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OBJECTIVE: To provide a comprehensive review of the epidemiology, diagnosis, and prevention of Lyme disease with a focus on the Lyme disease vaccine. DATA SOURCE: A computerized search of MEDLINE (January 1996-December 1998) was used to identify articles regarding Lyme disease, Borrelia burgdorferi, epidemiology, prevention, and vaccine. DATA SYNTHESIS: Lyme disease is a condition caused by infection with B. burgdorferi. The organism is carried by certain species of Ixodes ticks and is the most common tick-borne disease in the US. In patients with clinical manifestations of Lyme disease, various pharmacotherapeutic approaches have proven effective in treatment of the clinical features. Prevention strategies exist; however, their application is sometimes difficult. A vaccine for the prevention of Lyme disease is available, and another is being considered for approval. The recombinant outer surface protein A (OspA) vaccines to prevent Lyme disease are immunogenic and have an acceptable adverse effect profile. These vaccines are highly efficacious for the prevention of Lyme disease. CONCLUSIONS: Lyme disease is the most common tick-borne disease in the US. The infection, caused by B. burgdorferi, results in dermatologic, neurologic, cardiovascular, and musculoskeletal manifestations. Until recently, tick bite prevention strategies were the only means of decreasing the risk of acquiring the infection. The OspA vaccines are efficacious for the prevention of infection. Although universal immunization with these vaccines is unlikely, the availability of effective vaccines represents an important tool for the prevention of Lyme disease in endemic regions of the US.

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The epidemiology, relationship to giant cell arteritis (GCA), pathogenesis, pathology, clinical and laboratory features, differential diagnosis, and treatment of polymyalgia rheumatica (PMR) are reviewed. Patients with PMR are usually over 50 years of age, white, and female. There is an association between GCA and PMR that has important implications because of the risk of blindness and other severe vascular complications in patients with GCA. The causes of PMR and GCA are unknown, although the immune system is implicated in the pathogenesis of these diseases. PMR is characterized by muscle pain and stiffness in the shoulders and hips. The principal laboratory finding is an elevated erythrocyte sedimentation rate. The differential diagnosis of PMR includes a number of diseases that cause symmetrical arthritis. It may be particularly difficult to distinguish between PMR and GCA because patients with GCA usually have symptoms associated with PMR. Nonsteroidal anti-inflammatory agents may be effective in mild cases of PMR. However, corticosteroids, usually prednisone or prednisolone, are the class of drugs most widely used to treat PMR. They are effective in relieving the pain and reversing the abnormal laboratory values in most patients; responses can be apparent in 24-48 hours. Steroid-sparing agents such as methotrexate, dapsone, and azathioprine have no established role at present. Patients taking corticosteroids for PMR should be monitored for the occurrence of GCA and development of adverse effects associated with drug therapy. Corticosteroids are effective in treating PMR. Although patients with PMR must be monitored for the development of GCA, the prognosis for these patients is excellent.

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The performance of pharmacists in using an interactive computer-based patient simulation program and their attitudes toward the simulations are reported. The Institutional Patient Medication Simulation program is designed to enhance and evaluate the medication problem-solving skills of pharmacists. Each simulation consists of patient data-gathering, case question, and therapy decision modules with initial assessment and monitoring nodes. Five simulations were tested: gout, urinary-tract infection, congestive heart failure, antimicrobial prophylaxis in surgery, and hypertension. Pharmacists from nine hospitals were recruited for the study. Participants were asked to perform the simulations within a specified period and to complete attitudinal questionnaires. Of the 91 pharmacists who volunteered, 72 (79%) completed the simulations and the questionnaires. The practitioners indicated that the simulations adequately tested their knowledge and that they would recommend them to colleagues. Performance scores for data gathering were less than 70%, with no significant differences among the simulations. Case question scores exceeded 80% and again were consistent among simulations, whereas therapy decision scores were more variable, with the lowest scores being recorded for antimicrobial-related simulations. Pharmacists with more hospital experience tended to perform better. Pharmacists completing a patient simulation program found the simulations to be worthwhile. Performance scores indicated some difficulty in gathering patient data and showed that correct therapeutic decisions may not always occur even if adequate information is obtained.

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Factors affecting outcomes of medication-history interviewing by pharmacy students were studied. Data were obtained from fourth-year pharmacy students enrolled in a required course in fall 1984. Each student conducted a medication-history interview with one of two simulated patients who presented a predetermined history; interviews were videotaped from behind a one-way mirror. Students also completed an interviewing-orientation survey and a personal report of communication apprehension (PRCA). Trained raters evaluated the videotaped interviews using measures of interview skill and interview completeness. The simulated patients completed a patient-satisfaction form after each interview. Two path models were developed that were identical except that one had completeness and one had patient satisfaction as the dependent variable. Interview skill was the final factor in each model, preceded by variables representing the student's background and orientation factors, PRCA, and simulated-patient gender. Of 112 students conducting the interview, 107 (95.5%) and 95 (84.8%) completed the PRCA and orientation surveys, respectively. The models explained 36% and 27% of the variance in patient satisfaction and completeness, respectively. Shown in parentheses are the significant direct predictors of variables in the model of patient satisfaction: satisfaction (skill, prepharmacy grade point average [preGPA], people and health-care [PHC] orientation); skill (interviewing orientation, preGPA); interviewing orientation PHC orientation, preGPA, PRCA); and (PHC orientation (student gender). All effects were positive except for PRCA on interviewing orientation. For the model of completeness, direct predictors were as follows: completeness (skill, PHC orientation, student gender, simulated-patient gender); skill (interviewing orientation, preGPA); interviewing orientation (PRCA, preGPA, PHC orientation); and PHC orientation (student gender). All effects were positive except for PRCA on interviewing orientation and PHC orientation on completeness. Results suggest that one path model reflects the patient's assessment of interviewer competence in terms of satisfaction, and the other reflects the clinician-rater's assessment of interviewer competence in terms of interview completeness. The interviewing process positively influences both patient satisfaction and interview completeness.

