Update of the evidence based, interdisciplinary guideline for anti-inflammatory treatment of uveitis associated with juvenile idiopathic arthritis

BACKGROUND

Uveitis in juvenile idiopathic arthritis (JIAU) is frequently associated with the development of complications and visual loss. Topical corticosteroids are the first line therapy, and disease modifying anti-rheumatic drugs (DMARDs) are commonly used. However, treatment has not been standardized.

METHODS

Interdisciplinary guideline were developed with representatives from the German Ophthalmological Society, Society for Paediatric Rheumatology, Professional Association of Ophthalmologists, German Society for Rheumatology, parents' group, moderated by the Association of the Scientific Medical Societies in Germany. A systematic literature analysis in MEDLINE was performed, evidence and recommendations were graded, an algorithm for anti-inflammatory treatment and final statements were discussed in a consensus meeting (Nominal Group Technique), a preliminary draft was fine-tuned and discussed thereafter by all participants (Delphi procedure).

RESULTS

Consensus was reached on recommendations, including a standardized treatment strategy according to uveitis severity in the individual patient. Thus, methotrexate shall be introduced for uveitis not responding to low-dose (≤ 2 applications/day) topical corticosteroids, and a TNFalpha antibody (preferably adalimumab) used, if uveitis inactivity is not achieved. In very severe active uveitis with uveitis-related deterioration of vision, systemic corticosteroids should be considered for bridging until DMARDs take effect. If TNFalpha antibodies fail to take effect or lose effect, another biological should be selected (tocilizumab, abatacept or rituximab). De-escalation of DMARDs should be preceded by a period of  ≥ 2 years of uveitis inactivity.

CONCLUSIONS

An interdisciplinary, evidence-based treatment guideline for JIAU is presented.

DigiTrain – Entwicklung und Evaluation eines digitalen Trainingsprogramms zur Rehabilitationsnachsorge bei chronischen Rückenschmerzen

Rückenschmerzen gehören zu den häufigsten Beschwerden in der deutschen Bevölkerung und stellen ein großes gesundheitliches wie gesundheitsökonomisches Problem dar. Die in der Rehabilitation von chronischen Rückenschmerzen erzielten Erfolge können nur nachhaltig gesichert werden, wenn die körperlich-sportlichen Aktivitäten im Alltag der Patienten regelmäßig und dauerhaft weitergeführt werden. Deshalb wurde das multimediale Trainingsprogramm „DigiTrain“ entwickelt. Das Programm soll durch einen interaktiven Trainer (Avatar) die weitergehende individuelle Betreuung und Begleitung (Coaching) des Patienten über den stationären Aufenthalt hinaus sicherstellen.

In dem Beitrag werden die Zielgruppe sowie die Inhalte und die Struktur des Programms „DigiTrain“ dargestellt. Ebenso wird ein Einblick in die technische Umsetzung und Produktion des Programms gegeben, bevor abschließend das Studiendesign für die wissenschaftliche Evaluation von DigiTrain vorgestellt wird.

[Colonization-outbreak of two clonally different strains of Serratia marcescens in a neonatal intensive care unit]

We describe an outbreak of two clonally different strains of Serratia marcescens in a neonatal intensive care unit. Three colonization cases in the first outbreak phase were related to contact transmission from an index patient during emergency respiratory treatment while eight colonizations in the second phase were caused by contaminated bathing lotion. All transmissions resulted in colonization only and no infections were recorded. Based on our experience and the literature review sufficient staffing levels, basic hygiene and a goal-directed investigation of the environment are the cornerstones of a rapid outbreak termination. The epidemiological search for parallels in cases should be assisted by sophisticated electronic records.

[Juvenile fibromyalgia syndrome]

OBJECTIVE

The aim was to develop a guideline for diagnostic procedures and treatment of juvenile fibromyalgia syndrome (JFMS) in cooperation with 10 German medical and psychological associations and 2 patient self-help groups.

METHODS

A systematic literature search, including all controlled studies evaluating diagnosis and treatment of JFMS, was performed in the Cochran Collaboration Reviews (1993-12/2006), Medline (1980-12/2006), PsychInfo (1966-12/2006) and Scopus (1980-12/2006). Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. Grading of the strengths of recommendations was performed according to the German program for disease management guidelines. Standardized procedures to reach a consensus on recommendations were used.

