Atlantoaxial instability in a patient with neck pain and rheumatoid arthritis

Context: The purpose of this report is to describe the clinical decision-making process for a patient with rheumatoid arthritis with neck pain with underlying atlantoaxial instability.Findings: The patient was evaluated for worsening upper neck pain that began insidiously 1 year prior. The patient denied numbness or tingling in her upper or lower extremities, dizziness or lightheadedness, difficulty maintaining balance with walking, or muscle weakness. Cervical spine range of motion was limited in all planes due to pain and apprehension. The patient’s neurological examination was unremarkable. Prior flexion and extension radiographs of the cervical spine were interpreted as unremarkable with alignment preserved in flexion and extension. However, upon further inspection, the cervical spine flexion radiograph was concerning for inadequate cervical motion, which may have limited the diagnostic utility of these radiographs. Additionally, a Sharp-Purser test was performed, which was positive for excessive motion. Flexion and extension radiographs of the cervical spine were then repeated ensuring the patient adequately flexed and extended during the imaging. Severe anterior subluxation of C1 relative to C2 with cervical flexion was noted, as C1 moved as much as 8–9 mm anterior to C2 with cervical flexion. Given the degree of atlantoaxial instability, the patient subsequently underwent successful posterior fusion from the occiput to C2.Conclusion/Clinical Relevance: This case report demonstrates the importance of properly screening for upper cervical spine instability in patients with rheumatoid arthritis and neck pain and understanding the importance of obtaining adequate and appropriate diagnostic imaging.     

Reproducibility and diagnostic value of a new method using ratios to diagnose anterior atlanto-axial subluxation on plain radiographs

ObjectivesMeasures on conventional radiography are used to detect, especially in rheumatoid arthritis, upper cervical spine instabilities (CSIs) with the anterior and posterior atlanto-dental intervals (AADI and PADI) measurements. Our objective was to evaluate the diagnostic performance and reliability of AADIs and PADIs extrapolated based on ratios in assessing anterior atlanto-axial subluxation (aAAS) when plain radiographs do not allow the measures.MethodsRadiographies of 119 patients were randomly selected. Two blinded observers performed two measurements of the odontoid sagittal diameter (O), axis body base sagittal diameter (C2), AADI, PADI, Clark station and Ranawat index, and the AADI/O, AADI/C2, PADI/O and PADI/C2 ratios were calculated. The diagnostic value of AADI and PADI extrapolated from the AADI/O, AADI/C2, PADI/O and PADI/C2 ratios was evaluated using ROC curves, with AADI > 2.9 mm used as the gold standard.ResultsAmong the 119 patients, 12 patients had aAAS (AADI > 2.9 mm), 6 of them had severe aAAS (AADI > 8.9 mm and/or a PADI < 14 mm), and 6 patients had vertical AAS (Clarks station = 2 or 3 and/or Ranawat index < 13 mm). The AADI extrapolated from the AADI/O and AADI/C2 ratios has excellent intra- and inter-observer reproducibility. The diagnostic value of the extrapolated AADI was high for aAAS (sensitivity 92%; specificity of 100%) and severe aAAS (sensitivity75%; specificity 100%). The diagnostic value of the extrapolated PADI was good but lower than the diagnostic value of the extrapolated AADI.ConclusionExtrapolated AADI can be used instead AADI to detect aAAS and severe aAAS.     

Sex differences in clinical characteristics and their influence on clinical outcomes in an observational cohort of patients with rheumatoid arthritis

ObjectiveRheumatoid arthritis (RA) is more prevalent in women, but sex differences remain incompletely understood. This study aimed to elucidate sex differences in clinical characteristics and their potential impact on clinical outcomes in a large Korean cohort of patients with RA.MethodsIn total, 5376 RA patients from the KORean Observational study Network for Arthritis (KORONA) database were examined at baseline and for 3 consecutive years using the disease activity score 28 (DAS28), health assessment questionnaire (HAQ), and patient-reported outcomes (PROs). Within a subgroup with active disease (DAS28 ≥ 3.2) at baseline, sex impacts on clinical outcome during follow-up were analyzed using generalized estimating equation (GEE) models. The factors related to achieving clinical remission were analyzed using Cox-proportional hazard regression.ResultsAt baseline, women (n = 4574) were younger and had more erosive disease and longer disease duration than men (n = 802) with higher scores in DAS28, HAQ, and PROs. The prevalence of interstitial lung disease, cardiovascular disease, and diabetes in men was higher than that of women. In a RA subgroup with active disease at baseline, GEE analyses demonstrated that women RA significantly influenced the rate of change of DAS28 over time. In that group, men are associated with achieving DAS28 sustained remission and point remission.ConclusionsWomen with RA in Korea report higher levels of disease activity and PROs compared to men, whereas most comorbidities were more prevalent in men. The longitudinal change in disease activity and the rate of achieving clinical remission were found to be worse in women with RA.     

