Thursday, 17 Oct 2019

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EULAR 2016: Name that Country Part II

Like the EULAR Congress of 2010, the 2016 version was in the giant ExCel center out in the Docklands area.  The meeting rooms are cavernous, big as some basketball stadiums.  The ExCel is so big that it is served by two stations of the DLR railroad and it is probably long enough to function as a runway with planes that fly overhead on the way to London City Airport. Ed Sullivan would have called the ExCel “really, really big.” Donald Trump would say it is “yuge.”  

To reward those of you who patiently read this far, I will give you some highpoints of talks that I attended.  

The treatment of lupus nephritis can be successful using much lower doses of prednisone than the classic starting regimen of 1 mg/kg.

Rather than thinking that rheumatoid arthritis (RA) is complicated by comorbid conditions such as cardiovascular disease (CVD), think about it in a more holistic and unified way in which multimorbidities coexist to interact and influence each other. As such, a therapy impacting one morbidity (e.g., methotrexate for inflammatory arthritis) may have benefits on another such as CVD.

Patterns of abnormal gene expression in the skin of someone with systemic sclerosis may have a counterpart in the lung affected by pulmonary fibrosis.  

Biosimilars in the treatment of RA are proliferating and are here to stay. In one lecture, I heard that 30-that’s right 30-TNF blockers are under development and may soon be on the market.  So far, these products seem to be truly similar but the goal for similarity has not been pharmacology.  It’s price.

On the last day of the meeting, I had the honor to co-chair a session with Professor Gerd Burmester of Berlin on the important EULAR initiative called “Time is Joints.” At the heart of this initiative is the idea that inflammatory arthritis is an emergency and that the faster the diagnosis is made and effective treat to target (T2T) therapy started, the less damage and disability will occur. Instead of a chronic disease, RA can be viewed as an acute disease with chronic and often severe consequences.

As speakers and discussants at this very informative session described, the treatment of RA has improved significantly and delays to the start of T2T have gone down once the diagnosis is made, with effective DMARDs instituted in a few months. Unfortunately, delays in referral to specialty care and the start of T2T have been persistent and still approach a year.  

Given all of the attention to the treatment of inflammatory arthritis in the past two decades, why still the delay?

At least two factors are at play. The first relates to the patient. While RA is a serious condition where the clock ticks on permanent damage, its onset can be vague and subtle, marked by little more than fatigue and arthralgia. These pains may be nagging and noisome but are not alarming enough to the patients to prompt an appointment with a physician, especially when OTC NSAIDs can provide some measure of relief. As one speaker noted, patient education does not adequately inform the public about the crucial differences between rheumatoid and other forms of inflammatory arthritis, on one hand, and osteoarthritis, on the other.

Another factor contributing to delay relates to the realm of primary care which is the usual entry point of people with RA into the health care system. While musculoskeletal complaints are very common in primary care (perhaps the reason for as many as one-third of all visits), RA and other forms of inflammatory arthritis are actually quite uncommon. One speaker at the session indicated that the average primary care provider may see a new RA case once in every two to three years. These providers may therefore be unfamiliar with the various presentations of inflammatory arthritis, never really going down the learning curve, unaware of the red flags, relying on symptomatic therapy.  

This situation is not surprising since education on musculoskeletal disease remains sparse in most curricula for health professionals. Arthritis receives little attention in comparison to that allotted for cardiovascular disease, diabetes and hypertension which remain a large part of primary care. Much work needs to be done for education of primary care providers (and others like sports medicine physicians and physiotherapists) to enable them to recognize RA more rapidly and hopefully refer patients to rheumatologists. Congratulations to EULAR on undertaking this important public health program. As a member of the American College of Rheumatology and President of the United States Bone and Joint Initiative, I look forward to its success.

(See, this article does have substance).

The session on “Time is Joints” took place on Saturday morning and did not conclude until 10 AM. Even though there were more sessions later in the day, I decided that I learned enough and wanted time to enjoy London, one of my favorite cities (It is number three after Durham, North Carolina, and New York City). That Saturday was a very special day because of the official celebration of Queen Elizabeth’s 90th birthday (her actual birthday is April 21) and the Trooping the Color military parade led by the Coldstream Guard. As a boy, I remember watching her coronation on our big box Zenith television set which had grainy images of black and white that often flickered or degenerated into static. Queen Elizabeth has had a fantastic reign which seemingly gets better as time goes on, giving a definite boost to the idea of a monarchy even in a democracy.

To get to the heart of the city, I took the Jubilee tube line over to Westminster, not too far from where I was staying.  I arrived too late to get a glimpse of the Queen’s visit to St. Paul’s Cathedral. Nevertheless, the air still sparked with excitement. The Parliament building at Westminster is a glorious structure that rivals any European cathedral in its grandeur and awesomeness. Around the building crowds were still dense as people with joyous faces carried British flags, adding to the patriotic zeal provided by the profusion of Union Jacks waving in the bright morning sun in a small park right across the street from Big Ben.

