Thomas P. Olenginski

The Official Positions of the International Society for Clinical Densitometry: Vertebral Fracture Assessment

Vertebral fracture assessment (VFA) is a low-cost method of accurately identifying individuals who have clinically unrecognized or undocumented vertebral fractures at the time of bone density test. Because prevalent vertebral fractures predict subsequent fractures independent of bone mineral density and other clinical risk factors, their recognition is an important part of strategies to identify those who are at high risk of fracture, so that prevention therapies for those individuals can be implemented. The 2007 Position Development Conference developed detailed guidelines regarding the indications for acquisition of, and interpretation and reporting of densitometric VFA tests. The purpose of the 2013 VFA Task Force was to simplify the indications for VFA yet keep them evidence based. The Task Force reviewed the literature published since the 2007 Position Development Conference and developed prediction models based on 2 large cohort studies (the Study of Osteoporotic Fractures and the Osteoporotic Fractures in Men Study) and the densitometry database of the University of Chicago. Based on these prediction models, indications for VFA were reduced to a simplified set of criteria based on age, historical height loss, use of systemic glucocorticoid therapy, and self-reported but undocumented prior vertebral fracture.

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.

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.

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.

Indications of DXA in Women Younger Than 65 yr and Men Younger Than 70 yr: The 2013 Official Positions

Dual-energy X-ray absorptiometry (DXA) is the method of choice to assess fracture risk for women 65 yr and older and men 70 yr and older. The 2007 International Society for Clinical Densitometry Official Positions had developed guidelines for assessing bone density in younger women during and after the menopausal transition and in men 50-69 yr and the 2008 National Osteoporosis Foundation (NOF) guidelines recommended testing in postmenopausal women younger than 65 yr and men 50-69 yr only in the presence of clinical risk factors. The purpose of the 2013 DXA Task Force was to reassess the NOF guidelines for ordering DXA in postmenopausal women younger than 65 yr and men 50-69 yr. The Task Force reviewed the literature published since the 2007 Position Development Conference and 2008 NOF, reviewing clinical decision rules such as the Osteoporosis Screening Tool and FRAX and sought to keep recommendations simple to remember and implement. Based on this assessment, the NOF guidelines were endorsed; DXA was recommended in those postmenopausal women younger than 65 yr and men 50-69 yr only in the presence of clinical risk factors for low bone mass, such as low body weight, prior fracture, high-risk medication use, or a disease or condition associated with bone loss.

Using mobile DXA to improve access to osteoporosis care: unit design, program development, implementation, and outcomes.

Osteoporosis diagnosis and monitoring is best accomplished with dual X-ray absorptiometry (DXA), but technology availability can hinder access to care. We designed a mobile DXA program incorporating a Hologic Delphi-C trade mark bone densitometer housed in a specially configured 30-ft Winnebago trade mark. The mobile DXA program provided osteoporosis testing and education at the convenience of the patients primary care site within our rural health care system. DXA results were sent electronically to the patients physician within 48-72 h. The mobile DXA patient group tended to be older and at high risk for future fracture. The service provided was rated as excellent by patients. Given the volume of patients studied, the program was financially self-sustaining. Other healthcare systems or groups should consider development of a similar program.

A rare lymphoma in a patient with amyopathic dermatomyositis.

A 37-year-old Caucasian woman was evaluated for a photosensitive dermatitis. A positive anti-nuclear antibody with a titer of 1 : 1280 and a speckled pattern was noted and she was diagnosed with subacute cutaneous lupus erythematosus (SCLE). Although the initial dermatologic diagnosis was SCLE, a skin biopsy suggested the additional possibility of dermatomyositis because of increased dermal mucin. We began following her at the request of the dermatology department, and a diagnosis of amyopathic dermatomyositis was made based on the lack of objective muscle weakness, normal muscle enzymes, negative double-stranded DNA, SSA/SSB, and RNP/Smith antibody panel, and especially on the cutaneous examination findings.A malignancy evaluation included a normal CT scan of her chest, abdomen, and pelvis, esophagogastroduodenoscopy, colonoscopy, mammography, pelvic ultrasound, Papanicolaou smear, and endometrial biopsy. She developed vaginal bleeding 1 year after the onset of her skin manifestations. Repeat gynecologic evaluation, including cervical biopsy, revealed a large B-cell cervical lymphoma.Amyopathic dermatomyositis and lymphoma of the cervix are both rare conditions. Our case emphasizes the importance of considering underlying malignancy at the time of diagnosis and while the patient is followed clinically. Additionally, the clinician must remain vigilant in evaluating any new clinical changes in follow-up care. To our knowledge, this is the first documented case of lymphoma of the cervix in the setting of amyopathic dermatomyositis.

Leveraging Scarce Resources With Bone Health TeleECHO to Improve the Care of Osteoporosis

Osteoporosis is a common condition with serious consequences because of fractures. Despite availability of treatments to reduce fracture risk, there is a large osteoporosis treatment gap that has reached crisis proportions. There are too few specialists to provide services for patients who need them. Bone Health Extension for Community Health Care Outcomes (TeleECHO) is a strategy using real-time ongoing videoconferencing technology to mentor health care professionals in rural and underserved communities to achieve an advanced level of knowledge for the care of patients with skeletal diseases. Over the first 21 months of weekly Bone Health TeleECHO programs, there were 263 registered health care professionals in the United States and several other countries, with 221 attending at least 1 online clinic and typically 35 to 40 attendees at each session at the end of the reported period. Assessment of self-confidence in 20 domains of osteoporosis care showed substantial improvement with the ECHO intervention (P = 0.005). Bone Health TeleECHO can contribute to mitigating the crisis in osteoporosis care by leveraging scarce resources, providing motivated practitioners with skills to provide better skeletal health care, closer to home, with greater convenience, and lower cost than referral to a specialty center. Bone Health TeleECHO can be replicated in any location worldwide to reach anyone with Internet access, allowing access in local time zones and languages. The ECHO model of learning can be applied to other aspects of bone care, including the education of fracture liaison service coordinators, residents and fellows, and physicians with an interest in rare bone diseases.