High-risk osteoporosis clinic (HiROC): improving osteoporosis and postfracture care with an organized, programmatic approach.

SUMMARY: A programmatic outpatient high-risk osteoporosis clinic (outpatient HiROC) and inpatient fracture liaison service (inpatient HiROC) is described. Results document that this population is more effectively treated and followed up in this specialty pathway than with primary care follow-up. INTRODUCTION: We describe a programmatic approach to outpatient care of high-risk osteoporosis patients (outpatient HiROC). We similarly describe an inpatient fracture liaison service (inpatient HiROC), which integrates into the existing outpatient HiROC pathway. METHODS: The development of outpatient HiROC and inpatient HiROC is described. Outpatient visits (July 29, 2008 to October 27, 2011) are included with a 200 patients random sample calculation. Inpatient consultation visits between November 18, 2008 and October 27, 2011 are included. RESULTS: Between July 29, 2008 and December 31, 2011, 1917 outpatient consults were seen. Of the 200 patient samples, 87% were female, mean age of 69.8 years, previous fractures occurred in 34% patients, and glucocorticoid users constituted 10.6%. Eighty-six percent of this group was high risk, where drug therapy is indicated, and such treatment was started in 89%. A total of 1041 inpatient fracture consults were seen during the evaluable period; 14.7% of this population died before the 6-month follow-up. Females comprised 77.6%, mean age was 76.1 years, and 58.2% of fractures were hip fragility, 11.6% vertebral, and 1.7% midshaft and 1.6% subtrochanteric. Patients seen in our outpatient HiROC pathway were significantly more likely to be treated than those followed up by one of our primary care doctors (80.6 versus 32.2%, P<0.0001). Mean vitamin D levels at baseline (27.0 ng/mL) improved to 34.6 ng/mL at 6-month follow-up (P<0.0001). CONCLUSIONS: Our outpatient and inpatient HiROC model is efficient and effective in risk stratifying and treating patients at high risk for fractures.

Improving detection and treatment of osteoporosis: redesigning care using the electronic medical record and shared medical appointments.

UNLABELLED: To determine whether a process redesign could improve detection and treatment of osteoporosis, at-risk women over the age of 65 were identified using an electronic medical record and proactively contacted by letter and phone call. This resulted in a significant increase in testing for osteoporosis by DXA scan. The high-risk patients were then offered a shared medical appointment, which resulted in improved treatment outcomes compared to usual care. INTRODUCTION: Our objective was to determine if redesigning care through proactive contact with women 65 at-risk of osteoporosis increased BMD testing and to determine if a shared medical appointment (SMA) improved treatment for high-risk women. METHODS: Two primary care sites received the redesign intervention and two other sites served as the usual care controls. At the intervention sites, all women 65 who had not had a DXA scan performed in the prior 2 years were contacted by mail and phone calls. High-risk patients were invited to attend a SMA or follow-up visit with their primary physician. RESULTS: A significantly higher proportion of women at the intervention sites had a DXA (39.6% vs. 13.2%, p < 0.0001). Patients who attended the SMA were more likely to have calcium and vitamin D recommended, a vitamin D level checked, and receive a prescription medicine than those patients who had follow-up with their primary care physician. CONCLUSIONS: The redesigned process was highly effective in improving BMD testing for women 65. The SMA was shown to be a more effective method to make calcium and vitamin D recommendations, to evaluate secondary causes of low bone density, and to prescribe prescription medications, compared to usual care with the PCP.

Redesigning the care of rheumatic diseases at the practice and system levels. Part 1: practice level process improvement (Redesign 101).

Redesigning the delivery-of-care processes for rheumatic diseases within rheumatology practices and health systems is critical to improving the outcomes and costs of care for the patients we serve. This work is best accomplished using Continuous Quality Improvement Methods, also known as Plan-Do-Study-Act (PDSA) cycles that are widely utilized in many other industries, but not often in health care or among physicians. This first of two companion articles provides background on health care redesign, understanding of PDSA methods, and examples of successful rheumatology practice process redesigns based on PDSA. It is offered as a starting point for rheumatologists preparing for this necessary work.

Redesigning the care of rheumatic diseases at the practice and system levels. Part 2: system level process improvement (Redesign 201).

