[How to finance and increase the appeal of rheumatology training : view of the Association of Rheumatology Clinics in Germany (VRA) on challenges and successful strategies]

Due to the general lack of physicians in German hospitals new approaches are necessary to be successful in acquiring doctors for training in inpatient rheumatology.Although the financing of rheumatology education is still included in the general payment of hospitals, currently the diagnoses-related groups,,as it has already been fixed in the regulation on hospital care rates in Germany since 1994, new strategies may help to improve the financial situation of hospital units.The implementation of a binding structural quality, endorsed by the Association of Rheumatology Clinics in Germany (VRA), as well as the application of clinical pathways will optimize revenues.Further financial improvements can result from the implementation of case management, the implementation of interdisciplinary treatment, the promotion of a high quality treatment, from a differentiated approach towards outpatient treatment and a specialization within inpatient rheumatology units.Incorporating these strategies the advantages may not only affect the financial situation of hospitals but may also offer valuable incentives for physicians to start their professional career in inpatient rheumatology.

Functional characteristics of an endophyte community colonizing rice roots as revealed by metagenomic analysis

Roots are the primary site of interaction between plants and microorganisms. To meet food demands in changing climates, improved yields and stress resistance are increasingly important, stimulating efforts to identify factors that affect plant productivity. The role of bacterial endophytes that reside inside plants remains largely unexplored, because analysis of their specific functions is impeded by difficulties in cultivating most prokaryotes. Here, we present the first metagenomic approach to analyze an endophytic bacterial community resident inside roots of rice, one of the most important staple foods. Metagenome sequences were obtained from endophyte cells extracted from roots of field-grown plants. Putative functions were deduced from protein domains or similarity analyses of protein-encoding gene fragments, and allowed insights into the capacities of endophyte cells. This allowed us to predict traits and metabolic processes important for the endophytic lifestyle, suggesting that the endorhizosphere is an exclusive microhabitat requiring numerous adaptations. Prominent features included flagella, plant-polymer-degrading enzymes, protein secretion systems, iron acquisition and storage, quorum sensing, and detoxification of reactive oxygen species. Surprisingly, endophytes might be involved in the entire nitrogen cycle, as protein domains involved in N(2)-fixation, denitrification, and nitrification were detected and selected genes expressed. Our data suggest a high potential of the endophyte community for plant-growth promotion, improvement of plant stress resistance, biocontrol against pathogens, and bioremediation, regardless of their culturability.

[Strategies for improved healthcare of people with the endemic disease rheumatism exemplified by rheumatoid arthritis]

New therapeutic principles and considerable diagnostic advances have made it possible to define different rheumatic diseases and especially rheumatoid arthritis (RA) at an early stage and by starting an early and aggressive medication a considerable proportion of patients with RA will reach the status of low disease activity or even remission. With the additional development of composite measures to estimate the disease activity of RA, it was the goal of an international working group consisting of rheumatologists and patients to develop recommendations for treating rheumatoid arthritis in a similar way as for patients with hypertension or diabetes, with the aim to achieve remission as often as possible. This treat-to-target initiative has taken off in quite a number of different countries including Germany leading to discussions on how this initiative can be integrated into the specific national healthcare systems and what possibilities would exist for its implementation. To develop strategies for an improved healthcare of people suffering from rheumatic diseases and using RA as an example, action elements and postulates were developed which will be discussed in more detail in the present manuscript.

Haemophilia management: time to get personal?

The possibility of alloimmunization in patients receiving protein replacement therapy depends on (at least) three risk factors, which are necessary concomitantly but insufficient alone. The first is the degree of structural difference between the therapeutic protein and the patient's own endogenous protein, if expressed. Such differences depend on the nature of the disease mutation and the pre-mutation endogenous protein structure as well as on post-translational changes and sequence-engineered alterations in the therapeutic protein. Genetic variations in the recipients' immune systems comprise the second set of risk determinants for deleterious immune responses. For example, the limited repertoire of MHC class II isomers encoded by a given person's collection of HLA genes may or may not be able to present a 'foreign' peptide(s) produced from the therapeutic protein - following its internalization and proteolytic processing - on the surface of their antigen-presenting cells (APCs). The third (and least characterized) variable is the presence or absence of immunologic 'danger signals' during the display of foreign-peptide/MHC-complexes on APCs. A choice between existing therapeutic products or the manufacture of new proteins, which may be less immunogenic in some patients or patient populations, may require prior definition of the first two of these variables. This leads then to the possibility of developing personalized therapies for disorders due to genetic deficiencies in endogenous proteins, such as haemophilia A and B. [Correction made after online publication 11 July 2011: several critical corrections have been made to the abstract].

