Rheumatoid arthritis and falls: the influence of disease activity

Foot function in rheumatoid arthritis: Correlation between the Rheumatoid and Arthritis Outcome Score and performance-based physical tests

BACKGROUND

Foot function is usually assessed using self-reported outcome measures which remain subjective in patients with rheumatoid arthritis (RA). Physical performance tests were recommended for functional assessment in lower limb osteoarthritis. However, foot function assessment's guidelines in RA are lacking. We aimed to investigate the correlation between a self-reported outcome measure and two performance-based physical tests for assessing foot function in RA patients.

METHODS

A cross-sectional study was performed over 7 months' period including RA patients. We used Rheumatoid and Arthritis Outcome score (RAOS) as a self-reported functional tool. Physical performance tests were 4-min walk test (4-MWT) and Timed up and go test (TUGT).

RESULTS

Fifty RA patients were included with 96% females and a mean age of 54.7 ± 10.4 years. Foot involvement occurred since the diagnosis of RA in 36% of patients. Foot pain was reported by 68% of patients (48% forefoot), and foot stiffness in 46% of patients. Skin lesions of the feet were found in 78% of patients, 90% had foot deformities and 56% had inflammatory disorders of feet. Radiographic lesions were found in 94% of patients. The most impaired RAOS subscales were Sports and Recreation and Quality of life. Poor physical-based performance was found in 34% of RA patients according to 4-MWT, in 42% of RA patients according TUGT, and in 46% of patients based on at least one performance test. RAOS was negatively correlated to the 4-MWT and positively correlated in the subscales pain, other symptoms, activities of daily living, and Sport/Rec of the RAOS. Poor performance-based physical tests were significantly associated with advanced age, sedentary lifestyle, higher disease activity score and impaired functional status. Foot-related parameters significantly associated with poor performance-based physical tests were: foot pain, foot deformity and inflammatory disorders. Multivariate analysis identified foot deformities and higher functional impairment as predictive factors for lower gait speed (4-MWT) and older age and higher functional impairment for higher duration of TUGT.

CONCLUSION

RAOS was significantly associated with performance-based physical function. In the era of connected technologies, these results encourage the regular assessment of rheumatoid foot function by the RAOS score through a connected programme using wearable trackers.

Prevalence and risk factors of falls in adults with rheumatoid arthritis: A systematic review and meta-analysis

BACKGROUND

Despite the fact that the estimated prevalence and risk factors of falls in adults with rheumatoid arthritis (RA) are widely reported, these results have not been synthesized. The systematic review and meta-analysis aimed to investigate the prevalence and risk factors of falls in adults with RA.

METHODS

PubMed, EMBASE, Web of Science, the Cochrane Library, Cumulative Index to Nursing & Allied Health Literature (CINAHL), Wanfang Database, China Knowledge Resource Integrated Database (CNKI), Weipu Database (VIP), and Chinese Biomedical Database (CBM) were searched for relevant studies published from the inception of the database until July 4, 2022. Stata 15.0 Software was used to perform the meta-analysis. For the prevalence of falls in adults with RA and risk factors that were investigated in at least 2 studies in a comparable way, we calculated pooled incidence and odds ratios (ORs) using random-effects models, with a test for heterogeneity. A study protocol was registered in PROSPERO (CRD42022358120).

RESULTS

A total of 6,470 articles were screened and data from 34 studies involving 24,123 subjects were used in meta-analysis. The pooled prevalence of any falls was 34% (95% confidence interval, CI: 29% to 38%, I²=97.7%, P<0.001), and 16% for recurrent falls (95% CI: 12% to 20%, I²=97.5%, P<0.001). 25 risk factors were considered, including sociodemographic, medical and psychological, medication, and physical function. The strongest associations were found for history of falls (OR=3.08, 95%CI: 2.32 to 4.08, I²=0.0%, P = 0.660), history of fracture (OR=4.03, 95%CI: 3.12 to 5.21, I²=97.3%, P<0.001), walking aid use (OR=1.60, 95%CI: 1.23 to 2.08, I²=67.7%, P = 0.026), dizziness (OR=1.95, 95%CI: 1.43 to 2.64, I²=82.9%, P = 0.003), psychotropic medication use (OR=1.79, 95%CI: 1.39 to 2.30, I²=22.0%, P = 0.254), antihypertensive medicine/diuretic (OR=1.83, 95%CI: 1.37 to 2.46, I²=51.4%, P = 0.055), taking four or more medicine(OR=1.51, 95%CI: 1.26 to 1.81, I²=26.0%, P = 0.256), and HAQ score(OR=1.54, 95%CI: 1.40 to 1.69, I²=36.9%, P = 0.135).

CONCLUSIONS

This meta-analysis provides a comprehensive evidence-based assessment of the prevalence and risk factors for falls in adults with RA, confirming their multifactorial etiology. Understanding the risk factors of falls can provide healthcare personnel with a theoretical basis for the management and prevention of RA patients.

Geriatric Syndromes among Patients with Rheumatoid Arthritis: A Comparison between Young and Elderly Patients

Background

In the general geriatric population, Geriatric syndromes (GSs) predict greater likelihood of hospitalization, increased health care use and cost. The present study aimed to compare GSs among young and elderly patients with rheumatoid arthritis (RA).

Methods

In a cross-sectional study a total of 98 participants, including 65 elderly (≥60 years) and 33 young adult patients (<60 years) with RA who referred to the geriatric and rheumatologic clinic were enrolled. Patients were categorized into three groups (healthy elderly, n=27; elderly with RA, n=38; and young people with RA, n=33). GSs were assessed using mini-mental state exam (MMSE), five-item geriatric depression scale-15 (GDS-15), mini nutritional assessment (MNA), and asking patients about history of falls in the past year. The RA activity in patients was assessed using disease activity for rheumatoid arthritis score-28 (DAS-28) scale, serum ESR (mm/h) level.

Results

There was a statistically significant differences in terms of DAS-28 (2.23±1.01 vs. 0.64±0.97, P=0.025) and ESR (28.10±6.64 vs. 23.09±7.65 mm/h, P=0.042) between healthy elderly and RA elderly patients. Elderly patients with RA were significantly more prone to have cognitive impairment (P=0.002), fall (P=0.005), malnutrition (P<0.001), urinary incontinence (P<0.001), and functional disability (P=0.021) compared to healthy elderlies and young RA patients. The results of binary logistic regression revealed that in elderly RA patients, higher DAS-28 score [odds ratio (OR) = 1.96; 95% CI 1.03, 3.84; P=0.041] was an independent risk factors for the GSs.

Conclusion

The prevalence of some features of GSs were higher in the elderly RA patients than healthy elderly and young RA patients.

Balance and prospective falls in patients with rheumatoid arthritis

Background

Postural control is associated with fall risk. Patients with rheumatoid arthritis (RA) have a higher risk to fall than healthy subjects. The objective of this study was to identify associations between variables of postural control with prospective falls in patients with RA.

