Acute low back pain findings and management in an academic medical center.

To compare medical records of patients treated for acute low back pain in the departments of Family Medicine, Internal Medicine, Occupational Medicine and Emergency Medicine in an academic medical center to determine if there was variation in patient population, diagnostic and treatment procedures and outcomes. Records were randomly reviewed using a standardized form for patients diagnosed with ICD 9 codes pertaining to back pain. Of the 96 patients with acute back pain seen in outpatient areas, 66 were seen by Family Medicine, 26 by Medical Group Practice (MGP), and four by Occupational Medicine. One hundred seven were seen in the Emergency Department. There was no significant difference in duration or type of pain or the type of findings or treatment. Very few had positive physical findings, (9% outpatient and 10% Emergency Department), but many more, (38% outpatient and 17% ED), had psychosocial findings (smoker, dissatisfaction with work, previous psychiatric history, psychosomatic history, or abnormal social adjustment) documented, Plain films of the lumbrosacral spine done in both practice settings did not change treatment.

Public knowledge, perception, and expressed choice of telemedicine in rural West Virginia.

OBJECTIVE: It is doubtful that any new health care delivery system that requires as much adjustment as telemedicine does will be sustained if its users do not fully support it. We sought to determine the familiarity with, perceptions of, and attitudes toward telemedicine among rural adults in West Virginia. METHODS: Data were collected in a statewide telephone survey of 461 non-institutionalized rural adults. The survey contained questions about familiarity with telemedicine, perceptions about its attributes and benefits, and willingness to use it for routine, specialty, and emergency care. Responses were examined in relation to the subjects' age, sex, socioeconomic status, access to care, and insurance coverage. RESULTS: Despite mass media coverage of the subject, only one third of the respondents had heard of telemedicine. Nearly two thirds thought patients would find it less satisfactory than seeing a physician in person. Male subjects, younger subjects, and those with higher incomes were more likely to think telemedicine would be as satisfactory as a face-to-face meeting. There was a general consensus on the benefits of telemedicine, such as greater convenience and easier contact with specialists. For chronic conditions, 47% of the respondents would use telemedicine if no physician was available locally, whereas 27% would go out of town to see another physician in person, and 25% would wait for their own physician. For emergency care, these figures were 41%, 58%, and 0. Three fourths of the respondents were somewhat or very willing to use telemedicine for routine or specialist care. CONCLUSION: More work needs to be done to demonstrate the efficacy of telemedicine and disseminate this knowledge to the public.

MDTV Telemedicine Project: technical considerations in videoconferencing for medical applications.

In spite of the many advances in technology, complex problems must be addressed in establishing and maintaining a telemedicine system. Although most such systems are built around interactive videoconferencing (IAVC) equipment, clinical requirements dictate that these systems offer more than traditional IAVC systems. Input from system users should be obtained early in the design process to ensure the functionality necessary to achieve maximum utilization. Surprisingly, audio, rather than video, signals may present the greatest challenge to achieving consistent, high-quality videoconferencing encounters. Audio technical problems can be frustrating for patients and providers alike and can undermine user confidence in IAVC as a vehicle for healthcare delivery. A capability for remote access and control of components at distant sites seems essential to providing cost-effective and technically reliable service.

Liver disease, erroneously attributed to methotrexate, in a patient with rheumatoid arthritis.

We describe a patient with rheumatoid arthritis and Felty's syndrome who developed evidence of hepatic dysfunction initially attributed to a short course of methotrexate therapy. He was subsequently found to have nodular regenerative hyperplasia.

Evaluating the complaint of fatigue in primary care: diagnoses and outcomes.

