Telling You Where to Go (12.19.2025) Save
Transcription
It's December the 19th, 2025, and this is the RheumNow podcast. Hi, I'm Jack Cush with RheumNow when I reviewed this week's content. I was scratching my head saying, "Who'd have thunk it?" A relationship between FMF and psoriatic arthritis. Labs predicting who's going to get ILD if you have scleroderma. What IgA rheumatoid factor could be important or that recombinant zoster vaccines may not work in those on JAK inhibitors when they need it. What about if I just got upset by all this and I told you where you could go and that's where we're going to start. This is where you can go if you want to be a rheumatologist and want to practice somewhere. The top 10 states to practice rheumatology in are number one, North Dakota, number two, Wisconsin, three Alaska, four Montana, five South Dakota, six Nebraska, seven Minnesota, eight Washington, nine Utah, and 10 Maine. I can tell you that I have been banned from at least six of those states. Maybe that's why you should go there. Why those states? Well, this is a publication I found that was looking at salary potential, growth opportunities, supportive health care and public health infrastructure. Those are states where there's probably a good need for rheumatologists and hence the salaries are good and the lifestyles are good and plus if you go there, you won't see me in at least six of those states.
An interesting study this week comes out from Lilly. It's the phase three TRIUMPH 4 trial where they have a new GLP-1. It's a dual GIP GLP-1 glucagon receptor agonist — retatrutide — and this was given to people without diabetes who were obese who had knee osteoarthritis. This is a phase three trial. This is just a press release, but I put it up because I think it's really important. Weight loss at 68 weeks, a little more than a year, was 29% with a significant reduction by 76% in their WOMAC pain scores. So, we've hinted, and I first learned this from Joel Block about GLP-1s possibly being effective in osteoarthritis, and this is another study showing the same thing. So, there's a few studies out there. This is a new sort of next generation GLP-1 drug and I think you'll be hearing more about this next year which is right around the corner, is it not?
I found a nice review article about IgA rheumatoid factor and IgA ACPA. IgA RF seen in 50% of RA patients, IgA ACPA in 20 to 40% — they are just as specific as the other normal tests that we do. The interesting thing about this article is it points out a few reasons why this could be important. Number one, that you can find these — and others by the way, IgG, IgM — in serum, saliva, and synovial fluid; that at least the IgA and its importance with surface immunology may underlie the mucosal hypothesis of RA; and IgA RF has been seen in worse RA patients with more severe outcomes, more extraarticular manifestations, and a blunted TNF inhibitor response. I thought, gee, you know, I've kind of always not paid attention to this IgA literature because it just seems like another thing to do and you got to wait for it and whatnot. And there's people who are always saying, hey, but what about IgA rheumatoid factor, IgA ACPA? The bottom line is that the ability of IgA autoantibodies to identify RA in the cases of seronegative RA — meaning they're RF negative and traditional CCP or ACPA negative — it's limited; there's only a few patients. However, if you wanted to, you could go that far and detection would confirm the diagnosis or confirm a future risk of developing RA in those who may have preclinical presentations. It's a nice review of IgA autoantibodies and their role in RA. I still don't think I'm going to do it though. Maybe you can convince me.
The Lancet had a nice review of skin cancer basically asking the question, "Isn't it about time that we started doing skin exams?" I don't know about you — actually I do know about you. You're not doing skin exams like you're supposed to. Did you know that everyone on TNF inhibitors is supposed to get a skin exam periodically, annually? Look at the package insert. It says that. Why does it say that? Number one, RA patients are at higher risk for some cancers and lower risk for others. One of the cancers they're at higher risk for is skin cancer, non-melanoma skin cancer, and probably melanoma skin cancers. And then that association carries over to an association with some drugs. And when TNF inhibitors were being developed, they said you should do skin exams, you know, once every year and whatnot. This Lancet review basically points out the association between skin cancer and inflammatory arthritis. And it's a strong one, especially for the non-melanoma skin cancers, but also melanoma. It's increased in RA, PsA, and other forms of inflammation. So again, I'll remind you the package insert says that you should do it with TNF inhibitors. By the way, it doesn't say that with
IL-17 inhibitors. And what it does say is that skin exam should be done periodically. If someone's had a skin cancer and you're going to put them on a biologic, I would recommend that they see a dermatologist for complete skin exams annually. I don't know about you, I go to my skin doctor for annual, actually more than annual skin exams. And yeah, I got to get almost totally naked. And they're all over me with microscopes and all kinds of lamps. I'm on 3D. I'm UV light. It's just kind of a scary but fun kind of encounter. But I leave there with a lot of assurances that I'm okay and I'll come back whenever they tell me to.
