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Musculoskeletal Clinical Metrology. Nicholas Bellamy. Boston Kluwer Academic Publishers 1993. 367 pp. Illustrated. Indexed. 170.00

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increase in granulocyte precursor cells such as promyelocytes and metamyelocytes, as well as, on some occasions,
myeloblasts (Lieschke GJ, Burgess AW: Granulocyte colonystimulating factor and granulocyte-macrophage colony stimulating factor [first of two parts]. N Engl J Med 327:28-33,
1992). The long-term effects of rHuG-CSF, as well as the
efficacy of the long-term administration of rHuG-CSF, on
bone marrow cells in patients with Felty’s syndrome should
therefore be examined.
Masayuki Yasuda, MD, PhD
Toru Kihara, MD
Tetsuya Wada, MD
Satoshi Shiokawa, MD, PhD
Eiichi Furuta, MD
Yasuo Suenagu, MD
Shiro Nonaka, MD
Masashi Nobunaga, MD, PhD
Kyushu University
Kazunori Yoshioka, MD
Tetsuro Isayama, MD
Beppu National Hospital
Beppu, Japan
Rheumatologists’ ability to provide primary care:
comment on the article by Branch
To the Editor:
I am deeply disturbed by the implication, in the
special article by Branch (Branch WT: Primary care practice
and training in rheumatology. Arthritis Rheum 37:305-306,
1994), that rheumatologists, who have traditionally been in a
nonprocedural, cognitive subspecialty of internal medicine
for the duration of their subspecialty practice, are somehow
incapable of delivering primary care without having further
training during their fellowships and residency. I would point
out that we are all certified in internal medicine, and have not
suffered major mental deficits simply because we have
engaged in a 2-3-year training program in rheumatology .The
office practice of rheumatology is by definition a cognitive,
clinical, nonprocedural practice, and I think the majority of
rheumatologists would take deep offense at the implication
that our daily practice is not that of a primary care physician.
I would add that rheumatology is strongly oriented to
chronic disease care, multisystem integration, and related
social problems.
In the state of Washington, subspecialty internists
are being given the choice of becoming either purely a
primary care physician who is not allowed to practice the
subspecialty or purely a subspecialist, but are not allowed to
combine the two. This is a position that is neither financially
nor clinically viable, and I fear that, unless we as a subspecialty organization make it very clear that we are in fact well
prepared to provide primary care without further training,
this will simply eliminate the availability of rheumatologists
in many areas of the country.
I hope I am not alone within the American College of
Rheumatology in my feelings that Dr. Branch, despite his
good intentions, is not particularly familiar with the clinical
expertise and practice of rheumatologists.
James D. Prickett, MD
Consultants in Medicine, Inc.
Bellingharn, W A
To the Editor:
We should distinguish between recommendations for
what should be done in the present and recommendations for
the future. In the present, I think it would do more harm than
good to state that rheumatologists are not capable of delivering primary care. I have tremendous respect for the
clinical skills of rheumatologists and for the fact that they,
like general internists, have chosen a cognitive field of
practice. We must currently assume that physicians completing training in internal medicine are qualified to practice
primary care, with updating if they have been away or
engaged in a narrow subspecialty.
My article was meant to address what might be done
better in the future. In this regard, I think we can offer much
better training for primary care practice. Traditional internal
medicine residencies have lacked many of the features that
primary care residencies developed to provide special expertise in such areas as preventive medicine, ambulatory
medicine, patient/doctor communication, and social and
psychological issues, among others. My suggestion is to
reorganize training by incorporating expertise in these areas
much more fully into either fellowships (e.g., in specialties
like rheumatology where primary care will most likely be a
major component) or residencies (e.g., by incorporating all
of these elements into all internal medicine residency programs in the future, without losing the rigor of sufficient
in-hospital training). Since the future is approaching very
rapidly, I believe we should start to discuss the various
options for enhancing, by a whole order of magnitude, the
primary care-giving skills of future practitioners.
I hope that the thrust of my article was toward
general internal medicine and rheumatology joining together,
with others who want to care for the “whole patient,” in
designing future training.
