Objective. To examine the effects of cyclophosphamide (CYC) on the development of malignancies and on the long-term survival of patients with rheumatoid arthritis (RA).Methods. We used a longitudinal cohort design in which 119 patients (76 women and 43 men) with refractory RA who were treated with oral CYC between 1968 and 1973 were compared with 119 control patients with RA (matched for age, sex, disease duration, and functional class) who were evaluated during the same time period but did not receive CYC.Results. There was increased risk of malignancy in the CYC-treated group, with 50 cancers found in 37 patients in the CYC group compared with 26 cancers in 25 of the control patients (P < 0.05). The relative risk of cancer for those treated with CYC was 1.5 (95% confi-

This research, which may be the first of its kind in South Sudan, provides evidence that a WFA training course in South Sudan is efficacious. These findings suggest that similar training opportunities could be used in other parts of the world to improve basic medical knowledge in communities with limited access to medical resources and varying levels of education and professional experiences.

This report describes a 29-year-old bodybuilder taking anabolic steroids who presented with urinary retention, arthralgias, and peripheral edema, subsequently developed acute lower-extremity paralysis, and was diagnosed as having transverse myelitis and membranous glomerulonephritis secondary to systemic lupus erythematosus (SLE). The association of anabolic steroid use and hyperprolactinemia, and their possible link to the development of SLE, are reviewed.Systemic lupus erythematosus (SLE) is a heterogeneous disorder in which sex hormone abnormalities are common and may, via immunomodulation, play a role in the development of disease or in some cases lead to SLE flares. Both male and female SLE patients demonstrate relative hyperestrogenism with altered estradiol-to-testosterone ratios (1-3). Elevated levels of prolactin have also been associated with SLE in some but not all studies (4-8). There is increasing evidence that prolactin may function as an immunostimulatory hormone either directly through immunocompetent cells or through its effect on testosterone levels. In supraphysiologic amounts, prolactin inhibits gonadotropin-releasing hormone, leading to suppression of both estrogens and androgens. This may be particularly important in male SLE patients, in whom lower levels of circulating androgens may tip the balance in favor of activation of disease.This report describes a male bodybuilder who developed SLE soon after taking a 6-week cycle of nandrolone (19-nortestosterone), a synthetic anabolic steroid frequently used by bodybuilders. It is postulated that the ingestion of nandrolone led to a reduction in tology Associates, 51 Sewall Street, Portland, ME 04102.revised form May 27, 1997.endogenous testosterone and that this, in association with mild hyperprolactinemia, triggered SLE. CASE REPORTThe patient, a 29-year-old male bodybuilder, was admitted to the hospital with a 1-month history of arthralgias, lower-extremity edema, and anemia and a 3-day history of lower thoracic back pain and urinary retention. There was no previous significant medical history except for a positive purified protein derivative reaction 2 years previously, for which he had been treated with a 6-month course of isoniazid. There was no family history of SLE or other connective tissue disorder. He had recently completed a 6-week cycle of oral nandrolone, 75 mg daily. He denied using any other medications or drugs.Physical examination revealed a temperature of 38.5"C, a pulse of 95 beats per minute, and a blood pressure of 128/60 mm Hg. Bilateral flank pain in response to palpation was present, along with pitting edema of the legs midway to the knees. The findings of rheumatologic examination were remarkable only for bilateral knee effusions.Laboratory studies revealed a mild normocytic anemia (hemoglobin 12.2 gm/dl; normal 14.0-18.0), normal white blood cell count, and a platelet count of 351,000/mm3. The serum creatinine level was 1.2 mgidl (normal 0.5-1.4). The serum albumin value was low at 2.1 mg/dl (normal 3.5-5.0), and the c...