Joint and tendon subclinical involvement suggestive of gouty arthritis in asymptomatic hyperuricemia: an ultrasound controlled study

Prevalence of crystal deposits in asymptomatic hyperuricemia according to different scanning definitions: A comparative study

BACKGROUND/AIM

The appropriate sonographic protocol for assessing urate crystal deposits in asymptomatic hyperuricemia (AH) is undefined, as well as how the choice would impact on deposit rates and accompanying sonographic, clinical and laboratory features.

METHODS

Patients with AH (serum urate ≥7 mg/dL) underwent musculoskeletal ultrasound of 10 locations for OMERACT elementary gout lesions (double contour [DC] signs, tophi, aggregates). Different definitions for AH with deposits were applied, varying according to deposits (any deposits; only DC and/or tophi); gradation (any grade; only grade 2-3 deposits), location (10 locations; 4-joint scheme including knees and 1MTPs; >1 location with deposits), or pre-defined definitions (DC sign in femoral condyles/1MTP and/or tophi in 1MTP). We evaluated crystal deposits rates and compared between other sonographic features, clinical and laboratory variables.

RESULTS

Seventy-seven participants with AH showed a median 1 location (IQR 0-2) with tophi, 1 (IQR 1-2) with aggregates, and 0 locations (IQR 0-1) with DC sign. The deposition rate ranged from 23.4% (in >1 location with grade 2-3 DC or tophi) to 87.0% (in any deposit in all 10 locations). Accompanying inflammation - assessed by a positive power-Doppler (PD) signal - and erosions were found in 19.5% and 28.4% of participants, respectively. Positive PD signal was better discriminated by criteria requiring grade 2-3 or >1 location with lesions. Erosions and the different clinical and laboratory variables were similar among protocols.

CONCLUSION

Rates of sonographic deposition in AH varied dramatically among studied protocols, while some could discriminate accompanying inflammation, all highlighting the need for a validated, consensus-based definition.

Association Between Hyperuricemia and Ultrasound-Detected Hand Synovitis

OBJECTIVE

Although hand synovitis is prevalent in the older population, the etiology remains unclear. Hyperuricemia, a modifiable metabolic disorder, may serve as an underlying mechanism of hand synovitis, but little is known about their relationship. We assessed the association between hyperuricemia and hand synovitis in a large population-based sample.

METHODS

We performed a cross-sectional study in Longshan County, Hunan Province, China. Hyperuricemia was defined as a serum urate level >420 μmol/L in men and >360 μmol/L in women. Ultrasound examinations were performed on both hands of 4,080 participants, and both gray-scale synovitis and the Power Doppler signal (PDS) were assessed using semiquantitative scores (grades 0-3). We evaluated the association of hyperuricemia with hand gray-scale synovitis (grade ≥2) and PDS (grade ≥1), respectively, adjusting for age, sex, and body mass index.

RESULTS

All required assessments for analysis were available for 3,286 participants. The prevalence of hand gray-scale synovitis was higher among participants with hyperuricemia (30.0%) than those with normouricemia (23.3%), with an adjusted odds ratio (aOR) of 1.28 (95% confidence interval [CI] 1.00-1.62). Participants with hyperuricemia also had a higher prevalence of PDS (aOR 2.36; 95% CI 1.15-4.81). Furthermore, hyperuricemia positively associated, both at the hand and joint levels, with the presence of gray-scale synovitis (aOR 1.27; 95% CI 1.00-1.60 and adjusted prevalence ratio [aPR] 1.26; 95% CI 1.10-1.44, respectively) and PDS (aOR 2.35; 95% CI 1.15-4.79 and aPR 2.34; 95% CI 1.28-4.30, respectively).

CONCLUSION

This population-based study provides more evidence for a positive association between hyperuricemia and prevalent hand synovitis.

Ultrasound Features in Gout: An Overview

The accurate diagnosis of gout frequently constitutes a challenge in clinical practice, as it bears a close resemblance to other rheumatologic conditions. An undelayed diagnosis and an early therapeutic intervention using uric acid lowering therapy (ULT) is of the utmost importance for preventing bone destruction, the main point of managing gout patients. Advanced and less invasive imaging techniques are employed to diagnose the pathology and ultrasonography (US) stands out as a non-invasive, widely accessible and easily reproducible method with high patient acceptability, enabling the evaluation of the full clinical spectrum in gout. The 2023 EULAR recommendations for imaging in diagnosis and management of crystal-induced arthropathies in clinical practice state that US is a fundamental imagistic modality. The guidelines underline its effectiveness in detecting crystal deposition, particularly for identifying tophi and the double contour sign (DCS). Its utility also arises in the early stages, consequent to synovitis detection. US measures of monosodium urate (MSU) deposits are valuable indicators, sensitive to change consequent to even short-term administration of ULT treatment, and can be feasibly used both in current daily practice and clinical trials. This paper aimed to provide an overview of the main US features observed in gout patients with reference to standardized imaging guidelines, as well as the clinical applicability both for diagnosis accuracy and treatment follow-up. Our research focused on summarizing the current knowledge on the topic, highlighting key data that emphasize gout as one of the few rheumatological conditions where US is recognized as a fundamental diagnostic and monitoring tool, as reflected in the most recent classification criteria.

Gouty destruction of a patellar tendon reconstruction and novel revision reconstruction technique: A case report

BACKGROUND

Gout is a disease characterized by hyperuricemia, and resultant deposition of uric acid crystals in tissues. While typically manifested as intraarticular crystals or tophi, gout can also cause pathology at entheses. Gouty deposition within tendinous structures put them at risk for traumatic and degenerative rupture. Furthermore, allografts can also be at risk of rupture in the setting of severe gout. We present the case of a 56-year-old female with severe gouty disease who sustained a re-rupture of a patellar tendon allograft reconstruction.

CASE SUMMARY

A 56-year-old female presented to clinic after feeling her left knee pop and collapse beneath her while descending stairs. She had a history of tophaceous gout and left patellar tendon rupture with reconstruction and multiple revisions over the course of 19 years. This patient presented with pain and extensor lag. A magnetic resonance image demonstrated a ruptured patellar tendon allograft reconstruction and avulsion fracture at the tibial tubercle. The patient was treated with a novel intervention of Achilles allograft with bone block in a unique configuration with a dermal allograft incorporated into the reconstruction. She was made non-weight bearing in the operative extremity in extension for the first four weeks postoperatively and was then progressed to active flexion over the course of eight weeks. At twelve weeks, she was able to fully extend her operative knee and at five months she was resuming her normal activities and exercises.

CONCLUSION

Failed patellar tendon reconstruction due to gouty infiltration is treated with dermal allograft augmented Achilles tendon reconstruction with bone block.

Hyperuricemia May Increase Risk of Achilles Tendon Rupture: A Case Control Study

It has been demonstrated in a number of studies that high levels of uric acid can cause crystal deposition in the tendons of the lower extremities, which in turn can impair the Achilles tendon. This study aimed to interpret whether hyperuricemia is relevant with Achilles tendon rupture. Patients diagnosed with Achilles tendon rupture at the same institution between 2013 and 2022 were included in the case group. Healthy subjects who had physical examinations during the same period were included in the control group. Propensity score matching was used to match in a 1:1 ratio. Demographic and clinical characteristics of patients in both groups were compared. Five hundred and fourteen patients were included in the study (ATR=257; Control group=257). The proportion of individuals with hyperuricemia varied significantly between the 2 groups (Achilles tendon rupture group=43.6%; control group=27.6%; p<0.001). The Achilles tendon rupture and hyperuricemia were linked by conditional logistic regression (p<0.001; OR=2.036; 95CI%=1.400-2.961). Compared with healthy subjects, patients with hyperuricemia have a higher risk of Achilles tendon rupture. Further studies are required to verify the effects of hyperuricemia and monosodium urate crystals on Achilles tendon structure.

2023 EULAR recommendations on imaging in diagnosis and management of crystal-induced arthropathies in clinical practice

OBJECTIVE

To formulate evidence-based recommendations and overarching principles on the use of imaging in the clinical management of crystal-induced arthropathies (CiAs).

