Integrating acupuncture with exercise-based physical therapy for knee osteoarthritis: a randomized controlled trial.

BACKGROUND: Knee osteoarthritis is a chronic disease associated with significant morbidity and economic cost. The efficacy of acupuncture in addition to traditional physical therapy has received little study. OBJECTIVE: The objective of this study was to compare the efficacy and safety of integrating a standardized true acupuncture protocol versus nonpenetrating acupuncture into exercise-based physical therapy (EPT). METHODS: This was a randomized, double-blind, controlled trial at 3 physical therapy centers in Philadelphia, PA. We studied 214 patients (66% African Americans) with at least 6 months of chronic knee pain and x-ray-confirmed Kellgren scores of 2 or 3. Patients received 12 sessions of acupuncture directly following EPT over 6 to 12 weeks. Acupuncture was performed at the same 9 points dictated by the traditional Chinese "Bi" syndrome approach to knee pain, using either standard needles or Streitberger non-skin-puncturing needles. The primary outcome was the proportion of patients with at least a 36% improvement in Western Ontario and McMaster Universities Osteoarthritis Index score at 12 weeks. RESULTS: Both treatment groups showed improvement from combined therapy with no difference between true (31.6%) and nonpenetrating acupuncture (30.3%) in Western Ontario and McMaster Universities Osteoarthritis Index response rate (P = 0.5) or report of minor adverse events. A multivariable logistic regression prediction model identified an association between a positive expectation of relief from acupuncture and reported improvement. No differences were noted by race, sex, or age. CONCLUSIONS: Puncturing acupuncture needles did not perform any better than nonpuncturing needles integrated with EPT. Whether EPT, acupuncture, or other factors accounted for any improvement noted in both groups could not be determined in this study. Expectation for relief was a predictor of reported benefit.

Synovial xanthomatosis: are there clues to mechanisms for this rare disease?

We report a 64-year-old man with arthritis and nodules to describe that this picture can be caused by normo-lipidemic xanthomas. Light and electron microscopy (EM) plus polymerase chain reaction (PCR) studies were performed for diagnosis and investigation. These showed features typical of xanthomas plus PCR and EM evidence of possible infection with Chlamydia pneumoniae as a pathogenetic mechanism deserving consideration. With such rare diseases, any clues to possible mechanisms seem important to record and thus to encourage future investigations. This uncommon cause of arthritis and nodules had been confused with rheumatoid arthritis by others in this case.

Efficacy of acupuncture as a treatment for chronic shoulder pain.

OBJECTIVES: The aim of this study was to evaluate the efficacy of acupuncture as a treatment for chronic shoulder pain and to compare the efficacy of individualized acupuncture to fixed, standard point acupuncture treatment. DESIGN: The study was a single-blind randomized, controlled trial. SETTINGS/LOCATION: The study was conducted in an outpatient rheumatology clinic at the VA Medical Center of Philadelphia. SUBJECTS: The participants were adults with shoulder pain for at least 8 weeks with a diagnosis of osteoarthritis or rotator cuff tendonitis and a total Shoulder Pain and Disability Index (SPADI) score of > or =30. INTERVENTIONS: Thirty-one (31) subjects were randomized to one of three treatment groups: individualized acupuncture points according to the approaches of Traditional Chinese Medicine; fixed, standard acupuncture points conventionally used for shoulder pain; and sham nonpenetrating acupuncture. Subjects received 12 treatments over 6 weeks and were reassessed using the SPADI at the end of the 6 weeks. OUTCOME MEASURES: The primary outcome evaluated was the mean change in total SPADI score in each group from baseline to 6 weeks. RESULTS: After 6 weeks of treatment, the mean total SPADI score improved in all three groups, but the change was clinically significant (> or =10 points) only in groups 1 and 2 (-20.3 and -20.4, respectively, versus -6.5 in group 3). The treatment effects of groups 1 and 2 compared to the sham acupuncture group were -13.8 (95% confidence interval: -2.2 to -25.4, p < 0.015) and -13.9 (-2.0 to -25.8, p < 0.013), respectively. There was no difference between the individualized acupuncture and standardized acupuncture treatments. CONCLUSIONS: Acupuncture may be an effective treatment for chronic shoulder pain. There may be no difference in efficacy between individualized and standardized acupuncture treatment. This suggests that the use of standard points may make treatment easier for patient care and for further research studies.

