Talk:Rheumatoid arthritis/Archive 2

Criteria for TNF therapy
those who don't meet elegibility criteria but get biologicals anyway typically have a poorer response. JFW | T@lk  11:25, 21 May 2008 (UTC)

Alcohol
Two users have now tried to insert information on alcohol supposedly reducing the risk of RA. This seems to be based on, an article that has not yet appeared in print and therefore has not yet received the scrutiny of the scientific community. The authors state that their findings need to be confirmed in further studies. This should probably be a prospective study. The paper also does not really explain why alcohol would interact with HLA-DRB1 except on an epidemiological level. JFW | T@lk  17:25, 12 June 2008 (UTC)


 * ... and Jfdwolff wrote in the summary of his reversion: "this is meaningless - what, pray, would explain this phenomenon and how would it influence anything?"
 * (pol098 writing) What I wrote was the following (I did check that there was nothing about this in Talk beforehand, as it happens):
 * A 2008 study with 3000 subjects found a significant inverse association between alcohol intake and risk of RA. Together with the recent demonstration of a preventive effect of alcohol in experimental arthritis, it concludes that alcohol may protect against RA. The authors recommend additional studies on potential RA prevention.
 * There's no attempt to explain this; it's reported to be a significant statistical correlation, which is perfectly valid in its own right (a great deal of science is empirical; attempts to explain follow). Whether it influences anything or not doesn't matter; it is relevant to the topic.
 * Agreed, it's only been published online so far; but it appears to be a respectable study, the sample size is not small and the reported correlation is statistically significant. If this were a printed encyclopedia which would remain on record for years one would take a different attitude; but in an online resource which can be updated instantly it is quite appropriate to report early results, without waiting for them to be incorporated into the standard model.
 * I think what I wrote is about right, perhaps with the addition of something like: "the article was published online on 5 June 2008 and has not yet been scrutinsed by the scientific community". So I'd propose this study should be mentioned at this time, and updated as necessary. What do others say? Pol098 (talk) 21:03, 12 June 2008 (UTC)

Have you ever seen that used in a Wikipedia article? That sounds like editorialising and fails WP:NOR. I have already explained my misgivings with the study. On the whole, citing single studies on anything is to be avoided on Wikipedia, as we cannot possibly place such a study in context. Multiple studies are easier, systematic reviews and meta-analyses are even easier. And finally the high-quality clinical review in a high-impact factor journal is the bee's knees. The only exception occurs when a single study is cited heavily for its remarkable achievements or notoriety. is such a study. It was never repeated but it is highly cited.

If you can find anything better on RA vs alcohol I'd be only too pleased to recommend it. The Scandinavian study contradicts earlier work, such as, but is supported by , and finds no definite answer. I think that the literature is too contradictory to suggest that alcohol protects against RA, and there is no systematic review that we can cite to the effect that "the jury is still out". JFW | T@lk  09:37, 15 June 2008 (UTC)

Cannabis
A single preliminary study is not sufficient to state that cannabis is used for RA. The survey cited in support by the authors does not differentiate reliably between OA and RA so that is specious. I strongly suggest we avoid discussing cannabis here; it has no regulatory approval and is illegal in many countries. JFW | T@lk  22:22, 2 August 2008 (UTC)


 * The researchers behind the survey states that We can conclude from this review of the original data, that the illicit use of cannabis by patients with rheumatoid arthritis is widespread, and that there is anecdotal evidence of effectiveness. They also report about their sample that Of the 2969 respondents to the survey, 784 (26%) stated that they had ‘arthritis’. Of these, 247 patients indicated that they suffered from rheumatoid or osteoarthritis (the remainder did not specify). A total of 155 respondents stated that they continued to use illicit cannabis for the purpose of symptom relief. Around 111 of them (46%) had rheumatoid arthritis. They thus clearly distinguish between OA and RA. That cannabis has no regulatory approval and is illegal in many countries has no bearing on whether its medicinal use should be covered in Wikipedia. Terjen (talk) 00:27, 3 August 2008 (UTC)

Antibiotic therapy
The article now seems not to mention antibiotics at all. Should we not have under Treatment a subsection "Alternative or controversial treatments" which can mention the use of antibiotics as discussed above on this talk page ? or if antibiotics are no longer used maybe it could be mentioned in the History section ? Rod57 (talk) 06:44, 26 November 2008 (UTC)


 * I think antibiotics, particularly those with antiinflammitory properties have already been discussed (see above). Fuzbaby (talk) 16:40, 20 June 2009 (UTC)


 * They are only mentioned on this talk page, not in the article itself - which seems unbalanced given what is in the article under Other therapies. Antibiotics clearly were used in the past. The history section could mention that and say why/when the usage has stopped or reduced. Rod57 (talk) 16:52, 12 December 2009 (UTC)

Acupuncture
Review for acupuncture WLU (t) (c) Wikipedia's rules: simple/complex 01:35, 10 October 2009 (UTC)

Causes?
There seems to be little here about the causes of the disease. I was interested to see the earlier comment that RA is nothing to do with old age - it is a disease. I would like to know more about 'the disease'. Maybe I missed it. Spanglej (talk) 13:54, 28 October 2009 (UTC)

Alimentary antigens & the Etiology of Rheumatoid arthritis
Hello Jfdwolff,

You reverted to the revision of 23:46, 20 October 2009 by Jfdwolff (your revision) argumenting that the contributions consisted in "addition of poorly sourced and dubious content". While this may be true for some contributions (word "pig" inserted or unsourced text on Ayurveda), I feel this does not apply for the contributions I (Hippo99) have made. Therefore, I would like to know your reasons. The version of 12:37, 23 October 2009 included a clearer structure of chapter 3. Etiology & Pathophysiology by adding headings. Furthermore, I made an extensive review on the role of Alimentary antigens which was also well-sourced. Or was it just a Twinkle-accident ? Thank you for exposing your attitude towards the implication of alimentary antigens in the etiology of RA. Hippo99 (talk) 07:54, 29 October 2009 (UTC)


