[Treat to participation : Position paper of the German Society for Rheumatology on sustained improvement of functional health of patients with rheumatic and musculoskeletal diseases]

From the perspective of patients with rheumatic diseases, the reduction of inflammatory disease activity alone is not a sufficient treatment goal. In addition the functional health and participation also have to be improved. Starting with the first symptoms the empowerment for the self-management of the disease is important for the patients; therefore, the established treat to target-strategy has to be expanded by the functional dimension to treat to participation. The position paper of the German Society for Rheumatology (GSR) summarizes the relevant fields of the multiprofessional action that is frequently necessary. This includes the acquirement of function-related competencies during training, further education and advanced training as well as implementation in the everyday practice of patient care. Furthermore, the GSR acknowledges the need for research related to functional and sociomedical consequences of rheumatic diseases and to individual and combined function-related programs in outpatient and inpatient care in rheumatology.

[Trends in rehabilitation of patients with rheumatic diseases in Germany]

Recent Deutsche Gesellschaft für Rheumatologie (DGRh, German Society of Rheumatology) guidelines emphasized the significance of coordinated multidisciplinary care and rehabilitation of patients with inflammatory rheumatic diseases. Nationwide data from the German pension insurance funds showed that inpatient rehabilitation due to rheumatoid arthritis (RA) varied by a factor of 2.6 between the different German states. From 2000 to 2012 rehabilitation measures were reduced by one third, most significantly in men with ankylosing spondylitis (AS). Rehabilitation measures because of RA or AS were provided up to 14 times more frequently by the German statutory pension insurance scheme compared with a large compulsory health insurance which is responsible for rehabilitation measures after retirement. In rehabilitation centers with high numbers of patients with inflammatory rheumatic diseases, higher structural and process quality were demonstrated. In 2011 a total of 40 % of RA patients in the national database of the collaborative arthritis centers showed medium or severe functional limitations. Among these disabled RA patients inpatient rehabilitation was reduced by about 50 % between 1995 and 2011. Out of all RA patients from outpatient rheumatology care with severe functional limitations 38 % had no functional restoration therapy within the previous 12 months with a high variation between rheumatologists. Experiences from other European countries may inspire German rheumatologists and other involved health professionals to initiate a wider range of rehabilitative interventions in the future.

[Diagnostics]

The round-table group "diagnostic" discussed the laboratory-based diagnosis of rheumatic diseases under the following three main questions: "What is necessary?"; "What is possible?" and "What has been achieved?".

Skin sclerosis is only of limited value to identify SSc patients with severe manifestations--an analysis of a distinct patient subgroup of the German Systemic Sclerosis Network (DNSS) Register

OBJECTIVES

In SSc, diagnosis and classification is based mainly on skin sclerosis. Herein, we investigated in a large multicentre cohort, to what extent skin sclerosis reflects organ involvement and additional clinical symptoms.

METHODS

A total of 1200 SSc patients from the register of the German Systemic Sclerosis Network (DNSS), classified as either lcSSc or dcSSc, were analysed for their serological characteristics, clinical symptoms and organ manifestations in relation to skin involvement measured by the modified Rodnan skin score (mRSS).

RESULTS

SSc patients with different mRSS did not differ significantly in their disease duration and in most of the clinical symptoms. They showed a similar distribution of most organ manifestations such as pulmonary arterial hypertension as well as cardiac, renal and nervous system involvement. More severe skin thickening was found to be associated with pulmonary fibrosis and gastrointestinal symptoms, as well as with digital ulcers and musculoskeletal involvement.

CONCLUSIONS

In patients with SSc, potentially life-threatening complications and clinical symptoms with high impact on the quality of life occur independently from the extent of skin sclerosis. The diagnosis in SSc patients with a low mRSS could be missed or they could be insufficiently treated.

Comparison of patients with and without digital ulcers in systemic sclerosis: detection of possible risk factors

BACKGROUND

Digital ulcers (DU) are a major complication in the course of systemic sclerosis (SSc). In recent years, efficacious, but expensive therapies (e.g. iloprost, sildenafil, bosentan) have been shown to improve healing or to reduce the recurrence of DU. For optimal management it would be useful to identify the risk factors for DU. Such statistical analyses have been rare because they require a high number of patients.

OBJECTIVES

To identify potential risk factors for DU in patients with SSc.

