Diagnosis of gout by ultrasound. Ultrasound imaging for the rheumatologist XXXVI. Sonographic assessment of the foot in gout patients. Ultrasonography shows disappearance of monosodium urate crystal deposition on hyaline cartilage after sustained normouricemia is achieved Existing joint erosions increase the risk of joint space narrowing independently of clinical synovitis in patients with early rheumatoid arthritis Association of baseline disease and patient characteristics with response to etoricoxib and indomethacin for acute gout* Relationship between structural joint damage and urate deposition in gout: a plain radiography and dual-energy CT study Improvements in early mortality and coagulopathy are sustained better in patients with blunt trauma after institution of a massive transfusion protocol in a civilian level I trauma center. Rilonacept in the treatment of acute gouty arthritis: a randomized, controlled clinical trial using indomethacin as the active comparator Comparison of triamcinolone acetonide with indomethacin in the treatment of acute gouty arthritis. Effect of alignment of the medial tibial plateau and x-ray beam on apparent progression of osteoarthritis in the standing anteroposterior knee radiograph. Chuanhu Anti-Gout Mixture versus Colchicine for Acute Gouty Arthritis: A Randomized, Double-Blind, Double-Dummy, Non-Inferiority Trial
OBJECTIVES To establish the usefulness of ultrasonography ( US ) for diagnosing gout and to determine whether there are sonographic features that are characteristic for gout but not for other arthropathies . METHODS We retrospectively compared joint images of gout patients with matching images from patients with other rheumatic conditions . Images of 37 joints of 23 patients with monosodium urate ( MSU ) crystal-proven gout were review ed . MSU crystals were identified in at least one joint in each patient . Our control group had 23 r and omly selected patients with 33 examined joints with rheumatic conditions other than gout . RESULTS Specific diagnostic features included a hyperechoic , irregular b and over the superficial margin of the articular cartilage described as a double contour sign in 92 % of gouty joints and in none of the controls ( P < 0.001 ) ; hypoechoic to hyperechoic , inhomogeneous material surrounded by a small anechoic rim , representing tophaceous material , was seen in all gouty metatarsophalangeal ( MTP ) joints , in all metacarpophalangeal ( MCP ) joints and in none of the controls ( P < 0.001 ) ; erosions adjacent to tophaceous material were seen in 65 % of MTP joints and in 25 % of MCP joints . One erosion was seen in a MTP joint in a control patient with psoriatic arthritis . CONCLUSIONS US can detect deposition of MSU crystals on cartilaginous surfaces ( P < 0.001 ) as well as tophaceous material and typical erosions . US may serve as a non-invasive means to diagnose gout OBJECTIVES This study aims to investigate the relationship between clinical and US findings together with the prevalence and distribution of US findings indicative of monosodium urate ( MSU ) crystal deposition within the foot in patients with gout . METHODS A total of 50 patients with gout attending the in-patient and the out-patient clinics of the Rheumatology Departments were prospect ively enrolled in this multi-centre study . Multiplanar examination of the following 15 joints was performed : talo-navicular , navicular-cuneiform ( medial , intermediate and lateral ) , calcaneo-cuboid , medial , intermediate and lateral cuneiform-metatarsal , cuboid-4th metatarsal , cuboid-5th metatarsal and all five metatarsophalangeal ( MTP ) joints . RESULTS The following US findings were indicative of gout : enhancement of the superficial margin of the hyaline cartilage , intra-articular tophus , and extraarticular tophus . In 46 patients , a total of 1380 foot joints were investigated . In 1309 joints that were not clinical ly involved , US detected signs indicative of joint inflammation in 9 % ( 121/1309 ) . Talo-navicular joint and the first MTP joint were the joints in which the highest number of US findings were found at mid-foot and fore-foot , respectively . At MTP joint level , dorsal scans allowed the detection of a higher number of US findings indicative of joint inflammation , and MSU crystal deposits rather than on the volar plane . CONCLUSIONS This study demonstrated that US detected a higher number of inflamed foot joints than clinical examination , and that the first MTP and the talo-navicular joints were the anatomic sites with the highest prevalence of US signs of MSU crystal aggregates This study aim ed at determining whether lowering serum urate ( SU ) to less than 6 mg/dl in patients with gout affects ultrasonographic findings . Seven joints in five