 * Hello Jfdwolff,
 * It is now end of february 2010 and I still have no response regarding your unexplained revertion.
 * Summary of my contribution:
 * - Etiology section added
 * - Psychological factors subsection added
 * - Alimentary antigens subsection added (containing 3 further subsections)
 * As beforestated, all new content has been thoroughly sourced by scientific publications.
 * I invite you to discussion here in case you disagree with any point of my contribution.
 * Hippo99 (talk) 10:20, 26 February 2010 (UTC)
 * Have you seen WP:MEDRS and this review from the Cochrane Library? Gabbe (talk) 10:19, 19 March 2010 (UTC)
 * Hello Gabbe,
 * Thanks for the link to the 2009 review of which I obtained the full text PDF ( Dietary interventions for rheumatoid arthritis (Review) ). However, I still do not understan why you erased my contribution.
 * First, yes I have seen MEDRS ("Wikipedia:Reliable sources (medicine-related articles)") - I cited Biomedical Journals which all are reliable. Please let me know if you consider a specific journal I cited as 'unreliable'.
 * Second, the Hagen et al. review mainly focused on the following types of diets/dietary interventions:
 * Second, the Hagen et al. review mainly focused on the following types of diets/dietary interventions:


 * elimination diets
 * Mediterranean/Cretan diet
 * vegetarian diet
 * vegan diet
 * acid-base balance
 * fasting
 * elemental diets
 * However, the sections which I introduced were reviewing publications on the impact of:


 * Dairy products
 * Cereals
 * Raw food diets
 * Advanced glycation end products (AGEs)
 * ... on parametres of Rheumatoid arthritis.
 * As you can see, my citations and the review were not focused on the same foods/diets.
 * Also, a main aspect of the Hagen review was "safety of dietary interventions".
 * However, it would be interesting i you could add a subsection with the (negative) results of this review to complete the section on the impact o diet on RA.
 * I will thereforere-install the sections you erased.
 * Best regards, Hippo99 (talk) 18:21, 20 March 2010 (UTC)

Gabbe cited a Cochrane Review, perhaps the highest standard of medical evidence, to the fact that there is simply insufficient evidence to recommend any form of dietary approach to RA. The studies you have been quoting are consistently primary research studies, and WP:MEDRS makes very clear recommendations about the standard of references. Now before you reinsert your content please address the concerns raised by Gabbe and myself. JFW | T@lk  22:50, 20 March 2010 (UTC)
 * I agree with JFW. Original sources (like the studies) should only be used with great care, per WP:PSTS. MEDRS doesn't say that "if it's been published in a biomedical journal, it's always OK to include it in an article". MEDRS, rather, says the opposite, specifically that secondary sources (such as systematic reviews) are much more preferable. When it comes to such reviews, Cochrane Reviews are pretty much the gold standard. And the specific Cochrane review was about whether any diets are efficient in treating RA. Gabbe (talk) 07:44, 21 March 2010 (UTC)

Hi Hippo99,

It sounds like you really want to figure out what the problems are. Here's my reaction to the first paragraph ("Alimentary antigens"). Perhaps it will help you figure out how MEDRS is applied. As a most important point, every single source you use should comply with all of MEDRS. It's not good enough to say that this one complies with the first section, and that one complies with the second standard: The best sources are, e.g., recent AND multi-study reviews AND published in reputable peer-reviewed journals AND so forth.

What your sources actually support is far smaller than what you seem to want to say: "Two decades ago, there was some interest in whether diet affects RA, either in triggering the onset of the disease, or in exacerbating symptoms."

I apologize if this seems like a hatchet job on your efforts, but there are serious problems, and I know that you want to be able to do better. WhatamIdoing (talk) 16:57, 21 March 2010 (UTC)

I concur with JFW's actions, and WhatamIdoing's comments. -- Scray (talk) 20:48, 21 March 2010 (UTC)

mechanism of spreading
My addition to ==pathophysiology== of : ===Mechanism of spreading=== RA seems to spread from joint to joint and there is evidence that this is due to rheumatoid arthritis synovial fibroblasts (RASFs) traveling via the bloodstream.

was removed apparently as it was supported by only a single study. However in case it is useful I leave it here for now. Rod57 (talk) 01:38, 21 November 2009 (UTC)


 * Please review WP:MEDRS, which states expressly that single studies are not usually admissible. JFW | T@lk  14:01, 21 March 2010 (UTC)

Inflammatory arthritis
What's the difference between rheumatoid arthritis and inflammatory arthritis?--达伟 (talk) 11:25, 24 April 2010 (UTC)

Reverted edits of 71.234.114.124
Obvious POV edits with bad sources and no prior discussion. Mothball666 (talk) 18:54, 28 June 2010 (UTC)

Herbal Remedies
My Rheumatoid arthritis started 42 years ago when I was only thirteen years old. I am not certain but it started shortly after receiving a smallpox vaccination for a trip to Turkey. Over the years I tried many remedies but nothing was satisfactory, however two years ago I found a herbalist in our local French street market selling the dried root of Devil's Claw (Harpagophytum)after making an infusion I felt pain relief within 15 minutes of drinking and have now got tolerable pain levels and localised swelling markedly decreased within a few days. May be further investigation is worth while although I suspect that the pharmaceutical companies will not be keen because I only pay 2.3 Euros for two weeks supply of dried root. Hampshireoak (talk) 08:43, 19 October 2010 (UTC)Hampshireoak 19th October 2010
 * What you're describing is a lot of original research, not directly relevant to WP articles. The crux of your query, which would have been appropriate here, could be stated as: "please consider adding infusion made from dried root of Devil's Claw (Harpagophytum) to the section on ____".  Your personal experience has no bearing here - only reliable sources should be cited.  -- Scray (talk) 14:44, 19 October 2010 (UTC)

"considered as"
I often see this phrase in WP articles and elsewhere, and change it wherever i find it. Maybe it's a stylistic difference of taste. Maybe i need to retune my ear, but to me it sounds wordy and unencyclopedic. Comments welcomed. Ragityman (talk) 15:25, 15 December 2010 (UTC)

Smoking and Sugiyama2010
removed the statement that smokers have a fourfold risk of lung cancer, citing 10.1136/ard.2008.096487 (Sugiyama et al) in his support. The problem is, Sugiyama is a pretty good WP:MEDRS on the subject, and it makes some very definite statements about smoking vs RA. I therefore thought it might be better to add some freely phrased information on the basis of this paper. Again, this was removed on the basis that I should have done a better job at representing the conclusions, but without an attempt to improve the content (reaction on Seanwal's talkpage).

