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ZusammenfassungDas Sjögren-Syndrom (SjS) stellt eine mögliche autoimmune Ursache einer interstitiellen Lungenerkrankung dar. Die Abklärung in Richtung SjS ist aber im Vergleich zu anderen systemischen Autoimmunerkrankungen bisher kaum standardisiert. Die subjektive Sicca-Symptomatik, die Anti-SS-A/Ro-Antikörper und selbst die ANA-Diagnostik als Suchtest haben alle relevante Einschränkungen in ihrer Sensitivität und/oder Spezifität. Vor diesem Hintergrund haben wir in einer interdisziplinären Diskussion einen Konsens für die SjS-Abklärung entwickelt, den wir hier für die breitere Diskussion vorstellen. Neben ANA sollten sowohl Anti-SS-A/Ro-Antikörper als auch Antikörper gegen α‑Fodrin bestimmt werden. Wichtig ist die Objektivierung der Trockenheit mittels Schirmer- und Saxon-Test und bei fehlenden typischen Autoantikörpern die Speicheldrüsenbiopsie.

Osteoarthritis of the hand (HOA) is one of the most common musculoskeletal diseases affecting health. Osteophytes, documented by imaging procedures are often used as diagnostic criteria. The gold standard is the radiographic image, however, more sensitive and saver methods such as ultrasound are gaining in importance. We investigated the prevalence, grade and pattern of osteophytes by high resolution ultrasound investigation (US) in a population-based cross-sectional study. Factory workers were recruited at work. 26 finger joints of each participant were examined with US with grading the occurrence of osteophytes in a semiquantitative score ranging 0-3, increasing scores indicated larger osteophytes. 427 participants (mean age 53.5 years, range. 20-79 years) were investigated, resulting in 11,000 scored joints. At least one osteophyte was found in 4,546/11,000 (41.3%) joints or 426/427 (99.8%) participants but grade 2 or 3 osteophytes were seen in only 553 (5.0%) joints. The number of os-teophyte sum score increased with age (0.18/year of age increase, p

This article deals with the spread of misinformation in a general context and specifically in the health sector. It presents a theoretical view of the problem and analyzes its characteristics with a focus on medicine and mainly rheumatology. Finally, conclusions from the previous analysis are formulated as well as suggestions for reducing the dimensions of the problem in the health sector.

ZUSAMMENFASSUNGDie Digitalisierung des deutschen Gesundheitswesens schreitet stetig voran. Vielfältige digitale Gesundheitsangebote stehen dabei für verschiedene Indikationen und immer mehr Gruppen an Nutzer*innen zur Verfügung. Vermehrt wird sich daher mit der Adhärenz bei solchen digitalen Technologien auseinandergesetzt, die man als effektive Nutzung einer digitalen Anwendung oder Technologie gemäß den Vorgaben und Anleitungen der Hersteller*innen definieren kann. Diese digitale Adhärenz wird von einer Vielzahl an Faktoren beeinflusst. Betrachtet man insbesondere das Alter der Nutzer*innen, so zeigt sich, dass dieser Faktor weder einen generell-negativen noch generell-positiven signifikanten Einfluss auf die Adhärenz hat. Für eine hohe Adhärenz ist es wichtig, dass Entwickler*innen digitale Technologien nutzerorientiert konzipieren und die individuellen Bedürfnisse einzelner Nutzer*innen berücksichtigen. Aktuelle Forschung in der Rheumatologie beschäftigt sich ebenfalls mit digitalen Gesundheitsangeboten, in denen großes Potenzial für eine bessere und effizientere Versorgung liegt, sowie mit der Adhärenz dieser Angebote. Dabei zeigt sich eine große Bereitschaft zur Nutzung digitaler Technologien, unter anderem auch bei älteren Nutzer*innen. Dieser Artikel gibt einen Überblick über Nutzung und Adhärenz digitaler Gesundheitsangebote unter besonderer Berücksichtigung des Alters der Nutzer*innen und betrachtet die Implikationen für die Rheumatologie als Fachbereich.

In recent years, much research evaluating the radiographic destruction of finger joints in patients with rheumatoid arthritis (RA) using deep learning models was conducted. Unfortunately, most previous models were not clinically applicable due to the small object regions as well as the close spatial relationship. In recent years, a new network structure called RetinaNets, in combination with the focal loss function, proved reliable for detecting even small objects. Therefore, the study aimed to increase the recognition performance to a clinically valuable level by proposing an innovative approach with adaptive changes in intersection over union (IoU) values during training of Retina Networks using the focal loss error function. To this end, the erosion score was determined using the Sharp van der Heijde (SvH) metric on 300 conventional radiographs from 119 patients with RA. Subsequently, a standard RetinaNet with different IoU values as well as adaptively modified IoU values were trained and compared in terms of accuracy, mean average accuracy (mAP), and IoU. With the proposed approach of adaptive IoU values during training, erosion detection accuracy could be improved to 94% and an mAP of 0.81 ± 0.18. In contrast Retina networks with static IoU values achieved only an accuracy of 80% and an mAP of 0.43 ± 0.24. Thus, adaptive adjustment of IoU values during training is a simple and effective method to increase the recognition accuracy of small objects such as finger and wrist joints.

Um die Telemedizin erfolgreich in den rheumatologischen Alltag zu integrieren, sind sowohl die Patienten- als auch Arztperspektive wichtig. Hierzu wurde eine ausfuhrliche Studie mittels webbasierter Umfrage durch die Arbeitsgemeinschaft Junge Rheumatologie der Deutschen Gesellschaft fur Rheumatologie (DGRh) und die Deutsche Rheuma-Liga Bundesverband e. V. durchgefuhrt. Mittels Subgruppenanalyse der Daten im Hinblick auf die Videosprechstunde galt es nun herauszufinden, welche Anforderungen und Wunsche unter den Patienten/innen und Arzte/innen an die Videosprechstunde gestellt wurden. Die prospektive Umfrage wurde uber die sozialen Medien, QR-Code und E‑Mail verteilt. Es wurden deskriptive Statistiken und Regressionsanalysen in Bezug auf die Videosprechstunde durchgefuhrt und Korrelationen aufgezeigt. Die Daten zeigen eine positive Einstellung zur Videosprechstunde sowohl aufseiten der Patienten/innen (n = 299) als auch der Rheumatologen/innen (n = 129) auf. Eine Korrelation zwischen Alter und positiver Meinung zur Videosprechstunde zeigte sich unter den Patienten/innen (r = 0,161, p = 0,006), insbesondere bei den weiblichen Patienten fand sich mit zunehmendem Alter ein positiver Zuspruch fur die Videosprechstunde (r = 0,244, p

Sodium magnetic resonance imaging (MRI) can be used to evaluate the change in the proteoglycan content in Achilles tendons (ATs) of patients with different AT pathologies by measuring the 23Na signal-to-noise ratio (SNR). As 23Na SNR alone is difficult to compare between different studies, because of the high influence of hardware configurations and sequence settings on the SNR, we further set out to measure the apparent tissue sodium content (aTSC) in the AT as a better comparable parameter. Ten healthy controls and one patient with tendinopathy in the AT were examined using a clinical 3 Tesla (T) MRI scanner in conjunction with a dual tuned 1H/23Na surface coil to measure 23Na SNR and aTSC in their ATs. 23Na T1 and T2* of the AT were also measured for three controls to correct for different relaxation behavior. The results were as follows: 23Na SNR = 11.7 ± 2.2, aTSC = 82.2 ± 13.9 mM, 23Na T1 = 20.4 ± 2.4 ms, 23Na T2s* = 1.4 ± 0.4 ms, and 23Na T2l* = 13.9 ± 0.8 ms for the whole AT of healthy controls with significant regional differences. These are the first reported aTSCs and 23Na relaxation times for the AT using sodium MRI and may serve for future comparability in different studies regarding examinations of diseased ATs with sodium MRI.

