[Quality in acute inpatient rheumatology 2021 : Current aspects of the KOBRA quality label of the Association of Rheumatological Acute Care Clinics]. / Qualität in der akutstationären Rheumatologie 2021 : Aktuelle Aspekte zum KOBRA-Qualitätslabel des Verbandes Rheumatologischer Akutkliniken (VRA e.V.).

A comprehensive health policy quality campaign launched in 2021 aims to improve the quality and transparency of hospital care for people with diseases in Germany. Legal requirements for minimum volumes and the expansion of quality contracts between cost units and hospitals as well as the use of quality indicators relevant to planning for demand-oriented and quality-oriented further development of inpatient care will increase competition in the quality of care between hospitals. The topic of development and definition of quality in medicine was also comprehensively addressed by the Association of Rheumatological Acute Care Clinics (VRA) shortly after its foundation in 1998. At the center of acute inpatient quality management are binding structural criteria linked to the continuous outcome benchmarking in acute rheumatology care (KOBRA) project launched in 2003 in rheumatology (and continuously implemented to date) measuring process and outcome quality. Based on this framework (fulfillment of the structural quality and participation in the KOBRA project) successfully participating rheumatology units can acquire the KOBRA seal of approval for 2 years at a time, which is awarded by the project management, the aQua Institute. The outstanding position of the project is exemplified by data evaluation on treatment change in active rheumatoid arthritis, diagnosis confirmation of connective tissue diseases and vasculitis during the inpatient stay as well as on participatory decision-making processes concerning rheumatoid arthritis (referring to the results of the data collection period 2018). By anchoring projects for structural, process and outcome quality acute inpatient rheumatology is well prepared for the paradigm shift demanded by health policies. Additionally, the KOBRA project is a good prerequisite to meet the requirements concerning quality management fixed in the Federal Joint Committee (G-BA) guidelines for recognition as a rheumatology center.

The influence of the SARS-CoV-2 lockdown on patients with inflammatory rheumatic diseases on their adherence to immunomodulatory medication: a cross sectional study over 3 months in Germany.

OBJECTIVES: To evaluate the influence of the SARS-CoV-2 pandemic on the adherence of patients with inflammatory rheumatic diseases (IRD) to their immunomodulatory medication during the three-month lockdown in Germany. METHODS: From 16th March until 15th June 2020, IRD patients from private practices and rheumatology departments were asked to answer a questionnaire addressing their behaviour with respect to their immunomodulating therapy. Eight private practices and nine rheumatology departments that included rheumatology primary care centres and university hospitals participated. A total of 4252 questionnaires were collected and evaluated. RESULTS: The majority of patients (54%) were diagnosed with RA, followed by psoriatic arthritis (14%), ankylosing spondylitis (10%), connective tissue diseases (12%) and vasculitides (6%). Most of the patients (84%) reported to continue their immunomodulatory therapy. Termination of therapy was reported by only 3% of the patients. The results were independent from the type of IRD, the respective immunomodulatory therapy and by whom the patients were treated (private practices vs rheumatology departments). Younger patients (<60 years) reported just as often as older patients to discontinue their therapy. CONCLUSION: The data show that most of the patients continued their therapy in spite of the pandemic. A significant change in behaviour with regard to their immunomodulatory therapy was not observed during the three months of observation. The results support the idea that the immediate release of recommendations of the German Society of Rheumatology were well received, supporting the well-established physician-patient relationship in times of a crisis.

[A cross sectional study on patients with inflammatory rheumatic diseases in terms of their compliance to their immunsuppressive medication during COVID-19 pandemic]. / Einstellung von Patienten mit entzündlich-rheumatischen Erkrankungen zur immunsuppressiven Therapie im Rahmen der COVID-19 Pandemie ­ eine Situationsanalyse.

The current COVID-19 pandemic inherits an unprecedented challenge for the treating rheumatologists. On the one hand, antirheumatic drugs can increase the risk of infection and potentially deteriorate the course of an infection. On the other hand, an active inflammatory rheumatic disease can also increase the risk for an infection. In the recommendations of the German Society for Rheumatology (www.dgrh.de), it is recommended that our patients continue the antirheumatic therapy to maintain remission or low state of activity despite the pandemic. In this study, patients with inflammatory rheumatic disease were asked in the first weeks of the pandemic on their opinion of their immunomodulating therapy. The result shows that over 90% of the patients followed the recommendation of the rheumatologist to continue the antirheumatic therapy, and only a small percentage of the patients terminated the therapy on their own. This result was independent of the individual anti-rheumatic therapy. Taken together, the results of this study illustrate not only the trustful patient-physician partnership in a threatening situation but also the high impact of state-of-the art recommendations by the respective scientific society.

