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Study on clinical and paraclinical characteristics of patients with gout disease diagnosed by the 2015 EULAR/ACR criteria

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Objectives: To analyze the clinical and para-clinical characteristics of patients with gout disease diagnosed by the 2015 EULAR/ACR criteria. Subjects and methods: 31 patients who were diagnosed with gout disease were selected. The study had focused on age, gender, lifestyles, history and current patterns of gout, VAS (Visual Analog Scale) index, plasma uric acid levels, hs-CRP, ESR, ultrasound images of affected joints.

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STUDY ON CLINICAL AND PARACLINICAL CHARACTERISTICS

OF PATIENTS WITH GOUT DISEASE DIAGNOSED BY THE 2015

EULAR/ACR CRITERIA

Ton Thanh Tung*; Nguyen Ngoc Chau*

SUMMARY

Objectives: To analyze the clinical and para-clinical characteristics of patients with gout disease diagnosed by the 2015 EULAR/ACR criteria Subjects and methods: 31 patients who were diagnosed with gout disease were selected The study had focused on age, gender, lifestyles, history and current patterns of gout, VAS (Visual Analog Scale) index, plasma uric acid levels, hs-CRP, ESR, ultrasound images of affected joints Results: The majority were male (96.8%) The mean age of onset was 47.3 ± 15.2 years, the common age group of onset was from 20 to 40 (41.9%) and commonly with the heavy pain (74.2%) 45.2% of patients were not diagnosed with the first episode of gout lower than previous study’s with statistical significance, the mean time for the definite diagnosis was 4.64 ± 4.4 years Hs-CRP and ESR were two common inflammatory markers 19.4% of patients had normal range of uric acid The double contour lesion accounted for 29.0% There was a moderate positive correlation between the

2015 EULAR/ACR classification criteria for gout scores and the frequency of recurrence attacks

of gout per year (r = 0.46; p < 0.05) Conclusions: The clinical and para-clinical characteristics of patients were almost consistent with the previous studies There was an increase in the rate of patients diagnosed with the first attack of gout The higher score of the EULAR/ACR 2015 classification for gout predicted the higher frequency of recurrence attacks of gout per year

*Keywords: Gout disease; EULAR/ACR 2015; Clinical, paraclinical characteristics

INTRODUCTION

Gout is the most prevalent form of

inflammatory arthritis and is associated

with impaired quality of life There are

many criteria for diagnosing gout disease,

existing criteria for the classification of

gout have suboptimal sensitivity and/or

specificity and were developed at a time

when advanced imaging was not available

Therefore, it is necessary to develop a

new diagnostic tool The 2015 EULAR/ACR

gout classification criteria are developed

using a data-driven and decision analytic

approach, have excellent performance

characteristics and incorporate current modern evidence regarding gout, has higher sensitivity (92%) and higher specificity (89%) than existing criteria In Vietnam, Bennett & Wood classification criterion has been mainly used to diagnose gout disease, the advantages of these criteria are to diagnose based on clinical manifestations, easy to remember and apply but with low sensitivity and specificity

Thus, this study aims: To use new criteria EULAR/ACR 2015 to diagnose gout disease and analyze the collected clinical and paraclinical characteristics of patients

* 103 Military Hospital

Corresponding author: Nguyen Ngoc Chau (chau70@gmail.com)

Date received: 30/06/2017 Date accepted: 06/08/2017

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SUBJECTS AND METHODS

1 Subjects

* Inclusion criteria:

31 patients including 30 male patients

were treated in the Rheumatology and

Endocrinology Department, 103 Hospital

- Diagnosed with gout disease by the

EULAR/ACR 2015 criteria

- The affected joints were in inflammatory

condition with or without joint effusion

* Exclusion criteria: Suspected bacterial

infection of the joints or other infection

conditions that affect to the evaluation of

the inflammatory investigation results

2 Methods

Cross-sectional, descriptive analysis

* Examination and diagnosis:

- Take a history, age, gender; examine

the affected joints and assess pain levels

of joints (VAS), investigate ESR, hs-CRP,

plasma uric acid concentration, performed

ultrasound the affected joints for detecting

double contour

- Patients with gout disease were

definitely diagnosed by the 2015

EULAR/ACR criteria

* Method of data analysis:

Collected data were analyzed by the

medical statistical method using SPSS

23.0 software

RESULTS AND DISCUSSIONS

1 Clinical and paraclinical

characteristics

* Clinical characteristics:

