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ASSESSING DISEASE ACTIVITY IN ANKYLOSING SPONDYLITIS
1072
often inappropriate to the needs of their country, and often failed to provide a sensible balance of training for their future careers. The services they provided were, however, essential for the running of the National Health Service in its lower grades. Yet there were three times as many doctors in some of these so-called "training posts" than were needed to fill the number of senior places which would become available. Overseas doctors who had become domiciled in the country for several years, and who understandably attempted to follow permanent careers in the UK, rather than returning home, increased this surplus, which can be illustrated by figures for registrar posts in general surgery: in September, 1985, there were 681 registrars (of whom about 300 were foreign graduates) whereas only some 250 were needed to fill future requirements for senior posts. Put bluntly, overseas doctors are needed to fill the training grades, but there are more than enough graduates to take up the senior posts in due course. Under the 1984 regulation of, at most, a four-year limited contract, the quality of the training and experience made available in this period must be sufficiently high for overseas graduates to want to apply and for their own countries to regard it as a worthwhile and recognised training on their return. If they are approved and granted provisional registration by the General Medical Council, overseas applicants will be able to enter a rotational training programme which would provide a balance of general and some specialist surgical experience, including, in most cases, a period at a teaching
hospital
or
specialist
centre.
Subject
to
satisfactory
by the consultants involved and the submission of an operating log book, a certificate of sponsored training would be awarded. There would also be an opportunity to take the final FRCS, and applicants wishing to do so must hold the primary examination before entering the scheme. Unfortunately such rotations may be seen by some as subsidiary or second-rate compared with those of UK graduates. This view must not be allowed to prevail, for, if it does, Britain would be failing not only those overseas graduates who are in the scheme but also their sponsors, who would soon realise what was happening and stop people from entering the scheme, with serious consequences for the NHS. Overseas doctors accepted for the scheme will in fact undertake senior house officer and registrar rotational training which exactly corresponds to that of local graduates: the two groups will be working side by side. Now that the Royal College of Surgeons of England is setting its seal on the scheme and is itself administering it, the arrangements have been much strengthened. assessment
mixture of the two, with systemic complications.2 In general, it is easier to define disease activity in patients with or a
extra-articular manifestations such as uveitis and anaemia ; short-term evaluation of patients with predominantly spinal involvement is more difficult. Moreover, the readily measurable process measurements, such as erythrocyte sedimentation rate3and plasma viscosity, may bear little relation to outcome measurements such as functional activity, sense of wellbeing, and personal cost in terms of suffering and money. Attempts to introduce more complex technological assessments such as radionuclide scanning4 or measurement of vital capaciiy5 have been disappointingly
non-specific or unhelpful. In contradistinction
to
the situation in rheumatoid
arthritis, in which the synovium is the main focus of pathological change, the enthesis is the site of primary disease activity in ankylosing spondylitis. But formal measurement of disease activity at the site of the enthesis has not received much attention.
Now Mander and colleagues in Newcastle report the measurement of point tenderness over some seventy sites of ligament insertion, including costochondral joints, epicondyles, iliac crests, and lumbar spine processes. These workers claim that the evaluation takes only three minutes and that the result is a convenient non-invasive and non-distressing measurement of disease severity. It is appealing to see a study that avoids unnecessary technological investigation, elucidates the presence of extra-spinal involment, and consists simply of the laying 9IÍ of hands. Unfortunately, controls were not included. It would have been interesting to see how patients with fibromyalgia, depression, or other inflammatory joint disorders responded. It is also possible that patients with rheumatoid disease or other chronic painful conditions would score highly, even though they have predominantly synovial rather than enthesopathic disease. The Newcastle workers do not comment on the relation of their "enthesis index" to functional outcome; they report that the index improved with treatment, but in the absence of a placebo group any change may simply reflect expectation. Whether the index will perform as well as a newly introduced self-administered ankylosing spondylitis assessment questionnaire8 remains unclear. The questionnaire can be completed in under a minute, is known to be reproducible, correlates well with both radiological and metrological evaluation of the patient, and performed better than the Health Assessment Questionnaire developed by Stanford University.9 Perhaps a composite of all these clinical measures will be helpful. Further research should focus on both short-term therapeutic studies and on
long-term outcome. ASSESSING DISEASE ACTIVITY IN ANKYLOSING SPONDYLITIS FOR many years research into ankylosing spondylitis and spondylarthropathies has been hampered by the difficulty in defming activity, severity, progress, and outcome of the disease. The problem is compounded by the fact that ankylosing spondylitis is not a homogeneous disorder. Thus some patients simply have sacroiliac disease (defmed radiologically) in association with inflammatory joint symptoms,l whereas others have extrapelvic spinal disease or extra-spinal articular involvement,
the other seronegative
J, Fries JF, et al The clinical history as a screening test in ankylosing spondylitis. JAMA 1977; 237: 2613-14.
