Demographic change and agrowing shortage of healthcare professionals pose significant challenges to the German healthcare system. Rheumatology is particularly affected due to increasing patient demand and evolving societal expectations regarding work-life balance, family compatibility, and gender equity. As aresult, flexible working time models are gaining importance. This study aimed to assess existing and desired working time models in rheumatology, their feasibility, and perceived barriers from the perspectives of both employees and leadership. The Commission of Equal Opportunities of the German Society for Rheumatology (DGRh) developed two online questionnaires targeting rheumatology healthcare professionals in employee and leadership roles asking about their current employment situation, existing flexible working time models, and preferences and feasibility of various working time models. The survey was distributed between September 2024 and March 2025 via the mailing lists of the DGRh and the Association of Rheumatological Acute Clinics (VRA), and via personal contacts by email, and subsequently evaluated descriptively. Atotal of 151 individuals participated (111 employees, 40leaders). Part-time work, especially in outpatient care, was common and frequently desired. The 4‑day workweek and hybrid models (e.g., home office) were considered attractive but posed organizational challenges. Of the employees, 24% reported having changed jobs due to alack of flexible options; 30% of leaders had lost staff for the same reason. Most respondents prioritized flexibility over reduced working hours. Flexible working time models are generally desired and often feasible in rheumatology but require tailored implementation and structural support. They are essential for improving job satisfaction and staff retention and should be strategically promoted to ensure sustainable rheumatologic care.

Diagnostic accuracy and trajectories of referrals for gout to rheumatology.

Assess whether drinking freshly squeezed lemons in water (lemon water) influences serum urate (SU) levels, glomerular filtration rate (GFR), and urine pH levels in gout patients and individuals with hyperuricemia. In this cohort study, we retrospectively analyzed the medical records of patients who presented to two outpatient Polish rheumatology clinics. Patients who consumed the juice of two squeezed lemons mixed with 2 L of water each day, according to a general recommendation made by clinic providers, were included in this analysis. We collected all relevant medical and medication histories from each patient. SU levels, GFR, and urine pH were extracted from the medical record. The study included 90 patients who reported consumption of lemon juice. The mean age was 49.2 years, and 69% were men. The patients were categorized into three groups: Group A consisted of gout patients, Group B included individuals with hyperuricemia but without gout, and Group C served as a control group with diagnoses other than gout. After six weeks, SU levels decreased from baseline in Group A compared to Group B (p = 0.03) and in Group B compared to Group C (p = 0.003), and there was an increase in GFR when comparing Group A to Group B (p = 0.03) and Group A to Group C (p = 0.0007). After 6 weeks of drinking lemon water, a statistically significant reduction in SU level and improved GFR was observed. Lemon water may serve as a beneficial adjunct therapy for individuals with gout and hyperuricemia.

To examine the association of patient resilience with health-related quality of life (HRQOL) in systemic lupus erythematosus (SLE). We used data from a prospective cohort study of patients with SLE enrolled across 15 rheumatology clinics across the US who viewed a patient decision aid for SLE management during a regular clinic visit. We examined the association of high resilience with HRQOL on 29-item Patient Reported Outcomes Measurement Information System (PROMIS-29) domains using multivariable linear mixed-effects model analysis, adjusted for demographics, social determinants of health (SDOH), flare, site, time, and comorbid rheumatic diseases. Out of 945 patients with SLE, 27% had high resilience, with a 2-item Connor-Davidson Resilience Scale (CD-RISC2) score of 8. Compared to patients who had low resilience, those with high resilience were more likely to report excellent or very good health (46% vs 17.7%); lower SLE activity (3.94 vs 5.18 on a 0-10 scale), and higher SLE wellness (7.54 vs 6.15 on a 0-10 scale). We noted that high resilience was associated with a positive moderate effect size (Cohen d > 0.5) for physical functioning, social participation, emotional anxiety, emotional distress, fatigue, pain interference, and pain intensity, as well as a favorable small effect size (Cohen d 0.2-0.49) for sleep disturbance, in unadjusted analyses. In a multivariable-adjusted mixed linear regression analysis, high resilience was associated with all 8 HRQOL scale scores. High patient resilience was independently associated with better HRQOL outcomes in SLE after adjusting for demographics, SDOH, SLE flare, site, time, and comorbid rheumatic diseases. Interventions to promote resilience have the potential to improve HRQOL outcomes in SLE. (ClinicalTrials.gov: NCT03735238).

