The impact of a structured one-day seminar on disease-specific knowledge, lifestyle habits and disease impairment in ANCA-associated vasculitis. Results of a randomized, controlled study.

OBJECTIVE: Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a complex, chronic autoimmune disease, and its diagnosis triggers considerable anxiety and uncertainty for those affected. There are currently no valid data describing the impact of disease-specific patient education on the disease knowledge, subjective impairment, and changes in lifestyle habits related to AAV. METHOD: We designed a one-day educational programme to serve AAV patients with information about their disease and its treatment. Patients were randomized into an intervention group and a waiting list control group. Increase in knowledge was measured with a multiple-choice test. The intervention group completed the questionnaire before, directly after, and 3 months after the seminar, while the waiting list control group was additionally tested 3 months before the seminar to rule out non-specific learning. Furthermore, we investigated the burden of the disease and the impact of our intervention on this burden. RESULTS: Compared with the control group, the intervention increased the knowledge (mean ± sd score difference 2.2 ± 1.0, 95% confidence interval 0.1-4.3, p = 0.04). From the patients' point of view, their understanding of the disease had improved and the subjective impairment caused by their rheumatic disease had decreased. There was a tendency to include disease-relevant behaviour, such as nasal care or dietary recommendations, more often in everyday life. CONCLUSION: A one-day seminar is suitable to increase the disease-specific knowledge of patients with AAV in a sustainable manner. In addition, our measure positively affected the disease-relevant behaviour.

[Rheumatology in German MD curricula]. / Rheumatologie im Medizinstudium.

Transmitting a substantial amount of basic knowledge in Rheumatology to all medical students is essential for the future medical care of patients with rheumatic diseases for two reasons: on the one hand, future general practitioners will need to master the patterns of rheumatic diseases to recognize them fast enough in new-onset patients and to refer them in time and directly to rheumatologists. On the other hand, the shortage of rheumatologists can only then be relieved in the future when we are able to inspire enthusiasm for our specialty. Adequate rheumatological structures are established only in some of the German faculties of medicine. Structural improvements happen in small steps only but were achieved at several sites. The better the local structures, the higher the chances of committed university teachers in rheumatology to reach all medical students. Probably from 2026 onwards, the learning objectives relevant for examinations will be defined by the national competence-based catalogue of learning objectives in medicine (NKLM), which is currently in the final stages of completion together with the German Federal Institute for Medical and Pharmaceutical Examinations (IMPP). It now appears that systemic autoimmune diseases and inflammatory rheumatic diseases are adequately depicted in this catalogue. If this is achieved, students will know more about these diseases in the future and will diagnose them faster in patients. Work on the NKLM is therefore of highest importance. In addition to the work on the learning objectives, up to date learning materials are required, which have to be available throughout Germany. A Rheumatology script just finished by the committee for medical student education of the German Society of Rheumatology (DGRh) and now available on the DGRh homepage should close this gap.

[Specialist training situation in rheumatology from a trainer's perspective]. / Weiterbildungssituation in der Rheumatologie aus Sicht der Weiterbilder.

This article focuses on the training situation of rheumatologists from the perspective of trainers regarding the existing and potentially increasing deficits of specialists for internal medicine and rheumatology. According to the new regulations defining the rheumatologist training, a substantial part of the training schedule is required to be completed in a hospital setting in order to become a specialist rheumatologist. In this context, the increased training capacity necessitates additional hospital training positions. In addition, the rheumatology residents desire a structured training program. Significantly, the work-life balance is an important factor to make working as a specialist for internal medicine and rheumatology more attractive.

[Slowly progressive joint destruction in an older man as expression of hydroxyapatite disease. Case report and literature review]. / Langsam progrediente Gelenkzerstörung bei einem älteren Mann als Ausdruck einer Hydroxylapatiterkrankung. Fallbericht und Literaturübersicht.

This article reports the case of a 75-year-old male patient presenting with arthralgia of the large joints that had existed for 10 years. Clinically, bursitis of the right elbow joint was found. Laboratory tests showed elevated inflammatory markers and imaging revealed erosive joint destruction. A surgical bursectomy was performed. Histologically, hydroxyapatite crystals were detected in alizarin red S staining and a crystal arthropathy was diagnosed. The diagnostics are difficult since crystals can only be detected by electron microscopy or special staining methods.

