[Treat to target-participation of the patient]. / Treat-to-Target ­ Beteiligung der Patienten.

An increase in general health literacy and a targeted patient information are important prerequisites for coping with the chronic disease in people with inflammatory rheumatic diseases. The education programs of the Working Group of Regional Cooperative Rheumatism Centers in the German Society for Rheumatology (AGRZ), such as StruPI, the offers of the German Rheumatism League (Deutsche Rheuma-Liga) and other elements provide a framework for those affected and their relatives, in which a participative decision-making (PEF) on equal terms can be possible. The physician-patient communication changes in the sense of a PEF and hopefully leads to a sustainably better patient compliance. Non-medicinal treatment, comorbidities and changes in life style are important issues in such cases. The StruPI is an established format for information and education of patients, particularly in outpatient rheumatism patients. In the midterm patient education (outpatient and inpatient) and self-management courses will be offered and honored nationwide, analogue to other chronic diseases, e.g. asthma and diabetes. Patients can influence the course of the disease by life style changes. The treatment of chronic diseases can only function in the long term in a consensual partnership.

Feasibility and reproducibility of the PsAMRIS-H score for psoriatic arthritis in low-field-strength dedicated extremity magnetic resonance imaging.

OBJECTIVES: The psoriatic arthritis magnetic resonance imaging scoring system (PsAMRIS-H) for the evaluation of inflammatory and destructive changes in PsA hands was validated on 0.6-T scanners. The applicability of the PsAMRIS-H on a low-field MRI system as a well-accepted, low-cost imaging modality was evaluated. METHOD: In 65 consecutive patients (31 males, median age 52 years), 73 scans on a 0.2-T dedicated extremity MRI system were obtained for evaluation of PsA. Images were scored for synovitis, tenosynovitis, periarticular enhancement, bone erosion, bone oedema, and proliferation, and the PsAMRIS-H score was calculated. The intraclass correlation coefficient (ICC) was calculated and the paired t-test conducted. RESULTS: Intra-reader reliability for the total PsAMRIS-H score was good, with an ICC of 0.81 and 0.77 for readers 1 and 2, respectively, and inter-reader agreement was moderate (0.57 for each reader). However, the PsAMRIS-H score differed significantly between the two readers (22 vs. 31; p < 0.05). When individual components of the PsAMRIS were evaluated, intra- and inter-reader agreement was poor to moderate, especially for tenosynovitis and periarticular inflammation. CONCLUSIONS: Low-field 0.2-T MRI is capable of quantifying the PsAMRIS-H with good intra-reader reproducibility. However, low signal-to-noise ratio (SNR), low spatial resolution, and system artefacts limit the application of the PsAMRIS-H, leading to low inter- and intra-reader agreement for individual features.

The European ankylosing spondylitis infliximab cohort (EASIC): a European multicentre study of long term outcomes in patients with ankylosing spondylitis treated with infliximab.

OBJECTIVES: To study the long-term efficacy and safety of treatment with infliximab in patients with ankylosing spondylitis (AS) in a real life setting. METHODS: AS patients from 6 European countries who had finished the 2-year trial ASSERT were invited to participate in the open- label investigator-driven study EASIC. At baseline, 2 groups were formed: patients of group 1 had not been treated with infliximab after ASSERT, while those of group 2 had continuously received it. Patients of group 1 were further subdivided in group 1a: patients with a relapse and 1b: in remission. All patients of group 1a and 2 continuously received infliximab for 96 weeks, mean dose 5 mg/kg, intervals 6-8 weeks. Patients of group 1b were also treated in case of relapse. RESULTS: A total of 103/149 patients (69%) were included in EASIC, 1.3 ± 0.9 years after the end of ASSERT: 9 in group 1a, 5 in group 1b and 89 in group 2. Most patients were male (83%), mean age 44 years. Most patients of group 2 completed the trial (86%) vs. only 5 of group 1 (33%) - mostly due to allergic reactions after readministration of infliximab. In total, there were 22 drop-outs due to 6 adverse events, 4 lack of efficacy, 3 planned pregnancy. All standard assessments indicated beneficial values over time, at week 96 significantly better than at baseline of ASSERT. CONCLUSIONS: The majority of patients were continuously and successfully treated with infliximab for 5 years, whereas discontinuation and reintroduction of therapy was less satisfactory due to the frequent occurrence of hypersensitivity reactions. Anti-TNF therapy with infliximab proved to be effective and safe on a long-term basis.

