A baseline skin score > or =20 was associated with heart involvement at baseline and predicted mortality and SRC over the subsequent 4 years. Improvement in skin score in these patients with diffuse cutaneous scleroderma was associated with improvement in hand function, inflammatory indices, joint contractures, arthritis signs, overall functional ability, and the examining investigator's global assessment of improvement.

Iloprost is effective for the short-term palliation of severe Raynaud phenomenon in patients with systemic sclerosis.

U.S. Department of Veterans Affairs, Health Services Research & Development Service.

The course of the skin score and the frequencies of SRC and mortality in the high-dose D-Pen group were not different from those in the low-dose D-Pen group. Eighty percent of the adverse event-related withdrawals occurred in the high-dose D-Pen patients. Although this study cannot answer the question of whether low-dose D-Pen is effective, it does suggest that there is no advantage to using D-Pen in doses higher than 125 every other day.

One hundred eighty-nine patients with rheumatoid arthritis were entered into a prospective, controlled, double-blind multicenter trial comparing placebo amd methotrexate (MTX).721 bles measured, including joint paidtenderness and swelling counts, rheumatoid nodules, and patient and physician assessment of disease activity. MTX treatment demonstrated statistically significant improvement over placebo in patients with anemia, elevated erythrocyte sedimentation rate, and rheumatoid factor. However, nearly one-third of the patients receiving MTX were withdrawn for adverse drug reactions, of which elevated levels of liver enzymes was the most common. Pancytopenia occurred in 2 patients taking MTX. All adverse drug effects resolved without sequelae. MTX appears to be effective in the treatment of active rheumatoid arthritis but requires close monitoring for toxicity.

U.S. Department of Veterans Affairs Health Services Research and Development Service

A cDNA encoding the Mac-2 antigen, a surface marker highly expressed by thioglycollate-elicited macrophages, has been cloned by immunoscreening of a lambda gt11-P388D1 expression library. The nucleotide sequence of the cDNA is identical to that of carbohydrate-binding protein 35, a galactose-specific lectin found in fibroblasts and highly homologous to a rat IgE-binding protein from basophilic leukemia cells. The in vitro synthesized Mac-2 protein displayed the expected carbohydrate- and IgE-binding properties. By pulse-chase analysis and subcellular fractionation studies, the Mac-2 protein was found in the cytosol but was also seen to accumulate in the extracellular medium. The latter finding was surprising in view of the fact that the cDNA did not encode a signal peptide or transmembrane domain. An alternatively spliced cDNA with the potential to encode a NH2 terminally extended Mac-2 protein with a stretch of hydrophobic amino acids at its NH2 terminus was also found, but it is not clear whether it is the source of the extracellular Mac-2. Possible functions for the Mac-2 protein based on its lectin- and IgE-binding properties are discussed.

Clinical decision making can be described as answering one question: "What is the best next thing for this patient at this time?" In addition to incorporating clinical information, research evidence, and patient preferences, the process requires considering contextual factors that are unique to each patient and relevant to their care. The failure to do so, thereby compromising that care, can be called a "contextual error." Although proponents of evidence-based clinical decision making and many scholars of the medical interview emphasize the importance of individualizing care, no operational definition is provided for the concept, nor is any methodology proposed for the interpretation of clinically relevant patient-specific variables. By conceptualizing the physician-patient encounter as a participant-observer case study with an N of 1, this essay describes how existing approaches to studying social systems can provide clinicians with a systematic approach to individualizing their clinical decision making. prescriptive model of evidence-based decision making mentions patient "circumstances" (see Fig. 1), the term is narrowly qualified as "physical" and "clinical circumstances." 2 There has been little methodological consideration of how one identifies, from the complexity of each patient's life, that which is pertinent to their care. J GEN INTERN MEDThe cognitive challenge of individualizing clinical decisions at a discrete moment and place with limitations of resources and possibilities is the point of departure for this paper. While a number of models of the medical interview outline the overarching goals and objectives of the physician-patient encounter, few conceptualize the reasoning applied in answering the ever-present question: "Under the circumstances, what is the best next thing for this patient at this time?" In his seminal writing on the biopsychosocial model, George Engel introduces general systems theory as a framework for broadening conceptions of illness beyond the biomedical model to include social, psychological, and behavioral dimensions, noting that "Systems theory holds that all levels of organizations are linked to each other in a hierarchical relationship so that change in one affects change in the others."3 In a subsequent essay, "The clinical application of the biopsychosocial model," he illustrates how perturbations in biomedical and psychosocial systems affect one another. 4 What he does not offer, however, is a methodology for tracking those perturbations amid the infinite complexity of a patient's life, given the constraints of time and resources during a medical encounter.Received