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In two research projects, rheumatological patient education programmes were updated. The first step was to develop an expert consented framework for all rheumatological patient education programmes. From this, curricula and working materials for rheumatoid arthritis (RA) and axial spondyloarthritis (AS) were derived and two exemplary patient education manuals developed. A randomized controlled trail was designed for the five-hour RA basic education program. Finally, existing train-the-trainer training courses were adapted for these patient education programmes.

In two research projects, rheumatological patient education programmes were updated. The first step was to develop an expert consented framework for all rheumatological patient education programmes. From this, curricula and working materials for rheumatoid arthritis (RA) and axial spondyloarthritis (AS) were derived and two exemplary patient education manuals developed. A randomized controlled trail was designed for the five-hour RA basic education program. Finally, existing train-the-trainer training courses were adapted for these patient education programmes.

In 2015 EULAR published recommendations for patient education of people with inflammatory arthritis. The recommendations included two superior principles and eight recommendations based on the level of evidence and expert knowledge. The German translation of the recommendations was evaluated by 15 German experts. Experts graded the strength of the recommendations (SOR) on an 11 point numerical rating scale (from 0 = no agreement to 10 = total agreement). The mean score was 8,8 ± 0,49.

Objective Indocyanine green–enhanced fluorescence optical imaging (FOI) is a novel diagnostic tool for the assessment of inflammation in arthritis. We undertook this study to compare FOI with magnetic resonance imaging (MRI) in 32 patients with early and very early untreated arthritis (mean disease duration 7.1 months). Methods FOI images were acquired with the commercially available Xiralite system. Image interpretation was done for an early phase (phase 1), an intermediate phase (phase 2), and a late phase (phase 3), and for an electronically generated composite image. The results were compared with those of clinical examination (960 joints) and contrast (gadolinium)–enhanced 1.5T MRI (382 joints) of the clinically more affected hand. Additionally, we evaluated FOI in a control group of 46 subjects without any signs of inflammatory joint disease (1,380 joints). Results With MRI as the reference method, the sensitivity of FOI was 86% and the specificity was 63%, while the composite image, phase 1, and phase 3 reached high specificities (87%, 90%, and 88%, respectively). The results differed considerably between the composite image and the phases. FOI did not detect inflammation in 11 joint regions that showed palmar tenosynovitis on MRI. Intrareader and interreader agreements were moderate to substantial (κ = 0.55–0.73). In the control group, FOI showed positive findings in 5% of normal joints in phase 2. Conclusion Further multicenter studies will address the question of whether FOI allows sensitive and reliable detection of inflammatory changes in early arthritis, as suggested by our initial findings. If this is confirmed, FOI has the potential to be a sensitive and valuable tool for monitoring disease activity on site in clinical settings and for serving as an outcome parameter in clinical trials.

Viele Patienten mit ankylosierender Spondylitis (AS, M. Bechterew) sind davon uberzeugt, durch ihr eigenes Verhalten zu einem positiven Krankheitsverlauf beitragen zu konnen. Standardisierte und konsentierte Empfehlungen hierzu existieren jedoch nicht, weder national noch international. Ziel war es daher, aufgrund von Evidenz und Expertenmeinung einen ersten Kernsatz von Empfehlungen zur Weitergabe durch den behandelnden Rheumatologen zu erstellen. Eine systematische Recherche wissenschaftlicher und patientenorientierter Literatur ergab 70 Empfehlungen. Diese Empfehlungen wurden zunachst beim Delegiertentreffen der Ankylosing Spondylitis International Federation (26 Teilnehmer aus 13 Landern) im November 2011 nach ihrer Wichtigkeit bewertet. Die danach verbliebenen 59 Empfehlungen wurden bei einem Gruppensprecherseminar des Landesverbands Bayern der Deutschen Vereinigung Morbus Bechterew im Marz 2012 (80 Teilnehmer, 95 % davon AS-Patienten) ausfuhrlich diskutiert, erganzt, teilweise umformuliert und diejenigen mit der hochsten Prioritat ausgewahlt. Der Kernsatz enthalt zum einen ein generelles Statement zum Leben mit AS und gibt zum anderen Empfehlungen zu den Bereichen allgemeines Verhalten, Sitzhaltung, Verhalten beim Gehen, beim Schlafen, bei der Arbeit sowie Bewegungsubungen, Sport- und Freizeitaktivitaten, Ernahrung und Lebensstil, Sexualitat und Schwangerschaft, Sturzvermeidung, Autofahren und Mitgliedschaft in einer AS-spezifischen Patientenorganisation. Einige Empfehlungen (z. B. zur Sturzvermeidung oder zum Autofahren) betreffen eher Patienten nach langerer Krankheitsdauer, d. h. mit fortgeschrittener knocherner Versteifung und Osteoporose. Die Zustimmung zu den Empfehlungen war mit 80–100 % der Patienten hoch. Erstmalig wurde unter Mitarbeit vieler Betroffener ein Kernsatz von Empfehlungen zum Patientenverhalten entwickelt, der dem Rheumatologen bei der Erlauterung der Krankheit und ihrer moglichen Folgen als Richtschnur und dem Patienten als Gedachtnisstutze und Erganzung dieser Erlauterungen dienen kann. Hier wird die deutschsprachige Version dieses international erarbeiteten Kernsatzes prasentiert.

