Reporting Sacroiliac Joint Imaging Performed for Known or Suspected Axial Spondyloarthritis: Assessment of SpondyloArthritis International Society Recommendations.

Whereas previous projects attempted to standardize imaging in patients with axial spondyloarthritis (axSpA), few studies have been published about the need for specific details regarding the image acquisition and lesions that may be less familiar to general radiologists. This work reports consensus recommendations developed by the Assessment of SpondyloArthritis International Society (ASAS) that aim to standardize the imaging reports in patients suspected of having or with known axSpA. A task force consisting of radiologists and rheumatologists from ASAS and one patient representative formulated two surveys that were completed by ASAS members. The results of these surveys led to the development of 10 recommendations that were endorsed by 73% (43 of 59) of ASAS members. The recommendations are targeted to the radiologist and include best practices for the inclusion of clinical information, technical details, image quality, and imaging findings in radiology reports. These recommendations also emphasize that imaging findings that indicate differential diagnoses and referral suggestions should be included in the concluding section of the radiology report. With these recommendations, ASAS aims to improve the diagnostic process and care for patients suspected of having or with known axSpA.

Bibliometric analysis of Advanced Oxidation Processes studies with a focus on Life Cycle Assessment and Costs.

Advanced oxidation processes (AOPs) are wastewater treatment technologies that stand out for their ability to degrade Contaminants of Emerging Concern (CECs). The literature has extensively investigated these removal processes for different aqueous matrices. Once technically mature, some of these systems have become accredited to be applied on a large scale, and therefore, their systemic performances in the environmental and cost spheres have also become essential requirements. This study proposed corroborating this trend, analyzing the available literature on the subject to verify how experts in the AOP area investigated this integration during 2015-2023. For this purpose, a sample of publications was treated by applying the Systematic Review (SR) methodology. This resulted in an extract of 83 studies that adopted life-cycle logic to estimate environmental impacts and process costs or evaluated them as complementary to the technical dimension of each treatment technology. This analysis found that both dimensions can be used for selecting or sizing AOPs at the design scale. However, the appropriate choice of the impact categories for the environmental assessment and establishing a methodology for cost analysis can make the approach still more effective. In addition, a staggering number of processes would broaden the reality and applicability of the estimates, and adopting multicriteria analysis methodologies could address essential aspects of decision-making processes during the design of the arrangements. By meeting the original purposes, the study broadened the requirements for designing AOPs and disseminating their use in mitigating the discharge of CECs.

Assessment of medical students' knowledge of primary limb sarcomas.

INTRODUCTION: Typically, oncology is not a structured part of the curriculum in Brazilian medical schools. Furthermore, sarcomas, which are uncommon tumors, are seldom covered in depth. A lack of comprehensive education on sarcomas might result in medical professionals being ill-equipped to care for patients with this condition. OBJECTIVES: To assess medical students' understanding and awareness of sarcomas and the specific principles related to these tumors. MATERIALS AND METHODS: A quantitative, cross-sectional study was conducted using a questionnaire, applied to medical students, focusing on the epidemiology, pathophysiology, and treatments of bone and soft tissue sarcomas. In all tests, the significance level adopted was 5%. The SPSS version 25.0 software was used. RESULTS: Of the 825 questionnaires distributed, 325 were returned. Educational sessions on sarcomas did not appear to significantly improve the student's knowledge. Only 29.5% of students identified the lack of pain as an indicator of potential malignancy in soft tissue sarcomas, while 73.8% correctly recognized pain as a symptom of bone sarcomas. Limb amputation as the optimal surgical method for patient recovery was incorrectly reported by 39.1% of the sample. CONCLUSION: A great part of the surveyed population does not have adequate knowledge about the basic concepts associated with limb sarcomas. The minority of them are satisfied with the knowledge gained during their medical education about these tumors. Inadequate medical academic training may initially lead to the wrong clinical management of patients with bone and soft tissue tumor lesions. An educational effort is needed to enhance oncology education for medical students, especially concerning sarcomas.

Enhancing Stress Detection: A Comprehensive Approach through rPPG Analysis and Deep Learning Techniques.