1 Calin A, Porta
ED, Ruddy S, Sledge CG, eds. Textbook of rheumatology. 2nd ed. Philadelphia: WB Saunders, 1985: 1007-20 Nashel DJ, Petrone DL, Ulmer CC, Sliwinski AJ. C-reactive protein: a marker for disease activity in ankylosing spondylitis and Reiter’s syndrome. J Rheumatol 1986; 13: 364-67 Spencer DG, Adams FG, Horton PW, Buchanan WW. Scintiscanning in ankylosing spondylitis. Rheumatol Rehabil 1979; 12: 135-42. Franssen MJAM, van Herwaarden CLA, van de Putte LBA, Gritnau FWJ Lung function in patients with ankylosing spondylitis. A study of the influence of disease activity and treatment with nonsteroidal antiinflammatory drugs. JRheumatol 1986; 13: 936-40. Ball J. Enthesopathy of rheumatoid and ankylosing spondylitis. Ann Rheum Dis 1971, 30: 213-23. Mander M, Simpson JM, McLellan A, Walker D, Goodacre JA, Dick CW Studies with an enthesis index as a method of clinical assessment in ankylosing spondylitis. Ann Rheum Dis 1987; 46: 197-202. Nemeth R, Smith F, Elswood J, Calin A. Ankylosing spondylitis (AS)—an approach to the measurement of severity and outcome: ankylosing spondylitis assessment questionnaire (ASAQ)—a controlled study. Br J Rheumatol 1987; 26 (S1): 69 Fnes JF, Spitz P, Kraines RG, Holman HR. Measurement of outcome in arthritis Arthritis Rheum 1980; 23: 137-45.
2. Calin A. Ankylosing spondylitis. In: Kelly WN, Harris 3.
4. 5.
6. 7.
8.
9.
often inappropriate to the needs of their country, and often failed to provide a sensible balance of training for their future careers. The services they provided were, however, essential for the running of the National Health Service in its lower grades. Yet there were three times as many doctors in some of these so-called "training posts" than were needed to fill the number of senior places which would become available. Overseas doctors who had become domiciled in the country for several years, and who understandably attempted to follow permanent careers in the UK, rather than returning home, increased this surplus, which can be illustrated by figures for registrar posts in general surgery: in September, 1985, there were 681 registrars (of whom about 300 were foreign graduates) whereas only some 250 were needed to fill future requirements for senior posts. Put bluntly, overseas doctors are needed to fill the training grades, but there are more than enough graduates to take up the senior posts in due course. Under the 1984 regulation of, at most, a four-year limited contract, the quality of the training and experience made available in this period must be sufficiently high for overseas graduates to want to apply and for their own countries to regard it as a worthwhile and recognised training on their return. If they are approved and granted provisional registration by the General Medical Council, overseas applicants will be able to enter a rotational training programme which would provide a balance of general and some specialist surgical experience, including, in most cases, a period at a teaching
hospital
or
specialist
centre.
Subject
to
satisfactory
by the consultants involved and the submission of an operating log book, a certificate of sponsored training would be awarded. There would also be an opportunity to take the final FRCS, and applicants wishing to do so must hold the primary examination before entering the scheme. Unfortunately such rotations may be seen by some as subsidiary or second-rate compared with those of UK graduates. This view must not be allowed to prevail, for, if it does, Britain would be failing not only those overseas graduates who are in the scheme but also their sponsors, who would soon realise what was happening and stop people from entering the scheme, with serious consequences for the NHS. Overseas doctors accepted for the scheme will in fact undertake senior house officer and registrar rotational training which exactly corresponds to that of local graduates: the two groups will be working side by side. Now that the Royal College of Surgeons of England is setting its seal on the scheme and is itself administering it, the arrangements have been much strengthened. assessment
mixture of the two, with systemic complications.2 In general, it is easier to define disease activity in patients with or a
extra-articular manifestations such as uveitis and anaemia ; short-term evaluation of patients with predominantly spinal involvement is more difficult. Moreover, the readily measurable process measurements, such as erythrocyte sedimentation rate3and plasma viscosity, may bear little relation to outcome measurements such as functional activity, sense of wellbeing, and personal cost in terms of suffering and money. Attempts to introduce more complex technological assessments such as radionuclide scanning4 or measurement of vital capaciiy5 have been disappointingly
non-specific or unhelpful. In contradistinction
to
the situation in rheumatoid
arthritis, in which the synovium is the main focus of pathological change, the enthesis is the site of primary disease activity in ankylosing spondylitis. But formal measurement of disease activity at the site of the enthesis has not received much attention.
