[History of reactive arthritis. Historical milestones and future]. / Geschichte der reaktiven Arthritis. Historische Meilensteine und Zukunft.

The introduction of the term reactive arthritis (ReA) for the joint inflammation observed after infection with Yersinia enterocolitica, in which "a causative pathogen cannot be isolated from the synovial fluid", and the association with the HLA-B27 were the historical milestones for a new classification and assignment to the spondylarthritides (SpA). The division into postinfectious and reactive arthritis proposed in 1976 was put into perspective in the 1990s because of investigations with the newly available molecular biological method of the polymerase chain reaction. Microbial products could be identified from joint samples of patients with ReA. Therefore, it was proposed to abandon the distinction between the two groups of diseases and to prefer the term ReA for both. This created a terminological and nosological issue. On the one hand, there are generally accepted classification and diagnostic criteria for the classical HLA-B27-associated ReA that are assigned to SpA. On the other hand, an increasing number of bacterial pathogens, viruses, amoebas, helminths as well as antiviral and antibacterial vaccinations are described as triggers of arthritis, which have been published under the term ReA. Since the beginning of the SARS-CoV­2 pandemic, cases of acute post-COVID-19 arthritis have been described, which were also classified as ReA because of comparable clinical features.

[Post-Corona-Virus-Disease­19 arthritis. Manifestation under the clinical picture of a reactive arthritis]. / Post-COVID­19-Arthritis. Manifestation unter dem klinischen Bild einer reaktiven Arthritis.

A total of 13 case reports of reactive arthritis reported in the literature in connection with coronavirus disease 2019 (COVID­19) are reviewed. Men were affected more frequently than women. The arthritis was manifested 4-44 days after the infection or the occurrence of the COVID­19 symptoms. Acute arthritis was monoarticular or oligoarticular. Only 1 out of 7 patients examined was human-leucocyte-antigen(HLA)-B27 positive. A direct viral infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) could not be detected in the synovial fluid and was not investigated in the synovial membrane. The arthritis was successfully treated with nonsteroidal anti-inflammatory drugs and/or intra-articular or systemic corticosteroids. The pathogenesis of post-COVID­19 reactive arthritis is unknown.

[Bertolt Brecht. Did he really have rheumatic fever?] / Bertolt Brecht. Hatte er wirklich ein rheumatisches Fieber?

The writer Bertolt Brecht (1898-1956) is known for his poems, dramas and the "epic or dialectical theater" he founded. He was retrospectively postulated to have had rheumatic fever because of heart problems and neuromuscular symptoms in his youth. Based on current rheumatological knowledge, it cannot be deduced with certainty from the available documents that Brecht had rheumatic fever. At most, a very unusual manifestation of rheumatic fever can be suspected with atypical rheumatic chorea and a very atypical course of rheumatic carditis. Several deviations from the classical clinical picture-the absence of fever and arthritis, no typical symptoms of Sydenham's chorea, the lack of a diagnosis of heart valve defects in adolescence-lead to extensive differential diagnostic considerations. A possible psychosomatic origin through functional heart complaints must even be postulated if a temporary previous organic cause cannot be excluded. Only the use of the advanced diagnostics available today with Doppler sonography of the heart, cardiac magnetic resonance imaging (MRI), throat swabs for Streptococci and streptococcal serology would have made it possible to diagnose Brecht's cardiac symptoms in his adolescence without a doubt and to differentiate them from functional heart complaints. His death is verified by medical documents clearly documenting bacterial endocarditis with evidence of coli bacteria caused by urological interventions with subsequent febrile episodes and pyelonephritis.

[Rheumatism and art : Max Slevogt. The bon viveur and artist plagued by gout]. / Rheuma und Kunst : Max Slevogt. Von Gicht geplagter Genussmensch und Künstler.

