A personal experience with Guillain-Barré syndrome: are the psychologic needs of patient and family being met?

We present a dialogue that illustrates how difficult an episode of severe illness is for both the suffering patient and the confused family. The powerful emotions engendered can be successfully managed only when physicians and nurses are aware of and address this turbulence that the patient and family are experiencing.

Effect of age and sex on the erythrocyte sedimentation rate.

In a study designed to reevaluate standard normal values for the erythrocyte sedimentation rate (ESR) determined by modified Westergren method, we analyzed samples obtained from individuals in infancy through age 80 years. We found upper limits of normal to be slightly above generally accepted standard laboratory values. An age related increase (stepwise for women and more abrupt in the 5th decade for men) suggests that standard normal values for the Westergren method should be modified.

Health outcomes for a chronic disease in prepaid group practice and fee for service settings. The case of rheumatoid arthritis.

The authors compare health care use and outcomes of a panel of persons with rheumatoid arthritis receiving health care in prepaid group practice and fee-for-service settings. In 1982, they randomly sampled one half of all 114 board-certified or eligible rheumatologists in Northern California. Those who participated provided the names of all patients with rheumatoid arthritis presenting during a 1-month period; 812 of these patients (97% of those listed) were interviewed. In 1984, 745 of them (92% of the baseline cohort) were interviewed; 569 receive care in fee-for-service settings and 176 in prepaid group practice. As in the baseline survey year, the prepaid patients received similar amounts and kinds of health care as their fee-for-service counterparts. The prepaid and fee-for-service patients achieved similar outcomes, as measured by symptoms of illness, functional status, and work disability. The fee-for-service patients reported poorer overall health status. The authors conclude, after 2 years of follow-up study, that patients in prepaid group practice receive similar medical care inputs and achieve outcomes at least as good as those in fee-for-service.

Stress management and mutual support groups in rheumatoid arthritis.

Stress management and mutual support groups are employed widely in chronic illness, although their efficacy has not been established. To determine the effect of these measures on morbidity and psychologic health in rheumatoid arthritis, 105 patients meeting diagnostic criteria for rheumatoid arthritis were evaluated for depression, life satisfaction, functional disability, and indicators of disease activity. Patients were randomly assigned to one of three groups: (1) stress management; (2) mutual support; (3) no intervention (control). After completion of 10 weekly sessions, identical tests were performed for all patients in the intervention and control groups. Patients in the intervention groups showed greater improvement in joint tenderness than did the control patients but did not differ significantly from the patients in the control group in any of the other outcome measures.

Recognition of information in renal biopsies of patients with lupus nephritis.

To evaluate the informational value of renal biopsy in nephritis of systemic lupus erythematosus, we selected the records of 30 patients who had a renal biopsy done and also had a known clinical outcome. Detailed case histories were prepared, and three distinct randomly chosen cases were given to 197 academic rheumatologists. The rheumatologists estimated the probability of future clinical events (worsened serum creatinine, worsened urine protein, renal death, and aggressive therapy) at 3 and 12 months after the biopsy. Biopsy results were given in detail, and probability estimates were made of the same clinical events using the additional information. The accuracy of each probability estimate was measured using a scoring function that depends on the estimates and the actual outcomes. Knowledge of the renal biopsy failed to improve predictive accuracy scores of estimates of future serum creatinine levels, urine protein levels, and renal death at 3 and 12 months (p less than 0.0001), and for estimates of the probability of the use of aggressive therapy at 12 months (p less than 0.007). The renal biopsy information improved only the accuracy of predictions concerning the use of aggressive therapy at 3 months (p less than or equal to 0.0003). Knowledge of the renal biopsy results failed to add important prognostic information about the future course of treated lupus nephritis to information already obtained from history, physical examination, and laboratory tests.

The information content from renal biopsy in systemic lupus erythematosus.

We analyzed data for the 12-month period after renal biopsy was done in 130 patients with systemic lupus erythematosus to examine whether renal biopsy provides useful information on the nephritis of systemic lupus erythematosus beyond that clinically available. A stepwise linear regression analysis was used to construct a linear before biopsy model that predicted the change in renal function 12 months after biopsy. The model included serum creatinine, patient age, 24-hour urine protein, a laboratory index of renal activity, antibodies to DNA, urinalysis protein, change in inverse creatinine from 6 weeks before biopsy, and urine light chain protein, and had a squared multiple correlation coefficient (R2) of 0.246. Four prospectively chosen renal biopsy variables (glomerular cell counts, percent of sclerotic glomeruli, percent of glomeruli with crescents, and interstitial fibrosis) resulted in a 0.079 improvement in R2 (p less than or equal to 0.012). Both the percent glomerular sclerosis (p less than or equal to 0.0032) and subendothelial deposits shown by electron microscopy (p less than or equal to 0.0026) added significantly to the predictive power of the before biopsy model. Histologic classification did not add significantly to the before biopsy model. The renal biopsy information increased the power of a linear regression model to predict the effect of 12 months of treatment of active lupus nephritis.

Assigning normal blood glucose values by probability plot analysis.

Blood glucose results for 2,601 specimens obtained at multiphasic health examination, divided into three age groups, were analyzed using probability plot paper. Two straight lines could be fitted to each distribution. The assumption was made that the lower lines correspond to "normal-healthy" persons, whereas the upper lines correspond to persons with defective control of blood sugar. It was concluded that the mean of the presumed normal-healthy subgroups rises only a few mg/dl per decade.

Membranous lupus nephropathy initially seen as idiopathic membranous nephropathy. Possible diagnostic value of tubular reticular structures.

When a renal lesion is the sole manifestation of systemic lupus erythematosus (SLE), differentiation from other nephropathies is difficult. The membranous form of lupus nephritis is especially difficult to distinguish from idiopathic membranous nephropathy, particularly when multisystem and serologic features of SLE are absent. We report two cases in which the initial renal biopsy findings suggested idiopathic membranous nephropathy and in which the subsequent emergence of SLE might have been predicted by the presence of tubular reticular structures. We identified these structures in 177 of 183 (96.7%) renal biopsy specimens from patients with SLE, but in only three of 128 (2.3%) renal specimens from patients with membranous nephropathy. Tubular reticular structures are markers of the renal lesion of SLE and may be helpful in differentiation from membranous nephropathy.

Nails and systemic disease.

Important diagnostic clues may be provided by changes in the nails. Because nail findings are easily observable and yield valuable information, attention to these features is often rewarding. Some of the nail changes that may be observed in systemic disorders are reviewed.