Fibrositis (fibromyalgia). A common non-entity?

The literature on fibrositis (fibromyalgia), which originated in the early years of the last century in the UK and proliferated there in the first half of this century, has since diminished there in the last 30 years or so, but has increased in Canada and the US. Criteria suggested for diagnosis have created a syndrome with no diagnostic tests, serological or radiological signs, and no truly objective physical signs, but with predictable tender spots on pressure. The syndrome is largely, but not completely, confined to females, mostly of middle age; the symptoms include widespread aching of more than 3 months' duration, disturbed sleep, morning fatigue and stiffness, a failure to respond satisfactorily to any one form of therapy and a tendency to persist over long periods, but without permanent tissue changes. Features of psychological disturbance are present in many patients but not in all or even the majority. Definition of the condition as a disorder of pain modulation - a pain amplification syndrome - would seem to fit the facts best. Most would agree that an abnormal response to stress is an important factor in the appearance of the syndrome, as other stress related disorders, such as the irritable bowel syndrome and tension headaches, may coexist. Response to therapy, whether physical or pharmacological, is on the whole unsatisfactory. This type of patient has been well recognised in hospital clinic and general practice for many years.(ABSTRACT TRUNCATED AT 250 WORDS)

Polymyalgia rheumatica. Its correct diagnosis and treatment.

Giant cell (temporal) arteritis was first described by Horton and colleagues in 1932, and polymyalgia rheumatica in 1957 by Barber who suggested this title for an entity resembling, but distinct from, rheumatoid arthritis of unknown aetiology in the elderly. Arteritic features were sufficiently common in polymyalgia rheumatica to suggest an arteriopathy as a cause, further evidence of this being the change from the clinical picture picture of polymyalgia rheumatica to giant cell arteritis and vice versa in many patients such that the alternative title polymyalgia arteritica was suggested. The clinical picture of polymyalgia rheumatica is that of an elderly patient, more often female than male, usually over 60 years of age, with painful stiffness in the girdle joints and muscles of the shoulders and hips, but seldom with findings in peripheral or intermediate joints. The painful stiffness in the shoulders, hips and thighs is worse in the early morning. An erythrocyte sedimentation rate over 50mm in 1 hour is usual, and there is a rapid and dramatic response to small doses of corticosteroids (around 10mg prednisolone daily). Arteritic and axial arthritic features have been noted by different authors in different ratios, the disorder gradually abating naturally over periods varying from several months to 7 to 10 years. Deaths, when they occur in this elderly group of patients, have usually been unrelated to the disease or its treatment, but osteoporotic vertebral crush fractures are not uncommon. Partial or complete blindness may occur in patients with either giant cell arteritis or polymyalgia rheumatica, often appearing rapidly after cessation of corticosteroid therapy or rapid reduction of dosage.(ABSTRACT TRUNCATED AT 250 WORDS)

Rational use of analgesics in the treatment of the rheumatic disorders.

To the average arthritic patient, pain relief is usually his or her first priority in treatment. Thus, analgesics still have a part to play in the treatment of most arthritic conditions, even though the non-steroidal anti-inflammatory drugs (NSAIDs) have the major therapeutic role in most cases. In the treatment of acute gout, the NSAIDs are the most important, and simple analgesics are relatively unimportant, but in the treatment of rheumatoid and osteoarthritis and other arthropathies, analgesics taken as and if required to cover the more painful periods of a day do have a role, usually in conjunction with NSAIDs and other agents. In general, the simple analgesics are better tolerated than the NSAIDs and less likely to produce gastrointestinal irritation. Although many clinicians consider that simple analgesics have little part to play in the treatment of rheumatoid arthritis and other inflammatory arthropathies, the patient often takes them without the physician's knowledge, in addition to the prescribed treatment. Some recently introduced analgesics bridge the gap between the simple analgesics and the more potent potentially addictive drugs such as pethidine and morphine, which are only indicated in extremely painful crises or after traumatic episodes and surgical operations.

Regressive systemic sclerosis.

Systemic sclerosis is a disease which usually progresses or reaches a plateau with persistence of symptoms and signs. Regression is extremely unusual. Four cases of established scleroderma are described in which regression is well documented. The significance of this observation and possible mechanisms of disease regression are discussed.