The painter Max Slevogt (1868-1932), together with Lovis Corinth and Max Liebermann, was one of the most important representatives of German impressionism. Slevogt, a gourmet who appreciated fine food and good wines, suffered from acute recurrent gouty arthritis starting at the age of 27 years. His medical history is reconstructed for the first time from the published and previously unpublished letters of his doctor János Plesch. After gout attacks at longer intervals in the first years of the disease, the attacks increased and from 1917 onwards were manifested in 1-2-year intervals with no evidence of a chronic gouty arthritis. Many of his attacks of gouty arthritis are illustrated by drawings that document the involvement of the feet and knees. Slevogt usually treated the gout attacks with bed rest, which prevented him from painting. He used a drug treatment with Colchicum only rarely. Dietary measures, a health cure for weight loss and multiple spa treatments in the last years of life at annual intervals, were among the other treatment modalities. The gout and heavy smoking resulted in coronary heart disease from which he died shortly before his 65th birthday.

Optimized testing for C. trachomatis DNA in synovial fluid samples in clinical practice.

AIM: No standardized polymerase chain reaction (PCR) assay is available for detection of Chlamydia trachomatis (C. tr.) in synovial fluid (SF) for diagnostic use in clinical practice. This study tested the performance of two optimized molecular biology methods, to determine which is best suited for detecting C. tr. in SF clinical samples from patients with various rheumatologic diseases. METHODS: Two DNA extraction methods, i.e., (1) alkaline lysis and (2) QIAEX II Gel Extraction Kit® + cetyltrimethylammonium bromide (CTAB; Qiagen, Hilden, Germany), and C. tr.-omp1-152 bp PCR were tested in SF samples from a total of 329 patients with the following diagnoses: reactive arthritis (ReA; n = 10, 4 patients had posturethritic ReA), undifferentiated arthritis (UA; n = 66), rheumatoid arthritis (RA; n = 169), psoriatic arthritis (PSA; n = 12), and osteoarthritis (OA) n = 72. RESULTS: In SF samples, C. tr.-omp1-152 bp PCR in combination with alkaline lysis DNA extraction allowed detection of more C. tr.-positive samples: 3/10 (30%) ReA patients (all with posturethritic ReA) and 20/66 (38%) UA patients were positive, compared to the 0/10 (0%) patients with ReA and 1/66 (2%) with UA detected using the QIAEX II Gel Extraction Kit® + CTAB. Moreover, 2/12 (17%) SF samples from PSA patients tested positive with alkaline lysis. All samples from patients with OA and RA tested negative. CONCLUSION: Alkaline lysis in combination with C. tr.-omp1-152 bp PCR emerged as the most sensitive method for identification of C. tr. in clinical SF samples.

[Therapy of rheumatoid arthritis with methotrexate. Claims data analysis of treatment patterns]. / Therapie der rheumatoiden Arthritis mit Methotrexat. Analyse von Versorgungsaspekten anhand von GKV-Routinedaten.

Methotrexate (MTX) is the most important disease-modifying antirheumatic drug (DMARD) and is recommended by national and international guidelines as the first choice for treatment of rheumatoid arthritis (RA). Recent studies reporting prescription data of MTX captured only patients who were treated by rheumatologists. Therefore, the aim of the present study was to analyse several aspects of the prescription of MTX based on claims data. Outpatient and inpatient diagnoses as well as prescription data was available for 9579 RA patients for the years 2005-2008. Of the patients 45% were treated exclusively with parenteral MTX, 8% were treated exclusively with oral MTX and 48% switched between both forms of application. The average weekly dosage presribed in 70% of the patients was between 10 and 25 mg. The most common DMARD combination was MTX plus leflunomide with 16%. In 16% RA patients were treated with a combination of MTX and TNF-α inhibitors. Glucocorticoids were prescribed temporarily in 81% together with MTX and supplementation with folic acid was given only in 65%. The results of this study provide important insights into the drug supply of MTX to RA patients in the German statutory health care sector. In particular, the high frequency of prescriptions of parenteral MTX and the inadequate prescription of folic acid are different from the recently published multinational recommendations of the 3E initiative for the use of MTX.

A dose of only 5 mg prednisolone daily retards radiographic progression in early rheumatoid arthritis - the Low-Dose Prednisolone Trial.

