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 care was linked to a higher uptake of and adherence to urate lowering therapy (ULT) compared with usual care, according to a study published in 

“Currently, gout management, particularly ULT, is often suboptimal,” wrote a team of investigators led by Claus Rasmussen, MD, associated with the Department of Rheumatology, North Denmark Regional Hospital in Hjorring, Denmark. “Nurses successfully manage various diseases including gout. As gout prevalence is rising, and rheumatologists and general practitioners face shortages, a new approach is imperative.”

Despite the established recommendations for ULT, less than half of patients are prescribed ULT and treatment adherence is generally poor. Further, the doses are often fixed without titration, which hinders a patient’s ability to obtain target plasma urate (p-urate) concentrations.

In the real-life prospective cohort study, investigators assessed the effectiveness of a nurse-led care program that used a treat-to-target strategy for the management of gout over a span of 2 years.

Patients with clinically confirmed gout diagnosed between June 2017 and June 2021 who were treated at the Clinic of Rheumatology in the North Denmark Regional Hospital were recruited into the study. The nurse-led management program provided a structured treatment plan including consultations, patient leaflets, laboratory monitoring, and telephone contacts. Patients were required to have had ≥ 1 visit or telephone call with the nurse-led clinic and nurses were given specialized training in gout management, with a focus on overcoming established barriers to treatment.

At the 1-year mark, patients were cared for in general practice for the remainder of the trial. The primary endpoint was obtaining target p-urate levels, defined as < .36 mmol/L, at 2 years. Other endpoints were treatment adherence and the achievement of target p-urate levels among specific subgroups. These results were compared with patients diagnosed with gout in the same clinic but receiving usual care.

A total of 114 patients with gout were recruited into the nurse-led group and 172 patients received usual care.

Among the nurse-led cohort, 82% (n = 92/112) achieved target p-urate levels and 98% continued treatment with ULT. Results were comparable among patient subgroups. Most (90%, n = 101/112) patients received allopurinol treatment with an average daily dosage of 308 mg. Conversely, only 44% (n = 63/144) of patients in the usual care group obtained target p-urate with insufficient doses of allopurinol (67%, n = 97/144), with a mean daily dosage of 235 mg. Additionally, fewer patients (73%) in this group continued ULT. The nurse-led care averaged 2 visits and 3 telephone calls over a 336-day period.

The overall mortality rate at the end of 2 years was 15%, with 4% (n = 4/114) in the nurse-led group compared with 23% (n = 39/172) in the usual care group (95% confidence interval [CI] .1547 [.04 — .43], 

Investigators mentioned limitations including selection bias and a lack of alternative comparison groups. However, by examining and comparing the nurse-led and usual care groups, they were able to obtain valuable insights regarding treatment efficacy and could better understand potential trends and associations that may impact future research and clinical practice.

“Our study demonstrates that a low-cost nurse-led gout clinic, primarily based on telephone interventions for 1 year, can be highly successful in achieving a clinically relevant reduction in p-urate levels,” investigators concluded. “This reduction significantly decreases the risk of disease progression, complications and potentially even mortality rates.”

Rasmussen C, Larsen JW, Christensen HM, et al. Optimising gout treatment: insights from a nurse-led cohort study. 

. 2024;10(2):e004179. Published 2024 Apr 24. doi:10.1136/rmdopen-2024-004179

Bavanendrakumar M, Robinson PC. Management of patients with gout and achievement of target serum Urate levels at a tertiary rheumatology service in Australia. Intern Med J 2020;50:337–41. doi:10.1111/imj.14445

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Among the nurse-led cohort, 83% of patients with gout achieved target p-urate levels and 98% continued treatment with urate lowering therapy.

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Nurse-Led Gout Care Linked to Better Medication Adherence 

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Credit: University of Alabama at Birmingham

 in two large clinical cohorts experienced elevated tricuspid regurgitation velocity (TRV), a surrogate marker for pulmonary hypertension, according to new research.

Evidence from the cross-sectional, multi-center study revealed pediatric patients with a history of chronic kidney disease (CKD) and cerebrovascular disease demonstrated a higher prevalence of abnormal TRV, suggesting the need for an echocardiogram in clinical assessment.

