An integrated care system for musculoskeletal disorders in a managed care setting.

Practice guidelines, education, consensus building, and extensive communication were the tools used in developing a musculoskeletal care system. Primary care physicians directed patient care using practice guidelines for common musculoskeletal conditions. Patient education and empowerment were emphasized. Specialist consultations were made available by telephone/voicemail to advise primary care physicians regarding treatment plans and the need for specialty referrals. Significant reductions in medical service utilization for this patient population were achieved while high levels of patient satisfaction were maintained. Such integrated systems are likely to work well within other MCOs.

From futility to triage.

Basic disagreements about what makes human life valuable hinder use of the concept of futility to decide whether it is appropriate to continue life support for one in a permanent state of unconsciousness, or to provide intensive medical care to one in the last stages of a terminal illness (the "paradigm cases"). Triage planning (the process of establishing criteria for health care prioritization) is an attractive alternative framework for addressing the paradigm cases. Triage planning permits society to see the cases in the context of diverse moral perspectives, limited resources, and competing health care demands. Furthermore, at least one essential question posed by the paradigm cases is whether treatment is wasteful, and triage planning is a useful model for identifying and eliminating wasteful medical care. The authors describe how triage planning can be implemented to address the paradigm cases, and conclude that it offers one way of moving debate about these cases beyond futility.

A comparison of cyclobenzaprine and placebo in the management of fibrositis. A double-blind controlled study.

The efficacy of cyclobenzaprine (Flexeril), as compared with placebo, was tested in a 12-week, double-blind, controlled trial of 120 patients with fibrositis. Of the patients who received placebo, 52% dropped out due to lack of efficacy of the drug, compared with 16% of patients taking cyclobenzaprine. The dropout rate due to adverse reactions was similar in the 2 groups. Patients taking cyclobenzaprine experienced a significant decrease in the severity of pain and a significant increase in the quality of sleep. There was a trend toward improvement in the symptoms of fatigue, but morning stiffness was not alleviated. These improvements in symptoms were associated with a significant reduction in the total number of tender points and in muscle tightness. Our findings indicate that cyclobenzaprine is a useful adjunct in treating patients with the fibrositis syndrome.

Patient outcome following inpatient vs outpatient treatment of rheumatoid arthritis.

To assess the short and longterm efficacy of intensive inpatient treatment of active rheumatoid arthritis (RA), 16 patients, the test group, admitted to a hospital based rheumatic disease unit (mean length of stay 12.4 days) were studied, using clinical and laboratory variables. The comparison group was similarly evaluated, using 10 outpatients with active RA to whom hospitalization was recommended, but refused by the patients. Both groups were studied intensively over a 12-week period. In addition, a 2-year followup was performed on 12 test group inpatients and 8 comparison group outpatients, using the same variables plus a functional status questionnaire. Health care costs were determined for both groups and corrected for a 1985 dollar value. The test group showed significant improvement in morning stiffness, pain, and joint score, whereas the comparison group improved only in pain score during the initial 12-week period. At 2 years, the test group and the comparison group showed significant improvement in morning stiffness, pain, grip strength, and joint score. The comparison group initially had a somewhat lower index of disease activity. The test group maintained their initial improvement and none required rehospitalization. Functional status scores were similar for both groups. Health care costs were initially higher for the test group ($5,065); followup care cost for the test group was $99 less/year than the comparison group over 2 years. Hospitalization on a rheumatic disease unit brought about prompt, sustained improvement in 2 weeks which required nearly 2 years to achieve in the comparison group. Such hospitalization of uncomplicated RA seems warranted to decrease disability and increase the quality of life.

Pharmacotherapeutics in fibrositis.

Fibrositis (fibromyalgia) is best treated by attaining patient acceptance of and compliance with a comprehensive treatment program. This includes education, physical therapy, muscle and mental relaxation, examination and adjustment of goals and priorities, and pacing of activities, as well as pharmacotherapeutics. Of the medications in use, anti-inflammatory agents with a high degree of analgesia are more effective than "pure" anti-inflammatory agents. Tricyclic derivatives are beneficial muscle relaxants. The use of long-acting agents improves compliance and is therefore favored. Local agents are of adjunctive value in some cases. Double-blind, placebo-controlled studies show cyclobenzaprine to be an effective medication in the treatment of fibrositis (fibromyalgia).

