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Background Dietary supplements are frequently used for the treatment of several medical conditions, both prescribed by physicians or self administered. However, evidence of benefit and safety of these supplements is usually limited or absent. Objectives To assess the efficacy and safety of dietary supplementation for people with chronic gout. Search methods We performed a search in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and CINAHL on 6 June 2013. We applied no date or language restrictions. In addition, we performed a handsearch of the abstracts from the 2010 to 2013 American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) conferences, checked the references of all included studies and trial registries. Selection criteria We considered all published randomised controlled trials (RCTs) or quasi-RCTs that compared dietary supplements with no supplements, placebo, another supplement or pharmacological agents for adults with chronic gout for inclusion. Dietary supplements included, but were not limited to, amino acids, antioxidants, essential minerals, polyunsaturated fatty acids, prebiotic agents, probiotic agents and vitamins. The main outcomes were reduction in frequency of gouty attacks and trial participant withdrawal due to adverse events. We also considered pain reduction, health-related quality of life, serum uric acid (sUA) normalisation, function (i.e. activity limitation), tophus regression and the rate of serious adverse events. Data collection and analysis We used standard methodological procedures expected by The Cochrane Collaboration. Main results We identified two RCTs (160 participants) that fulfilled our inclusion criteria. As these two trials evaluated different diet supplements (enriched skim milk powder (SMP) and vitamin C) with different outcomes (gout flare prevention for enriched SMP and sUA reduction for vitamin C), we reported the results separately. One trial including 120 participants, at moderate risk of bias, compared SMP enriched with glycomacropeptides (GMP) with unenriched SMP and with lactose over three months. Participants were predominantly men aged in their 50's who had severe gout. The frequency of acute gout attacks, measured as the number of flares per month, decreased in all three groups over the study period. The effects of enriched SMP (SMP/GMP/G600) compared with the combined control groups (SMP and lactose powder) at three months in terms of mean number of gout flares per month were uncertain (mean ± standard deviation (SD) flares per month: 0.49 ± 1.52 in SMP/GMP/G60 group versus 0.70 ± 1.28 in control groups; mean difference (MD) -0.21, 95% confidence interval (CI) -0.76 to 0.34; low-quality evidence). The number of withdrawals due to adverse effects was similar in both groups although again the results were imprecise (7/40 in SMP/GMP/G600 group versus 11/80 in control groups; risk ratio (RR) 1.27, 95% CI 0.53 to 3.03; low-quality evidence). The findings for adverse events were also uncertain (2/40 in SMP/GMP/G600 group versus 3/80 in control groups; RR 1.33, 95% CI 0.23 to 7.66; low-quality evidence). Gastrointestinal events were the most commonly reported adverse effects. Pain from self reported gout flares (measured on a 10-point Likert scale) improved slightly more in the SMP/GMP/G600 group compared with controls (mean ± SD reduction -1.97 ± 2.28 points in SMP/GMP/G600 group versus -0.94 ± 2.25 in control groups; MD -1.03, 95% CI -1.96 to -0.10; low-quality evidence). This was an absolute reduction of 10% (95% CI 20% to 1% reduction), which may not be of clinical relevance. Results were imprecise for the outcome improvement in physical function (mean ± SD Health Assessment Questionnaire (HAQ)-II (scale 0 to 3, 0 = no disability): 0.08 ± 0.23 in SMP/GMP/G60 group versus 0.11 ± 0.31 in control groups; MD -0.03, 95% CI -0.14 to 0.08; low-quality evidence). Similarly, results for sUA reduction were imprecise (mean ± SD reduction: -0.025 ± 0.067 mmol/L in SMP/GMP/G60 group versus -0.010 ± 0.069 in control groups; MD -0.01, 95% CI -0.04 to 0.01; low-quality evidence). The study did not report tophus regression and health-related quality of life impact. One trial including 40 participants, at moderate to high risk of bias, compared vitamin C alone with allopurinol and with allopurinol plus vitamin C in a three-arm trial. We only compared vitamin C with allopurinol in this review. Participants were predominantly middle-aged men, and their severity of gout was representative of gout in general. The effect of vitamin C on the rate of gout attacks was not assessed. Vitamin C did not lower sUA as much as allopurinol (-0.014 mmol/L in vitamin C group versus -0.118 mmol/L in allopurinol group; MD 0.10, 95% CI 0.06 to 0.15; low-quality evidence). The study did not assess tophus regression, pain reduction or disability or health-related quality of life impact. The study reported no adverse events and no participant withdrawal due to adverse events. Authors' conclusions While dietary supplements may be widely used for gout, this review has shown a paucity of high-quality evidence assessing dietary supplementation.

ObjectiveTo perform an update of a review of the efficacy and safety of disease-modifying antirheumatic drugs (DMARDs) in psoriatic arthritis (PsA).MethodsThis is a systematic literature research of 2015–2018 publications on all DMARDs in patients with PsA, searching Medline, Embase and the Cochrane Library. Efficacy was assessed in randomised controlled trials. For safety, cohort studies, case–control studies and long-term extensions (LTEs) were analysed.Results56 publications (efficacy: n=33; safety n=23) were analysed. The articles were on tumour necrosis factor (TNF) inhibitors (n=6; golimumab, etanercept and biosimilars), interleukin (IL)-17A inhibitors (n=10; ixekizumab, secukinumab), IL-23-p19 inhibitors (n=2; guselkumab, risankizumab), clazakizumab (IL-6 inhibitor), abatacept (CD80/86 inhibitor) and ABT-122 (anti-TNF/IL-17A), respectively. One study compared ustekinumab (IL-12/23i) with TNF inhibitor therapy in patients with entheseal disease. Three articles investigated DMARD tapering. Trials on targeted synthetic DMARDs investigated apremilast (phosphodiesterase-4 inhibitor) and Janus kinase inhibitors (JAKi; tofacitinib, filgotinib). Biosimilar comparison with bio-originator showed non-inferiority. Safety was evaluated in 13 LTEs, 9 cohort studies and 1 case–control study investigating malignancies, infections, infusion reactions, multiple sclerosis and major cardiovascular events, as well as efficacy and safety of vaccination. No new safety signals were identified; however, warnings on the risk of venous thromboembolic events including pulmonary embolism when using JAKi were issued by regulators based on other studies.ConclusionMany drugs in PsA are available and have demonstrated efficacy against placebo. Efficacy varies across PsA manifestations. Safety must also be taken into account. This review informed the development of the European League Against Rheumatism 2019 updated PsA management recommendations.

Background The treatment of Systemic Lupus Erythematosus (SLE) has improved over the last decades. However, patients are more vulnerable for sick leave, work disability and unemployment compared to the general population. It is therefore important to understand the magnitude of the problem and the factors that might affect work participation in patients with SLE, to evaluate which actions can be taken to limit the burden on a patient and society level. The aim of this research is to summarize the existing literature on 1) the prevalence of work disability, 2) prognostic factors for work participation and 3) the effectiveness of interventions to improve work participation in patients with SLE. Methods A scoping review, using the PRISMA-ScR statement will be conducted. Full-text original articles published before April 2019 were identified by literature search performed in MEDLINE, Cochrane, Embase and CINAHL. Articles in all languages, concerning work participation in patients with SLE, aged ≥18 years were included. Results In total, 2050 non-duplicate citations were screened. After title/abstract screening, 75 articles were retrieved. Relevant articles will be identified and reference lists will be searched for additional articles by two independent researchers. Information on author(s), year of publication, study location, intervention type, comparator, duration of the intervention, study population, aims of the study, methodology, outcome measures and important results will be collected. The results will be presented at the congress. Conclusion Based on this scoping review, implications for future research including a research agenda and daily practice will be identified.

