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Hao Y, Oon S, Nikpour M. Efficacy and safety of treat-to-target strategy studies in rheumatic diseases: A systematic review and meta-analysis. Semin Arthritis Rheum 2024; 67:152465. [PMID: 38796922 DOI: 10.1016/j.semarthrit.2024.152465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND The concept of treat-to-target (T2T), a treatment strategy in which treatment is directed to reach and maintain a defined goal such as remission or low disease activity (LDA), has been explored for several diseases including rheumatic diseases such as rheumatoid arthritis (RA). However, a comprehensive review of T2T in all rheumatic diseases has not recently been undertaken. OBJECTIVE To perform a systematic review and meta-analysis of the efficacy and safety of a T2T strategy in the management of adult patients with inflammatory rheumatic diseases. METHODS PUBMED, EMBASE and CINAHL were searched from January 1990 to December 2023 using key words related to a T2T strategy and rheumatic diseases; T2T strategy clinical trials or observational studies were included. Clinical, physical function and radiologic outcomes, cost-effectiveness, and adverse events (AEs) of the T2T strategies were investigated and a random-effect meta-analysis was conducted for the most commonly used outcomes in RA studies. RESULTS The search identified 7896 studies, of which 66 fit inclusion criteria, including 50 in RA, 3 in psoriatic arthritis (PsA), 1 in spondyloarthritis (SpA) and 12 in gout. For the studies comparing a T2T strategy with usual care (UC) in RA, 83.3% (20/24) showed a T2T strategy could achieve significantly better clinical outcomes, and the meta-analysis showed that patients treated with a T2T strategy were more likely to be in remission (pooled RR: 1.68 (1.47-1.92), p<0.001] and achieve DAS-28 response (pooled standardised mean difference (SMD): 0.47 (0.26-0.69), P<0.001] at 1 year than patients treated with UC. Sensitivity analyses showed that a T2T strategy with a predefined treatment protocol had better clinical efficacy than that without protocol. In terms of improving physical function and health-related quality of life (HRQoL), 11/19 (57.9%) studies found a T2T strategy was significantly more likely to achieve these than UC, with the meta-analysis for the mean change of HAQ score supporting this conclusion (pooled SMD: 1.48 (0.46-2.51), p=0.004). Five out of 9 studies (55.6%) demonstrated greater benefit regarding radiographic progression from a T2T strategy. In terms of cost-effectiveness and AEs, 2/2 studies found a T2T strategy was more cost-effective than UC and 8/8 studies showed no tendency for AEs to occur more often with a T2T strategy. For the studies in PsA and SpA, a T2T strategy was also demonstrated to be more effective than UC in clinical and functional benefits, but not in radiologic outcomes. All gout studies showed that sUA level could be controlled more effectively with a T2T strategy, and 2 studies revealed that the T2T strategy could inhibit erosion development or crystal deposition. CONCLUSIONS For patients with active RA, a T2T strategy has been shown in mulitple studies to increase the likelihood of achieving clinical response and improving HRQoL without increasing economic costs and AEs. Limited studies have shown clinical and functional benefits from T2T strategies in active PsA and SpA. A T2T strategy has also been found to improve clinical and radiologic outcomes in gout. T2T trials in other rheumatic diseases are lacking.
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Affiliation(s)
- Yanjie Hao
- The University of Melbourne at St Vincent's Hospital, 29 Regent Street, Fitzroy, VIC 3065, Australia
| | - Shereen Oon
- The University of Melbourne at St Vincent's Hospital, 29 Regent Street, Fitzroy, VIC 3065, Australia; Department of Rheumatology, St. Vincent's Hospital Melbourne, 35 Victoria Parade, Fitzroy, VIC 3065, Australia.
| | - Mandana Nikpour
- The University of Melbourne at St Vincent's Hospital, 29 Regent Street, Fitzroy, VIC 3065, Australia; Department of Rheumatology, St. Vincent's Hospital Melbourne, 35 Victoria Parade, Fitzroy, VIC 3065, Australia; Sydney MSK Research Flagship Centre, The University of Sydney School of Public Health, Room 132, Edward Ford Building, Fisher Road, University of Sydney, NSW 2006, Australia; Royal Prince Alfred Hospital Institute of Rheumatology and Orthopedics, 59 Missenden Rd, Camperdown NSW 2050, Australia.
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Richette P, Dalbeth N. Treat-to-target or treat-to-dissolve strategy to improve gout treatment. Nat Rev Rheumatol 2024; 20:393-394. [PMID: 38671197 DOI: 10.1038/s41584-024-01117-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Affiliation(s)
- Pascal Richette
- Department of Rheumatology, INSERM U1132, Lariboisière Hospital, Université Paris-Cité, Paris, France.
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand
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Peral-Garrido ML, Gómez-Sabater S, Caño R, Bermúdez-García A, Lozano T, Sánchez-Ortiga R, Perdiguero M, Caro-Martínez E, Ruiz-García C, Francés R, Pascual E, Andrés M. Prevalence of crystal deposits in asymptomatic hyperuricemia according to different scanning definitions: A comparative study. Semin Arthritis Rheum 2024; 68:152470. [PMID: 38924926 DOI: 10.1016/j.semarthrit.2024.152470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/24/2024] [Accepted: 05/16/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND/AIM The appropriate sonographic protocol for assessing urate crystal deposits in asymptomatic hyperuricemia (AH) is undefined, as well as how the choice would impact on deposit rates and accompanying sonographic, clinical and laboratory features. METHODS Patients with AH (serum urate ≥7 mg/dL) underwent musculoskeletal ultrasound of 10 locations for OMERACT elementary gout lesions (double contour [DC] signs, tophi, aggregates). Different definitions for AH with deposits were applied, varying according to deposits (any deposits; only DC and/or tophi); gradation (any grade; only grade 2-3 deposits), location (10 locations; 4-joint scheme including knees and 1MTPs; >1 location with deposits), or pre-defined definitions (DC sign in femoral condyles/1MTP and/or tophi in 1MTP). We evaluated crystal deposits rates and compared between other sonographic features, clinical and laboratory variables. RESULTS Seventy-seven participants with AH showed a median 1 location (IQR 0-2) with tophi, 1 (IQR 1-2) with aggregates, and 0 locations (IQR 0-1) with DC sign. The deposition rate ranged from 23.4% (in >1 location with grade 2-3 DC or tophi) to 87.0% (in any deposit in all 10 locations). Accompanying inflammation - assessed by a positive power-Doppler (PD) signal - and erosions were found in 19.5% and 28.4% of participants, respectively. Positive PD signal was better discriminated by criteria requiring grade 2-3 or >1 location with lesions. Erosions and the different clinical and laboratory variables were similar among protocols. CONCLUSION Rates of sonographic deposition in AH varied dramatically among studied protocols, while some could discriminate accompanying inflammation, all highlighting the need for a validated, consensus-based definition.
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Affiliation(s)
- María-Luisa Peral-Garrido
- Vinalopó University Hospital, Elche, Spain; University Miguel Hernández de Elche (UMH), Alicante, Spain
| | - Silvia Gómez-Sabater
- University Miguel Hernández de Elche (UMH), Alicante, Spain; Rheumatology Section, Dr. Balmis General University Hospital, Alicante, Spain
| | - Rocío Caño
- University Miguel Hernández de Elche (UMH), Alicante, Spain; Rheumatology Section, Dr. Balmis General University Hospital, Alicante, Spain
| | - Alejandra Bermúdez-García
- University Miguel Hernández de Elche (UMH), Alicante, Spain; Rheumatology Section, Dr. Balmis General University Hospital, Alicante, Spain
| | - Teresa Lozano
- Rheumatology Section, Dr. Balmis General University Hospital, Alicante, Spain; Cardiology Service, Dr. Balmis General University Hospital, Alicante, Spain
| | - Ruth Sánchez-Ortiga
- Rheumatology Section, Dr. Balmis General University Hospital, Alicante, Spain; Endocrinology and Nutrition Service, Dr. Balmis General University Hospital, Alicante, Spain
| | - Miguel Perdiguero
- Rheumatology Section, Dr. Balmis General University Hospital, Alicante, Spain; Nephrology Service, Dr. Balmis General University Hospital, Alicante, Spain
| | - Elena Caro-Martínez
- Internal Medicine Service, Sant Vicent del Raspeig Hospital-HACLE, San Vicente del Raspeig, Spain
| | | | - Rubén Francés
- University Miguel Hernández de Elche (UMH), Alicante, Spain; Rheumatology Section, Dr. Balmis General University Hospital, Alicante, Spain; Biomedical Research Network Center for Hepatic and Digestive Diseases (CIBEREHD), Spain
| | - Eliseo Pascual
- University Miguel Hernández de Elche (UMH), Alicante, Spain; Alicante Healthcare and Biomedical Research Institute (ISABIAL), Alicante, Spain
| | - Mariano Andrés
- University Miguel Hernández de Elche (UMH), Alicante, Spain; Rheumatology Section, Dr. Balmis General University Hospital, Alicante, Spain; Alicante Healthcare and Biomedical Research Institute (ISABIAL), Alicante, Spain.