Immediate rehabilitation of a rheumatoid arthritis patient with single-piece implants

Introduction and importanceThe aim of this article is to report the long-term outcome of full mouth rehabilitation with single piece, smooth surface implants following immediate loading protocol on a patient suffering with RA and severe unilateral condylar resorption.Case presentationHere, we present a challenging case of a patient suffering from Rheumatoid Arthritis who was stabilized and completed successfully with a 4 year follow-up period. Prosthetic management optimized the inter-occlusal relationship to maintain both function and esthetic integrity. Single piece implants are designed to engage and take support from the cortical bone low in metabolic activities thus promoting the force transmission through apical threads that are engaged in the cortical bone.DiscussionRheumatoid Arthritis [RA] is an auto-immune inflammatory condition in which the inflamed and hypertrophic synovial membrane grows into the articulation surfaces. The Temporomandibular Joints [TM] are frequently involved in rheumatoid arthritis. According to the literature on RA, due to frequent periodontitis, decreased salivary secretion, medication, as well as decrease in bone regenerative potential, RA is often considered as a relative contraindication in the use of implants. Atrophic jaws and cases with comorbidities like osteoporosis, diabetes, rheumatoid arthritis, periodontally infected cases are restored with high success by single piece smooth surface.ConclusionTo the best of our knowledge, this may be the first case of immediate functional loading by bi-cortical single piece implants.     

Higher mortality rates associated with rheumatoid arthritis in Saskatchewan,Canada, 2001–2019

ObjectivesTo estimate provincial all-cause mortality rates of Saskatchewan people with rheumatoid arthritis (RA) for comparison with the general population over time and between different geographic regions.MethodsSaskatchewan provincial administrative health databases (2001–2019) were utilized as data sources. Two RA case definitions were employed: (1) ≥ 3 physician billing diagnoses, at least 1 from a specialist (rheumatologist, general internist or orthopaedic surgeon) within 2 years; (2) ≥ 1 hospitalization diagnosis (ICD-9 code 714, and ICD-10-CA codes M05, M06). Data from these definitions were combined to create an administrative data RA cohort. All-cause mortality rates across geographic regions, between rural/urban residences and between sexes were examined.ResultsOver an 18-year span, between fiscal-year 2001–2002 and fiscal-year 2018–2019, age- and sex-adjusted mortality rates ranged from 17.10 to 21.04 (95% CI 14.77, 19.44; 18.03, 24.05)/1000 RA person-years, compared with mortality rates for the general Saskatchewan population without RA, which ranged from 9.37 to 10.88 (95% CI 9.23, 9.51; 10.72, 11.05)/1000 person-years. Fiscal-year mortality rate ratios ranged from 1.82 to 2.13 (95% CI 1.56, 2.13; 1.83, 2.46). Provincial mortality rates were higher in men than in women for both general and RA populations. Northern Saskatchewan mortality rates were significantly higher in the general population but did not achieve significance compared with other provincial regions for the RA population. Regression analysis identified age, male sex, RA and geographic region as factors contributing to increased mortality. A trend towards lower mortality rates over time was observed.ConclusionHigher mortality rates were observed in the RA population overall. Men had higher mortality rates, as did residents of Northern Saskatchewan compared with residents of other regions for the general population.     

HLA—DR4基因与类风湿关节炎的关联性研究

目的探讨人类白细胞抗原HLA-DR4基因与类风湿关节炎(RA)的关联性.方法采用特异性引物聚合酶链反应(PCR-SSP)方法对山东地区汉族人群132例类风湿关节炎患者及130例正常健康者的HLA-DR4基因进行分析,并测定其基因频率.结果 HLA-DR4基因在132例类风湿关节炎患者中的基因频率(46.2%)显著高于其在130例正常对照组中的基因频率(19.2%,x2=21.624,P＜0.01).结论 HLA-DR4基因与山东地区人群的类风湿关节炎易感性有关联.     