Stress has emerged as a major concern in modern society, significantly impacting human health and well-being. Statistical evidence underscores the extensive social influence of stress, especially in terms of work-related stress and associated healthcare costs. This paper addresses the critical need for accurate stress detection, emphasising its far-reaching effects on health and social dynamics. Focusing on remote stress monitoring, it proposes an efficient deep learning approach for stress detection from facial videos. In contrast to the research on wearable devices, this paper proposes novel Hybrid Deep Learning (DL) networks for stress detection based on remote photoplethysmography (rPPG), employing (Long Short-Term Memory (LSTM), Gated Recurrent Units (GRU), 1D Convolutional Neural Network (1D-CNN)) models with hyperparameter optimisation and augmentation techniques to enhance performance. The proposed approach yields a substantial improvement in accuracy and efficiency in stress detection, achieving up to 95.83% accuracy with the UBFC-Phys dataset while maintaining excellent computational efficiency. The experimental results demonstrate the effectiveness of the proposed Hybrid DL models for rPPG-based-stress detection.

Global Perspective on the Impact of the COVID-19 Pandemic on Rheumatology and Health Equity.

Although the public health emergency associated with the COVID-19 pandemic has ended, challenges remain, especially for individuals with rheumatic diseases. We aimed to assess the historical and ongoing effects of COVID-19 on individuals with rheumatic diseases and rheumatology practices globally, with specific attention to vulnerable communities and lessons learned. We reviewed literature from several countries and regions, including Africa, Australia and New Zealand, China, Europe, Latin America, and the US. In this review, we summarize literature that not only examines the impact of the pandemic on individuals with rheumatic diseases, but also research that reports the lasting changes to rheumatology patient care and practice, and health service use. Across countries, challenges faced by individuals with rheumatic diseases during the pandemic included disruptions in health care and medication supply shortages. These challenges were associated with worse disease and mental health outcomes in some studies, particularly among those who had social vulnerabilities defined by socioeconomic, race, or rurality. Moreover, rheumatology practice was impacted in all regions, with the uptake of telemedicine and changes in health care utilization. While many regions developed rapid guidelines to disseminate scientific information, misinformation and disinformation remained widespread. Finally, vaccine uptake among individuals with rheumatic diseases has been uneven across the world. As the acute phase of the pandemic wanes, ongoing efforts are needed to improve health care access, stabilize rheumatology drug supplies, improve public health communication, and implement evidence-based vaccination practices to reduce COVID-19 morbidity and mortality among individuals with rheumatic diseases.

International Guideline for Idiopathic Inflammatory Myopathy-Associated Cancer Screening: an International Myositis Assessment and Clinical Studies Group (IMACS) initiative.

Adult-onset idiopathic inflammatory myopathy (IIM) is associated with an increased cancer risk within the 3 years preceding and following IIM onset. Evidence- and consensus-based recommendations for IIM-associated cancer screening can potentially improve outcomes. This International Guideline for IIM-Associated Cancer Screening provides recommendations addressing IIM-associated cancer risk stratification, cancer screening modalities and screening frequency. The international Expert Group formed a total of 18 recommendations via a modified Delphi approach using a series of online surveys. First, the recommendations enable an individual patient's IIM-associated cancer risk to be stratified into standard, moderate or high risk according to the IIM subtype, autoantibody status and clinical features. Second, the recommendations outline a 'basic' screening panel (including chest radiography and preliminary laboratory tests) and an 'enhanced' screening panel (including CT and tumour markers). Third, the recommendations advise on the timing and frequency of screening via basic and enhanced panels, according to risk status. The recommendations also advise consideration of upper or lower gastrointestinal endoscopy, nasoendoscopy and 18F-FDG PET-CT scanning in specific patient populations. These recommendations are aimed at facilitating earlier IIM-associated cancer detection, especially in those who are at a high risk, thus potentially improving outcomes, including survival.

Assessment of Medical Students' Knowledge of Imaging Methods for Bone Sarcomas.

