Krankenhaus Bruneck

Patients with inflammatory rheumatic and musculoskeletal diseases (iRMDs) such as rheumatoid arthritis, connective tissue diseases, vasculitides and spondyloarthropathies are at a higher risk of osteoporosis and fractures than areindividuals without iRMDs. Research and management recommendations for osteoporosis in iRMDs often focus on glucocorticoids as the most relevant risk factor, but theylargely ignore disease-related and general risk factors. However, the aetiopathogenesis of osteoporosis in iRMDs has many facets, including the negative effects on bone health of local and systemic inflammation owing to disease activity, other iRMD-specific risk factors such as disability or malnutrition (for example, malabsorption in systemic sclerosis), and general risk factors such as older age and hormonal loss resulting from menopause. Moreover, factors that can reduce fracture risk, such as physical activity, healthy nutrition, vitamin D supplementation and adequate treatment of inflammation, are variably present in patients with iRMDs. Evidence relating to general and iRMD-specific protective and risk factors for osteoporosis indicate that the established and very often used term 'glucocorticoid-induced osteoporosis' oversimplifies the complex inter-relationships encountered in patients with iRMDs. Osteoporosis in these patients should instead be described as 'multifactorial'. Consequently, a multimodal approach to the management of osteoporosis is required. This approach should include optimal control of disease activity, minimization of glucocorticoids, anti-osteoporotic drug treatment, advice on physical activity and nutrition,and prevention of falls, as well as the management of other risk and protective factors, thereby improving the bone health of these patients.

Background:In giant cell arteritis (GCA), various ultrasound composite scores, including the provisional OMERACT GCA ultrasonography score (OGUS), the Southend Halo score and the Halo count, have recently been introduced as a monitoring tool for clinical trials [1,2]. Patient-based reliability of these ultrasonography (US) composite scores remain elusive so far.Objectives:To test the reliability of the OGUS and the other US scores in a patient-based reliability exercise involving experts and non-experts in vascular ultrasonography.Methods:Twelve experts and 12 non-experts were asked to evaluate 6 GCA patients. Each patient was scanned twice (2 rounds separated by ≥3 hours) by each participant.Experts had a half-day meeting ahead to align on US settings and procedures. Non-experts received a training module (90 minutes of theoretical and 240 minutes of practical instructions) after round 1. US examinations were conducted at bilateral common superficial temporal arteries, frontal and parietal branches as well as the axillary arteries. The Intima-media complex was measured at the thickest site of the deep wall of individual arteries, preferentially in longitudinal scan to calculate the OGUS, the Southend score and the Halo count. In case of missing values, a normalized score was calculated by considering the available segments. Inter- and intra-reader reliability were tested by Intraclass correlation coefficient (ICC).Results:Mean age of GCA patients was 78±5.1 years, 2 (33%) were female. All had established disease and were in clinical remission, median disease duration was 22.5 (IQR 16.3-28.3) months. Experts and non-experts had a median of 16.5 years (IQR 9.8-20.0) and 1.8 years (IQR 0-3.3) of experience with vascular US, respectively. According to experts, all patients had at least one pathological vessel, mean OGUS was 0.83 (±0.07), mean Southend score was 19.0 (±4.6) and mean Halo count was 2.8 (±1.4). As depicted in Table 1, expert inter-rater ICC of the OGUS was moderate in both rounds, fair for the Southend score and the Halo count in round 1 and moderate in round 2. Expert intra-rater reliability was good for all scores.For non-experts, inter-rater reliability was poor in round 1 for all scores as well as for individual measurements. In round 2, a moderate reliability was found for the OGUS, the normalized Halo count and individual IMT measurements, while reliability remained poor for the normalized Southend score (detailed in Table 1).Conclusion:We demonstrate fair to moderate inter-rater reliability and good intra-rater reliability of the OGUS, the Southend score and the Halo count among experts. A short training program for non-experts improved their inter-rater reliability.REFERENCES:[1] Dejaco C, Ponte C, Monti S, et al. The provisional OMERACT ultrasonography score for giant cell arteritis. Ann Rheum Dis 2023;82:556-64.[2] van der Geest KSM, Borg F, Kayani A, et al. Novel ultrasonographic halo score for giant cell arteritis: assessment of diagnostic accuracy and association with ocular ischaemia. Ann Rheum Dis 2020;79:393–9.Table 1.Inter-rater (experts and non-experts in vascular ultrasonography) as well as intra-rater reliability (experts) on ultrasonography scores in GCA.Inter-raterRound 1Inter-raterRound 2Intra-raterScorenICC95% CInICC95% CIMedian ICCIQRExperts in vascular ultrasonographyOGUS60.600.33-0.9060.600.33-0.910.860.65-0.92Southend Score60.400.17-0.8260.510.24-0.870.810.61-0.87Halo Count60.450.20-0.8460.520.25-0.870.650.40-0.84Individual IMT measurements480.790.72-0.86480.840.78-0.900.880.80-0.95Non-experts in vascular ultrasonographyOGUS60.200.05-0.6560.520.25-0.88Southend Score200-0.961n.d.Normalized Southend Score60.220.06-0.6660.350.13-0.78Halo Count200-0.981n.d.Normalized Halo Count60.350.14-0.7860.570.31-0.90Individual IMT measurements4500-0.34400.630.52-0.75CI, confidence interval; ICC, intra-class correlation coefficient; IMT, intima media thickness; IQR, interquartile range; n, number; n.d., not determined; OGUS, OMERACT ultrasonography score for GCA; normalized Southend Score and Halo count, calculated in case of missing values.Acknowledgements:We thank the Austrian team of Canon for providing the Ultrasound machines, used in the reliability exercise.Disclosure of Interests:None declared.

