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Régis C, Abikhzer G, Harel F, Pelletier-Galarneau M. Molecular imaging of large vessel vasculitis. J Med Imaging Radiat Sci 2024; 55:S10-S16. [PMID: 38097449 DOI: 10.1016/j.jmir.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 11/27/2023] [Accepted: 11/27/2023] [Indexed: 05/29/2024]
Abstract
Large vessel vasculitis (LVV) affects mainly large arteries with giant cell arteritis (GCA) and Takayasu arteritis (TAK) being the two most frequent forms. Clinical symptoms can be non-specific, including headache, fatigue, weight loss, and change in vision. Untreated, LVV may also lead to serious complications such as blindness, aortic aneurysm and dissection. Therefore, rapid recognition of the disease leading to accurate diagnosis and appropriate treatment is essential. FDG-PET/CT imaging has emerged as a sensitive marker of active vascular inflammation and its use in the management of LVV is now integrated in guidelines. In this article, we will discuss the role of FDG-PET/CT for the diagnosis of LVV and monitoring of therapy, as well as review technical and interpretation parameters.
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Affiliation(s)
- Claudine Régis
- Department of Medical Imaging, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Gad Abikhzer
- Department of Medical Imaging, Jewish General Hospital, Montreal, Quebec, Canada
| | - Francois Harel
- Department of Medical Imaging, Montreal Heart Institute, Montreal, Quebec, Canada
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Betrains A, Moreel L, Mulders-Manders CM, Auwaerter PG, Torné-Cachot J, Weitzer F, Terasawa T, Ly KH, Schönau V, Blockmans D, Wright WF, Rovers C, Vanderschueren S. Comparison of diagnostic spectrum between inflammation of unknown origin and fever of unknown origin: A systematic review and meta-analysis. Eur J Intern Med 2024; 124:115-121. [PMID: 38431500 DOI: 10.1016/j.ejim.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 02/01/2024] [Accepted: 02/22/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Patients with inflammation of unknown origin (IUO) and fever of unknown origin (FUO) are commonly considered a single population. Differences in underlying causes between both groups may steer the diagnostic work-up. METHODS PubMed, Embase, Web of Science, and ClinicalTrials.gov were searched from July 2009 through December 2023. Studies including both FUO and IUO patients with a sample size of ≥20 were considered. The primary outcome was the difference in the rate of patients affected by predefined diagnostic categories according to meeting FUO or IUO criteria. Data were pooled using random-effects models. RESULTS A total of 8 studies met criteria for inclusion, with a total of 1452 patients (466 with IUO and 986 with FUO). The median rate of IUO patients among the included studies was 32 % (range 25-39 %). Patients with IUO had a lower likelihood of infection (OR 0.59 [95 % CI; 0.36-0.95]; I2 0 %). There were no significant differences in the rate of noninfectious inflammatory disorders, malignancies, miscellaneous disorders, or remaining undiagnosed. Comparison of diagnostic subgroups revealed that IUO patients were less likely to have systemic autoinflammatory disorders (OR 0.17 [95 % CI, 0.05-0.58]; I2 42 %) and more likely to have vasculitis (OR 2.04 [95 % CI, 1.23-3.38]; I2 21 %) and rheumatoid arthritis or spondylarthritis (OR 3.52 [95 % CI, 1.16-10.69]; I2 0 %). CONCLUSION Based on our findings, there is little reason to assume that FUO and IUO patients would benefit from a different initial diagnostic approach.
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Affiliation(s)
- Albrecht Betrains
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.
