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.