中医药治疗痛风性关节炎的研究进展

对痛风性关节炎中医药治疗研究进展情况进行研究和分析。论述了中医辨证思路及痛风性关节炎中医药治疗等相关知识。对于痛风性关节炎,采用中医药治疗较为普遍,临床效果较好,患者无明显不良反应。     

The clinical significance of gelatinase B in gouty arthritis of the knee

BACKGROUND: Clinically, gouty arthritis is associated with severe inflammation, such as pain, swelling and erythema of the joints. Gelatinase A and B (matrix metalloproteinase-2 and -9, MMP-2 and -9) participate in the degradation of the extracellular matrix (ECM) components in a variety of arthritis, especially in the inflammatory arthritis. METHODS: We examined the levels of MMP-2 and -9 in 40 synovial fluids (SFs) from the knee joints of 24 patients with gouty arthritis and compared them with the clinical and laboratory variables of inflammation. RESULTS: Gelatin zymography revealed that not only activated MMP-2 levels but also proMMP-9 levels in SF from the knee joints of gouty arthritis were associated with the local arthritis activity scores (LAS) (p < 0.001) and correlated well with the neutrophil counts in SF as well (p < 0.001). A similar correlation between proMMP-9 levels and LAS was also found within the individual patients before and during treatment with nonsteroidal antiinflammatory drugs (NSAIDs; p < 0.001). ProMMP-2 appeared in all SFs irrespective of LAS and neutrophil counts. CONCLUSIONS: The analysis of MMP-9 in SF samples can reveal the inflammatory condition of the knee joints with gouty arthritis. Joint aspiration may decrease the amount of MMPs in SF to attack the ECM of joint whether it is normal or not.     

老年痛风性关节炎临床特点分析

目的：痛风性关节炎是一种以高尿酸血症为病理基础,具有多种临床表现的炎症性关节疾病。本研究拟探索老年痛风性关节炎患者有别于中青年痛风性关节炎患者的临床特点。方法痛风性关节炎患者依照年龄分为老年组(年龄≥60岁)和非老年组(年龄<60岁),参照2012美国风湿病学会(ACR)痛风及高尿酸血症治疗指南,将所有患者的痛风临床症状根据病情程度分为1~9级。比较两组患者急性痛风性关节炎的临床症状及血液生化指标。结果研究共纳入了71例原发性痛风性关节炎患者的数据,其中老年组34例(女性3例),非老年组37例(女性1例)。老年组患者平均年龄(74.9±7.5)岁;老年组患者与非老年组患者比较,发生痛风石或慢性痛风性关节炎(痛风分级≥4级)的比例差异无统计学意义(P >0.05)。老年组发生慢性肾功能不全慢性肾脏病3(CKD3)期以上的患者更多(n =14,P <0.01),24小时尿尿酸排泄能力也更低(2.23±0.14)mmol/L vs (3.12±0.22)mmol/L(P <0.05)。老年组患者缓解期血清尿酸水平(446.82±117.09)μmol/L,较非老年组略低,但差异无统计学意义(P >0.05)。老年组的平均体质量指数(BMI)23.08±3.14,明显低于非老年组患者(P <0.01)。进一步研究两组患者的糖脂代谢数据发现,老年组发生2型糖尿病比例与非老年组比较差异无统计学意义(32.4% vs 18.9%,P >0.05),空腹总胆固醇(TC)、甘油三酯(TG)、低密度脂蛋白胆固醇(LDL-C)水平均低于非老年组,TC(3.98±0.19)mmol/L vs (4.54±0.15) mmol/L(P <0.05);TG(1.13±0.13)mmol/L vs (1.79±0.79)mmol/L(P <0.01);LDL-C(2.48±0.17)mmol/L vs (3.04±0.12)mmol/L(P <0.01)。结论老年痛风性关节炎患者的肾脏病变较中青年患者更加严重,发生终末期肾病的比例更高,故对老年痛风性关节炎患者的治疗应更加注意保护肾脏。     

Mechanism of Action of Colchicine in the Treatment of Gout

Purpose

The aims of this article were to systematically review the literature about the mechanism of action of colchicine in the multimodal pathology of acute inflammation associated with gout and to consider the clinical utility of colchicine in other chronic inflammatory diseases.