METHODS

We used the registry of the German Network for Systemic Scleroderma and evaluated the data of 1881 patients included by August 2007. We assessed potential risk factors for DU by comparing patients with (24.1%) and without active DU at time of entry (75.9%).

RESULTS

Multivariate analysis revealed that male sex, presence of pulmonary arterial hypertension (PAH), involvement of the oesophagus, diffuse skin sclerosis (only when PAH was present), anti-Scl70 antibodies, young age at onset of Raynaud's phenomenon (RP), and elevated erythrocyte sedimentation rate (ESR) significantly impacted on the appearance of DU. Certain combinations increased the patients' probability of presenting with DU, with the highest probability (88%) for male patients with early onset of RP, ESR>30 mm h(-1), anti-Scl70 antibodies and PAH. Patients with DU developed RP, skin sclerosis and organ involvement approximately 2-3 years earlier than patients without DU.

CONCLUSIONS

The results reveal possible risk factors for the occurrence of DU in SSc. As DU are prone to local complications, prophylactic vasoactive treatment for patients presenting with these factors may be justified.

[Patient education in rheumatologic care--a review]

Patient education is a medical intervention for patients with chronic diseases to increase knowledge of their disease, self-efficacy, self-management and consumer behaviour. The goal is to improve their disease outcome, social participation and quality of life. This article reviews concepts, modalities and knowledge on effectiveness of patient education. The results of different studies in different rheumatic diseases on efficacy will be summarized including a small number of cost-benefit analyses. Most studies report on significant and relevant improvements of knowledge, self-efficacy and health status. With respect to disease specific outcomes low to moderate effect sizes with a short duration have been observed. Especially good results have been reported when physical training or other methods of rehabilitation were included. There are marked improvements in consumer behaviour of health measures and sickness leave. A better understanding of information needs and baseline characteristics of patients is necessary to develop more appropriate educational interventions focussed on relevant outcomes that can be improved by educational measures.

The registry of the German Network for Systemic Scleroderma: frequency of disease subsets and patterns of organ involvement

Objective. Systemic sclerosis (SSc) is a rare, heterogeneous disease, which affects different organs and therefore requires interdisciplinary diagnostic and therapeutic management. To improve the detection and follow-up of patients presenting with different disease manifestations, an interdisciplinary registry was founded with contributions from different subspecialties involved in the care of patients with SSc.

Methods. A questionnaire was developed to collect a core set of clinical data to determine the current disease status. Patients were grouped into five descriptive disease subsets, i.e. lcSSc, dcSSc, SSc sine scleroderma, overlap-syndrome and UCTD with scleroderma features.

Results. Of the 1483 patients, 45.5% of patients had lcSSc and 32.7% dcSSc. Overlap syndrome was diagnosed in 10.9% of patients, while 8.8% had an undifferentiated form. SSc sine scleroderma was present in 1.5% of patients. Organ involvement was markedly different between subsets; pulmonary fibrosis for instance was significantly more frequent in dcSSc (56.1%) than in overlap syndrome (30.6%) or lcSSc (20.8%). Pulmonary hypertension was more common in dcSSc (18.5%) compared with lcSSc (14.9%), overlap syndrome (8.2%) and undifferentiated disease (4.1%). Musculoskeletal involvement was typical for overlap syndromes (67.6%). A family history of rheumatic disease was reported in 17.2% of patients and was associated with early disease onset (P < 0.005).

Conclusion. In this nationwide register, a descriptive classification of patients with disease manifestations characteristic of SSc in five groups allows to include a broader spectrum of patients with features of SSc.

[Fibromyalgia]

The characteristic symptoms of fibromyalgia are chronic widespread musculoskeletal pain in various parts of the body and abnormal tenderness at 18 specified tender points. Associated symptoms often reported include stiffness, sleep disorders, fatigue, and problems with concentration. The prevalence is about 3.5% for women and 0.5% for men. The impact of the disease is considerable both for those directly affected (restriction in activities of daily living and in ability to take part in family, professional, and social life) and for society as a whole (direct and indirect costs). The disease usually has a chronic course. An abnormality of the central pain-processing mechanisms is highly relevant for the pathogenesis. In addition to early diagnosis and intensive patient education, pharmacotherapy, exercise therapy, behavior therapy, and multidisciplinary treatment are particularly important for the management of fibromyalgia.