“Our findings suggest that adolescent patients may benefit from universal echocardiography performed at steady state if they have been identified with either cerebrovascular disease or albuminuria,” wrote the investigative team, led by Chibuzo Ilonze, MD, division of pediatric hematology and oncology, University of Alabama at Birmingham (UAB).

Determining those at risk for multi-organ disease progression can be crucial for initiating appropriate disease-modifying therapies in young patients with SCD.

 Clinical guidelines in SCD provide screening suggestions for the development of end-organ disease—however, the American Society of Hematology (ASH) and American Thoracic Society (ATS) have differing recommendations for screening echocardiogram for pulmonary hypertension.

The evidence-based ASH guideline suggests against screening echocardiograms in the absence of cardiopulmonary symptoms, abnormal cardiac examination, or history of pulmonary embolism.

 However, both guidelines admit elevated TRV is associated with early mortality in adults, suggesting more evidence is required to support or refute the role of echocardiograms as a screening tool for pediatric patients at risk of pulmonary hypertension.

For this analysis, Ilonze and colleagues sought to measure the associations between multi-organ dysfunction in children with SCD aged 1–21 years across two large sickle cell cohorts from 2012 to 2022.

 The team hypothesized children with SCD, and abnormal surrogate markers of pulmonary hypertension (≥2.5 m/s) would have increased odds of having either cerebrovascular disease or CKD.

Children were recruited from the UAB sickle cell cohort and the Sickle Cell Clinical Research and Intervention Program (SCCRIP) cohort at St. Jude Children’s Research Hospital. A total of 204 patients with SCD received care at the comprehensive sickle cell center at UAB and 166 participants were included for analysis. A total of 1,300 patients were identified in the SCCRIP cohort at St. Jude’s and 325 children completed ≥1 echocardiogram between 2009 - 2019.

These cohorts were combined for 491 children with an echocardiogram performed at a steady state. Together, the prevalence of elevated TRV was 21% (n = 104) in both the UAB and SCCRIP cohorts. The SCCRIP cohort was comparable to the UAB cohort in age, sex, and the prevalence of elevated TRV and persistent albuminuria, but the UAB cohort exhibited a higher statistical prevalence of cerebrovascular disease (55% vs. 42%; 

Among 104 participants with elevated TRV and cerebrovascular disease assessments, 61% had a history of cerebrovascular disease, correlating with higher odds of elevated TRV than those without history. After controlling for age, sex, SCD-modifying therapy, and site, elevated TRV was significantly associated with greater odds of cerebrovascular disease (odds ratio [OR], 1.88; 95% CI, 1.12 - 3.15; 

Among 88 individuals with elevated TRV and multiple albumin–creatinine ratio measurements, 36% demonstrated persistent albuminuria, suggesting higher odds of persistent albuminuria than those without elevated TRV. After controlling for age, sex, SCD-modifying therapy, and site, elevated TRV was associated with higher odds of persistent albuminuria (OR, 1.81; 95% CI, 1.07 - 3.06; 

Ilonze and colleagues indicated these findings provide evidence that children with a history of CKD and cerebrovascular disease exhibit a higher prevalence of abnormal TRV. They noted pediatric sickle cell providers may consider performing echocardiograms in children with these additional comorbidities.

“These data provide additional evidence needed to support future guideline statements for screening echocardiography,” they wrote.

 “Furthermore, we identified that elevated TRV is more prevalent in adolescent patients, which may reflect early signs of accumulated cardiovascular complications in older children.”

Ilonze C, Rai P, Galadanci N, et al. Association of elevated tricuspid regurgitation velocity with cerebrovascular and kidney disease in children with sickle cell disease. Pediatr Blood Cancer. Published online April 21, 2024. doi:10.1002/pbc.31002

DeBaun MR, Kirkham FJ. Central nervous system complications and management in sickle cell disease. 

. 2016;127(7):829-838. doi:10.1182/blood-2015-09-618579

Liem RI, Lanzkron S, D Coates T, et al. American Society of Hematology 2019 guidelines for sickle cell disease: cardiopulmonary and kidney disease [published correction appears in Blood Adv. 2023 Jul 25;7(14):3530]. 

. 2019;3(23):3867-3897. doi:10.1182/bloodadvances.2019000916

Klings ES, Machado RF, Barst RJ, et al. An official American Thoracic Society clinical practice guideline: diagnosis, risk stratification, and management of pulmonary hypertension of sickle cell disease. 

