[2022 Update of the Austrian Society for Rheumatology and Rehabilitation nutrition and lifestyle recommendations for patients with gout and hyperuricemia]. / Empfehlungen der Österreichischen Gesellschaft für Rheumatologie und Rehabilitation zu Ernährung und Lebensstil bei Gicht und Hyperurikämie ­ Update 2022.

BACKGROUND: Gout is the most frequent inflammatory joint disease in the western world and has a proven genetic background. Additionally, lifestyle factors, such as increasing life expectation and standard of living, sufficient or excess nutrition and a growing prevalence of obesity in the population as well as e.g. alcohol consumption, contribute to the rising incidence of hyperuricemia and gout. Apart from an adequate medication, medical consultation on nutrition and lifestyle is an essential part of the management of gout patients, who have a high risk of internal comorbidities. OBJECTIVE: In 2015 the Austrian Society for Rheumatology and Rehabilitation (ÖGR) working group for osteoarthritis and crystal arthropathies published nutrition and lifestyle recommendations for patients with gout and hyperuricemia. Since then, a multitude of studies have been published addressing this topic, which necessitated an update. METHODS: First, the authors performed a hierarchical literature search to screen for the literature published since 2015. Considering references given in the first publication, the relevant literature was selected and the recommendations from 2015 were either kept as published, reformulated or recreated. Finally, the evidence level and the level of agreement for each recommendation were added by the authors. RESULTS: Based on this process, 10 recommendations were generated instead of the initial 9. As in the original publication, a graphical presentation with symbols was constructed to complement the written text. CONCLUSION: The ÖGR recommendations on nutrition and lifestyle for patients with gout and hyperuricemia were updated in accordance with the most recent relevant literature. These are supposed to serve as information and education material for patients and updated information for physicians.

[Austrian nutrition and lifestyle recommendations for gout and hyperuricemia]. / Österreichische Ernährungs- und Lebensstilempfehlungen bei Gicht und Hyperurikämie.

BACKGROUND: Gout is the most common inflammatory arthropathy in the Western world. This is mainly due to the high socioeconomic status, sufficient even superfluous nutrition, overweight and alcohol consumption. Despite adequate medication, information and advice on nutrition and lifestyle are one of the cornerstones in the management of these patients. OBJECTIVE: The aim was to provide recommendations on nutrition and lifestyle in cases of gout and hyperuricemia by a group of rheumatologists, based on a review of the most recent literature. MATERIALS AND METHODS: The study group for osteoarthritis and crystal arthropathies of the Austrian Society for Rheumatology and Rehabilitation (ÖGR) carried out a literature search on this topic. The selected papers were listed according to the level of evidence. RESULTS: Based on this literature search nine recommendations were generated and modified via a Delphi approach: four red "don'ts" concerning nutrition and beverages to be avoided, three green "do's" concerning favorable food as well as two blue general lifestyle recommendations. The format of the recommendations is a two-page leaflet with the list of recommendations, level of evidence, strength of recommendation and literature citations on the front page and a colored icon presentation of food and beverages in a circle, matching the colors of the written recommendations, on the reverse. CONCLUSION: For the first time in Austria, nine recommendations on nutrition, beverages and lifestyle for patients with gout and hyperuricemia were defined for everyday practice, as education material for patients and updated information for physicians.

[Diagnosis and management of gout in Austria. Survey of current practice considering the EULAR recommendations]. / Diagnose und Therapiestandard der Gicht in Österreich. Umfrage unter Berücksichtigung der EULAR-Empfehlungen.