用差示PCR法筛选类风湿性关节炎滑膜细胞中的高表达基因

目的 筛选类风湿性关节炎（RA）滑膜细胞中的高表达基因,以探讨RA滑膜细胞发生肿瘤样增殖和侵蚀软骨的分子机理。方法 以骨性关节炎（osteoarthritis,OA)滑膜细胞作对照,采用差示PCR（differentially display PCR)方法,克隆RA滑膜细胞中高表达的cDNAs片段,经反向点杂交排除假阳性克隆后,将阳性克隆进行基因序列分析,结果共回收76仆差异条带,得到42个有插段的克隆,经反向点杂交后得到22个阳性克隆,对其中19个克隆进行基因序列分析表明,最长片段为501bp长,最短片段为145bp长,大部分在300bp,有13个克隆为已知基因,其中包括组织蛋白酶,其它6个克隆为未知序列,这些未知序列中除一个序列外酶,其它6个克隆为未知序列,这些未知序列中除一个序列外都为基因的非编码区,结论 差示PCR方法在筛选差异表达基因方面存在着很大的局限性,组织蛋白酶B可能与RA滑膜细胞的软骨侵蚀性有关。     

木犀草素通过TLR/MyD88/NF-κB 通路参与急性痛风性关节炎大鼠的抗炎作用

目的：探讨木犀草素通过Toll样受体(Toll-like receptors,TLR)/髓样分化因子(myeloid differentiation factor 88, MyD88)/核因子κB(nuclear factor kappa-B,NF-κB)通路减轻急性痛风性关节大鼠炎症的作用及其机制。方法： 将60 只雄性Wistar 大鼠随机分为5 组：正常对照组、尿酸钠(monosodium urate,MSU)组、秋水仙碱组、木犀草素低剂量 组(50 mg/kg)、木犀草素高剂量组(150 mg/kg)。于大鼠踝关节局部注射尿酸钠晶体混悬液制备急性痛风性关节炎模 型,观察各组大鼠不同时间点的关节肿胀指数,并测定各组大鼠血清及滑膜中白细胞介素1β (interleukin-1β,IL-1β)、 白细胞介素6(interleukin-6,IL-6)、肿瘤坏死因子-α(tumor necrosis factor-α,TNF-α)的水平,采用实时PCR检测滑膜 组织中TLR2,TLR4,MyD88 mRNA 水平,蛋白质印迹测定滑膜组织中TLR2,TLR4,MyD88,磷酸化核因子 κBp65(phosphorylated-nuclear factor κB,p-NF-κB p65)蛋白表达,HE染色观察踝关节及其周围软组织炎症细胞情况, 免疫组织化学法测定NF-κB表达。结果： 与MSU组相比,木犀草素高、低剂量组及秋水仙碱组的关节肿胀指数均明 显降低(P<0.05),IL-1β,IL-6,TNF-α 的水平也显著降低(P<0.01),TLR2,TLR4,MyD88 mRNA和蛋白水平及NF- κB的蛋白水平均显著降低(P<0.01)。免疫组织化学结果显示：与正常对照组比较,木犀草素和秋水仙碱组大鼠踝关 节的炎症细胞明显减少,滑膜增生减少,软骨表面光滑,无明显软骨和骨侵蚀。结论： 木犀草素可通过下调TLR/ MyD88/NF-κB通路减轻急性痛风性关节炎的炎症反应,有望成为治疗急性痛风性关节炎的有效药物。     

足底板对类风湿性关节炎患者足底压的影响

目的 :测定类风湿性关节炎病人足底压 ,评价足底板的生物力学效应。方法 :12名女性类风湿性关节炎病人和 8名健康女性进行年龄和体重匹配。用 F- Scan系统进行动态足底压测量 ,Kistler床反力平台用以校正测量精确性。测量足底峰压和垂直分力 ,评价足底板的生物力学表现。结果 :类风湿性关节炎病人中足底压明显高于健康人。使用足底板后 ,足底总的峰压明显降低 ,前足、后足峰压减低 ,中足峰压增高。而垂直分力改变不大。结论 :足底板能显著降低足底压力 ,使足底压力重分布 ,减轻类风湿足痛。特殊设计的足底板对类风湿足痛的治疗能起重要的作用