Labordiagnostik bei systemischer Sklerose

For systemic sclerosis, laboratory tests can play a supplementary role to clinical investigations, imaging techniques and functional tests. Typical autoantibodies support early diagnosis and help in assigning patients to subgroups of the disease; negative results for antinuclear antibodies suggest exclusion of the diagnosis. To detect organ involvement and comorbidity, the laboratory contributes by clinical chemistry, in certain cases by histopathological findings and by the cytological assessment of broncho-alveolar lavage fluid. Inflammatory parameters are of minor importance. Multiple autoantibody determinations in the course of the disease are not yet helpful. Numerous additional laboratory parameters are of value for investigating pathogenesis, but have not yet been generally introduced into the routine diagnostics of systemic sclerosis.

[Systemic sclerosis - diagnosis and classification]

Systemic sclerosis (SSc) is a polymorphic and heterogenic systemic disorder with inflammation, fibrosis and vascular damage. Early diagnosis and classification may be difficult if disease expression is oligosymptomatic (undifferentiated), presenting with only Raynaud's phenomenon or limited scleroderma. Scleroderma specific antinuclear autoantibodies, which are present early and persistently in about 90% of the patients with SSc, play an important taxonomic role. Scleroderma specific findings in nailfold capillary microscopy are sensitive and predictive for evolving SSc. An algorithm will be presented for the diagnosis and classification of SSc using clinical, capillaroscopic and serologic criteria, which are also useful for mixed or special forms of SSc. The 6th Outcome Measures in Rheumatology Clinical Trials (OMERACT) conference proposed different outcome measurements for clinical studies, however, for daily clinical practice there is as yet no consensus on status indices for disease activity, disease related damage or suitable prognostic criteria.

Sklerodermie-assoziierte Autoantikörper – klinische und diagnostische Relevanz

In systemic sclerosis (SSc) and its variants, autoantibodies are the best known immunological aberration. In more than 95% of the patients, antinuclear antibodies or other autoantibodies can be detected. In about 90% of SSc patients with antinuclear antibodies, scleroderma associated autoantibodies highly specific for systemic sclerosis are found. These autoantibodies usually exclude each other in individual patients, and they are detectable early, persisting during the course of the disease. SSc patients characterized by scleroderma associated autoantibodies belong to disease subsets which are relatively homogeneous in clinical, genetic and prognostic terms. Besides these diagnostically relevant autoantibodies, numerous additional ones have also been described. These are neither SSc specific nor mutually exclusive, and their antigens have only been partially characterized. Some, however, are thought to be relevant to the as yet unanswered question of whether autoantibodies are directly involved in SSc pathogenesis.

Entzündliche Muskelkrankheiten

Dermatomyositis, polymyositis, inclusion body myositis and myositis overlap syndromes are systemic immune disorders of unknown origin with muscle weakness and elevated values of creatinkinase in the serum. Muscle biopsy is pivotal for a proper clinical diagnosis. Extramuscular findings at the skin, the joints or internal organs (lung, heart) are characteristic for the different clinical presentations of dermato- or polymyositis and are usually absent in inclusion body myositis. With the exception of inclusion body myositis myositis-associated autoantibodies are frequently present and associated with distinct clinical manifestations (e. g. antisynthetase syndrome). The rate of malignancy is elevated for several years after onset of myositis. Especially in polymyositis an appropriate differential diagnosis of infectious, endocrine, metabolic or neuromuscular causes of muscle disease is necessary. Glucocorticosteroids are the first choice of treatment in dermato- or polymyositis. Methotraxate, azathioprine, cyclophosphamamide, i.v. immunoglobulins and other drugs are used in diseases courses with continuous high dose requirement of corticosteroids.

PM-Scl-Antikörper positive systemische Sklerodermie assoziiert mit Einschlusskörper-Myositis

We describe a 72- year-old patient with a ten year history of anti-PM-Scl positive systemic sclerosis associated with inclusion-body myositis. While the association of dermatomyositis and polymyositis with anti-PM-Scl positive systemic sclerosis is frequently reported, inclusion-body myositis was, to the best of our knowledge, only previously described once in association with anti-PM-Scl-positive systemic sclerosis. The distinction between inclusion-body myositis and other forms of inflammatory myopathy, like the histopathologically well distinguishable polymyositis or dermatomyositis, is relevant because of the poor response of inclusion- body myositis to immunosuppressive treatment. Our case underlines that in patients with anti-PM-Scl-positive systemic sclerosis and treatment resistant progressive myopathy the diagnosis of inclusion body myositis should be considered.