BACKGROUND AND OBJECTIVES: Gout shows an increasing incidence and has become a major health problem in the Western world. Despite effective treatment options, neither diagnosis nor therapeutic efforts can be regarded sufficient to date. It was of interest to investigate current handling of gout among Austrian rheumatologists. MATERIAL AND METHODS: In 2012, a survey of Austrian rheumatologists concerning diagnosis and management of hyperuricemia and gout was performed. With the consent of the Austrian Society of Rheumatology, 574 society members (343 via electronic mail, 23 via mail) were sent a questionnaire consisting of 17 questions. This is the first survey assessing the management of gout among Austrian rheumatologists. RESULTS: The overall response rate was 22.1 %. Of all the contacted members (email and mail), 19.9 % answered the questionnaire electronically and only 5.6 % by mail. The adherence to the EULAR recommendations for gout ranged between 69 and 95 % (median 84 %). CONCLUSION: Among Austrian rheumatologists, the knowledge about gout, its diagnostic and imaging procedures, management and therapeutic goals is good and mainly in line with current international recommendations. To improve the management of patients with gout and hyperuricemia, a more frequent referral to rheumatologists could be beneficial.

A tool for the assessment of hand involvement in rheumatic disorders in daily routine--the SF-SACRAH (short form score for the assessment and quantification of chronic rheumatic affections of the hands).

OBJECTIVE: To establish a questionnaire for quantification of hand involvement in osteoarthritis (OA) of the hands and rheumatoid arthritis (RA) meeting daily routine requirements. PATIENTS AND METHODS: The smallest number of questions of the modified score for the assessment and quantification of chronic rheumatic affections of the hands (M-SACRAH) providing reasonable reliability was identified by factor analysis and calculating Cronbach's alpha, subsequently resulting in a five-item scale, the short form-SACRAH (SF-SACRAH), which was then administered to 176 RA and 71 hand-OA (HOA) patients simultaneously with the M-SACRAH. Additionally, patient's satisfaction (PatSAT) with disease status was assessed (according to the Austrian school marking system from 1 to 5). Gamma was calculated to assess the agreement of the SF-SACRAH with the M-SACRAH and between the single corresponding questions of different formats. The Wilcoxon rank test was applied to estimate the relationship between PatSAT and the SF-SACRAH. RESULTS: Alpha for the SF-SACRAH in 176 RA and 71 HOA patients amounted to 0.869 and to 0.897, respectively, indicating high internal consistency. In both patient groups the SF-SACRAH was found to be significantly correlated to the M-SACRAH (both P(s)<0.01). Agreement between the corresponding questions of both scales was significant in both patient groups by calculating gamma (average gamma 0.683 in HOA and 0.847 in RA). PatSAT and SF-SACRAH values were highly significantly correlated (P<0.001) proving the score's external validity. CONCLUSION: The SF-SACRAH proved to be a brief and practicable tool to assess hand involvement in OA and RA meeting the requirements of daily routine.

Comparison of three rheumatoid arthritis disease activity scores in clinical routine.

OBJECTIVE: To evaluate whether the revised disease activity cut-off values for the Simplified Disease Activity Index (SDAI) and the Clinical Disease Activity Index (CDAI) are in congruence with the Disease Activity Score including a 28-joint count (DAS28) disease activity criteria in daily clinical routine. PATIENTS AND METHODS: A total of 570 rheumatoid arthritis (RA) outpatients were assessed and categorized according to the DAS28, the SDAI, and the CDAI. These results were compared to the respective DAS28 disease activity categories. Statistical evaluation was carried out by calculating alpha, the Spearman rank correlation, and kappa-statistics. RESULTS: DAS28, SDAI, and CDAI levels were significantly correlated to one another on a group level (p < 0.001). Internal consistency was the highest for the CDAI (alpha = 0.783) and the lowest for the DAS28 (alpha = 0.664). Kappa-statistics revealed a substantial degree of agreement with respect to mild, moderate, and high disease activity according to the three scores, with exceptions concerning the definition of a remission-like state. Further categorization showed that an additional 44% of patients were found to be in remission according to the DAS28 disease activity criteria relative to those defined by the SDAI or the CDAI disease activity categories respectively. CONCLUSION: The revised SDAI limits for disease activity and the respective CDAI thresholds proved to be in congruence with the DAS28 disease activity categories in daily clinical routine. The SDAI and the CDAI were found to be more stringent in defining remission.