An Austrian study of a thousand patients called the Paracelsus cohort. Actually, I looked up what Paracelsus was and now I forgot, but it's got a story behind it. You can look it up. Out of their thousand patients with RA, they analyzed the ones that they could include and they found from 9,665 patients that 3.1% of those people had RA. And then they looked to see — this is actually a study of laboratory tests in the population — and they showed that there was a higher CKD stage three CKD and worse in RA versus controls. RA patients had an almost 12% risk of CKD versus 6.7% in controls. The dominant finding was albuminuria was the major manifestation of renal disease. But again, I think that, you know, this has been brought up before that there may be a risk of CKD in RA patients. It's a low risk and aren't you already getting plenty of routine laboratory screenings, certainly creatinine. So it's something to keep in mind. And there are probably multiple etiologies that may underlie that.
A Japanese retrospective study did an important study that actually mirrors what the Swedes did a few years ago at ACR. There are 194 RA patients that are taking a JAK inhibitor. 74 of them were vaccinated against the recombinant zoster vaccine that we call Shingrix in the United States. It's RZV, recombinant zoster vaccine, is its initials. And compared to 120 JAK inhibitor RA patients who are not vaccinated. Yes, if you took the RZV, you had a lower risk of developing zoster going forward. 4.8 per 100 years versus 7.8. Actually, zoster vaccine rates are often reported per 1,000 patient years. So that's 48 on the RZV versus 78 per 1,000 that were not vaccinated. By the way, those are very very high in rheumatology terms. The average rate risk of all of us is less than 10 per 1,000 patient years; an inflammatory arthritis patient or an OA patient is like I don't know 14 to 17; a GPA patient on steroids and his cytotoxics might have 25 to 35; a patient on a JAK inhibitor could be as high as 45. These rates are high, but it may be in a more endemic region.
But here's the important point. Overall vaccine efficacy was 59%, meaning it wasn't as high as has been reported in the ZOE-50 and ZOE-70 studies for the zoster vaccine Shingrix, which was like greater than 90%. So the point is that if you're on a JAK inhibitor and you're going to take the zoster vaccine, it may not be 100% effective. Maybe you should stop the JAK inhibitor for two weeks or one week like you do methotrexate and then do the zoster vaccine. Again, that's not part of their study. They basically said that the predictive features for getting zoster was having a lower lymphocyte count, higher CRP, higher ESR. So, you know, they have more activity. Stopping the JAK inhibitor for one or two weeks could be a little risky, right? So, not a lot of clarity here, but I think I'm going to in the future probably hold the JAK inhibitor for a week and give the zoster vaccine and then resume it. Actually, I'm sorry, give the zoster vaccine. Yeah, hold it for a week, give the zoster vaccine, start it a week later or a few days later would be the way I'll go.
Interesting study on 177 patients with systemic sclerosis. 61 did not have ILD, 116 did have ILD. Those who had systemic sclerosis-related ILD had more diffuse disease, more Raynaud's, more GI disease. They found that you could predict the development of ILD in systemic sclerosis by having this triad: one, an elevated neutrophil-to-lymphocyte ratio — I'd assume that's greater than 4.0 — a prolonged prothrombin time, and the presence of an anti-SCL-70 antibody. The area under the curve here was almost 88%, sensitivity 83%, specificity 85%. Seems pretty easy, seems pretty cheap. If you have your patient with systemic sclerosis, look at the CBC, look at the neutrophil-to-lymphocyte ratio, order a PT, and you'll already know hopefully their status as far as SCL-70.
