Turkey Tryptophan (11.28.2025) Save
Dr. Jack Cush reviews the news and reports from this past week on RheumNow.com, including reports on FDA resurrections, FM seasonal worsening, and do you fight switch or swap biologics in PsA TNFi nonresponders?
Transcription
It's the 11/28/2020. This is the RheumNow podcast. Hi, I'm Jack Cush with RheumNow. This week on the podcast: seasonal worsening of fibromyalgia and in psoriatic arthritis it's not responding. What do you do?
Do you fight, switch or swap? Let's begin with a national health survey that gives you some data about disability and arthritis in The United States. This is the 2023 NHIS survey, and they looked at adults in The United States between the ages of 18 and 64. And specifically they studied the number of people who have work limitations due to arthritis. Arthritis attributable work limitations.
What do you think the number is? You know, you know the numbers of arthritis in The United States, like, you know, fifty seven million, that sort of thing, most recent estimates. This number, I think, is an astronomical thirty eight point eight percent. And, oh, by the way, that's no different than it was four years ago. These numbers are even higher in certain subgroups.
Hispanics fifty percent, American Indians and Alaskan Native Americans fifty six percent, people disabled not surprising sixty two percent, but veterans fifty two percent. It's a long report, it's a good report. It really does say that what we do is a major, major part of health care delivery. And you know the numbers: at least twenty five percent of people present to outpatient medicine with a musculoskeletal complaint, at least fifty percent will, in the course of an outpatient visit, be found to have a musculoskeletal problem, and it is the number one cause of disability in The United States. Good news: Zantac is back!
Ranitidine was removed from the market. What year was that? It was like, 2019, I think I wrote about it on RheumNow. It was taken off of the market because of a contaminant, an impurity issue with NMDA. NMDA at the time was touted as being maybe carcinogenic.
You know, it's an uncommon food additive, it's an uncommon contaminant that was found. And then it's been studied really since 2019, it went back on the market because the manufacturers, and these are many generic manufacturers, have basically approved a reformulated version. And it was thought that NMDA was maybe posing a cancer risk, but also tended to change the, I guess, the durability of the drug or the pharmacokinetics of the drug as well. Anyway, it's back on the market. I don't if you're a big prescriber of Zantac and H2 blocker.
It was, like, you know, not too long ago, the number one anti acid drug in The United States before PPIs took over. I think it merits consideration again, and now you can add that to the other H2 blockers like Pepcid and others. This reminds me of many drugs that have taken us off the market. You know, there have been, most recently, Propoxyphene or Darvon, as being risky but not really effective. I think the most notable one, and since this is Turkey Week, I'm going bring up L tryptophan.
L tryptophan, during my fellowship, was a big drug that you would use to treat as an adjunctive agent in depression, but more importantly, because it drove serotonin levels, it was also good at sleep. And so it was a natural sort of sleep aid, if you would. Five hundred milligram tablets, know, you could take a few at night and it worked very well. Was taken off the market in 1989 because of reported cases of the eosinophil myalgia syndrome. And what happened was that it wasn't from the tryptophan, it was due to an impurity in the manufacture of tryptophan, and it actually went back on the market in 2005.
I must say I haven't used a lot of L tryptophan since, but I have more patients coming to me on it. I think it's a perfectly safe and reasonable natural product. I like Valerian Root as well as a sleep aid. I think melatonin's gigantic a waste of time. It doesn't work at sleep, it doesn't put people to sleep, it doesn't keep people to sleep.
It's good for time travelers, people going over time zones, and people who go back to the future like Michael J Fox did. Is good at that, but otherwise it's useless. But I think tryptophan and valerian root, I would endorse those. Anyway, for the right dose, look it up. I think someone should study this, again, because it was such a mainstay drug back in the late 80s.
Some gout reports that are interesting: colchicine, when used in gout, has been shown to, prevent the need for total joint arthroplasty. This is a study of over nearly thirty two thousand people starting colchicine, followed for almost five years, and they showed a hazard ratio of zero point eight eight, a twelve percent reduced risk of joint replacement, and a twenty three percent lower risk of joint replacement for hip and knee replacements. And I think these are significant, I mean, the point is that colchicine is good at preventing attacks and repeated attacks will get you more damage, and more damage will get you more surgery. So we know colchicine we talked about colchicine and its cardiovascular benefits it clearly has an articular benefit much more certainly even than cardiovascular. Interesting cardiac study looked at, an ECHO study of two hundred plus patients with hyperuricemia, half having gout, the other half having asymptomatic hyperuricemia, and they showed that when you compared gout patients to the asymptomatic hyperuricemics, gout patients had significantly worse diastolic dysfunction than did the hyperesaemic patients alone.
