Gout is a common inflammatory arthritis preceded by chronically elevated levels of serum urate. In addition to leading to gouty flares, hyperuricemia can result in stone-like deposits of monosodium urate crystals (tophi) being deposited in joints and soft tissue, where they cause severe pain and damage. Although gout is an ancient disease with a well-characterized etiology, its treatment landscape has not kept pace with that of other rheumatic conditions. Therapy centers on lowering serum urate concentrations, with urate-lowering drugs falling into three categories: xanthine oxidase inhibitors (e.g., allopurinol, febuxostat) that reduce urate production by blocking the conversion of hypoxanthine to uric acid; uricosurics [primarily urate transporter-1 (URAT1) inhibitors, including probenecid, lesinurad] that promote the renal excretion of urate; and recombinant uricases (e.g., pegloticase) that convert uric acid to allantoin (a water-soluble compound that is more readily excreted). Some treatments have been available for decades, but are often limited by toxicities, primarily relating to the liver and kidneys. Recent research has focused on developing more potent and specific URAT1 inhibitors in the hope that these safety concerns can be overcome, and that better tolerated, more effective therapies can be made available. Newer uricosurics have different chemical structures from their predecessors, resulting in greater URAT1 selectivity in order to reduce off-target effects. Several of these have shown promising results in clinical trials and could prove to be viable alternatives to suboptimal existing therapies. Indeed, newer generation uricosurics may have the potential to become viable therapies in indications other than gout, such as some metabolic diseases. In this narrative review, we discuss the position of uricosurics (primarily URAT1 inhibitors) in the landscape of chronic gout treatment of the past, present, and future.

Co-prescription of anti-inflammatory prophylaxis with colchicine, non-steroidal anti-inflammatory drugs (NSAIDs), or corticosteroids when initiating urate-lowering therapy (ULT) for gout is recommended in clinical guidelines to prevent ULT-induced flares and optimise adherence to ULT. Colchicine prophylaxis is highly clinically and cost-effective and there has been great interest recently in its cardioprotective effects. However, one in four people initiating ULT without prophylaxis in randomised trials do not have a gout flare within six months of initiation, raising the question of whether all people initiating ULT for gout should receive prophylaxis. Uptake of prophylaxis varies and appears to be common in secondary care settings but less commonly used in primary care, where most people with gout are managed and gout may be less severe. Recent clinical guidelines have highlighted that the patient’s perspective is important and that the pros and cons of prophylaxis should be discussed with people with gout initiating ULT. Uptake of prophylaxis seems likely to be influenced by perception of an individual’s risk of ULT-induced flares, as well as concerns about adverse events, polypharmacy, drug interactions, and cost. We advocate a personalised approach between people with gout and clinicians to reach shared treatment decisions when considering co-prescription of prophylaxis when initiating ULT, empowering people with gout to make decisions about their care.

Obesity is widely recognized as being associated with both the onset and advancement of gout, exerting a detrimental effect on health outcomes in society. In the realm of gout management, theoretical frameworks support weight loss as a beneficial strategy for people impacted by overweight or obesity. Existing empirical evidence is limited to a handful of predominantly observational studies with low methodological rigor. A recent exploratory clinical trial which included 61 people with obesity and gout randomly allocated participants to either an intensive diet group (n = 29) or a control diet group (n = 32). After 16 weeks, a significant difference in body weight change was observed between the intensive diet group and the control diet group [−7.7 kg (95% confidence interval −10.7 to −4.7)]. Although the results leaned towards favoring a low-energy diet, differences in changes in serum urate (SU) levels and fatigue between the groups could not be confirmed. For the majority of individuals who lose weight a key challenge is long term maintenance. Novel agents such as glucagon-like peptide-1 receptor agonists (GLP-1Ras) have a role in weight loss and its maintenance. In this manuscript we propose what we consider the ideal target trial for weight loss in gout. We envision a two-year randomized trial with participants allocated to either a GLP-1Ra or placebo and evaluated and monitored over a two-year period.

Immune checkpoint inhibitors (ICI) such as cytotoxic T-lymphocyte associated protein-4 (CTLA-4), programmed cell death-1 (PD-1), programmed death ligand-1 (PD-L1), and lymphocyte activation gene-3 (LAG-3) are increasingly used to treat cancer patients since they were shown to reduce tumor progression and increase survival of patients with different types of cancer. However, ICI may also affect self-tolerance and lead to immune-related adverse events (irAEs) which are not very frequent but can present in almost all organ systems including joints, tendons, and muscles. Indeed, arthritis and myositis are among the most frequent irAEs. Glucocorticoids, immunosuppressants, and biologics are used to treat affected patients. This commentary deals with the question of whether Janus kinase inhibitors could be an option in this clinical situation.

The COVID-19 pandemic changed healthcare practices and social media played a significant role in those changes. While social media and online practice communities allow collaboration and engagement, education and knowledge dissemination, research and publication, promotion, and the potential for improved clinical care, their use also involves perils and pitfalls. The literature suggests that rheumatologists use innovative social media platforms for both professional and social purposes. Similarly, many patients with rheumatic disease use social media for education and communication. This review outlined the background of social media platforms, the reasons for their use, and associated risks. This review further discussed the need to better understand the benefits of social media and online communities as well as the potential negative effects that could impact the practice of rheumatology.

Gout is a common and disabling form of arthritis. Despite widely available, highly effective, urate-lowering therapies, such as allopurinol, studies continue to demonstrate poor care for individuals with gout in healthcare systems worldwide. In this commentary, we highlight strategies that can be utilised to overcome real-world barriers to optimal gout care, including allied health professional input, patient and clinician education, self-management strategies, and electronic health record solutions.

Oral urate-lowering therapy (ULT) is key to treating gout. However, many patients receiving oral ULT do not achieve the target serum urate (SU) levels, partly because some patients cannot tolerate or have contraindications to their use, mainly due to comorbidities. This may lead to uncontrolled gout. In species other than humans and some non-human primates, uricase (urate oxidase) converts urate to allantoin, which is more readily excreted by the kidney. Exogenous uricases, considered “enzyme replacement therapy”, are a therapeutic option for patients with refractory or uncontrolled gout. Current uricases on the market include pegloticase and rasburicase. Uricase treatment rapidly reduces hyperuricemia and tophaceous deposits and improves the quality of life. This review discusses currently approved uricases on the market and some in development; how best to minimize flares, anti-drug antibody (ADA) formation, infusion reactions, and loss of efficacy, and combination with immunomodulation in patients with gout requiring uricase therapy.