Methods

The English-language literature on PubMed was searched for articles published between 1990 and October 2013, with a cross-reference to citations across all years. Relevant articles pertaining to the mechanism of action of colchicine and the clinical applications of colchicine in gout and other inflammatory conditions were identified and reviewed.

Findings

The molecular pathology of acute inflammation associated with gouty arthritis involves several concurrent pathways triggered by a variety of interactions between monosodium urate crystals and the surface of cells. Colchicine modulates multiple pro- and antiinflammatory pathways associated with gouty arthritis. Colchicine prevents microtubule assembly and thereby disrupts inflammasome activation, microtubule-based inflammatory cell chemotaxis, generation of leukotrienes and cytokines, and phagocytosis. Many of these cellular processes can be found in other diseases involving chronic inflammation. The multimodal mechanism of action of colchicine suggests potential efficacy of colchicine in other comorbid conditions associated with gout, such as osteoarthritis and cardiovascular disease.

Implications

Colchicine has multiple mechanisms of action that affect inflammatory processes and result in its utility for treating and preventing acute gout flare. Other chronic inflammatory diseases that invoke these molecular pathways may represent new therapeutic applications for colchicine.     

炎症标志物在感染性和痛风性关节炎中鉴别诊断的应用价值

目的 研究不同炎症标志物在不同类型关节炎中的鉴别诊断价值。方法 2013年1月～2014年1月在沈阳军区总医院骨科病房住院患者中,33例感染性关节炎和29例痛风性关节炎病人中,检测血浆中白细胞数量、C反应蛋白以及尿酸水平和关节滑液中乳酸、葡萄糖、尿酸、乳酸脱氢酶、白细胞等相关炎症标志物,再通过受试者工作曲线分析不同标志物的诊断价值。结果 在两组患者中,只有血浆白细胞和C反应蛋白水平不存在统计学差异,关节滑液中乳酸浓度检测的诊断价值最高,曲线下面积(AUC)为0.898,特异度为72.4%,敏感度为96.9%; 其次为血清尿酸和滑液尿酸两项指标,AUC分别为0.818和0.808。结论 在感染性关节炎中乳酸标志物有良好的诊断价值,滑液中乳酸水平高于1.7 mmol/L基本可以诊断为感染性关节炎。     

Clinical review: Serious adverse events associated with the use of rituximab - a critical care perspective

ABSTRACT: The advent of biologic agents has provided a more specific and targeted approach to the treatment of various hematological malignancies and other autoimmune disorders. Such biologic agents have been relatively well tolerated with fewer adverse events reported as compared with many other chemotherapeutic agents. Rituximab is a monoclonal antibody to the B-cell marker CD20 and is a common biologic agent widely used for the treatment of B-cell lymphoma, lymphoproliferative disorders, and inflammatory conditions that are refractory to conventional treatment, including rheumatoid arthritis and some vasculitides. However, through randomized controlled trials and post-marketing surveillance, an increasing number of serious adverse events are being associated with the use of rituximab, often leading to or complicating an intensive care unit admission. The purpose of this review is to focus on the severe complications that are associated with the use of rituximab and that require critical care. Management and prevention strategies for the most common complications along with some examples of its uses within the critical care setting are also discussed.     

208例痛风病人的伴发病及发病因素的回顾性研究

目的探讨痛风性关节炎与高血压、高脂血症、脂肪肝、糖尿病等伴发病的关系,及与饮食、疲劳、季节、遗传等因素的关系。方法本文收集了208例痛风病人,从性别、年龄、体重、病程、诱发因素、好发部位、好发季节、急性发作的间歇期、伴发病及家族遗传史、血尿酸水平等方面进行临床观察。结果痛风性关节炎病人中伴发高血压占68．75％,高血脂占53．37％,有家族史占21．15％;由高嘌呤饮食诱发占65．87％,疲劳诱发占32．21％;以第一跖趾关节好发的占42．79％。痛风病人的体重指数与血尿酸水平呈正相关（P〈0．05）。结论痛风性关节炎的发作与饮食、气候、疲劳因素等有相关性;往往与高血压、高血脂、糖尿病等代谢性疾病并发;有明显的家族遗传性;好发于下肢小关节,以第一跖趾关节最多见。     