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Mandl P, D'Agostino MA, Navarro-Compán V, Geßl I, Sakellariou G, Abhishek A, Becce F, Dalbeth N, Ea HK, Filippucci E, Hammer HB, Iagnocco A, de Thurah A, Naredo E, Ottaviani S, Pascart T, Pérez-Ruiz F, Pitsillidou IA, Proft F, Rech J, Schmidt WA, Sconfienza LM, Terslev L, Wildner B, Zufferey P, Filippou G. 2023 EULAR recommendations on imaging in diagnosis and management of crystal-induced arthropathies in clinical practice. Ann Rheum Dis 2024; 83:752-759. [PMID: 38320811 PMCID: PMC11103298 DOI: 10.1136/ard-2023-224771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 01/30/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVE To formulate evidence-based recommendations and overarching principles on the use of imaging in the clinical management of crystal-induced arthropathies (CiAs). METHODS An international task force of 25 rheumatologists, radiologists, methodologists, healthcare professionals and patient research partners from 11 countries was formed according to the EULAR standard operating procedures. Fourteen key questions on the role of imaging in the most common forms of CiA were generated. The CiA assessed included gout, calcium pyrophosphate deposition disease and basic calcium phosphate deposition disease. Imaging modalities included conventional radiography, ultrasound, CT and MRI. Experts applied research evidence obtained from four systematic literature reviews using MEDLINE, EMBASE and CENTRAL. Task force members provided level of agreement (LoA) anonymously by using a Numerical Rating Scale from 0 to 10. RESULTS Five overarching principles and 10 recommendations were developed encompassing the role of imaging in various aspects of patient management: making a diagnosis of CiA, monitoring inflammation and damage, predicting outcome, response to treatment, guided interventions and patient education. Overall, the LoA for the recommendations was high (8.46-9.92). CONCLUSIONS These are the first recommendations that encompass the major forms of CiA and guide the use of common imaging modalities in this disease group in clinical practice.
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Affiliation(s)
- Peter Mandl
- Division of Rheumatology, Department of Internal Medicine 3, Medical University of Vienna, Wien, Austria
| | - Maria Antonietta D'Agostino
- Rheumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Irina Geßl
- Department of Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Garifallia Sakellariou
- Istituti Clinici Scientifici Maugeri SpA SB IRCCS, Pavia, Italy
- Università degli Studi di Pavia, Pavia, Italy
| | | | - Fabio Becce
- Department of Medical Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | | | | | - Emilio Filippucci
- Rheumatology Unit-Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Jesi, Italy
| | - Hilde Berner Hammer
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
- University of Oslo Faculty of Medicine, Oslo, Norway
| | - Annamaria Iagnocco
- Scienze Cliniche e Biologiche, Università degli Studi di Torino, Turin, Italy
| | - Annette de Thurah
- Rheumatology, Aarhus University Hospital, Aarhus N, Denmark
- Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Esperanza Naredo
- Department of Rheumatology and Bone and Joint Research Unit, Hospital Universitario Fundación Jiménez Díaz, IIS Fundación Jiménez Díaz, Madrid, Spain
| | | | - Tristan Pascart
- Department of Rheumatology, Lille Catholic University, Saint-Philibert Hospital, Lomme, France
| | - Fernando Pérez-Ruiz
- Rheumatology Department, Osakidetza, Ezkerraldea-Enkarterri-Cruces, Cruces University Hospital, Biocruces-Bizkaia Health Research Institute and University of the Basque Country, Basque Country, Spain
| | - Irene A Pitsillidou
- EULAR Patient Research Partner, Cyprus League Against Rheumatism, Nicosia, Cyprus
| | - Fabian Proft
- Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Juergen Rech
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie (DZI), Friedrich Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | | | - Luca Maria Sconfienza
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Lene Terslev
- Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Copenhagen University, Copenhagen, Denmark
| | | | - Pascal Zufferey
- Rheumatology, University of Lausanne, CHUV, Lausanne, Switzerland
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Gessl I, Sakellariou G, Wildner B, Filippou G, Mandl P, D'Agostino MA, Navarro-Compán V. Systematic literature review to inform the EULAR recommendations for the use of imaging in crystal-induced arthropathies in clinical practice. Ann Rheum Dis 2024:ard-2023-225247. [PMID: 38702175 DOI: 10.1136/ard-2023-225247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 04/02/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVE To summarise current data regarding the use of imaging in crystal-induced arthropathies (CiAs) informing a European Alliance of Associations for Rheumatology task force. METHODS We performed four systematic searches in Embase, Medline and Central on imaging for diagnosis, monitoring, prediction of disease severity/treatment response, guiding procedures and patient education in gout, calcium pyrophosphate dihydrate deposition (CPPD) and basic calcium phosphate deposition (BCPD). Records were screened, manuscripts reviewed and data of the included studies extracted. The risk of bias was assessed by validated instruments. RESULTS For gout, 88 studies were included. Diagnostic studies reported good to excellent sensitivity and specificity of dual-energy CT (DECT) and ultrasound (US), high specificity and lower sensitivity for conventional radiographs (CR) and CT. Longitudinal studies demonstrated sensitivity to change with regard to crystal deposition by US and DECT and inflammation by US and structural progression by CR and CT. For CPPD, 50 studies were included. Diagnostic studies on CR and US showed high specificity and variable sensitivity. There was a single study on monitoring, while nine assessed the prediction in CPPD. For BCPD, 56 studies were included. There were two diagnostic studies, while monitoring by CR and US was assessed in 43 studies, showing a reduction in crystal deposition. A total of 12 studies with inconsistent results assessed the prediction of treatment response. The search on patient education retrieved two studies, suggesting a potential role of DECT. CONCLUSION This SLR confirmed a relevant and increasing role of imaging in the field of CiAs.
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Affiliation(s)
- Irina Gessl
- Division of Rheumatology, Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Garifallia Sakellariou
- Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy
- Istituti Clinici Scientifici Maugeri SpA SB IRCCS, Pavia, Italy
| | | | - Georgios Filippou
- Rheumatology, IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Peter Mandl
- Division of Rheumatology, Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Maria Antonietta D'Agostino
- Rheumatology Department, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, IRCSS, Rome, Italy
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Yang S, Lin X, Gao Y, Liang N, Han Y, Sun H, Qu S, Chen H. The association between gout flares and monosodium urate burden assessed using musculoskeletal ultrasound in patients with gout. Ther Adv Musculoskelet Dis 2024; 16:1759720X241240837. [PMID: 38559313 PMCID: PMC10981851 DOI: 10.1177/1759720x241240837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
Background Ultrasound (US) has a high sensitivity in detecting monosodium urate (MSU) deposition in gout patients. However, the value of US in predicting gout flares has been reported only in a few monocentric studies. Objective To investigate the association between gout flares in the previous year and US-detected MSU burden using two different US scores. Design A retrospective study. Methods Patients with gout were consecutively recruited to undergo musculoskeletal US examinations of their knees, ankles, and feet. The score derived from Outcome Measure in Rheumatology (hereinafter referred to as MSU score) and musculoskeletal US features-based (hereinafter referred to as MSKF score) were used to quantify the MSU burden of gout. Odds ratios for frequent gout flares were calculated. Results We enrolled 1894 patients with gout (mean age: 45 years; gout duration: 5 years; males: 96.1%), experiencing a median of three flares over the past year. Of these, 428 (22.6%) patients reported frequent (⩾7) gout flares. The MSU and MSKF median scores were 6 and 9, respectively. For each five-point increase in MSU and MSKF score, the odds ratio of frequent gout flares increased 1.13-fold and 1.24-fold, respectively. The area under the curve (AUC) for the MSU and MSKF score was 0.635 [95% confidence interval (CI): 0.604-0.665] and 0.688 (95% CI: 0.659-0.718), respectively, (AUC difference 0.054, p value for AUC difference < 0.001). Conclusion The MSU and MSKF scores were significantly associated with the number of gout flares in the previous year. The MSKF score outperformed the MSU score in terms of frequent gout flare discrimination.
