Delegation ärztlicher Leistungen an rheumatologische Fachassistenten: Effekte auf Depression und Angst bei Patienten mit rheumatoider Arthritis

Background: At least 1 comorbidity occurs in 80% of patients with rheumatoid arthritis (RA). In addition to cardiovascular comorbidities psychological comorbid conditions are common. The prevalence of depression and anxiety is higher in patients than in the general population. Screening for comorbidities is crucial. A shortage of outpatient specialist care barely allows resources for this. The implementation of team-based care holds the potential to improve the standard of care while simultaneously working against the shortage of care. Objective: The aim of the study was to examine the effects of care on the course of depression and anxiety in patients with seropositive RA and active disease. Material and methods: A multicenter pragmatic randomized controlled trial was conducted over the course of 1 year with 224 patients. After baseline, five more visits followed. In the intervention group (IG), three were initially carried out by qualified rheumatological assistants. Depression, anxiety and patient satisfaction with outpatient care were looked at in detail. Results: In the IG the anxiety symptoms significantly improved over 12 months (p = 0.036). The proportions of patients with anxiety also significantly changed in the IG (p < 0.001), while there was no change in the control group between baseline and month 12. The values of the depression scale did not differ significantly (p = 0.866). In terms of the information dimension of the satisfaction questionnaire, patients in the IG felt significantly better informed after 6 months (p = 0.013) and 12 months (p = 0.003). Conclusion: A positive effect of team-based care on the course of depression and anxiety in patients with seropositive RA and active disease could be shown.Hintergrund: Bei 80 % der Patienten mit einer rheumatoiden Arthritis (RA) tritt mindestens eine Komorbidität auf. Neben kardiovaskulären Komorbiditäten sind psychische Erkrankungen häufig. Die Prävalenz von Depression und Angst ist bei Betroffenen höher als in der Allgemeinbevölkerung. Ein Screening auf Komorbidität ist hoch relevant. Die Unterversorgung im fachärztlichen Bereich lässt dies kaum zu. Die Implementierung einer Visite durch die rheumatologische Fachassistenz (RFA) bietet Potenzial, die Versorgung zu verbessern und der Unterversorgung zu begegnen. Fragestellung: Ziel ist, Auswirkungen einer teambasierten Versorgung auf den Verlauf von Depression und Angst bei Patienten mit einer seropositiven RA im Krankheitsschub zu untersuchen. Material und Methoden: Es handelt sich um eine multizentrische, pragmatische, randomisierte, kontrollierte Studie über 1 Jahr mit 224 Patienten. Nach Baseline folgen 5 Visiten. In der Interventionsgruppe (IG) fanden 3 zunächst bei der RFA statt. Depression, Angst und Behandlungszufriedenheit werden genauer betrachtet. Ergebnisse: In der IG hat sich die ängstliche Symptomatik über 12 Monate signifikant verbessert (p = 0,036). Auch die Anteile der Patienten mit Ängstlichkeit verändern sich signifikant in der Interventionsgruppe (p < 0,001), während es in der Kontrollgruppe im Vergleich zwischen Baseline und Monat 12 zu keiner Veränderung kam. Die Werte der Depressionsskala unterschieden sich nicht signifikant (p = 0,866). Bei der Dimension „Information“ des Zufriedenheitsfragebogens haben sich die Patienten in der IG nach 6 (p = 0,013) und 12 Monaten (p = 0,003) signifikant besser informiert gefühlt. Diskussion: Ein positiver Effekt der teambasierten Versorgung auf den Verlauf von Depression und Angst bei Patienten mit einer seropositiven RA im Krankheitsschub konnte gezeigt werden

Effect of nurse-led care on outcomes in patients with ACPA/RF-positive rheumatoid arthritis with active disease undergoing treat-to-target: a multicentre randomised controlled trial