RESULTS

Pain in children/adolescents involving several body areas and lasting >3 months without an obvious somatic cause is called JFMS or pain amplification syndrome. Therapeutically, a multidisciplinary concept with psychotherapy and physiotherapy, relaxation techniques and patient education is recommended.

CONCLUSION

These guideline will contribute to a better recognition and standardized care of patients with JFMS and facilitate clinical studies.

Safety and efficacy of combination of etanercept and methotrexate compared to treatment with etanercept only in patients with juvenile idiopathic arthritis (JIA): preliminary data from the German JIA Registry

Objective:

Etanercept monotherapy has been studied and approved for treatment of polyarticular juvenile idiopathic arthritis (JIA). The following study evaluates the safety and efficacy of combination therapy of etanercept and methotrexate compared to etanercept monotherapy in JIA.

Methods:

We perfomed an open, non-randomised study on patients who had previously failed to respond to at least one disease-modifying antirheumatic drug (DMARD). A total of 722 patients with JIA in whom at least 1 item of follow-up data was recorded were identified; of these, 118 patients treated with further slow acting drugs were excluded. In all, 504 patients were treated with a combination of etanercept and methotrexate. A total of 100 patients treated with etanercept only were in the control group. Efficacy was calculated using the American College of Rheumatology paediatric scores for 30, 50 and 70% improvement (PedACR30/50/70). Adverse events (AEs) and serious adverse events (SAEs) were reported.

Results:

After 12 months 55 patients in the monotherapy group and 376 patients in the etanercept and methotrexate group were available for comparison. For the intention to treat analysis, 65 patients discontinuing treatment prematurely were included. All activity parameters decreased significantly in both treatment groups. After 12 months 81%/74%/62% of patients of the etanercept and methotrexate group and 70%/63%/45% of patients of the etanercept monotherapy group achieved PedACR30/50/70 scores, respectively (p<0.05 for PedACR30, p<0.01 for PedACR70). The likelihood of achieving a PedACR70 increased with combination therapy with an odds ratio of 2.1 (95% CI 1.2 to 3.5). In total, 25 infectious and 23 non-infectious SAEs including 3 malignancies occurred in the etanercept and methotrexate group, and 1 infectious and 3 non-infectious SAEs occurred in the single etanercept group.

Conclusions:

The patients’ disease activity improved during etanercept monotherapy and etanercept and methotrexate combination therapy. Tolerability in both treatment groups was comparable.

Confirmed cases and report of clusters of severe infections due to Clostridium difficile PCR ribotype 027 in Germany

In late September 2007, the local health authorities in Trier, Rhineland-Palatine, in south-western Germany, were informed of four cases with a severe course of Clostridium difficile-associated disease (CDAD) on several wards in a local hospital.

[Inhibitors of tumour necrosis factor-alpha for the treatment of arthritis and uveitis in childhood]

BACKGROUND

Chronic uveitis in childhood is a common complication of juvenile idiopathic arthritis (JIA) that frequently leads to loss of vision. Besides from corticosteroids and immunosuppressive drugs, Tumour necrosis factor-alpha (TNF-alpha) inhibitors are used frequently.

MATERIALS AND METHODS

The literature published before September 2006 was evaluated for the usefulness of TNF-alpha inhibitors (etanercept, infliximab, adalimumab) for the treatment of JIA-associated uveitis.

RESULTS

TNF-alpha inhibitors are effective drugs for the treatment of chronic uveitis in childhood. The response rate of uveitis in childhood to etanercept was approximately 50%. However, disease recurrence, first manifestations of uveitis and new complications occurred during the treatment. Infliximab and adalimumab appear to be more effective for the treatment of uveitis in childhood than etanercept.

CONCLUSIONS

The therapy with TNF-alpha inhibitors is expensive and increases the long-term risk for secondary diseases, such as tuberculosis and probably malignant lymphoma. Their use should be restricted to uveitis patients not responding to corticosteroids and at least one of established immunosuppressive drugs.