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Affiliation(s)
- Shaoling Yang
- Department of Endocrinology and Metabolism, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xiaojing Lin
- Department of Endocrinology and Metabolism, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yining Gao
- Department of Endocrinology and Metabolism, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Nan Liang
- Department of Endocrinology and Metabolism, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Yali Han
- Department of Endocrinology and Metabolism, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hang Sun
- Department of Endocrinology and Metabolism, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shen Qu
- Department of Endocrinology and Metabolism, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, No. 301 Yanchang Middle Road, Shanghai 200072, China
| | - Haibing Chen
- Department of Endocrinology and Metabolism, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, No. 301 Yanchang Middle Road, Shanghai 200072, China
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Sanchez C, Campeau A, Liu-Bryan R, Mikuls T, O'Dell J, Gonzalez D, Terkeltaub R. Sustained xanthine oxidase inhibitor treat to target urate lowering therapy rewires a tight inflammation serum protein interactome. RESEARCH SQUARE 2024:rs.3.rs-3770277. [PMID: 38260556 PMCID: PMC10802734 DOI: 10.21203/rs.3.rs-3770277/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Background Effective xanthine oxidoreductase inhibition (XOI) urate-lowering treatment (ULT) to target significantly reduces gout flare burden and synovitis between 1-2 years therapy, without clearing all monosodium urate crystal deposits. Paradoxically, treat to target ULT is associated with increased flare activity for at least 1 year in duration on average, before gout flare burden decreases. Since XOI has anti-inflammatory effects, we tested for biomarkers of sustained, effective ULT that alters gouty inflammation. Methods We characterized the proteome of febuxostat-treated murine bone marrow macrophages. Blood samples (baseline and 48 weeks ULT) were analyzed by unbiased proteomics in febuxostat and allopurinol ULT responders from two, independent, racially and ethnically distinct comparative effectiveness trial cohorts (n=19, n=30). STRING-db and multivariate analyses supplemented determinations of significantly altered proteins via Wilcoxon matched pairs signed rank testing. Results The proteome of cultured IL-1b-stimulated macrophages revealed febuxostat-induced anti-inflammatory changes, including for classical and alternative pathway complement activation pathways. At 48 weeks ULT, with altered purine metabolism confirmed by serum metabolomics, serum urate dropped >30%, to normal (<6.8 mg/dL) in all the studied patients. Overall, flares declined from baseline. Treated gout patient sera and peripheral blood mononuclear cells (PBMCs) showed significantly altered proteins (p<0.05) in clustering and proteome networks. CRP was not a useful therapy response biomarker. By comparison, significant serum proteome changes included decreased complement C8 heterotrimer C8A and C8G chains essential for C5b-9 membrane attack complex assembly and function; increase in the NLRP3 inflammasome activation promoter vimentin; increased urate crystal phagocytosis inhibitor sCD44; increased gouty inflammation pro-resolving mediator TGFB1; decreased phagocyte-recruiting chemokine PPBP/CXCL7, and increased monocyte/macrophage-expressed keratin-related proteins (KRT9,14,16) further validated by PBMC proteomics. STRING-db analyses of significantly altered serum proteins from both cohorts revealed a tight interactome network including central mediators of gouty inflammation (eg, IL-1B, CXCL8, IL6, C5). Conclusions Rewiring of inflammation mediators in a tight serum protein interactome was a biomarker of sustained XOI-based ULT that effectively reduced serum urate and gout flares. Monitoring of the serum and PBMC proteome, including for changes in the complement pathway could help determine onset and targets of anti-inflammatory changes in response to effective, sustained XOI-based ULT.Trial Registration: ClinicalTrials.gov Identifier: NCT02579096.
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Calabuig I, Marty-Ané A, Norberciak L, Budzik JF, Legrand J, Martínez-Sanchis A, Pascart T, Andrés M. Prediction of renal and cardiometabolic outcomes in gout during urate-lowering therapy by sonography. Int J Rheum Dis 2023; 26:2450-2459. [PMID: 37786305 DOI: 10.1111/1756-185x.14935] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/06/2023] [Accepted: 09/21/2023] [Indexed: 10/04/2023]
Abstract
OBJECTIVES To assess whether the extent of monosodium urate (MSU) crystal deposition estimated by ultrasound could predict renal and cardiometabolic events during urate-lowering therapy (ULT). METHODS A prospective study on gout patients from two referral centers initiating ULT who underwent baseline ultrasound and were followed for 1 year. Ultrasound scans assessed six joints for double-contour (DC) signs and tophi. A five-point change (mL/min/1.73 m2 ) in the glomerular filtration rate at month 12 (M12) was considered significant. Outcomes of interest were renal function degraded versus improved and a composite cardiometabolic outcome (new hypertension, diabetes, atherosclerotic disease, and cardiovascular death). Homogeneity analyses and Cox regression models were performed. RESULTS One hundred sixty patients were recruited. At baseline, 81.1% of patients (n = 129) showed sonographic tophi with a mean number of 1.4 joints (±1.3) with a DC sign. At M12, 18 patients (11.3%) were lost to follow-up. The serum urate (SU) target (<6.0 mg/dL) was reached in 86 patients (69.9%). Regarding renal function, 15.9% of patients showed improvement, while in 31.0% it degraded. Fourteen new cardiometabolic events occurred in 12 patients. Neither the DC sign nor tophi showed any significant impact on the outcomes of interest. Baseline SU level was higher in those with renal improvement but not with renal decline, while achieving the SU target protected against new cardiometabolic events (HR = 0.2; 95% CI: 0.05-0.81). CONCLUSIONS Sonographic MSU crystal burden was unhelpful in predicting renal and cardiometabolic events during the first year of ULT. Reaching the SU target prevented cardiometabolic events, while its benefit in preserving/improving renal function is unclear.
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Affiliation(s)
- Irene Calabuig
- Rheumatology Department, Dr. Balmis General University Hospital-ISABIAL, Alicante, Spain
| | - Anne Marty-Ané
- Rheumatology Department, Hôpital Saint-Philibert, Lille Catholic Hospitals, Lille, France
| | - Laurène Norberciak
- Research Department, Biostatistics, Hôpital Saint-Philibert, Lille Catholic Hospitals, Lille, France
| | - Jean-François Budzik
- Diagnostic and Interventional Imaging Department, Lille Catholic Hospitals, Lille, France
| | - Julie Legrand
- Diagnostic and Interventional Imaging Department, Lille Catholic Hospitals, Lille, France
| | | | - Tristan Pascart
- Rheumatology Department, Hôpital Saint-Philibert, Lille Catholic Hospitals, Lille, France
| | - Mariano Andrés
- Rheumatology Department, Dr. Balmis General University Hospital-ISABIAL, Alicante, Spain
- Clinical Medicine Department, Miguel Hernández University, Alicante, Spain
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Terkeltaub R. Emerging Urate-Lowering Drugs and Pharmacologic Treatment Strategies for Gout: A Narrative Review. Drugs 2023; 83:1501-1521. [PMID: 37819612 DOI: 10.1007/s40265-023-01944-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/13/2023]
Abstract
Hyperuricemia with consequent monosodium urate crystal deposition leads to gout, characterized by painful, incapacitating inflammatory arthritis flares that are also associated with increased cardiovascular event and related mortality risk. This narrative review focuses on emerging pharmacologic urate-lowering treatment (ULT) and management strategies in gout. Undertreated, gout can progress to palpable tophi and joint damage. In oral ULT clinical trials, target serum urate of < 6.0 mg/dL can be achieved in ~ 80-90% of subjects, with flare burden reduction by 1-2 years. However, real-world ULT results are far less successful, due to both singular patient nonadherence and prescriber undertreatment, particularly in primary care, where most patients are managed. Multiple dose titrations commonly needed to optimize first-line allopurinol ULT monotherapy, and substantial potential toxicities and other limitations of approved, marketed oral monotherapy ULT drugs, promote hyperuricemia undertreatment. Common gout comorbidities with associated increased mortality (e.g., moderate-severe chronic kidney disease [CKD], type 2 diabetes, hypertension, atherosclerosis, heart failure) heighten ULT treatment complexity and emphasize unmet needs for better and more rapid clinically significant outcomes, including attenuated gout flare burden. The gout drug armamentarium will be expanded by integrating sodium-glucose cotransporter-2 (SGLT2) inhibitors with uricosuric and anti-inflammatory properties as well as clinically indicated antidiabetic, nephroprotective, and/or cardioprotective effects. The broad ULT developmental pipeline is loaded with multiple uricosurics that selectively target uric acid transporter 1 (URAT1). Evolving ULT approaches include administering selected gut anaerobic purine degrading bacteria (PDB), modulating intestinal urate transport, and employing liver-targeted xanthine oxidoreductase mRNA knockdown. Last, emerging measures to decrease the immunogenicity of systemically administered recombinant uricases should simplify treatment regimens and further improve outcomes in managing the most severe gout phenotypes.
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Affiliation(s)
- Robert Terkeltaub
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, University of California, 9500 Gilman Drive, San Diego, La Jolla, CA, 92093, USA.
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10
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Chen L, Gamble GD, Horne A, Drake J, Doyle AJ, Uhlig T, Stamp LK, Dalbeth N. Changes in Tophus Composition During Urate-Lowering Therapy: A Dual-Energy Computed Tomography Study. Arthritis Care Res (Hoboken) 2023; 75:1949-1954. [PMID: 36594401 DOI: 10.1002/acr.25084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 11/15/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The gouty tophus is an organized structure composed of monosodium urate (MSU) crystals and chronic inflammatory soft tissue. This dual-energy computed tomography (DECT) study aimed to determine whether the composition of the tophus changes during urate-lowering therapy. METHODS Serial DECT scans from 32 people with gout were obtained over 2 years of allopurinol therapy, dose-escalated to serum urate of <0.36 mmoles/liter. Up to 5 index tophi were selected for each patient, with 103 separate tophi included in the analysis. Using manual outlining methods of conventional CT and DECT scans, the same index tophi were serially measured for total tophus volume and urate volume. For each tophus, the soft tissue volume was then calculated by subtracting the urate volume from the total tophus volume. RESULTS The mean ± SD serum urate reduced from 0.43 ± 0.03 mmoles/liter at baseline to 0.31 ± 0.02 mmoles/liter at year 2. The mean ± SD total tophus volume reduced over the 2-year period from 5.17 ± 5.55 cm3 to 2.61 ± 2.73 cm3 (P < 0.0001). Greater reductions in tophus urate volumes than tophus soft tissue volumes were observed; the tophus urate volume decreased by 70.6%, and tophus soft tissue volume decreased by 37.8% (P < 0.0001). The mean tophus urate:soft tissue ratio reduced from 0.15 at baseline to 0.05 at year 2 (P < 0.001). CONCLUSION The composition of the tophus is dynamic and changes during urate-lowering therapy for gout management. The soft tissue component of the tophus is slower to respond and may persist without measurable MSU crystal deposition.
