Utilization of care for rheumatic disorders was studied in two primary care units. In both units 12% of visits concerned some form of rheumatic disease. This diagnostic group (chapter XIII of ICD) ranked third after cardiovascular and respiratory diseases. The total number of visits per inhabitant was higher for all diagnoses, as well as for the rheumatic disorders, in the most remote primary care unit. The distribution of rheumatic diagnoses was similar in the two units. Back disorders were most frequent among men, whereas soft tissue rheumatism and back disorders each accounted for one-third of the cases among women. Inflammatory rheumatic diseases and osteo-arthritis played only a minor part. Visits due to rheumatic disorders decreased after retirement age, particularly among men. The findings were representative of primary care in rural areas of Sweden. Only 20% of referrals from primary care to the rheumatology department gave a tentative diagnosis and half of these suggestions were changed after examination. The majority of referred patients without any suggested diagnosis suffered from soft tissue rheumatism or inflammatory rheumatic disorders other than rheumatoid arthritis.

Utilization of rheumatological care by individual patients was studied in a Swedish county at all levels of the health care system. Calculated per population at risk, 0.6--0.8% per year were seen for rheumatoid arthritis. Of these, 35--81% were patients at the rheumatology department, varying according to distance of residence from the university hospital. The number of patients with other inflammatory diseases was, however, larger in primary care than in the specialist department. Only a minor part of the total care for rheumatic disorders (Chapt. XIII of ICD) in the county was provided by the rheumatology department. Back disorders constituted the largest diagnostic group of rheumatic disorders in primary care. During a period of one year a total of 12--14% of the population had contact with primary care, of the district hospital and/or the rheumatology department, because of rheumatic disorders. The results show the value of epidemiological studies to follow the development of and to define the future objectives of rheumatological care.

OBJECTIVE:To follow hand function and activity of daily living (ADL) capacity prospectively during a 5-year period in a cohort of outpatients with rheumatoid arthritis (RA).METHODS:Forty-three patients (28 women, 15 men), mean age 53.7 years and mean disease duration 7.5 years, were included. The Grip Ability Test (GAT), grip strength, the Keitel Function Test (KFT), the Health Assessment Questionnaire (HAQ), self-estimated hand function, and pain scales were used. Need of personal assistance in the HAQ components was recorded as ADL dependence.RESULTS:After 5 years, the GAT, the KFT, and 3 HAQ components were significantly worse in women. Improved GAT was the only significant change in men. An additional 12 patients needed personal ADL assistance, bringing the total to 21 patients (49%).CONCLUSIONS:Hand function deteriorated during a 5-year period in female RA patients. Hand disability (GAT) improved in the male RA group, although hand impairment (grip strength, KFT) was unchanged. Over one-fourth of each gender group had developed a new handicap (dependence).

OBJECTIVE:To determine the effectiveness of self-management education and physical training in decreasing fibromyalgia (FMS) symptoms and increasing physical and psychological well being.METHODS:A pretest-posttest control group design was used. Ninety-nine women with FMS were randomly assigned to 1 of 3 groups; 86 completed the study. The education only group received a 6-week self-management course. The education plus physical training group received the course and 6 h of training designed to assist them to exercise independently. The control group got treatment after 3 months.RESULTS:The experimental programs had a significant positive impact on quality of life and self-efficacy. Helplessness, number of days feeling bad, physical dysfunction, and pain in the tender points decreased significantly in one or both of the treated groups when retested 6 weeks after the end of the program. Longterm followup of 67 treated subjects showed significant positive changes on the Fibromyalgia Impact Questionnaire primarily in the physical training group. Among all subjects, 87% were exercising at least 3 times/week for 20 min or more; 46% said they had increased their exercise level since participating in the program; 70% were practicing relaxation strategies as needed; 46% were working at least half time as opposed to 37% at pretest.CONCLUSION:Self-efficacy of the treated groups was enhanced significantly by the program. Other changes were smaller and more delayed than had been expected. Recommendations for future trials include a longer education program, more vigorous physical training, and longterm followup.

The effect of active hand exercise and warm wax treatment was evaluated in 52 rheumatoid arthritis patients randomized into four groups: (1) both exercise and wax bath, (2) exercise only, (3) wax bath only, and (4) controls. Treatment was given three times a week for 4 weeks. Deficits in flexion and extension in digits II-V bilaterally, grip function, grip strength, pain, and stiffness were measured before and after the treatment period. The control group was measured at corresponding times. Wax bath treatment followed by active hand exercise resulted in significant improvements of range of motion (ROM) and grip function. Active hand exercise alone reduced stiffness and pain with nonresisted motion and increased ROM. Wax bath alone had no significant effect.