Beim Morbus Bechterew (ankylosierende Spondylitis, AS) sind laut neuerer Literatur einige geschlechtsspezifische Besonderheiten aufgefallen. Ziel der Arbeit war es, basierend auf einer Literaturrecherche einen Uberblick zu diesem Thema zu geben. Manner sind etwa doppelt so haufig von M. Bechterew betroffen als Frauen. Bei Frauen ist der entzundliche Charakter der Erkrankung in Achse und Peripherie oft starker, radiologische Zeichen und AS-typische Einsteifung der Wirbelsaule sind spater und seltener, hypermobile/instabile Segmente konnen bleiben. Die Schmerzen sind mindestens gleich stark, Funktionseinschrankung und Erschopfung bei Frauen starker als bei Mannern ausgepragt. Die AS verlauft bei Frauen nicht milder, aber oft anders als bei Mannern.

In 2015 EULAR published recommendations for patient education of people with inflammatory arthritis. The recommendations included two superior principles and eight recommendations based on the level of evidence and expert knowledge. The German translation of the recommendations was evaluated by 15 German experts. Experts graded the strength of the recommendations (SOR) on an 11 point numerical rating scale (from 0 = no agreement to 10 = total agreement). The mean score was 8,8 ± 0,49.

Background Indocyanine green (ICG)-enhanced fluorescence optical imaging (FOI) is an established technology for imaging of inflammation in animal models. In experimental models of arthritis, FOI findings corresponded to histologically proven synovitis. This is the first comparative study of FOI with other imaging modalities in humans with arthritis. Methods 252 FOI examinations (Xiralite system, mivenion GmbH, Berlin, Germany; ICG bolus of 0.1 mg/kg/body weight, sequence of 360 images, one image per second) were compared with clinical examination (CE), ultrasonography (US) and MRI of patients with arthritis of the hands. Results In an FOI sequence, three phases could be distinguished (P1–P3). With MRI as reference, FOI had a sensitivity of 76% and a specificity of 54%, while the specificity of phase 1 was 94%. FOI had agreement rates up to 88% versus CE, 64% versus greyscale US, 88% versus power Doppler US and 83% versus MRI, depending on the compared phase and parameter. FOI showed a higher rate of positive results compared to CE, US and MRI. In individual patients, FOI correlated significantly (p

ZusammenfassungSeit mehr als 100 Jahren wird Radon in seinen unterschiedlichen Applikationsarten bewusst therapeutisch genutzt, und zwar vorwiegend bei chronischen Erkrankungen des Bewegungsapparates, der Atemwege und der Haut. Schmerzlindernde und entzündungshemmende Effekte mit langer Wirkdauer und konsekutiver Medikamenteinsparung (NSAR, Kortison) sowie mit Reduktion von gastrointestinalen Komplikationen sind anhand von mehreren kontrollierten klinischen Studien aufgezeigt worden. Für die empirisch beobachteten weiteren Effekte (antiallergisch, immunstabilisierend) fehlen bisher beweisende Studien. Die aktuelle Grundlagenforschung impliziert eine Wirkung von Radon via Apoptose auf der Ebene der Zytokine (TGF-Beta1-Aktivierung) und der neuroregulatorischen Peptide (Substanz-P-Downregulation, Beta-Endorphin- und Enkephalin-Erhöhung) sowie der Reduktion freier Radikale (SOD-Aktivierung) und der Stimulation des DNA-Repairs. Im Vergleich zur durchschnittlichen jährlichen natürlichen Strahlenbelastung des deutschen Bundesbürgers (von 2,4 mSv) wird in der balneologischen Anwendung von Radon mit moderaten Dosen (von 0,02-1,8 mSv) gearbeitet.