I think the conclusions of this paper should be represented in the article, as it gives a good idea about how smoking might adversely modify the risk of RA, and I am open to suggestions about how it should be phrased. JFW &#124; T@lk  10:21, 11 March 2011 (UTC)

Diagnosis criteria
I see in the "Criteria" section you say that the new criteria is for diagnosing new onset RA, yet in the new Harrison (18) it specifically says that the new criteria is not for diagnosis and I quote "It is important to emphasize that the new 2010 ACR-EULAR criteria are "classification criteria" as opposed to "diagnostic criteria" and serve to distinguish patients at the onset of disease with a high likelihood of evolving into a chronic disease with persistent synovitis and joint damage."

Just thinking it would be wise to emphasize that here as well. Thank you — Preceding unsigned comment added by Avig70 (talk • contribs) 18:55, 18 October 2011 (UTC)

Introduction
The introduction seems to be a bit disorganized.

It looks like a laundry list of symptoms, in which somebody tried to work in as many technical concepts as possible -- as if they were preparing for an exam. The technical terms make it difficult for a non-specialist reader WP:NOTPAPER. I tried to improve that by adding the lay terms, but it's still difficult to read. It's still hard for me to read. It's more like a word puzzle than a clarifying explanation.

Another serious flaw is that it has no WP:RS. Basically this definition is somebody's WP:OR.

Last month's review article in the NEJM has what I consider a good introduction. In fact it has 2 good paragraphs both of which could be the basis of a good introduction:


 * Rheumatoid arthritis is a common autoimmune disease that is associated with progressive disability, systemic complications, early death, and socioeconomic costs. The cause of rheumatoid arthritis is unknown, and the prognosis is guarded. However, advances in understanding the pathogenesis of the disease have fostered the development of new therapeutics, with improved outcomes. The current treatment strategy, which reflects this progress, is to initiate aggressive therapy soon after diagnosis and to escalate the therapy, guided by an assessment of disease activity, in pursuit of clinical remission.

and


 * Rheumatoid arthritis is characterized by synovial inflammation and hyperplasia (“swelling”), autoantibody production (rheumatoid factor and anti–citrullinated protein antibody [ACPA]), cartilage and bone destruction (“deformity”), and systemic features, including cardiovascular, pulmonary, psychological, and skeletal disorders.

NEJM, 8 Dec 2011, 365(23): 2205, Mechanisms of disease: The pathogenesis of rheumatoid arthritis, Ian B. Mcinnes and Georg Schett. http://www.nejm.org/doi/full/10.1056/NEJMra1004965

I think this introduces some important points: (1) RA is a systemic disease which most prominently affects the joints but also affects other systems, particularly the heart and lungs (2) RA is life-threatening, not just painful. (3) The progress of these life-threatening complications (and the pain) can be controlled by new drugs.

The main misconception I grew up with about RA is that it's a just a painful disease of the joints, like osteoarthritis. I think the introduction should make clear the important message that RA is not just a joint disease, it's an autoimmune disease. Also, it's not a bag of symptoms. There's an underlying autoimmune process, and each of those symptoms is the result of that process.

Wikipedia isn't a patient information handout; we're trying to help people understand the disease, whether they're patients or high school and college students who will later go on to study the disease. Wikipedia is also not a medical school exam preparation book. We don't have to start the introduction with a list of every symptom. How does it help the reader to understand RA to start out by knowing that it manifests in the sclera? How does it help the reader to understand RA if he or she first has to figure out a list of technical terms like "sclera" and "pericardium"?

Another issue is the new research into the molecular biology and immunology of RA, of which the NEJM article has quite a bit. I think that's more important than the details of diagnosis and pathology. --Nbauman (talk) 17:22, 2 January 2012 (UTC)

Future treatments
The following was added by under "Future Treatments":

As rheumatoid arthritis primarily attacks the synovial joints, future therapies may very well involve more targeted approaches through the use of nanoparticle drug delivery against the synovial fibroblasts. Hyperplasia in rheumatoid arthritis occurs primarily due to the cellular increase in numbers of the synovial fibroblasts. Although the reason is currently unknown, some research has indicated that an impaired apopotosis or senescence in these cells can explain the effect. Recent research has shown that statins, competitive inhibitors of HMG-CoA reductase, utilized in lowering cholesterol may have anti-inflammatory effects that are beneficial to treating synovial fibroblast hyperplasia. Namely, these effects include suppressing pro-inflammatory cytokines and chemokines. In 2006, various statin molecules were shown to decrease synovial fibroblast viability in a concentration and time dependent manner. Simvastatin was shown to have a more pronounced effect on reducing viability in synovial fibroblasts than atorvastatin at concentrations greater than 3μM. However differences due to time were only observed after 72 hours of administration. The 2006 paper also showed that TNF-α stimulated fibroblast synovial cells, an important component of the pathogenesis of RA, showed a larger decrease in viability than unstimulated cells for both atorvastatin and simvastatin. Utilizing a TUNEL assay, the authors indicated that this reduced viability was primarily due to induction of apoptosis. In 2004 only atorvastatin was tested in a clinical trial with clinically significant but very modest outcomes in patients. This may be due to an ineffective targeting of synovial fibroblasts, which could be overcome with future technology such as nanoparticle drug delivery.

