Polycystic ovary syndrome metabolic and hormonal dysfunction in relation to osteoarthritis onset and development: innocent bystander or major risk factor?

The close link between osteoarthritis (OA) and metabolic disorders on the one hand and hormonal disorders on the other suggests a possible association between OA and endocrine-metabolic disorders, such as PCOS. The aim of this review is to analyze the relationship between PCOS and OA, to consider the common pathogenetic mechanisms between the two conditions, and to summarize the data accumulated so far in the literature. For the purposes of our narrative review, a comprehensive search was conducted within credible databases. Our literature search found that epidemiological studies have shown a higher incidence of knee and hip OA in women with PCOS. This can be partly explained by obesity, which is a common intersection between the two conditions. Potential mechanisms among OA, PCOS, and obesity were considered. Another common point between OA and PCOS is that both conditions can be considered as highly heterogeneous syndromes with various etiologies, the result of a combination of systemic (genetic, hormonal, and metabolic) and local factors. To date, hyperandrogenism and greater cartilage thickness in young women with PCOS remain unclear in terms of determining the risk of developing OA. Prospective longitudinal studies are needed to assess the “fate” of the weight-bearing joints in women with PCOS, who are more likely to suffer from knee joint complaints.

Methods for assessment of microcirculation

To date, many methods have entered rheumatological practice in order to evaluate more accurately the microcirculation. Most of them are non-invasive or minimally invasive, easily accessible, providing different information depending on the specifics of the study. Over the years, some of them (such as chromametry and volumetry) have lost their routine application and have acquired rather historical significance, while others have become an integral part of the rheumatological armentarium. An example of this is video capillaroscopy, which, through its dynamic development over the last 20 years, has evolved in the knowledge of changes in microcirculation in systemic sclerosis, as well as in other systemic connective tissue diseases. The expansion of knowledge in this area has led to the updating of the classification criteria for systemic sclerosis, allowing the addition of capillaroscopic changes as recognized by the European League against Rheumatism (EULAR). Another important indication for performing video capillaroscopy is the differentiation of primary from secondary Raynaud's phenomenon. Laser Doppler perfusion imaging is also used to detect secondary Raynaud's phenomenon in order to distinguish whether reduced blood flow is due to systemic autoimmune disease. Thermography also has a helpful role in diagnosing Raynaud's phenomenon, but unlike the other two methods, it has a much more limited application due to the lack of discriminative ability to distinguish nutritional from thermoregulatory blood flow, which leads to erroneous conclusions in pathological conditions. Venous occlusive plethysmography is one of the "gold standards" in the assessment of vascular function in health and disease and is an accurate, reproducible and convenient method to assess the effect of new vasoactive drugs. However, its application in everyday rheumatological practice is quite limited.

RECOMMENDATIONS OF BULGARIAN SOCIETY OF RHEUMATOLOGY FOR VACCINATION OF PATIENTS WITH MUSCULOSKELETAL AND AUTOIMMUNE RHEUMATIC DISEASES

Not applicable.

Feasibility and surgical technique of percutaneous transforaminal discectomy for the treatment of lumbar disc herniation

Percutaneous transforaminal endoscopic discectomy (PTED) is an alternative minimally invasive technique for the treatment of lumbosacral radicular syndrome resulting from lumbar disc herniation. The latter is performed with the help of local anesthesia and sedation in an awake patient with the advantage of direct feedback. Access to the target is lateral and follows a safe trajectory through the Kambin triangle. The main advantages of this surgical technique are the possibility of early discharge within 2 hours after its completion, negligible blood loss, lower risk of infectious complications, convenience in patients with obesity, reduced risk of epidural fibrosis. There are currently no large randomized trials of good quality demonstrating the advantage of PTED over open interlaminar access established in practice. In the worst case, endoscopic discectomy is not known to pose additional risks to patients. The operative technique with a clinical case and a discussion about the applicability of the new approach for the treatment of lumbar disc herniations are presented.

OSTEOARTHRITIS AND IMMUNITY

Low-grade inflammation is part of the pathogenesis of osteoarthritis (OA) from its earliest stages and contributes to the acceleration of the degenerative process. Innate immunity has a leading role in it. Activation of the innate immune response is initiated by stimulation of the receptors on the cell membrane to recognize the secreted PAMPs (pathogen-associated molecular patterns). However, PAMPs can also be activated by endogenous damage-related molecular patterns (DAMPs). The group of DAMPs also includes toll-like receptors (TLRs).The disruption of matrix homeostasis in the course of OA is an example of activation of these receptors in chronic damage. The complement system is a key element of the innate immune system. It is one of the serum enzyme systems whose function is to opsonize antigens. The complement receptors on the surface of the cell membranes adhere to the targets for phagocytosis. The C3R fraction activates the complement cascade itself, as well as the oxygen metabolism of the cell, which is essential for the phagocytosis. The cartilage damage products released during joint damage are a separate class of potent complement modulators. Complement fractions bind to complement receptors on the surface of the chondrocyte and the synoviocyte cell membranes by TLR. The complement system is involved in many processes in the course of osteoarthritis: chondrocyte degeneration, ECM degradation, low-grade inflammation in the osteoarthritis, cell lysis, unbalanced bone remodeling, osteophyte formation, and neoangiogenesis. Whether drug control of complement activation may be a future therapeutic strategy in the treatment of OA and prevent its progression is a subject of future studies.