[Quality of a multidisciplinary orthopaedic-rheumatological consultation]. / Qualität einer interdisziplinären Sprechstunde in der Rheumaorthopädie.

AIM: An interdisciplinary approach plays an important role in orthopaedic rheumatology. The aim of this study was to test the quality of an interdisciplinary consultation, which analyzed a pool of orthopaedic patients in terms of rheumatological disease. METHOD: Orthopaedic patients (n=100) were transferred to a multidisciplinary team of experts in a two-stage selection process. Patient data were examined with regard to diagnosis and therapy. A patient interview analyzed the course of disease and effects of the consultation. Patients were questioned on the development of pain, diagnostics and therapy as well as their general satisfaction. RESULTS: Rheumatological disease was diagnosed in 42% of patients, while specific anti-rheumatic therapy was started in 41%. An improvement in symptoms as a result of treatment was seen in 63% of cases. Patient examinations revealed an above-average level of satisfaction in 63% of patients. CONCLUSION: Interdisciplinary consultation led to improved and faster diagnosis and therapy of rheumatological diseases, which was positively evaluated by the pool of patients treated.

Persistent clinical efficacy and safety of anti-tumour necrosis factor alpha therapy with infliximab in patients with ankylosing spondylitis over 5 years: evidence for different types of response.

BACKGROUND: There is insufficient evidence for the long-term efficacy and safety of anti-tumour necrosis factor therapy in patients with ankylosing spondylitis (AS). This is the first report on the treatment with infliximab over 5 years. METHODS: As part of a multicentre randomised trial, 69 patients with active AS at baseline (BL) have been continuously treated with infliximab (5 mg/kg i.v. every 6 weeks)--except for a short discontinuation after 3 years (FU1). The primary outcome of this extension was remission according to the ASsessment in Ankylosing Spondylitis (ASAS) criteria at the end of year 5 of the study (FU2). RESULTS: Of the 43 patients who completed year 3, 42 agreed to continue, 38 of which (90.5%) finished year 5 (55% of 69 initially). Partial clinical remission was achieved in 13 of 38 patients (34.2%) at FU1 and FU2. At FU2, the mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) was 2.5+/-1.9 (BL:6.4, FU1:2.5). BASDAI values <4 were seen in 79% of patients at both, FU1 and FU2. ASAS 20% and 40% responses were seen in 32 (84%) and 24 (63%) patients at FU2, respectively. Most patients classified as non-responders at FU2 were part-time responders, as all but one patient achieved an ASAS 20% response at least once within the last 2 years. Three types of responders were identified. No major side effects occurred during years 4 and 5 of infliximab therapy. CONCLUSIONS: Infliximab is safe and efficacious in AS patients over 5 years. The majority of the patients remained on treatment and had rather persistent levels of low disease activity. Different response types could be identified.

Learning at the computer: evaluation of an intelligent tutoring system.

The aim of the study was to test the efficacy of a new courseware. In a pre and post test frame, students were given the software to be used during one semester. A significant increase in the students' general study motivation was shown at the end of the semester. A change in the use and attitudes towards computers could not be observed. In a follow-up survey at the end of the semester, the students stated that the program was indeed helpful and useful but that they have had difficulties with the program's technical aspects and the general use. Furthermore, the results show that the majority of the participating students accepted the program's content, the general study motivation was high and the students showed a significant increase in learning gains, determined by the differences from pre and post test values. Especially students with low pre test values seemed to profit from the additional use of learning material, resp. the presented courseware. At the end of the semester the students with low and middle pre test results showed an increase in performance as well as an alignment in the performance for diagnosing rheumatological diseases to the students of the upper third pre test results.

