Rheumatology in practice - 2007

Comment: In the middle of a revolution, a place for thoughtful debate
Paul Emery
pp 2-2
This is a critical period for the interaction between primary and secondary care, particularly so for specialties such as rheumatology. The pace of change in the NHS, the culture of targets and the redistribution of funding have made these uncomfortable times. Rheumatology, in particular, is going through a revolution, both in its therapeutic possibilities and in payers’ assessment of it as a primary/secondary care interface specialty. The models and standards of care for the most common inflammatory rheumatic condition, rheumatoid arthritis (RA), vary greatly across the country. Rheumatology in practice provides the opportunity for an interface: for those in primary and secondary care to have their say and hold a debate that is informed by evidence.

Why GPs have a pivotal role in caring for patients with RA
Louise Warburton
pp 3-5
To be diagnosed with rheumatoid arthritis (RA) was once a life sentence of disability. With gold injections and steroids being the mainstays of treatment, most patients would have had crippling joint disease and only a small minority would have been able to continue working in their jobs. Today, however, younger doctors could soon qualify and develop their careers without seeing any of the end-stage manifestations of RA. This is because of the advent of disease-modifying antirheumatic drugs (DMARDs) and anti-tumour necrosis factor drugs (anti-TNFs), which can halt the progression of RA and return the patient to almost pre-disease levels of fitness and capability.

Stem cell therapy: an exciting prospect for rheumatology
Cosimo De Bari
pp 6-8
In recent years, stem cell research has generated great interest. In rheumatology, haematopoietic stem cell (HSC) transplantation has become a clinically feasible therapy for patients with severe autoimmune diseases. This technique attempts to reset the deregulated immune system and restore a proper immune homeostasis. Other emerging therapies involve the use of mesenchymal stem cells (MSCs), which are cells that have the ability to differentiate into mesenchymal tissues, such as cartilage and bone, and to exert immunomodulatory effects with inhibition of immune responses. MSCs have been used in tissue engineering to repair lost joint tissue components. Their use in treating autoimmune diseases is being explored.

Ultrasonography: a powerful tool, in the right hands
Jackie Nam and Richard Wakefield
pp 9-12
Imaging is playing an increasingly important role in the diagnosis and management of patients with rheumatic conditions. Conventional radiography has been the cornerstone of imaging for many years but advances in technology have pushed imaging techniques such as ultrasonography, MRI and CT to the fore. The focus of this article is on the current role of ultrasonography in rheumatology. The first report of musculoskeletal ultrasonography was published by Dussik et al in 1958. However, while ultrasonography evolved in other areas of medicine, progress in rheumatology was initially slow. It was not until the development of higher frequency transducers and faster digital processing in the late 1980s and early 1990s that the technology first became a viable and practical tool for imaging the musculoskeletal system.

New criteria for classifying PsA in clinical research
Phillip Helliwell
pp 13-15
In the last five years there has been an explosion in the number of articles on psoriatic arthritis (PsA). A MEDLINE search shows that fewer than ten papers per year were published from 1966 to the mid-1980s, from which point this rose to between 70 and 80 papers per year, until the millennium when 200 were published. That is still less than 10% of the number of papers on rheumatoid arthritis (RA), where a smaller increase has been observed. This activity is partly down to an increase in the number and size of journals, but it also indicates the interest in PsA that has been driven by the development of new and effective treatments for the condition. Paradoxically, this has exposed the traditional disease-modifying antirheumatic drugs, which have, in comparison to the newer arrivals, a poor evidence base.

Are coxibs really more risky than standard NSAIDs?
Marwan Bukhari
pp 16-18
Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used in rheumatology practice. They are, however, associated with an increased risk of gastrointestinal (GI) perforations, ulcers and bleeds as well as other GI symptoms, such as dyspepsia. There is currently a debate on whether or not selective COX-2 inhibitors (coxibs) offer any added benefit over standard NSAIDs. Although coxibs offer increased GI safety, some studies have shown them to increase the risk of cardiovascular and thromboembolic events. This article examines the evidence on coxibs, to enable an informed clinical choice on their place in treatment. Here, only celecoxib, etoricoxib and umiracoxib are considered to be true specific coxibs, while all other NSAIDs are referred to as non-specific NSAIDs (nsNSAIDs).

Things I wish I had done to treat anklosing spondylitis
Andrei Calin
pp 19-19
One of the sadder aspects of dealing with ankylosing spondylitis is that, even now, there are often years between initial symptoms developing and a diagnosis being made that allows the patient to be referred to a rheumatologist. AS is an inflammatory form of back pain. Back pain is highly prevalent in the general population so GPs may be reluctant to diagnose what is essentially a rare form. Nevertheless, doctors, physiotherapists and others should think of AS; patients who have suffered for years feel immense relief when they are diagnosed and treatment begins.

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