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Inpatient consultations in private rheumatologic practice.

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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.
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