SLE in a United States-Mexico border community.

This report describes the results of a clinic-based study conducted to verify a community-reported excess prevalence of systemic lupus erythematosus (SLE) and a possible connection between ethnicity and environmental factors in the reporting of SLE in the United States-Mexico border town of Nogales, Arizona. A community group in Nogales reported 37 cases of SLE in its community, suggesting a prevalence rate of 200 per 100,000. This report describes 19 definite and 7 probable cases of SLE using the 1982 American College of Rheumatology criteria. All definite and probable cases were self-identified, Mexican-American females. This yields a prevalence rate of 94 per 100,000, among the highest reported to date. The majority of cases resided within 3 miles of the United States-Mexico border and within 1 mile of the polluted Nogales Wash or ground wells with documented toxins. It remains to be determined whether this confirms that SLE is more common in Mexican-Americans or whether environmental factors, especially pollutants, are predominantly responsible. In addition to the need to be aware about the apparent increased risk of SLE in many Latin-Americans, clinicians should ask about possible environmental factors.

Adhesive capsulitis: a sticky issue.

The shoulder is a very complex joint that is crucial to many activities of daily living. Decreased shoulder mobility is a serious clinical finding. A global decrease in shoulder range of motion is called adhesive capsulitis, referring to the actual adherence of the shoulder capsule to the humeral head. Adhesive capsulitis is a syndrome defined as idiopathic restriction of shoulder movement that is usually painful at onset. Secondary causes include alteration of the supporting structures of and around the shoulder, and autoimmune, endocrine or other systemic diseases. The three defined stages of this condition are the painful stage, the adhesive stage and the recovery stage. Although recovery is usually spontaneous, treatment with intra-articular corticosteroids and gentle but persistent physical therapy may provide a better outcome, resulting in little functional compromise.

Sciatica-like pain arising in the sacroiliac joint.

Sacroiliac joint disease is an under-considered cause of sciatica-like pain. One hundred thirty-three patients studied over 14 years, with sciatica-like pain, had their sacroiliac joints instilled with a combination of lidocaine/triamcinolone acetonide under fluoroscopy. Each patient had a normal myelogram or magnetic resonance imaging (or both) of their lumbar spine before entering the series. We described a reproducible fluoroscopic technique that other rheumatologists can use, if appropriate, to instill medication into the joint. Patients with pseudosciatica arising from their sacroiliac joints found relief with correctly placed instillations. The duration of relief varied considerably. Sciatic-like pain may indeed arise in the sacroiliac joints.

Viral infection as a cause of arthritis.

Rheumatic complaints secondary to viral infections are usually brief, self-limited and nondestructive. They may accompany almost any type of viral illness, and the arthritic presentation is nonspecific. These manifestations are protean, ranging from arthralgia to vasculitis. Often the cause of the rheumatic complaint remains elusive because of the prompt resolution of the viral infection. Evaluation for autoimmune diseases should be postponed until the symptoms have been present for at least six weeks. However, some viral diseases, such as parvovirus, chronic hepatitis B virus and hepatitis C virus infections, can produce long-lasting rheumatic symptoms. Since the arthritis associated with hepatitis C infection has only recently been recognized, it is important to search for this association in patients who have atypical rheumatic complaints, risk factors for hepatitis and alterations in liver enzymes, so that an accurate diagnosis can be established and the pathophysiology can be better understood.

Histological appearance of the synovium in early rheumatoid arthritis.

This report reviews and discusses studies on the synovial fluid and biopsy specimens of synovial membrane obtained during the first 6 weeks of synovitis that evolved into rheumatoid arthritis (RA). Five previously unreported cases are described. Early changes in the microvasculature and synovial lining seem to antedate the classical chronic inflammation of established RA. Further characterization in the joint tissues in very early RA offers opportunities for identification of exogenous triggers and may allow more appropriate targeting of early therapy to potentially reversible aspects of pathogenesis.

AI/Learn/Rheumatology. A computer-assisted educational system for teaching about rheumatic diseases.

Education of health professionals about the rheumatic diseases is in need of improvement. The computer is an instrument that can be used efficiently to educate large numbers of users. With specific educational principles in mind, we developed AI/Learn/Rheumatology, a computer-assisted interactive videodisc system for teaching the rheumatic diseases. While interacting with the user, it conveys knowledge using visual and problem-solving techniques. The system is efficient, enjoyable to use, and useful for small groups and independent study. It is applicable for teaching medical and allied health professional students, postgraduate trainees, and primary care physicians.

