91
EDITORIAL T h e eighteenth volume (1975) of ARTHRITIS AND two evolutionary changes in the Journal: a new Editor (Dr. J. Claude Bennett) will initiate his service in July 1975, and beginning with this issue the physical appearance of the Journal has been altered. T h e larger format offers several advantages. There are anticipated economies in type-setting and printing. There are the prospects of increased rev6nue from advertising and of higher quality of half-tone reproductions, and the entire Table of Contents can be printed on the back of each issue. Additionally, in the Editor’s opinion, the new style is more appealing than the familiar 7 x 10 inches format. T h e slightly unesthetic step in bound volumes on the library shelf seems the only disadvantage of the change. I n reviewing the gradual evolution of the Journal over eighteen years, the Editor is impressed with the importance of its relationship to the society that sponsors ARTHRITIS AND RHEUMATISM. T h e Journal is not the property of the Editor, the Editorial Board or the ARA Committee for the Publication of A&R. These bodies accept the stewardship for operation of the Journal for finite terms, but the American Rheumatism Association Section of T h e Arthritis Foundation provides a continuity of support and direction that is lacking in some journals. A subsequent communication will deal more specifically with the transferral of the Editorial Office to Birmingham, Alabama. RHEUMATISM marks
CHARLES L. CHRISTIAN, M D
Editor
LETTERS Chrysotherapy for Rheumatoid Arthritis in Rural Alaska T o the Editor: Gold salts have been used in the treatment of rheumatoid arthritis for almost 50 years and have traditionally been administered under the direct supervision of a physician in the hospital or clinic setting. I n southwest Alaska SOYo of the population live in rural villages accessible only by air. T h e purpose of this communication is to present our experience in treating rheumatoid arthritis with gold in rural villages, using a village native health aide as primary supervisor of the patients. Arthritis and Rheumatism, Vol. 18, No. 1 (January-February,1955)
There are 15,100 people living in 52 villages in southwest Alaska scattered over an area of about 40,000 square miles. Two-thirds are Eskimos, one-sixth are Athabascan Indian and one-sixth are Caucasian. T h e Public Health Service Hospital in Bethel is responsible for the health care of the area. Each village has one to three native health aides who are the primary care practitioners for the people of their village. These aides maintain daily radio call to the hospital in Bethel, where doctors are available to advise them. A doctor visits each village once or twice a year and a Public Health nurse, three to five times a year. Since there are no roads from Bethel to any of the villages, travel is by plane, snow m a c h i n e , b o a t o r d o g team. Patients with definite or classic rheumatoid arthritis, as defined by the American Rheumatism Association criteria, whose disease was not satisfactorily controlled on sufficient salicylate to maintain levels between 20 and 30 mgyo for 3 to 6 months, were c o n sitlered for gold treatment. When a patient was selected as a candidate for gold, both the patient and the health aide were brought to the hospital in Bethel. T h e health aide was instructed by one of the authors on basic disease concepts and treatment of rheumatoid arthritis, as well as gold therapy and its side effects. I n addition, the health aide spent time in the laboratory learning to draw blood and in the pharmacy learning how to give gold injections. T h e aide then checked the patient’s urine specimen for protein, drew the blood sample and administered the patient’s gold shot under the supervision of the physician and nurse. I n the village clinic, the health aide gave 25 mg of hlyochrysine for 2 weeks, then 50 mg weekly until 500 mg was administered. Each week she filled out the gold flow sheet, checking urine for protein and asking the patient about rash, nausea or metallic taste. If the patient had a rash or more than trace protein, gold was withheld and the health aide called Bethel hospital for advice. I n addition, the aide drew blood for a CBC every other week (or after alternate injections) and handed the tube to the mail plane pilot who carried it to the Bethel airport where it was picked up and brought to the hospital lab. In most cases the blood count was determined within 24 hours of being drawn. After having received 500 mg of gold, the patient traveled to the hospital for evaluation by the doctor and then returned to the village to continue weekly injections until a dose of 1000 to 1200 was
92
reached. He then returned to Bethel for reevaluation and, if there had been a response to gold, he continued injections every other week for 6 weeks and then once a month. I n addition to gold, therapy is augmented with salicylates to tolerance, periodic intraarticular steroid injections, and physical therapy instructions. Eleven patients have been treated in the villages with gold therapy over the last 2 years. T h e age range of patients was from 48 to 62, with 10 of the 11 being females. Six of 11 demonstrated a good response, with decreased joint pain and swelling and improvement in function, and continue on chrysotherapy. Toxicity developed in 4 patients, 3 of whom developed a rash and 1 proteinuria. Gold treatment was stopped in the 4 but resumed in 2 when the rash cleared. I n each instance the health aide recognized the early signs of toxicity and alerted the physician. Since most of Alaska’s native population lives in small villages remote from physicians and hospitals, treatment and management of RA has been difficult. Our experience shows that paramedical personnel can be taught to administer gold therapy successfully to the RA patient. All aides were able to manage gold treatments and recognize side effects. Formal health aid training varied from 6 to 18 weeks while the years of duty as a village health aide ranged from 1 to 14. We are currently beginning to use pharmacists to follow the course of therapy and monitor the WBC counts. T h e physician then will see the patient initially, twice during the initial course of weekly gold injections, and yearly thereafter so long as the arthritis is controlled and no toxicity arises. Our experience has wider application than the Alaska Native Health Service. Since village health aides are able to manage patients on gold therapy, other paramedical personnel, physicians assistants, nurse practitioners, or office nurses could do the same. T h e benefits are several. T h e number of physician visits and cost of gold treatment could be reduced. I n rural areas patients with RA who need gold therapy but live a distance from a physician could be monitored by paramedical personnel near to their home.
