- Email: [email protected]
What should we foster in India: clinical immunology or rheumatology?
Indian Journal of Rheumatology 2006 June Volume 1, Number 1; pp. 26–28
Perspective
What should we foster in India: clinical immunology or rheumatology? R Misra1
BACKGROUND Rheumatology in our country has been established as a superspecialty of medicine and paediatrics in last several years. It is pertinent, therefore, to define the training component so that future growth of the specialty is satisfactory and comprehensive. Rheumatology is intimately associated with clinical immunology, the study of diseases caused by the immune system and diseases of the immune system.1 The subcategories of this broad discipline include immunodeficiency, autoimmunity, allergy, and transplant immunology. With translational research seeing the light of the day, particularly in rheumatic diseases, one is caught up with a nomenclature dilemma, ‘Rheumatology’ or ‘Clinical immunology’.
duration, was started at the Madras Medical College, Chennai and the first DM programme, of 3 years’ duration, in clinical immunology was started at the Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow in 1988. Both programmes are recognised by the Medical Council of India. The clinical immunology syllabus covers not only supervised clinical training but also training in basic and laboratory aspects of immunology. The trainee spends around a year in the laboratory doing bench work. These training programmes build a team of skilled rheumatologists/clinical immunologists who are well equipped to care for patients with musculoskeletal problems. The Clinical Immunology division of the Department of Medicine at AIIMS has changed its name recently to ‘Division of Clinical Immunology and Rheumatology’. In principle, however, there is no difference in the content of the training programme offered.
HISTORICAL PERSPECTIVE In our country, the first specialty clinic to deal with rheumatological diseases was established in the All India Institute of Medical Sciences (AIIMS), New Delhi way back in 1973. It was named as ‘Immunology Clinic’. One of the reasons for not naming it ‘Rheumatology’ was that the Orthopaedics Department was already running a clinic by this name. This posed a challenge to rheumatologists, which continues even today as vast majority of arthritis patients still consult orthopaedic surgeons, rather than rheumatologists or clinical immunologists who are specifically trained to manage these ailments.
TRAINING Clearly, there is paucity of specialists in our country. The first DM training programme in rheumatology, of 2 years’ 1
CLINICAL IMMUNOLOGY 8-4575 RHEUMATOLOGY Clinical immunology deals with diseases that arise from aberrations of the immune system, while rheumatology mainly deals with problems involving the joints and softtissues.2 The term rheumatology originates from the Greek word rheuma, meaning “that which flows as a river or stream” and ology, meaning “the study of”. The debate on nomenclature is a perpetual one. The term, as derived from antiquity, is somewhat vague and would include many of the diseases included in clinical immunology. The Harrison’s Principles of Internal Medicine (16th edition) includes the majority of diseases that interest us under the broad banner of ‘diseases of the immune system, connective tissue, and joints’.3 Rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), vasculitis, systemic sclerosis (SSc), myositis, Sjögren’s syndrome, amyloido-
Professor of Clinical Immunology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
Correspondence: email: [email protected]
Clinical immunology versus rheumatology
sis and sarcoidosis have been subcategorised as ‘disorders with immune-mediated injury’. Under the subcategory of ‘diseases of the joints and adjacent tissues’, osteoarthritis (OA), crystal arthropathy and soft tissue diseases like fibromyalgia and periarticular diseases are included. Thus there is a categorical inclusion of the bulk of immuno-inflammatory diseases under the banner of immune system diseases. The scope of clinical immunology is even broader, in that it includes allergic diseases, transplant medicine and immunodeficiency diseases. As regards allergic diseases, internists or chest physicians deal with bronchial asthma and dermatologists deal with skin allergies. Congenital immunodeficiency diseases are managed by paediatricians and acquired ones including acquired immunodeficiency syndrome (AIDS) mostly by clinical immunologists and internists.
