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It’s not the symptoms, it’s the context.

More on the Art of Doctoring in my conversation with the one and only Baktash Ahadi

Objective. People with RA have episodes of worsening disease activity (flares) that prompt them to seek clinical review or medication change. This study explored patients’ perspectives of flare that prompts them to seek medication review.

Methods. Fourteen focus groups across five countries comprised 67 RA patients. Transcripts were analysed by several researchers and a patient, using inductive thematic analysis.

Results. Patients use flare for five different scenarios, including flare that prompts medical help-seeking, where six themes were identified. In ‘Symptoms and early warnings’, pain is intense (wanting to die), constant and persistent and considered a key feature. Systemic features predominate, including fatigue, feeling generally ill (flu-like), physical and cognitive shut-down and social withdrawal. Warning signs (prodrome) comprise fatigue and flu-like symptoms. ‘Self-management of intensifying symptoms’ includes pacing, heat/cold, rest and increasing medication, often without medical advice. Patients ‘Define this as uncontrollable flare’ when clusters of unprovoked, persistent symptoms halt their ability to run daily life, until prompted into ‘Seeking help when symptoms can’t be contained’. Underpinning themes are ‘Individual context’ (e.g. different symptom clusters) and ‘Uncertainty’ (e.g. when to seek help). Patients report that the current patient global visual analogue scale (VAS) does not capture flare.

Conclusion. Patients use flare for multiple events and seek help for complex clusterings of intense, unprovoked symptoms that defy self-management, not necessarily captured in joint counts or global VAS. Flare terminology and definition have implications for clinical practice and trials, therefore further research should establish a professional/patient consensus.

Hewlett et al

Photo by Marten Newhall on Unsplash

COVID-19 will impact more than those with the virus

The December, 2019 coronavirus disease outbreak has seen many countries ask people who have potentially come into contact with the infection to isolate themselves at home or in a dedicated quarantine facility. Decisions on how to apply quarantine should be based on the best available evidence. We did a Review of the psychological impact of quarantine using three electronic databases. Of 3166 papers found, 24 are included in this Review. Most reviewed studies reported negative psychological effects including post-traumatic stress symptoms, confusion, and anger. Stressors included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma. Some researchers have suggested long-lasting effects. In situations where quarantine is deemed necessary, officials should quarantine individuals for no longer than required, provide clear rationale for quarantine and information about protocols, and ensure sufficient supplies are provided. Appeals to altruism by reminding the public about the benefits of quarantine to wider society can be favourable.

Brookes et al The Lancet Volume 395, Issue 10227, 14–20 March 2020, Pages 912-920

Photo by Bailey Torres on Unsplash

What good is a cold?

It is often quoted that 50% of people will succumb to an upper respiratory tract infection in the course of a year. The usual pathogens involved are viruses.

Rhinoviruses with more than 100 serotypes are the most common pathogens, causing at least 25% of colds in adults. Coronaviruses may be responsible for more than 10% of cases. Parainfluenza viruses, respiratory syncytial virus, adenoviruses and influenza viruses have all been linked to the common cold syndrome. All of these organisms show seasonal variations in incidence. The cause of 30% to 40% of cold syndromes has not been determined.

Purushothama V. Dasaraju and Chien Liu.

The natural history of a cold is typically complete resolution within seven to ten days. There is no cure and regardless of what treatment is offered most people are miserable during that time with a runny nose, cough, sneezing, fatigue and sore throat. This is one of the commonest reasons people seek medical advice if not the most common reason. Colds are typically seasonal, highly infectious and responsible for a huge cost to society . Not to mention the risk of being offered inappropriate treatment, especially antibiotics.

We might ponder a philosophical question- Who benefits from a cold? Certainly viruses do- they spread from host to host at an alarming rate. However viruses that cause a cold do not mutate like the flu virus does, so spreading through the community doesn’t support their evolution. The condition is not fatal therefore it does not appear to support the host’s natural selection. So what is the point of an infection that makes us miserable up to three or four times a year? We lose time off work, we take medicines that provide temporary relief and life simply becomes a little more difficult. Possibly the only part of society that benefits are those who sell medicines!

Research now suggests that not everyone suffers to the same extent.

The epidemiologic data suggest that endurance athletes are at increased risk for URTI during periods of heavy training and the 1-to 2-week period after marathon-type race events.


Even after adjustment for other variables, men were significantly more likely to ‘over-rate’ their symptoms in comparison with the clinical observer than were women.


We found that high physical activity was associated with a lower risk of contracting URTI for both men and women.

Fondell et al

Data analysis showed that higher incidence of URTI was significantly associated with increased training ( tennis) duration and load, and competition level, on a weekly basis.

Novas et al

The risk of self-reported manifestations of the common cold was higher in workers who reported symptoms of depression.

Kim et al

Most of the relevant studies show a significant relationship between psychosocial factors and the onset or progression of acute respiratory tract illness. However, the psychosocial variables were not consistently evaluated across the included studies, and different methodological approaches were used to examine the association between psychosocial factors and acute respiratory tract illness.

Falagas et al

And finally most intriguing of all

Training in meditation or exercise may be effective in reducing ARI illness burden.

Barrett et al

This suggests that the URTI may serve as a barometer for stress in many people. This perspective may help those who advise or care for people who are experiencing symptoms of an URTI to consider what if anything can be done to address the other issues in their lives that may be problematic. By corollary people presenting for help with an URTI require the most skilled healthcare and not just a lecture on how paracetamol is the only treatment available.

Photo by Brittany Colette on Unsplash