Reumatoidartriidi bioloogilise ravi varasema alustamise kulutõhusus võrreldes bioloogilise ravi tavapraktikaga Eestis

Taust. Bioloogiliste haigust modifitseerivate ravimite tõhususe tõttu soosib reumatoidartriidi (RA) ravijuhendite üldine suundumus bioloogilise ravi varasemat alustamist.Eesmärk. Hinnata RA ravis kasutatavate bioloogiliste haigust modifitseerivate ravimite varasema kasutamise kulutõhusust ja eelarvemõju. Artikkel tugineb TÜ peremeditsiini ja rahvatervishoiu instituudis koostatud tervisetehnoloogiate hindamise raportile.Metoodika. Uuringus analüüsiti varem alustatud bioloogilise ravi tulemuslikkust ja kulutõhusust modelleerimise meetodil. Simulatsioonil kasutati Eesti andmeid ja nende puudumisel andmeid teaduskirjandusest. RA bioloogilise ravi tavapraktika hindamiseks analüüsiti Ida-Tallinna Keskhaigla bioloogilise ravi patsientide raviandmeid. Markovi mikrosimulatsioonimudeliga hinnati varasema bioloogilise raviga kaasnevaid tervisetulemeid ning ravi- ja töövõime kaotusest tulenevaid kulusid. Eelarvemõju analüüsis hinnati varem alustatud ravi mõju haigekassa eelarvele.Tulemused. RA ravi tavapraktikas kasutatakse enne bioloogilise ravi algust keskmiselt 3,4 (standardhälve = 0,9) haigust modifitseerivat sünteetilist ravimit (sHMR). Kui bioloogilist ravi alustatakse pärast ravikuuri 1 või 2 sHMR-iga, võidetakse eluea jooksul keskmiselt 0,1–0,2 QALYt (ingl quality adjusted life year) patsiendi kohta ja võidetud QALY maksumus on keskmiselt 67 000 eurot. Bioloogilise ravi varasema alustamisega kaasnev lisakulu haigekassale on 0,4–0,8 miljonit eurot aastas.Järeldused. RA varem alustatud bioloogilise raviga võidetud tervisetulem on pigem väike ja selle maksumus suhteliselt suur, kuid haigekassa eelarve suurenemine ei ole märkimisväärne. Seega tuleb sHMR-ide arvulise piirangu muutmisel lähtuda ravijuhenditest ja solidaarse tervisekindlustuse võimalustest.Eesti Arst 2017; 96(7):391–39

Educational needs and preferences of young European clinicians and physician researchers working in the field of rheumatology

Funding Information: CB: Grant BE 5191/1-1 of the Deutsche Forschungsgemeinschaft.Objectives: To understand the educational needs and preferences of young clinicians and physician researchers in the field of rheumatology in Europe. Methods: An international online survey was performed as a joint venture of ESCET and EMEUNET. The survey assessed the acceptance of and the access to the current European League Against Rheumatism (EULAR) educational portfolio, as well as the unmet educational needs and learning preferences among individuals below the age of 40 years working in rheumatology in Europe. Results: Among 568 European clinicians and physician researchers, 65% indicated that the existing EULAR educational portfolio adequately covers their educational needs. Within the EULAR portfolio, the online course on rheumatic diseases and the postgraduate course were the most appreciated. Participants were very much in favour of new educational courses on imaging techniques, and 63% of participants indicated a particular interest in musculoskeletal ultrasound. A strong interest in refresher (60%) and general review (55%) courses was observed. Lack of funding was considered the major obstacle to participating in existing EULAR programmes. Finally, participants showed diverse preferences regarding learning modalities with common interests in live courses and conferences. Conclusions: EULAR's training opportunities are well appreciated among young clinicians and physician researchers in rheumatology. The results from this survey will help to develop EULAR's future educational portfolio.publishersversionPeer reviewe

Determinants of sleep impairment in psoriatic arthritis. an observational study with 396 patients from 14 countries