METHODS

An international task force of 25 rheumatologists, radiologists, methodologists, healthcare professionals and patient research partners from 11 countries was formed according to the EULAR standard operating procedures. Fourteen key questions on the role of imaging in the most common forms of CiA were generated. The CiA assessed included gout, calcium pyrophosphate deposition disease and basic calcium phosphate deposition disease. Imaging modalities included conventional radiography, ultrasound, CT and MRI. Experts applied research evidence obtained from four systematic literature reviews using MEDLINE, EMBASE and CENTRAL. Task force members provided level of agreement (LoA) anonymously by using a Numerical Rating Scale from 0 to 10.

RESULTS

Five overarching principles and 10 recommendations were developed encompassing the role of imaging in various aspects of patient management: making a diagnosis of CiA, monitoring inflammation and damage, predicting outcome, response to treatment, guided interventions and patient education. Overall, the LoA for the recommendations was high (8.46-9.92).

CONCLUSIONS

These are the first recommendations that encompass the major forms of CiA and guide the use of common imaging modalities in this disease group in clinical practice.

Associations between hyperuricemia and ultrasound-detected knee synovial abnormalities in middle-aged and older population: a cross-sectional study

OBJECTIVES

Knee synovial abnormalities, potentially treatment targets for knee pain and osteoarthritis, are common in middle-aged and older population, but its etiology remains unclear. We examined the associations between hyperuricemia and knee synovial abnormalities detected by ultrasound in a general population sample.

METHODS

Participants aged ≥ 50 years were from a community-based observational study. Hyperuricemia was defined as serum urate (SU) level > 416 µmol/L in men and > 357 µmol/L in women. Ultrasound of both knees was performed to determine the presence of synovial abnormalities, i.e., synovial hypertrophy, effusion, or Power Doppler signal (PDS). We examined the relation of hyperuricemia to prevalence of knee synovial abnormalities and its laterality, and the dose-response relationships between SU levels and the prevalence of knee synovial abnormalities.

RESULTS

In total, 3,405 participants were included in the analysis. Hyperuricemia was associated with higher prevalence of knee synovial abnormality (adjusted odds ratio [aOR] = 1.21, 95% confidence interval [CI]: 1.02 to 1.43), synovial hypertrophy (aOR = 1.33, 95% CI: 1.05 to 1.68), and effusion (aOR = 1.21, 95% CI: 1.02 to 1.44), respectively. There were dose-response relationships between SU levels and synovial abnormalities. Additionally, the hyperuricemia was more associated with prevalence of bilateral than with that of unilateral knee synovial abnormality, synovial hypertrophy, or effusion; however, no significant association was observed between hyperuricemia and PDS.

CONCLUSION

In this population-based study we found that hyperuricemia was associated with higher prevalence of knee synovial abnormality, synovial hypertrophy and effusion, suggesting that hyperuricemia may play a role in pathogenesis of knee synovial abnormalities.

Hyperuricemia as an independent risk factor for achilles tendon rupture in male: a case-control study

OBJECTIVE

To study the correlation between achilles tendon rupture (ATR) and hyperuricemia, also verify the known risk factors for ATR.

METHODS

A retrospective review of 488 subjects was performed (182 with Achilles tendon rupture, 306 controls with ankle sprains). Demographic variables and risk factors for rupture were tabulated and compared. The baseline data and related indicators were compared, and the risk factors of ATR were analyzed by constructing a binary logistic regression model.

RESULTS

Univariate logistic analysis showed that BMI, smoking, and hyperuricemia were risk factors for the development of ATR (OR = 1.65, 95%CI 1.13-2.42, P = 0.01; OR = 1.47, 95%CI 1.00-2.24, P < 0.05; OR = 2.85, 95%CI 1.84-4.42, P < 0.01). Multifactorial analysis showed that BMI ≥ 25 kg/m2, smoking, and hyperuricemia were independent risk factors for the development of ATR (OR = 1.66, 95%CI 1.11-2.49, P = 0.01; OR = 2.15, 95%CI 1.28-3.60, P < 0.01; OR = 3.06, 95%CI 1.92-4.89, P < 0.01). Among the blood biochemical indicators, total cholesterol (TC) and uric acid (UA) were independent risk factors for the occurrence of ATR (OR = 1.54, 95% CI 1.12-2.12, P = 0.01; OR = 1.01, 95% CI 1.01-1.01, P < 0.01).

CONCLUSION

Our study confirmed that, as in previous results, higher BMI, smoking, and total cholesterol are risk factors for ATR, Hyperuricemia may contribute to the development of ATR, and adjunctive tests for TC and UA in the blood biochemistry may be helpful in predicting the risk of ATR.

The Role of Ultrasound Semi-Quantitative Scoring in the Diagnosis and Assessment of Gout and Hyperuricemia

OBJECTIVES

To develop an ultrasound semi-quantitative scoring system for the diagnosis and evaluation of gout and hyperuricemia.

METHODS

This study included 348 male patients: 81 patients with asymptomatic hyperuricemia, 182 patients with gout, and 85 patients with other arthritis. Clinical data were collected, ultrasound was detected, gout activity score was calculated to assess disease activity, and statistical analysis was performed.

RESULTS

Monosodium urate crystal deposition and subclinical arthritis were detected in 17 patients with asymptomatic hyperuricemia, with lesions concentrated in the metatarsophalangeal joint, ankle and peroneus-longus and brevis at rate of 91.8%. Gout was significantly higher than non-gouty arthritis in crystal scores (sum scores of double contour, aggregates, and tophi), but not in inflammation scores (sum scores of synovial hypertrophy, power Doppler [PD] activity, and tenosynovitis) and bone erosion. The optimal cut-off score for the diagnosis of gout by the crystal score was 2. The sensitivity, specificity, and AUC were 95.4%, 97.1%, and .965, respectively. Gout flare had higher inflammation scores than intercritical gout, while bone erosion scores were lower than intercritical gout. The active gout patients had higher ultrasound scores of tophi, bone erosion, and PD activity than the remission group (P < .001). The sensitivity, specificity and area under the receiver operating characteristic curve (AUC) for the identification with high disease activity gout by ultrasound semi-quantitative composite score were 76.2%, 84.2%, and .812, respectively.

CONCLUSION

Ultrasound helps early identification of patients at risk in asymptomatic hyperuricemia. Ultrasound semi-quantitative scoring allows for more objective and accurate assessment of gout lesions, correlates with disease activity, and helps in the diagnosis and assessment of gout.

The JUMPFOOD study: additional effect of hydrolyzed collagen and vitamin C to exercise treatment for patellar tendinopathy (jumper's knee) in athletes-study protocol for a double-blind randomized controlled trial

BACKGROUND

Patellar tendinopathy (PT) is a common problem in jumping athletes. Management can be challenging and treatment outcome is not always successful. In combination with tendon loading exercises, hydrolyzed collagen/vitamin C supplementation appears to have a promising effect on the recovery of tendinopathy. The aim of this study is to evaluate whether the use of oral supplementation of hydrolyzed collagen and vitamin C in combination with progressive tendon loading exercises (PTLE) is superior to PTLE and placebo on VISA-P score (which rates pain, function, sports participation) after 24 weeks for athletes with PT.

METHODS

The JUMPFOOD study is a double-blinded, two-armed randomized controlled trial, in which the effectiveness of oral supplementation of hydrolyzed collagen/vitamin C combined with PTLE compared to PTLE with placebo on pain and recovery of function in athletes with PT will be investigated. Seventy-six athletes aged 16-40 years, with symptoms of PT for at least 12 weeks, who play sports at least once a week will be included. All participants will receive education, advice with regard to load management and a PTLE program according to the Dutch guidelines for anterior knee pain. In addition, the intervention group will receive daily 10 g hydrolyzed collagen and 40 mg vitamin C supplementation for 24 weeks whereas the control group receives 10 g maltodextrin placebo supplementation. Measurements will take place at baseline and at 12 and 24 weeks' follow-up. Primary outcome is the VISA-P score, which evaluates pain, function, and sports participation. For secondary outcome measures, data with regard to pain during functional tests, flexibility measurements, blood withdrawals, imaging characteristics of the tendon, and health questionnaires will be collected. During the follow-up period, participants will register sports participation, amount of training and tendon load, pain during sports, co-medication, and side-effects in a digital weekly diary.