痛风汤配合放血疗法治疗痛风性关节炎临床疗效分析

目的观察痛风汤配合放血疗法治疗痛风性关节炎的临床疗效。方法 40例符合纳入标准的患者随机分为2组,治疗组予痛风汤、秋水仙碱及针刺放血疗法,对照组仅予口服秋水仙碱。观察主要症状(红、肿、热、痛)改善情况、不良反应发生率以及综合疗效。结果治疗组总有效率达100.0%,显著高于对照组(68.4%)(P<0.05)。2组患者治疗后症状积分均较治疗前显著下降(P<0.01);且治疗后治疗组症状积分明显低于对照组(P<0.01)。2组患者治疗期间无不良反应发生。结论口服痛风汤配合放血疗法治疗痛风性关节炎可显著提高疗效,且安全性高,值得推广。     

Gout: current views. Stage oriented treatment

Gout is a common disease arising due to abnormal purin metabolism and excessive accumulation of uric acid in the blood (hyperuricemia) and manifesting with attacks of acute gouty arthritis. In long duration of gout uric acids accumulate in the bones and periarticular tissues as tophuses. Repeat attacks lead to development of chronic gouty arthritis. Purins restriction diet is an important component of gout treatment. Treatment of acute arthritis should be started early, in initial pains before the development of the attacks. Gouty arthritis in the presence of continuous hyperuricemia, tophyses and urolithiasis is treated with allopurinol. Its intake should be long and controlled by the blood level of uric acid. Balneotherapy is recommended for patients with chronic gouty arthritis associated with cardiovascular diseases, urolithiasis.     

Analysis of synovial inflammatory markers to differ infectious from gouty arthritis

ObjectivesSeptic and gouty arthritis show the same clinical symptoms, but septic arthritis is an orthopedic emergency and needs immediate surgical intervention, whereas a systemic drug therapy is needed in acute gouty arthritis. The aim of this study was to investigate which inflammatory markers allow an accurate differentiation of septic and gouty arthritis.Design and methodsThis was a retrospective examination of serum markers (peripheral white blood cells, C-reactive Protein and uric acid) and inflammatory markers in the synovial fluid (lactate, glucose, uric acid, lactate dehydrogenase, synovial fluid white blood cell count, total protein, and interleukin-6) in 53 patients with culture-verified septic arthritis and 29 with gouty arthritis. Receiver-Operating-Characteristic-curves with corresponding Area under the curve (AUC), sensitivity, specificity, likelihood-ratio and interval likelihood-ratios were calculated to define the diagnostic potential of the inflammatory markers.ResultsSynovial lactate showed the greatest diagnostic potential (AUC = 0.901, sensitivity = 89.5%, specificity = 77.3%, negative likelihood-ratio = 0.14) followed by synovial glucose (AUC = 0.853) and synovial uric acid (AUC = 0.841).ConclusionsLactate in the synovial fluid has excellent diagnostic potential to differ septic arthritis from gouty arthritis. Synovial lactate levels above 10 mmol/L almost proofed septic arthritis, lactate levels lower than 4.3 mmol/L make it very unlikely.     

A systematic review and meta‐analysis of randomized controlled trials: Skin‐patch of Chinese herbal medicine for patients with acute gouty arthritis

Aims

To evaluate the evidence of the effectiveness and safety of Chinese herbal medicine skin‐patches for patients with acute gouty arthritis.

Background

Acute gouty arthritis is a problem that can limit the level of activity and impair the quality of life. In China, many clinical studies have demonstrated that skin‐patches of Chinese herbal medicines benefit patients with acute gouty arthritis. However, the reported clinical effects vary.

Design

A systematic review and meta‐analysis of randomized controlled trials.

Data sources

Three English databases including CENTRAL (1993 to February 2017), PubMed (1966 to February 2017) and EMBASE (1974 to February 2017) and four Chinese databases including Chinese National Knowledge Infrastructure, Chinese VIP Information, SinoMed and Wanfang (all, 1949 ‐ February 2017) were searched. Randomized controlled trials that compared skin‐patches of Chinese herbal medicine with or without conventional treatments to conventional treatments, no treatment or a placebo treatment for patients with acute gouty arthritis were included.

