Korean guidelines for the management of gout

Gout is the most common form of arthritis, with the prevalence increasing worldwide. The present treatment guidelines provide recommendations for the appropriate treatment of acute gout, management during the inter-critical period, and prevention of chronic complications. The guidelines were developed based on evidence-based medicine and draft recommendations finalized after expert consensus. These guidelines are designed to provide clinicians with clinical evidence to enable efficient treatment of gout.

Korean guidelines for the management of gout

Gout is the most common form of arthritis, with the prevalence increasing worldwide. The present treatment guidelines provide recommendations for the appropriate treatment of acute gout, management during the inter-critical period, and prevention of chronic complications. The guidelines were developed based on evidence-based medicine and draft recommendations finalized after expert consensus. These guidelines are designed to provide clinicians with clinical evidence to enable efficient treatment of gout.

Patient Perspectives and Preferences Regarding Gout and Gout Management:Impact on Adherence

Background@#Patient-centered management is becoming increasingly important in gout, but there are limited studies exploring patients' perspectives and preferences. We aimed to investigate patients' perspectives and preferences regarding gout and gout management, and their impacts on adherence to urate lowering therapy (ULT). @*Methods@#A paper-based survey was performed in patients with gout seen at the rheumatology outpatient clinics of 16 tertiary hospitals. The survey included questions regarding demographics, comorbidities, gout attacks, current treatment and adherence, and patients' perspectives and preferences regarding gout and gout management. Multivariate regression analysis was performed to determine the factors associated with ULT adherence. @*Results@#Of 809 surveyed patients with gout, 755 (94.5%) were using ULT. Among those using ULT, 89.1% had ≥ 80% adherence to ULT. Majority of the patients knew management strategies to some extent (94.8%), perceived gout as a life-long disease (91.2%), and were making efforts toward practicing at least one lifestyle modification (89.2%). Most patients (71.9%) obtained information about gout management during their clinic visits.Approximately half of the patients (53.6%) preferred managing their disease with both ULT and lifestyle modification, 28.4% preferred ULT only, and 17.4% preferred lifestyle modification only. Adherence was better in patients with older age (odds ratio [OR], 1.03), those with better knowledge of gout management strategies (OR, 3.56), and those who had preference for ULT (OR, 2.07). @*Conclusion@#Patients' perspectives and management preferences had high impacts on adherence to ULT in gout. Consideration of patients' perspectives and preferences is important for achieving the desired clinical outcome in gout.

Patient Perspectives and Preferences Regarding Gout and Gout Management:Impact on Adherence

Background@#Patient-centered management is becoming increasingly important in gout, but there are limited studies exploring patients' perspectives and preferences. We aimed to investigate patients' perspectives and preferences regarding gout and gout management, and their impacts on adherence to urate lowering therapy (ULT). @*Methods@#A paper-based survey was performed in patients with gout seen at the rheumatology outpatient clinics of 16 tertiary hospitals. The survey included questions regarding demographics, comorbidities, gout attacks, current treatment and adherence, and patients' perspectives and preferences regarding gout and gout management. Multivariate regression analysis was performed to determine the factors associated with ULT adherence. @*Results@#Of 809 surveyed patients with gout, 755 (94.5%) were using ULT. Among those using ULT, 89.1% had ≥ 80% adherence to ULT. Majority of the patients knew management strategies to some extent (94.8%), perceived gout as a life-long disease (91.2%), and were making efforts toward practicing at least one lifestyle modification (89.2%). Most patients (71.9%) obtained information about gout management during their clinic visits.Approximately half of the patients (53.6%) preferred managing their disease with both ULT and lifestyle modification, 28.4% preferred ULT only, and 17.4% preferred lifestyle modification only. Adherence was better in patients with older age (odds ratio [OR], 1.03), those with better knowledge of gout management strategies (OR, 3.56), and those who had preference for ULT (OR, 2.07). @*Conclusion@#Patients' perspectives and management preferences had high impacts on adherence to ULT in gout. Consideration of patients' perspectives and preferences is important for achieving the desired clinical outcome in gout.