DISCUSSION

The JUMPFOOD study is the first large RCT to study the effectiveness of hydrolyzed collagen/vitamin C supplementation in combination with the PTLE program in athletes with patellar tendinopathy. If supplementation of collagen/vitamin C appears to be effective, this treatment can be implemented in daily sports medicine practice to improve the treatment outcome of patients with PT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05407194. Registered on 7 June 2022.

Evaluating the effectiveness and safety of acupuncture on serum uric acid in asymptomatic hyperuricemia population: a randomized controlled clinical trial study protocol

Background

The clinical dangers of asymptomatic hyperuricemia to human health have become increasingly prominent over the past 20 years. Previous studies have shown the potential benefits of acupuncture on uric acid levels in the body. However, definitive evidence is lacking. Our objective is to evaluate the efficacy and safety of acupuncture on serum uric acid (SUA) in individuals with asymptomatic hyperuricemia.

Methods

This is a randomized, single-blind, sham-controlled trial. A total of 180 eligible patients with asymptomatic hyperuricemia will be recruited at three hospitals in China. Patients will be randomly assigned in a 1:1 ratio to receive 16 sessions of manual acupuncture or sham acupuncture for 8 weeks. Patients will be followed up for 12 weeks. The primary outcome will be the change in SUA levels at week 8 after randomization. Secondary outcomes will include dynamic changes in SUA levels, efficacy rates, proportion of gout flare, body weight, and acute medication intake. The MGH Acupuncture Sensation Scale and adverse events related to acupuncture will be measured after each treatment. A blinding assessment will be performed on patients who receive at least one session of acupuncture. Data analyses will be performed on a full analysis set and a per-protocol set.

Ethics and dissemination

Ethics approval has been obtained from the Clinical Trial Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (approval no. 2021-S135). Written informed consent will be obtained from enrolled patients. The findings will be disseminated in a peer-reviewed journal.

Clinical trial registration

ClinicalTrials.gov identifier, NCT05406830.

Time to redefine hyperuricemia? The serum uric acid cut-off level for precipitation might be lower: a pilot study

BACKGROUND

Hyperuricemia is classically defined as serum uric acid (SUA) value higher than 6.8 mg∕dL; between hyperuricemic patients, only 15-20% will develop gout. Our first goal was to find if there is a specificity of the "snowstorm" feature on ultrasound (US) for hyperuricemia. Moreover, we aimed to determine if there is a level of SUA from which the urates tend to appear in the synovial fluid, without generating a typical clinical gouty flare.

PATIENTS, MATERIALS AND METHODS

We conducted a cross-sectional, transverse study, including 108 consecutive patients that displayed a set of clinical and imaging features, such as swollen knee and US proof for knee joint effusion.

RESULTS

Performing binary logistic regression, the relation between the explanatory variable (hyperechogenic spots) and the response variable (SUA) was demonstrated to be a significant one (p=0.005). The value of 0.397 for the statistical phi coefficient suggests a medium intensity association between the diagnosis of gout or asymptomatic hyperuricemia and whether the patients have hyperechogenic spots or not. We found the cut-off value for SUA equal to 4.815 mg∕dL, regardless of gender, from which, the urate starts to precipitate. Values for men tend to be higher in comparison to the ones found for women (4.95 mg∕dL vs. 3.9 mg∕dL).

CONCLUSIONS

The "snowstorm" aspect of the fluid might be the result of an increased level of SUA and more than this, the cut-off level for SUA to precipitate might be lower than the fore used values.

Senescent CD4+CD28null cells are increased in chronic hyperuricemia, show aberrant effector phenotypes, and are reversed after allopurinol therapy: a proof-of-concept pilot study

To characterize CD4⁺CD28^null cells in chronic hyperuricemia and investigate whether allopurinol could restore CD28 expression and the balance of T helper phenotypes. Asymptomatic individuals with chronic hyperuricemia and ultrasonographic findings evocative of urate deposition in the joints. Age- and gender-matched normouricemic individuals were also studied. Oral allopurinol at 150 mg/day for 4 weeks, followed by 300 mg/day through week 12. Color-flow cytometry on peripheral blood mononuclear cells (PBMC) with antibodies against CD4, CD28, T-bet (Th1), GATA-3 (Th2), and RORγt (Th17). Six patients (five men, median age of 53 years) and seven controls were studied. At baseline, hyperuricemic patients had more CD4⁺CD28^null/CD4⁺ cells than normouricemic subjects (36.8% vs. 6.1%; p = 0.001), with a predominance of T-bet⁺ cells (98.5% vs. 6.6%; p = 0.001) and few RORγt⁺ cells (0.7% vs. 89.4%; p = 0.014). In hyperuricemic patients, the number of CD4⁺ cells/10,000 PBMC was similar before and after allopurinol (3378 vs. 3954; p = 0.843). Conversely, CD4⁺CD28^null cells decreased from 36.8% (23.0-43.7) to 15.8% (4.7-28.1; p = 0.031). CD4⁺CD28^nullT-bet⁺ cells decreased from 98.5% (95.0-99.4) to 88.3% (75.2-98.9; p = 0.062), CD4⁺CD28^nullGATA-3⁺ cells increased from 0% (0-4.0) to 2.8% (0.1-15.6; p = 0.156), and CD4⁺CD28^nullRORγt⁺ cells increased from 0.7% (0.4-7.0) to 4.5% (1.3-28.1; p = 0.031). The CD4⁺CD28^null cell subset is abnormally expanded in chronic hyperuricemia, despite the absence of overt urate-related disease. Allopurinol may partially restore CD28 expression on CD4⁺ cells while enhancing the homeostatic balance of T helper phenotypes. ClinicalTrials.gov, number NCT04012294.

In Vivo Effects of Orally Administered Different Concentrations of Silver Oxide Nanoparticles in Hyperuricemic Mice

Silver oxide nanoparticles (AgO-NPs) antioxidant, anti-cancer, anti-microbial, and tissue repair properties. Gouty arthritis is the inflammation of tissues and joints caused by the deposition of monosodium urate crystals. In this experiment, we investigated the anti-hyperuricemic effectiveness of different concentrations of AgO-NPs in mice. The present study aimed to investigate the effect of administration of AgO-NPs in monosodium urate (MSU)-induced gouty mice for the very first time. Monosodium urate (MSU) crystals were administered intraperitoneal for gout induction, followed by 5, 10, and 20 µg/mL doses of AgO-NPs for 2 weeks. The positive control was provided with the commercially available drug allopurinol to compare the effects of AgO-NPs and allopurinol. The main purpose of the study was to investigate the effectiveness of the nanoparticles in comparison with commercially available drugs. AgO-NPs have been shown to improve the condition of gouty arthritis by reducing significantly (P ˂ 0.001) increased levels of ALT, AST, and total bilirubin. The total protein estimation results showed significant improvement at concentration of 20 µg/mL of AgO-NPs. The lipid profile results showed that high concentration (20 µg/mL) of AgO-NPs decrease the lipid content significantly as compared to control. It was concluded from this study that the antioxidant, anti-inflammatory, and antilipidemic properties of AgO-NPs may improve the hyperuricemic condition in gouty arthritis mice.

