Jay B. Higgs

Does starting allopurinol prolong acute treated gout? A randomized clinical trial.

BackgroundTraditionally, allopurinol is not initiated during an acute gout attack to avoid prolonging the painful arthritis. The 2012 American College of Rheumatology Guidelines for the Management of Gout suggest that urate-lowering therapy can be started during an acute attack, based on “consensus opinion of experts, case studies, or standard of care.” ObjectiveThe aim of this study was to determine whether initiating allopurinol will adversely affect the resolution of acute, treated gout. MethodsWe conducted a 28-day, placebo-controlled, double-blind study of allopurinol initiation in patients with acute gout. Patients with crystal-proven gout by arthrocentesis were enrolled if they presented to the rheumatology clinic with an acute gout attack within 72 hours from initial therapy. The patients were also required to meet at least 1 additional criterion for urate-lowering therapy including (1) the presence of gouty tophi, (2) more than 1 acute gout attack per year, (3) a history of nephrolithiasis, or (4) urate overproduction (>1000 mg in 24-hour urine collection). Patients were excluded from the study if they had a glomerular filtration rate of less than 50 or liver function test of greater than 1.25 times the upper limit of normal. The treating physician determined therapy for the acute gout attack. Standard prophylaxis, with colchicine or nonsteroidal anti-inflammatory drugs, was prescribed. Allopurinol or placebo was initiated at 100 mg daily for the first 14 days and then increased to 200 mg daily for the next 14 days. The primary end point was protocol defined days to resolution of acute gout, incorporating patient-rated joint pain and physician examination. Secondary measures included Physician Global Assessment, patient-rated pain, adverse effects of therapy, and serum uric acid. ResultsThirty-one patients (17 on placebo, 14 on allopurinol) completed the study. Both intent-to-treat and completer analyses showed only a statistically insignificant difference in days to resolution (15.4 days in the allopurinol group completers vs 13.4 days in the placebo group; P = 0.5). The secondary measures revealed that the acute phase of pain rapidly improved in both groups. ConclusionsWe initiated allopurinol at low doses during an acute gout attack in patients who met criteria for starting urate-lowering therapy and did not have abnormal kidney or liver function. In this cohort, allopurinol did not prolong the acute, treated attack.

Evolution of Musculoskeletal Ultrasound in the United States: Implementation and Practice in Rheumatology

Introduction Ultrasonography (US) uses nonionizing sound waves to produce 2or 3-dimensional gray-scale images. Although adopted earlier in other fields of medicine, the first US descriptions of normal and abnormal musculoskeletal (MS) tissues were published in 1958 and 1972, respectively (1,2). The use of color/power Doppler for synovitis was first described in 1994 (3). Annual publications on MSUS have increased exponentially from 7 in 1991 to 175 in 2011 (4). In addition to orthopedic surgery, physiatry, and podiatry, the use of MSUS has gained increasing acceptance in the field of rheumatology (5,6). Combining clinical findings, a strong understanding of the immunobiology of rheumatic diseases, and the potential for realtime dynamic imaging makes the use of MSUS a powerful addition to the diagnostic skills of the rheumatology provider. Applications of MSUS include the diagnosis of inflammatory and noninflammatory rheumatic disease, the assessment of an individual’s response to treatment, and guidance for procedures (7–9) (Table 1). MSUS is gaining acceptance as an imaging modality among rheumatologists, but little has been published regarding the experience in the United States. Many entities, including the Ultrasound School of North American Rheumatologists (USSONAR) and the American College of Rheumatology (ACR), have taken a proactive role in the use of MSUS by offering educational courses, training educators, and developing a set of reasonable use criteria and certification. Despite many challenges in academic settings, inroads have been made at the fellowship training level by clinician educators to incorporate MSUS into individual program curricula. This review describes the evolution of this modality with its beginnings in Europe and its further adoption in the United States, reviews the necessary components for its practice, examines the economic and education-related challenges to its implementation, and offers solutions and resources to overcome these barriers.

