Early detection of interstitial lung disease in rheumatic diseases: A joint statement from the Portuguese Pulmonology Society, the Portuguese Rheumatology Society, and the Portuguese Radiology and Nuclear Medicine Society

INTRODUCTION

Interstitial lung disease (ILD) contributes significantly to morbidity and mortality in connective tissue disease (CTD). Early detection and accurate diagnosis are essential for informing treatment decisions and prognosis in this setting. Clear guidance on CTD-ILD screening, however, is lacking.

OBJECTIVE

To establish recommendations for CTD-ILD screening based on the current evidence.

METHOD

Following an extensive literature research and evaluation of articles selected for their recency and relevance to the characterization, screening, and management of CTD-ILD, an expert panel formed by six pulmonologists from the Portuguese Society of Pulmonology, six rheumatologists from the Portuguese Society of Rheumatology, and six radiologists from the Portuguese Society of Radiology and Nuclear Medicine participated in a multidisciplinary discussion to produce a joint statement on screening recommendations for ILD in CTD.

RESULTS

The expert panel achieved consensus on when and how to screen for ILD in patients with systemic sclerosis, rheumatoid arthritis, mixed connective tissue disease, Sjögren syndrome, idiopathic inflammatory myopathies and systemic lupus erythematous.

CONCLUSIONS

Despite the lack of data on screening for CTD-ILD, an expert panel of pulmonologists, rheumatologists and radiologists agreed on a series of screening recommendations to support decision-making and enable early diagnosis of ILD to ultimately improve outcomes and prognosis in patients with CTD.

Cardiovascular safety of Janus kinase inhibitors in inflammatory bowel disease: a systematic review and network meta-analysis

BACKGROUND AND OBJECTIVE

Janus kinase (JAK) inhibitors (JAKinibs) are effective for inflammatory bowel disease (IBD), but their cardiovascular safety is inconclusive. We aim to assess the cardiovascular risks associated with JAKinibs in IBD patients.

PATIENTS AND METHODS

Systematic searches of seven databases and ClinicalTrials.gov from inception to February 2024 were conducted. Outcomes included major adverse cardiovascular events (MACE), venous thromboembolism events (VTE) and cardiovascular events (CVE), which were separately evaluated based on whether or not the dose was considered. P-score was applied to rank interventions.

RESULTS

A total of 26 trials involving 10,537 IBD patients were included, and results showed no significantly increased risk of MACE, VTE and CVE was associated with JAKinibs. However, when the dose was considered, Tofacitinib 5 mg BID (versus placebo) showed a trend towards an increased risk of MACE [odds ratio (OR)=1.05, 95% confidence interval (CI): 0.23-4.82], as well as Upadacitinib 30 mg QD (versus placebo) showed a trend towards increased risks of VTE (OR=1.36, 95% CI: 0.23-8.03) and CVE (OR=1.08, 95% CI: 0.24-4.85), and ranked higher than placebo for the risk of VTE [P-score=0.766 (versus 0.722)]. Notably, Deucravacitinib ranked lowest for all cardiovascular risks, and significantly decreased the risks of VTE (OR=0.03, 95% CI: 0.00-0.87) and CVE (OR=0.03, 95% CI: 0.00-0.87) compared with placebo.

CONCLUSIONS

Although a trend of increased cardiovascular risks was found considering dose, no significantly increased cardiovascular risk was associated with JAKinibs in IBD patients, and Deucravacitinib significantly decreased the risks of VTE and CVE.

Combining preoperative expectations and postoperative met expectations to predict patient-reported outcomes after knee surgery

Introduction

Both preoperative expectations and postoperative met expectations can independently influence patient-reported outcomes (PROs), however, their combined effect on PROs is not well understood. This study aimed to determine the prognostic significance of categorizing non-arthroplasty knee surgery patients into clusters based on both preoperative expectations and postoperative met expectations.

Methods

638 patients who underwent non-arthroplasty knee surgery from June 2015 to May 2021 at a single academic institution were analyzed. Patients were grouped based on both preoperative expectations and two-year postoperative met expectations scores using cluster analysis. Four distinct expectations cluster groups were formed: high preoperative-high met expectations (HIGH-HIGH), low preoperative-high met expectations (LOW-HIGH), high preoperative-low met expectations (HIGH-LOW), and low preoperative-low met expectations (LOW-LOW). Socioeconomic data and PROs were compared based on cluster group, and logistic regression was performed to determine the likelihood of achieving a patient-perceived "completely better" status based on cluster group.

Results

Patients with high met expectations, regardless of preoperative expectations, reported better two-year PROs compared to patients with low met expectations. Patients with high preoperative expectations achieved better outcomes only when those expectations were met postoperatively. Low preoperative expectations did not preclude patients from achieving good outcomes, as long as those expectations were met. The HIGH-HIGH group had increased odds of achieving completely better status compared to the LOW-HIGH group (OR = 1.68, p = .02), HIGH-LOW group (OR = 16.69, p < .001), and LOW-LOW group (OR = 5.17, p < .001). The HIGH-LOW group had decreased odds of achieving completely better status compared to the LOW-LOW group (OR = .31, p = .01).

Conclusion

Met expectations may be a stronger predictor of postoperative outcomes than preoperative expectations in non-arthroplasty knee surgery. This study highlights the importance of setting realistic preoperative expectations and focusing on achieving expectations postoperatively. These findings offer valuable insights for clinicians to manage patient expectations effectively based on individual characteristics and expected treatment outcomes.

The added value of coupling anti-dsDNA and anti-chromatin antibodies in follow-up monitoring of systemic lupus erythematosus patients

Objective

The autoimmune response to chromatin (Chr) or one of the nucleosome components (double stranded (ds)DNA and histones) is typically associated with the development of systemic lupus erythematosus (SLE). Related autoantibodies (Ab) are heterogeneous and, among them, anti-dsDNA Ab are part of the classification criteria and recommended for monitoring SLE with regards to lupus flares and therapy responses. However, anti-dsDNA Ab biomarker performances are weak; therefore, coupling anti-dsDNA with anti-Chr Ab can be proposed, which is the aim of this study.

Methods

In this single center study from 2009 to 2024, 269 SLE patients with follow-up information were retrospectively selected from a population of 646 individuals, including 325 SLE patients, who tested positive for anti-dsDNA and/or anti-Chr Ab (Bioplex 2200™). Bio-clinical information during follow-up were assessed at several time points through medical records in order to explore associations between the anti-dsDNA/Chr Ab profile with disease presentation, and anti-dsDNA/Chr Ab fluctuations with disease activity using clinical SLEDAI-2K, flares requiring specific treatment, and the therapeutic response.

Results

At inclusion in the follow-up analysis, corresponding to diagnosis (116/269, 43.1 %) or flare (153/269, 56.9 %), SLE patients were subdivided into three serological groups: the double positive dsDNA/Chr group (DP+, 190/269: 70.6 %), followed by the single positive Chr group (SP-C+, 42/269: 15.6 %), and the single positive dsDNA group (SP-D+, 37/269: 13.8 %). The DP + group, which presented important anti-dsDNA/Ab variations during follow-up, was at risk to develop lupus nephritis (56.8 % versus 2.4 % in SP-C+ and 29.7 % in SP-D+ groups, p < 0.04) and serositis (30 % versus 9.5 % in SP-C+ group, p = 0.006). During follow-up, anti-dsDNA and Chr Ab levels in the SP-C+ and SP-D+ groups remained stable over time irrespective of disease activity, flares, and therapeutic response. Regarding the DP + group, disease activity was correlated with both anti-dsDNA (RmCorr = 0.46, p = 1.6x110-91) and anti-Chr (RmCorr = 0.38, p = 2.8x10-60) Ab levels, which can be used to predict flares. Following therapy introduction, Ab reduction occurred in all patients from the DP + group with a more pronounced effect reported in complete responders.

Conclusion

coupling anti-dsDNA with anti-Chr Ab detection at disease initiation/flare allows definition of endotypes, which is useful to follow disease activity, predict lupus nephritis/serositis, and anticipate therapeutic response in the DP + group.

Large soluble CD18 complexes with exclusive ICAM-1-binding properties are shed during immune cell migration in inflammation

The family of heterodimeric CD11/CD18 integrins facilitate leukocyte adhesion and migration in a wide range of normal physiologic responses, as well as in the pathology of inflammatory diseases. Soluble CD18 (sCD18) is found mainly in complexes with hydrodynamic radii of 5 and 7.2 nm, suggesting a compositional difference. Earlier work reported that the complexes include at least part of the CD11a or CD11b chains containing the intercellular adhesion molecule (ICAM)-1 binding domain, and that sCD18 is capable of quantitatively competing with the cell membrane-bound form for ICAM-1 binding. However, it is not clear if the size differences between the sCD18 complexes reflect any functional variance regarding shedding from the cell membrane or binding to ICAM-1. Here, we show evidence that sCD18 found in serum regulates release of the proinflammatory cytokine monocyte chemoattractant protein-1 (MCP-1/CCL2) from fibroblast-like synovial cells. Further, only large sCD18 complexes are capable of binding to ICAM-1. Migrating neutrophils shed large, but not small, sCD18 complexes. Together, these observations explain results measured from patients with rheumatoid arthritis (RA), where large sCD18 complexes dominated in local inflammatory processes involving neutrophil influx into zones of inflammation. Our data points to a previously unappreciated aspect of sCD18 integrin biology as regulators of inflammation in the context of migrating leukocyte. Surprisingly, this regulation is tied to sCD18 complex size, opening new opportunities for therapeutic intervention in serious inflammatory diseases such as arthritis.

Differences in myocardial involvement between new onset and longstanding systemic lupus erythematosus patients assessed by cardiovascular magnetic resonance

Objectives

Subclinical myocardial involvement is common in systemic lupus erythematosus (SLE), but differences between new onset and longstanding SLE are not fully elucidated. This study compared myocardial involvement in new onset versus longstanding SLE using cardiovascular magnetic resonance (CMR).

Materials and methods

We prospectively enrolled 24 drug-naïve new onset SLE patients, 27 longstanding SLE patients, and 20 healthy controls. All participants underwent clinical evaluation and CMR examination. We analyzed left ventricular (LV) morphological, functional parameters, and tissue characterization parameters: native T1, T2, extracellular volume fraction (ECV), and late gadolinium enhancement (LGE).

