Background This study aimed to explore the association of the sarcopenia questionnaire Strength, Assistance with walking, Rise from a chair, Climb stairs, Falls (SARC-F) with muscle strength, physical performance, daily activity, patient-reported outcomes (PROs) and body composition in patients with axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA).Methods In this cross-sectional study, patient and disease characteristics including physical function, performance measures and body composition assessed by dual-energy X-ray absorptiometry (DXA) were analysed. Variables were compared between patients with a SARC-F score ≥4 and <4, higher versus lower sarcopenia risk. Linear regression examined associations, adjusted for age and sex.Results Overall, 54 of 213 patients with SpA (65.7% axSpA, 34.3% PsA) had a SARC-F score ≥4 (24.4%). DXA identified sarcopenia and sarcopenic obesity in 4 patients each (7.7%). Patients with SARC-F scores ≥4 were older, predominantly female or obese, had longer disease duration, higher disease activity, lower physical performance, decreased muscle strength and daily activity and more unfavourable body composition. Total SARC-F score was consistently associated with muscle strength, physical performance, PROs and DXA components. Higher body mass index and patient global assessment were independently associated with higher SARC-F scores. The SARC-F ≥4 threshold showed moderate specificity (76%) but low sensitivity (50%) for DXA-defined sarcopenia, with a high negative predictive value (97%).Conclusions SARC-F was significantly associated with disease activity, muscle strength and physical performance, but showed limited ability to identify DXA-defined sarcopenia. Further research is needed to clarify its clinical utility for risk stratification in rheumatic diseases.

A high prevalence of early-onset interstitial lung disease, including pulmonary fibrosis, in pediatric patients with Stimulator of interferon genes (STING)-Associated Vasculopathy with onset in infancy (SAVI) suggests a critical role for the cGAS-STING pathway in the pathogenesis of pulmonary fibrosis. We identified an endothelial-to-mesenchymal transition (EndMT) signature in lesional lung biopsies from SAVI patients, marked by a loss of endothelial and acquisition of mesenchymal markers. Consistently, induced pluripotent stem cell-derived endothelial cells (iECs) from SAVI patients harboring gain-of-function STING1 mutations spontaneously undergo EndMT, a process rescued in isogenic-correction. In endothelial cells, STING activation induces IRF3-independent STAT3 phosphorylation, initiating a SLUG-dependent mesenchymal transcriptional program while repressing SOX18 and an epigenetically-regulated endothelial maintenance network. Our studies define a non-canonical cGAS-STING-STAT3 signaling axis that couples a mesenchymal transcriptional program with epigenetic silencing of an endothelial maintenance program, promoting TGFβ-independent STING-mediated EndMT and endothelial dysfunction, and suggesting STING as a therapeutic target for inflammatory pulmonary fibrosis.

The Build Better Bones website was developed using a robust stakeholder-engaged approach to be a self-management resource for people with osteoporosis and for care partners of people with osteoporosis. The website focuses on providing education and resources for exercise, nutrition, home safety, and advice for care partners. INTRODUCTION:Osteoporosis is a common chronic disease that requires effective self-management, including optimal diet, exercise, and home safety practices. The COVID-19 pandemic disrupted traditional outpatient care and increased the need for remote resources. In response, the International Osteoporosis Foundation (IOF) Rehabilitation Working Group developed a web-based platform "Build Better Bones" to support individuals with osteoporosis and their care providers. METHODS:The website's development followed a design thinking, iterative process informed by input from diverse stakeholders, including patients, healthcare professionals, and design experts. Qualitative feedback from 24 stakeholders across three countries shaped the platform's usability and content. Key features include an evidence-based exercise library, practical nutritional guidance, and home safety recommendations. To ensure inclusivity, the site was designed to accommodate a global audience through translation into five languages and culturally diverse animated characters. RESULTS:Stakeholders emphasized the primacy of site navigation and readability, empowering and inclusive images, and compassionate language. The website provides exercises tailored to the management of osteoporosis, focusing on exercise and nutrition with an emphasis on home safety to minimize the risk of fracture. The inclusion of interactive elements, multilingual support, and visually appealing content was guided by stakeholder input. Patients identified the accordion-style presentation and focus on empowering self-management, while clinicians valued the evidence-based exercise recommendations. Qualitative input highlighted the need for inclusive language, accessibility improvements, and practical guidance for safe practice at home. CONCLUSION:The "Build Better Bones" platform bridges a gap in osteoporosis care by providing evidence-based resources tailored to both clinicians and patients that can be disseminated to a global audience. Iterative stakeholder feedback has ensured that the platform is aligned with user needs, making it scalable and adaptable to real-world conditions. Future efforts will focus on expanding content, improving tailored features, and integrating additional languages to serve a global audience.

