Intra-articular therapy with methotrexate or tumor necrosis factor inhibitors in rheumatoid arthritis: a systematic review.

BACKGROUND: Persistent monoarthritis in otherwise well-controlled rheumatoid arthritis presents a therapeutic challenge. Intra-articular (IA) steroids are a mainstay of treatment, though some have queried whether IA disease modifying anti-rheumatic drugs (DMARD) and biologics can be used in those who fail steroid injections. METHODS: A systematic literature review was conducted using four medical databases to identify randomized, controlled trials assessing IA therapies in RA patients. Included studies underwent Cochrane Risk of Bias 2 assessment for quality. RESULTS: Twelve studies were included, 6 of which examined intra-articular (IA) TNF inhibitors (TNFi), and 6 studies evaluating IA methotrexate. Of those evaluating IA TNFi, one study reported statistical improvement in TNFi therapy when compared with placebo. The remaining 5 studies compared IA TNFi therapy with steroid injections. IA TNFi had statistically improved symptom scores and clinical assessments comparable with IA steroid treatments. In the 6 studies evaluating IA methotrexate, the addition of methotrexate to steroid intra-articular therapy was not found to be beneficial, and singular methotrexate injection was not superior to the control arms (saline or triamcinolone). Risk-of-bias (ROB) assessment with the Revised Cochrane ROB tool indicated that 2 of 6 TNFi studies were at some risk or high risk for bias, compared with 5 out of 6 methotrexate studies. CONCLUSION: For persistent monoarthritis in rheumatoid arthritis, IA methotrexate was not found to have clinical utility. Intra-articular TNFi therapy appears to have equal efficacy to IA steroids, though the optimal dose and frequency of injections is yet unknown.

The Epidemiology of Antiphospholipid Syndrome: A Population-Based Study.

OBJECTIVE: To estimate the annual incidence and prevalence of and frequency of mortality associated with antiphospholipid syndrome (APS). METHODS: An inception cohort of patients with incident APS in 2000-2015 from a geographically well-defined population was identified based on comprehensive individual medical records review. All cases met the 2006 Sydney criteria for APS (primary definition) or had a diagnosis of APS confirmed by physician consensus (secondary definition). Levels of lupus anticoagulant, IgM and IgG anticardiolipin antibodies, and anti-ß2-glycoprotein I antibodies were tested in a centralized laboratory. Incidence rates were age- and sex-adjusted to the 2010 US white population. Prevalence estimates were obtained from the incidence rates, assuming that there was no increased mortality associated with APS and that migration in or out of the area was independent of disease status. RESULTS: Among this cohort in 2000-2015, 33 cases of incident APS, as defined by the Sydney criteria, were identified (mean age of patients 54.2 years; 55% female, 97% white). The annual incidence of APS in adults ages ≥18 years was 2.1 (95% confidence interval [95% CI] 1.4-2.8) per 100,000 population. Incidence rates were similar in both sexes. The estimated prevalence of APS was 50 (95% CI 42-58) per 100,000 population, and was similar in both sexes. Six patients (18%) had a concurrent diagnosis of systemic lupus erythematosus. The most frequent clinical manifestation was deep vein thrombosis. The overall frequency of mortality among patients with APS was not significantly different from that in the general population (standardized mortality ratio 1.61, 95% CI 0.74-3.05). CONCLUSION: APS occurred in ~2 persons per 100,000 population per year. The estimated prevalence was 50 per 100,000 population. Overall mortality was not notably different from that observed in the general population.

In vitro safety evaluation of a new ultrasound power toothbrush.

OBJECTIVE: To evaluate the safety of a novel ultrasound power toothbrush using a series of laboratory tests simulating extended brushing on the natural tooth surface, dental restorations, crowns, and orthodontic brackets. METHODS: To evaluate safety on the natural tooth and restored surfaces, human molars (n = 60) were prepared with restorations centered on the facial cementoenamel junction. The specimens received restorations of either 1) amalgam, 2) nanofilled composite resin, 3) glass ionomer, 4) cast gold-cemented with glass ionomer, or 5) pressed ceramic adhesively cemented with a composite resin cement. Orthodontic specimens (n = 33) were created by cementing brackets onto the buccal surfaces of extracted teeth. Crown specimens (n = 32) were created by cementing cast metal crowns onto identical pre-molar metal dies using zinc phosphate. All specimens were exposed to extended brushing in an environment controlled for time, brush head force, and dentifrice slurry. Treatment was assigned randomly to the specimens, and brushing was done with either the ultrasound toothbrush (Ultreo), or one of two positive controls: a manual toothbrush (Oral-B 35) and an oscillating-rotating power toothbrush (Oral-B Triumph). Negative control specimens remained unbrushed. Qualitative analysis via scanning electron microscopy was utilized to evaluate the tooth surface and restoration integrity. Shear and tensile testing was used to evaluate orthodontic bracket and crown retention, respectively. RESULTS: Exposure of the teeth and restored surface to the manual toothbrush resulted in some bristle furrows on cementum/dentin root surfaces, especially at the heights of contour and light grooves on the composite resin surfaces. The two power toothbrushes had no signs of root surface wear. None of the toothbrushes demonstrated breakdown of the restorative margins, any loss of cement, or any effect on the enamel. No significant treatment effect on the orthodontic bracket or crown retention force was found (ANOVA, p > 0.05). CONCLUSION: The new Ultrasound toothbrush was found to be safe on natural tooth surfaces and restorative materials, as established in comparison to positive and negative controls. Furthermore, no safety concerns related to orthodontic bracket or dental crown retention were identified with any treatment.