Patients with ankylosing spondylitis (AS) can contribute to a favorable disease course by their own behaviour and environmental adaptations. However, no standardized consensus recommendations on patient behavior and adaptations exist, neither internationally nor nationally. The aim of this study was to establish a core set of recommendations concerning favorable patient behavior to be given to patients with AS by rheumatologists.An extended literature research in the scientific and patient-oriented literature revealed 70 recommendations. These recommendations were evaluated and ranked by importance at a meeting of the Ankylosing Spondylitis International Federation (ASIF, 26 participants from 13 countries) in November 2011. The remaining 59 recommendations were extensively discussed, supplemented, partially reworded, condensed and those with the highest priority were selected by consensus at a seminar of local branch leaders of the AS patient organization in Germany (Deutsche Vereinigung Morbus Bechterew) in March 2012 (80 participants, 95% patients with AS).The core set encompasses 1) a general statement on living with AS and 2) recommendations in the areas of sitting position, walking, sleeping, at work, exercising, sports and recreational activities, diet and life style, sexuality and pregnancy, fall prevention, car driving and membership in an AS-specific patient organization. The selected recommendations received agreement by 80-100% of the patients. Some recommendations (e.g. fall prevention and car driving) are more relevant to patients with advanced and usually longstanding disease, i.e. with advanced ankylosis or osteoporosis.For the first time a core set of recommendations for the behavior of patients with AS was created in collaboration with many persons affected by the disease. Patients with AS should receive these recommendations from their rheumatologists, ideally early in the disease course. The German version of this core set is presented in this article.

Die Geschichte des schmerztherapeutischen Einsatzes von Radon reicht viele Jahrhunderte zuruck. Die Thermalquellen in Bad Gastein (Osterreich) interessierten schon Paracelsus, den heisen Thermal-Sand auf der Insel Ischia (Italien) nutzten schon die Romer — nur wusste man bis zum Beginn des 20. Jahrhunderts nicht, dass Radon das wesentliche Agens dieser Heilmittel war.

Background ICG-enhanced fluorescence optical imaging (FOI) is a novel technology for the assessment of inflammation in arthritis [1,2]. Previous studies were mainly focused on articular findings. Extraarticular changes have not yet been studied systematically. Objectives This is the first report of extraarticular FOI patterns in a large cohort of subjects with psoriatic arthritis (PsA). Methods 201 FOI sequences in 172 patients with PsA (59% females, mean age 54,1 years, mean disease duration 5,8 years (median 3,1 years, range 2 weeks – 42,7 years), mean DAS28 3,0) were selected from our FOI registry. FOI was performed according to the standard procedure [1,2]. 36 regions (both hands: nail, nail fold, middle phalanx of D 2-5, proximal phalanx of D 1-5, metacarpal area) were read for the sum image (PVM) and the phases P1 and P2 [1]. Different FOI patterns were identified, characterized and classified by the method of categorical morphological analysis. 30 subjects with seropositive, anti-CCP-positive rheumatoid arthritis (mean disease duration 4,6 years, median 1,9 years, mean DAS28 3,5) served as control. Results 16 distinct extraarticular FOI patterns could be identified in subjects with PsA in the following areas. (A) Nail: Cold Nail, Green Nail, Hot Nail, Caldera, Half Moon. (B) Nail fold: Werner9s sign [1], Bishop9s crook. (C) Phalanges: Hourglass, Pyramid, Caterpillar, Barrel, Stripe, Thread. (D) Metacarpal area: Island, Archipelago, Geographic Map. Nail fold changes were the most common finding (72% of sequences), followed by stripe (58%), hourglass (32%), pyramid (30%), barrel (28%) and thread (28%). Patterns in area A-C were mainly seen in PVM and P2, patterns in area D almost exclusively in P1. 66 subjects did not have any clinical signs in the region of the hands (no swollen or tender joints). At least one extraarticular pattern was present in all of those subjects. Hourglass patterns were more frequent in PsA comparing to RA (32% vs 7%). Archipelago patterns (group of small islands) were observed exclusively in subjects with PsA. Areas of reduced perfusion and deviations from the typical course of the phases were seen in 19% of PsA sequences vs 3% in RA. Conclusions Extraarticular FOI findings were common in PsA. The classification of their morphologies in PsA enables a standardized assessment of FOI sequences beyond the quantitative fluorescence optical imaging score FOIAS [1,2]. Some patterns may be characteristic for PsA and could have a diagnostic value. Extraarticular signal intensities in the hands of patients with clinically asymptomatic hand and finger joints probably represent subclinical disease activity. This observation could play a role in early diagnosis and in the assessment of therapeutic response. References Werner SG, Langer HE, Ohrndorf S et al, Inflammation assessment in patients with arthritis using a novel in vivo fluorescence optical imaging technology. Ann Rheum Dis 2011;71(4):504-510 Werner SG, Langer HE, Schott P, et al: Indocyanine Green–Enhanced Fluorescence Optical Imaging in Patients With Early and Very Early Arthritis: A Comparative Study With Magnetic Resonance Imaging. Arthritis Rheum 2013; 65(12):3036–3044 Acknowledgements The research was supported in part by a research grant of Pfizer Pharma GmbH Germany Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2590