Routineberichterstattung zur medizinischen Rehabilitation bei muskuloskelettalen Krankheiten

The commission "Rehabilitation" of the German Society of Rheumatology compiled a data set for a routine report of the rehabilitation system for muskuloskeletal diseases. More than 250 rehabilitation hospitals offer inpatient rehabilitation for patients with musculoskeletal diseases. The prevalence of inpatient rehabilitation decreased due to new legislative rules in 1997, increased again thereafter but has not reached the former level. The prevalence of inpatient rehabilitation during the preceding year in patients with inflammatory rheumatic diseases treated by rheumatologists amounts to 12% with higher figures in men than in women and lower figures in the area of the former German Democratic Republic. The prevalence of outpatient rehabilitation increased during the last few years but, currently, does not exceed 5% of the entire rehabilitation procedures.

[Patient education "systemic sclerosis"]

We report on the development of an education program for patients with systemic sclerosis. The program was developed by a multi professional group in cooperation with scleroderma patients and the scleroderma patient organization. Patient education will be carried out by professional trainers as a weekend seminar within a group of 6 to 12 participants according to the method of subject focussed interaction. The program consisting of 7 modules is now in the final test phase.

[How reliable are statements on extensive noninflammatory pain? Comparison of patients with fibromyalgia, backache, and other local pain]

PURPOSE

The effect yielded by the degree of differentiation of two methods for measuring pain on patient statements regarding the extent of clinical pain was analyzed. At the same time, the reference time frame for the patient reports was varied.

METHODS

The influence exerted by differentiated questioning was determined by comparing two pictorial body diagrams. Three reference time frames were specified (current pain, last week, last half year).

RESULTS

Patients with wide-spread pain reacted stronger to variations in differentiated questioning the older the pain experienced was and the longer the time frame reported on. Upon differentiated questioning, patients with juxta-articular pain however remembered a lower number of pain sites in the past than on global assessment. Patients with backache reported their current pain to be less widely spread when assessed differentially than on global assessment.

CONCLUSION

Patient reports on the extent of pain mainly differ in those patients with extensive pain depending on the degree of differentiation during questioning. In these cases, the probability is high that the symptomatic complaints first became established, at least in part, as a reaction to the situational questioning conditions and therefore cannot be generalized to other questioning conditions.

[New aspects in autoantibody diagnosis in collagen diseases]

Distinct, especially non-organ specific autoantibodies are closely associated with connective tissue diseases and in many cases are vital elements of the laboratory diagnostics of these disorders. Their inclusion into the common classification criteria is quite heterogeneous. None of the autoantibodies is 100% specific for a certain disease, and diagnostic specificity is usually reduced when application of the test is broadened and when more sensitive methods are used. In individual patients with scleroderma and/or myositis related diseases, typical autoantibodies usually exclude each other; however, there are characteristical exceptions from that rule. Evidence is accumulating that autoantibodies are detectable early during disease course and often even in preclinical stages. Variations of antibody levels during disease course are different in different systems and in some cases have been shown to correlate with disease activity. Negative results in sensitive screening assays are often essential to exclude a connective tissue disease. Although it has certain drawbacks and is being disputed, the indirect immunofluorescence assay with HEp-2 cells still serves as a standard first step in connective tissue disease-related antibody detection. In case of positive results in this assay, further steps should be performed carefully, considering the signs and symptoms of the suspected disease as well as the immunofluorescence pattern, and being aware of the peculiarities and limitations of the assay methods used.

Coexistence of antitopoisomerase I and anticentromere antibodies in patients with systemic sclerosis

BACKGROUND

Antibodies targeting DNA topoisomerase I (ATA) or centromere proteins (ACA) are associated with clinical subsets of patients with systemic sclerosis (SSc). The occurrence of those autoantibodies is considered to be mutually exclusive.

OBJECTIVE

To describe the clinical and immunogenetic data of three patients who are co-expressing both antibodies, and then review previous publications.

