Development of a patient decision aid for the initiation of urate-lowering therapy in gout patients
Aim: Shared decision-making improves patients’ experiences with care, satisfaction with management decisions and possibly health outcomes. This study describes the development of a decision aid (DA) that supports patients with gout and their physicians in a face-to-face clinical setting to (a) decide whether or not to (re)start urate-lowering therapy (ULT) and (b) agree on the preferred ULT.
Methods: Recommendations of the International Patient Decision Aid Standards group guided the development. A steering group of experts in gout and health services research specified the scope. Nominal group technique meetings were organised in which patients ranked the importance of preidentified potential characteristics/attributes of ULT and discussed further needs regarding the DA. A literature search was conducted to collect evidence on gout outcomes with and without ULT. Subsequently, the DA prototype was designed and adjusted using feedback from the steering group and results of cognitive debriefing interviews among five gout patients.
Results: The final DA consists of six pages. First, the DA clarifies the decision at stake and describes gout including its risk factors, the role of lifestyle and treatment of flares. Next, risk of future flares with and without ULT in relation to serum uric acid levels is described and visualised. Relevant attributes of ULT are presented in an option grid distinguishing first-line and second-line ULT. Finally, patients’ believes and preferences are explicitly addressed before making the shared decision.
Conclusion: This study provides initial support for usability of a DA for gout patients eligible for starting ULT.
Gout is associated with worse post-PCI long term outcomes
Background: Gout is a common chronic inflammatory disease with increasing prevalence over the last decades. However, there is limited evidence on outcomes of PCI in patients with gout.
Methods: A Retrospective cohort study of all adult patients who underwent PCI in a large [1000 bed] tertiary care center from January 2002 to August 2020. Patients were stratified according to a diagnosis of gout. The primary outcome was defined as the first event of all-cause mortality or major CV event that included acute coronary syndrome -(ACS) or congestive heart failure -(CHF) related admission. To examine the association between gout and outcome, a multi-variable cox proportional hazard model was used.
Results: Out of 12,951 who patients underwent PCI during the study period, 344 (2.7%) had a diagnosis of gout. The study median follow-up time was 105 months. Patients with gout had significantly higher crude rates of clinical events (73.8% vs. 59.5%, p < 0.001). Gout was associated with increased risk for ACS and HF-admissions [HR 1.24 95%CI (1.07-1.43), p = 0.04; HR 1.99, 95%CI (1.57-2.54) p < 0.001, respectively], as well as for any clinical event (HR 1.2 95%CI (1.04-1.38), P = 0.01).
Conclusion: Gout is associated with increased post-PCI cardiovascular risk. Therefore, patients with gout should be considered as a higher risk cohort.
Distinct Gut Microbiota in Patients with Asymptomatic Hyperuricemia: A Potential Protector against Gout Development
Purpose: Here, we aimed to elucidate the differences in microbiota composition between patients with gout and those with asymptomatic hyperuricemia (asHU) and determine the effect of uric acid-lowering therapy (ULT) on the gut microbiome.
Materials and methods: Stool samples from patients with asHU (n=8) and three groups of gout patients, i.e., acute gout patients before ULT (0ULT, n=14), the same acute gout patients after 30-day ULT (30ULT, n=9), and chronic gout patients after ≥6-month ULT (cULT, n=18) were collected and analyzed using 16S rRNA gene-based pyrosequencing. The composition of microbial taxonomy and communities, species diversity, and relationships among microbial communities were elucidated by bioinformatic analysis.
Results: Gout patients showed less diverse gut microbiota than asHU patients. The microbiota of the asHU group exhibited a higher Firmicutes-to-Bacteroidetes (F/B) ratio and lower Prevotella-to-Bacteroides (P/B) ratio than the gout group; significantly, the F/B ratio increased in gout patients after ULT. Moreover, a balanced enterotype populated asHU patients compared to gout patients. Notably, the gut microbiota in asHU patients had a higher proportion of taxa with potentially anti-inflammatory effects compared to the gut microbiota in gout patients.
Conclusion: We found that microbial composition differs between asHU and gout patients. The differential gut microbiota in asHU patients may protect against gout development, whereas that in gout patients may have a role in gout provocation. ULT in gout patients altered the gut microbiota, and may help alleviate gout pathology and mitigate gout progression.
CT image findings of spinal gout
Background: Spinal gout is uncommon. The clinical manifestations of spinal gout are not characteristic. Huge tophi can invade the vertebral joints and protrude into the spinal canal, even causing spinal canal stenosis, which may result in irreparable spinal cord injury. Therefore, early diagnosis and treatment is very important. Summarizing the imaging features of spinal gout may help clinicians with an early diagnosis and promptly intervention.
Study design: Retrospective case series.
Objectives: To describe the findings from computed tomography (CT) images of spinal gout, including the tophi location, growth pattern, involvement of adjacent joints, and differentiation from other spinal lesions.
Methods: We analyzed CT images from the atlantoaxial joint and lumbar spine in 17 cases with spinal gout.
Results: 17 cases had tophi as high-density masses. 14 (82.4%) cases involved lumbar facet joints, including 7(41.2%)cases involving single vertebral facet joints and 7(41.2%) cases involving multiple vertebral facets. CT imaging showed bone resorption and erosion of the facet joints, as well as narrowing of the joint space. The other three cases (17.6%) involved the atlantoaxial joint, showing a high-density mass around the odontoid process with bone resorption and invasion under the articular surface. One case was secondary to a pathological fracture. Four cases (23.6%) showed a huge mass protruding into the spinal canal where the nerve root was compressed, and even spinal cord injury, leading to serious lower back pain symptomatic of brachial plexus or sciatic nerve compression, and even affected the motor function of lower limbs.
Conclusions: In cases with gouty arthritis involving the axial spine, the lower lumbar spine is mainly involved, high-density tophi grow forward and backward around the facet joints, CT image shows bone resorption, erosion of facet joints, and narrowing of the joint space. With atlantoaxial joint involvement, there was evidence of bone resorption combined with joint.
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Gout. What’s up doc?
A considerable improvement in the knowledge of gout has taken place in the 2decades of the XXIth century. Definitions of disease, estate, and clinical situations, along with a new nomenclature, have been agreed. More importantly, the concept of gout as a “curable” or “controllable” disease has been settled. We know for the first time its prevalence in Spain. Factors associated to disease, the genetics that condition the predisposition to develop hyperuricemia and the structure and functions of the transportome complex that control the renal and intestinal handling of urate have been examined. Imaging techniques have come to support diagnosis.
Different primary therapeutic targets have been defined depending on the burden of disease, and targets for secondary prevention considered. We know how to best prescribe available medications and prevent the risk of adverse events. Finally, we have understood the importance of adherence, education, and empower patients during treatment instead of blaming them.