Objective To determine the non-inferiority of nurse-led care (NLC) in patients with anticitrullinated protein antibody (ACPA)-positive and/or rheumatoid factor (RF)-positive rheumatoid arthritis (RA) with active disease who are starting disease-modifying antirheumatic drug therapy, following treat-to-target (T2T) recommendations.Methods A multicentre, pragmatic randomised controlled trial was conducted to assess clinical effectiveness, anxiety, depression and patient satisfaction following a non-inferiority design. The participants were 224 adults with ACPA/RF-positive RA who were randomly assigned to either NLC or rheumatologist-led care (RLC). The primary outcome was the Disease Activity Score in 28 Joints measured with C reactive protein (DAS28-CRP) assessed at baseline and after 3, 6, 9 and 12 months. A DAS28-CRP difference of 0.6 was set as the non-inferiority margin. Mean differences between the groups were assessed following per-protocol and intention-to-treat strategies.Results Demographic data and baseline characteristics of patients in the NLC group (n=111) were comparable to those of patients in the RLC group (n=113). The improvement in disease activity (change in DAS28-CRP, primary outcome) over the course of 12 months was significant in both groups (p&lt;0.001). No significant differences were observed between the NLC and RLC groups (p=0.317). Non-inferiority of NLC was shown for the primary outcome and all secondary outcomes.Conclusion This study supported the non-inferiority of NLC in managing T2T and follow-up care of patients with RA with moderate to high disease activity and poor prognostic factors in addition to RLC.Trial registration number DRKS00013055

Human liver histology.

<p><b>a) Human hepatic Sirius Red staining.</b> Liver specimen of healthy control and NCIPH were stained with Sirius red to detect collagen fibers. The staining of Sirius red was increased in NCIPH patients compared to healthy controls. <b>b) Human hepatic αSMA staining.</b> Liver specimen of healthy control and NCIPH were stained with αSMA to detect activated hepatic stellate cells. The staining of αSMA was increased in NCIPH patients compared to healthy controls. <b>c) Human hepatic CD105 staining.</b> Liver specimen of healthy control and NCIPH were stained with CD105 to detect endoglin, which is involved in the cytoskeletal organization affecting cell morphology and migration of endothelial cells. The staining of CD105 was increased in NCIPH patients compared to healthy controls. <b>d) Quantification of human hepatic stainings.</b> Sirius red, αSMA and CD105 stainings were quantified in human NCIPH liver specimen and compared to healthy controls using computerized image capture (Histoquant; 3DHistech, Budapest, Hungary). All stainings were significantly increased in NCIPH liver specimens compared to healthy controls. */**/***p<0.05/0.001/0.0001.</p

General characteristics of the patients with NCIPH.

<p>General characteristics of the patients have been investigated in all patients and are shown in all patients. Characteristics of the parenchyma and of the liver have been evaluated by senior pathologists in specimens of the liver biopsies.</p

Portal and systemic hemodynamic assessment and the NCIPH model.

<p><b>a) Portal pressure.</b> Portal pressure was taken every week in weekly embolized and in control rats. In single embolized rats, the PP was taken at the beginning and the end of experiment. Portal pressures are shown in mmHg. Significant differences are evaluated using paired t-Test within the same group. <b>b) Portal pressure at the end of experiments.</b> At the end of experiments, the portal pressures were measured invasively in all rats. After weekly embolization, the PP was significantly higher compared to rats after a single embolization. The portal pressures are shown in mmHg. The significant difference to single embolized rats is evaluated using the nonparametric Mann-Whitney test. <b>c) Mesenteric blood flow.</b> The mesenteric blood flow was investigated at the end of experiment. The results are shown in ml/min/100g/kg body weight. The mesenteric blood flow was increased significantly in weekly embolized rats compared to single embolized and control rats. <b>d) Mesenteric shunt volume.</b> The mesenteric shunt volume was assessed at the end of experiment. The results of weekly, single embolized and control rats are shown in ml/min/g liver. The mesenteric shunt volume was increased most in weekly embolized rats and less in single embolized rats. In control rats the mesenteric shunt volume was lowest. <b>e) Splanchnic vascular resistance.</b> At the end of experiments the splanchnic vascular resistance was assessed using the coloured microsphere technique. The splanchnic vascular resistance was significantly decreased after weekly embolization in rats. The results of are shown in mmHg/min/100g/ml. *p<0.05 / **p<0.005 / ***p<0.0008 vs. Control; #p<0.05 vs. single embolization.</p

