双能CT在诊断痛风心血管损害中的应用价值

痛风是由尿酸钠结晶沉积在关节或其他组织中引起的一种常见的疾病,其发病率和患病率呈逐年上升趋势,高尿酸血症是发展为痛风最重要的危险因素。近年来许多流行病学和实验研究均证实痛风与高血压、冠心病和心肌梗死等心血管疾病的发生和死亡密切相关。而双能CT作为一种新型的无创性影像学检查手段,可以特异性并定量显示尿酸盐结晶,近年来已成为诊断痛风的一个有效工具,有研究发现其在痛风心血管损害的诊断中也有着很好的临床价值。该综述分析痛风与心血管疾病之间复杂的相关性,以及双能CT在诊断痛风心血管损害中的优势和应用价值。     

双源CT诊断痛风性关节炎临床分析

目的 采用非侵入性双源CT观察关节及周围组织的尿酸盐结晶,以探索临床诊断痛风或鉴别诊断其他关节疾病。方法 选择近2周发作过单关节肿或（和）痛患者17例,均行病变关节双源CT检查。部分患者在B超下穿刺取关节液镜检。结果 13例痛风患者发现33处有尿酸盐结晶,最常沉积的关节部位为双侧足趾关节(7/33)、近端指关节(5/33)、远端指间关节周围(4/33)、跖关节(4/33)、胫骨下端(3/33)。发现尿酸盐结晶易沉积在近关节骨表面,肌肉、韧带等关节周边软组织。关节肿痛部位与尿酸盐结晶沉积部位一致。尿酸盐结晶大小可以测量。结论 双源CT可以清晰显示尿酸盐结晶,为无创检测手段。在鉴别诊断不明原因单关节肿痛方面有很好的价值。     

双能CT在痛风临床病程中的诊断价值

［摘要］　目的　探讨应用双能CT、X线平片、核磁共振(MRI)在痛风不同临床病程分期中的诊断价值。方法　选择2020年1月至2021年8月在合浦县人民医院门诊或住院的80例高尿酸血症和痛风患者,根据痛风临床病程分期标准分为无症状高尿酸血症期组7例,急性发作期组37例,发作间歇期组12例,慢性痛风石病变期组24例。痛风部位足踝关节56例,膝关节21例,手关节10例,两个部位17例,多部位8例。采用双能CT、X线平片和MRI检查,分析三种影像学检查在痛风临床病程分期中的阳性结果。结果　双能CT、X线平片和MRI总阳性率分别为93.8%、37.5%、58.8%。双能CT在无症状高尿酸血症期阳性率达57.1%,而X线平片和MRI未有阳性征象发现。结论　双能CT检查有助于发现痛风患者关节及周围软组织中的尿酸盐晶体,较X线影像和MRI影像更早出现阳性结果,作为痛风特异性诊断方法在临床有较高的应用价值。     

痛风患者足踝双能CT尿酸盐结晶沉积特点分析

目的 应用双能CT分析关节周围尿酸盐结晶沉积特点,预测与痛风性关节炎急性发作相关的解剖和形态学特征.方法 选择近期足踝部发作过关节肿和(或)痛患者84例(其中确诊痛风患者68例,无症状高尿酸血症患者1 1例,单纯其他类型关节炎患者5例),入选患者均完成足踝部双能CT检查.应用x2检验及Logistic回归模型分析尿酸盐结晶沉积的解剖、形态学特征与关节炎症急性发作的关系.结果 痛风组共发现278处尿酸盐结晶,最常出现结晶沉积的部位依次为第一趾中远端(18.2％)、第一跖趾关节(16.8％)、跟骨(17.5％)、胫骨下端(11.8％),无症状高尿酸血症组发现34处尿酸盐结晶沉积,分布趋势与痛风组相似.对患者结晶沉积部位与关节炎症急性发作情况进行分析后发现,第一跖趾关节(x2=8.47,P＜0.01)及胫骨下端(x2=3.93,P＜0.05)出现结晶沉积的患者临床上更易出现相应部位关节炎的急性发作.且第一跖趾关节附近的尿酸盐结晶如果沉积于肌腱(x2=5.03,P＜0.05)或软组织(x2=5.19,P＜0.05)中,更易引起痛风性关节炎;而对于踝关节周围的尿酸盐结晶,如果其沉积于踝关节伸面(x2=4.42,P＜0.05)或呈点状(x2=4.76,P＜0.05)或为多个(x2=4.97,P＜0.05)则更易出现关节炎症发作.并且Logistic多元回归分析结果也提示,痛风性关节炎急性发作有潜在的危险因素.结论 双能CT可以清晰显示尿酸盐结晶,有助于痛风的诊断及随防研究.尿酸盐结晶沉积的部位、形状、大小、数量以及受累部位是否伴有软组织肿胀、骨侵蚀等因素,对痛风性关节炎的急性发作有影响.     