Cancer is a leading cause of death in Brazil and worldwide. However, Brazilian medical education fails to include oncology as an essential topic. This creates a gap between the health status of the population and medical education. Bone sarcomas fall into both the group of malignant neoplasms and rare diseases and are thus doubly influenced by misinformation. To assess medical students' knowledge of imaging diagnostic methods for bone sarcomas. A cross-sectional, quantitative study was undertaken by obtaining the responses of medical students to a questionnaire containing radiographic images and questions about the radiological aspects of bone sarcomas. The categorical variables were compared using the chi-square test. The level of significance was 5% for all the tests. SPSS software version 25.0 was used for the analysis. A total of 325 responses were collected, with 72% of the participants having no interest in oncology and 55.6-63.9% not knowing how to diagnose a periosteal reaction on bone radiography. Only 11.1-17.1% of the students correctly interpreted the radiographic image of osteosarcoma. Medical students fail to correctly interpret images of bone sarcomas. It is important to promote oncology undergraduate education in general and to include the approach to bone sarcomas in this context.

Measuring quality of life of patients with axial spondyloarthritis for economic evaluation.

OBJECTIVES: To estimate the relationship between EQ5D (three levels, UK version) and the Ankylosing Spondylitis Disease Activity Score (ASDAS) for use in the economic evaluation of health technologies for people with axial spondyloarthritis (axSpA). To compare against the relationship with the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). METHODS: An electronic, prospective, Portuguese, nationwide, rheumatic disease register (Reuma.pt) provided data on 1140 patients (5483 observations) with a confirmed diagnosis of axSpA. We estimated models of EQ5D as a function of ASDAS, alone or in combination with measures of functional impairment, using bespoke mixture models which reflect the complex distributional features of EQ5D. The SPondyloArthritis Caught Early cohort provided data from 344 patients (1405 observations) in four European countries and was used for validation. A previously published model of BASDAI/Bath Ankylosing Spondylitis Functional Index (BASFI) was also used to generate predicted EQ5D scores and model performance compared. RESULTS: A non-linear relationship exists between EQ5D from ASDAS. The final model included ASDAS, ASDAS squared, age and age squared and demonstrated close fit in both datasets except where data were sparse for patients with very high levels of disease activity (ASDAS >4). This finding held in the validation dataset. Models that included BASFI improved model fit. The ASDAS based models fit the data marginally less well than models using BASDAI. CONCLUSIONS: Mapping models linking ASDAS to EQ5D allow results from clinical studies to be used in economic evaluation of health technologies with confidence. There is some loss of information compared with BASDAI but this has only a marginal impact.

Axial Spondyloarthritis: Mimics and Pitfalls of Imaging Assessment.

Axial spondyloarthritis (axSpA) is a chronic inflammatory disorder that predominantly involves the axial skeleton. Imaging findings of axSpA can be divided into active changes, which include bone marrow edema, synovitis, enthesitis, capsulitis, and intra-articular effusion, and structural changes, which include erosions, sclerosis, bone fatty infiltration, fat deposition in an erosion cavity, and bone bridging or ankylosis. The ability to distinguish between imaging lesions suggestive of axSpA and artifacts or lesions suggestive of other disorders is critical for the accurate diagnosis of axSpA. Diagnosis may be challenging, particularly in early-stage disease and magnetic resonance imaging (MRI) plays a key role in the detection of subtle or inflammatory changes. MRI also allows the detection of structural changes in the subchondral bone marrow that are not visible on conventional radiography and is of prognostic and monitoring value. However, bone structural changes are more accurately depicted using computed tomography. Conventional radiography, on the other hand, has limitations, but it is easily accessible and may provide insight on gross changes as well as rule out other pathological features of the axial skeleton. This review outlines the imaging evaluation of axSpA with a focus on imaging mimics and potential pitfalls when assessing the axial skeleton.

Revisiting the use of remission criteria for rheumatoid arthritis by excluding patient global assessment: an individual meta-analysis of 5792 patients.

