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The training of professionals in rheumatologic care requires review and study. To improve teaching methods, 6 patients with stable rheumatic disease were trained to evaluate and teach medical students by using themselves as models for musculoskeletal examinations. Checklists for scoring performance and content were developed. Criteria established to give evidence of the validity of the checklists and of the reliability of the patient instructors in their scoring were met or exceeded. The patient instructors are now an integral part of the Preparation for Clinical Medicine curriculum at our institution and serve as resources for evaluation and Address reprint requests to Eric P. Gall, MD, Rheumatology, Allergy & Immunology Section, University of Arizona Health Sciences Center, Tucson, AZ 85724.Submitted for publication August 8, 1983; accepted in revised form December 12. 1983. teaching in the continuing education of practicing professionals.Two recent international workshops on rheumatology manpower and education have focused on the inadequacy of current training in rheumatic diseases (1,2). This problem is highlighted by the fact that 95% of all rheumatologic care is being provided by primary care physicians who have limited knowledge of the musculoskeletal examination (2).An informal record review of general medicine inpatients and outpatients cared for by faculty and house staff at the University of Arizona Health Sciences Center in Tucson was conducted by the authors, and it substantiated these assertions. Although Tucson is a city with a high incidence of arthritis (Warren Benson, Southern Arizona Arthritis Foundation: personal communication), we found that most of the records failed to mention rheumatic diseases in either the history or physical examination. When musculoskeletal abnormalities were noted, they were described in vague or general terms such as "arthritic deformities," rather than by a precise medical definition of the physical findings.In an effort to improve training in rheumatologic diagnosis and care, both in course work for medical students and in continuing education for practicing health professionals, we have developed a patient instructor (PI) program based on the "simulated patients" model originally developed by Barrows and Abrahamson (3). Unlike the simulated patients, who were normal individuals trained to simulate abnormalities, the PIS in our program are real patients who are trained in history-taking and the musculoskeletal examination. 558 GALL ET ALThe simulated patients appear to be adequate models for some medical problems, but not for others. In Barrow's original program, normal individuals trained to simulate abnormal neurologic signs were used to teach neurology students (4) and to test neurology board candidates (3). Nonphysicians have also been used to assess interviewing skills of pediatric students who questioned mothers of newborn infants (5). This procedure was extended by Stillman, Sabers, and Redfield at the University of Arizona. Those investigators trained non...

A B S T R A C T Deficiency of the seventh component of complement has been found in the serum of a 42-yr-old Caucasian woman who has Raynaud's phenomenon, sclerodactyly, and telangiectasia. Partial deficiency was found in the serum of the patient's parents and children, indicating a pattern of inheritance of autosomal codominance. Transfusion experiments indicated that exogenous C7 had a 91-h half-life in the patient. There was no evidence for C7 synthesis after transfusion. No C7 inhibitors were detected in the patient's serum. The patient's serum was found to support the activation of complement by both the classical and properdin pathways to the C7 stage. The addition of C7 to the patient's serum permitted it to support hemolytic reactions initiated by either pathway. No defects could be detected in plasma or whole blood coagulation. The patient's serum was deficient in opsonizing unsensitized yeast particles in serum and in the generation of chemotactic factor by antigen-antibody complexes and endotoxin. Both deficiencies were corrected by the addition of C7. These observations suggest a key role for C7 for in vitro yeast phagocytosis and chemotaxis generation. However, the patient's lack of infections indicates a relatively minor role for C7 in human resistance to infection.

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Clinically healthy humans as well as patients suffering from various autoimmune diseases produce natural antibodies against a variety of self-components. Such antibodies have been proposed to carry out a physiologic role in maintaining the integrity of self, as well as potentially destructive roles in the generation of autoimmune diseases. Because human autoantigens, particularly membrane proteins, are usually present in extremely small amounts, it is generally impossible to obtain enough to carry out a detailed characterization of the antibodies or the antigenic determinants recognized. To circumvent this difficulty, we developed synthetic autoantigens predicted from the gene sequence of two functionally critical membrane proteins; the band 3 anion transport protein which is found on all cells, and the T-cell receptor (β chain) which is the antigen-specific receptor on thymus-derived lymphocytes. We have investigated the natural human IgM and IgG antibody responses to peptides selected on the basis of predicted molecular surface exposure and previously known antigenicity, and correlate levels of binding with changes in age and by comparison with autoimmune diseases. We report that the IgM response to synthetic autoantigens tends to be higher than that of IgG molecules, but significant IgG binding occurs to some peptides. This situation is particularly noticeable in comparison of rheumatoid arthritis patients with normal individuals. Distinct peptide portions of individual molecules are recognized differently by the autochthonous immune system as manifested by age dependence of the response and differential levels of IgM and IgG activity. The synthetic autoantigens that tend to generate the highest amounts of natural antibody are those that are either exposed on the surface of the cell (band 3 peptides) or are exposed in the predicted 3-dimensional folding of the molecule (T-cell receptor β peptides). Rheumatoid arthritis patients tend to give higher IgM reactivities to both band 3 and Tcr β peptides than do normals, with this effect being less pronounced in the distinct autoimmune disease systemic lupus erythematosus. Studies of normal humans ranging in age from 20 to 90 years suggest two major patterns for the IgM natural antibody response to synthetic peptides giving high response. The first is that the level of IgM reactivity is high early in life and remains high throughout. The second pattern is one in which the reaction is high in younger individuals, but diminishes substantially in the latter decades of life. Although there is substantial variation in the IgG autoantibody responses, which most probably are strongly dependent upon T-cell help, the overall pattern is for these to be low early in life, and to increase with increasing age. We speculate that the antibody activities detected in the normal individuals carry out a physiologic regulatory role, as opposed to a destructive autoimmune dysfunction, because these molecules can be present in high levels throughout life.