An Israeli retrospective cohort study looked at almost 10,000 patients with FMF and they matched them against controls. And what they found here was that patients that were on colchicine with FMF — actually it was a retrospective database that looked at people
on colchicine and they found that the FMF patients on colchicine had a higher risk of developing psoriatic arthritis. Wow. 43 versus 119 in those who had FMF on colchicine — hazard ratio 3.5-fold increased risk. Risk was increased by having — being older, being a smoker, and socioeconomic status, and we know that smoking and age and socioeconomic status are risk factors for psoriatic arthritis. If you looked at the patients who had FMF in the study, had a higher risk of psoriasis, had a higher risk of obesity, had a higher risk of metabolic disease like diabetes and hypertension. So I'm not sure that FMF and colchicine is the risk factor as much as being sick in that Israeli cohort of FMF patients where it's much more prevalent makes you at higher risk of developing psoriatic arthritis. But nonetheless, why not? Why not there be — and they did the exercise, you should consider it.
Another study in psoriasis was a small study called the MEDISPO study. This was a study of 38 patients, half of whom were given a Mediterranean diet for 16 weeks. The other half was given a low-fat diet, and at the end of 16 weeks the patients on the Mediterranean diet had a significant reduction in PASI scores — a minus 3.4 versus zero on the control diet — and almost half the patients, 47%, achieved PASI 75 response as opposed to none on the others. We know the importance of diet, especially in psoriasis, and we do also know the importance of the anti-inflammatory diet, the Mediterranean diet, in especially psoriasis but also even rheumatoid and other inflammatory conditions. So here's a good example again where diet leads to better outcomes in the underlying disorder, this case being psoriasis.
A few reports — you know, this month is a month devoted to nurse practitioners, physician assistants, advanced practice providers. A few reports on that that I thought were interesting. The nurse practitioner association did a survey of almost 2,400 nurse practitioners, mostly primary care, and asked about their interaction with rheumatology and rheumatology consult and rheumatologists. They basically said that there needs to be improvement in communication, and the nurse practitioners requested more education on RA management. When we asked them about their confidence — these nurse practitioners — their confidence in managing RA, only 47% said they were somewhat confident, 6% said they were very confident, 19% not too confident. The point is that if you're the consultant and you're communicating with a nurse practitioner, you need to educate them about the condition that you're asking their help with as well. I think this is important about how we actually communicate and deal with our consultants. It is not enough to make a diagnosis and a treatment plan. Somewhere in your note, somewhere in that process, you've got to teach them about what you know so they can also better help your patient.
Wolters Kluwer, a med company, did a survey of 203 physician assistants. Most of them said that they wish they had more clinical experience before they were released out into the world. And most of them wanted more training on AI. A lot of them said that they were using AI — 56% were using AI daily, 19% were using AI, artificial intelligence, extensively. Yet the majority of them, nine out of 10, said they need to learn more about AI. They desire more formal employer-led training on AI. And again, nine out of 10 said that AI is going to change the way they practice. But one-third said that there are no — at least one-third said that there are no clear guidelines on how AI should be used in their practice. Again, there's a tremendous need here. It's going to be used. If you're not adopting it, training on it, having dos and don'ts — I like to say things like, "Tell me five things I can't do. Tell me the guardrails where it doesn't work." One notorious guardrail with AI is: don't trust references provided by AI on any topic. Like, tell me everything about clinically amyopathic dermatomyositis, often associated with MDA5 antibodies, and give me seven references. If you go and check those references — at least on the earlier versions of ChatGPT and other forms — you're going to find some inaccuracies there, maybe some things that are made up. But AI is going to be used. We need to be guiding that.
