Changes in spino-pelvis-lower extremity alignment in patients with knee osteoarthritis: a prospective radiographic study

PURPOSE

Osteoarthritis (OA) is a prevalent, debilitating ailment among the elderly. Humans need a correct sagittal spino-pelvis-lower extremity alignment to stand upright. Pathology in trunk or lower extremity section might disrupt this harmony, causing compensatory alterations in other segments. The aim of the present study was to evaluate spino-pelvis-lower extremity alignment and association among the various spino-pelvic, knee, and ankle radiological angles in patients with knee osteoarthritis (OA).

MATERIALS AND METHODS

This prospective study enrolled 70 adults over 50 years of age of either sex who complained of knee pain and met the American College of Rheumatology criteria for symptomatic OA of at least one knee. The radiological assessment comprised anteroposterior and lateral lower extremity full-length scans, as well as the Kellgren-Lawrence radiographic classification of OA. We measured hip, knee, ankle, and spino-pelvic angles using Horos software. We calculated descriptive statistics and linear correlation between continuous variables.

RESULTS

There was a significant association (p < 0.05) between age and the majority of the spino-pelvic, knee, and ankle angles and between age and severity of OA. Significant variables linked with 'SFA' include HKAA (p = 0.008), mLDFA (p < 0.001), TJLA, FS-TS, Cond-Plateau, and femoral bowing (p = 0.007). We found significant associations between 'PFA' and mMPTA (p = 0.005), Cond-Plateau (p = 0.005), Tibial Bowing (p = 0.003), and 'LL' with HKAA, mLDFA, FS-TS, and Cond-Plate. SSA was significantly associated with mLDFA, mMPTA, TJLA, Cond-Plateau, and HKAA; while, FI' was significantly associated with FS-TS, femoral bowing, and tibial bowing (p < 0.001). The variables 'SS' was substantially linked with TTA (p = 0.008), TT (p = 0.004), PP (< 0.001), GP (p < 0.001), and GT (p = 0.010). 'PI' was substantially linked to TT (p = 0.001), GP (p = 0.005), and GT (p = 0.042), and 'PT' to TT (p < 0.001) and GT (p = 0.012). 'SFA' and 'PFA' only correlated with TT (p = 0.012 and 0.010). Lower limb angles were significantly associated with TT, PP, GP, GT, mLDFA, and mMPTA (p = 0.031, p = 0.026, p = 0.009, p = 0.009, TT, GP, GT, p < 0.001). GP was the sole significant association for 'TJLA' (p = 0.016). 'FS-TS' substantially correlated with PP (p = 0.015), GP (p < 0.001), and GT (p < 0.001). "Femoral Bowing" was significantly linked to PP (p = 0.017), GP (p = 0.007), and GT (p < 0.001), and "Cond-Plateau" was significantly linked to GP (p = 0.002) and GT. "Tibial Bowing" was significantly linked to TTA (p < 0.001), TAS (p = 0.003), LDTA (p = 0.002), TC (p < 0.001), GP (p = 0.007), and GT (p < 0.001). Age, gender, BMI, and the severity of knee OA significantly influenced the association among these various angles.

CONCLUSION

Osteoarthritis of the knee disrupts the harmonious alignment of the spine and pelvis with the lower limbs, resulting in compensatory changes in the ankle and spine. The severity of knee osteoarthritis and the patient's gender, age, and BMI impact compensatory adaptations.

TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION

CTRI/2021/08/036088 [Registered on: 31/08/2021] - Trial Registered Prospectively.

Radiological Approach to Assessment of Lower-Limb Alignment-Coronal and Transverse Plane Analysis

Lower-limb alignment deformities constitute a significant clinical concern, as they can lead to serious complications, including progressive degenerative diseases and disabilities. Rotational deformities may give rise to conditions such as joint arthrosis, patellar instability, and the degeneration of the patellofemoral cartilage. Therefore, a comprehensive evaluation of lower-limb alignment is essential for the effective patient management, preoperative planning, and successful correction of these deformities. The primary assessment method employs full-length standing radiographs in the anteroposterior (AP) projection, which facilitates accurate measurements of the anatomical and mechanical axes of the lower limb, including angles and deviations. The outcomes of this analysis are vital for the meticulous planning of osteotomy and total knee arthroplasty (TKA). In addition, computed tomography (CT) provides a specialized approach for the precise evaluation of femoral and tibial rotation. In this area, there are potential opportunities for the implementation of AI-based automated measurement systems.

Baseline and 2-year differences in spinal symptoms and spinal and hip mobility in early axial spondyloarthritis and non-axial spondyloarthritis chronic back pain patients

OBJECTIVE

To compare spinal symptoms and spinal/hip mobility at baseline and 2 years in early axial spondyloarthritis (axSpA) and non-axSpA chronic back pain (BP) patients.

METHODS

Baseline and 2 years data of the SPondyloarthritis Caught Early cohort were analysed. Outcomes assessed: overall BP, BP at night, morning stiffness (MS) intensity, MS duration, occiput-to-wall distance (OWD), cervical rotation, chest expansion, lateral spinal flexion (LSF), modified Schober test (mSchober), intermalleolar distance (IMD) and Bath Ankylosing Spondylitis Metrology Index (BASMI). Linear or zero-inflated negative binomial regression was used to compare 2 years outcomes between groups (adjusting for baseline value, sex, age and use of non-steroidal anti-inflammatory drugs).

RESULTS

There were 294 axSpA and 123 non-axSpA patients (mean symptom duration: 13 months). At baseline, non-axSpA patients had worse symptoms and mobility, except OWD (eg, mean(SD): BP at night 3.6 (2.9) axSpA vs 4.6 (2.7) non-axSpA; OWD 0.5 (1.2) vs 0.1 (0.7)). After 2 years, all symptoms and cervical rotation significantly improved in both groups, but LSF and mSchober only in axSpA. In multivariable analyses, axSpA was associated with larger improvements in BP at night (β (95% CI): -0.85 (-1.47; -0.23)), mSchober (0.26 (0.03; 0.50)), IMD (4.86 (1.93; 7.80)) and BASMI (-0.24 (-0.41; -0.08)), and with lower likelihood of a normal OWD (OR (95% CI): 0.09 (0.01; 0.83)).

CONCLUSION

Over 2 years, all spinal symptoms and some mobility measures improved in both groups, but impairments remained prevalent (particularly in non-axSpA). Nevertheless, axSpA was associated with larger improvements in BP at night, mSchober, IMD and BASMI, but with more OWD impairment.

Radiographic Assessment of Bone Union in Proximal Tibia and Distal Femur Osteotomies: A Systematic Review

Background

Osteotomies around the knee are a well-established treatment option for early and moderate unicompartmental osteoarthritis combined with a lower extremity malalignment. Moreover, osteotomies are often combined with cartilage treatment. Current image-based bone union assessments lack an accepted definition despite widespread use in research and clinical settings. The aim of this systematic review was to identify definitions and classification systems for bone union on radiographs after a proximal tibia or distal femur osteotomy.

Methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we systematically searched MEDLINE and Embase database, applying specific inclusion and exclusion criteria. Two independent reviewers screened abstracts and full-texts. The modified Cochrane Risk of Bias Tool and Risk of Bias in Nonrandomized Studies of Interventions tool were used. Data extraction included study characteristics, imaging modality, bone union definition, classification systems, assessment of gap fillers, use of modifiers, and osteotomy type.

Results

Of the 1,180 screened titles and abstracts, 105 studies were included, with the majority (69 studies [65.7%]) using a retrospective design. Fifty-five studies (52.4%) defined bone union based on one or more criteria, while 50 studies (47.6%) used a classification system. There were 13 different criteria for bone union and 9 different classification systems. Interestingly, none of the classification systems incorporated negative criteria, such as hardware failure. Notably, 137 studies (49.1%) described bone union as either a primary or secondary outcome but do not describe a system for assessing bone union.

Conclusion

This systematic review highlights the lack of consensus in the literature in defining bone union after a proximal tibia or distal femur osteotomy, revealing many criteria and different classifications. None of the classification systems were applicable to osteotomies with and without gap filler. This systematic review shows the need for a straightforward, reproducible, and accurate method to assess bone union after a proximal tibia or distal femur osteotomy.

