Feasibility of methotrexate discontinuation following tocilizumab and methotrexate combination therapy in patients with long-standing and advanced rheumatoid arthritis: a 3-year observational cohort study.

OBJECTIVES: Methotrexate (MTX) is associated with extensive side effects, including myelosuppression, interstitial pneumonia, and infection. It is, therefore, critical to establish whether its administration is required after achieving remission with tocilizumab (TCZ) and MTX combination therapy in patients with rheumatoid arthritis (RA). Therefore, the aim of this multicenter, observational, cohort study was to evaluate the feasibility of MTX discontinuation for the safety of these patients. METHODS: Patients with RA were administered TCZ, with or without MTX, for 3 years; those who received TCZ+MTX combination therapy were selected. After remission was achieved, MTX was discontinued without flare development in one group (discontinued [DISC] group, n = 33) and continued without flare development in another group (maintain [MAIN] group, n = 37). The clinical efficacy of TCZ+MTX therapy, patient background characteristics, and adverse events were compared between groups. RESULTS: The disease activity score in 28 joints-erythrocyte sedimentation rate (DAS28-ESR) at 3, 6, and 9 months was significantly lower in the DISC group (P < .05, P < .01, and P < .01, respectively). Further, the DAS28-ESR remission rate at 6 and 9 months and Boolean remission rate at 6 months were significantly higher in the DISC group (P < .01 for all). Disease duration was significantly longer in the DISC group (P < .05). Furthermore, the number of patients with stage 4 RA was significantly higher in the DISC group (P < .01). CONCLUSIONS: Once remission was achieved, MTX was discontinued in patients who responded favorably to TCZ+MTX therapy, despite the prolonged disease duration and stage progression.

Insidious Onset Compartment Syndrome of the Forearm in a Teenager: A Case Report and Review of the Literature.

Compartment syndrome affecting the upper extremities is a relatively underreported event compared with compartment syndrome affecting the lower extremities. Moreover, insidious onset forearm compartment syndrome has been rarely reported and is usually limited to single case reports. We report a compartment syndrome of the forearm in a teenager. She hit her right proximal forearm lightly on the cash register, but there was no pain. However, the next day, she had difficulty in moving her right hand. Although she underwent electrotherapy, her right forearm gradually became swollen, and she felt numbness in the ring and little fingers of her right hand. Six day after the onset, she came to our hospital and underwent fasciotomy. There was no aftereffect, and very good functional recovery was obtained. All clinicians need to keep the case of forearm compartment syndrome in a young individual with a diffuse course, such as in this case in mind.

Pyogenic tenosynovitis of the wrist due to Corynebacterium striatum in a patient with dermatomyositis: A case report.

INTRODUCTION: Corynebacterium striatum is common contaminant in clinical specimens. Here, we report a rare case of pyogenic tenosynovitis of the wrist caused by C striatum in a dermatomyositis patient taking oral immunosuppressants. PATIENT CONCERNS: A 67-year-old Japanese woman with dermatomyositis had a history of multiple intraarticular injections of corticosteroids to the right wrist joint for the treatment of osteoarthritis. She was admitted to our hospital with a painful lump on the right dorsal wrist lasting for three months. MRI revealed cellulitis of the dorsum of the right wrist and hand and fluid collection in the extensor tendon sheath. C striatum was detected in the cultures of three samples of synovial fluid taken from the dorsal hand. DIAGNOSIS: Pyogenic tenosynovitis of the wrist due to C striatum. INTERVENTIONS: The infection was successfully controlled with synovectomy and adjuvant antibiotic therapy. OUTCOMES: There has been no sign of recurrence for 12-months after the surgical treatment. LESSONS: This is the first reported case of pyogenic tenosynovitis due to C striatum in a patient with dermatomyositis. Clinicians should be aware that patients undergoing immunosuppressive therapy have a risk of C striatum infection.

Distribution of Solitary and Multiple Enchondromas of the Hand.

BACKGROUND/AIM: Although some patients with enchondroma have multiple lesions, no study has investigated the distribution of lesions in patients with multiple enchondromas. PATIENTS AND METHODS: This retrospective study included 118 patients with enchondroma of the hand. The incidence and characteristic feature of multiple enchondromas of the hand were investigated. RESULTS: Four patients (3.4%) had multiple enchondromas. In all the patients with multiple enchondromas, the lesions occurred in the middle phalanx, proximal phalanx, and metacarpal bone in the same digital ray. CONCLUSION: The development of the hand rapidly progresses from intrauterine day 33 to day 54. The digital rays are evident on intrauterine day 41, and separation of the distal phalanx, middle phalanx, proximal phalanx, and metacarpal bone is completed until intrauterine day 54. The successive occurrence of multiple enchondroma lesions in the same digital ray in all four cases suggests that the occurrence of lesions preceded the separation of the hand bones and the lesions were divided during the development of these bones.

Treatment of aneurysmal bone cysts using endoscopic curettage.