. 2014;189(6):727-740. doi:10.1164/rccm.201401-0065ST

A higher TRV was significantly associated with cerebrovascular disease and persistent albuminuria in children with SCD across two large cohorts.

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Tricuspid Regurgitation Velocity Linked to Cerebrovascular, Kidney Disease in SCD

An automatic electronic health record (EHR)-based 

 register was proven to be a feasible and valid option for assessing and improving gout management, according to a study published in 

 During the analysis, investigators also noted a substantial under-reporting and underdiagnosis of the disease since the beginning of the COVID-19 pandemic.

Although guidelines for the management of gout and how to treat acute flares or chronic gouty arthritis are readily available, previous research has shown the disease remains undertreated. For example, a recent study reported only 30% — 50% of patients with gout are prescribed urate lowering therapy and fewer than half of these patients adhere to their medication.

“Despite the high prevalence of this disease, existing gout registers predominantly come from rheumatology settings which do not fully capture the disease’s spectrum,” wrote a team of investigators led by Nils Bürgisser, MD, associated with the Division of Rheumatology at Geneva University Hospitals (HUG) in Switzerland. “One of the barriers to create larger gout registers is their labor-intensive nature, requiring manual data collection by healthcare professionals. Furthermore, administrative datasets, a common source for research studies, often lack relevant clinical information such as laboratory data and specific patient-centered outcomes.”

The EHR collected information from all adult patients aged > 18 years from HUG, a French-speaking tertiary academic hospital, between January 2013 and December 2022. Gout diagnosis was based on 6 criteria: urate-lowering therapy prescription, monosodium urate crystals in joint aspiration, the International Classification of Diseases 10 (ICD 10) gout diagnosis, and gout-related terms in the problem lists, clinical reports, or imaging reports. The team evaluated the positive predictive value (PPV) and negative predictive value (NPV) of the query by the chart reviews.

Among a total of 2,110,902 patients, 10,289 exhibited ≥ 1 criteria for gout. A combination of joint aspiration or diagnostic in the problem list or ≥ 2 other criteria created a subcategory of 5138 patients. Of this register, 92.4% had a PPV (95% confidence interval [CI] 88.5% — 95.0%) and 94.3% had a NPV (95% CI 91.9% — 96.0%). The PPV and NPV were comparable among inpatients and outpatients.

The incidence was 2.9 per 1000 patient-years, which dropped by 30% at the beginning of the COVID-19 pandemic.

Patients with a gout diagnosis were predominantly male (76.5%), overweight (69.5%), had several comorbidities, and had an average age of 71.2 years. The most common comorbidities were hypertension (69.4%) and cardiovascular and ischemic disease (53.0%). Over half (57.4%) were prescribed a urate lowering therapy, 6.7% had either ≥ 2 flares within a year or were hospitalized due to gout, and 32.9% received a consultation from a rheumatologist.

Investigators noted selection bias as a main limitation of the study, which could also hinder generalizability. Additionally, the EHR could not evaluate any patients who consulted with clinicians in private clinics or practices and those who did not ultimately seek medical attention. However, HUG provides free care to the majority of the regional population, including inpatient and outpatient care to more vulnerable patients. Other important limitations were the use of a single hospital for the register, the possibility of misdiagnosis, and the chance that some patients with gout went undiagnosed due to missing information within the EHR.

“The automatic nature of the query makes this register inexpensive and sustainable, facilitating the assessment of the adequacy of gout management, the monitoring of indicators following quality improvement projects, and the detection of gout patients to be included in new studies or trials,” investigators summarized. “Also, the decline of gout diagnoses since 2020, especially evident in inpatient settings, prompts questions about how the pandemic may have affected healthcare access, patient behaviors and diagnostic approaches.”

Bürgisser N, Mongin D, Mehouachi S, et al. Development and validation of a self-updating gout register from electronic health records data. 

. 2024;10(2):e004120. Published 2024 Apr 24. doi:10.1136/rmdopen-2024-004120

Dehlin M, Jacobsson L, Roddy E. Global epidemiology of gout: prevalence, incidence, treatment patterns and risk factors. Nat Rev Rheumatol 2020;16:380–90. doi:10.1038/s41584-020-0441-1

The incidence of gout was 2.9 per 1000 patient-years, which dropped by 30% at the beginning of the COVID-19 pandemic. 

