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Discussion of recent JCR articles, PANLAR issues, controversies, and special areas of interest. We encourage readers of JCR, as well as PANLAR members, to participate and extend the dialogue.
Wednesday, July 08, 2015

The JCR has initiated a series of articles in a new section:  “Clinical Practice Forum” that have begun to address concerns of and opportunities for clinical rheumatologists and their practices. The first few papers have focused on observations clearly related to practices in the United States:

 Clinical Practice Extenders in Rheumatology, (,

Advocacy in Rheumatology,

( ).

We are certain that some of these subjects will be of interest to rheumatologists in other countries even though medical care delivery may be different.  In the June 2015 JCR the topic was “Advocacy”. Advocacy as  defined in the article, is an effort to get support and research funding for  our patients and for our specialty. Major efforts are being made by professional organizations, by disease oriented patient and volunteer groups, and by individuals. In the USA much attention is addressed to the federal and state governments.  I hope you will take a look at this and compare your institution’s or country’s strategy for Advocacy.   Is government helpful?  Do they provide research funding in rheumatology? Are there different traditions of volunteer help or charity? We hope you will enjoy this series & will let us know situations in your countries. Please even consider contributing a paper to this series, or a letter to the editor.


El JCR ha iniciado una serie de artículos en una nueva sección: "Foro de Práctica Clínica" que han comenzado a abordar las preocupaciones y oportunidades de los reumatólogos clínicos y sus prácticas. Los primeros trabajos se han centrado en observaciones claramente relacionados con las prácticas de los Estados Unidos:

Extensores de Práctica Clínica en Reumatología, (,

Abogacía en Reumatología, (

Estamos seguros de que algunos de estos temas serán de interés para los reumatólogos en otros países a pesar de que el cuido médico puede ser diferente. En junio 2015 JCR el tema era "Advocacy". Esta Abogacía como se define en el artículo, es un esfuerzo para obtener apoyo y financiación de la investigación para nuestros pacientes y para nuestra especialidad. Mayor esfuerzos  están siendo realizados por las organizaciones profesionales, y organizaciones orientados a  los pacientes y grupos  voluntarios. En EE.UU , se dirige la atención a los gobiernos federales y estatales. Espero que echen un vistazo a esto y comparan  la  estrategia de su país o su institución. ¿En sus países es útil el gobierno? ¿Proporcionan financiación de la investigación en reumatología? ¿Hay tradiciones diferentes de ayuda voluntaria o de la caridad? Esperamos que usted disfrute de esta serie y nos hará saber las situaciones en sus países. Por favor, considere contribuir un artículo a esta serie, o una carta al editor.


H. Ralph Schumacher, MD

Joan M. Von Feldt, MD

Friday, June 13, 2014

Hasn’t anyone who reads newspapers or periodicals, watches TV, listens to radio or surfs the web been alarmed enough to create enough stir to get more attention to direct to consumer health advertising in the U.S.?  Certainly there have been reports about this (1-3) but seemingly to no avail.

How do other countries get along without such ads?  Many of them have what are generally conceded to be better overall health outcomes by various measures (and lower total costs of health care).  We have queried Latin American rheumatologists in PANLAR from the JCR editorial board and the several who have responded have all confirmed that there are no such commercials except for some over the counter products. There are obviously other very different cultures in other countries and different health care systems in other ways making it seemingly impossible to assess what impact these ads or their absence is having.

Ads purported to be public services are suspiciously almost always focused on high cost activities or medications.  My own university health system seems to publicize the most lucrative procedure requiring services such as orthopedics on radio and TV and has not yet emphasized the cognitive strengths of our rheumatologic diagnosticians.

Physicians have recently been involved in a “choosing wisely” campaign directed to our role as “stewards of finite health care resources”. Interestingly societies often named other specialties services as of low value and rarely identified their own expensive and frequently publicized services (4). The ACR list did include a slightly qualified admonition to use methotrexate (or other DMARDS) for at least 3 months before adding a biologic (5).  How do (or will) direct to patient advertisements from physicians and hospitals impact our role?  I especially am interested in by the increasing television ads often for an effective but extremely costly biologic agent used for rheumatoid or other arthritis.  Potential side effects are listed but with continued pleasant, distracting images on screen and certainly not with any image appropriate to side effects.  Is there any information about what impacts these ads have?  Presumably they are increasing the use of the advertised products.  However, is that at the expense of less use of less costly alternatives or even in appropriate use?


1. Ventola C. Lee.  Direct-to-Consumer Pharmaceutical Advertising. Therapeutic or Toxic? Pharmacy & Therapeutics Oct 2011; 36(10) 669-674, 681-684.

2. Oxman D. Hospital Advertising. The Hospitalist, January 2007. Is it time for a closer look?

3. Larson RJ, Schwartz LM, Woloshin S, et al. Advertising by academic medical centers.  Arch Intern Med 2005; Mar e8;165(6):645-51.

Thursday, August 15, 2013

I had editorialized recently about whether we are paying enough attention to the value of oral, inexpensive triple DMARDs for our patients with RA1. Since then this new report from O’Dell et al in the NEJM adds further support to the value of triple DMARDs as comparable to the biologic etanercept plus methotrexate2.  Unfortunately an accompanying editorial asks “we have to consider, however, whether these findings have arrived too late to influence modern practice, in which arguably a TNF inhibitor is the preferred next step when methotrexate alone is inadequate”3.  Is it really too late for us to consider the cost of health care as a concern of ours?  At the recent EULAR congress Strand noted that the CORRONA registry data is showing that after two years 58% of patients given a biologic had discontinued it.  Isn’t it time to not just automatically go to a biologic without giving triple DMARDs a try?   

1 Schumacher HR.  Are we being open enough to all approaches to therapy of rheumatoid arthritis?  J Clin Rheumatol. 2013;19:167-71.

2 O'Dell JR, Mikuls TR, Taylor TH, Ahluwalia V, Brophy M, Warren SR, Lew RA, Cannella AC, Kunkel G, Phibbs CS, Anis AH, Leatherman S, Keystone E; CSP 551 RACAT Investigators.  Therapies for active rheumatoid arthritis after methotrexate failure. N Engl J Med. 2013;369:307-18.

3 Bathon JM, McMahon DJ. Making rational treatment decisions in rheumatoid arthritis when methotrexate fails. N Engl J Med. 2013;369:384-5.





Monday, January 14, 2013
What do you think about the rules of guidelines in your practice?  See my editorial in the December 2012 JCR.  Who will do the needed studies on objective impacts of guidelines and algorithms in the various ways they are used?

Tuesday, November 06, 2012

This unusual joint fluid was aspirated from a swollen, painful knee joint.  What would your concerns be, and what do you think the patient had?  Please click on the link Figure 1 to view the image; ignore the hand image .  



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Journal of Clinical Rheumatology