MRI brain findings in Rheumatoid Arthritis: a review of the literature

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disorder that mainly attacks the joints and leads to early disability. Despite aggressive anti-inflammatory therapy, the risk of systemic complications remains high. Moreover, the rate of premature cardiovascular disease mortality in patients with active RA, as well as the risk for development of non-fatal cardiovascular and cerebrovascular complications is also high. Central nervous system (CNS) involvement is one of the main components of extra-articular manifestations of RA. Brain changes might be caused by systemic inflammatory response or by the drugs used for treatment. Assessment of brain involvement and its relationship to the characteristics of the disease in patients with RA are particularly useful. Early detection of changes without cerebral symptoms and rapid response in acute events are of particular importance. With the increasing use of more imaging modalities magnetic resonance imaging (MRI) has become highly specific, safe and non-invasive diagnostic tool for early detection and monitoring of different pathological processes involving the brain in patients with RA. Understanding MRI imaging findings in brain involvement is important for selecting appropriate treatment and control of disease progression. The aim of this review is to summarize literature data of brain changes in RA and their relationship with systemic inflammation as well as to demonstrate the role of MRI in their assessment.

OSTEOARTHRITIS – А MODERN CONCEPT OF ETIOLOGY AND PATHOGENESIS

Osteoarthritis (ОА) is a disease of synovial joints, damaging all the structures of the articular apparatus with a chronic progressive course, resulting in an articular dysfunction. The modern concepts present OA as a “disease of the entire organism” – an active disease process, determined by a group of factors –systemic (genetic, neuro-humoral, hormonal) and local ( biomechanical. These factors are “general” for the development of OA, but of different extent of significance in the different articular locations. In the descriptive review are presented the modern concepts of the role and the interaction between the different factors, concerning the aetiology and pathogenesis of the disease. Also a lot of data, referring to the incidence and prevalence of OA all over the world and in our region are pointed out.

HPV infections of the uterine cervix in women with rheumatic diseases

The relation between systemic autoimmune diseases that affect women in their reproductive age and the neoplasms of the lower genital tract caused by high-risk HPV strains are studied in many investigations. The studies have been focused mainly on patients with systemic lupus erythematosus exposed to glucocorticoids and immunosuppressive therapy. A higher risk of HPV infection persistence and premalignant and malignant cervical lesions formation is found among them. There are similar, though scantier data about other systemic rheumatic diseases – rheumatoid arthritis, Sjögren‘s syndrome, and systemic sclerosis. Presumably, this fact is determined by specific features of autoimmune inflammation and the impact of immunosuppressive treatment. It contributes to human papilloviruses persistence and their integration into cervical cells. HPV vaccines use in these patients have proved to be safe and effective, and is an object of special interest.

Actual possibilities and perspectives of biological drugs in treatment of systemic vasculitides. III. Biological drugs in giant cell arteritis

A review of the literary data about the hitherto exiting investigations on biological drugs (BDs) as an alternative of the corticosteroids (CSs) – the current basal therapy of giant cell arteritis (GCA) is presented. The TNF-alpha-inhibitors are already definitely discarded on the account of their inefficiency and inadequate tolerability. The favorable initial results of BDs against IL-1, CTLA4-iGg1 and especially IL-12/23 should receive a reliable assessment after completion of the additional large-scale investigations. Indisputably only the data on efficacy of tocilizumab (anti-IL-6) for induction and maintenance of GCA remission and its marked CS-saving effect are convincing. Reasonably, TCM received a permission for use as adjunctive therapy in the management of GCA.

ПРОУЧВАНЕ НА ЗАВИСИМОСТТА МЕЖДУ НЕВРОЛОГИЧНИЯ ДЕФИЦИТ И АНАТОМИЧНАТА ЛОКАЛИЗАЦИЯ ПРИ ПАЦИЕНТИ С ВЕНОЗНИ МОЗЪЧНИ ТРОМБОЗИ - РЕТРОСПЕКТИВЕН АНАЛИЗ

Резюме Целта на настоящето проучване е да се проучи връзката между анатомичната локализация на тромбозата и тежестта на неврологичния дефицит при пациенти с венозни мозъчни тромбози (ВМТ). Използваният диагностичен метод е МРТ-венография. Проучването е ретроспективно и включва 49 пациента, преминали през Клиника „Нервни болести” на ВМА в периода 2005-2015 г. Пациентите бяха разделени по групи в зависимост от тежестта на неврологичния дефицит и от анатомичната локализация на тромбозата. Потърсихме зависимост между тези два показателя. От проведения анализ не се установи статистически значима зависимост. Ключови думи: анатомична локализация, ВМТ, клинична изява