Bulletin of the NYU hospital for joint diseases最新文献

Neuropsychiatric (NP) systemic lupus erythematosus (SLE) is a complex entity comprising 19 different discrete syndromes. We report a case of a 32-year-old female with SLE and new onset neurological symptoms and radiographic evidence of a contrast enhancing lesion on brain MRI. The lesion was successfully excised and found to be granulomatous in nature. Infection and malignant etiologies were ruled out suggesting that the lesion was due to SLE. Subsequently, the development of multiple reversible hyperintense signal abnormalities on brain MRI suggested the possibility of posterior reversible encephalopathy syndrome (PRES). The lesions resolved after the withdrawal of immunosuppression. This article reviews both the clinical and pathological complexity of PRES in SLE and the state of the current literature. We conclude that more data is required to understand the spectrum of PRES and its management in SLE patients.

From an epidemiologic view, gout is an increasingly prevalent and increasingly pressing clinical problem. This fact, together with technical advances in biology, pharmacology, and imaging techniques, have led to a decade of increasingly rapid progress in our collective understanding of gout and hyperuricemia. Here we review some of the most important recent advances in gout over the past 12 to 18 months.

The management of rheumatoid arthritis (RA) depends more on the patient history than most other chronic diseases. A patient questionnaire provides a uniform, quantitative, protocolized, "scientific" patient history, with documented prognostic significance for work disability and mortality in RA greater than radiographs and laboratory tests and capacity to distinguish active from control treatment in clinical trials and to monitor clinical care with equivalent or greater significance than joint counts or laboratory tests. Therefore, a "scientific" approach to care of a person with a rheumatic disease involves review of patient function, pain, global status, fatigue, RAPID3, review of systems, self-report joint count, and recent medical history on an MDHAQ before conversation with the patient. This practice may be viewed as analogous to a doctor reviewing blood pressure, hemoglobin A1c, viral load, or radiograph before meeting with a patient who has hypertension, diabetes, HIV, or a healing fracture to provide a roadmap or agenda for the visit. Some sites have implemented RAPID3 without the remainder of MDHAQ, a practice that is discouraged. The MDHAQ requires only 5 to 10 minutes of the patient's time and involves a single sheet of paper, which is needed for a simple RAPID3, or even a patient global estimate of status to score a DAS28 or CDAI. Completion of MDHAQ/RAPID3 by each patient at each visit in the infrastructure of care with review by the doctor helps prepare the patient for the visit, improves doctor-patient communication, saves time for the doctor, and provides a roadmap or agenda for the visit.

Distal radius fractures are among the most commonly encountered fractures in the extremities. Volar plating of distal radius fracture has gained popularity in recent years with the introduction of the locked plating system. Complications of volar plating include extensor and flexor tendon rupture. Here we present a case report of an extensor indicis proprius and extensor digitorum communis to index finger tendon rupture after open reduction and internal fixation of distal radius fracture with locked plate.

Acinetobacter baumannii is an emerging gram-negative nosocomial pathogen that rarely causes infections in orthopaedic patients. We report a case of imipenem-resistant Acinetobacter baumannii paraarticular infection of the knee occurring in a healthy patient following one ambulatory steroid injection for the treatment of quadriceps tendinopathy. The infection was reduced by early surgical debridement of infected tissues, abscess drainage, and prolonged antibiotic therapy with colistin. To our knowledge, this is the first case in the literature reporting such an infection following single steroid injection in orthopaedic patients.