Glucocorticoids (GC) have been used to treat rheumatoid arthritis (RA) for more than 60 years. Despite this very long experience, there remains considerable debate concerning the adequate dosing and timing of these medications, primarily because of frequent and sometimes serious side effects, particularly in high doses. GCs are documented to provide immediate symptomatic relief and to decrease signs of inflammation in active disease. At the time when the Low-Dose Prednisolone Trial (LDPT) was designed, no clear evidence was available concerning whether low doses of GCs given over a long period add to slowing of structural damage in RA. The trial was therefore designed to test the hypothesis that even a low dose of prednisolone that was thought to cause no or only very limited harm could slow radiographic progression. The trial therefore included patients with active early RA (disease duration less than two years) who received either prednisolone 5 mg/day or placebo on concomitant DMARD therapy with parenteral gold or methotrexate for two years. Radiographs of hands and feet were taken at baseline, and at 6, 12 and 24 months. Structural damage was assessed using change in the Ratingen score (0-190 scale) as the primary outcome, and change in the Sharp/van der Heijde score (0-448 scale) for additional information concerning the same radiographs. Of 192 patients in the study, 166 were available for intention to treat analysis (ITT), and 76 completed the study per protocol (PP). Progression of the Ratingen score was significantly less at all consecutive time points in the prednisolone group compared to the control group, with the greatest difference after 6 months. At 24 months the increase in score in the prednisolone group was 1.2 ± 3.5, (95% CI 0.4-2.1) and in the placebo group 4.3 ± 6.8 (95% CI 2.7-5.9) (p=0.006, ITT-analysis). This was confirmed by the results of the Sharp/van der Heijde erosion and total score with an increase of the total score of 5.3 ± 10.7 units in the prednisolone compared to 11.4 ± 19.1 in the placebo group (p=0.022) at 24 months. The LDPT trial therefore confirmed that a very low daily dose of 5 mg prednisolone given over two years in combination with background DMARD therapy substantially decreases radiographically detectable damage in patients with early RA.

[Prophylaxis and treatment of osteoporosis in patients with rheumatoid arthritis (ORA study)]. / Medikamentöse Osteoporoseprophylaxe und -Therapie bei Patienten mit Rheumatoider Arthritis (ORA-Studie).

OBJECTIVE: The aim of this study was to examine bone mineral density (BMD), frequency of osteopenia and osteoporosis in a representative sample of patients with rheumatoid arthritis (RA) and to describe chemoprophylaxis and treatment of osteoporosis compared to evidence-based guidelines. PATIENTS AND METHODS: In 2005 and 2006, 532 patients with RA (98 men, 434 women) aged 23-87 years were recruited from 9 German rheumatology centers. Clinical examination included a detailed documentation of osteoporosis medication. Dual-energy X-ray absorptiometry (DXA) was used to measure BMD at the lumbar spine and femoral neck. Osteopenia and osteoporosis were defined according to the criteria of the World Health Organization. RESULTS: Of the RA patients 29% had normal BMD at the spine and femoral neck, 49% of the patients had osteopenia and 22% met the criteria for osteoporosis at any site. Of the patients 60% were receiving medication for prophylaxis or therapy of osteoporosis, 38% calcium/vitamin D alone, 20% as combinations mostly of calcium/vitamin D + bisphosphonate, 1% received bisphosphonate only and 1% hormone replacement therapy. Although the frequency of osteoporosis showed no significant differences between male and female patients, women with RA used osteoporosis medication more often than men (63% versus 49%, χ²-test, p <0.05). A total of 101 RA patients (83 menopausal women, 6 premenopausal women, 12 men) received corticosteroids in a daily dose of 7.5 mg or less for at least 3 months and had DXA T-scores below -2.0 at any site. In this patient group 41% of the menopausal women, 17% of the premenopausal women and 42% of the male patients were reported to receive medication with calcium/vitamin D + bisphosphonate. Calcium/vitamin D was used by 35% of the menopausal women, none of the premenopausal women and 50% of the male patients and 18% of the menopausal women, 67% of the premenopausal women and 8% of men received no prophylaxis or treatment for osteoporosis. CONCLUSION: According to the DVO (German Society for Osteoporosis) guidelines for osteoporosis (2009) menopausal women with corticosteroid therapy < 7.5 mg per day for at least 3 months and DXA T-scores below -2.0 should receive treatment with bisphosphonate and calcium/vitamin D. The data show that there were still deficits concerning prophylaxis and treatment of osteoporosis in RA.

