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Who has the rheumatology service they needComment on the article by Yelin et al.

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requirements for interaction of the integrins d p l , mpS, and
m/% with the central cell binding domain in fibronectin (abstract). Mol Biol Cell 6 (suppl):388a, 1995
Who has the rheumatology service they need?:
comment on the article by Yelin et a1
To the Editor:
Yelin and colleagues (1) raise important issues about
the utilization of subspecialist resources by persons with
musculoskeletal conditions in the San Mateo County, California community. The use of a screening question that
asked about pain or stiffness for longer than 6 months,
however, may have led to an underestimate of problems that
are presented to physicians, compared with other community survey estimates (2,3).
Looking at the issue in a worldwide context, we have
conducted a survey (4) to define the differences in attitudes
to musculoskeletal pain (MSP) in a “developing,” as opposed to a “developed,” country. We administered standard
questionnaires both to individuals known to be affected by
joint pain and to a matched control population unselected for
joint problems, from semirural communities in both Nigeria
(Igbo-Ora/Eruwa, Oyo state) and England (Sawston, Cambridgeshire).
In both communities, the affected individuals had
similar morbidity, but there was a nonsignificant trend for
more Nigerians to feel that drug treatment helped them (94%
versus 73%, P < 0.1). A surprising 94% (62/66) of the
affected Nigerian sample had seen a doctor for their joint
pain, but these were individuals who were believed most
likely to have inflammatory arthritis, which may have resulted in a sampling bias. None had visited a rheumatologist-a medical specialty which, in Nigeria, like so many
developing countries, has yet to emerge.
Control groups in Nigeria reported a higher prevalence of joint pain, compared with controls in England (48%
versus 31%, P < 0.025), suggesting that musculoskeletal
symptoms are, if anything, more, rather than less, prevalent
in Nigeria. It seems MSP is at least as common and disabling
in this Nigerian community as in the English community
studied, and that funding for the development of rheumatologic services overseas is still urgently required (3, in
tandem with support for those persons with musculoskeletal
conditions in the US who, as shown by Yelin et al, may
receive substandard care because of inadequate health insurance.
Fraser N. Birrell, MA, MRCP
Royal Shrewsbury Hospital
Shrewsbury, England
Adewale 0. Adebajo, MD
Brian L. Hazleman, MA, FRCP
Addenbrookes’ Hospital
Cambridge, England
1. Yelin E, Bernhard G, Pflugrad D: Access to medical care among
persons with musculoskeletal conditions: a study using a random
sample of households in San Mateo County, California. Arthritis
Rheum 38:1128-1133, 1995
2. Silman AJ, Ollier W, Holligan S, Birrell F, Adebajo A, Asuzu M,
Thomson W, Pepper L: Absence of rheumatoid arthritis in a rural
Nigerian population. J Rheumatol 20:618-622, 1993
3. Adebajo AO, Birrell F, Hazleman BL: The pattern of rheumatic
disorders seen amongst patients attending urban and rural clinics
in West Africa. Clin Rheumatol 11512-551, 1992
4. Birrell FN, Clubb T, Adebajo AO, Hazleman BL: Joint pain and
the stiff upper lip: a comparison between attitudes to musculoskeletal pain in semi-rural Nigerian and English communities.
(Submitted for publication)
5 . Adebajo AO: Rheumatology in the third world. Ann Rheum Dis
49:813-816, 1990
To the Editor:
Drs. Birrel, Adebajo, and Hazleman raise an important point in their comment on our article: the reported
prevalence of a musculoskeletal condition is dependent on
the required length of time that the respondent must have
had the condition (Kovar M, Poe G: The National Health
Interview Survey: design 1973-1984, and procedures 19751983. Vital and Health Stat [l] No. 18, 1985). We chose the
6-month timeframe for our study to reduce the chance that
conditions included in the analysis would be transient ones,
such as those associated with minor injuries. This, no doubt,
represents a conservative estimate of prevalence, but serves
to focus the study on the impact of chronic conditions.
Birrel et al have found that access to physicians was
quite good among Nigerians with musculoskeletal pain,
although, in that country, access to specialists was poor
because there were none. In the US, we also found that
access was poor, even though the number of available
rheumatologists in San Mateo County was substantial.
Edward Yelin, PhD
University of California, San Francisco
Gerson Bernhard, MD
Diane Pflugrad, MA
San Mateo Arthritis Project
San Mateo, California
Sulfasalazine in psoriatic arthritis: a new or
established indication?
To the Editor:
We read with interest the concise communication by
Jullien et a1 (1) about 2 cases of toxic epidermal necrolysis
after sulfasalazine (SSZ) treatment of mild psoriatic arthritis.
They pointed out the increased use of sulfasalazine in
psoriatic arthritis (2) and the possibility of life-threatening
adverse cutaneous reactions (3-9, and said that “It is
unlikely that SSZ will become routine therapy for psoriasis
and psoriatic arthritis; however, since this drug has been
reported to be efficacious in the treatment of these diseases,
it is being prescribed for them more than occasionally.”
In our opinion, SSZ will be widely used in psoriatic
arthritis in the future, and the report of these 2 cases is very
important in warning clinicians of the risk of severe cutaneous side effects (even if such an association has not been
reported previously) and the necessity of a clear assessment,
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