The inherent problem with all those treatments is that even treatments from positive studies don't necessarily get adopted into clinical practice. This entire section is about statins, which are certainly not the only drugs under investigation. For sections of this kind, the medical WikiProject has set some pretty clear parameters. I would completely avoid citing individual studies, because they do not give a clear picture as to what we might expect in the next 10 years. Rather, I would want to base this section completely in treatments considered as thoroughly studied and likely to be adopted in secondary sources (reviews, textbook chapters). JFW &#124; T@lk  06:24, 7 March 2012 (UTC)

i am not a doctor but there is academic paper about Flowers of Robinia pseudoacacia  it was written Chinese medicine is using that flowers for that disease. Maybe someone search — Preceding unsigned comment added by 176.30.26.195 (talk) 07:06, 27 May 2012 (UTC)
 * Per our guideline on reliable sources for medical claims we should be using secondary reviews (this appears to be a primary paper); this paper also mentions arthritis exactly once, in the introduction, and therefore appears to be off-topic for this particular Wikipeida article. Yobol (talk) 13:10, 27 May 2012 (UTC)

A review
Doc James (talk · contribs · email) (if I write on your page reply on mine) 09:54, 9 October 2012 (UTC)
 * Another  Doc James  (talk · contribs · email) (if I write on your page reply on mine) 13:51, 24 March 2013 (UTC)

Promising treatments
Wikipedia is a great stating resource, that users can then branch out for further research based upon the information here. For rheumatoid arthritis, there have been double-blind, placebo controlled studies that suggest various "natural remedies" for inflammation, such as curcumin, boswellia, and collagen. What is wrong with indicating that this research is preliminary and the reader can do their own further research?Sthubbar (talk) 13:08, 22 March 2013 (UTC)
 * Nothing if proper sources are found. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 00:33, 23 March 2013 (UTC)

Can we put one sentence for Omega-3
Right now there are 7 secondary review references supporting the safety and efficacy of omega-3 in the treatment of RA. Instead of having a sentence for each reference, can we just consolidate to one or two sentences? I prefer strong language like "There is overwhelming evidence that omega-3 is effective and safe for the treatment of RA." or "Omega-3 is safe and effective for the treatment of RA". I would find it unfair to put any suspect words like "might" "could" or "promising". We already have 7 review articles. The evidence is overwhelming. Your idea?Sthubbar (talk) 03:20, 25 March 2013 (UTC)

Replace all instances of "rheumatoid arthritis" with RA?
Should we be consistent and replace all instances of "rheumatoid arthritis" with RA, with the following exceptions: First instance remains defining the abbreviation, withing references will remain, hidden meta tags will remain, image titles will remain. Do you agree?Sthubbar (talk) 03:46, 25 March 2013 (UTC)
 * Sounds reasonable. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 05:55, 25 March 2013 (UTC)

Inflammatory arthritis
Doc James, OK if there are many instances of inflammatory arthritis, what is the difference and shouldn't IA have it's own page instead of redirect to RA? This question was asked above and didn't get answered. I have noticed papers on PubMed that mention IA and I just assumed it was an alternate name for RA preferred in different cultures. Should we create a separate page for IA? — Preceding unsigned comment added by 111.193.223.228 (talk) 12:25, 25 March 2013 (UTC) This was meSthubbar (talk) 12:28, 25 March 2013 (UTC)
 * Yes we should as I agree it should not redirect here. Inflammatory arthritis is a group of diseases which includes: RA, ankylosing spondylitis, psoriatic arthritis, reactive arthritis, enteropathic athritis and undifferentiated sponyloarthropathies. Google books is useful for these general concepts as a ref. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 12:53, 25 March 2013 (UTC)
 * I have removed the redirect and found one source that is similar to your definition.Sthubbar (talk) 08:24, 26 March 2013 (UTC)

I think major surgery might be needed
I have been reviewing the Tourette syndrome and Asperger syndrome FA quality articles and a key difference I see between them and this article is that they don't have many subsection for the major table of content areas. They simply have a few paragraphs for each major TOC topic. I think to follow their lead we should try and remove the sub-headings from each of the major topics and turn it into prose. I'll see what I can do to help on that front.Sthubbar (talk) 03:04, 26 March 2013 (UTC)
 * I have moved back the history section. Take a look at a larger number of articles both FA and GA like HIV/AIDS or obesity or anaphylaxis. Subsections are typically useful IMO. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 03:14, 26 March 2013 (UTC)
 * Have returned the subheadings. IMO they make the article better. Compare to newer featured articles. TS was passed a long time ago if I remember correctly. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 07:55, 26 March 2013 (UTC)
 * I agree. I have checked the 10 Top priority FA quality medicine articles and they all use sub-headings.  My initial sample size of Tourette Syndrome and Asperger Syndrome seems to have been a poor sample.Sthubbar (talk) 08:19, 26 March 2013 (UTC)

Change onto disability prognosis information
Due to the contradictory statements regarding patient percentaje and progression toward disability, I changed the opening statement about this subject( the opening section had different -much different- number than the number mentioned in the prognosis section); Not only it contradicted what was larter said on ths article but there was no -real- reference of it, because the appendix number only let to the John Hopkins Hospital Wikipedia page. It was not apropiate to put the first number about disability on the article opening section because this is a treatable disorder. —Preceding unsigned comment added by 206.248.106.166 (talk • contribs) 20:12, 5 December 2007

GA quality by March 5th
Doc James, how can you and I work together to get this article to GA quality by March 5th? I can add reference for the DMARD and other areas. You are doing a good job with writing stuff in a medically accurate and quality way. You up for the challenge?Sthubbar (talk) 12:30, 25 March 2013 (UTC)
 * Mar 5th. Do you mean April 5th? The GA bar is fairly high. Will likely need more time than this. I am willing to help. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 12:44, 25 March 2013 (UTC)
 * Apr 5th. Can we get some external reviewer to give us pointers on what is currently lacking for GA?  I'll go ahead and work on the DMARD references.  — Preceding unsigned comment added by Sthubbar (talk • contribs) 13:55, 25 March 2013 (UTC)
 * Doc James, you are right, we need more time.Sthubbar (talk) 23:52, 4 April 2013 (UTC)

Propose change initial description of RA
Doc James, I propose we state right away that RA is an auto-immune disease like the first sentence in the background here. I really like the first 3-4 sentences of that article. What do you think?Sthubbar (talk) 08:23, 26 March 2013 (UTC)
 * Sure done. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 08:25, 26 March 2013 (UTC)

CAM
I reverted the most recent change in the lead describing CAM for several reasons: Yobol (talk) 23:12, 3 May 2013 (UTC)
 * the change violates WP:LEAD, as the ACR recommendations do not appear in the text, and ignores multiple sources in the article body that state that no conclusion could be reached, or that CAM use is not recommended.
 * the change takes the ACR recommendation out of context of the source. The conclusion of the source is in part "In summary, the lack of high-quality clinical investigations does not permit defnitive conclusions to be drawn regarding the efficacy of CAM modalities in RA." Using the source to cite ACR while ignoring the conclusion of the actual source seems like cherry picking.
 * the change makes it appear that the NCCAM and Macfarlane sources support the use of CAM, when they explicitly do not
 * the ACR, as far as I can tell, doesn't actually recommend the use of herbal supplements. The ACR recommendation is not cited in the journal article, but we do have the ACR website, which says "There are no herbal medicines whose health claims are supported by sound scientific evidence." and "Because the FDA is currently unable to regulate the quality of herbal remedies and supplements, or to verify their effectiveness or safety, the use of herbal remedies is not recommended." It certainly does not appear that the ACR supports the use of herbal medicines.