ObjectivesReview of efficacy and safety of Janus kinase (JAK) inhibition in immune-mediated inflammatory diseases (IMIDs).MethodsA systematic literature research (SLR) of all publications on JAK inhibitors (JAKi) treatment published until March 2019 using MEDLINE, EMBASE and the Cochrane Library. Efficacy and safety were assessed in randomised controlled trials (RCTs), integrating long-term extension periods additionally for safety evaluation.Results3454 abstracts were screened with 85 included in the final analysis (efficacy and RCT safety: n=72; safety only: n=13). Efficacy of RCTs investigating tofacitinib (TOFA, n=27), baricitinib (BARI, n=9), upadacitinib (UPA, n=14), filgotinib (FILGO, n=7), decernotinib (DEC, n=3) and peficitinib (PEF, n=7) was evaluated. Six head-to-head trials comparing JAKi with tumour necrosis factor inhibitors (TNFi) were included. Efficacy of JAKi was shown in rheumatoid arthritis (RA) for all agents, psoriatic arthritis (TOFA, FILGO), ankylosing spondylitis (TOFA, FILGO), systemic lupus erythematosus (BARI), chronic plaque psoriasis (TOFA, BARI, PEF), ulcerative colitis (TOFA, UPA), Crohn’s disease (UPA, FILGO) and atopic dermatitis (TOFA, BARI, UPA). Safety analysis of 72 RCTs, one cohort study and 12 articles on long-term extension studies showed increased risks for infections, especially herpes zoster, serious infections and numerically higher rates of venous thromboembolic events. No increased malignancy rates or major adverse cardiac events were observed.ConclusionJAKi provide good efficacy compared to placebo (and to TNFi in RA and Pso) across various IMIDs with an acceptable safety profile. This SLR informed the task force on points to consider for the treatment of IMIDs with JAKi with the available evidence.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:\ud \ud \ud To determine the benefits and harms of marine oil supplements for people with rheumatoid arthritis (RA).

Objective Medical events such as myocardial infarction and cancer diagnosis can induce symptoms of posttraumatic stress disorder (PTSD). The optimal treatment of PTSD symptoms in this context is unknown. Methods A literature search of 6 biomedical electronic databases was conducted from database inception to November 2018. Studies were eligible if they used a randomized design and evaluated the effect of treatments on medical event-induced PTSD symptoms in adults. A random effects model was used to pool data when two or more comparable studies were available. Results Six trials met full inclusion criteria. Studies ranged in size from 21 to 81 patients, and included patients with PTSD induced by cardiac events, cancer, HIV, multiple sclerosis, and stem cell transplantation. All trials assessed psychological interventions. Two trials comparing a form of exposure-based cognitive behavioral therapy (CBT) with assessment-only control found that CBT resulted in lower PTSD symptoms [Hedges's g = −0.47, (95% CI -0.82 – −0.12), p = .009]. A third trial compared imaginal exposure (another form of exposure-based CBT) with an attention control and found a trend toward reduced PTSD symptoms. Three trials compared eye movement desensitization and reprocessing (EMDR) with active psychological treatments (imaginal exposure, conventional CBT, and relaxation therapy), and found that EMDR was more effective. Conclusion CBT and EMDR may be promising approaches to reducing PTSD symptoms due to medical events. However, additional trials are needed in this patient population.

Objectives Depression frequently co-occurs with multiple chronic diseases in complex, costly, and dangerous patterns of multimorbidity. The field of health psychology may benefit from evaluating the temporal characteristics of depression's associations with common diseases, and from determining whether depression is a central connector in multimorbid disease clusters. The present review addresses these issues by focusing on 4 of the most prevalent diseases: hypertension, ischemic heart disease, arthritis, and diabetes. Method Study 1 assessed how prior chronic disease diagnoses were associated with current depression in a large, cross-sectional, population-based study. It assessed depression's centrality using network analysis accounting for disease prevalence. Study 2 presents a systematic scoping review evaluating the extent to which depression was prospectively associated with the onset of the 4 prevalent chronic diseases. Results In Study 1 depression had the fourth highest betweenness centrality ranking of 26 network nodes and centrally connected many existing diseases and unhealthy behaviors. In Study 2 depression was associated with subsequent incidence of ischemic heart disease and diabetes across multiple meta-analyses. Insufficient information was available about depression's prospective associations with incident hypertension and arthritis. Conclusions Depression is central in patterns of multimorbidity and is associated with incident disease for several of the most common chronic diseases, justifying the focus on screening and treatment of depression in those at risk for developing chronic disease. Future research should investigate the mediating and moderating roles of health behaviors in the association between depression and the staggered emergence over time of clusters of multimorbid chronic diseases. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Background:The treatment of systemic lupus erythematosus (SLE) has improved over the last decades, however, absenteeism and work disability numbers remain higher than those observed in the general population (1). SLE has its onset between the ages of 20 and 40 years, and has a major burden on the lives of patients, both mentally and financially. A recent online survey amongst 2070 European SLE patients revealed that 69.5% of patients had their careers affected due to SLE (2).Objectives:To determine the magnitude of absenteeism and work disability in patients with SLE and to investigate the factors that might affect work participation in these patients in order to develop interventions to reduce the impact of the burden in the future.Methods:A systematic literature search was performed to identify published articles reporting on the prevalence of work related burden, as well as the relation of having SLE on employment status, sick leave and/or presenteeism. Full-text original articles (all languages) published before April 2019 were identified by literature search performed in MEDLINE, Cochrane, Embase and CINAHL.Results:In total, 2057 non-duplicate citations were screened after database searching and snowballing. Finally, 81 articles were included; most studies (n=59) had a cross-sectional design and the remaining 22 studies had a longitudinal design. Only 15 longitudinal cohort studies reported on associations, 6 studies described a longitudinal prediction model, 2 studies reported on associations and described a prediction model, and 3 studies had a longitudinal design but only reported on prevalences over time. In total, 3500 working patients were included in the studies reporting on associations or describing a longitudinal prediction model. In the association studies, the most frequently used outcome measures were respectively being employed/probability of being employed and work loss/job cessation. Other studies used loss of days from (non)workforce activities/sick leave days, work disability, productivity loss or work entry. Most associations with work outcome were found for demographic variables and two or three disease variables, like Systemic Lupus Activity Questionnaire (SLAQ) score and depressive symptoms. This was also the case in the prediction studies. Most studies did not assess work related variables as possible predictors for work outcome.Conclusion:A large heterogeneity was found in type of study design and outcome measures, which limits comparison with other studies. More longitudinal studies are needed to truly assess the impact of SLE on work participation, and to identify factors that could be influenced during interventions, in order to encourage work participation of these patients.References:[1]Bultink IE, Turkstra F, Dijkmans BA, Voskuyl AE. High prevalence of unemployment in patients with systemic lupus erythematosus: association with organ damage and health-related quality of life. J Rheumatol. 2008;35(6):1053-7.[2]Gordon C, Isenberg D, Lerstrom K, Norton Y, Nikai E, Pushparajah DS, et al. The substantial burden of systemic lupus erythematosus on the productivity and careers of patients: a European patient-driven online survey. Rheumatology (Oxford). 2013;52(12):2292-301.Disclosure of Interests:None declared