Changing delivery-of-care processes for rheumatic diseases to improve outcomes and costs will require redesign not only within rheumatology practices but also within health systems. Preventive services, acute care, management of chronic co-morbidities, and rheumatology care for rheumatic disease patients can only be accomplished through the close integration of multiple practices and other health system resources. Rheumatologists can play an important role in system-level process improvement without which our own patient care will be compromised. Continuous Quality Improvement methods, also known as Plan-Do-Study-Act (PDSA) cycles, are ideally suited for system-level process redesign. This second of two companion articles describes the properties of systems and explores the redesign of interdisciplinary rheumatic disease care.

Glucocorticoid-Induced Osteoporosis Program (GIOP): a novel, comprehensive, and highly successful care program with improved outcomes at 1 year.

INTRODUCTION: Patients who take chronic glucocorticoids (GC) are at increased risk of osteoporosis and fracture. Only a minority of patients who take chronic GC receive optimal osteoporosis prevention, diagnosis, and/or treatment. METHODS: An organized program of care--GIOP (Glucocorticoid-Induced Osteoporosis Program)--was designed and implemented. The program goals were to identify patients at risk of fracture, provide education, redesign and implement new pathways of care, and monitor outcomes. Two hundred chronic GC users were seen at baseline, and follow-up visits scheduled at 6 months and 1 year. RESULTS: Patient retention of knowledge, frequent exercise, and 25-OH Vitamin D levels all significantly improved at 1 year. A significant decrease in GC dose was seen. In terms of adherence, 91% of patients considered at high risk were taking a bisphosphonate or teriparatide at 1 year, and 96% of patients overall were adherent to their prescribed regimen of calcium, vitamin D, and prescription treatment (if indicated). Bone density at the spine and total hip increased significantly. CONCLUSIONS: GIOP is the first organized program of care for patients who take chronic GC that has demonstrated a clinically significant improvement in outcome. The program's design can be adapted and used by other health systems and organizations.

Osteoporosis disease management in a rural health care population: hip fracture reduction and reduced costs in postmenopausal women after 5 years.

A 5 year observational study is reported which reviews the implementation of the Geisinger Health System Osteoporosis Disease Management Program. This program includes Osteoporosis Clinical Practice Guidelines, physician and allied health care provider education, community education, and a bone density testing program. All women over the age of 55 years enrolled in the Geisinger Health Plan (GHP) from 1996 to 2000 were included in this analysis. The guidelines led health care providers to increase the evaluation of osteoporosis via bone density measurements and to increase the prescription treatment of osteoporosis. Most importantly, the age-adjusted incidence of hip fractures fell significantly in the entire group as well as in several age strata (65-74, 75-84 and 85+ years). Compared with a predictive model of no intervention, there was an overall reduction in health care costs to GHP estimated to be US$7.8 million over a 5 year period. This report is the first to suggest that an organized Osteoporosis Disease Management Program delivered by a health care system can result in increased evaluation and treatment of osteoporosis with a resultant significant decrease in hip fractures while decreasing the total direct costs of care to a health plan.

Juvenile dermatomyositis: a retrospective review of a 30-year experience.

BACKGROUND: Children with juvenile dermatomyositis (JDMS) have variable initial presentations. OBJECTIVE: Our purpose was to evaluate the epidemiology trends, presenting clinical features, laboratory data, and outcome of patients with JDMS. METHODS: A total of 16 patients were identified at Geisinger Medical Center by a 30-year retrospective chart review. RESULTS: Sex ratio, age at diagnosis, and outcome were similar to data published in previous studies. However, certain trends were noted. The most common initial physical examination findings were an extremity rash (94%) and periungual erythema (75%). New associations of JDMS that were uncovered included the findings of pruritus (38%) and a psoriasiform scalp dermatitis (25%). Nonspecific laboratory elevations were the most common initial laboratory changes (erythrocyte sedimentation rate, lactate dehydrogenase, and aspartate aminotransferase). Tubuloreticular inclusions as found on electron microscopy of muscle biopsy specimens were present in all 3 patients tested. One patient with tubuloreticular inclusions had otherwise normal muscle biopsy findings on hematoxylin-and-eosin staining. Two of the 16 patients had cutaneous findings of JDMS but did not exhibit muscle involvement after long-term follow-up at 4 and 5 years. CONCLUSION: Our study confirms that the initial physical and laboratory findings in patients with JDMS may be nonspecific. The heliotrope rash and Gottron papules classically associated with dermatomyositis appeared less commonly than an extremity rash and periungual erythema. Creatinine kinase and aldolase levels may not be elevated on initial presentation. Pruritus, a psoriasiform scalp dermatitis, and tubuloreticular inclusions found on muscle biopsy electron microscopy should be additional factors to consider. The long-term follow-up in 2 patients without muscle involvement lends support to the existence of amyopathic dermatomyositis.