[Future of rheumatologists: what are the perspectives? : Survey of resident physicians in rheumatology in middle Germany]. / Rheumatologin/Rheumatologe in spe: Wie geht es weiter? : Befragung der rheumatologischen Assistenzärzte und -ärztinnen in Mitteldeutschland.

BACKGROUND AND OBJECTIVE: The work environment for rheumatologists has significantly changed over the last years. The healthcare of patients with rheumatic diseases is at risk due to the age structure of specialized rheumatologists in middle Germany and the limited availability of training positions for rheumatologists. In this context, it is important to have detailed information on the resident physicians in rheumatology concerning their own visions regarding their future professional career. MATERIAL AND METHODS: A questionnaire was sent to resident physicians in 25 rheumatology training hospitals in the middle of Germany (Saxony, Saxony-Anhalt and Thuringia). The questionnaire was completed and returned by 27 participants (17 women and 10 men). RESULTS: Most of the participants (60%) aimed to qualify as a specialist in internal medicine followed by a specialization in rheumatology (altogether training for a minimum of 8 years). After finishing training 44% would prefer to work in an outpatient setting while 30% planned to work in a combined outpatient and clinical setting. Of the participants 48% would prefer to work as part-time rheumatologists and 74% (women 94% and men 40%) were interested in employment in an outpatient medical healthcare center. The compatibility of family and work as well as the work-life balance was considered to be highly relevant for the future professional life. CONCLUSION: Less than half of the participants intended to work exclusively in an outpatient setting after completing the training in rheumatology. In addition, the participants preferred a part-time employment with compatibility of professional and private life. Consequently, alternative models of employment should be created in rheumatology to be attractive for future physicians. On the other hand, the study revealed that the independent rheumatological practice has a lower priority for the young rheumatologists taking part in this survey.

[Establishment of the current classification criteria for axial spondylarthritis, rheumatoid arthritis and SLE in routine practice of German rheumatologists]. / Verankerung der aktuellen Klassifikationskriterien von axialer Spondyloarthritis, rheumatoider Arthritis und SLE im Alltag deutscher Rheumatologen.

BACKGROUND: In Germany, the numbers of patients with spondylarthritides (SpA) and rheumatoid arthritis (RA) have increased. This rise was possibly promoted by the introduction of new classification criteria (CC) that enable an earlier recognition and the inclusion of less severe cases. The study explores how the new CC for axial SpA (axSpA) are incorporated into the clinical practice, compared with the CC for RA and systemic lupus erythematosus (SLE). In addition, the study investigated whether the new entity of non-radiographic axSpA (nr-axSpA) is accepted and used in Germany. MATERIAL AND METHODS: In 2016, an online survey was performed among all rheumatologists registered in the German Society of Rheumatology (DGRh). In addition, 150 rheumatologists were invited to the survey at the national meeting of the DGRh in 2016. RESULTS: Among 119 participating rheumatologists, 99% were familiar with the new CC for SpA and 82% applied them in practice (RA 99% and 80%, SLE 50% and 56%). 78% differentiated between radiographic and nr-axSpA and 80% believed that a significant proportion of patients with nr-axSpA will never develop radiographic changes. 91% agreed that the new CC facilitated an earlier treatment start and 58% that the CC enabled more patients to receive biologicals. 50% shared the opinion that the criterion "chronic back pain" could lead to the classification of too many patients as having axSpA. It deemed possible to 65% that patients with nr-axSpA would be treated with biologicals in whom the diagnosis of axSpA could not be confirmed later on. 81% voted against the initiation of TNF inhibitors in nr-axSpA patients with normal CRP levels and normal MRI. 67% interpreted the MRI themselves and 30% stated that the MRI is evaluated according to validated standards by the radiologists. Among all axSpA criteria, HLA B27 and inflammatory back pain received the highest significance and the response to NSAID the lowest. CONCLUSION: The new CC and the entity of nr-axSpA are accepted by German rheumatologists. A relevant proportion saw weaknesses of the new CC in the differentiation between nr-axSpA and non-specific chronic back pain. In practise, the interpretation of the CC with respect to the start of biologics is relatively strict, especially in cases with normal CRP and MRI. A ranking of axSpA criteria is commonly applied, although this was not initially intended in the CC.

