From The New England Journal of Medicine, April 13, 2000
Rheumatic Diseases and the Environment reviews a number of topics with a common theme: the effect of environmental agents on the development of rheumatic disease. Most rheumatic disorders are thought to result from interactions between genetic and environmental factors, but evidence of the roles of specific environmental agents is scarce for most diseases. In this book, the term "environment" is used broadly to include a number of chemicals, drugs, and lifestyle factors, as well as emotional and physical distress, but not infectious agents or microbial products. Among the topics covered are fibrosing disorders such as the toxic oil syndrome, drug-induced autoimmunity, silicone-related disorders, diseases related to lifestyle, and occupational musculoskeletal disorders. The editors suggest that the book may be useful for physicians, biomedical scientists, and epidemiologists, as well as for lawyers, lawmakers, and regulators. Indeed, many of the topics that are reviewed concern environmentally or medically induced disorders that may involve questions about liability. The last section of the book examines public health risks, safety and surveillance, and legal issues. The rise in the number of products that can enter the environment has been accompanied by increased public awareness of their potential effects on health. It is therefore essential for physicians and administrators to know the potential effects of these products and to base their decisions and the information provided to patients and third parties on the best scientific evidence. The first two sections of the book review the basic concepts that one must be familiar with to understand the scientific data presented in subsequent sections. There is a good summary of epidemiologic methods -- information that is essential for assessing the validity of the literature in this area. The question of whether there is an association between silicone implants and disease is used to illustrate various types of epidemiologic studies. The sections on autoimmunity and genetics are easy for readers who are not experts in these areas to understand. The chapter on laboratory testing and diagnosis is somewhat out of context, because it discusses mainly laboratory abnormalities associated with idiopathic connective-tissue diseases. The discussion would have been more relevant if it had included issues specifically related to environmentally induced syndromes, with some guidance on how to evaluate a patient when such an association is suspected. The relation between fibrosing disorders and a variety of chemical exposures has been well documented by epidemiologic studies and is supported by animal models and bioassays. The pathogenesis of these syndromes is elusive, but the research points to a combination of direct effects of the exposure and abnormal immune responses triggered by the compound in question. Fibrosing disorders known to be induced by exposure to environmental agents include the toxic oil syndrome, the eosinophilia myalgia syndrome, and scleroderma-like conditions associated with exposure to organic compounds. The third section of the book provides an overview of the clinical manifestations and recognized pathogenetic mechanisms of these syndromes. The next section includes an assortment of unrelated topics: drug-induced autoimmunity, adverse effects of biologic therapies, lifestyle risk factors (e.g., smoking and diet), silicone-related disorders, fibromyalgia, and the multiple chemical sensitivity syndrome. Drug-induced disorders include lupus-like syndromes and pulmonary hypertension. A number of the alleged associations between specific drugs and autoimmune disease are based on data from case reports or small series, which are inadequate as evidence of a causal association, even if the symptoms resolved after the exposure was terminated. Rechallenge is clearly not an ethical option in most cases. Although interesting, some of these associations may be spurious. Some of the discussions emphasize laboratory findings. In the absence of solid evidence from clinical studies, readers should regard with caution the assumption that biologic plausibility indicates causality. Reports of an association between silicone implants and disease have provoked a heated debate in the press and among health care researchers and providers. It would therefore be unrealistic to expect that review of the topic would not stir up some controversy. The chapter on silicone-related disorders places a strong emphasis on the potential biologic effects of silicone. Animal and laboratory studies suggest that the induction of abnormal inflammatory and immune responses by silicones may result in autoimmune disease. Yet most of the reports of clinical disorders that developed after the receipt of silicone implants have been based on uncontrolled studies of case series. Epidemiologic studies have failed to identify any consistent associations. The author of the chapter discusses the possible pitfalls of these studies, but uncontrolled studies of case series and animal studies or bioassays cannot provide stronger evidence than observational studies of this problem. Silicone-induced immune abnormalities may not necessarily lead to disease. Other chapters review the effect of lifestyle and other environmental risk factors on the development of rheumatic disorders such as rheumatoid arthritis, gout, fibromyalgia, the chronic fatigue syndrome, and the multiple chemical sensitivity syndrome. The chapter on acquired risk factors and rheumatoid arthritis provides an excellent, systematic review of the often confusing epidemiologic studies linking such factors as smoking and the use of oral contraceptives to rheumatoid arthritis. There is a section on the role of the workplace in the development of soft-tissue and degenerative musculoskeletal diseases, with good reviews of the epidemiology of osteoarthritis and upper-extremity injuries. Rheumatic Diseases and the Environment is interesting and informative, and it provides information not found in other books. Some sections rely primarily on laboratory data to support a link between environmental agents and disease, but for some rare conditions, no other evidence may be available. Many of the topics covered by this book are also found in rheumatology textbooks, but with a different emphasis. Rheumatology textbooks are written primarily from a clinical perspective, whereas this book highlights the etiologic aspects of environmental exposures. Understandably, because of the book's breadth, not all syndromes and diseases are discussed in depth. Most sections of the book should be of interest to physicians and others who are not experts in the field. This book may be of particular interest to persons involved in the regulatory and legal aspects of environmentally induced disease. Reviewed by Maria Suarez-Almazor, M.D., Ph.D.
Copyright © 2000 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.


Book Description
Rheumatic Diseases & the Environment is a comprehensive, authoritative contributed volume that addresses the relationship between environmental and occupational factors, and the musculoskeletal diseases they manifest. The volume includes in-depth discussions on toxic oil syndrome, silicone-associated rheumatic disease, systemic lupus, carpal tunnel syndrome, and other areas continuing to gain profile in the public's eye. Regulatory, litigation and surveillance issues are also presented. This is the first time that all of the rheumatic conditions with an environmental/occupational origin, and conditions exacerbated by environmental/occupational factors, are compared and addressed as a unique entity.


Book Info
(Arnold) State Univ. of New York, Stony Brook. Discusses recent findings of the potential pathogenetic mechanisms underlying environmental exposure-associated rheumatic diseases. For physicians, researchers, and policy makers. DNLM: Rheumatic Diseases--etiology.

ANNOTATION

The book contains black-and-white illustrations.

'Rheumatic Diseases & the Environment' is a comprehensive, authoritative contributed volume that addresses the relationship between environmental and occupational factors, and the musculoskeletal diseases they manifest. The volume includes in-depth discussions on toxic oil syndrome, silicone-associated rheumatic disease, systemic lupus, carpal tunnel syndrome, and other areas continuing to gain profile in the public's eye. Regulatory, litigation and surveillance issues are also presented. This is the first time that all of the rheumatic conditions with an environmental/occupational origin, and conditions exacerbated by environmental/occupational factors, are compared and addressed as a unique entity.

ACCREDITATION