Importance There is limited information describing the presenting characteristics and outcomes of US patients requiring hospitalization for coronavirus disease 2019 (COVID-19). Objective To describe the clinical characteristics and outcomes of patients with COVID-19 hospitalized in a US health care system. Design, Setting, and Participants Case series of patients with COVID-19 admitted to 12 hospitals in New York City, Long Island, and Westchester County, New York, within the Northwell Health system. The study included all sequentially hospitalized patients between March 1, 2020, and April 4, 2020, inclusive of these dates. Exposures Confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by positive result on polymerase chain reaction testing of a nasopharyngeal sample among patients requiring admission. Main Outcomes and Measures Clinical outcomes during hospitalization, such as invasive mechanical ventilation, kidney replacement therapy, and death. Demographics, baseline comorbidities, presenting vital signs, and test results were also collected. Results A total of 5700 patients were included (median age, 63 years [interquartile range {IQR}, 52-75; range, 0-107 years]; 39.7% female). The most common comorbidities were hypertension (3026; 56.6%), obesity (1737; 41.7%), and diabetes (1808; 33.8%). At triage, 30.7% of patients were febrile, 17.3% had a respiratory rate greater than 24 breaths/min, and 27.8% received supplemental oxygen. The rate of respiratory virus co-infection was 2.1%. Outcomes were assessed for 2634 patients who were discharged or had died at the study end point. During hospitalization, 373 patients (14.2%) (median age, 68 years [IQR, 56-78]; 33.5% female) were treated in the intensive care unit care, 320 (12.2%) received invasive mechanical ventilation, 81 (3.2%) were treated with kidney replacement therapy, and 553 (21%) died. As of April 4, 2020, for patients requiring mechanical ventilation (n = 1151, 20.2%), 38 (3.3%) were discharged alive, 282 (24.5%) died, and 831 (72.2%) remained in hospital. The median postdischarge follow-up time was 4.4 days (IQR, 2.2-9.3). A total of 45 patients (2.2%) were readmitted during the study period. The median time to readmission was 3 days (IQR, 1.0-4.5) for readmitted patients. Among the 3066 patients who remained hospitalized at the final study follow-up date (median age, 65 years [IQR, 54-75]), the median follow-up at time of censoring was 4.5 days (IQR, 2.4-8.1). Conclusions and Relevance This case series provides characteristics and early outcomes of sequentially hospitalized patients with confirmed COVID-19 in the New York City area.

Post-traumatic stress disorder (PTSD) induced by life-threatening medical events has been associated with adverse physical and mental health outcomes, but it is unclear whether early interventions to prevent the onset of PTSD after these events are efficacious. We conducted a systematic review to address this need. We searched six biomedical electronic databases from database inception to October 2018. Eligible studies used randomized designs, evaluated interventions initiated within 3 months of potentially traumatic medical events, included adult participants, and did not have high risk of bias. The 21 included studies (N = 4,486) assessed a heterogeneous set of interventions after critical illness (9), cancer diagnosis (8), heart disease (2), and cardiopulmonary surgery (2). Fourteen psychological, 2 pharmacological, and 5 other-type interventions were assessed. Four of the psychological interventions emphasizing cognitive behavioral therapy or meaning-making, 1 other-type palliative care intervention, and 1 pharmacological-only intervention (hydrocortisone administration) were efficacious at reducing PTSD symptoms relative to control. One early, in-hospital counseling intervention was less efficacious at lowering PTSD symptoms than an active control. Clinical and methodological heterogeneity prevented quantitative pooling of data. While several promising interventions were identified, strong evidence of efficacy for any specific early PTSD intervention after medical events is currently lacking.

Objectives: To perform a systematic literature review on imaging techniques for diagnosis, outcome prediction and disease monitoring in large vessel vasculitis (LVV) informing the European League Against Rheumatism recommendations for imaging in LVV.\ud \ud \ud \ud Methods: Systematic literature review (until 10 March 2017) of diagnostic and prognostic studies enrolling >20 patients and investigating ultrasound, MRI, CT or positron emission tomography (PET) in patients with suspected and/or established primary LVV. Meta-analyses were conducted, whenever possible, obtaining pooled estimates for sensitivity and specificity by fitting random effects models.\ud \ud \ud \ud Results: Forty-three studies were included (39 on giant cell arteritis (GCA), 4 on Takayasu arteritis (TAK)). Ultrasound (‘halo’ sign) at temporal arteries (8 studies, 605 patients) and MRI of cranial arteries (6 studies, 509 patients) yielded pooled sensitivities of 77% (95% CI 62% to 87%) and 73% (95% CI 57% to 85%), respectively, compared with a clinical diagnosis of GCA. Corresponding specificities were 96% (95% CI 85% to 99%) and 88% (95% CI 81% to 92%). Two studies (93 patients) investigating PET for GCA diagnosis reported sensitivities of 67%–77% and specificities of 66%–100% as compared with clinical diagnosis or temporal artery biopsy. In TAK, one study each evaluated the role of magnetic resonance angiography and CT angiography for diagnostic purposes revealing both a sensitivity and specificity of 100%. Studies on outcome prediction and monitoring disease activity/damage were limited and mainly descriptive.\ud \ud \ud \ud Conclusions: Ultrasound and MRI provide a high diagnostic value for cranial GCA. More data on the role of imaging for diagnosis of extracranial large vessel GCA and TAK, as well as for outcome prediction and monitoring in LVV are warranted.

Objective The antifibrinolytic agent tranexamic acid (TXA) has demonstrated clinical benefit in trauma patients with severe bleeding, but its effectiveness in patients with traumatic brain injury (TBI) is unclear. We conducted a systematic review to evaluate the following research question: In ED patients with or at risk of intracranial hemorrhage (ICH) secondary to TBI, does TXA compared to placebo improve patients' outcomes? Methods MEDLINE, EMBASE, CINAHL, and other databases were searched for randomized controlled trial (RCT) or quasi-RCT studies that compared the effect of TXA to placebo on outcomes of TBI patients. The main outcomes of interest included mortality, neurologic function, hematoma expansion, and adverse effects. We used “Grading quality of evidence and strength of recommendations” to assess the quality of trials. Two authors independently abstracted data using a data collection form. Results from studies were pooled when appropriate. Results Of 1030 references identified through the search, 2 high-quality RCTs met inclusion criteria. The effect of TXA on mortality had a pooled relative risk of 0.64 (95% confidence interval [CI], 0.41-1.02); on unfavorable functional status, a relative risk of 0.77 (95% CI, 0.59-1.02); and on ICH progression, a relative risk of 0.76 (95% CI, 0.58-0.98). No serious adverse effects (such as thromboembolic events) associated with TXA group were reported in the included trials. Conclusion Pooled results from the 2 RCTs demonstrated statistically significant reduction in ICH progression with TXA and a nonstatistically significant improvement of clinical outcomes in ED patients with TBI. Further evidence is required to support its routine use in patients with TBI.

