Implicaciones bioéticas en el tratamiento integral al paciente afectado por enfermedades reumáticas / Bioethical implications in the integral treatment given to patients suffering from rheumatic diseases

La Ética es la parte de la filosofía práctica que se ocupa del hecho moral y de los problemas filosóficos que nacen de la conducta humana, la bioética resulta la rama de la ética que se dedica a proveer los principios para la correcta conducta humana; respecto a la vida. En el proceso de atención a los pacientes con enfermedades reumáticas se emplean variados procedimientos. Las nuevas tecnologías han mejorado notablemente su tratamiento integral; estos adelantos científicos deben ser empleados con la intención fundamental de no producir daño y previo consentimiento informado; por lo que resulta necesario argumentar acerca de las implicaciones bioéticas que resultan del empleo de los avances científico-tecnológicos en el tratamiento a los pacientes con enfermedades reumáticas(AU)

Ethics is the part of Practical Philosophy that deals with moral facts and philosophical problems that have their roots in human behavior. Bioethics is the branch of Ethics devoted to providing the principles for correct human behavior, with respect to life. Various procedures are used when treating patients with rheumatic diseases. New technologies have considerably improved their integral treatment; these scientific advances must be used with the main purpose of causing no harm and with prior informed consent. Therefore, it is necessary to argue on the bioethical implications that turn out from the use of scientific-technological advances in the treatment of patients with rheumatic diseases(AU)

[Indications and contraindications for radiosynoviorthesis]. / Indikationen und Kontraindikationen zur Radiosynoviorthese.

BACKGROUND: Radiosynoviorthesis (RSO) provides a simple method for the treatment of patients with chronic synovitis and has only few side effects. OBJECTIVES: Evidence-based indications and contraindications for performing RSO based on the current literature are presented. MATERIAL AND METHODS: Published information on the indications and contraindications for performing RSO in chronic synovitis were analyzed and summarized. RESULTS: According to the guideline recommendations of the German Society of Rheumatology indications for RSO are given in patients with rheumatoid arthritis, seronegative spondyloarthropathy, crystal arthropathy, villonodular synovitis and hemophilia with recurrent joint bleeding. Osteoarthritis with documented reactive synovitis is also regarded as an indication in the guidelines of the nuclear medicine societies. The European League Against Rheumatism (EULAR) and the German Society of Rheumatology (DGRh) have given no recommendations for using RSO in osteoarthritis. Given the correct indications RSO shows high success rates. CONCLUSION: The effects of RSO with the named secondary side effects last on average for 5 years. Crucial for the success of RSO are the correct indications, the correct timing and combination with other therapeutic procedures, such as surgical synovectomy.

DEGRO guidelines for the radiotherapy of non-malignant disorders. Part II: Painful degenerative skeletal disorders.

BACKGROUND AND PURPOSE: The purpose of this article is to summarize the updated DEGRO consensus S2e guideline recommendations for the treatment of benign painful degenerative skeletal disorders with low-dose radiotherapy. MATERIALS AND METHODS: This overview reports on the role of low-dose radiotherapy in the treatment of enthesiopathies (shoulder syndrome, trochanteric bursitis, plantar fasciitis, and elbow syndrome) and painful arthrosis (knee, hip, hand, and finger joints). The most relevant aspects of the DEGRO S2e Consensus Guideline Radiation Therapy of Benign Diseases 2014 regarding diagnostics, treatment decision, dose prescription as well as performance of radiotherapy and results are summarized. RESULTS: For all indications mentioned above, retrospective and some prospective analyses have shown remarkable effects in terms of pain relief. Nevertheless, the Level of Evidence (LoE) and the Grade of Recommendation (GR) vary: LoE 1b-4 and GR A-C. CONCLUSION: Low-dose radiotherapy for painful degenerative skeletal disorders is effective in the majority of the patients and therefore it may be a reasonable therapeutic alternative when simple and non-invasive methods have been used without persistent success. For all discussed entities, single fraction doses of 0.5-1.0 Gy and total doses of 3.0-6.0 Gy/series applied with 2-3 fractions per week are recommended.