OBJECTIVE:Sleep quality is diminished in patients with psoriatic arthritis (PsA) and close to 40% of PsA patients consider sleep difficulties a priority domain. This work analyzes determinants of impaired sleep in patients with PsA. METHODS: This was a cross-sectional analysis of an observational study (ReFlap, NCT NCT03119805), which included adult patients with definite PsA with ≥2 years disease duration from 14 countries. Sleep was assessed using the patient self-reported evaluation of sleep on a 0-10 numerical scale, included in the Psoriatic Arthritis Impact of Disease questionnaire (PSAID-12). A score ≥4 was considered as sleep impairment. Demographic and clinical variables associated to sleep impairment were assessed through univariate analysis and Poisson regression modeling leading to prevalence ratio (PR) [95% confidence interval]. RESULTS:A total of 396 patients were analyzed: mean age 51.9±12.6 years, 51% were females, 59.7% were receiving biologic therapy, 53.3% had 1-5% of body surface area affected by psoriasis; 23.7% were in remission and 36.9% in low disease activity according to the Disease Activity in Psoriatic Arthritis (DAPSA) score. Median (25th-75th) patient's self-evaluation of sleep difficulties was 2 (0-6), 157 (39.6%) had sleep impairment. In the Poisson regression model, self-reported levels of anxiety (PR: 1.05 [1.02-1.08], p=0.003) and pain (PR: 1.06 [1.04-1.09], p<0.001) were independently associated to sleep impairment. CONCLUSIONS: In this multicentric study, sleep impairment was present in 40% of PsA patients; pain and anxiety were associated to sleep impairment whereas inflammation was not. Impact on sleep appears multifactorial in PsA

Legittimazione della giustizia costituzionale e transizioni costituzionali: il caso della Polonia

Il saggio esamina la crisi costituzionale polacca generata dalla riforma della legge sul Tribunale Costituzionale del 2015, proponendone una lettura attraverso la prospettiva della degenerazione dei meccanismi di legittimazione delle Corti costituzionali, che nel caso della Polonia, lungi dal risolversi esclusivamente in una problematica interna, mette in discussione l'efficacia dei meccanismi di condizionalità posti in essere dalle istituzioni europee a sostegno della transizione democratica/adesione all'UE di tutti i Paesi dell'Europa centro-orientale

Determinants of Patient-Reported Psoriatic Arthritis Impact of Disease: An Analysis of the Association With Sex in 458 Patients From Fourteen Countries

Objective: Sex differences may modify symptoms, disease expression, and treatment effects. The objective of this study was to evaluate the link between life impact and sex in psoriatic arthritis (PsA). Methods: Remission and Flare in Psoriatic Arthritis (ReFlaP; ClinicalTrials.gov identifier: NCT03119805) was a study in 14 countries of consecutive adult patients with definite PsA. Participants underwent comprehensive PsA assessment using the following measures: Disease Activity in Psoriatic Arthritis (DAPSA), Minimal Disease Activity (MDA), and Psoriatic Arthritis Impact of Disease (PsAID). Disease activity was compared by sex using t-tests or Wilcoxon tests. The association of PsAID with sex was analyzed using hierarchical generalized linear models. Results: Of 458 participants, 50.2% were male and the mean ± SD age was 53.1 ± 12.6 years. The mean ± SD PsA duration was 11 ± 8.2 years, and 51.5% of participants were being treated with biologic disease-modifying antirheumatic drugs. Women, compared to men, had worse mean ± SD Leeds Enthesitis Index scores (0.8 ± 1.7 versus 0.3 ± 0.9), pain on a numerical rating scale (NRS; range 0–10) (4.7 ± 2.7 versus 3.5 ± 2.7), HAQ DI scores (0.9 ± 0.7 versus 0.5 ± 0.6), fatigue on an NRS (5.2 ± 3 versus 3.3 ± 2.8), and PsAID scores (4.1 ± 2.4 versus 2.8 ± 2.3) (P 4 and ≤14 for low disease activity; mean ± SD score 16.9 ± 14.9 in women versus 12.6 ± 16.6 in men) and MDA (25.7% versus 50.0%; P < 0.001 for all) scores. High life impact (PsAID score ≥4) was associated with female sex (odds ratio [OR] 2.3), enthesitis (OR 1.34), tender joints (OR 1.10)(P < 0.001 for all), and comorbidities (OR 1.22, P = 0.002). Conclusion: High life impact was independently associated with female sex, enthesitis, comorbidities, and tender joints. At treatment target, women had higher life impact compared to men. It is necessary for life impact to become a part of PsA treat-to-target strategies