[A 34-year-old patient with retropharyngeal tendinitis]. / Ein 34-jähriger Patient mit retropharyngealer Tendinitis.

This article reports the case of a 34-year-old male patient presenting with neck pain, massive pressure pain of the neck muscles and limited cervical rotational mobility. Laboratory tests showed elevated levels for markers of inflammation. Computed tomography (CT) and magnetic resonance imaging (MRI) detected a retropharyngeal tendinitis of the longus cervicis muscle. This rare clinical entity is probably responsible for a high number of unreported cases. A CT scan, which can identify prevertebral edema and light calcification inferior to the ventral aspect of the second cervical vertebra, was previously the gold standard. Meanwhile, MRI scans now show a higher sensitivity in the detection of prevertebral edema. The first line treatment is the administration of non-steroidal anti-inflammatory drugs (NSAIDs).

Treatment of adult idiopathic inflammatory myopathies with conventional immunosuppressive drugs : Results of a retrospective study.

OBJECTIVES: To gain information about the efficacy of immunosuppressive drugs as first-, second-, and third-line treatment of idiopathic inflammatory myopathies (IIM). METHODS: 112 treatment cycles of 63 patients with dermatomyositis (n = 23), polymyositis (n = 33), overlap syndromes (n = 4), and undifferentiated connective tissue diseases (n = 3) were analyzed by retrospective chart analysis. Data regarding muscle strength, muscle enzymes, treatment duration, and treatment discontinuation were collected. RESULTS: Azathioprine (38 cycles) and methotrexate (MTX; 24 cycles) were applied significantly longer than glucocorticoid monotherapy (9 cycles; 25 ± 21, 26 ± 29 and 7 ± 4 months, respectively; p < 0.05). MTX and azathioprine achieved a significant reduction of serum creatine kinase (CK), with MTX showing more marked effects. Treatment cycles with immunosuppressants other than MTX or azathioprine (n = 22) or with combinations of immunosuppressive drugs (n = 19) were mostly applied as third-line therapy, indicating their application in more refractory cases. Significant improvement of muscle strength was confined to MTX and azathioprine and to the first-line treatment. 8% of MTX patients withdrew due to the lack of efficacy, compared with 29% of patients taking azathioprine and 6 of 9 patients taking glucocorticoid monotherapy. In the 12 patients with Jo-1 syndrome, MTX treatment was effective for a longer time than azathioprine (44 ± 21 months vs. 27 ± 24 months, p < 0.05). CONCLUSION: Our data confirm the effectiveness of MTX and azathioprine in the treatment of inflammatory myopathies and stress the importance of a potent first-line therapy.

[Outcome of intensive medical care for inflammatory rheumatic diseases]. / Outcome intensivmedizinischer Betreuung bei rheumatischen Erkrankungen.

BACKGROUND AND OBJECTIVE: Very little is known about the outcome of patients with inflammatory rheumatic diseases in intensive care units (ICU). This retrospective study investigated the results of intensive medical treatment in these patients and the reliability of scoring systems used for the prediction of survival. MATERIAL AND METHODS: A case group consisting of 50 patients suffering from inflammatory rheumatic diseases was generated by analysis of patient records from the ICU at the University Hospital for Internal Medicine in Halle (Saale) in the years 2001-2010. The APACHE II score and SAPS II were used to estimate the probable mortality rate. The data were compared to those of a control group consisting of 72 patients treated on the ICU and suffering from non-inflammatory joint diseases. RESULTS: In the case group a higher mortality rate (38 % vs. 20.8 %) and a higher frequency of respiratory, nephrogenic and cardiovascular complications were observed. In addition, these patients more often underwent artificial ventilation (66 % vs. 35 %) and had a higher rate of infections (74 % vs. 40.3 %) compared to the control group. In patients with inflammatory rheumatic diseases the SAPS II was not useful for correctly predicting mortality, whereas the APACHE II score showed sufficient agreement with the actual mortality rate. CONCLUSION: Patients with inflammatory rheumatic diseases displayed a poorer outcome compared with the control group in the course of the intensive care treatment. Universally applied scoring systems used to predict mortality are of limited value in this patient population.

