TNF inhibitor treating osseous sarcoidosis and dactylitis: case and literature review.

A 49-year-old African American male with multiorgan sarcoidosis presented with recurrent episodes of dactylitis and arthritis. Imaging had shown sarcoid osseous involvement of both hands. This would improve temporarily with high-dose corticosteroids but once tapered, he would experience recurrent flares. Despite several different oral immunosuppressant regimens, significant improvement was only observed after the initiation of adalimumab. Not only was adalimumab successful in symptomatic relief, in addition, patient continues to be in remission with no recurrent episodes of dactylitis. Prednisone was successfully tapered from 40 to 3 mg daily. This improvement with TNF inhibitors has been reported with other manifestations of sarcoidosis including pulmonary and ocular involvements. Osseous sarcoidosis is a very rare presentation, and little information regarding treatment with TNF inhibitors is available. TNF inhibitors should be considered as the next-step therapy in resistant cases of osseous sarcoidosis and dactylitis not responding to corticosteroids and traditional immunosuppressant therapy.

Bone and joint infections of the hand.

BACKGROUND: Little guidance is currently available for standardized diagnostic protocols and therapeutic recommendations for bone and joint infections (BJIs) of the hand. OBJECTIVES: To summarize the available data in the scientific English-language literature on the diagnosis and treatment of native BJIs of the hand. To illustrate these concepts from a narrative point of view in areas where there is lack of evidence. SOURCES: We performed a systematic PubMed and Internet search of studies that investigated hand BJIs in adult patients. CONTENT: Few studies have systematically investigated and validated diagnostic concepts, classifications or surgical treatment protocols. Most concepts derive from traditional intra-institutional experience, expert opinions and extrapolations from infections in large joints and long bones. Similarly, there is no uniformly accepted infection definition of BJIs of the hand. The best-documented literature is available for microbiological findings and antibiotic treatment duration in uncomplicated native joint arthritis of the fingers. Retrospective studies and one prospective randomized trial suggest that post-surgical targeted antibiotic therapy of 2 weeks results in a microbiological cure rate of ≥88%. IMPLICATIONS: Studies on diagnostic workup and infection definition and classification are urgently needed to compare inter-institutional outcome results and generate guidelines for the best patient care. For uncomplicated pyogenic arthritis of native joints, current evidence suggests that a 2-week course of antibiotic therapy following surgery cures the infection.

Bone Health Index and bone turnover in pediatric patients with type 1 diabetes mellitus and poor metabolic control.

BACKGROUND: There is a need for a non-invasive, affordable, and reliable method for bone health screening in pediatric patients at risk. OBJECTIVE: To assess Bone Health Index (BHI) in pediatric patients with type 1 diabetes (T1D) and its relation to bone metabolism, age at onset, duration, control, and insulin dose. SUBJECTS AND METHODS: Left-hand radiographs were obtained from 65 patients with T1D, mean age 11.23 ± 3.89 years, mean disease duration 5.23 ± 3.76 years and mean glycosylated hemoglobin (HbA1c)-83 mmol/mol (9.7%). Blood and 24 hours urine samples were collected for bone and mineral metabolism assessment. BoneXpert was used to determine BHI, Bone Health Index standard deviation score (BHI SDS), and bone age. RESULTS: Mean BHI SDS was -1.15 ± 1.19 (n = 54). In 20.37% (n = 11) BHI SDS was < -2SD with mean value -2.82 ± 0. 69, P < .001. These patients had lower levels of beta cross laps (0.77 ± 0.33 ng/mL vs 1.17 ± 0.47 ng/mL), osteocalcin (47.20 ± 14.07 ng/mL vs 75.91 ± 32.08 ng/mL), serum magnesium (0.79 ± 0.05 mmol/L vs 0.83 ± 0.06 mmol/L) and phosphorus (1.48 ± 0.29 mmol/L vs 1.71 ± 0.28 mmol/L) but higher ionized calcium (1.29 ± 0.04 mmol/L vs 1.26 ± 0.05 mmol/L), P < .05, compared to patients with BHI SDS in the normal range. We found a positive correlation between BHI SDS and age at manifestation (r = 0.307, P = 0.024) and a negative one with disease duration (r = -0.284, P = .038). No correlations were found with HbA1c, insulin dose, height, weight, BMI. CONCLUSIONS: To the best of our knowledge, this is the first study to assess bone health in pediatric patients with T1D using BHI. We found significantly decreased cortical bone density and bone turnover in 20.37%. Earlier age at onset and diabetes duration may have a negative impact on cortical bone density in patients with poor control. Longitudinal studies are needed to follow changes or to assess future interventions.

