[The subanalysis of Rheuma-VOR demonstrates a considerable need for rheumatological care]. / Die Subanalyse von Rheuma-VOR zeigt den erheblichen Bedarf der rheumatologischen Versorgung auf.

BACKGROUND: Early diagnosis and treatment of inflammatory rheumatic diseases can prevent consequential damage such as permanently limited mobility and joint or organ damage. Simultaneously, there is an increasing deficit in medical care owing to the lack of rheumatological capacity. Rural regions are particularly affected. OBJECTIVES: The available unconfirmed diagnoses of the study Rheuma-VOR were analysed regarding another definitive inflammatory rheumatic disease. MATERIALS AND METHODS: The returned questionnaires of the rheumatologists participating in Rheuma-VOR were screened for definitive inflammatory rheumatic diseases other than the required diagnosis of rheumatoid arthritis, psoriatic arthritis or spondyloarthritis. RESULTS: Of 910 unconfirmed diagnoses, in 245 patients another definitive diagnosis could be confirmed. A total of 29.8% of the diagnoses corresponded to degenerative joint changes or chronic pain syndrome, whereas 26.1% involved different forms of inflammatory arthritis. The majority of diagnoses (40.5%) were collagenosis or vasculitis, DISCUSSION: The available data show that a rheumatological presentation was indicated for the majority of patients. Owing to the increasing deficits in medical care a prior selection of the patients is crucial to make optimal use of restricted rheumatological capacities.

[Nonpharmacological treatment measures, rehabilitation services and membership in patient support groups in axial spondylarthritis (The ATTENTUS axSpA study)]. / Nichtmedikamentöse Therapiemaßnahmen, Rehabilitationsleistungen und Mitgliedschaft in Selbsthilfeorganisationen bei axialer Spondyloarthritis (Die ATTENTUS axSpA-Studie).

BACKGROUND: The treatment of axial spondylarthritis (axSpA) includes pharmacological treatment measures (PTM) and nonpharmacological treatment measures (NPTM) as well as supporting resources, such as rehabilitation services (RS) and membership in patient support groups (PSG). Nevertheless, there are significant participation restrictions in patients with axSpA in Germany. OBJECTIVE: Investigation of functional deficits, participation restrictions and utilization of PTM, NPTM, RS and PSG membership in patients with axSpA. MATERIAL AND METHODS: Multicentric, observational study of 770 axSpA patients in Germany (ATTENTUS-axSpA). RESULTS: Substantial functional deficits and participation restrictions were observed in axSpA patients. Of the patients 39% did not receive treatment with biological disease-modifying antirheumatic drugs (bDMARD). In the NPTM 54% received physiotherapy less than once per week and 29% once per week. Physical activities were regularly performed by 86% of patients, mainly in the form of home exercises. Training in a gym (14%) or sports club (7%) was carried out much less frequently. Of the patients 54% received RS, one third had the last rehabilitation more than 5 years ago and 13% of the patients were members in a PSG. A significantly higher utilization of NPTM and rehabilitation was found in this group. CONCLUSION: Treatment options and resources were often utilized to a small extent and/or in low intensity by axSpA patients, which could be a possible explanation for persisting restrictions of participation. Membership in a PSG was associated with an increased utilization of NPTM and RS.

[Delegation of medical tasks in rheumatology]. / Delegation ärztlicher Leistungen in der Rheumatologie.

Modern rheumatology enables better and earlier diagnosis and therapy of inflammatory rheumatic system diseases. At the same time, the requirements for the care of rheumatologic patients have risen considerably for non-medical assistant professions and specialists for nursing professions. Since 2006 there has been established an education curriculum "Rheumatological Specialist Assistant DGRh-BDRh" (RFA) with the training to become a "Rheumatological Specialist Assistant (DGRh-BDRh)". In Europe and in parallel in Germany, assistant professions are increasingly involved in the early detection and care of patients with rheumatic diseases and entrusted with tasks.In this work, the overarching principles for delegation of medical tasks to RFA and recommendations for the delegation are published by the Commission for Delegation of the German Society for Rheumatology (DGRh). These recommendations are based on the requirements of the German Medical Association and have been legally evaluated. With the extension of the training of the RFA board certification is aimed for "MFA for Rheumatology". These recommendations enable more transparency and security for delegating doctors and the delegated RFA's.