Optimal reconstruction of historical water supply to a distribution system: A. Methodology.

The New Jersey Department of Health and Senior Services (NJDHSS), with support from the Agency for Toxic Substances and Disease Registry (ATSDR) conducted an epidemiological study of childhood leukaemia and nervous system cancers that occurred in the period 1979 through 1996 in Dover Township, Ocean County, New Jersey. The epidemiological study explored a wide variety of possible risk factors, including environmental exposures. ATSDR and NJDHSS determined that completed human exposure pathways to groundwater contaminants occurred in the past through private and community water supplies (i.e. the water distribution system serving the area). To investigate this exposure, a model of the water distribution system was developed and calibrated through an extensive field investigation. The components of this water distribution system, such as number of pipes, number of tanks, and number of supply wells in the network, changed significantly over a 35-year period (1962--1996), the time frame established for the epidemiological study. Data on the historical management of this system was limited. Thus, it was necessary to investigate alternative ways to reconstruct the operation of the system and test the sensitivity of the system to various alternative operations. Manual reconstruction of the historical water supply to the system in order to provide this sensitivity analysis was time-consuming and labour intensive, given the complexity of the system and the time constraints imposed on the study. To address these issues, the problem was formulated as an optimization problem, where it was assumed that the water distribution system was operated in an optimum manner at all times to satisfy the constraints in the system. The solution to the optimization problem provided the historical water supply strategy in a consistent manner for each month of the study period. The non-uniqueness of the selected historical water supply strategy was addressed by the formulation of a second model, which was based on the first solution. Numerous other sensitivity analyses were also conducted using these two models. Both models are solved using a two-stage progressive optimality algorithm along with genetic algorithms (GAs) and the EPANET2 water distribution network solver. This process reduced the required solution time and generated a historically consistent water supply strategy for the water distribution system.

Optimal reconstruction of historical water supply to a distribution system: B. Applications.

In a recently completed case-control epidemiological study, the New Jersey Department of Health and Senior Services (NJDHSS) with support from the Agency for Toxic Substances and Disease Registry (ATSDR) documented an association between prenatal exposure to a specific contaminated community water source and leukaemia in female children. An important and necessary step in the epidemiological study was the reconstruction of the historical water supply strategy of the water distribution system serving the Dover Township area, New Jersey. The sensitivity of solutions to: (1) pressure and pattern factor constraints, (2) allowable operational extremes of water levels in the storage tanks, and (3) the non-uniqueness of the water supply solution are analysed in detail. The computational results show that the proposed approach yields satisfactory results for the complete set of monthly simulations and sensitivity analyses, providing a consistent approach for identifying the historical water supply strategy of the water distribution system. Sensitivity analyses indicated that the alternative strategy obtained from the revised objective function and the variation of constraints did not yield significantly different water supply characteristics. The overall analysis demonstrates that the progressive optimality genetic algorithm (POGA) developed to solve the optimization problem is an effective and efficient algorithm for the reconstruction of water supply strategies in water distribution systems.

EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).