Reasons of mon- and oligoarthritis are heterogeneous. The diagnostic approach includes a detailed medical anamnesis, physical examination and imaging (conventional X-ray, sonography, MRI and, CT). Analysis of the synovial fluid is required in suspected septic arthritis and frequently helps in diagnosis and differential diagnosis of crystal arthropathies. Dual-energy-CT (DECT) detects sodium urate crystals and can replace joint puncture in some cases. In addition to crystal arthropathies and septic arthritis, differential diagnosis of mon-/oligoarthritis includes reactive arthritis, arthrosis and monarthritic courses of SpA/PsA. A rheumatologist should be consulted particularly in the case of persistent monarthritides, in order to initiate a specific therapy to prevent secondary damage.

Introduction To investigate drug survival for biologic disease-modifying antirheumatic drugs (bDMARDs) in a real-world cohort of German adult biologic-naïve patients with psoriatic arthritis (PsA). Methods Claims data for patients with a diagnosis of PsA, a bDMARD claims record (index date) between 1 January 2014 and 31 December 2017, and no bDMARD prescription for 365 days before the index date were retrospectively analyzed. The primary outcomes were the overall and individual bDMARD persistence rates over 12 months. Nonpersistence was defined as a treatment gap exceeding the days of supply plus 60 days or switching to a bDMARD other than the index therapy. Sensitivity analysis was performed, wherein the treatment gap was found to vary depending on the bDMARD regimen. Kaplan–Meier curves were plotted to determine persistence; the log-rank test was used to evaluate differences in the persistence rate. Factors associated with treatment discontinuation were evaluated using Cox regression analysis. Results Among 10,954 patients with a PsA diagnosis, 348 were eligible. The overall bDMARD persistence rate was 57.5%; individual bDMARD persistence rates were 81.3% for ustekinumab, 66.7% for infliximab, and 60.0% for golimumab. The mean (SD) overall persistence with bDMARDs was 289 (103) days; the mean persistence was 334 (72) days for ustekinumab, 309 (82) days for golimumab, and 305 (92) days for infliximab. The main reasons for nonpersistence were switching to another bDMARD (15.8%) and treatment discontinuation (26.7%). Male gender was significantly associated with a lower risk of treatment discontinuation (hazard ratio 0.54, 95% confidence interval 0.39–0.77; P

Scientific reports 10, 15106 (2020). doi:10.1038/s41598-020-72208-y, Published by Macmillan Publishers Limited, part of Springer Nature, [London]

Background Because of overlapping phenotypical presentations, the diagnostic differentiation of rheumatoid arthritis (RA) and psoriatic arthritis (PsA) remains challenging. Thus, this study aimed to examine the diagnostic value of distinct imaging features obtained by high-resolution 3-T MRI for the diagnostic differentiation. Materials and methods Seventeen patients with PsA and 28 patients with RA were imaged at high resolution using 3-T MRI scanners and a dedicated 16-channel hand coil. All images were analyzed according to the outcome measures in rheumatology clinical trials’ (OMERACT) RAMRIS (Rheumatoid Arthritis Magnetic Resonance Imaging Score) and PsAMRIS (Psoriatic Arthritis Magnetic Resonance Imaging Score) for the presence and intensity of synovitis, flexor tenosynovitis, bone edema, bone erosion, periarticular inflammation, bone proliferation, and joint space narrowing. Next, odds ratios (OR) were calculated to determine the strength of the associations between these imaging features, demographic characteristics, and the outcome RA vs. PsA. Results PsA could be differentiated from RA by extracapsular inflammatory changes (PsAMRIS sub-score “periarticular inflammation”), with low odds for the presence of RA (OR of 0.06, p Conclusion High-resolution imaging is beneficial for the identification of relevant imaging features that may assist the clinical differentiation of inflammatory conditions of the hand. At the MCP level, extracapsular inflammatory changes were strongly associated with PsA and may consequently allow the imaging differentiation of PsA and RA.

In der aktuellen SARS-CoV-2 Pandemie bestehen viele Fragen mit Blick auf die sichere Behandlung von Patienten mit entzundlich-rheumatischen Erkrankungen. Auf viele dieser Fragen gibt es zur Zeit noch keine evidenzbasierte Antwort und das macht die Betreuung der Patienten nicht leicht. Die Deutsche Gesellschaft fur Rheumatologie e. V. (DGRh) will mit diesen ersten Empfehlungen Hilfestellung fur spezielle Belange in der Betreuung von Rheumapatienten angesichts der aktuellen Bedrohung durch SARS-CoV-2 geben. Um den dynamischen weltweiten Erkenntnisgewinn fur unsere Patienten zu nutzen, werden die Empfehlungen regelmasig aktualisiert. Die aktualisierten Versionen der Empfehlungen werden auf der Homepage der DGRh hinterlegt.

Fur die Prognose entzundlich-rheumatischer Erkrankungen ist es wichtig, diese fruhzeitig zu erkennen und zu behandeln. In der nachfolgenden Ubersicht werden Symptome aufgelistet, die auf diese Erkrankungen hinweisen. Die Auswahl erfolgt dabei nach dem Kriterium „was wird haufig ubersehen“.

Objective To evaluate musculoskeletal ultrasound (MSUS) as a screening tool for rheumatoid arthritis (RA) and osteoarthritis (OA) patients in a rheumatology-screening program. Patients and methods To raise awareness for rheumatic diseases, a mobile rheumatology office was deployed in different cities of Germany (“Rheuma-Truck”). Standardized questionnaire assessment, testing for rheumatoid factor and citrullinated peptide antibodies and medical student driven MSUS of the clinically dominant hand/foot including wrist, MCP-II, -III, -V, PIP-II, -III, MTP-II and -V were offered free of charge to the population. In case of suspicious results, a rheumatologist was consulted. Results In MSUS, 192 of 560 selected volunteers (aged 18–89, mean 52.7 years; 72.9% female) had suspicious findings including synovitis or erosions primarily affecting the MTP-II (11.8%), dorsal wrist (8.9%), and MCP-II (7%). 354 of the 560 volunteers further visited a rheumatologist of whom 76 were diagnosed with RA. According to the ‘US7 Score’, a sum scores ≥ 5 was significantly predictive for RA (odds ratio (OR) 5.06; confidence interval (CI) 0.83–35.32). 313 volunteers displayed signs of OA including osteophytes, while MCP-II (36.2%), MCP-III (14.8%), and the wrist (10.5%) were mostly affected. Diagnosis of RA was favoured over OA if the wrist (OR 4.2; CI 1.28–13.95), MTP-II (OR 1.62; CI 1.0–2.6), and MCP-V (OR 2.0; CI 1.0–3.8) were involved. Conclusion Medical student driven MSUS by the ‘US7 Score’ can facilitate diagnosis of RA in rheumatology-screening programs due to the level of the score and the affected joints. A high rate of unknown OA signs was detected by MSUS. A mobile rheumatology office displays an opportunity to screen patients for RA and OA.