OBJECTIVES: To determine the impact of excluding patient global assessment (PGA) from the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) Boolean remission criteria, on prediction of radiographic and functional outcome of rheumatoid arthritis (RA). METHODS: Meta-analyses using individual patient data from randomised controlled trials testing the efficacy of biological agents on radiographic and functional outcomes at ≥2 years. Remission states were defined by 4 variants of the ACR/EULAR Boolean definition: (i) tender and swollen 28-joint counts (TJC28/SJC28), C reactive protein (CRP, mg/dL) and PGA (0-10=worst) all ≤1 (4V-remission); (ii) the same, except PGA >1 (4V-near-remission); (iii) 3V-remission (i and ii combined; similar to 4V, but without PGA); (iv) non-remission (TJC28 >1 and/or SJC28 >1 and/or CRP >1). The most stringent class achieved at 6 or 12 months was considered. Good radiographic (GRO) and functional outcome (GFO) were defined as no worsening (ie, change in modified total Sharp score (ΔmTSS) ≤0.5 units and ≤0.0 Health Assessment Questionnaire-Disability Index points, respectively, during the second year). The pooled probabilities of GRO and GFO for the different definitions of remission were estimated and compared. RESULTS: Individual patient data (n=5792) from 11 trials were analysed. 4V-remission was achieved by 23% of patients and 4V-near-remission by 19%. The probability of GRO in the 4V-near-remission group was numerically, but non-significantly, lower than that in the 4V-remission (78 vs 81%) and significantly higher than that for non-remission (72%; difference=6%, 95% CI 2% to 10%). Applying 3V-remission could have prevented therapy escalation in 19% of all participants, at the cost of an additional 6.1%, 4.0% and 0.7% of patients having ΔmTSS >0.0, >0.5 and >5 units over 2 years, respectively. The probability of GFO (assessed in 8 trials) in 4V-near-remission (67%, 95% CI 63% to 71%) was significantly lower than in 4V-remission (78%, 74% to 81%) and similar to non-remission (69%, 66% to 72%). CONCLUSION: 4V-near-remission and 3V-remission have similar validity as the original 4V-remission definition in predicting GRO, despite expected worse prediction of GFO, while potentially reducing the risk of overtreatment. This supports further exploration of 3V-remission as the target for immunosuppressive therapy complemented by patient-oriented targets.

Development and validation of an alternative ankylosing spondylitis disease activity score when patient global assessment is unavailable.

OBJECTIVE: To develop an alternative Ankylosing Spondylitis Disease Activity Score (ASDAS) to be used in research settings in axial SpA (axSpA) when Patient Global Assessment (PGA) is unavailable in databases. METHODS: Longitudinal data from four axSpA cohorts and two randomized controlled trials were combined. Observations were randomly split in a development (N = 1026) and a validation cohort (N = 1059). Substitutes of PGA by BASDAI total score, single or combined individual BASDAI questions, and a constant value, were established in the development cohort. Conversion factors for each substitute were defined by Generalized Estimating Equations, obtaining seven 'alternative' formulae. Validation was performed in the validation cohort according to the OMERACT filter, taking into consideration: (i) truth (agreement with original-ASDAS in the continuous score, by intraclass correlation coefficient and in disease activity states, by weighted kappa); (ii) discrimination [standardized mean difference of ASDAS scores between high/low disease activity states defined by external anchors, e.g. Patient Acceptable Symptom State; agreement (kappa) in the percentage of patients reaching ASDAS improvement criteria according to alternative vs original formulae]; and (iii) feasibility. RESULTS: Comparing various options, alternative-ASDAS using BASDAI total as PGA replacement proved to be: truthful (intraclass correlation coefficient = 0.98, kappa = 0.90), discriminative [ASDAS scores between Patient Acceptable Symptom State no/yes: standardized mean difference = 1.37 (original-ASDAS standardized mean difference = 1.43); agreement with original-ASDAS in major improvement/clinically important improvement criteria: kappa = 0.93/0.88] and feasible (BASDAI total often available, as questions required for the ASDAS; conversion coefficient ≈ 1). CONCLUSION: Alternative-ASDAS using BASDAI total score as PGA replacement is the most truthful, discriminative and feasible instrument.

