Graham D. Reid

Dual Energy Computed Tomography in tophaceous gout

Objective: To evaluate the potential utility of a dual energy CT (DECT) scan in assessing urate deposits among patients with tophaceous gout, and obtain computerised quantification of tophus volume in peripheral joints. Methods: 20 consecutive patients with tophaceous gout and 10 control patients with other arthritic conditions were included. DECT scans were performed using a renal stone colour-coding protocol that specifically assessed the chemical composition of the material (ie, urate coloured in red, calcium coloured in blue). An automated volumetric assessment of DECT was used to measure the volume of urate deposits in all peripheral joint areas. Results: All 20 patients with gout showed red colour-coded urate deposits on their DECT scans, whereas none of 10 controls showed urate deposits. DECT scans revealed a total of 440 areas of urate deposition in 20 patients, whereas physical examination showed 111 areas of urate deposition (mean 22 vs 6 per patient, respectively, p<0.001). Total urate volume in a given patient ranged from 0.63 cm3 to 249.13 cm3, with a mean of 40.20 cm3. Conclusions: DECT scans can produce obvious colour displays for urate deposits and help to identify subclinical tophus deposits. Furthermore, tophus volume can be measured by DECT scans through an automated volume estimation procedure.

Dual energy CT in gout: a prospective validation study

Objective The authors prospectively determined: (1) the specificity and sensitivity of dual energy CT (DECT) for gout; and (2) the interobserver and intraobserver reproducibility for DECT urate volume measurements. Methods Forty crystal-proven gout patients (17 tophaceous) and 40 controls with other arthritic conditions prospectively underwent DECT scans of all peripheral joints using a gout protocol that color-codes the composition of tissues. A blinded radiologist identified urate deposition to calculate specificity and sensitivity of DECT for gout. Inter-rater volumetric reproducibility was determined by two independent radiologists on 40 index tophi from the 17 tophaceous gout patients using automated software. Results The mean age of the 40 gout patients was 62 years, the mean gout duration was 13 years and 87% had a history of urate-lowering therapy (ULT). The specificity and sensitivity of DECT for gout were 0.93 (95% CI, 0.80 to 0.98) and 0.78 (0.62 to 0.89), respectively. When the authors excluded three gout cases with unreadable or incomplete scans, the sensitivity was 0.84 (95% CI, 0.68 to 0.94). The urate volumes of 40 index tophi ranged from 0.06 cm3 to 18.74 cm3 with a mean of 2.45 cm3. Interobserver and intraobserver intraclass correlation coefficients for DECT volume measurements were 1.00 (95% CI, 1.00 to 1.00) and 1.00 (95% CI, 1.00 to 1.00) with corresponding bias estimates (SD) of 0.01 (0.00) cm3 and 0.01 (0.03) cm3. Conclusions These prospective data indicate high reproducibility of DECT urate volume measures. The specificity was high, but sensitivity was more moderate, potentially due to frequent ULT use in our patients.

Femoroacetabular Impingement Syndrome: An Underrecognized Cause of Hip Pain and Premature Osteoarthritis?

Acetabular dysplasia is well recognized as a potential predisposing factor to the development of hip osteoarthritis (OA). In the orthopedic literature, other dysmorphic and orientation abnormalities of the femoral head, femoral head-neck junction, and the acetabulum have been reported, with increasing frequency in recent years, under the term femoroacetabular impingement syndrome (FAI). The studies have shown a clear association of these structural anomalies with patients’ symptoms and signs, radiographic and pathologic abnormalities, and the development of degenerative hip arthritis. FAI is now believed to be a very important predisposing factor for the development of degenerative hip arthritis, particularly in younger adults. Although the results of longterm studies are awaited, the hope is that early surgical intervention in patients with FAI will change the course or prevent the development of hip OA. It is well documented that early recognition of potential FAI surgical candidates, before OA is advanced, determines the postsurgical outcome. FAI has not been reported in the rheumatology literature, but since patients with FAI likely often initially present to rheumatology clinics for assessment of hip pain, it is important for rheumatologists to be aware of this condition and refer to orthopedics when appropriate. The objective of this review is to provide an outline of the basic concepts of FAI, including clinical presentation and radiographic findings, so that rheumatologists become more familiar with this important emerging entity.

Aortic insufficiency in association with juvenile ankylosing spondylitis

vitro m e a s u r e m e n t o f 22Na influx into red blood cells will establish the diagnosis o f Liddle syndrome pr ior to therapy in pat ients who have hyper tens ion and hypokalemia wi thou t demons t r ab l e renal or adrenal pathology. The demons t r a t i on o f increased t ranspor t o f sodium into erythrocytes and the absence of mineralocor t icoid excess suppor t the view that Liddle syndrome is due to a general ized m e m b r a n e abnormal i ty .

Sequential studies on synovial lymphocyte stimulation by rubella antigen, and rubella virus isolation in an adult with persistent arthritis.

The response of synovial lymphocytes from a 65-year-old lady with persistent polyarthritis, to rubella antigen and a number of other microbial agents was studied over a period of 11 months by [3H]thymidine incorporation. The results were correlated with the ability to isolate rubella virus from both peripheral blood and synovial fluid during the same period. The patient showed initially a maximal stimulation index to rubella antigen assayed on five occasions over a five-month period. Rubella virus was detected in both peripheral blood and synovial fluid samples on three occasions during this period. Five months later the lymphoproliferative response of her synovial lymphocytes to rubella antigen had dropped to low levels, and virus could no longer be isolated from synovial exudates. At this time the patients arthritis had become much less active, indicating that a good correlation existed between the presence of rubella virus, local lymphocyte sensitisation, and the inflammatory reaction.

Sequential follow up observations of a patient with rubella associated persistent arthritis.

In 1985 a patient was described whose persistent polyarthritis was found to be aetiologically linked to rubella virus infection through the detection of repeated maximal synovial lymphocyte proliferative responses to rubella virus antigen and by isolation of rubella virus from her synovium. Follow up over the succeeding seven years has shown continuing chronic polyarthritis and persistent synovial lymphocyte responses to rubella virus antigen with the additional observation that she has a defective humoral immune response against rubella virus.

Unusual Rheumatological and Cardiological Manifestations of Acute Myelogenous Leukemia in a Patient with Klinefelter's Syndrome

We report the case of a 40-year-old man with Klinefelters syndrome who presented with a complex multisystem illness, the predominant manifestations of which were rheumatological and cardiological. This disorder coincided with a diagnosis of acute myelogenous leukemia evolving out of a myelodysplastic syndrome and resolved completely after chemotherapy. It is concluded that the hematological malignancy probably played a causal role in the development of this unusual illness which was likely immunologically mediated.

Trump travel ban requires balanced discussion

The CMAJ missed an important opportunity to provide a balanced discussion of an important moral dilemma.[1][1] Dr. Stanbrook, like myself, is a white male physician. How much better would it have been if there had been an accompanying editorial from a physician who, by nature of demographics, was

Ungoutedly time for a change

Dalbeth et al 1 report the findings of dual-energy CT (DECT) scanning in patients with asymptomatic hyperuricaemia and symptomatic gout. This report reinforces the need to change our terminology, classification and management guidelines for gout as Dalbeth et al 2 have already suggested in another study. All current guidelines for the management of gout (recent review3) advise starting urate-lowering therapies for patients with …