[Mortality and nursing home admission of severely disabled patients]. / Sterblichkeit und Heimeinweisung bei Schwerpflegebedürftigen.

242 people had been interviewed 1-4 years (average 2 years) after first receiving benefits because of urgent need of nursing care. Meanwhile 57 persons had died at home. 17 persons had moved into a nursing home, and 8 of them had died there. For another two persons transfer to a nursing home was imminent. -Among those older than 60 years the probability of dying at home is more than three times greater than the risk of changeover to a nursing home. The highest transferrat to a nursing home (more than 18% within the observation period) was seen in women of 80 years of age and older.

Graphical knowledge acquisition for medical diagnostic expert systems.

Like many textbook authors use text systems for writing their books, expert system authors should have easy to use knowledge acquisition systems for entering and testing their knowledge bases by themselves without much help from 'knowledge engineers'. In this paper, we report on a graphical knowledge acquisition tool (CLASSIKA) based on an expert system shell for heuristic classification (MED2) and designed for direct use by domain experts. We demonstrate how the system has been used for building a rather large expert system for diagnosing rheumatology diseases which is now being tested in clinical use.

Stepwise development of a clinical expert system in rheumatology.

The evaluation of computer expert systems, a promising diagnostic tool for future application in clinical medicine, is of great importance. We present here the evaluation of our expert system, "RHEUMA". It is stressed, that repeated retrospective testing and updating of an expert system and its subsequent repeated assessment in clinical use and surroundings is mandatory. This increases the diagnostic accuracy of the system. For our system this is demonstrated under three separate conditions. In the first study the information available for the computer system (mainframe) came from medical histories only. Here an error rate of about 25%--similar to that of physicians themselves using the same information--was observed in 358 outpatients, compared to the final diagnoses of physicians also relying solely on information from medical histories. In a second step a completely new system on a personal computer was developed with all relevant diagnostic information. The error rate of this system (0.4%) was much too optimistic because the knowledge base was changed during the study, affecting about 30% of the 282 prospectively recruited outpatients. In a third step the efficacy of the expert system was tested in an additional hospital without the diagnostic involvement of the first testing clinic. The error rate of the system without changing the knowledge base reached 11% in 51 outpatients in this rheumatology clinic. This result reflects the diagnostic accuracy of the system today. Its ability to specify the same diagnoses which clinical experts reached approached 90%. Considerable time is needed for such prospective testing, with repeated updating of the knowledge base--in our case for both the two systems and field studies of 2 years each.(ABSTRACT TRUNCATED AT 250 WORDS)

[Assessment of risk factors and their modification in rehabilitation applicants]. / Risikobelastung und deren Anderung bei Reha-Antragstellern.

Compared with the general population male workers applying for medical rehabilitation show a higher risk-load, especially regarding smoking and alcohol consumption. However, at present it can't be decided, if the risk-load within this group of applicants is even higher than among the non-applying workmen. Such a selection would be intended. Overweight is the main risk-factor among applicants for medical rehabilitation. It is present far more often than generally within the general population and even within the working class. Male workers with repeated courses of medical rehabilitation exhibit a significant lower risk-load than applicants for a first rehabilitative procedure. A causal relation might be suggested, but at present other explanations regarding the observed relationship have to be considered. A long-term Follow-up study is necessary.

[Duration of work incapacity before and after inpatient therapeutic procedures]. / Arbeitsunfähigkeitstage vor und nach stationären Heilverfahren.

