Thomas M. Harrington

Osteoid osteoma: 95 cases and a review of the literature

Osteoid osteoma is a benign bone tumor occurring primarily in patients under the age of 30 yr. Bone pain at night and relief by aspirin or other nonsteroidal antiinflammatory agents is a common symptom complex. The proximal femur and spine are frequent sites of involvement, but almost any bone can be involved. If plain roentgenograms do not demonstrate the lesion, tomography or a bone scan may be helpful. Complete surgical excision is the therapy of choice with a low recurrence rate. Osteoid osteoma may present initially with symptoms suggestive of inflammatory arthritis, degenerative joint disease, neoplasm, or infection. This lesion can therefore be a difficult diagnostic problem, especially if routine roentgenograms are normal. A high index of suspicion is necessary to make the diagnosis.

Improved influenza and pneumococcal vaccination in rheumatology patients taking immunosuppressants using an electronic health record best practice alert

OBJECTIVE To examine whether an electronic health record (EHR) best practice alert (BPA), a clinical reminder to help guideline adherence, improved vaccination rates in rheumatology patients receiving immunosuppressants. Guidelines recommend yearly influenza and pneumococcal vaccination with revaccination for patients age >65 years who are taking immunosuppressive medications. METHODS A vaccination BPA was developed based on immunosuppressant treatment, age, and prior vaccinations. At site 1, a hospital-based academic practice, physicians ordered vaccinations. At site 2, a community-based practice, physicians signed orders placed by nurses. Demographics, vaccination rates, and documentation (vaccination or no administration) were obtained. Chi-square and Fishers exact test analysis compared vaccination and documentation rates for October 1 through December 31, 2006 (preBPA), and October 1 through December 31, 2007 (postBPA). Breslow-Day statistics tested the odds ratio of improvement across the years between the sites. RESULTS PostBPA influenza vaccination rates significantly increased (47% to 65%; P < 0.001), with significant improvement at both sites. PostBPA pneumococcal vaccination rates likewise significantly increased (19% to 41%; P < 0.001). PostBPA documentation rates for influenza and pneumococcal vaccinations also increased significantly. Site 2 (nurse-driven) had significantly higher preBPA vaccination rates for influenza (69% versus 43%; P < 0.001) than pneumococcal (47% versus 15%; P < 0.001). CONCLUSION The use of a BPA significantly increased influenza and pneumococcal vaccination and documentation rates in rheumatology patients taking immunosuppressants. A nurse-driven process offered higher efficacy. An EHR programmed to alert providers is an effective tool for improving quality of care for patients receiving immunosuppressants.

Polyarteritis nodosa presenting as acute myocardial infarction with coronary dissection

Coronary manifestations of polyarteritis nodosa (PAN) are rarely identified pre-mortem. We report a 51-year-old female with PAN causing a coronary dissection and new lesions developing over the next 5 days. PAN should be added to the list of differential diagnoses for spontaneous coronary dissections.

Cricoarytenoid arthritis: A cause of laryngeal obstruction

Cricoarytenoid arthritis, principally as a result of long-standing rheumatoid arthritis, is a disorder that may present to the emergency physician with a number of symptoms and signs referable to the larynx. The presentation of this disorder as acute laryngeal obstruction and collapse is uncommon. It is important to recognize early cricoarytenoid joint involvement and not mistakenly diagnose mild cases as asthma or psychoneurosis. The use of steroids in mild cases has been beneficial at times, but progressive airway obstruction and fatalities have occurred during their administration.

Remitting Seronegative Symmetrical Synovitis With Pitting Edema Syndrome in a Rural Tertiary Care Practice: A Retrospective Analysis

OBJECTIVE To review the clinical and laboratory features of remitting seronegative symmetrical synovitis with pitting edema (RS3PE) in a rural tertiary care rheumatology practice, describe treatments and outcomes, and compare our results to previous reports in the literature. PATIENTS AND METHODS We performed a retrospective chart review of all patients diagnosed as having RS3PE who were seen in the Department of Rheumatology at Geisinger Medical Center, Danville, PA, from January 1, 1992, to December 31, 2005. RESULTS We identified 12 men and 2 women, all of whom were white. Mean +/- SD age was 74.0 +/- 6.6 years; mean +/- SD erythrocyte sedimentation rate was 35.9 +/- 21.1 mm/h at presentation. Onset of illness was sudden in 9 patients and insidious in 5. All patients were initially treated with prednisone (15-20 mg/d). Although the response in all was excellent, 9 patients received disease-modifying antirheumatic drugs, either because of ongoing disease activity or in an effort to decrease the use of corticosteroids. Hydroxychloroquine was used alone in 7 patients. At the mean +/- SD time of last follow-up (31.4 +/- 23.1 months), 5 patients continued to receive therapy. Complications of treatment included worsening of preexisting hypertension in 3 patients, gastritis in 2, and exacerbation of preexisting diabetes mellitus in 1. Carpal tunnel syndrome occurred in 6 patients. Duration of therapy ranged from 5 to 120 months (mean, 29 months). Three patients developed malignancies, ie, non-Hodgkin lymphoma, transitional cell carcinoma of the bladder, and prostate carcinoma. CONCLUSION Our population of patients with RS3PE is similar to those documented in previous reports: elderly, predominantly male, and responsive to corticosteroids. However, our series is clinically differentiated by a greater use of adjunctive disease-modifying antirheumatic drugs (primarily hydroxychloroquine). Confirming previous reports, we also observed a possible association between RS3PE and malignancy.

Carpal tunnel syndrome due to tophaceous gout.