[Improvement of the diagnostic accuracy in patients with suspected rheumatic disease by preselection in the early arthritis clinic : An alternative to the appointment service point model of the Healthcare Improvement Act]. / Verbesserung der diagnostischen Treffsicherheit bei Patienten mit vermuteter rheumatischer Erkrankung durch Vorselektion in der Früharthritissprechstunde : Eine Alternative zum Termin-Servicestellen-Modell des Versorgungsstärkungsgesetzes?

The diagnosis and treatment of inflammatory rheumatic diseases can be delayed by a long waiting period for an appointment with a rheumatologist. This study investigated whether preselection of patients in an early arthritis clinic is a suitable tool to improve this situation. In 2006 an early arthritis clinic was founded by the Collaborating Center of Rheumatology in Halle (Saale). General practitioners refer patients by using a special registration form that helps to identify patients with an early joint swelling or inflammatory back pain. Patients are then allocated to a pool of participating rheumatologists and are seen by one of them within 2 weeks. For our scientific evaluation the data of 248 patients from the early arthritis clinic and data of 187 regular patients were gathered by means of an additional questionnaire for rheumatologists and patients. In the early arthritis clinic 40.3 % of patients received the diagnosis of an inflammatory rheumatic disease compared with 19.3 % in the control group. In the latter group 51 % were diagnosed as having degenerative joint or spine disorders compared with 22 % in patients from the early arthritis clinic; however, 61 % of patients who were referred to the early arthritis clinic did not fulfill the criteria of the registration form. On the other hand, patients in this group fulfilling these criteria had an inflammatory rheumatic disease in 68.1 % of the cases. The mean duration of symptoms at the time of first rheumatological consultation was significantly shorter in the early arthritis clinic than in the control group (6 vs. 39 months). Our data demonstrate that the preselection of patients can serve as a useful instrument to guide the referral of patients to rheumatologists. The high percentage of patients who did not fulfil the criteria of the registration form indicates that a further improvement of this form is necessary and stresses the need for intensive communication between rheumatologists and general practitioners. Early arthritis clinics may be an alternative to the current efforts of the legislative authorities to improve specialist care by centralized distribution of specialist appointments.

[Rheumatology - Integration into student training (RISA) : Current structure of clinical rheumatology in German universities (RISA III)]. / Rheumatologie - Integration in die studentische Ausbildung (RISA) : Zur aktuellen Struktur der internistischen Rheumatologie an deutschen Hochschulen (RISA III).

The German Society of Rheumatology and the Committee for Student Training investigated what effects the structures in university medicine have on student teaching. In February 2014 a questionnaire was sent to the teaching staff and Deans of each of the 37 medical faculties. Of the locations seven were classified as being independent rheumatological university hospitals and nine universities had a W2/W3/C3 grade professor as head of a department of clinical rheumatology but answerable to superiors. In the 37 faculties in Germany the proportion of lecture hours, the proportion of obligatory lecture hours, the number of hours for practical exercises and the number of hours for bedside teaching were distributed very differently and as a rule higher in universities with academic freedom. Not all medical faculties have obligatory teaching in the field of clinical rheumatology. On average medical students see five patients with rheumatological symptoms during their studies. In summary, over the past years it has not been possible to successfully utilize the great importance of rheumatology for society and the innovation potential of this discipline in order to improve the integration of clinical rheumatology into universities.

[Rheumatology training for medical students. Comparison of learning success and acceptance with virtual vs. real patient demonstrations]. / Rheumatologische Ausbildung für Studierende der Medizin. Vergleich von Lernerfolg und Akzeptanz bei virtueller und realer Patientendemonstration.

BACKGROUND: Recently, new teaching methods, such as internet-based e-learning, have gained importance at German universities. At the same time, however, students see fewer patients with rheumatic diseases during their medical education. OBJECTIVE: The aim of the study was to compare the gain of knowledge and the acceptance of the teaching methodology between educational films and patient-related teaching. MATERIALS AND METHODS: Both teaching methods communicated identical facts concerning representative rheumatic diseases. Afterwards, participants had to pass a knowledge test and had to evaluate both teaching methods. RESULTS: Patient-related teaching achieved a better increase of knowledge and better results in evaluations than the educational films. The combination of both teaching methods produced better results than any form on its own. CONCLUSIONS: Educational films are suited to improve the practical teaching. However, the results stress the importance of practical lessons with real-life cases and argue against the reduction of the educational capacity at German universities.