Seasonal Variations and Associated Factors of Gout Attacks: a Prospective Multicenter Study in Korea

Background@#We purposed to evaluate the seasonality and associated factors of the incidence of gout attacks in Korea. @*Methods@#We prospectively enrolled patients with gout attacks who were treated at nine rheumatology clinics between January 2015 and July 2018 and followed them for 1-year. Demographic data, clinical and laboratory features, and meteorological data including seasonality were collected. @*Results@#Two hundred-five patients (men, 94.1%) were enrolled. The proportion of patients with initial gout attacks was 46.8% (n = 96). The median age, body mass index, attack duration, and serum uric acid level at enrollment were 50.0 years, 25.4, 5.0 days, and 7.4 mg/dL, respectively. Gout attacks were most common during spring (43.4%, P < 0.001) and in March (23.4%, P < 0.001). A similar pattern of seasonality was observed in the group with initial gout attacks. Alcohol was the most common provoking factor (39.0%), particularly during summer (50.0%). The median diurnal temperature change on the day of the attack was highest in the spring (9.8°C), followed by winter (9.3°C), fall (8.6°C), and summer (7.1°C) (P = 0.027). The median change in humidity between the 2 consecutive days (the day before and the day of the attack) was significantly different among the seasons (3.0%, spring; 0.3%, summer; −0.9%, fall; −1.2%, winter; P = 0.015). One hundred twenty-five (61%) patients completed 1-year follow-up (51% in the initial attack group). During the follow-up period, 64 gout flares developed (21 in the initial attack group). No significant seasonal variation in the follow-up flares was found. @*Conclusion@#In this prospective study, the most common season and month of gout attacks in Korea are spring and March, respectively. Alcohol is the most common provoking factor, particularly during summer. Diurnal temperature changes on the day of the attack and humidity changes from the day before the attack to the day of the attack are associated with gout attack in our cohort.

Embryonal Carcinoma of the Pineal Gland Developed in an Adolescent Boy with Klinefelter Syndrome / 임상소아혈액종양

Klinefelter syndrome (KS) is characterized by small testes, gynecomastia, tall stature, and hypergonadotropic hypogonadism. This condition is associated with extra X chromosomes. It is well known that these aneuploidies predispose individuals to the development of several cancers. Moreover, there are many case reports that show KS patients to have a higher relative risk for the development of malignancy. However, incracranial germ cell tumor (ICGCT) associated with KS is very uncommon. Herein, we report delayed diagnosis of KS in a 15-year-old boy with ICGCT, embryonal carcinoma of the pineal gland, after multimodality treatment in Korea.

Clinical phenotypes of Korean patients with Behcet disease according to gender, age at onset, and HLA-B51

BACKGROUND/AIMS: The clinical manifestations of Behcet disease (BD) have been reported to differ according to country, region, and race. Gender, onset age, and human leukocyte antigen (HLA)-B51 have also been known as the factors that influence the clinical features of BD. The aim of this study is to investigate the clinical phenotypes of Korean patients who visited the rheumatology clinic with BD with respect to gender, onset age, and HLA-B51. METHODS: Total 193 Korean patients (129 females and 64 males) fulfilling the international criteria for BD were retrospectively assessed. RESULTS: The mean age at disease onset and disease duration of the BD patients were 32.2 ± 11.1 and 14.2 ± 9.3 years, retrospectively. Females suffered more frequently from genital ulcers (90.7% vs. 75.0%, p 40 years) suffered from neurologic involvement (15.9% vs. 4.2%, p = 0.007) more frequently than those with early onset of BD. The patients with HLA-B51 showed earlier onset of disease than without HLA-B51 (28.3 ± 11.4 years vs. 33.8±11.6 years, p = 0.02) and the neurologic and gastrointestinal involvements were more frequent in the patients without HLA-B51 than with HLA-B51 (17.2% vs. 2.5%, p = 0.02 and 20.7% vs. 2.5%, p = 0.01, respectively). CONCLUSIONS: The clinical phenotypes in Korean patients with BD may be influenced by gender, onset age and HLA-B51.

