The effect of intra-articular allogenic platelet rich plasma in Dunkin-Hartley guinea pig model of knee osteoarthritis

Objectives

To investigate the pathway for disease modifying effect of the PRP in osteoarthritis of knee.

Design

Two experimental models (group I and II) of Twelve Dunkin-Hartley guinea pigs each were enrolled as a part of a prospective controlled experimental study. One knee was enrolled for intervention and the other knee of the same animal used as control, the intervention being three intra-articular allogenic PRP injections given at a weekly interval. Equal volume of isotonic saline injection were given simultaneously in the control knees. Six animals from each model (subgroup IA, IIA) were euthanized at three months and the remaining six (subgroup IB, IIB) at six months post intervention. Samples of synovial fluid were collected from each knee joint for COMP level analysis by ELISA and bilateral knee joints were harvested for histopathological assessment of articular cartilage and synovium at the time of euthanasia.

Results

Mean synovial fluid COMP concentration was significantly lower in PRP treated knees (p<0.05) at three months. On histological examination mean synovitis scores and synovial vascularity were significantly lower in PRP treated knees as compared to controls at both three and six months (p < 0.05). Additionally mean articular cartilage degeneration was significantly lower in PRP treated knees in group 1 only (p<0.05).

Conclusion

Our preliminary data from the study has shown some evidence of positive influence of PRP in knee OA, possibly due to its anti-inflammatory effect and disease modifying effect, shown by short-term chondro-protective effect in PRP injected knees.

Level of evidence

V.

Diagnostic spectrum and 2-year outcome in a cohort of patients with very early arthritis

Objectives

To describe the diagnostic spectrum, arthritis persistency and clinical outcomes after 2 years in patients with inflammatory arthritis (IA) of less than 16 weeks’ duration.

Methods

Data from the Norwegian Very Early Arthritis Clinic, a 2-year longitudinal observational study of adults with IA of ≤16 weeks’ duration, were used. Exclusion criteria were arthritis due to crystal deposits, trauma, osteoarthritis and septic arthritis. In all patients who had any follow-up information (population A), clinical diagnoses and persistency of arthritis were described. For patients with 2-year follow-up (population B), we also studied other clinical outcomes (disease activity, pain, fatigue, functional disability and health-related quality of life).

Results

In population A (n=1017) median (25th–75th percentile) duration of joint swelling was 35.0 (13.0–66.5) days, mean (SD) age 45.7 (14.8) years, 55.2% were females and 17.8% anticitrullinated protein antibodies positive. The most common final diagnoses were undifferentiated arthritis (UA) (41.7%), rheumatoid arthritis (RA) (24.1%) and reactive arthritis (18.1%). After 2 years, the arthritis had resolved in 59% of the patients. The remaining 41.0% had persistent disease defined by disease modifying antirheumatic drug (DMARD) use (32.1%) or persistent joint swelling without DMARD use (8.9%). In population B (n=669), all clinical outcomes improved significantly (P<0.001). Baseline joint pain and fatigue were similar across diagnoses.

Conclusions

Among 1017 patients with IA of ≤16 weeks’ duration, UA was the most common diagnosis after 2 years, and less than one-fourth were diagnosed with RA. Arthritis resolved without DMARDs in the majority of the patients. All clinical parameters improved significantly over a 2-year course.

Synovial tissue macrophages: friend or foe?

Healthy synovial tissue includes a lining layer of synovial fibroblasts and macrophages. The influx of leucocytes during active rheumatoid arthritis (RA) includes monocytes that differentiate locally into proinflammatory macrophages, and these produce pathogenic tumour necrosis factor. During sustained remission, the synovial tissue macrophage numbers recede to normal. The constitutive presence of tissue macrophages in the lining layer of the synovial membrane in healthy donors and in patients with RA during remission suggests that this macrophage population may have a role in maintaining and reinstating synovial tissue homeostasis respectively. Recent appreciation of the different origins and functions of tissue-resident compared with monocyte-derived macrophages has improved the understanding of their relative involvement in organ homeostasis in mouse models of disease. In this review, informed by mouse models and human data, we describe the presence of different functional subpopulations of human synovial tissue macrophages and discuss their distinct contribution to joint homeostasis and chronic inflammation in RA.