Musculoskeletal ultrasound training and competency assessment program for rheumatology fellows

The purpose of this study was to establish standards for musculoskeletal ultrasound competency through knowledge and skills testing using criterion‐referenced methods.

Musculoskeletal Ultrasound Objective Structured Clinical Examination: An Assessment of the Test

To determine the reliability and validity of an objective structured clinical examination (OSCE) for musculoskeletal ultrasound (MSUS).

Giant cell arteritis presenting as ageusia and lower extremity claudication.

G iant cell arteritis (GCA) is a mediumand large-vessel vasculitis with a tendency to affect the cranial arteries and upper-extremity vasculature, in patients older than 50 years. The most common presenting features include a new temporal headache, visual changes, and jaw claudication in conjunction with systemic complaints. Aortitis and vascular involvement of the lower extremities have been rarely reported as an initial manifestation of GCA. Ageusia in association with GCA has been reported in only 2 patients. We describe a case of GCA presenting with both ageusia and lower-extremity claudication.

Musculoskeletal Ultrasound and Anatomy: Comment on the Article by Navarro‐Zarza et al

gene–environment process (2). In contrast, there is no indication that the prevalence of rheumatoid factor (RF) and anti–citrullinated protein antibodies (ACPA) may be higher in smokers than in the general population. Recently, 2 articles have suggested smoking as a potential risk factor for the radiologic severity of RA (3,4). However, after adjustment, it has been shown that the effect of smoking on joint damage was mediated via ACPA and that smoking was not an independent risk factor for radiologic progression in RA. In our study, to avoid this bias, we adjusted for potential confounders, including positivity for RF and ACPA and shared HLA–DRB1 epitope. In addition, it is unlikely that the hypothesis of a selection bias may explain some studies on established RA that have also supported a link between smoking and good outcome (5,6). Finckh et al observed a significant inverse dose-response relationship between current smoking intensity and radiographic disease progression (5), and Wolfe and Zwillich found that past or present smoking was protective for total joint replacement in patients with RA (6).

Utility of Musculoskeletal Ultrasound in a Department of Defense Rheumatology Practice: A Four-Year Retrospective Experience†

To analyze the utility of musculoskeletal ultrasound (MSUS) in a rheumatology department and characterize relevant clinical trends.

Musculoskeletal Ultrasound Instruction in Adult Rheumatology Fellowship Programs

Musculoskeletal ultrasound (MSUS) in rheumatology in the US has advanced by way of promotion of certifications and standards of use and inclusion of core fellowship curriculum. In order to inform endeavors for curricular integration, the objectives of the present study were to assess current program needs for curricular incorporation and the teaching methods that are being employed.

Non-popliteal synovial rupture.

The ruptured popliteal synovial cyst is a common complication of chronic knee arthritis. In contrast, non-popliteal synovial rupture is less well recognized and may present a diagnostic dilemma. We report an 81-year-old woman who presented with chest wall pain and ecchymosis. Ultrasonography of the shoulder region readily diagnosed a dissecting parasynovial cyst. She developed the unusual complication of contralateral recurrence. Literature review revealed a small but important set of non-popliteal synovial ruptures in the regions of the shoulder, elbow, wrist, spine, hip, knee, and ankle. Local swelling, inflammation, ecchymosis, and nerve impingement may mimic other conditions. Awareness of the clinical presentations and a high index of suspicion are required to avoid diagnostic confusion. Management data are limited to case reports of arthrocentesis, injection, and very rarely, surgery.

Fibromyalgia in Primary Care

Fibromyalgia is a common disorder and has substantial impact on quality of life. The cause remains unknown, but current evidence points to multifactorial involvement of pain processing. Clinical diagnosis is aided by evidence-based diagnostic criteria with subscores for widespread pain and symptom severity. Nonpharmacologic treatments, including cognitive behavioral therapy, sleep hygiene, and regular aerobic exercise, form the cornerstone of management. Pharmacologic intervention is an important adjunct, but benefit is variable. There is no cure for fibromyalgia at this time, but persistence and patience in management may lead to a satisfactory lifestyle.