Bulletin of the NYU hospital for joint diseases最新文献

Although neurological involvement in Behçet's disease is not so uncommon, isolated spinal cord disease is quite rare and reported to be observed in about 2% of all cases with neurological involvement. Here we report a Behçet's patient with spinal cord disease presented with anterior spinal cord syndrome. This rare syndrome is caused by hypoperfusion of the anterior spinal artery and to our knowledge has not been previously reported in patients with Behçet's disease. This report defines the characteristic clinical features of this entity and emphasizes the importance of early immunosuppressive treatment and initiation of rehabilitation.

The recent increase in life expectancy is expected to bring about a concurrent rise in the number of proximal humerus fractures. Those presenting with significant displacement, osteoporosis, and comminution present distinct clinical challenges, and the optimal treatment of these injuries remains controversial. As implant technologies and treatment strategies continue to evolve, the role and appropriateness of certain operative and nonoperative treatment modalities are being debated. Prior concerns regarding humeral head viability forced many physicians to abandon operative management in favor of nonoperative modalities. However, with greater appreciation and understanding of the factors governing humeral head viability, operative intervention is increasingly used and investigated. Nevertheless, sub-optimal results with earlier implants continue to cloud the debate between nonoperative and operative treatment modalities. This paper will review historical considerations, biologic considerations, and implant considerations in the management of three-and four-part proximal humerus fractures.

Operative fixation of distal radius fractures is one of the most commonly performed orthopedic procedures. However, there remains little consensus on the indications for operative versus nonoperative treatment of these injuries. The American Academy of Orthopaedic Surgeons has recently published clinical practice guidelines to help guide management of these injuries. The purpose of this paper is to review the biomechanical and clinical retrospective and prospective data pertinent to the indications for operative management of distal radius fractures. Conflicting data exists as to the optimal management of these injuries, especially in patients over the age of 55. Although there is some evidence to support operative fixation of distal radius fractures, better longterm, prospective, randomized studies with validated patient outcome measures are needed to definitively establish the optimal method of treatment for these injuries.

Fractures of the proximal fifth metatarsal are among the most common fractures of the foot. History, physical examination, and subsequent radiographic work-up can help with the diagnosis of such a fracture. Many fractures of the proximal fifth metatarsal can have an associated prodrome, thereby establishing a level of chronicity to the problem. Identification of the location of the fracture plane within the proximal fifth metatarsal can have prognostic implications in regards to fracture union rate and guide treatment options, due to the particular vascular anatomy of the region. Additional findings on physical exam, such as heel varus, can also impact prognosis and treatment options. Treatments can range from nonoperative to operative modalities, and time to weightbearing can vary. Within the realm of operative treatment, identification of certain parameters can aid in successful reduction and fixation of the fracture and thus impact healing. Careful consideration of the patient's particular constellation of social and professional needs, clinical and radiographic parameters, and acceptance of different options can help guide treatment recommendations in the individual patient.

The efficacy of initial and long-term prednisone < 5 mg/ day in treatment of rheumatoid arthritis (RA) by one academic rheumatologist over 25 years from 1980 to 2004 is summarized. Patient responses were assessed using a multidimensional health assessment questionnaire (MDHAQ), completed by all patients at all visits in the infrastructure of care. A database was maintained of all visits, which included medications and scores for physical function, pain, patient global estimate of status, and routine assessment of patient index data (RAPID3), an index of these 3 measures. Prednisone doses were higher in patients with more severe MDHAQ/RAPID3 scores, as expected, although formal criteria were not used to determine the initial dose. Similar improvements were seen in clinical status over 12 months in patients treated with < 5 vs ≥ 5 mg/day prednisone and maintained for > 8 years. Adverse effects were primarily bruising and skin-thinning; levels of hypertension, diabetes, and cataracts were not higher than expected, including in 148 patients monitored over > 4 years, 75 over > 8 years. Prednisone at initial and long-term doses of < 5 mg/day appears acceptable and effective for many patients with RA at this time, although further clinical trials and long-term observational studies are needed to optimize treatment of patients with RA with low-dose prednisone. The data also illustrate that MDHAQ scores in usual clinical care can be used to document results of therapy over long periods with no extra work for the physician.

Some of this past year's key papers or abstracts on psoriatic arthritis (PsA) assessment and treatment are reviewed in this paper. Treatment begins with identification of the PsA patient. Several screening questionnaires have been developed to be used in dermatology and primary care settings to identify which patients with psoriasis have developed PsA as opposed to other common musculoskeletal problems, such as osteoarthritis and fibromyalgia, thus increasing case-finding and targeting referral. PsA can present in a heterogeneous manner, involving arthritis, enthesitis, dactylitis, spondylitis, and skin and nail disease. Measures of these individual domains have been developed for use in clinical trials and improved PsA-specific composite measures of these domains are being evaluated as well. A quantitative therapy target, Minimal Disease Activity criteria, has been developed by the GRAPPA group. Treatment recommendations have been published by EULAR and GRAPPA. Obesity is a risk factor for the development of PsA and may adversely influence treatment outcomes. Although pharmacologic treatment often begins with methotrexate, a recent study does not provide clear evidence of its effectiveness. Anti-TNF therapies remain the gold standard of effectiveness. New therapeutic options are potentially emerging including ustekinumab, abatacept, several IL-17 inhibitors, apremilast, JAK inhibitors, and possibly IL-6 inhibitors.