Evaluation of hand bone loss by digital X-ray radiogrammetry as a complement to clinical and radiographic assessment in early rheumatoid arthritis: results from the SWEFOT trial.

BACKGROUND: To investigate hand bone loss (HBL) measured by digital X-ray radiogrammetry (DXR) in patients with early rheumatoid arthritis (RA) receiving different treatment regimens, and to evaluate if DXR change rates during the first 12 months correlate with radiological damage after 24 months. METHODS: From the total SWEFOT trial population, 159 patients had hand radiographs correctly timed and taken with same modality to be analyzed with DXR. All patients started treatment with methotrexate. After 3-4 months, patients with DAS28 > 3.2 were randomized to add sulfasalazine and hydroxychloroquine (triple therapy) or infliximab (MTX + INF). Those with DAS28 ≤3.2 were followed in regular care. Radiographic progression over 24 months was scored according to the Sharp van der Heijde score (SHS) and defined as >5 increase in T-SHS over 24 months. Hand bone mineral density (BMD) was measured by DXR at inclusion and 12 months and a change ≥2.5 mg/cm2/month was used as a cut-off for HBL. RESULTS: In the MTX responders, triple therapy, and MTX + INF groups, the proportions with HBL were 4.1%, 22.2% and 16.4%, respectively (p = 0.01), and the mean (SD) radiological progression in these groups was 3.91 (6.72), 7.40 (14.63) and 2.72 (4.55) respectively (p = 0.06). Patients with HBL had significantly greater risk for radiographic progression, compared with patients without HBL (odds ratio 3.09, 95% CI =1.20-7.79, p = 0.02). CONCLUSIONS: Non-responders to MTX had a significantly greater risk of HBL than MTX-responders, despite the add-on therapies. Patients with HBL during the 12 months had greater risk of radiographic progression after 24 months. Evaluation of HBL may help to identify patients who are at risk of radiographic progression.

Relationship between early bone mineral density changes and long-term function and radiographic progression in rheumatoid arthritis.

OBJECTIVE: To ascertain whether bone mineral density loss during the first year of treatment for early rheumatoid arthritis (RA) as assessed by dual x-ray absorptiometry (DXA) is associated with long-term function, quality of life, and radiographic progression. METHODS: Early RA patients, prior to commencing disease-modifying antirheumatic drug therapy, underwent evaluation with DXA scans of both hands, femoral neck, and lumbar spine at the time of diagnosis, then at 1 year and final followup at >6 years. Clinical and laboratory data and hands and feet radiographs were obtained at baseline and final followup. RESULTS: Sixty-four patients were assessed. At baseline, median disease duration was 6 months, mean 28-joint Disease Activity Score was 5.85, and median Health Assessment Questionnaire score was 1.38. Median followup was 6.4 years (range 5.1-7.2 years). For erosion scores, 86% of patients with hand bone density loss above the smallest detectable change after 1 year progressed versus 55% of those with no hand bone density loss (P = 0.006). However, baseline radiographs showed a similar strength of association. Eighty-four percent of patients with erosions at baseline had erosion progression versus 57% of those with no baseline erosions (P = 0.021). Additionally, first-year bone density loss was not associated with function and quality of life status at followup. CONCLUSION: Hand bone loss during the first year of treatment in early RA, as assessed with DXA, was associated with a high likelihood of radiographic progression; however, in the current study this was not superior to baseline radiographs. Furthermore, it was not associated with patient-reported outcomes.