Objective. The aim of this study was to systematically review outcome domains and measurement tools used in gout trials and their accordance with the preliminary OMERACT gout recommendations published in 2005. Methods. Randomized controlled trials (RCTs) and quasi-RCTs investigating any intervention for gout published up to February 2013 were included. Recruitment start dates and all measured outcomes were extracted. Risk of bias (RoB) was assessed with the Cochrane Collaboration tool. Numbers of OMERACT domains were compared for trials at low vs unclear/high RoB and for recruitment start date before 2005 or 2005 and later. Results. Of 9784 articles screened, 38 acute and 30 chronic gout trials were included. Mean (s.d.) number of OMERACT outcomes was 2.9 (1.1) (out of 5) and 2.5 (1.2) (out of 9) for acute and chronic gout trials, respectively. Health-related quality of life, participation and joint damage imaging were not assessed in any trial. Tools used to measure individual domains varied widely. There were no differences in the number of OMERACT outcomes reported in acute or chronic gout trials recruiting before 2005 vs 2005 or later [mean (s.d.): 3.0 (1.1) vs 3.5 (1.3), P = 0.859 and 2.7 (1.1) vs 2.8 (1.4), P = 0.960, respectively]. While both acute and chronic trials at low RoB reported more OMERACT domains than trials at unclear/high RoB, these differences were not significant. Industry-funded trials and trials performed by OMERACT investigators reported more OMERACT outcome domains. Conclusion. We found no appreciable impact of the OMERACT recommendations for gout trials to date

Objective. To systematically review the evidence on treatment available to prevent an acute attack of gout when initiating a urate-lowering therapy (ULT) and for how long this treatment should be continued. To also evaluate the evidence on the optimal time to start a ULT after an acute attack of gout. Methods. A systematic review as part of the 3e (Evidence, Expertise, Exchange) Initiative on Diagnosis and Management of Gout was performed using Medline, Embase, Cochrane Central Register of Controlled Trials (from 1950 to October 2011), and the European League Against Rheumatism (EULAR) and American College of Rheumatology (ACR) 2010/2011 meeting abstracts. Two reviewers independently screened titles and abstracts for selection criteria. Included articles were reviewed in detail, and a risk of bias assessment (using the Cochrane tool) was performed. Results. The search identified 8168 articles and 197 abstracts, from which 4 randomized controlled trials were included in the review. Two of these studies compared placebo with colchicine, 1 compared differing durations of colchicine, and 1 compared colchicine with canakinumab. Conclusion. Two randomized controlled trials have shown that colchicine prophylaxis for at least 6 months, when starting a ULT, reduces the risk of acute attacks. Canakinumab, although not currently licensed for gout, has been shown to provide prophylaxis superior to colchicine, when starting a ULT. There is no evidence on the optimum time to start a ULT after an acute gout attack.

Objective. To review the available literature on the likelihood of having cardiovascular (CV) risk factors and on developing CV comorbidities in patients with gout and/or asymptomatic hyperuricemia as an evidence base for generating multinational clinical practice recommendations in the 3e (Evidence, Expertise, Exchange) Initiative in Rheumatology. Methods. A systematic literature search was carried out using MEDLINE, EMBASE, and The Cochrane Library, and abstracts presented at the 2010/2011 meetings of the American College of Rheumatology (ACR) and the European League Against Rheumatism, searching for CV risk factors and new CV comorbidities in patients with asymptomatic hyperuricemia and/or a diagnosis of gout. Trials that fulfilled predefined inclusion criteria were systematically reviewed. Results. A total of 66 out of 8918 identified publications were included in this review. After assessment of the risk of bias, 32 articles with a high risk of bias were excluded. Data could not be pooled because of clinical and statistical heterogeneity. In general, both for asymptomatic hyperuricemia and for gout the hazard ratios for CV comorbidities were only modestly increased (1.5 to 2.0) as were the hazard ratios for CV risk factors, ranging from 1.4 to 2.0 for hypertension and from 1.0 to 2.4 for diabetes. Conclusion. Unlike the common opinion that patients with gout or hyperuricemia are at higher risk of developing CV disease, the actual risk to develop CV disease is either rather weak (for hyperuricemia) or poorly investigated (for gout).

To assess the efficacy and safety of non-biological therapies in patients with axial spondyloarthritis (axSpA) to inform the update of the Assessment of SpondyloArthritis international Society (ASAS)/European League Against Rheumatism (EULAR) recommendations for the management of axSpA. A systematic literature review (2009-2016) of all non-pharmacological treatments, non-biological drugs (except targeted synthetic disease-modifying antirheumatic drugs (DMARDs)) and surgical therapies was performed. Randomised controlled trials (RCTs) and clinical controlled trials were assessed for efficacy and safety, while observational studies with a comparator were assessed for safety. All relevant efficacy and safety outcomes were included. Study heterogeneity precluded data pooling. If possible, Cohen's effect size was calculated for non-pharmacological treatments. In total, 45 papers and 2 abstracts were included. Studies on non-pharmacological treatments were very heterogeneous but overall confirmed a benefit for regular exercises, with small improvements in disease activity, function and spinal mobility. New studies on non-steroidal anti-inflammatory drugs (NSAIDs) confirmed their efficacy and new safety signals were not found. NSAIDs used continuously compared with on-demand did not reduce the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) mean change over 2 years in patients with ankylosing spondylitis with normal C reactive protein (CRP

Importance\ud \ud The vascular risk attributable to HIV infection is rising. The heterogeneity of the samples studied is an obstacle to understanding whether HIV is a vascular risk across geographic regions.\ud \ud \ud \ud Objective\ud \ud To test the hypothesis that HIV infection is a vascular risk factor, and that the risk conferred by HIV varies by geographical region.\ud \ud \ud \ud Data sources\ud \ud A systematic search of publications was carried out in seven electronic databases: PubMed, The Cochrane Library, EMBASE, Web of Science, LILACS, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform from inception to July 2015.\ud \ud \ud \ud Study selection\ud \ud We included longitudinal studies of HIV+ individuals and their risk of vascular outcomes of ≥ 50 HIV+ cases and excluded studies on biomarkers of vascular disease as well as clinical trials.\ud \ud \ud \ud Data extraction and synthesis\ud \ud Data was extracted by one of the authors and independently confirmed by the other two authors. We used incidence rate (IR), incidence risk ratio (IRR) and hazard ratio (HR) with their 95% confidence intervals as measures of risk.\ud \ud \ud \ud Main outcome\ud \ud All-death, myocardial infarction (MI), coronary heart disease (CHD), any stroke, ischemic stroke (IS) or intracranial hemorrhage (ICH).\ud \ud \ud \ud Results\ud \ud We screened 11,482 references for eligibility, and selected 117 for analysis. Forty-four cohorts represented 334,417 HIV+ individuals, 49% from the United States. Compared with their European counterparts, HIV+ individuals in the United States had higher IR of death (IRR 1.78, 1.69–1.88), MI (IRR 1.61, 1.29–2.01), CHD (IRR 2.27, 1.92–2.68), any stroke (IRR 1.94, 1.59–2.38), IS (IRR 1.56, 1.23–1.98), and ICH (IRR 4.03, 2.72–6.14). Compared with HIV- controls and independent of geographical region, HIV was a risk for death (HR 4.77, 4.55–5.00), MI (HR 1.60, 1.49–1.72), any CHD (HR 1.20, 1.15–1.25), any stroke (HR 1.82, 1.53–2.16), IS (HR 1.27, 1.15–1.39) and ICH (HR 2.20, 1.61–3.02). Use of antiretroviral therapy was a consistent risk for cardiac outcomes, while immunosuppression and unsuppressed viral load were consistent risks for cerebral outcomes.\ud \ud \ud \ud Conclusions\ud \ud HIV should be considered a vascular risk, with varying magnitudes across geographical and anatomical regions. We think that strategies to reduce the HIV-related vascular burden are urgent, and should incorporate the disparities noted here.

