Faculty Bibliography

The hallmark of the inflammatory myopathies is muscle weakness. Although this feature can lead to significant disability and impairment of activities of daily living, its initial presentation may not be recognized early. Older individuals, in particular, may feel that the changes caused by myositis reflect the effects of aging rather than those of a disease process, and diagnosis, therefore, may be delayed. This factor has negative impact on the response to therapy. Inclusion body myositis, with its insidious onset in older people, and laboratory findings which may not be markedly abnormal, presents a diagnostic challenge. DM, with its characteristic symptomatic rash, is generally brought to medical attention more quickly. Another area of diagnostic concern occurs when associated organ involvement precedes myopathy. This has been observed, for example, with interstitial lung disease, and again represents a challenge to physicians. In this connection, the antisynthetase syndrome presenting with fevers, Raynaud's features, arthritis, or pulmonary involvement may not initially be recognized as a manifestation of inflammatory muscle disease. Each subgroup of IIM may present with a variety of extramuscular features that can complicate diagnosis and alter therapy and prognosis. This is particularly true for the pulmonary, GI, and cardiac manifestations and when cancer is associated with myositis. For these reasons, such features of IIM should be carefully evaluated, treated, and monitored over the course of the illness; in some cases these may play a greater role in determining the outcome of patients with IIM than the muscle involvement itself. It is hoped that in the future increased familiarity with the manifestations of the inflammatory myopathies, together with a better understanding of the underlying pathogenesis, will lead to more rapid diagnosis and more effective treatments

After careful examination, cardiac involvement can be found in certain patients with inflammatory muscle disease. The clinical significance is not always clear, although in some patients profound disturbances can become manifest. Currently, no laboratory assay can be relied on to detect cardiac disease with 100% accuracy. Cardiac troponin I is, however, the best test currently available

OBJECTIVE:To determine the incidence of disease flare during the first year of etanercept treatment for 88 patients with rheumatoid arthritis (RA) and compare it with the incidence of flare in those same patients in the year before etanercept use. METHODS:The outpatient clinic charts of all patients with RA who were prescribed etanercept in or before September 1999, who also had at least one year's follow up in the same outpatient clinic, were surveyed. The primary outcome measure was the number of disease flares in one year before and after etanercept use. The secondary outcome measures included the number of patients who did and did not flare, how flares were treated, and the drug alterations that were necessary during the same two time intervals. RESULTS:The total number of flares for all patients in the year before etanercept treatment was 214 (mean (SD) 2.43 (1.75)). The number of flares in the first year of etanercept treatment decreased to 83 (mean 0.94 (1.07)) (p<0.0001). The total number of patients who had at least one flare in the year before etanercept use was 80; eight had no flares. In their first year of etanercept treatment, 50 patients had at least one flare; 38 had no flares (p<0.0001). Twenty one patients (24%) stopped using etanercept before completing one year's treatment. CONCLUSION/CONCLUSIONS:This study of patients with RA in the "real world" shows that etanercept is effective in reducing the number of RA flares.

OBJECTIVE: To conduct a pilot study to identify rheumatologists' treatment preferences for first-line rheumatoid arthritis (RA) therapy and determine whether pharmacoeconomic variables modify physician choice(s). METHODS: A questionnaire describing 3 different RA scenarios was mailed to American College of Rheumatology members within 4 geographic regions of the US. Physicians were asked to identify their choice(s) of first-line therapy for each of the cases, first taking cost into consideration, second without considering the influence of cost, and third identifying the therapy that would be chosen for either themselves or a family member. RESULTS: Three hundred seventy-five questionnaires out of a total of 994 (37.7%) were returned between 3/12/00 and 4/25/00. Hydroxychloroquine was the most commonly cited medication for a mild disease activity/severity presentation, and methotrexate for a moderate-to-severe disease activity/severity presentation. For the severe disease activity/severity presentation, when cost was not considered, 217 (65%) rheumatologists included new disease-modifying antirheumatic drugs (leflunomide, etanercept, and infliximab) in their choice of first-line agents; this number decreased to 47 (14%) when cost was a consideration. CONCLUSION: Pharmacoeconomics appear to play a dominant role in rheumatologists' choice of treatment regimens, at times contrary to the physician's perception of the effectiveness of a drug. Future studies should address physician preferences in more depth with respect to cost and its various components.

Systemic lupus erythematosus (SLE) patients are frequently seen by multiple physicians and at multiple times. In each instance, most of the information important in clinical decision-making is gathered from the patient. There are no studies looking at reporting consistency of certain aspects of SLE patients' history. We studied this by administering the same nine-item questionnaire 4 months apart to the same cohort of SLE patients. In addition, a retrospective chart review was done to correlate the information obtained by prospective questioning and with that on the charts. Our results showed overall good consistency in the areas of general medical history, SLE-specific history and social history. The information gathered by the chart review, in general, went in parallel with that obtained by prospective questioning. This was also true for the poor correlation observed in the family history questions. Many studies and databases depend rather heavily on patient reporting and the quality of this information is usually not substantiated. Our study suggests that, even though SLE patients are generally consistent reporters of certain aspects of their histories, family history information provided is frequently not consistent with previous reporting.

To assess the frequency and clinical characteristics of methotrexate (MTX) oral toxicity in rheumatoid arthritis (RA) patients, 51 RA patients receiving MTX and 46 RA patients not receiving MTX were studied. A questionnaire, the credibility of which was tested on four separate patient groups including a group with Behcet's Syndrome, was used as a tool to determine the prevalence of stomatitis by a blind observer. In this first controlled study of the oral toxicity of MTX, prevalence of stomatitis was found in 37.2% in the group taking MTX and 19.5% in the group not taking MTX (P = 0.054). No statistical differences were detected with respect to number, duration, frequency, and site of stomatitis. Two of the 51 MTX taking patients temporarily reduced their MTX dosage and only one patient temporarily terminated MTX treatment. MTX and toxicity is usually of no major clinical concern in the treatment of RA.