Review methods

We conducted a systematic review and meta‐analysis following the Cochrane process. Two authors selected the studies, extracted the data and evaluated the risk of bias of the included trials.

Results

Nineteen studies met our inclusion criteria. After synthesizing the data, the results showed that skin‐patches of CHM combined with Western medicine seemed to be more effective than Western medicine alone for pain relief in patients with acute gouty arthritis and had fewer adverse events.

Conclusion

Due to the quality of the data, larger and more rigorously designed clinical trials with proper outcome measures are necessary.     

TNF-alpha antagonist induced lupus on three different agents

Tumor necrosis factor alpha (TNF alpha) antagonists are biologic agents used in the management of inflammatory conditions such as rheumatoid arthritis, seronegative spondyloarthropathies and inflammatory bowel disease. These agents have been recently shown to cause a syndrome called anti-TNF induced lupus (ATIL), a rare condition which has similar clinical manifestations to idiopathic systemic lupus erythematosus (SLE). Given that extra-intestinal manifestations of inflammatory bowel disease include arthritis, it can be difficult to separate arthritis due to underlying disease from drug-induced arthritis. We present a case of a 28-year-old female with Crohn’s disease, who developed disabling arthritis as a clinical manifestation of ATIL following treatment with three anti-TNF agents, namely infliximab, adalimumab and certolizumab.     

血浆置换疗法在痛风性关节炎治疗中的应用

目的观察治疗性血浆置换治疗痛风性关节炎的临床疗效。方法采用血浆置换法治疗17例痛风性关节炎患者,比较置换前后患者血尿酸（UA）、C-反应性蛋白（CRP）、血沉（ESR）的变化及临床症状的改善。结果17例患者经血浆置换后血尿酸、C-反应蛋白、血沉明显降低（P〈0.01）;临床症状明显好转,关节红、肿、热、痛症状消失。结论血浆置换结合药物治疗痛风性关节炎的疗效显著。     

Drug therapy of inflammatory arthritis

Inflammatory arthritis involves a diverse range of conditions in which an uncontrolled immune response occurs. A number of advances in assessment, diagnosis and treatment have been made in recent years. Drug therapies used in inflammatory arthritis aim to reduce symptoms and suppress inflammation, joint damage and disability. In rheumatoid arthritis (RA), immunosuppression is used in almost all patients, with an emphasis on early aggressive treatment to achieve clinical remission. This approach is less successful in spondylarthropathies, for which non-steroidal anti-inflammatory drugs remain first-line therapy. The use of biologic therapies has increased dramatically across a range of indications and has resulted in improved outcomes for patients. These agents are associated with an increased risk of infection, particularly tuberculosis in patients receiving tumour necrosis factor inhibitors. Alternative biologics have entered clinical practice for RA in recent years, and clinical trials using these agents, as well as novel non-biologic therapies, are in progress for RA and other conditions.     

Gout: Current Insights and Future Perspectives

Gout is a relatively common inflammatory arthritis that is typically known to occur in middle-aged men. The prevalence of gout appears to be shifting, however, and is increasing in the elderly population. Gout is characterized by severely intense pain and can greatly impact patient quality of life. The study of gout and associated conditions appears to have received research attention in the past, however there is a resurgence in gout interest due to the abundance of novel evidence surrounding its diagnosis, pathophysiology, and treatment. In this review we describe a general overview of gout including its assessment/diagnosis, clinical presentations, predisposing factors, pathophysiology, abortive and prophylactic therapy to control gouty inflammation, and the potential future direction of gout treatment.

Perspective

Gout is an underappreciated and extremely painful condition. Over the last 2 years new thought on pathophysiology of gout taking into account the inflammasome and new therapeutic agents have changed management strategies.     