Mechanisms of Osteoarthritic Pain. Studies in Humans and Experimental Models

Pain due to osteoarthritis (OA) is one of the most frequent causes of chronic pain. However, the mechanisms of OA pain are poorly understood. This review addresses the mechanisms which are thought to be involved in OA pain, derived from studies on pain mechanisms in humans and in experimental models of OA. Three areas will be considered, namely local processes in the joint associated with OA pain, neuronal mechanisms involved in OA pain, and general factors which influence OA pain. Except the cartilage all structures of the joints are innervated by nociceptors. Although the hallmark of OA is the degradation of the cartilage, OA joints show multiple structural alterations of cartilage, bone and synovial tissue. In particular synovitis and bone marrow lesions have been proposed to determine OA pain whereas the contribution of the other pathologies to pain generation has been studied less. Concerning the peripheral neuronal mechanisms of OA pain, peripheral nociceptive sensitization was shown, and neuropathic mechanisms may be involved at some stages. Structural changes of joint innervation such as local loss and/or sprouting of nerve fibers were shown. In addition, central sensitization, reduction of descending inhibition, descending excitation and cortical atrophies were observed in OA. The combination of different neuronal mechanisms may define the particular pain phenotype in an OA patient. Among mediators involved in OA pain, nerve growth factor (NGF) is in the focus because antibodies against NGF significantly reduce OA pain. Several studies show that neutralization of interleukin-1β and TNF may reduce OA pain. Many patients with OA exhibit comorbidities such as obesity, low grade systemic inflammation and diabetes mellitus. These comorbidities can significantly influence the course of OA, and pain research just began to study the significance of such factors in pain generation. In addition, psychologic and socioeconomic factors may aggravate OA pain, and in some cases genetic factors influencing OA pain were found. Considering the local factors in the joint, the neuronal processes and the comorbidities, a better definition of OA pain phenotypes may become possible. Studies are under way in order to improve OA and OA pain monitoring.

Novel joint selection methods can reduce sample size for rheumatoid arthritis clinical trials with ultrasound endpoints

OBJECTIVES

To determine whether novel methods of selecting joints through (i) ultrasonography (individualized-ultrasound [IUS] method), or (ii) ultrasonography and clinical examination (individualized-composite-ultrasound [ICUS] method) translate into smaller rheumatoid arthritis (RA) clinical trial sample sizes when compared to existing methods utilizing predetermined joint sites for ultrasonography.

METHODS

Cohen's effect size (ES) was estimated (ES^) and a 95% CI (ES^L, ES^U) calculated on a mean change in 3-month total inflammatory score for each method. Corresponding 95% CIs [nL(ES^U), nU(ES^L)] were obtained on a post hoc sample size reflecting the uncertainty in ES^. Sample size calculations were based on a one-sample t-test as the patient numbers needed to provide 80% power at α = 0.05 to reject a null hypothesis H₀ : ES = 0 versus alternative hypotheses H₁ : ES = ES^, ES = ES^L and ES = ES^U. We aimed to provide point and interval estimates on projected sample sizes for future studies reflecting the uncertainty in our study ES^S.

RESULTS

Twenty-four treated RA patients were followed up for 3 months. Utilizing the 12-joint approach and existing methods, the post hoc sample size (95% CI) was 22 (10-245). Corresponding sample sizes using ICUS and IUS were 11 (7-40) and 11 (6-38), respectively. Utilizing a seven-joint approach, the corresponding sample sizes using ICUS and IUS methods were nine (6-24) and 11 (6-35), respectively.

CONCLUSIONS

Our pilot study suggests that sample size for RA clinical trials with ultrasound endpoints may be reduced using the novel methods, providing justification for larger studies to confirm these observations.

Musculoskeletal ultrasonography for psoriatic arthritis and psoriasis patients: a systematic literature review

Objective

To systematically review the role of musculoskeletal US in patients suffering from PsA or psoriasis (Pso) in terms of prevalence, diagnosis, prognosis, monitoring and treatment.

Methods

A systematic literature review was conducted through medical databases (MEDLINE via PubMed, Embase) and the grey literature up to September 2015 to inform a new study of the Musculoskeletal Ultrasound Study Group of the Italian Society for Rheumatology. All articles reporting data on musculoskeletal US in PsA or Pso were included and extracted according to the underlying clinical question.

