors for atherosclerosis. At baseline and after 12 mo each patient underwent an abdominal ultrasonography for the assessment of presence of HS and the evaluation of its grade.

RESULTS: No difference was detected either in the prevalence of HS or in that of its distinct grades between the 3 groups of patients at baseline. After 12 mo, the HS grade unchanged in 20 patients (7 subjects treated with MTX, 7 with TNF-α inhibitors ± MTX and 6 Tocilizumab ± MTX); increased in 12 patients (4 subjects treated with MTX, 4 TNF-α blockers ± MTX and 4 Tocilizumab ± MTX); decreased in 4 (1 treated with MTX, 1 with anti-TNF-α + MTX and 2 with TCZ ± MTX (P = 0.75). No correlation was found between getting remission or low disease activity and the course of either MS or HS.

CONCLUSION: We failed to detect any influence of MTX ± TNF-α inhibitors or Tocilizumab in reducing MS and HS. A prospective study is needed to clarify the topic.

Role of Th17 cells in the pathogenesis of rheumatoid arthritis

Since early description of CD4/CD8 T cell duality, continuous discovery of functional T lymphocyte subsets and their related cytokines constitutes major progress in our understanding of the immune response. T-lymphocyte derived lymphokines and environmental cytokines are essential for both innate and antigen-specific immune responses to a wide variety of agents. Following immune battle and aggression overcome, cytokines may return against neighbored cells/organs, causing pathogenic hypersensitivity reactions, including autoimmune diseases. Due to their cytokine production, CD4⁺ T helper lymphocyte subsets may be considered as one the major players of the immune response. Among CD4⁺ T cell subsets, the identification of interleukin-17-producing cells (Th17) led to better understanding of coordinated cytokine involvement during inflammatory reactions together with the subsequent clarification of complex interactions between these mediators. In this review, we discuss Th17 cell differentiation, functions, and the role of this cell subset during rheumatoid arthritis pathogenesis together with therapeutic strategies to control these cells.

Juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatologic disease in childhood, which represents a nonhomogeneous group of disorders that share the clinical manifestation of arthritis lasting at least 6 wk under the age of 16. The exact diagnosis requires exclusion of other diseases that cause arthritis. The exact etiopathogenesis of JIA is still unknown. The interactions between genetic factors, environmental exposures and immune mechanisms are thought to contribute to pathogenesis of the disease. The “International League Against Rheumatism” classification divides JIA into 7 subtypes: oligoarticular JIA, rheumatoid factor (RF) positive polyarticular JIA, RF negative polyarticular JIA, systemic-onset JIA, enthesitis-related arthritis, juvenile psoriatic arthritis and undifferentiated JIA. Each subgroup of JIA is characterized by a different mode of presentation, disease course and outcome. The improvements in treatment of JIA in the last 2 decades, such as the early introduction of intraarticular corticosteroids, methotrexate and biologic agents, have dramatically upgraded the prognosis of the disease. If untreated, JIA may cause devastating results, such as disability from joint destruction, growth retardation, blindness from chronic iridocyclitis, and even multiple organ failure and death in systemic-onset JIA. The aim of treatment is the induction of remission and control the disease activity to minimize the pain and loss of function, and to maximize quality of life. JIA is a disease having a chronic course, which involves active and inactive cycles over the course of years. Recent studies showed that nearly half of the patients with JIA enter adulthood with their ongoing active disease. This review elucidates how recent advances have impacted diagnosis, pathogenesis and current treatment.

X chromosome inactivation and autoimmune diseases

The pathogenesis of autoimmune diseases (AIDs) is characterized by a female preponderance. The causes for this sex imbalance are based on several hypotheses. One of the most intriguing hypotheses is related to an X chromosome inactivation (XCI) process. Females are mosaics for two cell populations, one with the maternal and one with the paternal X as the active chromosome. Skewed XCI is often defined as a pattern where 80% or more of the cells show a preferential inactivation of one X chromosome. The role of skewed XCI has been questioned in the pathogenesis of several AIDs, such as autoimmune thyroid diseases and rheumatoid arthritis.

Dysphagia in rheumatological disorders

Dysphagia can be seen in rheumatological diseases. Due to life-threatening complications, early diagnosis and treatment of dysphagia is important. However, sufficient data is not available for the diagnosis and treatment of dysphagia especially in the group of rheumatological diseases. In this paper, the presentation of dysphagia in rheumatological diseases will be reviewed.

