Karina D. Torralba

The interplay between diet, urate transporters and the risk for gout and hyperuricemia: current and future directions.

Diet plays a significant role in the development of gout and hyperuricemia. Gout and hyperuricemia have likewise been associated with the development of cardiovascular disease and metabolic syndrome. Epidemiological studies have shown that certain foods influence levels of serum uric acid and the risk for development of gout.This article reviews the influence of dietary factors on serum uric acid levels and risk of gout, as well as the role of urate transporters in the development of hyperuricemia and gout.Various epidemiological studies have shown the effects of certain foods on the risk of developing gout and hyperuricemia. Low‐fat dairy products, purine‐rich vegetables, whole grains, nuts and legumes, and less sugary fruits, coffee and vitamin C supplements decrease the risk, whereas intake of red meat, fructose‐containing beverages and alcohol increase the risk of gout. There is also an increased although basic understanding of the effects of vitamin C, alcohol and fructose on urate transporters. Certain foods can lead to a decreased or increased risk of development of gout and hyperuricemia. Advances have established the interplay of certain foods on urate transporters and renal handling of urate. More studies, especially prospective ones, are needed to increase our understanding of the roles of foods and urate transporters and other molecular mechanisms on the risk of developing gout and hyperuricemia.

Association of industry funding with the outcome and quality of randomized controlled trials of drug therapy for rheumatoid arthritis

OBJECTIVE To assess the association of industry funding with the characteristics, outcome, and reported quality of randomized controlled trials (RCTs) of drug therapy for rheumatoid arthritis (RA). METHODS The Medline and Cochrane Central Register of Controlled Trials databases were searched to identify original RA drug therapy RCTs published in 2002-2003 and 2006-2007. Two reviewers independently assessed each RCT for the funding source, characteristics, outcome (positive [statistically significant result favoring experimental drug for the primary outcome] or not positive), and reporting of methodologic measures whose inadequate performance may have biased the assessment of treatment effect. RCTs that were registered at ClinicalTrials.gov and completed during the study years were assessed for publication bias. RESULTS Of the 103 eligible RCTs identified, 58 (56.3%) were funded by industry, 19 (18.4%) were funded by nonprofit sources, 6 (5.8%) had mixed funding, and funding for 20 (19.4%) was not specified. Industry-funded RCTs had significantly more study centers and subjects, while nonprofit agency-funded RCTs had longer duration and were more likely to study different treatment strategies. Outcome could be assessed for 86 (83.5%) of the 103 RCTs studied. The funding source was not associated with a higher likelihood of positive outcomes favoring the sponsored experimental drug (75.5% of industry-funded RCTs had a positive outcome, compared with 68.8% of non-industry-funded RCTs, 40% of RCTs with mixed funding, and 81.2% of RCTs for which funding was not specified). Industry-funded RCTs showed a trend toward a higher likelihood of nonpublication (P=0.093). Industry-funded RCTs were more frequently associated with double-blinding, an adequate description of participant flow, and performance of an intent-to-treat analysis. CONCLUSION Industry funding was not associated with a higher likelihood of positive outcomes of published RCTs of drug therapy for RA, and industry-funded RCTs performed significantly better than non-industry-funded RCTs in terms of reporting the use of some key methodologic quality measures.

Soft tissue infections.

Soft tissue infections are common and potentially fatal conditions. Infections are a major cause of morbidity and mortality in patients who have rheumatic disease. Patients who have rheumatic diseases may be at increased risk for soft tissue infections because of various factors, including inherent immunologic defects, genetics, and use of immunomodulatory therapy, including biologic agents. Timely diagnosis and management with the institution of antibiotics with or without surgical intervention is imperative for effective resolution of infection. This article provides a review of recent literature on the presentation and clinical course of infectious tenosynovitis, septic bursitis, pyomyositis, and necrotizing fasciitis, especially in relation to patients who have rheumatic disease.

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.

Randomized controlled trials of rheumatoid arthritis registered at ClinicalTrials.gov: what gets published and when.