They also, patients with gout had lower ejection fractions, sixty percent versus sixty five percent, five percent better. The diastolic dysfunction was thirty one percent versus eleven percent gout versus hyperuricemia. So again, I think that this gives us a good reason to worry about cardiovascular disease in patients with uncontrolled inflammation, recurrent bouts of inflammation, and that's not good for you. And that is probably the inflammation, and maybe not the uric acid itself, that drives that cardiovascular risk. Nonetheless, I think this is a reminder that we probably need to do cardiovascular monitoring in our patients with gout, if not hyperuricemia.
A few studies on myositis: two thousand two hundred and eighty patients with either dermatomyositis and polymyositis looked at those who were treated with short term corticosteroids, less than three months, or long term corticosteroids, more than three months. And they showed that, compared to short term use, those that were on long term exposure of glucocorticoids had a significantly higher risk an eighty percent higher risk of heart failure. That was unsurprising to me. Not surprising: a doubling of the risk of osteoporosis, and a four fold higher risk of hospital admissions related to polymyositis or dermatomyositis, and obviously a significantly higher cost of care, all associated with longer term steroid use. I don't know about you, you know, we talk a lot about steroids, the hazards of steroids, we worry about it in lupus, where we use hydrosteroids or vasculitis.
I've seen more disasters in polymyositis, dermatomyositis, and I think it's because we often don't think of it as being as dangerous in that condition, when in fact it is. I've seen patients get avascular necrosis many of them with just four months of high dose steroids. It happens. And so we've got to worry about it in inflammatory myositis patients, as well as our others who we use high dose steroids in. Two reports on fibromyalgia an Italian fibromyalgia registry did a study.
Why they would do this? I don't know, but it's kind of brilliant. They studied two thousand six hundred and fourteen patients, and they looked at seasonal changes in pain using a number of different fibromyalgia tools and tools for widespread pain index, etc. And they found that using the fibromyalgia assessment tools and the WPI and FAS, they showed that autumn was associated with significant worsening of pain in fibromyalgia. That's autumn compared to summer and autumn compared to winter.
Now take all the other four season combinations: there's no differences in pain. It's year round pain, it's widespread pain, is it not? But why is it worse in autumn? Isn't that interesting? They pointed out that Crohn's patients and IBD patients have worse endoscopic scores in autumn compared to summer.
They pointed out that there are seasonal variations in acute phase reactants in some patients. I think the easy answer here is that you do better in summer because of there's more holidays, there's more activity because the weather is good, and that starts to then change during the fall. And maybe autumn is when things go to hell in a handbasket, as they say. I thought that was interesting. Another interesting study I wouldn't have thought I mean, we certainly know that if you're you have fibromyalgia patients in your clinical trial, it's going to ruin your data because it's going to skew pain scores, function scores, etc.
A lot of scores that we do: RAPID, CDAI, I do the GASS score, -twenty eight they're all going to be higher in patients with fibromyalgia. In this study of fifty eight patients, they did usual fibromyalgia indices, the FIQ, the symptom severity score, and they did the BASDAI. And they showed that when the BASDAI was abnormal and elevated at four points or higher, that was seen in ninety one percent of fibromyalgia patients and only thirteen percent of controls. BASDAI score associated or correlated with the pain, fatigue and stiffness in the FiQ, and also in the symptom severity scores, and those are all highly significant. Point being: one) Fibromyalgia will drive your index of disease activity up.
Two) It may not be a bad idea to actually use the five questions that you ask in the BASDAI that can be used in fibromyalgia as an outcome measure. Interesting. Psoriasis is in the news this week. The global burden of psoriasis increased from two thousand and I'm sorry, from 1990 to 2021, a thirty one year period. It went from like, I don't know, sixty to seventy per one fifty seven to sixty one per 1,000 persons, a 10% increase in that thirty year period.
So a slow, modest increase, but psoriasis is going up, and of course that may go up for a lot of reasons. We don't know the pathogenesis, we do know obesity is involved. Obesity has certainly gone up, a lot higher than that. The risk was highest in North America and Western Europe, and they did show interestingly that the peak incidence of psoriasis was ages 40 to 70, and the risk of psoriasis was highest with higher incomes. So medium to high incomes and high incomes had a much higher risk of developing psoriasis compared to low incomes.
