4.1Background and Overview

4.1.1 Need for Written Information

In the limited time available for the rheumatology consult or follow-up visit, it is often not possible

R.I. Fox ( )

Rheumatology Clinic, Scripps Memorial Hospital and Research Foundation, La Jolla, CA, USA e-mail: robertfoxmd@mac.com

to address each of these areas that directly affects the patientÕs questions about diagnostic and therapeutic needs. Indeed, the Òload of informationÓ may too great to be absorbed by the patient during their increasingly mandated time-limited revisits. Also, physicians in other disciplines and oral health care professions need to receive copies of information as part of the Òhealth care teamÓ in order to provide an integrated program of care to their patients.

Although patient competence with computers will vary widely among patient groups, it is

surprising how quickly patients as ÒconsumersÓ have learned how to access information over the Internet. However, with respect to medical issues, this ease of availability of information may have the problem of Òinformation overloadÓ or ÒmisinformationÓ provided to the patient. Increasingly, physicians should assume that at least a proportion of their patients are going to search the Internet regarding diagnoses and therapies. Thus, we should take steps to guide their searches in positive, helpful, and productive directions.

In the time allowed for patient revisits, the SS patient has the most Òvested interestÓ in understanding the details of therapy. They also have the most Òtime availableÓ in optimizing their own care and understanding their medical tests and treatments. We have found that the most effective way to guide their efforts is to provide them a broad-stroke ÒoverviewÓ of the plan and then follow-up with accurate written information and instructions by email and links to proper websites.

Providing information that the patient can understand is the best approach to gaining compliance and patient education for these Òquality of lifeÓ issues that is often not possible during their time in the rheumatologistÕs ofÞce. Thus, the physician must treat the patient as a partner in the therapy of their disease and present the information in a form that allows patient choices to be made on a rational basis. Providing them written information that they can read at their leisure will accomplish this.

We do not expect to change patients into ÒphysiciansÓ in terms of clinical decisionmaking, as it is our responsibility as physicians based on our training to make our bestinformed judgments about diagnosis and therapy. However, patients are increasingly diligent and intelligent consumers, and they will pursue information.

It is our obligation to present that information and to inform the rest of the health care team of the status of the patient. In cases where patients may not feel computer competent or language presents a barrier, we have found that information sent to children or family members proves useful.

4.1.2Use of Internet as a Method to Provide Information

(a)We email appropriate information to patients with our suggestions to avoid Òinformation overloadÓ at the time of ofÞce visit;

(b)We help counter potential misinformation that patients might receive from the Internet and ÒchatÓ groups regarding diagnosis and therapy;

(c)We provide copies of information from the Internet to other members of the health care team (i.e., referring physician, emergency

room, and surgical colleagues and their nursing staff).

In doing so, we help spare a few trees that would provide the paper for the handouts by Ògoing greenÓ with electronically transmitted information.

4.1.3 Patient Access to Computers

We are aware that not all patients have a home computer, but a surprising number of patients, even older patients, have their own computer. In those patients who do not have one, their children, grandchildren, or close friends often have a computer, and other patients may have access to a public library where they can establish a free email account.

4.1.4Types of Information Supplied to Patients and Referring Physicians

This chapter is a starting point for providing the informational content to patients and referring physicians on:

(a)Diagnostic criteria for SS and related diseases including SLE, scleroderma, and Þbromyalgia; not every patient with a positive ANA or SS-A antibody has SS or SLE.

(b)Pitfalls in interpretation of laboratory evaluations; there is a difference between sensitivity and speciÞcity of laboratory tests and signiÞcant variation between laboratories based on the method in which the test is performed.

(c)Therapeutic hints for glandular and extraglandular manifestations.

(d)Informational resources that might be mailed to the patient.

This information is in the Òpublic domainÓ on the web but may be spread over many different websites. One of the current problems of the Internet/web is that a search for some topics such as ÒSjogrenÕs syndromeÓ currently brings up over 400,000 Òhits,Ó and the shear volume of data will overwhelm any patient in search of speciÞc answers. Our goal is to make our patientsÕ search for information more narrowly and better focused so they may more efÞciently Þnd validated information.

4.1.5Future Guidelines of Diagnosis and Therapy Under Committee of the Sjogren’s Syndrome Foundation

We are also working with the Sjogren’s Syndrome Foundation (SSF) and the American College of Rheumatology (ACR) (see Chapter 13) to establish a standards of care and treatment guidelines website. Indeed, members of that collaborative committee provide many of the tables provided in this chapter. This website will initially be directed to physicians and include Òstandards of diagnosis and careÓ as well as a reference library and links to therapeutic studies.