patients with monosodium urate ( MSU ) crystal proven gout and hyperuricemia were examined over time with serial ultrasonography . Four of the five patients were treated with urate lowering drugs ( ULDs ) ( allopurinol , n = 3 ; probenecid , n = 1 ) . One patient was treated with colchicine alone . Attention was given to changes in a hyperechoic , irregular coating of the hyaline cartilage in the examined joints ( double contour sign or “ urate icing ” ) . This coating was considered to represent precipitate of MSU crystals . Index joints included metacarpophalangeal ( MCP ) joints ( n = 2 ) , knee joints ( n = 3 ) , and first metatarsophalangeal ( MTP ) joints ( n = 2 ) . The interval between baseline and follow-up images ranged from 7 to 18 months . Serial SU levels were obtained during the follow-up period . During the follow-up period , three patients treated with ULD ( allopurinol , n = 2 ; probenecid , n = 1 ) achieved a SU level of < 6 mg/dl . In two patients , SU levels remained above 6 mg/dl ( treated with allopurinol , n = 1 ; treated with colchicine , n = 1 ) . At baseline , the double contour sign was seen in all patients . In those patients who achieved SU levels of < 6 ml/dl , this sign had disappeared at follow-up . Disappearance of the double contour sign was seen in two knee joints , two first MTP joints , and one MCP joint . In contrast , disappearance of the double contour sign was not seen in patients who maintained a SU level ≥7 mg/dl . In one patient treated with allopurinol  , SU levels improved from 13 to 7 mg/dl during the follow-up period . Decrease , but not resolution of the hyperechoic coating was seen in this patient . In the patient treated with colchicine alone , SU levels remained > 8 mg/dl , and no sonographic change was observed . In our patients , sonographic signs of deposition of MSU crystals on the surface of hyaline cartilage disappeared completely if sustained normouricemia was achieved . This is the first report showing that characteristic sonographic changes are influenced by ULDs once SU levels remain ≤6 mg/dl for 7 months or more . Sonographic changes of gout correlate with SU levels and may be a non-invasive means to track changes in the uric acid pool . Larger prospect i ve studies are needed to further assess these potentially important findings Introduction Clinical synovitis is often associated with damage to bone and cartilage . Previous data have suggested that joint erosions ( JE ) are more prevalent than joint space narrowing ( JSN ) and that the two processes are partly independent of each other . The objective of this study was to evaluate whether the presence of JE in an individual joint can lead to development of JSN and if existing JSN leads to new onset of JE , in the absence of synovitis . Methods The Prospect i ve Multi-Centre R and omised , Double-Blind , Active Comparator-Controlled , Parallel-Groups Study Comparing the Fully Human Monoclonal Anti-TNFα Antibody Adalimumab Given Every Second Week With Methotrexate Given Weekly and the Combination of Adalimumab and Methotrexate Administered Over 2 Years in Patients With Early Rheumatoid Arthritis ( PREMIER ) enrolled early rheumatoid arthritis ( RA ) patients who were r and omized to one of three treatments : methotrexate ( MTX ) , adalimumab ( ADA ) , or ADA + MTX .  All evaluable joints with JE and JSN measures at 26 and 52 weeks and synovitis assessment s from week 26 to 52 were included . Synovitis was assessed every 2–8 weeks by swollen joint counts between weeks 26 and 52 . Radiographs were taken at week 26 and 52 . Two readers , blinded to time and sequence , scored 14 bilateral joints individually for JE and JSN . Multivariate logistic modeling was used to characterize the dependence of JE/JSN onset at 52 weeks . Analyses were performed based on treatment arm and were also performed within individual joints . Results JE and swelling were independently and comparably associated with onset of JSN at week 52 . Assessment by individual joints indicated that existing JE , independent of swelling , was significantly associated with JSN onset in higher proportions of metatarsophalangeal ( MTP ; 7/10 ) than proximal interphalangeal ( PIP ; 1/8 ) or metacarpophalangeal ( MCP ; 1/10 ) joints . Treatment with ADA + MTX  prevents JE/JSN progression independently of its ability to suppress synovitis and limits JE/JSN onset and progression in joints with existing damage . Conclusions Existing JE predisposes individual joints to development of JSN independently of synovitis in the same joint . Weight-bearing MTP joints with JE may be at increased risk for JSN when compared with MCPs and PIPs . Trial registration Clinical trials.gov NCT00195663 . Registered 13 September 2005 ABSTRACT Background and objective : Disease history and clinical features can influence treatment response in patients with acute gout . The purpose of this pooled subgroup analysis was to assess the association of baseline disease and patient characteristics with response to treatment in acute gout using data from two identical studies . Methods : Patients ≥ 18 years of age with onset of acute gout within 48 h associated with moderate , severe , or extreme pain involving less than four joints were eligible for inclusion in the primary studies , and were r and omized to etoricoxib 120 mg once daily ( N = 178 ) or indomethacin 50 mg three times daily ( N = 161 ) . The primary and secondary efficacy endpoints were analyzed using an analysis of covariance model to detect potential differential treatment responses across several subgroups : joint involvement ( mono-articular vs. oligo-articular ) , baseline pain severity ( moderate vs. severe ) , concomitant allopurinol and /or colchicine use ( users vs. nonusers ) , age ( < 45 , 45–55 , and > 55 years ) , gender , and race ( white or other ) . Results : Overall , etoricoxib and indomethacin demonstrated comparable efficacy across all subgroups . Compared with patients with oligo-articular disease , those with mono-articular disease had significantly greater improvements in patient assessment of pain , patient global assessment of response to therapy ( PGART ) , investigator global assessment of response to therapy ( IGART ) , and study joint tenderness ( p < 0.001 for all ) . Greater improvements were seen in patient assessment of pain ( p < 0.001 ) and study joint tenderness ( p < 0.05 ) for severe/extreme baseline pain compared with moderate baseline pain . Concomitant use of colchicine and /or allopurinol was associated with significantly worse IGART ( p < 0.05 ) . Conclusions : This pooled subgroup analysis demonstrated significantly greater response of acute gout to either etoricoxib or indomethacin among those with monoarticular disease , severe/extreme baseline pain , and non-use of colchicine and /or allopurinol . These results should be interpreted in the context of a pooled subgroup analysis with a limited sample size , and with the underst and ing that associations identified in such analyses do not define causation . Despite limitations , the results provide insights into the types of patients more likely to respond better to anti-inflammatory medication , and reiterate the importance of earlier effective control of the disease Objectives The aim of this work was to examine the relationship between joint damage and monosodium urate ( MSU ) crystal deposition in gout . Methods Plain radiographs and dual-energy CT ( DECT ) scans of the feet were prospect ively obtained from 92 people with tophaceous gout . Subcutaneous tophus count was recorded . The ten metatarsophalangeal joints were scored on plain radiography for Sharp – van der Heijde erosion and joint space narrowing ( JSN ) scores , and presence of spur , osteophyte , periosteal new bone and sclerosis ( 920 total joints ) . DECT scans were analysed for the presence of MSU crystal deposition at the same joints . Results  DECT MSU crystal deposition was more frequently observed in joints with erosion ( OR ( 95 % CI ) 8.5 ( 5.5 to 13.1 ) ) , JSN ( 4.2 ( 2.7 to 6.7 % ) ) , spur ( 7.9 ( 4.9 to 12.8 ) ) , osteophyte ( 3.9 ( 2.5 to 6.0 ) ) , periosteal new bone ( 7.0 ( 4.0 to 12.2 ) ) and sclerosis ( 6.9 ( 4.6 to 10.2 ) ) , p<0.0001 for all . A strong linear relationship was observed in the frequency of joints affected by MSU crystals with radiographic erosion score ( p<0.0001 ) . The number of joints at each site with MSU crystal deposition correlated with all features of radiographic joint damage ( r>0.88 , p<0.05 for all ) . In linear regression models , the relationship between MSU crystal deposition and all radiographic changes except JSN and osteophytes persisted after adjusting for subcutaneous tophus count , serum urate concentration and disease duration . Conclusions MSU crystals are frequently present in joints affected by radiographic damage in gout . These findings support the concept that MSU crystals interact with articular tissues to influence the development of structural joint damage in this disease INTRODUCTION Transfusion practice s across the country are changing with aggressive use of plasma ( fresh-frozen plasma [ FFP ] ) and platelets during massive transfusion with current military recommendations to use component therapy at a 1:1:1 ratio of packed red blood cells to FFP to platelets . METHODS A massive transfusion protocol ( MTP ) was design ed to achieve a packed red blood cell : FFP : platelet ratio of 1:1:1 We prospect ively gathered demographic , transfusion , and patient outcome data during the first year of the MTP and compared this with a similar cohort of injured patients ( pre-MTP ) receiving > or = 10 red blood cell ( RBC ) in the first 24 hours of hospitalization before instituting the MTP .  