Pharmacokinetics of the R(-) and S(+) enantiomers of ibuprofen in the serum and synovial fluid of arthritis patients.

Eight patients with arthritis and knee effusions received 13 doses of a single 800-mg ibuprofen tablet every 8 hours. Serum and synovial fluid samples were obtained after the first and last doses and assayed for the R(-) and S(+) enantiomers of ibuprofen by a stereospecific assay. Since only S(+)-ibuprofen inhibits cyclo-oxygenase, a description of the time course of this isomer in synovial fluid is needed for the development of suitable pharmacodynamic models. The isomers were significantly different with respect to peak concentrations and areas under the concentration-time curves (AUC) in synovial fluid levels. No significant accumulation of either isomer was observed in serum or synovial fluid levels between the first and the last doses. The steady-state concentration of both isomers fluctuated less in synovial fluid than in plasma, and the synovial fluid concentrations of the S(+) isomer were about twice that of the R(-) isomer. The mean synovial albumin concentration was about 60% of the serum albumin concentration, and the steady-state isomer AUC values in synovial fluid were significantly correlated with the corresponding serum values after the differences between the two fluids with respect to albumin concentration were corrected. The authors conclude that binding of the isomers to albumin and the serum-synovial fluid albumin ratio controls the steady-state distribution of the ibuprofen isomers into synovial fluid. The ramifications of these findings in the development of satisfactory concentration-response relationships are discussed.

Lethal midline granuloma with a novel T-cell phenotype as found in peripheral T-cell lymphoma.

Lethal midline granuloma (LMG), initially a clinical description, includes an uncommon group of disorders characterized by a relentless, destructive process involving the upper respiratory structures. Its etiology and pathogenesis are uncertain, probably varied, and the distinction between inflammatory and malignant processes is difficult despite extensive clinical and histopathologic evaluation. The need for new techniques for rapid diagnosis has important therapeutic implications. Using an extensive panel of T- and B-cell monoclonal antibodies the authors describe a patient with clinically and pathologically typical LMG demonstrating an "activated" T-cell phenotype with a "novel" pattern characteristic of peripheral T-cell lymphoma, strongly implying that some cases of LMG are more closely related to neoplastic T-cell lymphoproliferative disorders than to inflammatory conditions. Further studies using these immunotyping techniques may help clarify the pathogenesis of LMG, and may uncover specific diagnostic and prognostic phenotypic patterns.

Family practice and internal medicine clinical judgment in a university setting.

There were no significant differences between family practice and internal medicine residents in the proportion of total diagnoses that were reasonable (72 percent and 77 percent, respectively) and unreasonable (14 percent and 15 percent, respectively) or average number of consultations requested per examination (.15 and .16, respectively). There was a significant difference between the two types of physicians in the average number of laboratory tests requested per examination (1.42 per family practice and 1.88 per internal medicine) and average number of x-ray examinations requested per examination (0.35 for family practice and 1.02 for internal medicine). The average length of examination for internal medicine tended to be longer than for family practice. Although generalizability of this study is limited, the results suggest that there may be important differences in the practice patterns of family practice and internal medicine with implications for training programs.

Ibuprofen kinetics in plasma and synovial fluid of arthritic patients.

After administration of a single dose and at steady state, ibuprofen concentrations were measured simultaneously in plasma and synovial fluid obtained from eight patients with rheumatoid arthritis. By seven hours after a dose at steady state, the mean synovial fluid: plasma ibuprofen concentration ratios were constant, and the synovial fluid levels were, on average, greater than those in plasma. The extent to which ibuprofen was bound to protein was somewhat greater in plasma than in synovial fluid. As a result, the mean synovial fluid:plasma free concentration ratio for seven-hour and later specimens was greater than that based on total concentrations. The degree of accumulation of ibuprofen in each fluid was minimal, consistent with its short half-life.

Treatment of hemophilic arthritis with D-penicillamine: a preliminary report.