The past year has been a dynamic one for clinicians and researchers with an interest in osteoporosis. This update will focus on the issue of the relationship between bisphosphonate treatment and atypical femoral fractures, highlight the advances in imaging techniques that are increasingly being studied as adjuncts to bone density testing, and explore recent evidence that suggests that osteoporosis medications may be linked to an increase in life expectancy. Since the first case reports describing unusual femur fractures in long term users of bisphosphonates began to appear, there has been great interest in identifying why and whether this class of drug can cause these atypical fractures. There have been a significant number of large studies that seem to suggest that these fractures do occur with an increased frequency among subjects who have used bisphosphonates over an extended period of time, but that these events are relatively rare. The occurrence of these fractures have helped to fashion new treatment regimens with periods of "drug holidays" often recommended to people with lower short-term and intermediate-term fracture risk. It is important to remind the reader that bisphosphonates prevent many typical hip and vertebral compression fractures, particularly in the higher risk elderly patient and that a rational balance be struck so that those in need of continued osteoporosis treatment receive it. Advances in imaging, such as high resolution MRI and peripheral micro CT scanners, are allowing investigators to non-invasively assess bone microarchitecture and bone stiffness of individuals as a means of trying to more accurately define those subjects who might be at increased risk of fracture and who might benefit from bone strengthening medication. Finally, this update will briefly review the emerging data that suggests that anti-resorptive medication may extend life expectancy beyond that which can be expected solely by reducing the incidence of future fractures.

Biological processes and functions at all hierarchical levels are organized in time as biological rhythms of discrete periods. Circadian (24-hour) rhythms, which are of direct importance to clinical medicine, are orchestrated by a set of clock genes of the master brain clock situated in the suprachiasmatic nuclei of the hypothalamus plus numerous subservient peripheral cellular clocks of all tissues and organs. Circadian rhythms are kept in step with the surrounding physical and social milieu by periodic external time cues, the most important one being the 24-hour environmental light-dark cycle. The circadian time structure gives rise to predictable-in-time day-night patterns in morbid and mortal events plus symptom occurrence and severity of common chronic conditions, including rheumatoid arthritis (RA). The circadian pattern of various cytokines and hormones in RA disease activity suggests a new treatment paradigm (i.e., chronotherapy-timing medications to 24-hour rhythms in disease pathophysiology) to improve desired outcomes. Since the 1950s, RA chronotherapy in the United States and Europe has involved several nonsteroid anti-inflammatory drugs (NSAIDs), certain disease modifying antirheumatic drugs (DMARDs), and various synthetic corticosteroid medications.

The current approach to treatment of RA includes early and aggressive treatment with routine monitoring of outcomes to give patients the best chance of decreasing disease activity as much as possible, with low disease activity and remission being a realistic goal for many patients. In this quest, DMARDs, especially MTX, are the anchor treatment, and low dose prednisone should also be considered in combination with MTX as the best initial choice for RA treatment. Current data suggest that corticosteroids are disease modifying agents that enhance the effects of DMARDs with no real impact on adverse events. We are much better positioned now then in earlier times to provide a good outcome for our patients, and every available tool needs to be considered and utilized for this purpose.

An evidence-based visit is described based on quantitative, standard scientific data on two simple forms for a patient and a physician. The focus is rheumatoid arthritis (RA), but the principles may be applied to most rheumatic and chronic diseases. A quantitative patient history is recorded on a selfreport multidimensional health assessment questionnaire (MDHAQ), which includes scales for physical function, pain, patient global estimate, psychological distress, change in status, exercise status, morning stiffness, fatigue, and a template to score RAPID3 (routine assessment of patient index data 3). RAPID3, an index of only patient self-report measures, distinguishes active from control treatments in clinical trials at similar levels to a disease activity score (DAS28) and clinical disease activity index (CDAI) but is calculated in 5 seconds, compared to almost 2 minutes for DAS28 or CDAI. The MDHAQ also includes traditional "medical" matters-a self-report joint count, review of systems, recent medical history, medications, demographic data, and consents for future monitoring by mail and sharing data with research colleagues; these queries enhance acceptance by patients and save time for doctors. Patient questionnaire physical function scores-not radiographs or laboratory tests-are the most significant prognostic markers for long-term work disability and premature death in RA. The physician completes a "doctor evaluation" (DOCEVAL) form, which includes four visual analog scales for overall status, inflammation, damage, and "neither" (usually fibromyalgia), reflecting quantitatively the expertise of a rheumatologist to classify the etiology of pain and distress into one of these three broad categories in formulating a treatment plan. Quantitative data from patients and doctors on an evidence-based visit can advance rheumatology clinical care and clinical science.