Obesity and metabolic syndrome play a significant role in the complexity of chronic inflammatory arthritis. By promoting systemic inflammation and altering immune responses, these conditions can amplify joint-related symptoms, such as pain, synovitis, and enthesitis. This inflammatory and mechanical burden complicates clinical evaluation, as traditional disease activity scores may be skewed by excess weight, leading to inaccurate assessments. Imaging techniques like musculoskeletal ultrasound (MSUS) offer a promising tool to detect subclinical inflammation and improve diagnostic accuracy. This review examines the role of MSUS in the management of obese patients with inflammatory arthritis. We explore how MSUS can be leveraged to detect subclinical inflammation, improve diagnostic accuracy, and guide more effective management strategies. We also discuss the limitations of MSUS in this patient population, including the impact of excessive adipose tissue on image quality and the need for standardized protocols.

Objective:This study investigates gender disparities in clinical outcomes among patients with systemic sclerosis (SSc)-associated pulmonary arterial hypertension (PAH), focusing on cardiovascular events, right ventricular function, and survival. Introduction:PAH is a severe and life-threatening complication of SSc, with male patients often experiencing worse outcomes despite its higher prevalence in women. Comparative data on gender differences in this population remain limited. Methods:We conducted a retrospective, single-center study including 61 patients with SSc-associated PAH (52 women, 9 men), confirmed by right heart catheterization. Clinical, serological, pulmonary, and echocardiographic data were analyzed. Differences between sexes in cardiovascular events, right ventricular dilation, and survival were evaluated using appropriate statistical methods. Results:Male patients had a significantly higher incidence of cardiovascular events (median: 2.00 vs 1.00 in women; P = .031) and a greater prevalence of right ventricular dilation (100.00% vs 44.23%; P = .002). Kaplan-Meier analysis demonstrated reduced cardiovascular event-free survival (P = .001) and overall survival (P = .014) in men. Although mortality was higher in men (88.89%) than in women (57.69%), the difference was not statistically significant (P = .134). Conclusion:Men with SSc-associated PAH experience worse clinical outcomes, including more frequent cardiovascular events and reduced survival. The absence of estrogen's protective effects and the adverse influence of testosterone on cardiac remodeling may contribute to these disparities. These findings highlight the importance of early gender-specific risk stratification and the need for tailored therapeutic strategies to improve outcomes in this high-risk group.

OBJECTIVES:To describe the prevalence of gastrointestinal (GI) symptoms in SSc and Very Early Diagnosis of SSc (VEDOSS), identify clinical and serological features associated with GI involvement and explore a cranio-caudal pattern of symptom distribution, using data from the Italian SPRING-SIR registry. METHODS:This cross-sectional analysis included patients fulfilling 2013 ACR/EULAR SSc or VEDOSS criteria. GI involvement was defined as symptoms in at least one GI tract segment and categorized as upper and lower. Associations between GI involvement and clinical variables were assessed using logistic and ordinal regression models, adjusting for demographics, disease characteristics and autoantibodies. RESULTS:Among 1917 SSc patients, 56% had GI symptoms, associated with longer disease duration, dcSSc, interstitial lung disease (ILD), digital ulcers (DU), telangiectasias and tobacco exposure. Extensive GI involvement correlated with more severe disease. Ordinal regression identified female sex, dcSSc, ILD, DU, telangiectasias, tobacco exposure and anti-centromere antibodies as variables significantly associated with more extensive GI involvement. Disease duration did not show a significant association with GI symptom extent. Among 211 VEDOSS patients, 41.2% reported GI symptoms (mostly oesophageal), significantly associated with puffy fingers and dyspnoea. Among VEDOSS, puffy fingers and anti-centromere antibodies were independent predictors of presence of oesophageal symptoms. CONCLUSION:GI involvement in SSc is linked to more severe disease and longer disease duration. Disease duration resulted linked to the presence of GI symptoms rather than extent of GI involvement. Puffy fingers and anti-centromere antibodies may associate with presence of early oesophageal symptoms in VEDOSS.

