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Rheumatic diseases and the environment.
  1. D SYMMONS
  1. ARD Epidemiology Unit,University of Manchester

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    Rheumatic diseases and the environment. Lee D Kaufman and John Vaga. (Pp 240; £45.) London: Arnold, 1999. ISBN 0-412-07911-9.

    When a patient develops a rheumatic disease one of the first questions asked is “why me?” The answer is, of course, complex. For almost all rheumatic disorders there are genetic factors, host factors, and environmental factors. This book focuses predominantly on non-host environmental factors as triggers of rheumatic disorders. These are described as foods, drugs, chemicals, biologicals, radiation, noise, and emotional and physical stresses. The book is aimed at physicians and other healthcare providers, biomedical scientists, epidemiologists, toxicologists, regulators, law makers, and members of the legal profession. This is a very broad audience and it is difficult to judge whether the needs of people from such varying backgrounds will be met.

    There are 35 contributors and 21 chapters. The first section, which provides an overview of epidemiology and differential diagnoses, would appear very superficial to the epidemiologist and rheumatologist. It gives a brief description of epidemiological study designs and then reviews laboratory tests such as the erythrocyte sedimentation rate, full blood count, antinuclear antibodies, and rheumatoid factor. The clinical features of systemic lupus erythematosus (SLE), systemic sclerosis, and idiopathic inflammatory muscle disease are given in less than a page. This includes a list of the American Rheumatism Association criteria for SLE, which a rheumatologist would be likely to know and a lawyer likely to find incomprehensible.

    The second section deals with aetiopathogenic considerations. This includes tables of chemicals (mainly drugs) associated with autoimmunity and, in a different chapter, tables of the immunogenetic associations between drugs and autoimmunity. There follows a series of chapters which examine specific syndromes such as the toxic oil syndrome and silicone related rheumatic disorders. This represents a useful collection of reviews of syndromes which are often too rare to justify more than a paragraph or two in a standard text book. They provide a useful starting point for someone who has come across a syndrome for the first time and the list of references is usually sufficiently comprehensive to point the reader towards further source material.

    The third section deals with fibrosing disorders, the fourth section with rheumatic syndromes related to drugs and other environmental exposures, the fifth section deals with rheumatic syndromes and the work place, and the sixth section with surveillance, regulatory, and legal approaches to environmental exposure associated rheumatic disease. This last section contains interesting chapters on the safety surveillance of food and drugs, on the contrasting views of causation in law, science and medicine, and on surveillance and monitoring (lessons learnt from the eosinophilia-myalgia syndrome). These chapters are, however, written from an American perspective and so will be of limited practical value to an international audience, although the underlying theory is clearly of interest.

    Rheumatic Diseases and the Environment would be a valuable addition to a medical library with a rheumatology section. It is likely to be of interest to medical students, trainees in rheumatology, and to rheumatologists who wish to read a brief overview of any of the syndromes described within. With such a broad remit, it is perhaps inevitable that there is not space in the individual chapters to provide an in-depth review. Most of the chapters are no longer than six pages.

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