Methods

For the baseline, the balance performance of 289 men and women with RA, ages 24–85 years, was evaluated by SPPB, FICSIT-4 and Romberg tests. Postural sway for Romberg, semitandem, tandem and one-leg stands were measured with the Leonardo Mechanograph®. Self-reported disability was assessed using the Health Assessment Questionnaire (HAQ) and the Activity-specific Balance Confidence Scale (ABC-scale). Falls were reported in quarterly reports over a year. Univariate and multiple logistic regression analysis were used to explore any associations with falling. Receiver-operating characteristics were determined, and the area under the curve is reported.

Results

A total of 238 subjects completed the 1-year follow-up, 48 (20.2%) experienced at least one fall during the observational period. Age (OR = 1.04, CI 1.01–1.07), HAQ (OR = 1.62, 1.1–2.38), FICSIT-4 scoring 0–4 (OR = 2.38, 1.13–5.0), and one-leg standing (OR = 2.14, 1.06–4.31) showed significant associations with falls. With regard to the SPPB and ABC-scale, no statistically significant associations with falls were found. The quartiles containing the worst results of medio-lateral sway of Romberg (OR = 2.63, CI 1.03–6.69), total sway of semitandem (OR = 3.07, CI 1.10–8.57) and tandem (OR = 2.86, CI 1.06–7.69), and area of sway of semitandem (OR = 2.80, CI 1.11–7.08) stands were associated with falls.

Conclusions

The assessment of a one-leg stand seems to be a good screening tool to discriminate between high and low risk of falls in RA patients in clinical practice. A low FICSIT-4 score and several sway parameters are important predictors of falls.

Trial registration

The study has been registered at the German Clinical Trials Register and the WHO International Clinical Trials Registry Platform (ICTRP) since 16 March 2017 (DRKS00011873).

A quantitative assessment of the risk of falls in rheumatoid arthritis patients and determination of the risk factors

Objectives

The aim of this study was to compare the risk of falling in patients with rheumatoid arthritis (RA) to the healthy individuals and to identify the factors affecting the risk of falls.

Patients and methods

Between December 2015 and August 2016, a total of 100 consecutive patients with RA (16 males, 84 females; mean age: 49.5±11.1 years; range, 21 to 65 years) and 50 healthy controls (11 males, 39 females; mean age: 34.3±12.7 years; range, 19 to 63 years) were included in this prospective study. The fall risk was evaluated using the Tetrax Portable Balance System. The Health Assessment Questionnaire Disability Index (HAQ-DI), RA disease activity (Disease Activity Score 28 [DAS28], Clinical Disease Activity Index [CDAI], and Simple Disease Activity Index [SDAI]), and Falls Efficacy Scale International (FES-I) were applied to all participants.

Results

The fall risk scores and the FES-I scores were significantly higher in the patients with RA than the control group (p<0.001, p<0.001). A positive significant correlation was found between the Tetrax values of the patients and age, and the scores of the HAQ-DI, FES, DAS28, DAS28-C-reactive protein, CDAI and SDAI.

Conclusion

Our study results showed higher fall risk scores in patients with RA than healthy individuals an objective computerized technique, and this higher fall risk appeared to be affected by older age, disease activity, and disability.

Evaluation of peripheral neuropathy in lower limbs of patients with rheumatoid arthritis and its relation to fall risk

Background

Rheumatoid Arthritis (RA) is a chronic disabling systemic disease characterized by joint inflammation, and extra-articular manifestations, including peripheral neuropathy, a condition that can be associated with changes in muscle strength, proprioception and postural balance contributing for the risk of falls. The objective of this study is to analyze the incidence of peripheral neuropathy in patients with RA and its association with the occurrence of falls.

Methods

Patients were assessed by an electroneuromyography (ENMG) exam and by a questionnaire on accidental falls occurrence in the previous 12 months. They were also assessed on balance by the Short Physical Performance Battery (SPPB), functionality by the Health Assessment Questionnaire (HAQ), disease activity by the Disease Activity Score (DAS-28), neuropathic pain by the Questionnaire for the Diagnosis of Neuropathic Pain (DN4), and cutaneous sensitivity of the feet by the monofilament testing of Semmes–Weinstein. Monthly calls on falls were made in the subsequent six months. Data analysis was performed using the Shapiro–Wilk test for normality and Spearman, Chi-square, and T-student correlation tests, with a significant P level ≤ 0.05.

Results

A sample of 33 patients were evaluated. The incidence of peripheral neuropathy was 48.5%, of which 68.7% were axonal and 31.3% myelinic. The sensorimotor type was present in 64.7%, motor in 17.6%, and sensorial in 11.7% of the cases. Neuropathy was associated to balance (P = 0.026), neuropathic pain (P = 0.016), deep tendon reflexes absence (P = 0,049), altered skin sensitivity of the feet (P = 0.029) and fear of falling (P = 0.001). No association was found between peripheral neuropathy and age, gender, disease activity, or functionality. No significant association was found between peripheral neuropathy and occurrence of falls, in a 12-month retrospective and 6-month prospective evaluation.

Conclusion

Peripheral neuropathy has a high incidence in patients with RA, and is related to neuropathic pain, altered postural balance, but not to the occurrence of falls.

Association between sarcopenia, physical performance and falls in patients with rheumatoid arthritis: a 1-year prospective study

Background

Patients with rheumatoid arthritis (RA) are at increased risk of falls and fractures. Sarcopenia occurs more frequently in RA patients due to the inflammatory processes. Early diagnosis and prevention programmes are essential to avoid serious complications. The present study aims to identify risk factors for falls related to sarcopenia and physical performance.

Methods

In a 1-year prospective study, a total of 289 patients with RA, ages 24–85 years, were followed using quarterly fall diaries to report falls. At the baseline, medical data such as RA disease duration and Disease Activity Score (DAS28_CRP) were collected. Self-reported disability was assessed using the Health Assessment Questionnaire (HAQ). Appendicular skeletal mass was determined by Dual X-ray-Absorptiometry (DXA). Physical performance was evaluated by handgrip strength, gait speed, chair rise test, Short Physical Performance Battery, and FICSIT-4. Muscle mechanography was measured with the Leonardo Mechanograph®. Sarcopenia was assessed according to established definitions by the European Working Group on Sarcopenia in Older People (EWGSOP2) and The Foundation for the National Institutes of Health (FNIH). Univariate and multiple logistic regression analysis were used to explore associations with falling. Receiver-operating characteristics (ROC) were performed, and the area under the curve is reported.

Results

A total of 238 subjects with RA completed the 1-year follow-up, 48 (20.2%) experienced at least one fall during the observational period. No association was found between sarcopenia and prospective falls. Age (OR = 1.04, CI 1.01–1.07), HAQ (OR = 1.62, 1.1–2.38), and low FICSIT-4 score (OR = 2.38, 1.13–5.0) showed significant associations with falls.

Conclusions

In clinical practice, a fall assessment including age, self-reported activities of daily life and a physical performance measure can identify RA patients at risk of falling.

Trial registration

The study has been registered at the German Clinical Trials Register and the WHO International Clinical Trials Registry Platform (ICTRP) since 16 March 2017 (DRKS00011873).