Methodology of functional status assessment for musculoskeletal disorders has developed considerably in recent years. Reliability and sensitivity of measurements of physical functions are studied more systematically, and observer tests of activities of daily living functions have been developed with increased accuracy. A major area of interest, however, is reflected in studies of multidimensional assessments of functional limitations and the development of arthritis-specific questionnaires. The importance and difficulties of assessing function in clinical practice have been emphasized. Increasing interest among health planners and health economists in outcome measurements utilizing multidimensional functional assessments is evolving.

Gothenburg University and Sahlgren University Hospital, Gothenburg, Sweden Current Opinion in Rheumatology 1990, 2:340-343

Patients undergoing rotator cuff surgery often search the internet for information regarding the procedure. One popular source, Google, compiles frequently asked questions and links to websites that may provide answers. This study provides an analysis of the most frequently searched questions associated with rotator cuff surgery. We hypothesize that there will be distinct search patterns associated with online queries about rotator cuff surgery that could provide unique insights into patient concerns.A set of search terms were entered into Google Web Search using a clean-install Google Chrome browser. Frequently associated questions and their webpages were extracted to a database via a data mining extension. Questions were categorized by topics relevant for rotator cuff arthroscopy. Websites were categorized by source and scored for quality using the JAMA Benchmark Criteria. Pearson’s χ2 tests were used to analyze nominal data. Student t tests were performed to compare JAMA Benchmark Scores.Of the 595 questions generated from the initial search, 372 unique questions associated with 293 websites were extracted and categorized. The most popular question topics were activities/restrictions (20.7%), pain (18.8%), and indications/management (13.2%). The 2 most common websites searched were academic (35.2%) and medical practice (27.4%). Commercial websites were significantly more likely to be associated with questions about cost (57.1% of all cost questions, P = .01), anatomy/function (62.5%, P = .001), and evaluation of surgery (47.6%, P < .001). Academic websites were more likely to be associated with questions about technical details of surgery (58.1%, P < .001). Medical practice and social media websites were more likely associated with activities/restrictions (48.1%, P < .001, and 15.6%, P < .001, respectively). Government websites were more likely associated with timeline of recovery (12.8%, P = .01). On a scale of 0-4, commercial and academic websites had the highest JAMA scores (3.06 and 2.39, respectively).Patients seeking information regarding rotator cuff repair primarily use the Google search engine to ask questions regarding postoperative activity and restrictions, followed by pain, indications, and management. Academic websites, which were associated with technical details of surgery, and medical practice websites, which were associated with activities/restrictions, were the 2 most commonly searched resources. These results emphasize the need for orthopedic surgeons to provide detailed and informative instructions to patients undergoing rotator cuff repair, especially in the postoperative setting.

Utilization of care for rheumatic disorders (chapt XIII of ICD) was studied in an area of Sweden during 1978. In the total health care system, approximately 16 to 18% of the population with a rheumatic disorder were seen. The majority (12% of the population) of these patients were treated at the primary care centres. Only 1% were registered as in-patients, 1/4 of whom were admitted to the rheumatology department. Cases with back disorders constituted the largest diagnostic group of rheumatic disorders, both in primary care and in the departments of internal medecine, at the district level as well as in the regional hospital. The most important contribution of the rheumatology department was the care of a select group of patients — those with rheumatoid arthritis and systemic rheumatic diseases. However, primary care saw more patients also within the whole group of inflammatory rheumatic diseases. In the department of orthopaedic surgery, osteoarthritis was the major diagnosis among rheumatic disorders, totalling 38% of their rheumatic in-patients. Selection of patients for specialized care depended upon diagnosis, age, sex and distance to the hospital.

New methods to isolate and characterize the molecular weight distribution of hyaluronic acid have been applied to human synovial fluids from arthritic patients. Considerable variations in molecular weight distribution were found between the individual fluids. These methods facilitate a detailed characterization of hyaluronic acid--a prerequisite for understanding the role of hyaluronic acid for normal joint function and to evaluate the therapeutic use of local application in joint diseases.

Plasma exchange was performed in 2 patients with classical rheumatoid arthritis, complicated in one case by necrotic vasculitis, and in the other by mononeuritis multiplex. Immediate improvement in the peripheral circulation was observed in both patients with subsequent healing of necroses and nerve function, respectively. The treatment was combined with low doses of corticosteroids and cytostatic agents. After 2 years, both patients were still receiving intermittent plasma exchanges, performed at 3-4 month intervals. A correlation between immediate circulatory improvement and lowered plasma viscosity by the plasma exchange was indicated.

The cytology of joint exudates from patients with rheumatoid arthritis was examined by preparation of air-dried smears; a procedure that involved cytocentrifugation of synovial fluids following dilution in a balanced salt solution containing albumin. This procedure provided a monolayer of homogeneously distributed exudate cells with excellent preservation of morphological details. The dominant cell type in the exudates was polymorphonuclear leukocytes, often with signs of necrobiosis. The small and medium-sized mononuclear cells were lymphocyte-like and vital-looking. The large mononuclear cells displayed signs of extensive phagocytosis, especially phagocytosis of polymorphonuclear leukocytes. It is suggested that the granulocytes of the synovial fluid are cells which have reached their function compartment, where they work and die.