Results

A total of 86 publications were included. The prevalence of US abnormalities showed a wide range for each examined feature (e.g. 37-95% for entheses thickness of the lower limbs). The performance of US for diagnosis of disease or elementary lesions was variable across studies, but no study evaluated the overall performance of US in addition to clinical findings for diagnosing PsA. Considering US in defining PsA and Pso prognosis, several works focused on US of entheses of lower limbs in Pso, while for the monitoring of PsA activity five different scoring systems were identified. Last, the results of the role of US in guiding intra-articular interventions were controversial for the clinical outcomes, but in favour of US for accuracy.

Conclusion

despite the recognized importance of US in the management of PsA and Pso, this review clearly demonstrated the need of pivotal research in order to optimize the use of US in the diagnosis and monitoring of psoriatic disease.

What drives osteoarthritis?-synovial versus subchondral bone pathology

Subchondral bone and the synovium play an important role in the initiation and progression of OA. MRI often permits an early detection of synovial hypertrophy and bone marrow lesions, both of which can precede cartilage damage. Newer imaging modalities including CT osteoabsorptiometry and hybrid SPECT-CT have underlined the importance of bone in OA pathogenesis. The subchondral bone in OA undergoes an uncoupled remodelling process, which is notably characterized by macrophage infiltration and osteoclast formation. Concomitant increased osteoblast activity leads to spatial remineralization and osteosclerosis in end-stage disease. A plethora of metabolic and mechanical factors can lead to synovitis in OA. Synovial tissue is highly vascularized and thus exposed to systemic influences such as hypercholesterolaemia or low grade inflammation. This review aims to describe the current understanding of synovitis and subchondral bone pathology and their connection in OA.

Clinical features and radiological findings of 67 patients with SAPHO syndrome

OBJECTIVES

The purpose of this study was to facilitate the understanding of the SAPHO (Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis) syndrome by analyzing the clinical and radiological features of 67 Japanese patients with SAPHO syndrome.

METHODS

Sixty-seven Japanese patients (female/male: 44/23, mean age at onset: 48.5 years) were diagnosed with SAPHO syndrome from 2002 to 2013 at our hospital. Medical records and radiological imaging of these patients were retrospectively reviewed.

RESULTS

Among the 67 patients, 41 had dermatological manifestations, such as palmoplantar pustulosis, acne, and psoriasis. Initial symptom was local pain in all patients, and the most common initial site of the symptom was the anterior chest. Bacterial and fungal cultures from 20 bone biopsies were all negative. Histopathological diagnosis of the specimens was non-specific inflammation in all cases. Bone lesions were observed in 65 patients (97.0%). On the other hand, articular lesions including enthesitis were found in 31 patients (46.2%).

CONCLUSION

SAPHO syndrome had different clinical and radiological aspects. The clinical features were not remarkable, except the dermatological manifestations and the involvement of the anterior chest. Bone lesions including hyperostosis and osteitis were found radiographically in the majority of patients with SAPHO syndrome. These are the characteristics of the SAPHO syndrome, with the exclusion of other bone diseases.

Effect of radiosynoviorthesis on the progression of arthropathy and haemarthrosis reduction in haemophilic patients

INTRODUCTION

Repeated haemarthrosis is widely accepted as the triggering cause of synovitis and haemophilic arthropathy. A first-line treatment of chronic synovitis is radiosynoviorthesis (RS). The aim of this study was to evaluate the RS effects on the progression of arthropathy and on a reduction in bleeding in patients with haemophilia.

METHODS

An observational-retrospective study was performed. Bleeding episodes in the 12 months following and in the 12 months preceding RS was compared. The arthropathy was clinically and radiologically analysed by age range, joint and subject, comparing those undergoing RS (Radiosynoviorthesis Group, RSG) against those not undergoing this treatment (Non-Radiosynoviorthesis Group, Non-RSG).

RESULTS

One hundred and seventy-four RS were performed in 71 patients (⁹⁰ Y in Knees and ¹⁸⁶ Re in elbows/ankles/shoulder). RS resulted in significant reduction in bleeding (582 preintervention and 168 postintervention, P < .001). In general, the level of arthropathy measured clinically and radiologically was greater with age increase in both groups (RSG and Non-RSG), especially in the 25-40 age range. A significant increase (P < .05) in the progression of arthropathy was also observed, both globally by patient and specifically for each joint, in non-RSG and RSG group.