Clinical and biomechanical factors associated with falls and rheumatoid arthritis: baseline cohort with longitudinal nested case-control study

OBJECTIVE

To identify the clinical and biomechanical characteristics associated with falls in people with RA.

METHODS

A total of 436 people ≥60 years of age with RA completed a 1 year prospective survey of falls in the UK. At baseline, questionnaires recorded data including personal and medical history, pain and fatigue scores, health-related quality of life (HRQoL), physical activity and medication history. The occurrence of falls wasmonitored prospectively over 12 months by monthly self-reporting. A nested sample of 30 fallers (defined as the report of one or more falls in 12 months) and 30 non-fallers was evaluated to assess joint range of motion (ROM), muscle strength and gait parameters. Multivariate regression analyses were undertaken to determine variables associated with falling.

RESULTS

Compared with non-fallers (n = 236), fallers (n = 200) were older (P = 0.05), less likely to be married (P = 0.03), had higher pain scores (P < 0.01), experienced more frequent dizziness (P < 0.01), were frequently taking psychotropic medications (P = 0.02) and reported lower HRQoL (P = 0.02). Among those who underwent gait laboratory assessments, compared with non-fallers, fallers showed a greater anteroposterior (AP; P = 0.03) and medial-lateral (ML) sway range (P = 0.02) and reduced isokinetic peak torque and isometric strength at 60° knee flexion (P = 0.03). Fallers also showed shorter stride length (P = 0.04), shorter double support time (P = 0.04) and reduced percentage time in swing phase (P = 0.02) and in knee range of motion through the gait cycle (P < 0.01).

CONCLUSION

People with RA have distinct clinical and biomechanical characteristics that place them at increased risk of falling. Assessment for these factors may be important to offer more targeted rehabilitation interventions.

Analysis of the Associations between Arthritis and Fall Histories in Korean Adults

(1) Background: the purpose of the present study was to analyze the associations between arthritis and fall histories in Korean adults. (2) Methods: data from the 2015 and 2017 Korean Community Health Survey were analyzed. In total, 322,962 participants aged ≥40 years were included. The participants were divided into two different groups. First, the participants were divided into the ‘arthritis (osteoarthritis or rheumatoid arthritis) for entire life’ and ‘nonarthritis for entire life (comparison I)’ groups. Subsequently, the participants were divided into the ‘current arthritis’ and ‘noncurrent arthritis (comparison II)’ groups. Afterwards, we analyzed the prevalence odds ratios (pORs) of the fall histories of the participants using a logistic regression analysis with the 95% confidence interval (CI). The variables of income, education level, region of residence, smoking status, alcohol consumption, obesity, subjective health status, stress level, physical activity, and sleep hours were adjusted for as covariates. (3) Results: both the arthritis for entire life and current arthritis groups had higher prevalence rates of falls than the comparison I and comparison II groups, respectively (each p < 0.001). The pORs of falling ≥1 time and ≥2 times per year in the arthritis for the entire life group were 1.42 (95% CI = 1.38–1.46) and 1.69 (95% CI = 1.62–1.76), respectively. The adjusted pORs for falling ≥1 time and ≥2 times per year in the current arthritis group were 1.35 (95% CI = 1.31–1.39) and 1.56 (95% CI = 1.50–1.63), respectively. (4) Conclusions: previous arthritis has a significant impact on the risk of falling.

Falls in Rheumatoid Patients: Does Ankle and Foot Ultrasonography have a Predictive Role? A Single-blind Study

Background Rheumatoid arthritis (RA) patients have a higher prevalence of falls compared with the healthy population. Several risk factors of falls in RA have been postulated, including high disease activity, low balance, muscle weakness and non-treatment with biologics.

Aim of the work We investigated our hypothesis that the sonographically detected ankle and foot changes in RA patients can predict falls in this population. To our knowledge, no previous study had investigated this before.

Methods In a total of 101 RA patients, we performed assessments of disease activity, disability level, gait speed, balance status, clinical examination of ankle and foot and an MSUS assessment of the ankle and foot joints and tendons as possible risk factors of falls.

Results The Berg balance test had the highest fall-predicting power (71.3%), followed by a gait speed test and restricted range of motion (ROM) of the Rt. subtalar joint, each with a predictive power of 70.3%. Of the sonographic findings, erosion of the first metatarsophalangeal (MTP) joint was the most accurate fall predictor, followed by erosion of the talonavicular joint and tenosynovitis of the ankle dorsal flexors with an area under the curve of 0.656, 0.642 and 0.614, respectively.

Conclusion The use of the MSUS as an adjunct objective method for predicting falls in RA patients has not been studied before. It was found that clinical foot and balance testing was a superior and easier way of predicting falls in RA patients than using ultrasonography.

Effects of 12-week whole-body vibration exercise on fatigue, functional ability and quality of life in women with systemic lupus erythematosus: A randomized controlled trial

BACKGROUND

Systemic lupus erythematosus (SLE) is a complex rheumatic autoimmune disease characterized by periods of exacerbations that can present damage in organs with important clinical manifestations.

OBJECTIVE

The aim of this study was to evaluate the effect of 12-week whole-body vibration exercise (WBVE) on the fatigue, functional ability and quality of life of women with systemic lupus erythematosus (SLE) in chronic glucocorticoids use (CGU).

METHODS

Twenty-one women were allocated randomly in the WBVE group or isometry group. The participants of WBVE group were positioned on the vibrating platform with 130° knee flexion and received the intervention twice a week for 12 weeks. The isometry group performed the same position and time, but without the stimulus of mechanical vibration. Fatigue, functional ability and the quality of life were evaluated at weeks 0, 6, and 12.

RESULTS

From a sample of seventy-seven individuals, seventeen participants completed the study, 8 in WBVE group and 9 in isometry group. Fatigue reduced in the WBVE group at 6 and 12 weeks of intervention (p = 0.04) and (p = 0.03) respectively. There was a significant improvement in the functional ability evaluated by the Health Assessment Questionnaire in the WBVE group compared to the isometry group (p = 0.03).

CONCLUSION

WBVE would be a useful intervention for control of fatigue and improvement of the functional ability of women with SLE in CGU.

Revealing the Synergistic Mechanism of Multiple Components in Compound Fengshiding Capsule for Rheumatoid Arthritis Therapeutics by Network Pharmacology

BACKGROUND

Compound Fengshiding capsule (CFC), is a Chinese formulation from herbal origin including Alangium platanifolium, Angelicae dahurica, Cynanchum paniculatum and Glycyrrhiza uralensis. CFC is widely used as clinical therapy against rheumatoid arthritis. However, its exact mechanism of action has not been explored yet.

METHODS

In order to explore the synergistic mechanism of CFC, we designed a study adopting network pharmacology scheme to screen the action targets in relation to the CFC components. The study analyses target facts of salicin, paeonol, liquiritin and imperatorin from PubMed database, and explores the potential pharmacological targets of rheumatoid arthritis, cervical neuralgia and sciatica related diseases for their interaction.

