Gout – An update of aetiology, genetics, co-morbidities and management

Gout is an increasingly common chronic disorder of urate crystal deposition that manifests as flares of acute inflammatory arthritis. Hyperuricaemia is a prerequisite and a fifth of both men and woman are hyperuricaemic. The prevalence of gout is much lower than the prevalence of hyperuricaemia for reasons that are not currently clear. Gout is more common in men than women prior to menopause due to the uricosuric effects of oestrogen, but after menopause the incidence of gout rises substantially in women. Co-morbidities are an important issue in gout, with cardiovascular disease, diabetes mellitus, obesity and chronic kidney disease all common in patients with gout. Environmental factors like diet affect the incidence of gout but there is little evidence to support an emphasis on diet in treating established gout. The diagnosis of gout is often made without the use of joint aspiration and validated diagnostic rules are available for both primary and secondary care as well as classification criteria for research use. The overarching principle of the management of gout with pharmacotherapy is the need to reduce serum urate levels to below a target of 0.30 mmol/L or 0.36 mmol/L depending on whether it is tophaceous or non-tophaceous respectively. The use of allopurinol has been researched extensively and newer strategies for safer effective dosing are now recommended. Newer agents have been introduced for the treatment of gout, including febuxostat and lesinurad. A number of important questions in the field are under current investigation

Characteristics and outcomes of people with gout hospitalized due to COVID-19: data from the COVID-19 Global Rheumatology Alliance Physician - reported registry

Objective. To describe people with gout who were diagnosed with coronavirus disease 2019 (COVID-19) and hospitalized and to characterize their outcomes. Methods. Data on patients with gout hospitalized for COVID-19 between March 12, 2020, and October 25, 2021,were extracted from the COVID-19 Global Rheumatology Alliance registry. Descriptive statistics were used to describethe demographics, comorbidities, medication exposures, and COVID-19 outcomes including oxygenation or ventilation support and death. Results. One hundred sixty-three patients with gout who developed COVID-19 and were hospitalized were included. The mean age was 63 years, and 85% were male. The majority of the group lived in the Western Pacific Region (35%) and North America (18%). Nearly half (46%) had two or more comorbidities, with hypertension (56%), cardiovascular disease(28%), diabetes mellitus (26%), chronic kidney disease (25%), and obesity (23%) being the most common. Glucocorticoids and colchicine were used pre-COVID-19 in 11% and 12% of the cohort, respectively. Over two thirds (68%) ofthe cohort required supplemental oxygen or ventilatory support during hospitalization. COVID-19-related death wasreported in 16% of the overall cohort, with 73% of deaths documented in people with two or more comorbidities. Conclusion. This cohort of people with gout and COVID-19 who were hospitalized had high frequencies of ventilatory support and death. This suggests that patients with gout who were hospitalized for COVID-19 may be at risk of poor outcomes, perhaps related to known risk factors for poor outcomes, such as age and presence of comorbidity

Effects of a large wildfire on vegetation structure in a variable fire mosaic

Management guidelines for many fire-prone ecosystems highlight the importance of maintaining a variable mosaic of fire histories for biodiversity conservation. Managers are encouraged to aim for fire mosaics that are temporally and spatially dynamic, include all successional states of vegetation, and also include variation in the underlying "invisible mosaic" of past fire frequencies, severities, and fire return intervals. However, establishing and maintaining variable mosaics in contemporary landscapes is subject to many challenges, one of which is deciding how the fire mosaic should be managed following the occurrence of large, unplanned wildfires. A key consideration for this decision is the extent to which the effects of previous fire history on vegetation and habitats persist after major wildfires, but this topic has rarely been investigated empirically. In this study, we tested to what extent a large wildfire interacted with previous fire history to affect the structure of forest, woodland, and heath vegetation in Booderee National Park in southeastern Australia. In 2003, a summer wildfire burned 49.5% of the park, increasing the extent of recently burned vegetation (<10 yr post-fire) to more than 72% of the park area. We tracked the recovery of vegetation structure for nine years following the wildfire and found that the strength and persistence of fire effects differed substantially between vegetation types. Vegetation structure was modified by wildfire in forest, woodland, and heath vegetation, but among-site variability in vegetation structure was reduced only by severe fire in woodland vegetation. There also were persistent legacy effects of the previous fire regime on some attributes of vegetation structure including forest ground and understorey cover, and woodland midstorey and overstorey cover. For example, woodland midstorey cover was greater on sites with higher fire frequency, irrespective of the severity of the 2003 wildfire. Our results show that even after a large, severe wildfire, underlying fire histories can contribute substantially to variation in vegetation structure. This highlights the importance of ensuring that efforts to reinstate variation in vegetation fire age after large wildfires do not inadvertently reduce variation in vegetation structure generated by the underlying invisible mosaic. © 2017 by the Ecological Society of America

