Below is a reprint of an article I wrote for Just Joints, an online newsletter for health professionals distributed by the Arthritis Foundation Upper Midwest Region. This article will be posted in the archives eventually, but be sure to check out the other articles in this series.
Also, be sure to check out Episode 2 of The Rheumatology Podcast, where we discuss an article looking at starting allopurinol during acute gout attacks, as well as some of our other experiences with gout.
The incidence of gout has risen dramatically in the U.S. population, likely driven by the increased incidence of comorbid risk factors that include obesity, diabetes, chronic kidney disease, cardiovascular disease, and hypertension. Despite advances in current therapies for gout that can prevent unnecessary joint damage, tophi, and recurrent flares, many patients remain undertreated. In October 2012, the American College of Rheumatology (ACR) released guidelines on the management of gout in two parts. This article will briefly review part one of the recent ACR guidelines, which focus on nonpharmacologic and pharmacologic management of hyperuricemia, which is often misunderstood and mismanaged, but likely plays the biggest role in long term control of gout.
Beginning with focus on patient education on diet and lifestyle changes, most physicians are aware of recommendations on the avoidance of organ meats in the management of hyperuricemia, and are also aware of limiting servings of seafood, beef, lamb, and pork. Avoidance of alcohol, especially beer, is also widely recognized. Newer recommendations that clinicians might not be aware of are to avoid foods and beverages containing high-fructose corn syrup, which has recently been associated with gout.
One of the most important parts of the recent guidelines is the recommendation to lower serum uric acid levels to less than 6 mg/dl at a minimum, and to less than 5 mg/dl in more severely affected patients, such as those with tophi present. Initial treatment of hyperuricemia should begin with one of the xanthine oxidase inhibitors (XOI), typically allopurinol. The initial allopurinol starting dose recommended was 100 mg daily in patients with normal renal function (50mg daily in stage 4 or higher CKD), which needs to be titrated upward until uric acid is at target. Failure to titrate the dose of allopurinol until uric acid levels are at goal is a common mistake in the management of gout.
Some physicians might be undertreating hyperuricemia over concern regarding side effects when increasing the dose of allopurinol, stopping long before reaching the maximal FDA approved dose of 800mg per day. Even in the setting of CKD, with proper monitoring for toxicity, studies have shown that allopurinol doses can safely be increased above 300mg per day, which is also pointed out in the recent recommendations. There are certain patient populations who are considered high risk of severe allopurinol hypersensitivity reactions, especially Koreans with CKD, and those of Han Chinese or Thai descent, and these patients should be screened for the HLA-B*5801 allele prior to starting allopurinol, which is associated with increased risk of hypersensitivity in these groups.
The newer XOI, febuxostat, is typically reserved for patients who have experienced adverse events from allopurinol, or have not achieved uric acid target despite maximal doses of allopurinol. Additional uric acid lowering therapy with uricosuric agents, typically probenecid in the U.S., is advised in patients who do not reach target uric acid levels with an XOI, given they do not have contraindications to these agents such as nephrolithiasis or significant renal impairment. A newer agent given intravenously, pegloticase, which is a recombinant uricase that metabolizes uric acid, can be given to patients with refractory disease.
Part two of the recent gout guidelines give advice on prophylaxis for patients recently started on uric acid lowering therapy to prevent attacks, usually with colchicine, and also discusses management of acute gout flares. Current knowledge of therapeutic strategies for gout has become increasingly important, especially as we are likely to see more patients with this condition in the upcoming years.
This is an initial venture into podcasting for all three of us, and we’re happy with how the first episode turned out. We’re hoping that it will only improve over time as the show evolves and will be as educational for our listeners as it already has been for us.
At the time of this posting, plans are well underway for episode 2, with plans to discuss a specific article (to be revealed soon, so that listeners can read it prior to the episode), more discussion on the the use of social media in medicine, and other various topics in technology and rheumatology.
I’m proud to announce, that along with co-hosts Dr. Michael Laccheo and Dr. Suleman Bhana, that the inaugural episode of The Rheumatology Podcast will be released early this next week.
In the first episode, we discuss a bit about who each of us are, electronic medical records, misunderstandings about rheumatology and rheumatologists, social media use in medicine, a few of our takeaways from ACR 2012, and more.
I’ll post links to the first episode when available both here and on Twitter (@psufka).
Since entering the field of rheumatology, I have too frequently heard comments from clinicians admitting their lack of knowledge and understanding in the field of rheumatology.