A glance into the future of gout

Gout is characterized by monosodium urate (MSU) crystal deposits in and within joints. These deposits result from persistent hyperuricaemia and most typically lead to recurrent acute inflammatory episodes (gout flares). Even though some aspects of gout are well characterized, uncertainties remain; this upcoming decade should provide further insights into many of these uncertainties. Synovial fluid analysis allows for the identification of MSU crystals and unequivocal diagnosis. Non-invasive methods for diagnosis are being explored, such as Raman spectroscopy and imaging modalities. Both ultrasound and dual-energy computed tomography (DECT) allow the detection of MSU crystals; this not only provides a mean of diagnosis, but also has furthered gout knowledge defining the presence of a preclinical deposition in asymptomatic hyperuricaemia. Scientific consensus establishes the beginning of gout as the beginning of symptoms (usually the first flare), but the concept is currently under review. For effective long-term gout management, the main goal is to promote crystal dissolution treatment by reducing serum urate below 6 mg/dL (or 5 mg/dL if faster crystal dissolution is required). Current urate-lowering therapies' (ULTs) options are limited, with allopurinol and febuxostat being widely available, and probenecid, benzbromarone, and pegloticase available in some regions. New xanthine oxidase inhibitors and, especially, uricosurics inhibiting urate transporter URAT1 are under development; it is probable that the new decade will see a welcomed increase in the gout therapeutic armamentarium. Cardiovascular and renal comorbidities are common in gout patients. Studies determining whether optimal treatment of gout will positively impact these comorbidities are currently lacking, but will hopefully be forthcoming. Overall, the single change that will most impact gout management is greater uptake of international rheumatology society recommendations. Innovative strategies, such as nurse-led interventions based on these recommendations have recently demonstrated treatment success for people with gout.

Ultrasound Imaging Acquisition Procedures for Evaluating the First Metatarsophalangeal Joint: A Scoping Review

The aim of this scoping review was to investigate ultrasound imaging (USI) acquisition procedures and guidelines used to assess the first metatarsophalangeal joint (MTPJ). MEDLINE, CINAHL, AMED and SPORTDiscus were systematically searched in May 2021. Studies were included if they used grey-scale USI or power Doppler and reported a USI procedure to assess the first MTPJ. Screening and data extraction were performed by two independent assessors. The scoping review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews (PRISMA-ScR). A total of 403 citations were identified for screening, with 36 articles included in the final analysis. There was wide variation in USI acquisition procedures used to evaluate the first MTPJ. Inconsistencies in reporting may be attributable to the number of elements the USI acquisition procedure encompasses, which include the model of the USI device, the type of transducer, USI modalities and settings, patient position, transducer orientation, surfaces scanned and the scanning technique used. The review found inconsistencies against international guidelines and limited implementation of consensus-based recommendations to guide image acquisition. Current guidelines require further refinement of anatomical reference points to establish a standardised USI acquisition procedure, subsequently improving interpretability and reproducibility between USI studies that evaluate the first MTPJ.

Gouty Arthropathy: Review of Clinical Manifestations and Treatment, with Emphasis on Imaging

Gout, a crystalline arthropathy caused by the deposition of monosodium urate crystals in the articular and periarticular soft tissues, is a frequent cause of painful arthropathy. Imaging has an important role in the initial evaluation as well as the treatment and follow up of gouty arthropathy. The imaging findings of gouty arthropathy on radiography, ultrasonography, computed tomography, dual energy computed tomography, and magnetic resonance imaging are described to include findings of the early, acute and chronic phases of gout. These findings include early monosodium urate deposits, osseous erosions, and tophi, which may involve periarticular tissues, tendons, and bursae. Treatment of gout includes non-steroidal anti-inflammatories, colchicine, glucocorticoids, interleukin-1 inhibitors, xanthine oxidase inhibitors, uricosuric drugs, and recombinant uricase. Imaging is critical in monitoring response to therapy; clinical management can be modulated based on imaging findings. This review article describes the current standard of care in imaging and treatment of gouty arthropathy.

Update of the current role of ultrasound in asymptomatic hyperuricemia. A systematic literature review

Ultrasound (US) is a recognized imaging modality for the assessment of gout. Recently it is being explored for its potential role in the evaluation of subjects with asymptomatic hyperuricemia (AH). Preliminary reports demonstrated the presence of monosodium urate (MSU)-crystal deposits including aggregates, double contour sign and/or tophi in both intra-articular and periarticular tissues of AH individuals. Although these results are exciting, the value and potential application of US in AH remain to be clearly delineated. In this systematic literature review, we aim to summarise the recent publications regarding the role of US in the assessment of AH. We analyzed possible application of US in the daily clinical practice and its future clinical and research potential in the evaluation of AH individuals.

Reliability of knee joint sonography in the evaluation of gouty arthritis

Objective: To determine the reliability of knee joint sonography in the evaluation of gouty arthritis. Methodology: A search of Google Scholar, PubMed, NCBI, MEDLINE, and Medscape databases, from 1988 up to 2020. The key search terms used were knee joint; knee joint ultrasound; gout; gouty arthritis, knee joint pain; sensitivity; specificity. The reviewer independently screened the titles and abstracts of the relevant articles and full-text downloads to determine whether the inclusion or exclusion criteria were met. Results: In total, 103 articles were identified through the database search. In addition, 11 articles were identified through other sources. Then, screening was performed, and 9 articles were removed due to duplication. Further screening was done for 105 articles, and 27 articles were excluded due to insufficient information. Seventy-eight full-text articles were assessed for eligibility. A total of 13 full-text articles were excluded due to research performed on animals, as the study had been designed as a review of only human studies. Sixty-three studies were included that had a qualitative synthesis. Conclusion: The knee is a weight-bearing joint and may be affected by a myriad of different pathological conditions, therefore a proper diagnosis is of prime importance for a proper management plan. Ultrasound is a non-invasive, radiation-free, and readily available modality that has high sensitivity and specificity in the evaluation of gouty arthritis.

Entheseal involvement of the lower extremities in gout: an ultrasonographic descriptive observational study

OBJECTIVE

The aim of this study was to explore the prevalence and distribution of lower extremity entheseal abnormities by musculoskeletal ultrasound (US) in a cohort of gout patients, taking spondyloarthritis (SpA) patients and asymptomatic hyperuricemia (HUA) patients as controls.

METHOD

One hundred participants with gout, fifty patients with SpA, and twenty-nine patients with asymptomatic HUA were recruited. US was used to assess the bilateral quadriceps, patellar and Achilles tendons, and plantar fascia entheses according to the Outcome Measures in Rheumatology (OMERACT) definitions.

RESULTS

The US examination revealed the presence of one or more abnormalities in at least one enthesis in 45 out of 100 subjects (45.0%) and 152 out of 1000 entheses (15.2%) in the gout patients. Among the affected entheses, the patellar insertion of the quadriceps tendon was the most commonly involved area (38.0% in the gout patients versus 48.0% in the SpA patients with at least one pathological US finding, p = 0.241). There were no significant group differences in entheseal power Doppler (PD) signals, bone erosion, or enthesophytes. The patients with lower limb entheseal involvement in the gout group had an older age, longer disease duration, higher percentage of chronic tophaceous gout, and higher levels of inflammatory biomarkers of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Multivariate logistic regression analysis revealed that age (OR = 1.052, p = 0.001) and the ESR (OR = 1.023, p = 0.028) were correlated with lower limb enthesopathy in gout patients. In the subgroup analysis of gout patients without active inflammation, age (OR = 1.119, p = 0.001) and serum uric acid (UA, OR = 1.012, p = 0.002) were correlated with lower limb enthesopathy in gout.

CONCLUSION

Lower extremity entheseal involvement might be neglected but should be considered as an important element in the evaluation of gout patients. Enthesopathy most frequently involves in the patellar insertion of the quadriceps tendon and is characterized by entheseal hypoechogenicity and/or thickening. Key Points • Lower extremity enthesopathy might be neglected as an important element in gout. • Enthesopathy is most frequently involved in the patellar insertion of the quadriceps tendon in gout. • Age and ESR are correlated with lower limb enthesopathy in gout patients.

Musculoskeletal ultrasound features-based scoring system can evaluate the severity of gout and asymptomatic hyperuricaemia

Objectives:

To develop a tool which can evaluate the severity of the joint injury in individuals with gout and asymptomatic hyperuricaemia.