I agree with your general thrust about CAM, but it can be difficult to describe the failings of CAM in rigorous scientific terms. And we can't commit the same mistakes that CAM makes when we attack CAM.

It's true that if a treatment had good evidence to support it, it wouldn't be alternative medicine -- it would simply be medicine. OTOH, there are have been a (very) few CAM treatments that were finally supported by good evidence, so you can't rule them out. Artemisinin comes to mind. There aren't too many, but you don't want to miss something like artemisinin.

If we're going to write something attacking CAM, it has to strictly follow the scientific evidence and WP guidelines of WP:RS and WP:MEDMOS.

The original text said that the evidence for CAM is weak "and their use is not recommended," citing Efthimiou. I read the Efthimiou paper, and to my surprise, he didn't support that text; rather, he said what I put into the article, that the ACR recommends their careful use. If that differs from another ACR statement, I'd like to know the explanation.

I'm not sure what it means to say "their use is not recommended." I don't think it means anything. It's a passive voice, and it doesn't say who doesn't recommend their use. Besides, does it mean that "they" -- whoever "they" are -- recommend against their use, or that they simply have no recommendation?

The way you wrote the introduction, it says that "their use is not recommended." Who doesn't recommend their use? None of those 3 citations explicitly says that their use is not recommended. Efthimiou doesn't, Macfarlane doesn't, and even the NCCAM doesn't explicitly say that. Their statements are very qualified and guarded.

You can say that the ACR doesn't recommend it. You can't leave the implication that they recommend against it.

The politics of CAM are well known, which is why their statements are so qualified and guarded. But beyond that, there are many doctors, even academic doctors with any qualifications you can name, who not only accept CAM but use it themselves. And it is possible that some CAM treatments may be effective, but it just hasn't been proven yet.

When you write:


 * The American College of Rheumatology has stated, "There are no herbal medicines whose health claims are supported by sound scientific evidence"

the word "sound" is a weasel word. What's "sound scientific evidence"? That phrase itself is not scientific terminology. "sound scientific evidence" is evidence a scientist agrees with. If he doesn't agree with it, he says it's not sound scientific evidence. I think it's a no true Scotsman fallacy. I'm not sure how much you know about medicine, but most medical practice isn't supported by Level 1 evidence. What's the evidence for corticosteroids in long-term treatment of back pain? What's the evidence for surgery in so many orthopedic conditions? What's the evidence for all that radiology?

Furthermore, I'm not sure what the ACR's policy on CAM is. According to their program book, the 2012 annual meeting had the following session. They seem to support tai chi and yoga:

ACR/ARHP Annual Meeting, 2012

ACR SESSIONS 2:30 - 4:00 PM Ballroom A Complementary and Alternative Medicine: Evidence-based Options for Arthritis Patients Moderator: Sharon L. Kolasinski, MD Upon completion of this session, participants should be able to: •   contrast traditional physical therapy with alternative exercise options •   evaluate the literature supporting the use of alternative therapies •   appreciate the role of tai chi and yoga among exercise options for patients 2:30 PM Overview of Complementary and Alternative Medicine To be announced 3:00 PM Tai Chi for Arthritis Chenchen Wang, MD, MSc 3:30 PM Role of Yoga in the Management of Arthritis Susan J. Bartlett, PhD

I would say that the evidence for CAM, including herbal treatments, is weak and inconclusive. That's what we should say. Some doctors recommend against it, some recommend for it, some doctors are unable to make a recommendation. I've heard a lot of doctors say, "If it makes you feel better, and it doesn't cost too much, try it out." If you want to come up with a quote from Simon Singh or Quackwatch blasting CAM for arthritis, go ahead and include it. Some treatments are dangerous, and that should go in. But I don't think that a broad dismissal of all CAM, if you can find one by a reputable authority, represents the medical consensus. --Nbauman (talk) 04:33, 4 May 2013 (UTC)
 * Agree in retrospect that discussion of "recommendations" is problematic, so have restored a modified version of previous wording that doesn't use that wording. Regarding the use of the word "sound", that is a direct quote from the source.  Wikipedia is directed to a general audience, not the medical community, so using language accessible to them (as opposed to using obscure language cited to levels of evidence that you see in systematic reviews) is more appropriate.  What the ACR thinks is clear from the material it produces.  I doubt we can use a workshop at a conference sponsored by the ACR as an official endorsement of everything in that conference presentation. Yobol (talk) 20:00, 4 May 2013 (UTC)

COX2 Inhibitors and GI side effects
This was added "NSAIDs have a risk of gastrointestinal side effects such as stomach ulcers, while COX-2 inhibitors do not have that risk" COX2 inhibitors still have GI side effects just less than NSAIDs. Thus removed. Doc James (talk · contribs · email) (if I write on your page reply on mine) 21:09, 16 June 2013 (UTC)

Synovial fluid image
There is an image with caption: "Appearance of synovial fluid from a joint with inflammatory arthritis." The article would be improved if normal synovial fluid could be shown alongside. pgr94 (talk) 15:17, 19 July 2013 (UTC)
 * Good point. Will do this when I collect some normal fluid. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 15:35, 19 July 2013 (UTC)

American College of Rheumatology bias
The ACR is clearly biased with their statement "There are no herbal medicines whose health claims are supported by sound scientific evidence"

1) Why are two long quotes allowed? I have been told by Doc James to paraphrase and not to quote.  Why this exception?