Current medical management programs for established joint diseases in hemophiliacs are unsatisfactory and do not modify the eventual outcome. D-penicillamine, a drug effective in the proliferative synovitis of rheumatoid arthritis, was evaluated in a rabbit model of hemarthroses-induced arthritis and in four hemophiliacs with chronic synovitis. The animals had intra-articular injections of citrate (left knees) and autologous citrated whole blood (right knees). Eight weeks later, the rabbits were divided into two groups: no treatment and D-penicillamine (50 mg/kg/day, IM) until sacrificed at 6 months. The saline-injected joints showed no inflammation and no iron deposition. The blood-injected knees showed iron deposition in both groups, the D-penicillamine animals had marked suppression of chronic inflammation. Of the four patients treated, three had clinical responses (reduction in synovial thickness, reduction in number of bleeds in the affected joint). One patient, who did not respond, developed mild-moderate proteinuria. Those patients who responded received between 5.3 and 7.1 mg/kg/day of the drug. Mild abnormalities in platelet aggregation were seen in the responders. This preliminary study suggests that D-penicillamine is beneficial in the chronic synovitis/arthritis induced by hemarthroses. Further trials are recommended.

Assessing clinical judgment with standardized patients.

Family physicians and general practitioners see the majority of patients with uncomplicated rheumatic disease, yet information on database collection and clinical judgment in such practices is limited. Trained patients with uncomplicated rheumatic disease (standardized patients) were used to evaluate these abilities in 26 family physicians at the University of Arizona College of Medicine in blinded, but previously consented to, brief new encounters. Ability to formulate an assessment and to plan was evaluated as well as ability to collect diagnostic information. Few physicians explored the psychosocial impact of the illness (4 percent) or the role of depression (0 percent). In the brief encounter with a localized complaint, little inquiry was directed to systemic disease (46 percent). Physicians more uniformly asked about the chief complaint (96 percent) and time of onset (88 percent). Physical examination items most commonly omitted were evaluation of systemic joint involvement (69 percent) and muscle wasting in the involved area (59 percent). Referral occurred on 15 percent of encounters and patient education occurred in 62 percent. Three quarters of physicians developed an adequate assessment and virtually all developed an adequate patient care plan.

Hypersensitivity reaction to sulindac (Clinoril).

Sulindac (Clinoril), a nonsteroidal anti-inflammatory agent, has few reported neurologic toxic effects, all of which have been associated with systemic disease. To our knowledge, we describe the first reported case of isolated paresthesia and peripheral neuropathy, without systemic involvement, secondary to sulindac administration. A healthy, 30-year-old man, exposed to sulindac on two separate occasions, had an incapacitating isolated idential sensory neuropathy. The onset and duration of symptoms correlated directly to drug ingestion. This hypersensitivity response cannot be explained pathophysiologically by any mechanism. Repeated exposure and rechallenge of the subject to sulindac was deemed too dangerous, and precludes exact method to establish mechanisms to explain this transient, reproducible, idiosyncratic, adverse drug reaction.

The use of drugs in rheumatic diseases.

Specific information concerning the use of nonsteroidal anti-inflammatory agents, salicylates, analgesics, remittive drugs, and other adjunctive treatments used for rheumatic diseases are addressed. Based on a good diagnosis, pharmacotherapy combined with other approaches can result in successful treatment of most cases of arthritis.

Introduction and classification of rheumatic diseases.

Rheumatic diseases affect a large segment of the world's population. The rheumatic diseases may be classified by type or by several clinical schema of signs and symptoms.

Osteoporosis, osteomalacia, rickets, and Paget's disease.

Although the common form of osteoporosis associated with aging can be treated, it is best to avoid the problem by not letting the disease develop. Osteomalacia is caused by inadequate or delayed mineralization of bone and is treated by correcting the abnormal intake, loss, or metabolism of vitamin D, phosphate, and calcium. Paget's disease is characterized by osteoclastic resorption of bone with new bone laid down in a disorganized fashion.

The use of trained patient instructors for teaching and assessing rheumatologic care.

The training of professionals in rheumatologic care requires review and study. To improve teaching methods, 6 patients with stable rheumatic disease were trained to evaluate and teach medical students by using themselves as models for musculoskeletal examinations. Checklists for scoring performance and content were developed. Criteria established to give evidence of the validity of the checklists and of the reliability of the patient instructors in their scoring were met or exceeded. The patient instructors are now an integral part of the Preparation for Clinical Medicine curriculum at our institution and serve as resources for evaluation and teaching in the continuing education of practicing professionals.