IF THERE IS SO MUCH OF OVERLAP, THEN WHAT IS THE NEED FOR SEPARATE IDENTITIES? Probably one of the earliest societies of clinical immunology is the British Society of Allergy & Clinical Immunology (BSACI), which was established in 1947 as the British Association of Allergists.4 The society was renamed BSACI in 1973 reflecting the increasing strength in clinical immunology in the UK. The other major world society is the Clinical Immunology Society (CIS) of the USA. Underlying the birth of these societies are a rapidly upcoming group, the physician scientists and the realisation of the direction in which rheumatic diseases are going to develop.5 Physician scientists constitute a wellrecognised group that distinguishes itself from other physicians in their arduous involvement in research in addition to clinical activities. Thus, clinical immunology developed as an offshoot of rheumatology world over to emphasise on research and the necessity to understand the basics of these diseases. In fact, membership requirements in most of these clinical immunology societies include evidence of original scientific contributions to the field. Cutting edge research in rheumatology has mostly been in manipulating or correcting immune disruption. The introduction of infliximab, an offshoot of research in the immunology of rheumatoid arthritis has revolutionised the management of this crippling disease. It has also made a significant impact on the management of ankylosing spondylitis, psoriatic arthritis and Crohn’s disease. It is useful to have a broad based immunological knowledge to understand terms like ‘co-stimulation blockade’ and ‘Toll-
Perspective
27
like receptors’ in addition to the clinical skill. Biologicals have flooded the market as a result of continuing work in this exciting field. It is a milestone in clinical immunology that a clear distinction has been made from the way orthopaedicians manage arthritis and other allied conditions. The physicians in charge of rheumatic patients are under pressure to catch up with the recent advances. By staying aloof to advances in immunology, a rheumatologist is likely to fall behind the race. One can cite other examples of biomarkers including autoantibodies and the genetic markers. Training in immunology laboratory makes the student well-versed in techniques and interpretation of tests. It would be difficult to acquire grasp without proper laboratory exposure. It is important that the present generation of students is exposed to the advanced molecular biology and immunology techniques to withstand the current explosion of laboratorybased knowledge. It is a wishful thinking that the management of rheumatic diseases will be simply based on the art of clinical examination in future. It is a challenge for the current generation of teachers to update itself on these advances in biological sciences and lead from the front.
EVIDENCES FROM AMERICAN COLLEGE OF RHEUMATOLOGY 2005 The American College of Rheumatology (ACR) annual conference is probably the most important annual meeting of rheumatologists worldwide. Analysis of the 1998 abstracts presented in the last Conference held in November 2005 in San Diego, USA California was undertaken with an intention of picking up the general direction of cutting edge research in the field of rheumatology.6 Even after excluding the papers presented during the sessions on basic research, the core of majority of studies involved a substantial proportion of immunology, both in terms of basic information and research aspects (Table 1). Sixty-seven per cent (279/419) of abstracts presented in different sessions on RA and 63% of studies (56/89) in spondyloarthropathy covered either the use of biologicals or the intricate immunological networks in the disease. A good number of abstracts covered developments in musculoskeletal imaging and damage including cardiovascular morbidity of RA. During the sessions on SLE and vasculitis, 57% (146/255) and 40% (25/63) studies, respectively covered basic immunological techniques, pathogenesis or use of animal models. Most of the recent advances presented in sessions on osteoarthritis were on immunopathogenesis, the understanding of which requires
28
Indian Journal of Rheumatology 2006 June; Vol. 1, No. 1
Table 1 Abstracts from ACR 2005 conference Disease
Total abstracts (N)
Abstracts with core immunology involved
% representation of core immunology
Rheumatoid arthritis
419
279
67
Systemic lupus erythe-matosus
255
146
57
Spondyloarthropathy
89
56
63
Vasculitis
63
25
40
a sound knowledge of cartilage biology. Only sessions on soft tissue rheumatism (fibromyalgia) witnessed predominance of clinical work. The figures quite clearly show the necessity of sound knowledge and training in immunological principles to even comprehend the present day work.
EVIDENCES FROM RHEUMATOLOGY JOURNALS Three leading rheumatology journals were browsed to identify the research articles published in the latest issue. The April issue of Arthritis and Rheumatism had 32 original research publications, of which 21 papers were on immunological aspects of rheumatic diseases and two were on biological use. 7 The current issue of Rheumatology (Oxford) has 5 and 12 papers respectively on basic and clinical research.8 A look at the table of contents of the April issue of Arthritis, Research and Therapy, the third leading journal of rheumatology with an impact factor of 4.55 revealed that 15 out of 17 articles had strong immunology bias.9 It is logical to conclude that to get the best of each article one has to have sufficient knowledge of immunology and the related fields, such as molecular biology.
ARGUMENTS AGAINST CLINICAL IMMUNOLOGY Let us examine the other side of the coin: the disadvantages of fostering clinical immunology. To most members of medical fraternity clinical immunology is a broad term that relates to microbiology, biochemistry, and allergy, but not to a clinician. This is understandable because most of us have received training in immunology at undergraduate level as part of a basic subject training and had received hardly any training during the clinical years. Therefore, a clinical immunologist is likely to be viewed by others as a laboratory medical scientist rather than someone who
Misra
should be looking after patients. Rheumatology is favourably viewed as a clinical branch but the ground reality is that like clinical immunology, there is hardly any teaching at undergraduate and postgraduate level in the majority of medical colleges.