Objective ACHILLES aimed to demonstrate efficacy of secukinumab on Achilles’ tendon enthesitis in spondyloarthritis (SpA) patients. Methods Patients ≥18 years (n = 204) with active PsA or axial SpA and heel enthesitis were randomized 1:1 to secukinumab 150/300 mg or placebo up to week 24, and thereafter placebo patients were switched to secukinumab. Results At week 24, a higher, yet statistically non-significant (P = 0.136), proportion of patients in secukinumab vs placebo reported resolution of Achilles tendon enthesitis in affected foot (42.2% vs 31.4%; odds ratio [OR] = 1.63; 95% CI: 0.87, 3.08). Proportion of patients reporting resolution of enthesitis based on Leeds Enthesitis Index was higher with secukinumab vs placebo (33.3% vs 23.5%; OR = 1.65; 95% CI: 0.85, 3.25) at week 24. Mean change from baseline in heel pain at week 24 was higher in secukinumab patients vs placebo (−2.8 [3.0] vs −1.9 [2.7]). Greater improvements with secukinumab were observed in heel enthesopathy activity and global assessment of disease activity. Imaging evaluation by local reading confirmed heel enthesitis on MRI at screening for all patients. Based on central reading, 56% presented with bone marrow oedema and/or tendinitis; according to Heel Enthesitis MRI Scoring System (HEMRIS) post hoc analysis, 76% had signs of entheseal inflammation while 86% had entheseal inflammation and/or structural changes. Conclusion A substantial proportion of patients showed no signs of inflammation on the centrally read MRIs despite a clinical diagnosis of heel enthesitis, thus highlighting that the discrepancy between the clinical and imaging assessments of enthesitis requires further investigation. Although ACHILLES did not meet the primary end point, the study reported clinically meaningful improvements in patient-related outcomes. Trial registration clinicaltrials.gov, NCT02771210

Diagnostics : open access journal 12(2), 465 (2022). doi:10.3390/diagnostics12020465, Published by MDPI, Basel

Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014.After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added.The glucocorticoid dose should be reduced to as low as possible 2-3 months before elective surgery (in any case10 mg/day) but should be kept stable 1-2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1-2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3-4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing.Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.HINTERGRUND: Vor operativen Eingriffen stellt sich Ärzten und Patienten mit entzündlich rheumatischen Erkrankungen weiterhin die Frage nach einer Unterbrechung oder Fortsetzung der entzündungshemmenden Medikation. Die Deutsche Gesellschaft für Rheumatologie hat hierfür ihre Empfehlungen von 2014 aktualisiert.Nach einer systematischen Literaturrecherche mit Einschluss von Publikationen bis zum 31.08.2021 wurden die Empfehlungen zum Umgang mit Glukokortikoiden, konventionell synthetischen „disease-modifying antirheumatic drugs“ (csDMARDs) und Biologika (bDMARDs) überarbeitet und Empfehlungen zu neueren Substanzen und „targeted synthetic (ts) DMARDs“ ergänzt.Die Glukokortikoiddosis sollte 2 bis 3 Monate vor elektiven Eingriffen so niedrig wie möglich reduziert (in jedem Fall10 mg/Tag), 1 bis 2 Wochen vor und am Operationstag jedoch stabil gehalten werden. csDMARDs können in vielen Fällen fortgeführt werden, Ausnahmen sind eine Reduktion hoher Methotrexat-Dosierungen auf ≤15 mg/Woche und Auswaschen des Leflunomid bei hohem Infektionsrisiko. Azathioprin, Mycophenolat und Ciclosporin sollten 1 bis 2 Tage vor der Operation pausiert werden. Unter bDMARDs können Operationen zum Ende des jeweiligen Therapieintervalls geplant werden. Januskinase(JAK)-Inhibitoren sollten bei größeren Eingriffen für 3 bis 4 Tage pausiert werden. Apremilast kann fortgeführt werden. Bei notwendiger Unterbrechung gilt für alle Substanzen, die Therapie in Abhängigkeit der Wundheilung baldmöglichst wieder zu beginnen.Ob bDMARDs das Infektionsrisiko perioperativ erhöhen und welche Rolle die Absetzzeit dabei spielt, bleibt bei gegenwärtiger Evidenz noch unklar. Um das Risiko eines Krankheitsschubs unter längerer Therapiepause zu minimieren, wurde in den aktualisierten Empfehlungen die perioperative Pausierung von bDMARDs von mindestens 2 Halbwertszeiten auf ein Therapieintervall reduziert.

> If you think about the unthinkable long enough it becomes quite reasonable. > > Josephine Tey (1896–1952)British author Have you ever thought about what our life as specialists for rheumatic diseases will look like in 2049? The amount of data gathered from us and our patients is increasing exponentially, and eventually, these data will be used to improve and facilitate patient’s care. We, that means primarily rheumatologists and—as the responsibilities will also change with all data —all other health professionals involved in the care of patients with rheumatic diseases, should know what to expect and actively contribute to this process. It is 10:00 on a sunny 21 July in 2049 and you are currently at your most favourite place in the world: a small cottage in the mountains, a vineyard in France or your house with a breath-taking view of the sea. You just finished your morning round on your virtual ward and a glimpse at your computer shows that 99% of the 50 000 customers in your virtual practice do not have any complaints and are enjoying their life without health-related limitations. In fact, most of them have never even had any symptoms as they were diagnosed before disease manifestation and preventive measures have successfully been applied. Like every morning, the system reports a few patients that deviate from their normal status. In some patients, the system has already adapted or changed therapy or has given behavioural advice. Most patients do not need any further adjustments. The system has identified two customers who need personal assessment in your virtual clinic, and therefore, an appointment has already been made. Other patients are still on your agenda for the virtual expert meeting this afternoon, as they do not fit into the known disease entities or treatment standards. Your avatar will present these complex cases to the other …

Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014.After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added.The glucocorticoid dose should be reduced to as low as possible 2-3 months before elective surgery (in any case10 mg/day) but should be kept stable 1-2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1-2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3-4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing.Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.HINTERGRUND: Vor operativen Eingriffen stellt sich Ärzten und Patienten mit entzündlich rheumatischen Erkrankungen weiterhin die Frage nach einer Unterbrechung oder Fortsetzung der entzündungshemmenden Medikation. Die Deutsche Gesellschaft für Rheumatologie hat hierfür ihre Empfehlungen von 2014 aktualisiert.Nach einer systematischen Literaturrecherche mit Einschluss von Publikationen bis zum 31.08.2021 wurden die Empfehlungen zum Umgang mit Glukokortikoiden, konventionell synthetischen „disease-modifying antirheumatic drugs“ (csDMARDs) und Biologika (bDMARDs) überarbeitet und Empfehlungen zu neueren Substanzen und „targeted synthetic (ts) DMARDs“ ergänzt.Die Glukokortikoiddosis sollte 2 bis 3 Monate vor elektiven Eingriffen so niedrig wie möglich reduziert (in jedem Fall10 mg/Tag), 1 bis 2 Wochen vor und am Operationstag jedoch stabil gehalten werden. csDMARDs können in vielen Fällen fortgeführt werden, Ausnahmen sind eine Reduktion hoher Methotrexat-Dosierungen auf ≤15 mg/Woche und Auswaschen des Leflunomid bei hohem Infektionsrisiko. Azathioprin, Mycophenolat und Ciclosporin sollten 1 bis 2 Tage vor der Operation pausiert werden. Unter bDMARDs können Operationen zum Ende des jeweiligen Therapieintervalls geplant werden. Januskinase(JAK)-Inhibitoren sollten bei größeren Eingriffen für 3 bis 4 Tage pausiert werden. Apremilast kann fortgeführt werden. Bei notwendiger Unterbrechung gilt für alle Substanzen, die Therapie in Abhängigkeit der Wundheilung baldmöglichst wieder zu beginnen.Ob bDMARDs das Infektionsrisiko perioperativ erhöhen und welche Rolle die Absetzzeit dabei spielt, bleibt bei gegenwärtiger Evidenz noch unklar. Um das Risiko eines Krankheitsschubs unter längerer Therapiepause zu minimieren, wurde in den aktualisierten Empfehlungen die perioperative Pausierung von bDMARDs von mindestens 2 Halbwertszeiten auf ein Therapieintervall reduziert.