RESULTS

The results of boosted metabolic pathway showed that the chemical components of CFC interrupted many immune-related pathways, thus participating in immunity regulation of the body and playing a role in the treatment of rheumatism. Collectively, CFC has apoptotic, oxidative stress modulatory and anti-inflammatory effects that accumulatively serve for its clinical application against rheumatoid arthritis.

CONCLUSION

Conclusively, our findings from present study reconnoiters and compacts systematic theoretical approach by utilizing the network pharmacology mechanism of four effective components for the treatment of rheumatism indicating sufficient potential drug targets associated with CFC against rheumatism. These interesting findings entreaties for further in vitro and in vivo studies on the mechanism of compound active ingredient against rheumatism.

Frailty syndrome in rheumatoid arthritis and symptomatic osteoarthritis: an emerging concept in rheumatology

Musculoskeletal conditions such as rheumatoid arthritis (RA) and symptomatic osteoarthritis (OA) were the leading cause of disability in developed countries and disproportionately affects older adults. Frailty is an emerging concept in rheumatology, which represents an important construct to aid in the identification of in- dividuals who are vulnerable to adverse events and less favourable outcomes. The prevalence of frailty among the community-dwelling population increases with age: it ranges from 7% to 10% in those aged over 65 years and to 20-40% among octogenarians. Among patients with RA, the prevalence of frailty is comparable to, or even greater, that of older geriatric cohorts and pre-frailty, a condition including a major health vulnerability between robust and frail, is much more prevalent in RA than in geriatric cohorts. Clinical OA is also associated with frailty and pre-frailty in older adults in European countries. The overall prevalence of clinical OA at any site was 30.4%; frailty was present in 10.2% and pre-frailty in 51.0 %. The diagnosis of frailty is usually clinical and based on specific criteria, which are sometimes inconsistent. Therefore, there is an increasing need to identify and vali- date robust biomarkers for this condition. In the literature, different criteria have been validated to identify frail older subjects, which mainly refer to two conceptual models: the Physical Frailty (PF) phenotype proposed by Fried and the cumulative deficit approach proposed by Rockwood. The purpose of this review was to quantita- tively synthesize published literature on the prevalence of frailty in RA and OA and summarize current evidence on the validity and practicality of the most commonly used screening tools for frailty.

Evaluation of Risk Factors for Falls in Patients with Rheumatoid Arthritis

Background

The aim of our study was to investigate the risk factors for falls in the rheumatoid arthritis (RA) patient population in Poland. This would be a major step towards the development of new fall prevention programs.

Material/Methods

There were 450 RA patients who met the criteria of the American College of Rheumatology who participated in this study. The average age of patient participants was 54.2 years; the average RA duration was 15.1 years. All patients filled out the study questionnaire regarding falls, medications, and diseases, and they filled out the Polish version of the Health Assessment Questionnaire (HAQ).

Results

Of the 400 patients, 203 patients (51%) experienced falls. Out of the 268 falls experienced by study patients, 113 falls (42%) were due to an environmental cause, the remainder 155 falls were caused by health conditions. The number of falls positively correlated with HAQ scores (r=0.42, P<0.01) and the duration of RA (r=0.39, P<0.05). For individuals who had fallen 3 or more times, there was a stronger positive correlation between the number of falls and the total HAQ score (r=0.61, P<0.01). The main risk factors for falls in the study group were dizziness (odds ratio [OR]=3.42), the use of hypotensive medication (OR=2.82), foot deformities (OR=4.09), and a high HAQ score (OR=2.59). Other factors such as drug use (e.g., glucocorticoids), pain, and duration of RA were measured using a visual analogue scale, and were found not to have increased the risk for falls and fractures (P>0.05).

Conclusions

Knowledge about risk factors can help identify high-risk patients to help decrease their risk of falling, thus preventing fall-related injuries.

Predictors of Need for First and Recurrent Emergency Medical Service Transport to Emergency Department after Dialysis Initiation

Background: Dialysis patients are frequently transported to the emergency department (ED) by Emergency Medical Services (EMS) due to acute and severe illness. However, little is known about predictors of first and recurrent transport to the ED (EMS-ED), based on characteristics at the time of dialysis initiation.Methods: We analyzed a cohort of adult (≥18 years) patients affiliated with a large quaternary care center who initiated chronic dialysis from 2009 to 2013 (last follow-up: 2015). Data on patient characteristics at the time of dialysis initiation were linked to regional EMS data. Candidate predictors of first and recurrent EMS-ED transport included comorbid conditions, dialysis characteristics and frailty severity (using the first version of the clinical frailty scale score; CFS). Time to first EMS-ED was analyzed using a multivariable sub-hazards regression model accounting for competing events (transplantation or death). Time to recurrent EMS-ED was analyzed using the Anderson-Gill counting approach, accounting for competing risks.Results: A total of 455 patients were included in the study, 243 (53%) had 1+ EMS-ED events, 90 (20%) never required an EMS-ED at last follow-up, and 69 (15%) and 53 (12%) experienced transplant or death as their first event, respectively. The mean age of the cohort was 62 ± 15 years, 89% were Caucasian, and 35% were female sex. Patients were highly comorbid and 97/381 (25.5%) with available data on frailty severity had a CFS score of ≥5, inclusive of CFS scores ranging from mildly to severely frail. After adjustment, a CFS score of ≥5 (relative to 1-2) was associated with a > 2-fold increase in the risk of first EMS-ED (subdistribution relative hazard; SHR 2.28, 95% confidence interval; CI 1.30-3.98). A history of peripheral vascular disease (SHR 1.43, 95% CI 1.00-2.03) and rheumatologic disease (SHR 1.84, 95% CI 1.00-3.38) was also associated with first EMS-ED. Frailty severity was the only factor associated with recurrent EMS-ED.Conclusion: Patients are at a high risk of EMS-ED after dialysis initiation. Frailty severity (at the time of dialysis initiation) is a strong predictor of first and recurrent EMS-ED and this may be important to guide informed decision making and resource planning for dialysis patients who require EMS.

Impact of Rheumatoid Arthritis and Its Management on Falls, Fracture and Bone Mineral Density in UK Biobank

Objectives: Rheumatoid arthritis (RA) is a systemic chronic inflammatory disease which presents with polyarthritis in addition to extra-articular manifestations. Historically, studies have shown a link between RA and adverse musculoskeletal outcomes but these studies were reported before the widespread use of biologic therapies. The aim of this study was therefore to investigate associations between RA, RA medications and bone mineral density, falls and fractures, using UK Biobank data. Methods: Diagnosis of RA was made using Hospital Episode Statistics (HES) ICD-10 coding. We assessed RA relationships with estimated bone mineral density (eBMD) from heel quantitative ultrasound measurements, self-reported falls (in last year) and HES recorded fracture, adjusted for age, ethnicity, BMI, smoking status, and physical activity. Results: Of 502,543 participants, 3849 (1.4%) of women and 1643 (0.7%) of men had a diagnosis of RA. Median age of the participants was 57 years (IQR 50-63) in women and 58 (IQR 50-64) in men. RA was associated with lower eBMD (men: β -0.244, 95% CI -0.378, -0.110 p < 0.001; women: β -0.217, 95% CI -0.297, -0.138 p < 0.001) a reported fall in the last year (men: OR 1.54, 95% CI 1.26, 1.87 p < 0.001; women: OR 1.36, 95% CI 1.19, 1.56 p < 0.001) and fracture in women (OR 1.76, 95% CI 1.43, 2.16 p < 0.001). Corticosteroid therapy in men (β -0.934, 95% CI -1.565, -0.304 p = 0.004) and disease modifying anti-rheumatic drug (DMARD) use in both sexes (men: β -0.437, 95% CI -0.761, -0.112 p = 0.008; women: β -0.243, 95% CI -0.421, -0.065 p = 0.007), but not biologic therapy, were associated with a lower eBMD with RA. Conclusions: RA was associated with lower eBMD, increased falls and fracture. Corticosteroid and DMARD therapy, but not biologic therapy, were associated with lower eBMD.