Effects of etanercept versus sulfasalazine in early axial spondyloarthritis on active inflammatory lesions as detected by whole-body MRI (ESTHER): a 48-week randomised controlled trial

PURPOSE

To evaluate the potential of etanercept versus sulfasalazine to reduce active inflammatory lesions on whole-body MRI in active axial spondyloarthritis with a symptom duration of less than 5 years.

METHODS

Patients were randomly assigned to etanercept (n=40) or sulfasalazine (n=36) treatment over 48 weeks. All patients showed active inflammatory lesions (bone marrow oedema) on MRI in either the sacroiliac joints or the spine. MRI was performed at weeks 0, 24 and 48 and was scored for active inflammatory lesions in sacroiliac joints and the spine including posterior segments and peripheral enthesitis by two radiologists, blinded for treatment arm and MRI time point.

RESULTS

In the etanercept group, the reduction of the sacroiliac joint score from 7.7 at baseline to 2.0 at week 48 was significantly (p=0.02) larger compared with the sulfasalazine group from 5.4 at baseline to 3.5 at week 48. A similar difference in the reduction of inflammation was found in the spine from 2.2 to 1.0 in the etanercept group versus from 1.4 to 1.3 in the sulfasalazine group between baseline and week 48, respectively (p=0.01). The number of enthesitic sites also improved significantly from 26 to 11 in the etanercept group versus 24 to 26 in the sulfasalazine group (p=0.04 for difference). 50% of patients reached clinical remission in the etanercept group versus 19% in the sulfasalazine group at week 48.

CONCLUSION

In patients with early axial spondyloarthritis active inflammatory lesions detected by whole-body MRI improved significantly more in etanercept versus sulfasalazine-treated patients. This effect correlated with a good clinical response in the etanercept group.

A Utility-Theoretic Approach to Privacy in Online Services

Online offerings such as web search, news portals, and e-commerce applications face the challenge of providing high-quality service to a large, heterogeneous user base. Recent efforts have highlighted the potential to improve performance by introducing methods to personalize services based on special knowledge about users and their context. For example, a user's demographics, location, and past search and browsing may be useful in enhancing the results offered in response to web search queries. However, reasonable concerns about privacy by both users, providers, and government agencies acting on behalf of citizens, may limit access by services to such information. We introduce and explore an economics of privacy in personalization, where people can opt to share personal information, in a standing or on-demand manner, in return for expected enhancements in the quality of an online service. We focus on the example of web search and formulate realistic objective functions for search efficacy and privacy. We demonstrate how we can find a provably near-optimal optimization of the utility-privacy tradeoff in an efficient manner. We evaluate our methodology on data drawn from a log of the search activity of volunteer participants. We separately assess users’ preferences about privacy and utility via a large-scale survey, aimed at eliciting preferences about peoples’ willingness to trade the sharing of personal data in returns for gains in search efficiency. We show that a significant level of personalization can be achieved using a relatively small amount of information about users.

Persistent expression of biologically active anti-HER2 antibody by AAVrh.10-mediated gene transfer

Trastuzumab (Herceptin) is a recombinant humanized monoclonal antibody directed against an extracellular region of the HER2 protein. We hypothesized that a single adeno-associated virus mediated genetic delivery of an anti-HER2 antibody should be effective in mediating long term production of anti-HER2 and in suppressing the growth of human tumors in a xenograft model in nude mice. The adeno-associated virus gene transfer vector AAVrh.10αHER2 was constructed based on non-human primate AAV serotype rh.10 to express the cDNAs for the heavy and light chains of monoclonal antibody 4D5, the murine precursor to trastuzumab. The data demonstrates that genetically transferred anti-HER2 selectively bound human HER2 protein and suppressed proliferation of HER2 positive tumor cell lines. A single administration of AAVrh.10αHER2 provided long term therapeutic levels of anti-HER2 antibody expression without inducing anti-idiotype response, suppressed the growth of HER2 positive tumors and increased survival of the tumor-bearing mice. In the context that trastuzumab therapy requires frequent, repeated administration, this strategy might be developed as an alternate platform for delivery anti-HER2 therapy.