2) Herbal medicines do not make health claims.
 * Only organization or individuals can make a claim about a particular product. A pharmaceutical manufacturer that owns a particular chemical preperation can make claims and a statement can be said the "X company's health claims about Y drug are wrong".  It sort of makes sense in that case to say "Y drug's health claims are wrong" because only company X makes such claims.  For herbs, anyone can make a claim, and many do, so the following statement is also true "There are no natural water sources whose thirst quenching claims are true."  Complete nonsense.

3) Sound scientific evidence.
 * What is sound scientific evidence versus unsound scientific evidence? If it is unsound scientific evidence, doesn't that contradict that "scientific evidence" part?  So we can ignore the "sound" word completely.

4) The real meaning of the sentence.
 * The real meaning of this sentence is "There are no health claims for herbal medicines that are supported by scientific evidence."

5) Contradicts itself.
 * The ACR contradicts itself when they say "Chinese Thunder God Vine also relieves pain and inflammation". What are they basing this claim on?  Unsound scientific evidence?  If there is no scientific evidence for this claim why do they make it?  Obviously there is sound scientific evidence, they just don't like that and they warn that the drug is dangerous.
 * Now hold on, an effective dangerous herb is much different then no effective herb.

This should be enough evidence to prove conclusively that their first statement is clearly false and this should be made clear.Sthubbar (talk) 15:26, 22 July 2013 (UTC)
 * We should be summarizing the conclusions of secondary sources, not trying to debunk those conclusions through cherry picked quotes because individual editors do not like those conclusions. Yobol (talk) 15:33, 22 July 2013 (UTC)
 * Yobol, you did not address a single point. You don't deny that the ACR is biased.  You don't explain the clear contradiction of saying "no evidence", no = zero, nope, nada zip and the contradictory statement that there is evidence.  How does "there is evidence" = "no evidence".  Your definition of cherry picking seems to be trying to hold the ACR up to logical consistency.  Please explain how "no evidence" = "is effective"?  — Preceding unsigned comment added by Sthubbar (talk • contribs) 15:41, 22 July 2013 (UTC)
 * The ACR is highly quality secondary source for information on rheumatology. We summarize what high quality secondary sources say, we don't try to second guess them because we do not like their conclusions. That I have ignored your "points" should suggest that your "points" are immaterial as to whether this source is appropriate. Is the ACR a high quality secondary source? Yes. Should we be summarizing their conclusions in this article? Yes. Should we be second guessing their conclusions as editors because we don't like those conclusions? No. Those are the only points that need to be addressed, as far as I'm concerned. Yobol (talk) 15:46, 22 July 2013 (UTC)
 * Yobol, using logic and independently thinking is not second guessing. Let's make it simpler, please tell me how the following statement is wrong "There are health claims [relieves pain and inflammation] for herbal medicnes [Chinese Thunder God Vine] that are supported by scientific evidence [relieves pain and inflammation]."  They agree clearly that is does "relieve pain and medication" which must be based on sound scientific evidence otherwise they wouldn't say that it does.  Therefore the statement I just wrote is exactly supported by the article, which clearly contradicts the original quotation.  Please try and use logic and explain to me how you can accept both statements and if you don't accept one of them, please explain why.Sthubbar (talk) 15:54, 22 July 2013 (UTC)
 * I choose not to argue based on WP:OR. I just choose to summarize the conclusions of high quality secondary sources, as all editors should be doing. Yobol (talk) 15:58, 22 July 2013 (UTC)

Yobol, fair enough. I have summarized the statement that exactly summarizes the conclusions of the ACR.Sthubbar (talk) 16:03, 22 July 2013 (UTC)
 * Yobol, you are cherry picking. The conclusion stated at the top of the page is "Because the FDA is currently unable to regulate the quality of herbal remedies and supplements, or to verify their effectiveness or safety, the use of herbal remedies is not recommended."  This is the recommendation.  You are cherry picking from "Fast Facts."  I will accept modify the statement to "The ACR does not recommend herbal remedies because they are not regulated by the FDA."  This is exactly what they say.  Not the cherry picking of fast facts, otherwise we need to also cherry pick the supporting evidence in the article.  You can't have it both ways.Sthubbar (talk) 16:10, 22 July 2013 (UTC)
 * The "Fast Facts" are the conclusions. Yobol (talk) 16:15, 22 July 2013 (UTC)
 * Have added a paraphrase of why the ACR does not recommend herbal supplements due to the lack of regulation by the FDA, per your suggestion. Yobol (talk) 16:20, 22 July 2013 (UTC)

Yobol, this is way too much quoting and over weight given to this one article. I'm not an expert with all the WP:Rulewhatever, I'm pretty sure the is a WP:don'tquote and WP:weight rule. Please summarize all 3 of them and remove direct quotes. I propose "The ACR states that herbal remedies contain active ingredients similar to conventional medicine, are not regulated as drugs by the FDA and that there is no sound scientific evidence to support the health claims." What rewording will you accept?Sthubbar (talk) 16:27, 22 July 2013 (UTC)
 * Have added another sentence that summarizes the additional "fast fact" that was missing. Yobol (talk) 16:33, 22 July 2013 (UTC)
 * Yobol, you are ignoring the parts that say that herbal medicines are similar to conventinal medicine, therefore may have both powerful good and negative effect. Also the fact that they say that people may use herbal supplements.  Remove the quotes as per WP:PARAPHRASESthubbar (talk) 16:38, 22 July 2013 (UTC)
 * Yobol, BTW, why are you permitted to keep making changes to the article when it is obviously under contention and the rules are to come to consensus on the talk page to avoid edit wars. I have calmly stopped making any edits as I'm sure you would ban me like has been done before.  Just seems real hypocritical for you to keep making changes before any attempt at agreement here on the talk page.Sthubbar (talk) 16:43, 22 July 2013 (UTC)
 * The fact says that both herbal and conventional medications are chemicals, and that herbals are not safer just because they are natural. I have paraphrased this. I have been making a number of edits you have suggested. Yobol (talk) 16:49, 22 July 2013 (UTC)