[Diagnosis and treatment of osteoporosis and rheumatoid arthritis in accordance with German guidelines. Results of a survey of patients, primary care physicians and rheumatologists]. / Diagnostik und Behandlung der Osteoporose bei rheumatoider Arthritis vor dem Hintergrund der Leitliniennutzung. Ergebnisse einer Befragung von Patienten, Hausärzten und Rheumatologen (ORA-Studie).

In a cross-sectional study the prevalence of osteoporosis and osteopenia in patients with rheumatoid arthritis (ORA study) was investigated. Additionally, patients, their family doctors and rheumatologists were surveyed on their awareness of osteoporosis in RA, prevention, diagnosis, treatment and use of guidelines.In the years 2005 and 2006 a total of 532 patients with RA (98 men, 434 women) aged 23-87 years were consecutively recruited from 9 German centers for rheumatology. Clinical examination included a detailed documentation of osteoporosis medication. Dual-energy X-ray absorptiometry (DXA) was used to measure bone mineral density (BMD) at the lumbar spine and neck of the femur. Questionnaires on osteoporosis were sent to 119 family doctors (87 men, 32 women) and 44 rheumatologists (30 men, 14 women).The survey showed that rheumatologists had a higher awareness of osteoporosis in RA and compared to family doctors they estimated a higher frequency and tested RA patients more often for osteoporosis. In line with osteoporosis guidelines rheumatologists and family doctors saw an indication for densitometry in RA patients on steroid therapy and/or low intensity trauma fractures. In contrast to the 2006 recommendations of osteoporosis guidelines 50% of family doctors and rheumatologists preferred bisphosphonate off-label-therapy for premeopausal women with RA and comorbid glucocorticoid-induced osteoporosis. On the other hand 50% of premenopausal RA patients with osteoporosis did not receive any osteoporosis medication.The survey revealed a high degree of guideline compliance in diagnosing osteoporosis in RA but deficits were observed in the administration of osteoporosis medication, especially in premenopausal women.

["Memories of my sick hands": life and medical history of the painter Alexej von Jawlensky]. / "Erinnerungen an meine kranken Hände": Lebens- und Krankengeschichte des Malers Alexej von Jawlensky.

Alexej von Jawlensky (1864-1941), one of the most important expressionist painters and a member the artist group "The Blue Four", suffered from severe rheumatoid arthritis. He was the first painter in the twentieth century to create extensive series of paintings especially of human faces. The medical history of Jawlensky as documented in his letters, is a harrowing document of a great artist who suffered from rheumatoid arthritis at a time when medical treatment was limited to physical therapy, pain medication and other relatively ineffective modalities, including the unnecessary extraction of teeth. Jawlensky's disease was characterized by a rapidly progressive course with severe pain, rapid onset of disability and ending up with complete immobilization and paralysis for several years until his death.The artistic processing and sublimation of his illness and suffering resulting in a series of over 1,000 small format meditations are the impressive and touching example of creative coping with rheumatoid arthritis. The meditations are unique in the history of art and often compared with icons. However, knowing the medical condition of Jawlensky these paintings can also be seen as metaphors of suffering and in each image the great physical and mental effort is reflected in the artistic details. Therefore, his art agent Galka E. Scheyer formulated in a letter to him: "You are the painter of the human soul. I know of no other modern painter of the human soul."

Psychological stress in rheumatoid arthritis patients: a comparative Polish-German study: summary of the current conceptualization of the role of stress in rheumatoid arthritis.