| | - Lien Moreel
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | | | - Paul G Auwaerter
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States
| | | | - Friedrich Weitzer
- Division of Nuclear Medicine, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Teruhiko Terasawa
- Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kim H Ly
- Department of Internal Medicine, Limoges University Hospital, Limoges, France
| | - Verena Schönau
- Department of Rheumatology and Immunology, University Hospital Erlangen, Erlangen, Germany
| | - Daniel Blockmans
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - William F Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Chantal Rovers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Steven Vanderschueren
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
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González-Gay MÁ, Heras-Recuero E, Blázquez-Sánchez T, Caraballo-Salazar C, Rengifo-García F, Castañeda S, Largo R. Broadening the clinical spectrum of giant cell arteritis: from the classic cranial to the predominantly extracranial pattern of the disease. Expert Rev Clin Immunol 2024:1-12. [PMID: 38757894 DOI: 10.1080/1744666x.2024.2356741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 05/14/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Giant cell arteritis (GCA) is a large vessel (LV) vasculitis that affects people aged 50 years and older. Classically, GCA was considered a disease that involved branches of the carotid artery. However, the advent of new imaging techniques has allowed us to reconsider the clinical spectrum of this vasculitis. AREASCOVERED This review describes clinical differences between patients with the cranial GCA and those with a predominantly extracranial LV-GCA disease pattern. It highlights differences in the frequency of positive temporal artery biopsy depending on the predominant disease pattern and emphasizes the relevance of imaging techniques to identify patients with LV-GCA without cranial ischemic manifestations. The review shows that so far there are no well-established differences in genetic predisposition to GCA regardless of the predominant phenotype. EXPERT COMMENTARY The large branches of the extracranial arteries are frequently affected in GCA. Imaging techniques are useful to identify the presence of 'silent' GCA in people presenting with polymyalgia rheumatica or with nonspecific manifestations. Whether these two different clinical presentations of GCA constitute a continuum in the clinical spectrum of the disease or whether they may be related but are definitely different conditions needs to be further investigated.
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Affiliation(s)
- Miguel Ángel González-Gay
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, Madrid, Spain
- Department of Medicine and Psychiatry, University of Cantabria, Santander, Spain
| | | | | | | | | | - Santos Castañeda
- Division of Rheumatology, Hospital Universitario de La Princesa, IIS-Princesa, Madrid, Spain
| | - Raquel Largo
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, Madrid, Spain
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Seitz P, Lötscher F, Bucher S, Bütikofer L, Maurer B, Hakim A, Seitz L. Ultrasound intima-media thickness cut-off values for the diagnosis of giant cell arteritis using a dual clinical and MRI reference standard and cardiovascular risk stratification. Front Med (Lausanne) 2024; 11:1389655. [PMID: 38654833 PMCID: PMC11037081 DOI: 10.3389/fmed.2024.1389655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 03/25/2024] [Indexed: 04/26/2024] Open
Abstract
Objectives To derive segmental cut-off values and measures of diagnostic accuracy for the intima-media thickness of compressed temporal artery segments for the diagnosis of giant cell arteritis (GCA) on the patient level. To examine the influence of cardiovascular risk. Methods Retrospectively, patients evaluated for GCA with an ultrasound of the temporal arteries and an MRI of the head, including a T1-fatsat-black blood (T1-BB) sequence, were identified and classified based on cardiovascular risk and a dual reference standard of T1-BB on the segmental level and the clinical diagnosis on the patient level. Intima-media thickness of the common superficial temporal artery (CSTA), frontal and parietal branches (FB, PB) were measured by compression technique. Statistically and clinically optimal (specificity of approx. 90% for the patient level) cut-offs were derived. Diagnostic accuracy was evaluated on the patient level. Results The population consisted of 144 patients, 74 (51.4%) with and 70 (48.6%) without GCA. The statistically optimal cut-offs were 0.86 mm, 0.68 mm and 0.67 mm for the CSTA, the FB and PB, respectively. On the patient level sensitivity and specificity were 86.5 and 81.4%. Clinically optimal cut-offs were 1.01 mm, 0.82 mm and 0.69 mm and showed a sensitivity of 79.7% and a specificity of 90.0%. For patients without high cardiovascular risk, statistically optimal cut-offs showed a sensitivity of 89.6% and a specificity of 90.5%. Conclusion Newly derived ultrasound intima-media thickness cut-offs with a dual reference standard show high diagnostic accuracy on the patient level for the diagnosis of GCA, particularly in patients without high cardiovascular risk.
