Synovektomie der gro?en Gelenke in der ?ra der Biologika

Since the mid 1980s, a global decrease in surgical procedures related to rheumatoid arthritis (RA) has been documented for joint-preserving procedures such as synovectomy as well as joint replacement surgery. This reflects improvements in the early management of rheumatoid arthritis and availability of more effective medical treatment. The present review summarizes the recent literature on the frequency of orthopaedic surgery in RA patients as well as the role of synovectomy in the rheumatoid hip, knee and shoulder in times of biological RA therapy.     

Strukturelle Weiterentwicklung der Pflegeversicherung – nach der Reform ist vor der Reform

Ohne Zusammenfassung     

Gesundheits?konomische Bewertung der Kombinationstherapie der rheumatoiden Arthritis mit Methotrexat und Etanercept auf der Basis der TEMPO-Studie

Background

The TEMPO study has shown that the combination of etanercept and methotrexat (MTX) in the treatment of rheumatoid arthritis (RA) is superior to monotherapy. It further suggested that remission of RA is a realistic treatment objective. A health-economic assessment of the combination needs to demonstrate the suitability of the combination for daily clinical practice taking economic aspects into consideration.

Patients and methods

For the 686 patients in the TEMPO study, a re-analysis was carried out in the form of a Monte-Carlo-Markov-Chain simulation. Study types were cost-effectiveness analysis and cost-utility analysis. Comparators were combined etanercept and MTX vs. MTX alone; the perspective was that of society as a whole.

Results

The incremental cost-effectiveness ratio of the combination is €21,300 per life year in remission as compared with MTX alone. The incremental cost-utility ratio of the combination is €38,700 per quality-adjusted life year.

Conclusion

Both health-economic parameters suggest to adopt the combination therapy into daily clinical practice of RA patients.     

Klinische Untersuchungen zu der Frage der Bedeutung der Milz und der Leber für Kreislauf und Herz

Zusammenfassung Bei 19 Splenektomierten nach traumatischer Ruptur und bei 33 Leberverletzten, bei denen das Unfallereignis jeweils mehr als 2 Jahre zurücklag, konnten an Hand von eingehenden elektrokardiographischen und hämodynamischen Untersuchungen in Ruhe und bei Sauerstoffmangel in der Unterdruckkammer sowie bei verschiedenen Untersuchungen unter Arbeitsbelastung keine objektiv nachweisbaren krankhaften Veränderungen am Herzen und am Kreislauf festgestellt werden. Die Anpassungsfähigkeit des herzmuskels, der Lungenfunktionen und des Kreislaufs an stärkeren Sauerstoffmangel (4000 m Höhe) war, im Gegensatz zu den Tierversuchen vonRein, bei den von uns untersuchten Patienten nicht gestört. Ein Ausfall eines Regulationssystems Leber-Milz 2 Jahre nach einer Milzexstirpation oder Leberverletzung war nicht festzustellen. — Auf die versicherungsrechtliche Bedeutung der Untersuchungsergebnisse wurde hingewiesen.Mit 1 Abbildung     

Medikamentöse Therapie der Komplikationen der Leberzirrhose

Patients with liver cirrhosis bear a considerable risk of a variety of complications that involve virtually all organ systems. They can be addressed with a wide spectrum of drugs for acute interventions as well as for prophylactic purposes. At the same time treatment of the underlying disease, the identification and treatment of triggering factors and the possibility of liver transplantation should be kept in mind.     

Möglichkeiten der Regression bei der Arteriosklerose

We studied the hypercholesterolemic rabbit model in order to evaluate potentials of regression of arteriosclerosis by measuring various blood and plaque parameters. After induction of arteriosclerosis by feeding a 2% cholesterol-enriched diet (CHF) for 6 weeks, the highly increased blood lipid levels decreased significantly under normal diet, while the cholesterol concentration, the lumen stenosis, and the number of smooth muscle cells in the plaques of the thoracic aorta still significantly increased. Sixty-eight weeks after reaching normal blood lipid levels, cellular density and number of macrophages significantly diminished; cholesterol concentration and lumen stenosis did not change significantly, whereas the smooth muscle cells further increased. Arteriosclerotic arteries of elderly people demonstrated a similar structure as seen after long-term regression in our experiments.     

Untersuchungen zur Frage der Züchtbarkeit des Virus der myeloischen Leukämie der Maus in der Gewebekultur

Zusammenfassung Die Zellen der virusbedingten myeloischen Mäuseleukämie produzieren in der Gewebekultur mehrere Wochen lang aktives Virus, wie sich aus der starken leukämogenen Wirkung der zellfreien Kulturflüssigkeit, auch nach mehrfacher Erneuerung der Nährlösung ergibt. Auch in Kulturen von trypsiniertem normalem Mäuseembryonalgewebe findet nach Beimpfung mit zellfreiem Filtrat aus myeloischen Mäuseleukämien mehrere Wochen lang Virusneubildung statt. Elektronenmikroskopisch wurde nachgewiesen, daß die Reproduktion der Viruspartikel vorwiegend an der äußeren Membran der Leukämiezellen durch einen Knospungs- und Abschnürungsprozeß erfolgt.