Development and validation of psoriatic arthritis switch quality assessment tool (PASQAL) - an outcomes measurement tool to assess the quality of biologic switch decisions in psoriatic arthritis.

BACKGROUND: Switching between biologic therapies is a recommended strategy for Psoriatic Arthritis (PsA) patients that show an insufficient response or adverse events. Although the choice of the subsequent biologic may be dependent on many factors, assessing the quality of the switch decision is of utmost relevance. OBJECTIVES: To develop and validate two outcomes measurement tools (for patients with peripheral and axial PsA phenotypes) that address the quality of treatment decisions in PsA regarding the switch of biologic therapies in clinical practice. METHODS: A Task Force and an Expert Panel were specifically assembled for this purpose. The Psoriatic Arthritis Switch Quality Assessment tool (PASQAL) development comprised a modified-Delphi method in a four-step procedure: 1) literature search and experts' opinion collection about quality indicators for PsA management; 2) Delphi design to address the development of the measurement tool; 3) three Delphi questionnaire rounds; 4) final consensus meeting. This phase resulted in the definition of two measurement tools, one to evaluate the quality of biologic switch in peripheral (pPASQAL) and another one in axial PsA (axPASQAL). For the validation of PASQAL, 12 experienced rheumatologists were asked to evaluate and classify the biologic switch of 80 clinical cases (40 with predominant peripheral and 40 with predominant axial PsA). Clinical judgement was defined to be the "gold standard" against which the performance of PASQAL was assessed. The results were used to assess tools' performance (sensitivity/specificity analysis) and the agreement between the tools and the gold standard (Cohen's kappa). RESULTS: PASQAL consists of 6 domains (joint disease activity, dactylitis, enthesis, physical function, quality of life, and skin and nail manifestations), respective instruments and thresholds. The classification of the biologic switch was divided into three quality levels: "Good", based on treat-to-target thresholds; "Moderate", based on improvement from baseline; and the remaining as "Insufficient". pPASQAL was found to be highly sensitive (92%) with the "Good" quality level and specific (97%) with the "Insufficient" quality level. Whilst axPASQAL showed overall higher sensitivity and specificity for all quality levels, as well as a higher level of agreement between the tool and the gold standard than pPASQAL (k=0.87 vs k=0.71). CONCLUSION: PASQAL was developed and showed good criterion validity for the evaluation of the quality of switch in both peripheral and axial PsA phenotypes. These tools may be used in research as well as in clinical practice, to support rheumatologists in making more informed therapeutic decisions.

Using native and invasive livebearing fishes (Poeciliidae, Teleostei) for the integrated biological assessment of pollution in urban streams.

Invasive species are increasingly replacing native species, especially in anthropogenically transformed or polluted habitats. This opens the possibility to use invasive species as indicator taxa for the biological assessment of pollution. Integrated biological assessment, however, additionally relies on the application of multiple approaches to quantify physiological or cytogenetic responses to pollution within the same focal species. This is challenging when species are restricted to either polluted or unpolluted sites. Here, we make use of a small group of neotropical livebearing fishes (family Poeciliidae) for the integrated biological assessment of water quality. Comparing urban and suburban stream sections that receive varying degrees of pollution from industrial and domestic waste waters in and around the Brazilian city of Uberlândia, we demonstrate that two members of this family may indeed serve as indicators of water pollution levels. The native species Phalloceros caudimaculatus appears to be replaced by invasive guppies (Poecilia reticulata) at heavily polluted sites. Nevertheless, we demonstrate that both species could be used for the assessment of bioaccumulation of heavy metals (Pb, Cu, and Cr). Ambient (sediment) concentrations predicted concentrations in somatic tissue across species (R2-values between 0.74 and 0.96). Moreover, we used cytogenetic methods to provide an estimate of genotoxic effects of water pollution and found pollution levels (multiple variables, condensed into principal components) to predict the occurrence of nuclear abnormalities (e.g., frequencies of micro-nucleated cells) across species (R2 between 0.69 and 0.83). The occurrence of poeciliid fishes in urban and polluted environments renders this family a prime group of focal organisms for biological water quality monitoring and assessment. Both species could be used interchangeably to assess genotoxic effects of water pollution, which may facilitate future comparative analyses over extensive geographic scales, as members of the family Poeciliidae have become invasive in tropical and subtropical regions worldwide.

