Zhang W, Doherty M, Pascual E, Bardin T, Barskova V, Conaghan P, Gerster J, Jacobs J, Leeb B, Lioté F, McCarthy G, Netter P, Nuki G, Perez-Ruiz F, Pignone A, Pimentão J, Punzi L, Roddy E, Uhlig T, Zimmermann-Gòrska I
Academic Rheumatology, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, UK.
Ann Rheum Dis. 2006 Oct;65(10):1301-11. doi: 10.1136/ard.2006.055251. Epub 2006 May 17.
To develop evidence based recommendations for the diagnosis of gout.
The multidisciplinary guideline development group comprised 19 rheumatologists and one evidence based medicine expert, representing 13 European countries. Ten key propositions regarding diagnosis were generated using a Delphi consensus approach. Research evidence was searched systematically for each proposition. Wherever possible the sensitivity, specificity, likelihood ratio (LR), and incremental cost-effectiveness ratio were calculated for diagnostic tests. Relative risk and odds ratios were estimated for risk factors and co-morbidities associated with gout. The quality of evidence was categorised according to the evidence hierarchy. The strength of recommendation (SOR) was assessed using the EULAR visual analogue and ordinal scales.
10 key propositions were generated though three Delphi rounds including diagnostic topics in clinical manifestations, urate crystal identification, biochemical tests, radiographs, and risk factors/co-morbidities. Urate crystal identification varies according to symptoms and observer skill but is very likely to be positive in symptomatic gout (LR = 567 (95% confidence interval (CI), 35.5 to 9053)). Classic podagra and presence of tophi have the highest clinical diagnostic value for gout (LR = 30.64 (95% CI, 20.51 to 45.77), and LR = 39.95 (21.06 to 75.79), respectively). Hyperuricaemia is a major risk factor for gout and may be a useful diagnostic marker when defined by the normal range of the local population (LR = 9.74 (7.45 to 12.72)), although some gouty patients may have normal serum uric acid concentrations at the time of investigation. Radiographs have little role in diagnosis, though in late or severe gout radiographic changes of asymmetrical swelling (LR = 4.13 (2.97 to 5.74)) and subcortical cysts without erosion (LR = 6.39 (3.00 to 13.57)) may be useful to differentiate chronic gout from other joint conditions. In addition, risk factors (sex, diuretics, purine-rich foods, alcohol, lead) and co-morbidities (cardiovascular diseases, hypertension, diabetes, obesity, and chronic renal failure) are associated with gout. SOR for each proposition varied according to both the research evidence and expert opinion.
10 key recommendations for diagnosis of gout were developed using a combination of research based evidence and expert consensus. The evidence for diagnostic tests, risk factors, and co-morbidities was evaluated and the strength of recommendation was provided.
制定基于证据的痛风诊断建议。
多学科指南制定小组由19名风湿病学家和1名循证医学专家组成，代表13个欧洲国家。采用德尔菲共识法提出了10条关于诊断的关键命题。对每个命题进行了系统的研究证据检索。尽可能计算诊断试验的敏感性、特异性、似然比（LR）和增量成本效益比。估计了与痛风相关的危险因素和合并症的相对风险和比值比。根据证据等级对证据质量进行分类。使用欧洲抗风湿病联盟（EULAR）视觉模拟量表和序数量表评估推荐强度（SOR）。
通过三轮德尔菲法提出了10条关键命题，包括临床表现、尿酸盐结晶鉴定、生化检查、X线片以及危险因素/合并症等诊断主题。尿酸盐结晶鉴定因症状和观察者技能而异，但在有症状的痛风中很可能呈阳性（LR = 567（95%置信区间（CI），35.5至9053））。典型的足痛风和痛风石的存在对痛风具有最高的临床诊断价值（LR分别为30.64（95%CI，2）。高尿酸血症是痛风的主要危险因素，当根据当地人群的正常范围定义时，可能是一个有用的诊断标志物（LR = 9.74（7.45至12.72）），尽管一些痛风患者在调查时血清尿酸浓度可能正常。X线片在诊断中作用不大，不过在晚期或严重痛风中，不对称肿胀的X线改变（LR = 4.13（2.97至5.74））和无侵蚀的皮质下囊肿（LR = 6.39（3.00至13.57））可能有助于将慢性痛风与其他关节疾病区分开来。此外，危险因素（性别、利尿剂、富含嘌呤的食物、酒精、铅）和合并症（心血管疾病、高血压、糖尿病、肥胖和慢性肾衰竭）与痛风有关。每个命题的SOR根据研究证据和专家意见而有所不同。
结合基于研究的证据和专家共识，制定了10条痛风诊断的关键建议。对诊断试验、危险因素和合并症的证据进行了评估，并提供了推荐强度。
