Rheumato at Day 1

The inaugural issue of Rheumato exhibits the gamut of phenomenology that is inherent to why we became rheumatologists: our reliance on fundamentals, the quest to decipher apparently disparate findings, problem solving, hypothesis formation as to mechanisms and relationships, assessing the applicability and adaptability of new technologies and exploring the validity of old concepts/perspectives, and constantly reviewing our perspectives and performance.

Rheumatology in the 1970s seemed like a wild frontier, with many unknowns and problems to solve. Our approach was to concentrate on fundamentals, pursuing obsessive-compulsive patient histories, performing ultra-complete physical examinations, developing diagnostic laboratory techniques and refining and adopting/adapting radiologic techniques. We dealt with what seemed to be arcane diseases which seemingly did not fall into the standard categories of the time. As these appeared to be outside the scope of the available specialties, they were “orphans” and rheumatology became their “custodians”. Many of us considered ourselves super-internists, as we had all the subspecialty training inherent to internal medicine at the time plus education/training specifically aimed at these “orphans”. We were at the forefront of multidisciplinary medicine because of our in-depth exposure to physical/rehabilitation medicine (including physical and occupational therapy) and orthopedics. Our medical colleagues recognized our unique skillset related to phenomena which appeared to affect multiple body systems, and thus, they called upon us for help in deciphering the underlying problem.

All this is reflected in the inaugural issue of Rheumato, as illustrated by the following:

• The importance of fundamentals was emphasized. Rothschild [1] addressed the critical role of the polarizing examination of joint fluid for crystals and the challenge in diagnosing gout in the absence of such evidence. The team of Nomura, Mikami, Masuda, Kato, Nakazaki, Ikeda, Hirabayashi, Kusubae and Sameshima [2] emphasized the importance of recognizing subtle findings. Further relating those findings to identify the underlying disease characterizes one of the fundamental values that our specialty brings to medical care. Their discourse on Kawasaki disease is especially valuable considering some of its shared symptomatology with coronavirus (COVID) infection, in an issue that Hendriks and Chandran [3] discussed in detail.
• Preconceived notions as to the causes and implications of gout were considered. Ken Pritzker [4] reviewed the association of gout with wealthy men who overindulged in fancy foods, fine wines and other forms of debauchery, whilst remaining mindful of Gerald Rodnan’s collection of demonstrative images.
• An investigation of diet interactions in gout and connective tissue disease received attention. While Ken Pritzker [4] addressed dietary implications for gout, Oliviero, Galozzi, Zanatta, Gatto, Spinella and Doria [5] examined randomized clinical trials assessing the effect of diet on systemic lupus erythematosus, scleroderma, myositis, Sjogren’s syndrome and vasculitis.
• Laboratory testing in rheumatic diseases received attention, first from Rothschild [1], addressing the importance of crystal recognition for the diagnosis of gout, and additionally from the team of Bandeira, Gil, Santos, Romão, Mascarenhas, Filipe, Fonseca and Bicho [6], specifically examining a role of angiotensin-converting enzyme (ACE) activity and its genetics as a factor in predicting the severity of psoriasis.
• The character of the microbiome and its apparent alteration by or impact on (or at least correlation with) various disease states now receives significant attention. The team of Shimizu, Murayama, Miyabe and Suzuki [7] examined the effect of microbiota on the balance between regulatory (Treg) and helper (Th17) cells in a disease that is variously characterized as immunologic or vasculitic—Behcet syndrome.
• Rheumatology has a long history of adopting and modifying radiologic diagnostic approaches. We were in the forefront of magnification radiology as a method for increasing image resolution and explored the possible application of diagnostic ultrasound to our armamentarium. The importance of repetitive studies to monitor disease progress earned the technique a place in minimizing exposure to ionizing radiation. The team of Mosa, Abdelrahman and El-Bahnasawy [8] shared with us their experience with the various forms of juvenile inflammatory arthritis as a mechanism to avoid radiation effects.
• The interventional aspect of rheumatology practice was not ignored. The team of Versace, Aragona, La Rosa, Chiappalone, Tringali, de Gaetano, Moore, Sangari, Roberts and Bagnato [9] addressed, as only a multi-center team can, one of the major challenges we face as rheumatologists—the patient with a disease that is refractory to our intervention techniques.
• The team of Vanni, Ciaffi, Mancarella and Ursini [10] illustrated one of the somewhat unique aspects of rheumatology—the recognition of possible unique disease associations. Immunologic reactions appear to be rare consequences of vaccination, and they added polymyalgia rheumatica to those possibilities, noting the difficulty in distinguishing ordinary myalgia responses from that specific entity. When partners are affected, the natural question is whether the phenomenon was indeed shared.

Thus, the inaugural issue of Rheumato successfully presented articles representing the gamut of phenomenology that is inherent to our specialty: they illustrate the finest aspects of rheumatologic thinking, approaches and care.