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We have studied six patients who received streptokinase for acute myocardial infarction (MI). One of these patients experienced a serum sickness/vasculitis reaction nine days after receiving the drug. Immunologic investigation of serum obtained from these individuals demonstrated that IgE and IgG anti-streptokinase antibody concentrations (measured by radioimmunoassay) were significantly elevated, both pre and post (IgE antibody, 36-fold increase) drug exposure, in the individual having the serum sickness/vasculitis reaction. Two of five of the remaining MI patients receiving the drug had post-exposure elevation of IgE anti-streptokinase antibody, but no patient had the immunologic profile seen in the individual with vasculitis. One should be aware that the serum sickness/vasculitis reaction can occur late after administration of streptokinase when the acute MI patient is recuperating.

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The pathophysiology of primary osteoporosis and the various therapeutic regimens that have been used are reviewed. Osteoporosis is a major public health problem because the incidence of hip, wrist, and vertebral fractures associated with bone loss is high. Postmenopausal women are at increased risk for developing osteoporosis because bone mineral content is lower in women than in men, dietary calcium intake is frequently insufficient, intestinal absorption of calcium decreases with age, and the rate of bone loss accelerates at menopause. The efficacy of many single and combination therapies in preventing or treating osteoporosis has been studied. Differences in study design and diagnostic techniques and the heterogeneous nature of osteoporosis make evaluation of clinical trials difficult. Exercise helps to maintain skeletal mass, but amenorrhea caused by vigorous activity may be harmful. The efficacy of estrogen replacement therapy is documented best; many studies have shown that estrogens slow the rate of bone loss and reduce the incidence of fractures, but the association of estrogen use with endometrial cancer and breast cancer is of concern. Progesterones may protect against endometrial cancer, but undesirable effects of oral contraceptives have resulted in a hesitancy to use combination hormonal therapy. All adults should meet daily nutritional requirements for calcium, but this intake may be insufficient for elderly persons and is below recommended doses for treating osteoporosis. A daily intake of at least 1000-1500 mg of elemental calcium has been shown to slow the rate of bone loss. Nutritional requirements for vitamin D should be met, but benefits from pharmacologic doses have not been demonstrated. The role of fluoride, calcitonin, anabolic steroids, and vitamin D metabolites is unclear. Fluoride has the potential to increase bone mass, but effects on bone histology and fracture rates require further study. The major goals for the management of osteoporosis are maintenance of bone mass and prevention of fractures. An adequate intake of calcium and regular weight-bearing exercise are important preventive measures. Despite the documented effectiveness of estrogens, risks associated with long-term use are of concern.

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The efficacy and toxicity of low-dose, weekly oral methotrexate (MTX) therapy for inflammatory arthritis was evaluated. Fifty-nine patients with a diagnosis of inflammatory arthritis who had failed to respond to or developed toxicity to gold, penicillamine, or hydroxychloroquine therapy were treated with MTX 10-20 mg administered orally or intravenously once a week in divided doses. Various tests to assess arthritis were performed upon each patient's entrance into the study and at specified intervals throughout the 24-month study period. The mean duration of methotrexate therapy was 15.5 months. Patients showed significant improvement in number of swollen joints, duration of morning stiffness, amount of pain, and amount of activity during the study period. Of the 35 patients who had had roentgenographic studies of their hands performed initially and after one year of MTX therapy, 23 had no evidence of new joint erosions after one year. Biopsies of hepatic tissue from 20 patients showed no progressive changes when compared with pretreatment biopsies. Gastrointestinal symptoms, mucocutaneous lesions, or small increases in liver enzyme concentrations were observed in 31 patients; three patients developed pulmonary toxicity and had to be withdrawn from the study. MTX is an effective agent for the treatment of inflammatory arthritis in patients who do not respond to therapy with nonsteroidal anti-inflammatory drugs or slow-acting antirheumatic drugs. Short-term weekly oral MTX therapy does not appear to result in clinically important liver disease.

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The effectiveness of methoxsalen and ultraviolet light (PUVA) in treating is reviewed. The use of this therapy, its mechanism of action, pharmacology, pharmacokinetics, adverse reactions, dosage, and comparison with other forms of therapy, are discussed. Administered orally, methoxsalen in combination with long-range ultraviolet light (UVA) is effective in treating patients with moderate to severe forms of psoriasis. Although the short-term risks associated with PUVA therapy are minimal, the long-term risks of oncogenicity have not been evaluated thoroughly. Common adverse reactions to methoxsalen and UVA are nausea, pruritus, and erythema, but usually they can be managed by minor modifications in the treatment regimen. Methoxsalen and UVA therapy should be reserved for patients with moderate to severe forms of psoriasis that do not respond to other forms of therapy until the long-term risks of oncogenicity are evaluated.

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