Results

Both new onset and longstanding SLE groups showed elevated native T1, T2, and ECV values compared to the control group (all P < 0.05). Additionally, the new onset SLE group exhibited higher T2 values compared to the longstanding SLE group [55.3 vs. 52.8 ms, P < 0.05]. The new onset group also demonstrated higher left ventricular (LV) end-diastolic volume index (LVEDVi), LV end-systolic volume index (LVSVi), and LV mass index (LVMi) than controls (all P < 0.05), with LVEDVi significantly higher than in the longstanding group (P < 0.05).

Conclusion

CMR tissue characterization imaging can detect early myocardial involvement in patients with new onset and longstanding SLE. Patients with new onset SLE exhibit more pronounced myocardial edema than those with longstanding SLE. This suggests that SLE patients are at risk of myocardial damage at various stages of the disease, underscoring the need for early monitoring and long-term management to prevent the progression of myocardial remodeling.

Diagnosis and latest treatment strategies of ANCA‑associated glomerulonephritis (Review)

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a spectrum of conditions characterized by inflammation of the small- and medium-sized vasculature. Glomerulonephritis associated with AAV (AAV-GN) exerts a profound effect on patient survival and long-term prognosis, with renal impairment resulting in end-stage renal disease in ~20% of cases within a 5-year period. Therefore, the early detection of renal involvement is of pivotal significance. The present review aimed to summarize the diagnostic utility of serological and urinary assays, coupled with renal biopsy, in the context of AAV-GN, thus promoting the early diagnosis of the disease. Furthermore, standardized protocols for glucocorticoid and immunosuppressive therapy have been established in the last decade, with the development of subsequent targeted treatment regimens. The current review also summarized the current research developments associated with AAV-GN, thus providing more references for clinical practice and benefiting a greater number of patients.

Framework for implementing treat-to-target in systemic lupus erythematosus routine clinical care: consensus statements from an international task force

Implementation of Treat-to-Target (T2T) in routine clinical practice remains low in systemic lupus erythematosus (SLE). Real-world data reveal excessive use of glucocorticoids (GCs) and frequently inadequate disease control. Here, an international task force convened to develop a consensus framework for implementing T2T in routine clinical care of adult patients with SLE. This T2T task force comprised an international panel of 22 physicians involved in the care of SLE and 3 lupus patient research partners. Following a scoping review and online discussions, during which definitions and instruments available for T2T in SLE were examined, the panel developed potential framework statements for implementing T2T in SLE, which were extensively discussed before being agreed upon by Delphi consensus. Additionally, the current challenges of implementing T2T in SLE and how future research may address these issues were analyzed. The framework comprises 5 overarching principles and 11 statements. Despite the absence of formal evidence that T2T offers superiority to conventional SLE management, T2T in SLE has been recommended for over a decade. This task force offers a framework for effectively implementing T2T in SLE from a real-life perspective, informing a wide range of physicians, including those outside the limited circle of lupus specialists.

The operational definition of old age and impact on outcomes in DMARD-treated patients with rheumatoid arthritis: A systematic literature review

OBJECTIVE

To systematically review operational definitions of old(er) age in rheumatoid arthritis (RA) patients and investigate differences in disease-modifying anti-rheumatic drug (DMARD) efficacy, safety and drug survival between young(er) and old(er) patients.

METHODS

A systematic review was performed on studies conducting research in an old(er) RA patient population. Two reviewers independently performed data extraction and risk of bias assessment. Operational definitions of old(er) age were described using frequency statistics. For studies comparing effects of DMARDs, random effects meta-analyses estimated pooled odds ratios (ORs) of young(er) vs. old(er) patients reaching remission, experiencing adverse events (AEs) and discontinuing drug treatment due to unfavourable events.

RESULTS

This review included 324 studies. The operational definition for old(er) age ranged from 40.0 to 77.3 years. The most frequent definition was 65 (45.1 %), followed by 60 years or older (20.4 %). Fifty-eight percent of studies reported no reason for using a specific age-threshold. Seventy-nine studies evaluated DMARD efficacy, safety and/or survival, with 37 eligible for meta-analysis. No statistically significant difference in reaching remission was observed between old(er) and young(er) patients (OR=0.76 (95 %-CI: 0.57-1.02)) (n = 11 studies). AEs and drug discontinuation were experienced more often in old(er) patients (OR=1.33 (95 %-CI: 1.01-1.74) (n = 19 studies) and OR=1.12 (95 %-CI: 1.02-1.23) (n = 25 studies), respectively).

CONCLUSION

Definitions of old(er) age vary across studies including RA patients. Old(er) age appears to affect DMARD safety and discontinuation. To ensure meaningful comparisons across studies, studies should justify the chosen definition and report and account for potential impacts of indicators of ageing, such as multimorbidity, polypharmacy, and geriatric syndromes.

AI-MET: A deep learning-based clinical decision support system for distinguishing multisystem inflammatory syndrome in children from endemic typhus

The COVID-19 pandemic brought several diagnostic challenges, including the post-infectious sequelae multisystem inflammatory syndrome in children (MIS-C). Some of the clinical features of this syndrome can be found in other pathologies such as Kawasaki disease, toxic shock syndrome, and endemic typhus. Endemic typhus, or murine typhus, is an acute infection treated much differently than MIS-C, so early detection is crucial to a favorable prognosis for patients with these disorders. Clinical Decision Support Systems (CDSS) are computer systems designed to support the decision-making of medical teams about their patients and intended to improve uprising clinical challenges in healthcare. In this article, we present a CDSS to distinguish between MIS-C and typhus, which includes a scoring system that allows the timely distinction of both pathologies using only clinical and laboratory features typically available within the first six hours of presentation to the Emergency Department. The proposed approach was trained and tested on datasets of 87 typhus patients and 133 MIS-C patients. A comparison was made against five well-known statistical and machine-learning models. A second dataset with 111 MIS-C patients was used to verify the effectiveness and robustness of the AI-MET system. The performance assessment for AI-MET and the five statistical and machine learning models was performed by computing sensitivity, specificity, accuracy, and precision. The AI-MET system scores 100 percent in the five metrics used on the training and testing dataset and 99 percent on the validation dataset. Statistical analysis tests were also performed to evaluate the robustness and ensure a thorough and balanced evaluation, in addition to demonstrating the statistical significance of MET-30 performance compared to the baseline models.

Prioritising domains of glucocorticoid therapy to measure in trials: Results from a modified delphi exercise from the OMERACT glucocorticoid impact working group

INTRODUCTION

There is no consensus amongst patients and healthcare professionals about how to measure important adverse effects of glucocorticoids (GCs) that includes the patient's perspective. The OMERACT GC Impact working group sought to identify the domains of greatest importance to both patients and healthcare professionals for use in a proposed core outcome set.

METHODS

Patients and healthcare professionals participated in a Delphi consensus exercise to rate the importance of previously identified candidate domains. Those deemed critical to include by at least 70% in both groups, after three rounds of a Delphi exercise were identified as meeting consensus. All participants were asked which additional domains should be measured in all trials in a final survey; those domains selected by more than 70% of all participants were added, resulting in a final list of potential core domains.

RESULTS

In total, 363 people (295 patients and 68 healthcare professionals) participated in the Delphi process. The final list of potential core domains included: bone fragility, diabetes, eye problems and/or changes in vision, high blood pressure, infection, osteonecrosis, mood disturbance, fatigue, sleep disturbance, weight.

CONCLUSION

The 10 domains identified through this exercise informed the proposed core domain set of GC effects to be considered for use in future clinical trials involving GCs. This core domain set was endorsed at the OMERACT 2020 virtual workshop.

Comparative analysis of disease outcomes: Early vs. late transition from psoriasis to psoriatic arthritis

OBJECTIVES

Psoriasis typically precedes psoriatic arthritis (PsA). We explored whether the interval between the two diagnoses is associated with PsA phenotype and outcomes.

METHODS

We constructed an inception (PsA duration ≤2 years) cohort of patients who developed PsA after psoriasis from a prospective observational cohort. All patients were diagnosed with PsA prior to or at their presentation to the clinic (baseline). We divided the cohort into early and late transition groups based on the median transition period between the diagnoses of psoriasis and PsA of nine years. Features associated with early and late transition at baseline were studied using logistic regression. The impact of early versus late transition on disease activity was assessed using multivariate linear regression, with the 5-year adjusted mean swollen joint count (SJC) as the outcome. The influence on damage was evaluated using Cox regression, with time to radiographic progression as the outcome.

RESULTS

We included 702 patients. Late transition patients were observed to have a younger age at diagnosis of psoriasis and older age at diagnosis of PsA. At baseline, they had higher BMI and PASI and less frequent use of conventional synthetic DMARDs. There was a trend for lower disease activity over time in the late transition group. Radiographic progression was not significantly different.

CONCLUSION

There were no significant differences in the PsA features at baseline between the two groups. However, on follow-up, there was a trend for lower cumulative disease activity but not in the rate of radiographic progression in the late transition group.

More X's, more problems: how contributions from the X chromosomes enhance female predisposition for autoimmunity

Many autoimmune diseases exhibit a strong female bias. While sex hormones may influence sex bias in disease, recent studies suggest that the X chromosome itself directly contributes to female-biased susceptibility to autoimmunity. Females with two X chromosomes utilize X Chromosome Inactivation (XCI) to silence gene expression from one X chromosome, equalizing expression between the sexes. The X chromosome is highly enriched with immune-related genes, and recent work indicates that the fidelity of XCI maintenance in lymphocytes from female systemic lupus erythematosus patients is compromised, suggesting that aberrant X-linked gene expression contributes to autoimmune phenotypes. XCI is initiated and maintained by the long noncoding RNA XIST/Xist through its interactions with the inactive X chromosome and numerous interacting proteins, and recent studies also implicate XIST/Xist RNA in driving endosomal Toll-like receptor signaling and XIST/Xist RNA-protein complexes in serving as a source of autoantigens to respectively drive autoimmunity. Here, we will review these three distinct pathways that underscore the significance of X-linked genetics for understanding the origins of the female bias in autoimmune disease.