CONCLUSION Evidence presented above supports the argument that immunological principles will dominate the practice of modern day rheumatologists. Lack of basic immunological knowledge and laboratory techniques will clearly be a disadvantage. It will perhaps not matter today whether a practicing rheumatologist knows any immunology or not but in tomorrow’s world he will find himself lagging behind. For future rheumatologists it is as important to be equipped with clinical skills as also to know the basic and applied aspect of immunology, molecular biology and related fields. The sooner we accept these ground realities the better would we be able to take up the challenges of microarray-based rheumatology. One cannot endorse clinical immunology more strongly than this to save modern rheumatology.
REFERENCES 1. 2. 3.
4. 5.
6.
The Free Dictionary by Farlex. Available from: http://www.encyclopedia.thefreedictionary.com/. Wikipedia. The Free Encyclopedia. Rheumatology. Available from: http://en.wikipedia.org/wiki/Rheumatology. Kasper DL, Fauci AS, Longo DL, Braunwald E, Hauser SL, Jameson JL, editors. Harrison’s Principles of Internal Medicine. 16th ed. New York: McGraw-Hill, 2005. British Society for Allergy & Clinical Immunology. http://www.bsaci.org/whoarewe.html. Clinical Immunology Society. Membership eligibility requirements. Available from: http://www.clinimmsoc. org/membership/requirements.php. Abstracts of the American College of Rheumatology 69th annual meeting and the Association of Rheumatology Health Professionals 40th annual meeting. November 12–17, 2005, San Diego, California, USA. Arthritis Rheum 2005; 52 (Suppl 9): S31–741.
7. Tindall EA. Yesterday, today, and tomorrow. Arthritis Rheum 2006; 54: 1029–33. 8.
9.
Hinks A, Worthington J, Thomson W. The association of PTPN22 with rheumatoid arthritis and juvenile idiopathic arthritis. Rheumatology (Oxford) 2006; 45: 365–8. Available on www.arthritis-research.com Arthritis Research and Therapy 2006; 8 (4): Contents page.
Perspective
What should we foster in India: clinical immunology or rheumatology? R Misra1
BACKGROUND Rheumatology in our country has been established as a superspecialty of medicine and paediatrics in last several years. It is pertinent, therefore, to define the training component so that future growth of the specialty is satisfactory and comprehensive. Rheumatology is intimately associated with clinical immunology, the study of diseases caused by the immune system and diseases of the immune system.1 The subcategories of this broad discipline include immunodeficiency, autoimmunity, allergy, and transplant immunology. With translational research seeing the light of the day, particularly in rheumatic diseases, one is caught up with a nomenclature dilemma, ‘Rheumatology’ or ‘Clinical immunology’.
duration, was started at the Madras Medical College, Chennai and the first DM programme, of 3 years’ duration, in clinical immunology was started at the Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow in 1988. Both programmes are recognised by the Medical Council of India. The clinical immunology syllabus covers not only supervised clinical training but also training in basic and laboratory aspects of immunology. The trainee spends around a year in the laboratory doing bench work. These training programmes build a team of skilled rheumatologists/clinical immunologists who are well equipped to care for patients with musculoskeletal problems. The Clinical Immunology division of the Department of Medicine at AIIMS has changed its name recently to ‘Division of Clinical Immunology and Rheumatology’. In principle, however, there is no difference in the content of the training programme offered.
HISTORICAL PERSPECTIVE In our country, the first specialty clinic to deal with rheumatological diseases was established in the All India Institute of Medical Sciences (AIIMS), New Delhi way back in 1973. It was named as ‘Immunology Clinic’. One of the reasons for not naming it ‘Rheumatology’ was that the Orthopaedics Department was already running a clinic by this name. This posed a challenge to rheumatologists, which continues even today as vast majority of arthritis patients still consult orthopaedic surgeons, rather than rheumatologists or clinical immunologists who are specifically trained to manage these ailments.
