Arbeitsunfähigkeit im ersten Jahr der chronischen Polyarthritis. Ein Vergleich mit Pflichtmitgliedern der gesetzlichen Krankenversicherung

Zusammenfassung Obwohl Arbeitsunf?higkeit (AU) eine direkte Folge der durch die Erkrankung reduzierten Arbeitskraft ist, wurde sie im Frühstadium der chronischen Polyarthritis (cP) kaum untersucht. Deshalb wurden die H?ufigkeit und die Dauer der AU in einer multizentrischen Querschnittsstudie von Patienten im Frühstadium der cP (≤12 Monate Krankheitsdauer) im Vergleich zu Pflichtmitgliedern der gesetzlichen Krankenversicherung ermittelt. 134 ambulante erwerbst?tige Patienten erfüllten die Kriterien des American College of Rheumatology für die cP von 1987: 85 Frauen (63% von 134 Patienten), Alter im Median 50 Jahre. AU wurde entsprechend den Patientenangaben zur „Krankschreibung“ dokumentiert. Bei der im Median 7 Monate bestehenden Erkrankung trat bisher wenigstens einmal AU wegen cP bei 102 Patienten (76%) auf. Sie bestand bei den M?nnern für ca. 11 Tage pro Monat, d.h. ca. ein Drittel der Krankheitszeit, und bei den Frauen für 8 Tage pro Monat entsprechend ca. einem Viertel der seit Beginn der cP vergangenen Zeit. AU wegen cP dauerte fast fünfmal l?nger als aufgrund der Referenzdaten zu erwarten war. über die „Krankschreibung“ wegen cP hinaus waren diese Patienten wegen anderer Erkrankungen etwa im gleichen Ausma? wie in die Referenzpopulation arbeitsunf?hig. Der gro?e Anteil der von Arbeitsunf?higkeit wegen cP betroffenen Patienten und die Dauer der AU verdeutlichen das Ausma? gravierender Beeintr?chtigungen der Erwerbst?tigkeit bereits im ersten Jahr der cP. Eingegangen: 21. M?rz 1996 Akzeptiert: 11. November 1996     

Indikation für eine immunsuppressive Therapie bei chronisch entzündlichen Darmerkrankungen

Zusammenfassung Der immunsuppressiven Therapie kommt bei chronischen Darmerkrankungen gro?e Bedeutung zu, insbesondere dort, wo die Standardtherapie nicht den gewünschten Erfolg zeigt. Als Therapie der ersten Wahl gelten bei Colitis ulcerosa 5-Aminosalizyls?ure-freisetzende Medikamente, bei Morbus Crohn Kortikosteroide. Innerhalb der Gruppe immunsuppressiver Pr?parate gibt es erhebliche Wirkungsunterschiede. Darüber hinaus ist die Immunsuppression auch mit ernstzunehmenden Nebenwirkungen belastet. über den Stellenwert der Immunsuppression als Erg?nzung, m?gliche oder bei Unvertr?glichkeit notwendige Substitution der Standardtherapien von Colitis ulcerosa und Morbus Crohn wird hier eingehend referiert. Auch die Behandlung dieser Erkrankungen in der Schwangerschaft wird dabei erl?utert.     

Effects of the chemokine MIP-1alpha on anemia and inflammation in rheumatoid arthritis