Bone quantitative ultrasound at hand phalanges of women following breast cancer surgery.

Breast cancer surgery and its adjunctive therapy follow in lymphedema, decreased limb mobility and bone deterioration. The aim was to establish relation of postsurgical limb lymphedema with bone properties assessed by quantitative ultrasound (QUS) measurement of hand phalanges in postmenopausal women after breast cancer surgery. In all, 63 women aged 62.81 ± 8.83 years, after breast cancer surgery were compared with control group of 418 age-matched women. Their skeletal status was assessed by QUS measurements at proximal phalanges using DBM Sonic 1200. There were no statistically significant differences in QUS measurements (Ad-SoS) between groups of operated subjects and the controls, between limbs (operated vs. nonoperated side, with and without lymphedema), and regarding method of surgery. Ad-SoS was greater in estrogen-treated patients than in nontreated ones at the side with no breast surgery (1994.11 ± 67.83 vs. 1943.27 ± 58.34; P = 0.046). Ad-SoS was lower in patients with adjunctive antiestrogen therapy than without this therapy at the side of surgery (1937.35 ± 54.71 vs. 1966.78 ± 59.18; P = 0.0449), and nonbreast surgery side (1934.55 ± 52.06 vs. 1973.31 ± 57.17; P = 0.0066). Breast cancer surgery followed by concomitant therapies does not influence significantly QUS at hand phalanges. This was proven regarding method of surgery, side of surgery, and lymphedema. Additional hormonal treatment can influence phalangeal QUS in breast cancer survivors.

[Peculiarities of wrist bone growth as a criterion for determining the biological age of children living under different environmental conditions].

The paper had the objective to study growth dynamics of short tubular wrist bones in children aged from 5 to 16 years and residing in the cities of Shelekhov and Irkutsk. The growth rate in the girls from Irkutsk was shown to be fairly uniform and proportional; in the boys, it substantially increased at the age of 10-11 and 15 years. In the boys living in Shelekhov, the bone growth became activated at the age of 9 and 15 years. In the girls, it was periodically uniform until the age of 9; thereafter, periodicity in the growth of middle and distal phalanxes was no longer apparent.

[Analysis of the densitometric method of hand bone radiograms and assessment of early changes of bone structure in the children with Gaucher s disease on enzyme replacement therapy (ERT)]. / Analiza radiogramów kosci reki metoda densytometryczna w ocenie wczesnych zmian w strukturze kosci u dzieci z choroba Gauchera leczonych enzymatycznie.

In the study of changes of bone structure eighteen children with Gaucher s disease (ERT) at the 4 to 19.8 years, used was densitometric in vivo method of hand bone radiograms. On the basis of the radiogram assessed was the bone age of patient also optical bone density and dimension in the second metacarpal bone. Differential diagnostics was produced based on standardized cortical thickness and optical bone density, according to the norm of Polish population (1989, 2004). The analysis of hand bone radiograms in children with Gaucher's (ERT) shows that 55.5% of patients had normal skeletal status, 38.8% indicated osteopenia traits, one patient had osteoporotic traits.

[Analysis of the densitometric method of hand bone radiograms and assessment of early changes of bone structure in the children with Gaucher's disease on enzyme replacement therapy (ERT)]. / Analiza radiogramów kosci reki metoda densytometryczna w ocenie wczesnych zmian w strukturze kosci u dzieci z choroba Gauchera leczonych enzymatycznie.

In the study of changes of bone structure eighteen children with Gaucher's disease (ERT) at the 4 to 19,8 years, used was densitometric in vivo method of hand bone radiograms. On the basis of the radiogram assessed was the bone age of patient also optical bone density and dimension in the second metacarpal bone. Differential diagnostics was produced based on standardized cortical thickness and optical bone density, according to the norm of Polish population (1989, 2004). The analysis of hand bone radiograms in children with Gaucher's (ERT) shows that 55.5% of patients had normal skeletal status, 38.8% indicated osteopenia traits, one patient had osteoporotic traits.