CaseBook Challenges: Managing Gout,Hyperuricemia and Comorbidities—Dialogue with the Experts

The prevalence of gout and hyperuricemia are on the rise in the United States corresponding with an increase in risk factors for these conditions, such as obesity, metabolic syndrome, and the use of diuretics. A progressive disorder, untreated gout can be debilitating and result in tophi, chronic arthropathy, and recurrent kidney stones. Although joint aspiration is needed for a definitive diagnosis, the majority of patients are diagnosed presumptively based on medical history and presentation with characteristic signs and symptoms. Patients with gout also often have multiple comorbidities, and there is an increasing body of evidence that shows hyperuricemia is associated with incidence hypertension, diabetes, chronic kidney disease, and heart failure. Clinical strategies for the management of gout and hyperuricemia must include considerations for these and other common cardiometabolic and renal conditions. In addition to acute flare therapy and prophylaxis, the treatment of gout involves lowering serum uric acid (SUA) levels with the urate-lowering therapies (ULTs) allopurinol or febuxostat. Once begun, treatment with ULT is lifelong. However, inadequate dosing and patient nonadherence or intolerance to therapy often lead to treatment failure. Recent guidelines from the American College of Rheumatology stress tailoring therapy and target SUA level (traditionally <6 mg/dL, but lower levels may be needed for certain patients) based on gout severity and the presence of comorbid conditions. Because painful acute gout flares may result in trips to the emergency department and because the majority of gout cases are managed in primary care, it is important for clinicians practicing in these settings to be able to diagnose and treat this condition and communicate with patients to improve their understanding of the disease process and adherence to treatment.     

Axial (Spinal) Gout

Gout is a common metabolic disorder resulting from supersaturation of uric acid in extracellular fluid and deposition of monosodium urate crystals in tissues. Gouty arthritis typically affects the peripheral joints of the appendicular skeleton, especially the feet and hands. Gouty involvement of the spine, however, is not as rare as generally perceived. Although it may be asymptomatic, tophaceous axial gout is also a well-documented cause of acute back pain, radiculopathy, and frank cord compression. As with the appendicular skeleton, it takes several years of gout before radiological evidence of erosive change or tophi is apparent in the axial skeleton. This is best detected by CT imaging. The sequelae of cord compression can be reversed with timely surgical intervention and maintenance of uric acid–lowering therapy. The long-term effects of urate-lowering therapies on axial gout have not been studied.     

Gout in the age (author's transl)

The importance of the gout is growing in the GDR as its frequency has been increasing since the sixties. The gout is a disease of metabolism with the following accompanying phenomena: renal lesion in gout, hypertension, cardiac diseases and peripheral arterial diseases. Besides, there are proved relations between hyperuricemia and obesity, hyperlipoproteinemia, diabetes mellitus as well as steatosis hepatis. In describing the nature of the gout the peculiarities of age are stressed. The treatment of the gout depends on the clinical state.     

Improving Outcomes of Percutaneous Nephrolithotomy: Access

Percutaneous nephrolithotomy is a particularly effective procedure, commonly used to treat patients with complex renal calculi. Critical to the success of the procedure is proper patient selection. A thorough preoperative evaluation will serve to optimize treatment outcome. Careful attention to intraoperative details facilitates a safe and efficient access to the collecting system and subsequent stone removal. Postoperative decisions regarding drainage tubes must be well thought out. Performing the procedure as a single stage event optimizes many of these essential points.     

Improving Outcomes in the Post-Myocardial Infarction Setting

Heart disease is the leading cause of death in the United States, with African-American men having the highest rate of cardiovascular mortality in the US population. Although the clustering of multiple cardiovascular risk factors is particularly apparent in this group, a key reason for the higher rate of cardiovascular mortality among African-American men compared with other ethnic groups may be related to underdiagnosis and undertreatment. Studies have shown that minority persons with myocardial infarction are less likely than nonminorities to be diagnosed, to receive appropriate drug therapy, or to undergo bypass surgery. However, there are no data that suggest established treatments and secondary prevention strategies are less effective in African Americans. Appropriate therapy for secondary prevention—including thrombolysis, antiplatelet strategies, angiotensin-converting enzyme inhibition, β blockade, and lipid-lowering therapies—results in significant reductions in mortality for all patients.     

Identifying opportunities to address the congestive heart failure burden: the Improving Cardiovascular Outcomes in Nova Scotia (ICONS) study

BACKGROUND: Medical, social and economic costs of congestive heart failure (CHF) continue to rise. There exists a 'care gap' between what the optimal care populations with CHF should receive and actually do receive. Central to the goal to develop effective strategies against the 'care gap' is accurate measurement of the CHF burden. Administrative data are limited in detail and accuracy and clinical databases suffer from limited size. Improving Cardiovascular Outcomes in Nova Scotia (ICONS) is a province-wide population-based disease management study with access to all patient health data including outcomes. METHODS: Medical records of all patients admitted to any Nova Scotia health care institution with a cardiovascular disorder were prospectively examined by trained abstractors. Patients were followed up and health outcomes measured through assignment of unique identifier numbers and linkage with Vital Statistics Nova Scotia. This report summarizes baseline data for the population admitted to hospital with a diagnosis of CHF between October 15, 1997 and October 14, 1998. RESULTS: There were 2637 unique patients enrolled with 3547 hospitalizations. The median length of stay was eight days, with in-hospital mortality of 18.2%; 10.8% were discharged to long term care. The mortality rate was 38.7% at 12 months and the rehospitalization rate was 39.9%. Average age was 75 +/- 10 years (median 76) and 52% were female. There were 4.5 comorbidities per patient. Left ventricular ejection fraction (LVEF) was measured in fewer than 40%; of these, fewer than 39% had a documented ejection fraction less than 40%. At discharge, 61.3% of survivors were prescribed angiotensin-converting enzyme (ACE) inhibitors, 6.0% angiotensin blockers, 42.1% beta-blockers, 75.6% diuretics, 26.1% calcium channel blockers and 19.3% warfarin. Females were older and had lower rate of LVEF testing and ACE and warfarin usage. CONCLUSION: The burden of disease for CHF in Nova Scotia is large and affects an elderly population with multiple comorbidities. Adverse outcomes such as death, rehospitalization and admission to a chronic care facility are common. Measurement of the 'care gap' requires consideration of these factors and of elderly and female patients regardless of left ventricular function. Successful strategies will likely be multidisciplinary in scope with a focus toward improving access to care.     