CONCLUSION

RS is an effective method to reduce the number of haemarthrosis episodes in chronic synovitis. Moreover, RS can positively affect arthropathy by slowing down its progression. However, the results obtained suggest that arthropathy may be conditioned by the subject's age, regardless of whether or not the joint has undergone RS.

p-Coumaric acid, a dietary polyphenol ameliorates inflammation and curtails cartilage and bone erosion in the rheumatoid arthritis rat model

This study was designed to explore the underlying mechanism of p-coumaric acid (CA), a dietary polyphenol in adjuvant-induced arthritis (AIA) rat model with reference to synovitis and osteoclastogenesis. Celecoxib (COX-2 selective inhibitor) (5 mg/kg b.wt) was used as a reference drug. CA remarkably suppressed the paw edema, body weight loss and inflammatory cytokine and chemokine levels (TNF-α, IL-1β, IL-6, and MCP-1) in serum and ankle joint of arthritic rats. Consistently, CA reduced the expression of osteoclastogenic factors (RANKL and TRAP), pro-inflammatory cytokines (TNF-α, IL-1β, IL-6, and IL-17), and inflammatory enzymes (iNOS and COX-2) in arthritic rats. However, OPG expression was found elevated. Besides, the abundance of transcription factors (NF-κB-p65, and p-NF-κB-p65, NFATc-1, and c-Fos) and MAP kinases (JNK, p-JNK, and ERK1/2) expression was alleviated in CA administered arthritic rats. In addition, CA truncated osteoclastogenesis by regulating the RANKL/OPG imbalance in arthritic rats and suppressing the RANKL-induced NFATc-1 and c-Fos expression in vitro. Radiological (CT and DEXA scan) and histological assessments authenticated that CA inhibited TRAP, bone destruction and cartilage degradation in association with enhanced bone mineral density. Taken together, our findings suggest that CA demonstrated promising anti-arthritic effect and could prove useful as an alternative drug in RA therapeutics. © 2017 BioFactors, 43(5):698-717, 2017.

Immunohistochemical characterization of early and advanced knee osteoarthritis by NF-κB and iNOS expression

This study was performed to determine the differences in grade of synovitis and expression of NF-κB and iNOS in knee synovial membrane between early and advanced stage of osteoarthritis (OA). Thirty synovial membrane intra-operative biopsies of patients (ten controls, ten with early and ten with advanced OA according to Kellgren-Lawrence radiological score) were immunohistochemically (NF-κB and iNOS) and hystologically (Krenn synovitis score) analyzed and correlated to WOMAC clinical score and pain duration. Krenn synovitis score of patients with radiologically early OA was significantly higher than in patients with advanced OA (p < 0.001). NF-κB expression in both synovial intima (p < 0.001) and subintima (p < 0.001) was also higher in early OA. iNOS expression in subintima was significantly higher in early than in advanced OA (p < 0.001), while in intima iNOS showed no statistical difference between groups (p = 0.07). The lymphocytic nodules, located in synovial subintima, were significantly higher in advanced OA when compared to early OA (p = 0.006) and the control group (p < 0.001). These results suggest that in early OA, there is a localized inflammation of the synovial membrane with high expression of NF-κB and iNOS. In advanced OA, number of expressed factors is reduced, with the exception of intima cells that highly express iNOS, reflecting the ongoing localized inflammatory process of lower degree. In advanced OA, the density of the resident cells is reduced and lymphocytic nodules appear, confirming the important role of adaptive immunity in later OA stage. Clinical significance of this study is better understanding possibilities of preventive measures for synovitis and OA advancement. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1990-1997, 2017.

A fusion protein of interleukin-4 and interleukin-10 protects against blood-induced cartilage damage in vitro and in vivo

Essentials Targeted treatment for hemophilic arthropathy, still causing significant morbidity, is lacking. This study evaluates the efficacy of a fusion of protein of interleukin(IL)-4 and IL-10. In vitro the fusion protein prevents blood-induced cartilage damage in a dose-dependent manner. In hemophilic mice, the IL4-10 fusion protein ameliorates cartilage damage upon joint bleeding.

