Rheumatology

Foreword

The composition and authorship of the Manual of Rheumatology and Outpatient Orthopedic Disorders continues to reflect the fact that rheumatology and orthopedic surgery have a seamless interface in pursuit of education and patient care goals relative to muscoskeletal disease. The inter-relationship of these two disciplines is a special and unique feature of the Hospital for Special Surgery, where many of the authors have trained or practiced.

The primary goal of this manual has been to serve the needs of students and physicians-in-training. Yet professionals of all ages (perhaps especially senior colleagues) find it useful for reviewing miscellaneous things not successfully committed to memory. These include: American College of Rheumatology Criteria for Diagnosis and Classification of Rheumatic Disease, neurological dermatomes, molecular targets for autoantibodies, normal laboratory values, details in formulary, etc. Between the fourth and fifth editions, there has been an explosion of the rheumatologic formulary; there are new anti-inflammatory drugs and biologic disease modifying antirheumatic drugs, some based on new insights relative to the pathogenesis of rheumatoid arthritis.

Over the span of our five editions, several new chapters have been added, reflecting our knowledge of recent advances: antiphospholipid syndrome, pregnancy, and connective tissue diseases, rheumatic association with HIV infection, diagnostic imaging, patient education, perioperative management, ethical and legal considerations, measuring functional status, thinking like a rheumatologist, acute management of muscoskeletal and autoimmune disorders, and so on. In this edition, as in all previous ones, the emphasis remains the discussion of practical aspects of management of muscoskeletal disorders.

Charles L. Christian, MD
Physician-in-Chief Emeritus
Hospital for Special Surgery
New York, New York

This remarkable manual celebrates publication of its fifth edition this year. Innovations in diagnosis, therapeutics, and management strategies that have emerged in the four years since the last edition make this update timely. The succinct, authoritative, and didactic style of presenting the rationale and practical information in this publication will doubtless continue to assist and guide physicians in their clinical practice.

The scope of the book is comprehensive, covering the full spectrum of therapy and practice of rheumatology. The broad church of the specialty covered extends to regional pain syndromes, fibromyalgia, diseases of bone, sports injuries, and the principles and practice of surgery and rehabilitation. New chapters in the general sections cover not only immunology, genomics, and proteomics, but also ethical and legal issues, and psychological aspects of rheumatic disease.

Making knowledge-based therapeutic interventions that maximize benefit and minimize risk have increasingly become part of rheumatological practice since the last edition. The widespread use of anti-TNF biologics added to methotrexate therapy has profoundly altered the outcome of moderate-to-severe rheumatoid arthritis patients whose disease is not controlled by more effective regimens employing standard drugs as monotherapy or in combination. The recent emphasis on suppression of disease with judicious use of the available therapeutic armamentarium has permitted control of signs, symptoms, and joint damage in the majority of patients. Not only has this permitted maintenance of a good quality of life, but epidemiological data demonstrate that it has reduced cardiovascular complications and prolonged life expectancy of these patients.

The use of currently available biologics, and those in the development phase, have been shown to be effective not only in rheumatoid arthritis, but also in other inflammatory arthritides. The repertoire of targeted drugs that is now being developed shows promising results for systemic rheumatic disease and will enlarge the pharmacopoeia. However, these advances come at a price of unwanted side effects in some patients such as increasing infection rates. As another example, the widespread use of Cox II inhibitors that control pain with an improved gastric tolerance profile has apparently led to an increase in cardiovascular occlusive events. This has sparked a debate on the safety and indications of all non-steroidal anti-inflammatory drugs. The widespread public dissemination of this information has alarmed and confused patients at a time when the potential for the good of patients, resulting from technical and scientific developments, has never been greater.

The rheumatological practice landscape has changed, and will continue to change with the advent of targeted biological and chemical drugs and improvement in laboratory and imaging technologies. Managing this change will require a sharper focus and skill base in rheumatological practice. The responsibility and role of thought leaders and educationalists in this process has thus become increasingly important. It is worth recalling that the origins of research with Coley’s toxin that led to the discovery of TNF almost a century later, originated at Hospital for Special Surgery. The cooperation between surgeons and physicians and their allied health associates remains a hallmark of this institution in their quest for a better future for the health of patients. The Editors and authors of this book, coming from this center of excellence in research and practice, have much to offer in this regard to the community of rheumatological practitioners world-wide. Their book deserves a place on the desk of trainees and established practitioners.

Professor Sir Ravinder Maini, BA MB BChir, Hon DSc, FRCP FRCP(E) FMed Sci
Emeritus Professor of Rheumatology
The Kennedy Institute of Rheumatology Division
Imperial College
London, W6 8RF
United Kingdom

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