Calcium pyrophosphate deposition disease (CPPD), characterized by the presence of calcium pyrophosphate crystals in and around joints, poses diagnostic and therapeutic challenges in rheumatology. This review provides a comprehensive overview of CPPD, focusing on its diagnosis, differential diagnosis, therapeutic challenges, and monitoring, with insights into the association between CPPD and cardiovascular risk. Diagnostics in CPPD rely on identifying CPP crystals in synovial fluid or joint tissues, with imaging modalities such as ultrasound and conventional radiography emerging as valuable tools. The 2023 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria prioritize imaging evidence of CPP crystal deposition and recurrent episodes of acute inflammatory arthritis, aiding in standardized diagnosis. Differential diagnosis includes distinguishing CPPD from gout, osteoarthritis, rheumatoid arthritis, basic calcium phosphate deposition disease, and other inflammatory arthropathies. Therapeutic challenges in CPPD management revolve around symptomatic relief, with no targeted therapy to influence CPP deposition currently available. Management strategies include symptom-directed treatments like NSAIDs, steroids and colchicine. IL-6 inhibition with tocilizumab shows promise for refractory cases. Monitoring CPPD involves assessing joint symptoms, inflammation, and cardiovascular risk factors, with regular clinical evaluation. In conclusion, CPPD presents a complex challenge in rheumatology, requiring a nuanced approach to diagnosis and management. Ongoing research is needed to deepen our understanding of CPPD mechanisms and explore novel therapeutic avenues.

The aim of biosimilars is to alleviate the financial burden of biological medicinal products. A most relevant challenge for emerging countries is how to select the best option available. In most cases, price is the major determinant, as budgets are chronically scarce. However, initial savings due to price reductions can be overridden if there is a lack of supply due to product shortages or withdrawals. These events can be prevented by a best-value strategy. According to the concept of best-value medicinal products, price is only one of the various criteria to be considered. The purpose of the present paper is to provide suggestions of criteria that can be useful for selecting the best-value biological in emerging countries. Six criteria, that are not limitative, have been selected as follows: standards of regulatory approval, quality of the product, good distribution practices, security of supply, pharmacovigilance, and price.

Gout is common in people with chronic kidney disease and in general is sub-optimally managed. Lack of evidence due to the exclusion of people with chronic kidney disease from the majority of clinical trials, concerns about adverse effects and conflicting gout management guidelines all contribute to suboptimal management. Herein we review the evidence for the pharmacological treatment of gout, both flares and long-term urate-lowering, in people with concomitant chronic kidney disease.

Surgeons are exposed to a high prevalence of work-related musculoskeletal disorders (WMSDs). The scientific issues surrounding this problem are generating a growing body of work. The aim of this study is to obtain quantitative and visual information from articles about WMSDs and surgeons through bibliometric analysis. The keywords “surgeon” and “work-related musculoskeletal disorders” were searched in the PubMed/Medline database until March 2024. Data extraction and visualization were performed using VOSviewer version 1.6.20. and Microsoft Excel on the overall distribution of publications by year, sources, articles, authors and keywords. A total of 173 English-language publications were extracted between 1982 and 2024. The number of publications has increased over the years. A significant increase was observed from 2016. America is the leader with 82/173 publications (47.4%) and 3,276 citations. Work [impact factor (IF): 2.3] is the first top source which has 7 articles followed by Surgical Endoscopy (IF: 3.1) with 5 publications. Journal of Occupational Rehabilitation (IF: 3.3) is the top journal with 681 citations for 2 publications. Hallbeck MS, Yu D, and Vijendern A are the most productive authors with 23 publications. The analysis showed that the United States and the UK are the two most productive countries (journals, authors, citations). The most frequently used keywords were “ergonomics”, “musculoskeletal disorders”, “work-related musculoskeletal disorders”, and “surgeons”. Bibliometric analysis has shown that the prevalence of WMSDs in surgeons is a topic showing significant growth, particularly since 2016, dominated by American researchers. A synthesis of the WMSD prevalence by body area has been made based on the most cited articles. This field has evolved considerably. From a rather subjective analysis of prevalence based on questionnaires, work has moved towards a more ergonomic assessment using objective evaluation tools.

The automotive industry is growing worldwide with new technologies and seeking maximum cost savings. This sector is essential for the economic development of the country, with modern industries that invest in technological innovations and control of the activities of the production process. With this, the workstations become increasingly dynamic and characterized in the logic of productivity. Therefore, this study aimed to evaluate the work activity of operators of an assembly line of automotive components, from the ergonomic analysis. Through a descriptive and exploratory field study, the work activity of 30 operators of an assembly line of metallic components of the automotive industry was evaluated. Using instruments such as sociodemographic questionnaire; Nordic questionnaire; open interview, with collective questions about the development of the function, listed in an ergonomic demand items (EDIs) ranking; and complementary application of the NIOSH and OCRA methods. As a result, all respondents were male, with an average age of 30.13 ± 8.57 years, most had completed high school (76.7%), with an average working time in the company of almost two years (21.93 ± 12 months). Regarding relationships with coworkers, it was observed that the sector has a great relationship during the activities, with both colleagues and the boss. This study demonstrated a lower frequency of musculoskeletal symptoms in operators when compared to other studies. Symptoms that caused work leave were neck (3.3%), shoulders (3.3%), upper (6.7%) and lower back (6.7%), and hips/thighs (6.7%), ankle/foot (6.7%) were reported.

