Gout: An Evidence-Based Review

Uncovering the Potential Mechanisms and Effects of Hyperuricemia and its Associated Diseases on Male Reproduction

Male fertility and metabolic disorders, including obesity and diabetes, are closely connected. Since hyperuricemia and metabolic syndrome are strongly related, male fertility and hyperuricemia may, to some degree, be associated. According to recent studies, hyperuricemia imposes various effects on sex hormones, semen quality, and male erectile dysfunction. Some researchers claim that uric acid worsens male semen and raises the risk of erectile dysfunction (ED), while others state that it safeguards both penile erection and male semen. Additionally, it has been shown that gout and metabolic syndrome also raise the risk of ED. To clarify this controversy, the influence and potential mechanisms of hyperuricemia on ED, semen quality, sex hormone levels, and the effects of hyperuricemia-related disorders on ED will be comprehensively summarized.

Diet and metabolism are back: The oldest known Islamic medical manuscript bridges the gap from ancient to modern gout management

Gout is a chronic disease frequently associated with lifestyle; its prevalence is increasing in Western societies, as well as in the Middle East. Apart from its partial genetic features, diet accounts for 12% of the causality of the disease, while purine-rich foods contribute decisively to its development and evaluation. The influential Persian physician of the medieval ages, Abu Bakr Muhammad Ibn Zakariya al-Razi (or by his Latin name Rhazes; 860-925 AD), wrote a short book (20 chapters) entitled 'Treatise on gout'. Rhazes adopted the Hippocratic humoralism, and suggested that the disease results from metabolic excess in the peripheral blood, presenting sex dimorphism and age-dependence. His therapeutic guidelines include a diet prescribed by a physician, the use of laxatives and emetics, counter-balancing excess or deficiency of bile or phlegm and analgesics, bloodletting, foot and steam baths, as well as salves and poultices as preventive measures. He appends differential dietary restrictions/suggestions for phlegmatic or choleric patients: Small rations and intake of good quality foods low in purine by 20% for phlegmatic and 28% for choleric patients, as well as the restriction of foods high in purine by 27% for phlegmatic and 22% for the choleric patients. Finally, the acidic to alkaloid food intake ratio suggested is 2/5 for choleric and 3/7 for phlegmatic patients. His suggested foods and drugs are vitamin C and B-rich complexes, thereby inhibiting the accumulation of tophi.

Investigation of the Inhibition Mechanism of Xanthine Oxidoreductase by Oxipurinol: A Computational Study

Xanthine oxidoreductase (XOR) is an enzyme found in various organisms. It converts hypoxanthine to xanthine and urate, which are crucial steps in purine elimination in humans. Elevated uric acid levels can lead to conditions like gout and hyperuricemia. Therefore, there is significant interest in developing drugs that target XOR for treating these conditions and other diseases. Oxipurinol, an analogue of xanthine, is a well-known inhibitor of XOR. Crystallographic studies have revealed that oxipurinol directly binds to the molybdenum cofactor (MoCo) in XOR. However, the precise details of the inhibition mechanism are still unclear, which would be valuable for designing more effective drugs with similar inhibitory functions. In this study, molecular dynamics and quantum mechanics/molecular mechanics calculations are employed to investigate the inhibition mechanism of XOR by oxipurinol. The study examines the structural and dynamic effects of oxipurinol on the pre-catalytic structure of the metabolite-bound system. Our results provide insights on the reaction mechanism catalyzed by the MoCo center in the active site, which aligns well with experimental findings. Furthermore, the results provide insights into the residues surrounding the active site and propose an alternative mechanism for developing alternative covalent inhibitors.

Computational Characterization of the Inhibition Mechanism of Xanthine Oxidoreductase by Topiroxostat

Xanthine oxidase (XO) is a member of the molybdopterin-containing enzyme family. It interconverts xanthine to uric acid as the last step of purine catabolism in the human body. The high uric acid concentration in the blood directly leads to human diseases like gout and hyperuricemia. Therefore, drugs that inhibit the biosynthesis of uric acid by human XO have been clinically used for many years to decrease the concentration of uric acid in the blood. In this study, the inhibition mechanism of XO and a new promising drug, topiroxostat (code: FYX-051), is investigated by employing molecular dynamics (MD) and quantum mechanics/molecular mechanics (QM/MM) calculations. This drug has been reported to act as both a noncovalent and covalent inhibitor and undergoes a stepwise inhibition by all its hydroxylated metabolites, which include 2-hydroxy-FYX-051, dihydroxy-FYX-051, and trihydroxy-FYX-051. However, the detailed mechanism of inhibition of each metabolite remains elusive and can be useful for designing more effective drugs with similar inhibition functions. Hence, herein we present the computational investigation of the structural and dynamical effects of FYX-051 and the calculated reaction mechanism for all of the oxidation steps catalyzed by the molybdopterin center in the active site. Calculated results for the proposed reaction mechanisms for each metabolite's inhibition reaction in the enzyme's active site, binding affinities, and the noncovalent interactions with the surrounding amino acid residues are consistent with previously reported experimental findings. Analysis of the noncovalent interactions via energy decomposition analysis (EDA) and noncovalent interaction (NCI) techniques suggests that residues L648, K771, E802, R839, L873, R880, R912, F914, F1009, L1014, and A1079 can be used as key interacting residues for further hybrid-type inhibitor development.

Crosstalk between xanthine oxidase (XO) inhibiting and cancer chemotherapeutic properties of comestible flavonoids- a comprehensive update

Gout is an inflammatory disease caused by metabolic disorder or genetic inheritance. People throughout the world are strongly dependent on ethnomedicine for the treatment of gout and some receive satisfactory curative treatment. The natural remedies as well as established drugs derived from natural sources or synthetically made exert their action by mechanisms that are closely associated with anticancer treatment mechanisms regarding inhibition of xanthine oxidase, feedback inhibition of de novo purine synthesis, depolymerization and disappearance of microtubule, inhibition of NF-ĸB activation, induction of TRAIL, promotion of apoptosis, and caspase activation and proteasome inhibition. Some anti-gout and anticancer novel compounds interact with same receptors for their action, e.g., colchicine and colchicine analogues. Dietary flavonoids, i.e., chrysin, kaempferol, quercetin, fisetin, pelargonidin, apigenin, luteolin, myricetin, isorhamnetin, phloretinetc etc. have comparable IC₅₀ values with established anti-gout drug and effective against both cancer and gout. Moreover, a noticeable number of newer anticancer compounds have already been isolated from plants that have been using by local traditional healers and herbal practitioners to treat gout. Therefore, the anti-gout plants might have greater potentiality to become selective candidates for screening of newer anticancer leads.