Systemic disease demands systemic thinkers. In this mission statement we define rheumatology, describe the role of the German Society of Rheumatology and the rheumatologist's spirit to their discipline. Rheumatologists are dedicated to improving the quality of life of their acute, chronic, and rehabilitative patients on the basis of up to date evidence and strong physician-patient relations. We think, act and interact systemically, scientifically, consistently, transparently, reliably, inclusively, innovatively and enthusiastically.Bei einer systemischen Erkrankung ist systemisches Denken erforderlich. In diesem Leitbild definieren wir Rheumatologie, beschreiben die Rolle der Deutschen Gesellschaft für Rheumatologie und umschreiben den rheumatologischen „Geist“, der uns für und in unserem Fach antreibt. Rheumatologen widmen sich der Verbesserung der Lebensqualität ihrer Patienten im akuten, chronischen und Rehabilitationsstadium auf Basis der aktuellen Datenlage und einer tragfähigen Arzt-Patienten-Beziehung. Wir denken, handeln und interagieren systemisch, wissenschaftlich, konsequent, transparent, verlässlich, integrativ, innovativ und begeistert.

In order to successfully integrate telemedicine into the daily routine of rheumatology, both the patient's and the physician's perspective are important. For this purpose, a detailed study by means of a web-based survey was conducted by the Working Group Young Rheumatology (AGJR) of the German Society for Rheumatology (DGRh) and the German Rheumatism League National Association. By means of subgroup analysis of the data regarding video consultation, the aim was now to find out which requirements and wishes patients and physicians have for video consultations.The prospective survey was distributed via social media, QR code and email. Descriptive statistics and regression analysis related to video consultation were performed and correlations were shown.The data indicated positive attitudes toward video consultation on the part of both patients (n = 299) and rheumatologists (n = 129). A correlation between age and positive opinion of the video consultation was found among the patients (r = 0.161, p = 0.006), especially among female patients a positive approval of the video consultation was found with increasing age (r = 0.244, p 0.001 to male patients: r = -0.190, p = 0.145). Regarding the travelling time to the treating rheumatologist, male patients found the video consultation more attractive with increasing travelling time (r = 0.229, p = 0.078). With respect to the wishes of patients and physicians, video consultation should be used primarily for follow-up or emergency appointments. Video consultation for initial appointments, on the other hand, was very rarely mentioned.During the COVID 19 pandemic, video consultation was increasingly popular among rheumatology patients as well as among rheumatologists.EINLEITUNG: Um die Telemedizin erfolgreich in den rheumatologischen Alltag zu integrieren, sind sowohl die Patienten- als auch Arztperspektive wichtig. Hierzu wurde eine ausführliche Studie mittels webbasierter Umfrage durch die Arbeitsgemeinschaft Junge Rheumatologie der Deutschen Gesellschaft für Rheumatologie (DGRh) und die Deutsche Rheuma-Liga Bundesverband e. V. durchgeführt. Mittels Subgruppenanalyse der Daten im Hinblick auf die Videosprechstunde galt es nun herauszufinden, welche Anforderungen und Wünsche unter den Patienten/innen und Ärzte/innen an die Videosprechstunde gestellt wurden.Die prospektive Umfrage wurde über die sozialen Medien, QR-Code und E‑Mail verteilt. Es wurden deskriptive Statistiken und Regressionsanalysen in Bezug auf die Videosprechstunde durchgeführt und Korrelationen aufgezeigt.Die Daten zeigen eine positive Einstellung zur Videosprechstunde sowohl aufseiten der Patienten/innen (n = 299) als auch der Rheumatologen/innen (n = 129) auf. Eine Korrelation zwischen Alter und positiver Meinung zur Videosprechstunde zeigte sich unter den Patienten/innen (r = 0,161, p = 0,006), insbesondere bei den weiblichen Patienten fand sich mit zunehmendem Alter ein positiver Zuspruch für die Videosprechstunde (r = 0,244, p 0,001 zu männlichen Patienten: r = −0,190, p = 0,145). Bezüglich der Fahrtzeit bis zum behandelnden Rheumatologen tendierten die männlichen Patienten mit zunehmender Fahrzeit zur Videosprechstunde (r = 0,229, p = 0,078), dies war jedoch nur schwach positiv. Hinsichtlich der Wünsche von Patienten/innen und Ärzten/innen sollte die Videosprechstunde v. a. für Folge- oder Notfalltermine genutzt werden. Eine Videosprechstunde für die Erstvorstellungen war hingegen nur sehr selten gewünscht.Während der COVID-19-Pandemie hat die Videosprechstunde zunehmenden Zuspruch unter den rheumatologischen Patienten/innen als auch unter den behandelnden Rheumatologen/innen erhalten.

Background Tofacitinib is a novel Janus kinase (JAK) inhibitor approved for the treatment of rheumatoid arthritis, psoriatic arthritis, and ulcerative colitis. In clinical trials, the most common adverse events observed were nasopharyngitis, upper respiratory tract infections, and zoster. JAKs are found downstream of the type II cytokine receptor family used by a number of TH17 cell-associated cytokines for signal transduction. These cytokines lead to the secretion of antiviral and antimicrobial peptides (AMPs) by keratinocytes or synoviocytes. Blocking the JAK pathway might result in a diminished secretion of antimicrobial and antiviral peptides causing higher susceptibility to infections in patients treated with JAK inhibitors. Methods We treated primary human keratinocytes and synoviocytes with tofacitinib and subsequently added various cytokines and bacterial surface proteins before evaluation of the response via RT-qPCR. CD69 expression on tofacitinib-treated PBMCs was investigated via flow cytometry. Results We found a markedly reduced gene expression of all tested antiviral peptides such as MX1 or ISG15 in keratinocytes and synoviocytes in the presence of tofacitinib in vitro. Additionally, we found that JAK inhibition reduced activation of T cells after stimulation with bacterial LPS or viral VZV gE. Conclusions The antiviral immunity is strongly inhibited in the presence of tofacitinib in vitro, while the antimicrobial immunity does not seem to be affected. In T cells, the overall activation process seems to be influenced by tofacitinib. These findings suggest that tofacitinib has an impact on antiviral immunity such as patients treated with tofacitinib often show adverse events like herpes zoster. Graphical abstract