To examine characteristics associated with the publication and timeliness of publication of randomized controlled trials (RCTs) of treatment of rheumatoid arthritis (RA).

Financial conflicts of interest and their association with outcome and quality of fibromyalgia drug therapy randomized controlled trials

To evaluate the association of financial conflicts of interest (FCOI) with the characteristics, outcome and reported methodological quality of fibromyalgia drug therapy randomized controlled trials (FM‐RCTs).

Later Comes Earlier, Nowadays

> While we deliberate about beginning, it is already too late to begin. > > Quintilian, 35–96 BCE We all agree that early identification and treatment of rheumatoid arthritis (RA) with “tight” control currently provide us our best opportunities to optimize outcomes for patients1,2,3,4,5,6,7,8,9,10,11. At present we seek drug-induced suppression of disease for prevention of inflammatory damage and consequent disability. We expect remissions in half or more patients we are able to treat early. We hope an occasional patient will retain a remission when drugs are tapered and even stopped. We are thrilled to have at least 9 conventional and 9 biological disease-modifying antirheumatic drugs (DMARD) to choose from and combine. However, we are frustrated that we do not have better markers to allow us to select the best therapy for each patient without the trial-and-error process we now utilize. We are disappointed and saddened when treatments fail, and patients suffer rather than benefit from therapy, as still happens. We struggle, too often unsuccessfully, to provide expensive state-of-the-art medications to all we think should receive them. Early recognition and intervention for RA is one of the triumphs of an age of rheumatology that has truly transformed how we think about caring for patients. There is now urgency in finding RA patients and getting them to rheumatologists or comparable therapeutic programs. We now have new criteria that facilitate early classification of RA12. The 2010 revised classification criteria provide a framework to identify patients before the progression of disease (by eliminating the requirement of at least 6 weeks of disease or presence of nodules or erosions, and by focusing on the … Address correspondence to Dr. Panush. E-mail: panush{at}usc.edu

Teaching of clinical anatomy in rheumatology: a review of methodologies

Clinical anatomy may be defined as anatomy that is applied to the care of the patient. It is the foundation of a well-informed physical examination that is so important in rheumatologic practice. Unfortunately, there is both documented and observed evidence of a significant deficiency in the teaching and performance of a competent musculoskeletal examination at multiple levels of medical education including in rheumatology trainees. At the Annual Meeting of the American College of Rheumatology in Boston, MA, that took place in November 2014, a Clinical Anatomy Study Group met to share techniques of teaching clinical anatomy to rheumatology fellows, residents, and students. Techniques that were reviewed included traditional anatomic diagrams, hands-on cross-examination, cadaver study, and musculoskeletal ultrasound. The proceedings of the Study Group section are described in this review.

Scientific productivity: An exploratory study of metrics and incentives

Competitive pressure to maximize the current bibliometric measures of productivity is jeopardizing the integrity of the scientific literature. Efforts are underway to address the ‘reproducibility crisis’ by encouraging the use of more rigorous, confirmatory methods. However, as long as productivity continues to be defined by the number of discoveries scientists publish, the impact factor of the journals they publish in and the number of times their papers are cited, they will be reluctant to accept high quality methods and consistently conduct and publish confirmatory/replication studies. This exploratory study examined a sample of rigorous Phase II-IV clinical trials, including unpublished studies, to determine if more appropriate metrics and incentives can be developed. The results suggest that rigorous procedures will help reduce false positives, but to the extent that higher quality methods are accepted as the standard of practice, the current bibliometric incentives will discourage innovative studies and encourage scientists to shift their research to less informative studies of subjects that are already being more actively investigated. However, the results also suggest that it is possible to develop a more appropriate system of rewards. In contrast to the current bibliometric incentives, evaluations of the quality of the methods and reproducibility of the results, innovation and diversity of thought, and amount of information produced may serve as measures and incentives that maintain the integrity of the scientific literature and maximize scientific progress.