The Hacettepe University Vasculitis Research Centre (HUVAC) initiated prospective patient registration in 2014 to advance clinical and translational research in vasculitis. The transition to a web-based platform enabled the establishment of the Turkey Vasculitis Study Group (TRVaS), which was formally launched in 2021. By 2025, TRVaS had expanded from its initial six centers to a nationwide network comprising 46 centers—14 pediatric and 32 adult rheumatology clinics. Since its inception, TRVaS has developed structured, disease-specific registries and initiated multiple multicenter projects at both national and international levels. TRVaS continues to strengthen Türkiye’s vasculitis research capacity by fostering data collection, promoting large-scale collaboration, and enabling high-quality clinical and translational studies that contribute to global scientific efforts.

Background: Ankylosing spondylitis (AS) is a polygenic disorder. Copy number variations (CNVs) alter the expression of TLR7, T-bet, IL-12B, and FcγRIIIB genes, contributing to AS development via their immune system roles. Objective: The current study aimed to assess the correlation between AS susceptibility and CNVs of TLR7, T-bet, IL12B, and FcγRIIIB, as well as their influence on disease activity. Methods: The study involved 42 healthy controls and 72 patients with AS, recruited from the Rheumatology and Rehabilitation clinic of Zagazig University Hospitals, Zagazig, Egypt, from 01 November 2023 to 30 October 2024. Sociodemographic, clinical data and blood samples were collected from all participants. Copy number estimations for TLR7, T-bet, IL12B, and FcγRIIIB genes were performed using SYBR Green real-time polymerase chain reaction. Results: Of 72 cases aged 19 to 52 years, 47 (65.2%) were men and 25 (34.8%) were women. Controls included 42 participants aged 27 to 55 years, 22 (52.4%) men and 20 (47.6%) women. Higher IL12b and FcγRIIIB gene copy numbers were significantly associated with a higher risk of AS (p = 0.001, odds ratio [OR]: 3.8, 95% confidence interval [CI]: 1.7–8.07, and p < 0.001, OR: 5.5, 95% CI: 2.31–13.08, respectively). While T-bet and TLR7 gene CNVs showed no significant association with AS risk. No significant association was observed between the studied CNVs and AS activity. Conclusion: High copy numbers of IL12B and FcγRIIIB genes may be associated with increased AS risk. However, no significant correlation was found between AS risk and TLR7 or T-bet CNVs. What this study adds: The findings of this study revealed that genetic copy number variations may contribute to the risk of AS.

Background. Psoriatic arthritis (PsA) is a chronic inflammatory disease that significantly affects patients’ quality of life. Clinical trials are fundamental tools for improving therapeutic strategies and disease management; high patient adherence is desirable to reduce selection bias and ensure the generalizability of the results. However, data regarding patients’ willingness to participate in pharmacological and nutritional interventional studies are currently limited. The aim of this study is to evaluate the willingness of patients with PsA to participate in pharmacological and nutritional clinical trials, and to identify clinical and demographic factors potentially associated with such willingness. Materials and Methods. A cross-sectional, non-profit survey was conducted using a structured questionnaire administered consecutively to patients attending the rheumatology clinic between October 31, 2024 and January 7, 2025. For each participant, demographic data (sex, age, education level, body mass index [BMI]) and clinical data (disease duration, disease activity, current therapy, and comorbidities) were collected. Descriptive analysis was used to characterize the cohort. Results. A total of 225 patients with PsA were enrolled, with a mean age of 57.68 years (range: 28–85). The sample included 96 female participants (42.6%), with a mean BMI of 25.81. The median disease duration was 14 years; 94.2% of patients had disease activity ranging from remission to low activity. The main results are shown in Figure 1. Overall, 186 patients (82.7%) expressed willingness to participate in clinical studies; among these, 129 (57.3%) were willing to take part in both pharmacological and nutritional trials, while 45 patients (20%) reported willingness to participate exclusively in nutritional studies. Chi-square analysis did not reveal statistically significant associations between sex, BMI, education level, disease duration, and willingness to participate (p > 0.05 for all variables analyzed). Conclusions. Patients with PsA showed a greater inclination to participate in dietary intervention studies compared to pharmacological ones. This attitude was not significantly associated with sex, education level, BMI, disease duration, or disease activity. However, further studies with larger samples are needed to confirm these preliminary findings and to better explore the determinants of participation willingness in different patient subgroups. These results highlight the importance of personalized recruitment strategies, tailored to patients’ therapeutic and behavioral interests, in order to optimize enrollment and promote heterogeneous representation within clinical trials.

