2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of gout.

Although gout is the most common inflammatory arthritis, it is still frequently misdiagnosed. New data on imaging and clinical diagnosis have become available since the first EULAR recommendations for the diagnosis of gout in 2006. This prompted a systematic review and update of the 2006 recommendations. A systematic review of the literature concerning all aspects of gout diagnosis was performed. Recommendations were formulated using a Delphi consensus approach. Eight key recommendations were generated. A search for crystals in synovial fluid or tophus aspirates is recommended in every person with suspected gout, because demonstration of monosodium urate (MSU) crystals allows a definite diagnosis of gout. There was consensus that a number of suggestive clinical features support a clinical diagnosis of gout. These are monoarticular involvement of a foot or ankle joint (especially the first metatarsophalangeal joint); previous episodes of similar acute arthritis; rapid onset of severe pain and swelling; erythema; male gender and associated cardiovascular diseases and hyperuricaemia. When crystal identification is not possible, it is recommended that any atypical presentation should be investigated by imaging, in particular with ultrasound to seek features suggestive of MSU crystal deposition (double contour sign and tophi). There was consensus that a diagnosis of gout should not be based on the presence of hyperuricaemia alone. There was also a strong recommendation that all people with gout should be systematically assessed for presence of associated comorbidities and risk factors for cardiovascular disease, as well as for risk factors for chronic hyperuricaemia. Eight updated, evidence-based, expert consensus recommendations for the diagnosis of gout are proposed.

Risk of malignancy in rheumatoid arthritis patients initiating biologics: an historical propensity score matched cohort study within the French nationwide healthcare database.

OBJECTIVE: To compare the risk of malignancy between patients with rheumatoid arthritis (RA) initiating their first biological disease-modifying antirheumatic drug (bDMARD) and those continuing conventional synthetic DMARDs (csDMARDs). METHODS: Nine-year historical Propensity Score (PS) matched cohort study within the French national healthcare database (87% of the French population; ~57 million people), including adults RA without malignancy. Exposures started with the first use of any systemic treatment (csDMARDs and/or bDMARDs). Incident users of bDMARDs were matched on a dynamic PS to patients continuing csDMARDs. Their risk of malignancy was compared by Cox model. RESULTS: From 1 January 2007 to 31 December 2014, 83 706 patients with RA started their first systemic treatment (63 837 remained on csDMARDs and 19 869 initiated a bDMARD during follow-up). After dynamic PS matching, 19 727 bDMARD initiators were compared with 19 727 RA remaining on csDMARDs. They did not statistically differ in risk of overall malignancies (HR 0.99 (95% CI 0.86 to 1.14)), solid cancer (HR 0.95 (95% CI 0.82 to 1.11)), nor lymphoma (HR 1.35 (95% CI 0.72 to 2.53)). Results were similar when bDMARDs were given as monotherapy or in association with csDMARDs. Analyses restricted to patients starting TNF inhibitor as first bDMARD compared with matched RA remaining on csDMARDs, provided similar results (HR for overall malignancy 1.03 (95% CI 0.88 to 1.21)). Sensitivity analyses, varying carry-over periods (up to 5 years) to define risk periods, provided similar results. CONCLUSIONS: In this historical cohort study within the French nationwide healthcare database, the risk of overall, solid or haematological malignancies did not significantly differ between patients with RA initiating bDMARD and those continuing csDMARDs.

Papillary thyroid carcinoma presenting with a right preauricular and intracranial mass

p style=text-align: justify;strongOBJECTIVE:/strong To describe a case of a papillary thyroid carcinoma presenting with a preauricular and an intracranial mass and review the literature on the metastatic nature and invasiveness of papillary thyroid carcinoma.br /br /strongMETHODS:/strong br /strongDesign:/strong Case Report br /strongSetting:/strong Tertiary Private Hospital br /strongPatient:/strong One br /br /strongRESULTS:/strong A 46-year-old female with a 12-year anterior neck mass and a two-year right pre-auricular pleomorphic adenoma on fine needle aspiration biopsy was found to have an intracranial mass on CT- scan. Total thyroidectomy and section biopsy of the preauricular mass yielded a final histopathologic report of follicular variant of papillary carcinoma, thyroid gland; and metastatic papillary thyroid carcinoma, follicular type, pre-auricular mass. The condition of the patient precluded neurosurgical intervention and RAI therapy and she underwent 23 sessions of external radiotherapy using 46Gy with significant diminution in size of the intracranial metastasis.br /br /strongCONCLUSION:/strong Papillary thyroid malignancy may be an indolent tumor but it is capable of distant metastasis. We should be alerted by host and tumor factors which can be predictors of a more radical papillary malignant disease whose management entails proper staging evaluation and good communication of prognostic data and available, realistic therapeutic options to patients using a multidisciplinary approach./p