Axial spondyloarthritis (axSpA) is a frequent inflammatory rheumatic disease mainly affecting the axial skeleton causing inflammatory back pain. If chronic inflammation persists new bone formation may occur possibly leading to irreversible spinal stiffness. The disease has a strong genetic background with HLA-B27 as the major factor. For diagnostic purposes, imaging is of critical importance—especially conventional radiography and magnetic resonance imaging (MRI). While the former has advantages in the detection of bony changes such as the syndesmophytes, MRI is used to detect axial inflammation but also erosions in the sacroiliac joint. Treatment follows the treat-to-target strategy starting with non-steroidal anti-inflammatory drugs (NSAIDs) in the first line, and later, if high disease activity persists, therapy with biologic disease modifying anti-rheumatic drugs (bDMARDs) is according to international recommendations indicated. For the treatment of axSpA, important targets such as tumor necrosis factor alpha (TNFα) and interleukin (IL)-17 have been identified, and several of their inhibitors (i) including some biosimilars for the former have been approved. Recently, also inhibition of Janus kinases was shown to be efficacious. There is evidence that long term inhibition of inflammation with TNFi can reduce bone formation.

Screening for developmental dysplasia of the hip (DDH) in Greece is being performed according to the guidelines issued by the Institute of Child Health in 2015. Screening strategies include universal clinical screening and selective (based on clinical findings or risk factors) sonographic screening. Clinical examination is performed by neonatologists and paediatricians and findings are recorded in the baby’s Health-Book. Whenever clinical examination is suspicious (however non-specific), children are referred for an ultrasound scan and/or to a (paediatric) orthopaedic surgeon. In the case of a positive clinical examination, children are referred to a (paediatric) orthopaedic surgeon, who treats them, when needed. All types of abduction devices are used for treatment (Pavlik, Tubingen), as well as plaster cast, which is preferred in older babies. There are no official guidelines over the selection of the sonographic method for screening; however, the mostly used technique is Graf’s, according to publications from Greek centers. Training of operators on the sonographic examination technique is carried out during radiology residency, depending on hospital availability/expertise, through seminars with hands-on workshops and/or during fellowships. Radiologists and certified paediatric orthopaedic surgeons are the only ones legally allowed to perform neonatal/infantile hip sonography in Greece. Emphasis on the benefits of universal screening and standardized techniques are increasingly taught and repeated, which may eventually influence the decision-making process and standardize the performance of hip sonography within the next few years.

Calcium pyrophosphate deposition disease is known as crowned dens syndrome or peripheral arthritis, especially of knees, hips and shoulders. The disease course is asymptomatic, with acute or chronic disease activity related to osteoarthritis, especially in the elderly. Other risk factors are joint injury, osteoarthritis and metabolic conditions such as primary hyperparathyroidism, hemochromatosis, hypophosphatasia and hypomagnesemia. Genetic background should be considered before the age of 55 years. Only recently was the value of signs and symptoms weighted, allowing the introduction of classification criteria. Biomarkers include compensated polarized light microscopy findings, laboratory values and imaging. Imaging evidence refers to calcification of the fibrocartilage or hyaline cartilage. Chondrocalcinosis defined as such cartilage calcification is most commonly due to calcium pyrophosphate deposition disease. Calcification of the synovial membrane, joint capsule, or tendon should not be scored. Ultrasonography detects calcium pyrophosphate deposits with more than 80% sensitivity rates, which is superior to conventional radiography. In the future, dual-energy computerized tomography and Raman spectroscopy are promising new techniques to assess disease activity. Currently, the primary therapeutic goal is controlling inflammatory reactions and preventing further episodes. However, only hydroxychloroquine and magnesium carbonate have shown some efficacy and reduction of pain intensity so far. As patients report more significant unmet treatment needs than patients with gout, education is an essential issue of care. The new classification criteria will allow the validation of standardized outcome parameters with the definition of remission and low disease activity for developing treat-to-target strategies to perform well-designed interventional trials evaluating new treatment options and strategies.

Calcium pyrophosphate deposition disease (CPPD) is a cause of inflammatory arthropathy that increases in prevalence with increasing age, presents in acute and chronic forms, and is characterized by the finding of positively birefringent crystals on polarized microscopy of synovial fluid. This review finds that although strides are being made in CPPD diagnosis and classification, CPPD remains a poorly understood, unrecognized, and debilitating disease. As a consequence, treatment options usually lack supportive evidence and there has been little progress in novel drug development for the condition. This article aims to discuss the updated evidence on treatment options for CPPD and identifies promising future areas for improvement.

This editorial, “Sarcopenia: a hidden comorbidity of established rheumatoid arthritis” emphasizes the critical role of addressing comorbidities in rheumatoid arthritis (RA) management, focusing particularly on the clinical impact of sarcopenia. The first section highlights how advances in treating immune-mediated rheumatic diseases have improved RA management but also underscore the increasing necessity to integrate comorbidity management to enhance patient outcomes. The second part focused into sarcopenia as a significant yet overlooked comorbidity in RA, discussing its prevalence, impact on life quality, and the complexities of its diagnosis and management. The editorial advocates for a multidisciplinary approach involving rheumatologists, nurses, and primary care physicians to effectively tackle this issue. A call to action from scientific societies is suggested to raise awareness among healthcare professionals about sarcopenia, aiming to improve care for RA patients.

A 76-year-old male patient who has been suffering from psoriatic arthritis (PsA) for 15 years was diagnosed with chronic lymphocytic leukemia (CLL) 18 months ago. He has been treated him with a Bruton’s tyrosine kinase (BTK) inhibitor (ibrutinib) at a dose of 420 mg once daily (q.d.) for his CLL. For about two years, he received a quite successful treatment with methotrexate and the subcutaneously administered tumor necrosis factor (TNF) inhibitor (adalimumab) for his PsA, until his plaque psoriasis worsened. He consulted us when the severity of his skin condition necessitated a change in his treatment regimen. In the following discussion, we explore treatment options for this clinical scenario, with a particular focus on managing PsA in the context of CLL as a comorbidity. Additionally, we report on the initial phase of treatment with an anti-interleukin-23 (IL-23) inhibitor (guselkumab), specifically targeting his aggravated psoriasis.

Medical attention to uric acid (UA) has been increasing in recent years, mainly because this molecule has been shown to be associated with increased cardiovascular risk, both in the general population and in the hypertensive patients. A growing body of clinical and experimental data supports this view and prompts reconsideration of the role of UA in the development of atherosclerosis and the genesis of cardiovascular disease. It is known that this substance, in certain plasma concentrations, induces increased oxidative stress, a chronic inflammatory state, and a whole series of other modifications that are potentially deleterious at the cardiovascular level leading to hypertension, atherosclerosis, atrial fibrillation (AF), and other metabolic changes such as diabetes, metabolic syndrome, non-alcoholic fatty liver disease and kidney failure. Despite this epidemiologic and mechanistic evidence, the current guidelines from international cardiology scientific societies do not give precise indications in this regard, and some of them only suggest UA evaluation as part of an initial screening of the hypertensive patient. The purpose of this review is to briefly describe the main clinical and epidemiological evidence supporting the role of hyperuricemia as a possible emerging cardiovascular risk factor and to analyze the potential pathophysiological mechanisms through which elevated UA levels may exert a detrimental effect on the cardiovascular system.

