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Rheumors Volume 4, Number 2: April, 1993

POINTS ON JOINTS
By Norman S. Koval, M.D.

FOREIGN BODY INDUCED JOINT INFLAMMATION

The penetration of a foreign body into a joint, tendon sheath or the soft tissue surrounding the joint may cause a single joint (monoarticular) synovitis. Synovitis is the inflammation of the lining of a joint or tendon. The foreign bodies most commonly described in association with this inflammation include different plant thorns, wood splinters, and sea urchin spines. All of these may easily break inside a joint cavity causing inflammation. Other less frequently found agents for foreign body synovitis are fish bones, silica, silicon, metals, plastics, rubber, glass or gravel.

Patients with silicon or metallic prostheses (artificial joints) may develop synovitis due to the breakdown of the component parts, with small slivers inciting the inflammation. Lead may also cause a synovitis following penetration of a projectile into a joint or as part of the systemic manifestations of lead poisoning. The common mechanism is based on the fact that synovial fluid can act as a solvent for lead.

The joints most commonly involved are those unprotected by clothing. There may be variable degrees of joint swelling, thickening of the lining of the joint and the development of an effusion (accumulation of fluid in the joint). On occasion, patients with foreign body synovitis due to sea urchin spines or other foreign bodies of animal origin present with fever, muscle aches (myalgias), swelling of regional lymph nodes, and -2- synovitis of surrounding joints. Professional diving, other marine recreational activities, and gardening are well-recognized risk factors.

The attending physician must consider other causes of acute and chronic single joint inflammation as well as different types of total finger inflammation such as a erysipeloid, typical and atypical mycobacteria, sarcoidosis, as well as psoriasis. The latter two diagnoses have been discussed in prior installments of Rheumors.

Laboratory studies may show synovial fluid that is cloudy or bloody and have white counts that are in the inflammatory range between 10,000/60,000 cells per cubic millimeter. Inflammatory white cells predominate. Cultures for bacteria and fungi are negative except when an infectious agent has been introduced along with the foreign body. Fresh preparations of synovial fluid occasionally may reveal fragments of plant thorns, plastic, dark metallic particles, or needle shaped fiberglass.

X-ray studies detect only those foreign bodies that are radiodense such as metal, fish bone and sea urchin spines, and usually miss wood, plastic and plant thorns. Treatment of foreign body synovitis: Approximately 30% of patients with a foreign body synovitis will resolve spontaneously. The remaining patients require surgical intervention. After the surgical removal of the foreign bodies, a few patients may experience recurrent joint swelling, as well as new bone formation.

LEAD ARTICLE
HEALTH CARE REFORM, A PATIENT PRIMER
by Robert L. Rosenberg, M.D.

The 1992 Presidential election placed the issue of health care reform in sharp national focus. Candidate, and now President, Bill Clinton, rode the wave of dissatisfaction with our current health care system to the White House. We are at a critical juncture with health care reform no longer just a possibility, but a pending reality. On May 3, 1993, the 526 member White House Health Reform Task Force will submit its findings to Congress and the public. The future they present will both excite and scare us all.

Few will argue that health care costs are increasing too rapidly. Currently, 14% of the gross domestic product, or 1/7th of our entire economy, is devoted to health care. Adding to this problem, 37 million Americans are without health care coverage. Those with coverage are often locked into their jobs because of inability to carry their benefits with them when they seek other jobs, self-employment, or retirement. Bankrupt firms leave behind unemployed and uninsured workers. Hospitals, doctors, and other health care providers often suffer too by providing uncompensated or undercompensated care. Anyone who has seen their health care costs rise by 10% to 20% annually, knows the impact of this problem first hand. Is this is a crisis? More to the point, it is a chronic problem recognized by the medical community for the last twenty years. Health care costs have been a major topic of discussion by physicians since the 1970's and my -2- medical insurance was then only $400 per year! The political atmosphere, the accelerated growth of costs and the overwhelming budget deficits all have lead political Washington to discover this "new" twenty year old problem.

It is clear that medical costs have grown tremendously, but the reasons are numerous. New technology and new pharmaceuticals have saved and prolonged lives. The added burden of HIV related disease, drug, cigarette and alcohol related diseases, and an aging population, all require more and more complex care. Patients with end-stage renal and heart disease are able to survive for years with organ transplants that were science fiction a few generations ago. Technologies not even dreamed of 20 years ago are common today - laser surgery, laparoscopic surgery, coronary artery by-pass surgery, immune and genetic manipulation, and new imaging techniques. Also, the public has demanded and received payment for allied and alternative health care including massage therapy, chiropractic therapy, herbalist therapy, nutritional therapy, holistic medicine and others. They all share in increasing our medical care costs whether or not you as a consumer use them individually.