Background Inflammatory arthritides (IA) such as rheumatoid arthritis or psoriatic arthritis are disorders that can be difficult to comprehend for health professionals and students in terms of the heterogeneity of clinical symptoms and pathologies. New didactic approaches using innovative technologies such as virtual reality (VR) apps could be helpful to demonstrate disease manifestations as well as joint pathologies in a more comprehensive manner. However, the potential of using a VR education concept in IA has not yet been evaluated. Objective We evaluated the feasibility of a VR app to educate health care professionals and medical students about IA. Methods We developed a VR app using data from IA patients as well as 2D and 3D-visualized pathological joints from X-ray and computed tomography–generated images. This VR app (Rheumality) allows the user to interact with representative arthritic joint and bone pathologies of patients with IA. In a consensus meeting, an online questionnaire was designed to collect basic demographic data (age, sex); profession of the participants; and their feedback on the general impression, knowledge gain, and potential areas of application of the VR app. The VR app was subsequently tested and evaluated by health care professionals (physicians, researchers, and other professionals) and medical students at predefined events (two annual rheumatology conferences and academic teaching seminars at two sites in Germany). To explore associations between categorical variables, the χ2 or Fisher test was used as appropriate. Two-sided P values ≤.05 were regarded as significant. Results A total of 125 individuals participated in this study. Among them, 56% of the participants identified as female, 43% identified as male, and 1% identified as nonbinary; 59% of the participants were 18-30 years of age, 18% were 31-40 years old, 10% were 41-50 years old, 8% were 51-60 years old, and 5% were 61-70 years old. The participants (N=125) rated the VR app as excellent, with a mean rating of 9.0 (SD 1.2) out of 10, and many participants would recommend use of the app, with a mean recommendation score of 3.2 (SD 1.1) out of 4. A large majority (120/125, 96.0%) stated that the presentation of pathological bone formation improves understanding of the disease. We did not find any association between participant characteristics and evaluation of the VR experience or recommendation scores. Conclusions The data show that IA-targeting innovative teaching approaches based on VR technology are feasible.

Reasons of mon- and oligoarthritis are heterogeneous. The diagnostic approach includes a detailed medical anamnesis, physical examination and imaging (conventional X-ray, sonography, MRI and, CT). Analysis of the synovial fluid is required in suspected septic arthritis and frequently helps in diagnosis and differential diagnosis of crystal arthropathies. Dual-energy-CT (DECT) detects sodium urate crystals and can replace joint puncture in some cases. In addition to crystal arthropathies and septic arthritis, differential diagnosis of mon-/oligoarthritis includes reactive arthritis, arthrosis and monarthritic courses of SpA/PsA. A rheumatologist should be consulted particularly in the case of persistent monarthritides, in order to initiate a specific therapy to prevent secondary damage.

Im Mai 2018 wurde die Novellierung der (Muster‑)Weiterbildungsordnung (MWBO) fur die Facharztweiterbildung auf dem Deutschem Arztetag beschlossen, und somit stehen nun auch Anderungen fur die Rheumatologie an. Ziel dieser Arbeit war es, einen Uberblick uber die aktuelle Situation der arztlichen Weiterbildung im Fachgebiet der Rheumatologie zu gewinnen. Hierfur erfolgten sowohl eine quantitative als auch qualitative Analyse der rheumatologischen Facharztweiterbildung. Mittels schriftlicher Abfrage der Landesarztekammern wurde die Zahl der neu ausgebildeten Facharzte fur Rheumatologie in den Jahren 2015 bis 2017 ermittelt. Weiterhin wurde eine onlinebasierte Assistenzarztumfrage mit einem Fragebogen aus 22 Fragen erstellt und diese an 139 Chefarzte sowie Praxisinhaber deutschlandweit verschickt mit der Bitte, diese an ihre jeweiligen Assistenzarzte bzw. Facharzte zu verteilen. Zusatzlich wurde durch den Gebrauch der sozialen Medien sowie der Homepage und des E‑Mail-Verteilers von Rheumadocs e. V. eine breite Zielgruppe erreicht. Es beteiligten sich insgesamt 71 Arzte an der bundesweiten Umfrage. Laut Landesarztekammern absolvierten 53 Facharzte im Jahr 2015 und je 43 Facharzte fur 2016 und 2017 die Facharztprufung. In der Online-Umfrage der Assistenzarzte zeigte sich, dass die Befragten ihre Weiterbildung im Mittel mit der Note 3,1 (SD ± 1,1) beurteilten; 19,4 % der Teilnehmer gaben an, ein regelmasiges Mentoring zu erhalten, und bei 41,7 % der Arzte fanden Evaluationen am Arbeitsplatz statt. Defizite zeigten sich auch im Rahmen der praktischen Diagnostikfahigkeiten: 22,8 % der Befragten praktizierten laut Umfrage keine Gelenksonographie, und weitere 20 % fuhrten diese maximal 1‑mal monatlich durch. Nur 43,6 % der Befragten berichteten, dass sie mehr als 10 Gelenkpunktionen unter Anleitung durchgefuhrt hatten. Als offene Kritikpunkte* wurden von 46,6 % eine fehlende Struktur in der Weiterbildung genannt und 33,3 % bemangelten eine fehlende Supervision am Ausbildungsplatz. Positiv bewertet* wurden u. a. von 46,8 % die Vielfaltigkeit des Faches sowie von 17 % die Moglichkeit zum selbststandigen Arbeiten in der Rheumatologie. Die Mehrzahl der Befragten wunschte sich mehr Weiterbildungsoptionen, vermehrte Supervision sowie eine bessere praktische Ausbildung in der Ultraschalldiagnostik. Schlussfolgerung Die bundesweite Zahl der neu erworbenen Facharztqualifikation in der Rheumatologie zwischen den Jahren 2015 bis 2017 zeigt einen gleichbleibenden bis rucklaufigen Trend. Es ist zu befurchten, dass die Zahlen in den nachsten Jahren weiter stagnieren werden, weshalb es umso wichtiger ist, in die Qualitat der Weiterbildung zu investieren. Die Assistenzarztumfrage zeigte weiterhin, dass die aktuelle Weiterbildung in der Rheumatologie Defizite aufweist. Ein Leitfaden zur Verbesserung der Ausbildungsqualitat konnte die neue MWBO in der Rheumatologie sein, die Wege fur eine bessere und strukturierte Ausbildung schaffen soll. Dieses Curriculum sollte im Arbeits- bzw. Ausbildungsalltag fest im Sinne eines Teach-to-Target verwurzelt sein.

Objective.To assess associations of synovial perfusion, cartilage quality, and outcome in rheumatoid arthritis (RA).Methods.Synovial perfusion and cartilage quality were assessed by dynamic contrast-enhanced magnetic resonance imaging in metacarpophalangeal joints of 28 treatment-naive patients with RA at baseline and at 3 and 6 months after methotrexate. Analysis was by linear mixed modeling.Results.Synovial perfusion variables were associated with remission (p < 0.05) and cartilage quality (p < 0.004). Maximum synovial enhancement was associated to European League Against Rheumatism response (p < 0.05). Synovial perfusion improved in nonresponders over time (p < 0.05).Conclusion.Synovial perfusion relates to remission, response, and cartilage quality in a cohort of therapy-naive patients with early RA.