Early diagnosis of Systemic Sclerosis (SSc) is challenging due to nonspecific symptoms and clinical overlap with other autoimmune diseases. To investigate factors associated with diagnostic delays in SSc, focusing on the number and specialties of physicians consulted before diagnosis. This cross-sectional study included SSc patients registered at a university rheumatology clinic. Demographics, clinical features, and physical examination findings were recorded. The number and specialties of physicians consulted before diagnosis were obtained through structured face-to-face interviews. Of 240 screened patients, 135 were included (120 female, 88.8%; 55 with diffuse SSc, 40.7%; mean age 52.1 ± 11.5years). The median time to diagnosis was 36 months (IQR 12-96) from Raynaud's phenomenon (RP) onset and 11(IQR 0-35) months from the first non-RP symptom. Patients with limited SSc had a significantly longer RP-to-diagnosis interval than those with diffuse SSc (44 vs. 20 months, p = 0.024). The median number of physicians consulted before diagnosis was 3 (range 1-9). Higher educational level (IRR = 0.97, p = 0.036) and referral by a familiar healthcare professional (IRR = 0.78, p = 0.035) were independently associated with fewer pre-diagnostic consultations. Among 119 patients who recalled their first physician, 42 (35.3%) initially consulted an internist, 28 (23.5%) a family physician, 11 (9.2%) a dermatologist, and 10 (8.4%) a cardiovascular surgeon; the remainder visited other specialists. Only 8 patients (6.7%) received an SSc diagnosis at their first consultation. SSc diagnosis is often delayed, requiring multiple consultations. Greater physician awareness and timely rheumatology referrals are essential.

BackgroundOsteoarthritis (OA) is the most common form of arthritis, and its prevalence is increasing. We developed an educational tool to improve primary care provider (PCP) comfort with diagnosis and management of non-inflammatory arthritis.MethodsA pilot survey of PCP comfort with OA informed the creation of a two-page educational tool which was introduced at 28 clinics within the University of Vermont Health Network. The tool’s utility was assessed with pre- (n = 94) and post-intervention (n = 32) surveys. We conducted a chart review of adult patients diagnosed with OA at new patient rheumatology visits between 2020 and 2022.ResultsOA was the principal diagnosis at 9% of new patient rheumatology visits. Among 390 patients diagnosed with OA, 22 (5%) returned to rheumatology clinic within 6 months. Patients traveled on average 31 miles (SD ± 30) and 40 min (SD ± 31) one-way to reach new patient appointments. Pre-intervention, clinicians were least comfortable knowing when to refer to rheumatology and most comfortable diagnosing OA. Post-intervention, there were improvements in total comfort with OA management and when to refer to orthopedics. Half of clinicians (50%) used the tool in practice, 63% in medical education and 43% in shared decision making. Post-intervention, 34% expected a reduction in rheumatology referrals and 9% reported placing fewer referrals already.ConclusionsA small percentage of patients with OA require ongoing rheumatologic care, with patients traveling a significant distance for evaluation. The introduction of a concise educational tool for PCPs improved comfort managing non-inflammatory arthritis with anticipation of fewer referrals to rheumatology.Supplementary InformationThe online version contains supplementary material available at 10.1186/s41927-025-00595-8.

Objective: To identify associated risk factors in RA. The highest reported prevalence for RA was in the 42-52 years age group, with lower prevalence in over 80-year-old, for whom diagnosis may be more difficult. Study Design: Cross-sectional case-control study Place and Duration of Study: This study was conducted at the Thi-Qar Governorate in south of Iraq from 1st February 2025 to 30th June 2025. Methods: The link between vitamin D deficiency and rheumatoid arthritis and its possible consequences on disease activity and coexisting diseases were assessed. Fifty patients who had been clinically diagnosed with rheumatoid arthritis according to the 2010 ACR/EULAR classification criteria were enrolled from rheumatology clinics and hospitals in the area. A group of healthy subjects, age- and sex-matched and without any autoimmune and chronic inflammatory diseases was also studied for comparisons.Results: Males had a higher prevalence of Anaplasia compared to females, which might be associated with genetic and immune-related differences between males and females. Diabetic patients were more frequently infected (42%) than hypertensive patients (36%), indicating different effects of comorbidities on the progression of infection. In terms of hematological findings, mild anemia due to chronic inflammation was suspected in all cases, with significant vitamin D3 deficiency identified in more than 80% of cases. Conclusion: Vitamin D has an immunity-regulating role and could be useful in rheumatoid arthritis treatment. A global integrated strategy taking into account comorbid conditions, nutritional deficiencies and demographics in relation to vitamin D supplementation could potentially result better outcomes. In the future, more studies are required to improve the diagnosis and treatment of rheumatoid arthritis.

