Chronic Tophaceous Gout Presenting as Bilateral Knee Masses in an Adult Patient: A Case Report.

INTRODUCTION: Gout is a common disorder of uric acid metabolism that leads to the precipitation of monosodium urate crystals. It most commonly affects the first metatarsophalangeal joint but can also affect other joints such as knees, elbows, wrists, and ankles. Chronic gout can present as recurrent episodes of monoarticular or polyarticular inflammatory arthritis, tophaceous soft tissue deposits of monosodium urate crystals, uric acid renal calculi, and/or chronic nephropathy. CASE REPORT: We report the case of a 67-year-old Caucasian male patient with bilateral tophaceous gout to his knees involving the soft tissue and ulcerating skin breakdown to his left knee after an acute traumatic injury. Plain radiographs of the bilateral knees revealed large soft tissue masses anterior to the patella. Magnetic resonance imaging of the left knee was also performed which demonstrated heterogeneous masses consistent with tophi and peripheral enhancement with central necrosis. A diagnostic biopsy was performed to rule out malignancy the results confirmed gouty tophi. We report this case to note the atypical presentation of this disease. CONCLUSION: Chronic tophaceous gout presenting with ulcerating skin breakdown overlying a fungating tophaceous mass is uncommon considering the current availability of effective pharmaceutical treatments for hyperuricemia. Surgical intervention for tophaceous gout is seldom required and is traditionally reserved for atypical cases that present with deformities, severe pain, and joint destruction. Although ulcerative tophi are rare, they can have significant morbidity and greatly impact patients' quality of life. Surgical intervention was indicated in our patient to excise the mass and avoid infective complications.

Pediatric gunshot wound recidivism: Identification of at-risk youth.

BACKGROUND: Although penetrating injury is the most common reason for pediatric trauma recidivism, there is a paucity of literature specifically looking at this population. The objective of this study was to identify those in the pediatric community at the highest levels of risk for experiencing gunshot wound (GSW) on multiple occasions. METHODS: A retrospective review querying our urban Level I trauma database was performed. Patients aged 0 year to 18 years sustaining GSW from 2000 to 2011 were selected. This was further refined to include those who returned to the hospital for another firearm injury. Demographic data, including age of initial and subsequent presentation, sex, race, zip code, home address, and disposition were compiled. RESULTS: During the 12-year study period, 896 pediatric patients were discharged from the hospital after initial firearm injury with subsequent 8.8% recidivism rate. All recidivists were male, and 86% were 16 years to 18 years old at the time of the first injury. The subsequent incident occurs within the first year, 2 years, and 3 years 32%, 53%, and 66% of the time, respectively. Nine individuals in our study group experienced GSW on three separate occasions, with a mortality rate of 22%. Regarding the domicile, 53% of the patients were located in a 3-sq mi area containing four public high schools. CONCLUSION: Using demographic data, we have been able to identify an at-risk population where there is a greater than 1 in 12 chance of getting shot multiple times. Use of this type of demographic data can help target those at highest risk by allocating resources that can have the greatest impact on this societal burden. LEVEL OF EVIDENCE: Prognostic study, level III.

Prevalence of family history of breast and ovarian cancer in a single primary care practice using a self-administered questionnaire.

Women at high risk of hereditary breast and/or ovarian cancer require specific management strategies for cancer prevention and early detection. The goal of this study was to determine the prevalence of familial breast and ovarian cancer among patients in a primary care practice. Questionnaires were mailed to the 608 women less than 81 years of age in a single primary care practice. Additional mailings and phone calls were used for nonresponders. Data were analyzed by bloodline, the degree of relative, age of diagnosis and cancer type. Women were grouped into three categories of breast/ovarian family history: "no family history,""insignificant family history," and "significant potentially high-risk family history" (women with two or more relatives in a single bloodline with breast and/or ovarian cancer, a single individual with bilateral breast cancer or breast and ovarian cancer, or breast and/or ovarian cancer at less than 40 years of age). A pedigree analysis of women categorized as "significant potentially high-risk family history" further classified these women as to the likelihood of being at risk for hereditary cancer. Data were obtained from 567 women (93%); 27 patients with a personal diagnosis of breast and/or ovarian cancer were excluded. Of the 540 remaining respondents, 351 (65%) had no family history of cancer, 138 (25.6%) had an insignificant family history, and 51 (9.4%) had a significant family history. Based on pedigree analysis of these 51 patients, 19 were unlikely to be at high risk for hereditary cancer, and 32 (6%) were likely to be at significant risk and warrant intensive evaluation. The large proportion of women identified with a significant family history of breast and/or ovarian cancer has major implications regarding the magnitude of a population-based process to identify and manage high-risk individuals.