The GOUT-36 prediction rule for inpatient gout flare in people with comorbid gout: derivation and external validation.

OBJECTIVES: To develop and validate a gout flare risk stratification tool for people with gout hospitalized for non-gout conditions. METHODS: The prediction rule for inpatient gout flare was derived from a cohort of 625 hospitalized people with comorbid gout from New Zealand. The rule had four items: no pre-admission gout flare prophylaxis, no pre-admission urate-lowering therapy, tophus and pre-admission serum urate >0.36 mmol/l within the previous year (GOUT-36 rule). Two or more items are required for the classification of high risk for developing inpatient gout flares. The GOUT-36 rule was validated in a prospective cohort of 284 hospitalized people with comorbid gout from Thailand and China. RESULTS: The GOUT-36 rule had a sensitivity of 75%, specificity of 67% and area under the curve of 0.71 for classifying people at high risk for developing inpatient gout flares. Four risk groups were developed: low (no items), moderate (one item), high (two items) and very high risk (three or four items). In a population with frequent (overall 34%) in-hospital gout flares, 80% of people with very high risk developed inpatient flares while 11% with low risk had inpatient flares. CONCLUSION: The GOUT-36 rule is simple and sensitive for classifying people with high risk for inpatient gout flares. The rule may help inform clinical decisions and future research on the prevention of inpatient gout flares.

Effect of caffeinated and decaffeinated coffee on serum uric acid and uric acid clearance, a randomised within-subject experimental study.

OBJECTIVES: The effect of coffee on serum uric acid (SUA) has shown conflicting results. This study was to determine the effects of caffeinated coffee (CC) and decaffeinated coffee (DC) on SUA, serum xanthine oxidase activity (sXOA) and urine uric acid clearance (UAC). METHODS: This was a prospective randomised within-subject experimental study design of 51 healthy male participants. Each study period consisted of 3 periods, including a control, an intervention, and washout period for 1, 3 and 1 week, respectively. During the intervention period, the participants received 2, 4 or 6 gram/day of coffee, either CC or DC. RESULTS: For DC groups, SUA significantly decreased by 6.5 (±1.1) mg/dL to 6.2 (±1.1) mg/dL during the intervention period (p=0.014). sXOA significantly increased by 0.05 (±0.07) nmol/min/mL to 0.20 (±0.38) nmol/min/mL during the intervention period (p=0.010) of CC. For UAC, there was no significant change with CC or DC. In hyperuricaemic participants, SUA significantly decreased by 7.7 (±0.7) mg/dL to 7.2 (±0.7) mg/dL during the intervention period (p=0.028) of DC. For non-hyperuricaemic, CC significantly increased SUA by 5.9 (±0.7) mg/dL to 6.2 (±0.9) mg/dL during the intervention period (p=0.008) and significantly decreased SUA to 6.0 (±0.8) mg/dL (p=0.049) during the withdrawal period. A significant increase of sXOA according with SUA in CC groups from 0.05 (±0.07) nmol/min/mL to 0.25 (±0.44) nmol/min/mL during the intervention period (p=0.040) was presented in non-hyperuricaemic participants. CONCLUSIONS: DC had a significant decrease of SUA during the intervention period. However, in non-HUS participants, SUA significantly increased in CC.

Quality of gout care in the emergency departments: a multicentre study.

BACKGROUND: To report on prevalence of gout flare in emergency departments and to report the quality of gout care in emergency departments and causes of admission at emergency departments. METHODS: A retrospective chart review of visits that had a primary diagnosis in gout by the International Classification of Diseases, the tenth revision, at emergency departments from 6 universities in Thailand over a 5 year period from 1 January 2012 to 31 December 2016. RESULTS: Six hundred thirty-two visits were included to the study. Prevalence of gout flare in emergency departments was 0.04. Only 29.3% of the visits had arthrocentesis. 628/632 (99.4%) and 519/585 (88.7%) of the visits were prescribed medications in emergency departments and had home medications, respectively. Although all visits that were prescribed colchicine in emergency departments received adequate doses of colchicine, it was also found that more than 2.4 mg/day of colchicine was prescribed (3/394, 0.8%) for home medications. In addition, 183/343 (53.4%) of the visits with normal renal function were prescribed non-steroidal anti-inflammatory drugs (NSAIDs). However, prescribed NSAIDs in abnormal renal function (42/343, 12.2%) was also found. The interruption of dosing, including increase, decrease, addition or discontinuance of urate lowing therapy in a gout flare period was 42/632 (6.6%). The most common cause of admission was acute gouty arthritis (31/47, 66.0%). CONCLUSIONS: Quality of gout care in the emergency departments was not good. Inappropriate management of gout flare in emergency departments was demonstrated in our study, particularly with regard to investigations and pharmacological management. Gaps between clinicians and guidelines, the knowledge of clinicians, and overcrowding in emergency departments were hypothesized in the results.

The anatomical pathology of gout: a systematic literature review.