Measurement of synovial tumor necrosis factor-alpha in diagnosing emergency patients with bacterial arthritis

Because of the high morbidity and mortality in patients with bacterial arthritis, rapidly and correctly diagnosing this critical condition is a challenge to emergency clinicians. Synovial fluid samples were obtained from 75 patients with arthritis disorders who presented to an emergency service, and levels of tumor necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1β), and interleukin-6 (IL-6) were measured. Twenty patients with culture-proven bacterial arthritis had higher levels of synovial TNF-α than patients with osteoarthritis or with inflammatory arthritis, including gouty arthritis, rheumatoid arthritis, reactive arthritis, and lupus arthritis. There was a good sensitivity for synovial TNF-α level in diagnosing patients with bacterial arthritis. Nearly 100% of patients with bacterial arthritis had elevated synovial TNF-α levels. However, synovial IL-1β and IL-6 levels failed to discriminate bacterial arthritis from other inflammatory arthritis. Measurement of synovial TNF-α level may be useful as a diagnostic aid in emergency patients with bacterial arthritis disorders.     

肌骨超声评价痛风性关节炎患者骨质破坏的临床应用价值

目的 应用高频肌骨超声对痛风性关节炎患者进行超声扫查,分析不同超声表现与骨代谢指标的相关性,探究肌骨超声对痛风性关节炎的临床诊断和监测的应用价值。方法 回顾性分析2016年6月至2019年8月于我院风湿免疫科就诊的180名痛风性关节炎患者的病史及临床资料,对所有患者行关节超声检查,扫查双膝关节、双踝关节、双足第一跖趾关节。根据关节超声不同表现将患者分为3组：无聚集体组,聚集体组,和痛风石组。检测患者血清中骨代谢指标CTX、OC-N-MID、DKK1、RANKL的含量。分析三组患者骨代谢指标的差异,以及其与临床和实验室指标的相关性。结果：三组患者血清中CTX、OC-N-MID含量无显著性差异,而DKK1、RANKL浓度有统计学差异,痛风石组含量高于聚集体组,聚集体组高于无聚集体组。Pearson相关分析发现,病程越长,血尿酸水平越高,患者血清中DKK1浓度就越高,RANKL含量也增高。结论：肌骨超声可探查痛风性关节炎患者聚集体、双轨征、痛风石及骨质破坏的阳性表现。随着病程延长,骨质破坏指标升高提示骨质破坏加重,这表明肌骨超声能用于评价痛风性关节炎患者疾病进展,联合骨代谢指标能动态监测患者关节受累情况。     

双能量CT对急性痛风结晶的评估及相关因素分析

目的:采用单源双能量CT(dual energy CT,DECT)处理技术测定痛风性关节炎患者急性发作时的尿酸盐结晶沉积量多少,评估其临床诊断价值,探讨尿酸盐结晶及相关影响因素.方法:选取2018年1月—2020年12月在高新区人民医院因急性痛风性关节炎住院的116例拟诊患者的病例资料并进行分析.所有患者均接受关节DE...     

Phenobarbital rheumatism associated with gouty arthritis. Case report with 18-month follow-up

Anticonvulsivant-induced rheumatism has been described in the literature mostly in relation to phenobarbital therapy. We report the case of an 85-year-old male affected by generalized seizures and treated with phenobarbital for some months, who came to our observation on account of a long-lasting arthropathy which was diagnosed as unknown gouty arthritis. After treatment however, a clinical picture of shoulder-hand syndrome persisted: this latter disappeared after substitution of phenobarbital with phenytoin. The association of a syndrome of rheumatism induced by barbiturates with gouty arthritis has not been previously described in the literature.     

关节超声在急性痛风性关节炎诊断中的应用价值

目的研究关节超声在急性痛风性关节炎诊断中的应用价值。方法选择2016年5月至2018年12月本院接诊的50例急性痛风性关节炎患者为研究组,并将医院同期接诊的50例非急性痛风性关节炎患者设为对照组。两组给予关节超声检查,比较两组的超声表现。结果研究组关节内或者周围结节和双轨征比例均高于对照组(P<0.05)。研究组患者足趾关节和膝关节的双轨征阳性检出率高于腕关节与手关节(P<0.05)。结论于急性痛风性关节炎中合理运用关节超声检查法,可为疾病的鉴别诊断提供重要指导,建议临床推广。