Validation and reliability of a Behcet's Syndrome Activity Scale in Korea

BACKGROUND/AIMS: We prepared a cross-cultural adaptation of the Behcet's Syndrome Activity Scale (BSAS) and evaluated its reliability and validity in Korea. METHODS: Fifty patients with Behcet's disease (BD) who attended the Rheumatology Clinic of Gachon University Gil Medical Center were included in this study. The first BSAS questionnaire was administered at each clinic visit, and the second questionnaire was completed at home within 24 hours of the visit. A Behcet's Disease Current Activity Form (BDCAF) and a Behcet's Disease Quality of Life (BDQOL) form were also given to patients. The test-retest reliability was analyzed by intraclass correlation coefficients (ICC). To assess the validity, the total BSAS score was compared with the BDCAF score, the patient/physician global assessment, and the BDQOL by Spearman rank correlation. RESULTS: Twelve males and 38 females were enrolled. The mean age was 48.5 years and the mean disease duration was 6.7 years. Thirty-eight patients (76.0%) returned the questionnaire by mail. For the test-retest reliability, the two assessments were significantly correlated on all 10 items of the BSAS questionnaire (p < 0.05) and the total BSAS score (ICC, 0.925; p < 0.001). The total BSAS score was statistically correlated with the BDQOL, BDCAF, and patient/physician global assessment (p < 0.01). CONCLUSIONS: The Korean version of BSAS is a reliable and valid instrument to measure BD activity.

Behcet's Disease Current Activity Form as a Patient's Derived Measure

OBJECTIVE: This study measured the reliability of the Behcet's Disease Current Activity Form (BDCAF) questionnaire used as a patient self-report form. METHODS: A study was conducted among 63 patients with Behcet's disease who attended our rheumatology clinic. First, a physician administered a BDCAF questionnaire. Second, the patient completed a self-administered questionnaire at home within 24 hours of the visit. The test-retest reliability was analyzed using kappa tests. Kappa scores of >0.6 indicated good agreement. The BDCAF score was compared with the patient's/clinician's perception of disease activity and the Korean version of Behcet's Disease Quality of Life (BDQOL). RESULTS: The study included 17 males and 46 females. The mean age of participants was 47.7 years and the mean disease duration was 5.3 years at the first assessment. Fifty-three patients (84.1%) returned the questionnaires to us by mail. For test-retest reliability, good agreement was achieved with the items including headache, oral/genital ulceration, erythema, arthritis, and diarrhea with altered/frank blood per rectum; moderate agreement with skin pustules, arthralgia, and eye involvement; fair agreement with nausea/vomiting/abdominal pain, nervous system, and major vessel involvement. Significant associations were observed between BDCAF scores with the patient's/clinician's perception of disease activity and BDQOL (p<0.05). CONCLUSION: The BDCAF appears useful as a patient self-report instrument for assessment of disease status.

Viral Effects of a dsRNA Mycovirus (PoV-ASI2792) on the Vegetative Growth of the Edible Mushroom Pleurotus ostreatus

A double-stranded RNA (dsRNA) mycovirus was detected in malformed fruiting bodies of Pleurotus ostreatus strain ASI2792, one of bottle cultivated commercial strains of the edible oyster mushroom. The partial RNA-dependent RNA polymerase (RdRp) gene of the P. ostreatus ASI2792 mycovirus (PoV-ASI2792) was cloned, and a cDNA sequences alignment revealed that the sequence was identical to the RdRp gene of a known PoSV found in the P. ostreatus strain. To investigate the symptoms of PoV-ASI2792 infection by comparing the isogenic virus-free P. ostreatus strains with a virus-infected strain, isogenic virus-cured P. ostreatus strains were obtained by the mycelial fragmentation method for virus curing. The absence of virus was verified with gel electrophoresis after dsRNA-specific virus purification and Northern blot analysis using a partial RdRp cDNA of PoV-ASI2792. The growth rate and mycelial dry weight of virus-infected P. ostreatus strain with PoV-ASI2792 mycovirus were compared to those of three virus-free isogenic strains on 10 different media. The virus-cured strains showed distinctly higher mycelial growth rates and dry weights on all kinds of experimental culture media, with at least a 2.2-fold higher mycelial growth rate on mushroom complete media (MCM) and Hamada media, and a 2.7-fold higher mycelial dry weight on MCM and yeastmalt-glucose agar media than those of the virus-infected strain. These results suggest that the infection of PoV mycovirus has a deleterious effect on the vegetative growth of P. ostreatus.