Purpose This systematic review aims to summarize the current literature regarding potential effects of having both cancer and diabetes on patient-reported outcomes (PROs) and to provide directions for future research. Methods MEDLINE, The Cochrane Library, CINAHL, and PsycINFO were searched from inception to January 2015. All English peer-reviewed studies that included patients with both cancer and diabetes and assessed PROs were included. All included studies were independently assessed on methodological quality by two investigators. Results Of the 3553 identified studies, 10 studies were included and all were considered of high (40 %) or adequate (60 %) methodological quality. Eight of the 10 studies focused on health-related quality of life (HRQoL), functioning, or symptoms and 2 studies assessed diabetes self-management. Overall, HRQoL and functioning was lower, and symptoms were higher among patients with both cancer and diabetes as compared to having cancer or diabetes alone. Furthermore, one study reported that diabetes self-management was impaired after chemotherapy. Conclusions Having both cancer and diabetes resulted in worse PROs compared to having either one of the diseases, however, the considerable heterogeneity of the included studies hampered strong conclusions. Future studies are needed as this research area is largely neglected. As the majority of the included studies focused on HRQoL, future research should address the impact of both diseases on other PROs such as depression, patient empowerment and self-management. Implications for Cancer Survivor Having both cancer and diabetes might result in worse PROs, however, more research is needed as current evidence is scarce. Electronic supplementary material The online version of this article (doi:10.1007/s11764-015-0486-3) contains supplementary material, which is available to authorized users.

Objectives: The utility of nasogastric aspiration and lavage in the emergency management of patients with melena or hematochezia without hematemesis is controversial. This evidence-based emergency medicine review evaluates the following question: does nasogastric aspiration and lavage in patients with melena or hematochezia and no hematemesis differentiate an upper from lower source of gastrointestinal (GI) bleeding? Methods: MEDLINE, EMBASE, the Cochrane Library, and other databases were searched. Studies were selected for inclusion in the review if the authors had performed nasogastric aspiration (with or without lavage) in all patients with hematochezia or melena and performed esophagogastroduodenal endoscopy (EGD) in all patients. Studies were excluded if they enrolled patients with history of esophageal varices or included patients with hematemesis or coffee ground emesis (unless the data for patients without hematemesis or coffee ground emesis could be separated out). The outcome was identifying upper GI hemorrhage (active bleeding or high-risk lesions potentially responsible for hemorrhage) and the rate of complications associated with the nasogastric tube insertion. Quality of the included studies was assessed using standard criteria for diagnostic accuracy studies. Results: Three retrospective studies met our inclusion and exclusion criteria. The prevalence of an upper GI source for patients with melena or hematochezia without hematemesis was 32% to 74%. According to the included studies, the diagnostic performance of the nasogastric aspiration and lavage for predicting upper GI bleeding is poor. The sensitivity of this test ranged from 42% to 84%, the specificity from 54% to 91%, and negative likelihood ratios from 0.62 to 0.20. Only one study reported the rate complications associated with nasogastric aspiration and lavage (1.6%). Conclusions: Nasogastric aspiration, with or without lavage, has a low sensitivity and poor negative likelihood ratio, which limits its utility in ruling out an upper GI source of bleeding in patients with melena or hematochezia without hematemesis. ACADEMIC EMERGENCY MEDICINE 2010; 17:126–132 © 2010 by the Society for Academic Emergency Medicine

Objective.To determine the benefits and harms of nonsteroidal antiinflammatory drugs (NSAID) in axial spondyloarthritis (axSpA).Methods.Systematic review using Cochrane Collaboration methodology. Inclusion criteria: randomized controlled trials (RCT) and quasi-RCT (to June 2014), investigating NSAID versus any control for axSpA, and observational studies of longterm effects (≥ 6 mos) of NSAID on radiographic progression or adverse events. Main outcomes were pain, Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index, Bath Ankylosing Spondylitis Metrology Index, radiographic progression, number of withdrawals because of adverse events, and number of serious adverse events. Risk of bias was assessed.Results.Thirty-five RCT, 2 quasi-RCT, and 2 cohort studies were included. Twenty-nine RCT and 2 quasi-RCT (n = 4356) were included in pooled analyses [traditional NSAID vs placebo (n = 5), cyclooxygenase-2 (COX-2) vs placebo (n = 3), COX-2 vs traditional NSAID (n = 4), NSAID vs NSAID (n = 24), naproxen vs other NSAID (n = 3), and low- vs high-dose NSAID (n = 5)]. Compared with placebo, both traditional and COX-2 NSAID were consistently more efficacious at 6 weeks and equally safe after 12 weeks. No significant differences in benefits or harms between the 2 NSAID classes and no important differences in benefits or withdrawals because of adverse events between different NSAID were found, especially if studies with high risk of bias were excluded. Single studies suggest NSAID may retard radiographic progression, especially by continuous rather than on-demand NSAID use.Conclusion.High-quality evidence indicates that both traditional and COX-2 NSAID are efficacious for treating axSpA, and harms are not different from placebo in the short term. Various NSAID are equally effective.

Objective. To determine the efficacy and safety of lifestyle interventions for treating gout. Methods. Two Cochrane systematic reviews assessed the efficacy and safety of lifestyle interventions for the treatment of acute and chronic gout. We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials up to September 2011, and the 2010–2011 American College of Rheumatology and European League Against Rheumatism conference abstracts. Primary outcomes of interest were joint pain for acute gout, frequency of gout attacks for chronic gout, and withdrawals due to adverse events for both reviews. Results. One trial met inclusion criteria for each review. An unblinded trial (19 participants), at high risk of bias, found that topical ice added to prednisolone and colchicine for acute gout resulted in significantly greater pain reduction at 1 week [mean difference (MD) −3.33 cm, 95% confidence interval (95% CI) −5.84 to −0.82 on 10 cm visual analog scale]. Adverse events were not described. The second trial (120 participants), at moderate risk of bias, compared enriched skim milk powder (glycomacropeptide and G600 milk fat extract) to non-enriched skim milk and lactose powders for treating chronic gout. There were no between-group differences in gout attack frequency over 3 months [MD −0.21 (95% CI −0.76 to 0.34)] or withdrawals due to adverse events [relative risk 1.27 (95% CI 0.53 to 3.03)]. Conclusion. While there is observational evidence for an association between lifestyle risk factors and gout development, there are no high quality trials to support or refute the use of lifestyle interventions for treating acute or chronic gout.