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Affiliation(s)
- Leanne Chen
- University of Auckland, Auckland, New Zealand
| | | | - Anne Horne
- University of Auckland, Auckland, New Zealand
| | - Jill Drake
- University of Otago, Christchurch, New Zealand
| | - Anthony J Doyle
- Auckland District Health Board and University of Auckland, Auckland, New Zealand
| | - Till Uhlig
- Center for Treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
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11
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Lin TM, Lee HY, Chang CK, Lin KH, Chang CC, Wu BF, Peng SJ. Identification of tophi in ultrasound imaging based on transfer learning and clinical practice. Sci Rep 2023; 13:12507. [PMID: 37532752 PMCID: PMC10397312 DOI: 10.1038/s41598-023-39508-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/26/2023] [Indexed: 08/04/2023] Open
Abstract
Gout is a common metabolic disorder characterized by deposits of monosodium urate monohydrate crystals (tophi) in soft tissue, triggering intense and acute arthritis with intolerable pain as well as articular and periarticular inflammation. Tophi can also promote chronic inflammatory and erosive arthritis. 2015 ACR/EULAR Gout Classification criteria include clinical, laboratory, and imaging findings, where cases of gout are indicated by a threshold score of ≥ 8. Some imaging-related findings, such as a double contour sign in ultrasound, urate in dual-energy computed tomography, or radiographic gout-related erosion, generate a score of up to 4. Clearly, the diagnosis of gout is largely assisted by imaging findings; however, dual-energy computed tomography is expensive and exposes the patient to high levels of radiation. Although musculoskeletal ultrasound is non-invasive and inexpensive, the reliability of the results depends on expert experience. In the current study, we applied transfer learning to train a convolutional neural network for the identification of tophi in ultrasound images. The accuracy of predictions varied with the convolutional neural network model, as follows: InceptionV3 (0.871 ± 0.020), ResNet101 (0.913 ± 0.015), and VGG19 (0.918 ± 0.020). The sensitivity was as follows: InceptionV3 (0.507 ± 0.060), ResNet101 (0.680 ± 0.056), and VGG19 (0.747 ± 0.056). The precision was as follows: InceptionV3 (0.767 ± 0.091), ResNet101 (0.863 ± 0.098), and VGG19 (0.825 ± 0.062). Our results demonstrate that it is possible to retrain deep convolutional neural networks to identify the patterns of tophi in ultrasound images with a high degree of accuracy.
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Affiliation(s)
- Tzu-Min Lin
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Rheumatology, Immunology and Allergy, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Hsiang-Yen Lee
- Division of Rheumatology, Immunology and Allergy, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Ching-Kuei Chang
- Division of Rheumatology, Immunology and Allergy, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Ke-Hung Lin
- Division of Rheumatology, Immunology and Allergy, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chi-Ching Chang
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Rheumatology, Immunology and Allergy, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Bing-Fei Wu
- Institute of Electrical and Control Engineering, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Syu-Jyun Peng
- Professional Master Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, No. 250, Wuxing St., Xinyi Dist., Taipei City, 110, Taiwan.
- Clinical Big Data Research Center, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan.
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12
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Baxter B, Sanders S, Patel SA, Martin A, West M. Pegloticase in Uncontrolled Gout: The Infusion Nurse Perspective. JOURNAL OF INFUSION NURSING 2023; 46:223-231. [PMID: 37406337 PMCID: PMC10306337 DOI: 10.1097/nan.0000000000000510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
Infused biologics, such as pegloticase, are a core component of managing uncontrolled gout, which is increasing in prevalence. Pegloticase is often the last line of therapy for patients with uncontrolled gout; therefore, achieving a successful course of treatment is critical. The infusion nurse's role in patient education, serum uric acid monitoring, and patient medication compliance is essential for ensuring patient safety and maximizing the number of patients who benefit from a full treatment course of pegloticase. Infusion nurses are on the front lines with patients and need to be educated on potential negative effects associated with the medications they infuse, such as infusion reactions, as well as risk management methods like patient screening and monitoring. Further, patient education provided by the infusion nurse plays a large role in empowering the patient to become their own advocate during pegloticase treatment. This educational overview includes a model patient case for pegloticase monotherapy, as well as one for pegloticase with immunomodulation and a step-by-step checklist for infusion nurses to refer to throughout the pegloticase infusion process. A video abstract is available for this article at http://links.lww.com/JIN/A105.
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Affiliation(s)
- Britni Baxter
- Altus Infusion/Houk Rheumatology, Little Rock, Arkansas (Ms Baxter); Premier Specialty Network, Columbia, Missouri (Ms Sanders); and Horizon Therapeutics PLC, Deerfield, Illinois (Ms Patel, Ms Martin, and Mr West)
| | - Shayla Sanders
- Altus Infusion/Houk Rheumatology, Little Rock, Arkansas (Ms Baxter); Premier Specialty Network, Columbia, Missouri (Ms Sanders); and Horizon Therapeutics PLC, Deerfield, Illinois (Ms Patel, Ms Martin, and Mr West)
| | - Shilpa A. Patel
- Altus Infusion/Houk Rheumatology, Little Rock, Arkansas (Ms Baxter); Premier Specialty Network, Columbia, Missouri (Ms Sanders); and Horizon Therapeutics PLC, Deerfield, Illinois (Ms Patel, Ms Martin, and Mr West)
| | - Andrea Martin
- Altus Infusion/Houk Rheumatology, Little Rock, Arkansas (Ms Baxter); Premier Specialty Network, Columbia, Missouri (Ms Sanders); and Horizon Therapeutics PLC, Deerfield, Illinois (Ms Patel, Ms Martin, and Mr West)
| | - Michael West
- Altus Infusion/Houk Rheumatology, Little Rock, Arkansas (Ms Baxter); Premier Specialty Network, Columbia, Missouri (Ms Sanders); and Horizon Therapeutics PLC, Deerfield, Illinois (Ms Patel, Ms Martin, and Mr West)
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13
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Subhas N, Wu F, Fox MG, Nacey N, Aslam F, Blankenbaker DG, Caracciolo JT, DeJoseph DA, Frick MA, Jawetz ST, Said N, Sandstrom CK, Sharma A, Stensby JD, Walker EA, Chang EY. ACR Appropriateness Criteria® Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis, Crystalline Arthritis, or Erosive Osteoarthritis: 2022 Update. J Am Coll Radiol 2023; 20:S20-S32. [PMID: 37236743 DOI: 10.1016/j.jacr.2023.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 05/28/2023]
Abstract
Evaluation for suspected inflammatory arthritis as a cause for chronic extremity joint pain often relies on imaging. It is essential that imaging results are interpreted in the context of clinical and serologic results to add specificity because there is significant overlap of imaging findings among the various types of arthritis. This document provides recommendations for imaging evaluation of specific types of inflammatory arthritis, including rheumatoid arthritis, seronegative spondyloarthropathy, gout, calcium pyrophosphate dihydrate disease (or pseudogout), and erosive osteoarthritis. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Fangbai Wu
- Research Author, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Michael G Fox
- Program Director and Panel Chair, Mayo Clinic Arizona, Phoenix, Arizona
| | - Nicholas Nacey
- Panel Vice-Chair, University of Virginia Health System, Charlottesville, Virginia
| | - Fawad Aslam
- Mayo Clinic, Scottsdale, Arizona, Rheumatologist
| | - Donna G Blankenbaker
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jamie T Caracciolo
- Section Head, Musculoskeletal Imaging, Moffitt Cancer Center and University of South Florida Morsani College of Medicine, Tampa, Florida; and Chair, MSK-RADS (Bone) Committee
| | | | - Matthew A Frick
- Chair of Education, Department of Radiology, Chair of Musculoskeletal Imaging, Mayo Clinic, Rochester, Minnesota
| | | | - Nicholas Said
- Duke University Medical Center, Durham, North Carolina
| | - Claire K Sandstrom
- University of Washington Medical Center, Seattle, Washington; Committee on Emergency Radiology-GSER
| | - Akash Sharma
- Mayo Clinic, Jacksonville, Florida; Commission on Nuclear Medicine and Molecular Imaging
| | | | - Eric A Walker
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania and Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Eric Y Chang
- Specialty Chair, VA San Diego Healthcare System, San Diego, California
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14
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Lee ZC, Santosa A, Khor AYK, Sriranganathan MK. The Singapore Experience With Uncontrolled Gout: Unmet Needs in the Management of Patients. Cureus 2023; 15:e36682. [PMID: 36987445 PMCID: PMC10039979 DOI: 10.7759/cureus.36682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
Gout is the most common type of inflammatory arthritis, and its impact on cardiovascular health and quality of life is often underestimated. The prevalence and incidence of gout are increasing globally. Further, ischemic heart disease (IHD) and chronic kidney disease (CKD) are prevalent in gout patients. Some unmet needs for gout management include physicians' low initiation rate of urate-lowering therapy (ULT) and poor treatment adherence in patients with gout. There is also a lack of randomized controlled trials that establish safe doses of acute and long-term treatment for gout, particularly in patients with IHD and stage 4 CKD and above (including end-stage renal failure). Furthermore, there is also a lack of studies showing optimal serum uric acid (SUA) target and validated clinical outcome measures, including disease activity and remission criteria for gout tailored to treat-to-target approaches and the high cost of newer gout medications. The causal relationship between asymptomatic hyperuricemia or gout with comorbidities such as IHD and CKD has yet to be fully elucidated. There is a pressing need for collaborative international efforts to address the overall suboptimal management of gout.