Comparative safety of JAK inhibitors versus TNF or IL-17 inhibitors for cardiovascular disease and cancer in psoriatic arthritis and axial spondyloarthritis

OBJECTIVES

To compare the risk of cardiovascular disease (CVD) and common solid cancers between JAK inhibitors (JAKi) versus TNF or IL-17 inhibitors, among people with psoriatic arthritis (PsA) or axial spondyloarthritis (axSpA).

METHODS

We used real-world electronic health records data from a predominantly North American population of PsA or axSpA. Initiators of JAKi (tofacitinib or upadacitinib) and TNFi were 1:1 propensity score matched. Cox models were used to compare time to CVD (acute myocardial infarction, stroke or revascularization) or common solid cancers (breast, colorectal, lung or prostate) over 3 years. Analyses were repeated for JAKi versus IL-17i. We performed sensitivity analyses with follow-up over 1 or 5 years, in those aged ≥65 years, or those initiating treatment before 2021.

RESULTS

The JAKi vs TNFi comparison included 2,200 matched individuals in each group over 3,092 and 4,618 person-years, respectively. Compared to TNFi, JAKi was not associated with higher risk of CVD (HR 0.977; 95% 0.632, 1.510) or cancer (HR 0.710; 0.462, 1.091) over 3 years' follow-up. JAKi vs IL-17i comparison included 2,287 individuals over 3,190 and 4,312 person-years, respectively. Compared to IL-17i, JAKi was not associated with risk of CVD (HR 1.114; 0.720,1.722) or cancer (HR 0.737; 0.484,1.122). Results across stratified analyses were directionally concordant.

CONCLUSIONS

These results are reassuring that among a large population of people with PsA or axSpA, JAKi was not associated with increased risk of CVD or common solid cancers, compared to TNFi or IL-17i initiators. Ongoing monitoring of cardiovascular and cancer risks is needed.

Development of a Mouse Model of Enthesis-Specific NF-κB Activation

Enthesitis, or inflammation specific to sites in the body where tendon inserts into bone, can arise in isolated joints from overuse or in multiple joints as a complication of an autoimmune condition such as psoriatic arthritis or spondyloarthritis. However, the pathogenesis of enthesitis is not well understood, so treatment strategies are limited. A clinically relevant animal model of enthesitis would allow investigators to determine mechanisms driving the disease and evaluate novel therapies. Therefore, we developed a murine model of inducible enthesis-specific inflammation by constitutively activating the NF-κB pathway in Gli1+ cells. Gli1CreERT mice were crossed with IKKβ-overexpression mice and given tamoxifen injections 5 days postnatally to induce enthesitis. Sixteen weeks of IKKβ overexpression in enthesis cells led to impaired mechanical properties, subtle histologic changes, and changes to expression of extracellular matrix- and inflammation-related genes. Increased loading from treadmill overuse activity did not exacerbate this phenotype. Clinical significance: The new murine model may have utility for studying the pathogenesis of enthesitis and approaches to treat the condition.

The Cardiovascular Safety of Tumour Necrosis Factor Inhibitors in Arthritic Conditions: A Structured Review with Recommendations

There is accumulating evidence that inflammation is a key driver of atherosclerosis development and thrombotic complications. This pathophysiological mechanism explains, at least in part, the increased cardiovascular risk of patients with immune-mediated arthritis. Experimental and clinical studies have shown that tumour necrosis factor (TNF) plays a pathological role in both vascular and joint diseases, suggesting that TNF inhibitors (TNFis) may limit cardiovascular events in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) or spondyloarthritis (SpA). This review summarizes studies exploring the effects of TNFis on cardiovascular outcomes in patients with RA, PsA or SpA. Clinical studies suggest that TNFis reduce vascular inflammation and may improve (or prevent worsening of) endothelial dysfunction and arterial stiffness. There is evidence that TNFis reduce the incidence of cardiovascular events in patients with inflammatory arthritis compared with non-biological treatments, particularly in patients with rheumatoid arthritis. Fewer studies have compared the effects of different classes of biological therapy on outcomes, but found no significant difference in the risk of cardiovascular events between patients taking TNFis and other biological therapy. In contrast, patients at high cardiovascular risk may derive greater benefit from a TNFi than from a Janus kinase inhibitor (JAKi). The cardiovascular impact of JAKis is still under debate, with a recent safety warning. Targeted control of inflammation is a key strategy to reduce the risk of major adverse cardiovascular events in patients with inflammatory arthritis. Cardiovascular evaluation and risk stratification, using a multidisciplinary approach involving rheumatology and cardiology teams, are recommended to guide optimal immunomodulatory treatment.

Cardiovascular, cancer, and infection risks of Janus kinase inhibitors in rheumatoid arthritis and ulcerative colitis: A nationwide cohort study

BACKGROUND

Evolving evidence suggests that patients undergoing treatment with Janus kinase inhibitors (JAKi) may face an increased risk of cardiovascular events, malignancies, and serious infections.

OBJECTIVES

We assessed cardiovascular, malignancy, and serious infection risks associated with JAKi use compared to tumor necrosis factor inhibitor (TNFi) use, which served as the active comparator, in patients with rheumatoid arthritis (RA) or ulcerative colitis (UC).

METHODS

This study emulated a target trial using South Korea's nationwide claims database (2013-2023). We constructed two separate cohorts comprising new users of JAKi or TNFi with either RA or UC and performed overlap weighting to control for confounders. Outcomes included three-point-major adverse cardiovascular events (3P-MACE) (cardiovascular death, myocardial infarction, and stroke), malignancy, and serious infection. Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

The RA cohort included 14,972 patients, with 4759 initiating JAKi. The UC cohort included 2085 patients, with 347 initiating JAKi. In the overall RA cohort, the weighted HR was 0.92 (95% CI 0.59-1.42) for 3P-MACE, 1.61 (1.08-2.41) for malignancy, and 1.08 (0.94-1.23) for serious infection. In the overall UC cohort, the weighted HR was 0.98 (0.11-8.42) and 0.45 (0.26-0.78) for malignancy and serious infection, respectively. No 3P-MACE cases were observed in JAKi users.

CONCLUSIONS

JAKis were associated with an elevated risk of malignancy but no significant difference in the risk of 3P-MACE and serious infection among all patients with RA. Further data are needed regarding the risk of malignancy and 3P-MACE in patients with UC.

Hydroxychloroquine: A double‑edged sword (Review)

Hydroxychloroquine (HCQ) is an antimalarial drug that has historically been used to treat and prevent malaria. However, its mechanism of action has not yet been fully elucidated. HCQ affects various cellular and molecular pathways through different mechanisms. HCQ has also been shown to be a disease‑improving agent for the treatment of rheumatic diseases, including systemic lupus erythematosus, antiphospholipid syndrome, rheumatoid arthritis and primary Sjögren's syndrome. Although generally considered safe, adverse reactions have been reported with the use of HCQ and clinicians should carefully monitor patients with rheumatism when prescribing these drugs. The purpose of the present review is to strengthen the clinical use of HCQ for autoimmune diseases while highlighting the adverse effects that may occur during treatment.

Real-World-Evidence of Digital Health Applications (DiGAs) in Rheumatology: Insights from the DiGAReal Registry

INTRODUCTION

Prescribable digital health applications (DiGAs) present scalable solutions to improve patient self-management in rheumatology, however real-world evidence is scarce. Therefore, we aimed to assess the effectiveness, usage, and usability of DiGAs prescribed by rheumatologists, as well as patient satisfaction.

METHODS

The DiGAReal registry includes adult patients with rheumatic conditions who received a DiGA prescription. Data at baseline (T0) and the 3-month follow-up (T1) were collected through electronic questionnaires. Study outcomes included DiGA-specific outcome assessments as well as generic outcome assessments, including the Patient Global Impression of Change (PGIC), Patient Activation Measure (PAM®), and the German Telehealth Usability and Utility Short Questionnaire (TUUSQ). Changes between T0 and T1 were analyzed using descriptive statistics and paired tests.

RESULTS

A total of 191 patients were included between June 2022 and April 2023. Of these, 127 completed the 3-month follow-up, and 114 reported using the prescribed DiGA, with 66% reporting weekly use and 15% completing the full DiGA program. The most commonly prescribed DiGAs targeted pain management (53%). Symptom improvement was reported by 51% of patients using a DiGA, with significant reductions in exhaustion levels (p = 0.03). Significant DiGA-specific improvements were observed for DiGAs addressing back pain (p = 0.05) and insomnia (p = 0.006). However, no overall significant changes were detected in patient activation, health literacy, pain, overall health, or disease activity. Back pain and weight management DiGAs were the most effective, frequently used, and best-rated DiGAs, with symptom improvements reported by 50% to 82% of patients.

CONCLUSION

The findings suggest that DiGAs can improve symptom management in rheumatic patients, especially for conditions like back pain and weight control. Further real-world evidence is needed and may support value-based digital health efforts and reimbursement frameworks.

Acute pain trajectories in elderly patients with fragility hip fractures

BACKGROUND

Pain management for hospitalized elderly patients with fragility hip fractures (FHF) remains challenging. This study aims to distinguish acute pain trajectories in FHF patients that can inform personalized analgesia management.

METHODS

We conducted a prospective observational study of patients aged 65 and older with FHF at a Level I trauma center. The primary outcome was daily average pain assessed for five days post-injury using the Brief Pain Inventory (BPI). We used group-based trajectory modeling (GBTM) to distinguish acute pain trajectories. Then, factors and secondary outcomes (opioid use and hospital length of stay [LOS]) associated with more severe pain trajectories were identified.

RESULTS

We enrolled 100 consecutive patients with FHF between June 2022 and June 2023. We identified three distinct acute pain trajectories: minimal pain, subsiding pain, and persistent pain. Factors associated with more severe pain trajectories included higher initial pain on admission (OR 1.17, 95 % CI 1.02-1.36, P = 0.047), higher BMI (OR 1.15, 95 % CI 1.02-1.29, P = 0.021), and intertrochanteric fracture type (OR = 6.46, 95 % CI 1.49-27.98, P = 0.013). The persistent pain trajectory was significantly associated with 40 % more opioid use (P = 0.01) and a longer LOS (LOS ratio = 1.45, 95 % CI 1.21-1.74, P < 0.001).

CONCLUSION

Acute pain in FHF patients can be classified into distinct trajectories, providing a basis for personalized pain management. More severe pain trajectories are associated with higher opioid use and longer length of hospital stay.