Level of Evidence

Level III. See Instructions for Authors for a complete description of levels of evidence.

Management Considerations for Unicompartmental Osteoarthritis in Athletic Populations: A Review of the Literature

Unicompartmental osteoarthritis in the young athlete poses a challenge for both patients and providers. Coronal plane malalignment is frequently a concomitant finding that adds to the complexity of management. Military surgeons are presented unique challenges, in that they must consider optimal joint-preservation methods while returning patients to a high-demand occupational function. Management options range from lifestyle changes to surgical interventions. We present a concise review of the available literature on this subject, with a specific focus on indications and outcomes within the military and young athletic population.

Pyoderma Gangrenosum: A Presenting Feature of Rheumatoid Arthritis

Pyoderma gangrenosum (PG) is an uncommon inflammatory disorder that exhibits a range of clinical manifestations and levels of severity. It frequently occurs alongside an underlying condition, most often inflammatory bowel disease. PG, Sweet syndrome, palisaded neutrophilic granulomatous dermatitis (PNGD), interstitial granulomatous dermatitis (IGD) and rheumatoid neutrophilic dermatitis may be associated with rheumatoid arthritis (RA). We present a case of a 65-year-old woman with disseminated dermatosis to the hands, abdomen, buttocks, and lower limbs. The dermatosis presented with numerous ulcers of varying shapes, featuring clean bases, undermined edges, and a purplish erythematous appearance. Further investigations, including imaging studies and RA factor and anti-cyclic citrullinated peptide (anti-CCP) levels, led us to the diagnosis of RA. This case indicates that RA may be frequently undiagnosed and untreated in other patients with PG, as ulcers on the lower extremities can often be the main reason for seeking medical attention.

On the early uses of the word 'gout': novel evidence and a critical assessment of the published literature

Recognized since antiquity, gout is still a relevant pathology with rising prevalence and incidence. This study aims to assess the reference accuracy in journal articles mentioning the early use of the word 'gout'. Specifically, it investigates whether the term was indeed coined in the 13th century by the Dominican monk Randolphus of Bocking, as widely believed. Several historical sources in their original Latin were consulted to test the hypothesis of literary mentions predating Randolphus of Bocking's description. At the same time, biomedical articles spanning the last two decades were perused using specific keywords in different combinations to determine the accuracy level of references related to the earliest use of the word 'gout'. The results showed that several biomedical publications wrongly ascribed the origin of the word 'gout' to Randolphus of Bocking. Indeed, various texts predate his mention by many years. In particular, gutta, the Latin word used to indicate a host of rheumatological conditions including gout, is recorded as early as the 10th century in a biography dedicated to the martyred nun Saint Wiborada of St. Gall. Written by Swiss monks between AD 960 and 963, this text should be regarded as containing the earliest known adoption of the word. For this reason, scholars should now avoid quoting Randolph of Bocking's description as the first use of the word 'gout' in Western literature.

Consensus-Based Overarching Principles and Recommendations on the Use of Biosimilars in the Treatment of Inflammatory Arthritis in the Gulf Region

BACKGROUND

Though biologic agents have significantly improved the treatment of inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, and axial spondyloarthritis), high costs, stringent regulations, strict reimbursement criteria, and existing patents have limited patient access to treatments. While being highly similar in quality, safety, and efficacy to biologic reference products, biosimilars can reduce the financial burden and prevent underutilization of medication.

OBJECTIVE

The objective of this initiative was to develop an evidence-based consensus of overarching principles and recommendations aimed at standardizing the use of biosimilars in treating inflammatory arthritis in the Gulf region.

METHODS

A task force of practicing rheumatologists, a clinical pharmacist, a health economist, patients, regulators, and payors from across the Gulf region developed recommendations and overarching principles based on the outputs of a systematic literature review conducted to address Patient-Intervention-Comparison-Outcome (PICO) questions specific to key challenges regarding the use of biosimilars for the treatment of inflammatory arthritis in the region. As the data before 2017 have been previously reviewed in another publication, the current review focused on data published between January 2017 and August 2022 (PROSPERO ID CRD42022364002). Consensus on each statement required a level of agreement of 70% or greater.

RESULTS

Consensus was reached for five overarching principles and nine recommendations by the task force. The principles emphasize the importance of improving the awareness, understanding, and perception of biosimilars, as well as the need for regulated regional real-world data generation and protocols to make biosimilars a viable and affordable treatment option for all patients. The consensus recommendations advocate the need for shared treatment decisions between rheumatologists and patients when considering biosimilars. They further recommend that confirmation of a biosimilar's efficacy and safety in a single indication is sufficient for extrapolation to other diseases for which the reference product has been approved. Finally, there is a need for pharmacovigilance and national health policies governing the adoption and prescription of biosimilars in clinical practice across the region.

CONCLUSIONS

These are the first consensus recommendations for the Gulf region based on a systematic literature review and Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines, integrating clinical evidence with clinical expertise to optimize decision making for the use of biosimilars in patients with inflammatory arthritis. They were formulated based on predominantly international data because of the limited regional data and therefore can be generalized to serve as recommendations for healthcare professionals in other parts of the world.

Automated Radiographic Measurements of Knee Osteoarthritis

OBJECTIVE

Herewith, we report the development of Orthopedic Digital Image Analysis (ODIA) software that is developed to obtain quantitative measurements of knee osteoarthritis (OA) radiographs automatically. Manual segmentation and measurement of OA parameters currently hamper large-cohort analyses, and therefore, automated and reproducible methods are a valuable addition in OA research. This study aims to test the automated ODIA measurements and compare them with available manual Knee Imaging Digital Analysis (KIDA) measurements as comparison.

DESIGN

This study included data from the CHECK (Cohort Hip and Cohort Knee) initiative, a prospective multicentre cohort study in the Netherlands with 1,002 participants. Knee radiographs obtained at baseline of the CHECK cohort were included and mean medial/lateral joint space width (JSW), minimal JSW, joint line convergence angle (JLCA), eminence heights, and subchondral bone intensities were compared between ODIA and KIDA.

RESULTS

Of the potential 2,004 radiographs, 1,743 were included for analyses. Poor intraclass correlation coefficients (ICCs) were reported for the JLCA (0.422) and minimal JSW (0.299). The mean medial and lateral JSW, eminence height, and subchondral bone intensities reported a moderate to good ICC (0.7 or higher). Discrepancies in JLCA and minimal JSW between the 2 methods were mostly a problem in the lateral tibia plateau.

CONCLUSIONS

The current ODIA tool provides important measurements of OA parameters in an automated manner from standard radiographs of the knee. Given the automated and computerized methodology that has very high reproducibility, ODIA is suitable for large epidemiological cohorts with various follow-up time points to investigate structural progression, such as CHECK or the Osteoarthritis Initiative (OAI).

Muscle strength, not muscle mass, determines the health-related quality of life in Indonesian women with systemic lupus erythematosus

OBJECTIVE

No study evaluated the impact of low muscle strength and mass on the Sarcopenia-related Quality of Life (SarQoL) in women with SLE.

METHODS

This cross-sectional study recruited 145 women with SLE consecutively; muscle strength was measured with a calibrated Jamar handheld dynamometer, muscle mass was measured with appendicular muscle mass index (Tanita MC-780 MAP body impedance analyser) and health-related quality of life with SarQoL Questionnaire. The cut-off points for low muscle strength, low muscle mass and sarcopenia were derived from the Asian Working Group on Sarcopenia 2019. Statistical analysis was conducted with a t-test for mean difference, and logistic regression was used to evaluate for low muscle strength contributing factors.

RESULTS

There was a significant difference in the mean total score of SarQoL in individuals with normal compared with low muscle strength (74.36 vs 64.85; mean difference 9.50; 95% CI 2.10 to 5.33; p<0.001). On the other hand, there was no difference in individuals with normal compared with low muscle mass (71.07 vs 70.79; mean difference 0.28; -5.18 to 5.74; p=0.91). After minimally adjusted with age, we found moderate-severe joint pain (B -9.280; p<0.001) and low muscle strength (B -6.979; p=0.001) to be independently associated with low mean SarQoL total score.