Introduction Low back pain (LBP) is the leading cause of disability globally and clinical practice guidelines recommend active and conservative management. However, little is known regarding guideline adherence among German healthcare practitioners. Methods We conducted an online, cross-sectional clinical vignette-based survey of 658 German medical doctors, physiotherapists, and sport scientists between May 2022 and March 2023 to assess implementation of diagnostic and treatment recommendations for chronic non-specific LBP, specific LBP (axial spondyloarthritis), and acute lumbar radiculopathy. Guideline implementation was assessed for the survey responses against recommendations from four German national guidelines. Adherence was quantified using a predefined adherence matrix that translated agreement with guideline recommendations into percentage scores. The use of clinical practice guidelines and determinants of guideline adherence were calculated. Multiple regression analyses examined predictors of guideline adherence. Results Among 658 healthcare practitioners, overall guideline adherence was 57.8% (treatment: 59.8%; diagnostic: 50.6%). Adherence was highest for chronic non-specific LBP, while imaging was frequently overused for lumbar radiculopathy (MRI recommended by 84.3% (95% CI 81.1-87.5). Awareness of axial spondyloarthritis was poor, with only 32.7% (95% CI 29.2 to 36.4) correctly identifying the condition. Correct triage across the three vignettes emerged as the strongest predictor of overall guideline adherence. Conclusion Diagnostic and treatment adherence to national guidelines among German healthcare practitioners appears inadequate. Overuse of imaging for acute lumbar radiculopathy, delays in axial spondyloarthritis diagnosis, correct triage for specific LBP, and underutilization of active rehabilitation for chronic non-specific LBP are important areas for optimizing clinical care.

As populations age, the number of older adults living with rheumatic diseases is rising worldwide, creating urgent challenges for equitable access to effective therapies. This article compares health care financing models to show how coverage rules, pricing policies, and administrative requirements shape access to rheumatology care, with older age often marking critical shifts in benefit design. We highlight opportunities for shared learning across countries and identify common leverage points for policy change. By applying the universal health coverage framework, we move beyond descriptive typologies to offer measurable benchmarks for timely, affordable, and equitable care for older adults globally.

OBJECTIVE:The objective was to report the safety and efficacy of an anti-IFNAR1 antibody (anifrolumab) in a patient with STING-associated vasculopathy with onset in infancy (SAVI) who presented with vasculitic ulcers and systemic inflammation refractory to JAK inhibition (JAKi) and to the interferon-β-neutralizing monoclonal antibody dazukibart. METHODS:A patient with SAVI and a de novo STING1 p.(Asn154Ser) mutation, a known pathogenic variant, and uncontrolled disease received 21 doses of dazukibart under a compassionate use investigational new drug protocol, which was followed by treatment with the anti-IFNAR1 antibody anifrolumab. Clinical and laboratory parameters, including wound healing, whole-blood type I interferon (IFN I) signature, and safety markers were closely monitored throughout both treatment periods. RESULTS:Despite initial reductions in C-reactive protein levels and IFN I scores following dazukibart administration, the patient experienced rebound inflammation and recurrent vasculitic lesions. Dazukibart dose adjustments failed to sustainably control IFN I signaling. Subsequent combination therapy of baricitinib and tocilizumab proved partially effective. Treatment with anifrolumab, an IFNAR1 blocker, in conjunction with tocilizumab led to sustained suppression of IFN I scores, allowed discontinuation of JAKi, and resulted in significant improvement in vasculitic wounds. CONCLUSION:This case underscores the challenges in treating patients with SAVI and highlights the utility of IFN I scores as a theragnostic biomarker. Although high-dose JAKi and dazukibart failed to achieve sustained control of IFN I signaling, treatment with anifrolumab durably suppressed IFN scores and demonstrated promising efficacy, which allows for the investigation of the role of IFN I signaling in the disease pathogenesis of SAVI and other interferonopathies in future clinical trials.