Needle muscle biopsy.

We review our experience with needle muscle biopsy, including technique, results, complications, and outcome. We have collected data from 40 consecutive patients undergoing needle muscle biopsy of the quadriceps muscle. All biopsies were performed by the same operator and 98% were performed in the outpatient clinic. Specimens were sent to pathology for processing, staining, and interpretation. Follow-up clinical information was obtained by chart review. The ages of the patients ranged from 9 to 84 years, including three children. Of the 27 patients with a prebiopsy suspicion of idiopathic inflammatory myopathy (polymyositis, dermatomyositis, or inclusion body myositis) 13 had biopsies with consistent pathologic changes. Seven patients in this group had no pathologic diagnosis - none of these patients subsequently developed active myositis. Other conditions seen included mitochondrial myopathy, neuropathy, and type II fiber atrophy. Biopsies were very well tolerated, and no significant complications were seen. Therapeutic decisions were influenced most by needle muscle biopsy results obtained from patients suspected of having idiopathic inflammatory myopathy. Needle muscle biopsy charges were approximately 40% lower than those for open biopsies performed during the same interval. Needle muscle biopsy is a safe, care-effective, and cost-effective alternative to open muscle biopsy in the evaluation of a variety of myopathies.

The arthritis of primary biliary cirrhosis: clinical features and associated immune processes.

We have performed a survey to determine the percentage of patients with primary biliary cirrhosis (PBC) and arthritis followed at Geisinger Clinic, a rural tertiary care center. We have assessed the clinical features of the arthritis, delineated any signs that suggest the diagnosis of asymptomatic PBC in patients with arthritis, and explored coexisting immune diseases.From January 1988 through November 1993, 36 patients with PBC were identified from a computer search of the Geisinger Gastroenterology Clinic database. These records were reviewed for clinical information of an associated arthritis, other autoimmune processes, and demographic information.Twenty-five percent of the patients with PBC had an inflammatory arthritis. Two patients had classic, seropositive rheumatoid arthritis with erosions and nodules. The remaining seven patients had a predominantly symmetrical, nonnodular inflammatory arthritis involving both large and small joints. Tenosynovitis was the most common presenting rheumatic feature. Sjögren's syndrome, Raynaud's phenomenon, and hypothyroidism were more common in the subgroup of PBC patients with arthritis.A diagnosis of PBC should be considered in any patient presenting with tenosynovitis or an unexplained inflammatory arthritis, especially in the setting of Raynaud's phenomenon and signs of Sjögren's syndrome.

The Use of Low-dose Oral Methotrexate in the Treatment of Polymyositis and Dermatomyositis.

The objective of this study was to evaluate the efficacy of low-dose oral methotrexate (MTX) in improving muscle strength and reducing the corticosteroid requirement of patients with polymyositis (PM) and dermatomyositis (DM). The method used was a retrospective chart review of our clinic's PM/DM cohort, Between September 1989 and May 1993, 12 of 53 patients with PM/DM received low-dose oral MTX (mean maximum dose 14.4 +/- 1.2 mg/wk, range 7.5-20 mg/wk). A significant increase in strength coupled with a fall in prednisone requirement (42.5 +/- 5.8 mg/d to 13.0 +/- 5.4 mg/d) was seen during the mean follow-up time of 24.0 +/- 4.3 months of MTX therapy. The number of flares per year fell from 1.00 +/- 0.35 before oral MTX institution to 0.07 +/- 0.05 during oral MTX therapy. Toxicity was minimal. Three patients were able to stop corticosteroids altogether. Low-dose oral MTX therapy should be considered early in the treatment course of patients with PM/DM to improve strength and lower the required dose of corticosteroids.