Photosynthetic Parameters and Oxidative Stress during Acclimation of Crepe-Myrtle (Lagerstroemia speciosa (L.) Pers.) in a meta-Topolin-Based Micropropagation System and Genetic Fidelity of Regenerated Plants

An improved and stable micropropagation system using the cytokinin, meta-Topolin (N6 (3-hydroxybenzylamino purine—mT), with nodal explants in Lagerstroemia speciosa L. was established. Among the different doses of mT, the maximum number of shoots with the highest shoot length was obtained using Murashige and Skoog’s (MS) medium supplemented with 5.0 µM mT. The results were consistent throughout the proliferation period, when recorded at week 4, 8, and 12 of being cultured, with an average of 16.4 shoots per nodal explant, and having a mean length of 4.10 cm at week 8. Shoot proliferation rates could be further improved by a combination of 5.0 µM mT with 0.5 µM α-naphthalene acetic acid in MS medium; nodal explants produced an average of 24.3 shoots with a mean length of 5.74 cm after 8 weeks of being cultured. Among the five different concentrations of three auxins tested for the rooting of microshoots in MS medium, a 1.0 µM indole-3-butyric acid treatment was the best, with an average of 10.3 roots per microshoot at an average length of 3.56 cm in 93% of microshoots within 4 weeks of being transferred to this medium. A significant reduction of both chlorophyll a and b in leaves during the first week of acclimation corresponded with a high accumulation of malondialdehyde (MDH), indicating that lipid peroxidation affected chlorophyll pigments. From the second week of acclimation, photosynthetic pigment content significantly increased and MDH content decreased. The net photosynthetic rate and leaf carotenoid content showed almost linear increases throughout the acclimation period. Activity of antioxidant enzymes, namely, superoxide dismutase, catalase, and peroxidases, consistently increased throughout the acclimation period, corresponding with the accumulation of photosynthetic pigments, thus demonstrating the role of the improved antioxidant enzymatic defense system during acclimation. A comparison of parent plant DNA with that of the greenhouse acclimated plants using random amplified polymorphic DNA and inter-simple sequence repeat markers showed a monomorphic pattern indicating genetic stability and the suitability of the method for micropropagation of L. speciosa.

Exploring the binding characteristics of febuxostat, an inhibitor of xanthine oxidase with calf thymus DNA: Multi-spectroscopic methodologies and molecular docking

In this paper, the interacting characteristics of febuxostat (FBST), an inhibitor of xanthine oxidase for treating gout patients with hyperuricemia with calf thymus DNA (ctDNA) was investigated through multi-spectroscopic methodologies combined with theoretical calculation for understanding the interacting mode on ctDNA, affinity with ctDNA, interacting forces, as well as the alteration in the conformation of ctDNA after interacting FBST The experimental results demonstrated that interacting FBST with ctDNA formed 1:1 complex, the association constant was 913 M^-1 at 298 K, suggesting the affinity of FBST on ctDNA was very weak, the interacting mode of FBST on ctDNA was groove binding, and it inserted into the minor groove with rich A-T region of ctDNA. Based on the results of the thermodynamic analysis and theoretical calculation, it can be inferred that the dominated interacting forces between FBST and ctDNA were van der Waals forces and hydrogen bond. And, interacting FBST with ctDNA was a spontaneous, enthalpy-driven, and exothermic process because of ΔG⁰ < 0, ΔH⁰ < 0, and |ΔH⁰| > T|ΔS⁰|. The results of the circular dichroism (CD) measurements indicated the conformation of ctDNA was weakly disturbed after interacting with FBST but still maintained B-conform. The studied results offer significant insight into further clarifying whether it has genotoxicity.

Relationship between hyperuricemia with deposition and sexual dysfunction in males and females

PURPOSE

The association between gout, the most common crystal arthropathy, and sexual dysfunctions has often been investigated by studies in the last decades. Despite the presence of shared risk factors and comorbidities and the possible effects on sexual health of long-term gout complications, awareness of this association is severely lacking and the pathogenetic mechanisms have only partially been identified. In the present review, we aimed to investigate the current evidence regarding the potential mechanisms linking sexual dysfunctions and gout.

METHODS

A comprehensive literature search within PubMed was performed to provide a summary of currently available evidence regarding the association between gout and sexual dysfunctions.

RESULTS

Gout and sexual dysfunctions share several risk factors, including diabesity, chronic kidney disease, hypertension, metabolic syndrome, and peripheral vascular disease. Gout flares triggered by intense inflammatory responses feature severe pain and disability, resulting in worse sexual function, and some, but not all, treatments can also impair sexual health. Long-term gout complications can result in persistent pain and disability due to joint deformity, fractures, or nerve compression, with negative bearing on sexual function. The presence of low-grade inflammation impairs both sex steroids synthesis and endothelial function, further advancing sexual dysfunctions. The psychological burden of gout is another issue negatively affecting sexual health.

CONCLUSIONS

According to currently available evidence, several biological and psychological mechanisms link sexual dysfunctions and gout. Addressing risk factors and providing adequate treatment could potentially have beneficial effects on both conditions. Appropriate clinical evaluation and multidisciplinary approach are recommended to improve patient care.

Biomarkers of disease in human nails: a comprehensive review

Diagnostic, monitoring, response, predictive, risk, and prognostic biomarkers of disease are all widely studied, for the most part in biological fluids or tissues, but there is steadily growing interest in alternative matrices such as nails. Here we comprehensively review studies dealing with molecular or elemental biomarkers of disease, as opposed to semiological, pharmacological, toxicological, or biomonitoring studies. Nails have a long history of use in medicine as indicators of pathological processes and have also been used extensively as a matrix for monitoring exposure to environmental pollution. Nail clippings are simple to collect noninvasively as well as to transport and store, and the matrix itself is relatively stable. Nails incorporate, and are influenced by, circulating molecules and elements over their several months of growth, and it is widely held that markers of biological processes will remain in the nail, even when their levels in blood have declined. Nails thus offer the possibility to not only look back into a subject's metabolic history but also to study biomarkers of processes that operate over a longer time scale such as the post-translational modification of proteins. Reports on ungual biomarkers of metabolic and endocrine diseases, cancer, and psychological and neurological disorders will be presented, and an overview of the sampling and analytical techniques provided.

