Team managed outpatient care for early onset chronic inflammatory arthritis.

OBJECTIVE: To determine whether an outpatient team management program for persons with early chronic inflammatory arthritis would produce improved clinical outcomes and lower costs than traditional, nonteam outpatient rheumatologic care in a clinic setting. METHODS: One hundred eighteen patients with chronic inflammatory arthritis were randomly assigned to a team managed outpatient care program (TEAMCARE) or to traditional, one on one, nonteam managed rheumatologic care (TRADCARE). The TEAMCARE program consisted of a half day educational program, a needs assessment intake interview, and quarterly telephone calls, monthly team meetings, and routine rheumatologic care. TRADCARE patient received unconstrained, routine primary and specialty outpatient care as practised typically by rheumatologists at this large multi-specialty clinic. All patients had numerous physical and laboratory outcome assessments by rheumatologists at office visit. Every 6 months, patients completed several self-report measures of functional status, pain, psychosocial status, and costs. RESULTS: One hundred seven patients completed one year of study participation. No significant differences were found between groups in measures of physical status, physical functioning, psychosocial status, or pain. There were no differences between groups in economic or utilization measures. CONCLUSION: This team managed outpatient program for persons with recent onset chronic inflammatory arthritis afforded no advantage to routine outpatient care, characterized mainly by one on one relationships between patients and primary care doctors and rheumatologists, in our active outpatient clinical environment.

Special concerns in Lyme disease. Seropositivity with vague symptoms and development of fibrositis.

Fear of Lyme disease may be as powerful as the disease itself. Patients may insist on being tested for infection although little evidence of it exists, and a positive result in the face of vague symptoms can add to the problem. Physicians should explain to these patients the differences in "background" seropositivity in various geographic locations and the drawbacks of instituting unnecessary treatment. Fibrositis may evolve over time after Lyme disease infection. Many factors may trigger this disorder, but some investigators propose that it is a result of musculoskeletal pain, sleep disturbance, and anxiety over the disease.

Eosinophilia-myalgia syndrome associated with L-tryptophan use.

The eosinophilia-myalgia syndrome associated with the use of oral preparations of the amino acid L-tryptophan was recognized in late 1989. We describe the clinical and laboratory manifestations, pathological findings and early clinical course of 20 patients with the eosinophilia-myalgia syndrome. Prominent clinical findings included severe myalgias limiting function, fatigue, rashes, edema and weight gain, weight loss, muscle weakness and shortness of breath. Laboratory findings included eosinophilia (often marked), normal erythrocyte sedimentation rate, and elevated aldolase with normal or low creatine kinase values. On biopsy fascial inflammation was always seen consisting of lymphocytes, histiocytes and eosinophils in a perivascular distribution. Invasion of the vascular wall by lymphocytes was seen in 20%. Capillary and arteriolar endothelial cell thickening was found in most cases on electron microscopy and endothelial cell necrosis or mural invasion by lymphocytes was seen in 25% of cases. Two patients improved with no therapy. Ten patients responded to therapy with prednisone alone. Three patients have had progressive disease and one of these died. The relationship of this syndrome to previously described disease entities associated with eosinophilia is discussed.

Lyme disease. Recognizing its many manifestations.

Lyme borreliosis is a relatively new disease, so much remains to be learned about it. In this article, typical manifestations at each stage are reviewed. However, as the authors emphasize, diagnosis is still a challenge because a given patient may have from a few to all of the features discussed, stages often overlap, and characteristics come and go and may mimic other illnesses.

DeQuervain tenosynovitis in pregnant and postpartum women.

DeQuervain tenosynovitis, which involves the abductor pollicis longus and extensor pollicis brevis tendons, is much more common in women than men and is due to repetitive movements of the hand such as grasping and twisting. Housewives and persons involved in manual occupations using the hands and wrists account for most cases in previous series. In this series, six of 24 female patients (25%) were pregnant or postpartum at the time of onset. In five of the six, activities of infant care aggravated symptoms. Both pregnancy, per se, and mechanical factors appear to play a role in causing this condition.

Lyme disease. The tick bite, the rash, and the sequelae.

Lyme disease may present as a characteristic skin eruption, an acute arthritis, or less commonly, an acute neurologic or cardiac illness. A carefully taken history, including a travel history, provides the key to diagnosis. Laboratory tests other than spirochetal antibody studies are nonspecific. Prompt antibiotic treatment is important not only for reducing the intensity and duration of the skin eruption but for preventing major sequelae.

Serial circulating immune complexes and mononuclear phagocyte system function in infective endocarditis.

Twenty patients with infective endocarditis were followed prospectively and all had elevated levels of circulating immune complexes (CICs) detected by staphylococcal binding assay. Mean CIC levels declined for the group as a whole (193 micrograms/ml +/- 24 to 100 +/- 17, p less than 0.05) and became undetectable in eight patients (47%) who were cured. Patients who died or had complicated courses had higher mean CIC levels at the start and finish (254 micrograms/ml +/- 24 and 145 +/- 37) of antibiotic therapy than patients with uncomplicated courses (178 micrograms/ml +/- 19 and 38 +/- 24), p less than 0.05. CIC levels did not decline significantly in patients with glomerulonephritis or arthritis, in contrast to patients without these features. Despite elevated CIC levels, 10 patients had enhanced mononuclear phagocyte system (MPS) function as assessed by Fc-dependent IgG-coated red blood cell clearance. These data suggest that CICs probably are pathogenic in endocarditis and may contribute to the development of arthritis and glomerulonephritis. Elevated CICs in infective endocarditis do not appear to be directly related to defective MPS function.

Variability of the lupus band test. Results in 18 patients with systemic lupus erythematosus.

Six simultaneous skin biopsies were performed on each of 18 patients with systemic lupus erythematosus. Variability was found both in the lupus band test (LBT) findings and in the presence of its individual immunoglobulin components and C3 in adjacent biopsy specimens taken from both sun-exposed and sun-protected sites. This variability in immune deposits is a major factor in the lack of reproducible association between LBT findings and clinical and serologic indicators of disease activity.

Identification of bacterial antigens in circulating immune complexes of infective endocarditis.

The presence of circulating immune complexes (IC) in patients with infective endocarditis has been well documented but the contributions of host and bacterial components to these IC have not been defined. To study this question, IC were isolated from serum of a patient with Streptococcus faecalis endocarditis by differential polyethylene glycol precipitation and competitive binding to staphylococcal protein A. A rabbit antiserum raised against the purified IC had reactivity by crossed immunoelectrophoresis primarily with an antigen derived from the cytoplasm of the infective organism. The antigen was a protein with a 12,000-dalton molecular mass. In situ radiolabeling of the IC bound to the protein A demonstrated a component of the same molecular mass as the bacterial antigen recognized by the antiserum. The patient serum had multiple antibody specificities reactive with bacterial antigens, including the antigen recognized by the rabbit anti-IC antiserum. These techniques for isolation and characterization of circulating IC may have value in the study of IC diseases in which the inciting antigens are not known.