BACKGROUND: The aim of this systematic literature review was to comprehensively describe the anatomical pathology of tissues affected by gout. METHODS: We searched PubMed, The Cochrane Library, Excerpta Medica Database (EMBASE), and Web of Science Core Collection for all English language articles published before March 2018. Articles were included if they described the microscopic or macroscopic appearances of gout in human tissue. RESULTS: Four hundred and seventeen articles met inclusion criteria and were included in the review. Articles describing the anatomical pathology of gout in musculoskeletal structures, including bone, tendon and ligaments, synovium and cartilage, were most common. Articles describing skin and kidney pathology in gout were also common, with pathology in other sites such as visceral organs less common. At all sites, monosodium urate crystal deposition was reported, and the tophus was also described within many different tissues. During a gout flare, diffuse acute neutrophilic synovial inflammation was evident. The tophus was described as an organised chronic giant cell granulomatous structure consisting of monosodium urate crystals, innate and adaptive immune cells, and fibrovascular tissue. CONCLUSIONS: Consistent with the clinical presentation of gout, most studies describing the anatomical pathology of gout report involvement of musculoskeletal structures, with monosodium urate crystal deposition and tophus the most common lesions described. This review details the anatomical pathology features of gout at affected sites.

A Study of Interleukin-2 Production and Nck Adaptor Molecule Gene Expression in Systemic Lupus Erythematosus Patients.

Background: Systemic lupus erythematosus (SLE) is an autoimmune disease. The cause of the disease is related to multiple factors and involves immune responses. To the best of our knowledge, the relationship between the production of interleukin-2 (IL-2) and Nck adaptor molecule gene expression by lymphocytes in patients with SLE has not been studied. Objective: Assess the association between IL-2 levels and Nck mRNA gene expression in CD3/CD28 and PHA/PMA stimulated peripheral blood mononuclear cells (PBMCs) from SLE patients compared with those from healthy donors. Material and Method: The present study included 35 SLE patients and six healthy blood donors. Blood samples from these subjects were isolated to obtain PBMCs. Then Nck mRNA gene expression from these cells were quantitatively assessed using real-time reverse-transcriptase polymerase chain reaction (real-time RT-PCR). After stimulation of the PBMCs either with CD3/CD28 antibodies or PHA/PMA, IL-2 production and CD69 expression were assessed by enzyme-linked immunosorbent assay (ELISA) and flow cytometry, respectively. Results: First, a defect in IL-2 levels was not observed in either CD3/CD28 or PHA/PMA stimulated PBMCs when compared with controls. Second, there was no difference in the Nck1 and Nck2 mRNA expression between the SLE patients and the healthy subjects. Conclusion: We found that in SLE patients lymphocyte production of IL-2 did not decrease when compared with that of normal subjects. The Nck1 and Nck2 mRNA expression was not defective in SLE patients. We did not see any altered relation between IL-2 levels and Nck1 and Nck2 gene expression.

Inter- and Intra-Observer Reliability of Modified Rodnan Skin Score Assessment in Thai Systemic Sclerosis Patients: A Validation for Multicenter Scleroderma Cohort Study.

BACKGROUND: Assessment of the severity of skin tightness by the modified Rodnan skin score (mRSS) for systemic sclerosis (SSc) has been found feasible, valid, and reliable. Despite being a major clinical outcome, it has not yet been validated by Scleroderma Research Group. OBJECTIVE: To (a) determine the inter-observer variability vis-à-vis mRSS assessment by members ofthe Scleroderma Research Group before and after mRSS-assessment training by an experienced rheumatologist and (b) determine intra-observer variability. MATERIAL AND METHOD: Between June and August 2013, we conducted a descriptive study of Thai adult SSc patients and all rheumatologists in the Scleroderma Research Group at Srinagarind Hospital, Khon Kaen University, Northeast Thailand. Eleven rheumatologists assessed the mRSS of 22 SSc patients three times (i.e., before and after training, and eight weeks after training). The intra-class correlation coefficient (ICC) and its 95% CI were estimated at week 8 after training. RESULTS: The mean and standard deviation (SD) of mRSS for inter-observer variability analysis was slightly decreased from before training, after training (by an experienced rheumatologist), and at week 8 after training (17.3 ± 11.9, 16.5 ± 11.1, and 16.2 ± 10.3, respectively). Intra-observer variability had moderate agreement before training (ICC 0.59; 95% CI 0.38-0.78), which increased to good agreement after training and at week 8 after training (ICC 0.60; 95% CI 0.42-0.76 vs. 0.68; 95% CI 0.53-0.82, respectively). CONCLUSION: Inter-observer variability for mRSS assessment decreased after training and the reduction persisted for eight weeks after training. The ICC rose from moderate agreement at baseline to good agreement at the end of the study. The mRSS assessment by members of the Scleroderma Research Group was reliable.

Risk factors and clinical outcomes of extended spectrum beta-lactamase (ESBL)-producing Escherichia coli septicemia at Srinagarind University Hospital, Thailand.