An analysis has been made of days off work prior to and following a course of treatment in clinics for rehabilitation. A comparison of pre-treatment and after-treatment three-year periods revealed a small decrease of 8 days (9.2%). The youngest age group had the most time off work and--measured in terms of days off work--also the greatest response to treatment. Also after post-hospital rehabilitative treatment clear, though not statistically significant, reductions in the number of days off work were observed. The most striking changes were seen when (only) total number of working days lost prior to the course of treatment was recorded: in the case of high pre-treatment figures for working days lost, a considerable decrease was subsequently observed, while in the case of low working days lost figures, a marked increase in days off occurred. With respect to some of the groups participating, the methodological approach we employed did not make it appear probable that (measured in terms of total working days lost) these groups were "more pathological". It must be pointed out that these results were obtained in relatively small groups; it was not possible to extend the investigation.

[The medical computer as a diagnostic aid in joint pain--attitude of patients and results]. / Der Arztcomputer als Diagnoseunterstützung bei Gelenkschmerzen--Patientenmeinung und Ergebnisse.

409 unselected outpatients were asked standardized expert system questions on the medical history of joint complaints. An average number of 30.4 +/- 6.6 out of 60 questions with 346 different answers were asked in a mean time of 20.1 +/- 6.6 min. This time, required for the questions to be displayed on the computer screen and input assistance from a staff-member, proved to be comparable to the time required for a medical history to be taken on the same patients by a physician. In 75% of the cases the computer was able to predict the correct diagnosis on behalf of information of the medical history only. Using only medical history as a source of information, computer and physician had the same rate of wrong diagnoses. Before and after the standardized medical history on the computer screen all patients were asked about their opinion of the computer as a diagnostic aid. Male and younger patients more often appreciated computerized diagnosing. Just a few patients felt that their relation to the physician was disturbed by the computer or were inconvenienced themselves. Most patients stated they did not believe that physicians could ever be replaced by computers. Only a few of them had resignations about storage and statistical utilization of personal data.

Echocardiographic changes in patients with heterozygous and homozygous familial hypercholesterolemia: correlation with clinical findings.

59 heterozygous and 6 homozygous patients with familial hyperchole sterolemia were screened for atherosclerosis of the aortic root and cardiac valves by echocardiography. Pathological echocardiographic changes were found in 59% of heterozygotes and in all homozygotes. In heterozygotes, aortic root sclerosis usually appears after the age of 30 and its frequency increases progressively with age. Homozygotes showed severe changes before the age of 10. In heterozygotes, a pathological echocardiogram correlated strongly with the presence of overt coronary heart disease. Echocardiography proved to be a useful non-invasive method for better evaluation of the individual coronary risk in patients with familial hypercholesterolemia.

[Indications for sonography and follow-up studies. Initial results of a prospective study]. / Indikationen zur Sonographie und Folgeuntersuchungen. Erste Ergebnisse einer prospektiven Studie.

Ultrasonic examinations of the abdomen may result in expensive secondary imaging examinations. This prospective study was conducted in collaboration with the Zentralinstitut Köln. The first aim of our study was to compare the results of abdominal sonography in three different patient groups: The first group was comprised of patients referred for a medical check-up, the second group of patients referred because of upper abdominal pain and the third group of patients with generalized atherosclerosis. The second aim was to correlate sonographic findings (classified in three degrees of severity), with subsequently induced diagnostic procedures in the three groups. 2719 patients were enrolled, 2393 (88%) in group 1, 286 (11%) in group 2 and 40 (1%) in group 3. A total of 1792 abnormal findings were diagnosed. 65.6% of the findings in group 1, 65.7% in group 2 and 88% in group 3 were abnormal. Up to now, the findings led to a nearly equal number of subsequent diagnostic procedures in groups 1 and 2. The preliminary results show that abdominal sonography may be as effective in patients for a check-up as in patients referred because of a well-defined indication. Patients with defined abdominal symptoms show more abnormal sonographic findings than patients on a check-up. Higher costs resulting from subsequent examinations deserve critical assessment in the individual patient.

Genetic evidence from 7 families that the apolipoprotein B gene is not involved in familial combined hyperlipidemia.