I understand why rheumatology has gotten a reputation as being difficult. The basis for the understanding of rheumatic conditions is the immune system, where our knowledge is becoming ever complex. Many of the rheumatic conditions are uncommon, so clinicians are less comfortable recognizing and treating them. To make things worse, we order a number of oddly named antibodies and use medications that affect the immune system in strange ways.
Fortunately, the basics of rheumatology are not extremely difficult to understand.
The Pareto Principle (80/20 rule)
The Pareto Principle says that 80% of the results come from 20% of the effort, knowledge, or resources. This rule has been shown effective in numerous fields outside of medicine, especially business and finance, and can be used as an effective technique to approach any difficult topic.
With this in mind, I’ll try to focus on the 20% of rheumatology that I think is the most high yield for those outside of rheumatology to understand.
(Sorry fellow rheumatologists, this post isn’t intended to teach you much of anything, but might be helpful when you give guidance or mentor others. I would GREATLY appreciate any additions or corrections in the comments section below).
The unifying mechanism in the rheumatologic diseases is inflammation
Recognition of inflammation is really the first step in thinking about the rheumatologic diseases. With few exceptions, the first thing I’m trying to decide with every new patient I see in the office is whether an inflammatory condition is present, or not.
Recognition of inflammation goes back to the very basics of what we are taught in medicine: the history and physical exam
Joint pain is an extremely common complaint. Being able to differentiate inflammatory from non-inflammatory joint pain is likely the most high yield knowledge in rheumatology. Differentiating these two processes is important because the treatment strategy will vary greatly between the two types.
Taking a pain history: OPQRST
Many of us are taught early in our training the mnemonic “OPQRST” to remember the components of a taking a history. While likely very basic, this is worth reviewing, as details discovered here can greatly change suspicion for inflammation later on.
Onset – When did the symptoms start? Rapid or slow onset?
Provoking/palliating factors – How are the symptoms affected by use? What about rest? Do anti-inflammatories or other medications help? What else have they tried?
Quality (description) of the pain – Dull, aching, stiffness, burning, etc?
Regions/radiation – What joints or other areas are involved? (Remember to ask about the neck and back) Does the pain radiate from one area to another?
Severity – Generally rated on a scale of 0-10
Timing – Constant or intermittent symptoms? Does it change throughout the day (morning stiffness)?
In terms of differentiating inflammatory from non-inflammatory causes, the most helpful are the provoking/palliating factors, and the timing of the symptoms. Inflammatory arthritis is typically associated with pain that is worst in the morning or after resting, with stiffness typically lasting 30-60 minutes or more, and improves with activity.
The complete review of systems: finding the puzzle pieces
The next most powerful tool that rheumatologists use is the complete review of systems. Lack of comfort with what questions to ask, or the feeling that this takes too much time, is likely another reason that many clinicians are uncomfortable with rheumatology. In reality, the puzzle pieces found in the complete review of systems is often where the bigger picture starts to come into place. Feeling overwhelmed? Use the patient as a guide, starting head to toe, to help remember features to ask. Use a checklist if needed at first, or consider using this rheumatologic patient history form from the ACR.
The cardinal signs of inflammation on exam: if you don’t know what to look for, you won’t find it
Calor (heat): The joint is typically cooler than the surrounding tissues.
Functio laesa (loss of function): Typically decreased ROM due to tenderness. If joint function is normal, consider surrounding tissues as the cause of pain. This can be particularly helpful in differentiating cellulitis and/or bursitis from joint inflammation and septic joints.
Look for loss of “dimples” around the joint & decreased skin lines over the joint
Feel for the edges of the joint to feel “boggy/squishy” or less distinct
Feel small joint swelling/effusions by pushing with one finger & sensing with the other
With enough practice, you can learn to palpate synovitis (I have taught medical residents to do this in clinic over the course of a morning). Practice palpating your own joints (assuming they are normal), especially the hands. You typically should easily be able to feel the edges of the joint lines, with only the sense of a normal, thin layer of skin separating the joints from your fingers. If you feel boggy/squishy or less distinct joint lines, along with other features from above, inflammation is more likely.
In summary an ANA should be ordered when the pretest odds of autoimmune disease are high, which is based on findings from our history and physical, summarized in the table below:
Rheumatoid factor (RF): consider causes other than rheumatoid arthritis
Similar to the ANA, the RF should be ordered when the pretest odds of rheumatoid arthritis are high, which requires joint inflammation/synovitis to be present, and increases with the number of affected joints (refer to this excerpt from the 2010 ACR/EULAR RA Classification Criteria for Rheumatoid Arthritis; see also: link to complete pdf article). When suspicion of rheumatoid arthritis is high, typically an anti-CCP is also ordered.