Cultural differences in experiencing individual stress in rheumatoid arthritis (RA) patients might be observed. The aim of the study was to assess quality of life and psychological stress (distress) in RA patients, and to evaluate socio-demographic and disease specific variables predicting stress of patients. The study covered 300 Polish and 137 German RA patients. SF-36v2 scale was used to evaluate the patients' health. Psychological stress was defined as the feeling of "social isolation" and "being a burden" as demanding help in everyday activities. In both countries, the mental and physical health of patients deteriorated and about 50% of patients required support in everyday activities. 95% of Polish and 62% of German patients felt rejected from social activities. For the psychological stress perceived, functional capacity class 3 and male gender were shown to be predictive in Polish patients and living in a small town - in German patients. In the Polish group, the tertiary/bachelor level of education was linked with lower distress level. RA has a serious impact on the mental health owing to a great disease burden. Awareness of impact of the disease on quality of life and psychological stress of patients should be considered in routine clinical practice.

[Chronic musculo-skeletal pain in Switzerland: patient care from the view of physicians and patients]. / Chronische muskuloskelettale Schmerzen in der Schweiz: Die Betreuungsqualität aus Sicht der Arzte und der Patienten.

A considerable percentage of the population suffers from chronic musculoskeletal pain (CMP) and patient management does not appear to be optimal. The aim of the present investigations was to assess and evaluate epidemiologic data and discover eventual deficits in patient management. This investigation included several sequential steps: First a European study including Switzerland evaluated the prevalence and characteristics of patients with CMP as well as of the treating physicians. The results were discussed and elaborated in two workshops, where general practitioners and patients were included. In a further step the results of these workshops were evaluated again in a telephone survey addressing patients and physicians both in the French and German speaking parts of Switzerland. Considerable deficits were discovered in the management of patients with CMP: In 35% no firm diagnosis was established, the life quality was considerably reduced in about 13 of the patients, the patients' information on their disorders were found to be rather limited, furthermore, there were misconceptions about medical treatment. The two workshops confirmed the results of the first study. The causes of pain often remained unclear, there were considerable communication problems between patient and physician, medical treatment appeared to be inappropriate, and there were deficits in the time management during consultations. The telephone survey confirmed these deficits. In conclusion management of patients with CMP is characterized by considerable deficits such as missing or unclear diagnosis, misconceptions in medical contexts and treatment. Many of the deficits may be improved and call for measures for optimizing the management of patients with CMP.

Reactive and undifferentiated arthritis in North Africa: use of PCR for detection of Chlamydia trachomatis.

Little is known about the possible role of Chlamydia in patients with reactive or unclassified arthritis in North Africa. This study used polymerase chain reaction (PCR) to survey this population. In addition, we compared the results in three different laboratories for PCR analyses for Chlamydia trachomatis (Ct) in synovial fluid (SF) and tissue (ST) from these North African patients with reactive arthritis (ReA), undifferentiated arthritis (UA), and in rheumatoid arthritis (RA) and osteoarthritis (OA). Eight ReA (six posturethritic, two postenteritic), 23 UA, 13 OA, and 12 RA patients were studied in Algeria, Morocco, and Tunisia. Serum, SF, and ST were obtained from each patient. Ct-PCR was performed in the three different laboratories and compared to Ct-serology [microimmunofluorescence (MIF) and anti-hsp60 enzyme-linked immunosorbent assay (ELISA)] performed in one laboratory. The rate of Ct-PCR positivity in SF/ST was low: none out of the eight ReA and three out of 23 UA patients. In the controls, Ct DNA was detected in two OA SF and in one RA SF. There was no concordance for Ct-PCR positivity between the three laboratories. MIF suggested previous Ct infection (IgG-positive) in two out of five posturethritic ReA, none out of one postenteritic ReA, one out of 17 UA, and nine out of 21 RA/OA patients tested. No MIF-positive patient was PCR-positive from SF or ST. However, anti-hsp60 IgG was detected in all four out of four patients positive by PCR and in 11 out of 44 PCR-negative patients (p = 0.002). In this multinational comparative study, the rate of Ct-PCR-positive synovial specimens in North African ReA/UA patients was low. Concordance among the three PCR testing laboratories was poor indicating the need for test standardization. All Ct-PCR-positive patients were found positive by anti-hsp60 IgG serology.