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15
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Christiansen SN, Østergaard M, Slot O, Fana V, Terslev L. Retrospective longitudinal assessment of ultrasound gout lesions using the OMERACT semi-quantitative scoring system. Rheumatology (Oxford) 2022; 61:4711-4721. [PMID: 35298610 DOI: 10.1093/rheumatology/keac179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/07/2022] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES The objectives of this study were (i) to evaluate the responsiveness of gout-specific US lesions representing urate deposition in patients receiving treat-to-target urate-lowering therapy using a binary and the OMERACT-defined semi-quantitative scoring systems; (ii) to determine the most responsive US measure for urate deposition and the optimal joint/tendon set for monitoring this. METHODS US (28 joints, 14 tendons) was performed in microscopically verified gout patients initiating/increasing urate-lowering therapy and repeated after 6 and 12 months. Static images/videos of pathologies were stored and scored binarily and semi-quantitatively for tophus, double contour sign (DC) and aggregates. Lesion scores were calculated at patient level, as were combined crystal sum scores. Responsiveness of lesions-scored binarily and semi-quantitatively-was calculated at both patient and joint/tendon levels. RESULTS Sixty-three patients underwent longitudinal evaluation. The static images/videos assessed retrospectively showed statistically significant decreases in tophus and DC, when scored binarily and semi-quantitatively, whereas aggregates were almost unchanged during follow-up. The responsiveness of the semi-quantitative tophus and DC sum scores were markedly higher than when using binary scoring. The most responsive measure for urate deposition was a combined semi-quantitative tophus-DC-sum score. A feasible joint/tendon set for monitoring included knee and first-second MTP joints and peroneus and distal patella tendons (all bilateral), representing the most prevalent and responsive sites. CONCLUSION The OMERACT consensus-based semi-quantitative US gout scoring system showed longitudinal validity with both tophus and DC being highly responsive to treatment when assessed in static images/videos. A responsive US measure for urate deposition and a feasible joint/tendon set for monitoring were proposed and may prove valuable in future longitudinal studies.
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Affiliation(s)
- Sara Nysom Christiansen
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopedics, Rigshospitalet, Glostrup
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopedics, Rigshospitalet, Glostrup.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ole Slot
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopedics, Rigshospitalet, Glostrup
| | - Viktoria Fana
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopedics, Rigshospitalet, Glostrup
| | - Lene Terslev
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopedics, Rigshospitalet, Glostrup.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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16
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Critical appraisal of serum urate targets in the management of gout. Nat Rev Rheumatol 2022; 18:603-609. [PMID: 35974164 DOI: 10.1038/s41584-022-00816-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 11/08/2022]
Abstract
Gout management involves two broad aspects: treatment of gout flares to provide rapid symptomatic relief and long-term urate-lowering therapy to lower serum urate sufficiently to prevent gout flares from occurring. All of the major rheumatology societies recommend a target serum urate of <5 mg/dl (<0.30 mmol/l) or <6 mg/dl (<0.36 mmol/l), both of which are below the point of saturation for urate and therefore lead to monosodium urate crystal dissolution. In this Review, we describe the rationale for treat-to-target urate approach in the long-term management of gout and the current evidence and controversy around the appropriate serum urate targets.
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17
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Sivera F, Andres M, Dalbeth N. A glance into the future of gout. Ther Adv Musculoskelet Dis 2022; 14:1759720X221114098. [PMID: 35923650 PMCID: PMC9340313 DOI: 10.1177/1759720x221114098] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 06/29/2022] [Indexed: 12/03/2022] Open
Abstract
Gout is characterized by monosodium urate (MSU) crystal deposits in and within joints. These deposits result from persistent hyperuricaemia and most typically lead to recurrent acute inflammatory episodes (gout flares). Even though some aspects of gout are well characterized, uncertainties remain; this upcoming decade should provide further insights into many of these uncertainties. Synovial fluid analysis allows for the identification of MSU crystals and unequivocal diagnosis. Non-invasive methods for diagnosis are being explored, such as Raman spectroscopy and imaging modalities. Both ultrasound and dual-energy computed tomography (DECT) allow the detection of MSU crystals; this not only provides a mean of diagnosis, but also has furthered gout knowledge defining the presence of a preclinical deposition in asymptomatic hyperuricaemia. Scientific consensus establishes the beginning of gout as the beginning of symptoms (usually the first flare), but the concept is currently under review. For effective long-term gout management, the main goal is to promote crystal dissolution treatment by reducing serum urate below 6 mg/dL (or 5 mg/dL if faster crystal dissolution is required). Current urate-lowering therapies' (ULTs) options are limited, with allopurinol and febuxostat being widely available, and probenecid, benzbromarone, and pegloticase available in some regions. New xanthine oxidase inhibitors and, especially, uricosurics inhibiting urate transporter URAT1 are under development; it is probable that the new decade will see a welcomed increase in the gout therapeutic armamentarium. Cardiovascular and renal comorbidities are common in gout patients. Studies determining whether optimal treatment of gout will positively impact these comorbidities are currently lacking, but will hopefully be forthcoming. Overall, the single change that will most impact gout management is greater uptake of international rheumatology society recommendations. Innovative strategies, such as nurse-led interventions based on these recommendations have recently demonstrated treatment success for people with gout.
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Affiliation(s)
- Francisca Sivera
- Rheumatology Unit, Hospital General
Universitario Elda, Ctra Sax s/n, Elda 03600, Alicante, Spain
- Department Medicine, Universidad Miguel
Hernandez, Elche, Spain
| | - Mariano Andres
- Department Medicine, Universidad Miguel
Hernandez, Elche, Spain
- Rheumatology Unit, Hospital General
Universitario Alicante, Alicante, Spain
- Alicante Institute of Sanitary and Biomedical
Research (ISABIAL), Alicante, Spain
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18
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Hammer HB, Rollefstad S, Semb AG, Jensen G, Karoliussen LF, Terslev L, Haavardsholm EA, Kvien TK, Uhlig T. Urate crystal deposition is associated with inflammatory markers and carotid artery pathology in patients with intercritical gout: results from the NOR-Gout study. RMD Open 2022; 8:rmdopen-2022-002348. [PMID: 35863863 PMCID: PMC9310249 DOI: 10.1136/rmdopen-2022-002348] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 06/29/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Gout is of unknown reason associated with cardiovascular disease. Ultrasound is sensitive for detecting crystal deposition and plasma calprotectin is a sensitive inflammatory marker. This study explores the associations between crystal deposition, inflammation and carotid artery pathology. METHOD A cross-sectional analysis of baseline assessments from the NOR-Gout study was undertaken. Crystal deposition was assessed by ultrasound (double contour, tophi, aggregates) and dual-energy CT (DECT) and laboratory assessments included plasma calprotectin. The carotid arteries were bilaterally examined for carotid intima-media thickness (cIMT) and presence of plaques. Spearman correlations, Mann-Whitney tests and linear regression analyses were used to explore associations between crystal deposition, inflammatory markers,and carotid pathology. RESULTS 202 patients with intercritical gout (95.5% men, mean (SD) age 56.5 (13.8) years, disease duration 7.9 (7.7) years) were included. Calprotectin was correlated with all scores of crystal deposition by ultrasound (r=0.26-0.32, p<0.001) and DECT (r=0.15, p<0.05). cIMT was correlated with sum score aggregates (r=0.18-0.22, p<0.05). Patients with large tophi had higher levels of calprotectin as well as more frequent carotid plaque (p<0.05). CONCLUSIONS Study findings point towards crystal deposition contributing to subclinical inflammation with subsequent vascular implications. However, future longitudinal studies are needed to confirm such causal relationships.
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Affiliation(s)
- Hilde Berner Hammer
- Dept of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway .,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Silvia Rollefstad
- Peventive Cardio-Rheuma clinic, Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Anne Grete Semb
- Peventive Cardio-Rheuma clinic, Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Gro Jensen
- Clinical chemical laboratory, Diakonhjemmet Hospital, Oslo, Norway
| | | | - L Terslev
- Center for Rheumatology and Spine Diseases, Rigshospitalet, Kobenhavn, Denmark
| | - Espen A Haavardsholm
- Dept of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tore K Kvien
- Dept of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Till Uhlig
- Dept of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
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19
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Uhlig T, Karoliussen LF, Sexton J, Kvien TK, Haavardsholm EA, Perez-Ruiz F, Hammer HB. One- and 2-year flare rates after treat-to-target and tight-control therapy of gout: results from the NOR-Gout study. Arthritis Res Ther 2022; 24:88. [PMID: 35443675 PMCID: PMC9020166 DOI: 10.1186/s13075-022-02772-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/30/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To explore the frequency and predictors of flares over 2 years during a treat-to-target strategy with urate-lowering therapy (ULT) in patients with gout. METHODS In the treat-to-target, tight control NOR-Gout study patients started ULT with escalating doses of allopurinol. Flares were recorded over 2 years. Baseline predictors of flares during months 9-12 in year 1 and during year 2 were analyzed by multivariable logistic regression. RESULTS Of 211 patients included (mean age 56.4 years, disease duration 7.8 years, 95% males), 81% (150/186) of patients experienced at least one gout flare during the first year and 26% (45/173) during the second year. The highest frequency of flares in the first year was seen during months 3-6 (46.8% of patients). Baseline crystal depositions detected by ultrasound and by dual-energy computed tomography (DECT) were the only variables which predicted flares both during the first period of interest at months 9-12 (OR 1.033; 95% CI 1.010-1.057, and OR 1.056; 95% CI 1.007-1.108) and also in year 2. Baseline subcutaneous tophi (OR 2.42, 95% CI 1.50-5.59) and prior use of colchicine at baseline (OR 2.48, 95% CI 1.28-4.79) were independent predictors of flares during months 9-12, whereas self-efficacy for pain was a protective predictor (OR 0.98 per unit, 95% CI 0.964-0.996). CONCLUSIONS In patients with gout, flares remain frequent during the first year of a treat-to-target ULT strategy, especially during months 3-6, but are much less frequent during year 2. Baseline crystal depositions predict flares over 2 years, supporting ULT early during disease course. TRIAL REGISTRATION ACTRN12618001372279.
