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Huge knee effusionA record.

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LETTERS
formed an Ad Hoc Committee for IYDP chaired by
Prof. Veikko Laine of Finland.
The goals of the ILAR Committee for the IYDP
are: to adopt and implement the general objectives of
the UN plan for the IYDP, and to stress in its recommendations rheumatic disease as a cause of disability
and the special nature of this disability, characterized
by pain, chronicity, and the need for prolonged care
and rehabilitative procedures.
All the activities assumed by the ILAR Committee and all the activities planned and recommended
by the Committee for implementation by regional, national, and international societies and agencies will be
coordinated with the UN plan for the IYDP.
On the national level, the Committee is encouraging professional societies and voluntary agencies to
cooperate in the planning and implementation of a national program for the IYDP as follows:
1. To stress the problems of disabled persons in connection with their own activities, and to provide
relevant material for distribution to all concerned
with disability caused by arthritis.
2. To organize special groups of disabled sufferers
from different rheumatic diseases to express their
views effectively and to secure the right to participate actively in the work of policy-making bodies
in the management of their disability.
3. To direct information systems in the form of
health education to different target populations,
particularly those of schools and industry.
To
cooperate on national and local levels with
4.
other organizations and officials representing disabled persons in order to assemble and strengthen
their forces in joint programs.
On the regional level, the establishment of social
and community agencies to fight rheumatic disease and
disability will be encouraged in countries which at present have no such agencies.
On the international level, the ILAR Ad Hoc
Committee will stress the importance of rheumatic disorders as effectors of disability, as well as the deficiencies existing in the prevention of such disabilities. It
will influence the plans of the UN and WHO to include
the recognition of impairment caused by rheumatic disease among the disabilities defined by the UN Assembly. It will maintain cooperation with WHO by presenting well-defined joint projects designed to improve the
prevention of disabilities from arthritis.
In the United States, activities for the IYDP
have been initiated by a Federal Interagency Committee. The private sector is represented by the U.S.
109
Council for the IYDP, formed to promote through community commitment full participation in all aspects of
society by persons with disabilities. This Council has established long-term goals not only to increase public
awareness of the unmet needs of persons with disabilities, but also to improve the quality of their lives. In
support of the work of the IYDP, it has adopted the slogan, “Meeting the Challenge through Partnerships.”
The Arthritis Foundation has joined the U.S.
Council as a partner to “support the world-wide objective of the UN to establish goals and programs that will
enrich the lives of citizens with disabilities, support the
aims of the U.S. council both to fully integrate such
people into the community life, and to sharpen public
awareness of the problems and needs of persons with
disabilities.”
EMMANUEL
RUDD,MD
Co-Chair, Committee on Education and
Publications
International League Against
Rheumatism
Member, ILAR Ad Hoe Committee
for I YDP
Huge knee effusion: A record?
To the Editor:
Since the amount of fluid aspirated from a joint
is rarely reported, even if the volume is unusually large,
the record for large effusions is not definitely known.
However, an informal inquiry among a number of rheumatologists revealed that none had aspirated or known
of a joint effusion greater than 250 cc. Following is the
report of a case of psoriatic arthritis with a huge knee
effusion yielding 363 cc of fluid.
A 50-year-old white man with a 17-year history
of swollen and painful joints affecting the knees, wrists,
and hands was seen in consultation at a rheumatology
clinic. Four years earlier the patient had undergone a
rheumatologic evaluation and was diagnosed as having
seronegative active rheumatoid arthritis with an
erythrocyte sedimentation rate (ESR) of 88 mm/hour.
Treatment with aspirin and gold therapy was beneficial.
Eighteen months prior to the visit under discussion, he
developed psoriatic skin lesions and was treated by a
dermatologist. His symptoms at the time of consultation
were pain and swelling, primarily in the knees, which
did not significantly interfere with his job as a salesman.