OBJECTIVES: To develop evidence based recommendations for the management of hand osteoarthritis (OA). METHODS: The multidisciplinary guideline development group comprised 16 rheumatologists, one physiatrist, one orthopaedic surgeon, two allied health professionals, and one evidence based medicine expert, representing 15 different European countries. Each participant contributed up to 10 propositions describing key clinical points for management of hand OA. Final recommendations were agreed using a Delphi consensus approach. A systematic search of Medline, Embase, CINAHL, Science Citation Index, AMED, Cochrane Library, HTA, and NICE reports was used to identify the best available research evidence to support each proposition. Where possible, the effect size and number needed to treat were calculated for efficacy. Relative risk or odds ratio was estimated for safety, and incremental cost effectiveness ratio was used for cost effectiveness. The strength of recommendation was provided according to research evidence, clinical expertise, and perceived patient preference. RESULTS: Eleven key propositions involving 17 treatment modalities were generated through three Delphi rounds. Treatment topics included general considerations (for example, clinical features, risk factors, comorbidities), non-pharmacological (for example, education plus exercise, local heat, and splint), pharmacological (for example, paracetamol, NSAIDs, NSAIDs plus gastroprotective agents, COX-2 inhibitors, systemic slow acting disease modifying drugs, intra-articular corticosteroids), and surgery. Of 17 treatment modalities, only six were supported by research evidence (education plus exercise, NSAIDs, COX-2 inhibitors, topical NSAIDs, topical capsaicin, and chondroitin sulphate). Others were supported either by evidence extrapolated from studies of OA affecting other joint sites or by expert opinion. Strength of recommendation varied according to level of evidence, benefits and harms/costs of the treatment, and clinical expertise. CONCLUSION: Eleven key recommendations for treatment of hand OA were developed using a combination of research based evidence and expert consensus. The evidence was evaluated and the strength of recommendation was provided.

Lack of agreement between patients' and physicians' perspectives of rheumatoid arthritis disease activity changes.

OBJECTIVE: To obtain information on changes in patients' satisfaction (PATSAT) and physicians' global assessment (PhGASS) with regard to rheumatoid arthritis (RA) activity fluctuations. METHODS: Eighty-eight RA outpatients out of 207 investigated were assessed for 3 months on average after the initial evaluation. PATSAT (1 = excellent to 5 = unsatisfactory), PhGASS (visual analogue scale 1-100), and the 28-joint Disease Activity Score (DAS28) were assessed as at the first evaluation. The only prerequisite for enrolment was any therapeutic change at the first visit. Changes in PATSAT (SATCH) and PhGASS (PhGACH) were categorized and subsequently related to the DAS28 changes. Statistical evaluation was carried out by the Kruskal-Wallis test, the Mann-Whitney U-test, and by kappa statistics. RESULTS: To achieve a positive SATCH (n = 26/88 patients), a median DAS28 reduction of -1.06 (-25.0%) was necessary, whereas a considerably lower median increase of +0.16 (+10.5%) caused a negative SATCH. PhGASS (n = 38/88 patients) changed positively on a median DAS28 reduction of -0.82 (-16.0%), whereas it worsened at a mean DAS28 increase of +0.55 (+16.5%). Approximately 60% congruence between SATCH and PhGACH could be observed (kappa = 0.139). The DAS28 values preceding a positive SATCH and PhGACH were significantly higher (p < 0.001) than before a negative change. CONCLUSION: The patients' perspective with respect to improvement or worsening of RA is asymmetric. In contrast to the physicians' perspective, patients require greater improvement to be satisfied and less deterioration to be dissatisfied. These results may provide additional guidance in considerations about defining response and non-response in RA.

[Modern antirheumatic pharmacotherapy. Low molecular weight substances vs. biologicals]. / Moderne antirheumatische Pharmakotherapie Niedermolekulare Substanzen vs. Biologicals.

Rheumatoid arthritis potentially causes joint destruction, organ failures, and accompanying disorders. Therefore initiating therapeutic measures as early as possible is crucial, whereby symptomatic treatment only is definitely insufficient. Among the traditional disease-modifying antirheumatic drugs (DMARD) Methotrexate is regarded the gold standard. Increasing knowledge of cell-interactions, particularly of the cytokine-cascade, resulted in new therapeutic options. Direct impact via "biologicals" on key inflammatory mediators, primarily TNF-alpha, offers the possibility of effectively modulating or even arresting disease progression. Nowadays, those substances are applied in non-responders to traditional DMARD. Despite their benefits, cons like an increased risk for infections, for exacerbating latent tuberculosis and possibly for malignancies must be considered. Thus, a thorough patient check-up before initiating these therapies is mandatory. Pharmacoeconomic aspects influence the discussion about these "new therapies". The high costs of biologicals, however, should be related to the possible reduction of the diseases psychological, social and economic burdens.