I intended my stop at Westminster to be brief as I was going to the West End to see a fine play called “Mrs. Henderson Presents.” Originally a movie that starred Judi Dench and Bob Hoskins, the play is based on true story about a variety show at the Windmill Theatre at the time of World War II. The theatre stayed open during the terrible bombardment of London called the Blitz. The highlight of the variety show, as depicted in the movie and play, was a tableau of nude women who could not move so as to appear as statues and avoid the censorship of the Lord Chamberlain.  

As I entered the Westminster underground station for the trip over to the Embankment station, I saw three women walking ahead of me-perhaps friends or family.  The women were all in bright floral dresses and had spectacular hats. Two of the women had hats that looked like tendrils of flowers ascending in a garden while the older woman wore a purple hat that looked like the broad brim the Queen wore with her neon-green outfit. Like the Queen’s hat, this woman’s hat was decorated with shocking pink flowers.

The three women descended ahead of me on the escalator to wait the arrival of the train.  Standing nearby was a tall man-balding with a fringe of white hair, ruddy John Bull complexion-carrying an umbrella. He wore formal morning clothes, the kind with a black cutaway jacket and striped gray pants which can be worn at a wedding. No doubt these women and the man had dressed up in their finest to attend the festivities for the Queen. I was amazed, flabbergasted to see people dressed like this in a subway.  In all of my years riding the D Train from the Bronx to Manhattan, I never saw anyone looking so elegant and resplendent.

I alighted at the Embankment stop and walked up to the Strand on my way to the Noel Coward Theatre to see ‘Mrs. Henderson Presents.” The streets, which are always packed on Saturday afternoons for the matinees, were absolutely thick with people all of whom seemed in high spirits, many carrying flags; more than a few women wore intriguing and fanciful hats that had swirls, curlicues and bouquets of flower.   

As I was slowly making my way through the crowd just after 1 o’clock, I heard the penetrating buzz and drone of propeller planes in the sky and a cheer went up from the crowd. The planes were World War II fighters-Spitfires and Hurricanes-and flew in tight formation. Then come big transporters called the Hercules and, every 30 seconds, another wave of planes-Sentinels, Airseekers, Tornados- came overhead with an exhilarating and patriotic roar, each wave more imposing than the one before, everyone in the crowding gazing up, snapping photos with their smart phones, pointing to the sky, cheering, waving their Union Jacks.

The finale of the flypast was a squad of 9 fast jets called Hawks. They flew in a V-shaped formation called Big Battle and, in perfect synchrony, released red, blue and white smoke as they zoomed by. The roar of the crowd matched the roar of the engines as the planes zoomed over to Buckingham Palace to fete their beloved queen as she stood surrounded by the royal family and waved her white gloved hand at the flotilla flying overhead.  

In the bright sun of a jewel of a June day, my EULAR game of “Name that Country” had a predictable outcome.  Only one country in the world could put on such a display of pageantry for the Queen’s birthday. This answer is obvious and, to pay homage to the rich literary tradition of that country, I will use the immortal words of the great Bard of Stratford for the answer: this blessed plot, this earth, this realm, this England.

My challenge to you, Dear Reader, is to identify the speaker of those words and the play from which they came. In other words, to end this discourse, we shall play “Name that Play.”

Good luck and I hope that bell rings for you.  

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

David Pisetsky, MD, PhD is Professor of Medicine and Immunology at Duke University Medical Center and staff physician in Rheumatology at the Durham Veterans Administration Medical Center. He received his BA from Harvard College magna cum laude in 1967 and his PhD and MD degrees from the Albert Einstein College of Medicine in 1972 and 1973. He was then an intern and resident in Internal Medicine at the Yale-New Haven Hospital from 1973-1975.  From 1975-1978, he was a clinical associate at the National Cancer Institute. He joined the faculty of the Duke University Medical Center in 1978 as Chief of Rheumatology at the Durham VA Hospital, a position he held until the end of 2018. He served as Chief of Rheumatology and Immunology at Duke from 1996-2007. Dr. Pisetsky has conducted basic and translational research in the field of autoimmunity, focusing on the pathogenesis of systemic lupus erythematosus (SLE) and the immunological properties of nuclear macromolecules, including DNA.  More recently, he has investigated the immune activities of HMGB1, a nuclear protein with alarmin activity, as well as microparticles. These studies have provided new insights into the translocation of nuclear molecules during cell activation and cell death and the mechanisms by which cell death can influence innate immunity.  In 2001, he was awarded the Howley Prize from the Arthritis Foundation for his work on the immune properties of DNA.  Dr. Pisetsky has had grant funding from the NIH, Veterans Administration and foundations. He has published over 400 articles, reviews and chapters and has edited several textbooks and volumes. His essays and narratives have appeared in JAMA and Annals of Internal Medicine.  From 2000-2005, he served as Editor of Arthritis and Rheumatism and, from 2006-2011, he was the first Physician Editor of The Rheumatologist. In 2016, he was awarded the ACR Presidential Gold Medal - the highest award the ACR can bestow in recognition of outstanding achievements over an entire career. He has received a number of awards for his writing. He has served as the President of the United States Bone and Joint Initiative.


Rheumatologists' Comments

David, to read these 2 pieces is to have been an accompanist to your EULAR visit. Sadly or luckily, most of your readers did not get to see or learn what you have so easily written about. I had to look up the quote to find that it was from Shakespeares Richard II. Thanks for the great read. JJC