Physical examination revealed widespread
patches of psoriasis and pitting of the nails. No subcuta-
110
neous nodules were demonstrated. Asymmetric swelling
and tenderness of the metacarpophalangeal and wrist
joints were present to a modest degree. Swelling involving mostly the superior and medial aspect of each
knee (more marked on the right) was obvious on inspection. Both knees were moderately warm and had a
fluid thrill, though the conventional bulge sign for fluid
was absent because of excessive fluid tension. However,
there was only a mild degree of pain at extreme flexion
and extension of the knees. Results of the rest of the examination were normal.
On aspiration, the right knee yielded 363 cc of
fluid and the left knee 110 cc. Both knees were then injected with 60 mg of Depo-medrol. The mucin clot was
fair and the synovial fluid white blood cell count (WBC)
was 3,600, with 52% neutrophils. Blood test results included normal WBC and hematocrit, ESR of 30 mm/
hour, normal chemistry, and negative rheumatoid factor
and antinuclear antibody.
LETTERS
The knee effusion recurred twice bilaterally in
the next 5 months, yielding less than 100 cc of fluid on
each occasion. The patient now remains fairly well on
Clinoril and gold therapy after 10 months of followup.
It is interesting that despite a huge effusion in
each knee, the patient’s symptoms were only modest,
and synovial fluid was only mildly inflammatory. A
large collection of fluid in any joint, however, is detrimental because of mechanical stress factors.
Although a huge effusion as in this patient is
amusing at best to most physicians, it would be interesting to know if any physician has aspirated by needle
a larger volume of fluid from any joint. Who knows,
someday this may find its place in the Guiness Book of
Records!
MUHAMMAD
YUNUS,MD
Peoria School of Medicine
Peoria, Illinois 61605
BOOK REVIEWS
Rheumatology. Edited by Rodney Bluestone, MB. Boston, Houghton MiffIin Professional Publishers, 1980. 527
pages. Illustrated. Indexed. Contains CME post-test.
The concept of producing a multi-author book in
rheumatology from a single medical center was pioneered by Mason and Currey in London, and Rodney
Bluestone, transplanted from there to Los Angeles, has
adopted the concept for these shores. It is a valid one, as
it allows the editor and his authors to meet frequently to
exchange opinions, permits the editor to browbeat slow
contributors, and above all, gives the feeling of cohesion
to the volume by taking away some of the uneveness
that characterizes books whose authors are geographically remote from each other.
The editor is known as a dynamic and gifted lecturer; his prose, in the many chapters he has contributed, is worthy of him. His opinions are as forcefully delivered as ever, and not everyone shares all of them (but
then, because rheumatology is a clinical science, there is
still considerable controversy about many opinions
firmly held by some and disputed by others). Several of
his authors are equally forceful and the book as a whole
is easy reading and stimulating even to the cognoscenti.
Identified as aiming at internists, this would be a
good initial textbook for both students and housestaff,
including fellows. A fairly good exposition of contemporary rheumatology, it provides a good introduction.
Case reports which amplify the various disease concepts
are graced by pertinent references. However, the chapters on the various diseases, approaches, concepts, and
treatments do not include references; instead some suggested readings are listed at the end of the chapter. Although most of these are aptly chosen and appropriate,
some are not, and better choices could have been substituted (for example, a book on the psychology of arthritis listed is probably the worst I have ever encountered). Unlike some other books purporting to explain
rheumatology to clinicians, this one actually does. I can
recall, while serving in the Armed Forces, attending lectures that told me more about the subject than I really
wanted to know; I have encountered many articles and
books since then that would fit that description; this
book does not.
Having complimented the volume thus far, let
me also mention its flaws. Rheumatology is not of much
use to a clinician attempting to make a diagnosis, and it
suffers from the same drawbacks as the encyclopedic
works it so frequently cites. This book discusses the various diseases and syndromes, but one must already
know which condition is present to refer to this volume
when confronted with a patient. Also, while the case report mentions it, involvement of proximal interphalangeal joints in interphalangeal osteoarthritis is not
cited in the text, a serious omission since this symptom
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