[Anti-TNF-alpha therapy as a new option in treatment of rheumatoid arthritis?]. / Anti-TNF-alpha-Therapie als neue Option in der Behandlung der rheumatoiden Arthritis?

Due to intensive research in the field of cytokines during the last decade the knowledge of cytokine mediated processes has increased intensively. Modulation or even inhibition of the inflammatory cascade gave hope to effective therapeutic possibilities in sepsis or autoimmune diseases, particularly in rheumatoid arthritis (RA). Interestingly the application of biological immunomodulating substances could not increase the prognosis in sepsis, sometimes even deterioration occurred. However, in inflammatory bowel diseases and RA substantial efficacy could be revealed. Since blockade of II-1 or II-2 led to some beneficial results, but also sometimes to significant toxicity, TNF-alpha blockade gave hope to constitute a promising therapeutical target. Since the efficacy of a monoclonal anti-TNF-alpha antibody and a recombinant soluble TNF receptor p75 fusion protein had been demonstrated in animal studies and in vitro, these results could be confirmed in controlled multicenter trials, showing significant improvement of patients according to Paulus and/or ACR criteria. However, a final assessment of therapeutical TNF-alpha blockade in RA cannot be given yet, since the tolerability in long-term application, particularly with respect to the risk of infections and the induction of malignancies and antibodies (e.g. drug induced lupus erythematosus) has to be observed carefully for longer times. Also the cost effectiveness of this new therapeutic approach needs further investigations.

Development of the M-SACRAH, a modified, shortened version of SACRAH (Score for the Assessment and Quantification of Chronic Rheumatoid Affections of the Hands).

OBJECTIVES: The Score for the Assessment and Quantification of Chronic Rheumatoid Affections of the Hands (SACRAH) is a self-administered questionnaire assessing functional status, stiffness and pain in patients suffering from hand osteoarthritis (HOA) as well as rheumatoid arthritis (RA) of the hand. It consists of 23 questions in three domains, to be answered on 100 mm visual analogue scales (VAS). Our goal was to shorten the original SACRAH by elimination of redundant questions in order to make it easier to use for patients and physicians. METHODS: Following an arbitrary procedure employing high intervariable correlations, redundant questions were eventually eliminated. To validate the shortened version, 60 patients with HOA, recruited at four rheumatological centres in Austria, completed the original SACRAH as well as the shortened version. Fifty-five patients suffering from RA of the hands treated at the Second Department of Medicine, Humanis Klinikum Stockerau, also completed both questionnaires. RESULTS: A total of 11 questions (nine from the function domain and two from the pain domain) were eliminated, leading to the modified score consisting of 12 questions. Comparing the results of SACRAH and M-SACRAH, as well as the domain scores in individual patients, correlation coefficients were r = 0.978 for HOA patients (P < 0.0001) and r = 0.986 for RA patients (P < 0.0001). CONCLUSION: M-SACRAH, the shortened and simplified version of the original SACRAH questionnaire, proved to be as reliable and as representative as SACRAH for hand status in individual HOA and RA patients.

SACRAH: a score for assessment and quantification of chronic rheumatic affections of the hands.

OBJECTIVES: To establish a questionnaire to quantify the extent of the function and activities of the hand in patients with degenerative or inflammatory disease of the hand and finger joints. METHODS: One hundred and seventy-two patients with osteoarthritis (OA, n = 69) or rheumatoid arthritis (RA, n = 103) completed a new questionnaire, the SACRAH, that included 23 visual analogue scales covering the extent of hand function, stiffness and level of pain. SACRAH scores may range from 0 to 100. RESULTS: Comparing all studied patients, there was no significant difference in SACRAH scores between OA and RA patients (34 vs 32, not significant). Scores for both patient groups differed significantly from those for 30 healthy controls. Among patients taking NSAIDs only, individuals suffering from OA (n = 50) scored significantly lower than RA patients (n = 42) (36 vs 48, P < 0.004). Sixty-one RA patients taking DMARDs scored lower than the RA patient group treated with NSAIDs only (20 vs 48, P < 0.0001). Thirty-two RA patients were evaluated longitudinally at their first visit and 3 months after the initiation of DMARDs. Following therapy, SACRAH scores were significantly reduced from 50 to 11 (P < 0.0001). CONCLUSIONS: The questionnaire enables the quantification of compromised hand function, stiffness and pain in OA and RA patients, and is sensitive to therapy-related changes in RA patients.