ObjectiveTo analyse the impact of the COVID-19 pandemic on rheumatic patients’ and rheumatologists’ usage, preferences and perception of digital health applications (DHAs).MethodsA web-based national survey was developed by the Working Group Young Rheumatology of the German Society for Rheumatology and the German League against Rheumatism. The prospective survey was distributed via social media (Twitter, Instagram and Facebook), QR code and email. Descriptive statistics were calculated, and regression analyses were performed to show correlations.ResultsWe analysed the responses of 299 patients and 129 rheumatologists. Most patients (74%) and rheumatologists (76%) believed that DHAs are useful in the management of rheumatic and musculoskeletal diseases (RMDs) and felt confident in their own usage thereof (90%; 86%). 38% of patients and 71% of rheumatologists reported that their attitude had changed positively towards DHAs and that their usage had increased due to COVID-19 (29%; 48%). The majority in both groups agreed on implementing virtual visits for follow-up appointments in stable disease conditions. The most reported advantages of DHAs were usage independent of time and place (76.6%; 77.5%). The main barriers were a lack of information on suitable, available DHAs (58.5%; 41.9%), poor usability (42.1% of patients) and a lack of evidence supporting the effectiveness of DHAs (23.2% of rheumatologists). Only a minority (ConclusionThe COVID-19 pandemic instigated an increase in patients’ and rheumatologists’ acceptance and usage of DHAs, possibly introducing a permanent paradigm shift in the management of RMDs.

To investigate health care costs associated with biologic disease-modifying antirheumatic drugs (bDMARDs) in a German real-world cohort of adult biologics-naive patients with psoriatic arthritis (PsA).Claims data from the Institute for Applied Health Research Berlin (InGef) research database for patients with a PsA diagnosis and bDMARD claims record (index date) between January 1, 2014, and December 31, 2017, and no bDMARD prescriptions for 365 days before the index date were retrospectively analyzed. Primary outcomes were determination of health care resource utilization and associated annual health care costs for overall and individual bDMARDs in the 12-month pre-index and post-index periods. These outcomes were compared between persistent and nonpersistent groups. Nonpersistence was defined as treatment gap or switch to a bDMARD other than the index therapy.Among 10,954 patients with a PsA diagnosis, 348 were eligible. Although mean ± SD post-index costs were significantly higher in the persistent group than the nonpersistent group (€27,869 ± 8,001 versus €21,897 ± 10,600, P 0 .001) due to higher bDMARD acquisition costs (€23,996 ± 4,818 versus €16,427 ± 9,033, P 0.001), persistence reduced inpatient treatment costs (-€760), outpatient treatment costs (-€192), other drug costs (-€724), and sick leave costs (-€601).Although initiation of bDMARDs increased the total health care costs irrespective of persistence status, partial cost offsets were observed in the persistent patient population.

Physical therapy has always been a pillar of the treatment of inflammatory rheumatic diseases in addition to targeted drug treatment; nevertheless, it is only established in the treatment guidelines for a few diseases. Within the last two decades the discovery of myokines has uncovered the physiological correlations of the anti-inflammatory effect of physical activity. For rheumatoid arthritis and spondylarthritis, several randomized controlled trials provide sufficient evidence to make well-founded recommendations. For connective tissue diseases (CTD) the data situation is clearly sparser but nevertheless shows that the positive effects of physical activity prevail. In the following article the authors present the most important clinical studies on sport and inflammatory rheumatic diseases and from these derive possible therapeutic recommendations.Die physikalische Therapie stellt neben einer gezielten medikamentösen Therapie seit jeher eine Säule der Behandlung entzündlich rheumatischer Erkrankungen dar, ist aber bisher nur bei wenigen Erkrankungen in den Behandlungsleitlinien etabliert. Innerhalb der letzten 2 Jahrzehnte konnten durch die Entdeckung der Myokine die physiologischen Zusammenhänge von antiinflammatorischer Wirkung und sportlicher Betätigung aufgedeckt werden. Für die rheumatoide Arthritis und die Spondyloarthritiden liefern mehrere randomisiert kontrollierte Studien eine ausreichende Evidenz, um fundierte Empfehlungen geben zu können. Für die Kollagenosen ist die Datenlage deutlich spärlicher, zeigt aber dennoch, dass die positiven Effekte durch Bewegungstherapie überwiegen. In dem folgenden Beitrag stellen die Autoren die wichtigsten Studien zum Thema Sport bei entzündlich rheumatischen Erkrankungen vor und leiten daraus mögliche therapeutische Empfehlungen ab.

Background: To compare the effect of Adalimumab (ADA) plus Methotrexate (MTX) versus MTX monotherapy in patients with therapy naïve early rheumatoid arthritis (eRA) on cartilage quality measured by glycosaminoglycan (GAG) content in cartilage using gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC). Methods: Prospective double-blinded, randomized clinical trial of cartilage integrity in finger joints of eRA patients according to American College of Rheumatology/ European League Against Rheumatism. Patients were examined therapy-naïve, 12 and 24 weeks after initiation of Adalimumab+MTX or placebo+MTX with 3T-MRI, recording dGEMRIC values of metacarpophalangeal joints of index and middle finger. Results: The study was prematurely terminated due to theoretical safety concerns regarding gadolinium deposition in the brain after MR contrast agent application. Instead of 30 planned patients, 10 patients could be included in the Adalimumab group (ADA+MTX: 6 females, 44.9y, range: 19-65), four in the control group (Placebo+MTX: 2 females, 46.7y, range: 24-64). Between treatment groups, cartilage composition did not change significantly (ADA+MTX: dGEMRIC mean change 85.8ms, range -156.2–346.5ms; Placebo+MTX: mean change-30.75ms, range-273.0–131.0ms; W=27, p=0.37). Neverthless a significant increase of the dGEMRIC values over time was observed in the Adalimumab group (median change 75.88 ms p=0.0117), but not in the placebo group (median change 9.50, p=0.878).Conclusions: In patients with eRA, Adalimumab+MTX leads to a significant dGEMRIC improvement, indicating a possible reduction of cartilage damage in the finger joints. The level of significance for the difference of change in cartilage quality between groups, was not met, potentially due to lower than expected number of patients which could be recruited. Trial registration: The cartilage in early Rheumatoid Arthritis (CAR-ERA)-Study was approved by the local ethics committee of the Heinrich-Heine University of Duesseldorf (reference number: MO-LKP-719) and was registered at clinicaltrials.gov under the number NCT02150473 / CAR-ERA 2013-004604-19 (EudraCT Number).

Background The currently available scoring methods for enthesitis are often measures of pain but not of inflammation at entheseal sites. The Outcome Measures in Rheumatology Clinical Trials (OMERACT) psoriatic arthritis (PsA) magnetic resonance imaging (MRI) scoring system (PsAMRIS) assesses inflammation and damage in PsA and was particularly developed for the hands. The ACHILLES trial used clinical measures for heel enthesitis in combination with MRI scoring based on PsAMRIS. Methods Patients (age ≥ 18 years) with spondyloarthritis (SpA) and PsA were included in the trial if they presented with clinical and MRI-positive heel enthesitis. MRI of the affected heel was performed at three time points: screening, Week 24 and Week 52. Inflammatory MRI findings (tendinitis, bursitis and bone marrow oedema [BME]) in the area of the Achilles tendon and/or plantar aponeurosis, periarticular inflammation of the ankle joint and heel erosion were assessed qualitatively (absent/present). In addition, BME and bone erosion were quantitatively assessed based on PsAMRIS, where their proportion was compared to the volume of the affected bone. Mean scores of BME and bone erosion quantification were calculated, and the mean composite score (based on PsAMRIS) was calculated based on the individual score of each subject for periarticular inflammation, BME and bone erosion and further extended for bursitis and tendinitis. Modifications to PsAMRIS were introduced by categorising oedema length as ≤/> 0.5 cm and locating bone erosion. Conclusions In ACHILLES, MRI was used to assess and evaluate heel enthesitis. Due to the lack of a validated scoring system for heel enthesitis at the time of ACHILLES initiation, this trial applied quantitative scoring based on PsAMRIS, with specific adaptations for the heel. Trial registration National Clinical Trial Registry, NCT02771210. Registered 13 May 2016.