Optimal Value of Information in Graphical Models

Many real-world decision making tasks require us to choose among several expensive observations. In a sensor network, for example, it is important to select the subset of sensors that is expected to provide the strongest reduction in uncertainty. In medical decision making tasks, one needs to select which tests to administer before deciding on the most effective treatment. It has been general practice to use heuristic-guided procedures for selecting observations. In this paper, we present the first efficient optimal algorithms for selecting observations for a class of probabilistic graphical models. For example, our algorithms allow to optimally label hidden variables in Hidden Markov Models (HMMs). We provide results for both selecting the optimal subset of observations, and for obtaining an optimal conditional observation plan. Furthermore we prove a surprising result: In most graphical models tasks, if one designs an efficient algorithm for chain graphs, such as HMMs, this procedure can be generalized to polytree graphical models. We prove that the optimizing value of information is $NP^{PP}$-hard even for polytrees. It also follows from our results that just computing decision theoretic value of information objective functions, which are commonly used in practice, is a #P-complete problem even on Naive Bayes models (a simple special case of polytrees). In addition, we consider several extensions, such as using our algorithms for scheduling observation selection for multiple sensors. We demonstrate the effectiveness of our approach on several real-world datasets, including a prototype sensor network deployment for energy conservation in buildings.

[How effective is rituximab in rheumatoid arthritis?: lessons learned from clinical practice]

OBJECTIVES

Does experience with rituximab treatment of rheumatoid arthritis (RA) in daily clinical practice confirm the results of controlled randomized studies?

METHODS

This is a retrospective data-analysis of the first 50 patients from one center with rituximab treatment for RA. The patients received at least one cycle of 2 rituximab infusions (1000 mg, respectively) within 2 weeks. Clinical assessment was performed 3-5 months after the first infusion.

RESULTS

The patients were older (mean age, 59 years) as compared to previously published controlled studies. The DAS28 was lower (5.5). The mean prednisolone dose was high (13.4 mg/d). The rheumatoid factor was positive in 88% of patients. Only six patients would have fulfilled inclusion criteria for controlled studies such as prednisolone dose <or=10 mg/d, concomitant methotrexate treatment, previous TNF-inhibitor treatment, or absence of malignancy. Nevertheless, indications were compatible with recently published German Rheumatology Society recommendations on rituximab treatment. A total of 62% of patients achieved EULAR response, 20% good response and 10% remission. Response was greater in patients with concomitant methotrexate treatment (88% versus 53%). The results were independent of sex, presence of anti-CCP antibodies, ANA, and previous TNF-inhibitor treatment. Only three patients had pathologic infusion reactions at the first infusion and one patient at the second infusion.

CONCLUSIONS

Rituximab proved to be effective, particularly when combined with methotrexate. Most patients differed considerably from those who had entered randomized controlled studies. Recently published German Rheumatology Society recommendations proved to be feasible as they reflect daily clinical practice. Results of controlled studies could be confirmed.

Efficient Informative Sensing using Multiple Robots

The need for efficient monitoring of spatio-temporal dynamics in large environmental applications, such as the water quality monitoring in rivers and lakes, motivates the use of robotic sensors in order to achieve sufficient spatial coverage. Typically, these robots have bounded resources, such as limited battery or limited amounts of time to obtain measurements. Thus, careful coordination of their paths is required in order to maximize the amount of information collected, while respecting the resource constraints. In this paper, we present an efficient approach for near-optimally solving the NP-hard optimization problem of planning such informative paths. In particular, we first develop eSIP (efficient Single-robot Informative Path planning), an approximation algorithm for optimizing the path of a single robot. Hereby, we use a Gaussian Process to model the underlying phenomenon, and use the mutual information between the visited locations and remainder of the space to quantify the amount of information collected. We prove that the mutual information collected using paths obtained by using eSIP is close to the information obtained by an optimal solution. We then provide a general technique, sequential allocation, which can be used to extend any single robot planning algorithm, such as eSIP, for the multi-robot problem. This procedure approximately generalizes any guarantees for the single-robot problem to the multi-robot case. We extensively evaluate the effectiveness of our approach on several experiments performed in-field for two important environmental sensing applications, lake and river monitoring, and simulation experiments performed using several real world sensor network data sets.

[Which ultrasound scan is the best to detect glenohumeral joint effusions?]

PURPOSE

It has not yet been systematically investigated which ultrasound scan is the best for detecting effusions of the glenohumeral joint. This question will be addressed by this study. Furthermore, this study determines reference values for distances to distinguish effusions from normal findings.