BackgroundDespite the call for inclusion of routine mental health screening in pediatric rheumatology practice, the practical aspects of implementation in real world clinical settings have not yet been demonstrated. The aims of this study were: (1) to determine the acceptability and practicality of mental health screening in patients with Juvenile Idiopathic Arthritis (JIA) during routine visits at a pediatric hospital multidisciplinary clinic; (2) to understand the frequency and severity of anxiety and depressive symptoms within this sample.MethodsPatients with JIA aged 8–17 were invited to participate during their routine clinic appointments. Patients completed three questionnaires on an iPad: PROMIS Pediatric Anxiety (v3), PROMIS Pediatric Depression (v3), and an acceptability questionnaire. Caregivers completed an acceptability questionnaire. Participants were provided with feedback on their scoring profile and relevant mental health resources during their clinic visit.ResultsForty patient-parent dyads participated during routine follow-up appointments at the Rheumatology Clinic at BC Children’s Hospital between April and August 2024 (mean patient age = 13.5 years; 23 (57.5%) females). Overall, 92% of patients and 95% of caregivers reported the screening process to be ‘Acceptable’ or ‘Completely Acceptable’. The mean PROMIS Anxiety t-score was 51.79 (SD = 11.06) and the mean PROMIS Depression t-score was 50.54 (SD = 7.62). Six patients (15%) had elevated or very elevated anxiety scores, and two patients (5%) had elevated depression scores.ConclusionThere was high acceptability of the mental health screening process among patients and caregivers. The mean anxiety and depression scores were similar to the general population with a small proportion of patients reporting elevated scores. Mental health screening is practical within rheumatology clinic visits and should be considered by health professionals providing care for youth with JIA.

This study aimed to determine the frequency, causes, mortality rates, and predictors of mortality in patients with extreme hyperferritinemia (≥ 5000ng/mL) followed in rheumatology and hematology clinics. Patients with a ferritin level of ≥ 5000ng/mL were retrospectively screened using the electronic data recording system. Extreme hyperferritinemia was detected in 0.76% of 43,110 ferritin tests performed over 13years. The data of 139 patients, including 35 patients from the rheumatology clinic and 104 patients from the hematology clinic, were analyzed. In the study, 71.4% of rheumatology cases and 50.9% of hematology cases were female. The median ferritin value for the overall group was 7768ng/mL, and the mean value was 13,022 ± 17,141 (5017-100,000) ng/mL. Regarding the etiology of extreme hyperferritinemia, iron overload was detected in 42.4% of all patients, infection in 23.0%, and Still's disease in 14.4%. The most common cause was Still's disease (54.3%) in rheumatology patients and iron overload (55.8%) in hematology patients. Within the first month, 25 (18.0%) patients died. The most common cause of mortality was macrophage activation syndrome (MAS) in rheumatology patients and infection in the hematology group. In rheumatology patients, the risk factors for mortality in univariate analysis were the presence of MAS [HR = 13.257 (95% CI = 1.374-127.934, p = 0.025)]. Ferritin level can predict first month mortality in rheumatology patients with extreme hyperferritinemia (cutoff > 36,137.5ng/mL; sensitivity 100%, specificity 96.77%, p < 0.0001, AUC = 0.976, 95% CI = 0.915-1.000) but not in hematology patients. In conclusion, severe hyperferritinemia may be encountered in rheumatology and hematology practice. Ferritin level may be a good marker for predicting mortality, especially in rheumatology patients. Key points • In patients with extreme hyperferritinemia, the most common etiologies were Still's disease among rheumatology patients and iron overload among hematology patients. •The 1-month mortality rate was 11.4% in the rheumatology group and 20.2% in the hematology group. The leading cause of death was macrophage activation syndrome (MAS) in the rheumatology cohort and infection in the hematology cohort. •Among rheumatology patients, serum ferritin levels were a strong predictor of 1-month mortality, with a cutoff value of >36,137.5 ng/mL yielding a sensitivity of 100%, specificity of 96.77%, and an AUC of 0.976 (95% CI,: 0.915-1.000;, p < 0.0001). However, ferritin levels did not demonstrate predictive value for 1-month mortality in hematology patients.

