A multicenter trial of sulindac in osteoarthritis of the hip.

Sulindac (cis-5-fluoro-2-methyl-l-[(p-methyl sulfinyl)-benzylidene]-indene-3-acetic acid) is a new nonsteroidal antirheumatic drug recently evaluated in a double-blind trial of 91 patients with hip osteoarthritis. Consecutive patients with documented flare following previous drug withdrawal were randomly assigned to one of 3 treatment groups: (1) sulindac given twice daily, (2) sulindac given 4 times daily, and (3) placebo. The dosage of sulindac, 100 to 300 mg daily, was adjusted according to patient global response and tolerance at 3- to 7-day intervals over 3 wk. Of 15 efficacy measurements evalulated, there was no difference between sulindac given 2 or 4 times daily, but differences were disclosed between one or both sulindac treatment groups and placebo in 11 of the 15 efficacy measurements (p less than 0.05, less than 0.01). The frequency of adverse reactions was of the same order for each treatment group. These included gastrointestinal upset, rash, and dizziness, usually transient and mild to moderate in severity. Serial laboratory studies revealed no evidence of renal, hepatic, or hematopoietic toxicity.

Efficacy of diclofenac in ankylosing spondylitis.

Ankylosing spondylitis is a systemic rheumatic disorder characterized by inflammation of the spine, sacroiliac, and large peripheral joints. Effective management demands both immediate and long-term objectives. The physician must first relieve joint inflammation and discomfort with nonsteroidal anti-inflammatory drugs, then begin long-range planning with daily exercise and other supportive measures to prevent, delay, or correct deformity. Diclofenac sodium, a nonsteroidal anti-inflammatory drug that is used worldwide in ankylosing spondylitis, has not yet been marketed in the United States. This article highlights two American studies with diclofenac: (1) a short-term, double-blind comparison with indomethacin, and (2) a 38-week extension with diclofenac for long-term efficacy and safety data. The results of these trials demonstrate diclofenac to be effective and safe for both short- and long-term treatment. When compared with indomethacin, a standard reference drug in trials of ankylosing spondylitis, diclofenac was comparable in efficacy but had a more favorable side-effect profile.

Fibromyalgia (fibrositis) in children.

The features of fibromyalgia (fibrositis) in children are similar to those in adults with the syndrome. Both juveniles and adults report diffuse musculoskeletal aches and/or stiffness with typical modulating factors. Moreover, they have no systemic manifestations, and routine laboratory studies yield normal results. On physical examination in both children and adults, multiple soft-tissue tender points are evident at characteristic, symmetric sites but with no evidence of arthritis.

Sustained-release indomethacin in the management of ankylosing spondylitis.

Ankylosing spondylitis is a systemic rheumatic disorder that is characterized by inflammation of the spine, sacroiliac, and large peripheral joints. Although back pain is the most frequent presenting symptom, disease can begin in peripheral joints--especially in children and women--and, rarely, even with acute iritis. Whatever the mode of onset, recurrent back pain that is frequently nocturnal and of varying intensity is an eventual complaint, as is early morning stiffness that is typically relieved by activity. The long-term prognosis is clearly enhanced by early diagnosis and patient education, both of which are central to preventing or minimizing disability. By suppressing articular inflammation, pain, and stiffness, the nonsteroidal anti-inflammatory drugs facilitate exercise and other supportive measures. Currently, among these agents, indomethacin occupies an important place. By virtue of its 12-hour dosage system, sustained-release indomethacin can be prescribed only once or twice daily, providing the anti-inflammatory efficacy of indomethacin while promoting patient compliance.

Analgesic and anti-inflammatory therapy in the elderly.

In the United States today, the number of persons 65 years of age or older is about 25 million. Two thirds of this group have musculoskeletal complaints severe enough to cause them to use considerable quantities of over-the-counter medications to alleviate discomfort. In treating elderly patients with osteoarthritis, one of the most common rheumatic diseases of the elderly, it is imperative for physicians to be aware of the numerous physiologic aspects of aging and how these may affect the pharmacokinetic activity of various prescribed agents. Drug therapy in the elderly should be determined by the principle of least toxicity. Dosage titration is particularly advisable when pharmacokinetic activity of a drug is not known.

Sustained-release indomethacin in the management of the acute painful shoulder from bursitis and/or tendinitis.