Hip ultrasound, according to Graf, is a standardized sonographic method for the detection of developmental dysplasia of the hip (DDH) during the neonatal period. Graf established his method during the 1980s in his home country Austria. It was implemented in the Austrian Mother-Child Health Passport in 1992. Since then it served as a general screening method. The aim of this paper is to present the effects of general hip ultrasound screening in Austria by reviewing and analysing the literature of Austrian authors. This article described how the method was further developed and which prerequisites are currently required for a correct diagnosis. Moreover, it reports about the education in ultrasound screening according to Graf in Austria.

Since 1980, when Professor Reinhard Graf developed a novel technique, sonography of the infant hip has played a prominent role in the early diagnosis of developmental dysplasia of the hip (DDH). Brazil is a vast country, and disparities exist among regions and between the public and private health systems. In addition, healthcare professionals often have limited knowledge of DDH, and patients need to be referred to larger urban centers for definitive diagnosis and appropriate treatment. These reasons, and more, may hinder the early diagnosis of DDH. Following the successful implementation of similar neonatal screening programs for other conditions in Brazil, developing a screening program for DDH in Brazil is imperative. Such a program should consider training professionals to use Graf’s technique as a diagnostic procedure. It is recommended that more studies be conducted in every region of the country to provide a broader understanding of the current role of sonography in the screening and diagnosis of DDH in infants in Brazil.

The diagnosis of hip dysplasia has developed very differently in different countries over the last few decades. The development and current situation in Switzerland is described in this paper. In the meantime, early diagnosis by means of Graf hip sonography, corresponding to screening, has been established, although it varies from region to region. The training system for examiners is also clearly regulated. The massive reduction in costly treatments and operations documents the success of the efforts made in Switzerland.

The diagnosis of hip dysplasia has developed very differently in different countries over the last few decades. The development and current situation in Hungary is described in this paper. The Ortolani test is still the gold standard for clinical examination in most regions. Hip sonography is not officially established and is only used occasionally. However, thanks to private initiatives, more and more orthopaedic surgeons are now familiarising themselves with this method and the first courses are being held in accordance with International Interdisciplinary Consensus Committee on DDH Evaluation (ICODE) guidelines. A regional screening with Graf hip sonography was carried out in Szeged. The results of the evaluation impressively demonstrate the efficiency of this method.

This paper provides a review of the years of experience of hip sonography since the first ultrasound (US) course in Italy in 1987. Clinical and US findings were correlated in 1,000 newborns examined consecutively in a study in 1991. Developmental dysplasia of the hip (DDH) was present even in the absence of clinical signs, including the Ortolani sign. The percentage of US diagnosis of DDH in newborns was 2.8%, while instability according to the Ortolani test was present in 0.75%. After recommendations from the American Academy of Pediatrics against universal US screening, early diagnosis decreased from 74.4% in the period 1992–2002 (43,418 hips examined) to 52.7% in 2013–2014 (5,598 hips examined). In order to answer the question of whether early treatment of DDH has better outcomes, the acetabulum maturation was studied in 93 type III hips. The statistical analysis showed a strong dependency (P < 0.001) between the alpha-angle gain and the age at which treatment was started. The first 2 weeks of life is the optimum time for early diagnosis and treatment; after 6 weeks of life, treatment is less effective and the results are less predictable. Furthermore, the role of the labrum and its morphological changes was analyzed in 86 unstable dysplastic hips (13 type D, 49 type III and 24 type IV) in patients with an average age of 53 days (range 1–134 days) at DDH diagnosis and the beginning of treatment. The labrum was never inverted and underwent a statistically significant increase in echogenicity and dimensions with a frequency of 97% and 96% respectively, suggesting the labrum’s stabilizing role. Abnormal findings such as in achondroplasia, cleidocranial dysplasia, other rare osteochondrodysplasias and in coxa vara are underlined. Uncommon findings such as incomplete acetabular bony rim and eccentric position of the femoral head nucleus are also described.

Recent developments in digital health technologies are overwhelming, and their use in routine work is still difficult to anticipate. This narrative review summarizes the concept of consecutive cohorts in the literature, together with local research experiences in consecutive rheumatic outpatients. Digital health techniques have to reflect the clinicians’ needs, support real-life care of patients, and allow for the specific assessment of quality parameters fulfilling the Donabedian aspect of qualified health care, using quality indicators to improve health care and research. Rapidly growing observational cohorts will perform best to provide follow-up data as the basis for further development of healthcare approaches for rheumatic patients. The challenges of a selection bias, patients with limited disease expression, and chances of early detection of patients with rare diseases are addressed. For research purposes, sequential analyses with growing cohort size, comparative cross-sectional studies with sequential hypothesis testing and other prognostic, diagnostic, and therapeutic aspects of patient management can be performed. With the support of new technologies, young clinicians can easily approach such clinical topics, and learn about clinical data analyses. The use of quality standards as proposed in international recommendations for diagnostic issues and classification criteria, management recommendations, monitoring, and training issues can be supported by digital technologies. In conclusion, collaborative projects allow detailed clinical analyses of large cohorts, but local initiatives can prepare these co-operations, provide first local logistics and research experiences, and teach clinicians how to perform clinical research. Digital health technologies will strongly support these local initiatives.