CONCLUSION

There was a lower total SarQoL score in individuals with low muscle strength but not with low muscle mass.

Designer Fat Cells: Adipogenic Differentiation of CRISPR-Cas9 Genome-Engineered Induced Pluripotent Stem Cells

Adipose tissue is an active endocrine organ that can signal bidirectionally to many tissues and organ systems in the body. With obesity, adipose tissue is a source of low-level inflammation that contributes to various co-morbidities and damage to downstream effector tissues. The ability to synthesize genetically engineered adipose tissue could have critical applications in studying adipokine signaling and the use of adipose tissue for novel therapeutic strategies. This study aimed to develop a method for non-viral adipogenic differentiation of genome-edited murine induced pluripotent stem cells (iPSCs) and to test the ability of such cells to engraft in mice in vivo . Designer adipocytes were created from iPSCs, which can be readily genetically engineered using CRISPR-Cas9 to knock out or insert individual genes of interest. As a model system for adipocyte-based drug delivery, an existing iPSC cell line that transcribes interleukin 1 receptor antagonist under the endogenous macrophage chemoattractant protein-1 promoter was tested for adipogenic capabilities under these same differentiation conditions. To understand the role of various adipocyte subtypes and their impact on health and disease, an efficient method was devised for inducing browning and whitening of IPSC-derived adipocytes in culture. Finally, to study the downstream effects of designer adipocytes in vivo , we transplanted the designer adipocytes into fat-free lipodystrophic mice as a model system for studying adipose signaling in different models of disease or repair. This novel translational tissue engineering and regenerative medicine platform provides an innovative approach to studying the role of adipose interorgan communication in various conditions.

Clinical guidance of pyoderma gangrenosum 2022

Pyoderma gangrenosum (PG) is a rare, neutrophilic skin disease. For the purpose of accurate diagnosis and proper treatment of PG, the Japanese clinical practice guidance for PG developed by the Japanese Dermatological Association was published in 2022. In this guidance, clinical aspects, pathogenesis, current therapies, and clinical questions on PG are described from the viewpoints of current knowledge and evidence-based medicine. Here, the English version of the Japanese clinical practice guidelines for PG is presented and is intended to be widely referred to in the clinical examination and treatment of PG.

A De Novo Deleterious PHEX Variant Without Clinical Features of X-Linked Hypophosphatemia

X-linked hypophosphatemia (XLH), the most common form of hereditary rickets, is due to inactivation of PHEX, resulting in increased circulating fibroblast growth factor 23. Consequent renal phosphate loss leads to hypophosphatemia, rickets, and progressive bow deformity. Inheritance is X-linked dominant, such that heterozygous females are affected, as well as hemizygous males. A 10-month-old girl was referred for potential treatment for presumed XLH. Amniocentesis, performed following prenatal identification of duodenal atresia, polyhydramnios, and intrauterine growth restriction, revealed a de novo X-chromosomal deletion encompassing 10 genes, including PHEX. Postnatal genetic testing confirmed presence of the deletion in the baby. She demonstrated no phenotypic, biochemical, or radiographic features of XLH. Neither parent had features of XLH, nor carried the deletion. Given the discordance between genotype and phenotype, evaluation for skewed X-inactivation was pursued. Methylation analysis via the androgen receptor locus was inconclusive, thus RNA sequencing was pursued. Analysis of 12 high-quality single nucleotide polymorphisms (SNPs) that are expressed in mRNA revealed skewed X-inactivation. Heterozygous disruption of PHEX typically confers a diagnosis of XLH. Skewed X-inactivation, whereby one X chromosome is preferentially silenced, appears to have protected this patient from the expected expression of an X-linked dominant disorder.

A Case Report of Localized Vegetative Pyoderma Gangrenosum of the Foot in a Patient With Myasthenia Gravis in an Outpatient Setting

Pyoderma gangrenosum (PG) is a reactive, non-infectious inflammatory neutrophilic dermatoses that have historically presented as a diagnostic and therapeutic dilemma. It is often misdiagnosed as other disease processes, particularly ulcers, and is thus associated with a delay in care. Pyoderma gangrenosum, left untreated, carries a three times mortality risk compared to the general population. There are multiple subtypes and presentations reflected in the current research which shows that there is still much to be understood about this disorder. Here we examine the unique presentation of a vegetative type of pyoderma gangrenosum through the case of a 69-year-old male that presents with a persistent lesion on his foot.

Biomarkers of fibrosis, kidney tissue injury and inflammation may predict severity and outcome of renal ANCA – associated vasculitis

Background

Activity and chronicity of kidney involvement in ANCA-associated vasculitis (AAV) can be currently reliably evaluated only by kidney biopsy. In this study, we measured a panel of serum and urinary biomarkers collected at the time of kidney biopsy and hypothesized that they could reflect specific histopathological parameters in the biopsy and help to predict prognosis.

Methods

We examined a cohort of 45 patients with AAV and 10 healthy controls. Biomarker levels (DKK-3, CD163, EGF, PRO-C6 and C3M) were measured in this study by ELISA. Biopsies were scored with a scoring system for AAV (focal x crescentic x sclerotic x mixed class) and interstitial fibrosis was quantified.

Results

Levels of urinary DKK-3, CD163, EGF, PRO-C6 and C3M significantly differed among biopsy classes in AAV, with urinary DKK-3 and PRO-C6 levels being highest in the sclerotic class and lowest in the focal class, urinary CD163 levels highest in the crescentic class and urinary C3M levels highest in the focal class. Moreover, the urinary biomarkers were able to discriminate focal biopsy class from the other classes. Urinary DKK-3, EGF, PRO-C6 and C3M levels measured at the time of biopsy were also significantly related to the extent of fibrosis and to the final kidney function at the end of follow-up.

Conclusions

This small pilot study suggests that selected urinary biomarkers of fibrosis and inflammation may reflect changes in the kidney biopsy and be prognostic of kidney outcome in patients with AAV.

Oral manifestations of anti-neutrophil cytoplasmic antibody-associated vasculitis: an update and narrative review of the literature

Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a multisystem disorder of small blood vessels subdivided into granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). Oral manifestations (OMs) have been reported to include mucosal ulceration, gingival enlargement, alveolar bone necrosis, tooth loss, oro-antral communication, palatal perforation, parotitis, and candidal infection mainly in GPA. They may appear during the course of the disease, as a disease flare-up, or as the presenting sign. These OMs are often nonspecific and can mimic an array of conditions, therefore formulating a differential diagnosis can be challenging. This review updates the OMs of GPA, and, for the first, time includes OMs of other AAVs. It provides recommendations for the overall assessment and the diagnosis and management of all AAV OMs with considerations for treatment coordination. The role of oral health care providers in multidisciplinary care is highlighted.

Immune dysregulation and pathogenic pathways mediated by common infections in rheumatoid arthritis

Rheumatoid arthritis (RA) is one of the world's most prevalent inflammatory autoimmune diseases, affecting between 0.4 and 1.3% of the population. The susceptibility to RA appears to be influenced by a complex interaction between a favorable genetic background and the existence of a specific immune reaction against a wide range of environmental variables. Among the known environmental variables, infections are believed to have a significant role in promoting the formation of autoimmune disorders, which are frequently caused by specific microorganisms. Infections have been linked to RA in recent medical studies. In this study, we selected the most prevalent infections associated with RA from the literature and described the data confirming their pathogenic role in RA. Our investigation included Mycobacterium, Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Proteus mirabilis, Epstein-Barr virus, parvovirus, and Prevotella copri.

Interactive multiobjective optimization for finding the most preferred exercise therapy modality in knee osteoarthritis

BACKGROUND

There are no explicit guidelines or tools available to support clinicians in selecting exercise therapy modalities according to the characteristics of individual patients despite the apparent need.

OBJECTIVE

This study develops a methodology based on a novel multiobjective optimization model and examines its feasibility as a decision support tool to support healthcare professionals in comparing different modalities and identifying the most preferred one based on a patient's needs.