We read with interest the article on the impact of gender on outcomes in ankylosing spondylitis (AS).1 In their analysis of four controlled clinical trials, the authors found a higher burden of AS in female patients and less improvement in outcome measures compared with men, ‘despite women having a later disease onset and shorter disease duration’. They conclude that the mechanism behind this observation is …

Background Indocyanine green (ICG) enhanced fluorescence optical imaging (FOI) is a diagnostic tool for assessment of inflammation in arthritis. In cross-sectional studies FOI had a good agreement with MRI and US findings (1). The semiquantitative fluorescence optical imaging activity score (FOIAS) correlated with clinical (DAS 28) and MRI (RAMRI) scores of disease activity. Objectives To compare clinical assessment and FOIAS for measurement of treatment response in DMARD naive patients and in subjects with inadequate response to non-biologic DMARDs (DMARD-IR) and switch to biologicals. Methods 57 cases with rheumatoid (RA) and psoriatic (PsA) arthritis were examined before starting treatment with non-biological or biological DMARD (visit 1) and at follow-ups (visits after ≥3 months). FOI (Xiralite, mivenion GmbH, 0.1 mg/kg/BW of ICG i.v. over 6 minutes) sequences were analyzed for FOIAS (PVM, P1, P2, P3) (1). Treatment response was assessed using DAS28, physicians global (VAS 1-10), swollen joint count (SJC), tender joint count (TJC), CDAI, SDAI and FOIAS. Standardized response means (SRM) were calculated for measurement of treatment response. Results All scores showed a reduction of disease activity from visit 1 to visit 2. High treatment response (SRM >0.8) were seen for physicians global and DAS28, moderate response (SRM >0.5-0.8) for SJC, CDAI, SDAI, FOIAS PVM, P2 and P3 (2). Detailed results are shown in table. Conclusions The study suggests that treatment monitoring with FOI and the semiquantitative FOIAS are a suitable tools to assess treatment response in subjects with RA and PsA treated with DMARDs or biologicals. Further studies are required to evaluate FOIAS as a possible additional outcome measure in clinical trials and clinical practice. References Werner SG, Langer HE, Ohrndorf et al. Inflammation assessment in patients with arthritis using novel in vivo fluorescence optical imaging technology. Ann Rheum Dis Oct 12, Epub ahead of print. Husted JA, Cook RJ, Farewell VT, et al. Methods for assessing responsiveness: a critical review and recommendations. J Clin Epidemiol 2000;53:459–68. Disclosure of Interest S. Werner Grant/Research support from: Pfizer, H.-E. Langer Grant/Research support from: Pfizer, F. Spiecker: None Declared, S. Mettler: None Declared, G. Lind-Albrecht: None Declared, C. Hermsen: None Declared, M. Backhaus Grant/Research support from: Pfizer

