Arthroscopic guided synovial biopsy in rheumatology: current perspectives

Synovial membrane (SM) pathology has provided valuable insights into our current understanding of immunopathological processes and treatment responses in the inflammatory arthritides. Amongst various methods of synovial biopsy, arthroscopic techniques remain the ‘gold standard’ owing to better sampling from sites of interest, particularly in patients with partially treated disease and from areas within joints that may be difficult to access using other techniques. Newer sophisticated techniques of SM membrane analyses allow assessment of differentially regulated pathways, the knowledge of which may help elucidate diagnostic and therapeutic targets in an attempt towards developing strategies for personalised medicine in the current era of targeted biologic therapies.     

The state of research on complementary and alternative medicine in pediatric rheumatology

This article reviews available evidence on complementary and alternative medicine in pediatric rheumatology. Despite its common use in pediatric rheumatology (34%-92%), there is still uncertainty as to its efficacy and safety. Although results are promising for some treatments such as massage, acupuncture, mind-body interventions (eg, guided imagery and meditative breathing), and some natural health products (eg, calcium supplements and Tripterygium wilfordii), there is a need for high-quality trials investigating the long-term effects and underlying mechanisms of these therapies as well as research on their use in this population of patients.     

Risk factors for osteoporosis and fracture in patients attending rheumatology outpatient clinics

Background: Bone mineral density (BMD) using dual energy X-ray absorptiometry (DXA) scanning is the best predictor of osteoporotic fracture but may not be cost effective for all patient groups. Risk factors (RF) other than BMD may be useful for fracture prediction.
Aim: To assess the prevalence of RF for osteoporosis (OP) and fracture in patients attending a public hospital rheumatology clinic and to document physician awareness of these RF.
Methods: Two hundred and twenty rheumatology outpatients completed a self-administered questionnaire pertaining to known RF for OP and fracture. Initiatives were documented by the treating rheumatologist.
Results: One hundred and fifty-four females and 66 males completed questionnaires: 57% had an inflammatory disorder and 32% had received significant glucocorticoid therapy. Forty-five (68%) males and 126 (82%) females had three or more RF for OP and fracture. Diagnosis of rheumatoid arthritis or connective tissue disorder (CTD) was the variable most significantly associated with increasing numbers of RF. Anti-osteoporotic medication (AOM) use at assessment (64/219, 29.2%) was accounted for primarily by the use of hormone replacement therapy in females between 45–54 years. Prednisolone use predicted intervention in 103 (48%) patients.
Conclusion: Many rheumatology outpatients have multiple RF for OP and fracture. Infrequent AOM use could be explained by inadequate awareness of high risk patients and the lack of an ideal long term agent. With restricted outpatient resources, the feasibility of identifying high risk patients for OP and fracture would increase if the hierarchical status of RF was better understood.     

Biobanking: Basic concepts and role in rheumatology

Biobanking is a process of cryogenic preservation of various biological specimens for research and experimental purposes. The various steps in biobanking are collection, preservation and annotation of samples, and availing these for research purposes. Various models of biobanks are followed in different parts of the world. Biobanking is not without bottlenecks, most important of these being legal and ethical issues. This review is directed at a brief overview on some of these aspects of biobanking with purview on Indian perspective. The role of biobanking in rheumatology is discussed with special comments on common rheumatological disorders. Also in this review, its utility in understanding the pathophysiology of various rheumatological illnesses is emphasized.     

Comparative effectiveness of nonsurgical interventions in the treatment of patients with knee osteoarthritis: A PRISMA-compliant systematic review and network meta-analysis

