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Question addressed by the studyMethotrexate (MTX) is a key anchor drug for rheumatoid arthritis (RA) management. Fibrotic interstitial lung disease (ILD) is a common complication of RA. Whether MTX exposure increases the risk of ILD in patients with RA is disputed. We aimed to evaluate the association of prior MTX use with development of RA-ILD.MethodsThrough a case-control study design with discovery and international replication samples, we examined the association of MTX exposure with ILD in 410 patients with chronic fibrotic ILD associated with RA (RA-ILD) and 673 patients with RA without ILD. Estimates were pooled over the different samples using meta-analysis techniques.ResultsAnalysis of the discovery sample revealed an inverse relationship between MTX exposure and RA-ILD (adjusted odds ratio [OR], 0.46; 95% confidence interval [CI], 0.24–0.90; p=0.022), which was confirmed in the replication samples (pooled adjusted OR, 0.39; 95% CI, 0.19–0.79; p=0.009). The combined estimate using both the derivation and validation samples revealed an adjusted OR of 0.43 (95% CI, 0.26–0.69; p=0.0006). MTX ever users were less frequent among patients with RA-ILD compared to those without ILD, irrespective of chest high resolution computed tomography pattern. In patients with RA-ILD, ILD detection was significantly delayed in MTX ever users compared to never users (11.4±10.4 years and 4.0±7.4 years, respectively; p<0.001).Answer to the QuestionOur results suggest that MTX use is not associated with an increased risk of RA-ILD in patients with RA, and that ILD was detected later in MTX treated patients.

18F-FDG uptake of IgG4-RD lesions reflects immunological perturbations of the B cell compartment rather than fibroblast activation and extracellular matrix deposition. Conventional biomarkers of disease activity, namely IgG4-RD RI, ESR, CRP and serum IgG4 levels, do not appear to correlate with the radiometabolic activity of IgG4-RD lesions. In light of our results PET/CT represents a reliable instrument for assessing IgG4-RD activity, although lymph-node uptake deserves careful interpretation.

Purpose of review Remarkable insights have been gleaned recently with regard to the pathophysiology of IgG4-related disease (IgG4-RD). These findings have direct implications for the development of targeted strategies for the treatment of this condition. Recent findings Oligoclonal expansions of cells of both the B and T lymphocyte lineages are present in the blood of patients with IgG4-RD. Oligoclonal expansions of plasmablasts are a good biomarker for disease activity. An oligoclonally-expanded population of CD4+ cytotoxic T lymphocytes is found not only in the peripheral blood but also at tissue sites of active disease. This cell elaborates cytokines that may drive the fibrosis characteristic of IgG4-RD. T follicular helper cells (Tfhc), particularly the Tfhc2 subset, appear to play a major role in driving the class switch to IgG4 that typifies this disease. The relationship between malignancy and IgG4-RD remains an area of interest. Summary Advances in understanding the pathophysiology of IgG4-RD have proceeded swiftly, leading to the identification of a number of potential targeted treatment strategies. The completion of classification criteria for IgG4-RD, an effort supported jointly by the American College of Rheumatology and the European League Against Rheumatism, will further facilitate studies in this disease.

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Response to: 'COVID-19 pandemic: an opportunity to assess the utility of telemedicine in patients with rheumatic diseases' by Lopez-Medina et al We thank Lopez-Medina et al 1 for their comment on our paper and for sharing their experience with phone consultations. 2 Telemedicine, in the past years, has been progressively implemented into medical practice. However, it has not been able to fully take root into routine medical care yet. The COVID-19 pandemic provided the opportunity to take a further step towards the integration between virtual and traditional medical assistance in many medical specialties including rheumatology. The restriction rules, taken over by numerous countries, together with the necessity of assuring a proper continuity of care, have forced us to adopt telemedicine tools in our routine involving chronic patients. To overcome legal matters of privacy and data protection, we have recently set up a telemedicine software provided by our institution that allows us to have visual interaction with the patient and to share files in a password-protected virtual room. This approach has revealed a useful help with a major response rate by patients, achievable thanks to the broad internet coverage and connectivity with an increasing percentage of people owning a smartphone nowadays in Italy. As expected, we have observed high response rates among the younger population, with the older ones frequently needing support from other family members (G Zanframundo et al, submitted). Furthermore, visual contact may overcome the barriers of a simple phone call. Telemedicine perfectly fits for stable, long-standing conditions, and it can be useful for intermediate follow-up visits. This would markedly reduce the burden on medical resources, better balancing population medical needs and human resources in our health system, highly stressed by COVID-19. A role for a tele-rheumatological triage to better identify those patients needing urgent or specialist evaluation could be another potential benefit. It could greatly refine outpatient clinic access, reducing the workload on third-level referral centres, in turn improving medical care. Furthermore, an increased implementation of digital and cloudbased medical visits and prescriptions might propel specialistspecialist and specialist-general practitioner interactions for the benefit of the patient. Lastly, telemedicine might take advantage of the development of remote medical technologies. There is an increasing interest in the aid that wearable devices may provide to the global care of patients as already described in chronic inflammatory arthritides and virtually applicable in every rheumatological condition. 3 However, despite having represented an enormous help during the COVID-19 pandemic, telemedicine bears major caveats that must be carefully addressed and adapted to our new postpandemic routine. Indeed, certain rheumatological conditions require prompt diagnosis and rapid treatment initiation with a regular and objective follow-up. The treat-to-target appro...

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