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Affiliation(s)
- Till Uhlig
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Box 23, Vinderen, N-0319, Oslo, Norway. .,Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Lars F Karoliussen
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Box 23, Vinderen, N-0319, Oslo, Norway
| | - Joe Sexton
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Box 23, Vinderen, N-0319, Oslo, Norway
| | - Tore K Kvien
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Box 23, Vinderen, N-0319, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Espen A Haavardsholm
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Box 23, Vinderen, N-0319, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Fernando Perez-Ruiz
- Osakidetza, OSI EE-Cruces, Division of Rheumatology, Cruces University Hospital, Baracaldo, Spain.,Biocruces-Bizkaia Health Research Institute, Baracaldo, Spain.,Medicine Department, Medicine School, University of the Basque Country, Leioa, Spain
| | - Hilde Berner Hammer
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Box 23, Vinderen, N-0319, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
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20
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Li S, Xu G, Liang J, Wan L, Cao H, Lin J. The Role of Advanced Imaging in Gout Management. Front Immunol 2022; 12:811323. [PMID: 35095904 PMCID: PMC8795510 DOI: 10.3389/fimmu.2021.811323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 12/21/2021] [Indexed: 12/27/2022] Open
Abstract
Gout is a common form of inflammatory arthritis where urate crystals deposit in joints and surrounding tissues. With the high prevalence of gout, the standardized and effective treatment of gout is very important, but the long-term treatment effect of gout is not satisfied because of the poor adherence in patients to the medicines. Recently, advanced imaging modalities, including ultrasonography (US), dual-energy computed tomography (DECT), and magnetic resonance imaging (MRI), attracted more and more attention for their role on gout as intuitive and non-invasive tools for early gout diagnosis and evaluation of therapeutic effect. This review summarized the role of US, DECT, and MRI in the management of gout from four perspectives: hyperuricemia, gout attacks, chronic gout, and gout complications described the scoring systems currently used to quantify disease severity and discussed the challenges and limitations of using these imaging tools to assess response to the gout treatment.
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Affiliation(s)
- Shuangshuang Li
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Guanhua Xu
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Junyu Liang
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Liyan Wan
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Heng Cao
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jin Lin
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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21
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Calabuig I, Martínez-Sanchis A, Andrés M. Sonographic Tophi and Inflammation Are Associated With Carotid Atheroma Plaques in Gout. Front Med (Lausanne) 2022; 8:795984. [PMID: 34977097 PMCID: PMC8716736 DOI: 10.3389/fmed.2021.795984] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/29/2021] [Indexed: 12/22/2022] Open
Abstract
Objective: Gout and cardiovascular disease are closely related, but the mechanism connecting them remains unknown. This study aims to explore whether urate crystal deposits and inflammation (assessed by ultrasound) are associated with carotid atherosclerosis. Methods: We included consecutive patients with crystal-proven gout newly presenting to a tertiary rheumatology unit. Patients under urate-lowering treatment were excluded. Ultrasound assessment was performed during intercritical periods. Musculoskeletal scans evaluated six joints and four tendons for urate crystal deposits (double contour, aggregates, and tophi), and power Doppler (PD) signal (graded 0–3) as a marker of local inflammation. The sum of locations showing deposits or a positive PD signal (≥1) was registered. Carotids were scanned for increased intima-media thickness (IMT) and atheroma plaques, according to the Mannheim consensus. Associations were analyzed using logistic regression. Results: The study included 103 patients showing sonographic crystal deposits at the examined locations (mean sum 9.9, minimum 2); tophi were the most frequent. Two-thirds of participants presented a positive PD signal (30.1% grade 2–3). In the carotid scans, 59.2% of participants showed atheroma plaques, and 33.0% increased IMT. Tophi (odds ratio [OR] 1.24; 95% confidence interval [CI] 1.03–1.50) and a positive PD signal (OR 1.67; 95% CI 1.09–2.56) were significantly associated with atheroma plaques, while an increased IMT showed no sonographic association. Conclusion: Sonographic crystal deposits and subclinical inflammation were consistently observed in patients with intercritical gout. Tophi and a positive PD signal were linked to carotid atherosclerosis. Our findings may contribute to understanding the complex relationship between gout and atherosclerosis.
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Affiliation(s)
- Irene Calabuig
- Sección de Reumatología, Hospital General Universitario de Alicante-Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Agustín Martínez-Sanchis
- Sección de Reumatología, Hospital General Universitario de Alicante-Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Mariano Andrés
- Sección de Reumatología, Hospital General Universitario de Alicante-Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain.,Departamento de Medicina Clínica, Universidad Miguel Hernández, Alicante, Spain
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22
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Weaver JS, Vina ER, Munk PL, Klauser AS, Elifritz JM, Taljanovic MS. Gouty Arthropathy: Review of Clinical Manifestations and Treatment, with Emphasis on Imaging. J Clin Med 2021; 11:jcm11010166. [PMID: 35011907 PMCID: PMC8745871 DOI: 10.3390/jcm11010166] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/16/2021] [Accepted: 12/26/2021] [Indexed: 12/22/2022] Open
Abstract
Gout, a crystalline arthropathy caused by the deposition of monosodium urate crystals in the articular and periarticular soft tissues, is a frequent cause of painful arthropathy. Imaging has an important role in the initial evaluation as well as the treatment and follow up of gouty arthropathy. The imaging findings of gouty arthropathy on radiography, ultrasonography, computed tomography, dual energy computed tomography, and magnetic resonance imaging are described to include findings of the early, acute and chronic phases of gout. These findings include early monosodium urate deposits, osseous erosions, and tophi, which may involve periarticular tissues, tendons, and bursae. Treatment of gout includes non-steroidal anti-inflammatories, colchicine, glucocorticoids, interleukin-1 inhibitors, xanthine oxidase inhibitors, uricosuric drugs, and recombinant uricase. Imaging is critical in monitoring response to therapy; clinical management can be modulated based on imaging findings. This review article describes the current standard of care in imaging and treatment of gouty arthropathy.
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Affiliation(s)
- Jennifer S. Weaver
- Department of Radiology, University of New Mexico, Albuquerque, NM 87131, USA;
- Correspondence:
| | - Ernest R. Vina
- Department of Medicine, University of Arizona Arthritis Center, Tucson, AZ 85724, USA;
| | - Peter L. Munk
- Department of Radiology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada;
- Department of Radiology, Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
| | - Andrea S. Klauser
- Radiology Department, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria;
| | - Jamie M. Elifritz
- Departments of Radiology and Pathology, University of New Mexico, Albuquerque, NM 87131, USA;
- New Mexico Office of the Medical Investigator, Albuquerque, NM 87131, USA
| | - Mihra S. Taljanovic
- Department of Radiology, University of New Mexico, Albuquerque, NM 87131, USA;
- Departments of Medical Imaging and Orthopaedic Surgery, University of Arizona, Tucson, AZ 85721, USA
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23
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Wang Q, Bao H, Guo LH, Jin FS, Li XL, Yin HH, Yue WW, Zhu AQ, Wang LF, Sun LP, Xu HX. Quantitative assessment of crystal dissolution in gout during urate-lowering therapy with computer-aided MicroPure imaging: a cohort study. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1444. [PMID: 34733996 PMCID: PMC8506744 DOI: 10.21037/atm-21-4059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/10/2021] [Indexed: 11/25/2022]
Abstract
Background To evaluate whether MicroPure imaging, an ultrasound (US) image-processing technique with computer-aided analysis, can quantitatively detect crystal dissolution during urate-lowering therapy (ULT) in gout. Methods This was a prospective study of gout patients requiring ULT. The first metatarsophalangeal joints were examined using US and MicroPure before and after 3 months of ULT. Elementary lesions of gout, including the double contour sign (DCS), aggregates, tophi, erosion, and other US features were recorded at baseline and 3 months. MicroPure imaging features were automatically calculated by a self-developed software. Patients were divided into goal-achieved and goal-not-achieved groups according to their urate levels at 3 months. The US and MicroPure imaging features of the two groups were analyzed at baseline and 3 months. Results A total of 55 consecutive patients were enrolled (25: goal-achieved group; 30: goal-not-achieved group). US findings demonstrated that the power Doppler signal grade decreased at 3 months, regardless of the group (both P<0.05). From baseline to 3 months, tophi size and the DCS reduced in the goal-achieved group (both P<0.05), while the US aggregate features showed no difference (P=0.250). However, on the MicroPure imaging, the number and density of aggregates at 3 months decreased in the goal-achieved group (both P<0.05). There were no significant changes at 3 months in any of the MicroPure imaging features in the goal-not-achieved group (all P>0.05). Conclusions In comparison with B-mode US, computer-aided MicroPure imaging can sensitively and quantitatively detect aggregate dissolution during effective ULT after only 3 months of treatment.