Costs and emissions assessment of a Blue Corridor in a Brazilian reality: The use of liquefied natural gas in the transport sector.

Technical, economic, social and environmental conditions are turning natural gas into a feasible solution for sustainable transportation systems in the State of São Paulo (Brazil). Blue Corridors are routes that aim to enable the use of liquefied natural gas (LNG) for heavy vehicles as a substitute to Diesel oil. Therefore, this work proposes four scenarios for a Blue Corridor in the State of São Paulo and analyzes its environmental and economic impacts. The results are presented in cartographical figures and show that LNG costs up to 40% less than diesel, while reducing CO2 equivalent emissions by up to 5.2%. Particulate matter (PM) emissions are reduced by 88%, nitrogen oxides (NOx) by 75% and hydrocarbon emissions are eliminated. However, despite the economic and environmental advantages presented in the results of this study, LNG still faces regulatory barriers that must be addressed in order to allow its widespread use in the transportation sector.

Impact of Patient's Global Assessment on Achieving Remission in Patients With Rheumatoid Arthritis: A Multinational Study Using the METEOR Database.

OBJECTIVE: There is an ongoing debate about excluding patient's global assessment (PtGA) from composite and Boolean-based definitions of rheumatoid arthritis (RA) remission. This study aimed at determining the influence of PtGA on RA disease states, exploring differences across countries, and understanding the association between PtGA, measures of disease impact (symptoms), and markers of disease activity (inflammation). METHODS: Cross-sectional data from the Measurement of Efficacy of Treatment in the Era of Outcome in Rheumatology international database were used. We calculated the proportion of patients failing American College of Rheumatology/European League Against Rheumatism Boolean-based remission (4-variable remission) solely due to PtGA (PtGA-near-remission) in the overall sample and in the most representative countries (i.e., those with >3,000 patients in the database). Multivariable linear regression models were used to identify the main determinants of PtGA, grouped in predominantly inflammatory impact factors (28 tender joint counts, 28 swollen joint counts, and C-reactive protein level) and disease impact factors (pain and function). RESULTS: This study included 27,768 patients. Excluding PtGA from the Boolean-based definition (3-variable remission) increased the remission rate from 5.8% to 15.8%. The rate of PtGA-near-remission varied considerably between countries, from 1.7% in India to 17.9% in Portugal. One-third of the patients in PtGA-near-remission group scored PtGA >4 of 10. Pain and function were the main correlates of PtGA, with inflammation-related variables contributing less to the model (R2 = 0.57). CONCLUSION: PtGA is moderately related to joint inflammation overall, but only weakly so in low levels of disease activity. A considerable proportion of patients otherwise in biologic remission still perceive high PtGA, putting them at risk of excessive immunosuppressive treatment.

Update on outcome assessment in myositis.

The adult and juvenile myositis syndromes, commonly referred to collectively as idiopathic inflammatory myopathies (IIMs), are systemic autoimmune diseases with the hallmarks of muscle weakness and inflammation. Validated, well-standardized measures to assess disease activity, known as core set measures, were developed by international networks of myositis researchers for use in clinical trials. Composite response criteria using weighted changes in the core set measures of disease activity were developed and validated for adult and juvenile patients with dermatomyositis and adult patients with polymyositis, with different thresholds for minimal, moderate and major improvement in adults and juveniles. Additional measures of muscle strength and function are being validated to improve content validity and sensitivity to change. A health-related quality of life measure, which incorporates patient input, is being developed for adult patients with IIM. Disease state criteria, including criteria for inactive disease and remission, are being used as secondary end points in clinical trials. MRI of muscle and immunological biomarkers are promising approaches to discriminate between disease activity and damage and might provide much-needed objective outcome measures. These advances in the assessment of outcomes for myositis treatment, along with collaborations between international networks, should facilitate further development of new therapies for patients with IIM.