[Experiences and results from Rheuma-VOR]. / Erfahrungen und Ergebnisse aus Rheuma-VOR.

Rheumatoid arthritis, psoriatic arthritis and axial spondylarthritis are the most common chronic autoimmune rheumatic diseases. For all three diseases an early diagnosis and initiation of treatment is crucial. The proof of concept network study "Rheuma-VOR" is a further developed version of the predecessor project ADAPTHERA and was extended to several federal states. The aim of this prospective study is to improve the early diagnosis of rheumatoid arthritis, psoriatic arthritis and axial spondylarthritis and thus positively impact the quality of care for patients with the help of multidisciplinary coordinating centers. To date 3710 disease-specific questionnaires from patients with the suspected diagnosis of rheumatoid arthritis, psoriatic arthritis or axial spondylarthritis from 1298 different primary care providers were registered in the multidisciplinary coordination centers. A total of 1958 appointments were made with 1 of the 53 participating rheumatology specialists. In 876 patients, 1 of the 3 rheumatic diseases was diagnosed in an early stage. The waiting period was on average 42.5 days depending on the federal state, which is well below the nationwide average. It should also be noted that the coordinated cooperation and risk stratification of the Rheuma-VOR coordination centers relieved the capacity of rheumatology specialists by 1281 appointments (34.5%). In addition, the 2­week Rheuma Bus Tour and the accompanying initiatives in Rhineland-Palatinate (Rheuma-VOR screening app and the triage consultation) are showing first promising positive results.

[Early recognition and screening consultation: a necessary way to improve early detection and treatment in rheumatology? : Overview of the early recognition and screening consultation models for rheumatic and musculoskeletal diseases in Germany]. / Früh- und Screeningsprechstunden: Ein notwendiger Weg zur besseren Frühversorgung in der internistischen Rheumatologie? : Rheumatologische Früh- und Screeningsprechstundenmodelle in Deutschland.

In order to reduce the prognostically relevant time interval between the initial manifestation of a rheumatic and musculoskeletal disease and diagnosis as well as the consecutive initiation of an appropriate treatment, several rheumatological centers in Germany have improved the access to initial rheumatologic evaluation by establishing early recognition/screening clinics at their respective sites. Corresponding models located at Altoetting·Burghausen, Bad Pyrmont, Berlin Buch, Duesseldorf, Heidelberg, Herne, Mannheim as well as supraregional/multicenter initiatives Rheuma Rapid, RhePort and Rheuma-VOR are presented in this overview along with the respective characteristics, potential advantages and disadvantages, but also first evaluation results of several models. The aim of this publication is to promote early detection of rheumatic and musculoskeletal diseases as one of the most important challenges in current rheumatology by encouraging further rheumatologic centers and practices to launch their own early recognition/screening consultation model on the basis of aspects presented herein.

[Role-specific targets and teamwork in the operating room]. / Rollenspezifische Ziele und Teamarbeit im OP.

BACKGROUND: The primary goal of a surgical team is the successful performance of an operation on a patien; however, this primary goal can show discrepancies from the goals of individual team members. The main causes for differences of interests can be variations in subjective preferences and organizational differences. Subjective preferences are due to the values held by those involved. These values are of an intrinsic nature and therefore difficult to change. Another reason for individual goals is that hospitals and universities are professional bureaucracies. Experts working in professional bureaucracies are known to identify themselves to a greater extent with their respective profession than with their institution; however, teams in the operating room (OR) have to work together in multidisciplinary teams. The main goal of this analysis is to document role-specific targets and motivations within teams. METHODS: This was a case study at a university hospital with 40 operating rooms. The data collection resulted from the three pillars of the goal documentation instrument, which includes expert interviews, a utility analysis and card placement as a basis for communicative validation. The results were analyzed with a systematic method as a qualitative content analysis. The four-pillar success model, which maps aspects of a successful hospital, was used as a deductive coding scheme. The four pillars represent the level of medical quality (process, structure and outcome quality), economy and efficiency, client satisfaction (patients and referring physicians) and employee satisfaction. At a university hospital an additional focus is on research and teaching. In addition to the four pillar success model as a deductive coding scheme, an inductive coding scheme was introduced. Approximately 10% of the employees from each professional group (surgeons, anesthesiologists, OR nurses, nurse anesthetists) were interviewed resulting in 65 interviews overall. The interviews were conducted within a time span of 4 months. RESULTS: Considering the main categories quality of medical care, economy and efficiency, patient satisfaction and employee satisfaction as well as research and teaching, surgeons thought the categories of economy and efficiency (37%) and quality of medical care (34%) to be the most important. For anesthesiologists, however, the category of employee satisfaction (38%) was most important, followed by the category of economy and efficiency (31%). For the OR nurses as well as for the nurse anesthetists the category of employee satisfaction was of highest priority (61% and 57%, respectively). CONCLUSION: The results show that considering the main categories no dimension is equally important for the participating professional groups. This can result in goal conflicts. Additionally, the ad hoc teams make it impossible for team building to occur, making it difficult for the professional groups to adapt to each other and the individual goals. This presents a high potential for conflict. The difference in the perception of the importance of employee satisfaction is a crucial factor for emerging conflicts in the OR, as employee satisfaction correlates with productivity and patient satisfaction. Knowing and communicating the different goals is a first step for optimizing the OR management system.