Background:To find out, based on the available recent randomized controlled trials (RCTs), if the nonsurgical interventions commonly used for knee osteoarthritis patients are valid and quantify their efficiency.Methods:The database of MEDLINE and EMBASE were searched for RCTs evaluating nonsurgical treatment strategies on patients with mild to moderate knee osteoarthritis. A Bayesian random-effects network meta-analysis was performed. The primary outcome was the mean change from baseline in the Western Ontario and McMaster university (WOMAC) total score at 12 months. Raw mean differences with 95% credibility intervals were calculated. Treatments were ranked by probabilities of each treatment to be the best.Results:Thirteen trials assessed 7 strategies with WOMAC at 12 months: injection of platelet rich plasma (PRP), corticosteroids, mesenchymal stem cells (MSCs), hyaluronic acid, ozone, administration of nonsteroidal anti-inflammatory drugs with or without the association of physiotherapy. For treatment-specific effect size, a greater association with WOMAC decrease was found significantly for MSCs (mean difference, −28.0 [95% CrI, −32.9 to −22.4]) and PRP (mean difference, −19.9 [95% CrI, −24.1 to −15.8]). Rank probabilities among the treatments indicated that MSCs had a much higher probability (P = .91) of being the best treatment compared with other treatments, while PRP ranked as the second-best treatment (P = .89).Conclusion:In this systematic review and network meta-analysis, the outcomes of treatments using MSCs and PRP for the management of knee osteoarthritis were associated with long-term improvements in pain and function. More high quality RCTs would be needed to confirm the efficiency of MSCs and PRP for the treatment of patients with knee osteoarthritis.     

The analgesic evaluation of gabapentin for arthroscopy: A meta-analysis of randomized controlled trials

Introduction:The efficacy of gabapentin for pain management of arthroscopy remains controversial. We conduct a systematic review and meta-analysis to explore the influence of gabapentin versus placebo on the postoperative pain intensity of arthroscopy.Methods:We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through April 2020 for randomized controlled trials assessing the effect of gabapentin versus placebo on pain control of arthroscopy. This meta-analysis is performed using the random-effect model.Results:Five randomized controlled trials are included in the meta-analysis. Overall, compared with control group for arthroscopy, gabapentin remarkably decreases pain scores at 24 hour (standard mean difference [SMD]=-0.68; 95% confidence interval [CI]=-1.15 to -0.02; P = .21), analgesic consumption (SMD = -18.24; 95% CI=-24.61 to -11.88; P < .00001), nausea and vomiting (OR = 0.42; 95% CI = 0.21 to 0.84; P = .01), but has no obvious influence on pain scores at 6 h (SMD = −1.30; 95% CI = −2.92 to 0.31; P = .11) or dizziness (OR = 1.12; 95% CI = 0.56 to 2.24; P = .75).Conclusions:Gabapentin is effective for pain control after arthroscopy.     

The analgesic efficacy of pregabalin for shoulder arthroscopy: A meta-analysis of randomized controlled trials

Introduction:The efficacy of pregabalin for pain management of shoulder arthroscopy remains controversial. We conduct this meta-analysis to explore the influence of pregabalin versus placebo on the postoperative pain intensity of shoulder arthroscopy.Methods:We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through November 2019 for randomized controlled trials assessing the effect of pregabalin versus placebo on pain control of shoulder arthroscopy. This meta-analysis was performed using the random-effect model.Results:Three randomized controlled trials were included in the meta-analysis. Overall, compared with control group for shoulder arthroscopy, pregabalin remarkably decreased pain scores at 0 to 1 hour (Std. MD = −0.57; 95% CI = −1.04 to −0.09; P = .02) and 12 hours (Std. MD = −0.37; 95% CI = −0.72 to −0.02; P = .04), as well as analgesic consumption (Std. MD = −1.84; 95% CI = −2.24 to −1.44; P < .00001), but showed no notable influence on pain scores at 24 hours (Std. MD = −0.54; 95% CI = −1.47 to 0.38; P = .25), nausea or vomiting (RR = 0.84; 95% CI = 0.53–1.33; P = .45), dizziness (RR = 1.14; 95% CI = 0.89–1.47; P = .30).Conclusions:Pregabalin may benefit to pain control after shoulder arthroscopy.     