Keep in mind that a positive RF is common in a number of other rheumatic disorders (Sjogren’s syndrome and cryoglobulinemia being most common, but the other connective tissue diseases such as lupus to lesser degrees).
The most common other condition that causes a positive RF is hepatitis C infection, which must be ruled out when a positive RF is detected (additionally, hepatitis C infection is associated with an inflammatory arthritis).
Other conditions associated with positive RF include hepatitis B, lymphoproliferative disorders, malignancy, chronic infections, inflammatory lung conditions.
Common mistakes in gout management
When I asked for suggestions for high yield rheumatology topics on Twitter, gout quickly came up multiple times. Since the incidence of gout is on the rise, likely related to increased risk factors (obesity, diabetes, chronic kidney disease, cardiovascular disease, and hypertension), knowledge of appropriate management will only become more important.
Gout management is divided into acute management (typically treated with prednisone; colchicine, or NSAIDs) and management of hyperuricemia.
The management of hyperuricemia is where most errors in management occur, especially failure to lower the uric acid to 6.0 or less. In most patients, this is accomplished by titrating the allopurinol dose every few weeks until this is achieved, and many clinicians fail by never titrating to a high enough dose to reach this goal. Additionally, most patients are placed on prophylaxis against attacks when first initiating medications to lower uric acid, since risk of flare is highest during this time. These topics are covered nicely in a two part update, published in October 2012.
In closing, I hope this serves as a good starting point for clinicians to become more comfortable in the field of rheumatology. I invite my rheumatology colleagues to post additions, corrections, and any comments below.
I attended my fourth American College of Rheumatology Annual Meeting this past November in Chicago. Each year, prior to attending the biggest yearly meeting of rheumatologists in the world, I spend some time thinking about how to best optimize my limited time there.
The first three years I tried to make it to every lecture that I could, and heard some of the foremost experts in the field speak about many topics. Although I learned a ton of information doing this, I still had to ask if this was really the best use of my time.
My approach to attending large meetings has been much different since reading a post by author Seth Godin, who focuses readers on the important by asking you to think back to a conference a year prior and ask, “What do you remember?”
Seth brought up the point that all of these lectures are available online, and that the part of the meeting that we should focus on is the “engaged conversations.” In fact, because of changing part of focus to this at the Chicago meeting, I met a number of other rheumatologists and patients from around the globe, including Dr. Ronan Kavanagh, a rheumatologist from Ireland, who has also written that attending meetings is not just about sitting in lectures and how Twitter can be used to enhance your meeting experience.
With conferences getting bigger each year, and increasing numbers of lectures and other sessions available to attend, it is important to remember the one thing that you can do at a meeting that you can’t do anywhere else: meet with people. After I get home, in the comfort of my home or office, I can catch up on the lectures I missed.
“The extremes inform the mean, not vice-versa” – Timothy Ferriss
To the benefit of society, randomized controlled trials have formed the cornerstone of modern medical information. These types of trials have been instrumental in helping us characterize the best treatments for a number of diseases and conditions, improving healthcare quality overall. To make these studies applicable to the largest possible population, they are designed with very specific inclusion and exclusion criteria, which remove the atypical and extremes in order to formulate the best possible “average patient”.
However, in daily practice, a significant number of patients do not fit the criteria for being average. Despite not having a well-defined best therapy, these patients still need to be treated.
One of the most important parts of being a specialist in any field is knowing what to do when atypical or extreme situations arise. While the focus of most data available will be on the first, second, and third line therapies for the average patient, what really defines the experts among experts is knowing what to do in the most difficult situations.
This type of knowledge comes from three different sources. The first is experience, that for obvious reasons, takes years to develop. The second is by communicating with people with more expertise than yourself, which is made easier in the world of email and social media, but is still often limited to fairly specific questions.
The third option, which I find particularly high yield, is reading quality case reports and series in the literature. This portion of the literature allows you to actively seek out extreme situations and learn from them, which often have been written to summarize whatever data is available for guidance, often drawing on data from the more usual studies. As an added bonus, these articles usually end up being fairly interesting and memorable (or maybe just less likely to put you to sleep at your desk).
So, while it is always going to be important to keep up with the usual landmark trials in medicine, if you really want to separate yourself as an expert, you have to seek out the extremes.
