Thursday, 17 Oct 2019

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The Rheumatologist’s Rubaiyat: A Mug of Coffee, a Loaf of Bread and Thou Beside Me (Part 1)

In my experience, rheumatologists are very fine people. Since they are cognitive specialists, they are scholarly, thoughtful and prudent. Furthermore, they are sensitive to the vicissitudes of human existence. Rheumatology is probably the first subspecialty to consider the impact of a chronic painful illness on the spirit and soul and emphasize quality of life as an outcome. Seeking wisdom and knowledge from great minds, rheumatologists are also interested in culture, mindful that masters like Renoir and Klee were among their patients.

Not surprisingly, given their refined sensibility and cerebral nature, many rheumatologists are interested in wine.  Indeed, a recent essay in RheumNow by Professor Len Calabrese was a brilliant exposition about the significance of terroir and the intersection of wine and the microbiome. With wit and intellectual bravado, Calabrese described the possible influence of the prokaryotic world on the taste and structure of wine. Of course, while the soil where vines grow may overflow with microorganisms (fellow denizens of the holobiont), wine itself should be sterile and devoid of a microbiome. Alcohol is an excellent disinfectant and no organism could survive the 14% alcohol of some of the big behemoths from California.   

In some respects wine is a good fit for rheumatologists.  Rheumatologists, like oenophiles, regularly use grading schemes in their decision-making and there are as many grading scales for the quality of wine as there are for the disease activity for rheumatoid arthritis or lupus. I personally like the scale of Dr. Maynard Amerine, a giant in the field, called the UC Davis scoring system.  While perhaps outdated, this scale for “organoleptic evaluation” awards points for appearance; color; aroma and bouquet; volatile acidity; total acidity; sugar/sweetness; body; flavor; astringency and general quality.  20 points is the top, with 17-20 a very good score. That scale reminds me of the SLEDAI in its effort to enumerate variations in a complex entity.

Some of the more modern grading systems have upped the point total in a version of grade inflation. In the Robert Parker view of the world, 100 points is the ultimate and is awarded to extraordinary beverages that are hard to find and afford. Among these treasured beverages, United States wunderkind wines often cost as much as a grand cru from a splendid chateau in Bordeaux even if produced in a ramshackle warehouse in downtown Sonoma. I would suspect that rheumatologists would like this scale since it really is a global assessment.

While the merit of wine can be deconstructed by the application of senses such as sight, taste and smell, these systems do not take advantage of rheumatologists’ most developed and cultivated sense: touch. I know that a wine rater can talk about the “mouthfeel” of a wine, and after vigorous sloshing around the bouche, provide a descriptor like thick, hefty or chewy. The tongue, however, is not the finger.  Rheumatologists have great fingers and are world champions at pressing, squeezing, palpating, and balloting things, especially the joints. I bet that, just with their fingertips, my fellow clinicians are as good as an ultrasound or MRI in detecting even the slightest presence of synovitis or distinguishing a tophus from a nodule.  

As sensitive instruments, rheumatology fingers are in the league with the nose of a dog, especially the kind TSA employs to sniff out drugs or, in my case, an apple. Intended as a snack for a hike on the Coast Path in Wales, my apple had lodged forgotten under a sweater in the bottom of my knapsack. Quite unwittingly, as I was walking through customs, the scent attracted the attention of a sweet little beagle. Because of the sensitive schnozz on that pooch, I had to go to a special room in the RDU Airport where I was grilled by a USDA agent and given a stern lecture. Alas, I fear I am now on the watch list for rotten apples (pun intended).  

If it came to airport security, I am sure that a rheumatologist with a well-developed sense of touch would do a whale of a job doing pat downs. If nothing else, I am sure such examinations could find evidence of early knee arthritis or tender trochanteric bursa, a bonus personal health checkup while guarding airline security.

If rheumatologists had their druthers evaluating wine, my guess is that they would likely clean their hands with some Purell instant sensitizing foam and then stick a finger into a glass of the wine, circle it around and then take out a few drops to rub it between the thumb and pointer to get a sense of the density and viscosity. While such a maneuver would be quite rude and gauche, it would be in the wheelhouse of my good colleagues who are the last of the old school diagnosticians.

Another reason that wine and rheumatologists may not be the best fit is that much of wine appreciation is about evaluation not creation. I know that wine writing is a great act of creativity and demands an ability to capture the essence of sensations and translate them into words. Only an inventive and imaginative artist could say that the nose of the wine has hints of grapefruit, lemons and macadamia nuts.  Such a commentator would say that the nice light Sancerre reminded him of a cool breeze wafting off the coast on a warm summer night or that cabernet from Napa was jammy and had the strong aroma of blueberries and strawberries. I actually don’t know whether the jamminess of wine relates to its taste or its substance. The other night I had a bold red wine from Napa, a real bruiser, dark purple in color, gobs of fruit on the nose, almost 15% alcohol. I thought that the term jammy was apt.  The wine overwhelmed the grilled salmon I was eating and was so thick that I was tempted to save it for the next morning and spread it onto toast as an eye opener.

I am sure that rheumatologists could hold their own in crafting imaginative descriptions that delight wine writers and wine readers alike but rheumatologists actually like to do things and not just opine or discourse about them. Although they are cognitive specialists, rheumatologists are men and women of action. They are doers.  They like to treat patients and not just cogitate, contemplate and ruminate. They like early aggressive therapy and they treat to target.  In their therapeutic stance to rheumatoid arthritis, they are like an archer with a long bow pulled tight to send a sharp-tipped arrow zooming at the bull’s eye. Some of the imagery for the rheumatology treatments suggests raw power-“blast the patient with steroids”-and a willingness to stomp, smack and whack disease. Just think of a therapy called COBRA. The name calls to mind a mean venomous snake that can rear upwards and strike suddenly at its prey.   

I have a friend who says that neurologists can diagnose the untreatable while rheumatologists can treat the undiagnosable. I think that characterization is unfair to neurologists who do a very good job with conditions like seizures and migraines and have made excellent progress in improving outcomes in stroke and multiple sclerosis. On the other hand, the characterization of rheumatologists has a strong element of truth.  In certain settings such as vasculitis (especially of the central nervous system kind for which Professor Calabrese is justly famous), rheumatologists are frequently the decider when it comes to pulling the trigger of steroids. My colleagues are not afraid of therapeutic trials and even use the response to treatment as a criterion in diagnosing polymyalgia rheumatica.

Except for some home winemakers and some wealthy physicians who own vineyards (David Bruce of zinfandel fame was a dermatologist), the consumers of wine are not the creators. Their role is more passive, receiving and tasting a product made by someone else. They are the audience not the actors on stage. Isn’t giving a wine a 95 like a standing ovation?  

No, wine is not the rheumatologist’s beverage. To my mind, coffee is.

In the next installment I will explain why.

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

Dr. Pisetsky, ever since I read your "What we are made of" in 1999 I have been a huge fan of your writing. Thank you!