Dead Words Eulogy Save

The trouble with Rheum may be the words we live by. Dear brethren, welcome to the eulogy for Rheumatology Dead Words. We're gathered here today to celebrate the loss, the righteous loss of terms from rheumatology past. These are dead words in rheumatology, words fortified, unfortunately, by history and habit, and what hasn't prevailed are those terms that are more precise. This session, this decree, is to decry our worst words.

The lexicon of rheumatology is unique. It's challenging. It's mostly incomprehensible to those who don't know. But those are the cornerstones of the greatest of medical subspecialties, that being rheumatology. For inclusion in this boneyard, candidates must be terms that are imprecise, meaningless, too ill defined to survive.

The term that is historic or an eponym or acronym that has no or limited value is out. They can be replaced by and should be replaced by terms that are far superior and have pathological meaning. We are scientists driven by logic, knowledge, and righteousness, and should not be deterred by KOLs, laggards, or authors wishing to defend their bibliographies. We should not succumb, to letting others, allowing these terms to persist or be resurrected because they're in PubMed in citation list or there's an ICD-ten code. This ceremony is all about the word.

You know, that our patients give to us or show us. This is always helpful, except when they're not. But more importantly, the words we use with each other, how we communicate with our peers, how we document disease. These are the words from a colleague of mine who sent me a consult. This is amazing.

He wrote, The patient has multiple sites of a fairly severe rheumatoid arthritis type with pictures of mixed connective tissue disease and some SLE with organ involvement type overlap and Sjogren's syndrome. He also has some concomitant features of psoriatic arthritis with undifferentiated seronegative spondyloarthritis lumbar type, with chronic lumbago, oh my God, how many of these terms should be stricken? It seems like the whole darn paragraph. What did I learn about the patient's condition from this communication? Pretty much nothing.

We need to be more exacting and more precise. So let us begin. We humbly lay to rest the oft used and ill conceived term connective tissue disease or CTD. Those of you who are deaf diagnosticians have bestowed this diagnosis when an etiology that is beyond your grasp is really ascribed to the gooey stuff gone wrong in and around joints. It's a mesenchymal disease capable of explaining that which you don't know: fevers, rashes, dropped foot, weight loss, and palindromic things.

Unfortunately, the confused, continued use of CTD feigns some sort of physiologic understanding and buys you more time for misguided workups and hopefully not more steroid use. CTD has thankfully been replaced by over a 100 different distinct and diagnosable rheumatologic disorders. The connective tissue diagnosis may be gone, but it is not forgotten as the internet and social media still cling to it with a death grip. Here lies brachialgia, an eloquent, often misspelled, and bygone term that originates from the time of the cotton gin, and later seemed to have given rise to the seasonal hard candy company, I think, that made candy corn. For too many, the primary use of this term was to confidently confuse patients with an unexplained arm pain diagnosis.

On a positive note, brachialgia has been survived by the more exact cervical radiculopathy, but yet it is still in the lexicon of others who advertise and call themselves therapists. I just love Churg Strauss. I don't know who Churg Strauss was, but just the mere mention of Churg Strauss, I already know the answer to the test question, the test I should be ordering. But Churg Strauss, although it's been around a long time, has had a quicksand death. It was heralded in 2012 by the Chapel Hill Vasculitis Consensus Conference that declared that the old, Jerk Strauss, was out and the new, eosinophilic granulomatosis with polyangiitis, or EGPA, was now in.

Term was coined in 1951 by a paper from Drs. Jacob Churg and Lotte Strauss, and they reported on thirteen patients with a rare and unusual systemic necrotizing vasculitis that they call allergic granulomatosis, allergic angiotis and periarteritis nodosa. While many still cling to the familiarity of Churg Strauss, EGPA predominates. It has consensus, it has histopathology, and I think it has a federal agency, the EGPA. I don't know what they do.

Crest. Do you believe in it or not? Is it buried, or is it dead? Or tragically, was it buried alive? And if so, its demise is therefore riddled with criminal intent, is it not?

Those tight skinned aficionados have buried Crest in favor of their preferred limited scleroderma or limited systemic sclerosis. Mark Twain and I believe that rumors of CREST's death are greatly exaggerated. After all, CREST, calcinosis, Raynaud's, esophageal dysmotility, sclerodactyly and phalangiectasia remain a powerful, instructive and test question worthy acronym that fully informs a very scary disorder subset. So where do you stand? Are you going to join the mavens in modern rooms and take the scientific high road advocating for limited something or other?

Or are you like me? An online survey of over 100 rheumatologists shows that eighteen percent of you preferred the Crest term and seventy six percent, wait a second, I think there's a problem with my math, preferred limited systemic sclerosis. Similar numbers were achieved when asked, Is Elvis still alive or not? Oh my, everyone's favorite. Fibromyalgia, but when I was a medical student and a resident, I called it fibrositis.

Everything in rheumatology seemed like an it is. This derisive, eschewed, confused, and incorrect term, fibrositis, has forever been discarded. This malapropism is absurdly linked to alternative terminology and includes words like fibromyalgia, muscular rheumatism, psychogenic rheumatism, myofasciitis, fibromyalgia rheumatica, and chronic fatigue syndrome. In 1981, Doctor. Muhammad Yunus gave fibromyalgia its proper label, and since this has been the poorly considered and poorly treated condition that plagues us, It is a difficult condition to manage, shouldn't be difficult to diagnose, and certainly shouldn't be difficult to label.

Still, fibromyalgia runs amok. It is hidden behind the curtains of POTS, hypermobility syndrome, Sjogren's syndrome, irritable bowel syndrome, many more spasmotic disorders. Fibromyalgia is a lot like the weather. Everybody talks about it, nobody does anything about it. The least we can do is kill the monikers of misunderstood conditions like this.