Lymphedema and rheumatological disorders

In the literature, although the prevalence of lymphedema is low in inflammatory rheumatological diseases, rigorous approaches to diagnosis and treatment have led to significant improvement in patients’ quality of life. Lymphedema is observed more frequently in patients with rheumatoid arthritis with respect to case presentations, but it is also observed in psoriatic arthritis, ankylosing spondylitis, systemic sclerosis, and childhood inflammatory rheumatological diseases. Other rheumatological diseases and tumor-related secondary causes should also be kept in mind in the diagnosis of lymphedema. Complex decongestive therapy-skin care, manual lymph drainage, compression and exercise are the primary treatment approaches. Both basic drugs and tumor necrosis factor-α inhibitors have been tried in addition to complex decongestive physiotherapy programs. However, the success of alternative medical treatments is controversial in the literature. It may be useful to include the disease in post-diagnosis complex decongestive physiotherapy program and to use the drugs mentioned in the literature. However, more data are needed to reach conclusive results.

Hot topics in lupus pregnancy

Systemic lupus erythematosus (SLE) typically affects women in their childbearing age, who have the same fertility rates as the healthy population. The effect of pregnancy on the disease and the effect of SLE on pregnancy and the fetus are highly important issues for the attending physician. Whether lupus flares are more frequent during pregnancy remains controversial. Among the possible effects of SLE on pregnancy are a greater number of abortions, fetal loss, pre-term deliveries and perinatal mortality. The newborn may be affected by the onset of neonatal lupus erythematosus (neonatal LE), either as a skin or blood disease, or by the presence of congenital heart block. The frequent association between SLE and antiphospholipid syndrome represents another risk situation for the mother and the product of conception. Multiples drugs used in SLE patients should be evaluated. Those with teratogenic potential should be withdrawn before pregnancy, and when necessary, appropriate medications should be indicated to treat the mother without compromising the safety of the baby. In conclusion, pregnancies in lupus patients represent a challenge for the physician and must be closely followed up and treated if necessary, during all trimesters and in the puerperium period, to improve outcome.

B cell depletion in scleroderma lung disease: A promising new treatment?

Evidence suggests that B cells may participate in the fibrotic process Based on this experimental evidence, treatment with rituximab (RTX) has been tried in systemic sclerosis (SSc) with promising results. In a randomized controlled study from our research group it was shown that treatment with 2 courses of RTX leads to a significant improvement of lung function at 1 year compared to baseline. All relevant studies have so far reported clinical and/or histologic improvement of skin fibrosis something that adds further evidence in favor of a disease modifying role of RTX in SSc. It is more than obvious that novel therapies for SSc-associated lung disease are needed. A large scale, randomized, controlled study assessing the efficacy of RTX in SSc associated interstitial lung disease is warranted. If RTX turns out to be effective it would be a major therapeutic advance in SSc since it can be administered on a long term basis due to its acceptable safety profile.

Adrenocorticotropic hormone: A powerful but underappreciated therapeutic tool for acute crystal induced arthritis?

Treatment of acute gout is not always an easy task since patients usually have multiple comorbidities that preclude the use of nonsteroidal anti-inflammatory drugs and colchicine, the most widely used therapeutic tools. Adrenocorticotropic hormone (ACTH) has long been used in the treatment of acute gout and several studies have shown that it is highly effective and exhibits an excellent safety profile. ACTH belongs to a family of proteins called melanocortins; these molecules have strong anti-inflammatory properties and serve as natural inhibitors of inflammatory responses. We have recently reported that treatment of acute gout with 100 IU of synthetic ACTH is highly effective and associates with negligible side effects. It is note worthy that ACTH did not associate with significant “steroid related” side effects such as hypertension, hyperglycemia and hypokalemia. ACTH appears as a powerful and easy to use therapeutic tool for patients with multiple comorbidities. We believe that the role of ACTH as a treatment for acute gout should be reappraised, especially in light of new experimental data indicating that ACTH has pleiotropic anti-inflammatory properties and is not just a hormone that stimulates the release of steroids.

Cautionary note: Electronic medical records, a potential disaster in the making?