TRAINING Clearly, there is paucity of specialists in our country. The first DM training programme in rheumatology, of 2 years’ 1
CLINICAL IMMUNOLOGY 8-4575 RHEUMATOLOGY Clinical immunology deals with diseases that arise from aberrations of the immune system, while rheumatology mainly deals with problems involving the joints and softtissues.2 The term rheumatology originates from the Greek word rheuma, meaning “that which flows as a river or stream” and ology, meaning “the study of”. The debate on nomenclature is a perpetual one. The term, as derived from antiquity, is somewhat vague and would include many of the diseases included in clinical immunology. The Harrison’s Principles of Internal Medicine (16th edition) includes the majority of diseases that interest us under the broad banner of ‘diseases of the immune system, connective tissue, and joints’.3 Rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), vasculitis, systemic sclerosis (SSc), myositis, Sjögren’s syndrome, amyloido-
Professor of Clinical Immunology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
Correspondence: email: [email protected]
Clinical immunology versus rheumatology
sis and sarcoidosis have been subcategorised as ‘disorders with immune-mediated injury’. Under the subcategory of ‘diseases of the joints and adjacent tissues’, osteoarthritis (OA), crystal arthropathy and soft tissue diseases like fibromyalgia and periarticular diseases are included. Thus there is a categorical inclusion of the bulk of immuno-inflammatory diseases under the banner of immune system diseases. The scope of clinical immunology is even broader, in that it includes allergic diseases, transplant medicine and immunodeficiency diseases. As regards allergic diseases, internists or chest physicians deal with bronchial asthma and dermatologists deal with skin allergies. Congenital immunodeficiency diseases are managed by paediatricians and acquired ones including acquired immunodeficiency syndrome (AIDS) mostly by clinical immunologists and internists.
IF THERE IS SO MUCH OF OVERLAP, THEN WHAT IS THE NEED FOR SEPARATE IDENTITIES? Probably one of the earliest societies of clinical immunology is the British Society of Allergy & Clinical Immunology (BSACI), which was established in 1947 as the British Association of Allergists.4 The society was renamed BSACI in 1973 reflecting the increasing strength in clinical immunology in the UK. The other major world society is the Clinical Immunology Society (CIS) of the USA. Underlying the birth of these societies are a rapidly upcoming group, the physician scientists and the realisation of the direction in which rheumatic diseases are going to develop.5 Physician scientists constitute a wellrecognised group that distinguishes itself from other physicians in their arduous involvement in research in addition to clinical activities. Thus, clinical immunology developed as an offshoot of rheumatology world over to emphasise on research and the necessity to understand the basics of these diseases. In fact, membership requirements in most of these clinical immunology societies include evidence of original scientific contributions to the field. Cutting edge research in rheumatology has mostly been in manipulating or correcting immune disruption. The introduction of infliximab, an offshoot of research in the immunology of rheumatoid arthritis has revolutionised the management of this crippling disease. It has also made a significant impact on the management of ankylosing spondylitis, psoriatic arthritis and Crohn’s disease. It is useful to have a broad based immunological knowledge to understand terms like ‘co-stimulation blockade’ and ‘Toll-
Perspective
27
like receptors’ in addition to the clinical skill. Biologicals have flooded the market as a result of continuing work in this exciting field. It is a milestone in clinical immunology that a clear distinction has been made from the way orthopaedicians manage arthritis and other allied conditions. The physicians in charge of rheumatic patients are under pressure to catch up with the recent advances. By staying aloof to advances in immunology, a rheumatologist is likely to fall behind the race. One can cite other examples of biomarkers including autoantibodies and the genetic markers. Training in immunology laboratory makes the student well-versed in techniques and interpretation of tests. It would be difficult to acquire grasp without proper laboratory exposure. It is important that the present generation of students is exposed to the advanced molecular biology and immunology techniques to withstand the current explosion of laboratorybased knowledge. It is a wishful thinking that the management of rheumatic diseases will be simply based on the art of clinical examination in future. It is a challenge for the current generation of teachers to update itself on these advances in biological sciences and lead from the front.