An interesting article this week that's been presented at ACR and EULAR appears in Arthritis Care and Research, I believe — optimizing hydroxychloroquine blood levels in lupus patients. This was a study of 1,842 patients, amongst whom almost 5% had hydroxychloroquine ocular toxicity. And they showed that having ocular toxicity was associated with at least a two-fold higher rate of blood levels being greater than 1,150 nanograms per mL. And also the rate — the risk of ocular toxicity goes up with the
cumulative exposure of hydroxychloroquine being greater than 1,000 grams. So the idea here is that we should — I think everyone — and Don Thomas, a great rheumatologist very interested in lupus, said it's about time we start advocating for this and doing this. He's been doing it — I think he said since 2018 — and it clearly guides therapy, meaning you have to have blood levels definitely more than you know 500, but actually really more like 900, and you know whether you go up as high as 1150 as indicated by this article or whether you go as high as 1500 is sort of up to different publications, but at least you know 900 to 1150, and you can go higher, but clinical benefits may not be great after 1150 and toxicity risk may rise. Point is, are you doing it? And the point is, it's commercially available at LabCorp and most of the commercial labs that are out there, Quest, and probably at your site if you jump up and down and yell and scream about it.
Our last report — we have a few reports this week — this one was written by an AI in orthopedics, Jordan Lyons: five fractures you don't want to miss. It's a nice article. It's a quick read. It includes femoral neck fractures, which are often seen in the elderly, often due to low energy falls, and if you don't look for it you won't find it, and if you don't suspect it you won't look hard enough. A Jones fracture — I don't know what that is — it's a fracture of the fifth metatarsal at the metaphyseal-diaphyseal junction. And these are often related to inversion injuries and you need three views of the ankle to actually find that. And then scaphoid fractures. The scaphoid is really prone by its biology and vascular supply to fractures that often occur by falling on an outstretched hand. And you may see that, but you need again a three-view x-ray. And if you suspect it — because they have pain in the snuff box that's unrelenting and it's not found on x-ray — an MRI will prove the presence of a scaphoid fracture. The other two you're going to have to go to the article and read. One of them I can't pronounce. Maybe you should go and look at it.
RheumNow Live — it's coming in 2026, February 7th and 8th in Dallas, Texas. Go to RheumNow.live to register. It's filling up. We've got close to 300 people already registered. We're expecting about 500 total, both on-site and online. We hope that you'll be one of them.
It's the holiday season. We do hope that you're going to have a blessed and wonderful holiday with you and your family. It's all about love. It's all about friendship. It's all about good food. You can go off the Mediterranean diet for Christmas. Take care.
An interesting study this week comes out from Lilly. It's the phase three TRIUMPH 4 trial where they have a new GLP-1. It's a dual GIP GLP-1 glucagon receptor agonist — retatrutide — and this was given to people without diabetes who were obese who had knee osteoarthritis. This is a phase three trial. This is just a press release, but I put it up because I think it's really important. Weight loss at 68 weeks, a little more than a year, was 29% with a significant reduction by 76% in their WOMAC pain scores. So, we've hinted, and I first learned this from Joel Block about GLP-1s possibly being effective in osteoarthritis, and this is another study showing the same thing. So, there's a few studies out there. This is a new sort of next generation GLP-1 drug and I think you'll be hearing more about this next year which is right around the corner, is it not?
I found a nice review article about IgA rheumatoid factor and IgA ACPA. IgA RF seen in 50% of RA patients, IgA ACPA in 20 to 40% — they are just as specific as the other normal tests that we do. The interesting thing about this article is it points out a few reasons why this could be important. Number one, that you can find these — and others by the way, IgG, IgM — in serum, saliva, and synovial fluid; that at least the IgA and its importance with surface immunology may underlie the mucosal hypothesis of RA; and IgA RF has been seen in worse RA patients with more severe outcomes, more extraarticular manifestations, and a blunted TNF inhibitor response. I thought, gee, you know, I've kind of always not paid attention to this IgA literature because it just seems like another thing to do and you got to wait for it and whatnot. And there's people who are always saying, hey, but what about IgA rheumatoid factor, IgA ACPA? The bottom line is that the ability of IgA autoantibodies to identify RA in the cases of seronegative RA — meaning they're RF negative and traditional CCP or ACPA negative — it's limited; there's only a few patients. However, if you wanted to, you could go that far and detection would confirm the diagnosis or confirm a future risk of developing RA in those who may have preclinical presentations. It's a nice review of IgA autoantibodies and their role in RA. I still don't think I'm going to do it though. Maybe you can convince me.