The patient history often provides the most important information in diagnosis and management of rheumatoid arthritis (RA) and other rheumatic diseases. A multidimensional health assessment questionnaire (MDHAQ)-with templates to score RAPID3 (routine assessment the patient index data), an index of three patient self-report measures, physical function, pain, and patient global estimate-pro- vides a "scientific" patient history. MDHAQ/RAPID3 scores meet criteria for the scientific method seen for laboratory tests: standard format, quantitative data, protocol for col- lection, and recognition of prognostic implications of levels for management decisions. Extensive evidence supports a scientific rationale for MDHAQ/RAPID3 scores, which are as efficient as joint counts, laboratory tests, DAS28, and CDAI to distinguish active from control treatments in clinical trials and correlated significantly with DAS28 and CDAI scores in clinical trials and usual clinical care, including categories for high, moderate, low severity, and remission. Pragmatic advantages of MDHAQ/RAPID3 include that the patient does almost all the work and prepares for the encounter to focus on concerns to discuss with the doctor. MDHAQ/RAPID3 improves doctor-patient communication and saves time for the doctor with a 10 to 15 second overview of medical history data that otherwise would require 10 to 15 minutes of conversation. RAPID3 is scored in 5 seconds, compared to almost 2 minutes for a CDAI or DAS28, and can be used effectively for treat-to-target in RA. MDHAQ/ RAPID3 is informative in all rheumatic diseases, including systemic lupus erythematosus, osteoarthritis, ankylosing spondylitis, psoriatic arthritis, fibromyalgia, gout, and others. All rheumatologists may include MDHAQ/RAPID3 in all patients in the infrastructure of clinical care.

Purpose: Nonunions of the upper and lower extremity have been associated with pain and functional deficits. Recent studies have demonstrated that healing of these nonunions is associated with pain relief and both subjective and objective functional improvement. The purpose of this study was to determine which patient and surgical factors correlated with successful healing of a nonunion following surgical intervention.

Methods: Between September 2004 and February 2008, all patients with a "long bone nonunion" presenting to our academic trauma service were enrolled in a prospective data base. Baseline functional, demographic and pain status was obtained. Follow-up was obtained at 3, 6, and 12 months following surgical intervention, with longer follow-up as possible. One hundred and thirty-four patients with a variety of fracture nonunions were operated on by four different fellowship trained trauma surgeons with experience ranging from 2 to 15 years and variable nonunion surgery loads. Patients were stratified into one of three groups: 1. Patients who healed following one surgical intervention, 2. those who healed following multiple surgical intervention, and 3. those who failed to heal (remain ununited or underwent amputation). Healing was determined radiographically and clinically. Complications were recorded. Logistic regression analysis was performed to assess the cor-relation between specific baseline and surgical characteristics and healing.

Results: A minimum of 1 year follow-up was available for all 134 patients. One hundred and one patients (76%) with a mean age of 50 years healed at a mean of 6 months (range, 3 to 16) after one surgery. Twenty-two patients (16%) with a mean age of 47 years, who required more than one intervention, healed their nonunions at a mean of 11 months (range, 4 to 23). Eleven patients (8%) with a mean age of 50 years failed to heal at an average of 12 months follow-up. Complication rates were 11%, 68%, and 100% respectively for those who healed following one procedure, multiple procedures, and those who never healed. Higher surgeon volume (greater than 10 cases per year) was associated with 85% increased healing rates (OR = 0.15, 0.05-0.47 CI). The presence of a postoperative complication was associated with a 9 times lower likelihood of successful union as well (OR = 9.0, 2.6-31.7 CI). Patient age, sex, BMI, initial injury mechanism, tobacco use, and initial injury characteristics did not correlate with failure to heal.

Conclusion: Our data is similar to other studies assessing outcomes following other complex reconstructive procedures. It appears that more experienced (higher volume) reconstructive surgeons and the development of fewer postoperative complications is associated with greater success following repair of a long bone nonunion. Infection at any point during treatment is associated with failure to achieve successfu

Primary Sjogren's syndrome is an autoimmune disease wherein there is lymphocytic infiltration of salivary and lacrimal glands. This inflammation is thought to be caused by B-lymphocytes. The most common clinical feature of Sjogren's is dryness of the mouth and eyes, but rare complications can occur such as autoimmune cytopenias. Here we report two cases of immune mediated cytopenias that were diagnosed to be due to Sjogren's syndrome. In both cases, immune suppressive treatment was required.