OBJECTIVES:To assess the relationship between disease duration and the prevalence/distribution of nailfold videocapillaroscopy (NVC) patterns, named according to the current classification as 'early', 'active' and 'late', in a large cohort of systemic sclerosis (SSc) patients. METHODS:A cross-sectional analysis was conducted on 1689 patients undergoing standardized NVC. Clinical-serological data and treatments were collected. Statistical comparisons and multivariable logistic regression models were applied, including analyses based on disease duration. RESULTS:The prevalence of NVC patterns was as follows: 'early' 21.6%, 'active' 47.4%, 'late' 25.7% and normal/non-specific 5.3%. The distribution by disease duration showed that the three main patterns were always present. While the 'early' and 'active' progressively decreased (from 30.3% and 51.9% in patients with ≤5 yrs, to 14.6% and 43.5% in those >10 yrs, P < 0.01), the 'late' pattern increased from 13.2% (≤5 yrs) to 36.0% (>10 yrs) (P < 0.001) and was associated with internal organ involvement, anti-topoisomerase antibodies and more therapies (P < 0.01). Conversely, the 'early' and 'active' patterns were associated with the limited-cutaneous subset (P < 0.01) and anti-centromere antibodies (P < 0.001). Multivariable analysis confirmed a strong association between the 'late' pattern and skin/peripheral vascular involvement. Notably, the presence of the 'late' pattern in patients with ≤2 yrs (10.9%) was significantly associated with scleroderma renal crisis (P = 0.012). CONCLUSION:SSc-NVC patterns are not strictly time-dependent and can be observed at any stage of the disease, suggesting that microvascular damage progression is heterogeneous across different disease periods. Therefore, a revised classification of NVC changes considering both disease duration and NVC severity could improve its prognostic accuracy.

Background: Psoriatic arthritis (PsA) is a chronic inflammatory disease characterized by musculoskeletal and cutaneous involvement. While TNF inhibitors (TNFi) are commonly used as first-line biologic therapies, treatment failure is frequent. IL-23 inhibitors (IL23i) represent an alternative mechanism of action (MoA), but direct real-world comparisons between these drug classes remain limited. Objectives: To compare the effectiveness of TNFi versus IL23i in real-life PsA patients. Design: This multicenter retrospective observational study is part of the BIRRA (BIologics Retention Rate Assessment) project. Consecutive patients with PsA—classified according to the CASPAR criteria—were screened across 29 Italian rheumatology referral centers. Methods: We analyzed 1418 therapeutic lines for PsA initiated between 2019 and 2024 across 29 Italian rheumatology centers. Treatment lines were categorized as TNFi or IL23i based on the drug’s MoA. Demographic, clinical, and treatment-related data were collected. The primary outcome was treatment retention, evaluated by Kaplan–Meier survival analysis. A Cox proportional hazards model adjusted for a propensity score (PS) was used to account for confounding factors. Results: Among 1418 prescriptions (1270 TNFi; 148 IL23i), IL23i lines were associated with older age, longer disease duration, higher baseline disease activity, and more prior biologic disease-modifying antirheumatic drugs exposure. Despite this, no significant difference in crude retention was observed. After PS adjustment, IL23i prescriptions showed significantly longer treatment retention than TNFi (hazard ratio 0.53; 95% confidence interval: 0.31–0.90; p = 0.02). Axial or mixed PsA phenotype and higher baseline Disease Activity in Psoriatic Arthritis score were associated with lower retention. Conclusion: In this real-world cohort, IL23i prescriptions demonstrated comparable treatment persistence compared to TNFi, even in more challenging clinical scenarios. These findings support the inclusion of IL23i as a valid therapeutic option in PsA. Prospective studies are needed to confirm their positioning in treatment algorithms.