NEUTROPHIL EXTRACELLULAR TRAPS RELEASE IN GOUT AND PSEUDOGOUT DEPENDS ON THE NUMBER OF CRYSTALS REGARDLESS OF LEUKOCYTE COUNT

OBJECTIVES

Microcrystal-induced arthritis is still an unresolved paradigm for medicine. Overt inflammation may be absent even when crystals occur in synovial fluid. Recently, the production of neutrophil extracellular traps (NETs) embedding monosodium urate crystals (MSU) has been proposed as a possible mechanism of the auto-resolution of the inflammatory phase during gout. We aimed to verify and quantify the release of NETs in synovial fluids during gout and pseudogout attacks and to compare any differences with respect to crystals and neutrophils number, and to analyze activation of necroptosis pathway in synovial fluid from crystal-induced arthritis.

METHODS

Synovial fluid samples were obtained by arthrocentesis from 22 patients presenting acute crystal-induced arthritis, gout or pseudogout (n = 11 each group), and from 10 patients with acute non-crystal arthritis as controls. NETosis was quantified in synovial fluid by nucleic acid stain and by quantification of human neutrophil elastase. Activation of p-MLKL was assessed by western blot.

RESULTS

We observed that synovial fluid neutrophils encountering MSU and CPPD crystals during episodes of gout and pseudogout release NETs in relation to the number of crystals in synovial fluid and irrespective of neutrophil density and type of crystal. This release was accompanied by necroptosis through the activation of the MLKL pathway.

CONCLUSIONS

Our findings suggest that a role of NETs in crystal-induced arthritis is to "trap extracellular particles", including microcrystals. Embedding crystals in aggregates of NETs may be the basis of tophi and CPPD deposition and may have implications for disease evolution, rather than for spontaneous resolution of the acute attack.

The complete catalytic mechanism of xanthine oxidase: a computational study

In this article, quantum mechanical/molecular mechanical (QM/MM) methods were used to study the full catalytic mechanism of xanthine oxidase (XO).

Studies on the Anti-Gouty Arthritis and Anti-hyperuricemia Properties of Astilbin in Animal Models

The purpose of this study was to investigate potential anti-gouty effect of astilbin (AS) and its possible mechanisms. In mice with hyperuricemia induced by potassium oxonate (OXO) and yeast extract powder (YEP), AS and febuxostat (FB) reduced the serum uric acid (UA) and xanthine oxidase (XO). Moreover, AS and FB reduced the levels of reactive oxygen species and increased the content of superoxide dismutase (SOD), glutathione peroxidase and catalase present in the serum. In acute gouty arthritis rats induced by intraarticular monosodium urate crystal injection, AS and Colchicine (COL) alleviated the ankle joints swelling, and reduced the inflammatory cell infiltration. AS also reduced the levels of interleukin 1β, interleukin 6, tumor necrosis factor alpha and monocyte chemoattractant protein 1 in liver. The present study first confirmed the anti-gouty effect of AS in mice with hyperuricemia and rats with acute gouty arthritis, which provides the experimental evidence for further evaluation of AS as a candidate for gout treatment.

Antihyperuricemic effect of dietary polyphenol sinapic acid commonly present in various edible food plants

The present study was conducted to evaluate the antihyperuricemic effect of sinapic acid (SA). The results showed that SA potently inhibited xanthine oxidase (XOD) in a dose-dependent manner by entering the enzyme active site and thwarting the entrance of the substrate. These results were further confirmed by the quantum chemical descriptors analysis and ¹ H NMR titration analysis. The in vivo results indicated that SA not only has the potential to inhibit serum and hepatic XOD (p < .05), but also remarkably lowered serum and urine uric acid levels at 50 and 100 mg/kg bw. Furthermore, SA regulated serum creatinine and blood urea nitrogen levels to normal and lowered inflammation in the renal tubules. Thus, the utilization of SA as an antihyperuricemic agent may have considerable potential for the development of functional foods for the possible treatment of hyperuricemia. PRACTICAL APPLICATIONS: Plant-derived bioactive compounds have multiple health benefits. The present study assesses the effects of sinapic acid against hyperuricemia. The results suggested that sinapic acid may have a strong protective effect against uric acid-related complications and may be used for the formulation of functional foods. However, further mechanistic studies are required to verify this hypothesis.

Stevia residue extract alone and combination with allopurinol attenuate hyperuricemia in fructose-PO-induced hyperuricemic mice

The current project was designed to utilize flavonoids and chlorogenic acids enriched stevia residue extract (STVRE) against hyperuricemia (HU). The in vitro results showed that STVRE potently and synergistically inhibits Xanthine oxidase (XO) with allopurinol. The AFM results predicted that STVRE compounds bind with XO and alter its structure which further prevents the entrance of substrate with XO. These in vitro results were further confirmed in fructose-PO-induced hyperuricemic mice model. The results showed that supplementation of STVRE with allopurinol significantly attenuated HU, oxidative stress, and inflammation caused by UA via inhibiting the production of uric acid and lowering cyclooxygenase-2, tumor necrosis factor-alpha, prostaglandin E2, interleukin-6, and interleukin 1-beta levels in serum and renal tissues. Moreover, STVRE and allopurinol treatment attenuated, tubular dilation, infiltration of inflammatory cells, improved structure disorder of podocyte, and foot process fusion, and decreased glomerular basement membrane thickness. These findings suggested that STVRE can be used as an antihyperuricemic agent along with allopurinol. PRACTICAL APPLICATIONS: The results of present study showed that STVRE has a beneficial effect against fructose-PO-induced hyperuricemia by decreasing uric acid level, xanthine oxidase activity, improving oxidative stress and inflammation. These findings suggested that by-product of stevia (STVRE) enriched with polyphenolic compounds can be used as a functional ingredient against hyperuricemia and related diseases.

Anti‑gouty arthritis and anti‑hyperuricemia properties of celery seed extracts in rodent models

Gout is a type of serious arthritis that is caused by hyperuricemia. Celery is an umbelliferous plant that was shown to exhibit anti‑inflammatory activity in rodent. The present study aimed to investigate the effects and potential preliminary mechanisms of celery seed aqueous extract (CSAE) and celery seed oil extract (CSOL) for gout treatment. The components of CSAE and CSOL were systematically analyzed. In mice with hyperuricemia induced by potassium oxonate and yeast extract, CSAE and CSOL treatment reduced the serum levels of uric acid and xanthine oxidase. In addition, CSAE and CSOL reduced the levels of reactive oxygen species and increased the serum levels of superoxide dismutase and glutathione peroxidase in mouse serum. In rats with acute gouty arthritis induced by intra‑articular injection of monosodium urate crystals, CSAE and CSOL treatment alleviated the swelling of the ankle joints and reduced inflammatory cell infiltration around the ankle joints. In addition, CSAE and CSOL reduced the levels of interleukin (IL)‑1β and tumor necrosis factor α and increased the levels of IL‑10. The results of the present study suggested that celery seed extracts may have anti‑gout properties, partially through anti‑inflammatory and antioxidative effects.

