Nicht-interventionelles Versorgungsprojekt: Evaluation der Express-Sprechstunde für Patienten mit einer rheumatoiden Arthritis (RA-Express)

Background: Early stages of rheumatic musculoskeletal diseases (RMD) are difficult to diagnose and result in a high use of resources in outpatient clinics. The objective of this thesis is the evaluation of the project “RA-Express”, a structured screening system of the German treat to target initiative for rheumatoid arthritis (RA) for selecting and treating patients with RMD, especially RA, efficiently and early. Methods: 177 patients visited a screening appointment for early arthritis (EA). Inclusion criterion was arthritis in ≥ one joint for less than one year. Patients had three options for accessing the screening: phone call with qualified health professional assistants (HPA), online questionnaire or attending a walk-in clinic. All patients filled in a questionnaire about their symptoms. Patients were split into two groups. In group 1, an HPA gave a suspected diagnosis after having performed the joint count and having analyzed the questionnaire. Subsequently, a rheumatologist saw these patients and made a suspected diagnosis. In group 2, patients were examined directly by a rheumatologist. Additionally, some patients received a point of care test for rapid testing of CRP, Rheumatoid factor IgM and MCV. If an RMD had been suspected, patients received a new ap-pointment for completing diagnostics and starting a therapy. In case of high disease activity, treatment started immediately. Results: Patients had a mean age of 50.9±15.2 years, and 135 (76.3 %) patients were female. 160 (90.4 %) patients accessed to screening by phone call. Ten (5.7 %) patients used the online questionnaire, and seven (3.9 %) patients attended the walk-in clinic. Patients waited 3.1±1.8 weeks for a screening appointment. 34 (56.7 %) patients with an RMD visited the screening within six months after symptom onset. Two (1.7 %) patients had an RMD that had not been suspected by the HPA upon screening in group 1 and subsequently received conventional synthetic Disease-modifying anti-rheumatic drugs (csDMARDs) and glucocorticoids (GC). In group 2, three (4.9 %) patients received csDMARDs although in the screening an RMD had not been suspected by the rheumatologist. 69 (39.0 %) patients finally had an RMD, whereof 43 (24.3 %) patients had an RA. 44 (24.9 %) patients received therapy with csDMARDs, that started 44.8±41.9 days after screening. Six (3.4 %) patients refused a therapy with csDMARDs. 21 (11.9 %) patients started treatment at the screening appointment. Conclusions: A structured screening system using the support of the HPAs enables the early identification and treatment of RMD.Einleitung: Frühe Stadien rheumatischer muskuloskelettaler Erkrankungen (RMD) sind schwierig zu diagnostizieren und führen zu hohem Ressourcenverbrauch in ambulanten Einrichtungen. Das Ziel dieser Arbeit ist die Evaluation des Versorgungsprojekts „RA-Express“ der deutschen Treat to Target-Initiative für die rheumatoide Arthritis (RA) als ein strukturiertes Screening-System, um Patienten mit einer RMD, insbesondere einer RA, effizient zu erfassen und frühzeitig zu behandeln. Methoden: 177 Patienten besuchten einen Screeningtermin für Früharthritis. Eingeschlossen wurden Patienten mit einer Arthritis in mindestens einem Gelenk und einer Symptomdauer bis maximal 12 Monate. Die Patienten hatten drei Zugangsmöglichkeiten zum Screening: Telefonat mit einer qualifizierten rheumatologischen Fachassistenz (RFA), Onlinefragebogen oder offene Sprechstunde. Alle Patienten beantworteten den symptombezogenen Fragebogen. Die Patienten wurden zwei Gruppen zugeordnet. In der ersten Gruppe wurde zunächst von einer RFA der Gelenkstatus erhoben. Nach Prüfung des Fragebogens erstellte die RFA eine Verdachtsdiagnose. Anschließend untersuchte ein Rheumatologe die Patienten, um ebenfalls eine Verdachtsdiagnose festzulegen. In der zweiten Patientengruppe führte der Rheumatologe das Screening durch. Zusätzlich erhielt ein Teil der Patienten unabhängig von der Gruppe einen Point of Care Test zur Schnelltestung des CRP, Rheumafaktors IgM und MCV. Bei Verdacht auf Vorliegen einer RMD erhielten die Patienten einen zweiten Termin zur Komplettierung der Diagnostik und ggf. zur Einleitung einer Basistherapie. Im Fall einer hohen Krankheitsaktivität erfolgte die umgehende Behandlung der Patienten. Ergebnisse: Die Patienten waren im Durchschnitt 50,9±15,2 Jahre alt und 135 (76,3 %) Patienten waren weiblich. 160 (90,4 %) Patienten wählten den Zugangsweg des Telefons, zehn (5,7 %) nutzten den Onlinefragebogen und sieben (3,9 %) Patienten die offene Sprechstunde. Die Patienten warteten 3,1±1,8 Wochen auf einen Screeningtermin. 34 (56,7 %) Patienten mit einer RMD besuchten das Screening innerhalb von sechs Monaten nach Symptombeginn. Zwei (1,7 %) Patienten hatten eine RMD, die von der RFA im Screening nicht erkannt wurde und mit conventional synthetic Disease-modifying anti-rheumatic drugs (csDMARDs) und Glukokortikoiden (GC) behandelt wurde. In Gruppe 2 erhielten drei (4,9 %) csDMARDs, obwohl eine RMD im Screening vom Rheumatologen nicht vermutet wurde. Insgesamt hatten 69 (39,0 %) Patienten eine RMD, wovon 43 (24,3 %) Patienten eine RA hatten. 44 (24,9 %) der RA-Express-Patienten erhielten eine Therapie mit csDMARDs, die 44,8±41,9 Tage nach dem Screening begann. Sechs (3,4 %) Patienten lehnten eine empfohlene Therapie mit csDMARDs ab. 21 (11,9 %) Patienten begannen bereits beim Screeningtermin mit einer leitlinienorientierten Therapie. Schlussfolgerung Ein strukturiertes Screening-System mithilfe der RFA ermöglicht die frühzeitige Erkennung und Behandlung von RMD

