LETTERS 109

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 recom- mendations 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 Com- mittee and all the activities planned and recommended by the Committee for implementation by regional, na- tional, and international societies and agencies will be coordinated with the UN plan for the IYDP.

On the national level, the Committee is encour- aging professional societies and voluntary agencies to cooperate in the planning and implementation of a na- tional program for the IYDP as follows:

1.

2.

3.

4.

To stress the problems of disabled persons in con- nection with their own activities, and to provide relevant material for distribution to all concerned with disability caused by arthritis. To organize special groups of disabled sufferers from different rheumatic diseases to express their views effectively and to secure the right to partici- pate actively in the work of policy-making bodies in the management of their disability. 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 other organizations and officials representing dis- abled 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 pres- ent have no such agencies.

On the international level, the ILAR Ad Hoc Committee will stress the importance of rheumatic dis- orders as effectors of disability, as well as the defi- ciencies 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 dis- ease among the disabilities defined by the UN Assem- bly. It will maintain cooperation with WHO by present- ing 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 Com- mittee. The private sector is represented by the U.S.

Council for the IYDP, formed to promote through com- munity commitment full participation in all aspects of society by persons with disabilities. This Council has es- tablished long-term goals not only to increase public awareness of the unmet needs of persons with dis- abilities, but also to improve the quality of their lives. In support of the work of the IYDP, it has adopted the slo- gan, “Meeting the Challenge through Partnerships.”

The Arthritis Foundation has joined the U.S. Council as a partner to “support the world-wide objec- tive 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

International League Against

Member, ILAR Ad Hoe Committee

Publications

Rheumatism

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 rheu- matologists 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-

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neous nodules were demonstrated. Asymmetric swelling and tenderness of the metacarpophalangeal and wrist joints were present to a modest degree. Swelling in- volving mostly the superior and medial aspect of each knee (more marked on the right) was obvious on in- spection. 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 ex- amination were normal.

On aspiration, the right knee yielded 363 cc of fluid and the left knee 110 cc. Both knees were then in- jected 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 in- cluded normal WBC and hematocrit, ESR of 30 mm/ hour, normal chemistry, and negative rheumatoid factor and antinuclear antibody.

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 detri- mental because of mechanical stress factors.

Although a huge effusion as in this patient is amusing at best to most physicians, it would be inter- esting 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 61 605

BOOK REVIEWS

Rheumatology. Edited by Rodney Bluestone, MB. Bos- ton, 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 pio- neered 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 geographi- cally remote from each other.

The editor is known as a dynamic and gifted lec- turer; his prose, in the many chapters he has contrib- uted, is worthy of him. His opinions are as forcefully de- livered 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 contem- porary rheumatology, it provides a good introduction.

Case reports which amplify the various disease concepts are graced by pertinent references. However, the chap- ters on the various diseases, approaches, concepts, and treatments do not include references; instead some sug- gested readings are listed at the end of the chapter. Al- though most of these are aptly chosen and appropriate, some are not, and better choices could have been sub- stituted (for example, a book on the psychology of ar- thritis listed is probably the worst I have ever encoun- tered). Unlike some other books purporting to explain rheumatology to clinicians, this one actually does. I can recall, while serving in the Armed Forces, attending lec- tures 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 var- ious 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 re- port mentions it, involvement of proximal inter- phalangeal joints in interphalangeal osteoarthritis is not cited in the text, a serious omission since this symptom