Rheumatology, the medical specialty dealing with the diagnosis and treatment of rheumatic and musculoskeletal diseases (RMDs), is evolving with the emergence of digital health technologies, such as electronic health records (EHRs), virtual visits, mobile health (mHealth), wearable medical devices, social media, websites, digital therapeutics, artificial intelligence (AI) and machine learning. These technologies offer new opportunities to improve essential aspects of care, such as care access or disease management. They can significantly reduce the risk of errors and the workload of rheumatologists, while enhancing communication between physicians and patients, resulting in better quality of care. Moreover, digital health technologies can significantly improve research outcomes. However, digital health technologies in rheumatology also face specific barriers such as privacy, security concerns, incremental costs as well as limited digital health literacy and access. Therefore, further analysis, actions and strategies are needed to overcome these barriers. This article explores the impact of digital health technologies on rheumatology practice and highlights their contributions and challenges. By understanding the immense potential and overcoming the obstacles, the way for a future where digital health technologies are integrated into daily rheumatology care may be envisioned, in order to empower patients and healthcare providers.

Following anterior cruciate ligament (ACL) injury of the knee, the functional hop test (an averaging of 4 component hop tests including single-hop, triple-hop, cross-over-hop, and 6-meter-hop) is commonly used by sports medicine physicians, doctors of physical therapy, and athletic trainers in return-to-practice and return-to-play decision making. In this case report, the functional hop test was applied to a 31-year-old recreational basketball player status-post full-tear of the anterior talofibular ligament (ATFL) to examine the applicability of a standardized, efficient, and easy-to-administer functional test in making return-to-play decisions following an ankle injury. The functional hop test was administered 5 times across a treatment course of 11 physical therapy sessions emphasizing pain-free range of motion, baseline strength, weight-bearing loading, and sport-specific training. The functional hop test was found to be a helpful (albeit imperfect) tool for clinical decision-making following an ankle injury. Specifically, improvements in landing skill/confidence of single hop accounted for the greatest gains in total score in the early phase of rehabilitation, while momentum and plyometric skill/control of triple hop accounted for the greatest gains in total score in the later phase of rehabilitation. Modification of the functional hop test to include sub-component tests of strength, endurance, and/or lateral hops are discussed.

In this review article, newborn hip screening experience in Türkiye was summarized. The nationwide newborn hip screening program was officially initiated in 2013. The program currently includes the ultrasonographic examination of the hips of almost all newborns within the first two months of life. The rate of minor surgical interventions (closed/open reduction and casting) was 0.47 per 1,000 live births in 2015 and was 0.89 per 1,000 live births in 2020. Thus, an increase of 89% in the rate of minor surgical interventions was observed. The rate of major surgical interventions (pelvic/femoral osteotomies) was 0.74 per 1,000 live births in 2015 and was 0.21 per 1,000 live births in 2020. Thus, a decrease of 72% in the rate of major surgical interventions was observed between 2015 and 2020. While minor surgical interventions constituted about 39% of the overall surgical interventions in 2015, this ratio raised to 81% in 2020. Based on the experiences in Türkiye universal newborn ultrasonography (US) hip screening is advocated to lessen the rate of extensive surgeries in developmental dysplasia of the hip (DDH) during childhood and adulthood and to have as many as possible functional hips in the long-term follow-up of patients with DDH.

Soft tissue sarcoma (STS) is a rare malignancy with a high incidence. Early diagnosis can reduce the rate of amputations and increase survival, however, this is typically delayed. The diagnosis and treatment of smaller lesions have a better prognosis; nonetheless, patients present to physicians when the soft tissue mass is large with obvious signs of red flags. In addition, the symptoms of this disease are highly non-specific and overlap greatly with benign conditions, resulting in a lack of clinical suspicion and low awareness among practitioners and the general public. Thusly, it is entitled as “the loneliest cancer”. This can make an accurate diagnosis difficult, with a great proportion of misdiagnoses leading subsequent inadvertent to incomplete STS excision, affecting the overall prognosis of the disease and devastating consequences in the disease process. A timely and precise diagnosis is essential because half of people with STS progress toward quietly aggressive illness. The purpose of this review is to raise awareness of STSs so that early recognition, accurate work-up, overview of conventional treatment plans, and appropriate referral to a tumor center can be achieved, avoiding whoop situations, and improving patient outcomes. In addition, insight into the advances in immunotherapy, nanotechnology, and artificial intelligence (AI) can lead to STS diagnosis and treatment prognosis.

Upon self-reflection, some clinicians privately confess a lack of confidence in being able to safely perform trigger point dry needling (TrPDN) or trigger point injection (TrPI) on craniofacial muscles. Procedural performance anxiety seems to be more pronounced relative to those muscles that cannot be palpated and/or have an increased risk of iatrogenic injury to neurovascular structures. Participatory action ultrasound imaging (PAUI) can be a useful tool in enhancing clinician confidence. A clinician-subject with a left lateral pterygoid trigger point was dry-needled under ultrasound guidance by a clinician-needler with extensive training and experience relative to evaluation and treatment of patients with craniofacial pain. Prior to PAUI, both the clinician-needler and clinician-observer describe low-to-moderate anxiety in the performance of TrPDN of the lateral pterygoid, using a lateral-to-medial approach. By contrast, both the clinician-needler and clinician-observer expressed high anxiety, objectively confirmed by the state-trait anxiety inventory (STAI) form Y-1 (STAI Y-1), in the performance of a newly learned cephalo-caudal approach. Following an initial round of clinical training without PAUI, subjective anxiety remained high despite a lower theoretical risk to the maxillary artery using the cepalo-caudal approach. A second round of training was performed with the addition of PAUI; the clinician-needler was able to reach the target tissue within 2 min in each of 3 attempts. Upon visual inspection and interpretation of the images and cine, the clinician-needler and clinician-observer both expressed a “significant” decrease in self-reported anxiety in performing the cephalo-caudal approach, objectively verified by improvements in the STAI Y-1 score of both clinicians. This case report presents PAUI as a means for future research and clinician education regarding risk assessment of TrPDN or TrPI of muscles with risk of iatrogenic injury.

