[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.

Grain boundary study of technically pure molybdenum by combining APT and TKD.

Molybdenum is an eligible material for high performance applications. However, its applicability is limited because of a brittle-to-ductile transition around room temperature, depending on the grain size and the content of interstitial impurities present at grain boundaries. The total amount of impurities in the current quality of molybdenum has become very small in the last decades. Therefore, the atom probe with its atomic resolution is the only suitable site-specific analysis technique. Nevertheless, a site-specific specimen preparation by focused ion beam (FIB) is required to study the grain boundary chemistry effectively. With a novel method, which combines re-sharpening of pre-electro-polished tips by FIB with transmission Kikuchi diffraction (TKD), a grain boundary can easily be positioned in the first 200 nm of an atom probe sample. Furthermore, the high resolution technique of TKD gives the opportunity to get crystallographic information of the mapped area and, therefore, an analysis of the grain boundary character to support the interpretation of the atom probe data files. In the present study, APT specimens of technically pure molybdenum which contain grain boundaries were prepared by FIB in support of TKD and subsequently were measured in the atom probe. The difference of segregation content at unequal types of grain boundaries in the as-deformed and recrystallized state is discussed.

A novel approach for site-specific atom probe specimen preparation by focused ion beam and transmission electron backscatter diffraction.

Atom probe tomography (APT) is a suitable technique for chemical analyses with almost atomic resolution. However, the time-consuming site-specific specimen preparation can be improved. Recently, transmission electron backscatter diffraction (t-EBSD) has been established for high resolution crystallographic analyses of thin foils. In this paper we present the first successful application of a combined focused ion beam (FIB)/t-EBSD preparation of site-specific APT specimens using the example of grain boundary segregation in technically pure molybdenum. It will be shown that the preparation of a grain boundary can be substantially accelerated by t-EBSD analyses in-between the annular milling FIB procedure in the same microscope. With this combined method, a grain boundary can easily be recognized and positioned in the first 220nm of an APT sample much faster than e.g. with complementary investigations in a transmission electron microscope. Even more, the high resolution technique of t-EBSD gives the opportunity to get crystallographic information of the mapped area and, therefore, an analysis of the grain boundary character to support the interpretation of the APT data files. To optimize this newly developed technique for the application on needle-shaped APT specimens, a parameter study on enhanced background correction, acceleration voltage, and tilt angle was carried out. An acceleration voltage of 30kV at specimen surface tilt angles between -45° and -35° from horizontal plane leads to the best results. Even for molybdenum the observation of crystal orientation data up to about 200nm specimen thickness is possible.

Treatment continuation in patients receiving biological agents or conventional DMARD therapy.

OBJECTIVE: To compare drug continuation rates in patients with rheumatoid arthritis who start on a biological agent and in a control group of patients with a change in disease modifying antirheumatic drug (DMARD) treatment after previous DMARD failure. METHODS: Patients with rheumatoid arthritis enrolled in the German biologics register between May 2001 and September 2003 were included in the study. Data were available for 511 patients treated with etanercept, 343 with infliximab, 70 with anakinra, and 599 controls. Propensity scores were used to select a subsample of patients from the control group who were likely to be treated with biological agents because of their disease severity, as well as comparable infliximab and etanercept cases. RESULTS: Treatment continuation after 12 months was similar for etanercept (68.6% (95% confidence interval, 62% to 75%)) and infliximab (65.4% (58% to 73%)) but lower for anakinra (59% (41% to 77%)). Treatment continuation was more likely for patients on combinations of biological agents and DMARDs than for those on infliximab or etanercept alone. Patients treated with biological agents were more severely ill than those in the control group and had more previous DMARD failures. After adjustment for baseline differences, the continuation rates were higher in patients treated with biological agents than in comparable control patients treated with leflunomide or leflunomide/methotrexate. CONCLUSIONS: Treatment continuation of biological agents in clinical practice is less likely than in randomised clinical trials but more likely than in comparable controls treated with conventional DMARDs.

[Radiological changes in the cervical spine in rheumatoid arthritis -- prognostic factors obtained by a cross-sectional study]. / Röntgenologische Veränderungen der Halswirbelsäule bei der rheumatoiden Arthritis: Prognostische Faktoren an Hand einer Querschnittuntersuchung.

OBJECTIVE: The involvement of the cervical spine is the most serious skeletal manifestation of rheumatoid arthritis (RA). Instabilities of the upper cervical spine can lead to neurological complications and signs of vertebrobasilar insufficiency. The study investigates the relationship between the course of the RA and the degree of radiological changes in the cervical spine and describes prognostic factors of cervical spine involvement. MATERIAL AND METHODS: Clinical data were gathered from 205 patients with RA. Standardized X-ray examination of the cervical spine was performed and arthritic changes were assessed by a semiquantitative score. The association of clinical symptoms with defined radiological changes was evaluated. RESULTS: Radiological changes in the cervical spine related to RA were found in 67.8% of the patients. Anterior atlantoaxial dislocations were detected in 25.4%, subaxial dislocations in 55.6% and a vertical displacement of the dens in 21.5% of the cases. The degree of radiological changes in the cervical spine was not directly correlated with neurological symptoms. Age above 55 years, disease duration of more than 10 years, an onset of cervical pain later than 11 years after the diagnosis of RA, steroid therapy for more than 5 years, bilateral shoulder involvement and the presence of severe erosive changes in at least one peripheral joint were positively associated with the development of severe changes in the cervical spine. In patients with basilar impression, paraesthesia in the upper extremities was significantly more common. CONCLUSION: Prognostic factors are helpful for the assessment of risk of cervical spine involvement in RA. Since definite clinical hints for cervical involvement are absent, the cervical spine has to be included in the routine examination of patients with RA.

[Specialized and interdisciplinary team work in rheumatology]. / Spezialisierte und interdisziplinäre Arbeit in der Rheumatologie.

The large number of rheumatic diseases demands a clear differentiation between the individual forms of diseases. For this purpose are at first necessary knowledge concerning clinical criteria and in the second place knowledge about serological and radiological examinations. The serological programme shall be relevant to practice, consist of a basis diagnostics and for particular differential-diagnostic problems shall include specialized laboratory investigations. Necessary X-ray pictures must be performed with a special aim and comparison of the sides. For therapy the interdisciplinary team work, consisting in the cooperation of rheumatologists, orthopedic surgeons, specialized surgeons and physiotherapists stood the test. An important prerequisite is also the cooperation of the outpatient and inpatient rheumatological institution. For a complex rehabilitation programme apart from the physicians experienced coworkers for tasks of welfare, ergotherapy and physiotherapy are necessary.