Escherichia coli producing extended spectrum beta-lactamase (ESBL) has emerged as a worldwide, public health problem. The aims of this study were to determine the incidence of ESBL-producing E. coli septicemia and evaluate the factors associated with the infection and the clinical outcomes. We reviewed 145 cases of E. coli septicemia among adult patients admitted to Srinagarind University Hospital in northeastern Thailand between 2005 and 2006. The incidence of ESBL-producing E. coli septicemia was 9.9 cases per 10,000 hospital admissions. The factors significantly associated with ESBL-producing E. coli septicemia were: 1) hospital acquisition [odds ratio (OR) 6.46; 95% confidence interval (CI) 2.01-20.79], 2) previous use of a fluoroquinolone, (OR 19.14; 95% CI 5.82-62.96), and 3) use of a central venous catheter (OR, 8.59; 95% CI, 1.11-66.27). Seventy-two hours after receiving empiric treatment, a significantly greater proportion of patients with ESBL-producing E. coli septicemia had a worse clinical outcome than those with non-ESBL producing E. coli septicemia (p = 0.01). The overall mortality rate was significantly higher among the ESBL-producing E. coli septicemia group than the non-ESBL producing E. coli septicemia group (29% vs 11.5%, respectively, p = 0.02). A high APACHE II score, ESBL-producing E. coli septicemia, primary septicemia, and having a non-urinary tract infecting as a source of septicemia were significantly independent factors related to mortality among patients with E. coli septicemia. ESBL-producing E. coli septicemia is an important cause of nosocomial infection and is related to higher mortality risk, especially among those with primary septicemia and secondary septicemia due to a non-urinary tract infection.

Mid- to long-term outcomes of contemporary total knee arthroplasty in Charcot neuroarthropathy: a systematic review and meta-analysis.

Total knee arthroplasty (TKA) is an effective procedure to treat many patients with end-stage knee arthropathy. However, the extension of TKA for patients with Charcot neuroarthropathy (CNA) is controversial, with relatively limited evidence defining optimal reconstruction techniques.This systematic review of relevant studies that were published from January 2000 to June 2020 aimed to define survivorship, complications, reoperation, and component revision rates of contemporary TKA performed for CNA.We identified 127 TKA performed for CNA in five studies that comprised ≥ 7 knees with ≥ 5 years of follow-up.Overall implant survivorship was 85.4%. The overall complication rate was 26.4%, with the most common complications including instability (24.0%), periprosthetic fracture (17.4%), infection (13.0%), ligament injury (10.9%) and aseptic loosening (10.9%).The aetiology of CNA and prosthesis type had no influence on clinical outcomes, whereas the effect of staging of disease and ataxia status was still inconclusive.Understanding the potential determinants, survivorship and risk of complications related to TKA performed in CNA may help surgeons to deal with patient expectations. Cite this article: EFORT Open Rev 2021;6:556-564. DOI: 10.1302/2058-5241.6.200103.

Urate crystal deposition and bone erosion in gout: 'inside-out' or 'outside-in'? A dual-energy computed tomography study.

BACKGROUND: It is currently unknown whether bone erosion in gout occurs through an 'inside-out' mechanism due to direct intra-osseous crystal deposition or through an 'outside-in' mechanism from the surface of bone. The aim of this study was to examine the mechanism ('outside-in' vs. 'inside-out') of monosodium urate (MSU) crystal deposition in bone erosion in gout. Specifically, we used three-dimensional dual-energy computed tomography (DECT) to analyse the positional relationship between bone and MSU crystal deposition in tophaceous gout, and to determine whether intra-osseous crystal deposition occurs in the absence of erosion. METHODS: One hundred forty-four participants with gout and at least one palpable tophus had a DECT scan of both feet. Two readers independently scored all metatarsal heads (1433 bones available for scoring). For bones in contact with urate, the bone was scored for whether urate was present within an erosion, on the surface of bone or within bone only (true intra-osseous deposit). Data were analysed using generalised estimating equations. RESULTS: Urate in contact with bone was present in 370 (54.3 %) of 681 joints with urate deposition. For those bones in contact with urate, deposition was present on the surface of bone in 143 (38.6 %) of 370 joints and within erosion in 227 (61.4 %) of 370. True intra-osseous urate deposition was not observed at any site (p < 0.0001). For all bones with apparent intra-osseous deposition in one plane, examination in other planes revealed urate deposition within an en face erosion. CONCLUSIONS: In tophaceous gout, MSU crystal deposition is present within the joint, on the bone surface and within bone erosion, but it is not observed within bone in the absence of a cortical break. These data support the concept that MSU crystals deposit outside bone and contribute to bone erosion through an 'outside-in' mechanism.

The association of vitamin C, alcohol, coffee, tea, milk and yogurt with uric acid and gout.

About 2500 years ago, gout was observed by Hippocrates and many people suffered severe pain and deformity. Lifestyle and diet play a significant role in gout and serum uric acid levels. Epidemiological and research studies have supported this evidence. Many recommendations and guidelines from different parts of the world mention the impact of diet on gout. Recently, new research has shown associations between vitamin C, alcohol, coffee, tea, milk and yogurt with uric acid and the risk of gout. Our review summarizes recently published research regarding dietary impact on the risk of gout and serum uric acid levels.