Objective. To assess the efficacy and safety of gout-specific medications in gout patients with a comorbidity and/or comedication. Methods. A systematic literature search for gout, its medication, and the most common comorbidities and comedications, using serum uric acid (SUA) levels as the primary, and adverse events as the secondary outcomes. Results. Eight trials met inclusion criteria. Trials covered treatment with allopurinol, benzbromarone, rasburicase, or febuxostat in a gout population with mild or moderate renal insufficiency. High risk of bias (5/8 trials) and heterogeneity precluded formal metaanalysis. The trials showed the following hierarchy in efficacy (lowering the SUA below 6.0 mg/dl): febuxostat 80 mg (44%-71%) > febuxostat 40 mg (43%-52%) > allopurinol 100 mg or 200 mg (0-46%) after 6 months of therapy; rasburicase (46%) > allopurinol 300 mg (16%) after 7 days of therapy; benzbromarone 100-200 mg (93%) > allopurinol 100-200 mg (63%) after 9-24 months of therapy. The combination of allopurinol and benzbromarone seemed to be effective, with a significant reduction in the SUA from 7.8 to 5.7 mg/dl (p

To analyze the diagnostic utility of clinical, laboratory, and imaging items for gout.A systematic literature search was performed in MEDLINE, EMBASE, and The Cochrane Library; and a manual search of abstracts from the 2010/2011 meetings of the American College of Rheumatology (ACR) and the European League Against Rheumatism, as well as the reference lists of retrieved papers. Studies were included if they evaluated the diagnostic utility of clinical, laboratory, or imaging features or criteria for the diagnosis or classification of gout in adult patients. Two independent reviewers selected papers, extracted the data, and assessed the risk of bias.Nineteen studies were included in the review; 4 used the identification of monosodium urate (MSU) crystals as the reference standard (RS) and the rest used expert opinion or the ACR preliminary criteria. Most features were evaluated in a single study. Evidence for diagnostic utility, using MSU crystals as RS, of over 50 individual clinical, laboratory, and radiographic features was retrieved. Most items showed a positive likelihood ratio (LR+)3, except for the following: response of arthritis to colchicine (LR+ 4.3); presence of tophi on physical examination (LR+ 15.6-30.9); identification of the double-contour sign in ultrasound (US) (LR+ 13.6); and detection of urate deposits by dual-energy computed tomography (DECT) (LR+ 9.5).Individual clinical features show low diagnostic utility, with the exception of tophi and response to colchicine. Some US and DECT findings show better performance than most clinical features.

Objective. To systematically review the evidence on the efficacy, safety, and cost-effectiveness of urate-lowering therapy for gout: xanthine oxidase inhibitors (allopurinol and febuxostat), uricosuric medications (benzbromarone, probenecid and sulfinpyrazone), and uricases (pegloticase and rasburicase). Methods. A systematic review was performed as part of the 3e (Evidence, Expertise, Exchange) Initiative on Gout. The primary efficacy outcomes were frequency of acute gout attacks, study participant withdrawal due to adverse events, and cost-effectiveness. Serum urate-lowering was a secondary outcome and was the most commonly reported outcome in the included trials. Results. The search identified 17 articles for efficacy, 31 for safety, and 3 for cost-effectiveness. The main outcome described in these studies was serum urate-lowering. Allopurinol, febuxostat, and pegloticase are all effective at lowering serum urate compared to placebo and febuxostat (≥ 80 mg) was more effective at lowering serum urate than allopurinol. Compared to probenecid, benzbromarone was more effective at lowering serum urate. Regarding acute gout attacks, pegloticase and febuxostat (≥ 120 mg) resulted in more acute attacks than placebo. Regarding the primary safety outcome, more withdrawals due to adverse events were seen only when pegloticase was compared to placebo. The two trials of cost-effectiveness were inconclusive. Conclusion. There is currently moderate quality data supporting the efficacy and safety of allopurinol, febuxostat, benzbromarone, and probenecid in gout. Pegloticase, while efficacious, is associated with more withdrawals due to adverse events and infusion reactions. There is insufficient evidence currently with respect to the cost-effectiveness or the most optimal sequencing of urate-lowering therapy.

Objective. To systematically review the validity of serum uric acid (SUA) as a treatment target for patients with gout, and the clinimetric properties of the potential tools for monitoring these patients. Methods. A search was performed in Medline, Embase and the Cochrane Library from inception to October 2011, and the 2010–2011 American College of Rheumatology and European League Against Rheumatism meeting abstracts. Studies evaluating different SUA levels or SUA reduction with the achievement of outcomes, and studies assessing clinimetric properties of instruments used to follow patients with gout were selected. Intervention studies were also included in order to estimate responsiveness. Titles and abstracts of the identified references were screened, and included articles were reviewed in detail and data collected using ad hoc standard forms. Results. In total, 4575 articles were retrieved, 120 articles reviewed in detail, and 54 articles were included in the systematic literature review. SUA reduction was significantly associated with a reduction in acute attacks (6 studies), tophi regression (2 studies), and crystal clearance (3 studies). SUA 6.0 mg/dl was used as cutoff point in most of studies, but this level was found to be arbitrary. For followup of patients with gout, tophus measurement by caliper and ultrasound, the physical component of the Medical Outcomes Study Short Form-36 Survey, and Health Assessment Questionnaire have shown excellent clinimetric properties for this purpose. Conclusion. Reducing SUA is a valid treatment target for patients with gout, but the target level of reduction (cutoff point) is not clear. Some tools were found suitable for following patients with gout.

Visit-to-visit variability of blood pressure (BP) has been associated with cardiovascular disease (CVD) and mortality in some but not all studies. We conducted a systematic review and meta-analysis to examine the association between visit-to-visit variability of BP and CVD and all-cause mortality. Medical databases were searched through June 4, 2014, for studies meeting the following eligibility criteria: adult participants; BP measurements at ≥3 visits; follow-up for CVD, coronary heart disease, stroke, or mortality outcomes; events confirmed via database, death certificate, or event ascertainment committee; and adjustment for confounders. Data were extracted by 2 reviewers and pooled using a random-effects model. Overall, 8870 abstracts were identified of which 37 studies, representing 41 separate cohorts, met inclusion criteria. Across studies, visit-to-visit variability of systolic BP and diastolic BP showed significant associations with outcomes in 181 of 312 (58.0%) and 61 of 188 (32.4%) analyses, respectively. Few studies provided sufficient data for pooling risk estimates. For each 5 mm Hg higher SD of systolic BP, the pooled hazard ratio for stroke across 7 cohorts was 1.17 (95% confidence interval [CI], 1.07–1.28), for coronary heart disease across 4 cohorts was 1.27 (95% CI, 1.07–1.51), for CVD across 5 cohorts was 1.12 (95% CI, 0.98–1.28), for CVD mortality across 5 cohorts was 1.22 (95% CI, 1.09–1.35), and for all-cause mortality across 4 cohorts was 1.20 (95% CI, 1.05–1.36). In summary, modest associations between visit-to-visit variability of BP and CVD and all-cause mortality are present in published studies. However, these findings are limited by the small amount of data available for meta-analysis.

We aimed to develop evidence-based multinational recommendations for the diagnosis and management of gout. Using a formal voting process, a panel of 78 international rheumatologists developed 10 key clinical questions pertinent to the diagnosis and management of gout. Each question was investigated with a systematic literature review. Medline, Embase, Cochrane CENTRAL and abstracts from 2010-2011 European League Against Rheumatism and American College of Rheumatology meetings were searched in each review. Relevant studies were independently reviewed by two individuals for data extraction and synthesis and risk of bias assessment. Using this evidence, rheumatologists from 14 countries (Europe, South America and Australasia) developed national recommendations. After rounds of discussion and voting, multinational recommendations were formulated. Each recommendation was graded according to the level of evidence. Agreement and potential impact on clinical practice were assessed. Combining evidence and clinical expertise, 10 recommendations were produced. One recommendation referred to the diagnosis of gout, two referred to cardiovascular and renal comorbidities, six focused on different aspects of the management of gout (including drug treatment and monitoring), and the last recommendation referred to the management of asymptomatic hyperuricaemia. The level of agreement with the recommendations ranged from 8.1 to 9.2 (mean 8.7) on a 1-10 scale, with 10 representing full agreement. Ten recommendations on the diagnosis and management of gout were established. They are evidence-based and supported by a large panel of rheumatologists from 14 countries, enhancing their utility in clinical practice.