SUMMARY

Background Joint damage still causes significant morbidity in hemophilia. It results from synovial inflammation and direct cartilage-degenerating properties of blood components. Interleukin (IL)-4 and IL-10 have been shown to protect cartilage from blood-induced damage. Recently an IL4-10 fusion protein has been developed to combine the function of IL-4 and IL-10 and increase their bioavailability. Objectives In this study we evaluate whether this IL4-10 fusion protein protects against blood-induced joint damage. Methods In vitro, human cartilage explants were exposed to whole blood and simultaneously to a broad concentration range of the IL4-10 fusion protein. Effects on cartilage matrix turnover were compared with the individual cytokines. Moreover, the influence of the fusion protein and its individual components on IL-1β and IL-6 production was investigated. In hemophilia A mice, the effect of intra-articular treatment on synovitis and cartilage damage resulting from joint bleeding was evaluated by histochemistry. Results In vitro, the fusion protein prevented blood-induced cartilage damage in a dose-dependent manner, with equal effectiveness to the combination of the separate cytokines. In whole blood cultures 10 ng mL-1 fusion protein completely blocked the production of IL-1β and IL-6 by monocytes/macrophages. In hemophilic mice, intra-articular injection of IL-4 and IL-10 did not influence synovitis or cartilage degeneration. In contrast, equimolar amounts of the fusion protein attenuated cartilage damage upon repeated joint bleeding, although synovial inflammation was hardly affected. Conclusions Overall, this study shows that the IL4-10 fusion protein prevents blood-induced cartilage damage in vitro and ameliorates cartilage degeneration upon joint bleeding in hemophilic mice.

Dominant B cell receptor clones in peripheral blood predict onset of arthritis in individuals at risk for rheumatoid arthritis

BACKGROUND

The onset of seropositive rheumatoid arthritis (RA) is preceded by the presence of specific autoantibodies in the absence of synovial inflammation. Only a subset of these at-risk individuals will develop clinical disease. This impedes efforts to implement early interventions that may prevent onset of clinically manifest disease. Here we analyse whether clonal changes in the B cell receptor (BCR) repertoire can reliably predict onset of signs and symptoms.

METHODS

In a prospective cohort study in 21 individuals at risk for RA based on the presence of autoantibodies, the BCR repertoire of paired peripheral blood and synovial tissue samples was analysed using next-generation BCR sequencing. BCR clones that were expanded beyond 0.5% of the total repertoire were labelled dominant. The relative risk (RR) for onset of arthritis was assessed using the presence of ≥5 dominant BCR clones as cut-off. Findings in peripheral blood were validated in an independent prospective cohort of 50 at-risk individuals. Based on the test cohort, individuals in the validation cohort were considered positive if peripheral blood at study entry showed ≥5 dominant BCR clones.

FINDINGS

Both in the test and validation cohort, the presence of ≥5 dominant BCR clones in peripheral blood was significantly associated with arthritis development after follow-up (validation cohort RR 6.3, 95% CI 2.7 to 15, p<1×10^-4). Even when adjusted for a recently described clinical prediction rule the association remained intact (RR 5.0, 95% CI 1.2 to 20, p=0.024). When individuals developed arthritis, dominant BCR clones disappeared from peripheral blood and appeared in synovial tissue, suggesting a direct role of these clones in disease pathogenesis.

INTERPRETATION

Dominant BCR clones in peripheral blood predict onset of clinical signs and symptoms of RA in at-risk individuals with high accuracy. Our data suggest that during onset of RA these clones shift from peripheral blood to the target tissue.

Comparison of Pre-Revision Magnetic Resonance Imaging and Operative Findings in Mechanically Assisted Crevice Corrosion in Symptomatic Metal-on-Polyethylene Total Hip Arthroplasties

BACKGROUND

Failed total hip arthroplasty (THA) caused by mechanically assisted crevice corrosion (MACC) has serious consequences-notably, adverse local tissue reactions. Metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) has been used to evaluate failed THA for other reasons but has not been assessed for the analysis of cases of MACC in the setting of metal-on-polyethylene arthroplasties.

METHODS

We examined the correlation between preoperative MARS MRI and surgical findings in a cohort of 20 consecutive patients undergoing revision THA for symptomatic MACC without other associated orthopedic diagnoses. Surgical findings included soft tissue and bone evaluation, presence and location of fluid, abductor disruption, composite tissue damage grade, and prosthesis trunnion damage at the time of revision.

RESULTS

MARS MRI complex synovitis, thickened pseudocapsule, and extra-articular fluid extension each strongly correlated with both the soft-tissue damage grade and trunnion damage noted at surgery. Bone marrow edema was also found to strongly correlate with bone necrosis intraoperatively.