RESULTS One hundred sixteen MTP activations occurred . Twelve non-trauma patients and 31 who did not receive 10 RBC ( 15 deaths , 16 early bleeding controls ) were excluded . Seventy-three MTP patients were compared with 84 patients with pre-MTP who had similar demographics and injury severity score ( 29 vs. 29 , p = 0.99 ) . MTP patients received an average of 23.7 RBC and 15.6 FFP transfusions compared with 22.8 RBC ( p = 0.67 ) and 7.6 FFP ( p < 0.001 ) transfusions in pre-MTP patients . Early crystalloid usage dropped from 9.4 L ( pre-MTP ) to 6.9 L ( MTP ) ( p = 0.006 ) . Overall patient mortality was markedly improved at 24 hours , from 36 % in the pre-MTP group to 17 % in the MTP group ( p = 0.008 ) and at 30 days ( 34 % mortality MTP group vs. 55 % mortality in pre-MTP group , p = 0.04 ) . Blunt trauma survival improvements were more marked and more sustained than victims of penetrating trauma . Early deaths from coagulopathic bleeding occurred in 4 of 13 patients in the MTP group vs. 21 of 31 patients in the pre-MTP group ( p = 0.023 ) . CONCLUSIONS In the civilian setting , aggressive use of FFP and platelets drastically reduces 24-hour mortality and early coagulopathy in patients with trauma . Reduction in 30 day mortality was only seen after blunt trauma in this small subset Introduction In phase-3 clinical trials , the interleukin ( IL-1 ) blocker , rilonacept ( IL-1 Trap ) , demonstrated efficacy for gout flare prevention during initiation of urate-lowering therapy . This trial evaluated rilonacept added to a st and ard-of-care , indomethacin , for treatment of acute gout flares . Methods Adults , aged 18 - 70 years , with gout presenting within 48 hours of flare onset and having at least moderate pain as well as swelling and tenderness in the index joint were r and omized to subcutaneous ( SC  ) rilonacept 320 mg at baseline plus oral indomethacin 50 mg TID for 3 days followed by 25 mg TID for up to 9 days ( n = 74 ) ; SC placebo at baseline plus oral indomethacin as above ( n = 76 ) ; or SC rilonacept 320 mg at baseline plus oral placebo ( n = 75 ) . The primary efficacy endpoint was change in pain in the index joint ( patient-reported using a Likert scale ( 0 = none ; 4 = extreme ) ) from baseline to the average of values at 24 , 48 and 72 hours ( composite time point ) for rilonacept plus indomethacin versus indomethacin alone . Comparison of rilonacept monotherapy with indomethacin monotherapy was dependent on demonstration of significance for the primary endpoint . Safety evaluation included clinical laboratory and adverse event ( AE ) assessment s. Results Patient characteristics were comparable among the groups ; the population was predominantly male ( 94.1 % ) , white ( 75.7 % ) , with mean ± SD age of 50.3 ± 10.6 years . All treatment groups reported within-group pain reductions from baseline ( P < 0.0001 ) . Although primary endpoint pain reduction was greater with rilonacept plus indomethacin ( -1.55 ± 0.92 ) relative to indomethacin alone ( -1.40 ± 0.96 ) , the difference was not statistically significant ( P = 0.33 ) , so formal comparison between monotherapy groups was not performed . Pain reduction over the 72-hour period with rilonacept alone ( -0.69 ± 0.97 ) was less than that in the other groups , but pain reduction was similar among groups at 72 hours . Treatment with rilonacept was well-tolerated with no reported serious AEs related to rilonacept . Across all groups , the most frequent AEs were headache and dizziness . Conclusions Although generally well-tolerated , rilonacept in combination with indomethacin and rilonacept alone did not provide additional pain relief over 72 hours relative to indomethacin alone in patients with acute gout flare . Trial registration Clinical Trials.gov registration number NCT00855920 Twenty-seven patients presenting within 5 days of the onset of crystalline proven acute gout were prospect ively treated with either indomethacin 50 mg tid or triamcinolone acetonide 60 mg intramuscularly . Patients with contraindications to therapy with indomethacin  received triamcinolone acetonide . They were followed for 30 days . Resolution of all symptoms occurred at an average of 8 days for the indomethacin patients and 7 days in the triamcinolone patients . No side effects or episodes of rebound gout attacks occurred with the triamcinolone acetonide therapy . It is as safe and effective as indomethacin in the treatment of acute gout , and is particularly useful in patients with contraindications to therapy with nonsteroidal antiinflammatory drugs OBJECTIVE