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Affiliation(s)
- Pascal Seitz
- Department of Rheumatology and Immunology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Fabian Lötscher
- Department of Rheumatology and Immunology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Susana Bucher
- Department of Rheumatology and Immunology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Lukas Bütikofer
- CTU Bern, Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Britta Maurer
- Department of Rheumatology and Immunology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Arsany Hakim
- University Institute of Interventional and Diagnostic Neuroradiology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Luca Seitz
- Department of Rheumatology and Immunology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
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Estrada P, Moya P, Narváez J, Moragues C, Navarro V, Camacho O, Roig D, Cerdà D, Heredia S, Reina D, Corominas H. Utility of applying a diagnostic algorithm in giant cell arteritis based on the level of clinical suspicion. Med Clin (Barc) 2024:S0025-7753(23)00755-8. [PMID: 38278759 DOI: 10.1016/j.medcli.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/16/2023] [Accepted: 11/18/2023] [Indexed: 01/28/2024]
Abstract
INTRODUCTION To reach the diagnosis of giant cell arteritis (GCA), signs, symptoms, laboratory tests, imaging findings, and occasionally anatomopathological results from temporal artery biopsy are evaluated. This study describes the results of an algorithm analysis based on clinical and ultrasound evaluation of patients with suspected GCA, highlighting its diagnostic utility by contrasting its use in different clinical suspicion scenarios. METHOD Prospective multicenter study evaluating patients referred with suspected GCA through a preferential circuit (fast track), grouping them according to low or high clinical suspicion of GCA. Each of these scenarios is evaluated by biopsy and ultrasound for all patients, resulting in positive, indeterminate, or negative outcomes, yielding six possible groups. Potential areas of improvement are explored, emphasizing that, following a negative or indeterminate ultrasound, 18-FDG-PET-CT could be recommended. We analyze the results and application of a diagnostic algorithm, confirming its efficiency and applicability based on whether there is high or low clinical suspicion. RESULTS Sixty-nine patients (41 in the high suspicion group and 28 in the low suspicion group). There were 41 new diagnoses of GCA: 35 in the high suspicion group and 6 in the low suspicion group. Using ultrasound alone, the initial algorithm has an overall diagnostic efficiency of 72.5%, which improves to 80.5% when including 18F-FDG-PET/CT. The negative predictive value of ultrasound in patients with low clinical suspicion is 84.6%, and the positive predictive value of ultrasound in patients with high suspicion is 100%, improving sensitivity from 57.1% to 80.8% with 18F-FDG-PET/CT in this scenario. Temporal artery biopsy was performed on all patients, with no differences in sensitivity or specificity compared to ultrasound. In cases where all three tests - ultrasound, biopsy, and 18F-FDG-PET/CT - are performed, sensitivity increases to 92.3% in patients with high clinical suspicion. CONCLUSION In situations of high clinical suspicion, the algorithm provides sufficient information for the diagnosis of GCA if ultrasound is positive. A negative ultrasound is sufficient to rule out the diagnosis in the context of low clinical suspicion. 18-FDG-PET-CT may be useful in patients with high suspicion and negative or indeterminate ultrasound results.
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Affiliation(s)
- Paula Estrada
- Servicio de Reumatología,Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, Universitat de Barcelona (UB), Barcelona, España.