CONCLUSION

MARS MRI is an excellent diagnostic tool for evaluation of patients with elevated serum Co after metal-on-polyethylene THA. Patients with complex synovitis, a thick pseudocapsule, bone marrow edema, and extra-articular fluid should strongly consider revision surgery.

Developing anti-inflammatory therapeutics for patients with osteoarthritis

OA is the most common joint disorder in the world, but there are no approved therapeutics to prevent disease progression. Historically, OA has been considered a wear-and-tear joint disease, and efforts to identify and develop disease-modifying therapeutics have predominantly focused on direct inhibition of cartilage degeneration. However, there is now increasing evidence that inflammation is a key mediator of OA joint pathology, and also that the link between obesity and OA is not solely due to excessive load-bearing, suggesting therefore that targeting inflammation in OA could be a rewarding therapeutic strategy. In this review we therefore re-evaluate historical clinical trial data on anti-inflammatory therapeutics in OA patients, highlight some of the more promising emerging therapeutic targets and discuss the implications for future clinical trial design.

Agreement of clinical examination and ultrasound methods for detection of joints involvements in rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis is a chronic autoimmune disease characterized by synovial tissue inflammation and destruction of articular components which if not controlled properly, can cause disability in patients. For this reason, evaluation of disease activity and its control is very important. In recent years using sonography is promising for the evaluation of disease activity. This study aimed to compare "clinical examination" and "ultrasonography" methods in the detection of disease activity in patients with rheumatoid arthritis.

MATERIALS AND METHODS

This cross-sectional study was conducted during 2015 in Al-Zahra Hospital of Isfahan. Based on the American College of Rheumatology 2010 criteria, ninety patients with rheumatoid arthritis who diagnosed by rheumatologist entered into the study. All patients, collaborator by radiologists were subjected to sonography of specific joints structures using two methods, i.e., high-resolution ultrasonography and power Doppler.

RESULTS

A total of 2520 joints from ninety patients were examined by physical examination and ultrasonography that 244 joints (9.7%) in physical examination and 348 joints (13.4%) in ultrasonography were involved and the difference between the two groups was statistically significant (P < 0.001).

CONCLUSION

Probably, ultrasonography can diagnose joint involvement better than physical examination in patients with Rheumatoid arthritis.

Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforcePart 1: definition and development of a standardised, consensus-based scoring system

OBJECTIVES

To develop a consensus-based ultrasound (US) definition and quantification system for synovitis in rheumatoid arthritis (RA).

METHODS

A multistep, iterative approach was used to: (1) evaluate the baseline agreement on defining and scoring synovitis according to the usual practice of different sonographers, using both grey-scale (GS) (synovial hypertrophy (SH) and effusion) and power Doppler (PD), by reading static images and scanning patients with RA and (2) evaluate the influence of both the definition and acquisition technique on reliability followed by a Delphi exercise to obtain consensus definitions for synovitis, elementary components and scoring system.

RESULTS

Baseline reliability was highly variable but better for static than dynamic images that were directly acquired and immediately scored. Using static images, intrareader and inter-reader reliability for scoring PD were excellent for both binary and semiquantitative (SQ) grading but GS showed greater variability for both scoring systems (κ ranges: -0.05 to 1 and 0.59 to 0.92, respectively). In patient-based exercise, both intraobserver and interobserver reliability were variable and the mean κ coefficients did not reach 0.50 for any of the components. The second step resulted in refinement of the preliminary Outcome Measures in Rheumatology synovitis definition by including the presence of both hypoechoic SH and PD signal and the development of a SQ severity score, depending on both the amount of PD and the volume and appearance of SH.

CONCLUSION

A multistep consensus-based process has produced a standardised US definition and quantification system for RA synovitis including combined and individual SH and PD components. Further evaluation is required to understand its performance before application in clinical trials.

Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforce-Part 2: reliability and application to multiple joints of a standardised consensus-based scoring system

Objectives

To test the reliability of new ultrasound (US) definitions and quantification of synovial hypertrophy (SH) and power Doppler (PD) signal, separately and in combination, in a range of joints in patients with rheumatoid arthritis (RA) using the European League Against Rheumatisms–Outcomes Measures in Rheumatology (EULAR-OMERACT) combined score for PD and SH.