Yobol, I do not agree to any of the edits you have made. Consensus on the talk page means we agree here how to edit the sentence. You are pushing your point of view and ignoring the complete content of the article and all of the statements made. Get a consensus here before further edits. I also suggest to revert to the original wording until there is consensus here on the talk page.Sthubbar (talk) —Preceding undated comment added 16:57, 22 July 2013 (UTC) It's also convenient how you ignore the statement "Accupuncture is safe". If you put "Accupuncture is safe and it's affect may be the same as placebo" or just put the whole quote as you seem to be fond of quoting.Sthubbar (talk) 17:00, 22 July 2013 (UTC)
 * 88 words for one citation is way past WP:NPOV. There are 4 following citations that get 60 words.  So, 1 citation for 88 words or 1 citation for 15 words.  Seem neutral to you?Sthubbar (talk) 17:13, 22 July 2013 (UTC)
 * There are actually 10 citations for the subsequent 85 words that contradict what you are pushing. You are pushing 10 times the emphasis of the following citations.Sthubbar (talk) 17:18, 22 July 2013 (UTC)
 * It was your suggestion that all the "Fast Facts" be summarized. *shrug* Yobol (talk) 17:22, 22 July 2013 (UTC)

Yobol, I have stated very clearly that I disagree with every edit you have made. Your putting 88 words for your one citation should allow me to add 88 words for each of the following 10 citations instead of the current 8.5 words per citation. Sound good to you?Sthubbar (talk) 17:28, 22 July 2013 (UTC)
 * Your admitted lack of familiarity with WP policy is at the heart of this debate - and something you should rectify if you wish to contribute to this encyclopedia - because it is those policies that define this project. I sympathize with the time it takes to get to know them, but there's no deadline - take your time. The links above to relevant policies would be a great starting point, as would WP:Five pillars. Quoting a statement from an organization that provides internationally-recognized treatment guidelines is appropriate (when not overly long) to ensure that the meaning has not been changed. Of course, use of any such quotation should avoid distorting the meaning in the source, in terms of context and weight. I don't see a problem with those quotations. -- Scray (talk) 17:39, 22 July 2013 (UTC)
 * Scary, so you agree that this one source deserves 10 times the weight of each of the following 10 citations?Sthubbar (talk) 17:42, 22 July 2013 (UTC)
 * I disagree with measuring weight solely by words, but I looked at some of the references that follow the quotation (I assume that's what you mean by "the following 10 citations"). The first one, Boswellia, is a great example - it has extremely soft conclusions, i.e. its efficacy is unproven. That does not disagree with the ACR's broader statement - that there are no proven dietary supplements - so it makes sense to retain the broader statement and the other specific examples illustrate the same thing (therefore they don't need warrant individual elaboration). -- Scray (talk) 18:52, 22 July 2013 (UTC)
 * Scray, the ACR statement "There are no herbal medicines whose health claims are supported by sound scientific evidence" is clearly contradicted in their own article when they say "Chinese Thunder God Vine also relieves pain and inflammation". It should be end of discussion right there.  "No" means "zero".  Furthermore reference here also clearly says " the immunosuppressive, cartilage protective, and anti-inflammatory effects of TwHF extracts are well demonstrated, and TwHF extract is an alternative disease modifying anti-rheumatic drug (DMARD) for the patients with RA refractory to conventional therapy".  I agree that TwHF is dangerous and has been pointed out below.  That has no bearing on the fact that ACR is pushing "No" meaning none despite them admitting that there is at least one.  How can you accept that?  Yobol has refused to answer any such direct questions as he contends that using logic to compare different secondary sources is an act of original research.Sthubbar (talk) 23:34, 22 July 2013 (UTC)
 * Yep, that's original research you're doing. You can't dissect a big statement and choose one portion when it contradicts the top-line conclusion - the major conclusions are the meat of a reliable source. It is inappropriate for us to speculate about any conspiracy that is not covered in a reliable source. I think you should move on from this if you don't have stronger evidence. -- Scray (talk) 00:05, 23 July 2013 (UTC)

Why is American College of Rheumatology 10 times more trustworthy secondary source?
Why is this accepted as a reliable citation? It is written by a single doctor and reviewed by a "Communications and Marketing Committee". There are no citations that this document refers to that indicate it is a review article.Sthubbar (talk) 17:25, 22 July 2013 (UTC)
 * Please review WP:PSTS, as you seem to be confused as to what a secondary source is. A publication by the major rheumatology medical association in the US is certainly a high quality secondary source. Yobol (talk) 17:29, 22 July 2013 (UTC)
 * And why are you allowed to push 88 words for this one source versus the 8.5 words for the 10 following sources?Sthubbar (talk) 17:33, 22 July 2013 (UTC)
 * What does this have to do with the ACR being a secondary source? Yobol (talk) 17:35, 22 July 2013 (UTC)
 * I have changed the topic. Now will you answer?Sthubbar (talk) 17:39, 22 July 2013 (UTC)

This is an excellent source. I have paraphrased some of the comments in question. Doc James (talk · contribs · email) (if I write on your page reply on mine) 03:17, 23 July 2013 (UTC)
 * To answer Sthubbar's question, Wikipedia generally requires secondary sources in the peer-reviewed medical literature for medical articles. The governing policy is WP:PSTS.


 * There are some problems with the paragraph beginning "The following show promise..." I don't think we can wrap up all 5 compounds with the ruberic "show promise." We have to assess each one individually. Review articles are good, but one review article isn't the final word. If there are other reviews that come to different conclusions, we have to include them.


 * I can't find the specific cite but I believe Wikipedia guidelines prefer to have English language sources. It's difficult for us to verify foreign-language sources. There should be publications in English if the compounds are promising.


 * I agree that that the ACR statement is a good summary; however it has the weakness of not providing citations. I would expect that the ACR had a different statement, for physicians rather than patients, with citations.