| | - Patricia Moya
- Servicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, España
| | - Javier Narváez
- Servicio de Reumatología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| | - Carmen Moragues
- Servicio de Reumatología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| | - Vanessa Navarro
- Servicio de Reumatología,Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, Universitat de Barcelona (UB), Barcelona, España
| | - Oscar Camacho
- Servicio de Reumatología,Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, Universitat de Barcelona (UB), Barcelona, España
| | - Daniel Roig
- Servicio de Reumatología,Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, Universitat de Barcelona (UB), Barcelona, España
| | - Dacia Cerdà
- Servicio de Reumatología,Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, Universitat de Barcelona (UB), Barcelona, España
| | - Sergi Heredia
- Servicio de Reumatología,Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, Universitat de Barcelona (UB), Barcelona, España
| | - Delia Reina
- Servicio de Reumatología,Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, Universitat de Barcelona (UB), Barcelona, España
| | - Hèctor Corominas
- Servicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, España
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Nienhuis PH, van Nieuwland M, van Praagh GD, Markusiewicz K, Colin EM, van der Geest KSM, Wagenaar N, Brouwer E, Alves C, Slart RHJA. Comparing Diagnostic Performance of Short and Long [ 18F]FDG-PET Acquisition Times in Giant Cell Arteritis. Diagnostics (Basel) 2023; 14:62. [PMID: 38201371 PMCID: PMC10802840 DOI: 10.3390/diagnostics14010062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/14/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024] Open
Abstract
(1) Background: In giant cell arteritis (GCA), the assessment of cranial arteries using [18F]fluorodeoxyglucose ([18F]FDG) positron emission tomography (PET) combined with low-dose computed tomography (CT) may be challenging due to low image quality. This study aimed to investigate the effect of prolonged acquisition time on the diagnostic performance of [18F]FDG PET/CT in GCA. (2) Methods: Patients with suspected GCA underwent [18F]FDG-PET imaging with a short acquisition time (SAT) and long acquisition time (LAT). Two nuclear medicine physicians (NMPs) reported the presence or absence of GCA according to the overall image impression (gestalt) and total vascular score (TVS) of the cranial arteries. Inter-observer agreement and intra-observer agreement were assessed. (3) Results: In total, 38 patients were included, of whom 20 were diagnosed with GCA and 18 were without it. Sensitivity and specificity for GCA on SAT scans were 80% and 72%, respectively, for the first NMP, and 55% and 89% for the second NMP. On the LAT scans, these values were 65% and 83%, and 75% and 83%, respectively. When using the TVS, LAT scans showed especially increased specificity (94% for both NMPs). Observer agreement was higher on the LAT scans compared with that on the SAT scan. (4) Conclusions: LAT combined with the use of the TVS may decrease the number of false-positive assessments of [18F]FDG PET/CT. Additionally, LAT and TVS may increase both inter and intra-observer agreement.
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Affiliation(s)
- Pieter H. Nienhuis
- University of Groningen, University Medical Center Groningen, Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, 9713 GZ Groningen, The Netherlands
| | - Marieke van Nieuwland
- Hospital Group Twente, Department of Rheumatology and Clinical Immunology, 7600 SZ Almelo, The Netherlands; (M.v.N.); (C.A.)
- University of Groningen, University Medical Center Groningen, Department of Rheumatology and Clinical Immunology, 9713 GZ Groningen, The Netherlands
| | - Gijs D. van Praagh
- University of Groningen, University Medical Center Groningen, Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, 9713 GZ Groningen, The Netherlands
| | | | - Edgar M. Colin
- Hospital Group Twente, Department of Rheumatology and Clinical Immunology, 7600 SZ Almelo, The Netherlands; (M.v.N.); (C.A.)
| | - Kornelis S. M. van der Geest
- University of Groningen, University Medical Center Groningen, Department of Rheumatology and Clinical Immunology, 9713 GZ Groningen, The Netherlands
| | - Nils Wagenaar
- Hospital Group Twente, Department of Nuclear Medicine, 7555 DL Hengelo, The Netherlands
| | - Elisabeth Brouwer
- University of Groningen, University Medical Center Groningen, Department of Rheumatology and Clinical Immunology, 9713 GZ Groningen, The Netherlands
| | - Celina Alves
- Hospital Group Twente, Department of Rheumatology and Clinical Immunology, 7600 SZ Almelo, The Netherlands; (M.v.N.); (C.A.)