EBM Analyse: Klassische DMARDs (Disease modifying antirheumatic drugs) und Immunsuppressiva bei Arthritis und Uveitis

The best experience in the use of DMARDs/immunosuppressive drugs for treatment of juvenile idiopathic arthritis (JIA) and JIA-associated uveitis has been obtained with MTX. Controlled studies on the treatment of uveitis in JIA, however, are still lacking; this is also true for other DMARDs/immunosuppressive drugs. Thus, the grading of the evidence level for these substances only reaches evidence level III (expert opinion, clinical experience or descriptive studies). For the treatment of uveitis in JIA the utility of MTX in comparison to the new biological substance classes (e. g., tumor necrosis factor-alpha, blockers, interleukin-1 receptor antagonist) will have to be examined. Experience with Mycophenolate mofetil (MMF) in JIA uveitis is limited to single cases. According to data from a retrospective analysis cyclosporin A (CsA) appears to have a limited efficacy in JIA uveitis. The results with azathioprine are not consistent. Controlled studies which led to the approval of drugs for JIA are also mandatory for uveitis to offer the most effective and safe therapy for children.

Andere entzündlich rheumatische Erkrankungen mit Uveitis neben der juvenilen idiopathischen Arthritis

In childhood and adolescence, uveitis is part of the clinical spectrum of many inflammatory-rheumatic diseases. Besides juvenile idiopathic arthritis juvenile, ankylosing spondylitis, infection-associated arthritides, infantile sarcoidosis, systemic vasculitides, inflammatory bowel diseases, hereditary autoinflammatory syndromes and the TINU syndrome have to be excluded. These inflammatory diseases can be differentiated clinically in connection with immunogenetic and molecular genetic investigations. Early diagnosis of uveitis as well as the underlying diseases is mandatory for an early treatment and therefore for a good prognosis.

[Structural quality of rheumatology clinics for children and adolescents. Paper by a task force of the "Society of Pediatric and Adolescent Rheumatology" and of the "Association of Rheumatology Clinics in Germany"]

Rheumatic diseases in childhood and adolescence differ from those of adulthood according to type, manifestation, treatment and course. A specialized therapy, starting as early as possible, improves the prognosis, can prevent long-term damage and saves the costs of long-term care. Only a specialized pediatric care system can guarantee optimum quality of the processes involved and the results for rheumatology in childhood and adolescence within a global financial system. This requires adequate structural quality of the specialized clinics and departments for pediatric rheumatology. The management of rheumatic diseases in childhood and adolescence is comprehensive and requires a multidisciplinary, specialized and engaged team which can cover the whole spectrum of rheumatic diseases with their various age-dependent aspects. In order to guarantee an adequate, cost-efficient routine, a specialized center which concentrates on inpatient care should treat at least 300 patients with pediatric rheumatic diseases per year. The diagnoses should be divided among the various disease categories with at least 70% of them involving inflammatory rheumatic diseases. For the inpatient care of small children, an accompanying person (parent) is necessary, requiring adequate structures and services. Patient rooms as well as diagnostic (radiography, sonography, etc.) and therapeutic services (physiotherapy, occupational therapy, pool, etc.) must be adequate for small children and school children as well as adolescents. Suitable mother-child units must also be provided and a school for patients is required within the clinic. A pediatric rheumatologist must be available 24 h a day, and it must be possible to reach other specialists within a short time. For painful therapeutic procedures, age-appropriate pain management is obligatory. A continuous adjustment of these recommendations to changing conditions in health politics is intended.

Neufassung der Empfehlungen der Kommission Pharmakotherapie der DGRh

Inflammatory rheumatic illnesses are associated with various types of pain as well as handicaps. The so called basic therapies are not sufficiently effective in many patients or are terminated due to side effects. This is where tumor necrosis factor blockers (TNF) can be used. In many cases, they lead to a substantial improvement of the symptoms, a reduction in disease related laboratory parameters, improvement in quality of life to stopping disease related damage when their effect is rapid. Common and severe side effects are few, although long-term data are still limited. The following contribution lists recommendations for the indications and symptomatology for the use of TNF blockers.

Inactivation of influenza A virus on copper versus stainless steel surfaces

Influenza A virus particles (2 x 10(6)) were inoculated onto copper or stainless steel and incubated at 22 degrees C at 50 to 60% relative humidity. Infectivity of survivors was determined by utilizing a defined monolayer with fluorescent microscopy analysis. After incubation for 24 h on stainless steel, 500,000 virus particles were still infectious. After incubation for 6 h on copper, only 500 particles were active.