A Nonrestrictive Approach to Fluoroquinolone Stewardship at Two Community Hospitals

Background Fluoroquinolones are one of the most prescribed antimicrobials in the United States and have been increasingly used in inpatient and outpatient settings to treat various infectious diseases syndromes. Due to the unwanted collateral effects on antibiotic resistance, poor susceptibility rates among Gram-negative pathogens, and adverse effects, fluoroquinolones are often targeted by hospital antimicrobial stewardship programs to prevent overutilization. This study describes the association of nonrestrictive antimicrobial stewardship interventions at 2 nonacademic community hospitals on levofloxacin utilization, prescribing patterns on alternative antibiotics, and Pseudomonas aeruginosa nonsusceptibility rates to levofloxacin. Methods Nonrestrictive antimicrobial stewardship interventions included monitoring and reporting of fluoroquinolone susceptibility trends to physician groups, performing medication use evaluations of levofloxacin accompanied with prescriber detailing, daily prospective audit and feedback, implementation of beta-lactam-based institutional guidelines for empiric therapy in various infectious disease syndromes, review and adjustment of electronic medical record order sets containing fluoroquinolones, and intensive prescriber education. No preauthorization of levofloxacin was used during this study period. Antibiotic utilization data were collected for the time periods of August 2015 through January 2021. Correlation between levofloxacin and other broad-spectrum antibiotc use was investigated as well as the impact on Pseudomonas aeruginosa levofloxacin nonsusceptibility rates. Results Both hospitals showed an overall downward trend in the prescribing of levofloxacin during the time period of August 2015 to January 2021. There was a significant negative correlation between monthly ceftriaxone and levofloxacin days of therapy for both hospitals (P \u3c .0001). There was a positive correlation between levofloxacin days of therapy and P aeruginosa nonsusceptibility (P \u3c .02 at both hospitals). Conclusions Our results demonstrate that a nonrestrictive approach to fluoroquinolone stewardship interventions had a significant impact on reducing levofloxacin utilization, increasing ceftriaxone utilization, and improving P aeruginosa levofloxacin susceptibility

Appropriate dairy calf feeding from birth to weaning: “it’s an investment for the future”

© 2020 by the authors. Licensee MDPI, Basel, Switzerland. Dairy calves must be fed appropriately to meet their nutritional needs, supporting optimal growth and development to achieve the recommended target age at first calving (AFC) of 24 months. Traditional restricted milk feeding practices suppress growth, contribute to negative welfare states and may result in malnutrition and immunosuppression. Despite more recent recommendations to increase milk allowances for pre-weaned calves, restricted feeding remains a common practice. This study explored the rationales behind the calf feeding protocols used by dairy farmers in England. Forty qualitative interviews (26 farmers, 14 advisors) were conducted between May 2016 and June 2017, transcribed in full, then coded into themes. Results indicate that a variety of calf feeding regimes are used on farms, largely determined by farmers’ attitudes regarding ease of management and the wellbeing of calves. Advisors were concerned about widespread underfeeding of calves, which may be partially due to insufficiently clear recommendations for calf milk replacer (CMR) feeding rates. There was also evidence of uncertainty regarding best practices for weaning calves. Collaboration between academic research and industry is essential to establish a consensus on calf feeding standards which support physiological function, facilitate weaning, support growth targets and ensure calf health and welfare is protected

Personal non-commercial use only

ABSTRACT. Objective. The central strategy for effective gout management is longterm urate-lowering therapy to maintain the serum urate at a level below 0.36 mmol/l. We sought to determine the prevalence of gout and the quality of care in a national Australian general practice population. Methods. Data were from general practice point-of-care electronic records over a 5-year period (n = 1,479,449). Information was collected on patients with gout according to a validated definition. All patients who visited the same general practices over the study period formed the denominator group. We determined the estimated prevalence of gout, the frequency of allopurinol prescription, and serum urate testing, and the percentage of patients achieving a target serum urate level. Results. The crude prevalence of gout in this general practice population was 1.54% (95% CI 1.52-1.56). Prevalence in men was 2.67% and in women 0.53%. Prevalence increased with age in both men and women (4.90%, 95% CI 4.82-4.99, in men &gt; 65 yrs). Allopurinol was prescribed to 57% of patients with gout during the 5 years of the study. Only 55% of patients with gout had their serum urate tested at any time during the 5-year study period. A target serum urate concentration of &lt; 0.36 mmol/l at any time during the 5-year study period was documented in 22.4% of all people with gout. Conclusion. Gout is managed poorly in Australian primary care, with low levels of allopurinol prescribing and serum urate testing. Collectively, these factors probably contribute to low achievement of serum urate targets

