Controversies in Rheumatology

Rheumatology in Primary Care

N Engl J Med 1997; 337:1932-1933December 25, 1997DOI: 10.1056/NEJM199712253372620

Controversies in Rheumatology
Edited by David A. Isenberg and Lori B. Tucker. 169 pp. London, Martin Dunitz, 1997. (Distributed by Mosby, St. Louis.) $80. ISBN: 1-85317-395-9

Rheumatology in Primary Care
By Juan J. Canoso. 372 pp., illustrated. Philadelphia, W.B. Saunders, 1997. $45. ISBN: 0-7216-6080-0

No area of medicine is free from controversy. Few book titles are as intriguing as those that promise to explore controversial issues. In Controversies in Rheumatology each chapter is written by well-known experts in rheumatology and immunology.

The chapter on the HLA-DRB1 shared epitope in rheumatoid arthritis will probably be the most interesting one to rheumatologists. However, rather than deal with controversy, it provides a good exposition of genetic influences on the distribution and severity of the disease. The chapter on heat-shock proteins in the rheumatic diseases reviews current theories of the role of these proteins. The next chapter, on “gastroprotection” in patients taking nonsteroidal antiinflammatory drugs, is intriguing because it lists osteoporosis, colonic polyps and colonic cancer, and Alzheimer's disease as conditions for which nonsteroidal antiinflammatory drugs are appropriate therapy. Now this is controversial! The side effects of methotrexate, one of the most widely used drugs today in the treatment of inflammatory rheumatic diseases, receive a careful and thorough review. The use of monoclonal antibodies in the treatment of rheumatoid arthritis is creeping up on us. There is a good review of what is known about these agents and where we are going with them — not much controversy here. The chapter on the treatment of chronic pain goes over a number of therapies and describes many types of chronic pain syndromes. It correctly points out the deficiencies of physicians in their handling of these problems and advocates a team approach in therapy. The use of plasma-exchange therapy for the treatment of systemic lupus erythematosus is certainly controversial, but the chapter on this topic should have discussed the costs of the different therapies, since cost would be a bar to its use even if it were thought to be of value.

Mixed connective-tissue disease is a controversial topic in rheumatology. The authors elucidate the problems and review the pertinent literature. It is a big hit, albeit one of the shortest chapters in this book. The role of klebsiella in ankylosing spondylitis has been weaving its way through rheumatologic thought for the past 24 years. The authors approach this topic from several different directions and come to the conclusion that there is no conclusion. Also presented is the perennial argument about how to classify and use the nomenclature of arthritis in children. The chapter on the role of infection as a cause of chronic arthritis in children is a good review of all the evidence, but most of the data are from studies in adults and may not have the same relevance in children.

In a review of therapy of autoimmune diseases in children, oral gold is not discussed. The authors state that there are now a “number of reports” of the use of cyclosporine in dermatomyositis but provide only one reference. A considerable problem in juvenile dermatomyositis — the development of calcinosis — is also not discussed. Although the authors emphasize that children with systemic lupus erythematosus are not just small adults with the disease, the basic therapy they describe is similar to that used in adults.

This book of short chapters on various topics in rheumatology is on the whole well written. The degree of controversy in the subjects ranges from a little to a lot. As reviews of many areas in rheumatology, they are current and would be of interest to rheumatologists and to those who follow the field. Though this is not an essential book, it would also be of value to generalists who want to keep up with new concepts and therapies.

Rheumatology in primary care encompasses a whole range of problems: bone diseases, infectious arthropathies, gout, rheumatoid arthritis and the other autoimmune diseases, and the most prevalent problem, osteoarthritis. Primary care physicians are expected to deal with the majority of cases seen in their practice, with occasional help from specialists in rheumatology, orthopedics, infectious diseases, and physiatry. Rheumatology in Primary Care attempts to help primary care physicians deal with these conditions, guide them in diagnosis and therapy, and show them when to call on their specialist colleagues for help.

The author has laid the book out well, starting with a brief description of the physical examination and then pointing out various patterns in which specific diseases can be recognized. The examination of joint fluid, however, is best done in a clinical laboratory. The statement that most synovial aspirations are done to see whether crystals are present minimizes the importance of the procedure, which is often performed to reduce joint swelling, diagnose the condition, and treat it if necessary with injectable depot corticosteroids. The chapter on immunologic studies is well done, with a needed discussion on false positive antinuclear antibodies and the proper evaluation of the finding of HLA-B27 in a patient. The chapter on rheumatoid arthritis is notable for tables that list features of the disease such as systemic manifestations, its presentation in the elderly, and how to differentiate it from polymyalgia rheumatica. This type of presentation is especially well done in the chapter on systemic lupus erythematosus. Highlighting of important features of a disease in this way makes it easy for the physician to check out a particular point.

The references are remarkably timely and are from journals that can be found in virtually all medical libraries. The discussion of the relation of connective-tissue diseases to breast implants represents the latest thinking on this controversial topic. A problem that is often brought up is whether a biopsy is needed for the diagnosis of giant-cell arteritis. This book lists five features of the American College of Rheumatology criteria and states that three are sufficient for diagnosis. One of the five features is temporal-artery biopsy, but the author states that “diagnosis should be confirmed by temporal-artery biopsy.” If the diagnosis can be made without biopsy, why subject the patient to this operation?

Primary care physicians may be confused by the initial statement that for the diagnosis of Lyme disease a “positive ELISA [enzyme-linked immunoassay] is hard to argue against,” but the author later cautions that there is “a high false positive rate of ELISA” tests. The chapter on regional rheumatic diseases will be particularly helpful for primary care physicians. The author explains in detail the examination and differential diagnosis of pain in the hand and wrist, elbow, shoulder, neck and upper and lower back, hip, knee, and foot. The sections headed “When to Refer” will help physicians to decide when to call for help. Unfortunately, this book was written before the recent paper indicating that attending an educational program (back school) is of little or no value for patients with chronic back pain. The author thinks such programs are of benefit and should be used. There is also an incorrect description of hypermobility as extension of the knee and elbow past 0 degrees. Beighton defines hypermobility as hyperextension of the elbow and knee beyond 10 degrees. Furthermore, there is no role for joint replacement in the treatment of hypermobility.

The procedures for the instillation of depot corticosteroids into virtually every possible site are well described, but pictures or drawings would have been much more helpful, since in some cases the technique is not clearly described. For example, for injection of the trochanteric bursa, a mixture of corticosteroid and xylocaine is recommended, but in the description of the procedure, the site is infiltrated with xylocaine alone before the mixture is used.

The physical-therapy section is in general well done. I would disagree with the description of quadriceps setting exercises being done in bed. This would limit the amount of exercise that the patient can do, when in fact this exercise can be done while the patient is sitting.

This easy-to-handle, relatively small book (as compared with textbooks of rheumatology) can be recommended for use by the primary care physician. It would be good as well for house staff and for the beginning fellow in rheumatology as a basic textbook.

John Baum, M.D.
University of Rochester School of Medicine and Dentistry, Rochester, NY 14642