Methods

A stepwise approach was used: (1) scoring static images of metacarpophalangeal (MCP) joints in a web-based exercise and subsequently when scanning patients; (2) scoring static images of wrist, proximal interphalangeal joints, knee and metatarsophalangeal joints in a web-based exercise and subsequently when scanning patients using different acquisitions (standardised vs usual practice). For reliability, kappa coefficients (κ) were used.

Results

Scoring MCP joints in static images showed substantial intraobserver variability but good to excellent interobserver reliability. In patients, intraobserver reliability was the same for the two acquisition methods. Interobserver reliability for SH (κ=0.87) and PD (κ=0.79) and the EULAR-OMERACT combined score (κ=0.86) were better when using a ‘standardised’ scan. For the other joints, the intraobserver reliability was excellent in static images for all scores (κ=0.8–0.97) and the interobserver reliability marginally lower. When using standardised scanning in patients, the intraobserver was good (κ=0.64 for SH and the EULAR-OMERACT combined score, 0.66 for PD) and the interobserver reliability was also good especially for PD (κ range=0.41–0.92).

Conclusion

The EULAR-OMERACT score demonstrated moderate-good reliability in MCP joints using a standardised scan and is equally applicable in non-MCP joints. This scoring system should underpin improved reliability and consequently the responsiveness of US in RA clinical trials.

Should Arterial Embolization in Recurrent Spontaneous Hemoph ilic Hemarthroses Refractory to Intensive Prophylaxis be the First Invasive Resort?

BACKGROUND

Some reports have suggested that arterial embolization (AE) is a good indication to manage recurrent spontaneous hemartroses (RSH) that are refractory to intensive prophylaxis (RIP) in people with hemophilia (PWH).

OBJECTIVE

To clarify the role of AE in RSH that are RIP in PWH.

METHOD

A literature review of arterial embolization in patients with hemophilia was performed using MEDLINE (PubMed) and the Cochrane Library.

RESULTS

A total of 68 articles were found, of which 6 were selected and reviewed because they were deeply focused on the topic. The total number of AEs performed so far is 78 in 69 patients. Four second AEs were required (4/78), and a third AE in one (1/78). Two complications have been found so far: a pseudoaneurym (1/78) of the femoral artery at the puncture site (that eventually required surgical repair) and a patient (1/78) that had recurrence of bleeding for whom surgical exploration was required. AE seems to be a good procedure for RSH that are RIP.

CONCLUSION

AE seems to be too aggressive to be considered the first resort. Radiosynovectomy (RS) must always be the first resort. AE should only be indicated in RSH that are RIP to 3 RSs (with 6 month intervals) followed by an arthroscopic synovectomy. AE in PWH is technically challenging and should be performed by highly skilled interventional radiologists.

Pathophysiology of Hemophilic Arthropathy

Spontaneous joint bleeding and repeated hemarthroses lead to hemophilic arthropathy—a debilitating disease with a significant negative impact on mobility and quality of life. Iron, cytokines, and angiogenic growth factors play a pivotal role in the onset of the inflammatory process that involves the synovial tissue, articular cartilage, and subchondral bone, with early damages and molecular changes determining the perpetuation of a chronic inflammatory condition. Synovitis is one of the earliest complications of hemarthrosis, and is characterized by synovial hypertrophy, migration of inflammatory cells, and a high degree of neo-angiogenesis with subsequent bleeding. The pathogenic mechanisms and molecular pathways by which blood in the joint cavity causes articular cartilage and subchondral bone destruction have yet to be fully elucidated. Both cytokines and matrix metalloproteinases and hydroxyl radicals may induce chondrocyte apoptosis. Members of the tumor necrosis factor receptor superfamily (such as the molecular triad: osteoprotegerin—OPG; receptor activator of nuclear factor κB—RANK; RANK ligand—RANKL) seem instead to play a major role in the inflammatory process. These pathogenic processes interact with each other and ultimately lead to a fibrotic joint and the disabling condition characteristic of hemophilic arthropathy.

Post-radiosynovectomy imaging of Er-169 using scintigraphy and autoradiography

Currently, there is no protocol for the detection of intra‐articular distribution of Er‐169 citrate after radiosynovectomy. We propose post‐therapeutic imaging using scintigraphy and cobalt‐57 pen‐marker autoradiography. This technique evaluates the efficacy of the radiosynovectomy and patient safety and could be utilized for dosimetric protocol.

