Empiric parenteral antibiotic treatment of patients with fibromyalgia and fatigue and a positive serologic result for Lyme disease. A cost-effectiveness analysis.

PURPOSE: To examine the cost-effectiveness of empirical, parenteral antibiotic treatment of patients with chronic fatigue and myalgia and a positive serologic result for Lyme disease who lack classic manifestations. DATA SOURCES: Peer-reviewed journals, opinion of experts in the field, and published epidemiologic reports. STUDY SELECTION: Consensus by authors on articles that indicated methods for patient selection; on criteria used for diagnosis; on immunologic methods used for classifying patients; on the dose and duration of therapy; and on criteria by which responses to therapy were ascertained. DATA EXTRACTION: In a cost-effectiveness model, the costs and benefits of empirical parenteral therapy for patients seropositive for Lyme disease were compared with a strategy in which only patients having classical symptoms of Lyme disease were treated. DATA SYNTHESIS: In areas endemic for Lyme disease, the incidence of false-positive serologic results in patients with nonspecific myalgia or fatigue exceeds by four to one the incidence of true-positive results in patients with nonclassical infections. Treatment of the former group of patients costs $86,221 for each true-positive patient treated. The empirical strategy causes 29 cases of drug toxicity for every case in the more conservative strategy. If patients were willing to pay $3485 to eliminate anxiety about not treating possible true Lyme disease, the empirical strategy would break even. CONCLUSION: For most patients with a positive Lyme antibody titer whose only symptoms are nonspecific myalgia or fatigue the risks and costs of empirical parenteral antibiotic therapy exceed the benefits. Only when the value of patient anxiety about leaving a positive test untreated exceeds the cost of such therapy is the empirical treatment cost-effective.

Converging and diverging beliefs about arthritis: Caucasian patients, Spanish speaking patients, and physicians.

Ninety-eight Caucasian patients, 46 Spanish speaking patients, and 50 physicians (mainly rheumatologists) took part in surveys of salient beliefs about arthritis and its treatment. The beliefs of Caucasian patients and those of physicians were similar. However, beliefs of physicians about patients' beliefs and actual patient beliefs diverged as did the beliefs of Caucasian and Spanish speaking patients. These results suggest that arthritis education and treatment should be based on patients' perceptions rather than on physicians' beliefs about patients' perceptions.

Nonsteroidal anti-inflammatory agents in rheumatoid arthritis and ankylosing spondylitis.

The relative effectiveness of six nonsteroidal anti-inflammatory agents was studied in 33 patients with rheumatoid arthritis and 32 patients with ankylosing spondylitis in a double-blind, randomized, prospective study employing a six-way multiple crossover design with six-week trials of each agent. In ankylosing spondylitis, naproxen, indomethacin, and fenoprofen calcium were the most effective agents. In rheumatoid arthritis, relatively little mean difference between drugs was found. Most of this difference could be attributed to compliance factors, which favored drugs that required only a small number of pills daily. Despite the small differences in effect, patients had strong preferences. More than 85% of patients were still taking their preferred medication after a mean follow-up period of one year.

Rheumatoid hand deformities: pathophysiology and treatment.

Rheumatoid disease, as it affects the hand, is a disease of the synovium lining the joints and sheaths of the tendon. The proliferating synovium destroys the articular surfaces of the joint, interferes with the gliding mechanism of the tendons and weakens the supporting ligaments of the joints. The degree and variety of deformities is multifold. Treatment of the rheumatoid hand is aimed at conservation and restoration of hand function, as well as prevention of future deformities. Rheumatologists, physical therapists and hand surgeons carry out important functions in the well-planned, integrated regimen. Surgical treatment of the rheumatoid hand deformity may alleviate pain, lessen deformity and improve function in selected cases. It should be integrated in the general medical management of a patient. Treatment of tendon ruptures includes tenorrhaphy, tendon grafting and arthrodesis in the case of mallet finger deformity. The wrist joint is improved by synovectomy and carpal tunnel release is accomplished by median nerve decompression. Metacarpal phalangeal joint deformities may be treated by synovectomy or silastic joint replacement when there is destruction of the articular joint surface, severe subluxation, or persistent painful motion.

Some problems in the interpretation of clinical trials: longterm parallel study of fenoprofen in rheumatoid arthritis.

Fenoprofen calcium was compared with acetylsalicylic acid in the treatment of 27 patients with definite or classic rheumatoid arthritis, over a period of one year. Both drugs appeared efficacious, with a slight edge to fenoprofen in the doses employed. Fewer side effects were noted with fenoprofen. Effectiveness continued undiminished throughout the year, and mean values of most parameters continued to improve in both groups over the entire period. Three problems which influence extrapolation of results from this and similar studies to the general setting are discussed. (1) Individual patients show great variation from the mean and from one observation point to another. Thus, expectations developed from mean values will seldom be accurate in a particular patient. (2) The relative doses chosen for two drugs in the clinical trial can profoundly influence both efficacy and toxicity. The qualification "at the doses employed" is seldom emphasized in clinical reports. (3) Patient compliance in the general clinical setting is importantly different from that in a clinical trial, and this potential problem must be assessed by the physician choosing an appropriate medication for a particular patient.

Rheumatoid synovitis: complement and immune complexes.

The pattern of complement component utilization within the joint space of patients with RA is consistent with activation by immune complexes. Immunogluorescent studies of SF leukocytes revealed intracytoplasmic inclusions of immunoglobulins and complement components, particularly in cells from SF with low complement levels and containing materials which precipitated with either C1q and/or rheumatoid factor. RA patients with low levels of SF complement tended to have an unremitting course, subcutaneous nodules, and to have been treated with gold. Their joints had more periarticular demineralization, joint space narrowing, cortical impaction by X-ray; and synoviocytic giant cells, fibrosis, lymphocytes, congestion, and fibrin exudation by pathologic examination than did joints of RA patients without low levels of SF complement. Patients with systemic hypocomplementemia had active classical RA with evidence of severe joint involvement and vasculitis. These findings suggest that rheumatoid inflammation of joints is mediated by immunologic activation of the complement system.