Background and Purpose Posttraumatic stress disorder (PTSD) is common in survivors of acute life-threatening illness, but little is known about the burden of PTSD in survivors of stroke and transient ischemic attack (TIA). This study estimated the prevalence of stroke or TIA-induced posttraumatic stress disorder (PTSD) using systematic review and meta-analysis. Methods Potentially relevant peer-reviewed journal articles were identified by searching the Ovid MEDLINE, PsycINFO, PILOTS Database, The Cochrane Library and Scopus from inception to January 2013; all searches were conducted on January 31, 2013. Observational cohort studies that assessed PTSD with specific reference to a stroke or TIA that occurred at least 1 month prior to the PTSD assessment were included. PTSD rates and characteristics of the study and sample were abstracted from all included studies. The coding of all articles included demographics, sample size, study country, and method and timing of PTSD assessment. Results Nine studies (N = 1,138) met our inclusion criteria. PTSD rates varied significantly across studies by timing of PTSD assessment (i.e., within 1 year of stroke/TIA versus greater than 1 year post-stroke/TIA; 55% of heterogeneity explained; Q 1 = 10.30; P = .001). Using a random effects model, the estimated rate of PTSD following stroke or TIA was 23% (95% CI, 16%–33%) within 1 year of the stroke or TIA and 11% (95% CI, 8%–14%) after 1 year. Conclusions Although PTSD is commonly thought to be triggered by external events such as combat or sexual assault, these results suggest that 1 in 4 stroke or TIA survivors develop significant PTSD symptoms due to the stroke or TIA. Screening for PTSD in a large population-based prospective cohort study with cardiovascular outcome assessments is needed to yield definitive prevalence, and determine whether stroke or TIA-induced PTSD is a risk factor for subsequent cardiovascular events or mortality.

BACKGROUND: The World Health Organization (WHO) estimates that the number of obese or overweight individuals worldwide will increase to 1.5 billion by 2015. Chronic diseases associated with overweight or obesity include diabetes, heart disease, hypertension and stroke. OBJECTIVES: To assess the effects of interactive computer-based interventions for weight loss or weight maintenance in overweight or obese people. SEARCH METHODS: We searched several electronic databases, including CENTRAL, MEDLINE, EMBASE, CINAHL, LILACS and PsycINFO, through 25 May 2011. We also searched clinical trials registries to identify studies. We scanned reference lists of included studies and relevant systematic reviews. SELECTION CRITERIA: Studies were included if they were randomized controlled trials or quasi-randomized controlled trials that evaluated interactive computer-based weight loss or weight maintenance programs in adults with overweight or obesity. We excluded trials if the duration of the intervention was less than four weeks or the loss to follow-up was greater than 20% overall. DATA COLLECTION AND ANALYSIS: Two authors independently extracted study data and assessed risk of bias. Where interventions, control conditions, outcomes and time frames were similar between studies, we combined study data using meta-analysis. MAIN RESULTS: We included 14 weight loss studies with a total of 2537 participants, and four weight maintenance studies with a total of 1603 participants. Treatment duration was between four weeks and 30 months. At six months, computer-based interventions led to greater weight loss than minimal interventions (mean difference (MD) -1.5 kg; 95% confidence interval (CI) -2.1 to -0.9; two trials) but less weight loss than in-person treatment (MD 2.1 kg; 95% CI 0.8 to 3.4; one trial). At six months, computer-based interventions were superior to a minimal control intervention in limiting weight regain (MD -0.7 kg; 95% CI -1.2 to -0.2; two trials), but not superior to infrequent in-person treatment (MD 0.5 kg; 95% -0.5 to 1.6; two trials). We did not observe consistent differences in dietary or physical activity behaviors between intervention and control groups in either weight loss or weight maintenance trials. Three weight loss studies estimated the costs of computer-based interventions compared to usual care, however two of the studies were 11 and 28 years old, and recent advances in technology render these estimates unlikely to be applicable to current or future interventions, while the third study was conducted in active duty military personnel, and it is unclear whether the costs are relevant to other settings. One weight loss study reported the cost-effectiveness ratio for a weekly in-person weight loss intervention relative to a computer-based intervention as USD 7177 (EUR 5678) per life year gained (80% CI USD 3055 to USD 60,291 (EUR 2417 to EUR 47,702)). It is unclear whether this could be extrapolated to other studies. No data were identified on adverse events, morbidity, complications or health-related quality of life. AUTHORS' CONCLUSIONS: Compared to no intervention or minimal interventions (pamphlets, usual care), interactive computer-based interventions are an effective intervention for weight loss and weight maintenance. Compared to in-person interventions, interactive computer-based interventions result in smaller weight losses and lower levels of weight maintenance. The amount of additional weight loss, however, is relatively small and of brief duration, making the clinical significance of these differences unclear.

Background Acute coronary syndromes (ACS; myocardial infarction or unstable angina) can induce posttraumatic stress disorder (PTSD), and ACS-induced PTSD may increase patients’ risk for subsequent cardiac events and mortality. Objective: To determine the prevalence of PTSD induced by ACS and to quantify the association between ACS-induced PTSD and adverse clinical outcomes using systematic review and meta-analysis. Data Sources: Articles were identified by searching Ovid MEDLINE, PsycINFO, and Scopus, and through manual search of reference lists. Methodology/Principal Findings Observational cohort studies that assessed PTSD with specific reference to an ACS event at least 1 month prior. We extracted estimates of the prevalence of ACS-induced PTSD and associations with clinical outcomes, as well as study characteristics. We identified 56 potentially relevant articles, 24 of which met our criteria (N = 2383). Meta-analysis yielded an aggregated prevalence estimate of 12% (95% confidence interval [CI], 9%–16%) for clinically significant symptoms of ACS-induced PTSD in a random effects model. Individual study prevalence estimates varied widely (0%–32%), with significant heterogeneity in estimates explained by the use of a screening instrument (prevalence estimate was 16% [95% CI, 13%–20%] in 16 studies) vs a clinical diagnostic interview (prevalence estimate was 4% [95% CI, 3%–5%] in 8 studies). The aggregated point estimate for the magnitude of the relationship between ACS-induced PTSD and clinical outcomes (ie, mortality and/or ACS recurrence) across the 3 studies that met our criteria (N = 609) suggested a doubling of risk (risk ratio, 2.00; 95% CI, 1.69–2.37) in ACS patients with clinically significant PTSD symptoms relative to patients without PTSD symptoms. Conclusions/Significance This meta-analysis suggests that clinically significant PTSD symptoms induced by ACS are moderately prevalent and are associated with increased risk for recurrent cardiac events and mortality. Further tests of the association of ACS-induced PTSD and clinical outcomes are needed.

