Table 1

Final ratings following the second iteration of the physician survey.

Survey Items	Median (30th to 70th percentile)^†	Disagreement Index^††
Items agreed by physicians to be discriminatory
MSU crystals present in joint aspirate/tissue	9 (9 to 9)	0
Tophi (especially in typical sites such as hands, helix of the ear, olecranon bursa, and Achilles tendon)	9 (8 to 9)	0.13
MSU crystals still present in the joint fluid despite the patient being asymptomatic	9 (7 to 9)	0.29
Radiographic erosions with sclerotic margins and overhanging cortical edges	8 (8 to 8)	0
First metatarsophalangeal joint (podagra) involved at the very first episode	8 (7 to 8)	0.16
Abrupt onset of an attack that peaks around 12–24 hours	8 (7 to 8)	0.16
Conventional CT tophi (soft-tissue masses of intermediate density)	8 (7 to 8)	0.16
Recurrent stereotypical episodes of attacks	8 (7 to 8)	0.16
MRI tophi (low to intermediate signal intensity on T1-weighted images)	8 (7 to 8)	0.16
MRI tophi (variable intensity on T2-weighted images)	8 (7 to 8)	0.16
Dual-energy CT to detect urate deposits	8 (7 to 8)	0.16
First metatarsophalangeal joint involved ever	7.5 (7 to 8)	0.16
US double-contour sign (hyperechoic band on the surface of articular cartilage)	7.5 (7 to 8)	0.16
Severe pain that is maximal within 4–12 hours	7 (7 to 8)	0.16
US tophi (hyperechoic, heterogeneous lesion surrounded by an anechoic rim)	7 (7 to 8)	0.16
Serum uric acid elevated during the intercritical period^*	7 (7 to 8)	0.16
Attacks are monoarthritic in the first few years and become oligoarthritic and polyarthritic over time^*	7 (7 to 8)	0.16
Between attacks, the patient appears well with no signs of pain or obvious inflammation	7 (6 to 8)	0.37
Redness/erythema around the affected joint observed by the physician	7 (6 to 8)	0.37
Marked joint tenderness — patient protects the affected joint from use or from being knocked	7 (6 to 7)	0.22
Monoarticular joint involvement in acute attacks	7 (6 to 7)	0.22
Resolution of an attack within 7–14 days	7 (6 to 7)	0.22
Raised serum urate level^*	7 (6 to 7)	0.22
Joints of the midfoot are affected, observed by the physician^*	7 (6 to 7)	0.22
Uric acid nephrolithiasis (kidney stones)	7 (5.1 to 8)	0.62
US joint effusion (snowstorm appearance due to MSU crystals within the synovial fluid)	7 (5 to 7)	0.52
Items agreed by physicians to be of uncertain discrimination
Patient responds rapidly to low-dose colchicine treatment^*	6.5 (6 to 7)	0.22
Swelling resolves once symptoms subside, observed by the physician	6.5 (5 to 7)	0.52
Serum uric acid elevated during acute attack of gout^*	6.5 (5 to 7)	0.52
Warmth of skin overlying affected joint, as observed by the physician^*	6 (6 to 7)	0.22
Onset of a gout attack is generally at night^*	6 (6 to 7)	0.22
MRI erosion (a sharply marginated bone lesion with cortical bone defect)^*	6 (6 to 7)	0.22
Conventional CT to detect urate deposits^*	6 (6 to 7)	0.22
Conventional CT to detect erosion^*	6 (6 to 7)	0.22
Swelling of associated bursa, observed by the physician	6 (5.3 to 7)	0.42
Other joints affected that are typical of gout (midfoot, ankle, knee)	6 (5.1 to 7)	0.48
Swelling in the joint, as observed by the physician^*	6 (5 to 7)	0.52
Redness/erythema around the affected joint, as observed by the patient^*	6 (5 to 7)	0.52
Precipitation of an episode by purine-containing food (such as seafood or red meat), alcohol, dehydration, or drugs (such as diuretics)	6 (5 to 7)	0.52
Swelling resolves once symptoms subside, as observed by the patient^*	6 (5 to 7)	0.52
Chronic uric acid nephropathy^*	6 (5 to 7)	0.52
If the patient is female she is postmenopausal^*	6 (5 to 7)	0.52
Patient is unable to wear shoes^*	6 (5 to 7)	0.52
Skin peels/scales over the affected area as acute attack is resolving^*	6 (5 to 7)	0.52