Concern is expressed that electronic medical records may actually compromise care. Reports are electronically collated with patient charts, but when are they examined? Current electronic transmission of results to patients’ electronic medical records do not seem to notify of new information. The unknown time from prescription to patient action and the variable time required for individual test performance seem to mandate that a physician attempting to be conscientious would have to examine all sections of every patient medical record in their practice, every day. That is quite inefficient and error-prone. Electronic medical record still contains what appear to be dangerous “bugs” which compromise our ability to provide the care we believe our patients deserve? I remain unsure that outpatient electronic medical records are “ready for prime time.”

What qualifies as rheumatoid arthritis?

Expansion of diagnostic criteria for rheumatoid arthritis and deletion of exceptions increases sensitivity, but at the expense of specificity. Two decades later, modification of criteria included the caveat: “absence of an alternative diagnosis that better explains the synovitis.” That puts great faith in the diagnostic skills of the evaluating individual and their perspectives of disease. The major confounding factor appears to be spondyloarthropathy, which shares some characteristics with rheumatoid arthritis. Recognition of the latter on the basis of marginally distributed and symmetrical polyarticular erosions, in absence of axial (odontoid disease excepted) involvement requires modification to avoid failure to recognize a different disease, spondyloarthropathy. Skeletal distribution, pure expression of disease in natural animal models and biomechanical studies clearly rule out peripheral joint fusion (at least in the absence of corticosteroid therapy) as a manifestation of rheumatoid arthritis. Further, such studies identity predominant wrist and ankle involvement as characteristic of a different disease, spondyloarthropathy. It is important to separate the two diagnostic groups for epidemiologic study and for clinical diagnosis. They certainly differ in their pathophysiology.

Pulmonary arterial hypertension associated with systemic sclerosis: Current diagnostic approach and therapeutic strategies

Pulmonary arterial hypertension (PAH) represents a devastating vascular complication of systemic sclerosis (SSc) and is found in 10%-15% of cases carrying a severe prognosis. PAH has a dramatic impact on the clinical course and overall survival, being the single most common cause of death in patients with this entity. The clinical course and aggressive progression of PAH has led clinicians to perform annual screening for it, since early detection and diagnosis are the cornerstone of a prompt therapeutic intervention. The diagnosis of PAH can be challenging to clinicians, particularly in its early stages, since in the context of SSc, the multiple causes of dyspnea need to be assessed. Doppler echocardiography represents the best initial screening tool, however, right heart catheterization remains the gold standard and definitive diagnostic means. Remarkable advances have been achieved in elucidating the pathogenesis of PAH in the past two decades, leading to the development of disease-specific targeted therapies: prostacyclin analogues, endothelin receptor antagonists and inhibitors of five phosphodiesterase pathways. However, the clinical response to these therapies in SSc-associated PAH has not been as great as the one seen with idiopathic PAH. This review also focuses on the diagnosis and novel therapies that are currently available for PAH, as well as potential future therapeutic developments based on newly acquired knowledge of diverse pathogenic mechanisms.

Spinal accessory neuropathy in patients with chronic neck pain

AIM: To assess the presence of spinal accessory neuropathy in patients with chronic neck pain.

METHODS: Patients with pain either regional or focal in the neck or shoulders for at least 6 mo (chronic neck pain) were recruited randomly from the Rheumatology and Rehabilitation Outpatient Clinic at the Faculty of Medicine-Suez Canal University. Two groups were compared: 30 patients with chronic neck pain with mean age (36.97 ± 12.45 years) and 10 apparently healthy controls. Trapezius muscle examination including inspection and range of motion both active and passive was performed. A full clinical neurological examination was carried out to exclude peripheral neuropathy and motor neuron disease. According to the subject’s type of work, cases were categorized into labor-intensive and non-labor intensive tasks. A nerve conduction study (NCS) was performed on spinal accessory nerves at both sides for all patients and controls. Parameters including latencies and amplitudes of compound motor action potential (CMAP) were compared with the chronicity of neck pain using the neck disability score. This cross sectional study was carried in the Rheumatology and Rehabilitation Department, at Suez Canal University Hospital, Ismailia, Egypt.