Asthma Management: Curtailing Costs and Improving Patient Outcomes

As our understanding of asthma has evolved, so have pharmaceutical strategies for managing this disorder. Once considered a disorder of airway smooth muscle, asthma now is regarded primarily as a chronic inflammatory disorder of the airways. Traditional therapy sought to suppress bronchoconstriction and other signs and symptoms of asthma when they occurred, but contemporary strategies center on managing the underlying inflammation through long-term medications intended to reduce the overall risk of acute attacks. Direct and indirect costs of illness for asthma were estimated at $6.2 billion in 1990. Undoubtedly the costs are considerably higher today due to the increasing prevalence of the disorder. The costs associated with the illness are not distributed evenly among the 15 million Americans with asthma. About 20% of the patients account for 80% of the expenditures. By identifying the high cost patients and educating them regarding the proper use of medication, it may be possible to curtail costs associated with asthma. Healthcare professionals, especially in their role as educators, are critical to reducing morbidity, mortality, and costs associated with asthma patients.     

An Update on Parkinson's Disease: Improving Patient Outcomes

Neurologists are faced with many challenges in caring for patients with Parkinson's disease (PD). This chronic, long-term illness that affects at least one million people in the United States requires a coordinated healthcare partnership between the physician and the patient. The importance of early diagnosis is essential to delaying disease progression and early diagnosis and intervention may be aided by recent advances in biomarkers, genomics, and imaging. A misdiagnosis or late diagnosis will lead to deteriorating patient health. Additionally, physicians should incorporate current guidelines into their treatment strategies, and awareness of the reasoning behind these guidelines is critical for appropriate use. Physicians should be up to date on identifying the most appropriate therapies based on emerging science and disease staging, and should implement patient education into their practice. Due to limitations for currently available therapies, adjunctive therapies may lead to improved outcomes in patients with PD. The use of multiple therapies can improve myriad symptoms, more so than a monotherapy. Knowledge of these therapies is critical to achieving best outcomes in patients with PD.     

Asthma Management: Curtailing Costs and Improving Patient Outcomes

As our understanding of asthma has evolved, so have pharmaceutical strategies for managing this disorder. Once considered a disorder of airway smooth muscle, asthma now is regarded primarily as a chronic inflammatory disorder of the airways. Traditional therapy sought to suppress bronchoconstriction and other signs and symptoms of asthma when they occurred, but contemporary strategies center on managing the underlying inflammation through long-term medications intended to reduce the overall risk of acute attacks. Direct and indirect costs of illness for asthma were estimated at $6.2 billion in 1990. Undoubtedly the costs are considerably higher today due to the increasing prevalence of the disorder. The costs associated with the illness are not distributed evenly among the 15 million Americans with asthma. About 20% of the patients account for 80% of the expenditures. By identifying the high cost patients and educating them regarding the proper use of medication, it may be possible to curtail costs associated with asthma. Healthcare professionals, especially in their role as educators, are critical to reducing morbidity, mortality, and costs associated with asthma patients.     

Refractory In-Stent Restenosis: Improving Outcomes by Standardizing Our Approach

Purpose of Review

This review will focus on our approach for the treatment of refractory in-stent restenosis.

Recent Findings

The discovery of bare metal stents over three decades ago set a milestone in the evolution of percutaneous coronary intervention, which is currently the most widely performed procedure for the treatment of symptomatic coronary disease. However, the broad utilization of stents resulted in the new phenomenon of in-stent restenosis (ISR). Over the years, there has been an increase of the incidence of ISR despite continued improvement of drug-eluting stent (DES) technology. The mechanism of ISR is multifactorial, including biological, mechanical, patient, and operator-related factors. The most common factor is aggressive neointimal proliferation and neoatherosclerosis. ISR presentation is not benign, and treatment is challenging, especially in cases of DES-ISR.

Summary

We review available therapy modalities for ISR, including medical therapy, scoring balloons, atheroablative therapies, repeat DES, vascular brachytherapy, drug-coated balloons, and coronary artery bypass grafting.

     

Pediatric Kidney Disease: Tracking Onset and Improving Clinical Outcomes

Recent studies confirm that much of adult kidney disease may have its origins in childhood, often as a result of abnormal or suboptimal fetal kidney development. Understanding of the etiology and pathogenesis of CKD in children is rapidly evolving because of robust longitudinal clinical data, identification of monogenic mutations related to common causes of CKD, and improved knowledge of factors that influence the onset and progression of CKD. The Kidney Research National Dialogue, supported by the National Institute of Diabetes and Digestive and Kidney Diseases, asked the research and clinical communities to formulate and prioritize research objectives that would improve understanding of kidney function and diseases. This commentary outlines high-priority research objectives to assess factors associated with the predisposition to develop renal disease in children, and address the unique challenges in treating this population.