It's really quite dramatic if you look at the graphs. Leahy Eater from Toronto published a really nice paper about the obesity inflammation axis in psoriatic disease, showing that obesity is, we know, associated with less remissions and poorer drug responses. The etiology of that is discussed in the paper, and possibly due to the pro inflammatory adipokines biomechanical stress, which is a big factor in psoriatic disease, meaning psoriatic disease is higher in people who have physical, blue collar employment. Biomechanical stresses, not just being obese, but added obesity certainly has to it. And then, a lot in the literature and a lot of discussion amongst the Maywins about gut dysbiosis.
So, all this of course is backed up by the data showing clearly in psoriasis, more so than any other disease, that weight loss will improve outcomes and improve response to therapy. Another psoriatic trial of what happens this is from Artie Cavanagh and colleagues when you're a first line non responder to a TNF inhibitor with psoriatic arthritis. Four fifty two patients were studied. About two thirds of them either cycled to another TNF cyclers or hundred a one third, 177, swapped to an IL-seventeen inhibitor. They showed that swapping was better than cycling.
And, like, so retention being a measure, retention at one year: seventy eight percent versus sixty eight percent if you swapped, you did better than if you cycled. At thirty six months, or three years, it was sixty percent versus forty percent favoring those who swapped. Treatment failure was predicted by cycling disease activity, year of treatment, having axial disease or mixed axial and peripheral involvement. Lastly, I like this report about PMR, and PMR can look like, can be misdiagnosed, and could actually be due to parvovirus B19, viral infection. Seventy seven patients referred to rheumatology for possible PMR, and it turned out that seven percent of them, or five of them, had PMR features, met PMR criteria: five out of five having bilateral shoulder and neck pain, prolonged AM stiffness, fever is high, acute phase reactance.
Interestingly, these people did not have lower girdle or hip pain. Interestingly, they were almost all male, and they were also younger. So when you have atypical they're too young, they're not over I mean, you've to be in my opinion you have to have be 70 or 80 to have PMR. If it's 60, I'm worried. If it's 50, I'm not making the diagnosis, although I have one in my career that was 51 and clearly had PMR.
Interestingly also, that in this cohort of few patients five total out of the seventy seven that they were not rheumatoid I'm sorry, none of them were rheumatoid factor or CCP positive. There was two reports this week that I posted about perioperative DMAR use in patients who were undergoing arthroplasty. One, a Korean study of 34 patients, half continued their therapy, half modified therapy, and they modified it in accordance with the twenty seventeen ACR and American hip American Association of Hip and Knee Orthopedic Surgeons, the guideline authored by Susan Goodman, an ACR guideline that says that you continue conventional DMARDs throughout surgery. You do not stop. This is the guideline.
And that if you're on a biologic, that you hold it for no less than two weeks, or you half the dose, right? So, that was the guideline. Let me see And again, the biologics that they used: they continue were methotrexate, sulfasalazine, hydroxychloroquine and leflunomide. The biologics that they altered for a short period they hold for one dosing cycle and they restarted within two weeks of surgery completion, provided there was no contraindication. That applied to golimab, adalimumab, etanercept, abatacep, infliximab and cerdulizumab largely TNF inhibitors with abatacep thrown in.
So, that worked. It also worked in another study from Japan, much larger number and it worked as far as at two years, the endpoints being surgery and orthopaedic scores were the same. No difference, right? Another retrospective study from Japan looked at nineteen fifty three RA patients, all older, a third of them, were in low disease activity state and twenty percent were in remission, and they found no differences between continuing or stopping the DMARR therapy as far as going during the perioperative period. No differences in wound healing, infection and mortality.
However, if you did discontinue the drug, they had more disease flare ups. These are the kind of things that we need to hear about, and you're going to hear about it at RoomNow Live, February. Susan Goodman is one of our featured speakers. Susan Goodman is on the faculty at Hospital for Special Surgery. She led this effort with the Orthopedic Association to define what we should do in the perioperative period, and that's exactly what she's going to talk about in her half hour address on Saturday morning, February seventh.
You can go to roomnow.live to register. I hope you'll be there. Also, if you haven't seen our replays of RoomNow Live 2025, we ran them in the last four weeks, they're on the website, they're on YouTube, you can see what happened as far as the sessions we had in 2025. You'll see those, you'll want to go to 2026. We had again replays of RA vasculitis psoriatic arthritis and the last one was on spondylitis.
