[Choosing wisely recommendations in rheumatology : One year after their first publication]. / Klug-entscheiden-Empfehlungen in der Rheumatologie : Ein Jahr nach der Erstveröffentlichung.

Almost 1 year after publication of the Choosing wisely recommendations ("Klug-entscheiden-Empfehlungen," KEE) for rheumatology, it is evident that they have found their way into specialist and lay publications, the media used by self-help groups, online media, and continuing education congresses. As such, a broad target audience has been reached. In the meantime, newly established or updated guidelines have been published which incorporate the KEE for rheumatology. The KEE provide a gateway into clinical Standard Operating Procedures or recommendations.

[Viral arthritis and vasculitis]. / Virale Arthritiden und Vaskulitiden.

Viral arthritis and vasculitis are important differential diagnoses primarily in patients with acute polyarticular arthritis in association with fever and rash, in populations specially at risk and in returning travellers. Parvovirus B19 is the most frequent cause of viral arthritis in Europe, whereas rubella, hepatitis B and C viruses have become less common. Due to worldwide tourism arthritogenic alphaviruses, which are transmitted by mosquito vectors have come into the focus of tropical medicine and rheumatology. Viral arthritis is typically self-limiting but due to severe pain often requires symptomatic therapy with nonsteroidal antirheumatic drugs; however, arthritis and vasculitis may also be a manifestation of an important treatable viral infection, such as hepatitis B, C and human immunodeficiency viruses (HIV).

[Standards of care for people with rheumatoid arthritis in Europe : Translation and comments of the eumusc.net recommendations supported by EULAR performed by a national task force of the professional organisations DGRh and VRA supported by "Deutsche Rheumaliga"]. / Europäische Versorgungsstandards für Menschen mit rheumatoider Arthritis : Übersetzung und Kommentierung der von der EULAR unterstützten Vorschläge des eumusc.net durch eine Task Force von DGRh und VRA mit Unterstützung der Deutschen Rheuma-Liga.

In a joint initiative by the boards of the German Society for Rheumatology (DGRh) and the Association of Rheumatology Clinics (VRA) the European "standards of care" for rheumatoid arthritis, recently suggested by the European Musculoskeletal Conditions Surveillance and Information Network (eumusc.net) and supported by the European League Against Rheumatism (EULAR), were translated and annotated. The recommendations include aspects of the management of the disease, actual medical care, and access to information - this includes all types of support people with RA need, and, last but not least communication of the necessary knowledge. Furthermore, health care structures such as the availability of medical staff with relevant expertise are also important.

[Choosing wisely in internal medicine]. / Klug entscheiden in der Inneren Medizin.

"Choosing wisely - DGIM" is an initiative of the German Society of Internal Medicine (DGIM) to strengthen the quality of diagnostics and indications for therapy. Aspects of inappropriate patient care are identified based on scientific evidence in collaboration with12 internal medicine and associated societies. Identified aspects are reviewed and endorsed by an interdisciplinary consensus committee. Addressed are those diagnostic and therapeutic measures which are rarely used despite scientific evidence of their usefulness and those which are frequently used although clear evidence exists that the measures are not useful or even harmful. The resulting positive or negative recommendations are intended to support physicians in the assessment of indications. The relevance of the "Choosing wisely - DGIM" initiative is confirmed by a survey involving 4200 members of DGIM.

["Choosing wisely" in infectious diseases : Overuse of antibiotics - too few vaccinations]. / "Klug entscheiden" bei Infektionskrankheiten : Zu häufig Antibiotika - zu wenig Impfungen.

The "choosing wisely" recommendations of the German Society of Internal Medicine (DGIM) and its specialist societies address diagnostic and therapeutic procedures, which are of particular medical importance but applied too often or too rarely in clinical practice. The aim is to further improve treatment of patients. Important topics of overuse and insufficient treatment related to the diagnostics, therapy, prevention and exclusion of infectious diseases could be identified. These topics not only play an important role in the discipline of infectious diseases but are also relevant for other internal medical disciplines. These topics related to infectious diseases have also been integrated into the recommendations of the German Society of Gastroenterology, Digestive and Metabolic Diseases as well as the German Societies for Internal Intensive Care and Emergency Medicine, for Pneumology, for Nephrology and for Rheumatology. The pivotal issues of the recommendations are the inappropriate use of antibiotics and insufficient vaccination rates.

[Treatment of chronic back pain: current standards]. / Therapie des chronischen Kreuzschmerzes: Aktuelle Standards.

