Gout Self-Management in African American Veterans: A Qualitative Exploration of Challenges and Solutions From Patients' Perspectives.

OBJECTIVE: To explore gout self-management and associated challenges and solutions in African Americans. METHODS: We conducted semistructured interviews with 35 African American veterans with gout, who received health care at Birmingham or Philadelphia Veterans Affairs (VA) medical centers, had filled urate-lowering therapy (ULT; most commonly allopurinol) for at least 6 months, and had a ULT medication possession ratio ≥80%. The interview protocol was constructed to explore key concepts related to gout self-management, including initial diagnosis of gout, beginning medical care for gout, the course of the gout, ULT medication adherence, dietary strategies, comorbidity and side effects, and social support. RESULTS: Thirty-five African American male veterans with gout who had ≥80% ULT adherence (most commonly, allopurinol) were interviewed at Birmingham (n = 18) or Philadelphia (n = 17) VA medical centers. Mean age was 65 years, mean body mass index was 31.9 kg/m2 , 97% had hypertension, 23% had coronary artery disease, and 31% had renal failure. The main themes motivating African American veterans to better gout self-management were fear of pain, adherence to medications, self-discipline, lifestyle changes, information gathering, and developing a positive outlook. Birmingham participants more frequently revealed skipping gout medications. More Philadelphia participants discussed lifestyle/diet changes to prevent gout flares, indicated limiting social activities that involved drinking, and sought more information about gout self-management from health care providers and internet sources. CONCLUSION: Identified themes, including cultural differences by site, led to the development of a patient-centered intervention to improve gout self-management in African American men with gout.

Evaluating appropriate use of prophylactic colchicine for gout flare prevention.

OBJECTIVE: American College of Rheumatology and European League Against Rheumatism guidelines recommend colchicine to prevent gout flares in patients initiating and increasing uric acid­lowering therapy until serum uric acid is maintained at ≤6 mg/dl. We aimed to evaluate how well colchicine prescribing practices adhere to these guidelines and to examine factors associated with improved prescribing. METHODS: Electronic medical records were reviewed for 126 patients with active colchicine prescriptions for prophylaxis of gout flares. Colchicine prescribing was defined as inappropriate if 1) no concurrent urate-lowering therapy was prescribed, 2) uric acid was not at goal and urate-lowering therapy had not been increased in the past 3 months, or 3) uric acid goals were met for >1 year and flares had resolved in the absence of tophi. RESULTS: Colchicine use was considered inappropriate in 93 patients (73.8%). Thirty-four were prescribed no urate-lowering therapy, 50 were above the uric acid goal without urate-lowering therapy increase in the prior 3 months, and 9 were at the uric acid goal for >1 year without flares or tophi. Patients appropriately prescribed colchicine were younger and were more likely to have been seen by a rheumatologist. Allopurinol dose and allergy, uric acid level, and renal function were similar in the 2 groups. CONCLUSION: We found a high prevalence of what we considered inappropriate prophylactic colchicine use, driven largely by failure to prescribe concurrent urate-lowering therapies or adequately increase these medications. Rheumatology consultation was associated with improved colchicine prescribing.

Case report: acute thrombotic occlusion and pseudoaneurysm of the brachial artery diagnosed by Doppler ultrasound after nondiagnostic angiography.

The swift and accurate diagnosis of acute arterial occlusion and limb ischemia is critical to prevent morbidity from this vascular emergency as reported by Bettman et al. (Radiology 215:101-105, 2000). There are a number of imaging modalities available to the diagnosing physician. However, the most appropriate modality may vary according to the clinical presentation. We present an atypical case of acute thrombosis of the brachial artery, which could not be diagnosed by conventional angiography, but was identified successfully with Doppler ultrasound. We also briefly discuss the issues surrounding vascular imaging in this case and overview the strengths and weaknesses of available imaging modalities.

Synovial sarcoma of the foot mimicking acute gouty arthritis.

Synovial sarcoma is a slow-growing soft tissue sarcoma that mainly affects young adults. Patients commonly present with a slowly enlarging mass in the paraarticular regions of extremities. We describe a case of synovial sarcoma with an unusually acute presentation near the first metatarsophalangeal joint that resembled acute gouty arthritis.