[A dose-effect curve in the range of biological and therapeutic action of the radon treatment].

Optimal dose regimen for radon treatment in different diseases should be estimated with dose-effect curve in the range of a stimulating action of moderate doses. The range of therapeutic doses is situated on the ascending part of the resultant curve between minimal and maximal levels of the factor effect.

Radiation synovectomy of the upper extremity joints: does leakage from the joint to non-target organs impair its therapeutic effect?

Does leakage impair the therapeutic effect of radiosynoviorthesis (RSO)? Are there differences in leakage between (169)Erbium and (186)Rhenium? At baseline and at 6 and 12 months after RSO, six clinical parameters were scored. Changes in clinical variables over time were summed to a change composite index (CCI), ranging from 0 (no effect) to 12 (maximal effect). CCI >or= 6 was considered successful treatment. Differences in leakage between responders and non-responders, and between (169)Erbium and (186)Rhenium were examined. Regression analyses were performed to explore whether baseline variables predicted leakage. Both at 6 and 12 months response rates were 25 of 36 (69%). Five of 11 (45%) non-responders showed leakage versus 20 of 25 (80%) responders (P=0.06). Mean leakage to lymph nodes was 0.4+/-0.7% versus 2.4+/-0.8% (P=0.04). Median leakage to liver/spleen was 0% versus 0.3% (P=0.4). Only age at the time of injection correlated significantly with leakage to lymph nodes. The (169)Erbium group showed leakage in 1 of 7 (14%) versus 24 of 30 (80%) for the (186)Rhenium group (P=0.002). Mean leakage to lymph nodes was 0.11+/-0.3% versus 2.1+/-2.8% (P=0.001). Median leakage to liver/spleen was 0% versus 0.5% (P=0.006). Leakage to non-target organs does not impair the clinical effect of RSO. Only age predicted leakage to lymph nodes significantly. Other baseline characteristics did not predict leakage. (169)Erbium shows significantly lower leakage to non-target organs than (186)Rhenium in RSO.

Radon therapy for the treatment of rheumatic diseases--review and meta-analysis of controlled clinical trials.

OBJECTIVE: The aim of this study was to analyze the effect of radon therapy on pain in rheumatic diseases. METHODS: MEDLINE and MedKur databases were searched for the terms radon plus therapy, rheum, arthritis, and osteo. Radon therapy centers and experts in the field were contacted, proceedings hand-searched, and bibliographies checked for references of potential importance. Included were all prospective randomized controlled clinical trials that compared clinical effects of radon therapy with other interventions in patients with rheumatic diseases and studied pain intensity. Information concerning patients, interventions, results, and methodology were extracted in a standardized manner by all authors independently and summarized descriptively. Reports on pain reduction were pooled for meta-analysis. RESULTS: Five clinical trials with a total of 338 patients and comparing the effect on pain of radon baths (three trials) or radon speleotherapy (two trials) with control intervention in degenerative spinal disease (two trials), rheumatoid arthritis (one trial) and ankylosing spondylitis (two trials) met the inclusion criteria. In meta-analysis, the pooled data showed no difference immediately after treatment (P=0.13) but significantly better pain reduction in the radon group than the control group at 3 months (P=0.02) and 6 months (P=0.002) after treatment. CONCLUSIONS: The existing trials suggest a positive effect of radon therapy on pain in rheumatic diseases. With respect to the potential clinical effect and given the increasing public interest in radon therapy, there is an urgent need for further randomized controlled clinical investigations with long-term follow-up.

Scintigraphy in rheumatic diseases.

The aim of this review is to summarise the clinical role of nuclear medicine in rheumatology taking into consideration the most specific diagnostic applications and other worthwhile therapeutic contributions. Traditional bone scintigraphy and recent inflammation-targeting radiopharmaceuticals, such as radiolabelled leucocytes and immunoscintigraphy, now allow us to obtain highly sensitive total-body and tomographical imaging information that can be used for the diagnosis of osteoarticular disease. The most common extra-articular manifestations of rheumatic diseases due to digestive, central nervous, respiratory and cardiovascular system involvement can be diagnosed by specific scintigraphic methods. Radiosynovectomy plays an important role in providing effective treatment for some joint diseases that are resistant to pharmacological therapy. Diagnostic and therapeutic applications of nuclear medicine show the highest efficacy in the early phase of rheumatic diseases. In more advanced stages, scintigraphical techniques play a complementary role to radiographical investigations in the assessment of prognosis and therapy efficacy.