Neuropsychiatric manifestations in systemic lupus erythematosus and Sjogren's disease

INTRODUCTION

Autoimmune diseases often present in a systemic manner, affecting various organs and tissues. Involvement of the central and peripheral nervous system is not uncommon in these conditions and is associated with high morbidity and mortality. Therefore, early recognition of the neuropsychiatric manifestations associated with rheumatologic diseases is essential for the introduction of appropriate therapies with the objective of providing a better quality of life for individuals.

OBJECTIVE

To provide a literature review of the neuropsychiatric manifestations related to Systemic Lupus Erythematosus (SLE) and primary Sjögren's Disease (pSD), through the description of signs, symptoms, and immunological variables associated with these conditions.

METHODS

A literature review was conducted by searching for national and international articles available in the SciELO and PubMed databases related to the description of neurological and psychiatric manifestations in patients with the rheumatologic diseases of interest in this study.

RESULTS

The main NP manifestations presented in SLE and pSD are discussed, focusing on clinical presentation and etiology. Treatment option are, however, mainly based on expert opinion, since a few randomized controlled trials have been done.

CONCLUSIONS

There is a high prevalence of neuropsychiatric manifestations associated with SLE and pSD. The variety of physiopathology pathways may explain the variety of symptoms, however pathological findings are rare. Multicenter studies on attribution protocols and treatment are necessary to address the current gaps.

Disease-modifying strategies: Targeting protein kinases in multiple sclerosis and other autoimmune disorders

A wide variety of immunomodulatory therapies are already available for the treatment of multiple sclerosis (MS). Through fundamental insights from basic research with a gain of knowledge in the pathological processes underlying MS, the exploration of additional medical compounds within clinical trials has been ignited. Emerging novel medications with innovative mechanisms of action are being introduced. Those mechanisms of action include a broad therapeutic spectrum of substances targeting various protein kinases, some of which could also be used for the treatment of other autoimmune-mediated diseases. The advancement of new compounds could therefore enable a more personalized approach in treating MS, taking into consideration patients' co-existing autoimmune-mediated diseases. In this review, we discuss potential compounds targeting protein kinases, currently under investigation in clinical trials for various autoimmune diseases that could become viable treatment options for MS and comorbid autoimmune conditions in the future.

Diagnostic approach in giant cell arteritis

Giant cell arteritis (GCA), also known as temporal arteritis, is the most common form of vasculitis in the elderly. While initially described as involving the temporal arteries, GCA can also affect the aorta and its major branches. Despite the increased use of imaging modalities and the availability of temporal artery biopsy, diagnosing GCA remains challenging. GCA should be considered a spectrum, with diagnostic methodologies tailored to the prevalent symptoms. The sensitivity and specificity of different diagnostic approaches can vary depending on the clinical setting. Timing in diagnosing GCA is crucial to prevent serious complications, such as blindness and cerebrovascular ischemic events. While the prompt initiation of glucocorticoids (GCs) has reduced the incidence of major ischemic events, an uncertain diagnosis may expose the patient to unnecessary harm, such as complications from overtreatment or organ damage due to inadequate control of vasculitis. This narrative review will summarize the most widely available diagnostic techniques for GCA and outline our approach for cases where the diagnosis may be uncertain.

Immunomodulation for accelerated atherosclerosis in rheumatoid arthritis and systemic lupus erythematosus

In the last decades, consisting evidence supported a close relationship between both innate and adaptive immune systems and the accelerated cardiovascular (CV) disease characterizing autoimmune diseases, such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). Indeed, several cell lines involved in the pathogenesis of these autoimmune diseases, such as macrophages and dendritic cells, as well as different T and B lymphocyte subsets, and inflammatory cytokines, have been demonstrated to be directly involved in the mechanisms underlying early atherosclerotic arterial wall damage. Traditional CV risk factors play a concomitant role but do not sufficiently account for the increased prevalence of CV disease in these patients. Indeed, the pathophysiological link between RA and SLE and atherosclerosis is based on complex inflammatory pathways that interconnect these conditions and may explain the significant morbidity and mortality rates demonstrated in these patients, with consequent significant negative effects on quality of life and long-term survival. Consequently, it is intriguing to hypothesize that immunosuppressive drugs commonly used in the treatment of these pathologies may also exert an immunomodulatory and anti-inflammatory effect in mitigating the atherosclerotic damage that has been demonstrated to occur early in the initial stages of the disease. Recognizing risk factors, predicting occurrences and early intervention to prevent CV disease development have emerged as critical objectives in RA and SLE treatment. In this review, we aimed to provide an updated overview of the atherogenic effects exerted by the immune and inflammatory pathways involved in the pathogenesis of RA and SLE. Moreover, we examined the available evidence which may support the potential effects of immunosuppressive therapies in reducing CV damage and, consequently, CV disease risk in these patients.

Endometriosis and autoimmunity

Endometriosis is a female-specific chronic condition that affects 1 in 10 women and other individuals with a uterus worldwide with common symptoms that include pelvic pain and infertility. Reliable and effective non-invasive biomarkers for endometriosis do not exist, and therefore currently a diagnosis of endometriosis requires direct visualization of lesions at surgery. Similarly, few safe and effective management strategies exist for endometriosis, with hormonal interventions and surgery only providing temporary symptom control. The development of endometriosis involves the implantation and proliferation of ectopic endometrial cells which triggers local and systemic inflammation and fibrosis. While multiple genetic, environmental, and lifestyle factors appear to influence the natural history of endometriosis, chronic inflammation is a hallmark feature associated with development and progression of the disease. Data further shows that endometriosis commonly co-occurs with autoimmune diseases, adding evidence that immune dysfunction likely contributes to the pathogenesis of this disorder. Specific innate and adaptive immune system drivers of endometriosis remain to be identified and additional research is needed to elucidate the mechanistic underpinnings of this debilitating disease. In this narrative review, we discuss the shared biological mechanisms and plausible immune-related connections between endometriosis and autoimmunity.

Digital Interventions for Patients With Juvenile Idiopathic Arthritis: Systematic Review and Meta-Analysis

Background

Juvenile idiopathic arthritis (JIA) is a chronic rheumatic condition requiring long-term, multidisciplinary treatment, which consumes significant health care resources and family energy. This study aims to analyze the effectiveness of digital interventions on patient outcomes in individuals with JIA.

Objective

This meta-analysis aimed to evaluate the impact of digital interventions on alleviating symptoms and improving overall well-being in children and adolescents with JIA.

Methods

A systematic search of 5 databases identified randomized controlled trials assessing the impact of digital interventions on physiological and psychological outcomes in adolescents and children (average age ≤19 y). Outcomes included pain, physical activity, health-related quality of life, self-efficacy, and disease-related issues. A total of 2 reviewers independently screened papers and extracted data on intervention functionalities and outcomes, assessing the risk of bias. A meta-analysis using a random-effects model synthesized the results.

Results

The review included 11 studies involving 885 patients with JIA. Digital interventions included educational (eg, self-management training), therapeutic (eg, pain management), and behavioral (eg, promoting physical activity) approaches. These were delivered through websites, telephone consultations, video conferences, apps, and interactive games, with durations ranging from 8 to 24 weeks and no clear link observed between intervention length and outcomes. Compared with conventional control groups, digital interventions were significantly effective in alleviating pain (standardized mean difference [SMD] -0.19, 95% CI -0.35 to -0.04) and enhancing physical activity levels (SMD 0.37, 95% CI 0.06-0.69). Marginal improvements in health-related quality of life, self-efficacy, and disease-related issues were observed, but these did not reach statistical significance (SMD -0.04, 95% CI -0.19 to 0.11; SMD 0.05, 95% CI -0.11 to 0.20; and SMD 0.09, 95% CI -0.11 to 0.29, respectively). The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach rated the quality of evidence for pain, health-related quality of life, self-efficacy, and disease-related issues as moderate, while the evidence quality for physical activity was assessed as low.

Conclusions

Digital interventions can alleviate pain and enhance physical activity in patients with JIA. However, given the limited sample size and high risk of bias in some studies, further high-quality research is needed to improve the treatment and management of JIA.

Effect of antecedent B-cell depletion therapy for patients hospitalized with COVID-19 within a single health system: a propensity score analysis

B-cell depletion therapy is employed in a variety of clinical contexts from auto-immune diseases to malignancy. Prior research on patients with prior B-cell depletion treatment has suggested a mortality risk in patients hospitalized with COVID-19 however previous case-control studies have differed in their methods of patient comparison. Patients previously treated with B-cell-depletion hospitalized with COVID-19 were compared to matched controls in the Johns Hopkins Health System between March 1, 2020 and November 30, 2021. The primary outcome was 30-day all-cause mortality. Secondary outcomes included time to severe illness or death and time to clinical improvement. To eliminate bias due to imbalanced covariates, each patient who had previously received B-cell depletion therapy was matched with patients who had not received therapy based on age, sex, race, WHO severity score, admission date, COVID-19 specific treatment, and vaccination status. Propensity scores were calculated from a multivariable logistic regression model and performed on the matched sets, using B-cell depletion as the outcome, where the propensity score was the probability of receiving B-cell depletion therapy. The propensity score included matched covariates as well as smoking status, medical comorbidities, and vaccination status. Cox proportional-hazards regression models were applied on the matched sets to perform time to death, time to severe illness or death, and time to clinical improvement analyses. 50 patients were identified who had received B-cell depletion therapy and were compared to 186 matched controls. Patients treated with B-cell depletion experienced 30-day mortality of 6.0% compared to 3.8% in controls, adjusted hazard ratio (aHR) 1.45 (95% CI 0.30 to 6.95). B-cell-depleted patients experienced a longer time to clinical improvement, aHR 0.65 (95% CI 0.45-0.94). In this cohort, patients treated with B-cell depletion experienced a higher mortality rate compared to matched controls however this was not statistically significant. This group also experienced a prolonged time to clinical improvement based on WHO severity score.

