359 LETTERS toid arthritis. However, it is noteworthy that in addition to IFN, there is a set of influences, including physiologic and therapeutic effects, which result in quantitative changes in the expression and release of major histocompatibility complex (MHC) I-region antigens. For example, corticosteroids markedly decrease both expression arid detachment of b m (2), while surgical trauma causes an increase in the rate of cell release of a m (3). Possible consequences of these events may quantitatively influence MHC-related regulatory cooperation and lymphocytic activation. Whether the changes in the actual amount of membrane-attached and detached a m are related to the production of autoantibodies to p2m remdins obscure. Andras Falus, PhD National Institute of Rheumatology and Physiotherapy Budapest, Hungaty I . Sanderson AR, Beverley PCL: Interferon. P2-microglobulin and immunoselection in the pathway to malignancy. Immunology Today 4:211-213, 1983 2. Hokland M, Larsen B, Heron 1, Plesner T: Corticosteroids decrease the expression of &-microglobulin and histocompatibility antigens on human peripheral blood lymphocytes in vitro. Clin Exp Imrnunol44:239-246, 1981 3. Walenkamp GHIM, Vree TB, Guelen PJM, Jongman-Nix B: The effect of surgery on the renal excretion of P2-microglobulin. Clin Chim Acta 129:27-37, 1983 Inpatient consultations in private rheumatologic practice To the Editor: The potentially diverse. nature of private rheumatologic practice has been previously emphasized by Bohan (l), Mazanec (2), and Alarc6n-Segovia et al (3). These observations, which were based on analyses of consultative practices in several discrete settings, applied specifically to outpatients. Inpatient rheumatologic consultation appears to be equally expansive in its purview. I wish, therefore, to address this topic by providing a summary of my own experience. A total of 97 consultations (33 male patients, 64 female; mean age 57.7) were performed over a 2-year period, with the vast majority (93/97; 95.9%) originating at either of 2 local hospitals where I was the only rheumatologist on staff. Before my arrival in mid-1981, there had been no rheumatologist serving the community for several years. One hospital (A) was a private non-teaching institution, while the other (B) was a medium-sized teaching hospital at which the house staff was encouraged to seek subspecialty consultations on non-private (“service”) patients. Table 1. Diagnoses of 97 patients seen in consultation Diagnosis Rheumatoid arthritis Degenerative joint disease (osteoarthritis) Uncertain No rheumatologic diagnosis Gout Systemic lupus erythematosus Monarticular arthritis, etiology undermined Myopathy Septic arthritis Polymyositis Vasculitis Temporal arteritis Septic bursitis Fibrositi s Other* No. % 14 12 10 9 7 7 4 4 3 2 2 2 2 2 17 14.4 12.4 10.3 9.3 7.2 1.2 4.1 4. I 3.1 2. I 2.1 2. I 2. I 2.1 17.5 * One each of the following diagnoses: soft tissue trauma, traumatic arthritis, leukemic synovitis, calcium pyrophosphate deposition disease, mixed connective tissue disease, Hamman-Rich syndrome, polymyalgia rheumatica, shoulder-hand syndrome, costochondritis, “soft-tissue rheumatism,” serum sickness, immunodeficiency disorder, enteropathic arthritis, adhesive capsulitis, hyperuricemia, low hack syndrome, carpal tunnel syndrome. Table 1 lists diagnoses of all the patients seen. Private referrals constituted the majority of cases (57197; 58.7%), and these were primarily from hospital A. Inflammatory conditions accounted for 55.7% of the diagnoses, with rheumatoid arthritis the single most frequently encountered disorder. The term “uncertain” requires some clarification, as it was applied to a rather heterogeneous group of patients. Included in this group were patients with bona fide symptoms and findings that were not sufficiently specific to permit definitive diagnoses, as well as several others who demonstrated comparatively little evidence of rheumatic disease. The latter group was distinguished from those placed in the category of “no rheumatologic diagnosis,” which was reserved for those patients referred for problems erroneously believed to represent rheumatic disease (e.g., a case of cellulitis thought to be septic arthritis). As expected, the majority of the private referrals came from internists (4567; 78.9%) with general/family practitioners (14.0%), orthopedists (3.5%), 1 general surgeon (1.8%), and 1 urologist (1.8%) providing the remainder. Patients with inflammatoryhnfectious disorders constituted 60% (27/45) of the referrals from internists; this figure closely approximated the overall percentage indicated above. A comparison of the data concerning several other parameters, such as age distribution, sex ratio, and types of diagnoses seen in the private versus the non-private subset did reveal some minor differences which were not statistically significant. It is certainly reasonable to assume that analogous reviews of other practice situations might yield different results. When integrated with manpower statistics (4) and LETTERS 360 studies of primary care (3,such analyses may serve to further elucidate the present status and scope of rheumatologic practice. Barry Fomberstein, MD S t . Jolin's Episcopal Hospital Fur R o c k a w y , N Y I . Bohan A: The private practice of rheumatology: the first 1000 patients. Arthritis Rheum 24:1304-1307, 1981 BOOK REVIEW Maladies dites Systemiques-Systemic Diseases. M - F Kuhn and A . P . Paltier, edirors. Paris, Nammurion, 1982. 800 pages. Illustrated. This monumental work on a fascinating group of diseases of unknown origin, but of well-recognized pathogenic mechanism, was produced by 2 eminent French authors. It includes 54 contributors and 4,000 references. The first part contains the most up-to-date knowledge of inflammation, the cells involved, and the immunopathogenic considerations; genetic and microbiologic factors as possible causes of these diseases arc also explored. The second part of the textbook presents each clinical entity with current bibliographic references from world literature. Topics include well-defined entities such as rheumatoid arthritis, extraarticular manifestions of' ankylosing spondylitis, and systemic graft-versus-host reaction. as well as less clearly delineated conditions. The many difficulties in classifying connective tissue diseases are discussed skillfully and referenced with the most current literature. The nosology is traced of terms such as temporal arteritis (referred to in European literature as 2. MaLanec DJ: First year of a rheumatologist in private practice (letter). Arthritis Rheum 25:718-719, 1982 3. Alarc6n-Segovia D, Ramos-Niembro F. Conzhlez-Amaro RF: One thousand private rheumatology patients in Mexico City (letter). Arthritis Rheum 26:688-689, 1983 4. Epstein WV, Henke CJ: The nature of U.S. rheumatology practice 1977. Arthritis Rheum 24: 1177-1 187, 1981 5 . Stross J K . Bole GG: The impact of a new rheurnatologist on the management of rheumatic disease patients in community hospitals. Arthritis Rheum 26: 1033-1036, 1983 Horton's disease, after the Mayo Clinic physician who first described it in 1932) and multiple myeloma (called Kahler's disease in European literature). The clinical presentations are well done, the inventory of published in-depth studies is valuable, and the discussions of the significance of various laboratory tests in the diagnosis and the prognosis of rheumatic disease are excellent. For example, in their discussion on systemic lupus erythematosus, the authors stress and separate the cnormous amount of knowledge in experimental models from data acquired from humans. The newest approaches to treating this disease are presented with an objective and critical view. The enormous effort o n the part of the authors and their collaborators is evident in this textbook. It will serve as a useful reference and learning tool for students, residents, and internists. It is my understanding that this book is being translated into English so that it may benefit a larger international audience. Mike Rakic, MD Viricent ' s Medical Center of' Riclimond Staten Islund, N Y St.