Study on the diagnosis of gout with xanthine and hypoxanthine

BACKGROUND

Hyperuricemia is the only biochemical index in the classification of acute gouty arthritis in American Rheumatism Association 1977 and the main basis of clinical diagnosis for most doctors. However, nearly half of the time gout occurs without hyperuricemia, especially in an acute attack，which leads to an urgent need to find a new substitute diadynamic criteria of gout. Xanthine and hypoxanthine, as precursors of uric acid, have been reported to be high in gout patients with hyperuricemia and presumed to be gout biomarkers.

OBJECTIVES

To further explore the possibility of xanthine and hypoxanthine to be gout biomarkers as substitutes for uric acid.

METHODS

A reversed-phase HPLC-UV method was employed for simultaneous quantitative detection of uric acid (UA), xanthine (X), and hypoxanthine (HX) in gout patients' (with and without hyperuricemia) and healthy persons' serum.

RESULTS

The xanthine and hypoxanthine concentrations in gout patients with hyperuricemia and without hyperuricemia are higher than in healthy persons with a P < 0.001.

CONCLUSIONS

This study supplements previous researches by confirming that xanthine and hypoxanthine are significantly elevated in gout patients' serum especially in patients' with normouricemia, which supported xanthine and hypoxanthine may have clinical application for the diagnosis of gout.

Nutritional Culturomics and Big Data: Macroscopic Patterns of Change in Food, Nutrition and Diet Choices

BACKGROUND & OBJECTIVE

Nutritional culturomics (NCs) is a specific focus area of culturomics epistemology developing digital humanities and computational linguistics approaches to search for macro-patterns of public interest in food, nutrition and diet choice as a major component of cultural evolution. Cultural evolution is considered as a driver at the interface of environmental and food science, economy and policy.

METHODS

The paper presents an epistemic programme that builds on the use of big data from webbased services such as Google Trends, Google Adwords or Google Books Ngram Viewer.

RESULTS

A comparison of clearly defined NCs in terms of geography, culture, linguistics, literacy, technological setups or time period might be used to reveal variations and singularities in public's behavior in terms of adaptation and mitigation policies in the agri-food and public health sectors.

CONCLUSION

The proposed NC programme is developed along major axes: (1) the definition of an NC; (2) the reconstruction of food and diet histories; (3) the nutrition related epidemiology; (4) the understanding of variability of NCs; (5) the methodological diversification of NCs; (6) the quantifiable limitations and flaws of NCs. A series of indicative examples are presented regarding these NC epistemology components.

Uricase-containing coacervate microdroplets as enzyme active membrane-free protocells for detoxification of uric acid in serum

Based on the unique property of preferential sequestration of guest molecules, coacervate microdroplets are proposed as enzyme active membrane-free protocells, in which uricase is loaded for efficient detoxification of uric acid in serum.

Cost-Effectiveness Analysis of Lesinurad/Allopurinol Versus Febuxostat for the Management of Gout/Hyperuricemia in Italy

BACKGROUND

Until very recently the only therapeutic alternative for the management of patients affected by gout/hyperuricemia that did not respond to a first-line treatment based on allopurinol alone or who cannot tolerate allopurinol was febuxostat, a xanthine oxidase non-purine-selective inhibitor. Lately, however, a new therapeutic alternative has become available for the management of this pathology: lesinurad, a urate transporter inhibitor.

OBJECTIVE

To objective of this study was to evaluate the cost effectiveness of lesinurad/allopurinol in comparison with febuxostat as a second-line therapeutic strategy for the management of patients affected by gout and hyperuricemia that did not respond to a first-line therapy based on allopurinol alone.

METHODS

A Markov model was built based on the natural history of the pathology; patients entered the model according to their level of serum uric acid concentration and flowed across it according to their response to the therapy. The analysis was carried out considering the perspective of the Italian National Health Service on a lifetime horizon and 6-month cycles. Costs and quality-adjusted life-years (QALYs) were discounted at a 3.5% yearly rate. The results of the model were expressed in terms of incremental cost-effectiveness ratio (ICER). Both a one-way and a multi-way Monte-Carlo analysis were carried out in order to check the robustness of the results achieved.

RESULTS

The ICER derived from the comparison was equal to €77.53/QALY on the lifetime horizon, as there was a higher level of costs associated with the combination as compared with febuxostat (€10,658.27 vs. €10,645.87, for a differential of €12.40) and a higher level of QALYs achieved (7.77 vs. 7.61, for a differential of 0.16).

CONCLUSIONS

The lesinurad/allopurinol combination is recommended for the treatment of patients affected by gout/hyperuricemia in the Italian Health System as it appears to be cost effective and thus sustainable for the Italian healthcare sector.

Management of hyperuricemia through dietary polyphenols as a natural medicament: A comprehensive review

Hyperuricemia, a condition due to high serum uric acid level and is notorious to health. It is considered to be a potent risk factor for gout and dramatically associated in the development of many chronic diseases such as malignant tumor, cardiovascular disorders and renal failure. Modern innovative medicinal and therapeutic interventions are underlying these days to combat hyperuricemia. Previously reported studies revealed the significant impact of dietary polyphenols (e.g. anthocyanins, phenolic acids, flavonoids etc.) against hyperurecemia disorder. Dietary plant polyphenols, unlike anti- hyperuricemic agents, are not reported to have any side effects in curing hyperuricemia. The current comprehensive review figure outs the use of dietary polyphenols as a natural remedy for the management of hyperuricemia. The sources, affiliated pathways, mode of actions and factors affecting their efficiency to prevent hyperuricemia are deeply discussed in this article. Additionally, limitations and suggestions regarding previously reported studies are also highlighted.

'Shi Han Quan' natural soda water prevents development of gout

PURPOSE

This study aimed to explore the regulatory mechanism of the natural soda Shi Han Quan (SHQ) in the development of gout.

METHODS

Human umbilical vein endothelial cells (HUVECs) were stimulated with monosodium urate (MSU) for 24 h to induce acute gouty inflammation in vitro. HUVECs were divided into four groups: ddH₂ O group, ddH₂ O + MSU group, 1/2 ddH₂ O +1/2 SHQ + MSU group, and SHQ + MSU group. The effects of SHQ on cell viability, concentration and expression of intercellular adhesion molecule-1 (ICAM-1), and MSU-induced release of interleukin (IL)-1β and IL-6 were investigated. Additionally, cell viability and ICAM-1 concentration and expression were detected after HUVECs were incubated with the culture supernatant of THP-1 cells that had been treated with phorbol 12-myristate 13-acetate (PMA), MSU and SHQ for 24 h.