In total, we identified 31 patients with

gout disease In most cases, the

classification diagnosis was made by the

2015 EULAR/ACR criteria with the total mark more than 8 marks (96.8%) Only one patient with poor clinical findings was diagnosed by detecting urate crystal using polarized light microscopy

In our study, the mean age of onset was rather young (47.3 ± 15.2) The most common age group of onset was 20 - 40 (41.9%) This result was consistent with the result of Hoang Thi Thu Trang (48.8%) It also suggested that the onset

of gout had the tendency of rejuvenation This matched with the tendency of having metabolism diseases in our modern society

The group with overweight and obesity accounted for 41.9%, the mean BMI was 22.4 ± 2.6 This result was also consistent with the result of Hoang Thi Thu Trang studied on Vietnamese (50.1%) In the study of L Annemans (2010), obesity accounted for 27.7% of UK patients [2] According to Lucía Cea Soriano (2011), this rate was 65.99% [6] Recent studies have approved that obesity played an important role in increasing the prevalence

of gout [7]

The heavy pain was the highest ratio (74.2%) and the mean VAS was 73.5 ±

21.2 The result was consistent with the

result of Hoang Thi Thu Trang (68.8%) [1], Pham Thi Minh Nham (79.2%) [5] The result also matched with the intensely painful condition in the pathophysiology of gout

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Table 1: Inhabit of alcoholic beverage using

Min - Max

p

Alcohol (n = 26)

497.9 ± 110.4

Beer (n = 14)

485.2 ± 90.9

> 0.05

We have known that alcohol and beer had played a big role in increasing the uric acid concentration by the mechanisms of overproduction and reduced excretion uric acid In our study, 100% of patients had the history of using too much alcohol or beer in the long term (83.9% of patients used alcohol, 45.2% of patients used beer) The mean

quantity of alcohol using was 108.3 ± 80.9 g/day, the mean quantity of beer using was

57.3 ± 37.2 g/day However, in our study, alcohol and beer affected to the uric acid concentration equally without statistical significance (p > 0.05)

Table 2: Diagnostic features

Diagnosed with the first episode

Time to be definitely diagnosed with gout

disease (years)

4.64 ± 4.4 years

Diagnosing gout has been a challenge

to the physicians in many cases because

of its various manifestations In our study,

there was still a high ratio of patients who

were not diagnosed with the first episode

(45.2%) The mean time for the definite

diagnosis was 4.64 years In the study of

Hoang Thi Thu Trang, this rate was

higher than ours (68.75%, p < 0.05) This

may be in the study of Hoang Thi Thu

Trang using the Bennet Wood criteria so

the sensitivity and the specificity were

lower With whom the diagnosis was not

established by the first episode, the

shortest time for the definite diagnosis was 1 year, the longest time was 15 years and the mean time was 4.64 ± 4.4 years Our result was shorter than the previous study of Le Thi Vien (2006): 5.98 ± 5.9 years [3] and consistent with the result of Hoang Thi Thu Trang (2.34 ± 5.19 years) Because the patients paid more and more attention to their health, so they visited hospital earlier, at the same time, the level of expertise of general doctors have improved and physicians in primary health care facilities have had a better understanding of gout

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* Paraclinical characteristics:

80.6% of patients in our study had

elevated uric acid level The mean plasma

uric acid was 503.9 ± 106.4 µmol/L

These results were consistent with

previous studies Hoang Thi Thu Trang

(69.4%; 499.13 ± 143.0 µmol/L) [1], Pham

Hoai Thu (65.3%; 470.2 ± 120.1 µmol/L)

[4] However, 19.4% of patients were

diagnosed acute gout and acute flare of

chronic gout with normal plasma uric acid

concentration This rate was similar to the

result in the study by Hoang Thi Thu

Trang (30.6%) [1] This result showed that

the uric acid concentration was not the

definitive factor to activate the acute flares

of gout This had reported by previous

studies of many authors [8]