METHODS

Both antibodies were detected by different methods, including indirect immunofluorescence technique, enzyme linked immunosorbent assay, immunodiffusion, and immunoblot. Patients were HLA typed by serological and molecular genetic methods. Data were extracted from published reports for comparison. The search for published studies was through Medline and other database research programmes.

RESULTS

During routine laboratory diagnostics over several years three patients with scleroderma and coincidence of ATA and ACA were identified: patient 1 with diffuse SSc, Raynaud's phenomenon, puffy fingers and fingertip necrosis, contractures, and calcinosis; patient 2 with diffuse SSc, Raynaud's phenomenon, oedema of the hands, and interstitial calcinosis of hands, knees, and shoulders, and pulmonary fibrosis; patient 3 with scleroderma of hands, forearms, and face, Raynaud's phenomenon, puffy fingers, finger contractures, fingertip necrosis, and calcinosis. All three patients studied were carriers of HLA alleles known to be associated with these autoantibodies. In serial measurements the concentrations of the two antibodies showed independent or even reverse fluctuations. Screening of 100 patients with ACA for ATA and vice versa disclosed no further patients with coincidence of these antibodies. Twenty eight cases of ACA/ATA coexistence in 5423 patients (0.52%) with SSc or SSc associated symptoms were found in an analysis of published studies.

CONCLUSION

The expression of ATA and ACA is not totally mutually exclusive, but coincidence is rare (<1% of patients with SSc). Patients with both autoantibodies often have diffuse scleroderma and show immunogenetic features of both antibody defined subsets of SSc.

[Evidence-based therapy of systemic sclerosis]

For the treatment of different forms of systemic sclerosis (SSc), drugs play a predominant role. Depending on disease activity as well as type and severity of cutaneous, vascular and internal organ manifestations, different systemic (antiinflammatory, immunosuppressive, antifibrotic) or organ-specific therapies are used. The scientific basis of most treatment modalities is insufficient and incomplete. There is sufficient evidence for an antiinflammatory and antiproliferative efficacy of glucocorticosteroids, methotrexate, cyclophosphamide and cyclosporine A in the treatment of diffuse cutaneous systemic sclerosis. Vasoactive therapies play an important role in treating Raynaud's phenomenon (nifedipine or other dihydropyridines, prostaglandin analogs, losartan, prazosine), and arterial (ACE blockers, AT-1 antagonists) or pulmonary (epoprostenol) hypertension. Cyclophosphamide is effective in fibrosing alveolitis, prokinetic substances (metoclopramid, domperidone) in gastroesophageal dysmotility or octreotide in intestinal pseudoobstruction. Physical therapies (e.g., massage) are poorly studied. In particular cases, surgical measures (e.g., removal of calcifications) are necessary.

Combined spa-exercise therapy is effective in patients with ankylosing spondylitis: a randomized controlled trial

OBJECTIVE

To determine the efficacy of combined spa-exercise therapy in addition to standard treatment with drugs and weekly group physical therapy in patients with ankylosing spondylitis (AS).

METHODS

A total of 120 Dutch outpatients with AS were randomly allocated into 3 groups of 40 patients each. Group 1 (mean age 48 +/- 10 years; male:female ratio 25:15) was treated in a spa resort in Bad Hofgastein, Austria; group 2 (mean age 49 +/- 9 years; male:female ratio 28:12) in a spa resort in Arcen, The Netherlands. The control group (mean age 48 +/- 10 years; male:female ratio 34:6) stayed at home and continued their usual drug treatment and weekly group physical therapy during the intervention weeks. Standardized spa-exercise therapy of 3 weeks duration consisted of group physical exercises, walking, correction therapy (lying supine on a bed), hydrotherapy, sports, and visits to either the Gasteiner Heilstollen (Austria) or sauna (Netherlands). After spa-exercise therapy all patients followed weekly group physical therapy for another 37 weeks. Primary outcomes were functional ability, patient's global well-being, pain, and duration of morning stiffness, aggregated in a pooled index of change (PIC).