 * Other organizations, like the Arthritis Foundation, may be ore sympathetic to CAM, although I can't find anything specific on their web site. --Nbauman (talk) 03:42, 23 July 2013 (UTC)
 * One of the issues with some non English language studies is they sometimes have different standards for evidence. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 04:09, 23 July 2013 (UTC)
 * China is a special case. It's a big country. They have some of the best researchers in the world, who publish routinely in the top journals. They also have some of the worst incompetence and fraud, such as their indiscriminate brain surgery. You have to know which one you're dealing with. --Nbauman (talk) 05:29, 23 July 2013 (UTC)

Cannabis for arthritis
Here's a nice summary of the ACR 2013 session by a rheumatologist/blogger who was there.

http://www.ronankavanagh.ie/blog/cannabis-arthritis-whats-story/

Medical Marijuana and the Rheumatologist’ was presented by Dr. Jason McDougall and Dr. Mary Ann Fitzcharles at the American College of Rheumatology Annual Scientfic Meeting October 2013

This may be a WP:RS:

http://www.rheumatologyupdate.com.au/latest-news/time-to-get-serious-about-medical-marijuana

Bottom line: Many patients find it useful, and there's a plausible mechanism, but there are no rigorous studies to demonstrate efficacy, and there are poorly-characterized risks. --Nbauman (talk) 19:54, 7 November 2013 (UTC)

Rotten English
There are mistakes in the English here - too tired to look in detail - maybe tomorrow - but the English needs 'sharpening up' a bit to read well. — Preceding unsigned comment added by 87.206.188.230 (talk) 21:33, 15 May 2014 (UTC)

Rheumatoid arthritis (new section)
Hi from a personal experience can I suggest that cachexia merits an entry under e.g. symptoms or effects? Cachexia seems to be a significant aspect that is sometimes ignored. Gildomingue (talk) 15:27, 29 September 2014 (UTC) Gil Domingue. 29.09.2014

Mention of extra-articular manifestations of RA
Does the following description merit being in the lead section of RA? "RA can also produce diffuse inflammation in the lungs, the membrane around the heart, the membranes of the lung (pleura), and whites of the eye, and also nodular lesions, most common in subcutaneous tissue. " (Drsoumyadeepb (talk) 13:50, 17 October 2014 (UTC))
 * I would say yes User:Drsoumyadeepb Doc James  (talk · contribs · email) (if I write on your page reply on mine) 14:01, 17 October 2014 (UTC)

where should Epidemiology and History be positioned in articles
Was wondering if History and Epidemiology should be placed right after the lead rather than almost at the end.(Drsoumyadeepb (talk) 08:15, 19 October 2014 (UTC))
 * For consistency between articles we typically follow the recommendations at WP:MEDMOS. Doc James  (talk · contribs · email) 20:39, 3 November 2014 (UTC)

Substantial robust and replicable data on genetic basis of RA exists and genetic factors account for more than 50% of disease. Should be part of project.With GWAS data available we need to include genetic basis of complex diseases information too- might be as a pilot for the task force.

Safety of TNF inhibition
10.1016/j.amjmed.2014.06.036 is a meta-analysis of 44 trials looking into safety and discontinuation of anti-TNF biologics. Etanercept seems safer that the rest. JFW &#124; T@lk  09:07, 4 December 2014 (UTC)
 * Good review. Correction: DOI: http://dx.doi.org/10.1016/j.amjmed.2014.06.012


 * Also: Drugs for Rheumatoid Arthritis http://secure.medicalletter.org/TML-article-1458a The Medical Letter on Drugs and Therapeutics, 2014;56(1458):127 December 22, 2014 --Nbauman (talk) 20:42, 27 December 2014 (UTC)

Laser therapy
This article does not currently mention the use of laser therapy for the symptomatic relief of rheumatoid arthritis. This modality has been covered by Cochrane reviews and deemed an acceptable form of short-term symptom control. I don't think there is enough to warrant an entire section for laser, but I am unsure which existing section is an appropriate location for a mention. I thought to include it in the 'Alternative Medicine" section, but the section currently says that there are no RCTs available for Alternative Medicine treatments for RA. Since the cochrane review for laser therapy includes multiple RCTs, it seems that perhaps laser is not considered alternative medicine? I will leave it here, hopefully someone can find an appropriate way to include the info. — Preceding unsigned comment added by 70.65.253.158 (talk) 18:39, 18 January 2015 (UTC)
 * I see this article is being edited, but no one has commented about the lack of article content regarding laser therapy. Is this not the appropriate way to have content added to the article? Or is it just that the cochrane review is not enough to justify notability? — Preceding unsigned comment added by 70.65.253.158 (talk) 21:41, 5 February 2015 (UTC)

Vaccinations
There is clear data on multiple reviews as well as in text books that infectious agents do not have a role in the disease process. This has been mentioned in our Wikipedia article itself. Why have a section on Vaccinations which clearly does not have any role on the basis of just one narrative review. Has it come in any guidelines by notable health bodies ? (Drsoumyadeepb (talk) 17:57, 3 November 2014 (UTC)) Drawing attention of  Doc James
 * Actually I was surprised to find quite a few citations on periodontal disease and periodontal bacteria as a trigger of RA:
 * Kaur S, Bright R, Proudman SM, Bartold PM.
 * Does periodontal treatment influence clinical and biochemical measures for rheumatoid arthritis? A systematic review and meta-analysis.
 * Seminars in Arthritis and Rheumatism. 2014 Oct;44(2):113-22. doi: 10.1016/j.semarthrit.2014.04.009. Epub 2014 Apr 28.
 * Payne JB, Golub LM, Thiele GM, Mikuls TR
 * http://link.springer.com/article/10.1007/s40496-014-0040-9
 * The Link Between Periodontitis and Rheumatoid Arthritis: A Periodontist’s Perspective
 * Current Oral Health Reports
 * March 2015, 2(1):20-29. Online 24 Dec 2014. DOI 10.1007/s40496-014-0040-9
 * Rosenstein ED, Kushner LJ, and Kramer N
 * http://link.springer.com/article/10.1007/s40496-014-0038-3
 * Rheumatoid Arthritis and Periodontal Disease: A Rheumatologist's Perspective
 * Current Oral Health Reports
 * March 2015, 2(1): 9-19. Online 28 December 2014 DOI 10.1007/s40496-014-0038-3
 * http://www.semarthritisrheumatism.com/article/S0049-0172%2814%2900070-5/abstract
 * I'd like to check some of their citations before I include it but it's a legitimate theory. --Nbauman (talk) 21:37, 7 June 2015 (UTC)