The Lancet had a nice review of skin cancer basically asking the question, "Isn't it about time that we started doing skin exams?" I don't know about you — actually I do know about you. You're not doing skin exams like you're supposed to. Did you know that everyone on TNF inhibitors is supposed to get a skin exam periodically, annually? Look at the package insert. It says that. Why does it say that? Number one, RA patients are at higher risk for some cancers and lower risk for others. One of the cancers they're at higher risk for is skin cancer, non-melanoma skin cancer, and probably melanoma skin cancers. And then that association carries over to an association with some drugs. And when TNF inhibitors were being developed, they said you should do skin exams, you know, once every year and whatnot. This Lancet review basically points out the association between skin cancer and inflammatory arthritis. And it's a strong one, especially for the non-melanoma skin cancers, but also melanoma. It's increased in RA, PsA, and other forms of inflammation. So again, I'll remind you the package insert says that you should do it with TNF inhibitors. By the way, it doesn't say that with
IL-17 inhibitors. And what it does say is that skin exam should be done periodically. If someone's had a skin cancer and you're going to put them on a biologic, I would recommend that they see a dermatologist for complete skin exams annually. I don't know about you, I go to my skin doctor for annual, actually more than annual skin exams. And yeah, I got to get almost totally naked. And they're all over me with microscopes and all kinds of lamps. I'm on 3D. I'm UV light. It's just kind of a scary but fun kind of encounter. But I leave there with a lot of assurances that I'm okay and I'll come back whenever they tell me to.
An Austrian study of a thousand patients called the Paracelsus cohort. Actually, I looked up what Paracelsus was and now I forgot, but it's got a story behind it. You can look it up. Out of their thousand patients with RA, they analyzed the ones that they could include and they found from 9,665 patients that 3.1% of those people had RA. And then they looked to see — this is actually a study of laboratory tests in the population — and they showed that there was a higher CKD stage three CKD and worse in RA versus controls. RA patients had an almost 12% risk of CKD versus 6.7% in controls. The dominant finding was albuminuria was the major manifestation of renal disease. But again, I think that, you know, this has been brought up before that there may be a risk of CKD in RA patients. It's a low risk and aren't you already getting plenty of routine laboratory screenings, certainly creatinine. So it's something to keep in mind. And there are probably multiple etiologies that may underlie that.
A Japanese retrospective study did an important study that actually mirrors what the Swedes did a few years ago at ACR. There are 194 RA patients that are taking a JAK inhibitor. 74 of them were vaccinated against the recombinant zoster vaccine that we call Shingrix in the United States. It's RZV, recombinant zoster vaccine, is its initials. And compared to 120 JAK inhibitor RA patients who are not vaccinated. Yes, if you took the RZV, you had a lower risk of developing zoster going forward. 4.8 per 100 years versus 7.8. Actually, zoster vaccine rates are often reported per 1,000 patient years. So that's 48 on the RZV versus 78 per 1,000 that were not vaccinated. By the way, those are very very high in rheumatology terms. The average rate risk of all of us is less than 10 per 1,000 patient years; an inflammatory arthritis patient or an OA patient is like I don't know 14 to 17; a GPA patient on steroids and his cytotoxics might have 25 to 35; a patient on a JAK inhibitor could be as high as 45. These rates are high, but it may be in a more endemic region.