Accumulating evidence links skeletal and vascular aging, yet the pathological cross-talk between osteoporotic bone and vascular calcification remains insufficiently understood. In this retrospective exploratory study, we show that osteoporotic individuals exhibit a distinct systemic milieu characterized by elevated eosinophil, neutrophil, and platelet counts, as well as altered levels of sCD40L, PDGF-BB, osteopontin, and SDF-1. These changes correlate with both bone metabolism and arterial stiffness, indicating a multifactorial bone-vascular interplay. Moreover, osteoporotic sera accelerated calcification of human vascular smooth muscle cells in vitro , with PDGF-BB emerging as a central mediator. Inhibition of PDGF-BB downstream signaling blocked this effect, suggesting a mechanistic role of PDGF-BB in linking the osteoporotic milieu to vascular calcification. Conceptualizing this cross-talk as a complex adaptive system advances our understanding of the disease dynamics between localized bone loss and vascular pathologies. Furthermore, it may guide therapeutic strategies, with PDGF-BB as a potential target, to support healthier aging. ### Competing Interest Statement Bjoern Buehring has no relevant COI for this paper. He has received research support, consulting fees and/or honoraria from AbbVie, Alexion, AlfaSigma, Amgen, Astra-Zeneca, Biogen, BMS, Boehringer Ingelheim, Fresenius Kabi, GE/Lunar, Janssen, Galapagos, Gilead, Hexal/Sandoz, Medimaps, MSD, Sanofi Genzyme, Theramex, and UCB in the last 5 years. Doruk Akguen received a consultant fee from Arthrex GmbH and Medacta International. All other authors declare no competing interests. Bundesministerium für Bildung und Forschung (BMBF), FKZ 1315848A, 01ZX1612A, 01EC1402B Deutsche Forschungsgemeinschaft (DFG), GSC203, GE2512/2-2, CRC1444 Europäischer Fonds für regionale Entwicklung (EFRE), EFRE-0800411 to 0800414, EFRE-0800427 Einstein Stiftung Berlin, EZ-2016-289 Ruhr-Universitaet Bochum, research grant FORUM

Physical activity (PA) and sedentary behavior (SB) are two key lifestyle factors with profound implications for bone health across the lifespan. While PA is recognized for its positive effects on bone mineral density (BMD) and fracture prevention, emerging evidence highlights the detrimental consequences of prolonged sedentary time, independent of PA levels. This review synthesizes current knowledge on the impact of PA and SB on bone health outcomes, focusing on BMD and fracture risk in children, adolescents, adults, and older populations. A selection of epidemiological studies, systematic reviews, and meta-analyses was analyzed to explore the associations between movement behaviors and bone health indicators across different life stages. Particular attention was given to studies objectively measuring SB and PA and to the substitution effects of sedentary time with light or moderate-to-vigorous PA. In children and adolescents, higher levels of SB are associated with lower BMD, particularly at weight-bearing sites, while participation in weight-bearing and impact-loading PA positively influences bone mass accrual. In adults and older individuals, regular PA, including moderate-to-vigorous intensity weight-bearing PA and resistance training activities, is consistently linked to greater BMD and reduced fracture risk. Conversely, high sedentary time is associated with lower BMD and increased fracture incidence, particularly among frail or pre-frail individuals. Importantly, replacing sedentary time with even light-intensity PA yields measurable benefits for bone health, particularly among older adults and postmenopausal women, and may contribute to a reduced risk of fractures, although evidence remains limited. Promoting PA while minimizing SB should be central to clinical practice and public health policies aimed at maximizing and preserving skeletal health and preventing osteoporotic fractures, across the lifespan. Early intervention, continuous promotion across life stages, and adherence to WHO guidelines offer an effective, evidence-based framework for lifelong bone health maintenance.