PURPOSE: This case series describes associated diagnoses and prognoses of persistent fatigue in a community-based, primary care population. PATIENTS AND METHODS: All patients presenting to a private practice internist with a chief complaint of fatigue of more than 1 month's duration were prospectively evaluated with clinically directed examination and diagnostic testing. Patients were excluded if they had a previously diagnosed illness associated with fatigue. Fatigue was attributed to newly established diagnoses or medication use based on explicit criteria. Change in the state of each patient's fatigue was measured 6 months after entry. RESULTS: Fifty-two consecutive patients entered the study. The diagnoses associated with fatigue were a medical disorder in 25 patients, depression in 10 patients, and no definitive diagnosis in 18 patients. The mean cost of diagnostic testing was $131. At 6 months, 37 of 52 patients (72%) reported improvement in or resolution of their fatigue. CONCLUSION: In a primary care setting, many patients presenting with persistent fatigue have an associated, treatable disease that can be determined using a cost-effective, clinically directed approach. Most will experience an improvement in their fatigue.

Giant cell arteritis and polymyalgia rheumatica.

The close relationship between giant cell arteritis and polymyalgia rheumatica has not been clearly explained. These disorders affect the same patient population and often coexist in the same person. Monitoring of the erythrocyte sedimentation rate is a useful tool in both diagnosis and treatment. Management with varying doses of prednisone has proved effective in resolving symptoms.

Rethinking the therapeutic pyramid for rheumatoid arthritis. When are NSAIDs alone not enough?

A large number of agents that compare quite favorably to nonsteroidal anti-inflammatory drugs in terms of toxicity and efficacy are available to physicians for the treatment of rheumatoid arthritis. Primary care physicians need to familiarize themselves with the use of these drugs and consider prescribing them early in the course of the disease, when they may be of greatest benefit.

Musculoskeletal disorders. When are they caused by hormone imbalance?

Often, the source of a musculoskeletal problem can be traced to an endocrine disorder. For example, carpal tunnel syndrome is not uncommon in patients who are pregnant or have diabetes, hypothyroidism, or acromegaly. Joint problems and arthritis are other common findings in diabetes, pregnancy, and hyperparathyroidism. Muscle weakness or stiffness is seen in both hypothyroidism and hyperthyroidism, and muscle wasting is a characteristic of adrenocorticoid insufficiency. Bone disorders are common with glucocorticoid excess, acromegaly, and hyperparathyroidism. Some presentations are a classic picture of a specific endocrine condition and are readily recognized if the index of suspicion is appropriately high.

Conquest of the gout.

With students such as Hippocrates, Galen, Paracelsus, Sydenham, Herberden, Harvey, Cheyne, Boerhaave and Pare, the history of "The Gout" (L. gutta-drop), more than any other disorder, parallels the history of Western medicine. It also played important parts in modifying American and European culture and history. Such was the fear and honor it commanded in the last 3,000 years, that over a score of saints and holy men are credited with its cure. Long stated to be a disease of the upper class, at one time, it was considered so stylish that it was said that the only thing worse than having it was to be cured.

Herpes zoster in patients with rheumatoid arthritis treated with weekly, low-dose methotrexate.

PURPOSE: Herpes zoster occurred in nine patients with methotrexate-treated rheumatoid arthritis. We compared these patients to a large group of methotrexate-treated rheumatoid arthritis patients in order to uncover potential factors explaining the occurrence of herpes zoster. PATIENTS AND METHODS: Data from 187 patients taking methotrexate were reviewed and compared with data from another nine patients who developed herpes zoster while taking the drug for rheumatoid arthritis, all from the same university-based arthritis clinic. Literature pertinent to infection in rheumatoid arthritis patients treated with methotrexate is reviewed. RESULTS: Herpes zoster occurred in 14.5 cases per 1,000 patient-years in our methotrexate-treated rheumatoid arthritis patients, as compared with the general population incidence of 1.3 to 4.8 cases per 1,000 patient-years. The infection was unrelated to duration of methotrexate usage, prednisone treatment, or the co-existence of diabetes mellitus, but appeared to occur in patients with high titers of rheumatoid factor and an overall longer duration of rheumatoid arthritis. There were no cases of systemic dissemination or recurrence of herpes zoster despite 27.4 years cumulative follow-up on continued methotrexate therapy. CONCLUSIONS: Herpes zoster may occur more frequently in patients with rheumatoid arthritis treated with low-dose methotrexate than in the general population. Herpes zoster in rheumatoid arthritis patients treated with methotrexate appears to be self-limited, benign, and statistically related to methotrexate use in the presence of longer-term rheumatoid disease.