[Evidence-based recommendations for the management of undifferentiated peripheral inflammatory arthritis (UPIA). The German perspective on the international 3e initiative]. / Evidenzbasierte Empfehlungen zum Management einer undifferenzierten peripheren entzündlichen Arthritis (UPIA). Die deutsche Perspektive zur internationalen 3e-Initiative.

INTRODUCTION: Peripheral arthritis is the most common presenting complaint in clinical rheumatology. Unequivocal identification of the underlying entity can be difficult, particularly at an early stage. Such cases are commonly referred to as undifferentiated peripheral inflammatory arthritis (UPIA). Since evidence-based recommendations for the clinical management of UPIA are lacking, this international 3e initiative convened 697 rheumatologists from 17 countries to develop appropriate recommendations. METHODS: Based on a systematic literature research in Medline, EMBASE, Cochrane Library, and the ACR/EULAR abstracts of 2007/2008, 10 multinational recommendations were developed by 3 rounds of a Delphi process. In Germany, a national group of experts worked on 3 additional recommendations using the same method. The recommendations were discussed among the members of the 3e initiative and the degree of consensus was analyzed as well as the potential impact of the recommendations on clinical practice. RESULTS: A total of 39,756 references were identified, of which 250 were systematically reviewed for the development of 10 multinational recommendations concerning differential diagnosis, diagnostic and prognostic value of clinical assessments, laboratory tests and imaging techniques, and monitoring of UPIA. In addition, 3 national recommendations on the diagnostic and prognostic value of a response to anti-inflammatory therapy on the analysis of synovial fluid and on enthesitis were developed by the German experts based on 35 out of 5542 references. CONCLUSIONS: The article translates the 2011 published original paper of the international 3e initiative (Machado et al., Ann Rheum Dis 70:15-24, 2011) and reports the methods and results of the national vote and the additional 3 national recommendations.

[Personalized medicine in the choice of conventional immunosuppressants and disease modifying antirheumatic drugs]. / Personalisierte Medizin in der Auswahl konventioneller Immunsuppressiva und "disease modifying anti-rheumatic drugs"

The decision for a certain therapy for autoimmune diseases is influenced by various factors. These include well-defined arguments, such as approval of the drug for a certain disease, data from studies or registries, age and gender, family planning, risk for infections of the specific patient, side effects, price, data on the importance of genetic polymorphisms for tolerance and effectiveness of the drug or preferences in the way the drug is administered. On the other hand there are less definable factors which influence the choice of a certain drug, such as the mode of action and possibility to combine it with other drugs as well as individual preferences and experiences of patients and rheumatologists. As in the diagnostic procedure of complex rheumatologic diseases the discussion of the differential indications of a drug in the specific situation requires a mosaic-like assembly of many factors and aspects which argue for or against a certain drug in the individual patient, disease and situation. It would be desirable if definable factors were already available which could be recruited as substantial arguments pro or contra a drug in the sense of personalized medicine. This could improve the tolerance and effectiveness of therapeutic strategies. However, as this is not yet the case the authors have tried to assemble ideas which might argue pro or contra conventional disease modifying antirheumatic drugs (DMARD) and immunosuppressive drugs.

[Conventional basis therapy of rheumatoid arthritis. Effects within and outside cells]. / Konventionelle Basistherapie der rheumatoiden Arthritis. Wirkungen in und außerhalb der Zelle.

Conventional disease-modifying antirheumatic drugs (DMARDs) were formerly introduced into the treatment of rheumatoid arthritis and other rheumatic disorders on an empirical basis. In many cases their mode of action is only partially understood but as a rule of thumb they act on more than one point within the cellular metabolism. Less often they exert biological effects in the extracellular space or on the cell membrane.

[Methotrexate toxicity. Myths and facts]. / Methotrexat-Toxizität. Mythen und Fakten.

Methotrexate (MTX) is a safe and well-tolerated drug for the treatment of rheumatic diseases, even if the strictest safety standards are considered. Initial apprehension as to severe pulmonary or hepatic side-effects has not been confirmed. The risk of infection is not elevated compared with other disease-modifying antirheumatic drugs. In addition, a mutagenic potential could not be demonstrated even after long-term application. Therefore, MTX will maintain its significant role in antirheumatic therapy also in the near future.