Febuxostat treatment for gout: what the clinician needs to know.

Febuxostat is a new non-purine based inhibitor of xanthine oxidase that will be a useful addition to the drugs available to treat gout. This short review covers general principles of the management of gout and then focuses on practical aspects and use of febuxostat.

The practical management of gout.

Gout management requires a comprehensive strategy that considers both acute and chronic aspects of the disease. Acute gout flares should be treated with anti-inflammatory agents as rapidly as possible. The underlying hyperuricemia may be treated with urate-lowering agents initiated at a time appropriate for the individual patient. Successful urate lowering ultimately prevents flares and disease progression and should be started immediately in patients with advanced or tophaceous disease. When urate-lowering therapy is initiated, anti-inflammatory prophylaxis should be used to reduce the risk of flares induced by abrupt changes in urate levels. Regular monitoring of serum urate can ensure therapeutic dosing of urate-lowering agents to achieve levels below 6 mg/dL, which are associated with a reduction in flares and tophi.

Outcome evaluations in gout.

Methods to measure outcomes in gout still require consensus and validation. This Special Interest Group was assembled to identify domains of interest and is now evaluating a series of outcomes for features of acute gouty arthritis and chronic gout. To accomplish this, working groups have been formed and domains identified. Delphi methodology has been used to address gouty flares as an outcome of greatest interest. Studies addressing other outcome measures were reported at the OMERACT 8 meeting and validation has begun on some outcomes. There has been progress on developing a definition of a flare, and validating reproducibility of some chronic gout outcome measures in some domains, such as tophus size and patient perceptions. Use of these outcomes as well as a health-related quality of life measure are being studied in clinical trials. Pain on a Likert scale appears to be a valid outcome in acute gout. Final validation of these outcomes has not yet been achieved. In summary, the unique problems of evaluating outcomes in gout are finally being addressed. While no measures are available for use yet, an agenda has been developed.

[Decision-making about gout by physicians of China and influencing factors thereof].

OBJECTIVE: To investigate the decision-making about gout by physicians of China and influencing factors thereof. METHODS: A questionnaire survey, including 13 multiple choice questions, was divided into 2 stages. The first/stage questionnaire survey was conducted among 121 physicians of the departments of internal medicine and rheumatology respectively during the grand ward rounds, and the second-stage questionnaire survey was conducted among 75 physicians attending a national continuous medical education (CME) workshop of rheumatology. The data thus collected were pooled and analyzed by logistic regression models. RESULTS: 62 effective questionnaires were collected in the first/stage survey, and 38 effective questionnaires were collected in the second-stage survey, both with a missing rate < 10%. 78.3% of the respondents considered aspiration of the joint fluid as critical for the definitive diagnosis of gout, but only 2.4% of the respondents did so frequently. When treating acute gout in otherwise healthy patients, 69.2% of the respondents preferred oral colchicine, and while treating the patients with renal dysfunction, 41.7% of the respondents used corticosteroids or corticotrophin as the first choice. For long-term uric acid-lowering therapy, 99 of them (82.5%) described a variety of incorrect indications, 107 of them (89.2%) initiated the treatment too early (< or = 2 weeks after the remission), and 92 of them (76.7%) failed to sustain the treatment for at least 5 years. Only 17 physicians (14.2%) used prophylaxis while initiating the uric acid-lowering treatment and only 7 of them (5.8%) selected a prophylaxis time of 7 approximately 12 months. Multiple logistic regression analysis showed that only CMD on gout was associated with correct diagnosis strategy (OR 7.1, 95% CI 2.1 approximately 23.7). CONCLUSION: The management of gout by the physicians in China is often not consistent with that generally accepted internationally. High quality CME may improve the decision-making ability of physicians.