Ortho-Geriatric trauma centers (ATZ) specialize in the treatment of geriatric patients with osteoporotic fractures. In addition to the treatment of acute fractures, the certification of these centers also requires defined treatment paths for the treatment of concomitant diseases in these patients. An important component of this is the treatment of osteoporosis. The DVO guideline is particularly clear with regard to the implementation of basic diagnostics and treatment indications for the patient group treated in the ATZ. Patients in the ATZ are by definition over 70 years of age and have at least one fracture. This means that the indication for basic diagnostics and in most cases, even without bone density measurement, the indication for drug therapy for osteoporosis is already given. In the DVO Guideline 2023, fractures, especially vertebral and hip fractures, have the highest risk gradients and thus lead to a significant increase in fracture risk. Due to the high risk of subsequent fractures, rapid and sufficient initiation of treatment is necessary. The possible strategies can basically be divided into an induction and escalation strategy. This article presents the background and implementation of the DVO Guideline 2023 in the ortho-geriatric trauma center.

Alterstraumazentren (ATZ) sind auf die Behandlung von geriatrischen Patientinnen und Patienten mit osteoporotischen Frakturen spezialisiert. Neben der Versorgung der akuten Frakturen erfordert die Zertifzierung dieser Zentren auch festgelegte Behandlungspfade zur Behandlung der Begleiterkrankungen dieser Patientinnen und Patienten. Dazu gehört als wichtiger Baustein auch die Versorgung der Osteoporose. Insbesondere bei der im ATZ versorgten Patientengruppe ist die DVO-Leitlinie eindeutig in Bezug auf die Durchführung der Basisdiagnostik und der Therapieindikation. Patientinnen und Patienten im ATZ sind definitionsgemäß über 70 Jahre und es liegt mindestens eine Fraktur vor. Damit ist die Indikation zur Basisdiagnostik und in den meisten Fällen, auch ohne Knochendichtemessung, die Indikation zur medikamentösen Therapie der Osteoporose bereits gegeben. In der DVO-Leitlinie 2023 haben die Frakturen, vor allem Wirbel- und Hüftfrakturen, die höchsten Risikogradienten und führen somit zu einer starken Erhöhung des Frakturrisikos. Aufgrund des hohen Risikos für Folgefrakturen ist eine schnelle und suffiziente Therapieeinleitung notwendig. Die möglichen Strategien können grundsätzlich in eine Induktions- und Eskalationsstrategie unterteilt werden. In dem vorliegenden Beitrag sollen die Hintergründe und die Umsetzung der DVO-Leitlinie 2023 im Alterstraumazentrum dargestellt werden.

Compte tenu des mutations démographiques actuelles et du vieillissement de la population, près de la moitié des patients de plus de 65 ans sont atteints d’une forme de rhumatisme. Le diagnostic clinique des maladies rhumatismales chez le sujet âgé est compliqué par la convergence des changements physiologiques liés au vieillissement, des difficultés complexes de prise en charge et des manifestations cliniques atypiques. Dans cette revue, nous résumons les données qui permettent de guider le clinicien dans l’évaluation des patients gériatriques atteints de pathologies rhumatismales en ciblant plus spécifiquement les rhumatismes inflammatoires. Sur la base de la situation épidémiologique des troubles musculo-squelettiques, de la symptomatologie clinique, des tests diagnostiques disponibles et des changements physiologiques liés au vieillissement, cette revue met en évidence cinq pièges dans le diagnostic de la polyarthrite rhumatoïde chez les patients âgés. Ces pièges sont les suivants : 1) un large diagnostic différentiel, 2) présentations atypiques, 3) troubles cognitifs, de communication et sociaux, 4) rôle de l’âge chronologique versus biologique et 5) biais d’ancrage lié au postulat selon lequel les personnes âgées sont simplement de « jeunes adultes plus vieux ». Ces écueils sont discutés à la lumière des principes de gériatrie tels que les « marqueurs du vieillissement » et les changements physiopathologiques attendus au sein des systèmes d’organes. Nous passons également en revue les forces et faiblesses des tests diagnostiques utilisés dans les pathologies articulaires et proposons certains outils d’évaluation gériatrique qui visent systématiquement à détecter les multimorbidités et syndromes gériatriques. La meilleure compréhension des éventuels pièges diagnostiques, la connaissance des processus du vieillissement normal et pathologique, la distinction entre l’âge biologique et l’âge chronologique et le recours aux outils d’évaluation gériatrique dans l’optique de mieux caractériser les patients âgés, sont autant d’éléments qui guideront la pose du diagnostic et la prise en charge des affections rhumatismales dans cette population spécifique.