Of all the forms of nonarticular rheumatism, by far the most common are bursitis and tendinitis. Yet, the bursae and neighboring tendon sheaths are the most neglected anatomic structures of the body. Moreover, like the joints, they are lined by synovial membrane, secrete synovial fluid, and are common sites of rheumatic problems. The vast majority of painful shoulder problems are caused by acute subacromial (subdeltoid) bursitis and bicipital tendinitis. In the management of these periarticular disorders, the ultimate goal is to preserve shoulder motion. Although this is accomplished by daily range-of-motion exercises, it is clearly facilitated by suppression of periarticular inflammation and discomfort through the use of nonsteroidal anti-inflammatory drugs. Of these, sustained-release indomethacin provides the anti-inflammatory efficacy of indomethacin and by virtue of its sustained-release formulation, may promote patient compliance since it need be given only once or twice daily.

Family studies with HLA typing in Reiter's syndrome.

Twelve consecutive patients with Reiter's syndrome, nine with the B27 antigen (B27 positive) and three without (B27 negative), and their 45 first degree relatives were studied clinically and with HLA typing. Two of the four adult male first degree relatives with the B27 antigen had classic Reiter's syndrome. In addition, one of two B27 positive adult male second degree relatives studied in one family had classic Reiter's syndrome. The data, although limited, suggest that the familial occurrence of Reiter's syndrome is higher than previously recognized, especially in adult male first degree relatives with the B27 antigen, and is similar to the degree of familial aggregation reported in ankylosing spondylitis.

Optimum Management of juvenile chronic polyarthritis.

The early diagnosis of juvenile chronic polyarthritis rests on the recognition of 3 district modes of onset that are important in preventing deformities, blindness, and even death. Systemic onset is characterised by typical systemic features, including high spiking fever and rheumatoid rash; polyarticular onset is characterised by arthritis of more than 4 joints; and pauciarticular onset by involvement of 4 joints or less, most often a knee initially. Management must be individualised, including the use of non-steroidal anti-inflammatory drugs of which aspirin remains the drug of choice. The course of progressive polyarthritis, found in 15% of children, necessitates the additional use of slow-acting agents, such as intramuscular gold. Supportive measures include rest, splinting and exercise. Regular slit-lamp examination is mandatory to screen for asymptomatic iridocyclitis, which if undetected and untreated may result in blindness.

Lyme disease--a review of the literature.

It appears that a tick introduces an agent--presumably a spirochete--into the skin (see Fig. 1). Immune complexes form and become systemic during the rash. Some patients (identified by the presence of cryoglobulins containing IgM, Clq-reactive material, and depressed IgG and IgA levels) then alter their immune response and may develop neurologic, cardiovascular, or joint involvement. Despite systemic clearing in some patients, the immune complexes localize to the joints where a chronic synovitis develops, similar to rheumatoid arthritis. Why the immune complexes localize to the joints is an enigma. It is tempting to postulate that this localization occurs because of an altered immune response in a genetically predisposed group. However, three of 10 patients with chronic arthritis did not have the B-cell alloantigen DRw2.

Primary fibromyalgia (fibrositis): clinical study of 50 patients with matched normal controls.

Detailed clinical study of 50 patients with primary fibromyalgia and 50 normal matched controls has shown a characteristic syndrome. Primary fibromyalgia patients are usually females, aged 25-40 yr, who complain of diffuse musculoskeletal aches, pains or stiffness associated with tiredness, anxiety, poor sleep, headaches, irritable bowel syndrome, subjective swelling in the articular and periarticular areas and numbness. Physical examination is characterized by presence of multiple tender points at specific sites and absence of joint swelling. Symptoms are influenced by weather and activities, as well as by time of day(worse in the morning and the evening). In contrast, symptoms of psychogenic rheumatism patients have little fluctuation, if any, and are modulated by emotional rather than physical factors. In psychogenic rheumatism, there is diffuse tenderness rather than tender points at specific sites. Laboratory tests and roentgenologic findings in primary fibromyalgia are normal or negative. Primary fibromyalgia should be suspected by the presence of its own characteristic features, and not diagnosed just by the absence of other recognizable conditions. This study has also shown that primary fibromyalgia is a poorly recognized condition. Patients were usually seen by many physicians who failed to provide a definite diagnosis despite frequent unnecessary investigations. A guideline for diagnosis of primary fibromyalgia, based upon our observations, is suggested. Management is usually gratifying in these frustrated patients. The most important aspects are a definite diagnosis, explanation of the various possible mechanisms responsible for the symptoms, and reassurance regarding the benign nature of this condition. A combination of reassurance, nonsteroidal antiinflammatory drugs, good sleep, local tender point injections, and various modes of physical therapy is successful in most cases.