Induction of LY6E regulates interleukin-1β production, potentially contributing to the immunopathogenesis of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disorder characterized by the deposition of immune complexes (ICs) in various organs, especially the kidney, leading to lupus nephritis, one of the major and therapeutically challenging manifestations of SLE. Among the various cytokines induced in SLE, type I interferons (IFN-Is) play crucial roles in mediating immunopathogenesis, and anti-IFN-I treatment has been approved for SLE treatment. The uptake of ICs by macrophages results in macrophage activation, which initiates, triggers, and exaggerates immune responses in SLE. After observing the induction of an IFN-stimulated gene, LY6E, in monocytes from SLE patients, we demonstrated the colocalization of both LY6E and a macrophage marker in kidneys from pristane-induced lupus-prone mice and from patients with lupus nephritis. By studying mouse bone marrow-derived macrophages, we showed that LY6E regulated IFN-α- and IC-induced production and secretion of mature interleukin-1β (mIL-1β), foam cell formation and several mitochondria-associated mechanisms, such as the release of mitochondrial DNA (mtDNA) but not mitochondrial RNA (mtRNA) into the cytosol, the generation of mitochondrial reactive oxygen species (mtROS) and ROS, the activation of caspase 1, NLRP3, and the stimulator of interferon genes (STING) signaling pathway, and the activation of cytidine/uridine monophosphate kinase 2 (CMPK2), which were involved in LY6E-mediated immunomodulatory effects. In addition, synergistic effects of a combination of IL-1β and IFN-α and of IL-1β and ICs on the induction of the expression of IFN-stimulated genes were observed. In addition to revealing the proinflammatory roles and mechanisms of LY6E in macrophages, given that various subgroups of macrophages have been identified in the kidneys of patients with lupus nephritis, targeted treatment aimed at LY6E may be a potential therapeutic for lupus nephritis.

Guselkumab versus golimumab in patients with active psoriatic arthritis and inadequate response to an initial tumor necrosis factor inhibitor: study protocol for EVOLUTION, a pragmatic, phase 3b, open-label, randomized, controlled effectiveness trial

BACKGROUND

Psoriatic arthritis (PsA) is a multi-domain, inflammatory disease impacting joints, soft tissues, and skin; tumor necrosis factor inhibitors (TNFi) are typically the first biologic following inadequate response (IR) to conventional therapies. Although guidance is lacking on therapy selection after initial TNFi failure, data suggest TNFi-IR PsA patients may benefit from switching to a different mechanism of action (MOA) vs. cycling to another TNFi. Guselkumab is a fully human monoclonal antibody targeting the interleukin-23p19 subunit. Emphasizing practicality and applicability to routine clinical practice, EVOLUTION will pragmatically evaluate whether switching to guselkumab is more effective than cycling to a second TNFi (subcutaneous [SC] golimumab) in TNFi-IR PsA patients.

METHODS

The multicenter, longitudinal, prospective, observational Psoriatic Arthritis Research Consortium study guided eligibility criteria, outcome measures, and sample size estimates. Adults seen in clinical practice with active PsA (≥ 1 swollen joint) while receiving TNFi treatment will be eligible. Participants will be randomized (1:1:1) to guselkumab 100 mg every 4 weeks (Q4W); guselkumab 100 mg at Week 0, Week 4, and Q8W; or SC golimumab 50 mg Q4W (no washout period). The novel primary composite endpoint is achievement of clinical Disease Activity in Psoriatic Arthritis (cDAPSA) low disease activity (≤ 13) and an Investigator's Global Assessment (IGA) of psoriasis score of 0/1 (scale: 0-4) at Month12. Secondary endpoints include cDAPSA + IGA 0/1 at Month 6; achievement of minimal disease activity, resolution of enthesitis and dactylitis (among patients affected at baseline) at Months 6/12; and mean changes at Months 6/12 in the 12-item PsA Impact of Disease, Dermatology Life Quality Index, Patient-Reported Outcomes Measurements Information System fatigue and depression questionnaires, and Bath Ankylosing Spondylitis Disease Activity Index (patients with physician-determined axial disease). The target sample size is 150 participants (50/treatment group); all analyses are considered exploratory.

DISCUSSION

EVOLUTION will employ a pragmatic approach, including a novel primary endpoint relevant to clinical practice, to assess whether switching to an alternate MOA biologic with guselkumab is more effective than cycling to a second TNFi among TNFi-IR PsA patients.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov, NCT05669833, on 3 January 2023, https://www.

CLINICALTRIALS

gov/study/NCT05669833?term=%20NCT05669833&rank=1.

Isolated aortitis - is it truly isolated? An approach to diagnosis and management

PURPOSE OF REVIEW

With the rise in incidence of aortic aneurysm surgeries and the advances in large vessel imaging's ability to detect vessel wall inflammation, rheumatologists can expect to see an increase in isolated aortitis (IA) cases in their clinics. The purpose of this article is to review the latest data on IA, discuss its natural history and to provide an approach on how to diagnose and manage this inflammatory aortic disease.

RECENT FINDINGS

IA can be diagnosed on surgical histology or on imaging studies. Preoperative imaging in patients with thoracic aortic aneurysms does not detect all aortitis cases. Patients with IA have a high risk (up to 50%) of developing new aortic and branch lesions. Histologic and mechanistic studies show an overlap with giant cell arteritis.

SUMMARY

Evaluation for underlying infections and systemic diseases is recommended for diagnosis. Surveillance of patients with IA with repeated clinical assessments and imaging is recommended.

Nutritional guidance in spondyloarthritis: confronting the evidence gap

PURPOSE OF REVIEW

to summarize current evidence on the role of specific dietary patterns in spondyloarthritis (SpA) management.

RECENT FINDINGS

dietary interventions may offer a novel, complementary strategy to manage symptoms and enhance overall quality of life in many rheumatic diseases, including SpA. Evidence suggests that the Mediterranean diet may have beneficial effects on inflammation and SpA symptoms. Although there is growing interest in the ketogenic diet with some promising results, data is scarce. Some SpA patients may have sensitivities or intolerances to certain foods containing gluten, which can trigger or worsen their symptoms, especially when associated with intestinal inflammation. Hypocaloric diets and weight loss can provide significant benefit in overweight and obese patients with SpA, potentially reducing systemic inflammation. Finally, while the efficacy of probiotics remains a matter of debate, periods of fasting have proven effective in reducing disease activity indices.

SUMMARY

the importance of a healthy dietary lifestyle and its potential benefits in symptom management is acknowledged by the majority of the patients. There is an increased need and demand from patients to receive nutritional counseling that should be integrated into routine SpA management to enhance patient outcomes.

Development of an efficient expression system for human chaperone BiP in Pichia pastoris: production optimization and functional validation

BACKGROUND

Human BiP, or GRP78, is a molecular chaperone mainly found in the endoplasmic reticulum (ER). However, a growing amount of data also associates BiP with many distinct functions in subcellular locations outside the ER. Notably, several diseases have been BiP-related, so the protein could potentially be used for therapeutic purposes. This study aimed to optimize a high cell-density fermentation process for the production of recombinant human BiP (rhBiP) in yeast Pichia pastoris in a mineral medium.

RESULTS

P. pastoris cells successfully synthesized and secreted full-length rhBiP protein in a complex growth medium. However, secreted rhBiP titer was considerably lower when P. pastoris was cultivated in a defined mineral basal salt medium (BSM). During rhBiP synthesis optimization in shake flasks, it was found that the addition of reducing compounds (DTT or TCEP) to mineral BSM medium is essential for high-yield rhBiP production. Furthermore, rhBiP secretion in the BSM medium was significantly increased by feeding yeast with an additional carbon source. The addition of 2 mM DTT and 0.5-1.0% of glucose/glycerol to the BSM medium increased rhBiP titer ~ 8 times in the shake flasks. Glucose/methanol mixture feeding with added 2 mM DTT before induction was applied in high-density P. pastoris fermentation in bioreactor. Oxygen-limited fermentation strategy allowed to achieve ~ 70 mg/L rhBiP in BSM medium. Hydrophobic interaction and anion exchange chromatography were used for rhBiP protein purification. Approximately 45 mg rhBiP was purified from 1 L growth medium, and according to SDS-PAGE, ~ 90% purity was reached. According to data presented in this study, rhBiP protein derived from P. pastoris is a full-length polypeptide that has ATPase activity. In addition, we show that P. pastoris-derived rhBiP effectively inhibits neurodegenerative disease-related amyloid beta 1-42 (Aβ42) peptide and alpha-synuclein (α-Syn) protein aggregation in vitro.

CONCLUSIONS

A scalable bioprocess to produce rhBiP in P. pastoris was developed, providing a high yield of biologically active protein in a chemically defined mineral medium. It opens a source of rhBiP to accelerate further therapeutic applications of this important protein.

Drug survival and safety of biosimilars for treating psoriasis compared with originator adalimumab: a multinational cohort study

BACKGROUND

The lack of evidence from routine clinical settings has limited the widespread adoption of adalimumab biosimilars for the treatment of psoriasis.

OBJECTIVES

To compare the drug survival and safety of adalimumab biosimilars with Humira® in psoriasis.

METHODS

We conducted a prevalent new-user cohort study using data from the French National Health Data System (SNDS), the British Association of Dermatologists Biologics and Immunomodulators Register (BADBIR) and the Spanish Registry of Systemic Therapy in Psoriasis (BIOBADADERM). Adalimumab-naïve patients initiating adalimumab biosimilars (new users) were compared with Humira new users. Patients switching from Humira to biosimilars (switchers) were compared with those who continued Humira treatment. Patients were matched 1 : 1 based on previous adalimumab exposure time to create equal-sized cohorts of biosimilar and Humira users. Co-primary outcomes included drug discontinuation and serious adverse events (SAEs). Hazard ratios (HRs) were calculated using Cox proportional hazard models. Meta-analyses using random-effect models were performed to combine results from the three databases.

RESULTS

In total, 7387 biosimilar new users and 3654 switchers were matched and compared with Humira users. No differences in all-cause discontinuation were found between biosimilar and Humira new users [HR 0.99, 95% confidence interval (CI) 0.94-1.04]. Switching from Humira to biosimilars was associated with a higher discontinuation rate than remaining on Humira (HR 1.35, 95% CI 1.19-1.52). Similar results were observed for discontinuation due to ineffectiveness or adverse events. Risks of SAEs were similar between biosimilar new users and Humira new users [incidence rate ratio (IRR) 0.91, 95% CI 0.80-1.05] or between switchers and continuous Humira users (IRR 0.92, 95% CI 0.83-1.01).