OBJECTIVE:Mycophenolate mofetil (MMF) use in limited cutaneous systemic sclerosis (lcSSc) is relatively uncommon because of the lower fibrotic burden and the predominance of vascular complications. In vitro observations and clinical data from transplanted patients suggest a protective effect of MMF on endothelial function. Our aim was to evaluate the reasons for prescribing MMF treatment in patients with lcSSc and its impact on the need for escalation of vascular complication-related treatments during follow-up. METHODS:Patients with lcSSc enrolled in the Italian Systemic Sclerosis Progression Investigation registry were retrospectively evaluated. All patients treated with MMF were matched to patients not treated with MMF, which was based on a roll-entry time-dependent propensity score built on demographics, clinical features, and baseline treatment. The escalation of vasoactive or vasodilator treatment up to 60 months was defined as the introduction of iloprost, endothelin receptor antagonists, or phosphodiesterase-5 inhibitors on top of the ongoing treatment, because of uncontrolled or newly diagnosed vascular complications. A hazards Cox model was also adopted to quantify the association of MMF treatment with treatment escalation. RESULTS:A total of 1,435 patients with lcSSc were evaluated, of whom 152 were prescribed MMF (17.1% male; mean age at lcSSc onset 48.7 ± 13.9 years, 54.6% anti-Scl70 positive). The prescription of MMF was more common in men and in anti-Scl70 positive, anticentromere negative patients with interstitial lung disease, myositis, and without a history of digital ulcers. After matching 107 patients with MMF-untreated controls, the overall incidence of vasoactive/vasodilator treatment escalation events related to digital ulcers over a median follow-up of 40.5 months (interquartile range 23.3-60.0) was 0.3 per 100 patient-years in the MMF-treated group and 5.4 per 100 patient-years in the matched control group, with a significant difference in treatment escalation-free survival between the two groups (hazard ratio 0.05, 95% confidence interval 0.01-0.38; P value = 0.004). CONCLUSION:In patients with lcSSc, the introduction of MMF has reduced the need for escalation of vasoactive or vasodilator treatment, suggesting that it may also help to prevent vascular complications, which frequently affect patients with lcSSc.

Objective:To evaluate the real-world effectiveness of baricitinib (BARI) in rheumatoid arthritis (RA), compare outcomes in patients <65 years versus ≥65 years, and identify predictors of DAS28-ESR remission/low disease activity (LDA) at 6 and 12 months. Methods:Retrospective multicentre cohort (n=423). Baseline variables included age, sex, disease duration, and comorbidities. DAS28-ESR was recorded at baseline, 6 and 12 months; remission was defined as DAS28-ESR <2.6 and LDA as ≤3.2. Predictors of remission/LDA were assessed with multivariable logistic regression, reporting odds ratios (ORs), 95% confidence intervals (CIs), and p-values. Results:Median age was 60 years (IQR 50.5-69.5); 79% were female; median disease duration 76 months (IQR 31-157). Compared with patients <65, those ≥65 had longer disease duration (94 vs 65 months; p<0.05) and more diabetes (16% vs 5%), dyslipidaemia (47% vs 19%), and hypertension (62% vs 33%) (all p<0.05). Median DAS28-ESR fell from 5.42 (IQR 4.84-6.06) at baseline to 3.71 (2.83-4.59) at 6 months and 3.29 (2.42-4.19) at 12 months (global repeated-measures test significant). Remission+LDA was achieved by 135/421 (32.1%) at 6 months and 182/423 (43.0%) at 12 months; remission alone increased from 65/421 (15.4%) to 117/423 (27.7%). Age ≥65 was not associated with response (6 months: OR 0.71, 95% CI 0.44-1.14, p=0.16; 12 months: OR 0.83, 95% CI 0.55-1.24, p=0.37). ACPA positivity independently predicted remission/LDA (6 months: OR 2.32, 95% CI 1.43-3.77, p<0.05; 12 months: OR 1.71, 95% CI 1.12-2.59, p<0.05). Prior JAK inhibitor exposure was not associated with reduced response. Results were consistent in a per-protocol sensitivity analysis. Conclusion:In this large multicentre real-world cohort, BARI significantly reduced disease activity over 12 months, with comparable effectiveness across age groups. ACPA positivity emerged as an independent predictor of achieving remission/LDA, supporting its potential role in treatment stratification.

