Richard S. Panush

Vasculitis associated with malignancy. Experience with 13 patients and literature review.

Vasculitis is a syndrome which may complicate certain infectious, rheumatic, and allergic diseases. We identified 13 patients, over the past 17 years, who had both vasculitis and lympho- or myeloproliferative disorders and relate their clinical, laboratory, histologic, and immunologic features, course, therapy, and outcome. Nine patients were male, 4 female; ages ranged from 28 to 82 years. Ten of 13 patients presented with cutaneous vasculitis antedating malignancy by an average of 10 months. Three of 13 developed cutaneous vasculitis after malignancy. A statistically significant association between cutaneous vasculitis and lympho- or myeloproliferative malignancies was noted when compared with all other tumors. Dermatologic manifestations included palpable purpura (5 patients), maculopapular eruptions (4), urticarial and petechial lesions (3), and ulcers (1). Hepatitis B surface antigen, Coombs antibodies, rheumatoid factor and antinuclear antibodies were not found. Serum cryoglobulins were detected in 3 patients; serum C3 and C4 were normal in 8 of 9 patients evaluated. Histologic examinations revealed necrotizing leukocytoclastic vasculitis with disruption of endothelial integrity, destruction of endothelium, and neutrophil infiltration. Occasional perivascular mononuclear cell invasion was also noted in 4 patients. Immunofluorescent staining for IgG, IgA, IgM, C3, and C4 was negative in all patients studied. Symptoms were, in general, poorly responsive to therapy, which included nonsteroidal antiinflammatory drugs, antihistamines, antiserotonin agents, and corticosteroids. Chemotherapy directed at the underlying malignancy was also generally ineffective, although the vasculitis appeared to lessen in severity. Vasculitis appeared to lessen in severity as bone marrow function deteriorated. Ten patients died, all as a direct result of their malignancy. We have described a unique clinical syndrome of lympho- and myeloproliferative disease presenting with small-vessel vasculitis. Recognition that rheumatic symptoms may reflect or antedate malignancy may permit early diagnosis, aggressive treatment, and elucidation of pathogenesis.

Weber–christian Disease: Analysis Of 15 Cases And Review Of The Literature

We report 15 patients encountered over 13 years who presented with inflammation of subcutaneous fat and were given clinical and pathologic diagnoses of Weber--Christian disease (WCD). Prominent clinical features included female predominance, lower extremity nodules, fevers, arthritis/arthralgias, and myalgias. Notable laboratory features were elevated erythrocyte sedimentation rate, anemia, leukopenia, and hypocomplementemia, frequently with circulating 7S IgM or immune complexes at times of active symptoms. Histologic findings were lobular--together with frequent septal--panniculitis, fat-laden macrophages, variable cellular infiltrates, necrosis, and occasional vasculitis. Follow-up revealed the death of 2 patients and disease stabilization or improvement in 13 patients. Six patients developed features of other diseases (factitial disease, erythema nodosum, acute myelogenous leukemia, rheumatoid arthritis, systemic lupus erythematosus, and sarcoid) and a seventh may have had erythema induratum. We suggest that classic WCD, as originally described, reflects an increasingly recognized spectrum of panniculitides. These are syndromes of diverse etiology that share many clinical, inflammatory, and immunologic features.

Rheumatoid arthritis associated with eosinophilia.

Abstract Five patients with classical rheumatoid arthritis and peripheral eosinophilia ranging from 20% to 89% are described. These patients had clinical and radiological findings of severe, deform...