Previous diagnosis of gout made by another physician^*	6 (5 to 7)	0.52
Other joints are affected that are typical of gout such as ankle and knee, observed by the physician^*	6 (5 to 6)	0.32
Patient has a history of chronic, heavy alcohol intake^*	6 (5 to 6)	0.32
Patient is taking medication such as diuretics^*	6 (5 to 6)	0.32
Patient is a male^*	6 (5 to 6)	0.32
Patient is an organ graft recipient^*	6 (4.3 to 7)	0.81
Synovial fluid cultures of affected joint are negative for organisms (to exclude septic arthritis)^*	6 (4.3 to 6)	0.66
Family history of gout^*	5.5 (5 to 6)	0.32
Redness of skin with skip area (suggestive of gouty cellulitis), which can eliminate cellulitis (redness of skin without skip area)^*	5.5 (5 to 6)	0.32
US erosion (break in the cortical contour)^*	5 (5 to 6)	0.32
US tendon pathology (includes tenosynovitis, tendinosis, and intratendinous tophi)^*	5 (5 to 6)	0.32
Reduced renal uric acid excretion^*	5 (4.3 to 6)	0.66
Swelling of associated bursa, as observed by the patient^*	5 (4 to 6)	0.85
Warmth of skin overlying the affected joint, as observed by the patient^*	5 (4 to 6)	0.85
Asymmetric joint involvement, as observed by the physician^*	5 (4 to 6)	0.85
Patient has a high purine diet (i.e., consumes large amounts of red meat and shellfish)^*	5 (4 to 6)	0.85
Patient is obese^*	5 (4 to 6)	0.85
Patient has previously had a cardiovascular disease such as heart failure or myocardial infarction^*	5 (4 to 6)	0.85
US power Doppler signal (PWD 2–3) in monoarthritis^*	5 (4 to 6)	0.85
Elevated neutrophils within the synovial fluid^*	5 (4 to 5)	0.32
Patient is top aged (40–50 years old)^*	5 (4 to 5)	0.32
Swelling in the joint, as observed by the patient^*	5 (3 to 6)	0.97
Elevated leukocytes within the synovial fluid^*	5 (3 to 5)	0.52
Inflammatory cells present in fluid aspirated from affected joint^*	5 (3 to 5)	0.52
Pain is relieved by joint aspiration^*	4.5 (3 to 5)	0.52
Patient also suffers from diabetes^*	4 (4 to 5)	0.32
Elevated serum C-reactive protein^*	4 (3.3 to 5)	0.47
Pain prevents walking^*	4 (3 to 5.7)	0.81
Asymmetric joint involvement, as observed by the patient^*	4 (3 to 5)	0.52
Acute uric acid nephropathy^*	4 (3 to 5)	0.52
Elevated erythrocyte sedimentation rate^*	4 (3 to 5)	0.52
Aspiration of previously affected joint shows elevated leukocyte count in joint fluid^*	4 (3 to 4)	0.22
MRI synovitis (an area of synovial compartment is enhanced with contrast, and is thicker than the width of normal synovium)^*	4 (3 to 4)	0.22
US calcium deposits (focal hyperechoic deposits within hyaline cartilage)^*	4 (3 to 4)	0.22
Items agreed by physicians to be not discriminatory
Polyarticular disease, as observed by the physician^*	3.5 (3 to 4)	0.22
Fewer than 5 joints affected	3 (3 to 5)	0.52
Fever	3 (3 to 5)	0.52
Polyarticular disease, observed by the patient	3 (3 to 4)	0.22
Patient has hypertension^*	3 (3 to 4)	0.22
Functional disability (difficulty with daily activities)	3 (2 to 5)	0.65
Loss of function of the joint (due to loss of joint motion)	3 (2 to 4.9)	0.62
MRI cartilage pathology (focal and diffuse narrowing)	3 (2 to 4.9)	0.62
Calcium nephrolithiasis	3 (2 to 4)	0.37
Radiographic joint space abnormalities (includes widening, narrowing, and ankylosis)	3 (2 to 4)	0.37
Patient complains of flu-like symptoms	3 (1.1 to 4)	0.48
Malaise	3 (1.1 to 4)	0.48
Elevated platelet count	2 (1.1 to 4)	0.48
Early morning stiffness lasting > 30 minutes	2 (1 to 2.9)	0.27
Spinal involvement	2 (1 to 2)	0.13

↵* Rating from final iteration.
↵† Values of 1–3.5 indicate the item was considered not discriminatory for gout, 4–6.5 as uncertain, and 7–9 as discriminatory for gout.
↵†† Disagreement index > 1 indicates disagreement¹⁸. US: ultrasound; CR: conventional radiology; CT: computed tomography; MRI: magnetic resonance imaging; MSU: monosodium urate.