腕关节镜下滑膜切除术治疗类风湿性腕节炎

目的探讨关节镜下滑膜切除术治疗类风湿性腕关节炎的治疗效果.方法参照美国风湿病协会制订的类风湿关节炎分类标准选择Ⅰ～Ⅲ期病例共37例(61 个腕关节)施行手术.在腕关节牵引下,应用直径2.3mm30°与0°关节镜、小型刨削器、直径2.5mm刨削头、射频汽化仪,取背侧桡腕关节和腕中关节入路,镜下探查腕部疾病,证实为类风湿性滑膜病变后,应用刨削器与射频汽化仪彻底切除腕关节滑膜.结果全部病例手术顺利,无并发症,病理诊断符合类风湿性滑膜炎.经6～48个月随访,平均随访28.6个月,优良率达73.8%,其中Ⅰ、Ⅱ期患者的术后优良率(分别为70.6%、86.1%)明显高于Ⅲ期患者的术后优良率(25.0%),P＜0.01.结论关节镜下滑膜切除术可有效治疗Ⅰ、Ⅱ期类风湿性腕关节炎.     

自噬在类风湿关节炎中的作用及中药干预研究进展

类风湿关节炎(RA)目前临床上多使用糖皮质激素或免疫抑制剂进行治疗,但长期使用具有明显的毒副作用,且免疫抑制剂价格昂贵,一定程度限制其广泛的应用。中药治疗RA历史悠久,且毒副作用小,但其具体作用机制不甚明确。自噬的过程是细胞自身在受到外界的刺激,通过细胞内信号转导,触发的一系列细胞维持内环境稳定的一种主动的生物学过程,其异常参与多种疾病的发生。目前研究表明自噬异常与RA的发生发展过程关系密切,可以干预RA血管翳生成、滑膜炎症和骨破坏等关键病理环节,从而影响RA的进展和预后。近年来很多研究发现中药复方及其活性成分可以通过调节自噬过程,发挥治疗RA的作用。本文对中药调控自噬进而干预RA的相关文献进行调研,以期为中药治疗RA重要作用机制、新药开发及临床治疗提供新思路。     

An approach to evidence-based therapeutic apheresis

This review is derived from a memorial lecture honoring Dr. Francis Morrison, a former President of the American Society For Apheresis (ASFA). The author had numerous professional contacts with Dr. Morrison through ASFA in the early 1990s, having served with him on the Board of Directors and followed him as President, and also came to know him well on a personal level. Professionally, Dr. Morrison stood out as a courtly gentleman with a marvelous baritone voice whose ability to facilitate organization contributed to a growing sense of dignity and purpose in the affairs of the society. On the personal side, however, there wasn't an ounce of pretension in him. He was accessible and down-to-earth; a genuine character with an active and appealing sense of humor. Not surprisingly, he seemed to have a wealth of insight and "common sense," and since the topic of this study is a kind of common sense approach to assessing the effectiveness of therapeutic apheresis, it seems a fitting way to honor his memory.     

Efficacy and tolerance of immune checkpoint inhibitors in transplant patients with cancer: A systematic review

Solid organ transplant (SOT) is frequently complicated by cancers, which render immunosuppression challenging. Immune checkpoint inhibitors have emerged as treatments for many cancers. Data are lacking regarding efficacy and rejection risk in the SOT population. We conducted a systematic literature review and analyzed 83 cases of immune checkpoint inhibitor use for cancer in SOT. Two thirds of these patients received anti–programmed death ligand 1 therapy, 15.7% received anti–cytotoxic T lymphocyte–associated protein 4 therapy, and 10.8% received a combination. Allograft rejection occurred in 39.8% of patients, leading to end‐stage organ failure in 71.0% of cases. Outcomes were similar across organs and immunotherapy regimens. The use of immunosuppressants other than steroids, time since transplant, and prior episodes of rejection were associated with the risk of rejection. The median overall survival of patients was 36 weeks. Most of the deaths were related to cancer progression. In nonkidney recipients, graft rejection was strongly associated with worse survival. At the end of the study, 19.3% of the patients were alive, free from rejection and tumor progression. This study highlights the difficult tradeoff facing oncologists and transplant specialists managing transplant recipients with cancer, and the need for prospective data and novel biomarkers for identifying the patients likely to benefit from immunotherapy in the SOT setting.     

Performance of a new rapid diagnostic test the lactate/glucose ratio of synovial fluid for the diagnosis of septic arthritis

ObjectiveTo evaluate the diagnostic performance of the synovial lactate, glucose and lactate/glucose ratio assay for the diagnosis of septic arthritis.MethodsIn this monocentric cross-sectional study, synovial fluids were prospectively obtained from patients with acute joint effusion (<30 days) on native joint. Septic arthritis was defined using Newman's criteria. To evaluate diagnostic performance, Receiver Operating Characteristic (ROC) curves with Area under the curve (AUC), Sensitivities (Se), Specificities (Sp), LR+ their 95% confidence intervals were calculated. Synovial fluid cultures with gram staining, crystal analyses, synovial fluid white blood cell counts (WBC), lactate and glucose assays were performed.ResultsA total of 233 synovial fluids were included. 25 patients had septic arthritis and 208 had non-septic arthritis (104 crystal-induced arthritis, 15 RA, 8 SpA, 6 reactive arthritis, and 75 acute arthritis of undifferentiated origin). Synovial lactate/glucose ratio performed higher than the synovial lactate or glucose assay separately (AUC: 0.859 [0.772–0.945]). Best synovial lactate/glucose ratio threshold to differentiate septic arthritis from non-septic arthritis was 5 Se 52% [0.34–0.7], Sp 98.1% [0.95–0.99], LR+ 27.0[9.50–76.00]).ConclusionThe diagnostic performance of synovial lactate/glucose allows septic arthritis to be effectively and very quickly distinguished from other types of arthritis.     

