10 research outputs found

    Adherence to the 2012 American College of Rheumatology (ACR) Guidelines for Management of Gout: A Survey of Brazilian Rheumatologists

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    <div><p>Objective</p><p>To describe the current pharmacological approach to gout treatment reported by rheumatologists in Brazil.</p><p>Methods</p><p>We performed a cross-sectional survey study using an online questionnaire e-mailed to 395 rheumatologists, randomly selected, from among the members of the Brazilian Society of Rheumatology.</p><p>Results</p><p>Three hundred and nine rheumatologists (78.2%) responded to the survey. For acute gout attacks, combination therapy (NSAIDs or steroid + colchicine) was often used, even in monoarticular involvement, and colchicine was commonly started as monotherapy after 36 hours or more from onset of attack. During an acute attack, urate-lowering therapy (ULT) was withdrawn by approximately a third of rheumatologists. Anti-inflammatory prophylaxis (98% colchicine) was initiated when ULT was started in most cases (92.4%), but its duration was varied. Most (70%) respondents considered the target serum uric acid level to be less than 6 mg/dl. Approximately 50% of rheumatologists reported starting allopurinol at doses of 100 mg daily or less and 42% reported the initial dose to be 300 mg daily in patients with normal renal function. ULT was maintained indefinitely in 76% of gout patients with tophi whereas in gout patients without tophi its use was kept indefinitely in 39.6%.</p><p>Conclusion</p><p>This is the first study evaluating gout treatment in a representative, random sample of Brazilian rheumatologists describing common treatment practices among these specialists. We identified several gaps in reported gout management, mainly concerning the use of colchicine and ULT and the duration of anti-inflammatory prophylaxis and ULT. Since rheumatologists are considered as opinion leaders in this disease, a program for improving quality of care for gout patients should focus on increasing their knowledge in this common disease.</p></div

    Differences in discriminatory power between the approaches using either the absolute or the relative cell densities.

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    <p>A. Ratio of ratios. Strip chart (1-dimensional scatter plot, log<sub>10</sub>[y]) illustrating discrepancies between the absolute and the relative values in terms of quantitative differences (expressed as ratios) within paired comparisons among the sample groups. Separately for the absolute and the relative values, and for each of the five markers, ratios of expression values were computed for all of the 15 possible paired comparisons among the 6 sample groups, with the presumably more inflamed arthropathy constituting the numerator, resulting in separate expression ratios for the absolute and relative cell densities. Using trimmed means, the ratio of ratios was obtained by the formula: (absolute density<sub>(group 1)</sub> / absolute density<sub>(group 2)</sub>) / (relative density<sub>(group 1)</sub> / relative density<sub>(group 2)</sub>). B. Scatter plot illustrating differences in the discriminatory ability of the relative cell densities (y-axis) compared with the discriminatory ability of the absolute cell densities (x-axis). Each data point (symbol) corresponds to the area under the curve (AUC) for the discriminatory power of one marker within one of the 15 possible pairs of sample groups. AUCs were obtained with binary ROC analysis (Table 2). The black line, intercepting the origin, defines all markers where the absolute and relative methods yield identical AUCs. The red lines (with y-intercept equal to 0.07 and -0.17) define threshold bounds, values beyond which define scenarios in which discrepant AUCs resulted when the absolute and the relative cell densities were used (see legend to Supplemental Fig. S1 for details). The symbol shapes identify the markers used, and the symbol colors the sample group pairs to be differentiated, as detailed in the legends inside the graph. The oval line in the lower right quadrant identifies the paired comparisons in which using the relative cell densities resulted in a reversal of the positive state in the ROC analysis (only data points with significant AUCs [<i>p</i> <0.05, 95% CI not crossing the midline; Supplemental Table S4] were included). </p

    Selected immunohistochemical stains.

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    <p>Less inflamed specimens are arranged in the left column, more inflamed ones in the right column. Stains were done with standard 3-step immunohistochemistry, using diaminobenzidine (DAB) as chromogen (brown) and a hematoxylin counterstain. Original magnifications were 100, 200 or 400x. <b>A</b>: Normal synovium demonstrating the complete absence of CD15+ cells typical for this specimen group. <b>B</b>: Chronic septic arthritis, exhibiting marked infiltration of CD15+ cells (54CD15+ cells/mm<sup>2</sup>, 2% of total inflammatory cells (TIC). C: Normal synovium with low (25 cells/mm<sup>2</sup>) absolute CD68+ cell density, yet constituting a high proportion (55%) of TIC. <b>D</b>: Rheumatoid arthritis (RA) with the characteristic high (573 cells/mm<sup>2</sup>) CD68+ cell density, but representing only 19% of TIC. <b>E</b>: Orthopedic arthropathy with low-grade T cell infiltration (88CD3+ cells/mm<sup>2</sup>; 40% of TIC). The remaining 60% of infiltrating cells consisted nearly entirely of CD68+ cells. <b>F</b>: RA with high absolute (1409 cells/mm<sup>2</sup>) and relative (55% of TIC) CD3+ cell densities. <b>G</b>: Normal synovium demonstrating the characteristic absence of CD20+ cells. <b>H</b>: RA specimen with 236CD20+ cells/mm<sup>2</sup> (9% of TIC). <b>I</b>: Normal synovium demonstrating the characteristic absence of CD38+ cells. <b>J</b>: RA specimen with particularly CD38-rich infiltrates (absolute density: 1109CD38+ cells/mm<sup>2</sup>; relative density: 41% of TIC).</p

    Proportion of correctly classified disease states for the various marker categories as determined with the Bayes classifier.

