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Objectives 1) To explore the ultrasound (US) findings of muscle mass, muscle quality and muscle stiffness in systemic lupus erythematosus (SLE) patients and healthy subjects; 2) To investigate the relationship between the US muscle findings and physical performance in SLE patients and healthy subjects. Methods Quadriceps muscle thickness for muscle mass, muscle echogenicity (using a visual semiquantitative scale and grayscale analysis with histograms) for muscle quality, and shear-wave elastography (SWE) for muscle stiffness, were assessed in 30 SLE patients (without previous/current myositis or neuromuscular disorders) and 15 age, sex, and BMI-matched healthy subjects. Hand grip strength test and short physical performance battery (SPPB) were carried out in the same populations. Results No difference in the quadriceps muscle thickness was observed between SLE patients and healthy subjects (35.2 mm ±SD 6.8 vs 34.8 mm ±SD 6.0 respectively, p = 0.79). Conversely, muscle echogenicity was significantly increased in SLE patients (visual semiquantitative scale: 1.7 ±SD 1.0 vs 0.3 ±SD 0.5, respectively, p < 0.01; grayscale analysis with histograms: 87.4 mean pixels ±SD 18.8 vs 70.1 mean pixels ±SD 14.0 respectively, p < 0.01). Similarly, SWE was significantly lower in SLE patients compared with healthy subjects [1.5 m/s (IQR 0.3) vs 1.6 m/s (IQR 0.2) respectively, p = 0.01). Muscle echogenicity was inversely correlated with grip strength (visual semiquantitative scale Rho:-0.47, p = 0.01; grayscale analysis with histograms Rho:-0.41, p < 0.01) and SPPB (visual semiquantitative scale Rho:-0.50, p < 0.01; grayscale analysis with histograms Rho:-0,46, p < 0.01). Conclusions US assessment of muscle echogenicity and stiffness is useful for the early detection of muscle involvement in SLE patients.

B-cell depletion therapy is an effective option for RA treatment, but depletion is frequently incomplete (>0.0001x10 9 /L at week 2). Complete B-cell depletion (CD) after rituximab is associated with good clinical response (R) and this status (CD-R) leads to long-term maintenance of therapy. Low pretreatment plasmablasts, concomitant DMARDs, no smoking exposure, ACPA/RF+ and a low IFNsignature are predictive of CD-R. Half of the patients that achieve CD-R with rituximab eventually stop experiencing this outcome to further infusions; however 3/4 of them regain it in the following cycle. This suggests that loss of response is reversible and patients can still benefit from rituximab retreatment. Efficacy of lower doses of rituximab is under investigation, but preliminary results suggest these strategies are best used for maintenance especially in patients who suffer adverse events or are at high risk of infection. Infusion reactions are the most common adverse events; and IgG monitoring is crucial as low levels correlate with higher infection risk.

Sarcopenia is characterized by loss of muscle mass, altered muscle composition, fat and fibrous tissue infiltration, and abnormal innervation, especially in older individuals with immune-mediated rheumatic diseases (IMRDs). Several techniques for measuring muscle mass, strength, and performance have emerged in recent decades. The portable dynamometer and gait speed represent the most frequently used tools for the evaluation of muscle strength and physical efficiency, respectively. Aside from dual-energy, X-ray, absorptiometry, and bioelectrical impedance analysis, ultrasound (US) and magnetic resonance imaging (MRI) techniques appear to have a potential role in evaluating muscle mass and composition. US and MRI have been shown to accurately identify sarcopenic biomarkers such as inflammation (edema), fatty infiltration (myosteatosis), alterations in muscle fibers, and muscular atrophy in patients with IMRDs. US is a low-cost, easy-to-use, and safe imaging method for assessing muscle mass, quality, architecture, and biomechanical function. This review summarizes the evidence for using US and MRI to assess sarcopenia.

Background Musculoskeletal (MSK) symptoms are among the commonest reasons for primary care assessments; however, few individuals will be diagnosed with an inflammatory arthritis (IA) within the following year. The purpose of this study was to investigate, in individuals with new MSK symptoms, the association between patient factors and risk of progression to IA, in order to optimise primary care referrals to rheumatology. Methods Individuals ≥16 years old with new non-specific MSK symptoms and no clinical synovitis were recruited by primary care across the UK from July 2007 until May 2019. Those testing positive for the anti-CCP2 assay (anti-CCP+) were invited to Leeds for follow-up. Subjects with a negative result (anti-CCP−) were sent a 1-year questionnaire, and general practitioners were contacted to confirm whether the individual had been diagnosed with an IA by a rheumatologist. Predictors for progression were assessed using multivariable regression analysis. Results Six thousand seven hundred eighty individuals were recruited: 3% were anti-CCP+, of whom 45% progressed to IA, predominantly rheumatoid arthritis. Anti-CCP+ participants with high antibody levels had an odds ratio (OR) for progression to IA of 9.42 [P < 0.001, 95% CI (3.13–28.30)], hand pain, OR 2.74 [P = 0.043, 95% CI (1.03–7.27)] and foot pain, OR 4.10 [P = 0.003, 95% CI (1.59–10.54)]. In low-level anti-CCP+ individuals, absence of pain in hands or feet had a negative predictive value of 96% for progression to IA. One-year follow-up data were available for 5640 anti-CCP− individuals, of whom 53 were diagnosed with IA (0.93%). Pain in hands, OR 2.51 [P = 0.018, 95% CI (1.17–5.39)] or knees, OR 3.03 [P = 0.003, 95% CI (1.47–6.25)] were associated with development of IA within 12 months. Conclusions This is the largest prospective primary care study of individuals at risk of IA, and the first one to prospectively investigate the outcome of MSK symptoms in a large anti-CCP− cohort. High anti-CCP levels and pain in hands/feet indicated an increased likelihood of progression to IA. In patients with low anti-CCP level and no pain in the hands/feet, progression is unlikely. In anti-CCP− patients, those with hand or knee pain were at increased risk of progression. This study demonstrates that routinely available tests and joint symptoms provide useful discrimination that may be used to prioritise referrals to rheumatology and avoid a delayed diagnosis. Trial registration NCT, NCT02012764. Registered 25 January 2007.