Seronegative inflammatory arthritis in the myelodysplastic syndromes.

The myelodysplastic syndromes (MDS) are a group of therapeutically refractory anemias resulting from a clonal stem cell disorder often associated with cytogenetic abnormalities. Immunologic abnormalities and occasionally vasculitis have been reported although no series has characterized an associated arthritis. All cases of MDS diagnosed in 1990 by bone marrow biopsy and followed up at the authors' institution were reviewed. Of the 28 consecutive patients, 8 had acute seronegative inflammatory arthritis temporally related to the initial discovery of cytopenia. Five patients had a symmetric polyarthritis resolving only with use of steroids or upon evolution to leukemia, and 3 had episodes of oligoarthritis with systemic features including fever, pleuritis, pericarditis, and hemolytic anemia. Arthrocenteses in 2 cases did not show crystals or infection. Serological studies were nondiagnostic. The arthritis and systemic features responded to steroids in all 5 treated patients. Inflammatory arthritis appears to be common in MDS. Most compelling is the apparent bone marrow response to steroids in 2 cases, possibly identifying a treatable subgroup.

P-31 magnetic resonance spectroscopy in polymyositis and dermatomyositis. Altered energy utilization during exercise.

OBJECTIVE: To explore alterations in energy utilization as a potential etiology for weakness in polymyositis and dermatomyositis (PM/DM). METHODS: P-31 magnetic resonance spectroscopy studies were performed in patients with acute and treated PM/DM and in normal controls, at rest and with exercise. RESULTS: Patients with acute and treated PM/DM showed increased ratios of inorganic phosphate to phosphocreatine (PCr) during exercise, with loss of ATP disproportional to loss of PCr. CONCLUSION: This study demonstrates changes in energy utilization in PM/DM, thus supporting the notion of a metabolic etiology for the weakness associated with these diseases.

Clinical liver disease in patients with rheumatoid arthritis taking methotrexate.

Between 1981 and 1989, 3 of 134 patients with rheumatoid arthritis (RA) treated with methotrexate (MTX) developed clinically significant hepatic dysfunction and showed histologic evidence of severe liver disease (fibrosis and cirrhosis). Factors identified in these patients that may have been linked to liver toxicity included diabetes, congestive heart failure and Felty's syndrome. In the patient group that received a post-MTX liver biopsy, pulmonary fibrosis and obesity were significantly associated with hepatic fibrosis/cirrhosis. Severe liver disease may occur in patients with RA treated with low dose MTX (less than 3%). Early liver biopsy is recommended in selected cases.

Sulfasalazine therapy in psoriatic arthritis: clinical and immunologic response.

Sulfasalazine therapy has been shown effective in rheumatoid arthritis and ankylosing spondylitis. We treated 10 patients with active polyarticular psoriatic arthritis with 2 g/day of sulfasalazine for 16 weeks. Significant improvement was seen in joint count score, morning stiffness, and patient/physician assessment of disease activity. Toxicity requiring drug cessation was seen in only 1 patient. Patients with psoriatic arthritis had elevated B cells and immunoglobulin levels which fell with sulfasalazine therapy. Minimal changes were seen in T cell subsets. Sulfasalazine appears to be an effective second line agent for the treatment of psoriatic arthritis. Its mechanism of action may in part relate to alteration of B cell number and function.

Endothelin increases the synthesis and secretion of atrial natriuretic peptide in neonatal rat cardiocytes.

Endothelin (ET) effected a dose-dependent increment in atrial natriuretic peptide (ANP) secretion and ANP mRNA accumulation in neonatal rat atrial and ventricular cardiocytes but had no effect on the processing of the ANP prohormone to the mature ANP product. The secretagogue effect was not limited by cell density. Both basal and ET-dependent secretory activity were abrogated by the calmodulin antagonist calmidazolium but were unaffected by meclophenamate or pertussis toxin. The magnitude of the ET-dependent increment in ANP secretion was amplified by culturing the cells in a dynamically pulsating (vs. static) environment, implying an interaction between mechanical and agonist-mediated secretory stimuli in this system. ET also promoted immunoreactive ANP release from primary cultures of fetal rat hypothalamic cultures, suggesting that this regulatory function may be generally employed in ANP gene-expressing cells. These findings demonstrate that ET has parallel effects on ANP synthesis and secretion and support a role for this peptide in the regulation of local and circulating levels of the natriuretic hormone.