Radon progeny activity in sweat following radon exposure in a warm and humid environment.

The objective was to evaluate whether activity of radon progenies can be detected in sweat following speleotherapeutic radon exposure (40 kBq/m3) in a warm (38 degrees C) and humid (relative humidity > 70%) environment. A group of 11 male patients with spondyloarthropathy (n = 6) or non-inflammatory rheumatic diseases (n = 5) underwent a 1-h treatment in the gallery of the Gasteiner Heilstollen, and 20 min after leaving the treatment area radon progeny activity was measured in sweat by utilizing a special filter set. The results suggest that radon is discharged with sweat, causing a significant activity of radon and radon progenies on the skin. This finding may be important from a clinical point of view, since specialists experienced in radon therapy have repeatedly emphasized the importance of the degree of radioactivity on the skin for the effectiveness of treatment. It has even been claimed that the skin is the major target for radon therapy, possibly because of the influence on Langerhans' cell function.

Laser therapy for fibromyositic rheumatisms.

BACKGROUND AND OBJECTIVES: The objectives of this study is to treat the cases of fibromyositic rheumatisms untreatable with other therapies. The authors chose defocalized laser beams because some experimental studies had showed their analgesic and anti-phlogistic effects on experimental phlogosis. Since 1980 non-surgical laser effects were often noncomparable because of the lack of common treatment protocols. This summarizes fifteen years of clinical observations as to the purpose of identifying some indications on laser treatment of defined pathologies included in fibromyositic rheumatism. STUDY DESIGN/MATERIALS AND METHODS: 846 patients with different types of fibromyositic rheumatisms were submitted to defocalized laser therapy from 1980 to 1995. Criteria for selection included age, sex, and pathological pictures. Control groups were used to compare results with those of traditional methods. Diodes and CO2 lasers were employed, to exploit the photothermic and photochemical effects of the laser radiations to the fullest extent. RESULTS: On the whole, results were positive in comparison with other methods both as regards recovery time and persistence of results. Results were evaluated on the basis of subjective (such as local pain) and objective (hypomotility, phlogosis) criteria. CONCLUSIONS: Results obtained (approximately 2/3 of the patients benefited from the treatment) indicate that there are greater advantages in use of laser over other presently available methods. Standardalization of treatment protocols deserves further studies.

Clinical study of the effect of laser therapy in rheumatic degenerative diseases.

The effect of a 940-980 nm length wave laser radiation in rheumatic degenerative diseases was studied in 136 patients unresponsive to or with contraindications for antiinflammatory non-steroid therapy. The evolution was clinically estimated using four parameters; pain, muscular contracture, local edema and the impairment of the articular mobility. All patients presented a beneficial evolution appearing gradually during the treatment. The osteoarthritis of the knee, ankle and shoulder evolved worse than the painful back. The painful back presented an improved evolution when it was located at the thoracal level. No adverse reaction was observed during this study.

Pulsed magnetotherapy in Czechoslovakia--a review.

Pulsed magnetotherapy has been used in Czechoslovakia for more than one decade. It has been proved that this type of physical therapy is very efficient mainly in rheumatic diseases, in paediatrics (sinusitis, enuresis), and in balneological care of patients suffering from ischaemic disorders of lower extremities. Promising results have also been obtained in neurological diseases (multiple sclerosis, spastic conditions) and in ophthalmology, in degenerative diseases of the retina.

Novel therapies.

Extremely preliminary results from uncontrolled feasibility studies hint that minocycline and T-cell cytolitic strategies deserve further evaluation in RA, as does the use of high-dose intravenous gammaglobulin in chronic cutaneous vasculitis.