[Ambulatory healthcare center in the context of a rheumatology clinic]. / Rheumatologisches Medizinisches Versorgungszentrum an einer Akutklinik.

BACKGROUND: The chronic nature of most rheumatic diseases, the complexity of the course of the disease and types of therapy used necessitate a close interlocking of inpatient and outpatient treatment options. Some years ago in Germany the interdisciplinary outpatient and inpatient treatment was facilitated by statutory regulations. As the number of rheumatologists in private practice is not sufficient to provide adequate rheumatologic outpatient healthcare, the improvement of interface points between outpatient and inpatient care becomes more important. There are various ways for hospitals to take part in outpatient care, one of which is the foundation of an ambulatory healthcare center. METHODS: The introduction and integration of a medical healthcare center is described using an example. RESULTS: Against the background of insufficient rheumatology outpatient care in Cologne a city with 1 million inhabitants, the establishment of a rheumatology outpatient healthcare center at Porz am Rhein which is the only rheumatology clinic in this region is described.

[Muscle weakness and early stages of liver failure in a 22-year-old man]. / Muskuläre Schwäche und beginnendes Leberversagen bei einem 22-jährigen Mann.

A 22-year-old man without pre-existing medical conditions presented to our hospital with a progressive reduction of his physical overall performance, muscle weakness of the extremities, and diarrhea for the last 2 months concomitant with elevated liver enzymes and creatine kinase activity. After ruling out infectious diseases, neoplasia, and autoimmune disorders as a cause of these symptoms, the histology of liver and muscle samples led us to suspect a diagnosis of a rare lipid metabolism disorder. Molecular biologic testing provided the diagnosis of multiple acyl-coA dehydrogenase deficiency with ubiquinone deficiency and late onset. The course of disease was complicated by liver failure and severe pneumonia requiring ventilatory assistance. With the substitution of riboflavin and ubiquinone, the patient showed a gradual recovery of his clinical presentation and an improvement of his laboratory tests. A congenital lipid metabolic disorder might be a rare cause of severe myopathy and hepatopathy in a young adult.

Reliability of the novel 7-joint ultrasound score: results from an inter- and intraobserver study performed by rheumatologists.

OBJECTIVE: To assess the inter- and intraobserver reliability of 26 rheumatologists when performing the 7-joint ultrasound score (US7). METHODS: Six patients with rheumatoid arthritis were examined by 26 sonographers in 12 rater groups who performed the US7 score. The US7 score includes the clinically dominant wrist, the second and third metacarpophalangeal (MCP) and proximal interphalangeal joints, and the second and fifth metatarsophalangeal (MTP) joints, which were evaluated for synovitis, tenosynovitis/paratenonitis, and erosions from the dorsal side and palmar/plantar aspects by gray-scale and power Doppler (PD) ultrasound. Additional lateral scans were performed at the MCP2 and MTP5 joints. All of the groups repeated the examination in 4 patients in order to calculate the intraobserver reliability. The results of one group that included 2 expert sonographers were considered as the reference standard. Kappa values, median agreement rates (interobserver), and P values (intraobserver evaluation) were calculated. RESULTS: The median overall kappa value for detecting synovitis was 0.51, for tenosynovitis/paratenonitis was 0.57, and for erosions was 0.45. In detail, the best interobserver results were found for the detection of erosions in the MTP2 joint from the plantar aspect (κ = 1; median agreement rate 89.4%) and for PD signal detection in the palmar wrist region (κ = 0.79; median agreement rate 78.8%). Good agreement was found for detecting erosions in the MCP2 joint from the radial side (κ = 0.67; median agreement rate 77.3%). CONCLUSION: The inter- and intraobserver reliability of the US7 score shows moderate to substantial kappa values and good agreements. Therefore, this ultrasound score has the potential to be an important imaging tool, including multicenter analysis to assess structural changes.

[Do we need imaging techniques for the diagnosis of rheumatoid arthritis in 2011? The value of imaging in the new ACR/EULAR classification criteria for rheumatoid arthritis]. / Brauchen wir im Jahr 2011 bildgebende Verfahren für die Diagnose einer rheumatoiden Arthritis? : Stellenwert der Bildgebung in den neuen ACR/EULAR-Klassifikationskriterien der rheumatoiden Arthritis.