METHODS

Thirty-one exercise therapy modalities were considered from 21 randomized controlled trials. A novel interactive multiobjective optimization model was designed to characterize the efficacy of an exercise therapy modality based on five objectives: minimizing cost, maximizing pain reduction, maximizing disability improvement, minimizing the number of supervised sessions, and minimizing the length of the treatment period. An interactive model incorporates clinicians' preferences in finding the most preferred exercise therapy modality for each need. Multiobjective optimization methods are mathematical algorithms designed to identify the optimal balance between multiple conflicting objectives among available solutions/alternatives. They explicitly evaluate the conflicting objectives and support decision-makers in identifying the best balance. An experienced research-oriented physiotherapist was involved as a decision-maker in the interactive solution process testing the proposed decision support tool.

RESULTS

The proposed methodology design and interactive process of the tool, including preference information, graphs, and exercise suggestions following the preferences, can help clinicians to find the most preferred exercise therapy modality based on a patient's needs and health status; paving the way to individualize recommendations.

CONCLUSIONS

We examined the feasibility of our decision support tool using an interactive multiobjective optimization method designed to help clinicians balance between conflicting objectives to find the most preferred exercise therapy modality for patients with knee osteoarthritis. The proposed methodology is generic enough to be applied in any field of medical and healthcare settings, where several alternative treatment options exist.KEY MESSAGESWe demonstrate the potential of applying Interactive multiobjective optimization methods in a decision support tool to help clinicians compare different exercise therapy modalities and identify the most preferred one based on a patient's needs.The usability of the proposed decision support tool is tested and demonstrated in prescribing exercise therapy modalities to treat knee osteoarthritis patients.

The regulation of T helper cell polarization by the diterpenoid fraction of Rhododendron molle based on the JAK/STAT signaling pathway

The diterpenoid fraction (DF) prepared from fruit of Rhododendron molle was shown to have potential therapeutic effects on collagen-induced arthritis (CIA) rats based on our previous studies. As a continuation of those studies, herein, a lipopolysaccharide-induced endotoxin shock mouse model was used. The results showed that 0.2 mg/ml of DF significantly increased the mouse survival rate and had an anti-inflammatory effect. Further studies showed that DF could decrease the proportion of T helper cells (Th1 and Th17), and increase the proportion of Th2 and regulatory T cells (Tregs). Enzyme-linked immunosorbent assays indicated that DF inhibited the secretion of inflammatory cytokines such as TNF-α, IL-1β, and IL-6; western blotting showed that DF significantly reduced the levels of phosphorylated STAT1 and STAT3. In vitro, DF could dose-dependently inhibit the polarization of naive CD4⁺ T cells to Th1 or Th17 cells. DF at 10 μg/ml could markedly decrease the expression of mRNA encoding IFN-γ and T-bet, and suppress Th1 differentiation by downregulation of the activity of STAT1 and STAT4. Meanwhile, DF at 10 μg/ml remarkably reduced the expression of mRNA encoding IL-17a, IL-17f, and RORγt, and downregulated STAT3 phosphorylation, suggesting that DF could inhibit Th17 differentiation by reducing STAT3 activation. Taken together, DF blocked the JAK/STAT signaling pathway by inhibiting STAT1 and STAT3 phosphorylation, which clarified the important role of JAK/STAT signaling pathway in anti-rheumatoid arthritis.

Xanthorrhizol Ameliorates Oxidative Stress and Inflammation in Freund's Complete Adjuvant-Induced Rheumatoid Arthritis in Rats

Rheumatoid arthritis (RA) is an inflammatory disease and a common cause of disability. This study is aimed to ascertain the therapeutic potentials of the xanthorrhizol against Freund's complete adjuvant (FCA)-stimulated RA in rats. The RA was initiated in the rats via injecting FCA (0.1 ml) subcutaneously and then treated with xanthorrhizol (20 mg/kg) for 25 days. The hematological markers were investigated using the automated hematological analyzer. The organ index (spleen and thymus) and paw volume were inspected by standard methods. The ALP, SGOT, and SGPT activities were examined using kits. The levels of inflammatory biomarkers, i.e., IL-1β, IL-6, IL-10, and TNF-α, were inspected using assay kits. The status of MDA, SOD, CAT, GSH, COX-2, iNOS, and NF-κB was quantified using respective assay kits. The xanthorrhizol treatment appreciably improved the body weight and hematological parameters and reduced the arthritis score, organ index, and paw volume in the RA rats. The levels of RBCs and Hb were effectively improved, and activities of ALP, SGOT, and SGPT were decreased by the xanthorrhizol in the RA rats. The RA rats treated with 20 mg/kg of xanthorrhizol demonstrated the depleted IL-1β, IL-6, and TNF-α levels. The antioxidant markers SOD, CAT, and GSH were improved, and inflammatory biomarker levels such as COX-2, iNOS, and NF-κB were decreased by the xanthorrhizol in the RA rats. Overall, these outcomes witnessed that the xanthorrhizol effectively ameliorated the oxidative stress and inflammatory responses and attenuated the RA in rats. Hence, it could be a talented anti-arthritic medication to treat RA.

ANCA Associated Vasculitis (AAV): A Review for Internists

Anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) compromise a rare group of necrotizing small to medium vessel vasculitides that constitute three distinct disorders: granulomatosis with polyangiitis (GPA) (formerly known as Wegener's granulomatosis), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA) (formerly known as Churg-Strauss syndrome).AAV is characterized by the usual presence of circulating autoantibodies to the neutrophil proteins leukocyte proteinase 3 (PR3-ANCA) or myeloperoxidase (MPO-ANCA). These antibodies can activate neutrophils and the complement system resulting in vessel wall inflammation and damage.The clinical presentation of AAV varies from non-severe (non-life threatening) to severe often with potentially life-threatening multi-organ involvement. Early recognition and diagnosis are crucial. In the past two decades, advances in understanding the pathophysiology of AAV have led to development of new treatments and resulted in significant improvement in general outcomes and survival rates.This narrative review will focus on GPA and MPA. We will highlight clinical manifestations, diagnosis, disease monitoring, and treatment strategies in patients with AAV.

Periodontal Treatment for Chronic Periodontitis With Rheumatoid Arthritis

BACKGROUND

History of rheumatoid arthritis (RA) increases risk of periodontal diseases. A pro-inflammatory condition noted in periodontitis is considered a trigger for RA. Thus, periodontal treatment aimed at attenuating the pro-inflammatory state could aid in potentially reducing the risk of RA.

AIMS

The objective of this research was to assess the effect of periodontal therapy on rheumatoid factor, Disease Activity Score-28, anti-citrullinated protein antibody, and C-reactive protein levels in patients with chronic periodontitis (CP) and RA.

MATERIALS AND METHODS

The sample consisted of 28 patients with CP and RA. The study was designed to be a double-blind, randomised controlled clinical study. The samples were randomly categorised to either the treatment group (n = 13) or the control group (n = 15). CP status (plaque index, bleeding on probing, probing pocket depth, clinical attachment loss), clinical rheumatologic status (Disease Activity Score), and biochemical status (C-reactive protein, anti-citrullinated protein antibody, and rheumatoid factor) were assessed at baseline and at follow-up at 8 to 12 weeks.

RESULTS

The treatment group showed a highly statistically significant reduction in bleeding on probing (P < .005), probing pocket depth (P < .001), plaque index (P < .001), and C-reactive protein (P < .001); a gain in the clinical attachment loss (P < .001) and an improvement in Disease Activity Score-28 (P = .001) were observed at reassessment following nonsurgical periodontal treatment as compared to the control group. However, blood serum anti-citrullinated protein antibody (P = .002) and rheumatoid factor levels (P = .351) were found to increase from baseline to 8 to 12 weeks following subgingival scaling and root planing.

CONCLUSIONS

Reduction of inflammation in the periodontium by nonsurgical periodontal therapy did not reduce anti-citrullinated protein antibody and rheumatoid factor levels. However, it has shown improvement in periodontal conditions, and remarkable changes were observed in the clinical Disease Activity Score and C-reactive protein levels of individuals with RA.

