Smoking Increases Complications After Hip or Knee Arthroplasty

Jasvinder Singh MD MPH Professor of Medicine UAB Division of Clinical Immunology and Rheumatology Interview with:
Jasvinder Singh MD MPH
Professor of Medicine
UAB Division of Clinical Immunology and Rheumatology 

Medical Research: What is the background for this study? What are the main findings?

Dr. Singh: A systematic review of the effect of smoking on outcomes after total joint replacement showed that current smoking increased the risk of overall post-operative complications but that there were scarce data for smoking and specific surgical outcomes of arthroplasty. We performed a study using data from an institutional Total Joint Registry to answer this question.   In a study of for 7,926 patients who underwent hip or knee arthroplasty, 7% were current tobacco users. We found that compared to current non-users, current tobacco users had higher hazard ratios (95% CI) for deep infection, 2.37 (1.19, 4.72; p=0.01) and implant revision, 1.78 (1.01, 3.13; p=0.04) after total hip or knee arthroplasty. No significant differences were noted for periprosthetic fractures or superficial infections.

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MBDA Biomarker Score Predicts Rheumatoid Arthritis Disease Activity

Ron Rogers Executive Vice President, Corporate Communications Spokesman, Myriad Genetics, Inc. Salt Lake City, Utah 84108

Ron Rogers Interview with:
Ron Rogers

Executive Vice President, Corporate Communications
Spokesman, Myriad Genetics, Inc.
Salt Lake City, Utah 84108

Medical Research: What is the background for the MBDA test? What types of biomarkers are included in the score?

Response: Vectra DA is an advanced blood test for adults with rheumatoid arthritis (RA). It helps you and your doctor better understand your rheumatoid arthritis disease activity.  Vectra DA blood test for RA gives physicians a more complete look at your disease activity by measuring 12 markers of RA disease activity. Some other tests, such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR or “sed rate”), only measure one marker.

Vectra DA test scores can help track your disease activity over time with an objective measure that complements your doctor’s exam and your own assessment.  Patients with high Vectra DA scores have 7-fold higher risk for rheumatoid arthritis-related joint damage than patients with low or moderate Vectra DA scores.

You can learn more about the specific biomarkers at:

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Acute Gout Episodes Peaks in November Interview with:
Paras Karmacharya, MD
Internal Medicine Reading Health System
West Reading, PA 19611
Co-Authors: Ranjan Pathak MD, Madan Raj Aryal MD,
Smith Giri MD, Anthony A Donato MD MHPE

Medical Research: What is the background for this study?

Response: Studies describing seasonal variations in acute gouty arthritis note a seasonal trend, but disagree on timing, with most showing a peak in spring months while others showing peaks later in the year. However, serum uric acid (SUA) levels seem to peak in the summer months. This disparity has led to the hypothesis that the flares might be related to factors other than elevated serum uric acid levels. Various theories on the effects of weather and immune system changes on the chronobiology of the equilibrium and precipitation of monosodium urate crystals have been proposed. We aimed to shed light on this question by examining the seasonal variation in the incidence of acute gouty arthritis in the US using a large inpatient database.

Medical Research: What are the main findings?

Response: We used the Nationwide Inpatient Sample (NIS) database, a large national database that represents 20% of all hospital admissions, to identify adult patients with a primary diagnosis of acute gouty arthritis from 2009-2011 during their hospitalization. A total of 28,172 hospitalizations with primary diagnosis of acute gouty arthritis were reported from 2009-11. The peak incidence of acute gout was seen in the month of November (peak/low ratio 1.34, 95% CI 1.29-1.38, p<0.05) (Figure 1). The highest number of hospitalizations was observed in autumn months, while the lowest incidence was observed in spring (28.12% vs. 23.13%, p<0.001).

Medical Research: What should clinicians and patients take away from your report?

Response: Unlike previous studies, our analysis found the peak incidence of acute gout in the fall with its peak in the month of November. Various environmental (temperature, humidity, diet, physical activity) and biochemical factors (low cortisol levels, high absolute neutrophil counts and plasminogen activator inhibitor-1) have been implicated for the seasonal variation, but the data on this is conflicting. Whether our findings are reflective of purine and alcohol intake over the US holidays in November and December is a hypothesis that requires further testing.

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Majority of Gout Patients Do Not Achieve Target Uric Acid Level

Marsha A. Raebel, PharmD Senior Investigator Kaiser Permanente Colorado's Institute for Health Research

Dr. Raebel Interview with:
Marsha A. Raebel, PharmD
Senior Investigator
Kaiser Permanente Colorado’s Institute for Health Research

Medical Research: What is the background for this study? What are the main findings?