Rheumatoid arthritis (RA) is a prevalent chronic disease that is associated with numerous comorbidities. Accurate assessment of these coexisting conditions, as reported by clinicians, is critical for an improved understanding of the impact of the disease and patient care. This perspective aims to evaluate the utility of real-world data (RWD) for enhancing the understanding of comorbidities in RA and to assess its potential in reshaping clinical management. RWD approaches, specifically the use of structured databases or data extracted from electronic health records, offer promising alternatives to overcome the limitations of traditional methodologies. Structured databases provide a systematic approach to data analysis, utilizing diagnosis codes to study large patient cohorts, revealing the prevalence of conditions, and demonstrating the potential for long-term disease trend analysis. Meanwhile, natural language processing (NLP) and artificial intelligence (AI) image analysis can bridge the gap between structured and unstructured data, by extracting meaningful information from unstructured fields such as free text or imaging. NLP has proven effective in the identification of RA patients and research outcomes, while AI image analysis has enabled the discovery of hidden findings in cardiovascular assessments, establishing a basis for the assessment of comorbidities in RA. However, while the benefits of using RWD are substantial, challenges remain. Ensuring comprehensive data capture, managing missing data, and improving data detection are key areas requiring attention. The involvement of clinicians and researchers in rheumatology is crucial in unlocking the potential of RWD studies, offering the promise of significant improvements in disease characterization and patient health outcomes.

Remote monitoring technologies (RMTs) are an emerging tool for assessing, monitoring, and following up on patients with chronic diseases including autoimmune rheumatic diseases (AIRDs). The best use of these exponentially expanding technologies warrants optimum evidence. Rheumatoid arthritis (RA) is a chronic inflammatory process that requires close monitoring of disease activity, response to treatment, and the potential adverse effects. Though there are several studies that have explored RMTs in RA, there is little head-to-head comparison between the individual technologies or the standard of care. Before investing in potentially high-cost strategies like RMTs, it is prudent to estimate their pragmatic role in the management and potentially with long-term follow-up including drug titration. A thorough search of the literature was conducted across PubMed/MEDLINE, Scopus, and WebOfScience databases for recent and relevant literature looking at the acceptance, practical utility, and outcomes in RA using RMTs. This scoping review aims to summarize the current level of evidence in favor of RMTs, estimate real-world benefits and costs, potential hazards and limitations, and finally, identify future studies needed before endeavoring to mainstream RMTs. It emphasizes randomized trials using RMTs, patients reported outcomes and disparities in the usage of RMTs.

Diffuse idiopathic skeletal hyperostosis (DISH) is a common condition that affects the spine and peripheral joints, characterized by the progressive ossification of ligaments and tendons. It is a non-inflammatory degenerative disease that affects predominantly the elderly population. It has been associated with reduced mobility and chronic pain, which can have a significant impact on patients’ quality of life (QOL). Although DISH has always been considered a benign condition, patients with DISH report higher levels of pain, stiffness, and disability compared to the general population. It can affect their ability to perform daily activities and participate in social and recreational activities. In addition, extra-spinal manifestations such as enthesopathy and involvement of peripheral joints, but still dysphagia and airway obstruction have been described in DISH. These, although not as common, when present result in signs and symptoms significantly impacting the patient’s QOL. The objective of this review is to assess the QOL in individual with DISH. This involves an examination of various facets of the condition, including pain, spinal and extraspinal manifestations, fractures, and metabolic syndrome.

Psoriasis is a chronic immune-mediated disorder affecting about 2% of the population worldwide which is associated with significant morbidity. The disease usually presents as raised, well-demarcated erythematous plaques with adherent silvery scales. Psoriasis can appear at any age but it has two peaks occurring at 15–20 and 55–60 years of age. It affects males and females equally. Despite the multitude of investigations about psoriasis and even development of drugs with satisfactory results, its pathogenesis is not fully understood yet and its course is unpredictable. Various environmental triggers, e.g., obesity, stress and drugs may induce disease in genetically susceptible patients. Although psoriasis was considered primarily as a disease of the skin, more investigations have been revealed its systemic nature. Psoriatic arthritis (PsA) may complicate up to one-third of cases of psoriasis vulgaris (PV). Also, the association between psoriasis and a variety of other immune-mediated disorders such as inflammatory bowel disease (IBD) and celiac disease (CD) has been confirmed in various studies. Moreover, a growing body of evidences indicates that psoriasis shares some common histological and phenotypical properties with the spectrum of osteoimmunological diseases such as Paget’s disease of bone (PDB). Thus, exploring the common molecular and genetic mechanisms underlying psoriasis and related disorders is of paramount importance for better elucidating disease pathogenesis and designing more targeted treatments.

There is an increasing need for appropriate effective treatment and long-term disease control in patients with psoriasis because of the decreased quality of life, increased physicosocial deficits and associated co-morbidities. Systemic conventional treatments that are the first step in the management of moderate-to-severe plaque psoriasis include methotrexate (MTX), acitretin, cyclosporine and fumarates. MTX is considered the gold standard in the treatment of moderate-to-severe chronic plaque type psoriasis. It is also used to treat pustular psoriasis, erythrodermic psoriasis and psoriatic arthritis. Acitretin monotherapy is less effective than other conventional systemic treatments for plaque psoriasis, while superior to generalized, palmoplantar pustular, and hyperkeratotic variants. Cyclosporine is preferred in the presence of unstable acute clinical conditions (erythrodermic or generalized pustular psoriasis) and also in induction phase of rotational and sequential therapy for severe resistant psoriasis, due to its rapid effect. Dimethyl fumarate, which has similar efficacy to MTX, is an appropriate option in the induction and long-term systemic treatment for adult patients with moderate to severe plaque psoriasis without psoriatic arthritis. Although they are often overshadowed by biologics at the stage of preference by most physicians and patients today, they are classical and inexpensive agents with known long-term results. When the appropriate patient profile and psoriasis type are selected at the right time and necessary laboratory and clinical follow-ups are made, each of them is an effective treatment with reliable and satisfactory results. In this article, important points (recommendations according to patient characteristics, psoriasis type and comorbidities) to be considered in clinical practice when using the conventional anti-psoriatic agents in the treatment of psoriasis are overviewed.

Rheumatoid arthritis (RA) is the most common rheumatologic disease characterized by inflammation with a definite relationship with heart disease. Impaired immunity, chronic inflammation, genetic susceptibility, autonomic nervous system (ANS) dysfunction, altered metabolic profile have been blamed for ischemic and non-ischemic heart diseases in RA patients. Medications used in RA treatment can also modify the risk of heart diseases by different mechanisms. Understanding the pathogenesis is essential to prevent early cardiac dysfunction in RA patients. Fundamental cellular and molecular mechanisms of pathogenesis await further elucidation. Disease management is of great importance since the cardiovascular (CV) events are known to be reduced with low disease activity. Discovery of new mechanisms will pave the way for the development of novel treatment modalities. This review highlights the epidemiology, pathogenesis, risk factors, diagnosis and screening methods and management of CV comorbidities in RA patients. Besides impact of RA medications and exercise on CV risk are summarized.