Previous studies of knee osteoarthritis ( OA ) have yielded variable estimates of the rate of joint space narrowing ( JSN ) in the st and ing anteroposterior ( AP ) radiograph , due largely to longitudinal changes in the alignment of the medial tibial plateau ( MTP ) and x-ray beam . To characterize this bias , we examined serial radiographs  of subjects with knee OA in population -based and clinical OA cohorts from 3 locations in the United States and the United Kingdom . METHODS Radiographic features of knee OA ( e.g. ,  osteophytosis , JSN ) and MTP alignment in 428 OA knees were evaluated by consensus of 2 readers . Alignment was considered satisfactory if the anterior and posterior margins of the MTP were superimposed within 1 mm . Readers were blinded to subject identity , and films were read in r and om order . The minimum medial joint space width was also measured manually ( st and ard error of repeated measurements 0.20 mm ) in serial knee images . RESULTS Only 14 % of serial radiographs exhibited alignment of the MTP in both images . In OA knees with satisfactory alignment in both images , the mean rate of JSN over 2 - 3 years ( 0.26 mm/year ) was significantly larger ( P = 0.004 ) than that in OA knees with misalignment in 1 or both radiographs and was 86 % more rapid than the mean JSN in all OA knees . Moreover , the within-group st and ard deviation of JSN was significantly smaller among knees with reproduced alignment of the MTP than in knees in which misalignment occurred in 1 or both images ( P = 0.006 ) . CONCLUSION Poor st and ardization of knee positioning in serial st and ing AP radiographs in previous studies of OA progression has obscured the rate and variability of articular cartilage loss in subjects with knee OA . True JSN ( i.e. , JSN that is not attributable to longitudinal changes in the alignment of the MTP with the x-ray beam in serial radiographic examinations ) may occur more rapidly , and with less between-subject variability , than that previously thought to be characteristic of knee OA Background The Chuanhu anti-gout mixture has been used for many years in the treatment of gout in Chinese Traditional Medicine , and current methods for treatments for acute gouty arthritis have been either less effective or have had serious side effects . Methods In this 12-week , double-blind , double-dummy , non-inferiority study , outpatient individuals with newly diagnosed acute gouty arthritis were r and omly assigned to receive Chuanhu anti-gout mixture or colchicine . Both the study investigators and the participants were masked to the treatment assignments . The primary outcome was the recurrence rate of acute gouty arthritis , and the secondary outcomes were changes in white blood cells ( WHC ) and C-reactive protein ( CRP ) . This trial is registered at IS RCT N.org as trial IS RCT N65219941 . Results A total of 176 patients were r and omly assigned to receive either the Chuanhu anti-gout mixture or Colchicine . The overall recurrence rates in the Chuanhu anti-gout mixture group ( CH group ) and the Colchicine group ( Col group ) were 12.50 % vs 14.77 % ( difference -2.22 % , 95 % confidence interval ( 95 % CI ) : -10.78%~6.23 % ) , meeting the predefined non-inferiority criterion of 15 % , as did the data for WHC and CRP . The incidence of adverse events ( mainly diarrhea ) was less in the Col group than in the CH group ( 2.27 % vs 28.41 % , 95 % CI 0.01~0.26 ) . In addition , changes in blood uric acid , alanine aminotransferase , aspartate aminotransferase and creatinine in the CH group were significantly larger compared to those in the Col group ( P<0.05 ) . Conclusions The Chuanhu anti-gout mixture was non-inferior to colchicine for the treatment of acute gouty arthritis . The study suggested that the Chuanhu anti-gout mixture can be considered an alternative choice for the treatment of acute gouty arthritis because of its lower incidence of adverse events and its protection of kidney and renal function
1st MTP pain was a prominent feature in people with gout .
Imaging features were common at the 1st MTP including the double contour sign , tophi and erosions .
Conclusions 1st MTP acute arthritis is highly prevalent in people with gout and has a substantial impact on patient-reported pain and disability .
Gout affects the structure and function of the 1st MTP .
Microscopic and imaging studies have demonstrated crystal deposition and joint damage at the 1st MTP in people with gout
Background The aim of this review was to qualitatively synthesis e studies that have investigated characteristics of the  first metatarsophalangeal joint ( 1st MTP )  in gout and to undertake a meta- analysis to estimate the average prevalence of acute 1st MTP arthritis across studies in people with gout .