EVIDENCES FROM AMERICAN COLLEGE OF RHEUMATOLOGY 2005 The American College of Rheumatology (ACR) annual conference is probably the most important annual meeting of rheumatologists worldwide. Analysis of the 1998 abstracts presented in the last Conference held in November 2005 in San Diego, USA California was undertaken with an intention of picking up the general direction of cutting edge research in the field of rheumatology.6 Even after excluding the papers presented during the sessions on basic research, the core of majority of studies involved a substantial proportion of immunology, both in terms of basic information and research aspects (Table 1). Sixty-seven per cent (279/419) of abstracts presented in different sessions on RA and 63% of studies (56/89) in spondyloarthropathy covered either the use of biologicals or the intricate immunological networks in the disease. A good number of abstracts covered developments in musculoskeletal imaging and damage including cardiovascular morbidity of RA. During the sessions on SLE and vasculitis, 57% (146/255) and 40% (25/63) studies, respectively covered basic immunological techniques, pathogenesis or use of animal models. Most of the recent advances presented in sessions on osteoarthritis were on immunopathogenesis, the understanding of which requires
28
Indian Journal of Rheumatology 2006 June; Vol. 1, No. 1
Table 1 Abstracts from ACR 2005 conference Disease
Total abstracts (N)
Abstracts with core immunology involved
% representation of core immunology
Rheumatoid arthritis
419
279
67
Systemic lupus erythe-matosus
255
146
57
Spondyloarthropathy
89
56
63
Vasculitis
63
25
40
a sound knowledge of cartilage biology. Only sessions on soft tissue rheumatism (fibromyalgia) witnessed predominance of clinical work. The figures quite clearly show the necessity of sound knowledge and training in immunological principles to even comprehend the present day work.
EVIDENCES FROM RHEUMATOLOGY JOURNALS Three leading rheumatology journals were browsed to identify the research articles published in the latest issue. The April issue of Arthritis and Rheumatism had 32 original research publications, of which 21 papers were on immunological aspects of rheumatic diseases and two were on biological use. 7 The current issue of Rheumatology (Oxford) has 5 and 12 papers respectively on basic and clinical research.8 A look at the table of contents of the April issue of Arthritis, Research and Therapy, the third leading journal of rheumatology with an impact factor of 4.55 revealed that 15 out of 17 articles had strong immunology bias.9 It is logical to conclude that to get the best of each article one has to have sufficient knowledge of immunology and the related fields, such as molecular biology.
ARGUMENTS AGAINST CLINICAL IMMUNOLOGY Let us examine the other side of the coin: the disadvantages of fostering clinical immunology. To most members of medical fraternity clinical immunology is a broad term that relates to microbiology, biochemistry, and allergy, but not to a clinician. This is understandable because most of us have received training in immunology at undergraduate level as part of a basic subject training and had received hardly any training during the clinical years. Therefore, a clinical immunologist is likely to be viewed by others as a laboratory medical scientist rather than someone who
Misra
should be looking after patients. Rheumatology is favourably viewed as a clinical branch but the ground reality is that like clinical immunology, there is hardly any teaching at undergraduate and postgraduate level in the majority of medical colleges.
CONCLUSION Evidence presented above supports the argument that immunological principles will dominate the practice of modern day rheumatologists. Lack of basic immunological knowledge and laboratory techniques will clearly be a disadvantage. It will perhaps not matter today whether a practicing rheumatologist knows any immunology or not but in tomorrow’s world he will find himself lagging behind. For future rheumatologists it is as important to be equipped with clinical skills as also to know the basic and applied aspect of immunology, molecular biology and related fields. The sooner we accept these ground realities the better would we be able to take up the challenges of microarray-based rheumatology. One cannot endorse clinical immunology more strongly than this to save modern rheumatology.
REFERENCES 1. 2. 3.
4. 5.
6.
The Free Dictionary by Farlex. Available from: http://www.encyclopedia.thefreedictionary.com/. Wikipedia. The Free Encyclopedia. Rheumatology. Available from: http://en.wikipedia.org/wiki/Rheumatology. Kasper DL, Fauci AS, Longo DL, Braunwald E, Hauser SL, Jameson JL, editors. Harrison’s Principles of Internal Medicine. 16th ed. New York: McGraw-Hill, 2005. British Society for Allergy & Clinical Immunology. http://www.bsaci.org/whoarewe.html. Clinical Immunology Society. Membership eligibility requirements. Available from: http://www.clinimmsoc. org/membership/requirements.php. Abstracts of the American College of Rheumatology 69th annual meeting and the Association of Rheumatology Health Professionals 40th annual meeting. November 12–17, 2005, San Diego, California, USA. Arthritis Rheum 2005; 52 (Suppl 9): S31–741.
7. Tindall EA. Yesterday, today, and tomorrow. Arthritis Rheum 2006; 54: 1029–33. 8.
9.
Hinks A, Worthington J, Thomson W. The association of PTPN22 with rheumatoid arthritis and juvenile idiopathic arthritis. Rheumatology (Oxford) 2006; 45: 365–8. Available on www.arthritis-research.com Arthritis Research and Therapy 2006; 8 (4): Contents page.