Comparative cost analysis of outpatient and inpatient rehabilitation for musculoskeletal diseases in Germany.

OBJECTIVES: To examine the costs of inpatient and outpatient rehabilitation for musculoskeletal disorders from the perspective of a major statutory health insurance fund in Germany. METHODS: A nation-wide database from a major health insurance fund in Germany was used to evaluate all rehabilitation cases in 2005. In addition, to all direct cost domains of the rehabilitation itself, costs incurred in the preceding and the following year for hospital treatment, drugs and physical therapy were analysed. A cost-cost analysis in different institutional settings was chosen for the cost comparison of inpatient and outpatient rehabilitation. To minimize the influence of possible confounders, a statistical control system was implemented. RESULTS: After a preceding hospital stay, inpatient and outpatient rehabilitation results in mean costs of euro2047 and euro1111, respectively. If the rehabilitation was not preceded by a directly related hospital treatment, mean costs for inpatient (outpatient) rehabilitation were euro2067 (euro1310). No systematic differences could be found between inpatient and outpatient rehabilitation evaluating costs for hospital treatment, drugs or physical therapy in the year preceding and the year directly following the rehabilitation. CONCLUSIONS: Assuming comparable medical outcomes, outpatient rehabilitation seems to be a superior alternative compared with inpatient rehabilitation from an economic perspective. Hence, from the perspective of the statutory health insurance, fostering a higher market share of outpatient rehabilitation may add to a better allocation of overall health care resources. For this, regional differences in rehabilitation infrastructure have to be taken into account.

Bacterial triggers and autoimmune rheumatic diseases.

Autoimmune rheumatic diseases are generally considered as a multifactorial aetiology, mainly genetic susceptibility combined with environmental triggers of which bacteria are considered one of the most prominent. Among the rheumatic diseases where bacterial agents are more clearly involved as triggers are: reactive arthritis (ReA), rheumatic fever (RF) and Lyme disease. The role of bacterial infections in inducing other seronegative spondyloarthritis and antiphospholipid antibody syndrome has been hypothesized but is still not proven. The classic form of ReA is associated with the presence of HLA-B27 and is triggered by the urethritis or enteritis causing pathogens Chlamydia trachomatis and the enterobacteria Salmonella, Shigella, and Yersinia, respectively. But several other pathogens such as Brucella, Leptospira, Mycobacteria, Neisseria, Staphylococcus and Streptococcus have also been reported to cause ReA. RF is due to an autoimmune reaction triggered by an untreated throat infection by Streptococcus pyogenes in susceptible individuals. Carditis is the most serious manifestation of RF and HLA-DR7 is predominantly observed in the development of valvular lesions. Lyme disease is a tick-transmitted disease caused by the spirochete Borrelia burgdorferi. Knowledge is limited about how this spirochete interacts with human tissues and cells. Some data report that Borrelia burgdorferi can manipulate resident cells towards a pro- but also anti-inflammatory reaction and persist over a long period of time inside the human body or even inside human cells.

Persistent clinical efficacy and safety of anti-tumour necrosis factor alpha therapy with infliximab in patients with ankylosing spondylitis over 5 years: evidence for different types of response.