Muscle involvement in the scleroderma syndromes.

Muscle involvement was identified in 14 patients with scleroderma or a connective tissue disease overlap syndrome with predominant features of scleroderma. Patients presented with symmetrical proximal weakness indistinguishable from other inflammatory myopathies. Creatine kinase and electromyography were useful to demonstrate muscle involvement. Muscle histopathology demonstrated primarily the vasculopathy of scleroderma or polymyositis in similar numbers of patients. Scleroderma vasculopathy and polymyositis generally occur without specificity to diffuse scleroderma, the calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia syndrome, or an overlap syndrome with arthritis. Polymyositis also occurs when the vasculopathy of scleroderma involves other organ systems.

Hepatitis with bridging fibrosis and reversible hepatic insufficiency in a woman with rheumatoid arthritis taking methotrexate.

A patient with seropositive rheumatoid arthritis developed ascites while taking weekly doses of methotrexate (MTX). Her serum transaminase and albumin levels were normal. A liver biopsy revealed chronic hepatitis with bridging fibrosis and piecemeal necrosis. Upon discontinuation of MTX, her ascites resolved, and her arthritis became more active. This is the third report of reversible hepatic decompensation associated with prolonged MTX therapy in patients with rheumatoid arthritis.

EEG and pathologic findings in patients undergoing brain biopsy for suspected encephalitis.

Previous studies have suggested that EEG may be helpful in the diagnosis of herpes encephalitis (HE). To further define the value of EEG in an acutely ill, febrile, encephalopathic patient suspected as having encephalitis, we reviewed initial preoperative EEGs with the results of cerebral biopsies in 24 consecutive patients suspected of having encephalitis. Statistical analysis demonstrated that EEG patterns have only limited association with biopsy results. Since diseases which mimic encephalitis may also generate identical EEG changes, this is not an unexpected finding. EEG is useful in the evaluation and management of patients with encephalitis. However, the absence of specific wave forms or focal EEG abnormalities in the proper clinical setting should not deter consideration of HE or delay treatment.

Anti-histone antibodies in the serum of autoimmune MRL and NZB/NZW1 F1 mice.

Anti-histone antibodies have been reported in a number of human autoimmune diseases, most notably idiopathic and drug-induced lupus erythematosus. In the current study, anti-histone antibody activity was detected using ELISA and electroblotting techniques in sera from autoimmune NZB/W, MRL-lpr, and MRL-(+)/+ mice. Anti-histone activity increased with age, maturing earlier in females, in both NZB/W and MRL-lpr mice. Testosterone treatment decreased anti-histone activity in NZB/W mice and estrogen treatment from 2 weeks of age increased anti-histone activity in MRL-lpr mice, suggesting that gonadal hormones modified the expression of autoantibodies recognizing these protein antigens. Estrogen also increased serum IgG levels in MRL-lpr mice. Sex hormones affected expression of antibodies recognizing soy milk proteins but not ovalbumin in a similar manner. Nitrocellulose Western blots of SDS gels probed with sera from both types of autoimmune mice most often demonstrated reactivity with histone1. Some mice, usually mature females, also recognized histone4, histone3, and histone2.

Neurologic manifestations of rheumatologic disease.

Patients with pain, dysethesias, or dysfunction of an extremity may present to a neurologist or rheumatologist for the same complaints. A careful history, physical examination, and a simple investigation will usually, but not always, allow for assignment to the proper clinic. This article addresses the ground shared by these two specialties with particular emphasis on common diseases.