Zeitschrift fur Rheumatologie最新文献

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are autoimmune inflammatory small-vessel disorders with potentially life-threatening organ manifestations. Recent disease definitions and classification criteria allow distinction between granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA), and non-granulomatous microscopic polyangiitis (MPA). The discovery of ANCA-autoantibodies directed against proteolytic enzymes of neutrophil granules-has enabled earlier diagnosis of AAV and paved the way to stage-adapted treatments. ANCA testing initially relied on different immunofluorescence patterns, i.e., cytoplasmic ANCA (C-ANCA) vs. perinuclear ANCA (P-ANCA), in ethanol-fixed neutrophils. This is nowadays outperformed by well-standardized immunoassays against the ANCA target antigens proteinase 3 (PR3) and myeloperoxidase (MPO) for the diagnosis of small-vessel vasculitides. The discovery of ANCA has contributed substantially to unravelling the pathogenesis of AAV, which comprises neutrophil degranulation, NETosis with concurrently amplified ANCA antigen presentation, and intra- and transmural vascular inflammation involving the alternative complement system in susceptible individuals. There is a genetic disposition concerning certain HLA alleles and polymorphisms of the proteinase 3 gene. Furthermore, epigenetic modifications impact on disease activity and relapse. During follow-up, the ANCA titer is not a reliable mirror of disease activity; however, PR3-ANCA positivity is associated with a greater likelihood of relapse and a better treatment response to rituximab as compared to cyclophosphamide/azathioprine. Within the past 60 years, the discovery of ANCA has revolutionized the ability to diagnose, understand, classify, and treat AAV in a targeted manner.

Background: The StärkeR study has shown the non-inferiority of a team-based form of care with delegation to rheumatological specialist assistants (RFA) compared to standard care in patients with rheumatoid arthritis (RA) or psoriatic arthritis (PsA).

Objective: Exploratory analyses regarding a possible influence of the treatment setting (specialist practice/outpatient clinic) on various outcome parameters in patients with RA or PsA in the context of delegation to RFA.

Material and methods: Patients with RA or PsA and stable adjustment with low disease activity from 3 outpatient clinics and 14 rheumatological specialist practices that participated in the StärkeR study were included in this post hoc analysis. The effectiveness of the team-based form of care depending on the treatment setting was investigated using interaction analyses in linear regression models with respect to disease activity, functional capacity, pain and fatigue, among others.

Results: Out of 588 patients 466 were treated in specialized practices and 92 in hospital outpatient clinics. The analyses showed a significant interaction for one of nine outcomes examined: functional capacity (scale 0-1) had slightly lower values in the hospital outpatient clinics compared to standard care (-0.07 [-0.12; -0.02]), while no such difference was found in the practices. For other outcomes, the team-based form of care in the practice setting tended to show an advantage.

Discussion: These exploratory analyses point to the potential benefits of evaluating different forms of care, such as the delegation of medical services to qualified RFA, in terms of benchmarking.

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.

Spondyloarthritis (SpA) is a heterogenous group of diseases with an yet unknown exact pathogenesis. An interplay between genetic predispositionw (mainly HLA-B*27 positivity), a barrier leakage (of skin and gut) and environmental influences, such as the contact to certain microbiota are suspected to lead to an activation of the immune system and through this to the development and maintenance of the disease.

Reactive arthritis (ReA) is a disease caused by an extra-articular infection that manifests as a sterile joint inflammation. In contrast to bacterial septic arthritis no pathogens can be cultured from the joint in ReA but pathogen components, such as antigens or DNA are more frequently detectable in the joint, suggesting an intra-articular culture-negative persistent infection or at least an intra-articular interaction between the host and pathogen components. The primary extra-articular infection in classical ReA is of bacterial origin and usually affects either the urogenital, gastrointestinal or, less frequently, the respiratory tract. Chlamydia (C. trachomatis and less frequently C. pneumoniae) and enterobacteria are among the most common pathogens causing ReA. The prevalence of ReA is estimated at 40/100,000 and the incidence at 5/100,000. Typical clinical manifestations are mostly self-limiting peripheral arthritis (monoarticular or oligoarticular), dactylitis and, more rarely, axial involvement and in half of the cases, there is an association with HLA-B27. Due to these similarities, classical ReA is categorized as a form of spondyloarthritis (SpA). The diagnosis is made on the basis of a typical clinical picture, evidence of a previous or persistent infection and the exclusion of other causes of arthritis. Treatment includes physical measures, the use of anti-inflammatory agents such as nonsteroidal anti-inflammatory drugs (NSAID) or glucocorticoids, in the case of persistent arthritis, immunomodulating substances such as sulphasalazine, methotrexate and in individual cases biologics and Janus kinase inhibitors (JAKi) are used. In general, antibiotic treatment of ReA does not shorten the duration of the disease.