| | - Riemer H. J. A. Slart
- University of Groningen, University Medical Center Groningen, Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, 9713 GZ Groningen, The Netherlands
- University of Twente, Faculty of Science and Technology, Department of Biomedical Photonic Imaging, 7522 NB Enschede, The Netherlands
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Heras-Recuero E, Landaeta-Kancev LC, Martínez de Bourio-Allona M, Torres-Rosello A, Blázquez-Sánchez T, Ferraz-Amaro I, Castañeda S, Martínez-López JA, Martínez-Dhier L, Largo R, González-Gay MÁ. Positron Emission Computed Tomography Spectrum of Large Vessel Vasculitis in a Tertiary Center: Differences in 18F-fluorodeoxyglucose Uptake between Large Vessel Vasculitis with Predominant Cranial and Extracranial Giant Cell Arteritis Phenotypes. J Clin Med 2023; 12:6164. [PMID: 37834808 PMCID: PMC10573665 DOI: 10.3390/jcm12196164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
(1) Objective:To assess the spectrum of PET-CT-related large vessel vasculitis (LVV) in a Spanish tertiary center and to determine whether FDG uptake by PET-CT differs between giant cell arteritis (GCA) with predominant cranial or extracranial phenotypes. (2) Methods: The spectrum of patients diagnosed with LVV by PET-CT in a tertiary referral hospital that cares for 450,000 people over a period of two years was reviewed. Moreover, differences in FDG uptake between LVV-GCA with predominantly cranial and extracranial phenotype were analyzed. (3) Results: Eighty patients were diagnosed with LVV by PET-CT. Most were due to systemic vasculitis (n = 64; 80%), especially GCA (n = 54; 67.5%). Other conditions included the presence of rheumatic diseases (n = 4; 3.2%), tumors (n = 9; 7.2%) and infections (n = 3; 2.4%). LVV-GCA patients with predominant extracranial GCA phenotype were younger (mean ± SD: 68.07 ± 9.91 vs. 75.46 ± 7.64 years; p = 0.017) and had a longer delay to the diagnosis (median [interquartile range] 12 [4-18] vs. 4 [3-8]; p = 0.006), but had polymyalgia rheumatica symptoms more frequently than those with predominantly cranial GCA phenotype (46.3% vs. 15.4%, p = 0.057). When FDG uptake was compared according to the two different disease patterns, no statistically significant differences were observed. However, patients with extracranial LVV-GCA showed a non-significantly higher frequency of vasculitic involvement of lower-extremity arteries. (4) Conclusions: Regardless of the predominant phenotype, LVV identified by PET-CT is more commonly due to GCA in the Spanish population. In these GCA patients, younger age, PMR, and a higher frequency of lower-extremity artery vasculitis suggest the presence of LVV.
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Affiliation(s)
- Elena Heras-Recuero
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, Av. de los Reyes Católicos, 2, 28040 Madrid, Spain; (E.H.-R.); (A.T.-R.); (T.B.-S.); (J.A.M.-L.); (R.L.)
| | - Laura Cristina Landaeta-Kancev
- Department of Nuclear Medicine, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain; (L.C.L.-K.); (M.M.d.B.-A.); (L.M.-D.)
| | - Marta Martínez de Bourio-Allona
- Department of Nuclear Medicine, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain; (L.C.L.-K.); (M.M.d.B.-A.); (L.M.-D.)
| | - Arantxa Torres-Rosello
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, Av. de los Reyes Católicos, 2, 28040 Madrid, Spain; (E.H.-R.); (A.T.-R.); (T.B.-S.); (J.A.M.-L.); (R.L.)
| | - Teresa Blázquez-Sánchez
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, Av. de los Reyes Católicos, 2, 28040 Madrid, Spain; (E.H.-R.); (A.T.-R.); (T.B.-S.); (J.A.M.-L.); (R.L.)
| | - Iván Ferraz-Amaro
- Department of Internal Medicine, University of La Laguna (ULL), 38200 Tenerife, Spain;
- Division of Rheumatology, Hospital Universitario de Canarias, 38200 Tenerife, Spain
| | - Santos Castañeda
- Division of Rheumatology, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain;
| | - Juan Antonio Martínez-López
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, Av. de los Reyes Católicos, 2, 28040 Madrid, Spain; (E.H.-R.); (A.T.-R.); (T.B.-S.); (J.A.M.-L.); (R.L.)
| | - Luis Martínez-Dhier
- Department of Nuclear Medicine, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain; (L.C.L.-K.); (M.M.d.B.-A.); (L.M.-D.)
| | - Raquel Largo
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, Av. de los Reyes Católicos, 2, 28040 Madrid, Spain; (E.H.-R.); (A.T.-R.); (T.B.-S.); (J.A.M.-L.); (R.L.)
| | - Miguel Ángel González-Gay
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, Av. de los Reyes Católicos, 2, 28040 Madrid, Spain; (E.H.-R.); (A.T.-R.); (T.B.-S.); (J.A.M.-L.); (R.L.)
- Medicine and Psychiatry Department, University of Cantabria, 39008 Santander, Spain
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