Sonographic Characteristics of Extensor Tendon Abnormalities and Relationship With Joint Disease Activity in Rheumatoid Arthritis: A Pilot Study

OBJECTIVES

To characterize abnormalities in the dorsal extensor tendons of the hand and determine the importance of these findings in rheumatoid arthritis.

METHODS

A retrospective cross-sectional study was done on 26 patients with rheumatoid arthritis who had sonography of their hands. B-mode and power Doppler joint activity were scored, and the extensor tendons were examined for B-mode changes and power Doppler signals. B-mode changes included anechoic fluid around tendons, hypoechoic tissue around tendons, paratendon tissue and tendon thickening, as well as vascularity around the tendon, for which peritendon power Doppler signals were recorded.

RESULTS

Forty-one hands and 205 joints were reviewed. Anechoic fluid around the tendons and peritendon power Doppler signals were observed in 41% and 39%, respectively; 44% and 28% of patients had B-mode and power Doppler scores in the upper tertile, respectively. For both B-mode and power Doppler scores, 3 categories or tertiles were created, 0 to 0.9, 1 to 1.9, and 2 to 3. We reported the percentage of patients with power Doppler and B-mode scores in this category. The severity of synovitis was associated with anechoic fluid around the tendons and peritendon power Doppler signals according to the Cochran-Mantel-Haenszel test. The common odds ratio was 3.52 (95% confidence interval, 1.45- 8.53) for anechoic fluid around the tendons and severe synovitis. The common odds ratio was 2.52 (95% confidence interval, 1.13-5.63) for peritendon power Doppler signals and severe synovitis.

CONCLUSIONS

Findings at the dorsal extensor tendons were anechoic fluid around tendons, hypoechoic tissue around tendons, peritendon power Doppler signals, and tendon thickening. Patients with anechoic fluid and power Doppler signals were found to have more severe disease activity at the joints based on B-mode and power Doppler scores.

Mesenchymal Stem Cell-Derived Exosomes: Immunomodulatory Evaluation in an Antigen-Induced Synovitis Porcine Model

Synovitis is an inflammatory process associated with pain, disability, and discomfort, which is usually treated with anti-inflammatory drugs or biological agents. Mesenchymal stem cells (MSCs) have been also successfully used in the treatment of inflammatory-related diseases such as synovitis or arthritis. In the last years, the exosomes derived from MSCs have become a promising tool for the treatment of inflammatory-related diseases and their therapeutic effect is thought to be mediated (at least in part) by their immunomodulatory potential. In this work, we aimed to evaluate the anti-inflammatory effect of these exosomes in an antigen-induced synovitis animal model. To our knowledge, this is the first report where exosomes derived from MSCs have been evaluated in an animal model of synovitis. Our results demonstrated a decrease of synovial lymphocytes together with a downregulation of TNF-α transcripts in those exosome-treated joints. These results support the immunomodulatory effect of these exosomes and point out that they may represent a promising therapeutic option for the treatment of synovitis.

Serum calreticulin as a novel biomarker of juvenile idiopathic arthritis disease activity

OBJECTIVE

This study aimed to investigate the relations between calreticulin (CRT) serum level and both disease activity and severity parameters in juvenile idiopathic arthritis (JIA).

MATERIAL AND METHODS

In this study, 60 children with JIA and 50 age-and-sex-matched healthy subjects were enrolled. The assessment of the disease activity was done using juvenile arthritis disease activity score 27 (JADAS-27). The assessment of disease severity was done via gray-scale ultrasonography (US) and power Doppler US (PDUS). Enzyme-linked immunosorbent assay (ELISA) was used to assay the serum level of human CRT.

RESULTS

The mean serum CRT levels in JIA patients was 8.6±1.2 ng/mL and showed a highly significant increase (p=0.001) as compared to the mean serum levels in the controls (5.02±0.77 ng/mL). There were statistically significant positive correlations between the serum CRT levels and disease duration, tender joint count, swollen joint count, visual analog scale, erythrocyte sedimentation rate, JADAS-27, C-reactive protein, rheumatoid factor titer, and ultrasonographic grading for synovitis and neovascularization.

CONCLUSION

Elevated serum CRT levels in JIA patients and its correlations with JIA disease activity and severity parameters signified that CRT might be used as a novel biomarker for disease activity and severity in JIA.