Faculty Bibliography

OBJECTIVE: To compare clinical manifestations and activity of Behcet syndrome (BS) in the United States versus Turkey using validated outcome measures. METHODS: Consecutive patients with BS from the US National Institutes of Health (NIH), New York University, and the University of Istanbul were evaluated. Disease activity was measured using the Behcet's Syndrome Activity Scale (BSAS) and the Behcet's Disease Current Activity Form (BDCAF) with quality of life measured by the Behcet Disease Quality of Life (BDQOL) form. One-way ANOVA, t-tests, and multivariate regression analyses were performed. RESULTS: Mean age did not differ between sites; however, more women were seen in the United States versus in Turkey (p < 0.001), and disease duration was longer in the United States (p = 0.02). Organ manifestations were similar for oral and genital ulcers, skin disease, arthralgia, eye disease, and thrombosis. However, more gastrointestinal (p < 0.001) and neurologic disease (p = 0.003) was seen in the United States. BSAS and BDCAF scores were worse in the United States compared to Turkey (p = 0.013 and < 0.001, respectively). Worse mean BDQOL scores were observed at the NIH compared to Istanbul (not significant). Multivariable regression models showed worse scores in ethnically atypical patients for BSAS and BDCAF (p = 0.04 and p = 0.001), American patients for BDCAF (p = 0.01), older age for BDCAF (p = 0.005), and women for BDQOL (p = 0.01). CONCLUSION: Demographic and clinical manifestations of BS differ between sites with higher disease activity in the United States compared to Turkey. Referral patterns, age, sex, ethnicity, and country of origin may be important in these differences. These observations raise the question of whether pathogenic mechanisms differ in Turkish and American patients.

-

Objective: To analyze discordance between global estimates by patients (PATGL) and their physicians (DOCGL) according to demographic and self-report variables on a multidimensional health assessment questionnaire (MDHAQ), in patients with many rheumatic diseases seen in usual care. Methods: Each patient completes an MDHAQ at each visit, which includes scores for physical function, pain and PATGL, each found on the HAQ, and scores for sleep quality, anxiety, depression, self-report joint count and fatigue, which are not found on the HAQ. A random visit of 980 patients with any rheumatic diagnosis was analyzed in 3 categories: PATGL=DOCGL (within 2/10 units); PATGL>DOCGL (by >/=2/10 units); DOCGL>PATGL (by >/=2/10 units), using descriptive statistics and multinomial logistic regression models. Results: Patients included 145 with rheumatoid arthritis, 57 systemic lupus erythematosus, 173 osteoarthritis, 348 other inflammatory, and 257 other non-inflammatory diseases. Overall, PATGL=DOCGL in 509 (52%), PATGL>DOCGL in 371 (38%) and DOCGL>PATGL in 100 (10%). PATGL>DOCGL was associated significantly with older age, female gender, low formal education, Hispanic ethnicity, not working, high MDHAQ physical function and pain, and high scores for fatigue, poor sleep, anxiety, depression, and self-report joint count, not available on the HAQ. Pain and fatigue were significant in a final multinomial logistic regression; the other variables may raise awareness of discordance to clinicians. Conclusions: Global estimates of patients indicated significantly poorer status than estimates of their physicians in 38% of 980 patients with rheumatic conditions, and were associated with demographic and MDHAQ scores, 5 of which are not available on the HAQ. (c) 2013 American College of Rheumatology.

With no specific histologic, laboratory or imaging features the diagnosis/classification of Behcet's Disease (BD) remains clinical. As such, disease criteria are needed. The International Study Group Criteria set is the most widely used. It has some limitations, especially in telling BD from Crohn's disease. On the other hand the main issue, as it also applies to many of the other criteria sets in rheumatology, is our lack of appreciation of a list of misconceptions - some examples of which are unluckily also found in the 2010 ACR/EULAR RA Criteria set- about diagnostic/classification criteria making and their implementation. 1. The view that classification and diagnostic criteria should be different is ill advised in that the cerebral/arithmetic basis of both are the same. 2. The default promise of diagnostic criteria to come once we formulate a classification criteria set is an extension of the previous misconception. 3.Taking pains to avoid circularity in criteria making is unwarranted since the essence of criteria making is circular. In addition we fail to exploit the utility of the disease criteria in ruling out, rather than ruling in, the diseases we seek. Finally we also fail to appreciate the paramount importance of the Bayesian prior (the pretest) probability in formulating and implementing these disease criteria. To formulate criteria tailored to subspecialties, as well as giving the often forgotten family history more importance in our criteria sets are some ways to improve the prior probability on which our diagnostic/classification decisions will be based. We first have to reconcile with ourselves that probabilities are very important in our practice and research. Moreover that reconciliation must also be shared with the public, which includes our patients.

OBJECTIVES: There is concern that self-critique with authors acknowledging limitations of their work is not given due importance in scientific articles. We had the impression that this was more true for articles in basic compared with clinical science. We thus surveyed for the presence of self-critique in the discussion sections of the original articles in three rheumatology journals with attention to differences between the basic and the clinical science articles. STUDY DESIGN AND SETTING: The discussion sections of the original articles in January, May, and September 2012 issues of Annals of the Rheumatic Diseases, Arthritis and Rheumatism, and Rheumatology (Oxford) were surveyed (n = 223) after classifying each article as mainly related to clinical or basic science. The discussion sections were electronically scanned by two observers for the presence of the root word "limit" or its derivatives who also read each discussion section for the presence of any limitations otherwise voiced. RESULTS: A limitation discussion in any form was present in only 19 (20.2%) or 29 (30.1%) of 94 basic science vs. 95 (73.6%) or 107 (82.3%) of 129 clinical science articles (P < 0.0001 for either observer). CONCLUSION: Self-critique, especially lacking in basic science articles, should be given due attention.