Methods:

This retrospective study included 616 male patients: 245 with asymptomatic hyperuricaemia and 371 with intercritical gout. All patients underwent ultrasonography of the knee, ankle and first metatarsophalangeal (MTP) joints. Ultrasound features that were significantly different between groups were entered into a binary logistic regression analysis to identify discriminative factors. The ultrasound signs were scored based on their odds ratios, which were then used to evaluate the severity of gout and asymptomatic hyperuricaemia. The performance of the ultrasound score was validated in an additional population including 163 patients with asymptomatic hyperuricaemia and 196 patients with gout.

Results:

Ultrasound signs were scored as follows: knee joint: synovial effusion, 2 points, tophus, 5 points; ankle joint: synovial effusion, 2 points, synovial hypertrophy, 5 points, tophus, 3 points, bone erosion, 7 points; and first MTP joint: double contour sign, 2 points, synovial hypertrophy, 3 points, tophus, 9 points, bone erosion, 4 points. The maximum possible total score was 42. The optimal cut-off score for gout was 6.5. The sensitivity, specificity and area under the receiver operating characteristic curve (AUC) were 86.9%, 75.2% and 0.878, respectively. The patients were stratified according to their ultrasound score (range 0–42). The prevalence of intercritical gout, tophi, and bone erosion increased with the increase of the score. In the validation population, 83.20% of 193 patients with gout had ultrasound scores above 6.5; 76.10% of 163 patients with asymptomatic hyperuricaemia had ultrasound scores under 6.5.

Conclusion:

The scoring system based on the differential ultrasound signs can effectively evaluate the severity of joint injury in individuals with gout and asymptomatic hyperuricaemia.

Serum urate is related to subclinical inflammation in asymptomatic hyperuricaemia

OBJECTIVE

Asymptomatic hyperuricaemia (AHU) is associated with inflammatory disorders, including cardiovascular disease. Uric acid (UA) lowering therapies may reduce the risk of appearance or the progression of these comorbidities. In this work, we investigated the relationship between serum UA levels and inflammation in subjects with AHU.

METHODS

Serum levels of high-sensitivity CRP (hsCRP), TNF-α and IL-6, and mRNA expression of TNFa and IL6 in peripheral blood mononuclear cells were measured in individuals with AHU and without comorbid conditions and in a control group with similar characteristics and normal serum UA levels. Additionally, we determined the variations in the inflammatory profile in a subgroup of subjects after 6 months of treatment with allopurinol.

RESULTS

Subjects at higher tertiles of serum UA presented higher levels of hsCRP and increased serum and mRNA expression levels of both cytokines (P < 0.001). UA levels constituted an independent predictor of increased levels of inflammatory parameters in multiple regression models (P < 0.001) and a risk factor for the presence of a subclinical inflammation in multivariate logistic regression (P < 0.001). Allopurinol reduced UA and serum and mRNA expression of inflammatory cytokines (P < 0.001). There was a significant correlation between the variations in serum UA and the variations in serum TNF-α (P < 0.01) and IL-6 (P < 0.05), and mRNA expression of these cytokines (P < 0.05). This association remained significant and independent (P < 0.01).

CONCLUSION

In subjects with AHU, serum UA may be an inductor of subclinical inflammation. Therapeutic reduction of serum UA was associated with a modulation of the inflammatory profile.

The Urrah study

Uric acid has long been considered responsible for a single specific disease, namely gout. In recent years, novel knowledge has emerged linking serum uric acid with a variety of conditions and related risk factors, from hypertension, metabolic syndrome, and type 2 diabetes, to fatal/nonfatal cardiovascular diseases and all-cause death, with the underlying mechanisms involving disrupted neurohormonal and metabolic signaling as well as oxidative stress and inflammation. Importantly, the cut-off value of serum uric acid predicting the risk of incident events is within the range of normality and below the threshold for increased risk of gout. A large contribution to the advancement in knowledge in the cardiovascular implications of uric acid derives from the Italian study URic acid Right for heArt Health (URRAH). This review summarizes the mechanisms linking uric acid with cardiovascular risk and the major findings of the URRAH study. The need for a reappraisal of the definition of range of normality for uric acid is discussed.

The Management of Gout in Renal Disease

Gout, a debilitating inflammatory arthritis, currently affects more than 9 million Americans. Hyperuricemia, the laboratory abnormality associated with the development of gout, also occurs in a significant number of patients with chronic kidney disease (CKD), a condition that affects approximately 14% of the US population. Several recent studies have attempted to provide a definitive link between the presence of hyperuricemia and progression of CKD; however, the treatment of asymptomatic hyperuricemia in CKD is not supported by recent randomized controlled trials. The pharmacology of acute gout flares and urate lowering is complicated in patients who also have evidence of CKD, primarily because of an increased risk of medication toxicity. Recipients of kidney transplants are particularly at risk of debilitating gout and medication toxicity. We review the available data linking CKD, gout, and hyperuricemia, providing practice guidelines on managing gout in CKD patients and kidney transplant recipients. We advocate for much greater involvement of nephrologists in the management of gout in renal patients.

Gouty Involvement of Foot and Ankle: Beyond Flares

The foot and ankle are common locations of deposition of monosodium urate (MSU) crystals, as indicated by the clinical manifestations presented by patients with gout, which are not limited to the acute inflammation of the big toe. We present a narrative literature review aimed to update the gout involvement of foot and ankle and how it affects the quality of life. Cumulative reports indicate that gout, even at the non-tophaceous stage, could cause pain, gait impairment and limit the mobility at lower limbs. These patients may present difficulties in some activities of daily living such as choosing footwear, thus leading to an impaired quality of life. Gout is a curable disease by dissolving MSU crystals but remains unclear how this could modify some of these foot and ankle manifestations, especially when structural damage has already occurred. Furthermore, a collaboration between rheumatologists and podiatrists seems helpful to understand, relieve these symptoms and improve the quality of life in gouty patients.

Asymptomatic hyperuricemia: is it really asymptomatic?

PURPOSE OF REVIEW

Hyperuricemia is highly prevalent, affecting approximately 38 million individuals in the United States. However, the significance of asymptomatic hyperuricemia - hyperuricemia in the absence of gout - continues to be debated.

RECENT FINDINGS

Asymptomatic hyperuricemia results in monosodium urate crystal deposition in tissues, which may promote chronic inflammation. Intracellularly, hyperuricemia inhibits the master regulator adenosine monophosphate (AMP)-associated protein kinase and may condition innate immune responses through durable epigenetic modifications. At the population level, asymptomatic hyperuricemia is associated with multiple comorbidities, including hypertension, chronic kidney disease, coronary artery disease, and diabetes; limitations of these studies include that most are retrospective and some do not rigorously distinguish between asymptomatic hyperuricemia and gout. Treatment studies suggest that urate lowering may reduce the risk of incidence or progression of some of these comorbidities; unfortunately, many of these treatment studies are small or flawed, and not all study results are consistent.

SUMMARY

Accumulating evidence suggests that asymptomatic hyperuricemia contributes to the comorbidities with which it associates and that proper asymptomatic hyperuricemia treatment may reduce future risk. Additional prospective trials are needed to definitely establish causality and support decision-making as to whether, and which patients with asymptomatic hyperuricemia would warrant urate-lowering treatment.

Pilot study: asymptomatic hyperuricemia patients with obesity and nonalcoholic fatty liver disease have increased risk of double contour sign

BACKGROUND/AIMS

Double contour sign (DCS) is a representative ultrasonographic finding in gout. DCS is evidence of monosodium urate deposit in gouty arthritis and has been identified in some patients with asymptomatic hyperuricemia. However, the specific characteristics of asymptomatic hyperuricemia in patients with DCS have not yet been revealed.

METHODS

We enrolled patients with incidentally found hyperuricemia. Baseline characteristics were compared between asymptomatic hyperuricemia patients with and without DCS. Logistic regression analysis was performed to determine associated factors for DCS in patients with asymptomatic hyperuricemia.