Narrative Review of the Emerging Therapeutic Role of Brodalumab in Difficult-to-Treat Psoriasis

Psoriatic involvement in areas of the body such as nails, palms and soles (palmoplantar), and scalp is associated with dramatically negative effects on quality of life relative to involvement elsewhere in the body. Although numerous evidence-based studies demonstrate the efficacy of biologics for overall skin clearance in moderate-to-severe plaque psoriasis (including tumor necrosis factor α [TNFα] inhibitors and interleukin [IL]-17A, IL-12/IL-23, IL-23, IL-17F, and IL-17A/F inhibitors), large, randomized, placebo-controlled clinical studies of psoriasis with nail, palmoplantar, and scalp involvement are needed to better inform decision-making in clinical practice. Moreover, biologic failure caused by drug ineffectiveness is a common occurrence in patients who do not respond, lose response, or are intolerant to treatment. Brodalumab is a fully human IL-17 receptor A antagonist that demonstrates high rates of skin clearance among the latest generation of biologic therapies for treatment of moderate-to-severe psoriasis. This review summarizes current literature on the efficacy of brodalumab and other therapies in difficult-to-treat psoriasis including psoriasis in difficult-to-treat locations (such as psoriasis with nail, palmoplantar, or scalp involvement) and psoriasis in patients whose disease did not respond to other biologics.

The Role of Exposomes in the Pathophysiology of Autoimmune Diseases II: Pathogens

In our continuing examination of the role of exposomes in autoimmune disease, we use this review to focus on pathogens. Infections are major contributors to the pathophysiology of autoimmune diseases through various mechanisms, foremost being molecular mimicry, when the structural similarity between the pathogen and a human tissue antigen leads to autoimmune reactivity and even autoimmune disease. The three best examples of this are oral pathogens, SARS-CoV-2, and the herpesviruses. Oral pathogens reach the gut, disturb the microbiota, increase gut permeability, cause local inflammation, and generate autoantigens, leading to systemic inflammation, multiple autoimmune reactivities, and systemic autoimmunity. The COVID-19 pandemic put the spotlight on SARS-CoV-2, which has been called “the autoimmune virus.” We explore in detail the evidence supporting this. We also describe how viruses, in particular herpesviruses, have a role in the induction of many different autoimmune diseases, detailing the various mechanisms involved. Lastly, we discuss the microbiome and the beneficial microbiota that populate it. We look at the role of the gut microbiome in autoimmune disorders, because of its role in regulating the immune system. Dysbiosis of the microbiota in the gut microbiome can lead to multiple autoimmune disorders. We conclude that understanding the precise roles and relationships shared by all these factors that comprise the exposome and identifying early events and root causes of these disorders can help us to develop more targeted therapeutic protocols for the management of this worldwide epidemic of autoimmunity.

The Hunt Is On! In Pursuit of the Ideal Stem Cell Population for Cartilage Regeneration

Cartilage injury and degeneration are hallmarks of osteoarthritis (OA), the most common joint disease. OA is a major contributor to pain, loss of function, and reduced quality of life. Over the last decade, considerable research efforts have focused on cell-based therapies, including several stem cell-derived approaches to reverse the cartilage alterations associated with OA. Although several tissue sources for deriving cell-based therapies have been identified, none of the resident stem cell populations have adequately fulfilled the promise of curing OA. Indeed, many cell products do not contain true stem cells. As well, issues with aggressive marketing efforts, combined with a lack of evidence regarding efficacy, lead the several national regulatory bodies to discontinue the use of stem cell therapy for OA until more robust evidence becomes available. A review of the evidence is timely to address the status of cell-based cartilage regeneration. The promise of stem cell therapy is not new and has been used successfully to treat non-arthritic diseases, such as hematopoietic and muscle disorders. These fields of regenerative therapy have the advantage of a considerable foundation of knowledge in the area of stem cell repair mechanisms, the role of the stem cell niche, and niche-supporting cells. This foundation is lacking in the field of cartilage repair. So, where should we look for the ideal stem cell to regenerate cartilage? It has recently been discovered that cartilage itself may contain a population of SC-like progenitors. Other potential tissues include stem cell-rich dental pulp and the adolescent growth plate, the latter of which contains chondrocyte progenitors essential for producing the cartilage scaffold needed for bone growth. In this article, we review the progress on stem cell therapies for arthritic disorders, focusing on the various stem cell populations previously used for cartilage regeneration, successful cases of stem cell therapies in muscle and hemopoietic disorders, some of the reasons why these other fields have been successful (i.e., "lessons learned" to be applied to OA stem cell therapy), and finally, novel potential sources of stem cells for regenerating damaged cartilage in vivo.

Efficacy and Acceptability of Intermittent Aerobic Exercise on Polysomnography-Measured Sleep in People With Rheumatoid Arthritis With Self-Reported Sleep Disturbance: A Randomized Controlled Trial

OBJECTIVE

This study's objective was to investigate the efficacy and acceptability of intermittent aerobic exercise training on sleep parameters, fatigue, pain, depressive symptoms, physical function, and cardiorespiratory fitness in people with rheumatoid arthritis (RA).

METHODS

Thirty-eight people with RA were assigned to intermittent aerobic exercise training (three sessions/week for 6 weeks; intervention group, n = 17) or usual care (control group, n = 21). The primary outcome was a change in polysomnography-assessed sleep efficiency from baseline to the end of the intervention. Secondary outcomes were sleep quality (Pittsburgh Sleep Quality Index), fatigue (Bristol Rheumatoid Arthritis Fatigue Multi-Dimensional Questionnaire), depression (Center for Epidemiological Studies-Depression), and cardiorespiratory fitness (watt max test).

RESULTS

No between-group differences were found in changes in polysomnography-assessed sleep efficiency (0.04; 95% confidence interval [CI]: -0.02 to 0.09, P = 0.17). In the intervention group, sleep efficiency was improved significantly from baseline (0.84; 95% CI: 0.80-0.88) compared with the end of the intervention (6 weeks) (0.88; 95% CI: 0.85-0.92); however, there was no significant difference in the control group. Fatigue and depression measures were significantly lower in the intervention group than in the control group. Between-group differences were overall fatigue (-16.1; 95% CI: -25.1 to -7.0, P = 0.001), physical fatigue (-5.0; 95% CI: -7.3 to -2.7, P = 0.0001), cognitive fatigue (-2.4; 95% CI: -4.2 to 0.6, P = 0.009), living with fatigue (-2.5; 95% CI: -4.5 to -0.5, P = 0.01), and depressive symptoms (-6.8; 95% CI: -12.4 to -1.1, P = 0.02).

CONCLUSION

The intervention yielded no significantly better sleep efficiency compared with usual care. However, aspects of fatigue, including physical and cognitive fatigue, and depressive symptoms were significantly improved in the intervention group.

Aneuploidy, inflammation and diseases

This review discusses how numerical aneuploidy may trigger inflammation in somatic cells and its consequences. Therefore we: i) summarized current knowledge on the cellular and molecular pathological effects of aneuploidy; ii) considered which of these aspects are able to trigger inflammation; iii) determined the genetic and environmental factors which may modulate the link between aneuploidy and inflammation; iv) explored the rôle of diet in prevention of aneuploidy and inflammation; v) examined whether aneuploidy and inflammation are causes and/or consequences of diseases; vi) identified the knowledge gaps and research needed to translate these observations into improved health care and disease prevention. The relationships between aneuploidy, inflammation and diseases are complex, because they depend on which chromosomes are involved, the proportion of cells affected and which organs are aneuploid in the case of mosaic aneuploidy. Therefore, a systemic approach is recommended to understand the emergence of aneuploidy-driven diseases and to take preventive measures to protect individuals from exposure to aneugenic conditions.