Our medical patients are becoming increasingly complex. Patients come in with multiple preexisting problems and are taking many more medications than ever before. Electronic medical records (EMR) systems are being adopted across the country, with hopes that they will be able to help us organize and sort through the information in the patient’s charts.
The study compared using ICD-9 codes, (a system where each diagnosis is given a specific code [e.g. 714.0 for rheumatoid arthritis]) to the use of free text search to identify adverse events that occurred while the patient was in the hospital. The study showed that free-text search was able to identify more cases of acute renal failure than ICD-9 codes, and that the two methods were similar in identifying the other diagnoses included in their study (venous thromboembolism, pneumonia, sepsis, and postoperative myocardial infarction).
Many of the EMR systems that I have used personally have had limited functionality for searching within a patient chart. The EMR used by the VA in the above study, Computerized Patient Record System (CPRS), has had a search feature for some time.
While free text search will certainly be helpful in identifying adverse events after patients have left the hospital (and thus, help us learn to prevent further complications), it would also be helpful for clinicians currently working with patients in the hospital and clinics.
Why would advanced search function be helpful to clinicians? Because good patient care lies in the details.
We would be able to quickly and easily find (in a chart that might be a few inches thick if printed out):
The details of how a specific diagnosis was treated over time by going specifically to each note where that diagnosis was mentioned (e.g. making it easier to see that my patient with lupus nephritis may have never really gotten a good trial of MMF, before abandoning it as a treatment option) .
Specific details of side effects to medications (e.g. is this antibiotic listed as an allergy because of a rash and shortness of breath, or because of stomach upset?)
Finding the specific details of how a diagnosis may have evolved over time (e.g. such as how a patient with a scleroderma actually presented as a polyarticular inflammatory arthritis).
Details of why certain treatments were chosen at specific times (e.g. finding out that Dr. X chose a certain medication over another because of abnormal liver function tests at the time).
Also, further advanced search might be able to:
Fix our misspellings, or better yet, improve search accuracy by finding those misspellings within the patient record.
Suggest similar or related searches.
Search only records from a certain timeframe, or from certain physicians.
What about the problem of searching outside medical records — the records from another clinic that are scanned into the system? I see no reason that these cannot be searched equally as well as note that are written directly into the EMR sitting in front of you. Evernote, a free online service that I use to scan and organize documents, receipts, etc., offers the capability to search documents that I have scanned, and works extremely well.
Doctors enjoy seeing patients, and many clinicians consider the time they spend with their patients to be the best part of their day.
Unfortunately, for a multitude of reasons, doctors are unable to spend as much time as they would like directly interacting with patients. They can feel rushed to get to the next patient. Documentation, billing, and other paperwork takes up part of this time, and there is little that we can do about this. But what about some of the usual inefficiencies of the hospital, such as trying to locate a patient or trying contact other physicians (for instance, waiting by a phone after paging them, waiting for a callback).
Currently, more and more hospitals are adopting EMRs, and physicians are starting to embrace devices like the iPad, all with hopes that technology will optimize their time spent during the day.
Here are 7 ways that I think that technology could be used in the next few years to improve physician’s use of time in the hospital:
After first arriving at the hospital in the morning, my patient list would come up in order of priority, similar to Gmail priority inbox. With this, I’m able to see the patients that may need my more immediate attention, because of abnormal vital signs, labs, or because the patient’s nurse flagged the patient. Throughout the day, my patient list would be continually updated and prioritized by the system, with different alerts letting me know changes in the patient status, when abnormal vs normal tests have returned, or when a consultant has seen my patient.
I would be able to make a video call into the patient’s room as as I’m reviewing their chart. This way, if two or more patients may require more urgent attention, I’m able to visually triage where I’m going to go first. Speaking to them with the video phone, we could discuss the best time to visit in person, or get a sense if I should head to their room immediately. Also, I would be able to easily give them updates on test results quickly and easily throughout the day.
Instead of carrying a pager, I’ll have a smart phone with a fully functional EMR that I can use (for times when I don’t have my iPad or a desktop computer in front of me). Instead of paging, text messages with callback numbers to click on would be preferred for non-urgent issues, as opposed to directly calling physicians throughout the day (which could interrupt time with patients). More urgent issues could be given a different alert on my phone, with direct calls reserved for true emergencies.
If I have have any questions or want to discuss further while I’m reviewing notes from other physicians in the chart, I’m able to click on the name of the person that that wrote the note, bringing up a box that allows me to send a text message to their phone.