Medically induced labor:Epidural analgesia and women’s perceptions of pain in early labor

Introduction Approximately 25% of all deliveries in Denmark are medically induced, typically characterized by more intense uterine contractions. The aim of this paper is to investigate the differences in the administration of epidural analgesia and pain experience between spontaneous and medically induced labor in nulliparous and multiparous women. Methods This is a prospective case-controlled study of 100 participating women in labor. The primary outcome was the timing of administration of epidural analgesia, by delivery progression and frequency. Pain scores were indicated by the McGill Pain Questionnaire and the duration of pain was also notified. Results In nulliparous and multiparous women, medically induced labor was associated with earlier administration of epidural analgesia in relation to the onset of labor pain, compared to women with a spontaneous onset of labor (10.4 vs 26.10 hours, p=0.0). There was a trend, however not statistical, in the use of epidural analgesia in relation to delivery progression, assessed as dilation of the cervix (3 cm vs 4.5 cm, p=0.07) and towards higher frequency for medically induced labor (51.5% vs 32.8%, p=0.07). In nulliparous women, a reduced period of labor pain was shown in medically induced deliveries compared to spontaneous deliveries (9.30 vs 19.00 hours, p=0.03). However, no significant differences in experienced pain were shown (Score: 28.70 vs 29.60, p=0.194). Conclusions Epidural analgesia was administered earlier, and duration of experienced pain was shorter in medically induced labor, in comparison to spontaneous deliveries. However, the experienced pain was not different, possibly explained by a more intense labor process

Radiocarbon Dating of the Human Eye Lens Crystallines Reveal Proteins without Carbon Turnover throughout Life