Seasonality of Gout in Korea: A Multicenter Study

The object of this study was to evaluate the seasonality of gout in Korea. We retrospectively examined data from 330 patients seen at nine rheumatology clinics, treated with urate lowering therapy (ULT) more than one year after stopping prophylactic medication. Demographic data, clinical and laboratory features, and seasonality of gout onset and flares were collected. Season was classified in three-month intervals. The mean age was 52.2 yr and mean disease duration was 26.8 months. The male to female count was 318:12. The onset of acute gouty attacks was obtained in 256 patients. Gout developed most commonly in summer season (36.7%) (P<0.001) and in June (15.6%, P=0.002). During ULT, there were 147 (male 97.3%) gout flares. Although there was no statistically significant difference, gout flares were more common in summer (30.6%). Aggravating factors were identified in 57 flares: alcohol (72.0%) was most common. In the patients who attained target serum uric acid (<6 mg/dL) at the end of prophylaxis, gout flares were high in fall (35.8%) and September (17.0%). In Korea, the summer is most common season of gout onset and there is a tendency for gout flares to increase during ULT in summer/fall season.

Cross-cultural adaptation and validation of the Behcet's Disease Current Activity Form in Korea

BACKGROUND/AIMS: This study was undertaken to perform a cross-cultural adaptation of the Behcet's Disease Current Activity Form (BDCAF, version 2006) questionnaire to the Korean language and to evaluate its reliability and validity in a population of Korean patients with Behcet's disease (BD). METHODS: A cross-cultural study was conducted among patients with BD who attended our rheumatology clinic between November 2012 and March 2013. There were 11 males and 35 females in the group. The mean age of the participants was 48.5 years and the mean disease duration was 6.4 years. The first BDCAF questionnaire was completed on arrival and the second assessment was performed 20 minutes later by a different physician. The test-retest reliability was analyzed by computing kappa statistics. Kappa scores of > 0.6 indicated a good agreement. To assess the validity, we compared the total BDCAF score with the patient's/clinician's perception of disease activity and the Korean version of the Behcet's Disease Quality of Life (BDQOL). RESULTS: For the test-retest reliability, good agreements were achieved on items such as headache, oral/genital ulceration, erythema, skin pustules, arthralgia, nausea/vomiting/abdominal pain, and diarrhea with altered/frank blood per rectum. Moderate agreement was observed for eye and nervous system involvement. We achieved a fair agreement for arthritis and major vessel involvement. Significant correlations were obtained between the total BDCAF score with the BDQOL and the patient's/clinician's perception of disease activity p < 0.05). CONCLUSIONS: The Korean version of the BDCAF is a reliable and valid instrument for measuring current disease activity in Korean BD patients.

Chronic Tophaceous Gout in Multiple Spines: A Case Report and Literature Review

Gout typically affects the 1st metatarsophalangeal joint. Spinal gout is rarely reported. Moreover, involvement of extensive spines is remarkably unusual. We describe a case of a 76-year-old woman with gout involving cervical, thoracic, and lumbar spines and sacroiliac joint. She presented with fever, severe back pain, and polyarthralgia and had multiple tophi on both elbows and the left 2nd and 5th proximal interphalangeal (PIP) joints. Monosodium urate crystals were confirmed from tophi on the left 5th PIP joint by polarized optical microscopy. Magnetic resonance imaging and computed tomography showed joint space narrowing and bony erosions on cervical, thoracic, and lumbar spines, and sacroiliac joint. Fever, back pain, and polyarthralgia improved significantly with oral steroid therapy. Spinal gout can involve multiple spines and other joints and it can be improved by medical treatment only. It should be considered in patients with uncontrolled gout who have acute severe back pain.