William T. Branch, MD
Brigham and Women’s Hospital
Boston, M A
Cost of ketoprofen: comment on the article by Furst
To the Editor:
I read with interest the article by Dr. Furst, comparing nonsteroidal antiinflammatory drugs (NSAIDs) (Furst D:
Are there differences among nonsteroidal antiinflammatory
drugs? Comparing acetylated salicylates, nonacetylated
salicylates, and nonacetylated nonsteroidal antiinflammatory drugs. Arthritis Rheum 37:l-9, 1994). The cited cost
ranges are derived from old data and are therefore not
currently applicable, at least with regard to brand ketoprofen. Because ketoprofen’s new once-daily brand formulation, Oruvail, was approved in September 1993, old pricing
data (September 1992) cannot fairly be utilized. Today’s
current cost of Oruvail is $60.00 per month, much less than
that cited. In addition, a price range was given for all of the
NSAIDs listed except ketoprofen, for which the cost cited
was certainly at the upper limit.
Thank you for addressing these misleading data.
Ginger D. Constantine, MD
Wyeth-Ayerst Laboratories
Philadelphia, P A
To the Editor:
I appreciate Dr. Constantine’s comment relating to
the cost of ketoprofen. When writing the article, I consulted
the hospital pharmacy about NSAID costs. At that time, the
slow-release ketoprofen formulation was not on our formulary, so data on it were not included.
The implication of Dr. Constantine’s comment is a
good one. In an era of intense competition among NSAIDs,
the relative costs of these drugs may change. Thus, it is appropriate to check with one’s pharmacy periodically about
relative costs, so this factor can also be considered in NSAIDprescribing decisions.
Daniel E. Furst, MD
Virginia Mason Research Center
Seattle, W A
Musculoskeletal Clinical Metrology. Nicholas Bellamy . Boston, Kluwer Academic Publishers, 1993. 367 p p . Illustrated.
Indexed. $170.00.
Musculoskeletal Clinical Metrology is a comprehensive review of methods and techniques to assess the efficacy
of antirheumatic drugs in patients with musculoskeletal
disorders. It is a reflection of an increasing interest in the
field of outcome measurement that expands its view behind
biologic markers and imaging results to iatrogenic effects,
economic impact, and patient-perceived outcomes such as
disability and discomfort. Bellamy reviews the field, starting
with the early work of Taylor, Steinbrocker, Keele, and
Lansbury and proceeding to recent developments such as
the International Conference on Outcome Measures in
Rheumatoid Arthritis Clinical Trials, held in 1992.
Part 1 is an excellent introduction to the terminology
and techniques of clinical measurement (clinimetrics), including concepts such as reliability, validity, and responsiveness, and the criteria that should be considered when selecting assessment techniques for musculoskeletal clinical trials.
Part 2 provides an overview of outcome measures in rheumatic diseases, including a detailed chapter on pain measurement. The author describes the development, format, reliability, validity, and performance characteristics of health
status instruments, functional indices, articular indices, and
mechanical and electromechanical devices suitable for use in
assessment of several musculoskeletal disorders. Part 3
focuses on current measurement techniques applied in rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, and
fibromyalgia. There is a comprehensive review of the literature, including the guidelines of national and international
agencies, individual opinions, and the viewpoints of consensus development groups.
The final section, part 4, is a successful attempt to tie
theory to clinical practice. The reader will find standardized
assessment techniques for more than 100 clinical variables,
including methods of assessing joint swelling and tenderness, disease activity, and pain. The author thoroughly
distinguishes between observer-dependent and observerindependent outcome measures and provides multiple illustrations of certain techniques.
Those who are involved in designing clinical trials in
musculoskeletal diseases will find valuable data on standard
deviations for selected outcome measures and sample size
requirements. However, the text can’t replace biostatistical
support (e.g., when calculating sample sizes) or clinical
methodologic advice when selecting an appropriate outcome
instrument for drug trials in musculoskeletal disorders.
An appendix provides original reprints of selected
functional indices and health status measures that are commonly used in musculoskeletal disorders. Researchers are
encouraged to contact the authors of those instruments when
considering their inclusion in clinical trials.
The text is ideally suited for clinical investigators,
clinical epidemiologists, clinical pharmacologists, and allied
health professionals. It might be of particular interest for
researchers who want to become familiar with the terminology and methodology of musculoskeletal outcome research.
However, the cost of this volume may lead interested
individuals to use it primarily as a library resource.
Oliver Sangha, MD, MPH
Brigham and Women’s Hospital
Boston, M A
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kluwer, illustrated, 367, metrologia, academic, musculoskeletal, nicholas, 170, 1993, clinical, indexes, bellamy, boston, publisher
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