RESULTS

A total of 62 patients with asymptomatic hyperuricemia were enrolled, and 22 of the patients showed DCS. The metatarsophalangeal were the most commonly affected joints, and differences between asymptomatic hyperuricemia patients with and without DCS were seen in aspects of class II obesity and nonalcoholic fatty liver disease (NAFLD). Multivariate logistic regression analysis demonstrated that class II obesity and NAFLD significantly increased the risk of DCS in asymptomatic hyperuricemia patients (odds ratio [OR], 6.58, p = 0.022; OR, 5.21, p = 0.020, respectively).

CONCLUSION

Asymptomatic hyperuricemia patients with class II obesity and NAFLD had increased risk of DCS. Determining the presence of crystal deposition, such as DCS, among patients with asymptomatic hyperuricemia might help determine whether early pharmacologic intervention is needed, especially with severe obesity or NAFLD.

Cyr61 Promotes Inflammation of a Gouty Arthritis Model in Rats

Background

Cyr61 is considered a novel proinflammatory factor. Gouty arthritis (GA) is a self-limited inflammatory reaction caused by monosodium urate (MSU) crystals. In this study, we assessed the role of Cyr61 in the inflammatory process of GA.

Methods

We investigated the expression of Cyr61 in MSU-induced rat gout models and MSU-stimulated rat fibroblast-like synovial (FLS) cells. After inhibiting the expression of Cyr61, levels of IL-1β, TNF-α, and IL-6 were detected by ELISA, qPCR, western blot, and immunohistochemical methods. We probed the downstream NF-κB signaling pathway using the NF-κB inhibitor PDTC, and levels of NF-κB and p-NF-κB were detected by western blot and qPCR.

Results

Our results demonstrate that Cyr61 plays a potent role in the formation of local inflammation in vitro and in vivo. Cyr61 was highly expressed in synovial tissues of gout models, and the expression of Cyr61 protein was also significantly increased in MSU-stimulated FLS cells. Cyr61 promoted MSU-induced acute inflammation via the NF-κB signaling pathway.

Conclusions

Our study has revealed that Cyr61 is an important regulatory factor for the initiation of inflammation in GA. The high expression of Cyr61 protein can induce synovial cells to produce many inflammatory cytokines, such as IL-1β, TNF-α, and IL-6, partly in an NF-κB-dependent manner. Thus, inhibition of Cyr61 could be a new target and strategy for the prevention and treatment of GA.

Ultrasound shows rapid reduction of crystal depositions during a treat-to-target approach in gout patients: 12-month results from the NOR-Gout study

OBJECTIVES

As ultrasound is sensitive for detecting crystal depositions in patients with gout, our objectives were to explore the main locations for depositions and the extent of dissolution of depositions during a treat-to-target approach with urate lowering treatment (ULT) in patients with gout.

METHODS

Patients with a recent flare of gout were consecutively included in this single-centre study and managed by a treat-to-target approach with ULT. All patients were assessed at baseline, 3, 6 and 12 months including bilateral ultrasound examinations of joints/tendons/entheses of hands, elbows, knees, ankles and feet. A new semiquantitative scoring system of 0-3 of elementary lesions (double contour (DC), tophi and aggregates) was applied to quantify the amount of depositions during the follow-up.

RESULTS

209 of the patients were evaluated with ultrasound at baseline (mean (SD) age 56.4 (13.8) years and disease duration 7.9 (7.7) years, 95.2% men). The serum urate levels decreased from baseline to 12 months (mean (SD) 500 (77) to 312 (49) µmol/L) (p<0.001)). The first metatarsophalangeal joint was the most frequent location for all the elementary lesions and erosions were associated with higher levels of crystal depositions. From baseline to 12 months, mean sum scores decreased for DC (4.3 to 1.3), tophi (6.5 to 3.8) and aggregates (9.3 to 6.7) (p<0.001 for all), with DC being most sensitive to change.

CONCLUSIONS

The ultrasound scoring system for crystal depositions was sensitive to change and showed that a treat-to-target approach with ULT resulted in significant reductions of all the depositions, most extensively for DC.

Ultrasound evaluation in follow-up of urate-lowering therapy in gout: the USEFUL study

OBJECTIVES

We aimed to determine the ability of ultrasonography (US) to show disappearance of urate deposits in gouty patients requiring urate-lowering therapy (ULT).

METHODS

We performed a 6-month multicentre prospective study including patients with: proven gout; presence of US features of gout (tophus and/or double contour sign) at the knee and/or first metatarsophalangeal joints; and no current ULT. US evaluations were performed at baseline and at months 3 and 6 (M3, M6) after starting ULT. Outcomes were: the change in US features of gout at M6 according to final (M6) serum urate (SU) level (high, > 360 μmol/l, i.e. > 6 mg/dl; low, 300-360 μmol/l, i.e. 5-6 mg/dl; very low, < 300 μmol/l, i.e. < 5 mg/dl); and correlation between changed US features and final SU level.

RESULTS

We included 79 gouty patients (mean ± s.d., age 61.8 (14) years, 91% males, disease duration 6.3 (6.1) years). Baseline SU level was 530 ± 97 µmol/l (i.e. 8.9 mg/dl ± 1.6mg/dl). At least one US tophus and double contour sign was observed in 74 (94%) and 68 (86%) patients, respectively. Among the 67 completers at M6, 18 and 39 achieved a very low and low SU level, respectively. We found a significant decrease in US features of gout among patients with the lowest SU level (P < 0.001). Final M6 SU level was positively correlated with decreased size of tophus (r = 0.54 [95% CI: 0.34, 0.70], P < 0.0001), and inversely correlated with proportion of double contour sign disappearance (r=-0.59 [-0.74, -0.40]).

CONCLUSION

US can show decreased urate deposition after ULT, which is correlated with decreased SU level. The responsiveness of US in gout is demonstrated and can be useful for gout follow-up and adherence to ULT.

Ultrasonographic Features of Trigger Finger in Patients With Hyperuricemia

PURPOSE

The purpose of the current study was to compare demographic differences and ultrasonographic features in primary trigger finger and trigger finger in association with hyperuricemia.

METHODS

Between October 2008 and February 2010, a prospective review of consecutive cases of 54 patients with trigger finger and hyperuricemia, 76 patients with a trigger finger without hyperuricemia, and 80 control cases were enrolled. The clinical results were analyzed by descriptive epidemiology, an ultrasonographic measurement of the thickness of A1 pulley, cross-sectional area of the flexor tendon and synovium.

RESULTS

The middle finger was primarily affected, followed by the index and ring fingers in both trigger finger groups. The thickness of A1 pulley, cross-sectional area of the flexor tendon, and flexor tendon with synovium in trigger finger without hyperuricemia group were significantly larger than that in trigger finger with hyperuricemia and control groups. There was no significant difference between trigger finger with hyperuricemia and control groups. Double-contour sign and tophus were only observed in trigger finger with hyperuricemia group.

CONCLUSIONS

Thickness of A1 pulley, cross-sectional area of the flexor tendon, and flexor tendon with synovium were significantly larger in trigger finger without hyperuricemia group. These findings were not evident in trigger finger with hyperuricemia group.

Gout

Gout is a chronic disease caused by monosodium urate (MSU) crystal deposition. Gout typically presents as an acute, self-limiting inflammatory monoarthritis that affects the joints of the lower limb. Elevated serum urate level (hyperuricaemia) is the major risk factor for MSU crystal deposition and development of gout. Although traditionally considered a disorder of purine metabolism, altered urate transport, both in the gut and the kidneys, has a key role in the pathogenesis of hyperuricaemia. Anti-inflammatory agents, such corticosteroids, NSAIDs and colchicine, are widely used for the treatment of gout flare; recognition of the importance of NLRP3 inflammasome activation and bioactive IL-1β release in initiation of the gout flare has led to the development of anti-IL-1β biological therapy for gout flares. Sustained reduction in serum urate levels using urate-lowering therapy is vital in the long-term management of gout, which aims to dissolve MSU crystals, suppress gout flares and resolve tophi. Allopurinol is the first-line urate-lowering therapy and should be started at a low dose, with gradual dose escalation. Low-dose anti-inflammatory therapies can reduce gout flares during initiation of urate-lowering therapy. Models of care, such as nurse-led strategies that focus on patient engagement and education, substantially improve clinical outcomes and now represent best practice for gout management.