Objective To investigate prevalence and associations of kinesiophobia on patients with axSpA, and its relation to global functioning and health, disease activity, function, spinal mobility and physical activity in comparison to healthy controls (HC). Methods Cross-sectional, observational study in which consecutive axSpA patients with axSpA (n=100) and 20 healthy controls (HC) were examined by the Tampa scale of kinesiophobia (TSK), and the Fear avoidance belief questionnaire (FABQ). Patient reported outcomes and objective assessments of disease activity physical function, global health and functioning as well as the BASMI, the AS physical performance index (ASPI), the Short Physical Performance Battery (SPPB) and Epionics SPINE (ES) measurements, including range of motion (RoM) and kinematics (RoK) were collected. Results AxSpA patients showed higher TSK (25.5±6.8 vs. 14.0±5.1) and FABQ scores (40.1±22 vs. 3.1±6.9) compared to HC, all P≤0.001. Categorical analyses of kinesiophobia levels revealed that patients with higher levels performed significantly worse in ASPI and SPPB tasks, and they also showed impairments in BASMI and ES measures. TSK and FABQ scores correlated with ASAS HI (r=0.45 and r=0.52) and BASFI (r=0.38 and r=0.44), but not with ASPI, SPPB and RoK. Weak correlations were found for BASMI (r=0.24 and r=0.38) and BASDAI (both r=0.35). Conclusion Kinesiophobia seems to be a clinically relevant problem of axSpA patients, since the mobility of patients with moderate to high TSK and FABQ scores was much more impaired in this study. Of interest, the level of kinesiophobia showed stronger correlations with physical function, global functioning and health than with mobility and PA.

Abstract Objective Define the prevalence and location of inflammatory and structural lesions on magnetic resonance imaging (MRI) in patients with rheumatoid arthritis (RA) and radiographic axial spondyloarthritis (r-axSpA) with neck pain as leading clinical symptom. Methods Patients with diagnosis of RA and r-axSpA were consecutively included if they had chronic (> 3 months) neck pain. Clinical assessment, neck pain questionnaires and MRIs of the cervical spine (CS) were performed. Results 107 patients (59 RA and 48 r-axSpA) were included. While there was no difference in the Northwick-Park-Neck-Pain-questionnaire, patients with RA reported higher neck pain compared to r-axSpA on a numeric rating scale (5.0 ± 3.6 vs. 3.0 ± 3.1; p = 0.003). Inflammatory lesions occurred predominantly in the craniocervical area in RA and in the lower CS segments in r-axSpA. Bone marrow edema (BME) was more frequent in axSpA (BME-score axSpA/RA: 0.35vs0.17; p < 0.001) while synovitis was visible in both but was more prevalent in RA (synovitis-score axSpA/RA: 0.02vs0.1; p < 0.001). BME was found in 8 (13.6%) vertebral corner vs. 9 (18.8%), in 2 (3.4%) facet joints vs. 7 (14.6%) and in 1 (1.7%) spinous processes vs. 9 (18.8%) in patients with RA/r-axSpA. In contrast, more patients with RA (30.5% vs6.3%) showed erosive osteochondrosis with endplate BME (p = 0.002). Conclusion While involvement of upper cervical inflammation was typically present in RA, r-axSpA patients showed more BME in lower CS segments, vertebral corners, facet joints and spinous processes. Neck pain is linked to upper and lower inflammatory and structural lesions of the CS in both diseases.