Background: Nonadherence to statins limits the benefits of this common drug class. Individual studies assessing predictors of nonadherence haue produced inconsistent results. Objective: To identify reliable predictors of nonadherence to statins through systematic review and meta-analysis. Methods: Multiple databases, including MEDLINE, EMBASE, and PsycINFO, were searched (from inception through February 2009) to identify studies that evaluated predictors of nonadherence to statins. Studies were selected using a priori defined criteria, and each study was reviewed by 2 authors who abstracted data on study characteristics and outcomes. Relative risks were then pooled, using an inverse-variance weighted random-effects model. Results: Twenty-two cohort studies met inclusion criteria. Age had a U-shaped association with adherence; the oldest (≥70 years) and youngest (Conclusions: Several sociodemographic, medical, and health-care utilization characteristics are associated with statin nonadherence. These factors may be useful guides for targeting statin adherence interventions.

and history of cerebrovascular or cardiovascular diseases. The prevalence of diastolic dysfunction (E/e’ 15) and carotid artery stenosis (IMT > 1.5) were higher in those with high BPV compared to those with low BPV (29.2% vs. 10.4%, OR 3.54, 95%CI 1.16-10.81 for diastolic dysfunction; 62.5% vs. 22.9%, OR 5.61, 95%CI 2.30-13.67 for carotid artery stenosis). There was no difference in LVMI and ejection fraction. We conclude that high visit-to-visit BPV is associated with both diastolic dysfunction and carotid artery stenosis, but not with LV hypertrophy and systolic dysfunction. In addition to other well-defined risk factors, we propose to take the visit-to-visit BPV into account as a risk factor of diastolic heart failure and atherosclerosis.

Background The identification of MSU crystals in joints and tophi is the “gold standard” for the diagnosis of gout. Unfortunately and despite current recommendations, the search for crystals is not regularly performed [1] and many patients with gout are diagnosed on the basis of clinical and laboratory findings sometimes coupled with imaging techniques. Objectives To evaluate the diagnostic utility of clinical, laboratory and imaging for diagnosing gout. Methods A systematic literature search was performed in Medline, EMBASE and the Cochrane library from 1950 to October 2011 and in ACR and EULAR abstracts (2010-2011) identifying the studies on gout diagnosis. To be included, the studies had to evaluate the diagnostic value of clinical, laboratory or imaging features in gout and use MSU crystal identification as the reference standard. Titles and abstracts of the identified references were screened independently by 2 reviewers for the inclusion criteria. Subsequently, included articles were reviewed in detail and the data collected using ad hoc standard forms. A hand search was completed by reviewing the references of the included studies and all the publications or other information provided by experts were examined. Positive and negative likelihood ratios (LR) were calculated. Risk of bias was evaluated using the Cochrane tool for assessment of diagnostic tests. Results Of the 5,558 references retrieved, 5 papers (4 studies) fulfilled the inclusion criteria: 3 on clinical features, 1 on ultrasound (US) features and 1 on dual-energy CT (DECT). Overall risk of bias of these studies was moderate-low. Clinical and laboratory features that had a LR+ over 2.0 include: 1st MTP painful or swollen, unilateral podagra, unilateral tarsitis, presence of suspected tophi, response to colchicine, association of a cardio-vascular disease, beer consumption, hyperuricemia, serum uric acid (sUA) >7.06 (males)/5.72 (females) mg/dL, sUA >5.88 mg/dL, estimated glomerular filtration rate Conclusions MSU identification in a synovial fluid sample or after needling a tophus is the recommended diagnostic gold standard for gout diagnosis and should be performed whenever possible. However, some clinical, laboratory and imaging features show good LR and could be used as a diagnostic aid when MSU crystal identification is impracticable. References Perez-Ruiz F. J Clin Rheumatol 2011; 17 (7):349. Disclosure of Interest None Declared

Study objective The optimal diagnostic evaluation for establishing the risk of stroke among patients presenting to the emergency department (ED) with a transient ischemic attack has not been determined. The objective of this review is to assess the ability of diffusion-weighted magnetic resonance imaging (MRI) to predict the short-term risk of stroke. Methods MEDLINE, EMBASE, and the Cochrane Library were queried to identify studies examining the use of diffusion-weighted MRI in patients with classically defined transient ischemic attack. The primary outcome measure was the rate of stroke at 48 hours. Two reviewers determined study eligibility and extracted data. Quality was assessed according to published recommendations for the design and reporting of prognostic studies. Results One thousand six hundred ninety-six abstracts were identified and 35 articles underwent full-text review. Six cohort studies met the inclusion criteria but were limited by selection bias and differences in duration and completeness of follow-up. Results were not consistent across studies, with 5 reporting higher rates of stroke among diffusion-weighted MRI–positive patients, whereas 1 study reported higher rates in diffusion-weighted MRI–negative patients. Among the 4 studies (N=629 patients) reporting 48-hour outcomes, the risk of stroke ranged from 0% to 2.9% in patients with negative diffusion-weighted MRI findings compared with 0% to 9% among those with positive diffusion-weighted MRI results. Conclusion Studies of variable quality, consistency, and precision suggest that diffusion-weighted MRI may identify patients at sufficiently low risk to warrant ED discharge and close outpatient follow-up.

Study objective We seek to determine the diagnostic test characteristics of noncontrast computed tomography (CT) for appendicitis in the adult emergency department (ED) population. Methods We conducted a search of MEDLINE, EMBASE, the Cochrane Library, and the bibliographies of previous systematic reviews. Included studies assessed the diagnostic accuracy of noncontrast CT for acute appendicitis in adults by using the final diagnosis at surgery or follow-up at a minimum of 2 weeks as the reference standard. Studies were included only if the CT was completed using a multislice helical scanner. Two authors independently conducted the relevance screen of titles and abstracts, selected studies for the final inclusion, extracted data, and assessed study quality. Consensus was reached by conference, and any disagreements were adjudicated by a third reviewer. Unenhanced CT test performance was assessed with summary receiver operating characteristic curve analysis, with independently pooled sensitivity and specificity values across studies. Results The search yielded 1,258 publications; 7 studies met the inclusion criteria and provided a sample of 1,060 patients. The included studies were of high methodological quality with respect to appropriate patient spectrum and reference standard. Our pooled estimates for sensitivity and specificity were 92.7% (95% confidence interval 89.5% to 95.0%) and 96.1% (95% confidence interval 94.2% to 97.5%), respectively; the positive likelihood ratio=24 and the negative likelihood ratio=0.08. Conclusion We found the diagnostic accuracy of noncontrast CT for the diagnosis of acute appendicitis in the adult population to be adequate for clinical decisionmaking in the ED setting.

To systematically review the available literature on the management of tophi in gout. This article is based on the Cochrane Review Interventions for Tophi in Gout published in the Cochrane Database of Systematic Reviews.Medline, Embase, and The Cochrane Library were searched using a strategy developed with an experienced librarian. We also searched American College of Rheumatology and European League Against Rheumatism conference abstracts from 2010-2011. Included articles were reviewed in detail and a risk of bias (using the Cochrane tool) and quality assessment were performed.In total, 3206 references were recovered. Of these, 72 articles were selected based on our inclusion criteria. This included 1 report of 2 randomized controlled trials, 2 nonrandomized studies, and 69 case series and reports. The study with 2 randomized controlled trials looked at pegloticase. This showed improvement in tophi with treatment. One observational prospective trial looked at allopurinol and benzbromarone individually and in combination. It noted that achieving lower serum urate levels was associated with a faster reduction of tophi. An open-label extension trial noted that longterm maintenance of serum uric acid6.0 mg/dl with febuxostat led to a reduction in tophi. The case series and reports looked at surgical, pharmacological, and other interventions, as well as combination therapies. All surgical interventions reported improvement in pain and/or function. No report had objective measures of outcome.Treatment with urate-lowering therapy such as allopurinol, benzbromarone, allopurinol + benzbromarone in combination, febuxostat, or pegloticase can lead to reduction in tophi. There is some evidence that achieving a lower serum urate level leads to a faster rate of tophi reduction.