Cognitive behavioral therapy and aerobic exercise for Gulf War veterans' illnesses: a randomized controlled trial.

CONTEXT: Gulf War veterans' illnesses (GWVI), multisymptom illnesses characterized by persistent pain, fatigue, and cognitive symptoms, have been reported by many Gulf War veterans. There are currently no effective therapies available to treat GWVI. OBJECTIVE: To compare the effectiveness of cognitive behavioral therapy (CBT), exercise, and the combination of both for improving physical functioning and reducing the symptoms of GWVI. DESIGN, SETTING, AND PATIENTS: Randomized controlled 2 x 2 factorial trial conducted from April 1999 to September 2001 among 1092 Gulf War veterans who reported at least 2 of 3 symptom types (fatigue, pain, and cognitive) for more than 6 months and at the time of screening. Treatment assignment was unmasked except for a masked assessor of study outcomes at each clinical site (18 Department of Veterans Affairs [VA] and 2 Department of Defense [DOD] medical centers). INTERVENTIONS: Veterans were randomly assigned to receive usual care (n = 271), consisting of any and all care received from inside or outside the VA or DOD health care systems; CBT plus usual care (n = 286); exercise plus usual care (n = 269); or CBT plus exercise plus usual care (n = 266). Exercise sessions were 60 minutes and CBT sessions were 60 to 90 minutes; both met weekly for 12 weeks. MAIN OUTCOME MEASURES: The primary end point was a 7-point or greater increase (improvement) on the Physical Component Summary scale of the Veterans Short Form 36-Item Health Survey at 12 months. Secondary outcomes were standardized measures of pain, fatigue, cognitive symptoms, distress, and mental health functioning. Participants were evaluated at baseline and at 3, 6, and 12 months. RESULTS: The percentage of veterans with improvement in physical function at 1 year was 11.5% for usual care, 11.7% for exercise alone, 18.4% for CBT plus exercise, and 18.5% for CBT alone. The adjusted odds ratios (OR) for improvement in exercise, CBT, and exercise plus CBT vs usual care were 1.07 (95% confidence interval [CI], 0.63-1.82), 1.72 (95% CI, 0.91-3.23), and 1.84 (95% CI, 0.95-3.55), respectively. The OR for the overall (marginal) effect of receiving CBT (n = 552) vs no CBT (n = 535) was 1.71 (95% CI, 1.15-2.53) and for exercise (n = 531) vs no exercise (n = 556) was 1.07 (95% CI, 0.76-1.50). For secondary outcomes, exercise alone or in combination with CBT significantly improved fatigue, distress, cognitive symptoms, and mental health functioning, while CBT alone significantly improved cognitive symptoms and mental health functioning. Neither treatment had a significant impact on pain. CONCLUSION: Our results suggest that CBT and/or exercise can provide modest relief for some of the symptoms of chronic multisymptom illnesses such as GWVI.

Are there distinctive inflammatory flares after hylan g-f 20 intraarticular injections?

OBJECTIVE: This survey was designed to examine features of a group of patients with acute painful joint effusions following hylan G-F 20 (Synvisc) knee injections. METHODS: Eight patients with painful local reactions after intraarticular hylan G-F 20 injections for knee osteoarthritis were evaluated clinically, with detailed synovial fluid analysis, and followed for outcome. RESULTS: Leukocyte counts ranged from 3150 to 103,000/mm3. Crystals were seen in one patient. Inflammatory knee effusions occurred from 1 to 48 h after injections, but never with first injections. Synovial fluid volumes were 30 to 71 mm(3). Three patients had shiny clumps (not further characterized) that were noted in leukocytes on Wright stained smears. Most patients were treated with aspiration and depot steroids. Five of the 8 patients had moderate or greater improvement at 6 months. CONCLUSION: The majority of the occasional dramatic episodes of inflammation after hylan G-F 20 injection do not seem to be related to crystals. No detrimental lasting results were noted. The absence of post-hylan flares following the first intraarticular injection in this small series suggests that sensitization to or accumulation of hylan G-F 20 or its breakdown products may play an etiologic role in these flares.