Proteomics in rheumatology: a new direction for old diseases

OBJECTIVES: Completion of the human genome project has stimulated scientists to begin looking for the next step in unraveling normal and abnormal functions within biological systems. Consequently, there is new focus on the role of proteins in these processes. Proteomics is a rapidly growing field that may provide a valuable approach to evaluate the field of rheumatology. The objectives of this article is to provide an overview of biophysical techniques, as "re-invented" research tools, as applied to the investigation of rheumatoid arthritis and osteoarthritis. METHODS: MEDLINE search of articles in English-language journals from 1966 to 2004. The index words "Rheumatoid/osteoarthritis/connective tissue disorders" and the following co-indexing terms were used: "mass spec," "NMR," "SPR" and "Proteomics." Papers identified were reviewed, abstracted, and summarized. The authors' own work in the field is also presented. RESULTS: As we move into the postgenomics era, new and exciting tools are being developed to study protein expression and protein interactions and identify new biomarkers for disease diagnosis and prognosis. Proteomics is an emerging field with widespread potential applications to rheumatic disease. CONCLUSIONS: In this review the biophysical techniques of nuclear magnetic resonance, mass spectroscopy, and surface plasmon resonance as proteomic tools in the study of rheumatoid and osteoarthritis were reviewed. What is emerging is the identification of new biomarkers with clinical and therapeutic relevance.     

Anti‐tumor necrosis factor biosimilars and intended copies in rheumatology: Perspective from the Asia Pacific region

Although anti‐tumor necrosis factor (TNF) agents have greatly improved the management of rheumatic diseases, their cost limits access to many patients throughout the world. As a result, patients and clinicians have turned to biosimilars to provide similar efficacy at a lower cost. Many of the regulatory guidelines in the Asia Pacific region are largely based on those of the European Medicines Agency and the World Health Organization; however, there are variations between countries. Additionally, in some countries, intended copies are available that were approved prior to the development of guidelines and have not fulfilled the requirements of a biosimilar. We review the various regulatory requirements for biosimilars in the Asia Pacific region, the anti‐TNF biosimilars and intended copies approved in the region, and whether clinical data are available for these agents. We discuss concerns about the need for additional regulations and education, and we provide recommendations for a multidisciplinary pharmacovigilance approach that closely monitors the safety of biosimilar use.     

Evidence-based diagnosis and locoregional therapy for hepatocellular carcinoma

Early identification of hepatocellular carcinoma (HCC) is crucial to improving the results of therapy and for patients to be eligible for liver transplantation. Recent advances in noninvasive imaging technology include various techniques of harmonic ultrasound, new ultrasound contrast agents, multislice helical computed tomography and rapid high-quality magnetic resonance. The imaging diagnosis relies on the hallmark of arterial hypervascularity with portal venous washout. Since the use of better radiological techniques has improved the accuracy of noninvasive diagnosis, the role of liver biopsy in the diagnosis of HCC has declined. With recent advances in genomics and proteomics, a great number of potential markers have been identified and developed as new candidate markers for HCC. Locoregional therapies currently constitute the best options for early nonsurgical treatment of HCC. Percutaneous ethanol injection shows similar results to resection surgery for single tumors less than 3 cm in diameter. Radiofrequency ablation is superior to percutaneous ethanol injection in terms of local recurrence. Transarterial chemoembolization is currently the most common approach for the management of HCC without curative options since it improves patient survival, but the optimal embolizing agent, length of interval between sessions and whether the chemotherapeutic agent has any effect have not yet been determined. Combining transarterial chemoembolization with antiangiogenic agents, as well as with other techniques, such as radiofrequency ablation, may improve the results. Injection of radioisotopes such as yttrium-90, via the hepatic artery, may be particularly useful in patients with portal vein thrombosis. Comparisons with other transarterial techniques are needed.     

胸腔镜与经皮胸膜活检在胸腔积液诊断中的临床价值

目的比较内科胸腔镜和经皮胸膜活检在胸腔积液诊断中的价值。方法分析我院同期开展内科胸腔镜(胸腔镜组)和经皮胸膜活检(闭式活检组)的胸腔积液患者,比较两组的病理诊断阳性率及安全性。结果胸腔镜组病理诊断阳性率显著高于闭式活检组,胸腔镜组恶性肿瘤诊断率显著高于闭式活检组,胸腔镜组胸膜结核的诊断率与闭式活检组无显著性差异;两组并发症比较无显著性差异。结论经皮胸膜活检和内科胸腔镜对于胸腔积液诊断均是安全、有效的方法。