Size matters: observations regarding the sonographic double contour sign in different joint sizes in acute gouty arthritis

OBJECTIVE

In distinguishing urate arthritis (UA) from non-crystal-related arthritides, joint sonography including the detection of the double contour sign (DCS) and hypervascularization using power Doppler ultrasound (PDUS) is an important step in the diagnostic process. But are these sonographic features equally reliable in every accessible joint under real-life conditions?

METHODS

We retrospectively analyzed 362 patients with acute arthritis and evaluated the DCS and the degree of PDUS hypervascularization in patients with gout and in those with arthritis other than urate arthritis (non-UA). We classified all joints into the groups small, medium, and large. Sensitivities, specificities, positive and negative predictive values (PPV/NPV), and a binary regression model were calculated. We also evaluated the influence of serum uric acid levels (SUA) on the presence of a DCS in each joint category.

RESULTS

Sensitivity of the DCS in gout was 72.5% in the entire cohort, 66.0% in large, 78.8% in medium, and 72.3% in small joints. In wrist joints the DCS sensitivity maxed at 83.3%, with a specificity of 81.8%. The lowest rates of DCS sensitivity were found in gout patients with elbow joint involvement (42.9%). In all joints except metatarsophalangeal joint 1 (MTP-1), the incidence of a DCS increased by the increment of SUA levels above 7.5 mg/dl (p < 0.001). PDUS signals were most commonly found in medium and small joints and were only scarce in large joints, independent of the underlying diagnosis.

CONCLUSIONS

In our study we detected different rates of accuracy regarding DCS and PDUS in patients with acute arthritis. The best results were seen in medium-size joints, especially wrists.

Urate-lowering treatment and risk of total joint replacement in patients with gout

Objectives

To examine whether gout is an independent risk factor for total joint replacement (TJR) and whether urate-lowering treatment (ULT) reduces this risk.

Methods

Using the Taiwan National Health Insurance database and the UK Clinical Practice Research Datalink, 74 560 Taiwan patients and 34 505 UK patients with incident gout were identified and age and sex matched to people without gout. Cox proportional hazards models and condition logistic regression were used to examine the risk of TJR in gout patients and the association between cumulative defined daily dose (cDDD) of ULT and TJR.

Results

The prevalence rates of TJR in the patients at the time of diagnosis of gout and in people without gout were 1.16% vs 0.82% in Taiwan and 2.61% vs 1.76% in the UK. After a gout diagnosis, the incidence of TJR was higher in the patients with gout compared with those without (3.23 vs 1.91 cases/1000 person-years in Taiwan and 6.87 vs 4.61 cases/1000 person-years in the UK), with adjusted HRs of 1.56 (95% CI 1.45, 1.68) in Taiwan and 1.14 (1.05, 1.22) in the UK. Compared with patients with gout with <28 cDDD ULT, the adjusted ORs for TJR were 0.89 (95% CI 0.77, 1.03) for 28-90 cDDD, 1.03 (0.85, 1.24) for 90-180 cDDD and 1.12 (0.94, 1.34) for >180 cDDD ULT in Taiwan. In the UK, the respective ORs were 1.09 (0.83, 1.42), 0.93 (0.68, 1.27) and 1.08 (0.94, 1.24).

Conclusion

This population-based study provides evidence from two nation populations that gout confers significant TJR risk, which was not reduced by current ULT.

Risk factors for the formation of double-contour sign and tophi in gout

BACKGROUND

This study aimed to confirm the diagnostic accuracy of ultrasound (US) on gout and explore the potential risk factors for double-contour sign and tophi formation in gout patients.

METHODS

The US analyses were performed on all knee, ankle, and first metatarsophalangeal (MTP 1) joints to reveal the type and location of lesions. While a questionnaire and blood biochemical index were used to explore the potential risk factors for double-contour sign and tophi in gout, the SPSS17.0 software was used for statistical analysis in the present study.

RESULTS

Totally, 117 gout patients with 702 joints (38 lesions in knee joint, 93 lesions in ankle joint, and 112 lesions in MTP 1 joint) were enrolled in current analyses. Double-contour sign and joint effusion were the two most outstanding lesion manifestations in knee joints and ankle joints. Tophi and double-contour sign were the two most outstanding lesion manifestations in TMP 1 joints. Moreover, factors including uric acid (UA) level and the highest blood UA were potential risk factors of the double-contour sign, while age and history of US were potential risk factors for tophi.

CONCLUSION

US was effective on the joints of gout patients. There was US sensitivity for tophi and double-contour sign in MTP 1 joints. The double-contour sign was a potential specific manifestation in knee joints and ankle joints. Furthermore, UA and highest blood UA level were potential risk factors for double-contour sign, while age and US history were potential risk factors for tophi.

Gouty Achilles Tendinopathy: A Case Report

Tendinopathy in the presence of gouty arthropathy is relatively common, yet the clinical suspicion for gout involvement in acute tendon pain remains low. A 49-year-old man presented with an acute, tender, erythematous mass to the right posterior heel. A computed tomographic scan was obtained, which revealed a septated fluid collection superficial to the Achilles tendon. The patient was taken to the operating room for an incision and drainage with debridement, and the abscess was found to be filled with caseous material. The diagnosis of gout was confirmed with pathology. The calcaneus was submitted to biopsy, and the results were negative for osteomyelitis. The patient was returned to the operating room for repair of the Achilles tendon with flexor hallucis longus tendon transfer. Postoperatively, the patient was nonweightbearing for 6 weeks. Oral colchicine was used perioperatively, and a steroid taper was administered. The patient was started on allopurinol and colchicine for chronic treatment. At 14 months, the patient was walking without pain or recurrence of the mass. Although the relationship between hyperuricemia and tendinopathy is not completely understood, it is apparent that tendon involvement may be a sequela in patients with gout. When a patient presents with acute tendon pain, gout should be considered in the differential diagnosis.

2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of gout

Although gout is the most common inflammatory arthritis, it is still frequently misdiagnosed. New data on imaging and clinical diagnosis have become available since the first EULAR recommendations for the diagnosis of gout in 2006. This prompted a systematic review and update of the 2006 recommendations. A systematic review of the literature concerning all aspects of gout diagnosis was performed. Recommendations were formulated using a Delphi consensus approach. Eight key recommendations were generated. A search for crystals in synovial fluid or tophus aspirates is recommended in every person with suspected gout, because demonstration of monosodium urate (MSU) crystals allows a definite diagnosis of gout. There was consensus that a number of suggestive clinical features support a clinical diagnosis of gout. These are monoarticular involvement of a foot or ankle joint (especially the first metatarsophalangeal joint); previous episodes of similar acute arthritis; rapid onset of severe pain and swelling; erythema; male gender and associated cardiovascular diseases and hyperuricaemia. When crystal identification is not possible, it is recommended that any atypical presentation should be investigated by imaging, in particular with ultrasound to seek features suggestive of MSU crystal deposition (double contour sign and tophi). There was consensus that a diagnosis of gout should not be based on the presence of hyperuricaemia alone. There was also a strong recommendation that all people with gout should be systematically assessed for presence of associated comorbidities and risk factors for cardiovascular disease, as well as for risk factors for chronic hyperuricaemia. Eight updated, evidence-based, expert consensus recommendations for the diagnosis of gout are proposed.

Knowledge and practice in the management of asymptomatic hyperuricemia among primary health care physicians in Jeddah, Western Region of Saudi Arabia

Objectives:

To assess knowledge and practice levels in asymptomatic hyperuricemia (AH) and investigate predictors of urate-lowering therapy (ULT) misprescribing among primary health care (PHC) physicians.