The effect of deep or sustained remission on maintenance of remission after dose reduction or withdrawal of etanercept in patients with rheumatoid arthritis

Background

Biologic disease-modifying antirheumatic drugs (bDMARDs) are important options for managing rheumatoid arthritis (RA). Once patients achieve disease control, clinicians may consider dose reduction or withdrawal of the bDMARD. Results from published studies indicate that some patients will maintain remission; however, others will flare. We analyzed data from three etanercept down-titration studies in patients with RA to determine what extent of remission provides the greatest predictability of maintaining remission following dose reduction or discontinuation.

Methods

Patients with moderate to severe RA from the PRESERVE, PRIZE, and Treat-to-Target (T2T) randomized controlled trials were included. We determined the proportion of patients achieving remission with etanercept at the last time point in the induction period, and sustained remission (last two time points), according to the Disease Activity Score 28-joints (DAS28), the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) Boolean criteria, and the clinical disease activity index (CDAI). We also calculated the proportion achieving DAS28 deep remission (DAS28 ≤ 1.98), sustained deep remission (last two time points), and low disease activity (LDA), and LDA according to the CDAI. Then, we evaluated whether they maintained remission or LDA following etanercept dose reduction or withdrawal.

Results

Patients achieving sustained and/or deep remission were more likely than patients achieving remission or LDA to maintain remission/LDA after etanercept dose reduction or withdrawal. In PRESERVE, the proportions of patients with DAS28 sustained deep remission, deep remission, sustained remission, remission, and LDA who maintained remission following etanercept dose reduction were 81%, 67%, 58%, 56%, and 36%, respectively, P < 0.001 for trend. In PRESERVE, this trend was significant when etanercept was discontinued and when ACR/EULAR Boolean and CDAI remission criteria were used. Although some sample sizes were small, the PRIZE and T2T studies also demonstrated response trends according to ACR/EULAR Boolean and CDAI remission criteria, and T2T demonstrated response trends according to DAS28.

Conclusions

These results suggest that patients achieving disease control according to a stringent definition, such as sustained ACR/EULAR Boolean or CDAI remission, or a new definition of sustained deep remission by DAS28, have a higher probability of remaining in remission or LDA following etanercept dose reduction or withdrawal.

Trial registration

PRESERVE: ClinicalTrials.gov identifier: NCT00565409, registered 30 November 2007; PRIZE: ClinicalTrials.gov identifier: NCT00913458, registered 4 June 2009; T2T: ClinicalTrials.gov identifier: NCT01578850, registered 17 April 2012

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Medications associated with fracture risk in patients with rheumatoid arthritis

OBJECTIVE

To examine the fracture risk with use of disease-modifying antirheumatic drugs (DMARDs), statins, proton pump inhibitors (PPIs), opioids, non-opioid analgesics and psychotropic medications in a US-wide observational rheumatoid arthritis (RA) cohort.

METHODS

Patients with RA without prior fracture from 2001 through 2017 in FORWARD, a longitudinal observational registry, were assessed for osteoporosis-related site fractures (vertebra, hip, forearm and humerus). DMARD exposure was assessed in four mutually exclusive groups: (1) methotrexate monotherapy-reference, (2) tumour necrosis factor-α inhibitors (TNFi), (3) non-TNFi biologics and (4) others. Non-DMARDs and glucocorticoids were classified as current/ever use and based on treatment duration. Fracture Risk Assessment Tool (FRAX) scores estimating for 10-year major osteoporotic fractures were calculated. Cox proportional hazard models stratified by FRAX were used to adjust for confounders.

RESULTS

During median (IQR) 3.0 (1.5-6.0) years of follow-up in 11 412 patients, 914 fractures were observed. The adjusted models showed a significant fracture risk increase with use of any dose glucocorticoids ≥3 months (HR (95% CI) for <7.5 mg/day 1.26 (1.07 to 1.48) and for ≥7.5 mg/day 1.57 (1.27 to 1.94)), opioids (for weak: 1.37 (1.18 to 1.59); strong: 1.53 (1.24 to 1.88)) and selective serotonin reuptake inhibitors (SSRIs) (1.37 (1.15 to 1.63)). Fracture risk with opioids increased within 1 month of use (1.66 (1.36 to 2.04)) and with SSRIs >3 months of use (1.25 (1.01 to 1.55)). Statins (0.77 (0.62 to 0.96)) and TNFi (0.72 (0.54 to 0.97)) were associated with reduction in vertebral fracture risk only. PPIs and other psychotropic medications were not associated with increased fracture risk.

CONCLUSION

Use of opioids, SSRIs and glucocorticoids were associated with increased risk of any fracture in patients with RA, whereas statins and TNFi were associated with decreased vertebral fractures.

Disease-related outcomes influence prevalence of falls in people with rheumatoid arthritis

BACKGROUND

Patients with rheumatoid arthritis (RA) are at increased risk of falls, with potential adverse outcomes. There is a considerable variation across studies regarding the prevalence of falls and its correlation with clinical data, disease-related outcomes and physical performance tests.

OBJECTIVE

The aim of this study was to evaluate the prevalence of falls and its association with clinical data, disease-related outcomes and physical performance tests.

METHODS

In this cross-sectional study, 113 RA patients were divided into 3 groups - "non-fallers", "sporadic fallers" and "recurrent fallers" - and compared in terms of clinical data, Clinical Disease Activity Index (CDAI), lower-limb tender and swollen joint count, disability (Health Assessment Questionnaire-Disability Index [HAQ-DI]), Foot Function Index (FFI), Berg Balance Scale (BBS), Timed-up-and-go Test (TUG) and 5-Time Sit Down-To-Stand Up Test (SST5). Logistic regression analysis was performed to analyze the associations between the studied variables and the occurrence of falls, estimating odds ratios (ORs). We also analyzed the correlation between disease outcome measures (HAQ-DI and CDAI) and physical tests (BBS, TUG, SST5).