Feasibility and 3D Planning of a Novel Patient-Specific Instrumentation Technique in Medial Opening-Wedge High Tibial Osteotomy

A novel approach for opening-wedge high tibial osteotomy (OWHTO) with patient-specific instrumentation (PSI) was evaluated for its safety, feasibility, and accuracy. Next, the mechanical medial proximal tibial angle (mMPTA) was assessed as a potential planning angle by investigating the relation with the mechanical femorotibial angle (mFTA). Ten OWHTO cases were 3D planned using the mMPTA and operated with a customized 3D-printed wedge and cast which resembled the intended osteotomy opening. Patients were closely monitored for intraoperative and postoperative complications up to 1 year after surgery. Radiological assessment was conducted on full leg standing radiographs and supine lower limb computed tomography-scans preoperatively and 3 months after surgery. No intraoperative complications or logistical issues during PSI processing were observed. Absolute accuracy outcomes showed a correction error of 1.3° ± 1.1 mMPTA and 0.9° ± 0.6 mFTA with all osteotomies falling in (-2°; + 2°) mFTA around the target. The mMPTA and mFTA were found to have a strong correlation in both 3D (r = 0.842, p = 0.002) and 2D (r = 0.766, p = 0.01) imaging for effective correction. The study confirmed the development of a safe and feasible PSI technique in OWHTO with excellent accuracy outcomes. The strong correlation between the mMPTA and mFTA indicated that soft tissue changes after OWHTO are of minor significance to the final alignment in ligament-stable patients. Finally, the mMPTA was found to be a reliable planning angle in 3D software for obtaining the intended lower limb realignment and its use can therefore be recommended in modern OWHTO planning.

Radiological assessment of lower limb alignment

The full-length standing radiograph in an anteroposterior projection is the primary tool for defining and measuring limb alignment with definition of the physiological axes and mechanical and anatomic angles of the lower limb.

We define the deformities of the lower limb and the importance of correct surgical planning and execution.

For patients with torsional malalignment of the lower limb, computerized tomography scan evaluation is the gold standard for preoperative assessment.

Cite this article: EFORT Open Rev 2021;6:487-494. DOI: 10.1302/2058-5241.6.210015

The Application of Creatine Supplementation in Medical Rehabilitation

Numerous health conditions affecting the musculoskeletal, cardiopulmonary, and nervous systems can result in physical dysfunction, impaired performance, muscle weakness, and disuse-induced atrophy. Due to its well-documented anabolic potential, creatine monohydrate has been investigated as a supplemental agent to mitigate the loss of muscle mass and function in a variety of acute and chronic conditions. A review of the literature was conducted to assess the current state of knowledge regarding the effects of creatine supplementation on rehabilitation from immobilization and injury, neurodegenerative diseases, cardiopulmonary disease, and other muscular disorders. Several of the findings are encouraging, showcasing creatine's potential efficacy as a supplemental agent via preservation of muscle mass, strength, and physical function; however, the results are not consistent. For multiple diseases, only a few creatine studies with small sample sizes have been published, making it difficult to draw definitive conclusions. Rationale for discordant findings is further complicated by differences in disease pathologies, intervention protocols, creatine dosing and duration, and patient population. While creatine supplementation demonstrates promise as a therapeutic aid, more research is needed to fill gaps in knowledge within medical rehabilitation.

Activation of the Nrf2/HO-1 signaling pathway by dimethyl fumarate ameliorates complete Freund's adjuvant-induced arthritis in rats

The nuclear factor erythroid 2-related factor (Nrf2) signaling pathway has recently emerged as a novel therapeutic target in treating various diseases. Therefore, the present study aimed to assess the protective role of the Nrf2 activator, dimethyl fumarate (DMF) in the complete Freund's adjuvant (CFA)- induced arthritis model. DMF (25, 50, and 100 mg/kg) and dexamethasone (2 mg/kg) were orally administered for 14 days. Pain-related tests, paw volume, and arthritic scores were measured weekly. Serum TNF-α, IL-1β, cyclic citrullinated peptide (CCP), C-reactive protein (CRP), and rheumatoid factor (RF) levels were estimated. Nitrite, malondialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GPx), glutathione (GSH), catalase (CAT), and myeloperoxidase (MPO) levels were also evaluated. NF-κB, Nrf2, HO-1, and COX-2 levels were estimated in the joint tissue. DMF treatment exerted anti-arthritic activity by enhancing the nociceptive threshold, improving arthritis scores, and reducing paw edema. Also, DMF suppressed changes in oxidative stress markers and inflammatory mediators and enhanced Nrf2 and HO-1 levels in CFA-injected rats. These findings indicate that the anti-arthritic activity of DMF may be mediated by the activation of the Nrf2/HO-1 pathway, which reduced oxidative damage and inflammation.

Rheumatoid arthritis related interstitial lung disease

INTRODUCTION

Interstitial lung disease (ILD) represents a frequent extra-articular manifestation of rheumatoid arthritis (RA) deeply impacting both quality of life and overall prognosis. Areas covered: A literature search was performed including PubMed, Embase, Scopus, and Web of Science. Many retrospective studies investigated the possible risk factors for RA-related ILD (RA-ILD), aiming to identify patients at risk. Among them, males, smokers, positivity of anti-citrullinated peptide antibodies have been associated with RA-ILD, such as some genetic haplotypes. Usual interstitial pneumonia is the histologic and radiologic pattern most frequently observed, followed by nonspecific interstitial pneumonia. Since lung involvement can represent the RA onset, an early differential diagnosis with idiopathic interstitial pneumonia can be difficult or sometimes impossible. High-resolution computed tomography represents the gold standard for ILD diagnosis, while multidisciplinary discussion should be required to assess disease staging, severity and progression.  Expert opinion: Management of RA-ILD patients is challenging due to the lack of evidence-based data regarding both assessment and treatment. Moreover, the high variability of clinical presentation and evolution makes it difficult to establish the correct therapeutic strategy. Currently, multidisciplinary approach, including at least rheumatologists, pulmonologists, and radiologists, is desirable to define therapy and follow-up strategies.

Unilateral Pyoderma gangrenosum of the external ear in a resource-limited setting: Case report and literature review

Involvement of the external ear by PG is a rare encounter, and steroids remain to be the main stay in its treatment.

Patient Centeredness in Orthognathic Surgery

Patient centeredness in planning treatment and research has become paramount. The goal of this report was to describe a complex case in which untreated chronic pain was not properly addressed to reflect on the need to establish alternative protocols for controlling chronic orofacial pain. When a female underwent orthognathic surgery to correct her occlusion, she not only ended up with a worse occlusion, she developed chronic orofacial pain that could not be treated by opioids and only improved after the use of neuropathic medication, and finally disappeared after the use of low-level laser therapy. There is a need to incorporate alternative nonpharmacological approaches to manage chronic pain. Further, what the patient’s goals are for their treatments should be given priority in case of elective procedures.

Polyangiitis overlap syndrome: a novel presentation of microscopic polyangiitis and eosinophilic granulomatosis with polyangiitis

Polyangiitis overlap syndrome (POS) is a diagnostic term coined by Leavitt and Fauci that characterises patients with overlapping features of more than one vasculitis. Prior case studies of antineutrophil cytoplasmic antibodies (ANCA)-associated POS have only been published in patients with eosinophilic granulomatosis with polyangiitis (EGPA) and granulomatosis with polyangiitis alongside proteinase-3/cytoplasmic (C)-ANCA positivity. We present a case of a 60-year-old woman with dyspnoea, hemoptysis, positive perinuclear-ANCA and renal biopsy demonstrating evidence of microscopic polyangiitis. In addition, our patient also had asthma, mononeuritis multiplex, eosinophilia and migratory pulmonary infiltrates, thus fulfilling the criteria for EGPA. This novel case report suggests that POS is not limited to C-ANCA positivity and has variable presentations.

Consensus evidence-based clinical practice guidelines for the diagnosis and treat-to-target management of osteoporosis in Africa: an initiative by the African Society of Bone Health and Metabolic Bone Diseases

The objective of this consensus statement is to inform the clinical practice communities, research centres and policymakers across Africa of the results of the recommendations for osteoporosis prevention, diagnosis and management. The developed guideline provides state-of-the-art information and presents the conclusions and recommendations of the consensus panel regarding these issues.

