Changing clinical patterns in rheumatoid arthritis management over two decades:Sequential observational studies

This article attempts to examine the problem of friendship as it was understood by Seneca in his letters sent to Lucillus. The author scrutinizes the main items in the philosopher’s autobiography to investigate the influence of the events from Seneca’s biography in the shaping of the opinions of the thinker. Lucillus, the addressee of the letters, was actually Seneca’s long-time friend and confidant. The issue of friendship has a long and rich tradition of its own in the antique times. This particular relationship between human beings was of much interest to Plato, Aristotle, Epicurus, Cicero and many others. Seneca does not venture into an attempt at creating a vision for coherent science related to friendship. What he does though is to furnish a vast array of thoughts concerning such questions as: who is worthy of friendship, why is it worth having a friend and what forms the basis for friendship? Strangely enough, these establishments made by Seneca somehow seem to be more close to us than those in which the philosopher constructs the image of a superhuman wise man, a stoic

Changing clinical patterns in rheumatoid arthritis management over two decades:Sequential observational studies

BACKGROUND: Rheumatoid arthritis (RA) treatment paradigms have shifted over the last two decades. There has been increasing emphasis on combination disease modifying anti-rheumatic drug (DMARD) therapy, newer biologic therapies have become available and there is a greater focus on achieving remission. We have evaluated the impact of treatment changes on disease activity scores for 28 joints (DAS28) and disability measured by the health assessment questionnaire scores (HAQ). METHODS: Four cross-sectional surveys between 1996 and 2014 in two adjacent secondary care rheumatology departments in London evaluated changes in drug therapy, DAS28 and its component parts and HAQ scores (in three surveys). Descriptive statistics used means and standard deviations (SD) or medians and interquartile ranges (IQR) to summarise changes. Spearman’s correlations assessed relationships between assessments. RESULTS: 1324 patients were studied. Gender ratios, age and mean disease duration were similar across all cohorts. There were temporal increases in the use of any DMARDs (rising from 61 % to 87 % of patients from 1996-2014), combination DMARDs (1 % to 41 %) and biologic (0 to 32 %). Mean DAS28 fell (5.2 to 3.7), active disease (DAS28 > 5.1) declined (50 % to 18 %) and DAS28 remission (DAS28 < 2.6) increased (8 % to 28 %). In contrast HAQ scores were unchanged (1.30 to 1.32) and correlations between DAS28 and HAQ weakened (Spearman’s rho fell from 0.56 to 0.44). CONCLUSIONS: Treatment intensity has increased over time, disease activity has fallen and there are more remissions. However, these improvements in controlling synovitis have not resulted in comparable reductions in disability measured by HAQ. As a consequence the relationship between DAS28 and HAQ has become weaker over time. Although the reasons for this divergence between disease activity and disability are uncertain, focussing treatment entirely in suppressing synovitis may be insufficient