Introduction: Primary Sjögren’s (pSS) is an autoimmune disease that affects several organs, especially the heart, and raises cardiovascular risk. Investigating the associations of hemoglobin-to-red cell distribution width (RDW) ratio (HRR), vitamin D status, and cardiac function could provide valuable insights and biomarkers regarding early cardiovascular risk in patients with pSS. Method: This cross-sectional study involved 61 patients diagnosed with pSS based on ACR/EULAR criteria. Data on demographics, hematological (Hb, RDW), echocardiography, and serum vitamin D levels were collected. Echocardiograms were conducted by trained cardiologists following established guidelines, while vitamin D levels were measured using ELISA. Statistical analyses, including univariate linear regression, were performed with SPSS in order to identify whether HRR tertiles were related to cardiac function and vitamin D status. Results: A study of 61 pSS patients (mean age 59.8 years, 89% female) revealed that patients with a lower hemoglobin-to-RDW ratio (HRR ≤ 0.98) had significantly higher pulmonary artery pressures (PAPs) and lower values for the tricuspid annular plane systolic excursion (TAPSE)/PAPs ratio, contributing to poor right heart function. These associations were particularly strong in patients with insufficient levels of vitamin D (<30 ng/mL), while differences in other echocardiographic parameters remained nonsignificant between HRR groups. Conclusions: These findings underscore the clinical value of HRR as a composite biomarker that reflects the interplay between anemia, inflammation, and cardiovascular health in primary Sjögren’s disease. They also suggest that vitamin D status may be an important therapeutic consideration to mitigate cardiopulmonary risks in this population.

Background Tocilizumab (TCZ) has shown beneficial effects on interstitial lung disease (ILD) in systemic sclerosis (SSc). We aimed to assess the real-life safety and effectiveness of TCZ on several SSc-related domains using data from a French-Italian multicentre cohort.Methods We conducted a retrospective analysis of patients with SSc treated with TCZ across 15 referral centres. The following clinical data were collected at 12 months before TCZ initiation, at baseline and at 12 and 24 months of treatment: modified Rodnan skin score (mRSS), pulmonary function tests, Disease Activity Score in 28 joints using C reactive protein, digital ulcers and cardiac biomarkers. ILD progression was defined as a decline ≥5 in %predicted forced vital capacity (%pFVC) over 12±3 months.Results 197 patients were included (88% female; median age 57 years; median disease duration 9 years); 67% were antitopoisomerase I positive. TCZ monotherapy was used in 29% of cases, methotrexate was the most frequent combined treatment (35%). In SSc-associated ILD, %pFVC declined significantly from −12 months to baseline (81% to 77%; p=0.003). On TCZ introduction, %pFVC stabilised and the proportion of progressors declined from 43% to 24% (p=0.015). Among diffuse cutaneous patients, mRSS decreased significantly at 12 and 24 months. Digital ulcers, arthritis activity and cardiac biomarkers also improved. Infections were the most frequent adverse events (22.8%). TCZ was discontinued in 32% of patients, mainly for inefficacy. Pulmonary arterial hypertension and older age predicted TCZ failure, whereas elevated CRP predicted better response.Conclusions In this large real-life cohort, TCZ was safe and associated with consistent benefits across different domains, supporting its role as a potential disease-modifying treatment in selected patients with SSc.

Background:The sequence and temporal relationship between Raynaud's phenomenon (RP) and the first non-Raynaud's sign/symptom (NRP) in systemic sclerosis (SSc) have been partially investigated. Objectives:To evaluate whether the mode and ages of clinical onset are associated with disease endotype and survival in SSc. Design:We included SSc patients from the Systemic sclerosis Progression INvestiGation registry of the Italian Society of Rheumatology (SPRING-SIR) registry in a cohort study, with post hoc cross-sectional and longitudinal analysis. Methods:Patients were grouped based on age-RP and age-NRP quartiles. Additionally, categories were defined based on mode of onset: RP group-RP onset at least 1 year before NRP; Simultaneous group-RP onset within the same year of NRP; NRP group-RP onset after at least 1 year after NRP. Comparisons were made using Chi-square and ANOVA tests. Logistic, linear, and multinomial regression models were applied to assess associations, while Kaplan-Meier curves and Cox regression were used to assess mortality. Results:A total of 1748 patients were eligible: 682 (39.0%) in the RP group, 1026 (58.8%) in the simultaneous group, and 39 (2.2%) in the NRP group. A higher prevalence of anti-centromere antibodies was found In the RP group, while the simultaneous group had more diffuse cutaneous SSc (dcSSc), anti-topoisomerase-I antibodies, and higher Rodnan's skin score (mRSS). The NRP group presented higher prevalence of pulmonary arterial hypertension. On logistic regression, the simultaneous group was associated with a higher prevalence of dcSSc compared to the RP group (odds ratio, 1.491, 95% confidence interval (CI): 1.032-2.154). Younger age at RP onset was associated with lower systolic pulmonary artery pressure and mRSS. In 943 patients with available follow-up (median 24 months), the simultaneous group had higher mortality compared to the RP group (hazard ratio, 1.975, 95% CI: 1.002-3.893). Conclusion:The timing of RP and NRP onset may help define SSc endotype and survival. Patients with simultaneous RP-NRP onset have more severe disease features and higher mortality risk, emphasizing the relevance of onset timing in disease stratification.