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    <p><b>Grey bars</b>: prediction with complete sets. The ā€œRelativeā€ set comprised the relative values of CD15+, CD68+, CD3+, CD20+, or CD38+ cells. The set ā€œRelative + TICā€ comprises the ā€œRelativeā€ set plus total inflammatory cells (TIC, sum of absolute expression values of all five markers). The ā€œAbsoluteā€ set comprised absolute densities (cells/mm<sup>2</sup>) of cells expressing CD15+, CD68+, CD3+, CD20+, or CD38+ cells. The set ā€œAbsolute + TICā€ comprised the ā€œAbsoluteā€ set plus TIC. <b>Black bars</b>: wrapper-predicted subsets of markers. ā€œRelativeā€: relative densities of CD15+, CD38+, or CD68+ cells. ā€œRelative + TICā€ relative densities of CD15+ or CD68+ cells, plus TIC. Both the ā€œAbsoluteā€ and ā€œAbsolute + TICā€ sets comprised absolute values of CD15+, CD38+, or CD68+ cells. Abbreviation: TIC, total inflammatory cells.</p

    Multivariate-adjusted predictors of concordance between reported urate-lowering therapy management and the 2012 ACR gout guidelines.

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    <p>ACR: American College of Rheumatology; OR: odds ratio; CI: confidence interval; BSR: Brazilian Society of Rheumatology; CrCl: creatinine clearance. OR lower than 1 represents a reduced chance of concordance with the 2012 ACR gout guidelines.</p><p>Multivariate-adjusted predictors of concordance between reported urate-lowering therapy management and the 2012 ACR gout guidelines.</p

    Box plots comparing absolute and relative cell densities in the 6 sample groups.

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    <p>Synovial tissue sections were stained immunohistochemically for CD15, CD68, CD3, CD20, and CD38. The absolute cell densities (left half of the page, labeled ā€œAbsoluteā€, Panels A-E) are expressed as the number of positive staining cells per mm<sup>2</sup>. The relative cell densities (right half of the page, labeled ā€œRelativeā€, panels F-J) correspond to the cells expressing a given marker as a percentage of the inflammatory cell population, which is defined as the sum of all cells expressing any of the five markers, per mm<sup>2</sup>. Upper and lower borders of the box, 75<sup>th</sup> percentile and 25<sup>th</sup> percentiles; horizontal line, median; upper and lower whiskers, maximum and minimum; circles, outliers defined as values above or below the box by a >1.5-fold of the interquartile range.</p

    Management of urate-lowering therapy (ULT) during an acute gouty attack and anti-inflammatory prophylaxis of gout attacks.

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    <p><sup>1</sup>Answers in agreement with the 2012 ACR gout guidelines</p><p><sup>2</sup>participants who answered not to prescribe anti-inflammatory prophylaxis when initiating ULT were excluded from the other questions concerning this topic.</p><p>CI: confidence interval; NSAID: nonsteroidal anti-inflammatory drug.</p><p>Management of urate-lowering therapy (ULT) during an acute gouty attack and anti-inflammatory prophylaxis of gout attacks.</p

    Acute gout management: first choice drug(s) to treat an acute gouty attack in different scenarios (N = 309).

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    <p><sup>1</sup>Healthy besides gout</p><p><sup>2</sup>chronic kidney disease, defined here as creatinine clearance ā‰¤60 ml/min</p><p><sup>3</sup>colchicine 0.5 mg/hour until symptom resolution or side effect</p><p><sup>4</sup>colchicine ā‰¤2 mg/day. CI: confidence interval</p><p>NSAID: nonsteroidal anti-inflammatory drug; PO: <i>per os</i>; IM: intramuscular; IA: intra-articular.</p><p>Acute gout management: first choice drug(s) to treat an acute gouty attack in different scenarios (N = 309).</p

    Flow diagram of participantsā€™ selection.

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    <p>1: Practicing rheumatologists, members of the Brazilian Society of Rheumatology; 2: Random sample, stratified proportionally to the number of rheumatologists in each Brazilian geographic region.</p

    Urate-lowering therapy (ULT).

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    <p><sup>1</sup>Answers in agreement with the 2012 American College of Rheumatology gout guidelines</p><p><sup>2</sup>participants who reported not to adjust ULT for patients with tophaceous gout based on the SUA level were excluded from other questions that were based on the concept of a target SUA level</p><p><sup>3</sup>this question was offered only to those who answered that they would wait for the resolution of the acute gouty attack to initiate ULT.</p><p>CI: confidence interval; CKD: chronic kidney disease; SUA: serum uric acid; CrCl: creatinine clearance.</p><p>Urate-lowering therapy (ULT).</p
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