4.2Diagnostic Criteria for Sjogren’s Syndrome (SS), Systemic Lupus Erythematosus (SLE), Scleroderma, and Fibromyalgia

4.2.1Background: The Confusion Surrounding Criteria for Autoimmune Disorders

One of the initial problems encountered by the rheumatologist (and patient) is the distinction between SjogrenÕs syndrome (SS), systemic lupus erythematosus (SLE), scleroderma (PSS), and Þbromyalgia (FM). The same patient with the

same laboratory values may receive one or more of these diagnoses from their primary physician or specialist. Thus, it is worth providing the patient with the current criteria for diagnosis for each of these clinical entities, which has been diagnosed.

Although criteria for each of these diseases are available on the Internet, the shear volume of irrelevant and disconcerting information found on an Internet search for these topics is daunting. Thus, we have included these tables of diagnostic criteria as a ÒdesktopÓ reference. It is worth noting that the diagnostic criteria for SjogrenÕs syndrome is the only one of these diagnostic categories NOT listed on the ÒAmerican College of RheumatologyÓ website (http://www.rheumatology.org/practice/ clinical/classiÞcation/index.asp).

This is because the SS criteria were developed in Europe and not independently validated in the American population. Nevertheless, these criteria for SS have been accepted as the entrance criteria for studies recognized by the US FDA for drug development.

4.2.2 Criteria for Sjogren’s Syndrome

The question of whether a patient fulÞlls criteria for SS is a frequent source of referral to the rheumatologist as well as to ophthalmologist and oral medicine clinics.

In the patient with severe keratoconjunctivitis sicca, severe xerostomia, and characteristic autoantibodies, there is generally little debate over the diagnosis. However, a common scenario is the patient who presents with fatigue, vague myalgia, and cognitive symptoms and is found to have a positive anti-nuclear antibody (ANA) during evaluation. Indeed, the patient may get conßicting opinions about whether the diagnosis of SS is present or not.

The consensus criteria for SS were predominantly set up for research purposes, and they require both clinical and laboratory criteria. Thus, it is worth starting with the current EuropeanÐAmerican criteria for SS (Table 4.1). This provides a series of clinical questions and laboratory investigations that serve as a baseline.

It provides the patient and referring physician with the essential Òdata setÓ necessary.

Similarly, many SS patients have previously carried out the diagnosis of SLE (systemic lupus erythematosus), scleroderma (either limited or

diffuse), or Þbromyalgia. Therefore, these criteria are listed in Tables 4.2, 4.3, and 4.4; classification criteria for Sjogren’s syndrome: a revised version of the European criteria proposed by the American–European Consensus Group, Table 4.1 [1].

Lupus Erythematosus (SLE)

The initial SLE criteria of the American College of Rheumatology classiÞcation criteria were devised in 1982 (Table 4.2) [2, 3]. In 1997, the immunologic disorder criteria were revised by a committee (without validation). All 11 criteria in the American College of Rheumatology criteria set have limitations. One of the most important laboratory tests, hypocomplementemia, was excluded entirely [3]. A subset of patients with SLE also fulÞll criteria for SS and are termed ÒSLE with secondary SS.Ó

4.2.4Criteria for Systemic Sclerosis (SSc) (ACR and the ABCD CREST (Calcinosis, Raynaud’s Phenomenon, Esophageal Dysmotility, Sclerodactyly Telangiectasia Criteria)

Patients with early SSc may be difÞcult to distinguish from SS. Both groups of patients

typical capillaroscopic abnormalities (Table 4.3) [4Ð8]. Both groups may have heartburn and esophageal symptoms. However, SSc should be strongly considered if patients exhibit one of the following manifestations: digital ulcers/scars, puffy Þngers, extensive telangiectasia, abnormal esophageal manometry, and shortness of breath with Þbrotic lung disease on high-resolution chest CAT scan.

A subset of SSc patients have features suggestive of SS. Indeed, the salivary gland biopsies of some SSc patients show focal lymphocytic inÞltrates, while others present with Þbrosis of the glands in a pattern more consistent with the Þbrotic pathology found in their other organs [9Ð13].

In comparison, undifferentiated connective tissue disease (UCTD) is a diagnosis applied to patients with a speciÞc antibody (anti-RNP antibody) and capillaroscopic Þndings plus any disease manifestations listed above. With followup, many UCTD patients will subsequently fall into patterns more suggestive of SLE, SSc, or SS [14].