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Background: Adult parvovirus B19 (B19V) infection occurs with cyclic outbreaks and can be associated with inflammatory manifestations mimicking or heralding the onset of systemic autoimmune diseases. Little is known about clinical traits distinguishing patients with transient vs. persisting manifestations. Methods: Leveraging data from the 2024 B19V infection outbreak, we set up a retrospective, multicentre, observational study investigating the epidemiology and clinical phenotypes of patients with B19V infection presenting to tertiary care for immune-mediated manifestations, including patients with pre-existing autoimmunity. Results: A total of 39 B19V infections were identified, yielding an annual incidence of 1.78 cases/1000 patients. Autoimmune rheumatic diseases were pre-existing in 7/39 and newly diagnosed in 5/39. One patient was hospitalised. Arthritis was more frequent in new-onset (89%) than in pre-existing (14%; p = 0.010) or no autoimmunity (19%; p < 0.001). Anaemia was not found in patients with pre-existing autoimmunity in contrast to those with new autoimmune disease diagnoses (40%; p = 0.039) or transient manifestations (52%; p = 0.013). Skin manifestations were numerically less frequent in this latter group (56%) than in patients with pre-existing (100%) or newly onset autoimmunity (80%). Autoantibodies were detected in 44% of cases and were more frequent in patients with constitutional symptoms but were not confirmed in the long term in most cases. Glucocorticoids were more frequently employed in patients with new-onset rather than pre-existing autoimmune diseases (p = 0.006) or without chronic autoimmunity (p = 0.027). Conclusion: B19V-associated new-onset autoimmunity may occur in one in six cases observed in tertiary immunology care, show distinct clinical features, and require significant immunosuppression.

Background The beginning of the Covid-19 pandemic has forced many hospital departments worldwide to implement telehealth strategies for the first time. Telehealth represents the opportunity to increase value for all stakeholders, including patients and healthcare staff, but its success constitutes a challenge for all of them and particularly patients play a crucial role for their needed adherence. This study focuses on the experience of the Rheumatology Unit of Niguarda Hospital in Milan (Italy), where telehealth projects have been implemented for more than a decade with structured design and organized processes. The case study is paradigmatic because patients have experimented personalized mixes of telehealth channels, including e-mails and phone calls, Patient Reported Outcomes questionnaires, and home delivery of drugs. Given all these peculiarities, we decided to deepen patients’ perspective through three main aspects related to the adoption of telehealth: (i) the benefits perceived, (ii) the willingness to enrol in future projects, (iii) the preference on the service-mix between remote contacts and in-person visits. Most importantly, we investigated differences in the three areas among all patients based on the mix of telehealth channels experienced. Methods We conducted a survey from November 2021 to January 2022, enrolling consecutively patients attending the Rheumatology Unit of Niguarda Hospital in Milan (Italy). Our survey comprised an introductory set of questions related to personal, social, clinical and ICT skills information, followed by the central part on telehealth. All the answers were analysed with descriptive statistics and regression models. Results A complete response was given by 400 patients: 283 (71%) were female, 237 (59%) were 40–64 years old, 213 (53%) of them declared to work, and the disease most represented was Rheumatoid Arthritis (144 patients, 36%). Descriptive statistics and regression results revealed that (i) non-users imagined wide-ranging benefits compared to users; (ii) other things being equal, having had a more intense experience of telehealth increased the odds of accepting to participate to future projects by 3.1 times (95% C.I. 1.04–9.25), compared to non-users; (iii) the more telehealth was experienced, the higher the willingness to substitute in-person with online contacts. Conclusions Our study contributes to enlighten the crucial role played by the telehealth experience in determining patients’ preferences.