The frequency of radiographic signs of sacroiliac joint involvement (greater than or equal to 2 and greater than or equal to 3 according to the New York criteria) was significantly higher in 28 HLA-B27 positive patients with classical seropositive rheumatoid arthritis (RA), than in 28 B27 negative RA controls. The B27 positive RA patients had more subcutaneous nodules (p less than 0.01), worse functional class (p less than 0.05), and higher levels of erythrocyte sedimentation rate (ESR) (p less than 0.05) and haptoglobin (p less than 0.05). Sacroiliitis, independent of HLA-B27, was associated with higher levels of ESR (p less than 0.05), and with a higher frequency of positive ANA test (p less than 0.05). It is neither related to the functional class nor to the duration of the disease.

A clinical and radiographic survey of 110 members of 2 families with hereditary pyrophosphate arthropathy was performed. The mode of inheritance was autosomal, dominant with a variable penetrance. Twenty-two percent of the family members had joint involvement related to pyrophosphate arthropathy, 47% of those over 50 years of age had experienced acute attacks of arthritis and/or had joint calcifications. The majority of individuals with both arthritis and joint calcifications suffered from chronic pain that resulted in early retirement. A high frequency of back pain was observed, but no ankylosis or deformity. Surgery was performed for parathyroid hyperplasia on the propositus in 1 family, and several members of her family suffered from symptoms that suggested a disturbance of calcium phosphate metabolism. There were several differences between our patients and 50 cases of sporadic pyrophosphate arthropathy from the same area of Sweden. Familial cases had an earlier onset, a greater number of involved joints, and peripheral joint involvement more often. Back pain was more frequent, and calcifications of intervertebral discs were found only in the hereditary cases.

A review of available prevalence data illustrates the importance of criteria and sampling in the study of osteo-arthritis (OA). An interview survey and insurance data were used to investigate regional distribution of OA in Sweden. Reported longstanding illness, complaints, handicap or other debility due to OA were most prevalent in Northern and in a South-Eastern areas of Sweden. OA was more prevalent among women than among men after retirement age. It was a larger part of all longstanding disorders in the South-Eastern than in other parts of Sweden. Several factors of physical strain from work were frequent in the South-Eastern and Northern areas but complaints of hot and cold climate conditions at work place were the most significant factors. The frequency of early pension due to OA was highest in the North of Sweden but higher frequencies were registered also in the South-Eastern region compared to adjacent areas of Southern Sweden.

Genealogical links between three Swedish families with hereditary pyrophosphate arthropathy were found in the 18th century, indicating a possible founder effect, similar to earlier findings in Slovakia, France and Chile. However, no connection between the Swedish and other European families with the disease has so far been found. In accordance with other reported familial aggregations of pyrophosphate arthropathy, the transmission of the disease in the Swedish families appeared to be autosomal dominant with incomplete penetrance and variable expressivity. Severe symptoms related to homozygotic cases reported in some other families were not found in Sweden.

In 1973 rheumatology was reorganized in northern Sweden and a new center was developed to serve a county of 240,000 inhabitants. The results of this development from 1973 to 1977 are reported. Although the number of rheumatic disease beds available was slightly reduced an increased staff was able to reduce the average duration of hospital stay from 42 to 15 d. This was true for all diagnostic groups, both for conventional hospital wards and a comprehensive day-ward center. Initially, rheumatoid arthritis (RA) had the highest priority and the number of patients with this diagnosis increased. However, after 3 yr RA was diagnosed in only 12% of new out-patients and other rheumatic disorders became more frequent among both out- and in-patients. New patients were referred almost equally from primary care and other hospital departments. Although only 20% of patients came with a provisional diagnosis, half of these were changed after examination by the rheumatology department. An increased demand for diagnostic services and a rapidly changing diagnostic pattern are 2 important factors to be considered in the planning of any new rheumatology center.

The present state of epidemiological knowledge concerning rheumatoid arthritis is summarized. The potential for further epidemiological approaches to rheumatoid arthritis is indicated and priorities listed for the future directions of such studies.

Considerable variations in the prevalence of rheumatic disorders were found in a nation-wide interview survey of the adult Swedish population. Rheumatic disorders were more prevalent in Northern than in Southern Sweden, except for one South-Eastern area. Rheumatoid arthritis (RA), osteo-arthritis and back disorders followed the same, pattern. Other inflammatory rheumatic diseases than RA showed similar prevalence figures throughout the country. Soft tissue rheumatism was least frequent in the southernmost parts of Sweden, but otherwise equally distributed. Farming and forestry were most frequent in the Northern and in the South-Eastern areas of Sweden but physical strain from work was most frequent only in Northern Sweden. This variation in working conditions coincided with and may contribute to variations in the prevalence of rheumatic disorders in Sweden.