Estradiol down-regulation of the rat uterine estrogen receptor.

We have previously shown that neonatal exposure of rats to pharmacologic doses of diethylstilbestrol via daily injections resulted in a significant decrease in the estrogen-binding capacity of the uterine estrogen receptor (ER). In this study, we examined the effects of physiologic and pharmacologic doses of estradiol (E2) administered to adult ovariectomized rats via Silastic implants. Two days after implantation, uteri were removed, weighted, and homogenized, and ER levels were determined in the supernatant (hydroxylapatite assay) and low-speed pellet (nuclear exchange assay). Implants containing E2 concentrations of 0.005 or 0.05 mg/ml increased cytosolic but not total ER-binding capacity, whereas 0.5 or 5.0 mg of E2/ml implants decreased the binding capacity of cytosol ER to 40% and total ER to 50% of control values. The 0.005-mg/ml dose increased cytosol ER without increasing uterine weight; all higher doses significantly increased uterine weight. Determination of ER protein by an ER radioimmunoassay showed the same extent of reduction of ER concentration as the binding assays, demonstrating that the loss in E2 binding capacity is homologous down-regulation. The down-regulation of ER was maximal at 24 hr and was completely reversible after implant removal, although the time required to recover from down-regulation was dose dependent. Uterine weight also returned to control levels slowly after implant removal. Neither the sedimentation rate of the down-regulated ER nor the Kd of the cytosolic ER changed following long-term implantation; however, the Kd of the nuclear ER decreased significantly. This is the first demonstration of in vivo homologous down-regulation of uterine ER. ER down-regulation may play a role in several biologic processes.

Forskolin and methotrexate induce an intermediate trophoblast phenotype in cultured human choriocarcinoma cells.

The human placenta and its associated membranes are vital to the maintenance, nutrition, and protection of the developing fetus. During placental development some cytotrophoblasts give rise to the chorionic membrane whereas others fuse to form a differentiated syncytium of cells that are responsible for placental protein and steroid hormone production. The mechanisms involved in the differentiation of the trophoblasts are unknown; however, an intermediate stage with a characteristic phenotype has been documented in vivo. We have observed that chemically dissimilar xenobiotic agents induced BeWo choriocarcinoma cells to change their usual cytotrophoblastic phenotype and acquire morphologic and functional characteristics typical of intermediate trophoblast. Incubation of BeWo cell cultures in the presence of 1 mumol/L methotrexate for 48 hours stimulated human chorionic gonadotropin secretion (2.3-fold) and aromatase activity (4.9-fold). Morphologic findings associated with these hormonal changes, including increased nuclear size and cytoplasmic expansion, were also observed. With the use of a computer-interfaced image analyzer, planimetric morphometry of the nuclear area of the cells revealed a 1.8-fold increase after incubation with methotrexate. The effect of forskolin, a direct activator of adenylyl cyclase, was also evaluated by means of this model of cytotrophoblast differentiation. The addition of 10 mumol/L forskolin to BeWo cultures also resulted in dramatic changes in trophoblast cell phenotype. Increases in human chorionic gonadotropin synthesis (7.3-fold), aromatase activity (13.5-fold), and nuclear area (3.0-fold) were induced over those of untreated cells. In addition, increases in [3H]thymidine incorporation (1.7-fold) were afforded by both treatments. These results suggest that biochemical and cytologic changes associated with human trophoblast differentiation can be induced in vitro via activation of the adenylyl cyclase pathway by forskolin and through unknown and apparently independent signals by methotrexate.

Suppurative extensor tenosynovitis caused by Staphylococcus aureus.

Suppurative tenosynovitis is a rare infection, occurring almost exclusively in the flexor tendon sheath as a posttraumatic event. We report the case of a systemically ill woman with suppurative tenosynovitis of the extensor tendons caused by Staphylococcus aureus. Early recognition of this unusual infection may prevent unnecessary morbidity.