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In the beginning was the diagnosis
Manual of rheumatology and outpatient orthopedic disorders. Diagnosis and therapy.
  1. F A WOLLHEIM
  1. Department of Rheumatology
  2. Lund, Sweden

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    Manual of rheumatology and outpatient orthopedic disorders. Diagnosis and therapy. 4th ed. Eds Stephen A Paget, Allan Gibofsky, John F Beary III. (Pp 592; £36-95.) Philadelphia: Lippincott Williams and Wilkins, 2000. ISBN 0-7817-1576-8.

    The Hospital for Special Surgery in New York City has for many years ranked high among teaching and research institutions in rheumatology, and is where numerous American and European rheumatologists spent important formative years. This book is co-authored by almost 70 contributors who are or have been members of this institution. They have succeeded in producing a brief, balanced, and rather complete coverage of both common and unusual conditions. There are few illustrations and the text is by necessity dry, so this is not an alternative to an in depth textbook, but rather a complement and help for the student, trainee, and generalist working in their outpatient setting. The former chief of rheumatology at the Hospital for Special Surgery, Charles L Christian, stresses in the foreword “the seamless interface” between orthopaedics and rheumatology, a truth which deserves to be repeated. In practice, in many countries there still are barriers between the specialties, which are detrimental to training and patient care.

    The first part of the book is called “Musculoskeletal database”, and it starts with the important subject of history and joint examination. Here I would have liked a more practical guide to distinguish between damage and synovitis with the characteristic location of tenderness. The presentation of immunogenetics is an example where brevity may cause confusion. The nomenclature in the chapter on rheumatoid arthritis is up to date, whereas that in the table in the first part of the book is based on that used in the 1980s. It is nice to find a chapter on patient education, an often neglected subject.

    The description of regional complaints is adequate and reasonably comprehensive. Details can always be improved. Under carpal tunnel syndrome one might have mentioned the occupational factor so often present in, for example, automechanics. In coming editions I would perhaps devote a little more space to specified tendinitis, bursitis, and entrapment phenomena, which are so common in outpatient practice.

    Pharmacotherapy is also covered and on the whole in a good and balanced way; there are, however, misleading statements. In the chapter on rheumatoid arthritis it is mentioned that cyclosporin A is useful in patients who do not respond to methotrexate. This statement is based on one flawed study which used suboptimal doses of methotrexate. And the use of cyclosporin A in psoriasis seems to be particularly dangerous for the kidney.1 Unresolved concerns about the long term safety of cyclosporin A make the recommendation particularly unwise in a brief text. Another detail concerns the word “Reiter's” syndrome, which in coming editions should be omitted or replaced with “Fiessinger-Leroy's” syndrome in view of Reiter's war time activities and his scientific contribution, which was minor compared with that of the French authors.2 Most chapters are both comprehensive and up to date, like those on Raynaud's disease and vasculitis. In the chapter on enteropathic arthritis, the next edition might include the distinction between type I and type II peripheral arthritis, which is important and clinically helpful.3 In the chapter on septic arthritis, joint infection with staphylococci of low virulence and without fever in patients with rheumatoid arthritis should be mentioned.

    These few critical remarks should not distract from my, in general, strong praise for a very fine and scholarly product which should and will serve its purpose for years to come. Perhaps coming editions could be made more user friendly by introducing an easier leafing identification of index, contents, and individual chapters—for example, by printing on differently coloured paper, or by other means. And perhaps this book would also do well in translated form, in Spanish, for example, or other languages.

    Manual of rheumatology and outpatient orthopedic disorders. Diagnosis and therapy. 4th ed. Eds Stephen A Paget, Allan Gibofsky, John F Beary III. (Pp 592; £36-95.) Philadelphia: Lippincott Williams and Wilkins, 2000. ISBN 0-7817-1576-8.

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