RESULTS

Falls and fear of falling were reported by 59 (52.21%) and 71 (64.5%) patients, respectively. Significant associations were found between "recurrent fallers" and vertigo (OR=3.42; P=0.03), fear of falling (OR=3.44; P=0.01), low income (OR=2.02; P=0.04), CDAI (OR=1.08; P<0.01), HAQ-DI (OR=3.66; P<0.01), Lower-limb HAQ (OR=3.48; P<0.01), FFI-pain (OR=1.24; P=0.03), FFI-total (OR=1.23; P=0.04), lower-limb tender joint count (OR=1.22; P<0.01), BBS score (OR=1.14; P<0.01), TUG score (OR=1.13; P=0.03) and SST5 score (OR=1.06; P=0.02). On multivariate analysis, CDAI was the only significant predictor of recurrent falls (OR=1.08; P<0.01). Physical performance test scores (BBS, TUG, SST5) were correlated with the CDAI and HAQ-DI.

CONCLUSION

The prevalence of falls in RA is high, most influenced by disease-related outcomes and linked to worse performance on physical tests (BBS, TUG and SST5).

miR-145-5p Increases Osteoclast Numbers In Vitro and Aggravates Bone Erosion in Collagen-Induced Arthritis by Targeting Osteoprotegerin

BACKGROUND Osteoprotegerin (OPG) inhibits bone resorption and binds with strong affinity to receptor activator of NF κB ligand (RANKL), thereby preventing RANKL from binding to its receptor RANK. Osteoclasts have documented effects on bone erosion of rheumatoid arthritis (RA). The aim of this study was to examine the role of miR-145-5p in the regulation of RA osteoclast differentiation and bone erosion. MATERIAL AND METHODS Expression of microRNA-145-5p in human peripheral blood mononuclear cells (PBMC) and synovial tissue was assayed by real-time polymerase chain reaction (RT-PCR). OPG, RANK, and RANKL expression in RAW-264.7 cells was examined by RT-PCR and Western blot analysis. Osteoclast formation was detected by tartrate-resistant acid phosphatase (TRAP) staining. The effect of miR-145-5p on predicted target mRNAs was examined by luciferase reporter assays. Collagen-induced arthritis (CIA) was induced by injecting DBA/1 mice with bovine type II collagen (CII), and miR-145-5p agomir was administered by intravenous injection. Morphological changes in the CIA joint were assessed by micro-computed tomography (CT) and histopathology. RESULTS miR-145-5p levels significantly increased in RA PBMC and synovial tissue compared with normal PBMC and osteoarthritis (OA) tissue. After transfection of RAW-264.7 cells with miR-145-5p, RANK and RANKL expression increased significantly, while OPG expression decreased significantly. TRAP staining results showed osteoclast numbers increased. Micro-CT analysis of the arthritic joints showed that the miR-145-5p agomir caused bone erosion in mice, and histopathological analysis revealed that miR-145-5p agomir aggravates cartilage erosion. CONCLUSIONS Our findings indicate that administration of miR-145-5p aggravates joint erosion in CIA mice. This suggests that miR-145-5p is a potential target for the treatment of RA.

Static and Dynamic Balance Disorders in Patients With Rheumatoid Arthritis and Relationships With Lower Extremity Function and Deformities: A Prospective Controlled Study

Objectives

This study aims to evaluate the static and dynamic balance disorders of patients with rheumatoid arthritis (RA) and to disclose the relationships with clinical, functional, and radiological findings of lower extremities.

Patients and methods

A total of 81 patients with RA (15 males, 66 females; mean age 48.9±10.4 years; range 22 to 67 years) were compared with 84 age and sex-matched healthy controls (14 males, 70 females; mean age 45.9±12.1 years; range 24 to 70 years). Radiographic assessments of feet were performed to evaluate the presence of pes planus, hallux valgus, metatarsus primus varus, and splaying foot deformities. Foot functions of patients were determined with Foot and Ankle Outcome Score. The balance disorders of the subjects were evaluated with three static (modified clinical test of sensory interaction and balance, unilateral stance, weight bearing squat) and three dynamic (step-up-and-over, sit-to-stand, tandem walk) balance tests via the 'Neurocom Balance Master' device.

Results

Rheumatoid arthritis patients had significantly higher sway velocity in unilateral stance and modified clinical test of sensory interaction and balance tests, higher step width and lower speed when walking on a line, lower rising index and higher movement time in step-up-and-over test compared to healthy controls (p<0.05). Performances on the sit-to-stand and weight bearing squat tests were comparable between both groups. Of the patients, although 61% had hallux valgus, 52% had metatarsus primus varus, 33% had pes planus, and 26% had splaying foot, these deformities were not correlated with Foot and Ankle Outcome Score or balance disorders. Presence of swollen joint was determined as the most relevant factor for balance disorders of RA patients.

Conclusion

Patients with RA may have increased risk for balance disorders due to cumulative effect of the lower extremity impairments seen in the course of disease.

Fall Risk and Related Factors in Systemic Lupus Erythematosus

Objectives

This study aims to determine the fall risk in systemic lupus erythematosus (SLE) patients with an objective computerized technique and to evaluate the potential related risk factors for falls in these patients.

Patients and methods

A total of 48 female patients (mean age 37.8±12.6 years; range 18 to 65 years) with SLE and 30 female controls (mean age 39.1±15.7 years; range 19 to 66 years) were included. Age, disease duration, anamnesis of falls, fear of falling, and drugs used were recorded. Disease activity (measured with SLE disease activity index Safety of Estrogens in Lupus Erythematosus National Assessment modification) and damage (measured with Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index) were evaluated. For the evaluation of fall efficacy, we used the Falls Efficacy Scale International. Fall risk analysis was performed by using a computerized posturography device.

Results

Seven patients (15%) had anamnesis of falls during the last 12 months, whereas only one control (3%) had this anamnesis (p=0.042). Fear of falling was reported by 40% of the patients and 30% of the controls (p=0.042). Falls Efficacy Scale International scores were found to be higher in patients than in controls (p=0.042). With the computerized system used, higher fall risk results were recorded in patients than in controls (59.3±29.5 and 35.8±26.9, respectively; p<0.001). Low, moderate, and high fall risks were recorded as 31%, 15%, and 54% in the patients, respectively, and as 53%, 23%, and 23% in the controls, respectively. Low, moderate and high fall risk distribution was also worse in patients than in the controls (p=0.030). No significant correlation was found between fall risk and the other factors evaluated, except Falls Efficacy Scale International, which was significantly correlated with both fall risk assessment and fall risk category in the patients (r=0.311, p=0.031).

Conclusion

Fall risk was found to be higher in SLE patients than in controls. The higher fall risk in these patients seems to be affected by the disease itself rather than its other characteristics. Future studies investigating the possible coexisting balance problems in SLE may contribute to the management of the disease.

[Which kind of structures and facilities are needed for the care of elderly patients with rheumatic diseases?]

In the coming years the number of elderly patients with rheumatic diseases in Germany will continuously increase. Therefore, it is necessary that the structures of the healthcare system for elderly patients with rheumatic diseases are prepared for this challenge. Two important fields are of particular relevance: multimorbidity and the prevention of disability. Both points do not only affect elderly patients but are particularly important in this group. In order to solve the problems structures which facilitate interdisciplinary care should be supported. Moreover, institutions which provide rehabilitation should be utilized for the care of elderly patients with rheumatic diseases. Both can be performed in either outpatient or inpatient settings. Rheumatologists working in interdisciplinary fields, in outpatient practices, and in specialized rheumatology hospitals have key functions in the care of elderly patients with rheumatic diseases. However, practices and hospitals both have to solve the special problems of reimbursement and interfaces between the sectors.