RESULTS

The viability of HUVECs was significantly decreased with increasing transfection concentrations of MSU, and MSU treatment resulted in a significant increase of the concentration and expression of ICAM-1. In addition, SHQ improved the MSU-induced decrease in cell viability and alleviated MSU-mediated increase in ICAM-1 levels. Moreover, SHQ decreased MSU-induced release of IL-1β and IL-6. After HUVECs were incubated with the culture supernatant of THP-1 cells that had been treated with PMA, MSU and SHQ for 24 h, SHQ also markedly alleviated the effects of MSU, such as by increasing cell viability and decreasing ICAM-1 levels.

CONCLUSIONS

Drinking natural soda water may have a significant role in preventing gouty inflammation.

Anti-Gouty Arthritis and Antihyperuricemia Effects of Sunflower (Helianthus annuus) Head Extract in Gouty and Hyperuricemia Animal Models

This study was performed to investigate the therapeutic effects and possible mechanisms of sunflower (Helianthus annuus) head extract (SHE) on gout. First, the components of sunflower head powder and SHE were analyzed systematically. SHE, especially SHEB (extracted with 20% ethanol and 80% double-distilled water), strongly suppressed the swelling of the ankles in rats with acute gout induced by monosodium urate (MSU) crystals and reduced the levels of uric acid and xanthine oxidase (XO) in mice with hyperuricemia induced by oteracil potassium and yeast extract powder. Hematoxylin and eosin staining indicated that SHEB reduced inflammation cells and increased the joint space in the ankle compared with the control rats with MSU-induced gout. In the rats with acute gout, among 13 detected inflammatory cytokines, SHEB significantly enhanced the serum levels of interleukin-10 and the monocyte chemoattractant protein 1α. In the mice with hyperuricemia, SHEB reduced the levels of glutathione peroxidase, superoxide dismutase, malondialdehyde, and nitrogen monoxide in liver tissues. The potential therapeutic effects of SHE on gout are probably due to the production of anti-inflammatory cytokines and the suppression of XO activity via the modulation of oxidative stress status.

Asymptomatic Papules and Subcutaneous Nodules as First Sign of Gout

The authors describe a case report characterised by asymptomatic papules and non-tender subcutaneous nodules as the isolated manifestations of gout.

WX-132-18B, a novel microtubule inhibitor, exhibits promising anti-tumor effects

Cancer drug researchers have been seeking microtubule-inhibiting agents (MIAs) with higher bioactivity and lower toxicity than currently marketed drugs. WX-132-18B, a novel structural compound synthesized at our institute, specifically bound to the colchicine-binding site on tubulin rather than the vinblastine site, and concentration-dependently reduced microtubule content via depolymerization. It exhibited the same cellular phenotypic profiles as the classic MIAs (colchicine, vincristine, and taxol), including inducing cell cycle arrest at the G2/M phase, triggering tumor cell apoptosis, promoting nuclear membrane permeability, reducing mitochondrial membrane potential, and disrupting the redox system balance. Importantly, WX-132-18B displayed more potent in vitro bioactivity (IC₅₀ 0.45–0.99 nM) than did the classic MIAs; it inhibited the proliferation of human umbilical vein endothelial cells and seven types of human tumor cells, especially the taxol-resistant breast cancer cells MX-1/T. WX-132-18B also dose-dependently inhibited mice sarcoma, human lung, and gastric cancer xenograft tumors and the formation of tumor blood vessels in mice. In conclusion, WX-132-18B is a novel microtubule-depolymerizing agent that selectively acts on the colchicine-binding site of tubulin and exerts potent in vitro and in vivo anti-tumor effects. These characteristics, along with its anti-angiogenesis and anti-drug resistance properties, make WX-132-18B a promising anti-tumor drug candidate.

Future prospects of antibacterial metal nanoparticles as enzyme inhibitor

Nanoparticles are being widely used as antibacterial agents with metal nanoparticles emerging as the most efficient antibacterial agents. There have been many studies which have reported the mechanism of antibacterial activity of nanoparticles on bacteria. In this review we aim to emphasize on all the possible mechanisms which are involved in the antibacterial activity of nanoparticles and also to understand their mode of action and role as bacterial enzyme inhibitor by comparing their antibacterial mechanism to that of antibiotics with enzyme inhibition as a major mechanism. With the emergence of widespread antibiotic resistance, nanoparticles offer a better alternative to our conventional arsenal of antibiotics. Once the biological safety of these nanoparticles is addressed, these nanoparticles can be of great medical importance in our fight against bacterial infections.

Transcriptional induction of the heat shock protein B8 mediates the clearance of misfolded proteins responsible for motor neuron diseases

Neurodegenerative diseases (NDs) are often associated with the presence of misfolded protein inclusions. The chaperone HSPB8 is upregulated in mice, the human brain and muscle structures affected during NDs progression. HSPB8 exerts a potent pro-degradative activity on several misfolded proteins responsible for familial NDs forms. Here, we demonstrated that HSPB8 also counteracts accumulation of aberrantly localized misfolded forms of TDP-43 and its 25 KDa fragment involved in most sporadic cases of Amyotrophic Lateral Sclerosis (sALS) and of Fronto Lateral Temporal Dementia (FLTD). HSPB8 acts with BAG3 and the HSP70/HSC70-CHIP complex enhancing the autophagic removal of misfolded proteins. We performed a high-through put screening (HTS) to find small molecules capable of inducing HSPB8 in neurons for therapeutic purposes. We identified two compounds, colchicine and doxorubicin, that robustly up-regulated HSPB8 expression. Both colchicine and doxorubicin increased the expression of the master regulator of autophagy TFEB, the autophagy linker p62/SQSTM1 and the autophagosome component LC3. In line, both drugs counteracted the accumulation of TDP-43 and TDP-25 misfolded species responsible for motoneuronal death in sALS. Thus, analogs of colchicine and doxorubicin able to induce HSPB8 and with better safety and tolerability may result beneficial in NDs models.

