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Dr. FitzGerald served as the principal investigator and one of the lead author on the 2012 American College of Rheumatology Gout Guidelines. These guidelines outlined the principals for treating patients with gout including strategies to “treat to target”, the use of prophylaxis medication to prevent gout attacks and testing to make the diagnosis and treatment of gout easier.
The 3 most important quality measures from this work are the following. These measures have been incorporated into the UCLA Quality Improvement program and the American College of Rheumatology, Rheumatology Informatics System for Effectiveness (RISE) Registry. RISE is aimed at improving the quality of patient care by using data from electronic health records (EHRs). RISE is the first and largest national EHR-enabled rheumatology registry in the United States. There are more than 680 providers representing more than 1 million patients participating in RISE. The registry already has data from about 5 million patient encounters.
Gout is commonly diagnosed by withdrawing fluid from a joint, then examining it under a polarized microscope. Examining joint fluid under a polarized microscope for tiny crystals (10 um in length or smaller) takes a lot of time. The typical field of view for a microscope is approximately 0.2 mm2. It may be necessary to examine 20 high power fields of view to find a single crystal. Working with the Ozcan lab, a lens-free microscope has been developed to image gout (monosodium urate) and pseudogout (calcium pyrophosphate) crystals. Using this lens-free technology, a 20 mm2 field of view (100 times larger than microscope field of view) can be imaged with high resolution.
Figure 1: Artistic rendering of the Lens-Free imaging process.
The lens-free digital images have improved contrast over traditional microscope images for Gout (Figure 2) and pseudogout (Figure 3)
Figure 2: Lens-free images for gout (MSU) crystals.
(a) The full field of view (FOV) of the lens-free hologram is approximately one hundred times larger than a 40× microscope objective lens (yellow dashed circle). (b) A sub-region showing the lens-free differential polarized image. (c, d) Lens-free pseudo-colored images of two regions of interest (ROI) from (b). (e, f) 40× 0.75NA CPLM images of the same regions as (c, d). White arrows: crystals that result in a weak signature have better contrast in the lens-free pseudo-color images (c, d) than the CPLM images (e, f). Slow axis of polarization is +45o.
(a) A selected field of view (FOV ~0.25 mm2) rich with CPP crystals and a sub-region (b) with an easily identifiable CPP crystal with an associated cluster of crystals. The CPP crystals in the lens-free image (b) are more easily distinguished from their background than same CPP crystals from the comparable CPLM 100× 0.95NA image (c). The majority of the CPP crystals identified in the lens-free image can be found in the CPLM image, but due to their low birefringence it is hard to distinguish the crystals from the background. A non-linear, non-crystal object (black arrowhead) seen in CPLM is not reproduced in lens-free image (as it was not birefringent).
Patient with gout have a higher chance of heart attack or stroke than patients without gout. This risk is specific to gout and above and beyond any traditional risks for heart disease (such as high blood pressure, tobacco use, high cholesterol, or family history).
At UCLA, we have identified that the good component of cholesterol HDL (high-density lipoprotein) can behave badly in patients with Rheumatoid Arthritis, Lupus and now Gout. Due to ongoing inflammation, the HDL activates the bad cholesterol, LDL rather than removing it. This leads to growth of plaques and atherosclerosis.
We are using Dual Energy CT scans (special CT scans for gout) to measure a person’s total gout burden and comparing that to their HDL function. Describing this relationship between total gout, cholesterol and heart attack risk will help reduce gout patient’s risk for heart disease.
The dual energy computed tomography images demonstrate uric acid deposits (green color) at the right big toe.
See reference. Image courtesy of Mayo Clinic.