It has been suggested that diffuse idiopathic skeletal hyperostosis (DISH), a skeletal disease characterized by the ligamentous ossification of the anterolateral spine, is a radiological entity with no clinical implications; however, many patients suffer from chronic back pain, decreased spinal mobility, and postural abnormalities. Additionally, the pathological new bone formation at the cervical and thoracic levels may mainly produce dysphagia and breathing disturbances. Over the last 20 years, a close association between DISH, obesity, diabetes mellitus (DM), and metabolic syndrome (MS) has emerged. However, a causal relationship has not yet been established. It has been suggested that the longer life expectancy and the growing incidence of MS in Western populations, associated with the tendency of DISH to manifest in later life, may increase the DISH prevalence rates in the following decades. Future investigations should focus on the early DISH phase to clarify pathogenetic mechanisms and identify targeted therapies.

Diffuse idiopathic skeletal hyperostosis (DISH) and axial spondyloarthritis (axSpA) are diseases with inflammatory involvement of the axial skeleton that can result in new bone formation that may lead to total ankylosis of the spine and functional impairment of different extent in individual patients. In these diseases, the new bone formation may lead to total ankylosis of the spine and impaired mobility with functional impairment. This review will highlight the similarities and differences of these two conditions. In axSpA, the genetic background with the association with human leukocyte antigen-B27 (HLA-B27) is known for 50 years, while in DISH, a genetic contribution is not yet proven. The phenotype of new bone formation and its anatomic features are different between these diseases. In axSpA symmetric, thin and marginal syndesmophytes representing an ossification of enthesitic inflammation at the area of the attachment of the annulus fibrosus that may extend to the adjacent deeper layers anterior longitudinal ligament and are typical, while in DISH the so-called “chunky bridging osteophytes” grow as an additional layer on the anterior longitudinal ligament. Besides distinct anamnestic and clinical features, magnetic resonance imaging is helpful differentiating the two diseases since inflammatory changes with the typical pattern of axSpA are reliably visualized. Similar in both diseases is the high prevalence of vertebral fractures, which are mainly caused by the local osteoporosis and decreased flexibility of the affected bones, and therefore may occur even after minor traumata. The presence of extraarticular manifestations like uveitis, inflammatory bowel disease or psoriasis are only linked to axSpA. In contrast, DISH is associated with obesity, diabetes mellitus, and other metabolic diseases. Although DISH and axSpA are distinct conditions, the cooccurrence of these two diseases exists in some patients. Various therapeutic options are becoming available for axSpA, but no therapy has been approved for DISH yet.

Rheumatoid arthritis (RA) is an inflammatory arthritis that affects synovial joints, and it is not surprising that the temporomandibular joint (TMJ), a synovial joint, is also affected. However, TMJ is rarely the first affected joint in the course of RA. Often, RA patients come to the physician with more focus on complaints in other peripheral joints. Therefore, asking TMJ complaints and symptoms, and TMJ examination in RA patients is often neglected by doctors too, because they focus more on other joints. This neglect may cause serious damage to the joints and cause disability. Examination of TMJs, which is a crucial component of vital activities such as nutrition and speech, should be added to the routine. Also, further studies may be focused on adding TMJ assessment to disease activity scales and health assessment questionnaires.

Bone formation is a complex process that occurs throughout life, and is normally limited to the skeletal system. In bone formation, osteoprogenitor cells follow several developmental stages, including differentiation in osteoblasts, proliferation, matrix maturation, and mineralization. The mechanisms involved in the mineralization process of bone, such as in the new bone formation, are extremely complex and have been under intense investigation for many years. Bone formation follows two distinct processes, intramembranous and endochondral ossification; both are regulated by signaling pathways involving numerous genes. Disturbance of these signaling pathways may cause a large spectrum of skeletal diseases characterized by new bone formation and bone growth anomalies. This review will only focus on the key genetic pathways involved in heterotopic bone formation. Wingless/integrated (Wnt), hedgehog (HH), and transforming growth factor beta (TGFβ)/bone morphogenetic protein (BMP) signaling pathways are described and illustrated; their relation with new bone formation is demonstrated through their involvement in bone formation disorders.

Rheumatoid arthritis (RA) is a chronic immune-mediated inflammatory disease of unknown origin. Although it mainly affects joints, it can have extra-articular manifestations, with the lung being one of the most affected organs. The estimated incidence of diffuse interstitial lung disease (ILD) is 4 cases to 4.5 cases/1000 patient-years. The most common forms are usual interstitial pneumonia (UIP) and nonspecific interstitial pneumonia (NSIP; 44–46% and 33–44%, respectively), although there have been reports of cases involving all the histopathologic forms described for the disease. RA-ILD is associated with specific risk factors, such as male sex, older age, smoking, and positive rheumatoid factor (RF) and anti-citrullinated peptide antibody (ACPA) levels. The clinical course of ILD ranges from asymptomatic forms to rapidly progressive disease in a minority of cases. It has been estimated that the risk of death is up to 3-fold higher in patients with RA-ILD than in those without ILD, making RA-ILD the second most common cause of death after cardiovascular disease. Treatment of RA has improved considerably in recent years with the advent of biologics; however, the use of these agents has been restricted in patients with ILD owing to safety concerns. Many doubts continue to surround the treatment of patients with RA-ILD. Therefore, the objective of this review is to examine the current management of affected patients in terms of diagnosis, treatment, and follow-up.