Synovial fluid analysis for diagnosis of intercritical gout

BACKGROUND: The diagnosis of gout in the intercritical phase can be difficult. OBJECTIVE: To determine whether synovial fluid analysis allows the diagnosis of intercritical gout. DESIGN: Cross-sectional study. SETTING: Outpatient rheumatology clinics. PATIENTS: 101 patients with gout. INTERVENTION: Arthrocentesis of 80 knees and 21 first metatarsophalangeal joints (each joint from a different patient) that had been inflamed but were currently asymptomatic. MEASUREMENTS: Frequency with which arthrocentesis yielded synovial fluid; presence of monosodium urate crystals in the synovial fluid sample; and, for synovial fluid with crystals, the number of microscope fields that had to be scanned before crystals were found. RESULTS: Synovial fluid was obtained from 91 of 101 joints. The fluid from all 43 patients not receiving hypouricemic agents contained monosodium urate crystals. These crystals were found in the synovial fluid of only 34 of 48 patients receiving hypouricemic agents. In 90% of the synovial fluid samples that contained crystals, crystals were seen in the first five microscope fields examined. CONCLUSIONS: Arthrocentesis of asymptomatic knees and first metatarsophalangeal joints and synovial fluid analysis are simple procedures that facilitate the diagnosis of gout during intercritical periods.     

Hyperuricemia and gout: diagnosis and therapy

In our modern society hyperuricemia is one of the most frequent metabolism disturbances. So far, every fourth man and every tenth woman suffer from an asymptomatic or a symptomatic hyperuricemia named gout. Mostly, over nutrition and malnutrition as well as other secondary factors with a genetically determined renal secretion disturbance of uric acid lead to an increase of serum uric acid. By deposition of uric acid crystals in tissues with intermittent immunologic activation of inflammation cells a manifestation of gout can be seen. The clinical image of gout varies widely. It may manifest as acute or chronic arthritis, tophi on the skin, subcutaneous tissue and the skeletal system as well as urate nephropathy. To eliminate the consequences of hyperuricemia in the long term, apart from a thorough anamnesis of nutritional habits a general examination of metabolic parameters is necessary to exclude a metabolic syndrome and other causes for a secondarily caused hyperuricemia. As gout is very often primarily caused by a renal secretion disturbance of uric acid special diagnostics should be done. Basing on literature research and inclusion of experts opinions this article represents the therapeutically options in treatment of hyperuricemia and gout with their resulting side effects and contraindications.     

Treatment of acute gout: A systematic review

Objective

Acute gout is traditionally treated with NSAIDs, corticosteroids, and colchicine; however, subjects have multiple comorbidities that limit the use of some conventional therapies. We systematically reviewed the published data on the pharmacologic and non-pharmacologic agents used for the treatment of acute gouty arthritis.

Methods

A systematic search was performed using PubMed and Cochrane database through May 2013. We included only randomized controlled trials (RCTs) that included NSAIDs, corticosteroids, colchicine, adrenocorticotropic hormone (ACTH), interleukin-1 (IL-1) inhibitors, topical ice, or herbal supplements.

Results

Thirty articles were selected for systematic review. The results show that NSAIDs and COX-2 inhibitors are effective agents for the treatment of acute gout attacks. Systemic corticosteroids have similar efficacy to therapeutic doses of NSAIDs, with studies supporting oral and intramuscular use. ACTH is suggested to be efficacious in acute gout. Oral colchicine demonstrated to be effective, with low-dose colchicine demonstrating a comparable tolerability profile as placebo and a significantly lower side effect profile to high-dose colchicine. The IL-1β inhibitory antibody, canakinumab, was effective for the treatment of acute attacks in subjects refractory to and in those with contraindications to NSAIDs and/or colchicine. However, rilonacept was demonstrated to be not as effective, and there are no RCTs for the use of anakinra.

Conclusion

NSAIDs, COX-2 selective inhibitors, corticosteroids, colchicine, ACTH, and canakinumab have evidence to suggest efficacy in treatment of acute gout.     