Familial combined hyperlipidemia (FCHL) is the most common genetic form of hyperlipidemia in which affected individuals manifest multiple lipoprotein phenotypes. Although the molecular defect is still unknown, several kinetic studies have demonstrated increased turnover rates of apolipoprotein B (apo B) in patients with FCHL, irrespective of their lipoprotein phenotype. Using 3 restriction fragment length polymorphisms (RFLPs) of the apo B gene (XbaI, MspI and EcoRI) we have investigated 33 families which fulfill the diagnostic criteria of FCHL. No significant difference in allele frequency was found between 33 unrelated individuals with FCHL and 107 normolipidemic controls. 3-RFLP haplotypes were constructed in each pedigree. A co-segregation analysis was performed in 7 informative families. In no family was co-segregation observed between the haplotype of the apo B gene and the phenotype of FCHL. These data are not compatible with the hypothesis that FCHL is caused by mutations of the apo B gene acting as a simple mendelian trait.

Prospective application of an expert system for the medical history of joint pain.

An expert system with 60 questions about medical history was developed for 32 rheumatologic diseases: 358 outpatients with joint complaints have been examined. The final diagnosis (result of symptoms, signs, and findings) was compared with the computer diagnoses and with the independently assumed diagnoses of the physician. The only source of information available to the physician was the medical history. Misinterpretation of the computer diagnoses occurred in 25.6% of cases compared with 21.5% of the physician. The final clinical diagnosis remained uncertain in 32.6% of cases. The error frequency of the expert system was influenced by the underlying disease, the certainty of the assumed diagnosis by the physician, the user experience in rheumatology, the number of questions asked, and the time of application before or after the doctor-patient contact. Of the errors 44% were produced because of information deficits of the computer using standardized questions. The information of the physician in the diagnostic process is quite different to that of the computer.

[Life after urostomy. A retrospective study]. / Leben nach einer Urostomie-Operation. Eine retrospektive Untersuchung.

The study reported, which was based on a questionnaire and psychological tests, examined cystostomy patients with respect to the work-up and acceptance of their altered body. It was noted that 30% of the patients judged their situation as good, and 25% could accept the cystostomy, but a great many has to live with sexual disturbances, reduced social mobility, increased dependence, and psychic consequences; some had to give up their jobs. Sex, earlier psychosomatic diseases, developmental disorders in early childhood, which influence the personality, significantly affect the acceptance of the stoma. The problems are discussed. Suggestions are made, which include a plan for a holistic therapy.

Double-blind study of metaclazepam versus diazepam treatment of outpatients with anxiety syndrome.

The therapeutic efficacy and tolerance of metaclazepam and diazepam were compared in a double-blind study of outpatients suffering from a generalized anxiety syndrome. The investigators were general practitioners. A total of 168 male and female patients aged between 18 and 60 years were included in the study and received either 15 mg metaclazepam or 15 mg diazepam per day. The analysis of tolerance was made for all 168 included patients, the evaluation of efficacy is based on the results of 131 patients (42 males and 89 females) with valid data over four weeks. During the four-week therapy period four examinations were made on days 0, 7, 14, and 28. A significant improvement of the severity of illness after administering the drugs was found for both drugs in the Clinical Global Impressions (CGI), in the Hamilton Anxiety Scale (HAMA), in the List of Complaints (B-L), and in the Adjective Checklist (EWL-K). Metaclazepam showed a statistically significant superiority over diazepam as far as the CGI items "severity of illness" and "global improvement" were concerned. Metaclazepam was slightly superior to diazepam in the two HAMA subscales "psychic anxiety" and "somatic anxiety". In the items of the selfrating scales (B-L and EWL-K) the therapeutic results of the metaclazepam group were, almost without exception, better than those of the diazepam group. A comparison of tolerance showed that metaclazepam was better tolerated. This can be seen in the greater frequency of side effects like tiredness and drowsiness under diazepam. Especially at the beginning of treatment, tiredness and drowsiness were recorded 2 1/2 times more frequently for the patients on diazepam than for those on metaclazepam.