Hyperuricemia is known to be a necessary and causal condition for gout, but much more prevalent than gout. Medicine has standardized treatments for gout, but has no such determination for asymptomatic hyperuricemia. Nevertheless, people with hyperuricemia, gouty or not, too often continue to be at risk for shortened lifespans from life-threatening comorbidities, all of which are known to be consequences of obstructive sleep apnea (OSA), which is shown herein to cause most hyperuricemia. This review also presents the wide variety of OSA consequences, many of which are irreversible and life-threatening, as the rationale for treating all hyperuricemia (gouty and asymptomatic) by diagnostic testing and effective treatment for OSA as soon as hyperuricemia is detected. It advocates frequent ultrasonic screening for aggregated urate crystals. Multiple epidemiological studies have found OSA to be significantly more prevalent in those people with gout diagnosed with OSA than it is in those never diagnosed with it. A clinical study shows an even higher prevalence of OSA in people with gout. The pathophysiology of hypoxia from OSA explains how it would lead to both the overproduction and the underexcretion of uric acid, leading to hyperuricemia and the precipitation of monosodium urate crystals which cause a gout flare. Resolving OSA has been shown to prevent or even reverse life-threatening diseases that are recognized comorbidities of hyperuricemia and gout, and can prevent further gout flares. In order to extend the length and quality of life of people with gout or hyperuricemia, when either first manifests a patient sleep study is recommended, followed by effective OSA treatment as warranted.

Diffuse idiopathic skeletal hyperostosis (DISH) can lead to dysphagia, airway obstruction, and unstable vertebral fractures. Surgery can be performed to relieve cervical compression or stabilize fractures of the spinal column, with or without decompression of spinal cord injuries. In this review, the peri-operative surgical techniques in cases with DISH are discussed, as well as the pre-operative and post-operative pearls and pitfalls. It is essential for spine surgeons, including orthopedic surgeons and neurosurgeons, to be aware of the considerations, anticipations, and approaches for the management of dysphagia, airway obstruction, and fractures in DISH patients in order to improve patient outcomes for this specific at-risk patient population.

Systemic vasculitis is a heterogeneous group of disorders characterized by inflammation and necrosis in the vessel wall. Patients usually present a quite broad spectrum of manifestations which vary in terms of vessels’ size affected, organs involvement, and the extent of inflammatory process as well as an immunological diversity, including autoantibodies profile. Though, the diagnosis is based on clinical features, tissue biopsy, imaging investigations, and serologic tests. The main autoantibodies, important not only in the diagnosis but also in monitoring and prognosis of systemic vasculitides, are anti-neutrophil cytoplasmic antibodies (ANCA), anti-glomerular basement membrane antibodies (anti-GBM), anti-complement component C1q antibodies (anti-C1q), and cryoglobulins. Although other autoantibodies have been analyzed, their clinical utility still needs further investigation. The current work aimed to review the clinical associations of main autoantibodies in systemic vasculitis.

Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic condition characterized by the new bone formation and enthesopathies of the axial and peripheral skeleton. The diagnosis of DISH currently relies upon the end-stage radiographic criteria of Resnick and Niwayama, in which bridging osteophytes are present over at least four thoracic vertebras. The pathogenesis of DISH is not well understood, and it is currently considered a non-inflammatory condition with an underlying metabolic derangement. However, an inflammatory component was suggested due to the similarities between DISH and spondyloarthritis (SpA) in spinal and peripheral entheseal new bone formation. Magnetic resonance imaging (MRI) is the imaging modality of choice in the diagnostic work-up and follow-up of patients with SpA, as well as in understanding its pathogenesis. The aims of the current review were to evaluate the current and future role of MRI in imaging DISH.

Congenital fused/blocked vertebrae are an incidental finding in most cases. It remains asymptomatic unless there is a traumatic event or there is an increased biomechanical load which may be attributed to a task that is not typically performed by the individual. Symptomatic cases can present with several musculoskeletal symptoms including neck pain. Physiotherapy management strategies may help patients recover from the mechanical strains on the cervical neuromuscular structures. The present case is of a 21-year-old male engineering student who was referred for physiotherapy, he presented with complaints of neck pain (non-radiating in nature) for a week. The intensity of the pain had been intermittently increasing/decreasing for about a year and there were about 2–3 episodes in a month for approximately one year. He presented with an X-ray that showed C3–C4 cervical vertebrae synostosis (block vertebrae). The patient was managed using pain education and exercises along with ergonomic advice. Patient-reported pain decreased significantly from the initial visit and he was able to sit for a longer duration and had a considerable improvement in function.

Gout is the most common inflammatory arthritis and a global health problem. In addition to joint involvement, urate crystals induce chronic inflammation, leading to increased cardiovascular risk in gout. Thus, cardiovascular disease is the leading cause of death in gout and numerous studies have revealed an increase in cardiovascular-related mortality in these patients. However, despite the efficacy of urate-lowering therapies, such as allopurinol and febuxostat, suboptimal management of gout and poor adherence continue to make it difficult to achieve better outcomes. Treat-to-target strategy may help change this, as in other diseases such as rheumatoid arthritis. Nevertheless, even with a well-defined clinical target (absence of flares and tophi disappearance), the numerical target [serum uric acid (SUA) < 5 mg/dL or < 6 mg/dL] still varies depending on current guidelines and consensus documents. Recently, several trials [Long-Term Cardiovascular Safety of Febuxostat Compared with Allopurinol in Patients with Gout (FAST), REasons for Geographic And Racial Differences in Stroke (REGARDS)] have shown better cardiovascular outcomes in those patients who achieve SUA levels < 5 mg/dL. Likewise, some observational studies, mostly based on imaging tests such as ultrasound and dual-energy computed tomography, have found better results in the magnitude and speed of reduction of urate joint deposition when SUA < 5 mg/dL is achieved. Based on an analysis of the available evidence, SUA < 5 mg/dL is postulated as a more ambitious target within the treat-to-target approach for the management of gout to achieve better joint and cardiovascular outcomes in patients with cardiovascular risk or severe disease.

Gout often presents as acute arthritis but may also present with chronic joint inflammation. For the diagnosis of an acute gout attack with its typical symptoms, the differentiation towards a bacterial joint infection is critical and mandatory. The detection of intracellular uric acid crystals in the synovial fluid of affected joints is important for the initial diagnosis of gout. In the case of a chronic course with polyarticular joint involvement, the differentiation from other inflammatory rheumatic diseases such as rheumatoid arthritis (RA) can be challenging. The case presented here is of interest because the patient initially had characteristic clinical symptoms of tophaceous gout including a typical medical history—even though rheumatoid factor and anti-citrullinated protein antibodies (anti-CCP) were positive. The course of the disease and the critical evaluation of all findings also, and most interestingly, including histological results finally suggested a main diagnosis of RA.