To explore current management practices for PMR by general practitioners (GPs) and rheumatologists including implications for clinical trial recruitment. An English language questionnaire was constructed by a working group of rheumatologists and GPs from six countries. The questionnaire focused on: 1: Respondent characteristics; 2: Referral practices; 3: Treatment with glucocorticoids; 4: Diagnostics; 5: Comorbidities; and 6: Barriers to research. The questionnaire was distributed to rheumatologists and GPs worldwide via members of the International PMR/Giant Cell Arteritis Study Group. In total, 394 GPs and 937 rheumatologists responded to the survey. GPs referred a median of 25% of their suspected PMR patients for diagnosis and 50% of these were returned to their GP for management. In general, 39% of rheumatologists evaluated patients with suspected PMR >2 weeks after referral, and a median of 50% of patients had started prednisolone before rheumatologist evaluation. Direct comparison of initial treatment showed that the percentage prescribing >25 mg prednisolone daily for patients was 30% for GPs and 12% for rheumatologists. Diagnostic imaging was rarely used. More than half (56%) of rheumatologists experienced difficulties recruiting people with PMR to clinical trials. This large international survey indicates that a large proportion of people with PMR are not referred for diagnosis, and that the proportion of treatment-naive patients declined with increasing time from referral to assessment. Strategies are needed to change referral and management of people with PMR, to improve clinical practice and facilitate recruitment to clinical trials.

Extensive scientific and clinical microbiome studies have explored contemporary variation and dynamics of the gut microbiome in human health and disease1–3, yet the role of long-term life history effects has been underinvestigated. Here, we analyzed the current, quantitative microbiome composition in the older adult Bruneck Study cohort (Italians, Bruneck, n = 304 (male, 154; female, 150); age 65–98 years) with extensive clinical, demographic, lifestyle and nutritional data collected over the past 26 years4. Multivariate analysis of historical variables indicated that medication history, historical physical activity, past dietary habits and specific past laboratory blood parameters explain a significant fraction of current quantitative microbiome variation in older adults, enlarging the explanatory power of contemporary covariates by 33.4%. Prediction of current enterotype by a combination of past and contemporary host variables revealed good levels of predictability (area under the curve (AUC), 0.78–0.83), with Prevotella and dysbiotic Bacteroides 2 being the best predicted enterotypes. These findings demonstrate long-term life history effects on the microbiota and provide insights into lifestyle variables and their role in maintaining a healthy gut microbiota in later life.

This work will summarize the key results of comprehensive investigations regarding partial discharge localization in spatial distributed HV-windings. Therefore, filtering techniques are used and implemented in a special tool. Limitations and accuracy of the developed evaluation tool are discussed based on two case studies, a 4 kV motor winding and a 10 kV dry-type transformer. Along their windings PD-pulses are provoked, measured and assessed.

Interstitial lung disease (ILD) has been described as a possible pulmonary involvement in antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitides (AAV), mainly granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). Aim of this cross-sectional Italian national study was to describe demographic, clinical and serological profile of ILD related to MPA and GPA and investigate possible correlations between radiologic patterns of ILD and vasculitis features. We enrolled 95 consecutive patients with AAV-ILD, 56 affected by MPA (58.9%) and 39 by GPA (41.1%). NSIP was the most frequently detected ILD pattern, observed in c-ANCA patients in 60.9% of cases, followed by UIP pattern mainly observed in p-ANCA patients (47.7%, p=0.03). ILD represented the first clinical manifestation, preceding vasculitis diagnosis in 22.1% of cases and, globally, ILD was already detectable at AAV diagnosis in 66.3% of patients. The diagnosis of ILD preceded that of AAV in 85.7% of p-ANCA positive-patients, while only one patient with c-ANCA developed ILD before AAV (p= 0.039). Multivariate analysis confirmed the correlation of UIP pattern with p-ANCA-positivity and a diagnosis of ILD before AAV, also when adjusted for age and sex. Our study confirms that UIP is a frequent pattern of lung disease in AAVILD patients. Our results also suggest that ILD can represent an early complication of AAV but also occur in the course of the disease, suggesting the need of a careful evaluation by both pulmonologist and rheumatologist to achieve an early diagnosis. Further prospective studies are needed to define ILD prevalence and evolution in AAV patients.

Objectives: To investigate opinion and routine practice of specialists from different disciplines on imaging techniques for interventional procedures related to rheumatic and musculoskeletal diseases (RMDs).Methods: An English-language questionnaire was developed by an international working group and distributed to health care providers of various disciplines involved in the care of people with RMDs via an online survey tool (SoSci Survey®) from December 2019 to May 2020.Results: A total of 1,105 respondents from 56 countries completed the survey, over 60% of participants were rheumatologists. The majority of respondents (88%) performed interventional procedures in RMDs patients and 90% of them used imaging guidance. Ultrasonography was the most frequently used technique, particularly among rheumatologists. X-ray and computed tomography were mainly used by radiologists. A discrepancy emerged between the importance assigned to certain items such as the availability of a second operator and their actual implementation in clinical practice. Local barriers, lack of resources and facilities were mentioned as the most relevant obstacles in this regard. Lack of training on imaging and/or imaging guided procedures did not emerge as a barrier to perform such interventions; in fact, 19% of respondents performing the procedures indicated not to have received adequate training in this field.Conclusions: This is the first multinational multidisciplinary survey exploring in detail the opinions and practice on imaging guidance for interventional procedures in RMDs. A harmonization of protocols based on international guidelines, along with adequate training programmes and interventions on barriers at national/local levels are the main unmet needs requiring attention.