Close follow-up is mandatory in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS). During the Coronavirus Disease 2019 (COVID-19) pandemic, rheumatological care was rapidly reorganized during the first peak from March 1, 2020 to May 31, 2020, and all patients with RA, PsA, and AS being treated with a subcutaneous biologic disease-modifying anti-rheumatic drug or oral targeted synthetic disease-modifying anti-rheumatic drug were followed remotely. A retrospective database analysis of these 431 patients before and after this period is presented herein. A rheumatologist directly contacted all patients by telephone. Patients could also enter data on patient-reported outcomes remotely using the digital platform iAR Plus. General health (GH) and visual analog scale (VAS) pain were the main outcomes along with FACIT and disease-specific questionnaires (RADAI, ROAD, PROCLARA for RA, and BASDAI, BASGI, BASFI for AS). In all, 449 visits were postponed (69.9% of all scheduled visits); telephone evaluation was deemed inadequate in 193 instances, and patients underwent a standard outpatient visit. Comparing patients on telemedicine to those who underwent hospital visits, we found no statistically significant differences in GH (35.3 vs 39.3; p = 0.24), VAS (33.3 vs 37.1; p = 0.29), or other specific outcome measures in patients with RA, PsA, or AS. These results show that telemedicine has undoubted benefits, and in light of the ongoing COVID-19 pandemic, it is likely that many patients with these diseases may prefer it.

Objective. To develop and test an algorithm with the aim of optimizing the implementation of ultrasound in the diagnostic workflow in clinical practice. Methods. Through a consensus among the Musculoskeletal Ultrasound (MSUS) Study Group of the Italian Society for Rheumatology, we identified clinical and laboratory variables to be included in 1000minds surveys to develop an algorithm driving clinical diagnostic suspicion. The algorithm would identify potential differential diagnoses where MSUS protocols targeted for specific diseases (rheumatoid arthritis, psoriatic arthritis, gout, calcium pyrophosphate deposition disease, polymyalgia rheumatica, and osteoarthritis) could be applied. The joint sites and elementary lesions for each disease were selected based on a previously performed systematic literature review (SLR) and consensus. Finally, we conducted a pilot study on patients with new-onset arthritis to assess the performance of the algorithm, comparing the algorithm-based diagnosis with the final clinical diagnosis. Results. Based on the consensus and the surveys, age, the number of involved joints, anti-citrullinated protein antibody, rheumatoid factor, C-reactive protein, and erythrocyte sedimentation rate were included in the algorithm. The pilot study included 59 patients: median (interquartile range) age 62.2 (54.1-72.6) years, 78% female. The agreement between the diagnosis selected by the algorithm and the final diagnosis by the rheumatologist was 88.1%. The elementary lesions and joint sites included in the different MSUS protocols were selected based on the best diagnostic accuracy, as shown by the SLR and defined by the working group. Conclusions. The developed algorithm was accurate in identifying the correct diagnosis. Thus, it could reliably drive the decision on the MSUS assessment to perform. The RADIAL study will further investigate the feasibility and added value of MSUS in the diagnostic workflow according to this newly developed clinical suspicion-driven algorithm.

Objective To assess the extent of calcium pyrophosphate dihydrate (CPP) crystal deposition and the distribution of affected sites, using ultrasonography (US), in patients affected by CPP deposition disease (CPPD). Patients and methods 42 consecutive patients affected by definite CPPD according to the McCarty criteria were enrolled in the study. All patients underwent an US examination of metacarpophalangeal joints of II, III, IV and V fingers of both hands, wrists and knees, Achilles’ tendons and plantar fascia looking for CPP deposits. A dichotomous score for presence/absence of CPP and a semiquantitative score for extent of deposits (0–3: 0, absent; 1, 1–2 spots; 2, more than two spots covering <50% of the structure; 3, deposits covering >50% of the structure) were assigned to each site examined. A site distribution score (total number of affected sites) was then calculated as well as an extent score equal to the sum of the extent scores of all sites. Results The mean involvement in our patients was 4.7 sites (SD±1.7, range 2–8 sites). The knee was the most affected, site (41 of 42) followed by the wrist (at least one in 37 patients) the Achilles’ tendons (23 patients), plantar fascia (11 patients) and metacarpophalangeal joints (four patients). The highest mean values of the extent score were in the menisci, followed by the hyaline cartilage of the femoral condyles and the entheses. Conclusions The deposition of CPP crystals involves at least two sites with a mean of four sites involved in most patients affected by CPPD and is therefore an oligoarticular or polyarticular disease.