BACKGROUND: Although aneurysmal bone cysts (ABCs) are benign tumours, they have the potential to be locally aggressive. Various treatment approaches, such as en bloc resection, open curettage, radiotherapy, sclerotherapy, and embolization have been proposed, but the most appropriate treatment should be selected after considering the risk of tumour recurrence and treatment complications. Endoscopic curettage (ESC) may be a less invasive alternative to open curettage for ABC treatment. We aimed to describe the use of ESC for the treatment of ABCs and to report our clinical outcomes, including the incidence rate of recurrence, radiological appearance at final follow-up, time to solid union, complications, and postoperative function. METHODS: Between 1998 and 2015, 30 patients (18 men and 12 women; mean age, 17.4 years) underwent ESC for the treatment of primary ABCs at our hospital (mean postoperative follow-up, 55 months). ESC was performed under arthroscopic guidance for direct visualization, and curettage extended until normal bone was observed in the medullary cavity. To investigate bone healing after ESC, we evaluated the consolidation of cysts at the final evaluation (based on the modified Neer classification) and time to solid union after surgery, which was defined as sufficient cortical bone thickness to prevent fracture and allow physical activities. RESULTS: Recurrence was identified in 3 cases (10%). Curative outcomes were obtained after repeated ESC or open curettage. A log-rank analysis indicated that age < 10 years (p = 0.004) and contact of the tumour with the physis (p = 0.01) increased the risk of tumour recurrence. Residual tumours were identified in 9 cases (30%); these lesions remained inactive over the extended follow-up period. The average time to solid union after endoscopic curettage was 3.2 months. Transient radial nerve palsy was identified in 1 case. Good postoperative functional recovery occurred in all cases. CONCLUSIONS: ESC is a minimally invasive technique for the treatment of ABCs, and the tumour recurrence rate is comparable to that of other standard procedures. However, the application of this method should be carefully considered, especially for patients < 10 years and when the tumour comes in contact with the physis.

Treatment of simple bone cysts using endoscopic curettage: a case series analysis.

BACKGROUND: Endoscopic curettage is considered applicable for the treatment of simple bone cysts with the expectation that it might be less invasive than open curettage. In this study, we investigated the efficacy of endoscopic curettage for the treatment of simple bone cysts. The goal was to investigate the incidence of cyst recurrence and bone healing after endoscopic curettage. Moreover, complications and functionality at the final follow-up were evaluated. METHODS: From 2003 to 2014, 37 patients with simple bone cysts underwent endoscopic curettage. Twenty-four were male and 13 were female, with a mean age of 14.7 years. Endoscopic curettage was performed with the support of an arthroscope via 7-8 mm holes penetrated by cannulated drills with a small incision. The cysts underwent curettage using angled curettes, rongeurs, and an electrical shaver until the normal bone was observed in the medullary cavity. To investigate the bone healing after endoscopic curettage, we evaluated the consolidation of the cyst at the final evaluation (Modified Neer Classification) and the time to solid union after operation, which was defined as the sufficient thickness of the cortical bone to prevent fracture and allow physical activities. RESULTS: Recurrence occurred in seven patients (18.9%). A log-rank analysis revealed that contact with the physis was associated with recurrence (p = 0.006). Among 31 patients (83.7%), the consolidation of cyst was considered healed at the final X-ray follow-up period, and in these patients, the mean time taken for solid union of cortical bone thinning was 4.0 months (standard deviation, 2.4). With regard to major complications of endoscopic curettage, a transient radial nerve palsy and two postoperative fractures occurred. The former problem was managed conservatively and the latter problems by transient internal fixation; these problems were managed without any further complications. All patients had a good postoperative function. CONCLUSIONS: Endoscopic curettage might be a useful alternative as it is a minimally invasive procedure for the treatment of simple bone cysts. Considering the relatively smaller size of this study, further investigation should be necessary for deducing the reliable conclusion.

Clinical and structural remission rates increased annually and radiographic progression was continuously inhibited during a 3-year administration of tocilizumab in patients with rheumatoid arthritis: A multi-center, prospective cohort study by the Michinoku Tocilizumab Study Group.

OBJECTIVE: To evaluate the clinical and structural efficacy of tocilizumab (TCZ) during its long-term administration in patients with rheumatoid arthritis (RA). METHODS: In total, 693 patients with RA who started TCZ therapy were followed for 3 years. Clinical efficacy was evaluated by DAS28-ESR and Boolean remission rates in 544 patients. Joint damage was assessed by calculating the modified total Sharp score (mTSS) in 50 patients. RESULTS: When the reason for discontinuation was limited to inadequate response or adverse events, the 1-, 2-, and 3-year continuation rates were 84.0%, 76.8%, and 72.2%, respectively. The mean DAS28-ESR was initially 5.1 and decreased to 2.5 at 6 months and to 2.2 at 36 months. The Boolean remission rate was initially 0.9% and increased to 21.7% at 6 months and to 32.2% at 36 months. The structural remission rates (ΔmTSS/year ≤ 0.5) were 68.8%, 78.6%, and 88.9% within the first, second, and third years, respectively. The structural remission rate at 3 years (ΔmTSS ≤ 1.5) was 66.0%, and earlier achievement of swollen joint count (SJC) of 1 or less resulted in better outcomes. CONCLUSIONS: TCZ was highly efficacious, and bone destruction was strongly prevented. SJC was an easy-to-use indicator of joint destruction.