The DAS28 in rheumatoid arthritis and fibromyalgia patients.

OBJECTIVE: To compare the DAS28 (Disease Activity Score including a 28-joint count) values of rheumatoid arthritis (RA) and fibromyalgia (FM) patients, and to establish whether high pain levels and impaired mood influence DAS28 values. METHODS: DAS28 values were calculated in 62 consecutive patients with RA and in 26 patients suffering from FM. Values for DAS28 scores as well as for the single items of the patient cohorts were compared using Student's t-tests. To evaluate the item weighting and internal consistency of the total score factor analysis was performed and Cronbach's alpha calculated. RESULTS: RA patients showed a mean DAS28 score of 4.23 (+/-1.2; range 0.77-7.46) and in FM patients the mean DAS28 came to 4.04 (+/-1.13; range 1.19-6.28). DAS28 values of RA and FM patients were not significantly different statistically. Comparing the single components of the score, however, highly significant differences (P<0.0005) occurred between RA and FM patients. Cronbach's alpha for the DAS28 in RA patients amounted to 0.7329, indicating high internal consistency, whereas in FM patients it was 0.4832. CONCLUSION: The DAS28, as expected, proved to be inappropriate to express disease activity in FM patients. DAS28 values for expressing disease activity in RA patients may be flawed by coexisting FM and should therefore be regarded with caution as high pain levels more than impaired mood may lead to higher total scores.

EULAR response criteria for polymyalgia rheumatica: results of an initiative of the European Collaborating Polymyalgia Rheumatica Group (subcommittee of ESCISIT).

OBJECTIVE: To develop response criteria for polymyalgia rheumatica (PMR) for monitoring treatment and comparing alternative treatments regimens. METHODS: 76 patients, mean (SD) age 68.7 (7.7) years, were enrolled. Corticosteroids, and non-steroidal anti-inflammatory drugs (NSAIDs) were the only drugs allowed during the observation period. Erythrocyte sedimentation rate (ESR), C reactive protein (CRP), alpha(2) globulin, serum iron, pain, physician's global assessment (PGA), morning stiffness (MST), muscle tenderness (MT), myalgia, and the elevation of upper limbs (EUL) were determined regularly. The daily corticosteroid and NSAID doses as the corticosteroid response time were recorded. To ensure evaluation of an adequate number of patients (n = 57) week 24 was chosen for final analysis. RESULTS: ESR, CRP, alpha(2) globulin, pain, PGA, MST, myalgia, MT, and EUL showed significant improvement (p<0.0001) at week 24 compared with week 0. Multiple regression analysis showed that changes of ESR (p = 0.08), CRP (p = 0.41), alpha(2) globulin (p = 0.13), MST (p = 0.1), and MT (p = 0.07) were independent of pain, but myalgia (p<0.001) and EUL (p = 0.003) were pain dependent. Consequently, a core set of PMR response criteria, comprising ESR or CRP, pain, PGA, MST, and EUL was established. Assessment of treatment responses with this core set resulted in 90%, 70%, 50%, and 20% improvement in 31/57 (54%), 46/57 (81%), 51/57 (89%), and 54/57 (95%) of the patients, respectively. CONCLUSION: These PMR response criteria are a promising tool for better monitoring of disease activity and treatment in PMR. It is proposed that these criteria should be used in clinical trials in the near future to explore alternative treatment options for PMR.