Hip pain in patient with Crohn's disease. Occult retroperitoneal abscess as cause.

A 20-year-old man with Crohn's disease was seen as an outpatient for pain in the left hip and gait disturbance. Initially, arthritis of the hip was suspected, because of the absence of fever or abdominal abnormalities. Two weeks later, fever, malaise, and pneumaturia developed and urine culture grew Escherichia coli. Laparotomy revealed a large occult retroperitoneal abscess on the left side, which had been irritating the psoas muscle. Surgical drainage effected complete recovery of hip function. The abscess in this patient had a very unusual presentation and was diagnosed chiefly through a high index of suspicion after a careful physical examination.

Predominance of synovial fluid lymphocytes in early rheumatoid arthritis.

Evaluation of 158 synovial fluids, mainly from patients with rheumatoid arthritis (RA) and the crystal deposition fiseases (CDD), revealed differences in the differential white blood count and numbers of cytoplasmic inclusion bodies (CIB) present. Lymphocytes and CIB were increased in RA, suggesting a different pathologic mechanism from that of CDD. Lymphocyte-like cells contained CIB implying phagocytic capability. Lymphocytes were the initial predominant cell type in RA of less than six weeks disease duration. Later polymorphonuclear leukocytes increased, possibily representing a secondary non-specific inflammatory response similar to that seen in CDD.

Articular complications of homotransplantation and chronic renal hemodialysis.

Renal homotransplantaion and chronic hemodialysis are accepted methods of treating end-stage kidney disease. However, these procedures are fraught with complications involving bones, joints, and soft tissues. Transplantation and immunosuppressive therapy problems include "connective tissue-like" reactions, infections in joints and avascular necrosis of bone. Long term hemodialysis may accentuate secondary hyperparathyroidism, renal osteodystrophy, and metastatic calcification, which can be minimized by phosphorous control or calcium loading in the dialysate. In the presence of osteomalacia, vitamin D may be helpful and parathyroidectomy is indicated if autonomy is present. In one patient undergoing long term hemodialysis, a chalky material was aspirated from the olecranon bursa. Two inorganic solid phases were identified as being present - a major phase, octacalcium phosphate (ocp) and a minor phase, calcite (CaCO3). Because of its elusive properties, the role of OCP in biological systems is poorly known and can easily escape detection. Methods of identification of OCP and its potential role in crystal deposition syndromes are discussed.

Demonstration of macromolecular inhibitors of calcification and nucleational factors in fluid from calcifying sites in cartilage.

An extracellular fluid phase (C(f1)), aspirated by micropuncture techniques from the hypertrophic cell zone of calcifying epiphyseal certilage, has been characterized in a calcifying system in vitro in respect to the behavior of sedimenting and supernatant fractions after high speed ultracentrifugation. To perform these tests on the starting samples of 20 nl of C(f1), macroscopic analytical methods were scaled down for the identification of relevant organic components, including hexuronic acid and proteinpolysaccharides (PPL). The mineral accretion system was designed to simulate physiologic conditions in the calcifying cartilage septa of normal rats, and the mineral used for seeding was an immature calcium phosphate similar to native cartilage mineral. Normal C(f1) or its dilutions in synthetic lymph up to 1:4 completely prevented mineral accretion in vitro. The inhibitory action was localized to the sedimented fractions after ultracentrifugation and could be destroyed by incubation with trypsin or hyaluronidase. The sediment of C(f1) contained 2 mg of hexuronic acid per ml of C(f1) and gave a strong reaction of identification for a light fraction of PPL by fluorescent antibodies to rat PPL. PPL fractions were tested in the same mineral accretion systems as C(f1) and exhibited responses similar to those of C(f1). Also, there was evidence of a mineral phase in C(f1) of normal rats, in C(f1) of rats with healing rickets, but not in C(f1) of untreated rachitic rats. These results are interpreted to indicate that certain PPLs function as an inhibitor of crystal growth at extracellular sites premonitory to calcification. Evidence for a low density inhibitor of mineral accretion was found in normal serum but not in C(f1).