EHR-Based Gout Register May Improve Disease Management

A new cohort study provided insight into the association between 

, supporting an elevated risk after the immunization, with both vaccine type and post-vaccination period mediating the risk.

The cumulative incidence of uveitis was 8.6% and 16.8% during the 3-month and 1-year periods, respectively, indicating more than half of the uveitis incidences occurred shortly after vaccination. All 4 vaccine types were correlated with increased risk after the first dose.

“These results emphasize the importance of vigilance and monitoring for uveitis in the context of vaccinations, including COVID-19 vaccinations, particularly in individuals with a history of uveitis,” wrote the investigative team, led by Seong Joon Ahn, MD, PhD, department of ophthalmology, Hanyang University Seoul Hospital.

Given the scope of the COVID-19 pandemic, COVID-19 vaccines represented a breakthrough in efforts to combat the ongoing disease.

 Vaccines, including recombinant messenger RNA (mRNA) vaccine, adenovirus vector-based vaccine, and inactivated vaccine, received emergency use authorization from global regulatory agencies. An ongoing conversation surrounding vaccine safety led to heightened attention on short-term and long-term adverse events related to widespread vaccine use.

While rare, numerous ocular adverse events have been reported after vaccination, including uveitis and retinal vascular occlusion, although a causal link was not established.

 Among those with a history of uveitis, it is crucial to understand the risk of COVID-19 vaccination on uveitis, particularly its effect on the recurrence of the disease.

Ahn and colleagues noted the timing of vaccine administration and postvaccination is important for a comprehensive understanding of the temporal association between COVID-19 vaccination and uveitis.

 The team assessed the Korean National Health Insurance Service (NHIS) and Korea Disease Control and Prevention Agency (KDCA) databases, including data on approximately 500,000 individuals with a history of uveitis and their vaccination details.

The retrospective, population-based cohort study included individuals with uveitis, diagnosed between January 2015 and February 2021 in South Korea. After the exclusion of those without COVID-19 vaccination or with SARS-CoV-2 infection, the analysis included individuals with a history of uveitis had received ≥1 dose of a mRNA (BNT162b2 [Pfizer-BioNTech] or mRNA-1273 [Moderna]) or adenovirus vector-based (ChAdOx1 [AstraZeneca] or Ad26.COV2.S [Janssen]) COVID-19 vaccine.

A diagnosis of uveitis was categorized by onset (early, within 30 days, or delayed) and type (anterior or nonanterior). Overall, the study population included 473,934 individuals (mean age, 58.9 years; 51.3% female) with documented COVID-19 vaccination

Upon analysis, the cumulative incidence of postvaccination uveitis was 8.6% at 3 months, 12.5% at 6 months, and 16.9% at 1 year, with most individuals experiencing anterior uveitis type. Overall, Ahn and colleagues identified an increased risk of uveitis in the postvaccination period (hazard ratio [HR], 1.21; 95% CI, 1.19 - 1.24).

An investigation into early- and delayed-onset postvaccination uveitis demonstrated a higher risk in the early-onset period (HR, 1.64; 95% CI, 1.53 - 1.76), but the risk was maintained in the delayed-onset period (HR, 1.18; 95% CI, 1.15 - 1.21), compared with prevaccination periods.

Specifically, those who received the BNT162b2 (HR, 1.68; 95% CI, 1.52 - 1.86), mRNA-1273 (HR, 1.51; 95% CI, 1.21 - 1.89), ChAdOx1 (HR, 1.60; 95% CI, 1.43 - 1.79), and Ad26.COV2.S (HR, 2.07; 95% CI, 1.40 - 3.07) vaccines experienced the highest uveitis risk in the early-onset postvaccination period.

In a linked editorial, Nisha R. Acharya, MD, MS, F.I. Proctor Foundation, University of California, San Francisco, noted these findings add to the evidence on potential risks of ocular inflammation stemming from COVID-19 vaccination and prove the utility of population-based retrospective study designs in evaluating vaccine-associated events.

However, Acharya also pointed to the inherent limitations of the study design, including reliance on diagnostic coding for a uveitis outcome, not accounting for the healthy vaccinee bias, and a lack of contextualization on the greater risks of being unvaccinated for COVID-19.