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Summary In tissue culture the cells of viral induced myelogenous leukemia of the mouse produced active virus for several weeks. This was evident from the strong leukemogenic effect of the cell-free filtrate of the culture, even after the culture medium was renewed several times. After the inoculation of cultures of trypsinized tissues of normal mouse embryo with the cell-free filtrate from mouse myelogenous leukemia the formation of virus continued for several weeks. Electron-microscopically it could be shown, that virus particles reproduced chiefly on the outer membrane of the leukemic cells by means of budding and constricting processes.

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Mit 5 Textabbildungen

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Herrn Prof. Dr. Dr. A. Butenandt zum 60. Geburtstag gewidmet.     

Pulse Pressure in der Therapiesteuerung der Hypertonie?

Data from the Framingham and several other studies have demonstrated a relatively consistent increase of systolic blood pressure over lifetime but a decrease of diastolic blood pressure after the age of 50-60 years-resulting in an increase of pulse pressure (PP). Epidemiologic studies in the past 10-15 years have stressed the importance of PP as an independent risk factor for cardiovascular morbidity and mortality, especially myocardial infarction and congestive heart failure.A wide clinic PP (60-65 mmHg) has been shown to be a marker of increased arterial stiffness and an elevated cardiovascular morbidity. PP is determined by combined hemodynamic cardiac (ventricular ejection) and arterial factors, like arterial stiffness as well as the timing and intensity of wave reflections. Recent careful measurements have suggested that PP is transmitted much deeper into the microcirculation, which is strongly influenced by aging, hypertension, diabetes, and renal insufficiency (endothelial dysfunction, eutrophic and hypertrophic remodeling, progressive loss of microvessels).Antihypertensive drugs may improve vascular compliance and the alterations of microvascular architecture by reducing blood pressure, relaxing vascular smooth muscle, or promoting long-term effects on extracellular matrix, collagen, vascular smooth muscle, and cardiomyocyte growth and remodeling.Diuretics, beta blockers, long-acting calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors and angiotensin I (AT(1)) receptor antagonists were critically discussed in relation to their influence on vascular compliance, endothelial dysfunction, the remodeling process, PP, and cardiovascular morbidity and mortality.The vascular protective action of some (especially AT(1) antagonists, ACE inhibitors, calcium channel blockers) but not all (beta blockers) may contribute to improve the outcome of hypertensive patients, although this is presently unproven.     

Optimierung der Hämodynamik in der Device-Therapie

Ohne Zusammenfassung     

?Treat-To-Target�� aus der Sicht der niedergelassenen Rheumatologie

The development of evidence-based treat-to-target (T2T) recommendations alleviates decision-making for the rheumatologist and simultaneously promises substantial improvement of outcome for rheumatoid arthritis (RA) patients. For the office-based rheumatologist in Germany, however, implementation of T2T recommendations contains several difficulties. Limitations arise as a result of an insufficient number of rheumatologists as well as a lack of adequate remuneration both resulting in a lack of time for the individual RA patient. Furthermore budget limitations hinder the appropriate use of antirheumatic drugs and insofar counteract treating to the target of remission. Establishment of selective contracts for rheumatologists by health insurance funds might reduce many of these problems in future for the office-based rheumatologist in Germany.     

Was ist gesichert in der Therapie der COPD?

The treatment of chronic obstructive pulmonary disease (COPD) with or without emphysema includes prevention, management of exacerbation and of stable disease. Smoking cessation is the most important intervention to reduce the risk of developing COPD and stop its progression. Bronchodilator medications and inhaled glucocorticosteroids are given to reduce symptoms and exacerbations in long-term medical therapy. Pulmonary rehabilitation including exercise training and patient education improves symptoms and morbidity. The management of exacerbations includes intensified treatments with bronchodilators, systemic corticosteroids for 10–14 days, as well as the use of O₂ for patients with hypoxia and non invasive or invasive ventilation in the case of acidosis and hypercapnia.     

Klinische Ergebnismessgrößen bei Arthrose der Hand- und Fingergelenke aus der Perspektive der Patienten

Osteoarthritis (OA) is the most common joint disease. While research activities in OA have concentrated on the knee and hip in recent years, knowledge and research results in the field of hand OA are still limited. In order to measure the effects of treatment or to obtain information on the course of a disease and the health status of a patient, outcome measures are commonly used in rheumatology. Such measures are variables which can be quantified and which represent either the perspective of health professionals or the perspective of patients or both. The aim of this article is to evaluate clinical outcome measures and corresponding instruments which are currently used for patients with hand OA, and to examine whether these measures and instruments represent the perspective of patients. For hand OA, measurements of disease activity and inflammation, function and performance, pain, mobility and stiffness, deformity and aesthetic damage are recommended by experts. Corresponding instruments are available for most of these outcome measures, but these often do not sufficiently represent the perspective of the patients. Some instruments lack reliability because standardized protocols for measurement have not yet been developed.