RESULTS

Analysis of variance showed a statistically significant time-effect (P < 0.001) and time-by-treatment interaction (P = 0.004), indicating that the 3 groups differed over time with respect to the course of the PIC. Four weeks after start of spa-exercise therapy, the mean difference in PIC between group 1 and controls was 0.49 (95% confidence interval [CI] 0.16-0.82, P = 0.004) and between group 2 and controls was 0.46 (95% CI 0.15-0.78, P = 0.005). At 16 weeks, the difference between group 1 and controls was 0.63 (95% CI 0.23-1.02, P = 0.002) and between group 2 and controls was 0.34 (95% CI--0.05-0.73; P = 0.086). At 28 and 40 weeks, more improvement was found for group 1 compared with controls (P = 0.012 and P = 0.062, respectively) but not for group 2 compared with controls.

CONCLUSION

In patients with AS, a 3-week course of combined spa-exercise therapy, in addition to drug treatment and weekly group physical therapy alone, provides beneficial effects. These beneficial effects may last for at least 40 weeks.

[Outcome measurement in musculoskeletal diseases: recommendation for a core set of scales for use in rehabilitation]

By application of a standardized core set of outcome measurement instruments, comparison between studies as well as meta-analyses in rehabilitation research can be facilitated. The German Society for Rheumatology has commissioned its working group on rehabilitation with the development of a proposal for such a core set of outcome measurement instruments. In a first step, dimensions for outcome measurement in rehabilitation were defined by a group of experts which represented rehabilitation hospitals, acute care hospitals, and research groups specialized in outcome measurement. The Delphi method was used in a multiple step consensus process. In a second step, instruments and procedures to operationalize the relevant dimensions were chosen. Reliability, validity, sensitivity to change, and practicability were used as criteria for selecting measurement instruments. The main intention of the proposed core set of outcome measurement instruments is to facilitate the processes of planning and carrying out rehabilitation research studies. Furthermore, the proposed instruments can be used for clinical documentation systems as well as for internal or external quality assurance programs.

Clinical and serological aspects of patients with anti-Jo-1 antibodies--an evolving spectrum of disease manifestations

The aim of this study was to compare ELISA, immunodiffusion and immunoblot for the detection of anti-Jo-1 antibodies, and to investigate the association of the results with clinical manifestations. In two medical centres for rheumatology and one for pulmonology, all patients with suspected connective tissue disease were screened over a 5-year period for anti-Jo-1 antibodies by ELISA. Positive sera were controlled in another laboratory by immunodiffusion. If immunodiffusion was negative, sera were controlled again by ELISA. ELISA-positive immunodiffusion-negative sera were tested by immunoblotting. The patients were characterised clinically, and their clinical signs and symptoms were compared with those of 257 patients with anti-Jo-1 antibodies published in 15 case series and 30 case reports. Twenty-five patients had a positive ELISA test. Fifteen sera were positive by ELISA and immunodiffusion (group 1). Three sera showed high titres in both ELISA tests with negative immunodiffusion and immunoblot (group 2). Seven sera showed low titres in both ELISA tests. The results were negative in the other tests (group 3). Patients in groups 1 and 2 could be classified as Jo-1 syndrome patients. Of these 18 patients, 15 had arthritis, 14 had myositis and 14 had interstitial lung disease. Only four patients had myositis at disease onset. We describe four unusual patients with Jo-1 syndrome in detail: 1. Long history of seronegative rheumatoid arthritis; 2. Sjögren's syndrome with Ro- and La-antibodies; 3. Scleroderma and bronchial carcinoma with centromere antibodies; 4. Corticoid-sensitive psychosis. Patients with suspected connective tissue disease may be screened for anti-Jo-1 antibodies by ELISA. It detects some patients that are missed by immunodiffusion. Especially lower ELISA titres should be controlled by another method because of the low specificity of the test. The clinical picture is variable. Most patients have features other than myositis at disease onset.

[Guideline for the joint swelling symptom--primary physician problem management and referral indications. German Society of Rheumatology "Quality Assurance" Committee]

The guideline "Joint Swelling" is addressed to primary care physicians--general practitioners, internists or orthopedists without special experience in rheumatology. It provides a framework for interviewing patients, as well as for physical, laboratory and imaging examinations and for selection of treatment appropriate to the level of primary care. Situations which call for urgent evaluation and criteria for referral to rheumatologists are described. The appendix contains comments on signs and symptoms to differentiate arthralgia from joint swelling and on the diagnostic value of a history of joint swelling without confirmation by the physician. Further recommendations for the evaluation of patient history and physical and technical examinations are given in a tabular form. The significance of laboratory and imaging procedures is discussed.