So hope you enjoyed that. We'll see you next week. Go to roomnow.live to register.
Do you fight, switch or swap? Let's begin with a national health survey that gives you some data about disability and arthritis in The United States. This is the 2023 NHIS survey, and they looked at adults in The United States between the ages of 18 and 64. And specifically they studied the number of people who have work limitations due to arthritis. Arthritis attributable work limitations.
What do you think the number is? You know, you know the numbers of arthritis in The United States, like, you know, fifty seven million, that sort of thing, most recent estimates. This number, I think, is an astronomical thirty eight point eight percent. And, oh, by the way, that's no different than it was four years ago. These numbers are even higher in certain subgroups.
Hispanics fifty percent, American Indians and Alaskan Native Americans fifty six percent, people disabled not surprising sixty two percent, but veterans fifty two percent. It's a long report, it's a good report. It really does say that what we do is a major, major part of health care delivery. And you know the numbers: at least twenty five percent of people present to outpatient medicine with a musculoskeletal complaint, at least fifty percent will, in the course of an outpatient visit, be found to have a musculoskeletal problem, and it is the number one cause of disability in The United States. Good news: Zantac is back!
Ranitidine was removed from the market. What year was that? It was like, 2019, I think I wrote about it on RheumNow. It was taken off of the market because of a contaminant, an impurity issue with NMDA. NMDA at the time was touted as being maybe carcinogenic.
You know, it's an uncommon food additive, it's an uncommon contaminant that was found. And then it's been studied really since 2019, it went back on the market because the manufacturers, and these are many generic manufacturers, have basically approved a reformulated version. And it was thought that NMDA was maybe posing a cancer risk, but also tended to change the, I guess, the durability of the drug or the pharmacokinetics of the drug as well. Anyway, it's back on the market. I don't if you're a big prescriber of Zantac and H2 blocker.
It was, like, you know, not too long ago, the number one anti acid drug in The United States before PPIs took over. I think it merits consideration again, and now you can add that to the other H2 blockers like Pepcid and others. This reminds me of many drugs that have taken us off the market. You know, there have been, most recently, Propoxyphene or Darvon, as being risky but not really effective. I think the most notable one, and since this is Turkey Week, I'm going bring up L tryptophan.
L tryptophan, during my fellowship, was a big drug that you would use to treat as an adjunctive agent in depression, but more importantly, because it drove serotonin levels, it was also good at sleep. And so it was a natural sort of sleep aid, if you would. Five hundred milligram tablets, know, you could take a few at night and it worked very well. Was taken off the market in 1989 because of reported cases of the eosinophil myalgia syndrome. And what happened was that it wasn't from the tryptophan, it was due to an impurity in the manufacture of tryptophan, and it actually went back on the market in 2005.
I must say I haven't used a lot of L tryptophan since, but I have more patients coming to me on it. I think it's a perfectly safe and reasonable natural product. I like Valerian Root as well as a sleep aid. I think melatonin's gigantic a waste of time. It doesn't work at sleep, it doesn't put people to sleep, it doesn't keep people to sleep.
It's good for time travelers, people going over time zones, and people who go back to the future like Michael J Fox did. Is good at that, but otherwise it's useless. But I think tryptophan and valerian root, I would endorse those. Anyway, for the right dose, look it up. I think someone should study this, again, because it was such a mainstay drug back in the late 80s.
Some gout reports that are interesting: colchicine, when used in gout, has been shown to, prevent the need for total joint arthroplasty. This is a study of over nearly thirty two thousand people starting colchicine, followed for almost five years, and they showed a hazard ratio of zero point eight eight, a twelve percent reduced risk of joint replacement, and a twenty three percent lower risk of joint replacement for hip and knee replacements. And I think these are significant, I mean, the point is that colchicine is good at preventing attacks and repeated attacks will get you more damage, and more damage will get you more surgery. So we know colchicine we talked about colchicine and its cardiovascular benefits it clearly has an articular benefit much more certainly even than cardiovascular. Interesting cardiac study looked at, an ECHO study of two hundred plus patients with hyperuricemia, half having gout, the other half having asymptomatic hyperuricemia, and they showed that when you compared gout patients to the asymptomatic hyperuricemics, gout patients had significantly worse diastolic dysfunction than did the hyperesaemic patients alone.