Serum Gold Values 7’0 the Editor: Gottlieb et a1 reported in their paper published in ARTHRITIS AND RHEUMATISM, Volume 17, Number 2, Page 171, March 1974 that “their observations should help dispel the notion that serum gold values are a valuable guide to improve chrysotherapy.” Since we do not share this view, we suggest several possibilities for the “apparent discrepancy” between Gottlieb’s conclusion and ours. One reason may be that Gottlieb’s observations appear to be limited to the interval of “uninterrupted” or weekly gold administration. We had previously reported that serum gold values during the initial 20-week period often do exceed 300 pg% (Figure la) (1). When we compared efficacy between the conventional vs the individualized dosage administration (the latter based on serum gold values) for intervals extending beyond the initial 20-week treatment period, ie, from 1 to 5 years, we observed a n enhanced and a more sustained therapeutic response (2). Gottlieb et a1 reached their conclusion that there is no correlation between clinical response and blood gold levels on the basis of ambient gold values observed for patients on a fixed weekly dosage regimen. Our previously reported data, described in Figure la, are similar to Gottlieb’s experience, illustrating gold levels during the initial 20-week interval of weekly therapy. Though there is moderate individual variation in peak levels 1-2 hours after injection, and in subsequent daily values, the mean range for serum gold content tends to be maintained between 300-700 pg% prior to spacing out the interval of gold administration. Gold administration is thereafter arbitrarily decreased, usually to monthly intervals, with corresponding divergence of the patterns observed in serum SERUM DECAY
BRIAN MCMAHN, MD
US Public Health Seruice Bethel, Alaska MICHAEL B. ARMSTRONG, MD
Consultant in Rheumatoid Arthritis Alaska Native Medical Center Anchorage, Alaska 99501
b
a Figure 1
EDITORIAL T h e eighteenth volume (1975) of ARTHRITIS AND two evolutionary changes in the Journal: a new Editor (Dr. J. Claude Bennett) will initiate his service in July 1975, and beginning with this issue the physical appearance of the Journal has been altered. T h e larger format offers several advantages. There are anticipated economies in type-setting and printing. There are the prospects of increased rev6nue from advertising and of higher quality of half-tone reproductions, and the entire Table of Contents can be printed on the back of each issue. Additionally, in the Editor’s opinion, the new style is more appealing than the familiar 7 x 10 inches format. T h e slightly unesthetic step in bound volumes on the library shelf seems the only disadvantage of the change. I n reviewing the gradual evolution of the Journal over eighteen years, the Editor is impressed with the importance of its relationship to the society that sponsors ARTHRITIS AND RHEUMATISM. T h e Journal is not the property of the Editor, the Editorial Board or the ARA Committee for the Publication of A&R. These bodies accept the stewardship for operation of the Journal for finite terms, but the American Rheumatism Association Section of T h e Arthritis Foundation provides a continuity of support and direction that is lacking in some journals. A subsequent communication will deal more specifically with the transferral of the Editorial Office to Birmingham, Alabama. RHEUMATISM marks
CHARLES L. CHRISTIAN, M D
Editor
LETTERS Chrysotherapy for Rheumatoid Arthritis in Rural Alaska T o the Editor: Gold salts have been used in the treatment of rheumatoid arthritis for almost 50 years and have traditionally been administered under the direct supervision of a physician in the hospital or clinic setting. I n southwest Alaska SOYo of the population live in rural villages accessible only by air. T h e purpose of this communication is to present our experience in treating rheumatoid arthritis with gold in rural villages, using a village native health aide as primary supervisor of the patients. Arthritis and Rheumatism, Vol. 18, No. 1 (January-February,1955)
There are 15,100 people living in 52 villages in southwest Alaska scattered over an area of about 40,000 square miles. Two-thirds are Eskimos, one-sixth are Athabascan Indian and one-sixth are Caucasian. T h e Public Health Service Hospital in Bethel is responsible for the health care of the area. Each village has one to three native health aides who are the primary care practitioners for the people of their village. These aides maintain daily radio call to the hospital in Bethel, where doctors are available to advise them. A doctor visits each village once or twice a year and a Public Health nurse, three to five times a year. Since there are no roads from Bethel to any of the villages, travel is by plane, snow m a c h i n e , b o a t o r d o g team. Patients with definite or classic rheumatoid arthritis, as defined by the American Rheumatism Association criteria, whose disease was not satisfactorily controlled on sufficient salicylate to maintain levels between 20 and 30 mgyo for 3 to 6 months, were c o n sitlered for gold treatment. When a patient was selected as a candidate for gold, both the patient and the health aide were brought to the hospital in Bethel. T h e health aide was instructed by one of the authors on basic disease concepts and treatment of rheumatoid arthritis, as