Rheumatoid arthritis is the commonest chronic inflammatory arthritis. Oral methotrexate is recommended as the first-line disease modifying drug for its management, and subcutaneous injections are typically prescribed if there is gastrointestinal intolerance or suboptimal efficacy. It is not known whether subcutaneous methotrexate is more effective and cost-effective compared to oral methotrexate when used as first-line treatment in people diagnosed with rheumatoid arthritis. The Methotrexate Oral Or SubcutanEous (MOOSE) trial aims to compare the clinical and cost-effectiveness of subcutaneous and oral methotrexate when used as first-line disease modifying anti-rheumatic drug in adults with rheumatoid arthritis and collect information about the acceptability of both routes of administration. MOOSE is an open-label, multi-centre, assessor-blinded, two-arm randomised controlled trial, with an internal feasibility assessment, economic evaluation and qualitative study. It is a secondary care-based trial, involving NHS hospital rheumatology clinics. Potentially eligible patients will be approached to participate around the time of their initial clinic visit. Eligible patients who consent will be randomised to either oral or subcutaneous methotrexate. Randomisation will be minimised by trial centre, 28-joint disease activity score, and disease duration. Interventions will be prescribed open-label with participants and clinicians aware of treatment allocated. Outcome assessors will be blinded to treatment allocation. Each participant will be in the trial for 52weeks. The primary outcome is remission assessed at 24weeks. Secondary outcomes include disease activity, quality of life, mental health and employment. A qualitative study will involve semi-structured interviews to analyse the acceptability of interventions. The health economic study will use healthcare utilisation data, quality of life data, and cost-estimates to model cost-effectiveness. Whether to use subcutaneous or oral methotrexate first line for RA is an important question for patients and clinicians. MOOSE study will provide evidence on the clinical and cost-effectiveness of oral and subcutaneous routes of methotrexate administration to answer this important question. Prospectively registered with the International Standard Randomised Controlled Trial Number (ISRCTN) 14,403,521. Registered on 03 August 2023 https://doi.org/10.1186/ISRCTN14403521 .

Incorporating telemedicine into pharmacist services can promote medication adherence, reduce polypharmacy, and prevent adverse drug events as part of identification of drug-related problems. Our primary aim was to measure the acceptability to patients of telemedicine services using a standardized patient satisfaction survey and compare it to that for face-to-face services. Our secondary aim was to assess the feasibility of the telemedicine modality for pharmaceutical care interventions by measuring, quantifying, and categorizing drug-related problems identified during the service. The study followed a prospective crossover design from October 2021 to September 2022. Adult patients (21 years or older) with rheumatic diseases evaluated at a university-based outpatient clinic were eligible to be enrolled. After the intervention, patients completed a survey regarding satisfaction and perception of their appointment. Descriptive statistics were used for patient demographic characteristics. Patient satisfaction with the modalities was compared using a t test. In this study, 296 patients were enrolled with a mean (SD) age of 50.4 (12.5) years. Participating patients were utilizing a mean (SD) of 10.2 (4.7) medications. No significant differences (P < 0.05) were observed for any of the survey questions when comparing responses for the face-to-face and telemedicine encounters. In general, patients strongly agreed that they were satisfied with the services they received and perceived the services as unique and valuable in both types of encounters. Overall satisfaction was very high, and no differences were found in the perception of or satisfaction with services between the telemedicine and face-to-face modalities.