They also, patients with gout had lower ejection fractions, sixty percent versus sixty five percent, five percent better. The diastolic dysfunction was thirty one percent versus eleven percent gout versus hyperuricemia. So again, I think that this gives us a good reason to worry about cardiovascular disease in patients with uncontrolled inflammation, recurrent bouts of inflammation, and that's not good for you. And that is probably the inflammation, and maybe not the uric acid itself, that drives that cardiovascular risk. Nonetheless, I think this is a reminder that we probably need to do cardiovascular monitoring in our patients with gout, if not hyperuricemia.
A few studies on myositis: two thousand two hundred and eighty patients with either dermatomyositis and polymyositis looked at those who were treated with short term corticosteroids, less than three months, or long term corticosteroids, more than three months. And they showed that, compared to short term use, those that were on long term exposure of glucocorticoids had a significantly higher risk an eighty percent higher risk of heart failure. That was unsurprising to me. Not surprising: a doubling of the risk of osteoporosis, and a four fold higher risk of hospital admissions related to polymyositis or dermatomyositis, and obviously a significantly higher cost of care, all associated with longer term steroid use. I don't know about you, you know, we talk a lot about steroids, the hazards of steroids, we worry about it in lupus, where we use hydrosteroids or vasculitis.
I've seen more disasters in polymyositis, dermatomyositis, and I think it's because we often don't think of it as being as dangerous in that condition, when in fact it is. I've seen patients get avascular necrosis many of them with just four months of high dose steroids. It happens. And so we've got to worry about it in inflammatory myositis patients, as well as our others who we use high dose steroids in. Two reports on fibromyalgia an Italian fibromyalgia registry did a study.
Why they would do this? I don't know, but it's kind of brilliant. They studied two thousand six hundred and fourteen patients, and they looked at seasonal changes in pain using a number of different fibromyalgia tools and tools for widespread pain index, etc. And they found that using the fibromyalgia assessment tools and the WPI and FAS, they showed that autumn was associated with significant worsening of pain in fibromyalgia. That's autumn compared to summer and autumn compared to winter.
Now take all the other four season combinations: there's no differences in pain. It's year round pain, it's widespread pain, is it not? But why is it worse in autumn? Isn't that interesting? They pointed out that Crohn's patients and IBD patients have worse endoscopic scores in autumn compared to summer.
They pointed out that there are seasonal variations in acute phase reactants in some patients. I think the easy answer here is that you do better in summer because of there's more holidays, there's more activity because the weather is good, and that starts to then change during the fall. And maybe autumn is when things go to hell in a handbasket, as they say. I thought that was interesting. Another interesting study I wouldn't have thought I mean, we certainly know that if you're you have fibromyalgia patients in your clinical trial, it's going to ruin your data because it's going to skew pain scores, function scores, etc.
A lot of scores that we do: RAPID, CDAI, I do the GASS score, -twenty eight they're all going to be higher in patients with fibromyalgia. In this study of fifty eight patients, they did usual fibromyalgia indices, the FIQ, the symptom severity score, and they did the BASDAI. And they showed that when the BASDAI was abnormal and elevated at four points or higher, that was seen in ninety one percent of fibromyalgia patients and only thirteen percent of controls. BASDAI score associated or correlated with the pain, fatigue and stiffness in the FiQ, and also in the symptom severity scores, and those are all highly significant. Point being: one) Fibromyalgia will drive your index of disease activity up.
Two) It may not be a bad idea to actually use the five questions that you ask in the BASDAI that can be used in fibromyalgia as an outcome measure. Interesting. Psoriasis is in the news this week. The global burden of psoriasis increased from two thousand and I'm sorry, from 1990 to 2021, a thirty one year period. It went from like, I don't know, sixty to seventy per one fifty seven to sixty one per 1,000 persons, a 10% increase in that thirty year period.
So a slow, modest increase, but psoriasis is going up, and of course that may go up for a lot of reasons. We don't know the pathogenesis, we do know obesity is involved. Obesity has certainly gone up, a lot higher than that. The risk was highest in North America and Western Europe, and they did show interestingly that the peak incidence of psoriasis was ages 40 to 70, and the risk of psoriasis was highest with higher incomes. So medium to high incomes and high incomes had a much higher risk of developing psoriasis compared to low incomes.