But here's the important point. Overall vaccine efficacy was 59%, meaning it wasn't as high as has been reported in the ZOE-50 and ZOE-70 studies for the zoster vaccine Shingrix, which was like greater than 90%. So the point is that if you're on a JAK inhibitor and you're going to take the zoster vaccine, it may not be 100% effective. Maybe you should stop the JAK inhibitor for two weeks or one week like you do methotrexate and then do the zoster vaccine. Again, that's not part of their study. They basically said that the predictive features for getting zoster was having a lower lymphocyte count, higher CRP, higher ESR. So, you know, they have more activity. Stopping the JAK inhibitor for one or two weeks could be a little risky, right? So, not a lot of clarity here, but I think I'm going to in the future probably hold the JAK inhibitor for a week and give the zoster vaccine and then resume it. Actually, I'm sorry, give the zoster vaccine. Yeah, hold it for a week, give the zoster vaccine, start it a week later or a few days later would be the way I'll go.
Interesting study on 177 patients with systemic sclerosis. 61 did not have ILD, 116 did have ILD. Those who had systemic sclerosis-related ILD had more diffuse disease, more Raynaud's, more GI disease. They found that you could predict the development of ILD in systemic sclerosis by having this triad: one, an elevated neutrophil-to-lymphocyte ratio — I'd assume that's greater than 4.0 — a prolonged prothrombin time, and the presence of an anti-SCL-70 antibody. The area under the curve here was almost 88%, sensitivity 83%, specificity 85%. Seems pretty easy, seems pretty cheap. If you have your patient with systemic sclerosis, look at the CBC, look at the neutrophil-to-lymphocyte ratio, order a PT, and you'll already know hopefully their status as far as SCL-70.
An Israeli retrospective cohort study looked at almost 10,000 patients with FMF and they matched them against controls. And what they found here was that patients that were on colchicine with FMF — actually it was a retrospective database that looked at people
on colchicine and they found that the FMF patients on colchicine had a higher risk of developing psoriatic arthritis. Wow. 43 versus 119 in those who had FMF on colchicine — hazard ratio 3.5-fold increased risk. Risk was increased by having — being older, being a smoker, and socioeconomic status, and we know that smoking and age and socioeconomic status are risk factors for psoriatic arthritis. If you looked at the patients who had FMF in the study, had a higher risk of psoriasis, had a higher risk of obesity, had a higher risk of metabolic disease like diabetes and hypertension. So I'm not sure that FMF and colchicine is the risk factor as much as being sick in that Israeli cohort of FMF patients where it's much more prevalent makes you at higher risk of developing psoriatic arthritis. But nonetheless, why not? Why not there be — and they did the exercise, you should consider it.
Another study in psoriasis was a small study called the MEDISPO study. This was a study of 38 patients, half of whom were given a Mediterranean diet for 16 weeks. The other half was given a low-fat diet, and at the end of 16 weeks the patients on the Mediterranean diet had a significant reduction in PASI scores — a minus 3.4 versus zero on the control diet — and almost half the patients, 47%, achieved PASI 75 response as opposed to none on the others. We know the importance of diet, especially in psoriasis, and we do also know the importance of the anti-inflammatory diet, the Mediterranean diet, in especially psoriasis but also even rheumatoid and other inflammatory conditions. So here's a good example again where diet leads to better outcomes in the underlying disorder, this case being psoriasis.
A few reports — you know, this month is a month devoted to nurse practitioners, physician assistants, advanced practice providers. A few reports on that that I thought were interesting. The nurse practitioner association did a survey of almost 2,400 nurse practitioners, mostly primary care, and asked about their interaction with rheumatology and rheumatology consult and rheumatologists. They basically said that there needs to be improvement in communication, and the nurse practitioners requested more education on RA management. When we asked them about their confidence — these nurse practitioners — their confidence in managing RA, only 47% said they were somewhat confident, 6% said they were very confident, 19% not too confident. The point is that if you're the consultant and you're communicating with a nurse practitioner, you need to educate them about the condition that you're asking their help with as well. I think this is important about how we actually communicate and deal with our consultants. It is not enough to make a diagnosis and a treatment plan. Somewhere in your note, somewhere in that process, you've got to teach them about what you know so they can also better help your patient.
