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In defense of the ARA database.

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103 1
EDITORIAL
On page 1014 of this issue is the first of a series of
Radiologic Vignettes, presented by Dr. William Martel,
Professor of Radiology, University of Michigan. We
hope to use this feature to teach the differential diagnosis of radiologic abnormalities and to help rheumatologists to be increasingly aware of distinctive features
that are radiologically detectable. We also feel that this
new endeavor will be a significant advance in establishing ARTHRITISAND RHEUMATISM
as a vehicle for
continuing education in rheumatology.
J. CLAUDE
BENNETT,
M.D.
Editor, Arthritis and Rheumatism
Birmingham, Alabama
LETTERS
In Defense of the ARA Database
To the Editor:
The Uniform Database for Rheumatic Disease is
a defined list of clinical descriptors to be utilized in
whole or in part, and to which additional variables may
be added as required. It constitutes a standard vocabulary for clinical description, with a considerable measure
of national agreement. The database assists in pooling
results and in comparing data between institutions. It
serves to define clinical terms and to help ensure that a
given term has a stable meaning. It is a dictionary.
Denys Ford, never one to view the future with
equanimity, worries that the database will disturb the
past (Arthritis and Rheumatism 20:903-904, 1977). He
misunderstands and, we think, doth protest too much.
The database threatens his practice in the same way that
a dictionary threatens his ability to construct ponderous
sentences. If the 415 clinical descriptors of the database
were all to be measured on the same patient, that patient
would surely be nearly exsanguinated and totally insolvent. A tennis elbow requires less evaluation than
does polyarteritis. Depression may be a greater problem
than synovitis for some patients. These are truisms, but
have nothing to do with whether a dictionary is a useful
document or not. You use the words you need for a
particular purpose. The list reminds the physician of the
many complexities of rheumatic disease.
We would like to correct the misunderstanding of
Dr. Ford, and of any other readers who share his conArthritis and Rheumatism, Vol. 20, No. 4 (May 1977)
fusion. The database is not a standard of practice; it is a
vocabulary for clinical description. Experience with the
database now exceeds 15,000 patients and 100 physicians from many institutions. It has been abundantly
clear that nearly every application requires a different
format. Integration of the database into practice requires many different approaches, depending upon the
structure of the practice and upon the patient population. A university clinic seeing patients with multisystem diseases over long time periods may require a
time-oriented flow sheet format for efficient information
display and recall. A university clinic providing mainly
consultative services may prefer a single-visit detailed
check list. A private practice may effectively utilize a
very short flow sheet to allow for quick display of major
problems. The most successful applications have used
the uniform vocabulary in a manner tailored to the
needs of the particular service or practice. It provides an
accessible method for information recall of patient data
which should help the physician to provide better-patient care.
Far from encouraging unproductive use of time
and talent, activities of the database group encourage
selective and productive use of technology. A few examples will suffice. The databank, using the database, provides a strong tool for identifying medical activities not
associated with improved outcome, and discouraging
their use (1). Physician-generated costs have been quantitated and variability has been identified (2). The costs
of laboratory evaluation in a clinic using the database
have been demonstrated to decrease significantly (2).
Subsets of systemic lupus have been identified which
require little investigation or therapy (3). Studies of
clinic practice demonstrate that a formatted database
can save a physician time, both in recording and in
information access (4). Clinical investigation, research
information, and treatment studies are greatly facilitated. Its use as a teaching too1 is currently under study.
The database exists because our ingrown habits
of clinical description grow more disparate year by year,
and the resulting Tower of Babel prevents direct interinstitutional data comparison and pooling. The database is utopian in that it requests consensus on definition and meaning, and more uniform activities based
upon this consensus. In the rheumatic diseases, more
progress has been made toward a common language
than in any other specialty, and this success has been
due to the selfless and untiring efforts of many American
Rheumatism Association members ( 5 ) . The database
remains deficient in several areas, notably in describing
the child with arthritis, the functional outcomes of patients, and nonarticular rheumatism. Some variables of
1032
14
limited clinical value are still included, and the overall
list may still be too long. The common effort will continue, and succeeding evolutionary revisions of the database will assist in developing guidelines for efficient,
economic, outcome-directed patient care.
EVELYN
V. HESS,M.D.
JAMESF. FRIES,M.D.
JAMESKLINENBERG,
M.D.
A RA Computer Committee
REFERENCES
I . Fries JF: A data bank for the clinician. N Engl J Med 1976
(editorial)
2. Bombardier C: Physician-generated costs in the management of rheumatoid arthritis. Presented at a meeting of the
American Rheumatism Association, Chicago, Illinois, June
1976
3. Fries JF, Holman HR: Systemic Lupus Erythematosus.
Philadelphia, Saunders, 1975
4. Fries JF: Alternatives in medical record formats. Med Care
12:871-881, 1974
5. Hess EV: A uniform database for rheumatic diseases. Arthritis Rheum 19545-648. 1976
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DAYS POST ADJUVANT
Fig 1. Effects of virazole and saline on adjuvant-induced disease in rats.
Virazole and AdjuvantInduced Disease in Rats
To the Editor:
This letter reports that virazole inhibits adjuvantinduced disease (AID) in rats. We have previously
shown that AID can be inhibited by antiviral agents that
are interferon inducers (l,2). Virazole (I-P-D-ribofuranosyl- 1,2,4-triazole-3-carboxamide)(3) is a synthetic
nucleoside which is a non-interferon-inducing antiviral
agent.
M ycobacterial adjuvant was prepared and administered as previously described (1,2). Arthritis was
evaluated by assigning a single point for each involved
joint, up to a maximum of five points per extremity.
Virazole, 200 mg in 2 ml of saline, was given intraperitoneally (ip) 7 days after the administration of
adjuvant. Control animals received 2 ml saline ip, and
all groups consisted of 5 rats. Three independent experiments were performed over 6 months.
Figure 1 shows a representative result in which
there is marked inhibition of AID in virazole-treated
animals. Control rats lost an average of 10.9 g, whereas
treated rats gained 7.5 g.
Arthritis and Rheumatism, Vol. 20, No. 4 (May 1977)
The observation that both interferon and noninterferon-inducing antiviral agents can inhibit AID,
suggested that a virus, or viruslike microorganism plays
a role in the pathogenesis of this disease. Further studies
are underway to determine optimum schedules and
mode of action of this drug.
KOUROUNAKIS,
PH.D.
LYGERI
M.Sc.
MAVISYOUNG-RODENCHUK,
MORTONA.
KAPUSTA,
M.D., F.R.C.P.(C), F.A.C.P.
Jewish General Hospital
3755 Cote St. Catherine Road
Montreal, Quebec, Canada H3 T 1E2
REFERENCES
I . Kapusta MA, Mendelson J: Inhibition of adjuvant arthritis
by statolon. Proc SOCExp Biol Med 126:496-499, 1967
2. Kapusta MA, Mendelson J: The inhibition of adjuvant
disease in rats by the interferon-inducing agent pyran copolymer. Arthritis Rheum 12:463-471, 1969
3. Robins RK: Nucleosides and nucleotides: past, present and
future. Ann NY Acad Sci 255597-610. 1975
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