Macrophage inflammatory protein-1alpha (MIP-1alpha) is an interesting chemokine because in addition to its variety proinflammatory activities including chemotaxis and immunomodulation, it is a potent inhibitor of hematopoetic stem cell proliferation. Inhibition of erythroid progenitor cells due to MIP-1alpha or other cytokines can play a role in the pathogenesis of anemia which is one of the most common extra-articular features of active rheumatoid arthritis (RA). In 84 patients with RA, serological and immunological parameters were assessed to detect inflammatory mechanisms and anemia in relation to the serum concentrations of MIP-1alpha. All patients fulfilled the ACR criteria for the diagnosis of a definite or classic RA. We used a quantitative enzyme immuno assay for the detection of MIP-1alpha as well as for the measurement of the acute phase protein serum amyloid A (SAA), the erythropoiesis inducer erythropoietin (EPO) and the transferrin receptor (TfR). The immune activation marker neopterin was measured radioimmunologically. Half of the patients with RA were anemic with hemoglobin values below 12 g/dl. MIP-1alpha was found to be elevated significantly in serum of patients with active rheumatoid arthritis and in patients with anemia. Most of the anemic patients with markedly elevated acute phase reactions had an anemia with chronic diseases and not a functional iron deficiency alone. TfR correlated with EPO. The results show that enhanced expression of MIP-1alpha is indicative of systemic inflammation in RA. Moreover, besides the regulation of inflammatory processes, this chemokine may influence the pathogenesis of anemia in RA patients.     

Qualitätsmanagement im interdisziplinären Fachkrankenhaus

The aim of quality management in rheumatology is to improve care and outcome in patients with rheumatic diseases. This can be achieved by means of prospective long-term observation of the patient with regular documentation of clinical, radiological, biochemical and functional data using certain validated scoring methods (DAS, radiological score, ADL score Hanover or Health assessment questionnaire, SF36, etc.). Long-term observation and documentation including radiographs have been performed in the rheumatology hospital in Ratingen for 20 years without even knowing the term quality management. Quality management in a hospital for rheumatic diseases begins with certain structural prerequisites: possibility of direct admission of a patient to the hospital by the family physician, outpatient clinic to investigate and to follow patients over a long period of time, multidisciplinary team with specialists in rheumatology, orthopedic surgery, physiotherapy, ergotherapy, special care, psychological, and social services, close cooperation with specialists in neurology, dermatology, ophthalmology, etc., department of radiology, special laboratory, facilities for internal diagnostic and treatment. The hospital needs a training program for the qualification of rheumatologists and orthopaedic surgeons. The hospital staff should closely cooperate with the doctors in private practice who admit patients and should continuously support patient organizations. The quality of outcome is influenced by the process quality which depends on the following factors: selection, training and motivation of the hospital staff; supervision of clinical assessment and documentation by senior physicians, daily x-ray demonstrations and case reports, interdisciplinary case demonstrations at least every week in addition to daily consultation, team reports, regular education including review of actual literature for physicians, education programs exchanging knowledge with physiotherapists and nurses, and regular education programs for patients. Process quality can only be achieved by an interdisciplinary approach and regular communication between all participants including the patient, whose opinion must be noted and regarded. As far as possible, the same doctor who treats the patient in the hospital should follow her/him in the outpatient clinic. The quality of outcome can be improved by regular reinvestigation of the patient with control of medication, side effects, efficacy, documentation of clinical, biochemical, radiological, and functional data. Decisions for further treatment have to be based on these follow-up data. A standardized follow up and documentation system for all rheumatology units with prompt feedback could definitely improve the quality of rheumatologic care in Germany.     

Aplicación de un modelo de predicción de progresión de artritis reumatoide en pacientes con artritis indiferenciada

IntroductionDifferent prediction rules have been applied to patients with undifferentiated arthritis (UA) to identify those that progress to rheumatoid arthritis (RA). The Leiden Prediction Rule (LPR) has proven useful in different UA cohorts.ObjectiveTo apply the LPR to a cohort of patients with UA of northeastern Mexico.MethodsWe included 47 patients with UA, LPR was applied at baseline. They were evaluated and then classified after one year of follow-up into two groups: those who progressed to RA (according to ACR 1987) and those who did not.Results43% of the AI patients developed RA. In the RA group, 56% of patients obtained a score ≤ 6 and only 15% ≥ 8. 70% who did not progress to RA had a score between 6 and ≤ 8. There was no difference in median score of LPR between groups, p = 0.940.ConclusionMost patients who progressed to RA scored less than 6 points in the LPR. Unlike what was observed in other cohorts, the model in our population did not allow us to predict the progression of the disease.     