Now Mander and colleagues in Newcastle report the measurement of point tenderness over some seventy sites of ligament insertion, including costochondral joints, epicondyles, iliac crests, and lumbar spine processes. These workers claim that the evaluation takes only three minutes and that the result is a convenient non-invasive and non-distressing measurement of disease severity. It is appealing to see a study that avoids unnecessary technological investigation, elucidates the presence of extra-spinal involment, and consists simply of the laying 9IÍ of hands. Unfortunately, controls were not included. It would have been interesting to see how patients with fibromyalgia, depression, or other inflammatory joint disorders responded. It is also possible that patients with rheumatoid disease or other chronic painful conditions would score highly, even though they have predominantly synovial rather than enthesopathic disease. The Newcastle workers do not comment on the relation of their "enthesis index" to functional outcome; they report that the index improved with treatment, but in the absence of a placebo group any change may simply reflect expectation. Whether the index will perform as well as a newly introduced self-administered ankylosing spondylitis assessment questionnaire8 remains unclear. The questionnaire can be completed in under a minute, is known to be reproducible, correlates well with both radiological and metrological evaluation of the patient, and performed better than the Health Assessment Questionnaire developed by Stanford University.9 Perhaps a composite of all these clinical measures will be helpful. Further research should focus on both short-term therapeutic studies and on
long-term outcome. ASSESSING DISEASE ACTIVITY IN ANKYLOSING SPONDYLITIS FOR many years research into ankylosing spondylitis and spondylarthropathies has been hampered by the difficulty in defming activity, severity, progress, and outcome of the disease. The problem is compounded by the fact that ankylosing spondylitis is not a homogeneous disorder. Thus some patients simply have sacroiliac disease (defmed radiologically) in association with inflammatory joint symptoms,l whereas others have extrapelvic spinal disease or extra-spinal articular involvement,
the other seronegative
J, Fries JF, et al The clinical history as a screening test in ankylosing spondylitis. JAMA 1977; 237: 2613-14.
1 Calin A, Porta
ED, Ruddy S, Sledge CG, eds. Textbook of rheumatology. 2nd ed. Philadelphia: WB Saunders, 1985: 1007-20 Nashel DJ, Petrone DL, Ulmer CC, Sliwinski AJ. C-reactive protein: a marker for disease activity in ankylosing spondylitis and Reiter’s syndrome. J Rheumatol 1986; 13: 364-67 Spencer DG, Adams FG, Horton PW, Buchanan WW. Scintiscanning in ankylosing spondylitis. Rheumatol Rehabil 1979; 12: 135-42. Franssen MJAM, van Herwaarden CLA, van de Putte LBA, Gritnau FWJ Lung function in patients with ankylosing spondylitis. A study of the influence of disease activity and treatment with nonsteroidal antiinflammatory drugs. JRheumatol 1986; 13: 936-40. Ball J. Enthesopathy of rheumatoid and ankylosing spondylitis. Ann Rheum Dis 1971, 30: 213-23. Mander M, Simpson JM, McLellan A, Walker D, Goodacre JA, Dick CW Studies with an enthesis index as a method of clinical assessment in ankylosing spondylitis. Ann Rheum Dis 1987; 46: 197-202. Nemeth R, Smith F, Elswood J, Calin A. Ankylosing spondylitis (AS)—an approach to the measurement of severity and outcome: ankylosing spondylitis assessment questionnaire (ASAQ)—a controlled study. Br J Rheumatol 1987; 26 (S1): 69 Fnes JF, Spitz P, Kraines RG, Holman HR. Measurement of outcome in arthritis Arthritis Rheum 1980; 23: 137-45.
2. Calin A. Ankylosing spondylitis. In: Kelly WN, Harris 3.
4. 5.
6. 7.
8.
9.