The modified significance of radiological criterion in the new ACR/EULAR classification criteria for rheumatoid arthritis is based on the fact that the bone erosion seen using conventional radiology is the result of an already longstanding inflammatory process.In contrast, new imaging modalities such as magnetic resonance imaging (MRI) and ultrasound are able to visualize the typical features of active joint inflammation. However, according to the new criteria, the use of MRI and ultrasound is additional or complementary to confirm clinical findings, and does not represent a criterion in itself.

[Color Doppler sonography for investigation of peripheral joints and ligaments]. / Farbdopplersonographie bei der Untersuchung peripherer Gelenke und Sehnen.

Doppler ultrasound is able to visualize blood flow by the change in frequency (Doppler shift) of sound waves which are reflected by moving blood cells inside the vessels (Doppler effect). As hyperemia caused by vasodilatation and angiogenesis is the earliest detectable pathologic change in the beginning of synovitis, Doppler ultrasonography can be used to assess inflammatory activity. Several studies could show a strong correlation between magnetic resonance imaging (MRI) as well as histological findings (blood vessel density) and Doppler sonographic determination of synovial perfusion. Equipment settings must be adapted to slow blood flow in very small blood vessels to reach an appropriate imaging quality. Color and power Doppler ultrasound can depict different grades of intra-articular and peritendinous blood flow, which allows an estimation of inflammatory activity and facilitates the differentiation and monitoring of rheumatic diseases during follow up.

Evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: a pilot project.

OBJECTIVE: To introduce a new standardized ultrasound score based on 7 joints of the clinically dominant hand and foot (German US7 score) implemented in daily rheumatologic practice. METHODS: The ultrasound score included the following joints of the clinically dominant hand and foot: wrist, second and third metacarpophalangeal and proximal interphalangeal, and second and fifth metatarsophalangeal joints. Synovitis and synovial/tenosynovial vascularity were scored semiquantitatively (grade 0-3) by gray-scale (GS) and power Doppler (PD) ultrasound. Tenosynovitis and erosions were scored for presence. The scoring range was 0-27 for GS synovitis, 0-39 for PD synovitis, 0-7 for GS tenosynovitis, 0-21 for PD tenosynovitis, and 0-14 for erosions. Patients with arthritis were examined at baseline and after the start or change of disease-modifying antirheumatic drug (DMARD) and/or tumor necrosis factor alpha (TNFalpha) inhibitor therapy 3 and 6 months later. C-reactive protein level, erythrocyte sedimentation rate, rheumatoid factor, anti-cyclic citrullinated peptide, Disease Activity Score in 28 joints (DAS28), and radiographs of the hands and feet were performed. RESULTS: One hundred twenty patients (76% women) with rheumatoid arthritis (91%) and psoriatic arthritis (9%) were enrolled. In 52 cases (43%), erosions were seen in radiography at baseline. Patients received DMARDs (41%), DMARDs plus TNFalpha inhibitors (41%), or TNFalpha inhibitor monotherapy (18%). At baseline, the mean DAS28 was 5.0 and the synovitis scores were 8.1 in GS ultrasound and 3.3 in PD ultrasound. After 6 months of therapy, the DAS28 significantly decreased to 3.6 (Delta = 1.4), and the GS and PD ultrasound scores significantly decreased to 5.5 (-32%) and 2.0 (-39%), respectively. CONCLUSION: The German US7 score is a viable tool for examining patients with arthritis in daily rheumatologic practice because it significantly reflects therapeutic response.

Reliability of different Doppler ultrasound quantification methods and devices in the assessment of therapeutic response in arthritis.

OBJECTIVE: To evaluate the metric qualities of power Doppler ultrasound (PDUS) for different quantification methods and devices in the assessment of arthritis during anti-inflammatory treatment. METHODS: Twenty-four patients with active arthritis and first-time treatment with the TNF-alpha inhibitor adalimumab underwent sequential clinical, laboratory and US examination at baseline, weeks 2, 6 and 12. 2D and 3D PDUS was performed by two independent investigators. The images and movies were scored from 0 to 3 and the amount of colour pixels and voxels was calculated. In addition, the resistance index of a synovial artery was measured. Thirteen patients were examined with a second US machine. RESULTS: Treatment response was already observed at week 2 with a significant reduction of 2D (P < 0.01) and 3D scores (P < 0.001). A moderate correlation to 28-joint disease activity score was found for 3D voxel count (r(s) = 0.35, P < 0.001). Interobserver agreement was kappa or ICC >or= 0.8 for all methods except the resistance index (ICC = 0.60). Intermachine agreement was kappa = 0.57 for 2D PDUS score. CONCLUSIONS: The study demonstrates good to excellent interobserver and moderate intermachine reliability of different PDUS assessment methods in a longitudinal open-label study.

