Talking with patients about alternative and complementary medicine.

The growing use of alternative and complementary therapies in the United States as well as other parts of the world is a trend that the responsible rheumatologist cannot ignore. With chronic musculoskeletal conditions being the leading indication for the use of alternative and complementary therapies, rheumatologists must become experts on talking to patients and advising them about the use or avoidance of such therapies. Currently, there is a growing body of literature on the safety and efficacy of the multiple alternative and complementary therapies available. Much of this information is reliable and of high methologic quality; however, much of it is not. With an increase in the budget of the Office of Alternative Medicine from $20 to $50 million in 1999 and the status of the office changing to an independent center, an important step has been taken to try to assure improved research in the near future to validate or disprove many of the current alternative and complementary therapies. In the meantime, our patients are using these therapies and are likely to continue to do so, with or without our guidance. We must get beyond the "don't ask, don't tell" approach that characterizes many physicians' attitudes toward the subject of alternative and complementary therapies. Although all discussions need not end in agreement, they are still opportunities for shared decision making and "relationship-centered care." Ultimately, we should not be concerned with practicing what is perceived to be traditional versus alternative and complementary medicine or biomedicine versus naturalistic medicine but only with what is truly "good" medicine.

Diets, dietary supplements, and nutritional therapies in rheumatic diseases.

Rheumatoid arthritis and many other systemic rheumatic diseases remain illnesses of unknown cause for which current therapy is often inadequate. This leads patients to seek questionable remedies, prominent among which are dietary manipulations. Is there a role for dietary modifications in the routine therapy for patients with rheumatic diseases? This article discusses the relationships between diets, fasting, elemental nutrition, vitamins, minerals, and foods for rheumatic diseases. Known scientific-based evidence for the use, safety, and efficacy of diets and dietary-related practices subscribed by patients with rheumatic diseases are presented. Studies that link diet with arthritis offer the possibility of identifying new therapeutic approaches for selected patients and of developing new insights to disease pathogenesis. Dietary therapy for arthritis, however, is still being investigated.

Common painful foot syndromes.

The prevalence of foot problems in the general population is 10%, and in the elderly it ranges from 53% to 95%. Proximal plantar fasciitis is the most common cause of painful feet in clinical practice, and is twice as common among women as among men. Metatarsalgia is probably the most common cause of foot pain among middle-aged women.

Case management study: polyarthritis with fever.

In most cases, a thorough initial evaluation will reveal the cause of fever and polyarthritis. However, in some patients the initial diagnosis may be unclear and, as time passes, the characteristic clinical patterns emerge. Recurrent attacks are suggestive of other conditions such as crystal-induced arthritis, Lyme disease, and Mediterranean fever. In rheumatoid arthritis and Reiter's syndrome, the fever resolves and the articular findings predominate with the passage of time. Similarly, Still's disease is initially diagnosed on the basis of clinical criteria, and later confirmed by the evolution of chronic polyarthritis. Diagnostic approaches for the evaluation of patients presenting with acute arthritis have been published and are readily available (2,8,9). The most reliable way to establish the diagnosis for a rheumatic disease is thoughtful and thorough evaluation by an experienced clinician (3,10). Certain discriminating features and confirmatory tests can aid in the diagnosis of polyarthritis with fever (Tables 2 and 3).

It is lupus?

It has been said that the essence of medicine is the reduction of uncertainty for patients and physicians (Ludo Baghius). Confronting patients who have some symptoms suggesting lupus but who do not meet criteria for classic SLE is challenging. Evaluating and caring for these patients, when not making a diagnosis of SLE, demands clinical acumen, confidence, and effective communication skills.

Costs, outcomes, and patient satisfaction by provider type for patients with rheumatic and musculoskeletal conditions: a critical review of the literature and proposed methodologic standards.