PURPOSE

To reach an African expert consensus on a treat-to-target strategy, based on current evidence for best practice, for the management of osteoporosis and prevention of fractures.

METHOD

A 3-round Delphi process was conducted with 17 osteoporosis experts from different African countries. All rounds were conducted online. In round 1, experts reviewed a list of 21 key clinical questions. In rounds 2 and 3, they rated the statements stratified under each domain for its fit (on a scale of 1-9). After each round, statements were retired, modified or added in view of the experts' suggestions and the percent agreement was calculated. Statements receiving rates of 7-9 by more than 75% of experts' votes were considered as achieving consensus.

RESULTS

The developed guidelines adopted a fracture risk-centric approach. Results of round 1 revealed that of the 21 proposed domains, 10 were accepted whereas 11 were amended. In round 2, 32 statements were presented: 2 statements were retired for similarity, 9 statements reached consensus, whereas modifications were suggested for 21 statements. After the 3rd round of rating, the experts came to consensus on the 32 statements. Frequency of high-rate recommendation ranged from 83.33 to 100%. The response rate of the experts was 100%. An algorithm for the osteoporosis management osteoporosis was suggested.

CONCLUSION

This study is an important step in setting up a standardised osteoporosis service across the continent. Building a single model that can be applied in standard practice across Africa will enable the clinicians to face the key challenges of managing osteoporosis; furthermore, it highlights the unmet needs for the policymakers responsible for providing bone health care together with and positive outcomes of patients' care.

Spinal accessory neuropathy in patients with chronic trapezius myofascial pain syndrome

Background

Myofascial pain syndrome is a common musculoskeletal problem affecting the trapezius muscle. The aim was to assess the presence of spinal accessory neuropathy in patients with unilateral chronic trapezius myofascial pain syndrome.

Results

The study included 25 patients with unilateral chronic trapezius myofascial pain syndrome and 20 apparently healthy volunteers as the control group. There was a significantly delayed spinal accessory nerve latency on the symptomatic side in comparison to either asymptomatic side (P = 0.014) and control group (P = 0.001). Compound muscle action potential amplitude did not significantly differ between the symptomatic side versus the asymptomatic side and control group. Delayed spinal accessory nerve latency was present in seven patients (28%) and reduced compound muscle action potential amplitude in one of them (4%). The needle electromyography of the upper trapezius muscle revealed neuropathic motor units and incomplete interference pattern in the patient who showed reduced compound muscle action potential amplitude. Abnormal rest potentials were absent in all patients. Individually, seven patients (28%) had electrophysiological evidence of spinal accessory neuropathy, but only one (4%) of them had clinical evidence of spinal accessory neuropathy. Patients with abnormal electrophysiological findings had longer duration of complaint and more severe pain.

Conclusions

Spinal accessory neuropathy is common among patients with chronic trapezius myofascial pain syndrome. It could contribute to increased pain severity of myofascial pain syndrome. Electrodiagnosis is a good modality for identifying subclinical spinal accessory neuropathy.

Esophageal motility disorders in children with dysphagia: the utility of the Chicago classification

BACKGROUND

esophageal manometry is the standard criterion for the evaluation of dysphagia and the diagnosis of a primary motor disorder of the esophagus in adults and children.

AIMS

to describe the diagnosis according to the Chicago classification (CC) v3.0 in children with dysphagia, in whom an esophageal motility disorder was documented. The associated comorbidities were also determined.

METHODS

an observational retrospective study was performed of 54 patients evaluated for dysphagia, who had undergone a high-resolution manometry (HREM).

RESULTS

a normal HREM was found in 52 % (n = 28) of the children, whereas 48 % (n = 26) had some esophageal motility disorder. The most frequent diagnosis was ineffective esophageal motility and achalasia. Excluding previously healthy children, most children had a history of autoimmune disease and intellectual disability.

CONCLUSIONS

an esophageal motor disorder can be diagnosed in nearly half of infants and children with dysphagia. In this study, all esophageal diseases could be classified according to the CC v3.0. HREM should be considered for the evaluation of children with dysphagia, in addition to other studies.

Rheumatoid arthritis and osteoarthritis clinical practice guidelines provide few complementary and alternative medicine therapy recommendations: a systematic review

Sixty percent of patients with arthritis have used complementary and alternative medicine (CAM) therapies at least once. The two most common types of arthritis include rheumatoid arthritis (RA) and osteoarthritis (OA). The quality and quantity of CAM recommendations for RA and OA is currently unknown. The purpose of this research was to identify the quantity and assess the quality of CAM recommendations in clinical practice guidelines (CPGs) for the treatment and/or management of RA and OA. A systematic review was conducted to identify CPGs; MEDLINE, EMBASE and CINAHL were searched from 2008 to 2018. The Guidelines International Network and the National Center for Complementary and Integrative Health websites were also searched. Three independent reviewers evaluated the quality of reporting for each guideline that provided CAM recommendations, and the specific section providing CAM recommendations, using the AGREE II instrument. From 525 unique search results, seven guidelines (3 OA, 4 RA) mentioned CAM and 5 guidelines made CAM recommendations. Scaled domain percentages from highest to lowest were (overall, CAM) as follows: clarity of presentation (92.2% vs. 94.1%), scope and purpose (90.1% vs. 87.4%), rigour of development (72.6% vs. 64.2%), stakeholder involvement (64.8% vs. 49.6%), editorial independence (61.1% vs. 60.6%), and applicability (51.4% vs. 33.3%). None of the 5 guidelines was recommended by both appraisers for either the overall guideline or CAM section. For the overall guideline, appraisers agreed in their overall recommendation for 3 of 5 guidelines, including 3 Yes with modifications; of the remaining 2 guidelines, 1 was rated by the three appraisers as 1 No and 2 Yes with modifications, while 1 guideline was rated at 2 Yes and 1 Yes with modifications. For the CAM section, appraisers agreed in their overall recommendation for all 5 guidelines including 1 No, and 4 Yes with modifications. Roughly half of arthritis CPGs found included in this review provided CAM recommendations. The quality of CAM recommendations are of lower quality than overall recommendations across the scope and purpose, stakeholder involvement, rigour of development, applicability, and editorial independence domains. Quality varied within and across guidelines.

Micronuclei, inflammation and auto-immune disease

Auto-immune diseases (AUD) are characterized by an immune response to antigenic components of the host itself. The etiology of AUD is not well understood. The available evidence points to an interaction between genetic, epigenetic, environmental, infectious and life-style factors. AUD are more prevalent in women than in men; sex hormones play a crucial role in this sex bias. Micronuclei (MN) emerged as a new player in the induction of AUD, based on the capacity of DNA-sensors to detect self-DNA that leaks into the cytoplasm from disrupted MN and induce the cGAS-STING pathway triggering an innate auto-immune response and chronic inflammation. It was found that inflammation can induce MN and MN can induce inflammation, leading to a vicious inflammation-oxidative-DNA damage-MN-formation-chromothripsis cycle. MN originating from sex chromosome-loss may induce inflammation and AUD. We performed a systematic review of studies reporting MN in patients with systemic or organ-specific AUD. A meta-analysis was performed on lymphocyte MN in diabetes mellitus (10 studies, 457 patients/290 controls) and Behcet's disease (3 studies, 100 patients/70 controls) and for buccal MN in diabetes mellitus (11 studies, 507 patients/427 controls). A statistically significant increase in patients compared to controls was found in the meta-analyses providing an indication of an association between MN and AUD. A 36%-higher mean-MRi in buccal cells (3.8+/-0.7) was found compared to lymphocytes (2.8+/-0.7)(P = 0.01). The meta-MRi in lymphocytes and buccal cells (1.7 and 3.0 respectively) suggest that buccal cells may be more sensitive. To assess their relative sensitivity, studies with measurements from the same subjects would be desirable. It is important that future studies (i) investigate, in well-designed powered studies, the prospective association of MN-formation with AUD and (ii) explore the molecular mechanisms by which chromosome shattering in MN and the release of chromatin fragments from MN lead to the formation of auto-antibodies.