Optimism and coping as determinants of psychosocial adjustment to rheumatoid arthritis

Psychosocial adjustment in 66 patients with chronic rheumatoid arthritis, with a mean duration of 12 years with the disease, were evaluated in a prospective design, with 62% of the sample followed up 16 months later. It was predicted that dispositional optimism would predict adjustment over time and that perceived support and perceived control would be related to psychosocial adjustment at the time of concurrent measurement. At Time 1, psychosocial adjustment was associated with greater optimism and perceived support and less disability. Optimism at Time 1 was the only significant predictor of changes in adjustment at Time 2 controlling for Time 1 adjustment and Time 2 disability. It was found that optimism temporally precedes increases in psychosocial adjustment. In terms of coping strategies, wishful thinking was related to poorer social adjustment, whereas problem-focused coping was marginally related to positive adjustment. Neither coping strategy predicted adjustment across time. Optimism at Time 1 did predict problem-focused coping at Time 2. Perceived social support regarding a specific circumstance at a given point in time enables one to persist in solving a task. Interventions to enhance the quality of life of individuals coping with progressive deteriorative disease must look at the influence of their behavior and attitude on those who provide care for them.

Scleroderma esophagus: A nonspecific entity

Abstract Esophageal dysfunction develops in approximately 90% of patients with progressive systemic sclerosis (scleroderma) or mixed connective tissue disease (1). Abnormal esophageal motility may ...

DIETS, DIETARY SUPPLEMENTS, AND NUTRITIONAL THERAPIES IN RHEUMATIC DISEASES

Rheumatoid arthritis and many other systemic rheumatic diseases remain illnesses of unknown cause for which current therapy is often inadequate. This leads patients to seek questionable remedies, prominent among which are dietary manipulations. Is there a role for dietary modifications in the routine therapy for patients with rheumatic diseases? This article discusses the relationships between diets, fasting, elemental nutrition, vitamins, minerals, and foods for rheumatic diseases. Known scientific-based evidence for the use, safety, and efficacy of diets and dietary-related practices subscribed by patients with rheumatic diseases are presented. Studies that link diet with arthritis offer the possibility of identifying new therapeutic approaches for selected patients and of developing new insights to disease pathogenesis. Dietary therapy for arthritis, however, is still being investigated.

Exercise and the musculoskeletal system

1. Normal joints in individuals of all ages may tolerate prolonged and vigorous exercise without adverse consequences or accelerated development of OA. 2. Individuals who have underlying muscle weakness or imbalance, neurological abnormalities, anatomical variances, and who engage in significant amounts of exercise that stress the lower extremities, may accelerate the development of OA. 3. Individuals who have suffered injuries to supporting structures may also be susceptible to accelerated development of OA in weight-bearing joints, even without increased stress to the joint from exercise. 4. Certain individuals with established degenerative or inflammatory arthritis may benefit from supervised exercise programmes. 5. Still more information is needed so that physicians can identify subjects at risk for the development of OA, advise the millions of participants about the beneficial and deleterious effects of regular exercise and sports participation, and develop successful rehabilitation programmes for injured joints.

Association of Resident Coverage with Cost, Length of Stay, and Profitability at a Community Hospital

OBJECTIVE: The effect of care by medical residents on hospital length of stay (LOS), indirect costs, and reimbursement was last examined across a range of illnesses in 1981; the issue has never been examined at a community hospital. We studied resource utilization and reimbursement at a community hospital in relation to the involvement of medical residents.DESIGN: This nonrandomized observational study compared patients discharged from a general medicine teaching unit with those discharged from nonteaching general medical/surgical units.SETTING: A 620-bed community teaching hospital with a general medicine teaching unit (resident care) and several general medicine nonteaching units (no resident care).PATIENTS: All medical discharges between July 1998 and February 1999, excluding those from designated subspecialty and critical care units.MEASUREMENTS AND MAIN RESULTS: Endpoints included mean LOS in excess of expected LOS, mean cost in excess of expected cost, mean payments, and mean profitability (payments minus total costs). Observed values were obtained from the hospital’s database and expected values from a proprietary risk adjustment program. No significant difference in LOS between 917 teaching-unit patients and 697 nonteaching patients was demonstrated. Costs averaged

Back pain made simple: An approach based on principles and evidence

3,178 (95% confidence interval [CI] ±

Rheumatoid Cachexia: What Is It and Why Is It Important?

489) less than expected among teaching-unit patients and