Background/Objectives: The external validity of sarcopenia screening questionnaires in the elderly has been examined in several conditions but rarely evaluated in patients with rheumatoid arthritis (RA). This study aimed to determine the performance of five Thai versions of sarcopenia screening questionnaires (SARC-F [Strength, Assistance with walking, Rising from a chair, Climbing stairs, and Falls], SARC-CalF [SARC-F plus calf circumference], MSRA [Mini Sarcopenia Risk Assessment]-7, MSRA-5, and modified MSRA-5 questionnaires) in Thai RA patients, and evaluate the correlations among these instruments. Methods: In this cross-sectional study, consecutive adult RA patients (aged ≥20 years) from an outpatient rheumatology clinic completed the five sarcopenia screening questionnaires listed above. Sarcopenia was defined according to criteria of the 2019 Asian Working Group for Sarcopenia (AWGS). Appendicular skeletal muscle mass, grip strength, and physical performance were assessed using bioelectrical impedance analysis, a hand dynamometer, and a 6 m gait speed test, respectively. The cut-off values used for each sarcopenia screening questionnaire were pre-specified according to their respective established thresholds. Results: Of 299 RA patients (89.0% female, mean age of 61.3 ± 11.6 years, median [interquartile range] disease duration of 12.8 [8.2, 20.0] years), 37.5% and 27.4% of them had sarcopenia and severe sarcopenia, respectively. The areas under the receiver operating characteristic (ROC) curve for the SARC-F, SARC-CalF, MSRA-7, MSRA-5, and modified MSRA-5 questionnaires were 0.60, 0.74, 0.65, 0.62, and 0.65, respectively, with sensitivities of 34.8%, 73.2%, 77.7%, 68.8%, and 72.3% and specificities of 84.5%, 75.4%, 51.3%, 55.1%, and 58.3%, respectively. SARC-F demonstrated moderate correlations with the other questionnaires: SARC-CalF (r = 0.57), MSRA-7 (r = −0.52), MSRA-5 (r = −0.55), and modified MSRA-5 (r = −0.65), all with a p-value of <0.001. Conclusions: Sarcopenia is common among Thai RA patients. SARC-CalF had the best balance of sensitivity and specificity and is likely the most suitable sarcopenia screening questionnaire for Thai RA patients.

IntroductionThis study evaluated the efficacy and safety of anifrolumab (ANF) in patients with systemic lupus erythematosus (SLE) presenting with severe manifestations such as neuropsychiatric SLE (neuro-SLE), lupus nephritis, and antiphospholipid syndrome-associated SLE (APS-SLE), based on real-world clinical practice at a single center in Poland. This study is a retrospective analysis of patients with severe SLE who failed to achieve remission following previous immunosuppressive treatment and were subsequently started on ANF therapy.Material and methodsTen patients with SLE were treated at the Rheumatology Clinic of the National Institute of Geriatric, Rheumatology and Rehabilitation (Warsaw, Poland) between 15 March 2024 and 20 April 2025. Data collected included medical history, clinical and demographic information, imaging results, Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) score, and treatment details. All patients had severe forms of SLE, with some presenting active neuropsychiatric symptoms and others with active lupus nephritis. All were unresponsive to prior high-dose immunosuppressive therapy and glucocorticosteroids.ResultsAll 10 patients with severe manifestations, including neuro-SLE, lupus nephritis and APS-SLE, showed significant clinical improvement following ANF therapy, as evidence by reduced SLEDAI-2K scores.ConclusionsAnifrolumab appears to be a promising and safe therapeutic option for patients with severe SLE based on real-world data.

It is assumed that chronic immune-inflammatory rheumatic disease may be a factor increasing the likelihood of developing hypogonadism syndrome, and vice versa - the presence of uncompensated testosterone deficiency may predispose to a higher risk of developing or a more severe course of immune-inflammatory rheumatic disease. To study the frequency of hypogonadism in men with systemic sclerosis (SSc) and idiopathic inflammatory myopathy (IIM) and its associations with clinical manifestations of SSc and IIM. A total of 65 patients were included in the one-stage continuous study, including 39 with SSc and 26 with IIM, who were undergoing inpatient treatment at Nasonova Research Institute of Rheumatology. The patients underwent determination of the level of total testosterone with subsequent division into subgroups with normal (>12 nmol/l) and reduced levels. An intergroup comparison was performed using the main indicators used in clinical rheumatology practice to assess the clinical and demographic characteristics of SSc and IIM. A correlation analysis was performed between the level of total testosterone and some clinical and laboratory indicators. The frequency of detected testosterone deficiency in SSc was 23.1%, and in IIM - also 23.1%. Patients with hypogonadism and SSc, compared with the group with normal testosterone levels, were characterized by a higher body mass index - BMI (27.0 [25.8; 29.8] kg/m2 vs 23.5 [22.0; 26.1] kg/m2; p=0.033), were more often obese (77.8% vs 33.3%; p=0.022) and had a higher mean fasting glucose level (5.62 [5.27; 5.69] mmol/l vs 5.03 [4.82; 5.33] mmol/l; p=0.037). In addition, patients with hypogonadism were more often positive for anti-Scl70 (100.0% vs 40.7%; p=0.003) and had a trend towards higher titers of antinuclear factor (p=0.063). Significant inverse correlations were found between total testosterone levels and BMI, as well as antinuclear factor titer. Patients with IIМ and hypogonadism were characterized by a higher frequency of interstitial lung disease (66.7% vs 15.0%; p=0.012). Significant negative correlations were found between total testosterone levels and age, BMI and erythrocyte sedimentation rate. A high frequency of hypogonadism was shown in men with SSc and IIМ. Reduced testosterone levels were accompanied by some metabolic disorders, as well as a high frequency of antibodies and clinical features characteristic of a more unfavorable course of the disease.