Gouty arthropathy: Review of clinico-pathologic and imaging features

Gout is a common inflammatory arthropathy in adults, with the prevalence increasing in males of older age. It occurs when monosodium urate (MSU) crystals are deposited in joints and connective tissue causing inflammation. The gold standard for the diagnosis of gout is the demonstration of negatively birefringent, needle-shaped MSU crystals through synovial fluid aspiration. However, this is an invasive technique and may not always be conclusive or feasible. Imaging techniques have been developed to aid in diagnosis of gout non-invasively. Radiography has a low utility in the early diagnosis of gout and demonstrates erosions in late stages. Ultrasound (US) has a high overall sensitivity in diagnosing gout with the 'double contour' sign having a high specificity. Magnetic resonance imaging is good at detecting tophi, bone marrow oedema and erosions, but has a limited role in diagnosis because of its high cost and limited availability. Conventional computed tomography (CT) has no role in the routine diagnosis of gout before development of erosions and tophi. A newer technology, dual-energy CT (DECT) has been shown to be able to detect MSU crystals burden with high accuracy. It has a higher specificity and lower sensitivity that US in gout diagnosis. However, because of radiation exposure and cost, it has a better utility in diagnosing clinically suspected gout complicated by other concurrent rheumatologic conditions or if radiography, US and synovial aspiration are inconclusive or not feasible. This paper will review the clinico-pathologic and imaging features of gouty arthropathy.

A Systematic Review of the Economic and Humanistic Burden of Gout

BACKGROUND

Gout is a chronic and inflammatory form of arthritis that is often overlooked despite the associated pain caused by acute flares and associated joint damage caused by the development of debilitating tophi. The increasing burden of gout, due to an aging population and the increased prevalence of known risk factors for hyperuricaemia, means that there is a continued need for new and effective urate-lowering treatments. The evaluation of these treatments will require a comprehensive and comparative evidence base describing the economic and humanistic burden of gout, taken from the perspective of patients, the healthcare system, and wider society.

OBJECTIVE

The objective of this study is to review and summarise the current evidence of the disease burden related to chronic gout, assessed in terms of both cost and health-related quality of life (HRQL), and to identify key factors correlated with an increased burden. The overall aim is to support the economic evaluation of new treatments for gout, and to highlight key data gaps that may need further study and exploration.

METHODS

Relevant literature dating from January 2000 to July 2014 was sourced through searches of the MEDLINE database via PubMed and The Cochrane Library. Articles published in English and reporting either the economic burden (cost) or the humanistic burden (HRQL/utility) of gout were identified, and key data were extracted and summarised, with key themes and data gaps identified and discussed.

RESULTS

Of the 323 studies identified, 39 met the inclusion criteria, of which 17 and 26 were relevant to the economic and humanistic burden, respectively. The economic burden of gout varied according to numerous factors, most notably serum urate acid levels and number of flares and tophi, resulting in higher healthcare resource use most often attributed to hospitalisation and inpatient stay. The incremental direct cost of gout has been suggested in the range of US$3165 to US$5515 (2004 and 2005 values, respectively) climbing to US$10,222 to US$21,467 (2008 values) per annum where patients are experiencing regular acute flares and have tophi present. The humanistic burden of gout was largely due to physical disability and pain resulting from chronic clinical manifestations. Short Form 6 dimensions (SF-6D) assessed utility weights are estimated at 0.53 for a patient with severe gout (≥3 flares/year and tophi) compared with 0.73 for an asymptomatic gout patient with serum acid levels <6 mg/dl.

CONCLUSIONS

The evidence confirms that gout has a growing overall prevalence and represents a significant burden in terms of both direct healthcare cost and HRQL outcomes. In light of this, effective urate-lowering treatments are likely to be valued if they can be clearly demonstrated to be both clinically effective and cost effective. Published data to support healthcare decision making in non-US countries with regards to treatments for gout are currently limited, which is a key limitation of the current evidence base. More research is also required to extend our understanding of the impact of gout on indirect costs, and a need also exists to develop a more comprehensive set of comparative HRQL utility assessments.

Gouty panniculitis with ulcerations in a patient with multiple organ dysfunctions

Gouty panniculitis is a rare manifestation of gout. Clinically, it is characterized by indurated subcutaneous nodules in nonjoint areas. Pathologically, typical characteristic gouty tophi can be seen in subcutaneous tissue. It is postulated that gouty panniculitis develops as a consequence of uric acid accumulation in the body and localized inflammatory changes in subcutaneous tissue. We report a case of a 46-year-old man with 20-year history of gout, who developed multiple subcutaneous nodules over the abdomen and right groin/thigh area over a 2-year period. After a recent episode of congestive heart failure and acute renal failure, the nodules increased in size and the overlying skin became erythematous and ulcerated. Pathologic examination demonstrated typical tophi in the dermis and subcutaneous tissue. A review of the literature yielded fifteen similar cases that had been previously reported. We conclude that gouty panniculitis may be a manifestation of undertreated gout and may be exacerbated by the deterioration of other systemic functions.

Gout: joints and beyond, epidemiology, clinical features, treatment and co-morbidities

Gout is a common inflammatory arthritis precipitated by an inflammatory reaction to urate crystals in the joint. Gout is increasingly being recognised as a disease primarily of urate overload with arthritis being a consequence of this pathological accumulation. It is associated with a number of important co-morbidities including chronic kidney disease, obesity, diabetes and cardiovascular disease. The prevalence of gout is increasing around the world. Significant progress has been made in determining the genetic basis for both gout and hyperuricaemia. Environmental risk factors for gout have been identified as certain foods, alcohol and several medications. There is, however, little evidence that changing these environmental risks improves gout on an individual level. Treatment of gout encompasses two strategies: firstly treatment of inflammatory arthritis with non-steroidal anti-inflammatories, corticosteroids, colchicine or interleukin-1 inhibitors. The second and most important strategy is urate lowering, to a target of 0.36 mmol/L (6 mg/dL) or potentially lower in those with tophi (collections of crystalline urate subcutaneously). Along with urate lowering, adequate and prolonged gout flare prophylaxis is required to prevent the precipitation of acute attacks. Newer urate lowering agents are in development and have the potential to significantly expand the potential treatment options. Education of patients regarding the importance of life long urate lowering therapy and prophylaxis of acute attacks is critical to treatment success as adherence with medication is low in chronic diseases in general but especially in gout.

Study on the correlation between constituents detected in serum from Rhizoma Smilacis Glabrae and the reduction of uric acid levels in hyperuricemia

ETHNOPHARMACOLOGICAL RELEVANCE

Rhizoma Smilacis Glabrae (RSG) has been used in the clinical treatment of gout and hyperuricemia in China for thousands of years. Modern pharmacological studies have shown that RSG exhibits hypouricemic effects because of its significant inhibitory effect on the activity of xanthine oxidase.