[Infectious complications of biologic therapy in patients with rheumatoid arthritis]. / Infektionskomplikationen unter Biologika-Therapie bei Patienten mit rheumatoider Arthritis.

The introduction of biological disease-modifying drugs (DMARDs) has substantially improved the treatment options for patients with rheumatoid arthritis. However, infectious complications represent the most common side effects of these drugs, including severe infections as well as rare opportunistic infections. Treating patients on biological DMARDs is therefore one of the biggest challenges in rheumatology care. The present review describes the current state of knowledge regarding frequency and type of infectious complications associated with biological DMARDs. The article focuses mainly on risk management, in particular on diagnosis and recurrence prevention of tuberculosis and reactivation of hepatitis B virus infection. Furthermore, we discuss the importance of vaccinations in primary disease prevention in patients with rheumatoid arthritis.

[Usefulness of a VDD defibrillation electrode in recording atrial electrograms during atrial flutter and atrial fibrillation]. / Nutzen einer VDD-Defibrillationselektrode zur Aufzeichnung von atrialen Elektrogrammen bei Vorhofflimmern/-flattern.

BACKGROUND: Monitoring of atrial signals improves the accuracy in identifying supraventricular tachyarrhythmias to prevent inappropriate therapies in patients with implantable cardioverter-defibrillators (ICD). Since complications due to the additional atrial lead were found in dual chamber ICD systems with 2 leads, we designed a single-pass VDD-lead for use with dual chamber ICDs. PATIENTS AND METHODS: After promising animal experiments in a German multicenter study a prototype VDD lead (single-coil defibrillation electrode with 2 additional fractally coated rings for bipolar sensing in the atrium) was temporarily used in 20 patients. Atrial and ventricular signals were recorded during sinus rhythm, atrial flutter, atrial fibrillation and ventricular tachycardia or ventricular fibrillation. Terminations of ventricular arrhythmias were performed by internal DC shock. RESULTS: The implantation of the electrode was successful in 18 of 20 patients. Mean atrial pacing threshold was 2.45 +/- 0.9 V/0.5 ms, mean atrial impedance was 215 +/- 31 Ohm. Atrial amplitudes were greater during sinus rhythm (2.7 +/- 1.6 mV) than during atrial flutter (1.36 +/- 0.28 mV, p < 0.05) or atrial fibrillation (0.92 +/- 0.29 mV, p < 0.01). During ventricular fibrillation atrial "sinus"-signals had significantly (p < 0.01) lower amplitudes than during sinus rhythm. Mean ventricular sensing was 13.3 +/- 7.9 mV, mean ventricular impedance was 577 +/- 64 Ohm. Defibrillation was successful with 20 J shock. 99.6% of P waves could be detected in sinus rhythm and 85 +/- 9.9% of flutter waves during atrial flutter. During atrial fibrillation 55% of atrial signals could be detected without modification of the signal amplifier. CONCLUSIONS: A new designed VDD dual chamber electrode provides stable detection of atrial and ventricular signals during sinus rhythm and atrial flutter. For reliable detection of atrial fibrillation modifications of the signal amplifier are necessary.