Important determinants of the patient choice between TNF- vs. non-TNF Biologic disease-modifying anti-rheumatic drugs (DMARDs) for active rheumatoid arthritis (RA)

ObjectiveTo assess why patients choose TNF- versus non-TNF biologics for treating active rheumatoid arthritis (RA) after methotrexate-failure.MethodsParticipants responded to the question “What sort of things help a patient decide the treatment choice between the two types of injectable biologics, TNF biologic versus non-TNF biologic, for treating active rheumatoid arthritis when methotrexate fails to control RA disease activity?” They nominated responses, discussed and then voted.ResultsForty-four patients participated in 10 nominal groups (Birmingham; n = 6; New York City: n = 4), who were predominantly female (86%), 68% white, with a mean age of 65 (standard deviation [SD], 12) years. Present/past DMARDs included methotrexate in 91%, glucocorticoids in 11%, and biologics and/or Jak-inhibitors in 68% of participants. Pain and fatigue were mild-moderate with means of 3.9 (SD, 2.5) and 4.3 (SD, 2.5), respectively, on 0-10 scale; mean morning joint stiffness was 1.3 hours (SD, 2.1). The number of groups that nominated each response and total votes were as follows: (1) Side effects/fear of side effects: 10/10; 31% votes (82/264); (2) Efficacy/ability to reduce joint damage: 9/10; 30% votes (80/264); (3) Doctor's opinion, 6/10; 12% votes (32/264); (4) Cost, 7/10; 9% votes (25/264); (5) Other drugs/comorbidity, 4/10; 12% votes (31/264); (6) Experience of others/information-seeking/own research, 2/10; 2% votes (5/264); (7) Newness, 1/10; 2% votes (6/264); and (8) Convenience/frequency of use, 1/10; 1% votes (3/264).ConclusionsWe identified the patient perspective of choice between TNF versus non-TNF biologic for treating active RA. This knowledge can help in informative shared decision-making in clinical care.     

Determinants of sleep impairment in psoriatic arthritis: An observational study with 396 patients from 14 countries

ObjectiveSleep quality is diminished in patients with psoriatic arthritis (PsA) and close to 40% of PsA patients consider sleep difficulties a priority domain. This work analyzes determinants of impaired sleep in patients with PsA.MethodsThis was a cross-sectional analysis of an observational study (ReFlap, NCT NCT03119805), which included adult patients with definite PsA with ≥ 2 years disease duration from 14 countries. Sleep was assessed using the patient self-reported evaluation of sleep on a 0-10 numerical scale, included in the Psoriatic Arthritis Impact of Disease questionnaire (PSAID-12). A score ≥ 4 was considered as sleep impairment. Demographic and clinical variables associated to sleep impairment were assessed through univariate analysis and Poisson regression modeling leading to prevalence ratio (PR) [95% confidence interval].ResultsA total of 396 patients were analyzed: mean age 51.9 ± 12.6 years, 51% were females, 59.7% were receiving biologic therapy, 53.3% had 1–5% of body surface area affected by psoriasis; 23.7% were in remission and 36.9% in low disease activity according to the Disease Activity in Psoriatic Arthritis (DAPSA) score. Median (25th–75th) patient's self-evaluation of sleep difficulties was 2 (0–6), 157 (39.6%) had sleep impairment. In the Poisson regression model, self-reported levels of anxiety (PR: 1.05 [1.02–1.08], P = 0.003) and pain (PR: 1.06 [1.04–1.09], P < 0.001) were independently associated to sleep impairment.ConclusionsIn this multicentric study, sleep impairment was present in 40% of PsA patients; pain and anxiety were associated to sleep impairment whereas inflammation was not. Impact on sleep appears multifactorial in PsA.     

Metabolomics in the development and progression of rheumatoid arthritis: A systematic review

ObjectiveA systematic review and analysis of data from several rheumatoid arthritis metabolomics studies attempts to determine which metabolites can be used as potential biomarkers for the diagnosis of rheumatoid arthritis and to explore the pathogenesis of rheumatoid arthritis.MethodsWe searched all the subject-related documents published by EMBASE, PubMed, Web of Science, and Cochrane Library from the database to the September 2019 publication. Two researchers independently screened the literature and extracted the data. QUADOMICS tool was used to assess the quality of studies included in this systematic review.ResultsA total of 10 studies met the inclusion criteria of systematic review, including 502 patients with rheumatoid arthritis and 373 healthy people. Among them, the biological samples utilised for metabolomic analysis include: serum (n = 8), urine (n = 1) and synovial fluid (n = 1). Some metabolites play an important role in rheumatoid arthritis: glucose, lactic acid, citric acid, leucine, methionine, isoleucine, valine, phenylalanine, threonine, serine, proline, glutamate, histidine, alanine, cholesterol, glycerol, and ribose.ConclusionsMetabolomics provides important new opportunities for further research in rheumatoid arthritis and is expected to elucidate the pathogenesis of rheumatoid arthritis that has not been fully understood before.