Reactive arthritis induced by intravesical BCG therapy for bladder cancer: our clinical experience and systematic review of the literature

Objective

Intravesical instillation of BCG (ivBCG) is an effective and safe immunotherapy of bladder carcinoma but it may have, as side effect, a reactive arthritis (ReA). The authors describe 5 cases observed during their own clinical experience along with the updated review of the literature on this topic.

Methods

Seventy-three papers were present in the world literature, each reporting almost 1 case for a total of 112 patients. However, the review focused on 61 papers, selected on the basis of reporting suitable for a correct clinical evaluation; thus, a total of 89 patients, including the cases observed in our clinic, were carefully analyzed.

Results

Among the 89 patients identified 73 were males and 16 females. Europe is the geographical area with the higher number of reports, namely 80.6% of the papers including 74.2% of the patients. The Mediterranean area accounts for 62.9% of the papers and 59.6% of the cases. The symptoms of ReA appeared after a mean number of instillations of 5.8. Polyarthritis was present in 55.1%, oligoarthritis in 37.0% and monoarthritis in 7.9%. Polyarthritis was symmetric in 51.0% and asymmetric in 49.0% of the cases; oligoarthritis was symmetric in 33.3% and asymmetric in 66.7% of the cases. Overall, an asymmetric distribution of arthritis was present in 59.6%. Knee and ankle were the joints most frequently involved. The antigen HLA B27 was positive in 42.6%. The synovial fluid analysis was defined as flogistic–aseptic in 71.9% of the patients. Arthritis was recovered within 6 months in 93.2% of the cases and in 70.5% of the patients within the first two months. NSAIDs and corticosteroids, alone or in conjunction with other drugs, are used in 65.1% and in 40.4% of the cases, respectively. The clinical features of ivBCG ReA are compared with ReA from other triggering agents, from which it differs for some clinical aspects and overlaps for others.

Conclusions

Compared with a previous report, this review allows to modify some figures of this topic as a reduced prevalence of polyarthritis (from 70% to 55.1%) and of spinal and sacroiliac involvement; polyarthritis remains the more frequent clinical pattern of ivBCG ReA that, however, is characterized by rather asymmetrical distribution and involvement of the large joints of lower limbs. A definite linkage to HLA B27 is present, although without prognostic value. Moreover, arthritis is aseptic, has a latency time from antigen exposure, and is associated with extra-articular features as commonly observed in ReA from other triggering agents. Arthritis is usually benign and rarely develops into a chronic form. NSAIDs and/or corticosteroids are largely effective. Noteworthy, the overall clinical picture of arthritis triggered by ivBCG emerging from this updated review is comparable to that of ReA from other bacterial agents.     

Oligoarthritis im Kindes- und Jugendalter

Early onset pauciarticular juvenile arthritis is the most frequent cause of chronic arthritis in childhood. It affects mostly girls shortly after they started to learn to walk. Diagnosis is by clinical means and laboratory values may be completely normal. Treatment consists of counseling, physiotherapy and pharmacotherapy. After non-steroidal antirheumatic drugs intraarticular steroids are important drugs. Prognosis is favourable, if treatment is given continuously and if the disease does not become polyarticular or chronic iridocyclitis develops. Treatment of chronic arthritis has changed during the last 10 years: patients and their parents are justified to expect a better outcome and health care providers need to be highly qualified to meet these expectations. The early onset pauciarticular juvenile arthritis is part of the group of diseases called juvenile idiopathic arthritis. Patients are 16 years or younger at the onset of arthritis and had uninterrupted arthritis for at least 6 weeks. Oligoarthritis, arthritis in 4 or less joints, can also be found in other diseases including psoriatic arthritis and juvenile spondyloarthropathy. Classification of chronic arthritis in childhood is contradictory and alterations are to be expected.     