Dietary amaranths modulate the immune response via balancing Th1/Th2 and Th17/Treg response in collagen-induced arthritis

Imbalance between Th1/Th2 and Th17/Treg is crucial in RA progression. Various dietary factors can modulate the disease severity by restoring the balance in differentiation of CD4+ T cell subsets. Dietary amaranths hold an important part of diet as vegetables, where commonly consumed species includes Amaranthus cruentus (Ac), Amaranthus viridis (Av), and Amaranthus hybridus (Ah). The present study focuses on to evaluate whether these dietary amaranths can modulate the immune activation in collagen-induced arthritis. For in vivo study, Female Wistar rats were immunized with type II collagen and after immunization period, rats were separately supplemented with cooked Ac, Av, and Ah at 500 mg/100 g bwt concentration mixed with standard rat feed for 60 days. HPTLC fingerprint analysis identified peaks for compounds in these three amaranths. The results showed a protective role of immunomodulation in Th1/Th2 response of the three dietary amaranths, by significantly augmenting lymphocyte activation with increased IL-4 secretion, but decreased IFN-γ by cultured spleen lymphocytes subjected to collagen-induced inflammation. Moreover, Th17/Treg imbalance created by increase in IL-17 and decrease in IL-10 was significantly balanced by the three dietary supplemented groups. Furthermore, Th1/Th2 status reflected from Tbet/GATA3 ratio and Th17/Treg status reflected from RORγt/FOXP3 ratio was significantly decreased in the three dietary amaranth supplemented groups. Thus, dietary amaranths provide an immune-modulating role by keeping the balance between Th1/Th2 and Th17/Treg response in collagen-induced inflammation.

NF-κB signaling in rheumatoid arthritis with focus on fibroblast-like synoviocytes

The nuclear factor-κB (NF-κB) signaling pathway regulates multiple processes in innate and adaptive immune cells. This pathway is involved in inflammation through the regulation of cytokines, chemokines, and adhesion molecules expression. The NF-κB transcription factor also participates in the survival, proliferation, and differentiation of cells. Therefore, deregulated NF-κB activation contributes to the pathogenesis of inflammatory diseases. Rheumatoid arthritis (RA) is classified as a heterogeneous and complex autoimmune inflammatory disease. Although different immune and non-immune cells contribute to the RA pathogenesis, fibroblast-like synoviocytes (FLSs) play a crucial role in disease progression. These cells are altered during the disease and produce inflammatory mediators, including inflammatory cytokines and matrix metalloproteinases, which result in joint and cartilage erosion. Among different cell signaling pathways, it seems that deregulated NF-κB activation is associated with the inflammatory picture of RA. NF-κB activation can also promote the proliferation of RA-FLSs as well as the inhibition of FLS apoptosis that results in hyperplasia in RA synovium. In this review, the role of NF-κB transcription factor in immune and non-immune cells (especially FLSs) that are involved in RA pathogenesis are discussed.

Prevalence and severity of periodontitis in patients with established rheumatoid arthritis and osteoarthritis

Introduction

Periodontitis is associated with many chronic health conditions including diabetes, cardiovascular disease, and rheumatoid arthritis (RA). RA and periodontitis have similarities in inflammatory mechanism, morphology, and histopathology. Osteoarthritis (OA) is a chronic, multifactorial degenerative disease characterized by the deterioration of cartilage in joints.

Objective

The aim of this study was to evaluate the prevalence and severity of periodontal disease in patients with established RA and OA.

Materials and Methods

A total of 200 patients reporting to the Department of Orthopaedics, KIMSDU, Karad were included in the study. Patients were divided into two groups: Group 1 that included 100 patients with established RA diagnosed according to American College of Rheumatology (ACR) classification 1987 criteria and Group 2 that comprised 100 patients diagnosed with OA. Demographic profile, medical and dental history, oral hygiene practices, and smoking status of study participants were recorded. Periodontal status of the patients were evaluated using the simplified oral hygiene index (OHI-S), Loe and Silness gingival index (GI), probing pocket depth (PPD), and clinical attachment level (CAL). On the basis of the CAL score periodontitis severity was defined as slight, moderate, and severe. Rheumatoid Factor (RF) and C-reactive protein (CRP) were considered as a serological marker in RA. Serological tests were performed to measure RF and CRP. Periodontal parameters and serological tests were correlated.

Results

This study reported 45% severe periodontitis prevalence in RA compared to OA group, which was 33%. Severity of periodontitis is significantly greater in RF positive RA group with mean CAL 5.38 mm compared to RF negative RA group with mean CAL 2.81 mm (P = 0.001). There was moderate positive correlation found between RF titer and severity of periodontitis (r = 0.311).

Conclusion

The severity of periodontitis was significantly higher among the patients with established RA as compared to patients with OA. RF positive patients had higher periodontal disease compared to RF negative patients. There was an increase in the mean clinical attachment loss with increase in RF titer.

Treatment of Rheumatoid Arthritis-Associated Interstitial Lung Disease: Lights and Shadows

Rheumatoid arthritis (RA) is a chronic and systemic inflammatory disease affecting 0.5–1% of the population worldwide. Interstitial lung disease (ILD) is a serious pulmonary complication of RA and it is responsible for 10–20% of mortality, with a mean survival of 5–8 years. However, nowadays there are no therapeutic recommendations for the treatment of RA-ILD. Therapeutic options for RA-ILD are complicated by the possible pulmonary toxicity of many disease modifying anti-rheumatic drugs (DMARDs) and by their unclear efficacy on pulmonary disease. Therefore, joint and lung involvement should be evaluated independently of each other for treatment purposes. On the other hand, some similarities between RA-ILD and idiopathic pulmonary fibrosis and the results of the recent INBIULD trial suggest a possible future role for antifibrotic agents. From this perspective, we review the current literature describing the pulmonary effects of drugs (immunosuppressants, conventional, biological and target synthetic DMARDs and antifibrotic agents) in patients with RA and ILD. In addition, we suggest a framework for the management of RA-ILD patients and outline a research agenda to fill the gaps in knowledge about this challenging patient cohort.

Pirfenidone for the treatment of interstitial lung disease associated to rheumatoid arthritis: a new scenario is coming?

Introduction

Interstitial lung disease (ILD) is a frequent extra-articular manifestation of Rheumatoid arthritis (RA), but nowadays there are no randomized controlled clinical trials to support therapeutic guidelines. RA-ILD, especially with UIP pattern, shares some similarities with idiopathic pulmonary fibrosis, suggesting a possible role of antifibrotic therapy in these patients. To date, there are no published data supporting the use of pifenidone in RA-ILD.

We describe for the first time two patients with a diagnosis of RA-ILD successfully treated with hydroxychloroquine and pirfenidone, without adverse events.

Case presentation

Patient 1 and patient 2 were first diagnosed with IPF (UIP pattern at high-resolution computed tomography, no other signs or symptoms suggesting other forms of ILD, routine laboratory examinations and immunological texts negative). Patients started pirfenidone 2403 mg daily. Few months later, they referred to our multidisciplinary outpatient for arthritis. ACPA and RF were positive. A diagnosis of RA was performed and treatment with corticosteroids and hydroxychloroquine was started, in association with pirfenidone.

In both cases we assessed the stabilization of articular and lung manifestations, without adverse events.

Discussion

In absence of randomized controlled trials, the optimal treatment of RA-ILD has not been determined and remains challenging. When considering therapeutic options for RA-ILD, both pulmonary and extra-thoracic disease manifestations and degrees of activity should be assessed and taken into consideration. Future prospective research might change RA-ILD management, moving to a more personalized approach based on the identification of different phenotypes of the disease or to a combination of immunosuppressive and antifibrotic treatment.

•

Nowadays there are no randomized controlled clinical trials to support therapeutic guidelines in RA-ILD.

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RA-ILD shares some similarities with IPF, suggesting a possible role of antifibrotic therapy RA-ILD patients.

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We describe for the first time two patients with RA-ILD successfully treated with hydroxychloroquine and pirfenidone.

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A number of trials are ongoing to assess the efficacy/safety of pirfenidone in fibrosing ILDs other than IPF.

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To date, multidisciplinary approach in RA-ILD patients remains mandatory.