Use of copper cast alloys to control Escherichia coli O157 cross-contamination during food processing

The most notable method of infection from Escherichia coli O157 (E. coli O157) is through contaminated food products, usually ground beef. The objective of this study was to evaluate seven cast copper alloys (61 to 95% Cu) for their ability to reduce the viability of E. coli O157, mixed with or without ground beef juice, and to compare these results to those for stainless steel. E. coli O157 (NCTC 12900) (2 x 10(7) CFU) mixed with extracted beef juice (25%) was inoculated onto coupons of each copper cast alloy or stainless steel and incubated at either 22 degrees C or 4 degrees C for up to 6 h. E. coli O157 viability was determined by plate counts in addition to staining in situ with the respiratory indicator fluorochrome 5-cyano-2,3-ditolyl tetrazolium. Without beef extract, three alloys completely killed the inoculum during the 6-h exposure at 22 degrees C. At 4 degrees C, only the high-copper alloys (>85%) significantly reduced the numbers of O157. With beef juice, only one alloy (95% Cu) completely killed the inoculum at 22 degrees C. For stainless steel, no significant reduction in cell numbers occurred. At 4 degrees C, only alloys C83300 (93% Cu) and C87300 (95% Cu) significantly reduced the numbers of E. coli O157, with 1.5- and 5-log kills, respectively. Reducing the inoculum to 10(3) CFU resulted in a complete kill for all seven cast copper alloys in 20 min or less at 22 degrees C. These results clearly demonstrate the antimicrobial properties of cast copper alloys with regard to E. coli O157, and consequently these alloys have the potential to aid in food safety.

[Interdisciplinary guidelines on diagnosis and treatment for extracerebral amyloidoses--published by the German Society of Amyloid Diseases (www.amyloid.de)]

Within the past 10 years, a new range of knowledge has been achieved in the field of amyloidosis, especially with regard to pathogenesis, diagnosis and therapy. Amyloidosis leads to variable and distinct symptoms and is caused by different underlying conditions. Some amyloidoses are acquired secondary to a chronic condition; others are caused by genetic mutations. Amyloid and amyloidosis occur more frequently than they are perceived. Among the frequent localized forms are the cerebral amyloidosis linked to Alzheimer disease (AD) and the pancreatic amyloidosis linked to diabetes mellitus. Among the most frequent systemic (extracerebral) forms is AL amyloidosis, which often has a poor prognosis and if untreated can rapidly lead to death. Systemic amyloidosis that happen at infancy are mainly AA amyloidosis that can progress to death already at early or at middle adulthood. Amyloidosis can be treated but therapeutic success significantly depends upon early diagnosis and proper classification of the amyloid type. It is mandatory that differential diagnosis demonstrate the presence of amyloid and clearly identify the type of the disease. Development of methods and techniques have contributed to improvements in the diagnosis and treatment. Early diagnosis and proper classification of amyloid is decisive for therapeutic options and upon them depend quality of life and mortality. The therapeutic spectrum is various and includes organ transplantation, chemotherapy, and anti-inflammatory strategies. Gene therapy and biological active substances have to be considered in the near future.

Potential use of copper surfaces to reduce survival of epidemic meticillin-resistant Staphylococcus aureus in the healthcare environment

Epidemic meticillin-resistant Staphylococcus aureus (EMRSA) emerged in the early 1980s with EMRSA-15 and -16 being the most prevalent strains within the UK. MRSA transmission between patients is largely via the hands of healthcare workers, and contamination of the hospital environment may occur. The objective of this study was to evaluate the effectiveness of copper and brass to reduce the viability of air-dried deposits of three MRSA strains [MRSA (NCTC 10442), EMRSA-1 (NCTC 11939) and EMRSA-16 (NCTC 13143)] compared with stainless steel. MRSA and EMRSA [10(7)colony-forming units (CFU)] were inoculated on to coupons (1 cm x 1 cm) of copper, brass or stainless steel and incubated at either 22 degrees C or 4 degrees C for various time periods. Viability was determined by resuspending removed CFUs and plating out on tryptone soy agar plates in addition to staining with the respiratory indicator fluorochrome 5-cyano-2,3-ditolyl tetrazolium. On pure copper surfaces, 10(7) MRSA, EMRSA-1 and EMRSA-16 were completely killed after 45, 60 and 90 min, respectively, at 22 degrees C. In contrast, viable organisms for all three strains were detected on stainless steel (grade 304) after 72 h at 22 degrees C. At 4 degrees C, complete kill was achieved on copper for all three strains within 6 h. The results demonstrate an antimicrobial effect of copper on MRSA, EMRSA-1 and -16 in contrast to stainless steel. Consequently, the contemporary application of stainless steel in hospital environments for work surfaces and door furniture is not recommended.