Successful Treatment of Primary Biliary Cirrhosis with Adalimumab in a Patient with Overlap Syndrome

Primary biliary cirrhosis (PBC) is occasionally developed in patients with rheumatic diseases, such as systemic sclerosis or Sjogren's syndrome. However, there are a few reports of overlap syndrome with PBC. The authors report a case of a 36 year-old female with PBC and overlap syndrome. Systemic sclerosis was diagnosed in 2007, and rheumatoid arthritis in 2010. Adalimumab stopped because of her pregnancy plan in January 2012. One month after delivery, she felt increased hand joint pain and fatigue. Laboratory findings were as follows: elevated AST, ALT, ALP, r-GTP and positive anti-mitochondrial antibody. Histology of a liver biopsy revealed moderate porto-periportal and mild lobular inflammation with bile duct inflammation, which was consistent with PBC. She was treated with prednisolone and UDCA (urosodeoxycholic acid), but her disease was not controlled. From May 2013, she has been treated with adalimumab. Her arthritis was improved and liver function test normalized up until now.

A Case of Enterocolic Lymphocytic Phlebitis Mimicking Surgical Abdomen

Vasculitis that involves the gastrointestinal (GI) tract often occurs as part of a systemic inflammatory process. It is a well-recognized manifestation of the small and medium sized vessel vasculitides. Vasculitis of the GI tract may occur in isolation; although it can progress to a systemic illness. It usually involves the arterioles, venules, and capillaries; however, it is very rare for only the venules to be affected. Enterocolic lymphocytic phlebitis is a localized vasculitis, typically affecting the small and medium-sized intramural and mesenteric veins of the intestines. We report a case of enterocolic lymphocytic phlebitis of the colon. A 38-year-old woman was presented with hematochezia and severe abdominal pain on the day of admission. She had no history of intestinal disease or systemic disease. Computed tomography showed an extremely thickened wall of the colon, along with several air bubbles in the colon with diffuse subcutaneous emphysema in the abdominal wall. An emergency exploration laparotomy and extended right hemicolectomy was performed. The patient recovered completely after surgery and remains well without further therapy.

Duration of Prophylactic Therapy Affects the Frequency of Gout Flare

OBJECTIVE: To evaluate the effect of prophylactic therapy on gout flare during urate lowering treatment. METHODS: We retrospectively examined the data derived from 59 patients who had been treated with allopurinol for more than six months after stopping prophylactic medication at our rheumatology clinic. Demographic data (age, sex, disease duration, tophi and comorbidity), clinical and laboratory features, including presence of gout flare during urate lowering treatment, dose of allopurinol, serum uric acid level and creatinine clearance at initiation and six months later, were collected. For the subgroup analysis, the same data were collected in 46 patients who had been followed up at one year after stopping prophylactic medication. RESULTS: Twenty-eight patients among 59 (47.4%) had experienced at least 1 gouty attack during urate lowering therapy. The mean duration of prophylactic medication was not different between the flare group (3.8 months) and the non-flare group (5.9 months, p=0.617). Six months later, the mean serum uric acid level was 6.3 mg/dL (6.1 mg/dL vs. 6.5 mg/dL). According to the duration of prophylactic treatment ( or =6 months), there were more frequent flares in the or =6 months group (51.2% vs. 38.9% in the six month follow-up group, 70.6% vs. 50% in the one year follow-up group). CONCLUSION: Prophylactic medication for more than six months could be a favorable factor for the prevention of recurrent gout flare during urate lowering treatment.