“As long as investigators account for the inherent limitations associated with these methodologies and appropriately interpret findings in the context of comprehensive risk discussions, these studies are foundational in helping to guide clinical decisions relating to postvaccine monitoring, counseling, and risk mitigation,” Acharya wrote.

Kim J, Kwon HY, Ahn SJ. COVID-19 Vaccine–Associated Uveitis in Patients With a History of Uveitis. JAMA Ophthalmol. Published online April 25, 2024. doi:10.1001/jamaophthalmol.2024.0973

Kaur SP, Gupta V. COVID-19 Vaccine: A comprehensive status report. 

. 2020;288:198114. doi:10.1016/j.virusres.2020.198114

Mahendradas P, Mishra SB, Sangoram R, et al. Ocular manifestations following COVID-19 vaccination. 

. 2023;13(1):44. Published 2023 Sep 23. doi:10.1186/s12348-023-00358-x

Kumar A, Acharya NR. Real-World Vaccine Research and Clinical Practice. 

 Published online April 25, 2024. doi:10.1001/jamaophthalmol.2024.1049

Both vaccine type and period mediated the risk of uveitis after COVID-19 vaccination in patients with a history of the ocular inflammatory event.

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COVID-19 Vaccination May Raise Risk of Uveitis Recurrence

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Ohuabunwa discussed additional takeaways from her ACP conference talk on postdischarge care and other tips for internal medicine physicians.

Ugochi Ohuabunwa, MD: Preparing Patients for the Postdischarge Transition of Care

In this segment of her interview, Ugochi Ohuanbunwa, MD, discussed some of the points made in her 

American College of Physicians (ACP) Internal Medicine Meeting

 editorial team asked her about several elements, including how hospitalists prepare for the postdischarge transition of care, when to initiate "Goals of Care" conversations, and more.

Ohuanbunwa is known for her work as professor of medicine of the division of geriatrics and gerontology at Emory University in Georgia. Ohuabunwa was given several questions regarding the major takeaways from her ACP talk titled ‘Inpatient Geriatrics Management: Assessing Frailty and What to Avoid.’

“One of the things that's very important to understand in an older adult is the fact that there are multiple things that contribute to their post discharge,” Ohuabunwa explained. “So besides the actual reason for which the patient is there, the patient's functional status at the time of discharge and their cognitive status at the time of discharge would also determine how well they do. It's very important for the hospitals to do an assessment of the patient's functional status of the patient's cognitive status prior just prior to discharge, because that helps guide the discharge setting to which the patient should be discharged to some settings.

Ohuabunwa added that if a patient has very significant functional decline, it may be difficult and if left alone then it may be difficult for them to cope when they are discharged.

“Getting a detailed social history as to what their social support is very helpful,” she said. “Sometimes an older adult could say ‘I live with my son,’ but the son is out of the house 12 hours of the day and that patient if determined based on the functional assessment and cognitive assessment that they need much more help, then it means that going home is not really very appropriate. So it is very important for the hospitalist to do those assessments.”

Ohuabunwa was also asked about when hospitalists should initiate ‘Goals of Care’ conversations with such patients.

“In general, some Goals of Care discussions are best done in the outpatient setting, because that helps to prepare the patient in case they're hospitalized emergently,” she explained. “Sometimes, it's difficult to have those discussions in the inpatient setting. But on the other hand, over the last few years the Institute of Healthcare Improvement, the American Hospital Association, and the Catholic Hospital Association…came up with what's called ‘four M’s,’ and one of those ends at the four M's are essentially to help guide what you do with an older adult. The first ‘m’ is what matters most to that older adult.”

For additional information from Ohuabunwa’s 

, view the full interview segment posted above.

The quotes contained in this description were edited for the purposes of clarity.

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During this discussion, Ohuabunwa discussed additional takeaways from her ACP conference talk on postdischarge care and other tips for internal medicine physicians.

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Results showed a negative correlation between serum Gd-IgA1 and kidney function but found no association with several validated IgAN prognostic risk factors.

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Latest News

Nurse-Led Gout Care Linked to Better Medication Adherence

Tricuspid Regurgitation Velocity Linked to Cerebrovascular, Kidney Disease in SCD

EHR-Based Gout Register May Improve Disease Management

COVID-19 Vaccination May Raise Risk of Uveitis Recurrence

Ugochi Ohuabunwa, MD: Preparing Patients for the Postdischarge Transition of Care