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Affiliation(s)
- Qiao Wang
- Department of Medical Ultrasound, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China.,Department of Medical Ultrasound & Tumor Minimally Invasive Treatment, Shanghai Tenth People's Hospital, Shanghai, China.,Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Hui Bao
- Department of Nephrology and Rheumatology, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Le-Hang Guo
- Department of Medical Ultrasound, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China.,Department of Medical Ultrasound & Tumor Minimally Invasive Treatment, Shanghai Tenth People's Hospital, Shanghai, China.,Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Feng-Shan Jin
- Department of Medical Ultrasound & Tumor Minimally Invasive Treatment, Shanghai Tenth People's Hospital, Shanghai, China.,Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Xiao-Long Li
- Department of Medical Ultrasound & Tumor Minimally Invasive Treatment, Shanghai Tenth People's Hospital, Shanghai, China.,Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Hao-Hao Yin
- Department of Medical Ultrasound & Tumor Minimally Invasive Treatment, Shanghai Tenth People's Hospital, Shanghai, China.,Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Wen-Wen Yue
- Department of Medical Ultrasound & Tumor Minimally Invasive Treatment, Shanghai Tenth People's Hospital, Shanghai, China.,Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - An-Qi Zhu
- Department of Medical Ultrasound, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China.,Department of Medical Ultrasound & Tumor Minimally Invasive Treatment, Shanghai Tenth People's Hospital, Shanghai, China.,Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Li-Fan Wang
- Department of Medical Ultrasound, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China.,Department of Medical Ultrasound & Tumor Minimally Invasive Treatment, Shanghai Tenth People's Hospital, Shanghai, China.,Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Li-Ping Sun
- Department of Medical Ultrasound & Tumor Minimally Invasive Treatment, Shanghai Tenth People's Hospital, Shanghai, China.,Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Hui-Xiong Xu
- Department of Medical Ultrasound, Shanghai Skin Disease Hospital, School of Medicine, Tongji University, Shanghai, China.,Department of Medical Ultrasound & Tumor Minimally Invasive Treatment, Shanghai Tenth People's Hospital, Shanghai, China.,Ultrasound Research and Education Institute, Clinical Research Center for Interventional Medicine, School of Medicine, Tongji University, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Shanghai, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China
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24
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Uhlig T, Karoliussen LF, Sexton J, Borgen T, Haavardsholm EA, Kvien TK, Hammer HB. 12-month results from the real-life observational treat-to-target and tight-control therapy NOR-Gout study: achievements of the urate target levels and predictors of obtaining this target. RMD Open 2021; 7:rmdopen-2021-001628. [PMID: 33782189 PMCID: PMC8009238 DOI: 10.1136/rmdopen-2021-001628] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/01/2021] [Accepted: 03/05/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Gout is often not adequately treated, and we aimed to apply urate lowering treatment (ULT) combined with individual information to achieve target serum urate (sUA) in clinical practice, and to identify predictors of achievement of this sUA target. METHODS Patients with a recent gout flare and sUA >360 µmol/L (>6 mg/dL) were consecutively included in a single-centre study and managed with a treat-to-target approach combining nurse-led information about gout with ULT. All patients were assessed with tight controls at baseline, 1, 2, 3, 6, 9 and 12 months including clinical examination, information on demographics, lifestyle, self-efficacy and beliefs about medicines. The treatment target was sUA <360 µmol/L and multivariable logistic regression was used to identify predictors of target attainment with ORs and 95% CIs. RESULTS Of 211 patients (mean age 56.4 years, disease duration 7.8 years, 95% males), 186 completed the 12-month study. Mean sUA levels decreased from baseline mean 500 to 311 µmol/L at 12 months with 85.5% achieving the treatment target. Alcohol consumption at least weekly versus less frequently (OR 0.14; 95% CI 0.04 to 0.55) as well as beliefs in overuse of medicines (OR per unit 0.77; 95 CI 0.62 to 0.94) decreased the chance of reaching the treatment target, while higher self-efficacy for arthritis symptoms (OR 1.49 per 10 units; 95% CI 1.09 to 2.05) increased the likelihood. CONCLUSIONS This study shows that target sUA can be achieved with ULT in most patients. Less self-reported alcohol consumption, low beliefs in overuse of medicines and higher self-efficacy are associated with treatment success.
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Affiliation(s)
- Till Uhlig
- Rheumatology, Diakonhjemmet Hospital, Oslo, Norway .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | | | - Tove Borgen
- Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Espen A Haavardsholm
- Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tore K Kvien
- Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Hilde Berner Hammer
- Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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25
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Uhlig T, Eskild T, Karoliussen LF, Sexton J, Kvien TK, Haavardsholm EA, Dalbeth N, Hammer HB. Two-year reduction of dual-energy CT urate depositions during a treat-to-target strategy in gout in the NOR-Gout longitudinal study. Rheumatology (Oxford) 2021; 61:SI81-SI85. [PMID: 34247224 PMCID: PMC9015021 DOI: 10.1093/rheumatology/keab533] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/21/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES There is a lack of large longitudinal studies of urate deposition measured by dual-energy computed tomography (DECT) during urate lowering therapy (ULT) in people with gout. We explored longitudinal changes in DECT urate depositions during a treat-to-target strategy with ULT in gout. METHODS Patients with a recent gout flare and serum-urate (sUA) >360 µmol/l attended tight-control visits during escalating ULT. The treatment target was sUA <360 µmol/l, and <300 µmol/l if presence of tophi.A DECT scanner (General Electric Discovery CT750 HD) acquired data from bilateral forefeet and ankles at baseline and after one and two years. Images were scored in known order, using the semi-quantitative Bayat method, by one experienced radiologist who was blinded to serum urate and clinical data. Four regions were scored: the first metatarsophalangeal (MTP1) joint, the other joints of the toes, the ankles and midfeet, and all tendons in the feet and ankles. RESULTS DECT was measured at baseline in 187 of 211 patients. The mean (S.D.) serum urate level (μmol/l) decreased from 501 (80) at baseline to 311 (48) at 12 months, and 322 (67) at 24 months.DECT scores at all locations decreased during both the first and the second year (p< 0.001 for all comparisons vs baseline), both for patients achieving and not achieving the sUA treatment target. CONCLUSIONS In patients with gout, urate depositions in ankles and feet as measured by DECT decreased both in the first and the second year, when patients were treated using a treat-to-target ULT strategy.
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Affiliation(s)
- Till Uhlig
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tron Eskild
- Division for Clinical Service, Radiology, Diakonhjemmet Hospital, Oslo, Norway
| | - Lars F Karoliussen
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Joe Sexton
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Tore K Kvien
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Espen A Haavardsholm
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Nicola Dalbeth
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Hilde Berner Hammer
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
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26
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Cipolletta E, Di Battista J, Di Carlo M, Di Matteo A, Salaffi F, Grassi W, Filippucci E. Sonographic estimation of monosodium urate burden predicts the fulfillment of the 2016 remission criteria for gout: a 12-month study. Arthritis Res Ther 2021; 23:185. [PMID: 34243813 PMCID: PMC8268270 DOI: 10.1186/s13075-021-02568-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/28/2021] [Indexed: 12/27/2022] Open
Abstract
Objective To investigate whether baseline monosodium urate (MSU) burden estimated by ultrasound (US) predicts the achievement of the 2016 remission criteria for gout after 12 months. Methods In this 12-month prospective, observational and single-center study, patients with gout fulfilling all the domains of the 2016 preliminary remission criteria for gout at baseline and on urate-lowering therapy (ULT) for at least the preceding 6 months were consecutively enrolled. The US findings indicative of MSU deposits [aggregates, double contour (DC) sign, and/or tophi] were identified according to the Outcome Measure in Rheumatology US Working Group definitions. The US MSU burden was estimated by evaluating elbows, wrists, 2nd metacarpophalangeal joints, knees, ankles, and 1st metatarsophalangeal joints. Results Remission criteria were fulfilled in 21 (42.0%) out of 50 patients at 12 months. The baseline US MSU burden was significantly lower in patients who achieved remission than in those who did not fulfill the remission criteria at 12 months (1.9±1.8 vs 5.1±3.1, p<0.01). US scores and ongoing flare prophylaxis were the only significant predictors of remission with an odds ratio of 10.83 [(95%CI=1.14–102.59), p=0.04] for the absence of MSU deposits, 5.53 [(95%CI=1.34–22.76), p<0.01] for the absence of aggregates, 7.33 [(95%CI=1.71–31.44), p<0.01] for the absence of DC sign, 3.88 [(95%CI=1.08–13.92), p=0.04] for the absence of tophi, and 0.23 [(95%CI=0.07–0.75), p=0.02] for ongoing flare prophylaxis. Conclusion In gout, baseline US estimation of MSU burden is an independent predictor of the achievement of the remission criteria at 12 months. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-021-02568-x.