Introduction: Sjogren’s is an autoimmune disease that affects several organs, especially the heart, and raises cardiovascular risk. Investigating associations of hemoglobin-to-RDW ratio (HRR), vitamin D status, and cardiac function could provide valuable insights and biomarkers regarding early cardiovascular risk in patients with SD. Method: This cross-sectional study involved 61 patients diagnosed with primary Sjogren’s syndrome (pSS) based on ACR/EULAR criteria. Data on demographics, hematological (Hb, RDW), echocardiography, and serum vitamin D levels were collected. Echocardiograms were conducted by trained cardiologists following established guidelines, while vitamin D levels were measured using ELISA, and statistical analyses, including univariate linear regression, were adjusted for confounders. were performed with SPSS in order to identify whether HRR tertiles were related to cardiac function and vitamin D status. Results: A study of 61 Sjogren’s disease patients (mean age 59.8 years, 89% female) revealed that patients with a lower hemoglobin-to-RDW ratio (HRR ≤0.98) had significantly higher pulmonary artery pressures (PAPs) and lower values for the TAPSE/PAPs ratio, contributing to poor right heart function. These associations were particularly strong in patients with insufficient levels of vitamin D (< 30 ng/mL), while differences in other echocardiographic parameters remained nonsignificant between HRR groups. Conclusion: These findings underscore the clinical value of HRR as a composite biomarker that reflects the interplay between anemia, inflammation, and cardiovascular health in Sjogren’s disease. They also suggest that vitamin D status may be an important therapeutic consideration to mitigate cardiopulmonary risks in this population.

Pulmonary arterial hypertension (PAH) is a severe vascular complication of SSc and a leading cause of disease-related mortality. Despite the availability of validated screening tools and treatment recommendations, diagnosis delay and suboptimal therapeutic implementation remain frequent in real-world practice. The 2022 European Society of Cardiology/European Respiratory Society guidelines and 2025 EULAR recommendations advocate systematic annual screening and initial combination therapy with an endothelin receptor antagonist and a phosphodiesterase type 5 inhibitor at PAH diagnosis. In SSc patients already receiving a dual combination, escalation to triple therapy including selexipag, or in selected cases switching to riociguat, should be promptly considered. Given the rapid progression and poorer prognosis of SSc-PAH, follow-up within 3 months of diagnosis is critical. Structured referral networks, implementation of the DETECT algorithm and involvement of a dedicated case manager and/or nurse can further improve timely diagnosis and continuity of care. Optimizing SSc-PAH management requires a proactive, integrated approach that bridges rheumatology and cardiology expertise.

Background/Objectives: Systemic sclerosis (SSc) patients frequently develop osteoporosis; however, vertebral fracture risk factors remain poorly characterized. This study identifies general and SSc-specific predictors of vertebral fractures in SSc patients undergoing osteoporosis evaluation. Methods: This multicenter cross-sectional study enrolled consecutive SSc patients meeting ACR/EULAR 2013 criteria with suspected osteoporosis. Data included demographics, disease characteristics, bone density (DXA), and vertebral imaging. Stepwise logistic regression analyzed fracture associations (p ≤ 0.05 significant). Results: The majority of 103 enrolled patients were female and all were post-menopausal. The prevalence of osteoporosis was 52.4%, that of vertebral fractures was 38.8%, and that of osteopenia was 28.1%. General risk factor analysis identified family history of fragility fractures (OR 11.8, p = 0.008) and vertebral T-scores (OR 0.6, p = 0.049) as significant predictors. When adding SSc-specific factors, only family history (OR 13.8, p = 0.03) and gastrointestinal (GI) involvement (OR 4.8, p = 0.05) remained significant. Conclusions: Vertebral fractures in SSc patients are strongly linked to a family history of fractures. The suggestive association with GI involvement may imply a significant role for malabsorption-related metabolic impairment. Prioritizing bone density screening in SSc patients with GI symptoms may enable earlier intervention and reduce fracture risk.