Wolters Kluwer, a med company, did a survey of 203 physician assistants. Most of them said that they wish they had more clinical experience before they were released out into the world. And most of them wanted more training on AI. A lot of them said that they were using AI — 56% were using AI daily, 19% were using AI, artificial intelligence, extensively. Yet the majority of them, nine out of 10, said they need to learn more about AI. They desire more formal employer-led training on AI. And again, nine out of 10 said that AI is going to change the way they practice. But one-third said that there are no — at least one-third said that there are no clear guidelines on how AI should be used in their practice. Again, there's a tremendous need here. It's going to be used. If you're not adopting it, training on it, having dos and don'ts — I like to say things like, "Tell me five things I can't do. Tell me the guardrails where it doesn't work." One notorious guardrail with AI is: don't trust references provided by AI on any topic. Like, tell me everything about clinically amyopathic dermatomyositis, often associated with MDA5 antibodies, and give me seven references. If you go and check those references — at least on the earlier versions of ChatGPT and other forms — you're going to find some inaccuracies there, maybe some things that are made up. But AI is going to be used. We need to be guiding that.
An interesting article this week that's been presented at ACR and EULAR appears in Arthritis Care and Research, I believe — optimizing hydroxychloroquine blood levels in lupus patients. This was a study of 1,842 patients, amongst whom almost 5% had hydroxychloroquine ocular toxicity. And they showed that having ocular toxicity was associated with at least a two-fold higher rate of blood levels being greater than 1,150 nanograms per mL. And also the rate — the risk of ocular toxicity goes up with the
cumulative exposure of hydroxychloroquine being greater than 1,000 grams. So the idea here is that we should — I think everyone — and Don Thomas, a great rheumatologist very interested in lupus, said it's about time we start advocating for this and doing this. He's been doing it — I think he said since 2018 — and it clearly guides therapy, meaning you have to have blood levels definitely more than you know 500, but actually really more like 900, and you know whether you go up as high as 1150 as indicated by this article or whether you go as high as 1500 is sort of up to different publications, but at least you know 900 to 1150, and you can go higher, but clinical benefits may not be great after 1150 and toxicity risk may rise. Point is, are you doing it? And the point is, it's commercially available at LabCorp and most of the commercial labs that are out there, Quest, and probably at your site if you jump up and down and yell and scream about it.
Our last report — we have a few reports this week — this one was written by an AI in orthopedics, Jordan Lyons: five fractures you don't want to miss. It's a nice article. It's a quick read. It includes femoral neck fractures, which are often seen in the elderly, often due to low energy falls, and if you don't look for it you won't find it, and if you don't suspect it you won't look hard enough. A Jones fracture — I don't know what that is — it's a fracture of the fifth metatarsal at the metaphyseal-diaphyseal junction. And these are often related to inversion injuries and you need three views of the ankle to actually find that. And then scaphoid fractures. The scaphoid is really prone by its biology and vascular supply to fractures that often occur by falling on an outstretched hand. And you may see that, but you need again a three-view x-ray. And if you suspect it — because they have pain in the snuff box that's unrelenting and it's not found on x-ray — an MRI will prove the presence of a scaphoid fracture. The other two you're going to have to go to the article and read. One of them I can't pronounce. Maybe you should go and look at it.
RheumNow Live — it's coming in 2026, February 7th and 8th in Dallas, Texas. Go to RheumNow.live to register. It's filling up. We've got close to 300 people already registered. We're expecting about 500 total, both on-site and online. We hope that you'll be one of them.
It's the holiday season. We do hope that you're going to have a blessed and wonderful holiday with you and your family. It's all about love. It's all about friendship. It's all about good food. You can go off the Mediterranean diet for Christmas. Take care.
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