Back pain is a significant medical problem and one of the most common causes of medical consultations and missed work. In acute low back pain, patients with "red flags" indicating a serious underlying spinal or extraspinal disease must be identified by medical evaluation. Most cases of acute back pain are non-specific, and education, physical activity and pain medication is recommended. In addition, yellow flags (risks of developing chronic pain) should be recognized. The management of low back pain has been addressed by the German National Disease Management Guideline (NVL) low back pain published in 2010. This guideline evaluates the evidence and effectiveness of diagnostic and therapeutic interventions with a focus on nonspecific back pain. For chronic nonspecific low back pain intervention based on nondrug and drug therapy and a multiprofessional assessment is recommended. In patients with chronic inflammatory low back pain with onset before the age of 45, rheumatic spondyloarthritis should be considered. Recently, a guideline (S3-Leitlinie) for the management of axial spondyloarthritis including ankylosing spondylitis has become available. It provides evidence of physical and drug therapy including nonsteroidal antirheumatic and Tumor necrosis factor (TNF) inhibitor therapy.

[Therapy of psoriatic arthritis]. / Therapie der Psoriasisarthritis.

In psoriatic arthritis (PsA) the heterogeneous spectrum of the disease with arthritis/synovitis, axial manifestation, enthesitis, dactylitis, psoriatic skin disease and nail psoriasis has to be considered. Moreover, PsA activity and severity as well as comorbidities are of importance for making therapeutic decisions. Measurement instruments developed for therapeutic studies of rheumatoid arthritis or ankylosing spondylitis are often not appropriate for application in PsA investigations. In this paper established therapies with nonsteroidal antirheumatic drugs, disease modifying antirheumatic drugs (DMARDs) and TNF-alpha inhibitors and the current EULAR guidelines from 2012 are reviewed. However, there is a need for new therapeutic agents for those patients who do not respond to or do not tolerate the current therapies. Other biologic agents have also been tested for PsA with moderate effects only. New therapeutic options could result from the anti-IL12 and anti-IL23 receptor monoclonal antibody ustekinumab and from small molecules such as the oral PDE-4 inhibitor apremilast.

[Management of nonspecific low back pain. The new national guidelines 2011]. / Management des nichtspezifischen Kreuzschmerzes. Die neue Nationale VersorgungsLeitlinie 2011.

Low back pain is a frequent health problem and causes substantial costs. Between 2007 and 2010 a panel of interdisciplinary experts in Germany developed evidence-based national guidelines for the management of nonspecific low back pain. These guidelines cover diagnosis (red flags and yellow flags), treatment recommendations and health care algorithms. In acute nonspecific low back pain diagnostic imaging is not indicated and should be avoided. Education and patient information, maintenance of routine daily physical activities and pain therapy as needed are the cornerstones of acute nonspecific low back pain therapy. In order to prevent the development of chronic back pain in patients with acute nonspecific back pain, the early identification of parameters predictive of a high risk of chronicity (yellow flags) is of particular importance even in primary care.

[Rheumatoid arthritis and multiple myeloma as comorbidity. Is tocilizumab a therapy option?]. / Rheumatoide Arthritis und multiples Myelom als Komorbidität. Ist Tocilizumab eine Therapieoption?

Multiple myeloma (MM) is a disease of the elderly with an incidence of 4/100,000 per year and can occur as a comorbidity especially in elderly patients with rheumatoid arthritis (RA). For MM and also for RA interleukin-6 (IL-6) is a pathogenetically important cytokine in both disease events. This article presents the case of a female patient who achieved sustained remission of RA and stabilization of MM with quantitative reduction of paraprotein by treatment with tocilizumab. The question whether tocilizumab represents a meaningful treatment approach for treatment of RA when MM is also present will be discussed.

[Secondary vasculitides and vasculitis mimics]. / Sekundäre Vaskulitiden und Vaskulitis "Mimics"

Secondary vasculitis is a form of vasculitis for which an underlying disease is known. Diseases associated with secondary vasculitis include infections, drug hypersensitivity, malignancy, rheumatoid arthritis, collagen vascular disease and sarcoidosis. Moreover, there are numerous conditions that can mimic vasculitis clinically, in laboratory testing, radiographically and in histopathology. It is evident that distinguishing primary vasculitis from secondary vasculitis and also vascular inflammation from non-vasculitic disorders (vasculitis mimics) has significant therapeutic implications.

[Managing comorbidities of inflammatory rheumatic diseases]. / Behandlung der Komorbiditäten entzündlich-rheumatischer Erkrankungen.

Patients with inflammatory rheumatic diseases often suffer from considerable comorbidities that can arise due to the chronic systemic inflammatory activity of the rheumatic disease itself, disorders of immune defense, or as a result of antirheumatic treatment; they can also occur independently. For example, almost 50% of patients with rheumatoid arthritis already exhibit two further chronic diseases at the time of initial manifestation. With regard to the elevated mortality observed in patients with rheumatism, particularly cardiovascular morbidity and increased predisposition to infections are of note. In addition, this article addresses further important possible concomitant diseases, i.e., osteoporosis and tumor diseases. A ground rule is to identify comorbidities and treat them just as diligently as the underlying rheumatic disease so that the patient with rheumatism should be accompanied by an interdisciplinary team of internists during each phase of the disease. Effective control of the systemic inflammatory activity may serve to reduce the risk of certain cardiovascular and neoplastic comorbidities.