Role of imaging studies in the diagnosis and follow-up of large-vessel vasculitis: an update

Imaging studies play a central role in diagnosing and monitoringgiant-cell and Takayasu arteritis. Deep, large vessels can beexamined by CT or MRI, while colour Doppler ultrasound and MRIhave been used with promising results to investigate the temporalarteries. Positron emission tomography is very sensitive indetecting large-vessel inflammation, although it does not delineatethe vessel wall. Imaging procedures can also be used to monitorthe disease course. However, imaging signs of inflammation maysometimes persist despite clinical remission and, conversely,seemingly unaffected vessels may develop alterations later on. KEY WORDS: Angiography, MRI, Magnetic resonance angiography, Tomography, X-Ray computed, Ultrasonography, Doppler, Colour, PET, Takayasu arteritis, Giant-cell arteritis Submitted 30 September 2007; revised version accepted 18 December 2007.     

Gouty arthritis: decision-making following dual-energy CT scan in clinical practice,a retrospective analysis

To establish whether dual-energy CT (DECT) is a diagnostic tool, i.e., associated with initiation or discontinuation of a urate lowering drug (ULD). Secondly, to determine whether DECT results (gout deposition y/n) can be predicted by clinical and laboratory variables. Digital medical records of 147 consecutive patients with clinical suspicion of gout were analyzed retrospectively. Clinical data including medication before and after DECT, lab results, and results from diagnostic joint aspiration and DECT were collected. The relationship between DECT results and clinical and laboratory results was evaluated by univariate regression analyses; predictors showing a p?<?0.10 were entered in a multivariate logistic regression model with the DECT result as outcome variable. A backward stepwise technique was applied. After the DECT, 104 of these patients had a clinical diagnosis of gout based on the clinical judgment of the rheumatologist, and in 84 of these patients, the diagnosis was confirmed by demonstration of monosodium urate (MSU) crystals in synovial fluid (SF) or by positive DECT. After DECT, the current ULD was modified in 33 (22.4%) of patients; in 29 of them, ULD was started and in 1 it was intensified. Following DECT, the current ULD was stopped in three patients. In the multivariable regression model, cardiovascular disease (OR 3.07, 95% CI 1.26–7.47), disease duration (OR 1.008, 95% CI 1.001–1.016), frequency of attack (OR 1.23, 95% CI 1.07–1.42), and creatinine clearance (OR 2.03, 95% CI 0.91–1.00) were independently associated with positive DECT results. We found that the DECT result increases the confidence of the prescribers in their decision to initiation or discontinuation of urate lowering therapy regimen in of mono- or oligoarthritis. It may be a useful imaging tool for patients who cannot undergo joint aspiration because of contraindications or with difficult to aspirate joints, or those who refuse joint aspiration. We also suggest the use of DECT in cases where a definitive diagnosis cannot be made from signs, symptoms, and MSU analysis alone.     

Chronic tophaceous gout as the first manifestation of gout in two cases and a review of the literature

ObjectivesAcute gout is a common arthritis that may eventually develop into chronic tophaceous gout (CTG). CTG usually is manifested by recurrent gout attacks. The diagnosis and treatment of CTG is challenging. Although the emergence of CTG without previous gout attacks is uncommon, it is important to recognize this unusual gout presentation.MethodsHerein, we present two cases of CTG, occurring in elderly patients with chronic kidney disease (CKD) on diuretics, who presented without a prior history of acute gout attacks. We also searched PUBMED, Ovid MEDLINE, and Google scholar (1970–2017), for “tophi as the initial manifestation of gout” and “chronic gout without previous attacks”, and extracted relevant data.ResultsThe search disclosed one retrospective study and several case reports and case series describing 96 patients. Clinical and laboratory data was extracted from 34 patients. We found that a specific group of patients, e.g., elderly patients, most often female patients, suffering from CKD, and treated with diuretics, are specifically reported in the English medical literature to present with CTG as their first manifestation of gout.ConclusionThe two cases and our literature review try to emphasize the many faces of chronic gout, in particular, its presentation without previous gout attacks.     

Craniopharyngiomas in children and adults: systematic analysis of 121 cases with long-term follow-up