The management of gout at an academic healthcare center in Beijing: a physician survey.

OBJECTIVE: Gout is a less commonly diagnosed rheumatic disease in China compared with Western countries, but its prevalence appears to be climbing. It is not known how Chinese physicians diagnose and treat their patients with gout, so we evaluated physician management of gout at a major academic healthcare center in Beijing, and investigated factors associated with better decision-making. METHODS: A 13-question anonymous survey was distributed and collected at a medical grand rounds and then at a rheumatology grand rounds at a major teaching hospital in Beijing. Physician demographic data including educational background, work experience, job titles, specialty or subspecialties, gout patient volume seen in a year, and continuing medical education (CME) in gout were also collected in the survey. Data were analyzed by multivariate regression models to identify factors associated with appropriate answers. RESULTS: Twenty-seven residents and general internists, 26 rheumatologists and fellows, and 28 physicians and fellows of other medical subspecialties from the Department of Medicine including visiting physicians responded to the survey. Among respondents, 78% think it is important for a definitive diagnosis of gout, but few actually perform aspiration of the affected joint fluid. Eighty-four percent report that they often follow the serum urate level of their patients with diagnosed gout. When treating acute gout in otherwise healthy patients, most physicians (77%) prefer oral colchicine, and in patients with renal impairment, about half of them (48%) choose corticosteroids or corticotropin as their first treatment. For longterm urate-lowering therapy, most physicians (87%) described a variety of indications that we consider less appropriate. They (86%) tend to initiate it early (< 2 weeks) after acute flares. When urate-lowering therapy is used, 80% of physicians sustain it less than 5 years. Further, only 12% of physicians use antiinflammatory prophylaxis during the initiation of urate-lowering treatment, and only 5% maintain it for an appropriate period of time. Logistic regression analysis of physician demographic data, educational background, and work experience found no consistent independent factors associated with better decision-making, other than CME, that were associated with establishing the definite diagnosis correctly. Specifically, the number of gout patients seen by physicians was not related to better decision-making. CONCLUSION: The physicians' reported management of gout at this major academic healthcare center in Beijing was often inconsistent with current evidence. High quality CME is required to improve Chinese physician management of gout.

Gout: can we create an evidence-based systematic approach to diagnosis and management?

The management of gout can be subdivided into four phases. Asymptomatic hyperuricaemia represents the basic underlying metabolic abnormality that can lead to gout. Studies are evaluating whether interventions may be indicated in some cases. Diagnostic criteria for gout and acute flares are still not well defined unless urate crystals are found. Acute attacks of gout are treated with anti-inflammatory measures and the agent of choice is often determined by attack stage, severity and comorbidities that may contra-indicate one or more agents. After attacks subside, there are asymptomatic periods during which decisions must be made about when and how to start urate-lowering measures. If hyperuricaemia persists, there is generally persistence of urate crystals in the joint. Anti-inflammatory prophylaxis is needed when urate-lowering therapy is started. Lifestyle measures should be addressed. If chronic tophaceous gout is diagnosed, urate lowering should be started without delay. New agents are under development that may help with difficult cases.

Newer therapeutic approaches: gout.

Newer approaches to the treatment of gout have included modifications and further attention to aspects of current therapies, and development of interesting new therapies. Colchicine prophylaxis appears to be needed longer than previously recognized after introduction of a urate-lowering agent. Diet has received attention, though most dietary effects are small. New agents under investigation include pegylated formulations of uricase and a new potent xanthine oxidase inhibitor, febuxostat. Some cardiovascular drugs have been shown to be uricosuric.

Current trends in crystal identification.

PURPOSE OF REVIEW: This review is an attempt to keep current in the sparse literature addressing the still underutilized area of crystal identification. RECENT FINDINGS: The emphasis has been on the subtleties of the microscopic identification of common crystals and other less common potentially confusing crystals. Imaging is noted to provide increasing help, but microscopic crystal identification remains the gold standard. SUMMARY: Quality control is still a concern as is the infrequency of attempted arthrocentesis for crystal identification.