Duration of Prophylactic Therapy Affects the Frequency of Gout Flare

OBJECTIVE: To evaluate the effect of prophylactic therapy on gout flare during urate lowering treatment. METHODS: We retrospectively examined the data derived from 59 patients who had been treated with allopurinol for more than six months after stopping prophylactic medication at our rheumatology clinic. Demographic data (age, sex, disease duration, tophi and comorbidity), clinical and laboratory features, including presence of gout flare during urate lowering treatment, dose of allopurinol, serum uric acid level and creatinine clearance at initiation and six months later, were collected. For the subgroup analysis, the same data were collected in 46 patients who had been followed up at one year after stopping prophylactic medication. RESULTS: Twenty-eight patients among 59 (47.4%) had experienced at least 1 gouty attack during urate lowering therapy. The mean duration of prophylactic medication was not different between the flare group (3.8 months) and the non-flare group (5.9 months, p=0.617). Six months later, the mean serum uric acid level was 6.3 mg/dL (6.1 mg/dL vs. 6.5 mg/dL). According to the duration of prophylactic treatment ( or =6 months), there were more frequent flares in the or =6 months group (51.2% vs. 38.9% in the six month follow-up group, 70.6% vs. 50% in the one year follow-up group). CONCLUSION: Prophylactic medication for more than six months could be a favorable factor for the prevention of recurrent gout flare during urate lowering treatment.

The Urate-lowering Efficacy and Safety of Febuxostat in Korean Patients with Gout

OBJECTIVE: To compare the urate-lowering efficacy and the safety of febuxostat, allopurinol and placebo in Korean patients with gout for 4 weeks. METHODS: Subjects (n=182) with gout were randomized to febuxostat (40, 80, 120 mg), allopurinol 300 mg, or placebo group. The primary end point was the proportion of subjects whose serum urate concentration fell to less than 6.0 mg/dL after the 4-week treatment. RESULTS: The primary end point was reached at 25.7%, 80.0% and 83.3% of patients receiving 40, 80 and 120 mg of febuxostat, respectively, 58.3% of those receiving 300 mg of allopurinol and none of the placebo (p<0.001: each febuxostat dose or allopurinol group versus placebo group, p=0.0484 and p=0.0196: febuxostat 80 and 120 mg compared with allopurinol, respectively). The number and proportion of subjects who developed adverse events (AEs) were 13 subjects (37%), 14 (39%) and 18 (50%) in the febuxostat of 40, 80 and 120 mg group, respectively, 21 (57%) in the allopurinol 300 mg group and 17 (46%) in the placebo group. No statistically significant differences in the incidence rates of adverse events were observed between the groups. There was no significant difference in gout flare-up incidence. CONCLUSION: Febuxostat, 80 mg or 120 mg, was more effective than allopurinol (300 mg) or placebo, when lowering the serum urate. The safety of febuxostat and allopurinol was comparable.

Mediation Effect of Job Satisfaction between Internal Marketing and Organizational Commitment of Nurses in Small and Medium-sized Hospitals / 간호행정학회지

PURPOSE: The purpose of the study was to identify the mediating effects of job satisfaction between internal marketing and organizational commitment of nurses in small and medium-sized hospitals. METHOD: Data were collected from 208 nurses in 8 small and medium-sized hospitals and analyzed using descriptive statistics, Pearson correlations, and structural equation model (SEM) with the PASW 18.0 and AMOS 18.0 programs. RESULTS: There were positive relationships among all three variables, internal marketing, job satisfaction and organizational commitment. There was a mediating effect of job satisfaction between internal marketing and organizational commitment. CONCLUSION: The results of the study indicate that strategies which could enhance the job satisfaction of nurses should be developed by mangers in small and medium sized hospitals. Further study is needed on other factors which may influence nurses' job satisfaction and organizational commitment especially, in small and medium sized hospitals.

Mediation Effects of Self-Efficacy between Academic Stress and College Adjustment in First Year Nursing Students / 기본간호학회지

PURPOSE: The purpose of the study was to identify the mediating effects of self-efficacy between academic stress and college adjustment in first year nursing students. METHOD: Data were collected from 396 first year nursing students from 3 junior colleges and analyzed using descriptive statistics, Pearson correlations and structural equation model (SEM) with PASW 18.0 and AMOS 18.0 programs. RESULTS: There was a negative relationship between academic stress and college adjustment but a positive relationship between self-efficacy and college adjustment. There was a partial mediating effect of self-efficacy between academic stress and college adjustment. CONCLUSION: The results indicate a need to develop programs that effectively promote the self-efficacy of first year nursing students to decrease academic stress and maximize college adjustment. Further studies are needed in which other factors that could affect college adjustment are examined.