well as gold therapy and its side effects. I n addition, the health aide spent time in the laboratory learning to draw blood and in the pharmacy learning how to give gold injections. T h e aide then checked the patient’s urine specimen for protein, drew the blood sample and administered the patient’s gold shot under the supervision of the physician and nurse. I n the village clinic, the health aide gave 25 mg of hlyochrysine for 2 weeks, then 50 mg weekly until 500 mg was administered. Each week she filled out the gold flow sheet, checking urine for protein and asking the patient about rash, nausea or metallic taste. If the patient had a rash or more than trace protein, gold was withheld and the health aide called Bethel hospital for advice. I n addition, the aide drew blood for a CBC every other week (or after alternate injections) and handed the tube to the mail plane pilot who carried it to the Bethel airport where it was picked up and brought to the hospital lab. In most cases the blood count was determined within 24 hours of being drawn. After having received 500 mg of gold, the patient traveled to the hospital for evaluation by the doctor and then returned to the village to continue weekly injections until a dose of 1000 to 1200 was
92
reached. He then returned to Bethel for reevaluation and, if there had been a response to gold, he continued injections every other week for 6 weeks and then once a month. I n addition to gold, therapy is augmented with salicylates to tolerance, periodic intraarticular steroid injections, and physical therapy instructions. Eleven patients have been treated in the villages with gold therapy over the last 2 years. T h e age range of patients was from 48 to 62, with 10 of the 11 being females. Six of 11 demonstrated a good response, with decreased joint pain and swelling and improvement in function, and continue on chrysotherapy. Toxicity developed in 4 patients, 3 of whom developed a rash and 1 proteinuria. Gold treatment was stopped in the 4 but resumed in 2 when the rash cleared. I n each instance the health aide recognized the early signs of toxicity and alerted the physician. Since most of Alaska’s native population lives in small villages remote from physicians and hospitals, treatment and management of RA has been difficult. Our experience shows that paramedical personnel can be taught to administer gold therapy successfully to the RA patient. All aides were able to manage gold treatments and recognize side effects. Formal health aid training varied from 6 to 18 weeks while the years of duty as a village health aide ranged from 1 to 14. We are currently beginning to use pharmacists to follow the course of therapy and monitor the WBC counts. T h e physician then will see the patient initially, twice during the initial course of weekly gold injections, and yearly thereafter so long as the arthritis is controlled and no toxicity arises. Our experience has wider application than the Alaska Native Health Service. Since village health aides are able to manage patients on gold therapy, other paramedical personnel, physicians assistants, nurse practitioners, or office nurses could do the same. T h e benefits are several. T h e number of physician visits and cost of gold treatment could be reduced. I n rural areas patients with RA who need gold therapy but live a distance from a physician could be monitored by paramedical personnel near to their home.
Serum Gold Values 7’0 the Editor: Gottlieb et a1 reported in their paper published in ARTHRITIS AND RHEUMATISM, Volume 17, Number 2, Page 171, March 1974 that “their observations should help dispel the notion that serum gold values are a valuable guide to improve chrysotherapy.” Since we do not share this view, we suggest several possibilities for the “apparent discrepancy” between Gottlieb’s conclusion and ours. One reason may be that Gottlieb’s observations appear to be limited to the interval of “uninterrupted” or weekly gold administration. We had previously reported that serum gold values during the initial 20-week period often do exceed 300 pg% (Figure la) (1). When we compared efficacy between the conventional vs the individualized dosage administration (the latter based on serum gold values) for intervals extending beyond the initial 20-week treatment period, ie, from 1 to 5 years, we observed a n enhanced and a more sustained therapeutic response (2). Gottlieb et a1 reached their conclusion that there is no correlation between clinical response and blood gold levels on the basis of ambient gold values observed for patients on a fixed weekly dosage regimen. Our previously reported data, described in Figure la, are similar to Gottlieb’s experience, illustrating gold levels during the initial 20-week interval of weekly therapy. Though there is moderate individual variation in peak levels 1-2 hours after injection, and in subsequent daily values, the mean range for serum gold content tends to be maintained between 300-700 pg% prior to spacing out the interval of gold administration. Gold administration is thereafter arbitrarily decreased, usually to monthly intervals, with corresponding divergence of the patterns observed in serum SERUM DECAY
BRIAN MCMAHN, MD
US Public Health Seruice Bethel, Alaska MICHAEL B. ARMSTRONG, MD
Consultant in Rheumatoid Arthritis Alaska Native Medical Center Anchorage, Alaska 99501
b
a Figure 1