CONCLUSIONS

Adalimumab biosimilars can be considered viable alternatives to Humira for new patients, with comparable effectiveness and safety. However, owing to the higher likelihood of discontinuation, patients who switch from Humira to biosimilars may require closer monitoring and support.

RSAD2: A pathogenic interferon-stimulated gene at the maternal-fetal interface of patients with systemic lupus erythematosus

Pregnancy disorders in patients with autoimmune diseases or viral infections are often associated with an excessive response of type I interferons. We identify radical S-adenosyl methionine domain containing 2 (RSAD2) as a pathogenic interferon-stimulated gene (ISG) associated with pregnancy complications in systemic lupus erythematosus (SLE). The increased expression of RSAD2 mainly occurs in macrophages and structural cell populations at the maternal-fetal interface of pregnant patients with SLE. The elevation of RSAD2 leads to the accumulation of diacylglycerol lipids in the placenta, impairing the necessary vascular development for the fetus. Depletion of Rsad2 in pregnant mice models exposed to type I interferon inducers significantly reduces lipid accumulation, vascular injury, and embryo development disorders. An RSAD2 inhibitor, L-chicoric acid (LCA), alleviates lipid accumulation and vascular damage, improving pregnancy outcomes in SLE-induced and spontaneous mouse models. This study proposes the potential of targeting RSAD2 to improve pregnancy outcomes in individuals with heightened type I interferon response.

Deciphering the transcriptomic landscape of systemic lupus erythematosus-associated pulmonary arterial hypertension

BACKGROUND

Systemic lupus erythematosus (SLE) is an autoimmune disease that involves multi-organ damage. Pulmonary arterial hypertension (PAH) is one of the life-threatening complications of SLE. The underlying cause of systemic lupus erythematosus-associated pulmonary arterial hypertension has not been fully comprehended. Besides the mechanisms implicated in the development of PAH, such as damage to the endothelial cells, the aberrant activation of the immune system also plays a substantial role in the pathogenesis of SLE-PAH.

METHODS

In this study, peripheral blood samples from 100 patients with SLE-PAH and 95 patients of SLE without PAH (SLE-nonPAH) were obtained for RNA sequencing and comprehensive transcriptomic analysis. Pathway enrichment analysis was performed based on differentially expressed genes (DEGs) between SLE-PAH and SLE-nonPAH to elucidate the mechanisms potentially driving the development of PAH in SLE patients. Utilizing consensus non-negative matrix factorization (cNMF), we also conducted a detailed analysis to identify distinct subgroups within the SLE-PAH population. Meanwhile, the protein-protein interaction (PPI) analysis was performed and hub genes among the SLE-PAH subgroups were detected. Common transcription factors (TFs) of detected hub genes were also discovered to serve as potential therapeutic targets.

RESULTS

Inflammatory signaling pathways, notably those involving interferon and TNFα, were found to play an important role in the SLE-PAH. Utilizing cNMF method, three unique subgroups of SLE-PAH patients were delineated, each characterized by a distinct level of inflammatory activity. Specifically, the high inflammation subgroup, marked by the activity of Interleukin-6 (IL-6), exhibited a milder form of PAH. In contrast, the subgroup with moderate inflammation displayed the most pronounced PAH symptoms. Further disease enrichment analysis revealed that, beyond the dysregulated inflammatory pathways, patients with the most severe PAH exhibited distinct pathogenic transcriptomic profiles that disrupted vascular smooth muscle homeostasis, a critical component of vascular health. In the most severely affected subgroup, 13 hub genes were identified. Additionally, two transcription factors commonly associated with these genes, KLF1 and GATA1, were discovered, which may serve as potential therapeutic targets.

CONCLUSION

Our investigation establishes inflammation as a key driver in the development of SLE-PAH. Patients who presented with concurrent dysregulations in inflammatory responses along with PAH-specific pathogenic markers exhibited a marked increase in the severity of their PAH. The insights gleaned from our transcriptomic analysis reveal the intricate interplay between inflammatory mechanisms and the molecular substrates of PAH. This nuanced understanding paves the way for more targeted and effective therapeutic approaches for SLE-PAH.

Systemic lupus erythematosus: updated insights on the pathogenesis, diagnosis, prevention and therapeutics

Systemic lupus erythematosus (SLE) is a chronic inflammatory illness with heterogeneous clinical manifestations covering multiple organs. Diversified types of medications have been shown effective for alleviating SLE syndromes, ranging from cytokines, antibodies, hormones, molecular inhibitors or antagonists, to cell transfusion. Drugs developed for treating other diseases may benefit SLE patients, and agents established as SLE therapeutics may be SLE-inductive. Complexities regarding SLE therapeutics render it essential and urgent to identify the mechanisms-of-action and pivotal signaling axis driving SLE pathogenesis, and to establish innovative SLE-targeting approaches with desirable therapeutic outcome and safety. After introducing the research history of SLE and its epidemiology, we categorized primary determinants driving SLE pathogenesis by their mechanisms; combed through current knowledge on SLE diagnosis and grouped them by disease onset, activity and comorbidity; introduced the genetic, epigenetic, hormonal and environmental factors predisposing SLE; and comprehensively categorized preventive strategies and available SLE therapeutics according to their functioning mechanisms. In summary, we proposed three mechanisms with determinant roles on SLE initiation and progression, i.e., attenuating the immune system, restoring the cytokine microenvironment homeostasis, and rescuing the impaired debris clearance machinery; and provided updated insights on current understandings of SLE regarding its pathogenesis, diagnosis, prevention and therapeutics, which may open an innovative avenue in the fields of SLE management.

Variable Selection for Progressive Multistate Processes Under Intermittent Observation

Multistate models offer a natural framework for studying many chronic disease processes. Interest often lies in identifying which among a large list of candidate variables play a role in the progression of such processes. We consider the problem of variable selection for progressive multistate processes under intermittent observation based on penalized log-likelihood. An Expectation-Maximization (EM) algorithm is developed such that the maximization step can exploit existing software for penalized Poisson regression thereby allowing for the use of common penalty functions. Simulation studies show good performance in identifying important markers with different penalty functions. In a motivating application involving a cohort of patients with psoriatic arthritis, we identify which, among a large group of candidate HLA markers, are associated with rapid disease progression.

Exploring hand function in newly diagnosed primary Sjögren's syndrome: Clinical, radiographic, and ultrasonographic insights

BACKGROUND

Primary Sjögren's syndrome (pSS) is a chronic, systemic autoimmune disease. Musculoskeletal and neurological system involvement occurs in patients with pSS, which may lead to impairment in hand function. Hand dysfunction and its underlying causes remain an underexplored area in pSS.

PURPOSE

This study aims to evaluate hand function in patients with newly diagnosed pSS, exploring the associations with disease activity, clinical parameters, and radiographic and ultrasonographic findings.

STUDY DESIGN

Cross-sectional.

METHODS

Fifty patients with newly diagnosed pSS and 50 healthy controls were recruited in this study. Hand functions were evaluated using the Duruöz Hand Index (DHI) and hand grip strength measurements. Detailed hand physical examination was made. Carpal tunnel syndrome (CTS) was assessed with the CTS -6 questionnaire and electrodiagnostic methods. Hands A-P radiography was evaluated for joint erosion, joint space narrowing. Ultrasonographic assessment of hand was made for intercarpal and metacarpophalangeal joint synovitis and extensor tenosynovitis. Additional evaluations included the Hospital Anxiety and Depression Scale (HADS), Short Form-36 (SF-36), Fatigue severity scale (FSS) and the European League Against Rheumatism (EULAR) Sjögren's Syndrome Disease Activity Index (ESSDAI).

RESULTS

Patients with pSS exhibited significantly higher DHI scores compared to controls (p = 0.027, r = 0.22) and lower non-dominant hand grip strength (p = 0.016, r = 0.30), while dominant hand grip strength did not differ significantly (p = 0.520, r = 0.08). Higher HADS anxiety (p < 0.001, r = 0.63) and depression scores (p < 0.001, r = 0.55) were noted in pSS patients. Additionally, these patients had reduced SF-36 scores (p < 0.001, r = 0.53). DHI scores were significantly correlated with ESSDAI (ρ = 0.413, p = 0.003), SF-36 (ρ = -0.605, p < 0.001), HADS (**ρ = 0.307 for anxiety, p = 0.030; ρ = 0.286 for depression, p = 0.044), hand grip strength (ρ = -0.298 for dominant hand, p = 0.036; ρ = -0.280 for non-dominant hand, p = 0.049), Health Assessment Questionnaire (HAQ) (ρ = 0.893, p < 0.001), and FSS (ρ = 0.378, p = 0.007). Ultrasonographic evaluations revealed synovitis and/or tenosynovitis in 18% of patients, while CTS was detected in 32%.

CONCLUSIONS

This study highlights significant hand function impairments in newly diagnosed pSS patients, with DHI scores correlating with disease activity, psychological well-being, and general health. These findings underscore the importance of early and comprehensive hand assessments using advanced diagnostic tools to improve patient outcomes.

Lower Use of and Potential Barriers to Using Patient Portals Among Limited English Proficient Latino and Chinese American Adults: A Health Techquity Concern

INTRODUCTION

Patient portals are increasingly becoming the primary channel for communicating health information, raising concerns about the potential worsening of health care access disparities among limited English proficient (LEP) patients. The authors studied the use of a health plan patient portal and potential barriers to use by comparing LEP Latino and Chinese Health Plan members to those with English language preference (non-LEP).

METHODS

The authors used health record data for 480,833 Latino (31.8% LEP) and 137,904 Chinese (31.6% LEP) adult Kaiser Permanente Northern California members 25-85 years of age to study portal use during 2019. Clinic-collected survey data for 489 Latino and 1037 Chinese LEP patients was compared with data for 849 Latino and 426 Chinese non-LEP Kaiser Permanente Northern California 2020 Member Health Survey respondents to identify factors potentially inhibiting portal use. The authors used chi-square tests to assess differences in portal use and potential influencing factors across ethnic, language, and age subgroups.

RESULTS

During 2019, LEP Latino and Chinese adults were less likely than non-LEP adults to have a portal account and, among those with a portal account, to have sent secure messages and viewed laboratory results online. Portal use was lower among LEP Latino than LEP Chinese adults. Patient surveys identified lower educational attainment, health literacy, and access to and use of digital tools among LEP vs non-LEP Latino and Chinese adults.