Background:Digital health applications (DHAs) are gaining influence and promise great potential for the monitoring and management of rheumatic and musculoskeletal diseases (RMDs).Objectives:To analyse the impact of the COVID-19 pandemic on RMD patients’ and rheumatologists’ usage, preferences, and perception of digital health applications (DHAs) in Germany.Methods:A web-based national survey was developed by the Working Group Young Rheumatology of the German Society for Rheumatology and the German League against Rheumatism. The prospective survey was distributed via social media, QR-code, and email. Descriptive statistics were calculated, and regression analyses were performed to show correlations.Results:We analysed the responses of 299 patients and 129 rheumatologists. Most patients (74%) and rheumatologists (76%) believed that DHAs are useful in the management of RMDs and felt confident in their own usage thereof (90%; 86%). 38% of patients and 71% of rheumatologists reported that their attitude had changed positively towards DHAs and that their usage had increased due to COVID-19 (29%; 48%).Usage and recommendation of DHAs for both groups are shown in Figure 1:Figure 1.Usage or recommendation of digital health applications. Patients and rheumatologists were asked to indicate the specific digital health applications (DHAs) they used or were recommended.The majority in both groups agreed on implementing virtual visits for follow-up appointments in stable disease conditions. The most reported advantages of DHAs were usage independent of time and place (76.6%; 77.5%). The main barriers were a lack of information on suitable, available DHAs (58.5%; 41.9%), poor usability (42.1% of patients) and a lack of evidence supporting the effectiveness of DHAs (23.2% of rheumatologists) (Table 1).Table 1.Advantages and Barriers of DHA, n (%).AdvantagesBarriersPatientsRheumatologistsPatientsRheumatologistsLocation-Independence229 (76.6)100 (77.5)Too little information175 (58.5)54 (41.9)Time-independence223 (74.6)94 (72.9)Too little evidence of benefits36 (12.0)30 (23.3)Detailed documentation97 (32.4)47 (36.4)Poor quality of current apps47 (15.7)29 (22.5)Cost saving95 (31.8)37 (28.7)Concernsabout data protection52 (17.4)25 (19.4)More information88 (29.4)38 (29.5)Lack of usability126 (42.1)17 (13.2)Independenceof doctors+36 (12.0)-Lack of accessibility4 (1.3)-More flexibility107 (36.8)77 (59.7)High costs4 (1.3)23 (17.8)Preparationfor discussion+46 (15.4)-No suitable equipment17 (5.7)11 (8.5)No advantages at all18 (6.0)1 (0.8)Lack of user competenceNo Need9 (3.0)39 (13.0)-12 (9.3)Patients and rheumatologists were asked about the advantages and barriers of DHAs. Multiple answers were allowed. Patients had two additional potential advantages and potential barriers to choose from*.Only a minority (Conclusion:The COVID-19 pandemic instigated an increase in patients’ and rheumatologists’ acceptance and usage of DHAs, possibly introducing a permanent paradigm shift in the management of RMDs.Acknowledgements:The authors thank the following persons and societies for their great effort, distributing the online survey: P.Aries, A.Hueber, E.Feist, C.Fiehn, P.Korsten, I.Kötter, F.Mühlensiepen, A.Pfeil, M.Rudwaleit, M.Welcker, S.Zinke, Deutsche Vereinigung Morbus Bechterew e.V., Deutsche Rheuma-Liga Bundesverband e. V., Sklerodermie Selbsthilfe e.V.Disclosure of Interests:Anna Kernder: None declared, Harriet Morf: None declared, Philipp Klemm: None declared, Diana Vossen Speakers bureau: Novartis, Abbvie, Amgen, Consultant of: Abbvie Deutschland GmbH & Co. KG, Bristol-Myer Squibb, Celgene GmbH, Gilead Sciences Inc., Lilly Deutschland GmbH, Medac GmbH, Novartis Pharma GmbH, Pfizer Deutschland GmbH, UCB Pharma GmbH, Grant/research support from: Pfizer, Abbvie, Marco Meyer Consultant of: Medac, Isabell Haase Speakers bureau: Medac, Consultant of: Medac, Grant/research support from: UCB, Abbvie, BMS, Johanna Mucke Speakers bureau: AbbVie Deutschland GmbH & Co. KG, Amgen, Bristol-Myers Squibb, Chugai Pharma Germany GmbH, Celgene GmbH, Gilead Sciences Inc., GlaxoSmithKline, Janssen-Cilag GmbH, Lilly Deutschland GmbH, Novartis Pharma GmbH, Pfizer Deutschland GmbH and UCB Pharma GmbH., Consultant of: AbbVie Deutschland GmbH & Co. KG, Amgen, Bristol-Myers Squibb, Chugai Pharma Germany GmbH, Celgene GmbH, Gilead Sciences Inc., GlaxoSmithKline, Janssen-Cilag GmbH, Lilly Deutschland GmbH, Novartis Pharma GmbH, Pfizer Deutschland GmbH and UCB Pharma GmbH., Arnd Kleyer Shareholder of: yes, Speakers bureau: Lilly, Novartis, Consultant of: Abbvie, Lilly, Novartis BMS, Gilead,Janssen, Grant/research support from: Lilly, Novartis, Gilead,, Philipp Sewerin Consultant of: AbbVie, Amgen, Axiom Health, Biogen, Bristol-Myers Squibb, Celgene, Chugai Pharma Marketing Ltd./Chugai Europe, Deutscher Psoriasis-Bund, Fresenius Kabi, Gilead Sciences, Hexal Pharma, Janssen-Cilag, Johnson & Johnson, Lilly, Medi-login, Mediri GmbH, Novartis Pharma, Onkowissen GmbH, Pfizer, Roche Pharma, Rheumazentrum Rhein-Ruhr, Sanofi-Genzyme, Swedish Orphan Biovitrum, and UCB, Grant/research support from: AbbVie, Amgen, Biogen, Bristol-Myers Squibb, Bundesministerium fuer Bildung und Forschung (BMBF), Deutsche Forschungsgesellschaft (DFG), Deutscher Psoriasis-Bund, Fresenius Kabi, Gilead Sciences, Hexal Pharma, Janssen-Cilag, Lilly, Novartis Pharma, Pfizer, Rheumazentrum Rhein-Ruhr, Roche Pharma, Sanofi-Genzyme, and UCB, Gerlinde Bendzuck: None declared, Sabine Eis: None declared, Johannes Knitza Consultant of: Abbvie, Novartis, Lilly, Medac, BMS, Sanofi, Amgen, Gilead, UCB, ABATON, GSK, Grant/research support from: Novartis, UCB, Thermofisher, Sanofi, Martin Krusche Speakers bureau: Lilly, Medac, Novartis, Roche/Chugai, Consultant of: Abbvie, Lilly, Gilead, Medac, Novartis, Sobi, BMS, Amgen, GSK, Grant/research support from: Sanofi

Injection-site pain (ISP) is a subjective side effect that is commonly reported with the subcutaneous administration of biological agents, yet it may only be a concern to some. Multiple factors related to the product formulation, such as pH, volume and excipients, and/or to the injection process have the potential to contribute to ISP, while patient-related factors, such as low body weight, gender and age, can make an individual more susceptible to experiencing ISP. While total elimination of ISP remains unlikely with any subcutaneously administered agent, it can be minimised by helping the patient to develop a confident and competent injection technique via robust and effective training. Careful management of patient expectations along with open discussion regarding the potential risk of ISP may serve to minimise treatment-related anxieties and, importantly, allow the patient to remain in control of his/her treatment. Other interventions to help minimise ISP include psychological interventions, allowing biologics to reach room temperature prior to injection, using the most suitable injection device for the individual patient and selecting an alternative drug formulation, when available. Productive patient-physician communication remains important in order to support and optimise treatment experience and adherence, while also providing the opportunity for patients to discuss any ISP-related issues.