MATERIALS AND METHODS

The Rhizoma Smilacis Glabrae extract (RSGE) at 1 mL/100g oral administration was demonstrated to possess in vivo potent hypouricemic effects in hyperuricemic rats pretreated with oxonic acid potassium salt (200 mg/kg, 2 mL/kg). UPLC-MS was used to identify the constituents absorbed in the serum. In addition, a bivariate correlation analysis between the changes in the relative contents of the constituents from RSGE detected by HPLC and the serum uric acid levels in hyperuricemic rats at different points in time was used to calculate their correlation coefficients.

RESULTS

A total of 14 constituents were observed in the RSGE-treated rat serum, and 11 of these were inferred. An RSGE constituent was considered correlated with the hypouricemic effects if its correlation coefficient was above 0.5. The results suggested that only seven of the constituents absorbed in the serum of the hyperuricemic rats were correlated with hypouricemic effects, namely, palmitic acid, 3'-O-methyltaxifolin glucuronide, 3'-O-methyiastilbin glucuronide, astilbin glucuronide, 5-O-caffeoylshikimic acid glucuronide, resveratrol glucuronide, and dihydrokaempferol.

CONCLUSION

These findings provide potent evidence for the study on RSG as a pharmacodynamic material basis and for developing RSG as a safe and promising natural drug to prevent hyperuricemia and gout instead of allopurinol.

Gout: a critical analysis of scientific development

In recent years, scientific efforts on the topic "gout" have focused on pathogenetic aspects. This has opened new strategies of anti-inflammatory therapy and has improved urate-lowering therapy. So far, a scientometric analysis of the topic "gout" has not been generated despite an increased need for it in times of modified evaluation criteria for academic personnel and a subsequent tendency to co-authorship and author self-citation. The study aims to evaluate quality and quantity of scientific research dealing with the topic "gout" and to contribute to distinguish relevant research output. The current study uses scientometric methods and large-scale data analysis to evaluate quality and quantity of scientific efforts in the field of "gout." Data were gained from PubMed and ISI-Web. In the last 22 years (1990–2012), 4,424 items were published by 71 countries, of which the USA have been the most productive supplier with 32 % of all publications, followed in considerable distance by the United Kingdom, Japan, Spain and Germany, respectively. The USA have established their position as center of international cooperation. The most prolific journals in the field of gout were "Arthritis and Rheumatism," "Annals of the Rheumatic diseases" and the "Journal of Rheumatology." Our analysis specifies the most productive authors and institutions engaged with the topic, the most successful international and national cooperation and the most prolific journals and subject areas. Nevertheless, scientometric indicators, such as h-index, citation rate and impact factor, commonly used for assessment of scientific quality, should be seen critically due to distortion by bias of self-citation and co-authorship.

Rilonacept (interleukin-1 trap) for prevention of gout flares during initiation of uric acid-lowering therapy: results from a phase III randomized, double-blind, placebo-controlled, confirmatory efficacy study

OBJECTIVE

To evaluate the efficacy and safety of the interleukin-1 inhibitor rilonacept (interleukin-1 Trap) for gout flare prevention during initiation of uric acid-lowering therapy (ULT).

METHODS

In total, 241 adult patients with gout, ≥2 gout flares within the past year, and a serum urate level ≥7.5 mg/dl were initiated on allopurinol 300 mg daily and randomly allocated in a 1:1:1 ratio to receive 16 once-weekly subcutaneous injections of placebo, rilonacept 80 mg, or rilonacept 160 mg, with a double (loading) dose on day 1. Allopurinol was titrated to achieve a serum urate level of <6.0 mg/dl. The study was powered for the primary efficacy end point, the number of gout flares per patient through week 16.

RESULTS

More patients in the rilonacept groups (80.0% in the rilonacept 80 mg group, 86.4% in the rilonacept 160 mg group) completed the study than in the placebo group (72.5%; P < 0.05 for the rilonacept 160 mg group versus the placebo group). Over 16 weeks, the mean number of gout flares per patient was significantly reduced by rilonacept treatment (placebo: 1.06, rilonacept 80 mg: 0.29 [P < 0.001], rilonacept 160 mg: 0.21 [P < 0.001]). Significantly lower proportions of patients reported ≥1 gout flares with rilonacept 80 mg (18.8%) and rilonacept 160 mg (16.3%) relative to placebo (46.8%; P < 0.001 for both). Except for injection site reactions (1.3% in the placebo group versus 8.8% in the rilonacept 80 mg group [P = 0.0635, post hoc analysis] and 19.8% in the rilonacept 160 mg group [P = 0.0001, post hoc analysis]), the incidence of adverse events was generally balanced among the treatment groups.

CONCLUSION

Rilonacept markedly reduced the occurrence of gout flares associated with the initiation of ULT. The efficacy and safety profile suggests that rilonacept may have the potential to improve long-term disease control for some patients by improving adherence to ULT by reducing flares during the first months after ULT initiation.

Hypouricemic effect of the methanol extract from Prunus mume fruit in mice

CONTEXT

The fruit of the Prunus mume Sieb. et Zucc (Rosaceae) is used as a health food or medicinal material in traditional herb medicine for a long time in Eastern Asian countries.

OBJECTIVE

Our present study investigated the hypouricemic effect of the methanol extract from P. mume fruit (MPMF) in mice with potassium oxonate-induced hyperuremia.

MATERIALS AND METHODS

Effect of MPMF (35, 70 and 140 mg/kg, p.o.) administrated for 7 days on the serum, liver, urinary uric acid levels and liver xanthine oxidase (XO) activity were assessed in mice.

RESULTS

Hyperuricemic mice induced by potassium oxonate demonstrated an elevation in serum and liver uric acid levels (11.0 mg/dL and 0.52 mg/g tissue) and a reduction in urinary uric acid levels (49.9 mg/dL). Oral administration of 140 mg/kg MPMF for 7 days reversed the abnormalities in serum, liver and urinary uric acid levels (7.1 mg/dL, 0.37 mg/g tissue and 69.7 mg/dL, respectively). In addition, 70 and 140 mg/kg MPMF (3.1 and 2.9 nmol/min per mg protein) inhibited liver XO activity compared with hyperuricemic mice (3.9 nmol/min per mg protein).

DISCUSSION AND CONCLUSION

The results indicated that the beneficial hypouricaemic effect of MPMF may be mediated, at least in part, by inhibiting XO activity in the liver. Our study suggests that P. mume and its extracts may have a considerable potential for development as an anti-gout agent for clinical application.

