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Sixty-two patients with fibromyalgia were randomly assigned to receive 25 mg of amitriptyline at night, 500 mg of naproxen twice daily, both amitriptyline and naproxen, or placebo in a 6-week, double-blind trial. Amitriptyline was associated with significant improvement in all outcome parameters, including patient and physician global assessments, patient pain, sleep difficulties, fatigue on awakening, and tender point score. Patients taking the combined naproxen-amitriptyline regimen experienced minor, but not significant, improvement in pain when compared with patients who took amitriptyline alone. Amitriptyline, or amitriptyline and naproxen, is an effective therapeutic regimen for patients with fibromyalgia.

We surveyed general and family practitioners to evaluate their patterns of referring musculoskeletal disease patients to rheumatologists and orthopedists. Patients who had rheumatoid arthritis, systemic lupus erythematosus, and ankylosing spondylitis were most often referred to rheumatologists, whereas patients with osteoarthritis, persistent low back pain, and post-traumatic knee pain were most often referred to orthopedists. As conditions worsened in severity, referrals were more frequent. Patients with conditions that were difficult to diagnose, such as possible shoulder tendinitis that was unresponsive to initial nonsteroidal therapy, undiagnosed polyarthritis, and intermittent knee swelling with pain, were most often treated without referral and, when referred, were most often sent to orthopedists. Belief in the effectiveness of rheumatologists or orthopedists correlated strongly with reported referral behavior, yet most respondents considered themselves capable of managing the majority of patients with musculoskeletal diseases. Neither practice arrangement, board certification, nor educational background affected referral behavior. However, younger physicians were more likely (P = 0.002) to refer patients to rheumatologists. Multivariate analysis showed that the significant predictors of global referral behavior were belief in the effectiveness of subspecialists and a small number of musculoskeletal problems seen by the generalist. The predictors of referral to rheumatologists were belief in rheumatologist efficacy and young physician age.

One hundred eighteen consecutive patients with fibromyalgia were evaluated prospectively. Immunoglobulin deposits at the dermal-epidermal junction were found in only 4 of 36 patients. Twelve patients (14%) had at least one positive antinuclear antibody (ANA) test. Eight patients (7%) had at least one low C3. Thirty-five patients (30%) has a history of Raynaud's phenomenon and 22 (18%) had sicca symptoms, defined as symptomatic dry eyes and mouth and a positive Schirmer test. The 35 patients with Raynaud's phenomenon had a significantly higher prevalence of sicca symptoms, positive ANA or low C3 compared to the 83 patients who did not have Raynaud's phenomenon. Thus, a subset of patients with fibromyalgia may have features suggestive of a systemic connective tissue disorder.

The effort to identify elderly people at high risk of hip fracture can reasonably focus on patients who are prone to falling (identified by several criteria, including a history of falling) and perhaps those who are likely to be the most osteopenic. Efforts at treatment must be individualized. Increased use of estrogens by women now going through menopause may improve the statistics on hip fracture, beginning 10 to 20 years from now. Meanwhile, the tailoring of interventions in elderly people to prevent falls, to counter osteoporosis, and to identify and treat correctable causes of osteopenia may produce a more immediate improvement in the statistics.

Chondrocalcinosis and osteoarthritis (OA) both increase in prevalence with age, yet previous studies assessing their association have often been too small to adjust for age and have had biased selection of subjects. We assessed the prevalence of chondrocalcinosis and its link with OA in the Framingham Knee Osteoarthritis Study, a large population based study of the elderly. After controlling for age, we found a modestly increased rate of radiographic OA in those with chondrocalcinosis (relative risk = 1.52 (95% CI 1.22, 1.90). There was a similar link between chondrocalcinosis and severe radiographic OA (relative risk = 1.52). Chondrocalcinosis was positively associated with both symptomatic and asymptomatic radiographic OA. The proportion of radiographic OA potentially attributable to chondrocalcinosis was only 4.4%. Our results confirm that chondrocalcinosis is significantly associated with OA after controlling for age, but they also suggest that chondrocalcinosis and OA increase independently with age.