Personal non-commercial use only

ABSTRACT. Objective. The central strategy for effective gout management is longterm urate-lowering therapy to maintain the serum urate at a level below 0.36 mmol/l. We sought to determine the prevalence of gout and the quality of care in a national Australian general practice population. Methods. Data were from general practice point-of-care electronic records over a 5-year period (n = 1,479,449). Information was collected on patients with gout according to a validated definition. All patients who visited the same general practices over the study period formed the denominator group. We determined the estimated prevalence of gout, the frequency of allopurinol prescription, and serum urate testing, and the percentage of patients achieving a target serum urate level. Results. The crude prevalence of gout in this general practice population was 1.54% (95% CI 1.52-1.56). Prevalence in men was 2.67% and in women 0.53%. Prevalence increased with age in both men and women (4.90%, 95% CI 4.82-4.99, in men &gt; 65 yrs). Allopurinol was prescribed to 57% of patients with gout during the 5 years of the study. Only 55% of patients with gout had their serum urate tested at any time during the 5-year study period. A target serum urate concentration of &lt; 0.36 mmol/l at any time during the 5-year study period was documented in 22.4% of all people with gout. Conclusion. Gout is managed poorly in Australian primary care, with low levels of allopurinol prescribing and serum urate testing. Collectively, these factors probably contribute to low achievement of serum urate targets

Maternal serum retinol and B-carotene concentrations and neonatal bone mineralisation: Results from the Southampton Women's Survey cohort

Background: studies in older adults and animals have suggested contrasting relations between bone health and different vitamin A compounds. To our knowledge, the associations between maternal vitamin A status and offspring bone development have not previously been elucidated.Objective: we examined the associations between maternal serum retinol and ?-carotene concentrations during late pregnancy and offspring bone mineralization assessed at birth with the use of dual-energy X-ray absorptiometry.Design: in the Southampton Women’s Survey mother-offspring birth cohort, maternal health, lifestyle, and diet were assessed prepregnancy and at 11 and 34 wk of gestation. In late pregnancy, maternal serum retinol and ?-carotene concentrations were measured. Offspring total body bone mineral density (BMD), bone mineral content (BMC), and bone area (BA) were measured within 2 wk after birth.Results: in total, 520 and 446 mother-offspring pairs had measurements of maternal serum retinol and ?-carotene, respectively. Higher maternal serum retinol in late pregnancy was associated with lower offspring total body BMC (? = ?0.10 SD/SD; 95% CI: ?0.19, ?0.02; P = 0.020) and BA (? = ?0.12 SD/SD; 95% CI: ?0.20, ?0.03; P = 0.009) but not BMD. Conversely, higher maternal serum ?-carotene concentrations in late pregnancy were associated with greater total body BMC (? = 0.12 SD/SD; 95% CI: 0.02, 0.21; P = 0.016) and BA (? = 0.12 SD/SD; 95% CI: 0.03, 0.22; P = 0.010) but not BMD.Conclusions: maternal serum retinol and ?-carotene concentrations had differing associations with offspring bone size and growth at birth: retinol was negatively associated with these measurements, whereas ?-carotene was positively associated. These findings highlight the need for further investigation of the effects of maternal retinol and carotenoid status on offspring bone developmen

Bringing Agriculture into the GATT: Assessing the Benefits of Trade Liberalization

International Relations/Trade,

High rates of infection by blood parasites during the nestling phase in UK Columbids with notes on ecological associations

Studies of blood parasite infection in nestling birds rarely find a high prevalence of infection. This is likely due to a combination of short nestling periods (limiting the age at which nestlings can be sampled) and long parasite prepatent periods before gametocytes can be detected in peripheral blood. Here we examine rates of blood parasite infection in nestlings from three Columbid species in the UK. We use this system to address two key hypotheses in the epidemiology of avian haemoparasites: first, that nestlings in open nests have a higher prevalence of infection; and second, that nestlings sampled at 14 days old have a higher apparent infection rate than those sampled at 7 days old. Open-nesting individuals had a 54% infection rate compared with 25% for box-nesters, probably due to an increased exposure of open-nesting species to dipteran vectors. Nestlings sampled at 14 days had a 68% infection rate compared with 32% in nestlings sampled at 7 days, suggesting that rates of infection in the nest are high. Further work should examine nestlings post-fledging to identify rates of successful parasite infection (as opposed to abortive development within a dead-end host) as well as impacts on host post-fledging survival and behaviour