Intraerythrocytärer Cyanidstoffwechsel bei chronischer Niereninsuffizienz

Zusammenfassung Zur Frage einer gestörten Cyanidentgiftung als Ursache der in früheren Untersuchungen festgestellten Serumrhodaniderniedrigung bei chronischer Niereninsuffizienz wurden Aktivitätsmessungen des Enzyms Thiosulfat-Sulfurtransferase (EC 2.8.1.1.) nach der Methode von Sörbo durchgeführt. In vitro-Bestimmungen in Leber und Nebenniere der Ratte nach Homogenisation in urämischem Serum erbrachten keinen Unterschied gegenüber Kontrollen; intracrythrocytäre Aktivitätsanalysen ergaben ebenfalls keine Abweichung. In einer enzymatischen Analyse wurde nach Zufügung des Substrates Thiosulfat zu Erythrocytenhomogenaten das intraerythrocytäre, maximal umgesetzte Cyanid als Eisenrhodanidkomplex photometrisch gemessen. Bei 11 chronisch hämodialysierten Patienten war der Cyanidumsatz mit 56,4±34,0 nMol/ml Erythrocytenkonzentrat signifikant erniedrigt (Kontrollkollektiv: 143±61,9 nMol/ml Erythrocytenkonzentrat) und wies eine negative Korrelation zur Höhe des Serumharnstoffs auf. Als Ursache des erniedrigten Serumrhodanidspiegels wird somit eine verminderte endogene Cyanidbildung bei chronischer Niereninsuffizienz angesehen, deren Ausmaß offensichtlich vom Grad der urämischen Intoxikation abhängt; der enzymatische Cyanidentgiftungsmechanismus verläuft ungestört.     

Tagesprofile von Plasmalipiden und Lipoproteinen bei Patienten mit endogener Hypertriglyzeridämie (Typ IV-Hyperlipoproteinämie)

Zusammenfassung Bei 10 Patienten mit primärer endogener Hypertriglyzeridämie (Typ IV-Hyperlipoproteinämie) wurden akute (Tagesprofile) und chronische Wirkungen von 2 fetthaltigen (50 und 37 kcal%) und einer fettfreien, kohlenhydratreichen, isokalorischen Diät auf Plasmalipide und Lipoproteine untersucht. Die zwei fetthaltigen Kostformen mit identischem P/S Quotient und die fettfreie Kostform führten zu ähnlichen Cholesterinspiegeln. Bei den Plasmatriglyzeriden lagen die Nüchternwerte nach den fetthaltigen Kostformen zwar niedriger als nach der kohlenhydratreichen Diätperiode, Tagesprofile zeigten jedoch bei 8 der 10 Patienten eine schlechtere Einstellung. Postprandial kommt es nach fetthaltigen Kostformen neben einer Chylomikronämie auch zu ausgeprägten Veränderungen von Konzentration und Zusammensetzung anderer Lipoproteinklassen.Wenn in Analogie zur Diabetestherapie als Einstellungskriterium der Hypertriglyzeridämie Lipidtagesprofile herangezogen werden, scheint bei der Mehrzahl von Patienten mit endogenen Hypertriglyzeridämien eine relativ kohlenhydratreiche, fettarme Diät fettreicheren Kostformen überlegen zu sein.Mit Unterstützung der Deutschen Forschungsgemeinschaft. SFB 90     

Thrombangiitis obliterans: Eine Übersicht

Thromboangiitis obliterans is a vascular disease characterized by a segmental, non‐atherosclerotic inflammation of the small and medium‐sized arteries and veins. The vascular changes are mainly found on the distal extremities. Involvement of visceral organs is rare. Affected patients are mostly young male smokers, who develop ulcers and gangrene of the toes and fingers as a result of the vascular ischaemia. Diagnosis is made using characteristic clinical criteria as well as pathological findings in arteriography and histopathology. Although the exact underlying causes of Buerger's disease are still unknown, the disease is strongly associated with tobacco smoking. Although most investigators speculate about an autoimmune mechanism, no causative antigens have yet been discovered. The only definite form of therapy is the discontinuation of tobacco use. On the basis of smoking cessation, further therapies (e. g. administration of prostacyclin analoga) are possible. The mortality rate for patients with Buerger's disease is not higher than that for the rest of the adult population, but patients often require minor and major limb amputation due to ulcerations.