Falls and their association with physical tests, functional capacity, clinical and demographic factors in patients with rheumatoid arthritis

OBJECTIVE

To evaluate the occurrence of falls reported by rheumatoid arthritis patients and its relation to disease activity, functional capacity and physical fitness.

MATERIALS AND METHODS

A cross-sectional study constituted by a sample of 97 rheumatoid arthritis patients from the city of Marília (SP) from 2012 to 2013, were assessed for disease activity. Instruments validated for Brazilian population in order to evaluate physical and functional capacity were used. Data analysis was carried out with descriptive statistics, Spearman correlation and Chi-squared test, considering p<0.05.

RESULTS

88.7% were female subjects with a mean age of 56 (±11.7) years. The median duration of rheumatoid arthritis was 10 years (P25=6 and P75=17) and the mean of disease activity was 3.6 (±1.3), what was considered a moderate activity. In the last 12 months 37.1% of patients experienced at least one fall, with a total of 52 episodes, and fear of falling was reported by 74.2% of them, but this was not associated to the occurrence of a fall (χ²=1.19, p=0.27). Gender, number of medications, age, disease activity, duration of rheumatoid arthritis, functional capacity, and physical tests showed no associations with history of falls in the past year.

CONCLUSION

It was observed that the occurrence of falls and the fear of falling are quite common in this population. The occurrence of falls in this sample of rheumatoid arthritis patients bears no relation to disease activity, functional capacity, or physical fitness tests.

Fear of falling and foot pain, impairment and disability in rheumatoid arthritis: a case-control study

Fear of falling, foot pain, impairment and disability are commonly reported in rheumatoid arthritis (RA). However, the relationship between fear of falling and foot pain, impairment and disability has not been investigated in established RA. The aim of the study was to evaluate the relationship between fear of falling and foot pain, walking velocity and foot impairment and disability in women with established RA. A secondary aim was to evaluate differences between fear of falling, foot pain, walking velocity and foot impairment and disability in women with established RA and age- and sex-matched control participants. Twenty-one women with established RA and twenty-one age- and sex-matched controls were assessed for fear of falling, foot pain, foot impairment and disability and walking velocity. Pearson's r-correlations were used to examine relationships between fear of falling and the foot measures. Independent samples t tests evaluated the differences in fear of falling and foot measures between the two groups. In people with RA, significant correlations were found between fear of falling and foot impairment (r = 0.53, p = 0.015), foot disability (r = 0.77, p <0.001) and walking velocity (r = 0.56, p < 0.001). No correlation was found between fear of falling and foot pain (r = 0.36; p = 0.11). Significant differences between cases and control participants were found between fear of falling (p = 0.001), foot impairment (p = 0.004) and foot disability (p < 0.001). Foot impairment and disability relates to fear of falling in women with established RA. A better understanding of fear of falling in people with established RA may contribute to more efficient falls assessments in order to identify at risk individuals.

Evaluating and mitigating fracture risk in established rheumatoid arthritis

Patients with rheumatoid arthritis are predisposed to systemic bone loss, and they are at an increased risk of fractures. Although there are similarities in the patient demographics between rheumatoid arthritis patients and the general population of osteoporosis patients, there are factors, particularly the use of glucocorticoids, which are specific to rheumatoid arthritis. These factors can lead to an increased risk of bone loss and fracture. Given that fractures are often very debilitating, especially in elderly patients, it is of paramount importance for the practicing rheumatologist to be aware of ways to reduce the risk of fracture in patients with rheumatoid arthritis. This review discusses currently available modalities for fracture risk assessment as well as pharmacologic and lifestyle interventions available to treat and prevent bone loss in rheumatoid arthritis patients.

Total Saponin from Anemone flaccida Fr. Schmidt Prevents Bone Destruction in Experimental Rheumatoid Arthritis via Inhibiting Osteoclastogenesis

Anemone flaccida Fr. Schmidt is used in the clinical compound prescription for the treatment of rheumatoid arthritis (RA) in China and has the traditional use of draining dampness, diminishing swelling, and relieving pain. Total saponins (TS) are the characteristic components and also the main active ingredients of A. flaccida. Previous reports indicated that TS possess anti-inflammatory and immunoregulatory properties; however, the effects of TS on bone destruction of RA have not been evaluated. In this study, our data first showed the therapeutic effects of TS on severity of arthritis and arthritis progression in collagen-induced arthritis (CIA) rats. Then, by microfocal computed tomography (CT) quantification, TS significantly increased bone mineral density, bone volume fraction, and trabecular thickness and decreased trabecular separation of inflamed joints both at peri-articular and extra-articular locations. TS also diminished the level of the bone resorption marker CTX-I and simultaneously increased the bone formation marker osteocalcin in sera of CIA rats. Interestingly, TS prevented bone destruction by reducing the number of osteoclasts in inflamed joints, reducing the expression of receptor activator of nuclear factor-κF (RANK) ligand (RANKL) and RANK, increasing the expression of osteoprotegerin (OPG), at both mRNA and protein levels, and decreasing the ratio of RANKL to OPG in inflamed joints and sera of CIA rats. This was further confirmed in the co-culture system of human fibroblast-like synovial and peripheral blood mononuclear cells. In addition, TS inhibited the levels of pro-inflammatory cytokines implicated in bone resorption, such as interleukin-1β (IL-1β), tumor necrosis factor-α (TNFα), IL-6, IL-17, and IL-23 in sera and joints. These findings offer convincing evidence that TS attenuate RA partially by preventing both focal bone destruction and systemic bone loss. This anti-erosive effect results in part from inhibiting osteoclastogenesis by regulating the RANKL/RANK/OPG signaling pathway. The suppression of systemic and local pro-osteoclastogenic cytokines by TS was also highly effective.

The impact of comorbidities on the physical function in patients with rheumatoid arthritis

OBJECTIVES

To investigate the association of comorbidities with mobility limitation and functional disability in patients with rheumatoid arthritis and to identify which comorbidity indicator is the most appropriate to determine this association.

METHODS

Sixty rheumatoid arthritis patients were enrolled in a cross-sectional study for a period of 11 months. Comorbidities were assessed using three indicators: (i) the total number of comorbidities; (ii) the Charlson comorbidity index; and (iii) the functional comorbidity index. Disease activity was assessed using the Disease Activity Score 28. Functional capacity was measured using the Health Assessment Questionnaire, and mobility was measured using Timed Up and Go Test and Five-Times-Sit-to-Stand Test. Statistical analysis was performed using a stepwise log-linear multiple regression with a significance level of 5%.

