Zeitschrift fur Rheumatologie最新文献

Background: The number and scope of work of rheumatology specialists are crucial for the care of patients with inflammatory rheumatic diseases. We report on current developments in numbers of rheumatologists up to 2024.

Methods: The number of internal medicine specialists in rheumatology is reported by age group, gender, field of activity, and scope of activity based on medical statistics from the German Medical Association (BÄK), the Federal Register of Physicians of the National Association of Statutory Health Insurance Physicians (KBV), basic data from hospitals, and extrapolated to the population figures of the Federal Statistical Office.

Results: As of 31 December 2024, there were 1161 practicing rheumatology specialists, of whom 531 (46%) were female and 386 (33%) were aged 60 or older. The number and proportion of rheumatologists under the age of 60 fell from 806 (73%) in 2020 to 775 (67%) in 2024. A total of 725 rheumatologists were accredited to work in outpatient practices for national health insurance patients. Of these, 301 (42%) were employed, an increase compared with 2020 (148 [30%]). In contrast, the number of licensed rheumatologists fell from 392 (57%) to 365 (50%). For every 100,000 adults in Germany, there were 1.7 practicing rheumatologists, 1.0 of whom was accredited to outpatient contracted care, with regional variations ranging from 0.8 in Saarland to 1.6 in Brandenburg and Hamburg (persons, not full-time employees). Since 2018, the number of rheumatologists in hospitals has risen from 360 to 386 in 2023; part-time employment increased from 25% to 39%. The annual average number of full-time inpatient staff has fallen from 340 to 312. Between 2020 and 2024, a total of 303 new rheumatology specialists were recognized, corresponding to an average of 61 specialists per year.

Conclusion: The decline in the number of younger rheumatology specialists, coupled with an increase in part-time work, is leading to a decrease in rheumatology capacity in Germany. The current rate of further training is not sufficient to compensate for the age-related retirement of rheumatologists, let alone the loss of full-time positions.

This review article presents the histopathological differential diagnostics of malignant and benign joint tumors as well as pseudotumors of the joints and the peri-implant tissue. Methodologically, these integrative diagnostics are based on conventional standard staining procedures, on immunohistochemical analyses of formalin-fixed and paraffin-embedded (FFPE) tissues and also on molecular diagnostic procedures, which can be particularly useful in the diagnosis of benign and malignant joint tumors. For joint tumors S100, smooth muscle (SM) actin, cluster of differentiation (CD) 68, CD34, signal transducer and activator of transcription (STAT) 6, clusterin, mucin 4 (Muc-4), beta-catenin and mouse double minute 2 homolog (MDM2) fluorescence in situ hybridization (FISH) are recommended. For the differential diagnostic typing of periarticular carcinoma metastases cytokeratin (CK, AE1/AE3), CK8, p63, thyroid transcription factor (TTF)-1, thyroglobin (TGB), prostate-specific antigen (PSA), androgen receptor, GATA, CD56, chromogranin, caudal type homeobox (CDX) 2, special AT-rich sequence-binding protein 2 (SATB2), spalt like transcription factor 4 (SALL4), estrogen and progesterone receptors, CD45LCA, CD30, CD79a and S100 are recommended. Necrosis, pronounced inflammatory infiltration and reparative inflammatory changes can make histopathological classification difficult. Therefore, the correlation with clinical, microbiological and radiological imaging data may be necessary in the sense of interdisciplinary integrative diagnostics. In the case of histopathological findings that reveal questionable representativeness, the report should definitely refer to the need for clinical or radiological control as well as the need for a second biopsy.

Amyloidosis denotes a group of rare, but often fatal diseases which result from abnormal folding and deposition of insoluble proteins with subsequent organ damage especially of the heart and the kidneys. Histologic identification of amyloid by Congo red staining and by immunohistochemistry in the musculoskeletal system by orthopedic pathology especially in specimens from surgery for carpal tunnel syndrome, lumbar spinal stenosis and spontaneous tendon rupture, but also from other sites of the musculoskeletal system may facilitate early diagnosis and treatment of amyloidosis. Appropriate techniques for the detection of amyloid should be included in the routine diagnostic workup of all rheumatologic pathology specimens.

An 81-year-old man presented with progressive tumorous swelling of the infrapatellar region of the left knee joint. X‑ray imaging was suggestive of bursosynovial chondromatosis or ectopic calcification. Histopathological examination of the resected tissue combined with laboratory findings of renal insufficiency and secondary hyperparathyroidism led to the diagnosis of tumoral calcinosis, which is a rare subentity of ectopic calcification.

The histopathological differential diagnoses of inflammatory infectious and inflammatory noninfectious diseases of the musculoskeletal system, particularly infectious and noninfectious arthritis, soft tissue inflammation and osteomyelitis in rheumatology are presented with a focus on the differential diagnostic possibilities and limitations; however, a diverse spectrum of pathogenic mechanisms underly these diseases, which can present with similar inflammatory response patterns. This wide spectrum of inflammatory pathogenesis of infectious and noninfectious diseases includes diseases such as rheumatoid arthritis, gouty arthritis, osteomyelitis and pyoderma gangrenosum, which cannot clinically be manifested thus necessitating a histopathological clarification. In terms of tissue sampling the following general principle applies: the larger the tissue sample and the more diverse the sites of tissue extraction, the more conclusive are the histopathological diagnostics. This diagnostic approach to infections, especially in a rheumatological context, is generally considered complementary and even supplementary to microbiological diagnostics. Furthermore, consideration of the virulence-resistance relationship, which can alter the inflammatory pattern, is of additional relevance. Consequently, definitive causal diagnostics are only achievable within the clinical, rheumatological, microbiological, laboratory medical and infectiological context.