Tophaceous gout is a recognized cause of carpal tunnel syndrome. Of 2649 carpal tunnel releases, 15 hands in 13 patients were identified with tophaceous gout in the carpal tunnel. The incidence of tophaceous gout in the carpal tunnel was 0.6%. Twelve of 13 patients were male, and 8 of 10 patients with a history of gout developed carpal tunnel syndrome despite adequate medical treatment. Thus, consideration should be given for tophi as a cause of carpal tunnel syndrome, especially in older men despite medical treatment for gout.

Tumor Necrosis Factor Antagonist Responsiveness in a United States Rheumatoid Arthritis Cohort

OBJECTIVE The study objective was to investigate responsiveness according to whether patients satisfy eligibility criteria from randomized controlled trials of tumor necrosis factor (TNF) antagonists in a multicentered US cohort. METHODS Biologic-naive patients with rheumatoid arthritis who were prescribed TNF antagonists (n=465) in the Consortium of Rheumatology Researchers of North America registry were included. Patients were stratified by whether they met eligibility criteria from 3 major TNF antagonist trials. Two cohorts were examined: Cohort A (n=336) included patients with complete American College of Rheumatology response criteria except acute phase reactants, and cohort B (n=129) included patients with complete response criteria. Study outcomes included modified American College of Rheumatology 20% and 50% improvement responses (cohort A) and standard American College of Rheumatology improvement (cohort B). RESULTS A minority of patients (5.4%-19.4%) prescribed TNF antagonists met trial eligibility criteria and predominantly had high disease activity (78.5%-100%). For patients who met eligibility criteria in cohort A, rates of 20% improvement (52.3%-63.6%) and 50% improvement (30.8%-45.5%) were achieved. Among patients failing to meet eligibility criteria, rates of 20% improvement (16.2%-20.4%) and 50% improvement (8.9%-10.8%) were consistently inferior (P<.05 all comparisons). For cohort B, similar differences were observed. CONCLUSION This multicentered US cohort study demonstrates that the majority of patients receiving TNF antagonists would not meet trial eligibility criteria and achieve lower clinical responses. These findings highlight the tradeoff between defining treatment responsive populations and achieving results that can be generalized for broader patient populations.

Tophaceous gout of the thoracic spine presenting as back pain and fever.

Spinal gout has been reported only rarely. We describe a 59-year-old man with a history of gout, who was receiving chronic immunosuppressive therapy after a renal transplant and who presented with fever and back pain. After an extensive work-up and biopsy, the diagnosis was thoracic tophaceous gout. The pain and fever responded to prednisone and allopurinol. Tophaceous gout is a rare cause of fever and back pain but should be considered in the differential diagnosis in the appropriate clinical setting.

Plant thorn synovitis : an uncommon cause of monoarthritis

Plant thorn synovitis (PTS) is an uncommon cause of monoarthritis. Seven cases of PTS were identified at our institution from January 1979 to July 1990, six of whom were men. Mean age was 27 years (range, 7 to 56 years). Symptoms included pain, swelling, and stiffness. Synovitis was present on examination along with decreased range of motion of affected joints in all patients. Roentgenograms were unremarkable in five patients, but disclosed demineralization in two others. Initial conservative treatment with nonsteroidal antiinflammatory drugs (NSAIDs), antibiotics, or splinting was usually unsuccessful; surgery was necessary in six patients. Findings included marked inflammatory synovial reactions with evidence of retained thorn in all patients. One patient had a positive operative wound culture (Enterobacter agglomerans) without evidence of osteomyelitis. All patients improved after surgery without sequelae. Despite a history suggesting thorn injury in many cases, diagnosis was often delayed; mean time to diagnosis was 10 weeks (range, 2 weeks to 9 months). PTS must be included in the differential diagnosis of monoarthritis. Histologically, PTS can mimic sarcoidosis, tuberculosis, or fungal infection. Optimal treatment of PTS is arthrotomy, foreign body removal, and extensive synovectomy.

Clinical research studyTumor Necrosis Factor Antagonist Responsiveness in a United States Rheumatoid Arthritis Cohort

OBJECTIVE The study objective was to investigate responsiveness according to whether patients satisfy eligibility criteria from randomized controlled trials of tumor necrosis factor (TNF) antagonists in a multicentered US cohort. METHODS Biologic-naive patients with rheumatoid arthritis who were prescribed TNF antagonists (n=465) in the Consortium of Rheumatology Researchers of North America registry were included. Patients were stratified by whether they met eligibility criteria from 3 major TNF antagonist trials. Two cohorts were examined: Cohort A (n=336) included patients with complete American College of Rheumatology response criteria except acute phase reactants, and cohort B (n=129) included patients with complete response criteria. Study outcomes included modified American College of Rheumatology 20% and 50% improvement responses (cohort A) and standard American College of Rheumatology improvement (cohort B). RESULTS A minority of patients (5.4%-19.4%) prescribed TNF antagonists met trial eligibility criteria and predominantly had high disease activity (78.5%-100%). For patients who met eligibility criteria in cohort A, rates of 20% improvement (52.3%-63.6%) and 50% improvement (30.8%-45.5%) were achieved. Among patients failing to meet eligibility criteria, rates of 20% improvement (16.2%-20.4%) and 50% improvement (8.9%-10.8%) were consistently inferior (P<.05 all comparisons). For cohort B, similar differences were observed. CONCLUSION This multicentered US cohort study demonstrates that the majority of patients receiving TNF antagonists would not meet trial eligibility criteria and achieve lower clinical responses. These findings highlight the tradeoff between defining treatment responsive populations and achieving results that can be generalized for broader patient populations.