Dr. Raebel: Gout is an inflammatory arthritis that affects at least 7.5 million American adults. A hallmark of gout is high serum uric acid that can result in urate crystals being deposited in joints, causing pain and joint damage. The American College of Rheumatology (ACR) guidelines recommend lowering serum uric acid to target values in patients with gout to prevent urate crystal deposition in joints and to promote crystal dissolution. For most patients, serum uric acid levels should be reduced to < 6mg/dL and maintained below that level. Measuring serum uric acid is a necessary step when titrating urate-lowering medications using a treat to target approach, but little is known about either serum uric acid measurement practices or attainment of target serum uric acid levels outside of clinical trials. We set out to characterize uric acid measurement and target serum uric acid attainment in patients with gout in the usual ambulatory care settings of the Kaiser Permanente integrated health system in the United States.

We identified 72,803 patients newly-diagnosed with gout in three Kaiser Permanente regions; 61% had at least one serum uric acid measurement within the baseline year prior to their gout diagnosis. Over each 12 month interval after the gout diagnosis, fewer patients had a serum uric acid measured. For example, serum uric acid measurement decreased to 40% of the patients the first year after the gout diagnosis, and to 26% of patients the second year after the gout diagnosis. While median serum uric acid levels across all patients decreased from 8.0 to 6.6 mg/dL over the entire 12 years of follow-up, almost 60% of patients never achieved a serum uric acid level less than 6 mg/dL. Achievement of this target serum uric acid level was more frequent in those who had a lower serum uric acid at baseline. Less than 12% of patients achieved all follow-up serum uric acid levels in the target range.

Medical Research: What should clinicians and patients take away from your report?

Dr. Raebel: Clinicians should be aware that, although most patients had at least one serum uric acid measured at some time, regular serum uric acid assessment was infrequent. Infrequent serum uric acid assessment impedes optimal use and monitoring of urate-lowering therapy. More than half of patients did not achieve any serum uric acid value within the target range of less than 6mg/dL. Given that the majority of patients with new-onset gout never reach the target serum uric acid level, more frequent serum uric acid measurement is urged.

Specifically, patients should adhere to having serum uric acid monitored as recommended by their physician and should request that their physician periodically order laboratory serum uric acid testing for them at frequencies based on treatment guidelines. To assist in reaching serum uric acid target levels, patients should take their urate-lowering medication as prescribed by their doctor. Furthermore, they should not stop their urate-lowering therapy without having been so advised by their doctor.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Raebel: We recommend developing interventions that support physicians and patients with gout in monitoring serum uric acid and treating to target serum uric acid levels. For example, best practice alerts could be developed and implemented in electronic health records that prompt physicians to order serum uric acid laboratory testing when more than a year has passed between measurements for any patient with gout or more frequently for patients who are not in the target range.


Abstract presented at the 2015 ACR meeting November 2015

Treating to Target in Gout: The Epidemiology of Serum Urate Measurement Among Patients with Incident Gout in Usual Care Settings in the United States

Marsha A. Raebel, PharmD (2015). Majority of Gout Patients Do Not Achieve Target Uric Acid Level 

microRNAs in Joint Fluid As Biomarker For Antibiotic Refractory Lyme Arthritis Interview with:
Robert B. Lochhead PhD
Clinical Fellow in Medicine 
Division of Rheumatology, Allergy & Immunology
Massachusetts General Hospital
Harvard Medical School, Boston, MA

Medical Research: What is the background for this study? What are the main findings?

Dr. Lochhead: Lyme arthritis (LA), caused by the tick-borne spirochete Borrelia burgdorferi, usually resolves appropriately with antibiotic treatment, called antibiotic-responsive Lyme arthritis. However, in some patients, arthritis persists for months or years after spirochetal killing with oral and IV antibiotic therapy, called antibiotic-refractory Lyme arthritis. Synovial lesions in these patients show marked synovial proliferation, inflammation, and vascularization, accompanied by autoimmune T and B cell responses. MicroRNAs (miRNAs) regulate many biological processes including inflammation, immune responses, and cell proliferation, and are effective biomarkers that may reveal molecular mechanisms of disease. Our objective here was to identify extracellular miRNAs (ex-miRNAs) in synovial fluid (SF) that distinguish regulated (responsive) from dysregulated (refractory) immune responses in Lyme arthritis, thereby providing insights into underlying biological processes and potential diagnostic biomarkers to distinguish between  these disease courses.

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