PURPOSE: To compare the outcomes of care provided by generalists with that provided by specialists for patients with musculoskeletal and rheumatic conditions. DATA SOURCES: English-language studies published between 1986 and April 1996 were identified through a MEDLINE search. STUDY SELECTION: Studies that compared generalists' and specialists' treatment preferences, appropriateness of care, or outcomes with regard to musculoskeletal and rheumatic conditions were examined. DATA EXTRACTION: Studies were reviewed for methodologic rigor and outcomes. DATA SYNTHESIS: Low back pain is treated by many types of providers, without consistent differences in outcomes across provider types. In one study, however, patients were more satisfied with chiropractic care than with care provided by primary care physicians, although the former cost twice as much as the latter. For osteoarthritis of the hip, rheumatologists and primary care providers reported using different therapeutic regimens. For acute mono- and oligoarthritis, rheumatologists performed arthrocentesis more appropriately than nonrheumatologists and produced shorter durations of hospitalization. In the management of gout, rheumatologists used colchicine during the introduction of urate-lowering therapy more appropriately than other providers. In two population-based cohorts of patients with rheumatoid arthritis, patients cared for by rheumatologists were prescribed significantly more disease-modifying agents and had less disability than patients cared for by generalists. CONCLUSIONS: Although empirical data are scant, there seem to be differences between generalists and specialists for a range of outcomes in various musculoskeletal and rheumatic conditions. Studies to data have important methodologic limitations that need to be addressed in future research.

Giant cell arteritis: diagnosis and management.

Giant cell arteritis should not be a diagnosis of exclusion, an afterthought, or a last thought. There is urgency to establishing this diagnosis and initiating therapy. All practitioners who treat adults will be confronted with these patients. Some will have classic presentations, some will have subtle presentations. When patients complain of fever, fatigue, malaise, weight loss, or painless vision loss, GCA should be suspected. An ESR will aid in the diagnosis (although a normal ESR does not rule it out), and sometimes temporal artery biopsy will provide certainty. Giant cell arteritis is usually easy to recognize, easy to treat, and satisfying to manage.

Review: corticosteroid usage: observations at a community hospital.

Corticosteroids have revolutionized the medical treatment of many diseases. However, their value is limited by substantial potential adverse effects. Therefore, the authors reviewed their clinical use at their community medical center by comparing physician decisions about therapeutic management with the indications published in the current medical literature. They retrospectively reviewed 100 consecutive charts of patients from 1993 to 1994 who received corticosteroid therapy during their hospital stay. They found that 36 patients received appropriate corticosteroid intervention, 49 received partially appropriate corticosteroid intervention, and 15 received inappropriate corticosteroid intervention when compared with current medical literature recommendations for patients with the corresponding diagnoses. Ninety-five percent of patients given "partially appropriate" corticosteroid therapy and 73% given "inappropriate" corticosteroid therapy experienced medication-related side effects compared with 19% of patients given appropriate corticosteroid therapy intervention (P < 0.05). No patient records addressed the possibility of steroid-related osteoporosis. There were no significant differences in the clinical course of the three groups of patients treated with corticosteroids. On the basis of these data, the majority of hospitalized patients given corticosteroids did not receive them entirely in accordance with literature recommendations; these patients experienced increased medication toxicity and did not receive prophylaxis for osteoporosis. These limited observations suggest opportunities to improve patient care.

Factitial illness mimicking rheumatic disease with panniculitis.

Factitial disorders can present with a wide spectrum of clinical features and might be overlooked. We identified two patients believed to have factitial disorders mimicking panniculitis at one medical center within 15 months. Both were females in their early forties who had long histories of cutaneous ulcerations, recurrent cellulitis, abscesses, atrophy, and scarring with sparing of inaccessible body areas. They had a) undergone surgical interventions during multiple hospitalizations, b) demonstrated no response to apparently appropriate medical management, c) had thick charts, clinical depression, "hollow" histories, and borderline personalities, and d) exhibited "peregrination" and "laparotomaphilia migrans." Their biopsies suggested amorphous birefringent material of exogenous origin on polarized light microscopy. Factitial disease is an underrecognized clinical syndrome. This diagnosis can be established when it is considered and when thoughtful evaluation is undertaken; this disorder may be amendable to management if patients return for care.