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GOUT, OSTEOPOROSIS, OSTEOMYELITIS AND Paget’s DISEASE J. Steuart Richards, MD Assistant Chief, Rheumatology Section VAMC, Washington, DC Assistant Professor of Medicine Georgetown University
Definitions Gout is a syndrome caused by an inflammatory response to the formation of mono-sodium urate monohydrate crystals which develop secondary to hyperuricemia Hyperuricemia occurs when the serum uric acid level is > 7.0 mg/dl (420 μmol/L) Asymptomatic hyperuricemia occurs when serum uric acid is elevated but there are no signs of gout or renal calculus
Prevalence of Gout Overall prevalence is 4.6% in men and 2% in women > 451 6%-7% of VA population is estimated to have gout Incidence of gout estimated at 45.9/100,000 in 1995 -96 vs. 20.2/100,000 in 1977-782 Contributing factors include - ↑ longevity, ↑ HTN, ↑ obesity, ↑ metabolic syndrome, ↑ ESRD, ↑ aspirin, ↑ transplantation use of cyclosporine 1US National Health Survey of 1996 on self reported prevalence 2Arromedee et al J Rheumatol 2002;29:2403-06
Evolution of Hyperuricemia and Gout Over time, untreated, chronic hyperuricemia increases body urate stores, advancing the severity of the disease Painful Intercritical Segments Painless Intercritical Segments Flares last longer Flares occur more often Pain Intercritical segments decrease Persistent pain and stiffness Advanced Gout Asymptomatic Hyperuricemia Acute Flares Time Adapted from Klippel et al, eds. In: Primer on the Rheumatic Diseases. 12th ed. Arthritis Foundation; 2001:313.
2 1 1 3 1. Photos courtesy of Brian Mandell, MD, PhD, Cleveland Clinic. 2. Photo courtesy of N. Lawrence Edwards, MD, University of Florida. 3. ACR Clinical Slide Collection on the Rheumatic Diseases, 1998.
Diagnosis of Gout Clinical Presence of monosodium urate crystals Presence of tophii Radiographic features Uric acid
Causes of Disability in Gout Acute short term limitation of activity Dependent on: Location Severity Number of joints Frequency of attacks Duration of attacks Chronic Chronic limitation of activity Dependent on: Location Number of joints Severity of joint damage Superimposed flares
Rates were highest for Caucasian and Asian men compared with AA men, Hispanic men were intermediate
Mortality rate following hip fractures is almost double that of women 31% vs. 17%2
1Looker AC et al J Bone Miner Res 11997; 2:1761-1768 2Forsen L et al Osteoporosis Int 1999;10:73
VA Perspective Prevalence of Osteoporosis in Men in a VA Rehabilitation Center Arthur Swislocki, MD; Jon A. Green, MD, PhD; Gerhard Heinrich, MD; Charles A. Barnett, MD; Ivan D. Meadows, MD; Ernest B. Harmon, BS; Mary F. Rank, RN, FNP; and Robert H. Noth, MD
Disability and Osteoporotic Fractures Vertebral Fractures Pain Sleep disturbance Loss of height Respiratory disease Depression Loss of mobility Hip Fractures Loss of ambulation Need for walking aids or wheelchair Loss of independence, unable to live alone Chronic pain
Osteomyelitis Definition: Infection of bone Acute or chronic Risk Factors: Trauma Diabetes Hemodialysis IV drug abuse Surgery Skin infections
Disability from Osteomyelitis Acute Pain Limitation of function of affected bone Restricted movement for treatment with IV antibiotics Chronic Pain Fatigue Loss of function of affected limb Amputation Social isolation Depression
Paget’s Disease Definition: Osteitis Deformans Focal disorder of bone metabolism leading to accelerated remodeling and bone overgrowth Involves: Pelvis Spine Skull long bone
Paget’s Disease Often asymptomatic Symptoms depend on the bone involved: Pain Skeletal deformities Osteoarthritis Fractures Tumors Heart Failure Neurological symptoms Deformity of the affected bone
Disability from Paget’s Disease Osteoarthritis Pain Limitation of movement Requiring assistive devices – cane, walker, wheelchair Sleep disturbance Heart Failure Limitation of work and exercise capacity Sleep disturbance