CONCLUSIONS

Patient portal use is lower among LEP than non-LEP Latino and Chinese patients. Health care systems should take action to decrease barriers to use, but they also should consider patient communication preferences.

The unique challenges of childhood-onset systemic lupus erythematosus and lupus nephritis patients: a proposed framework for an individualized transitional care plan

Childhood-onset systemic lupus erythematosus (cSLE) is a severe lifelong and life-threatening autoimmune disease with multi-organ involvement. Compared to those with adult-onset disease, cSLE patients have more aggressive disease with a higher prevalence of early lupus nephritis (LN) causing worse kidney and patient outcomes. The transfer of adolescent patients to adult healthcare poses several major challenges, from a disease as well as a psychosocial perspective. Transitional care even in tertiary centers can be heterogenous, suboptimal, and often even non-existent. In this comprehensive review of the literature, we synthesize the obstacles adolescents and young adults (AYA) with systemic lupus erythematosus (SLE) and LN face and how these challenges impact the transfer to adult health care. Finally, we propose a framework for a structured and individually modifiable transitional care plan, tailored to the unique needs of this population and taking into account their social and cultural background. This framework includes suggestions for the timing of the preparatory phase and the transfer itself, the composition of the transitional care team, increasing transition readiness and treatment adherence, and establishing a supportive network of peers. Efficient transitional care will optimize long-term patient outcomes.

Sex bias consideration in healthcare machine-learning research: a systematic review in rheumatoid arthritis

OBJECTIVE

To assess the acknowledgement and mitigation of sex bias within studies using supervised machine learning (ML) for improving clinical outcomes in rheumatoid arthritis (RA).

DESIGN

A systematic review of original studies published in English between 2018 and November 2023.

DATA SOURCES

PUBMED and EMBASE databases.

STUDY SELECTION

Studies were selected based on their use of supervised ML in RA and their publication within the specified date range.

DATA EXTRACTION AND SYNTHESIS

Papers were scored on whether they reported, attempted to mitigate or successfully mitigated various types of bias: training data bias, test data bias, input variable bias, output variable bias and analysis bias. The quality of ML research in all papers was also assessed.

RESULTS

Out of 52 papers included in the review, 51 had a female skew in their study participants. However, 42 papers did not acknowledge any potential sex bias. Only three papers assessed bias in model performance by sex disaggregating their results. Potential sex bias in input variables was acknowledged in one paper, while six papers commented on sex bias in their output variables, predominantly disease activity scores. No paper attempted to mitigate any type of sex bias.

CONCLUSIONS

The findings demonstrate the need for increased promotion of inclusive and equitable ML practices in healthcare to address unchecked sex bias in ML algorithms.

PROSPERO REGISTRATION NUMBER

CRD42023431754.

A review on microneedle patch as a delivery system for proteins/peptides and their applications in transdermal inflammation suppression

Transdermal delivery is one of the most recent modes of administration studied due to several shortfalls observed for intra-venous, and oral drug administrations. Among, microneedle-based transdermal delivery is the popular choice due to non-invasive procedure and minimal toxicological effects. Microneedle devices consist of micron scaled needle patch entrapped with the target specific drug molecules. Due to body's immune response and occasional pathogen attack, various inflammatory diseases are developed such as psoriasis, dermatitis, rashes, rheumatoid arthritis, gouty arthritis, and fibrosis. These inflammatory conditions can be treated by microneedle assisted transdermal delivery. Moreover, for localized suppression of pain and inflammation, various therapeutic peptides and proteins have been investigated. Although, these therapeutic agents can show reduced activity and undergo enzymatic degradation when administered orally or intra-venously. Hence, a microneedle-based delivery system can be used as an effective way to localize these peptides/proteins and reduce the inflammation. Herein, this review includes various microneedle fabrication methods for enhancing drug delivery for suppression of inflammation. Moreover, recent development in microneedle devices of peptide and protein delivery applications are discoursed. At last, future scope and challenges endured for preparing an efficient microneedle patch for peptide and protein delivery are also elaborated.

A theory of change for patient-initiated follow-up care in rheumatoid arthritis

BACKGROUND

Timely, high-quality care is critical to rheumatoid arthritis (RA) management. In Alberta, thousands of individuals with RA are waiting for care due to the resource-intensive nature of lifelong follow-ups and rheumatologist shortages. With 20-50% of routine follow-ups not leading to treatment changes or raising new concerns, many appointments may be avoidable if care were restructured. Patient-initiated models extend rheumatologist follow-up intervals beyond 12 months where appropriate, which can reduce inefficiencies and improve care access. To address provincial RA care challenges, we co-developed a theory of change (TOC) for patient-initiated follow-up care.

METHODS

A TOC serves to define health services interventions and their intended impact prior to implementation testing. We worked with 35 healthcare leaders, implementation experts, and patient partners to co-develop a TOC for patient-initiated RA follow-up care. During the scoping phase, we held discussions with healthcare leaders and reviewed evidence on patient-initiated follow-up models to assess their implementation potential. During the development phase, we drafted a TOC map using scoping phase findings and clinical and patient expertise. During the refinement phase, feedback was collected to optimize the TOC. Meetings were recorded, transcribed, and analyzed using deductive qualitative content analysis alongside anonymous poll results and informal feedback to guide TOC refinement.

RESULTS

The scoping phase identified challenges in RA care, including long waitlists and unnecessary appointments, which patient-initiated follow-up models have the potential to address. TOC discussions highlighted two intended impacts: (1) efficient and effective care for patients when needed, and (2) a sustainable model for RA care. Feedback in the refinement phase covered 4 topics: (1) preference for an interdisciplinary flare clinic, (2) patient selection, (3) patient education, and (4) patient monitoring. Tools and strategies were co-developed with partners to support patients (e.g., decision tool for patient-provider discussions) and the health system (e.g., monthly meetings to monitor burden). The final TOC for patient-initiated follow-up in RA details the care pathway, key resources and considerations, and evaluation outcomes.

CONCLUSIONS

A patient-centered, context-specific patient-initiated RA follow-up care model was co-developed with patient and healthcare partners. An implementation pilot will test its ability to address RA care challenges.

CLINICAL TRIAL REGISTRATION

Not applicable.

Mendelian randomization and mediation analysis reveal the role of immune cell subsets in the causal pathways between blood cell perturbation responses and rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by complex immune interactions. Elucidating the causal relationships between blood cell perturbations, immune cell subsets, and RA can provide valuable insights into its pathogenesis.

METHODS

This study employed bidirectional two-sample Mendelian Randomization (MR) to explore the causal effects of blood cell perturbations on RA risk, with a focus on immune cell mediation. Genetic data from large-scale Genome-Wide Association Studies (GWAS) were utilized to select instrumental variables (IVs) for exposure, mediator, and outcome. Inverse Variance Weighted (IVW) analysis was applied, supplemented by sensitivity tests. Mediation analysis was conducted to assess the indirect effects mediated by immune cells.

RESULTS

Significant causal associations were identified between perturbations in reticulocytes, monocytes, and lymphocytes and specific immune cell subsets, including CD3 + CD39 + regulatory T cells (Tregs) and CD45RA + terminally differentiated CD8 + T cells (CD45RA + TD CD8 + cells). Erythropoiesis perturbation was associated with a reduced RA risk, while perturbations in monocytes and lymphocytes were found to facilitate RA progression through immune-mediated mechanisms.

CONCLUSION

This study underscores the pivotal role of immune cell subsets in mediating the effects of blood cell perturbations on RA development. These findings suggest that targeting immune cell-mediated pathways, particularly those involving Tregs and CD8 + T cells, can provide new therapeutic strategies for RA management. Key Points • Causal Relationships: Mendelian randomization (MR) analysis identified significant causal relationships between specific blood cell disturbances (e.g., reticulocytes, monocytes, and lymphocytes) and rheumatoid arthritis (RA). • Role of Immune Cells: CD3 + CD39 + regulatory T cells (Tregs) and CD45RA + Terminally Differentiated CD8 + T cells (CD45RA + TD CD8 + cells) mediate the association between blood cell disturbances and RA. • Protective Role of Reticulocytes: Reticulocyte disturbances under potassium chloride (KCl) conditions are negatively associated with RA, potentially protecting joints from inflammatory damage by reducing oxidative stress. • Protective Role of Non-Classical Monocytes: Baseline disturbances in monocyte median side scatter are negatively associated with RA, suggesting non-classical monocytes may reduce RA-related inflammation. • Positive Association of Lymphocyte Disturbances with RA: Lymphocyte side scatter standard deviation under colchicine disturbances shows a significant positive association with RA, indicating abnormal T cell activation may exacerbate RA progression.AQ.

Major adverse cardiovascular events or venous thromboembolism in patients with rheumatoid arthritis initiating biological or targeted synthetic disease-modifying antirheumatic drugs: a nationwide, population-based cohort study

Background

Rheumatoid arthritis (RA) is complicated by a high risk of cardiovascular disease and requires the initiation of biological or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) for persistently active disease despite first-line therapies. The influence of b/tsDMARDs, especially tsDMARDs, on cardiovascular risk in Taiwanese patients with RA remains unclear.

Objectives

To compare the risk of major cardiovascular adverse events (MACEs) or venous thromboembolism (VTE) amongst RA patients initiating approved b/tsDMARDs for up to 5 years.

Design

A nationwide, population-based, retrospective cohort study.

Methods

Using Taiwan National Health Insurance (NHI) Research Database, we identified patients with RA initiating NHI-reimbursed b/tsDMARDs indicated for RA between 2001 and 2020. Study outcomes were newly developed MACEs or VTE within 5 years of the first b/tsDMARD initiation. Time-dependent Cox regression analysis was performed to determine the association between b/tsDMARDs and MACEs or VTE and independently associated or protective factors. Subgroup analyses by age at b/tsDMARD initiation and cardiovascular risk levels, as well as sensitivity analyses of b/tsDMARD initiation after 2012, were performed.

Results

We enrolled 12,332 adults with RA initiating the first b/tsDMARD during pre-determined period. The incidence rates of MACE and VTE were 894 and 283 per 100,000 person-years, respectively. After adjustment, other b/tsDMARDs were not associated with a higher risk of MACEs or VTE than tumour necrosis factor inhibitors (TNFis) up to 5 years after initiation. Subgroup analyses by age at b/tsDMARD initiation and cardiovascular risk levels revealed consistent findings. Factors associated with or protective against MACEs or VTE were identified.

