Week 7

This week we needed to send our data to the biostatistician for final analysis, so much of the week was spent getting our data ready and formatted.  The rest of my week involved the usual meetings and conferences and seeing patients with Dr. Goodman.
At CAP conference this week, a patient was discussed who had been diagnosed with Lupus in 1990 and is now speaking to the orthopedic surgeons about a TKR due to debilitating knee pain.  While the surgeons agreed that she would be a good candidate for surgery, they and the rheumatologists questioned her Lupus diagnosis and wanted that question answered before moving forward with surgery.  This patient was diagnosed with Lupus nephritis in 1990 and went on a round of steroids for treatment.  This was also when her SLE was diagnosed.  But it is unclear if a biopsy was performed to confirm the diagnosis.  After the Lupus nephritis cleared up, she stopped taking the steroids or any medications for Lupus symptoms/management for almost a decade when she went on another round of steroids for unclear reasons.  Since that incident she has not had any medication for her disease and does not appear to be at all symptomatic which is extremely rare in SLE patients.  It is because of her current lack of symptoms that the surgeons and rheumatologists believe she was misdiagnosed in 1990.  To cover all their bases, the surgeons want to figure out the correct diagnosis before agreeing to operate on this patient.  A patient with confirmed SLE and bilateral hip and knee pain was also discussed.  This patient was diagnosed with Lupus at age 17 and later suffered from severe Lupus nephritis which resulted in dialysis and later kidney transplantation.  Unfortunately, at some point during her hospitalization she got an MRI with gadolinium contrast agent and she had a severe reaction to the gadolinium resulting in what appears to be nephrogenic systemic fibrosis.  This is a very rare reaction to the contrast agent (none of the attendings in the room had ever seen a patient with it before).  The patient's skin across her entire body had become fibrosed (appearing like severe scleroderma) and her x-rays showed heterotopic ossifications throughout her body (which was likely the cause of her joint pain).  Due to the systemic nature of this condition, the surgeons agreed that there was not anything they could do to help her pain and decided that her best move would be to get a formal diagnosis of nephrogenic systemic fibrosis and to see a specialist in this condition (though the surgeons did not have any specific doctors in mind).  Though this kind of reaction to gadolinium is rare, there are several documented cases and a quick google search will tell you that it is most common in patients with compromised kidney function.  Unfortunately, there does not appear to be an easy/cheap method for determining if a patient will have an adverse reaction.  But now that she has had the reaction, she is stuck with the condition which has no known cure and treatment options with only moderate success.
In journal club this week, an interesting study was presented which examined the variation in orthopedic surgery amongst RA patients in the U.S.  It was found that the liklihood of an RA patient having a surgery for RA-related joint problems depended on the density of orthopedic surgeons and rheumatologists in the patient's geographical area.  While it is not all too surprising that a patient who lives in a region with 10 times more orthopedic surgeons than rheumatologists is more likely to undergo an orthopedic surgery than a patient who lives in an area with more rheumatologists, I was surprised with the amount of variation in the density of doctors across the country.  Rheumatologists seem to be concentrated more in coastal cities whereas orthopedic surgeons seem to be more evenly spread throughout the country.  This leads to the question of how patients can have access to proper care if there aren't any rheumatologists in their area.
This week I spent a day in the OR with Dr. Rodeo.  I observed an arthroscopic shoulder labrum repair.  While it was weird to see a shoulder with a bunch of tools sticking out of it, it was awesome to be able to see the whole procedure up close on the screen.  I was able to see the debridement, the suture anchor placement, and the reattachment of the labrum in great detail.  I also observed an open shoulder procedure.  This patient had undergone a shoulder procedure previously and was complaining of pain and weakness again.  The MRI showed that the pain and weakness could be due to a subscapularis insufficiency and joint capsule insufficiency.  To address these issues, a portion of the pecularis muscle was rerouted to the subscap insertion to increase strength and an achilles tendon allograft was used to repair the insufficient joint capsule.  Unfortunately, because this procedure was not athroscopic it was much more difficult to see exactly what was going on, but the descriptions sounded very interesting.  I was surprised that an achilles tendon was  being used as an allograft since the tendon is somewhat cellularized, I was wondering what kind of immune response it would cause.