Given current demographic shifts, the number of older adults continues to grow, with almost half of patients over 65 being diagnosed with some form of arthritis. Rheumatic diseases pose unique diagnostic challenges in older patients due to the convergence of physiologic changes of aging, confounding difficulties to care, and atypical disease manifestations. This review summarizes the current published evidence to guide clinicians in evaluating geriatric patients with rheumatologic concerns, focusing on inflammatory arthritis. Using the background of epidemiologic data on various musculoskeletal diseases, clinical presentations, current diagnostic tests, and known physiologic changes of aging, this review highlights five diagnostic pitfalls in inflammatory polyarthritis among older patients. The pitfalls include: 1) broader differential diagnosis; 2) atypical presentations; 3) communication, cognitive, and social impairments; 4) the role of chronological vs. biological age; and 5) anchoring bias by assuming older adults are simply "older young adults". These pitfalls are discussed in the context of geriatric principles such as the "hallmarks of aging" and the expected pathophysiologic changes of organ systems. Furthermore, the review discusses the strengths and weaknesses of diagnostic tests used in arthritis and introduces some of the geriatric assessment tools that systematically evaluate multimorbidity and geriatric syndromes. With familiarity of the potential diagnostic pitfalls, knowledge of both normal and pathologic aging processes, awareness of the difference between biological and chronological age, and the ability to use geriatric assessment tools to better characterize older patients, clinicians will be better able to diagnose and manage rheumatic conditions in this population.

The global population is ageing and the rheumatology workforce should be prepared to take care of the inevitable complexities of ageing patients. We can learn from our colleagues and experts in geriatrics about how best to manage multimorbidity, polypharmacy, geriatric syndromes, and shifting priorities of older patients in the context of delivering care for rheumatic diseases. One approach to learning and adopting key ageing constructs within rheumatology practice is to incorporate the established Geriatric 5Ms—principles fundamental to caring for older adults. In this Series paper we discuss the 5Ms in the context of rheumatology practice (1) multicomplexity: assessing and managing multimorbidity and challenging biopsychosocial situations, (2) medications: ensuring that medications do not interfere with the other Ms, (3) mind: managing neurocognitive disorders and comorbid mental health conditions, (4) mobility: ensuring older adults can move independently and safely, and (5) what matters most: aligning care with an older adult's specific goals.

Osteosarcopenia, the concurrent presence of sarcopenia and osteopenia/osteoporosis, poses a significant health risk to older adults, yet its impact on clinical outcomes is not fully understood. The aim of this prospective, longitudinal multicentre study was to examine the impact of osteosarcopenia on 3-year mortality and unplanned hospitalizations among 572 older hospitalized patients (mean age 75.1 ± 10.8 years, 78% female). Sarcopenia and low bone mineral density (BMD) were evaluated using Dual Energy X-ray Absorptiometry and the European Working Group on Sarcopenia in Older People (EWGSOP2) and WHO criteria, respectively. Among participants, 76% had low BMD, 9% were sarcopenic, and 8% had osteosarcopenia. Individuals with osteosarcopenia experienced a significantly higher rate of mortality (46%, p < 001) and unplanned hospitalization (86%, p < 001) compared to those without this condition. Moreover, “healthy” subjects—those without sarcopenia or low BMD—showed markedly lower 3-year mortality (9%, p < 001) and less unplanned hospitalization (53%, p < 001). The presence of osteosarcopenia (p = 0.009) increased the 3-year mortality risk by 30% over sarcopenia alone and by 8% over low BMD alone, underscoring the severe health implications of concurrent muscle and bone deterioration. This study highlights the substantial impact of osteosarcopenia on mortality among older adults, emphasizing the need for targeted diagnostic and therapeutic strategies.