It's really quite dramatic if you look at the graphs. Leahy Eater from Toronto published a really nice paper about the obesity inflammation axis in psoriatic disease, showing that obesity is, we know, associated with less remissions and poorer drug responses. The etiology of that is discussed in the paper, and possibly due to the pro inflammatory adipokines biomechanical stress, which is a big factor in psoriatic disease, meaning psoriatic disease is higher in people who have physical, blue collar employment. Biomechanical stresses, not just being obese, but added obesity certainly has to it. And then, a lot in the literature and a lot of discussion amongst the Maywins about gut dysbiosis.
So, all this of course is backed up by the data showing clearly in psoriasis, more so than any other disease, that weight loss will improve outcomes and improve response to therapy. Another psoriatic trial of what happens this is from Artie Cavanagh and colleagues when you're a first line non responder to a TNF inhibitor with psoriatic arthritis. Four fifty two patients were studied. About two thirds of them either cycled to another TNF cyclers or hundred a one third, 177, swapped to an IL-seventeen inhibitor. They showed that swapping was better than cycling.
And, like, so retention being a measure, retention at one year: seventy eight percent versus sixty eight percent if you swapped, you did better than if you cycled. At thirty six months, or three years, it was sixty percent versus forty percent favoring those who swapped. Treatment failure was predicted by cycling disease activity, year of treatment, having axial disease or mixed axial and peripheral involvement. Lastly, I like this report about PMR, and PMR can look like, can be misdiagnosed, and could actually be due to parvovirus B19, viral infection. Seventy seven patients referred to rheumatology for possible PMR, and it turned out that seven percent of them, or five of them, had PMR features, met PMR criteria: five out of five having bilateral shoulder and neck pain, prolonged AM stiffness, fever is high, acute phase reactance.
Interestingly, these people did not have lower girdle or hip pain. Interestingly, they were almost all male, and they were also younger. So when you have atypical they're too young, they're not over I mean, you've to be in my opinion you have to have be 70 or 80 to have PMR. If it's 60, I'm worried. If it's 50, I'm not making the diagnosis, although I have one in my career that was 51 and clearly had PMR.
Interestingly also, that in this cohort of few patients five total out of the seventy seven that they were not rheumatoid I'm sorry, none of them were rheumatoid factor or CCP positive. There was two reports this week that I posted about perioperative DMAR use in patients who were undergoing arthroplasty. One, a Korean study of 34 patients, half continued their therapy, half modified therapy, and they modified it in accordance with the twenty seventeen ACR and American hip American Association of Hip and Knee Orthopedic Surgeons, the guideline authored by Susan Goodman, an ACR guideline that says that you continue conventional DMARDs throughout surgery. You do not stop. This is the guideline.
And that if you're on a biologic, that you hold it for no less than two weeks, or you half the dose, right? So, that was the guideline. Let me see And again, the biologics that they used: they continue were methotrexate, sulfasalazine, hydroxychloroquine and leflunomide. The biologics that they altered for a short period they hold for one dosing cycle and they restarted within two weeks of surgery completion, provided there was no contraindication. That applied to golimab, adalimumab, etanercept, abatacep, infliximab and cerdulizumab largely TNF inhibitors with abatacep thrown in.
So, that worked. It also worked in another study from Japan, much larger number and it worked as far as at two years, the endpoints being surgery and orthopaedic scores were the same. No difference, right? Another retrospective study from Japan looked at nineteen fifty three RA patients, all older, a third of them, were in low disease activity state and twenty percent were in remission, and they found no differences between continuing or stopping the DMARR therapy as far as going during the perioperative period. No differences in wound healing, infection and mortality.
However, if you did discontinue the drug, they had more disease flare ups. These are the kind of things that we need to hear about, and you're going to hear about it at RoomNow Live, February. Susan Goodman is one of our featured speakers. Susan Goodman is on the faculty at Hospital for Special Surgery. She led this effort with the Orthopedic Association to define what we should do in the perioperative period, and that's exactly what she's going to talk about in her half hour address on Saturday morning, February seventh.
You can go to roomnow.live to register. I hope you'll be there. Also, if you haven't seen our replays of RoomNow Live 2025, we ran them in the last four weeks, they're on the website, they're on YouTube, you can see what happened as far as the sessions we had in 2025. You'll see those, you'll want to go to 2026. We had again replays of RA vasculitis psoriatic arthritis and the last one was on spondylitis.
So hope you enjoyed that. We'll see you next week. Go to roomnow.live to register.
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