BACKGROUND: Craniopharyngiomas account for 2-5% of all primary intracranial tumours. Despite their benign histological appearance, they are often associated with an unfavourable prognosis and their optimal treatment remains controversial. AIM: To analyse the natural history and treatment outcome of children and adults presenting to the Departments of Paediatrics and Endocrinology with craniopharyngioma between 1964 and 2003. PATIENTS AND METHODS: The records of 121 patients (age range 2.5-83 years, 42 aged < 16 and 79 aged > or = 16) were identified. The mean follow-up period since presentation was 103 months (8.6 years) (range 0.3-468 months). Sixteen patients underwent gross total removal (A), 3 gross total removal + radiotherapy (B), 51 partial removal (C), 33 partial removal + radiotherapy (D), 6 cyst evacuation alone (E) and 3 cyst evacuation + radiotherapy (F). The clinical, imaging and endocrinological data at presentation and during follow-up were analysed. RESULTS: Headache and visual field defects were the most common presenting clinical features (64% and 55%, respectively). Ninety-four per cent of the tumours had an extrasellar component and 23% of them were associated with hydrocephalus. There was a significant difference in the recurrence-free survival rates between groups A-D [at 10 years: 100% (A), 100% (B), 38% (C) and 77% (D), P < 0.01], which persisted even when analysing patients operated after 1980. The median time of first recurrence was 2.5 years (range 0.5-36). The peri-operative mortality of the patients who had any type of neurosurgical intervention due to recurrence was higher than that observed after primary surgery (24%vs. 1.8%) (P < 0.01). The rate of re-accumulation of the cyst fluid was 58% during the first year in patients of group E, whereas none of the subjects of group F experienced such an event during their follow-up period. There was no reversal of pre-existing pituitary hormone deficits after any surgical intervention. The probabilities of GH, FSH/LH, ACTH, TSH deficiency and diabetes insipidus at the 10-year follow-up were 88%, 90%, 86%, 80% and 65%, respectively. After excluding the non-tumour-related deaths, the 10-year survival rate following presentation was 90%. Patients with recurrence had a significantly lower probability for survival compared with those without it (at 10 years: 70%vs. 99%, P < 0.01). At the 10-year follow-up the probability of the presence of major visual field defects was 48%, hyperphagia/obesity 39%, epilepsy 12% and hemi-/monoparesis 11%. In this large series no substantial differences in the outcome of tumours diagnosed during childhood or adult life were found. CONCLUSIONS: Craniopharyngiomas remain tumours associated with significant morbidity. Gross total removal provides favourable results in terms of recurrences. If this cannot be achieved safely, adjuvant radiotherapy is beneficial in preventing tumour re-growth. Childhood- and adult-onset lesions generally behave similarly.     

Role of contrast-enhanced dynamic CT in the diagnosis of active tuberculoma

STUDY OBJECTIVES: To assess the role of contrast-enhanced dynamic CT in the diagnosis of active tuberculoma. SETTING: Hospitals with an isolated ward for tuberculosis. METHODS: Fifty-five subjects with newly diagnosed active tuberculoma and 24 subjects with inactive tuberculoma were examined and evaluated retrospectively. Six subjects with active tuberculomas and seven subjects with inactive tuberculomas were confirmed by histologic and microbiologic evaluation of resected specimens, whereas the remainder of the subjects with tuberculoma were confirmed clinically. The subjects were receiving iopamidol, 370 mg/mL IV, at a rate of 3.0 mL/s on contrast-enhanced dynamic CT. The time-attenuation curve was obtained and adapted to a gamma function. The peak height (PH), maximum attenuation subtracted by the background attenuation, relative flow (RF), and mean regional flow were used for comparison. Measurements and results: In the surgically confirmed group, the PH and RF values of six subjects with active tuberculomas were significantly higher than those of the seven subjects with inactive tuberculoma (p < 0.05). Similarly, in the subjects with noninvasive diagnoses, the PH and RF values of 49 subjects with active tuberculoma were significantly higher than those of the subjects with inactive tuberculoma (mean +/- SD PH, 43.4 +/- 4.1 Hounsfield units [HU] vs 11.6 +/- 2.7 HU, p < 0.0001; RF, 0.012 +/- 0.001/s vs 0.006 +/- 0.001/s, p < 0.05). When the cutoff value was defined as mean +/- 2 SD, the sensitivity and specificity of the diagnosis for active tuberculoma were 77.1% and 96.4% in PH, and 68.5% and 88.8% in RF, respectively. CONCLUSION: Contrast-enhanced dynamic CT is a potentially valuable tool for the diagnosis of active tuberculoma.     

Secondary gout in hemoglobinopathies: Report of two cases and review of the literature

Although patients with hemolytic hemoglobinopathies characteristically are over-producers of urate, and hyperuricemia is frequently recognized, clinical gout has rarely been reported in such patients. Our evaluation of 2 premenopausal women with gout led to the diagnosis of previously unrecognized hemoglobinopathies (SC disease and CC disease). Investigation of these 2 patients and review of the reported cases of gout in patients with hemoglobin S or C disorders suggest that relatively minor abnormalities of renal function in these patients may lead to early development of significant hyperuricemia. With increasing lifespan of patients with hemolytic hemoglobinopathies and the likelihood of increased occurrence of renal function abnormalities, it is anticipated that gout will more frequently be responsible for joint symptoms in such patients.