BACKGROUND: Lens crystallines are special proteins in the eye lens. Because the epithelial basement membrane (lens capsule) completely encloses the lens, desquamation of aging cells is impossible, and due to the complete absence of blood vessels or transport of metabolites in this area, there is no subsequent remodelling of these fibers, nor removal of degraded lens fibers. Human tissue ultimately derives its (14)C content from the atmospheric carbon dioxide. The (14)C content of the lens proteins thus reflects the atmospheric content of (14)C when the lens crystallines were formed. Precise radiocarbon dating is made possible by comparing the (14)C content of the lens crystallines to the so-called bomb pulse, i.e. a plot of the atmospheric (14)C content since the Second World War, when there was a significant increase due to nuclear-bomb testing. Since the change in concentration is significant even on a yearly basis this allows very accurate dating. METHODOLOGY/PRINCIPAL FINDINGS: Our results allow us to conclude that the crystalline formation in the lens nucleus almost entirely takes place around the time of birth, with a very small, and decreasing, continuous formation throughout life. The close relationship may be further expressed as a mathematical model, which takes into account the timing of the crystalline formation. CONCLUSIONS/SIGNIFICANCE: Such a life-long permanence of human tissue has hitherto only been described for dental enamel. In confront to dental enamel it must be held in mind that the eye lens is a soft structure, subjected to almost continuous deformation, due to lens accommodation, yet its most important constituent, the lens crystalline, is never subject to turnover or remodelling once formed. The determination of the (14)C content of various tissues may be used to assess turnover rates and degree of substitution (for example for brain cell DNA). Potential targets may be nervous tissues in terms of senile or pre-senile degradation, as well as other highly specialised structures of the eyes. The precision with which the year of birth may be calculated points to forensic uses of this technique

The Distribution Pattern of \u3cem\u3eHalicephalobus gingivalis\u3c/em\u3e in a Horse is Suggestive of a Haematogenous Spread of the Nematode

The majority of Halicephalobus gingivalis-infections in horses have been fatal and are usually not diagnosed before necropsy. Therefore, knowledge about the nematode and the pathogenesis of infection in horses is limited. This has resulted in an on-going discussion about the port of entry and subsequent dissemination of H. gingivalis within the host. The present case of H. gingivalis-infection in a horse was diagnosed ante mortem. Post mortem findings, the distribution pattern of H. gingivalis nematodes in the brain, a high prevalence of inflammation in close relation to blood vessels, and the presence of the nematode in multiple organs with a disseminated pattern of distribution strongly suggested a haematogenous spread of the nematode in the horse

Vagus nerve stimulation as a novel treatment for systemic lupus erythematous:study protocol for a randomised, parallel-group, sham-controlled investigator-initiated clinical trial, the SLE-VNS study

INTRODUCTION: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease. SLE is treated with immunosuppressants with suboptimal efficacy and high risk of serious side effects. Patients with SLE have increased risk of mortality, organ damage and debilitating treatment-resistant fatigue. Autonomic nervous system dysfunction (AD) is present in approximately half of the patients and may promote autoimmunity by weakening the vagally mediated anti-inflammatory reflex. Recent studies suggest that transcutaneous vagus nerve stimulation (tVNS) has few side effects and beneficial effects on fatigue, pain, disease activity and organ function. This study investigates whether adjuvant tVNS improves measures of fatigue (primary end point), AD, clinical disease activity, inflammation, pain, organ function and quality of life. Hence, this study will contribute to the understanding of AD as a potentially important precursor of fatigue, disease activity, progression and complications in SLE, and how tVNS mechanistically may attenuate this. As adjuvant tVNS use may reduce the need for traditional immunosuppressive therapy, this trial may prompt a shift in the treatment of SLE and potentially other autoimmune disorders. METHODS AND ANALYSIS: Eighty-four patients with SLE with fatigue and AD will be randomised 1:1 to active or sham tVNS in this double-blinded parallel-group study. In period 1 (1 week), participants will receive a 4 min tVNS 4 times daily and report on fatigue daily. After a 2-week pause, period 2 (8 weeks) will entail tVNS twice daily and participants will report on fatigue, pain and disease activity weekly. Secondary end points will be assessed before and after each period and after 1 week in period 2. ETHICS AND DISSEMINATION: The study is approved by the Danish Medical Research Ethical Committees (case no: 2120231) and results will be published in international peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05315739