Sensitivity and Specificity of Autoantibodies Against CD 74 in Nonradiographic Axial Spondyloarthritis

ObjectiveAutoantibodies against CD74 (anti-CD74) are associated with ankylosing spondylitis (AS). The present multicenter study, the International Spondyloarthritis Autoantibody (InterSpA) trial, was undertaken to compare the sensitivity and specificity of anti-CD74 and HLA-B27 in identifying patients with nonradiographic axial spondyloarthritis (axSpA). MethodsPatients ages 18-45 years with inflammatory back pain of 2 years' duration and a clinical suspicion of axSpA were recruited. HLA-B27 genotyping and magnetic resonance imaging of sacroiliac joints were performed in all patients. One hundred forty-nine patients with chronic inflammatory back pain (IBP) not caused by axSpA served as controls, and additional controls included 50 AS patients and 100 blood donors whose specimens were analyzed. ResultsOne hundred patients with inflammatory back pain received a diagnosis of nonradiographic axSpA from the investigators and fulfilled the Assessment of SpondyloArthritis international Society (ASAS) criteria. The mean age was 29 years, and the mean symptom duration was 12.5 months. The sensitivity of IgA anti-CD74 and IgG anti-CD74 for identifying the 100 axSpA patients was 47% and 17%, respectively. The specificity of both IgA anti-CD74 and IgG anti-CD74 was 95.3%. The sensitivity of HLA-B27 was 81%. The positive likelihood ratios were 10.0 (IgA anti-CD74), 3.6 (IgG anti-CD74), and 8.1 (HLA-B27). Assuming a 5% pretest probability of axSpA in chronic back pain patients, the posttest probability, after consideration of the respective positive test results, was 33.3% for IgA anti-CD74, 15.3% for IgG anti-CD74, and 28.8% for HLA-B27. A combination of IgA anti-CD74 and HLA-B27 results in a posttest probability of 80.2%. ConclusionIgA anti-CD74 may be a useful tool for identifying axSpA. The diagnostic value of the test in daily practice requires further confirmation

Entwicklung von Qualitätsstandards für die Versorgung von Patient*innen mit rheumatoider Arthritis zur Anwendung in Deutschland

Trotz einer qualitativ und strukturell guten Versorgung von Patient*innen mit rheumatoider Arthritis (RA) in Deutschland bestehen weiterhin potenziell behebbare Defizite in der Qualität der Versorgung. Aus diesem Grund hat die Deutsche Gesellschaft für Rheumatologie (DGRh) eine Expert*innengruppe, in der verschiedene Interessengruppen vertreten waren, beauftragt, nationale Qualitätsstandards (QS) mit dem Ziel zu entwickeln, die rheumatologische Versorgung von Patient*innen mit RA in Deutschland qualitativ zu verbessern. QS dienen der Festlegung und quantitativen Messung guter Versorgungsqualität unter dem Vorbehalt von Relevanz und Realisierbarkeit. Als Grundlage für die Entwicklung dienten die kürzlich publizierten Standards von NICE und ASAS und eine systematische Literatursuche. Insgesamt wurden 8 hiermit erstmals veröffentlichte QS konsentiert, die als Grundlage dienen können, die Versorgungsqualität von Patient*innen mit RA in Deutschland zu messen und weiter zu optimieren.Despite a qualitatively and structurally good care of patients with rheumatoid arthritis (RA) in Germany, there are still potentially amendable deficits in the quality of care. For this reason, the German Society for Rheumatology (DGRh) has therefore decided to ask a group of experts including various stakeholders to develop quality standards (QS) for the care of patients with RA in order to improve the quality of care. The QS are used to determine and quantitatively measure the quality of care, subject to relevance and feasibility. The recently published NICE and ASAS standards and a systematic literature search were used as the basis for development. A total of 8 QS, now published for the first time, were approved with the intention to measure and further optimize the quality of care for patients with RA in Germany