Multizentrumstudie über ESPrit™ 3G für Nucleus 22

BACKGROUND

Cochlear implant recipients often report additional difficulty in comprehension of speech in noisy conditions and of softly spoken speech. The aim of this clinical study was to evaluate and compare the performance advantages offered by the ear level ESPrit 3G for experienced Nucleus Mini 22 cochlear implantees.

PATIENTS AND METHODS

Twenty-eight German-speaking implanted subjects, who had had experience with either the Spectra 22 or the ESPrit 22 for at least 6 months, were evaluated with their current processor and the ESPrit 3G (on microphone, M, and whisper, W, settings) following a 4-week trial. Freiburger monosyllabic words (FMW) were used at soft and conversational levels in quiet conditions and Oldenburger sentences (OLSA) were used in noisy conditions to compare performance. Subjective impressions of sound quality and user aspects were evaluated and combined with data from 31 English-speaking subjects from a parallel study.

RESULTS

In comparison to the previously worn processor, statistically significantly superior performance (p<0.001) was observed at soft and conversational levels in quiet conditions for FMW in 15 subjects when using the W setting and in noisy conditions for the OLSA in 21 subjects when using the M setting (p<0.001). The ESPrit 3G was preferred by 86% of subjects (51/59).

CONCLUSION

The ESPrit 3G for Nucleus 22 users has the potential to further improve speech understanding in quiet conditions at soft intensity levels and also in noisy conditions at conversational levels relative to the currently worn speech processor, the Spectra 22 or the ESPrit 22, for the majority of subjects. Subjectively, together with the improvement in sound quality, the majority of subjects also reported improved ease of use and wearer comfort.

M. Gaucher, M. Fabry und Mukopolysaccharidose Typ I

The lysosomal storage diseases Gaucher disease, Fabry disease and MPS I are rare inheritable metabolic disorders that are now treatable with enzyme replacement therapy. In order to avoid irreversible complications, an early diagnosis and initiation of therapy is important. Due to the musculoskeletal symptoms associated with these storage diseases, patients are likely to visit a rheumatologist, who should, therefore, be able to recognise and diagnose these rare diseases. On the basis of the causal factors behind Gaucher disease, Fabry disease und MPS I (here Scheie syndrome), key symptoms that the rheumatologist (internist or paediatrician) should be familiar with for the differential diagnosis of these patients will be discussed. In addition, a short introduction to the pathophysiology and data on the prognosis and therapy for these diseases will be presented.

The survival of Escherichia coli O157 on a range of metal surfaces

Escherichia coli O157:H7 is a serious pathogen causing haemorrhagic colitis. It has been responsible for several large-scale outbreaks in recent years. E. coli O157:H7 is able to survive in a range of environments, under various conditions. The risk of infection from contaminated surfaces is recognised, especially due to the low infectious dose required. In this study, a high concentration (10(7) cells) of E. coli O157 was placed onto different metals and survival time measured. Results showed E. coli O157 to survive for over 28 days at both refrigeration and room temperatures on stainless steel. Copper, in contrast, has strong antibacterial properties (no bacteria can be recovered after only 90 min exposure at 20 degrees C, increasing to 270 min at 4 degrees C) but its poor corrosion resistance and durability make it unsuitable for use as a surface material. Other copper-containing alloys, such as copper nickels and copper silvers, have improved durability and anticorrosion properties and greatly reduce bacterial survival times at these two temperatures (after 120 min at 20 degrees C and 360 min at 4 degrees C, no E. coli could be detected on a copper nickel with a 73% copper content). Use of a surface material with antibacterial properties could aid in preventing cross-contamination events in food processing and domestic environments, if standard hygiene measures fail.