RESULTS

In the final model, only comorbidity was associated with mobility limitation. The functional comorbidity index score explained 19.1% of the variability of the Five-Times-Sit-to-Stand Test (coefficient of determination [R(2)]=0.191) and 19.5% of the Timed Up and Go Test variability (R(2)=0.195). With regard to functional disability, the associated factors were comorbidity and disease activity, which together explained 32.9% of the variability of the Health Assessment Questionnaire score (adjusted R(2)=0.329).

CONCLUSION

Comorbidities were associated with mobility limitation and functional disability in rheumatoid arthritis patients. The functional comorbidity index proved to be an appropriate comorbidity indicator to determine this association.

Uncovering pharmacological mechanisms of Wu-tou decoction acting on rheumatoid arthritis through systems approaches: drug-target prediction, network analysis and experimental validation

Wu-tou decoction (WTD) has been extensively used for the treatment of rheumatoid arthritis (RA). Due to lack of appropriate methods, pharmacological mechanisms of WTD acting on RA have not been fully elucidated. In this study, a list of putative targets for compositive compounds containing in WTD were predicted by drugCIPHER-CS. Then, the interaction network of the putative targets of WTD and known RA-related targets was constructed and hub nodes were identified. After constructing the interaction network of hubs, four topological features of each hub, including degree, node betweenness, closeness and k-coreness, were calculated and 79 major hubs were identified as candidate targets of WTD, which were implicated into the imbalance of the nervous, endocrine and immune (NEI) systems, leading to the main pathological changes during the RA progression. Further experimental validation also demonstrated the preventive effects of WTD on inflammation and joint destruction in collagen-induced arthritis (CIA) rats and its regulatory effects on candidate targets both in vitro and in vivo systems. In conclusion, we performed an integrative analysis to offer the convincing evidence that WTD may attenuate RA partially by restoring the balance of NEI system and subsequently reversing the pathological events during RA progression.

The effects of sandals on postural stability in patients with rheumatoid arthritis: an exploratory study

BACKGROUND

Rheumatoid arthritis results in postural instability, pain and functional limitations. As rheumatoid arthritis progresses, localised forefoot deformities such as hallux valgus and clawing of the lesser toes occur, leading to a high proportion of people with rheumatoid arthritis wearing sandals. Sandals may affect postural stability due to poor motion control. The aim was to assess two different open-toe sandals on postural stability in people with rheumatoid arthritis.

METHODS

Twenty women with rheumatoid arthritis were assessed in quiet standing under four conditions: (1) open-back sandal; (2) closed-back sandal; (3) own footwear and (4) bare feet. Postural stability was assessed as postural sway in the anterior-posterior and medial-lateral directions, with eyes open and eyes closed, using a pressure mat. Repeated measures analysis of variance tested the interaction effect of the footwear and eye conditions on anterior-posterior and medial-lateral sway.

FINDINGS

In eyes-open, there was no significant difference in anterior-posterior sway (P=.169) and medial-lateral sway (P=.325) for footwear conditions. In eyes-closed testing, compared with barefoot conditions, increased anterior-posterior sway was observed with participants' footwear (P<.0001), the open-back sandal (P=.005), and the closed-back sandal (P=.017). With eyes closed, increased anterior-posterior sway was also observed with the participants' footwear compared with the closed-back sandal (P=.041). Increased medial-lateral sway was observed with the closed-back sandal compared with bare feet (P=.014).

INTERPRETATION

Sandals may be detrimental to older women with well-established rheumatoid arthritis when eyes are closed. Further investigation is needed to evaluate the effect of sandals on dynamic tasks.

Navigating traditional chinese medicine network pharmacology and computational tools

The concept of "network target" has ushered in a new era in the field of traditional Chinese medicine (TCM). As a new research approach, network pharmacology is based on the analysis of network models and systems biology. Taking advantage of advancements in systems biology, a high degree of integration data analysis strategy and interpretable visualization provides deeper insights into the underlying mechanisms of TCM theories, including the principles of herb combination, biological foundations of herb or herbal formulae action, and molecular basis of TCM syndromes. In this study, we review several recent developments in TCM network pharmacology research and discuss their potential for bridging the gap between traditional and modern medicine. We briefly summarize the two main functional applications of TCM network models: understanding/uncovering and predicting/discovering. In particular, we focus on how TCM network pharmacology research is conducted and highlight different computational tools, such as network-based and machine learning algorithms, and sources that have been proposed and applied to the different steps involved in the research process. To make network pharmacology research commonplace, some basic network definitions and analysis methods are presented.

A systems biology-based investigation into the pharmacological mechanisms of wu tou tang acting on rheumatoid arthritis by integrating network analysis

Aim. To investigate pharmacological mechanisms of Wu Tou Tang acting on rheumatoid arthritis (RA) by integrating network analysis at a system level. Methods and Results. Drug similarity search tool in Therapeutic Targets Database was used to screen 153 drugs with similar structures to compositive compounds of each ingredient in Wu Tou Tang and to identify 56 known targets of these similar drugs as predicted molecules which Wu Tou Tang affects. The recall, precision, accuracy, and F1-score, which were calculated to evaluate the performance of this method, were, respectively, 0.98, 0.61, 59.67%, and 0.76. Then, the predicted effector molecules of Wu Tou Tang were significantly enriched in neuroactive ligand-receptor interaction and calcium signaling pathway. Next, the importance of these predicted effector molecules was evaluated by analyzing their network topological features, such as degree, betweenness, and k-coreness. We further elucidated the biological significance of nine major candidate effector molecules of Wu Tou Tang for RA therapy and validated their associations with compositive compounds in Wu Tou Tang by the molecular docking simulation. Conclusion. Our data suggest the potential pharmacological mechanisms of Wu Tou Tang acting on RA by combining the strategies of systems biology and network pharmacology.

Triptolide Prevents Bone Destruction in the Collagen-Induced Arthritis Model of Rheumatoid Arthritis by Targeting RANKL/RANK/OPG Signal Pathway

Focal bone destruction within inflamed joints is the most specific hallmark of rheumatoid arthritis (RA). Our previous study indicated that the therapeutic efficiency of triptolide in RA may be due partially to its chondroprotective and anti-inflammatory effects. However, its roles in bone destruction are still unclear. In this study, our data firstly showed the therapeutic effects of triptolide on severity of arthritis and arthritis progression in collagen-induced arthritis (CIA) mice. Then, by micro-CT quantification, triptolide treatment significantly increased bone mineral density, bone volume fraction, and trabecular thickness and decreased trabecular separation of inflamed joints. Interestingly, triptolide treatment could prevent the bone destruction by reducing the number of osteoclasts in inflamed joints, reducing the expression of receptor activator of NF-κB (RANK) ligand (RANKL) and RANK, increasing the expression of osteoprotegerin (OPG), at both mRNA and protein levels, and decreasing the ratio of RANKL to OPG in sera and inflamed joints of CIA mice, which were further confirmed in the coculture system of human fibroblast-like synovial and peripheral blood mononuclear cells. These findings offer the convincing evidence for the first time that triptolide may attenuate RA partially by preventing the bone destruction and inhibit osteoclast formation by regulating RANKL/RANK/OPG signal pathway.