Swedish rheumatology in good health at 50.

T Swedish model for social security and health care was dependent on a growing economy and full employment. With some 8.5% of open unemployment and faced with growing national debt problems, severe cuts have been implemented in the system and more are to come. How has this affected rheumatologic care? The number of hospital based units remains intact but a general reduction in beds has taken place. Our department in Lund as an example used to have four wards with a total of 62 beds, 12 of which are for day care. This has been reduced to 48, 11 of which are for day care. A complete integration of outand in-patient services has allowed some staff reductions. However, this has also reduced the total capacity and leads to long waiting lists for out-patient revisits. As the direct costs paid by patients have increased, health care workers are faced with the novel experience of patients’ difficulties to pay medication or afford hospitalization. It should, however, be mentioned that there is an annual maximum of fees for medication of 1300 SEK and services including hospitalization of 900 SEK. One SEK corresponds to approximately 75 pence. However, the most serious threat to the patients is the overall reduction of capacity. In this context new ethical issues have to be faced, and in a typical Swedish way a commission was formed to deal with priorities in health care [1]. This was headed by an emeritus professor of oncology, Jerzy Einhorn, and its strength lies in the fact that all political parties were represented and reached a broad consensus. The highest priority was given to ‘care of life-threatening acute diseases and diseases which, if left untreated will lead to permanent disability or premature death’, followed by ‘care of severe chronic diseases, palliative care and care of people with reduced autonomy’ [1]. The universities have not escaped cutbacks but so far this has not affected rheumatology in any major way. The department at Karolinska in Stockholm has, under its new professor Lars Klareskog, undergone a very dynamic rejuvenation and is starting ambitious clinical and experimental programmes. Johan Rönnelid defended his thesis on reactivity to type II collagen and C1q in various clinical situations May of 1997. The resources in Stockholm have now been concentrated to the two teaching hospitals, with Bo Ringertz and Ingiäld Hafström in charge at Karolinska and Huddinge, respectively. The Huddinge group is continuing their research on neutrophil function in inflammation. In Gothenburg Andrej Tarkowski was appointed as professor in 1996. He has developed a strong academic programme dealing with a new model of septic arthritis, which started with a chance observation by a laboratory technician and which has generated a number of PhD thesis projects, the first was completed by Thomas Bremell, now chief physician of the department. Hans Carlsten is persuing hormonal influences on experimental models of arthritis. Basic T-lymphocyte work is connected with therapeutic investigations, for instance the use of cholera toxin B in induction of oral tolerance. Tarkowski’s group has also recently produced good evidence for lymphocyte traffic from the gut to the synovium. Giant cell arteritis has been studied for a number of years in Gothenburg starting with the thesis of B. A . Bengtsson and E. B. Malmwall in 1981. The most recent thesis was defended in May 1997 by Christopher Schaufelberger, and included T-lymphocyte cloning and early work on use of T-cell receptors by lymphocytes in peripheral blood and in the lesion. Epidemiologic data showed increased mortality among biopsy negative patients with polymyalgia rheumatica. This disease was also studied in Umeå by Agneta Uddhammar. In Uppsala, Professor Roger Hällgren has been interested in the study of local events in the gut wall by using a catheter technique allowing local sampling in closed segments. In collaboration with Professor Brandzaeg in Oslo surface immunoglobulins can now be studied in a more precise way. Hällgren has also recently presented data indicating the rationality of administering prednisolone at 2 a.m. rather than in the early morning. In Lund Tore Saxne’s group is now also involved in studies of early events in osteoarthritis and Ingemar Petersson will soon complete his thesis dealing with cartilage and bone derived serum markers in this disease. Of particular interest are results regarding COMP and its relation to clinical, radiological, and other imaging data including scintigraphy. One message will be that bone and cartilage changes both seem to commence early and may be able to distinguish between stationary and progressive phases of the disease. Gunnar Sturfelt’s group is involved in SLE studies, making use of a prospective epidemiological cohort and incidence study in a defined population. They find constant annual incidence figures around 5/100 000, and increased mortality in vascular diseases notably early myocardial infarcts in young women. Eva Fex and Kerstin Eberhardt are studying their cohort of rheumatoid arthritis patients. One-third of these patients, despite optimal conventional care,