[Guideline for the joint swelling symptom--primary physician problem management and referral indications. German Society of Rheumatology "Quality Assurance" Committee]

The guideline "Joint Swelling" is addressed to primary care physicians--general practitioners, internists or orthopedists without special experience in rheumatology. It provides a framework for interviewing patients, as well as for physical, laboratory and imaging examinations and for selection of treatment appropriate to the level of primary care. Situations which call for urgent evaluation and criteria for referral to rheumatologists are described. The appendix contains comments on signs and symptoms to differentiate arthralgia from joint swelling and on the diagnostic value of a history of joint swelling without confirmation by the physician. Further recommendations for the evaluation of patient history and physical and technical examinations are given in a tabular form. The significance of laboratory and imaging procedures is discussed.

[Expanded anamnesis and psychodiagnostic classification of psychosomatic rheumatic patients. I: Anamnestic indications of psychosomatic correlations with manifestations of the locomotor system]

The author describes the information gained from anamnesis which points to a psychogenetic cause of rheumatic complaints. These symptoms are part of the diagnostically important criteria which must be supplemented still further by means of a personal discussion with the patient. A great deal depends on the skill of the physician in conducting these talks, with regard to obtaining relevant information on personal problems which may be underlying the disease patterns. Of course the possibility of a connection of the detected problems with the clinical picture should be given.

[Expert assessment of psychosomatic disorders in rheumatology]

There are often big problems regarding expert evidences of psychosomatic clinical pictures, because, contrary to the complaints expressed and perceived by the patient, somatic findings are not evident to justify a permanent disablement. Nearly without exception it is a question of chronified cases of psychosomatic complaints up to real psychoneuroses. The diagnosis and delimination from a simulation is difficult and is frequently failed. Without doubt there are cases, in which only the psychic component determines the vocational disablement.

[Work disability and the granting of pensions in psychogenic rheumatic diseases]

This paper is the result of a symposium that addressed the problem of disablement and social pension for patients with psychosomatic-rheumatological complaints. This especially concerns patients suffering from psychosomatic manifestation at the locomotor apparatus, who are increasingly disabled and necessitating a pension, without actual somatic findings justifying a vocational disablement. Primarily it is a clinical picture of a generalized tendomyopathy, often underestimated in its importance. Definitions, causes, and clinical pictures are presented. A critical phase decisive for the disablement, the personality of the would-be pensioner, considerations for the physician regarding diagnostic and therapeutic efforts, elements of time and environment, and conditions at the work-place are discussed. In some cases a pension will be unavoidable and justifiable, even if the somatic findings seem not to be sufficient. The psychogenic picture must be carefully determined differentiated from simulation; determining the cause of aggravation is essential.

[HLA B27-associated rheumatic diseases from the clinical viewpoint]

On the basis of the description of the possible variable courses and symptoms of ankylosing spondylitis, Reiter's syndrome, and reactive arthritides (spondarthritides) frequently produced by intestinal infections, all of which show HLA B27 as the predisposing hereditary antigen in about 90% of the cases, it is discussed whether these conditions represent a disease entity in which additional unknown factors determine the expression and the tendency of the course of the disease.

[Seronegative, HLA B 27-associated spondylarthritis. - New orientation in nomenclature and classification?]

It is shown that the concept of "seronegative HLA B 27 associated spondarthritis," which is unsatisfactory even as a name, cannot be accepted as a new overgroup in a logically constructed classification. HLA B 27 occurs in certain of these illnesses almost inevitably as a predisposing antigen; in others it is merely a factor modifying the pattern of disease. The illnesses thus are obviously different. In any case, the concept itself is not a diagnosis, in spite of the fact that it is at present often employed as a diagnostic term.

[Non-steroidal antirheumatic agents - questions of the clinician to the pharmacologist]

The problems of clinical application and effects of the non-steroidal antirheumatic drugs have been critically described and pointed at known pharmacological data and clinical publications. Especially still not sufficiently examined connections are emphasized, because their examination could contribute to an aimed use of the antirheumatic drugs. Furthermore the existing declarations concerning the clinical efficacy and the comparison of the effects are critically discussed with regard to their validity. Suitable presuppositions for subsequent trials and for the interpretation of their results are given.

[Prednisolone reduction by benoxaprofen]

The prednisolone sparing effect of benoxaprofen has been examined in only 13 cases of rheumatoid arthritis. The examination was terminated prematurely because of an accumulation of side effects of the skin. The results of these 13 cases are not significant, but the drug seems to show a relatively high mean value of its prednisolone sparing effect but it seems to cause a high proportion of side effects, especially of the skin. This preliminary result should be reported in regard to possibly following studies with simular observations.

[Investigations on the clinical effect of the antirheumatic agent piroxicam (author's transl)]

In the glucocorticoid-sparing test, which shows certain advantages compared with other experimental procedures, the clinical efficacy of the new antirheumatic substance piroxicam (Feldene) was investigated. It was shown that a single daily dose of 20 mg piroxicam gave at least an equal, if not better, effect compared with other substances tested earlier, as far as comparison is permissible between two collectives treated with different substance. The mean saving of prednisone was 5.7 mg/day and according to another evaluation 64.7% of the previously required dose of prednisolone. It is worth noting that owing to the long half-life there is a remarkable clinical effect over at least 24 hours with a single daily dose. Tolerance was good. Pathological laboratory values which were definitely to be attributed to the preparation were not seen in a trial period of a maximum of four weeks.

[Azathioprine in rheumatology]

The indication for azathioprine (Imurek) has to be strictly adjusted, but amongst the immunosuppresive drugs it is without doubt the best tolerated substance and--provided that regular controls are carried out--is therefore also suitable for long-term treatment in practice.