Quantification of the synovial perfusion in rheumatoid arthritis using Doppler ultrasonography.

In the past decade, Power Doppler ultrasound (PDUS) has been established as a new imaging modality for the evaluation of synovial perfusion in the inflamed joints of patients with rheumatic diseases. Various studies have been dealing with the problem of a reproducible quantification method in PDUS as this still appears to be one of the main disadvantages in comparison with magnetic resonance imaging and also with contrast-enhanced ultrasound technique. The main studies addressing this problem are presented and compared to the recently described three-dimensional power Doppler ultrasound by outlining the advantages and the remaining difficulties in quantifying synovial vascularity with PDUS.

Interobserver agreement in two- and three-dimensional power Doppler sonographic assessment of synovial vascularity during anti-inflammatory treatment in patients with rheumatoid arthritis.

PURPOSE: To compare the interobserver agreement in qualitative and quantitative two- (2D) and three-dimensional (3D) power Doppler ultrasonographic assessment of joint vascularity in wrist arthritis of patients with rheumatoid arthritis (RA) during anti-inflammatory therapy. MATERIALS AND METHODS: Tender and swollen wrists of 15 patients with RA were examined by two independent ultrasound investigators before and at day 3, 7, 14 and 42 after the initiation of an anti-inflammatory therapy. Besides the assessment of clinical and laboratory disease activity parameters, a linear array transducer was used to produce grey-scale images of synovitis and effusion as well as 2D and 3D power Doppler sonographic images and movies of synovial vascularity. Interobserver agreement was evaluated with regard to the obtained qualitative information such as grading of synovitis and Doppler signal intensity and compared with the correlations of quantitative assessments such as measurement of synovial thickening, resistance index (RI), 3D blood vessel count, computerized pixel count and first described computerized voxel count. RESULTS: High interobserver agreement was found for the measurement of synovial thickening (r = 0.86), the computerized voxel count (r = 0.85) and the 3D blood vessel count (r = 0.83) in contrast to significantly lower levels of agreement for RI measurement, the computerized pixel count, the grading of synovitis and the 2D and 3D Doppler grading. A significant decrease of synovial perfusion could be demonstrated by means of 2D and 3D Doppler ultrasound under the anti-inflammatory treatment in accordance with an improvement in clinical and laboratory disease activity. CONCLUSION: Quantification of 3D power Doppler images (voxel count) showed higher interobserver agreement compared with 2D quantitative analyses as well as with 2D and 3D semiquantitative grading, indicating this method as a reliable approach to measure synovial perfusion as sign of inflammatory activity in arthritis.

The influence of strongly reducing conditions on strong metal-support interactions in Cu/ZnO catalysts used for methanol synthesis.

A systematic series of binary and ternary copper catalysts was investigated using the methanol synthesis reaction at atmospheric pressure. Strong metal-support interactions between copper and zinc oxide induced by strongly reducing conditions were probed by the adsorption of carbon monoxide, which was monitored qualitatively and quantitatively by a combination of microcalorimetry, temperature-programmed desorption experiments and Fourier transform infrared spectroscopy. For the zinc oxide-containing catalysts, the pretreatment in flowing carbon monoxide at 493 K resulted in a severe decoration of the copper metal particles with ZnOx adspecies, whereas after methanol synthesis at 493 K the state of the copper was essentially identical to that seen after hydrogen reduction. Copper was always found to be present in its zero-valent state.

Microkinetic modeling of CO TPD spectra using coverage dependent microcalorimetric heats of adsorption.

CO adsorption on the ternary methanol synthesis Cu/ZnO/Al2O3 catalyst was studied in detail by means of adsorption microcalorimetry and flow temperature-programmed desorption (TPD). Based on these experimental data, we established a microkinetic analysis method, which provides information about the adsorption kinetics of CO on the catalyst surface. Experimentally derived microcalorimetric heats of adsorption were applied in a microkinetic model to simulate TPD curves with varying initial coverage. Two approaches were used: an integral approach based on evaluation of the integral heats of adsorption which predicts the experimental TPD curves roughly and provides first approximations for the preexponential factors. The second, more detailed approach was based on the simulation of the adsorption isotherm taking the experimentally determined coverage-dependence of the heat of adsorption into account. This approach led to a significantly improved agreement between experimental and simulated TPD curves. Moreover, it was possible to derive the standard entropy of adsorption. The general applicability of our approaches is demonstrated by analyzing the CO TPD and microcalorimetry data obtained with a binary ZnO-free Cu/Al2O3 catalyst.