Where can we improve? For a start, we can improve with preventative care. Weight control, exercise, smoking cessation, reduction of alcohol consumption, childhood immunizations, prenatal care, and cholesterol and cancer screening are essential. We need a system that encourages and pays for these efforts.

The Health Care Task Force recommendations will likely support a form of "managed competition", a much touted but little understood concept. Managed competition supports a system of guaranteed basic health coverage contracted for by -3- groups of large and small employers who can negotiate as a group to get the best possible price for health care services, usually through a managed care operation. The managed care operation may consist of any of one of a group of alphabet soup designations (HMO, PPO, IPA) that offers basic medical services at an agreed upon contract price. By buying coverage in large groups, costs presumably can be kept low while preserving access to health care. Unfortunately, an emphasis on delivery of "quality" health care is missing.

Advocates of a single payer system point to our northern neighbor Canada as a model. In Canada the government is the single payer and administers all health care. While many Canadians speak highly of their health care system, many other Canadians seek health care in the USA on a fee for service basis. Currently the Canadian system, like ours, is experiencing an explosion in costs, though the magnitude of their cost rise is not as great as ours.

Regardless of how you feel about the current system, there are some basic truths. Eighty percent of Americans want a change in the health care system and most physicians agree. The changes will affect all of us. Our new system will initially be more disruptive and probably more expensive with the hope that costs can be kept in line in later years. Access to your family doctor may be sacrificed and your choice of physician will be limited. Medical care will likely no longer be "on demand". Everything that we do as physicians will come under increased scrutiny, often by non-physicians. We will all face these major changes together with the goal of providing the best quality care available anywhere.

As patients and health care consumers, you must be informed and involved in the decision process. Please write or call your representatives and tell them what you think about health care reform. Arthritis & Rheumatism Associates wants to provide the best health care available under any system.

RHEUMINATIONS

KEEP IN TOUCH WITH YOUR REPRESENTATIVES
KEY TELEPHONE NUMBERS AND ADDRESSES

Senate and House Bill Status.............202-225-1772

Senate Addresses

Street addresses in Washington, DC 20510
SD ... Dirksen Building ..............1st & C Sts., NE
SH ... Hart Building..................2nd & C Sts., NE
SR ... Russell Building...............1st & C Sts., NE
S.... Capitol Building

House Addresses
Street addresses in Washington, DC 20515

Rooms listed with 3 numbers:
CHOB:
Cannon House Office Bldg.
1st St. & Independence Ave., SE

Rooms listed with 4 numbers beginning with 1:
LHOB:
Longworth House Office Bldg.
Independence & New Jersey Aves., SE

Rooms listed with 4 numbers beginning with 2:
RHOB
Rayburn House Office Bldg.
Independence Ave. & S. Capitol St., SW

Other office buildings:
OHOB (O'Neill).........
New Jersey Ave. & C St., SE

FHOB (Ford)
300 D St., SW

H
Capitol Building

WHEN WRITING, these addresses and salutations are suggested:

The Honorable John Doe
The United States Senate
Washington, DC 20510

Dear Senator Doe:


The Honorable Jane Doe
U.S. House of Representatives
Washington, DC 20515

Dear Congresswoman Doe:


TO PHONE Senate and Representative offices directly, dial 202 and the telephone number shown below, opposite the members names.

Senators
Sen. Paul S. Sarbanes (D)
SH-309 202-224-4524
3rd Term Expires...... 1995

Sen. Barbara A. Mikulski (D)
SH-320 202-224-4654
2nd Term Expires...... 1999

House of Representatives
Wayne Gilchrest (R - 1st) 412
CHOB 202-225-5311
2nd Term

Helen Delich Bently (R - 2nd) 1610
LHOB 202-225-3061
5th Term

Term Benjamin L. Cardin (D - 3rd) 227
CHOB 202-225-4016
4th Term

Albert Wynn (D - 4th) 423
CHOB 202-225-8699
1st Term

Steny H. Hoyer (D - 5th) 1705
LHOB 202-225-4131
7th Term

Roscoe Bartlett (R - 6th) 312
CHOB 202-225-2721
1st Term

Kweisi Mfume (D - 7th) 2419
RHOB 202-225-4741
4th Term

Constance A. Morella (R - 8th) 223
CHOB 202-225-5341
4th Term

QUESTION & ANSWERS
By Evan L. Siegel, M.D.