A Hydrogel Sensing Pathological Urate Concentrations

Metabolite-responsive hydrogels that detect pathological metabolite concentrations and react by releasing a therapeutic stimulus hold high promises in treating metabolic diseases. In this study, a hydrogel is described that discriminates between physiological and pathological concentrations of urate, the causative agent of gouty arthritis. The hydrogel is synthesized by coupling a dimeric variant of the Deinococcus radiodurans-derived urate repressor HucR to linear polyacrylamide. The protein-grafted polymer is crosslinked to form a hydrogel by a multimeric hucO DNA sequence [hucO]n specifically binding HucR. At elevated urate concentrations, HucR dissociates from [hucO]n thereby weakening the hydrogel structure and resulting in its dissolution.

Efficacy and Tolerability of Celecoxib in the Treatment of Acute Gouty Arthritis: A Randomized Controlled Trial

Objective.

To evaluate the analgesic efficacy of high-dose celecoxib in the treatment of moderate to extreme pain and inflammation associated with acute gouty arthritis.

Methods.

A multinational, randomized, double-blind, double-dummy, active-controlled trial was done with patients (aged ≥ 18 years) with acute gouty monoarthritis or oligoarthritis (onset of pain ≤ 48 h before enrollment). Patients were treated for 8 days with 1 week followup and were randomized 1:1:1:1 to receive celecoxib 50 mg bid, celecoxib 400 mg (followed by 200 mg later on Day 1 and then 200 mg bid for 7 days), celecoxib 800 mg (followed by 400 mg later on Day 1 and then 400 mg bid for 7 days), or indomethacin 50 mg tid.

Results.

Of 443 patients screened, 402 were randomized and 400 received treatment. Baseline demographics were comparable among treatments. Patients receiving high-dose celecoxib (800/400 mg) experienced a significantly greater reduction in pain intensity on Day 2 compared with low-dose celecoxib 50 mg bid [least squares (LS) mean difference −0.46; p = 0.0014]. For high-dose celecoxib 800/400 mg, the change in pain scores from baseline to Day 2 was comparable with indomethacin 50 mg tid (LS mean difference 0.11; p = 0.4331). There were significant differences in adverse events when the combined celecoxib groups (29.5%) were compared with patients taking indomethacin (43.1%; p = 0.0116). There was no change in median serum creatinine levels for any treatment. There were more discontinuations due to adverse events (8.8% vs 3%; p = 0.0147) with indomethacin than with the combined celecoxib groups.

Conclusion.

High-dose celecoxib (800/400 mg) was significantly more effective than low-dose celecoxib (50 mg bid) and comparable to indomethacin in the treatment of moderate to extreme pain in patients with acute gouty arthritis. Further, celecoxib was well tolerated.

Giant gouty tophi of the hand and wrist

Gout is an inflammatory-rheumatic disease characterized by an elevated serum urate concentration and recurrent flares, including painful, hot, red, and swollen joints and surrounding tissue. Untreated gout often develops into a chronic disease with tophi and destruction of joint surfaces. Giant tophi are often resistant to medication and change in diet.This article presents a case of a 44-year-old man with giant gouty tophi at his hand and wrist. The last acute gout flare in his left wrist was approximately 3 years prior. For 2 years he had refused adequate nutrition, such as a low-purine diet, and had refused to take any preventive medication. Blood urate level was elevated to 8.7 mg/dL (normal range, 3.4-7.0 mg/dL). In time, the tophi led to a massive limitation of motion and use of especially the left wrist and thumb. Under the condition that the patient changed his diet and took the medication for his underlying disease, we surgically removed the almost skin-perforating tophi. Surgical debulking significantly improved joint function and cosmetic appearance.The best treatment for gouty tophi is prevention by ensuring adequate nutrition, treating the underlying causes, and taking effective medication. In the case of massive limitation of joint motion, skin breakdown with risk of infection, and compression of neurovascular structures, surgical debulking of the tophi should be considered.

Improved management of acute gout during hospitalization following introduction of a protocol

AIM

To determine whether implementation of a protocol to manage in-hospital acute gout has improved the care of patients by non-rheumatologists.

METHOD

Two systematic case-file reviews were performed to determine the management of acute gout in all episodes occurring in hospitalized patients before (April 2005-December 2006) and after (November 2008-September 2009) introduction of a protocol for acute gout management in a tertiary referral hospital. The protocol targeted non-rheumatologists with primary intentions to continue baseline anti-gout medications on admission, prevent inappropriate prescriptions of colchicine, non-steroidal anti-inflammatory drugs (NSAIDs) and allopurinol in the hospital, encourage invitations for assistance by rheumatology, and promote combination therapy in cases of severe gout.

RESULTS

Excluding patients under the primary care of a rheumatologist, 118 cases of acute gout occurring during hospitalization were reviewed before and 89 cases after introduction of the gout protocol. Post-protocol, there was a significant increase in continuation of baseline allopurinol (P = 0.01), significantly less inappropriate prescriptions of colchicine (P < 0.001) and allopurinol (P = 0.02), and a fall in the occurrence of overall adverse events (P = 0.01). After protocol introduction, when monotherapy was prescribed, NSAID usage declined and prednisone usage increased (P = 0.04), but there was no significant shift toward combination therapy use. Delays from symptom recognition to treatment were significantly reduced (P < 0.001), and rheumatology involvement significantly increased from 33.9% pre-protocol to 51.7% post-protocol.

CONCLUSION

Following introduction of a hospital-wide protocol for acute gout management, there have been significant improvements in the management of acute gout by non-rheumatologist clinicians.

Clinical diagnostic criteria for gout: comparison with the gold standard of synovial fluid crystal analysis

BACKGROUND

Several classification or diagnostic criteria sets for gout have been proposed but none validated.

OBJECTIVE

This small pilot study considered urate crystal identification as the gold standard for diagnosis and compared the clinical aspects of 3 proposed criteria sets with that standard.

METHODS

Eighty-two subjects who had synovial fluid analyses in a VA medical center were studied. ARA (ACR), Rome, and New York clinical criteria sets and individual criteria were recorded in the 30 patients who had urate crystals versus the remainder with no urate crystals.

RESULTS

Presence of 2 of 3 Rome clinical criteria had the highest positive predictive value at 76.9%. None of the 3 studied criteria sets were more than 70% sensitive or 88.5% specific. The clinical features of the ARA (ACR) preliminary classification criteria had 70% sensitivity and 78.8% specificity.

CONCLUSIONS

The various proposed clinical criteria can provide support for a diagnosis or exclusion of gout, but unless improved criteria can be developed crystal identification should remain the gold standard.

Febuxostat treatment for gout: what the clinician needs to know

Febuxostat is a new non-purine based inhibitor of xanthine oxidase that will be a useful addition to the drugs available to treat gout. This short review covers general principles of the management of gout and then focuses on practical aspects and use of febuxostat.