Gout is an inflammatory joint disease

So investigating the markers of inflammatory

condition could show us the level of the

inflammation Hs-CRP, ESR and WBC

were the common inflammatory markers

In our study, the elevated level of hs-CRP

was more common (80.6%), followed by the elevated level of ESR (53.6%), WBC was almost normal (54.8%) with the mean WBC 8.39 ± 4.9 These results were consistent with the results of Hoang Thi Thu Trang (93.8%, 73.1% and 55.9%) [1] The results matched with the clinical manifestations of acute gout and acute flares of chronic gout disease The WBC increased without statistically significant difference (42.5% vs 54.8%, p > 0.05), this was absolutely consistent with the infectious inflammatory process of gout disease Synovitis was the most common lesion

on the ultrasound (41.9%), followed by the double contour (29.0%) This result was also similar to a previous study [1] The double contour was a very valuable lesion for diagnosing gout on ultrasound

It indicated the deposition of urate crystals

in the joints and distributed 4 marks into the total 2015 score if positive In our study, we met 2 cases who were detected tophi on ultrasound (6.5%)

Table 3: Plasma uric acid features

Plasma acid uric

(µmol/L)

80.6% of patients had elevated uric acid level, 19.4% of patients had a normal plasma uric acid level The mean plasma uric acid was 503.9 ± 106.4 µmol/L There was no difference of uric acid level between acute gout and acute flare of chronic gout (p > 0.05)

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2 The correlation of the EULAR/ACR 2015 classification for gout scores with the frequency of recurrent attacks per year

Through analyzing the data of 31 patients, we found that there was a moderate positive correlation between the 2015 EULAR/ACR criteria classification for gout scores and the frequency of recurrence attacks of gout per year (r = 0.46; p < 0.05) These result showed that the higher scores of the EULAR/ACR 2015 classification for gout may predict the higher frequency of recurrence of gout No previous studies mentioned about this We considered if there will be a cut-off value of the 2015 EULAR/ACR classification criteria for gout scores that has meaning in prevention

management of gout but needs more studies

y = 0.8842x - 2.8457

0

5

10

15

20

25

30

EULAR/ACR classification for gout marks

Figure 1: Thecorrelation between theEULAR/ACR 2015 classification for gout scores

with the frequency of recurrence attacks of gout per year

CONCLUSION

- The majority were male (96.8%) with

the mean age of onset 47.3 ± 15.2 years,

the common age group of onset was from

20 to 40 (41.9%) and commonly with the

heavy pain (74.2%) 45.2% of patients

were not diagnosed with the first episode

lower than previous study’s with statistical

significance, the mean time for the

definite diagnosis was 4.64 ± 4.4 years

- 19.4% of patients who were diagnosed

acute gout and acute flare of chronic gout,

had normal value Hs-CRP and ESR were

two common inflammatory markers The double contour lesion accounted for 29.0%

- There was a moderate positive correlation between the EULAR/ACR

2015 classification for gout scores and the frequency of recurrence attacks of gout per year (r = 0.46; p < 0.05)

REFERENCES

1 Hoàng Thị Thu Trang Khảo sát tinh thể

urat trong dịch khớp ở bệnh nhân gout và một

số yếu tố liên quan Luận văn Thạc sỹ Y học Trường Đại học Y Hà Nội 2015

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2 Phạm Thị Minh Nhâm Nghiên cứu giá

trị của một số tiêu chuẩn chẩn đoán bệnh

gout Trường Đại học Y Hà Nội 2011

3 Lê Thị Viên Nghiên cứu đặc điểm lâm

sàng, cận lâm sàng và đánh giá kết quả điều

trị bệnh gout có hạt tôphi Luận văn Tốt

nghiệp Bác sỹ Chuyên khoa Cấp II Trường

Đại học Y Hà Nội 2006

4 Phạm Hoài Thu Nghiên cứu đặc điểm

lâm sàng, cận lâm sàng và hình ảnh siêu âm

khớp cổ chân trong bệnh gout Trường Đại

học Y Hà Nội 2010

5 Annemans L et al Gout in the UK and

Germany: prevalence, comorbidities and

management in general practice 2000 - 2005

Annals of the Rheumatic Diseases 2008, 67

(7), pp.960-966

6 Cea Soriano L et al Contemporary

epidemiology of gout in the UK general population Arthritis Research & Therapy

2011 13 (2), p.R39

7 Smith E.U et al Epidemiology of gout:

an update Best Pract Res Clin Rheumatol

2010, 24 (6), pp.8118-27

8 Schlesinger N Diagnosis of gout:

clinical, laboratory, and radiologic findings

Am J Manag Care 2005, 11 (15 Suppl),

p.S465-8

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