Wait, generational geniuses have recodified and reinvented fibromyalgia with new terms. Why? Myalgic encephalomyositis, also called ME or MECFS, post viral syndrome, EBS, chronic fatigue, immune dysfunction syndrome, CFIDS, or systemic exertion intolerance disease, SEID, and now what about long COVID? Oh my. Let us pray.

God help us all, everyone. The knuckle. You know the knuckle. It's either something you rub on someone's head or it's a patient description of the problem. We all think we knew him well, but did we?

Is it a joint, a diarthrodial prominence, is it a bump on the fist? The knuckle term is used by those who know not their anatomy and easily confuse RA and OA. Its wanderings and its placement lead to some calling this joint more precisely the first knuckle or the major knuckle of the MCP or the second knuckle, the PIP, or the third knuckle, DIP. I've never used the third knuckle, that seems stupid. But these are bones, not movements in a concerto.

We should be more exact about our anatomy and discard the knuckle, only should it be employed by those who are guilty of erroneous thinking. We would call them, of course, knuckleheads. The death rattle has long passed for lumbago. The vagueness of this condition radiates somewhere over the lower spine. Lumbago isn't the sound your back makes when you stand up.

It's not the name of a lake, in Italy. Rather, it's a medieval term that dates back to 1734 when Seidenheim labeled lumbago as the third form of rheumatism. You know the first two. I don't. Lumbago survived and lived well beyond mesmerism and folk medicine.

As a spinal without a cause condition, it has been retired in lieu of better clinical assessments, better imaging technology and those who understand the pathway of low back pain. I believe it was Sting who said, or sang, I want my MCTV. MCTV or mixed connective tissue disease was first described by Gordon Sharp in 1972 in an American Journal of Medicine article, where he described 25 patients with high titer ANAs, high titer U1RNP antibodies, and a constellation of symptoms that was a prototypical overlap of lupus RA scleroderma and myositis. When I was a fellow, I went to an ACP meeting and heard Doctor. Robert Bennett brilliantly describe this disorder as a laboratory finding in search of a clinical syndrome, the laboratory finding being high titer ANA and RNP, as many patients really over time will ultimately evolve into a predominant picture of either RA, myositis, scleroderma, or lupus.

Yet many are still married to this acronym. It's comforting to believe that the grayness of such terms, is the way you want to go. But again, negotiating black and white is really what you get paid for. So the preferred terminology should be undifferentiated connective tissue disease, or or overlap syndrome, where you basically describe the prevailing disorders or elements of disease, and you treat those elements, because after all, there is no one treatment for MCTD. Hans Reiter was not the author of A Children's Tale or a historic woodworker, and nor was he the first to describe the well known triad that bears his name.

Nonetheless, decades have gone by with this eponym being entrenched in medicine. It wasn't until Reiter himself was deemed unsuitable and unworthy that the terms changed to reactive arthritis. Reiter himself really didn't know that he was going to bear this label. The change to reactive arthritis has led to a clearer understanding of the pathogenesis of reactive oligoarticular etiologies. So the obvious loss here is that every medical student trained in the last seventy five years knows the answer to the question, conjunctivitis, arthritis and urethritis, what's the diagnosis say you?

Oh my. Education and propriety still prevail. Here lies rheumatism, bow your heads, a term that means everything and nothing at the same time. Rheum, a Greek word for flow, is grouped with the -ism suffix, which means and defines doctrines or beliefs at its root. The term rheumatism means nothing.

Arthritis and rheumatism, or arthritis and rheumatology, thought that this was an obsolete term and changed it in 2013. But as early as 1997, ACR considered this change from rheumatism to rheumatology. It wasn't until twenty twelve, twenty thirteen when ACR and Gary Firestein, who headed up the publications committee, noted that the new name, arthritis and rheumatology, was necessary because it's emblematic of our evolution into a molecular and mechanism based approach to understanding and treating patients with rheumatic diseases. Still, rheumatism lives on in the misdiagnosis of many and is used by the lay populace as they lay undiagnosed with aches and pains. Defining what you are by stating what you ain't seems to be a failure of diagnostic certainty.

Like JRA, spondyloarthritis bears no relationship to rheumatoid arthritis, and clearly has a serology and test battery of its own. Early on, SPA was intended to encompass the B27 related conditions that included ankylosing spondylitis, reactive arthritis, psoriatic arthritis, and enteropathic arthritis. Clearly, the misuse of seronegative with SPA sets us back many, many years. Even today, there are still rheumatologists who misuse this term while misdiagnosing patients who have something other than RA. I would think our practice is much more advanced in grouping all diagnoses into being RA or not RA.

And obviously, you know, it doesn't accentuate the importance of sacroiliitis in B27. Thus, seronegative spondyloarthropathy should be strictly from all chapters, classification schemes, or discussions that would include any mention of seronegative. Herein in this session, we've seen how nosology evolves from the historic to the scientific. In rheumatology, there's been a call to replace eponym based diagnoses with more scientifically accurate terms. Many, advance our understanding while others are promoted by tainted or questionable legacies known to the eponym.

Such was the dagger dealt to Wegener as that diagnosis was relabeled as granulomatosis with polyangiitis or GPA. Doctor. Janette recently stated, No matter how logical and appropriate a name may be, if it is not usable or used, it is of no lasting value. And eponyms are less effective than more descriptive terms that refer to one or more distinctive elements of a disorder. So by this session, you and I and RheumNow hereby buries these words as dead and gone, impractical and medically abhorrent, and should never be said and should be stricken from the lips and letters of rheumatologists, those who know best.

Thank you.