Objective: This study aimed to examine the effects of a remote video-based cervical stabilization exercise program on cervical proprioception, functional status, and disease-related quality of life in patients with rheumatoid arthritis (RA).

Design: Patients with RA were evaluated regarding cervical joint positioning error, cervical region functional status (Neck Disability Index), general functional status (Health Assessment Questionnaire), and disease-related quality of life (Rheumatoid Arthritis Quality of Life Scale). Patients were randomized to exercise (n = 14, 10 female) and control (n = 12, 9 female) groups. Patients in the exercise group performed a video-based home exercise program consisting of progressive cervical stabilization exercises three times a week for six weeks in addition to their routine medication. The patients in the control group continued their routine medication only. Evaluations were repeated in both groups in the seventh week following the baseline evaluation.

Results: Groups were similar at baseline (p > 0.05). Patients in both groups had low disease activity (DAS-28 CRP ≤ 3.2). The remote video-based exercise program led to significant improvements in cervical proprioception, functional status, and disease-related quality of life (p < 0.05). No significant changes were detected in any parameters in the control group (p > 0.05). Obtained changes were superior in the exercise group compared to the control group (d > 1.00, p < 0.05).

Conclusion: Cervical stabilization exercises may increase cervical proprioception, improve functional status, and enhance disease-related quality of life in patients with RA when administered as a remote program.

Trial number: https://clinicaltrials.gov/study/NCT04948775 , NCT04948775.

Objective: This study aimed to analyze the published data pertaining to the correlation between venous thromboembolism (VTE) and systemic sclerosis (SSc).

Methods: We conducted manual searches and explored MEDLINE, EMBASE, and Cochrane databases to review papers reporting the risk of VTE in patients with SSc. A meta-analysis was performed exploring the relative risks (RRs) of deep vein thrombosis (DVT), pulmonary embolism (PE), and VTE in these individuals.

Results: Six trials that included 41,105 patients with SSc were eligible for inclusion. A meta-analysis of the six included studies revealed a statistically significant correlation (RR 2.372, 95% confidence interval [CI] = 1.608-3.500, p < 0.001) between the risk of VTE and SSc. Regional subgroup study revealed a strong correlation between SSc and VTE risk in Americans, Europeans, and Asians. Additionally, a significant correlation between SSc and PE risk was observed (RR 3.154, 95% CI = 1.320-7.539, p = 0.010). Finally, the meta-analysis revealed a substantial correlation (RR 5.190, 95% CI = 1.513-17.01, p = 0.009) between the risk of DVT and SSc.

Conclusion: This meta-analysis showed that SSc is linked to an increased risk of DVT, PE, and VTE. This finding underscores the importance of close monitoring for the emergence of these conditions in patients with SSc.

Digital health applications (DHAs) are revolutionising patient care by improving access to evidence-based therapy and promoting active self-management. The continuously growing number of DHAs enables patients to act more independently through digital support. The budget-neutral prescription and cost coverage by statutory health insurance companies reduce financial barriers for practitioners and patients. Initial studies show that DHAs can be used successfully to treat comorbidities and rheumatic diseases. Several DHAs for inflammatory rheumatic diseases are at an advanced stage of development. The identification of suitable patients and support through shared decision making are crucial for successful implementation. Challenges remain in adherence and acceptance of the applications. This article provides an overview of prescription in clinical routine, initial data and experiences from the reality of rheumatology care, and reports on current developments.

This article summarizes the current guidelines and recommendations published by the European Alliance of Associations for Rheumatology (EULAR), the Kidney Disease Improving Global Outcomes (KDIGO) and the American College of Rheumatology (ACR). In addition to glucocorticoids (GC), treatment with biologics is nowadays an established option to treat Anti-Neutrophil Cytoplasmic Antibody (ANCA)-associated vasculitis (AAV). Rituximab (RTX) is used for remission induction and maintenance in organ-threatening and non-organ-threatening granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA). For eosinophilic GPA (EGPA) anti-interleukin 5 (IL5) strategies are an important component of treatment for remission induction and maintenance of refractory or relapsing non-organ-threatening diseases in conjunction with GC. The dosing of GC for remission induction in GPA and MPA is now lower than was previously used and additionally, avacopan is approved as a new GC-sparing medication for GPA and MPA over 52 weeks. Conventional strategies, such as cyclophosphamide (CYC) are important for remission induction in severe or refractory organ-threatening disease for all AAVs. The use of methotrexate (MTX) and azathioprine (AZA) is becoming less prominent. The most important unanswered questions in the treatment of AAVs are with respect to the duration of remission maintenance treatment and the individualized treatment guidance based on biomarkers.