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Hospital de Órbigo, Spain

Sivera F.,Hospital General Universitario Of Elda | Andres M.,Hospital General Universitario Of Alicante | Pascual E.,Hospital General Universitario Of Alicante | Pascual E.,University Miguel Hernandez
Current Opinion in Rheumatology | Year: 2016

Purpose of review Calcium pyrophosphate (CPP) crystal disease is a common rheumatologic disorder that has received limited attention from the scientific community. This review is aimed at summarizing current evidence for managing CPP disease (CPPD), focusing on recently reported advances. Recent findings New data from case series indicate that interleukin-1b inhibitors can help patients with refractory forms of CPPD. Methotrexate, formerly a promising agent, failed to demonstrate benefits in a recent trial, but still merits consideration for some patients. No significant advances on crystal dissolution have been achieved to date. Proper characterization of the CPP crystal disease picture is needed, ruling out the possible coexistence of another persistent arthritis unrelated to the CPP deposition. Summary Advances on CPP crystal dissolution and establishing definitions of the clinical spectrum of CPPD remain the main challenges for CPP crystal disease management. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.. Source

Andres M.,Hospital General Universitario Of Elda | Sivera F.,Hospital General Universitario Of Elda | Pascual E.,Hospital General Universitario Of Alicante | Pascual E.,University Miguel Hernandez
International Journal of Clinical Rheumatology | Year: 2014

Monosodium urate crystals dissolve and are eliminated from joints and soft tissues as serum uric acid levels drop below its saturating point (400 μmol/l). Time to crystal clearance relates to disease duration and to the serum uric acid level achieved with therapy. The current recommended target level by most guidelines is 360 mol/l (6 mg/dl), but evidence supporting this target is scant. Lower targets warrant a faster crystal clearance-and therefore a faster disease cure-and might be appropriate in the general gouty population but most especially in selected patients such as those with significant cardiovascular risk, poor renal function or tophaceous gout. © 2014 Future Medicine Ltd. Source

Sivera F.,Hospital General Universitario Of Elda | Andres M.,Hospital General Universitario Of Alicante | Carmona L.,Camilo Jose Cela University | Kydd A.S.R.,University of British Columbia | And 30 more authors.
Annals of the Rheumatic Diseases | Year: 2014

We aimed to develop evidence-based multinational recommendations for the diagnosis and management of gout. Using a formal voting process, a panel of 78 international rheumatologists developed 10 key clinical questions pertinent to the diagnosis and management of gout. Each question was investigated with a systematic literature review. Medline, Embase, Cochrane CENTRAL and abstracts from 2010-2011 European League Against Rheumatism and American College of Rheumatology meetings were searched in each review. Relevant studies were independently reviewed by two individuals for data extraction and synthesis and risk of bias assessment. Using this evidence, rheumatologists from 14 countries (Europe, South America and Australasia) developed national recommendations. After rounds of discussion and voting, multinational recommendations were formulated. Each recommendation was graded according to the level of evidence. Agreement and potential impact on clinical practice were assessed. Combining evidence and clinical expertise, 10 recommendations were produced. One recommendation referred to the diagnosis of gout, two referred to cardiovascular and renal comorbidities, six focused on different aspects of the management of gout (including drug treatment and monitoring), and the last recommendation referred to the management of asymptomatic hyperuricaemia. The level of agreement with the recommendations ranged from 8.1 to 9.2 (mean 8.7) on a 1-10 scale, with 10 representing full agreement. Ten recommendations on the diagnosis and management of gout were established. They are evidence-based and supported by a large panel of rheumatologists from 14 countries, enhancing their utility in clinical practice. Source

Pascual E.,University Miguel Hernandez | Addadi L.,Weizmann Institute of Science | Andres M.,University Miguel Hernandez | Sivera F.,Hospital General Universitario Of Elda
Nature Reviews Rheumatology | Year: 2015

The mechanisms and sites of monosodium urate monohydrate (MSU) crystal deposition in gout have received little attention from the scientific community to date. Formalin fixation of tissues leads to the dissolution of MSU crystals, resulting in their absence from routinely processed pathological samples and hence neglect. However, modern imaging techniques - especially ultrasonography but also conventional CT and dual-energy CT - reveal that MSU crystals form at the cartilage surface as well as inside tendons and ligaments, often at insertion sites. Tophi comprise round white formations of different sizes surrounded by inflammatory tissue. Studies of fibres recovered from gouty synovial fluid indicate that these fibres are likely to be a primary site of crystal formation by templated nucleation, with crystals deposited parallel to the fibres forming transverse bands. In tophi, two areas can be distinguished: one where crystals are formed on cellular tissues and another consisting predominantly of crystals, where secondary nucleation seems to take place; this organization could explain how tophi can grow rapidly. From these observations based on a crystallographic approach, it seems that initial templated nucleation on structural fibres - probably collagen - followed at some sites by secondary nucleation could explain MSU crystal deposition in gout. © 2015 Macmillan Publishers Limited. Source

Taylor W.J.,University of Otago | Fransen J.,Radboud University Nijmegen | Dalbeth N.,University of Auckland | Neogi T.,Boston University | And 26 more authors.
Annals of the Rheumatic Diseases | Year: 2016

Objectives. To compare the sensitivity and specificity of different classification criteria for gout in early and established disease. Methods. This was a cross-sectional study of consecutive rheumatology clinic patients with joint swelling in which gout was defined by presence or absence of monosodium urate crystals as observed by a certified examiner at presentation. Early disease was defined as patient-reported onset of symptoms of 2 years or less. Results. Data from 983 patients were collected and gout was present in 509 (52%). Early disease was present in 144 gout cases and 228 non-cases. Sensitivity across criteria was better in established disease (95.3% vs 84.1%, p<0.001) and specificity was better in early disease (79.9% vs 52.5%, p<0.001). The overall best performing clinical criteria were the Rome criteria with sensitivity/specificity in early and established disease of 60.3%/84.4% and 86.4%/63.6%. Criteria not requiring synovial fluid analysis had sensitivity and specificity of less than 80% in early and established disease. Conclusions. Existing classification criteria for gout have sensitivity of over 80% in early and established disease but currently available criteria that do not require synovial fluid analysis have inadequate specificity especially later in the disease. Classification criteria for gout with better specificity are required, although the findings should be cautiously applied to nonrheumatology clinic populations. Source

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