APLAR recommendations on the practice of telemedicine in rheumatology.

INTRODUCTION: The COVID-19 pandemic led to rapid and widespread adoption of telemedicine in rheumatology care. The Asia Pacific League of Associations for Rheumatology (APLAR) working group was tasked with developing evidence-based recommendations for rheumatology practice to guide maintenance of the highest possible standards of clinical care and to enable broad patient reach. MATERIALS AND METHODS: A systematic review of English-language articles related to telehealth in rheumatology was conducted on MEDLINE/PubMed, Web Of Science and Scopus. The strength of the evidence was graded using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach as well as the Oxford Levels of Evidence. The recommendations were developed using a modified Delphi technique to establish consensus. RESULTS: Three overarching principles and 13 recommendations were developed based on identified literature and consensus agreement. The overarching principles address telemedicine frameworks, decision-making, and modality. Recommendations 1-4 address patient suitability, triage, and when telemedicine should be offered to patients. Recommendations 5-10 cover the procedure, including the means, data safety, fail-safe mechanisms, and treat-to-target approach. Recommendations 11-13 focus on training and education related to telerheumatology. CONCLUSION: These recommendations provide guidance for the approach and use of telemedicine in rheumatology care to guide highest possible standards of clinical care and to enable equitable patient reach. However, since evidence in telemedicine care in rheumatology is limited and emerging, most recommendations will need further consideration when more data are available.

Effect of a 9-week exercise training regimen on expression of developmental genes related to growth-dependent fat expansion in juvenile rats.

This study examined the association between changes in mRNA expression of development-related genes including those of the homeobox (Hox) family and growth-dependent increases in inguinal, mesenteric, and epididymal white adipose tissue (WAT) at 4, 6, 10, and 14 weeks of age in rats. We also examined the effects of a 9-week exercise training regimen starting at 5 weeks of age on the mRNA levels of the genes of interest. HoxC8, HoxC9, Gpc4, Bmpr1a, Pparγ, Pgc1α, Adrb3, Hsl, leptin, and adiponectin in each type of WAT - except HoxA5, Gpc4, and Pgc1α in epididymal - showed a positive association between WAT weights and WAT mRNA levels; however, the slope of the regression lines exhibited fat depot-specific differences. HoxA5 showed no significant association, and Gpc4 and Pgc1α showed a negative association in epididymal WAT. After exercise training, the mean HoxA5, HoxC8, HoxC9, HoxC10, Gpc4, Pparγ, and Pgc1α mRNA levels in inguinal WAT were outliers on the regression line between mean mRNA level and WAT weight in control rats - that is, mean HoxA5 and Pgc1α mRNA level was higher, whereas HoxC8, HoxC9, HoxC10, Gpc4, and Ppar levels were lower in exercise-trained rats than in same-age controls. Pparγγ and adiponectin levels were upregulated in epididymal WAT, while HoxA5 was downregulated, but HoxC9, Gpc4, Pparγ, and adiponectin levels were upregulated in mesenteric WAT. These results suggest that some of the developmental genes tested may have fat depot-specific roles in the growth-dependent expansion of WAT, and that Hox genes that are activated in response to exercise training also vary among different WAT types.

Hormone-sensitive lipase is critical mediators of acute exercise-induced regulation of lipolysis in rat adipocytes.

The purpose of the present study was to investigate the effect of acute exercise on lipolysis via coordination of hormone-sensitive lipase (HSL) and scaffold proteins, i.e., perilipin A and comparative gene identification-58 (CGI-58), in rat primary adipocytes. Glycerol release was significantly elevated immediately (0h) and three hours (3h) after exercise. Both activity and localization to the pellet of HSL were significantly greater in the pellet fraction, which is included in lipid droplet associated-proteins, than in the supernatant fraction. In the pellet fraction, although neither perilipin A nor CGI-58 protein level changed, level of perilipin A/CGI-58 complex was significantly reduced, accompanied by up-regulated association of perilipin A/HSL at 0h and 3h after exercise. On the other hand, there were no changes in these molecules at 24h after exercise, despite a significant decrease in lipolysis that was observed in response to isoproterenol. These findings suggest that acute exercise enhances lipolysis up to at least 3h after exercise in a manner dependent on modification of HSL and its association with and alteration in scaffold protein.

Beta-adrenergic receptor trafficking by exercise in rat adipocytes: roles of G-protein-coupled receptor kinase-2, beta-arrestin-2, and the ubiquitin-proteasome pathway.

The effect of exercise on beta-adrenergic receptor (beta-AR) trafficking was investigated in rat adipocytes. The binding sites of a hydrophilic ligand, [(3)H]CGP12177, increased immediately (0 h) and at 3 h after exercise (3 h) but decreased at 24 h after exercise (24 h). The data of immunoblotting revealed that the alterations in the binding sites mainly paralleled the alterations in the beta2-AR proteins in membrane fractions. The protein expressions of both G-protein-coupled receptor kinase (GRK)-2 and beta-arrestin-2 were reduced, with a decline in beta2-AR ubiquitination at 0 h and 3 h. The protein expressions of beta2-AR, GRK-2, beta-arrestin-2, the beta2-AR/beta-arrestin-2 complex, and beta2-AR ubiquitination returned to their respective control levels at 24 h, whereas the beta2-AR mRNA level was reduced. Administration of either lactacystin or propranolol did not alter GRK-2 and beta2-AR protein expressions after exercise. Thus, the mechanism underlying the increased density of beta2-AR up to at least 3 h may involve alterations in a multistep event involving the coordinate interaction among proteins mediating beta2-AR trafficking, in which both the receptor-agonist interactions and ubiquitin-proteasome pathway have a key role. However, the decreased protein expression of beta2-AR at 24 h might be due to some change occurring at the translational levels.

Acute exercise alters Galphai2 protein expressions through the ubiquitin-proteasome proteolysis pathway in rat adipocytes.

The effects of acute exercise on the protein expressions of heterotrimeric G protein alpha subunits were examined in rat adipocytes. Galphai2 protein expression was significantly reduced 0 and 3h after exercise but increased 24h after exercise, without alterations in Galphai2 mRNA expressions. The protein expressions of other alpha subunits, Galphas, Galphai1, and Galphai3, were not influenced. Both the 26S proteasome activity and polyubiquitination of Galphai2 protein were significantly increased 0 and 3h after exercise. Whereas, proteasome activity was decreased, and the polyubiquitination of Galphai2 protein was returned to the control level 24h after exercise. The reductions in Galphai2 protein expressions 0 and 3h after exercise were completely prevented by the injection either of a proteasome inhibitor or of a beta-adrenergic receptor blocker prior to exercise. Thus, acute exercise altered the expression of Galphai2 protein via mechanisms which involve the coupling of beta-adrenergic receptors to an agonist with subsequent ubiquitin-proteasome-dependent proteolysis.