The present pilot study aimed to assess the feasibility of a \"teletriagerheum\" service before the first rheumatology visit and identify potential benefits and disadvantages by comparing a regular visit with a first face-to-face visit preceded by the \"teletriagerheum\" service. A prospective monocentric pilot study was conducted from October to December 2021. Consecutive patients were contacted to investigate their willingness to receive a phone call (\"teletriagerheum\" service) from a physician of the Rheumatology Unit before the first rheumatology visit. The number of definite diagnoses at the first visit in the \"teletriagerheum\" group was compared with patients receiving a regular first visit, as well as socio-demographic characteristics, the reason for the visit, face-to-face visit duration, and the number of additional exams. Overall, 75 patients performed the \"teletriagerheum\" (\"teletriagerheum\" group), and 74 patients were included in the control group. In the \"teletriagerheum\" group, a higher number of conclusive diagnoses was observed (72% vs. 58%, p=0.020) with a higher probability of receiving a conclusive diagnosis compared with the control group, both at univariate [odds ratio (OR) 2.28, p=0.021] and multivariate analyses adjusting for the only differences between the two groups (marital status and information and communication technologies skills; OR 2.95, p=0.007). At the first face-to-face visit, fewer additional tests were prescribed in the \"teletriagerheum\" group; however, the overall number of tests (including those prescribed during teletriage) was higher. A telephone-based telerheumatology service could be an effective triage tool for first visits of new outpatients, enabling more definitive diagnoses, thanks in part to the ability to perform the required investigations in a timely manner in most cases.

ObjectivesThe Gout, Hyperuricaemia and Crystal-Associated Disease Network (G-CAN) has developed a calcium pyrophosphate deposition (CPPD) nomenclature project. This systematic literature review constituted its first step and aimed to provide a state-of-the-art analysis of the medical literature of the last 20 years.MethodsA systematic literature search was undertaken in the PubMed, Cochrane and Embase databases between 2000 and 2022, restricted to studies on humans and in the English language. Eight reviewers independently and manually extracted labels related to CPPD concepts, according to an a priori list generated by the authors: pathogenic conditions and pathogenic crystal labels, elementary imaging condition elements and asymptomatic and symptomatic condition states. For each concept, labels were analysed to determine their frequency.ResultsAmong the 2375 articles identified, 886 articles were included, of which 394 (44.5%) were case reports and 169 (19.0%) were scoping reviews. Overall, the most common labels used to designate the pathogenic condition were ‘pseudogout’ in 365/783 (46.6%), ‘chondrocalcinosis’ in 207/783 (26.4%) and ‘calcium pyrophosphate deposition disease’ in 181/783 (23.1%) occurrences. The most common abbreviation was ‘CPPD’ in 312/390 (80.0%), but with different meanings. CPPD clinical phenotypes were often described as ‘pseudo-form’ labels.ConclusionThose results demonstrate the heterogeneity of labels used to describe CPPD condition concepts, with wide variation in condition labels in the medical literature. This work provides the rationale and basis to achieve agreement about CPPD technical nomenclature.

To identify the prevalence of calcium pyrophosphate crystal deposition (CPPD) using ultrasound and conventional radiology at peripheral joints in patients with suspected or definite CPPD. A systematic literature search was performed in PubMed and Embase using pre-defined search strategies from inception to April 2021 to identify studies that evaluated conventional radiology and ultrasound in detecting CPPD at peripheral joints, including definite or suspected CPPD [Research question 1 (RQ1) and Research Question 2 (RQ2), respectively]. For the meta-analysis, the first, second, and third sub-analysis included studies with the knee, and knee or wrist as the index joint for CPPD (without restrictions on the reference standard) and synovial fluid analysis or histology as a reference standard (without restrictions on the index joint), respectively. One-thousand eight hundred and twenty-seven manuscripts were identified, of which 94 articles were finally included. Twenty-two and seventy-two papers were included in RQ1 and RQ2, respectively. The knee had the highest prevalence for RQ1 and RQ2 by both conventional radiology and ultrasound, followed by the wrist with the highest prevalence for RQ1. The hand had the lowest CPPD prevalence. The third sub-analysis showed a higher CPPD prevalence on ultrasound than conventional radiology at the knee (only data available). Among all peripheral joints, the knees and wrists could be regarded as the target joints for CPPD detection by imaging. Furthermore, ultrasound seems to detect a higher number of calcium pyrophosphate deposits than conventional radiology, even when using a more restrictive reference standard.