The significance of inflammatory rheumatic diseases (IRDs) and their therapies for the risk of patients with respect to SARS-CoV-2 infection and the course of COVID-19 is still not fully understood. In particular, it is not completely clear whether IRDs, their therapies or other factors in patients with IRDs pose a risk to patients and what consequences should be drawn to protect patients with IRDs. In their manuscript, Nunez et al 1 describe that in a real-world-setting SARS-CoV-2-infected patients with IRDs often require hospitalisation. Important in their observation is that this was associated with systemic autoimmune conditions (as opposed to well-controlled chronic inflammatory arthritis) and related to risk factors known also for the non-rheumatic population, such as advanced age or comorbidities, but not with the immunomodulating, antirheumatic therapy. These data are reassuring, as they underline once again that well-controlled IRDs per se do not pose a risk of contracting SARS-CoV-2 nor do ongoing immunomodulating therapies pose a threat for patients with IRD.2–5 Therefore, in order to avoid reactivation of an underlying IRD and to prevent the risk of increased susceptibility to infection and a possibly necessary administration of glucocorticoids to control immunological activity, several professional societies have advocated in their recommendations for the management of patients with IRDs in times of SARS-CoV-2/COVID-19 the continuation of therapy with anti-inflammatory drugs, provided that clinical symptoms of COVID-19 do not develop.6–8 On the other hand, these guidelines also recommend strict adherence to the hygiene and distance measures to reduce the risk of exposure to the virus. In this respect, several recent comparative surveys of patients with IRDs and the non-rheumatic population have shown that patients with IRDs do not actually have a different risk of infection than the general …

BACKGROUND Inflammatory arthritides (IA) such as rheumatoid arthritis or psoriatic arthritis are disorders that can be difficult to comprehend for health professionals and students in terms of the heterogeneity of clinical symptoms and pathologies. New didactic approaches using innovative technologies such as virtual reality (VR) apps could be helpful to demonstrate disease manifestations as well as joint pathologies in a more comprehensive manner. However, the potential of using a VR education concept in IA has not yet been evaluated. OBJECTIVE We evaluated the feasibility of a VR app to educate health care professionals and medical students about IA. METHODS We developed a VR app using data from IA patients as well as 2D and 3D-visualized pathological joints from X-ray and computed tomography–generated images. This VR app (Rheumality) allows the user to interact with representative arthritic joint and bone pathologies of patients with IA. In a consensus meeting, an online questionnaire was designed to collect basic demographic data (age, sex); profession of the participants; and their feedback on the general impression, knowledge gain, and potential areas of application of the VR app. The VR app was subsequently tested and evaluated by health care professionals (physicians, researchers, and other professionals) and medical students at predefined events (two annual rheumatology conferences and academic teaching seminars at two sites in Germany). To explore associations between categorical variables, the χ2 or Fisher test was used as appropriate. Two-sided P values ≤.05 were regarded as significant. RESULTS A total of 125 individuals participated in this study. Among them, 56% of the participants identified as female, 43% identified as male, and 1% identified as nonbinary; 59% of the participants were 18-30 years of age, 18% were 31-40 years old, 10% were 41-50 years old, 8% were 51-60 years old, and 5% were 61-70 years old. The participants (N=125) rated the VR app as excellent, with a mean rating of 9.0 (SD 1.2) out of 10, and many participants would recommend use of the app, with a mean recommendation score of 3.2 (SD 1.1) out of 4. A large majority (120/125, 96.0%) stated that the presentation of pathological bone formation improves understanding of the disease. We did not find any association between participant characteristics and evaluation of the VR experience or recommendation scores. CONCLUSIONS The data show that IA-targeting innovative teaching approaches based on VR technology are feasible.

A few days after the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was declared a pandemic, the German Society for Rheumatology (DGRh) compiled the first group of recommendations for the care of patients with inflammatory rheumatic diseases in light of SARS-CoV-2/coronavirus disease 2019 (COVID-19). These first recommendations were based on an expert consensus and were largely non-evidence-based. Now that the first scientific data from registries, cross-sectional studies, case reports and case series are available, the DGRh has developed a timely update. This update is based on a literature search of publications available through 15 June 2020 and addresses preventive measures (such as hygiene measures or vaccinations) and the use of immunomodulatory/immunosuppressive drugs. Driven by the commitment to let patients benefit from these new evidence-based recommendations as quickly as possible, the DGRh published the update in German on its homepage and in the Zeitschrift für Rheumatologie immediately after completion. Here we report the key recommendations to make them available to the international community, provide the scientific methodology used to develop the recommendations, give additional thoughts and advice for the management of patients with rheumatic diseases during the COVID-19 pandemic and discuss our recommendations in the context of other international recommendations.

Background To compare the glycosaminoglycan (GAG) content of lumbar intervertebral disks (IVDs) of patients with ankylosing spondylitis (AS) and healthy volunteers and to investigate the association of GAG depletion and disease-related clinical and imaging features. Methods Lumbar spines of 50 AS patients (mean age 50 ± 10.5 years) and 30 age-matched volunteers were studied with 3-T magnetic resonance imaging (MRI) and conventional radiographs (CR). The MRI protocol included high-resolution morphological sequences and the compositional GAG chemical exchange saturation transfer imaging technique (gagCEST). Morphological images were analyzed by three raters for inflammatory activity, fat deposition, disk degeneration, and structural changes on CR. Clinical and serological measures included the Bath AS Disease Activity (BASDAI) and Bath AS Function (BASFI) Indices and C-reactive protein (CRP) levels. GagCEST values of both groups were compared using a linear mixed model. Kendall-Tau correlation analyses were performed. Results GagCEST values were significantly lower in AS patients (2.0 ± 1.7%) vs. healthy volunteers (2.4 ± 1.8%), p = 0.001. Small, yet significant correlations were found between gagCEST values and CRP levels (τ = − 0.14, p = 0.007), BASFI (τ = − 0.18, p

Background Even though cartilage loss is a known feature of psoriatic arthritis (PsA), little is known about its role in the pathogenesis of PsA. Using delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) as a non-invasive marker of the tissue’s proteoglycan content, such early (i.e., pre-morphological) changes have been associated with inflammation in rheumatoid arthritis (RA). Yet, this association has not been studied before in PsA. Methods The metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints of 17 patients with active PsA were evaluated by high-resolution clinical standard morphological and dGEMRIC sequences using a 3T MRI scanner (Magnetom Skyra, Siemens) and a dedicated 16-channel hand coil. Images were analyzed by two independent raters for dGEMRIC indices, PsA MRI scores (PsAMRIS), and total cartilage thickness (TCT). Kendall tau correlation coefficients (τ) were calculated. Results We found significant negative correlations between dGEMRIC indices and total PsAMRIS (τ = − 0.5, p = 0.012), synovitis (τ = − 0.56, p = 0.006), flexor tenosynovitis (τ = − 0.4, p = 0.049), and periarticular inflammation (τ = − 0.72, p