Abstract Background Among patients diagnosed with rheumatoid arthritis (RA) and psoriatic arthritis (PsA), several factors have been associated with hepatic fibrosis, including exposure to methotrexate (MTX) and metabolic syndrome. In this study, we compared the prevalence of hepatic fibrosis in RA and PsA patients who had been taking MTX, and explored factors associated with hepatic fibrosis in these patients. Methods Patients with RA or PsA who were treated with MTX and managed at the rheumatology clinic, Thammasat University Hospital, between November 2022 and December 2023 were included. Hepatic fibrosis was detected using transient elastography (TE). The prevalence of hepatic fibrosis was compared between the RA and PsA patients. Multivariable linear regression analysis was performed to determine the factors associated with hepatic fibrosis, with emphasis on metabolic syndrome and cumulative methotrexate dose. Results Among the 295 recruited patients, 185 (62.7%) were diagnosed with RA and 110 (37.2%) with PsA. Hepatic fibrosis detected by TE was found in 28.6% of RA patients and 45.5% of PsA patients, respectively. Higher prevalence of metabolic syndrome was observed in the PsA subgroup than that in RA subgroup. The linear regression analysis identified the association between hepatic fibrosis and metabolic syndrome (regression coefficient: 4.127; 95% confidence interval: 3.389 to 4.864; p &lt; 0.001). Notably, cumulative MTX dose and MTX dose per body weight were not associated with hepatic fibrosis in the current analysis. Conclusions Patients with PsA have a higher prevalence of metabolic syndrome and hepatic fibrosis than those with RA. Metabolic syndrome is associated with hepatic fibrosis, even after adjusting for MTX exposure and types of inflammatory arthritis.

Abstract Background Lupus Nephritis (LN) is one of the most common and serious manifestations which occur in 50-80% of pediatric systemic lupus erythromatosis (SLE) patients. Urinary activated leukocyte cell adhesion molecule (ALCAM) is a potential non-invasive biomarker that may predict renal pathology activity index in LN and may serve as a valuable surrogate marker of renal histopathology. We aimed at evaluating the role of urinary ALCAM as a diagnostic biomarker in LN and its relation to the disease activity and histopathological severity. Methods This study was a cross-sectional study, where we included pediatric SLE patients from 6 to 18 years, who follow up regularly at Pediatric Allergy, Immunology and Rheumatology clinic, Children’s Hospital, Ain Shams University, and similar number of age and gender matched controls. Patients were divided into two equal groups; group 1: SLE LN, group 2: SLE Non-LN. Clinico-demographics, and laboratory data were collected and analyzed to assess disease activity by total and renal SLEDAI score, also, renal biopsy results for LN. Urinary ALCAM levels were measured using ELISA, and correlated to disease activity and histopathology severity. Results We included 60 SLE patients (30 patients with LN and 30 non- LN), and 60 controls with mean±SD age of 12.38±2.35, and 13.4±2.43 years (p &amp;gt; 0.05) respectively. The mean±SD SLE duration and SLEDAI score of all SLE patients (10 days before enrolment) was 18.19±18.97 months and11.3±3 respectively. In LN group, the median renal SLEDAI (IQR) was 6.5 (2.4), and class II (40%) was the most common class with median (IQR) chronicity and activity indices of 2 (IQR1-3), and 5.5 (IQR2-9) respectively. The median (IQR) urinary ALCAM levels were significantly higher in LN group than non- LN group and controls [1001.6 (766.4 - 1186) vs 229.7 (182 - 270.5), 209.7 (150 - 250.5) ng/mL respectively] (p &amp;lt; 0.001).Urinary ALCAM was positively correlated with 24-hour urinary proteins, and renal SLEDAI score (p &amp;lt; 0.005), meanwhile it showed no statistically significant correlation with LN class, activity and chronicity indices. Conclusion Urinary ALCAM levels were significantly higher in LN patients compared to non-LN SLE patients and healthy controls, indicating its potential role in LN detection. Additionally, it correlated positively with proteinuria and renal SLEDAI scores, suggesting its association with disease activity. Meanwhile, it reflects renal inflammation, but it does not necessarily predict histological severity.