Purpose: The aim of this article is to examine the extent of structural and inflammatory lesions by ultrasound in elderly subjects with hand osteoarthritis (HOA) fulfilling the ACR classification criteria (Group A), in subjects with painless enlarged finger joints (Group B), and in individuals without clinical abnormalities at hands (Group C). Methods: This study was nested within the population-based, prospective Bruneck study; 293 subjects of ⩾65 years of age were assessed. Clinical and ultrasound assessment was conducted at wrists and finger joints. Gray scale synovitis (GSS), Power Doppler (PD), osteophytes, and erosions were scored semiquantitatively (0–3). The Short Form Score for the Assessment and Quantification of Chronic Rheumatic Affections of the Hands (SF-SACRAH), the Health Assessment Questionnaire (HAQ), and the Functional Index for Hand Osteoarthritis (FIHOA) were retrieved. Results: Most subjects had ⩾1 ultrasound abnormality, of which osteophytes were the most prevalent finding in all groups (Group A: 100%, Group B: 99.4%, and Group C: 93.9%). GSS and PD-signals were more common in Group A than in Group B (94% versus 67% and 33% versus 13%, respectively). In Group C, GSS was observed in 39.4% of subjects. In subjects with HOA, the SF-SACRAH correlated with osteophyte scores (corrcoeff = 0.48), and the FIHOA correlated with the osteophyte (corrcoeff = 0.42) and PD scores (corrcoeff = 0.33). Conclusion: GSS and PD were more frequent in patients with symptomatic HOA than in cases with painless bony enlargements and subjects without clinical joint abnormalities. Functional restriction in HOA is associated with structural and inflammatory ultrasound changes.

Differential diagnosis in early arthritis is challenging, especially early after symptom onset. Several studies applied musculoskeletal ultrasound in this setting, however, its role in helping diagnosis has yet to be clearly defined. The purpose of this work is to systematically assess the diagnostic applications of ultrasonography in early arthritis in order to summarize the available evidence and highlight possible gaps in knowledge. In December 2017, existing systematic literature reviews (SLR) on rheumatoid arthritis (RA), osteoarthritis (OA), psoriatic arthritis (PsA), polymyalgia rheumatica (PMR), calcium pyrophosphate deposition disease (CPPD), and gout were retrieved. Studies on ultrasound to diagnose the target conditions and detecting elementary lesions (such as synovitis, tenosynovitis, enthesitis, bone erosions, osteophytes) were extracted from the SLRs. The searches of the previous reviews were updated and data from new studies fulfilling the inclusion criteria extracted. Groups of reviewers worked separately for each disease, when possible diagnostic accuracy (sensitivities, specificities) was calculated from primary studies. When available, the reliability of ultrasound to detect elementary lesions was extracted. For all the examined disease, recent SLRs were available. The new searches identified 27 eligible articles, with 87 articles included from the previous SLRs. The diagnostic performance of ultrasound in identifying diseases was addressed by 75 studies; in most of them, a single elementary lesion was used to define diagnosis, except for PMR. Only studies on RA included consecutive patients with new onset of arthritis, while studies on gout and CPPD often focused on subjects with mono-arthritis. Most of the remaining studies enrolled patients with a defined diagnosis. Synovitis was the most frequently detected lesion; clinical diagnosis was the most common reference standard. The diagnostic performance of ultrasound across different conditions was extremely variable. Ultrasound to identify elementary lesions was assessed in 38 studies in OA, gout and CPPD. Its performance in OA was very variable, with better results in CPPD and gout. The reliability of ultrasound was moderate to good for most lesions. Although a consistent amount of literature investigated the diagnostic application of ultrasound, in only a minority of cases its additional value over clinical diagnosis was tested. This SLR underlines the need for studies with a pragmatic design to identify the placement of ultrasound in the diagnostic pathway of new-onset arthritis.