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The management of acute gout in the hospital setting may be challenging since most patients are elderly with multiple unstable comorbidities. However, there are no prospective clinical trials for hospitalized patients with gout to guide optimal management. Evidence indicates that steroids or adrenocorticotropic hormone (ACTH) may be effective and safe therapeutic options for these patients. This study aimed at directly comparing the efficacy and safety of ACTH vs betamethasone for the treatment of gout in hospitalized patients. This is the first prospective clinical trial for hospitalized patients with gout. We designed a randomized, open label study to assess the efficacy and safety of a single intramuscular injection of either ACTH or betamethasone in hospitalized patients with acute gout. Primary efficacy endpoints were the change in intensity of pain as recorded using a Visual Analogue Scale (VAS) at baseline compared to 24 h (ΔVAS24h), and 48 h. Moreover, we assessed safety and effects on the hypothalamic-pituitary-adrenal (HPA) axis, glucose and lipid homeostasis, bone metabolism, electrolytes and renal function. 38 patients were recruited. Both treatments were highly effective. The mean ± SE ΔVAS24h and ΔVAS48h for ACTH was 4.48 ± 0.29 and 5.58 ± 0.26, respectively. The mean ± SE ΔVAS24h and ΔVAS48h for betamethasone was 4.67 ± 0.32 and 5.67 ± 0.28, respectively. Direct comparison between the two groups at 24 h and 48 h did not show statistically significant differences. Both treatments were well tolerated and safe. The effects on all metabolic parameters were mostly minimal and transient for both treatments. However, ACTH may affect less the HPA axis and bone metabolism compared to betamethasone, thus leading to the conclusion that. ACTH and betamethasone are effective and safe for the management of acute gout in hospitalized patients but that ACTH may associate with less disturbance of the HPA axis and bone metabolism. Our data support the use of both drugs as first line treatments for hospitalized patients with gout.Clinical trial registration: ClinicalTrials.gov NCT04306653.

Einstein's equations with two commuting Killing vectors and the associated Lax pair are considered. The equations for the connection $A(\varsigma, \eta, \gamma)=\Psi_{,\gamma}\Psi^{-1}$, where $\gamma$ the variable spectral parameter are considered. A transition matrix ${\cal T}= A(\varsigma, \eta, \gamma)A^{-1}(\xi, \eta, \gamma)$ for $A$ is defined relating $A$ at ingoing and outgoing light cones. It is shown that it satisfies equations familiar from integrable pde's theory. A transition matrix on $\varsigma={\mbox constant}$ is defined in an analogous manner. These transition matrices allow us to obtain a hierarchy of integrals of motion with respect to time, purely in terms of the trace of a function of the connections $g_{,\varsigma}g^{-1}$ and $g_{,\eta}g^{-1}$. Furthermore a hierarchy of integrals of motion in terms of the curvature variable $B=A_{,\gamma}A^{-1}$, involving the commutator $[A(1), A(-1)]$, is obtained. We interpret the inhomogeneous wave equation that governs $\sigma=ln N$, $N$ the lapse, as a Klein-Gordon equation, a dispersion relation relating energy and momentum density, based on the first connection observable and hence this first observable corresponds to mass. The corresponding quantum operators are $\frac{\partial}{\partial t}$, $\frac{\partial}{\partial z}$ and this means that the full Poincare group is at our disposal., Comment: arXiv admin note: substantial text overlap with arXiv:1002.0524

Background: Hospitalized patients usually have significant comorbidities and receive multiple medications which leads to a high frequency of contraindications to standard treatment options for acute gout (NSAIDs, colchicine, steroids). Adrenocorticotropic hormone (ACTH) has long been used in acute gout, exhibiting significant clinical efficacy and an excellent safety profile. Aim: To assess 1) the clinical efficacy of ACTH in gout compared to betamethasone in hospitalized patients 2) the safety profile of ACTH vs betamethasone and 3) the effect of ACTH on immune responses and metabolic parameters. Methods: This is a randomized, open label comparative study directly comparing ACTH vs betamethasone for acute gout. We plan to recruit 60 hospitalized patients who will be randomly assigned to either the ACTH or the betamethasone group on a 1:1 basis. Patients will be clinically assessed at baseline and at 24, 48, 72h and 5days time points. (Intensity of pain, physician and patient global assessment, tenderness, swelling and redness). Serum and plasma samples will be collected at baseline and at the 24, 48, 72h time points from all study subjects. We will assess the effect of ACTH vs betamethasone on several metabolic parameters concentrating on glucose homeostasis. Results: The study is currently recruiting patients. Conclusions: If the efficacy and safety profile of ACTH is verified in this randomized controlled trial, the use of ACTH for the treatment of gout in the hospital setting will be strongly supported.

It is shown that an asymptotically flat solution of the stationary axisymmetric vacuum Einstein equations is reflection-symmetric, if and only if its Ernst potential on a portion of the positive z-axis extending to infinity, , obeys where * denotes complex conjugation. For rational e the above relation implies the form for , a constant. These solutions are the superposition of n Kerr particles on the axis of symmetry, for the balance of the parameters that corresponds to reflection symmetry.