METHODS

Ultrasound was performed according to extended DEGUM and EULAR guidelines on 200 shoulders of 100 consecutive patients with shoulder complaints and on 40 shoulders of 20 healthy controls. Distances were measured between the surface of the humerus and the joint capsule in 3 positions: Axillary recess, dorsal transverse scan with 60 degrees internal rotation and with maximum external rotation. Normal values were calculated by ROC analysis.

RESULTS

The mean age of patients and controls was 58 and 55 years, and 67 % and 70 % were female, respectively. Ultrasound detected effusions in 81 shoulders of 56 patients. Effusions were seen in the dorsal scan with 60 degrees internal rotation in 30 %, in the axillary scan in 49 %, and in the dorsal scan in maximum external rotation in 94 % (p < 0.001, respectively). Five percent of the effusions were exclusively detected in the axillary scan. The upper normal limits for the distance between bone surface and joint capsule were 3.7 mm for the axillary recess, 2.7 mm for the dorsal region in 60 degrees internal rotation and 3.1 mm for the dorsal region in maximum external rotation .

CONCLUSIONS

Dynamic ultrasound examination including the dorsal scan with maximum external rotation is essential for detecting glenohumeral joint effusions. The axillary scan is superior to the dorsal transverse scan with 60 degrees internal rotation.

IgG1 and IgG4 are the predominant subclasses among auto-antibodies against two citrullinated antigens in RA

OBJECTIVE

Antibody subclasses reflect specific immunological processes and may be indicative of the underlying pathological pattern in an autoimmune disease like RA. We therefore quantified anti-cyclic citrullinated peptides (CCP) and anti- citrullinated vimentin (MCV) IgG subclass titres in RA patients and compared them with the respective titres of antibodies directed against the varicella zoster virus (VZV) and to total serum titres.

METHODS

Sera of 77 patients fulfilling the ACR criteria for RA were collected. An IgG subclass-specific ELISA system was then established and combined with commercially available MCV, CCP and VZV pre-coated microtitre plates.

RESULTS

Even though IgG1 is the predominant subclass among antibodies against CCP and MCV in RA patients, IgG4 is second with respect to titres and frequencies. This increase in IgG4 among RA-specific antibodies is independent of disease duration and does not reflect a general skewing of the immune response in these patients as overall serum titres and antibodies directed against VZV show a normal distribution of IgG1, IgG2, IgG3 and IgG4.

CONCLUSION

Elevated IgG4 titres are specific for auto-antibodies against citrullinated antigens in RA and are indicative of a Th2-biased environment during the generation of auto-reactive plasma cells. We discuss here an indirect role for IgG4 auto-antibodies in hindering the elimination of auto-reactive B and plasma cells and thus driving the autoimmune process.

Prognosis of large-vessel giant cell arteritis

OBJECTIVE

The prognosis of large-vessel GCA (LV-GCA) has not yet been investigated. How does it compare to GCA without arm vasculitis (GCA controls)?

METHODS

Charts of 53 LV-GCA patients and 53 GCA controls were reviewed following a predetermined protocol. Telephone interviews of patients or their primary care physicians were conducted. Forty LV-GCA patients underwent follow-up duplex ultrasound examinations of proximal arm arteries.

RESULTS

The mean observation time was 50 (s.d. +/- 31) months. None of the LV-GCA patients developed ischaemic arm complications. In 30%, proximal arm artery wall swelling disappeared completely. It decreased in 53%. In 8% it remained unchanged, in 5% it increased and in 5% arteries occluded with collateral flow. After the start of treatment, anterior ischaemic optic neuropathy developed neither in LV-GCA patients nor in GCA controls, amaurosis fugax occurred in 4 and 6%, arterial hypertension in 53 and 66%, strokes in 9 and 9%, myocardial infarction in 2 and 2%, diabetes mellitus in 30 and 25%, osteoporosis in 38 and 23%, and osteoporotic fractures in 15 and 4%, respectively. Mean corticosteroid dose was 3.7 mg/day. Mean duration of therapy was 42 months. All differences were insignificant. Four LV-GCA patients developed vasculitic popliteal artery stenoses.

CONCLUSIONS

The prognosis of LV-GCA is benign with regard to ischaemic complications. Proximal artery wall swelling decreases in most cases. Its course is similar to GCA without proximal arm arteritis.