Extensor tendon repair in the emergency department.

Extensor tendon lacerations of the hand are commonly seen in the emergency department. These injuries can often be definitively managed by the emergency physician who has a working knowledge of the complex extensor mechanism anatomy plus basic surgical skills. A thorough initial assessment including a tourniquet examination for adequate exposure is the key to making the complete diagnosis. Surgical indications, materials, techniques, complications, and postoperative management involved in extensor tendon repair are reviewed. The emergency physician's decision to treat or refer these injuries will depend greatly on the clinical setting, familiarity with the procedure, and the availability of and relationship with appropriate consultants.

The seronegative spondyloarthropathies. A graduated approach to management.

The seronegative spondyloarthropathies can create multiple and complex therapeutic problems. Consequently, the primary care physician needs to offer continuous encouragement and support to the patient, who must maintain a lifelong regimen of antiinflammatory drug therapy, daily exercise, and other supportive measures to retain mobility. With comprehensive care, the vast majority of patients can lead full, productive lives. However, management can succeed only with active participation of patients who have been adequately educated about their disease.

Juvenile rheumatoid arthritis. Mode of onset as key to early diagnosis and management.

Juvenile rheumatoid arthritis, which affects almost a quarter of a million American children, is diagnosed at the patient's first visit to the physician in only about half of all cases. Early diagnosis rests on recognition of three distinct modes of onset and is important in preventing deformities, blindness, and even death.

Growing pains: fact or fiction?

Growing pains are recurrent limb pains peculiar to children. Brief episodes of leg pains occurring intermittently at night are typical, but the clinical spectrum is variable. A diagnosis of growing pains can be made with certainty only after other possible conditions have been ruled out by appropriate studies and after the child has been observed carefully for a period of months. The two diseases most often confused with this syndrome are rheumatic fever and juvenile rheumatoid arthritis. Aspirin and supportive measures are beneficial.

Juvenile rheumatoid arthritis.

The early diagnosis of JRA rests on the recognition of three distinct modes of onset that are important in preventing deformity, blindness, and even death. Systemic onset is characterized by typical systemic manifestations, particularly high spiking fever and the rheumatoid rash, polyarticular onset is noted by arthritis of more than four joints, and pauciarticular onset is distinguished by involvement of four joints or less, most often a knee initially. In JRA, fundamental to the heart of successful management is patient and parental education regarding both the nature of the disease and goals of therapy. Whereas the NSAIDs are adequate for the control of active disease in most patients, two key issues must be resolved. First, it is important to recognize that the choice of drug for the individual patient is frequently a matter of trial and error. Second, it is critical to prescribe antiinflammatory quantities of a given drug. The slow-acting (remittive) agents, such as intramuscular or oral gold, are reserved for patients with prolonged active polyarthritis, which affects 15 per cent of all patients with JRA. There are several drawbacks to the use of remittive agents. They must be tried for several months, often in the presence of rapidly developing joint limitation and erosions on radiograph, before their effectiveness can be determined. Also, when using these drugs, one must often follow a meticulously graduated dosage regimen, while carefully monitoring the patient for toxic and potentially lethal side effects. It follows, therefore, to never use these agents unless you are familiar with their administration and potential toxicity and to seek help from a specialist.

Contemporary management of ankylosing spondylitis.

The comprehensive management of ankylosing spondylitis has both immediate and long-term objectives. The physician must first suppress the patient's articular discomfort and inflammation with NSAIDs, then begin long-range supportive measures such as postural training and daily exercise in order to prevent, delay, or correct deformity. Acute anterior uveitis and other systemic manifestations must be promptly recognized and treated, often with the help of specialists. While the capacity to function and work can be adequately maintained for most patients, it depends largely on patient education and compliance. Educational material for patients with AS may be obtained from either a local chapter or the national headquarters of the Arthritis Foundation (17 Executive Park Drive, NE, Suite 480, Atlanta, GA 30329), as well as the Ankylosing Spondylitis Association (ASA). Patients should be urged to join the ASA in order to receive the monthly newsletter. The address for ASA membership is 3985 Witzel Drive, Sherman Oaks, CA 91403.