BACKGROUND: There is insufficient evidence for the long-term efficacy and safety of anti-tumour necrosis factor therapy in patients with ankylosing spondylitis (AS). This is the first report on the treatment with infliximab over 5 years. METHODS: As part of a multicentre randomised trial, 69 patients with active AS at baseline (BL) have been continuously treated with infliximab (5 mg/kg i.v. every 6 weeks)--except for a short discontinuation after 3 years (FU1). The primary outcome of this extension was remission according to the ASsessment in Ankylosing Spondylitis (ASAS) criteria at the end of year 5 of the study (FU2). RESULTS: Of the 43 patients who completed year 3, 42 agreed to continue, 38 of which (90.5%) finished year 5 (55% of 69 initially). Partial clinical remission was achieved in 13 of 38 patients (34.2%) at FU1 and FU2. At FU2, the mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) was 2.5+/-1.9 (BL:6.4, FU1:2.5). BASDAI values <4 were seen in 79% of patients at both, FU1 and FU2. ASAS 20% and 40% responses were seen in 32 (84%) and 24 (63%) patients at FU2, respectively. Most patients classified as non-responders at FU2 were part-time responders, as all but one patient achieved an ASAS 20% response at least once within the last 2 years. Three types of responders were identified. No major side effects occurred during years 4 and 5 of infliximab therapy. CONCLUSIONS: Infliximab is safe and efficacious in AS patients over 5 years. The majority of the patients remained on treatment and had rather persistent levels of low disease activity. Different response types could be identified.

EULAR evidence-based recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases.

OBJECTIVE: To develop evidence-based recommendations for the management of systemic glucocorticoid (GC) therapy in rheumatic diseases. METHODS: The multidisciplinary guideline development group from 11 European countries, Canada and the USA consisted of 15 rheumatologists, 1 internist, 1 rheumatologist-epidemiologist, 1 health professional, 1 patient and 1 research fellow. The Delphi method was used to agree on 10 key propositions related to the safe use of GCs. A systematic literature search of PUBMED, EMBASE, CINAHL, and Cochrane Library was then used to identify the best available research evidence to support each of the 10 propositions. The strength of recommendation was given according to research evidence, clinical expertise and perceived patient preference. RESULTS: The 10 propositions were generated through three Delphi rounds and included patient education, risk factors, adverse effects, concomitant therapy (ie, non-steroidal anti-inflammatory drugs, gastroprotection and cyclo-oxygenase-2 selective inhibitors, calcium and vitamin D, bisphosphonates) and special safety advice (ie, adrenal insufficiency, pregnancy, growth impairment). CONCLUSION: Ten key recommendations for the management of systemic GC-therapy were formulated using a combination of systematically retrieved research evidence and expert consensus. There are areas of importance that have little evidence (ie, dosing and tapering strategies, timing, risk factors and monitoring for adverse effects, perioperative GC-replacement) and need further research; therefore also a research agenda was composed.

[Cooperation between primary care physicians and rheumatologists in Lower Saxony. Results of a survey of primary care physicians]. / Kooperation zwischen Hausärzten und Rheumatologen in Niedersachsen. Ergebnisse einer Hausarztbefragung.

AIM: Between 2000 and 2003 the collaborative arthritis center Hanover implemented a quality management program for patients with rheumatoid arthritis (RA). Fourteen rheumatologists in private practice participated in this model project. One of the aims of the project was to improve the cooperation between primary care physicians and rheumatologists. A survey of the primary care physicians was conducted to evaluate rheumatological care. METHODS: A total of 340 patients with RA were included in the study. All primary care physicians of these patients were informed about the goals of the project and asked to answer a questionnaire on cooperation with rheumatologists. The questionnaire contained 14 questions and was sent to 270 primary care physicians. RESULTS: Of the primary care physicians, 83% returned the questionnaire, and 81% percent of these were family practitioners. The primary care physicians treated a mean of 19 patients with RA, of whom 14 were attended in cooperation with rheumatologists. High mean values were found for satisfaction with different aspects of rheumatological patient care on a numerical rating scale from 0 (not satisfied at all) to 10 (completely satisfied). Mean values for satisfaction: diagnosis 7.9, therapy recommendations 7.6, follow-up 7.2,and usefulness of medical report 7.7. A total of 70% of primary care physicians reported difficulties in realizing the recommendations of the rheumatologists. Of the respondents, 90% saw a need for improvement in cooperation with rheumatologists, the most frequently mentioned being the difficulty of consultation with appointments. CONCLUSION: This survey of primary care physicians of patients with RA reveals a positive assessment of the cooperation with rheumatologists. The problems which exist mainly concern the realization of recommendations. There is a great requirement for further improvement in the cooperation between primary care physicians and rheumatologists.