RESULTS: Physical examination revealed that 80% of cases had spinal trapezius muscle spasm. Restricted neck motion was present in 16.6% of cases. No one suffered from muscle wasting or weakness. Pain was bilateral in 18 patients (60%), localized to the right side in six patients (20%) and localized to the left side in six patients (20%). The causes of neck pain in the patients studied were nonspecific, due to physical stresses, cervical spondylosis and mild cervical disc herniation. Mean disease duration in patients with labor-intensive tasks was (3.9 ± 2.1 years), which was longer than that in patients with non-labor intensive tasks (3.1 ± 1.9 years); however, this difference was statistically insignificant. Spinal accessory NCSs were performed while subjects were in sitting positions and relaxed with naturally suspended arms to minimize muscular movement. The results of electrophysiological studies revealed that mean right and left latencies of the spinal accessory nerve were 2.96 ± 0.69 ms, 2.98 ± 0.61 ms in the patient group and 2.44 ± 0.38 ms, 2.33 ± 0.36 ms in control group respectively. These differences were statistically significant with P = 0.028 and 0.006 respectively. Spinal accessory NCS showed normal CMAP amplitude in both patients and controls. Comparing the results of the neck disability index (NDI) to different characteristics in patients with chronic neck pain, showed that patients with labor-intensive work had a higher NDI score mean (34.7 ± 9.5) compared to those with non-labor-intensive work, with significant statistical difference (P = 0.011). In addition, mean NDI scores were higher in males, and patients aged over 40 years and this difference was statistically significant (P = 0.007 and P = 0.009 respectively). Correlation studies between right and left spinal accessory nerve latencies and disability percent calculated using the NDI revealed a positive correlation. Moreover, there was a positive correlation between age and disability percent.

CONCLUSION: This study demonstrates electrophysiological evidence of demyelination in a significant proportion of patients with chronic cervical pain.

Role of Apo2L/TRAIL in immunity: Applications to rheumatoid arthritis

Rheumatoid arthritis (RA) is the most common inflammatory disease of the musculoskeletal system primarily affecting the joints. It is characterized by massive synovial hyperplasia and subsequent destruction of articular cartilage and bone. Although various aspects in the pathogenesis of RA remain unclear, genetic, environmental and of course immunological factors have been involved. Defects in apoptosis seem to play a role in both initiation and perpetuation of RA. Apo2 ligand/ tumor necrosis factor (TNF) related apoptosis-inducing ligand (Apo2L/TRAIL) is a cytokine that belongs to the TNF superfamily capable of inducing apoptosis on tumor cells through activation of the extrinsic pathway. Besides this function, like other members of the TNF superfamily, Apo2L/TRAIL has been shown to exert important functions in the regulation of the immune system. Concerning pathological conditions, the Apo2L/TRAIL signaling pathway plays an important role in the response to infections, in immune surveillance against tumors and in autoimmune diseases such as RA. Furthermore, its implication in suppression of autoimmunity suggests that Apo2L/TRAIL has potential as therapeutic agent not only in cancer but also in autoimmune diseases. In fact, Apo2L/TRAIL-based therapies have been shown effective in various animal models of RA. This review summarizes the current knowledge on the biology of Apo2L/TRAIL and its role in RA.

What is the purpose of launching World Journal of Rheumatology?

The first issue of World Journal of Rheumatology (WJR), whose preparatory work was initiated on December 16, 2010, will be published on December 31, 2011. The WJR Editorial Board has now been established and consists of 116 distinguished experts from 29 countries. Our purpose of launching WJR is to publish peer-reviewed, high-quality articles via an open-access online publishing model, thereby acting as a platform for communication between peers and the wider public, and maximizing the benefits to editorial board members, authors and readers.

Synovial mesenchymal stem cells in vivo: Potential key players for joint regeneration

Unlike bone marrow (BM) mesenchymal stem cells (MSCs), whose in vivo identity has been actively explored in recent years, the biology of MSCs in the synovium remains poorly understood. Synovial MSCs may be of great importance to rheumatology and orthopedics because of the direct proximity and accessibility of the synovium to cartilage, ligament, and meniscus. Their excellent chondrogenic capabilities and suggested transit through the synovial fluid, giving unhindered access to the joint surface, further support a pivotal role for synovial MSCs in homeostatic joint repair. This review highlights several unresolved issues pertaining to synovial MSC isolation, topography, and their relationship with pericytes, synovial fibroblasts, and synovial fluid MSCs. Critically reviewing published data on synovial MSCs, we also draw from our experience of exploring the in vivo biology of MSCs in the BM to highlight key differences. Extending our knowledge of synovial MSCs in vivo could lead to novel therapeutic strategies for arthritic diseases.