Abstract Introduction ANCA-associated vasculitis (AAV) typically presents with renal or pulmonary involvement, while skeletal muscle manifestations are rare. This case highlights a diagnostic dilemma where a predominantly neuromuscular presentation—initially attributed to infection or primary myopathy—ultimately revealed systemic vasculitis on renal biopsy. This case underscores the importance of recognising non-classical presentations of AAV where inflammatory myopathy is the predominant initial manifestation. The diagnostic pathway was complex and highlighted the value of multidisciplinary collaboration, together with careful balance of immunosuppressive agents. Case description An 80-year-old female presented with a two-week history of lethargy, fever, weight loss, dyspnoea, and progressive lower limb weakness. She was initially managed for presumed community-acquired pneumonia following but chest imaging revealed no consolidation, and empirical antibiotics were ineffective. Blood tests showed elevated inflammatory markers and a mildly raised creatine kinase. Neurological evaluation revealed bilateral lower limb weakness and EMG changes consistent with inflammatory myopathy. MRI of the thighs and spine revealed symmetrical muscle oedema. Despite a negative myositis antibody screen, autoimmune testing revealed strong MPO-ANCA positivity. While rheumatology initially favoured an infective cause, she subsequently developed significant proteinuria and rising creatinine levels. Renal biopsy confirmed necrotising glomerulonephritis consistent with ANCA vasculitis. Immunosuppressive treatment was initiated with rituximab, avacopan and a tapering course of corticosteroids. The patient responded well to treatment initially but experienced a relapse upon steroid tapering, with worsening renal function and neuromuscular symptoms. Increasing the steroid dose led to marked clinical improvement. She continues to be followed in renal and rheumatology clinic, with gradual steroid tapering and ongoing monitoring of renal and neurological function. Discussion This case presented diagnostic and therapeutic challenges due to its atypical features. The initial clinical picture mimicked infection, and the presence of inflammatory myopathy—uncommon in AAV—diverted attention from vasculitis. Negative myositis serology further complicated the picture. However, persistent symptoms and MRI findings prompted a broader autoimmune work-up, leading to the diagnosis. Steroid initiation provided early benefit, and the addition of rituximab and avacopan was appropriate given the renal involvement and steroid-sparing need. However, the relapse during tapering highlights the complexity of managing steroid-dependent disease in elderly patients and raises questions about optimal tapering speed and maintenance strategies. This case underscores the importance of considering vasculitis in the differential diagnosis of unexplained myopathy, especially when accompanied by systemic symptoms. It also illustrates the value of timely renal biopsy in identifying pathology that can be masked by non-specific presentations. Discussion points include the evolving role of avacopan in AAV management, its impact on relapse rates during tapering, and the potential overlap between inflammatory myopathy and vasculitis. This case reinforces the need for a multidisciplinary approach and highlights the benefit of early rheumatology input when classical features are absent. Key learning points • Atypical presentations: AAV can present initially with neuromuscular symptoms, including inflammatory myopathy, before classic renal or pulmonary features emerge. • Diagnostic complexity: Negative myositis serology does not exclude immune-mediated myopathy. Persistent systemic symptoms should prompt consideration of vasculitis, especially in older adults with multisystem involvement. • Multidisciplinary approach: Early involvement of rheumatology, neurology, nephrology, and radiology was essential in reaching a diagnosis and guiding tailored treatment. • Therapeutic considerations: The patient responded well to a combination of corticosteroids, rituximab, and avacopan. However, her relapse during steroid tapering highlights the need for careful balancing of immunosuppression, especially in elderly and frail patients.