Background Early diagnosis of psoriatic arthritis (PsA) is a major challenge. ICG-enhanced fluorescence optical imaging (FOI) is a novel technology that enables detection of inflammation in the hands with high sensitivity and specificity comparable to MRI arthrosonography (1). Objectives To report for the first time of FOI in subjects with arthralgia and psoriasis or family history of psoriasis but without signs of clinically established arthritis. Methods 19 subjects (12 female, 7 male; mean age 43 years, range 15-88) were referred to the early arthritis clinic with cutaneous manifestations of psoriasis or family history of psoriasis and pain in various joints (monarticular, oligoarticular, polyarticular). None had a history of actual or previous arthritis or tendinitis or any signs of active synovitis at clinical examination. FOI was performed following the usual procedure (1). The findings were compared to FOI in 8 patients (7 female, 1 male, mean 53 years, range 29-70 years) with very early PsA (mean disease duration of 8 weeks, range 1-12 weeks). Results FOI displayed inflammatory changes in all subjects. Joint-related signal intensities were seen in 19/19 (100%), and extraarticular increases signal intensities in 17/19 sequences (89%). The morphology of FOI inflammation (figure 1 right) was indistinguishable from the findings that were seen in patients with very early PsA (figure 1 left) and showed a marked difference compared to FOI in healthy subjects. 5/19 individuals (26%) without clinical symptoms in the hands had positive FOI changes in all small joint regions (wrist, MCP, PIP, DIP). 17/19 FOI findings (89%) showed a triangular, slightly accurate enhancement in projection of the synovio-entheseal complex (2) that may be pathognomonic for PsA (1). Image/graph Conclusions The detection of typical inflammatory changes in subjects with cutaneous manifestations of psoriasis or family history of psoriasis and joint pain but without clinical signs of synovitis or tendinitis suggests that a non-arthritic, subclinical disease stage may precede the onset of clinically active PsA. With the visualization of inflammation in those subjects FOI possibly is a new diagnostic opportunity in incipient PsA. Further investigations with follow up examinations to proof this concept are necessary. References Werner SG, Langer HE*, Ohrndorf S*, Bahner M, Schott P, Schwenke C, Schirner M, Bastian H, Lind-Albrecht G, Kurtz B, Burmester GR, Backhaus M.*equal contribution: Inflammation assessment in patients with arthritis using a novel in vivo fluorescence optical imaging technology. Ann Rheum Dis. 2012 Apr;71(4):504-10 McGonagle D, Lories RJ, Tan AL, et al. The concept of a “synovio-entheseal complex” and its implications for understanding joint inflammation and damage in psoriatic arthritis and beyond. Arthritis Rheum 2007;56:2482–91. Disclosure of Interest None Declared

Objectives We have developed a managed care model for early arthritis that combines the following principles: a) treat to target (clinical remission, functional capacity, radiologic progression); b) tight control; c) prospective identification of subjects with poor prognosis and stratification of therapy by a risk-tailored strategy; (d) guidance of therapy according to predefined algorithms. Methods From 2005-2012 616 patients with early arthritis (≤ 2 years) registered for the model. On entry, a modified Visser score (1) plus shared epitopes and MRI findings as additional prognostic markers was used for an initial appraisal of prognosis. For a following treatment period of 3 months, patients were assigned to one of four risk groups: low ( Results The intended objectives could be achieved in defiance of different treatment modalities and different assignment of resources. The majority of subjects reached low disease activity within the first 3 months and had sustained low disease activity over a follow-up of up to 84 months. At 60 months, 26/61 patients (43 %) were in clinical remission (DAS28 Conclusions In patients with early arthritis, a risk-tailored strategy with individualized stratification of tight control and a prognosis-orientated, differentiated allocation of man power and of cost-intensive therapies enables appropriate outcomes with economic, effective and efficient usage of resources. References Visser H, et al: Arthritis Rheum. 2002;46:357 (2) Emery P, et al: Lancet 2008; 372: 375 (3) Breedveld FC, et al: Arthritis Rheum. 2006;54:26 Disclosure of Interest None Declared