When I’m with patients, I’m able to show them their imaging and lab results on the TV in their hospital room, using Airplay on my iPad.
Patients have RFID tags on their wrist bands, which immediately update the EMR if they are somewhere else in the hospital, such as in radiology getting tests done, or just walking around the wards.
When doing my daily notes with voice recognition software, the EMR recognizes the diagnosis and problems of the patient I’m working with, and automatically brings up a number of references that I’m able to click to review, if necessary. Also, physicians are able to easily attach links to relevant journal articles within notes, with highlighting of key points.
Any other ways that we could possibly be using technology to improve time in the hospital? Share your thoughts in the comments…
People say the quantity of medical information doubles every 5 years.
Somehow each of us has to figure out how we organize all of this information that is presented to us.
Every great physician mentor I’ve known has been able to quickly pull excellent journal articles from their personal “archive” of literature that they’ve gathered over the years. Sometimes, these key articles directly changed the management of a patient for the better.
As any physician can attest, keeping up with current medical literature is no small feat. Journals seem to arrive in the mail on an almost continuous basis, and even after learning to quickly discard the “throw away” journals, they quickly pile up in offices, floors, bathrooms, etc.
Finding a way to organize, store, and quickly access the important articles is a critical skill for current physicians.
Enter the world of mobile technology. Only a few years ago, many medical residents were starting to carry around a palm pilot with references for drug prescribing and various medical equations.
Today, access to information on the internet is nearly ubiquitous. Almost everyone has a smart phone in their pocket that can access the internet at any time (either through high-speed 3G/4G networks or local Wi-Fi). We can hardly remember the days we actually had to go in front of a computer to Google something (much less try to remember what life was like before Google existed). The iPad was released in April 2010 (only about 15 months ago as of this writing) and has only further advanced how we access information.
Despite being constantly connected to the internet, only recently has “Cloud Computing” become popular, which is giving us new ways to store and access our own personal files from just about any location on earth.
My personal cloud storage service of choice is Dropbox, which I have been using since September 2008 (when beta invites first started becoming available to the public). With Dropbox, I’m able to keep files synced in a folder on Mac at home with my smartphone and iPad, as well as able to access those files from any computer I happen to be using with an internet connection. There are also ways built in to easily share your files with others.
Ways that I use Dropbox include:
Storing and accessing journal articles from multiple locations
Working on and accessing powerpoint/keynote presentations from multiple locations
Working on papers from multiple locations
Storing copies of a number of documents, including my CV, for access from any location
Storing the multiple login names and passwords for various things using a secure password manager (Personally I use KeePass on my Mac and Android phone; many people seem to prefer 1Password)
***I don’t advocate storing any confidential patient information on Dropbox. Although I think the risk of confidential patient information being lost is likely low, the potential consequences of any breach strongly outweighs any current benefits.***
As always, starting out with a new system for organization is a lot of work and takes a little discipline, but in the end, really makes it worth it when you’re able to find the article you want within seconds. Here’s how I do it:
Step 1: Organize the articles into folders based on diseases as below:
Step 2: Do something about the stack of articles already piled on your floor!
From here, you usually only need to enter the year, volume, and page number to find the article you are looking for:
And this is what comes up:
Now simply download the pdf, then put it in the appropriate folder. Dropbox will sync it and take care of the rest. If accessing these articles requires you to be at your local hospital or university library to access the journals, just login to your Dropbox account on the web and upload the files from that computer.
Step 3: Access your articles:
If you’ve made it with me this far, accessing your files on your desktop/laptop should be fairly straightforward.
For mobile devices (iPhone/iPad and Android), the Dropbox app has a built in pdf reader that works extremely well.
For accessing pdf files on the iPad, I personally use GoodReader. This app gives you the option of downloading a copy of your Dropbox folders, so you have access to them at times when Wi-Fi is not available. It also allows you to annotate your pdfs (highlighting, etc.) for later reference.
Any other ways that you are using cloud computing as a physician? Please, let me know in the comments!
I’ll be speaking on the second day of the conference, from 11:10-11:55am on Recent Advances in Rheumatology for Primary Care Physicians.
After attending this talk, participants should: “Be able to apply recent updates in the diagnosis and treatment of common rheumatologic conditions, including rheumatoid arthritis, gout, and giant cell arteritis.”
I’ll also be helping with the 7:00am morning Joint Injection Skills Course: Elbow, Knee, Shoulder and Wrist, on September 23rd.
Click here or on the above link for registration or more information.