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Affiliation(s)
- Edoardo Cipolletta
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital, Via Aldo Moro 25, Jesi (Ancona), Italy.
| | - Jacopo Di Battista
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital, Via Aldo Moro 25, Jesi (Ancona), Italy
| | - Marco Di Carlo
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital, Via Aldo Moro 25, Jesi (Ancona), Italy
| | - Andrea Di Matteo
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital, Via Aldo Moro 25, Jesi (Ancona), Italy
| | - Fausto Salaffi
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital, Via Aldo Moro 25, Jesi (Ancona), Italy
| | - Walter Grassi
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital, Via Aldo Moro 25, Jesi (Ancona), Italy
| | - Emilio Filippucci
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital, Via Aldo Moro 25, Jesi (Ancona), Italy
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27
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Xu G, Lin J, Liang J, Yang Y, Ye Z, Zhu G, Cao H. Entheseal involvement of the lower extremities in gout: an ultrasonographic descriptive observational study. Clin Rheumatol 2021; 40:4649-4657. [PMID: 34156566 DOI: 10.1007/s10067-021-05826-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 06/06/2021] [Accepted: 06/15/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The aim of this study was to explore the prevalence and distribution of lower extremity entheseal abnormities by musculoskeletal ultrasound (US) in a cohort of gout patients, taking spondyloarthritis (SpA) patients and asymptomatic hyperuricemia (HUA) patients as controls. METHOD One hundred participants with gout, fifty patients with SpA, and twenty-nine patients with asymptomatic HUA were recruited. US was used to assess the bilateral quadriceps, patellar and Achilles tendons, and plantar fascia entheses according to the Outcome Measures in Rheumatology (OMERACT) definitions. RESULTS The US examination revealed the presence of one or more abnormalities in at least one enthesis in 45 out of 100 subjects (45.0%) and 152 out of 1000 entheses (15.2%) in the gout patients. Among the affected entheses, the patellar insertion of the quadriceps tendon was the most commonly involved area (38.0% in the gout patients versus 48.0% in the SpA patients with at least one pathological US finding, p = 0.241). There were no significant group differences in entheseal power Doppler (PD) signals, bone erosion, or enthesophytes. The patients with lower limb entheseal involvement in the gout group had an older age, longer disease duration, higher percentage of chronic tophaceous gout, and higher levels of inflammatory biomarkers of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Multivariate logistic regression analysis revealed that age (OR = 1.052, p = 0.001) and the ESR (OR = 1.023, p = 0.028) were correlated with lower limb enthesopathy in gout patients. In the subgroup analysis of gout patients without active inflammation, age (OR = 1.119, p = 0.001) and serum uric acid (UA, OR = 1.012, p = 0.002) were correlated with lower limb enthesopathy in gout. CONCLUSION Lower extremity entheseal involvement might be neglected but should be considered as an important element in the evaluation of gout patients. Enthesopathy most frequently involves in the patellar insertion of the quadriceps tendon and is characterized by entheseal hypoechogenicity and/or thickening. Key Points • Lower extremity enthesopathy might be neglected as an important element in gout. • Enthesopathy is most frequently involved in the patellar insertion of the quadriceps tendon in gout. • Age and ESR are correlated with lower limb enthesopathy in gout patients.
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Affiliation(s)
- Guanhua Xu
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, No.79 Road Qingchun, Hangzhou, 310003, Zhejiang Province, China
| | - Jin Lin
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, No.79 Road Qingchun, Hangzhou, 310003, Zhejiang Province, China
| | - Junyu Liang
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, No.79 Road Qingchun, Hangzhou, 310003, Zhejiang Province, China
| | - Yang Yang
- Zhejiang University School of Medicine, Hangzhou, China
| | - Zi Ye
- The First People's Hospital of Linhai, Linhai, China
| | - Guohui Zhu
- The First People's Hospital of Linhai, Linhai, China
| | - Heng Cao
- Department of Rheumatology, The First Affiliated Hospital, Zhejiang University School of Medicine, No.79 Road Qingchun, Hangzhou, 310003, Zhejiang Province, China.
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28
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Ultraschall bei Gicht: Uratsenkende
Therapie verringert
sichtbar Kristalle. AKTUEL RHEUMATOL 2021. [DOI: 10.1055/a-1296-0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Kristallablagerungen bei Gichtpatienten lassen sich im Ultraschall
nachweisen. Norwegische Wissenschaftler haben untersucht, wo sich die
Ablagerungen am häufigsten mit Ultraschall detektieren lassen
und wie sie sich während einer Urat-senkenden Behandlung
verändern.
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29
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Christiansen SN, Filippou G, Scirè CA, Balint PV, Bruyn GA, Dalbeth N, Dejaco C, Sedie AD, Filippucci E, Hammer HB, Iagnocco A, Keen HI, Kissin EY, Koski J, Mandl P, Martin J, Miguel ED, Möller I, Naredo E, Pineda C, Schmidt WA, Stewart S, Antonietta D'Agostino M, Terslev L. Consensus-based semi-quantitative ultrasound scoring system for gout lesions: Results of an OMERACT Delphi process and web-reliability exercise. Semin Arthritis Rheum 2021; 51:644-649. [PMID: 33468347 DOI: 10.1016/j.semarthrit.2020.11.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/27/2020] [Accepted: 11/05/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This study aimed to develop (1) a new ultrasound definition for aggregates and (2) a semi-quantitative ultrasound scoring system (0-3) for tophus, double contour and aggregates. Furthermore, the intra- and inter-reader reliabilities of both the re-defined aggregates and the semi-quantitative scoring system were assessed using static image exercises. METHODS Thirty-seven rheumatologists were invited. A Delphi process was used for re-defining aggregates and for selecting a semi-quantitative scoring system with >75% agreement obligate for reaching consensus. Subsequently, a web-based exercise on static ultrasound images was conducted in order to assess the reliability of both the re-defined aggregates and the semi-quantitative scoring system. RESULTS Twenty rheumatologists contributed to all rounds of the Delphi and image exercises. A consensual re-definition of aggregates was obtained after three Delphi rounds but needed an overarching principle for scoring aggregates in patients. A consensus-based semi-quantitative ultrasound scoring system for gout lesions was developed after two Delphi rounds. The re-definition of aggregates showed good intra- and inter-reader reliability (κ-values 0.71 and 0.61). The reliabilities of the scoring system were good for all lesions with slightly higher intra-reader (κ-values 0.74-0.80) than inter-reader reliabilities (κ-values 0.61-0.67). CONCLUSION A re-definition of aggregates was obtained with a good reliability when assessing static images. The first consensus-based semi-quantitative ultrasound scoring system for gout-specific lesions was developed with good inter- and intra-reader reliability for all lesions when tested in static images. The next step is to assess the reliabilities when scoring lesions in patients.
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Affiliation(s)
- Sara Nysom Christiansen
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Georgios Filippou
- Section of Rheumatology, Department of Medical Sciences, University of Ferrara, Italy; Rheumatology Unit, Luigi Sacco University Hospital of Milan, Milan, Italy
| | - Carlo Alberto Scirè
- Section of Rheumatology, Department of Medical Sciences, University of Ferrara, Italy
| | - Peter V Balint
- 3rd Rheumatology Department, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | - George Aw Bruyn
- Department of Rheumatology, MC Groep, Lelystad, the Netherlands
| | - Nicola Dalbeth
- Bone & Joint Research Group, Faculty of Medicine, University of Auckland, Auckland, New Zealand
| | - Christian Dejaco
- Department of Rheumatology, Medical University of Graz, Graz, Austria and Hospital of Brunico (SABES-ASDAA), Department of Rheumatology, Brunico, Italy
| | | | - Emilio Filippucci
- Rheumatology Department, Clinica Reumatologica, Università Politecnica delle Marche, Jesi, Ancona, Italy
| | - Hilde B Hammer
- Rheumatology Department, Diakonhjemmet Hospital and University of Oslo, Oslo, Norway
| | - Annamaria Iagnocco
- Academic Rheumatology Centre, DSCB Università degli Studi di Torino, Turin, Italy
| | - Helen I Keen
- School of Medicine and Pharmacology Fiona Stanley Hospital Unit, University of Western Australia, Perth, Australia
| | | | - Juhani Koski
- Department of Internal Medicine, Mikkeli Central Hospital, Mikkeli, Finland
| | - Peter Mandl
- Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Julia Martin
- Bone & Joint Research Group, Faculty of Medicine, University of Auckland, Auckland, New Zealand
| | - Eugenio De Miguel
- Department of Rheumatology, Hospital Universitario La Paz, Madrid, Spain
| | - Ingrid Möller
- Instituto Poal de Reumatologia, University of Barcelona, Barcelona, Spain
| | - Esperanza Naredo
- Department of Rheumatology, Joint and Bone Research Unit, Hospital Universitario Fundación Jiménez Díaz, IIS Fundación Jiménez Díaz and Universidad Autónoma de Madrid. Madrid, Spain
| | - Carlos Pineda
- Division of Musculoskeletal and Rheumatic Diseases, Instituto Nacional de Rehabilitacion, Mexico City, Mexico
| | - Wolfgang A Schmidt
- Rheumatology Department, Immanuel Krankenhaus Berlin, Medical Centre for Rheumatology, Berlin-Buch, Berlin, Germany
| | - Sarah Stewart
- Bone & Joint Research Group, Faculty of Medicine, University of Auckland, Auckland, New Zealand
| | - Maria Antonietta D'Agostino
- Department of Rheumatology, Ambroise Pare´ Hospital, and Versailles Saint-Quentin-en-Yvelines University, Boulogne-Billancourt, France
| | - Lene Terslev
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Hung PC, Lin DH, Ker A, Yang CC, Chien HW, Wei JCC. Correspondence on ‘Ultrasound shows rapid reduction of crystal depositions during a treat-to-target approach in gout patients: 12-month results from the NOR-Gout study’. Ann Rheum Dis 2020; 81:e235. [DOI: 10.1136/annrheumdis-2020-218846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 08/16/2020] [Indexed: 11/04/2022]
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