Conclusion

No non-TNFi b/tsDMARD had a higher risk of MACEs or VTE than TNFis up to 5 years after initiation amongst patients with RA, and this remained consistent for those initiating their b/tsDMARD at age 65 years and older or with high cardiovascular risk.

Associations of sociodemographic, clinical factors and HLA-B alleles with enthesitis and peripheral arthritis in patients with ankylosing spondylitis

OBJECTIVES

Factors associated with peripheral arthritis and enthesitis, especially Achilles tendonitis and plantar fasciitis, were examined in a longitudinal cohort of 1075 patients with ankylosing spondylitis (AS) (also known as radiographic axial spondyloarthritis).

METHODS

Patients were derived from the Prospective Study of Outcomes in Ankylosing Spondylitis cohort. Disease activity and functional indices, as well as physical examination and medications used, were measured at every study visit. Univariable and multivariable analyses of the association of peripheral arthritis and enthesitis with clinical, sociodemographic factors were performed. Human leucocyte antigen (HLA)-B alleles were analysed by single-stranded conformational polymorphism analysis.

RESULTS

Those with peripheral arthritis on examination were more likely to have psoriasis (p=0.001, OR=1.68; CI, 1.11, 2.54), greater functional impairment (p<0.001 OR=1.72; CI, 1.31, 2.27), higher erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels (p<0.001), greater tumour necrosis factor (TNF) inhibitor (p<0.001, OR=1.50; CI, 1.14, 1.97) and use methotrexate/sulfasalazine (p<0.001, OR=2.25, CI [1.57, 3.23]). Patients with enthesitis were less likely to be male (p<0.001, OR=0.57; CI, 0.43, 0.75) and have peripheral arthritis (p<0.001, OR=2.35; CI, 1.47, 3.75), greater functional impairment (p<0.001, OR=1.91; CI, 1.43, 2.55) and higher ESR/CRP levels (p<0.001). Patients with plantar fasciitis and/or Achilles' tendonitis on examination were less likely to male (p<0.001 OR=0.57; CI, 0.43, 0.75), to have significant functional impairment (p<0.001), to be using TNF inhibitors (p<0.001, OR=1.48; CI 1.13, 1.93) and to be using either sulfasalazine or methotrexate (p<0.001, OR=1.86, CI, 1.30, 2.67). HLA-B*15 (p=0.03, OR=1.84; CI, 1.05, 3.21) and HLA-B*37 (p=0.04, OR=3.00; CI, 1.03, 8.74) were marginally increased in frequency in those with peripheral arthritis on examination compared with those without.

CONCLUSION

There was a higher prevalence of peripheral musculoskeletal manifestations in women with AS, with significant impact on physical function and greater use of methotrexate or sulfasalazine and TNF inhibitors and enrichment for certain non-HLA-B27 HLA-B alleles.

Vaccination and rheumatoid arthritis: an updated systematic review and meta-analysis of data from 25,949,597 participants

OBJECTIVES

This systematic review and meta-analysis aimed to investigate the association between vaccinations and the risk of rheumatoid arthritis (RA), specifically addressing concerns about a potential increased risk among vaccinated individuals.

METHODS

A systematic search for cohort studies and case-control studies examining the association between vaccinations and RA was conducted using Medical Subject Headings and relevant keywords across PubMed, EMBASE, and Cochrane Library databases from inception to September 2024. The risk of bias of included studies was assessed using the Newcastle-Ottawa Scale. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was employed to evaluate the overall certainty of evidence. Statistical analyses, i.e., pooling of relative risk (RR) and corresponding 95% confidence intervals (CI), were performed using a random-effects model on STATA software (version 14.0). Due to the I² value exceeding 50%, we did not perform an asymmetry test to assess publication bias.

RESULTS

This meta-analysis included 16 observational studies conducted between 2008 and 2024 and involving a total of 25,949,597 participants. The follow-up duration ranged from 0.03 to 9 years, while the data collection period varied from 2.75 to 9.5 years. The analysis found no significant association between vaccination exposure and RA [RR = 1.03, 95% CI (0.95-1.11), I²=93.4%, P = 0.456, low level of evidence]. Sensitivity analyses confirmed the robustness of this result. Subgroup analyses revealed no significant risk of RA associated with HPV vaccination [RR = 1.27 95% CI (0.78-2.08), I²=81.4%, P = 0.339], influenza vaccination [RR = 1.10, 95% CI (0.98-1.23), I²=52.4%, P = 0.112], Anthrax vaccination [RR = 2.21, 95% CI (0.75-6.52)], Herpes Zoster vaccination [RR = 2.70, 95% CI (1.70-4.29)], or COVID-19 vaccination [RR = 0.94, 95% CI (0.82-1.07), I²=97.4%, P = 0.340]. However, the subgroup with a follow-up duration varying between 0.5 and 1.8 years showed that (HPV & COVID-19) vaccination had a significant protective effect on RA [RR = 0.92, 95% CI (0.87-0.98), I²=95.3%, P = 0.005].

CONCLUSION

The evidence for the association between vaccination and RA risk is insufficient, and vaccination may serve as a protective factor for RA over a less than one year follow-up duration.

Identification of Association Between Mitochondrial Dysfunction and Sarcopenia Using Summary-Data-Based Mendelian Randomization and Colocalization analyses

BACKGROUND

Mitochondrial dysfunction has been demonstrated to be an important hallmark of sarcopenia, yet its specific mechanism remains obscure. In this study, mitochondrial-related genes were used as instrumental variables to proxy for mitochondrial dysfunction, and summary data for sarcopenia-related traits were used as outcomes to examine their genetic association.

METHODS

A total of 1 136 mitochondrial-related genes from the human MitoCarta3.0 database were extracted. Genetic instruments for them were obtained from gene expression quantitative trait locus (eQTLs) study (n = 31 684). Aggregated data for sarcopenia-related traits including low hand grip strength (LHGS), appendiceal lean mass (ALM), and usual walking pace (UWP) were provided by large-scale genome-wide association studies (GWASs). We integrated eQTLs data with GWAS data to estimate genetic association between mitochondrial dysfunction and sarcopenia using summary-data-based Mendelian randomization (SMR) analysis. Additionally, we implemented colocalization analysis to strengthen their association. Finally, eQTLs data from skeletomuscular tissue (n = 706) was used to validate the primary findings.

RESULTS

By integrating the analysis results from the 3 sarcopenia-related traits, 2 mitochondrial genes genetically associated with sarcopenia were identified, namely UQCC1 (tier 2 evidence) and ETFDH (tier 3 evidence). Specifically, elevated expression levels of UQCC1 increased LHGS risk (OR = 1.114; 95% CI, 1.078-1.152; P-FDR = 1.70 × 10-7), which matched the negative association between it and UWP (Beta = -0.015; 95% CI, -0.021 to -0.010; P-FDR = 6.70 × 10-5). Furthermore, elevated expression levels of ETFDH were found to be associated with both lower ALM (Beta = 0.031; 95% CI, 0.020-0.042; P-FDR = 1.41 × 10-6) and UWP (Beta = 0.013; 95% CI, 0.006-0.021; P-FDR = 0.029). Of note, consistent results were replicated in specific skeletomuscular tissues, further suggesting our findings were robust.

CONCLUSIONS

Our analyses revealed the genetic association between 2 mitochondrial-related genes, ie, UQCC1 and ETFDH, and sarcopenia, highlighting the pivotal role of mitochondrial dysfunction driven by these genes in the pathogenesis of sarcopenia. Importantly, these candidate genes represent potential clinical drug targets for the treatment of sarcopenia.

Prevalence of frailty and prefrailty in systemic lupus erythematosus: A systematic review and meta-analysis

OBJECTIVE

Frailty is associated with mortality in systemic lupus erythematosus (SLE), but the prevalence is unclear. The aim of this systematic review and meta-analysis was to investigate the prevalence of frailty and prefrailty in SLE patients.

METHODS

Four databases, namely PubMed, Cochrane, EMBASE, and Web of Science, were systematically searched from their inception to November 2024 to identify studies that fulfilled the predefined a priori inclusion criteria for systematic review and meta-analysis, and that specifically investigated frailty and prefrailty in patients with SLE. The quality assessment of the included studies was conducted according to the Newcastle-Ottawa scale (NOS).

RESULTS

Fifteen studies were retrieved according to the inclusion criteria, and their data were combined in the eventual review. Data from studies including 46,060 patients with SLE were included. The analysis showed that the pooled prevalence of frailty in patients with SLE was 27 % (95 % CI: 19 % - 36 %), the pooled prevalence of prefrailty was 65 % (95 % CI: 54 % - 76 %). Analysis of subgroups revealed that the prevalence of frailty was 26 % (95 % CI: 14 % to 41 %) when measured by Systemic Lupus International Collaborating Clinics-Frailty Index (SLICC-FI) and 22 % (95 % CI: 18 % to 26 %) when assessed using Fried phenotype (FP).

CONCLUSION

Both frailty and prefrailty are highly prevalent conditions among patients with SLE. There is an urgent need to better understand and address frailty in this population to enhance patient outcomes and quality of life.

Progressive Pulmonary Fibrosis and Interstitial Lung Abnormalities: AJR Expert Panel Narrative Review

Progressive pulmonary fibrosis (PPF) and interstitial lung abnormalities (ILA) are relatively new concepts in interstitial lung disease (ILD) imaging and clinical management. Recognition of signs of PPF and identification and classification of ILA are important tasks during chest high-resolution CT interpretation to optimize management of patients with ILD and those at risk of developing ILD. However, in professional society guidance, the role of imaging surveillance remains unclear for stable patients with ILD, asymptomatic patients with ILA who are at risk of progression, and asymptomatic patients at risk of developing ILD without imaging abnormalities. In this AJR Expert Panel Narrative Review, we summarize the current knowledge regarding PPF and ILA and describe the range of clinical practice with respect to imaging patients with ILD, those with ILA, and those at risk of developing ILD. In addition, we offer suggestions to help guide surveillance imaging in areas with an absence of published guidelines, where such decisions are currently driven primarily by local pulmonologists' preference.