Ook reuma kan ondraaglijk zijn:Euthaniasie reële optie bij patiënten met uitzichtlose reumatoïde artritis

Reumatoïde artritis is weliswaar niet op korte termijn dodelijk, maar kan wel ondraaglijk en uitzichtloos zijn. Voor zulke patiënten is euthanasie soms de enige uitweg, betogen reumatoloog Evert-Jan ter Borg en collega’s aan de hand van twee praktijkvoorbeelden

Validation of quantitative salivary gland scintigraphy in relation to the American-European concensus criteria for Sjögren's syndrome

Purpose The aim of this retrospective study was to evaluate the diagnostic value of semiquantitative parameters in salivary gland scintigraphy (SGS) in the diagnostic work-up of primary Sjögren's Syndrome (SS) using the American-European consensus criteria (AECC) as the gold standard. Patients and methods 99mTc-pertechnetate-SGS was performed in 110 patients with suspected primary SS. Uptake ratios (URs) and excretion fractions (EFs) for all parotid and submandibular salivary glands were calculated. Patients were divided into SS-positive, SS-negative, and SS-equivocal groups on the basis of the AECC criteria. SGS semiquantitative parameters were compared per group and cut-off values were defined. Results Ninety-six (87%) women and 14 (13%) men with a mean age of 51 years (range: 18-77 years) were included. All patients underwent SGS, labial biopsy, Schirmer's test, and antibody tests (anti-SS-A and anti-SS-B). Twenty-four patients were SS positive, 56 patients were SS negative, and 30 patients were SS-equivocal. UR of the parotid glands did not differ between SS-positive and SS-negative groups [mean (range): 3.4 (1.4-6.9) and 3.9 (2.2-6.5), respectively], whereas UR of the submandibular glands were significantly lower in SS-positive patients [mean (range): 2.7 (1.1-5.6) and 3.5 (2.3-5.3), respectively]. EF in both parotid and submandibular glands was significantly lower in SS-positive patients compared with SS-negative patients: parotid 24% (range:-4 to 53%) and 36% (range: 15-58%), respectively; submandibular 16% (range:-5 to 46%) and 29% (range: 9-49%), respectively. On the basis of a cut-off value of 2.0 for UR and 20% for EF, the sensitivity, specificity, positive predictive value, and negative predictive value were 0.67, 0.86, 86, and 67%, respectively. Of 30 SS-equivocal patients, 15 had a positive SGS, whereas the other 15 were SGS negative. In both, there was no correlation with the AECC criteria IV (histopathology) and VI (antibodies). In these cases, the SGS result was decisive. Conclusion Quantitative SGS is a valuable tool in the diagnostic management of patients with suspected primary SS, especially in those in whom the nonscintigraphic AECC criteria are not conclusive. The straightforward quantitative analysis of SGS used in this study can be implemented in any nuclear medicine department

Validation of quantitative salivary gland scintigraphy in relation to the American-European concensus criteria for Sjögren's syndrome

Purpose The aim of this retrospective study was to evaluate the diagnostic value of semiquantitative parameters in salivary gland scintigraphy (SGS) in the diagnostic work-up of primary Sjögren's Syndrome (SS) using the American-European consensus criteria (AECC) as the gold standard. Patients and methods 99mTc-pertechnetate-SGS was performed in 110 patients with suspected primary SS. Uptake ratios (URs) and excretion fractions (EFs) for all parotid and submandibular salivary glands were calculated. Patients were divided into SS-positive, SS-negative, and SS-equivocal groups on the basis of the AECC criteria. SGS semiquantitative parameters were compared per group and cut-off values were defined. Results Ninety-six (87%) women and 14 (13%) men with a mean age of 51 years (range: 18-77 years) were included. All patients underwent SGS, labial biopsy, Schirmer's test, and antibody tests (anti-SS-A and anti-SS-B). Twenty-four patients were SS positive, 56 patients were SS negative, and 30 patients were SS-equivocal. UR of the parotid glands did not differ between SS-positive and SS-negative groups [mean (range): 3.4 (1.4-6.9) and 3.9 (2.2-6.5), respectively], whereas UR of the submandibular glands were significantly lower in SS-positive patients [mean (range): 2.7 (1.1-5.6) and 3.5 (2.3-5.3), respectively]. EF in both parotid and submandibular glands was significantly lower in SS-positive patients compared with SS-negative patients: parotid 24% (range:-4 to 53%) and 36% (range: 15-58%), respectively; submandibular 16% (range:-5 to 46%) and 29% (range: 9-49%), respectively. On the basis of a cut-off value of 2.0 for UR and 20% for EF, the sensitivity, specificity, positive predictive value, and negative predictive value were 0.67, 0.86, 86, and 67%, respectively. Of 30 SS-equivocal patients, 15 had a positive SGS, whereas the other 15 were SGS negative. In both, there was no correlation with the AECC criteria IV (histopathology) and VI (antibodies). In these cases, the SGS result was decisive. Conclusion Quantitative SGS is a valuable tool in the diagnostic management of patients with suspected primary SS, especially in those in whom the nonscintigraphic AECC criteria are not conclusive. The straightforward quantitative analysis of SGS used in this study can be implemented in any nuclear medicine department

Initiating tocilizumab, with or without methotrexate, compared with starting methotrexate with prednisone within step-up treatment strategies in early rheumatoid arthritis : an indirect comparison of effectiveness and safety of the U-Act-Early and CAMERA-II treat-to-target trials

OBJECTIVES: Methotrexate (MTX), often combined with low moderately dosed prednisone, is still the cornerstone of initial treatment for early rheumatoid arthritis (RA). It is not known how this strategy compares with initial treatment with a biological. We therefore compared the effectiveness of tocilizumab (TCZ), or TCZ plus MTX (TCZ+MTX) with MTX plus 10 mg prednisone (MTX+pred), all initiated within a treat-to-target treatment strategy in early RA. METHODS: Using individual patient data of two trials, we indirectly compared tight-controlled treat-to-target strategies initiating TCZ (n=103), TCZ+MTX (n=106) or MTX+pred (n=117), using initiation of MTX (n=227) as reference. Primary outcome was Disease Activity Score assessing 28 joints (DAS28) over 24 months. To assess the influence of acute phase reactants (APRs), a disease activity composite outcome score without APR (ie, modification of the Clinical Disease Activity Index (m-CDAI)) was analysed. Secondary outcomes were remission (several definitions), physical function and radiographic progression. Multilevel models were used to account for clustering within trials and patients over time, correcting for relevant confounders. RESULTS: DAS28 over 24 months was lower for TCZ+MTX than for MTX+Pred (mean difference: -0.62 (95% CI -1.14 to -0.10)). Remission was more often achieved in TCZ+MTX and in TCZ versus MTX+pred (p=0.02/0.05, respectively). Excluding APRs from the disease activity outcome score, TCZ-based strategies showed a slightly higher m-CDAI compared with MTX+pred, but this was not statistically significant. Other outcomes were also not statistically significantly different between the strategies. CONCLUSIONS: In patients with early RA, although TCZ-based strategies resulted in better DAS28 and remission rates compared with MTX+pred, at least part of these effects may be due to a specific effect of TCZ on APRs