Methods:

A cross-sectional study was conducted among 201 PHC physicians from December 2017 to May 2018. A based clinical guidelines for hyperuricemia management from American Professional Organizations, a semi-structured questionnaire was administered to collect demographic and professional data; knowledge and practice levels in management of AH; and barriers to the management of hyperuricemia and gout, with focus of the misprescribing of ULT in AH. A 2-stage stratified sampling technique was used to select 4 PHC centers were from each of the 5 advisory sectors in Jeddah, Kingdom of Saudi Arabia; and to recruit a minimum of 10 eligible participants per primary health care center (PHCC). Binary logistic regression was used to analyze predictors of ULT misuse in AH.

Results:

Only 32.8% participating physicians had adequate knowledge about AH. Regarding practice, while majority (88.1%) correctly recommended a low-purine diet and lifestyle changes to patients, almost half misprescribed ULT and 10.9% misprescribed non-steroid anti-inflammatory drugs. Lack of knowledge and awareness about guidelines were the most frequently self-reported barriers to adequate practice. Predictors of ULT misuse included the percentage of patients having gout (1-10%: OR=5.40, p=0.047) or receiving ULT (>10-20%: OR=20.02, p=0.001)among patients seen in clinic, attendance of rheumatology conferences (OR=2.55, p=0.017), and having a close relative with hyperuricemia or gout (OR=2.45, p=0.026).

Conclusion:

There are inadequate levels of knowledge regarding AH among Saudi PHC physicians increasing risk of malpractice including misprescription of ULT and anti-inflammatory medications.

Precipitation of Soluble Uric Acid Is Necessary for In Vitro Activation of the NLRP3 Inflammasome in Primary Human Monocytes

OBJECTIVE

To investigate the effects of soluble uric acid (UA) on expression and activation of the NOD-like receptor (NLR) pyrin domain containing protein 3 (NLRP3) inflammasome in human monocytes to elucidate the role of hyperuricemia in the pathogenesis of gout.

METHODS

Primary human monocytes and the THP-1 human monocyte cell line were used to determine the effects of short- and longterm exposure to UA on activation of the NLRP3 inflammasome and subsequent interleukin 1β (IL-1β) secretion by ELISA and cell-based assays. Expression of key NLRP3 components in monocytes from patients with a history of gout were analyzed by quantitative PCR.

RESULTS

Precipitation of UA was required for activation of the NLRP3 inflammasome and subsequent release of IL-1β in human monocytes. Neither monosodium urate (MSU) crystals nor soluble UA had any effect on activation of the transcription factor, nuclear factor-κB. Prolonged exposure of monocytes to soluble UA did not alter these responses. However, both MSU crystals and soluble UA did result in a 2-fold increase in reactive oxygen species. Patients with gout (n = 15) had significantly elevated serum UA concentrations compared to healthy individuals (n = 16), yet secretion of IL-1β and expression of NLRP3 inflammasome components in monocytes isolated from these patients were not different from those of healthy controls.

CONCLUSION

Despite reports indicating that soluble UA can prime and activate the NLRP3 inflammasome in human peripheral blood mononuclear cells, precipitation of soluble UA into MSU crystals is essential for in vitro NLRP3 signaling in primary human monocytes.

Atypical musculoskeletal manifestations of gout in hyperuricemia patients

Deposition of tophus is a common feature in chronic gout; however, signs and symptoms are not always well-pronounced in cases of uncommon sites. We report a case series of three patients, one with an acute locked knee suspected to be meniscus tear or intra-articular loose body, a second case with a lump on the dorsal hand suspected to be a benign lesion, and a third case with a finger flexion deformity with carpal tunnel syndrome; all three cases were later on found out to be tophaceous gout. White chalky monosodium urate crystal deposition was found to be the culprit of the symptoms of the patients.

Secretion of IL-1β From Monocytes in Gout Is Redox Independent

The pro-inflammatory cytokine interleukin-1β (IL-1β) plays important roles in immunity but is also implicated in autoimmune disease. The most well-established mechanism of IL-1β secretion is via activation of the NOD-like receptor family pyrin domain containing-3 (NLRP3) inflammasome which requires an initial priming signal followed by an activating signal. However, the precise mechanism by which the inflammasome is activated remains unclear. The role of reactive oxygen species (ROS) in this process is contradictory, with some studies suggesting that ROS are crucial while others describe opposite effects. In this study, we evaluated the effects of oxidative stress on IL-1β secretion. Gout is a disease driven solely by IL-1β secretion in response to monosodium urate (MSU) crystals which form during periods of hyperuricemia and thus presents an opportunity to study factors contributing to IL-1β secretion. Sera and monocytes were isolated from patients with gout to determine whether differences in antioxidant status could explain the susceptibility of these individuals to gout attacks. In addition, sera and monocytes were collected from patients with chronic kidney disease (CKD) for comparison as this condition is associated with high levels of oxidative stress and disturbances in serum uric acid levels. There were differences in some aspects of antioxidant defenses in gout patients and these were mainly due to higher serum uric acid. Monocytes from gout patients were more responsive to priming, but not activation, of the NLRP3 inflammasome. However, expression of the components of the NLRP3 inflammasome were unaffected by priming or activation of the inflammasome, nor were these expression levels differentially regulated in gout patients. Inhibition of ROS by N-Acetyl Cysteine inhibited TLR2-induced priming of the NLRP3 inflammasome, but had no effect on MSU-induced activation. Together these findings demonstrate that oxidative stress only affects priming of the NLRP3 inflammasome but does not influence activation.

Prevalence and discrimination of OMERACT-defined elementary ultrasound lesions of gout in people with asymptomatic hyperuricaemia: A systematic review and meta-analysis

OBJECTIVES

Ultrasound lesions of gout have been described in people with asymptomatic hyperuricemia. However, the anatomical sites and ultrasound lesions most frequently involved in asymptomatic hyperuricemia have not yet been established. This systematic review and meta-analysis aimed to determine the prevalence of the Outcome Measures in Rheumatology (OMERACT) elementary ultrasound lesions of gout (double contour, aggregates, tophus, erosion) at various sites in people with asymptomatic hyperuricemia and to determine which sites and lesions discriminate from people with normouricemia.

METHODS

A systematic search of electronic databases, conference abstracts and reference lists was undertaken. Studies were included if they used ultrasound to image people with asymptomatic hyperuricemia and reported ≥1 OMERACT-defined lesion of gout. Meta-analyses were undertaken for the pooled prevalence of site-specific lesions in people with asymptomatic hyperuricemia, and the pooled odds ratios of these lesions compared to people with normouricemia.

RESULTS

Twenty studies were included. The most common site scanned was the first metatarsophalangeal joint (1MTP) (n = 17 studies) and the most common lesion reported, the double contour (n = 18). Meta-analyses of pooled prevalence showed 1MTP double contour was the most frequent finding in people with asymptomatic hyperuricemia (0.31, 95% confidence interval (CI) 0.20-0.42), followed by femoral condyle double contour (0.16, 95%CI 0.08-0.24) and 1MTP tophus (0.16, 95%CI 0.03-0.29). The highest pooled odds ratios for asymptomatic hyperuricemia vs. normouricemia were 6.98 (95%CI 3.14-15.57) for 1MTP double contour, 13.67 (95%CI 5.42-34.49) for femoral condyle double contour and 6.10 (95%CI 1.55-24.04) for 1MTP tophus.

CONCLUSION

In people with asymptomatic hyperuricemia, scanning of the 1MTP and femoral condyle for double contour, plus the 1MTP for tophus, has the highest prevalence and discrimination compared to those with normouricemia.

How should we manage asymptomatic hyperuricemia?

The definition of asymptomatic hyperuricemia remains unclear, as no consensus exists about the serum urate cutoff or the relevance of ultrasound findings. Comorbidities associated with hyperuricemia have increased in frequency over the past two decades. Hyperuricemia (and/or gout) may be a cause or a consequence of a comorbidity. Whereas epidemiological studies suggest that hyperuricemia may be linked to cardiovascular, metabolic, and renal comorbidities, Mendelian randomization studies have not provided proof that these links are causal. Discrepancies between findings from observational studies and clinical trials preclude the development of recommendations about the potential benefits of urate-lowering therapy (ULT) in individual patients with asymptomatic hyperuricemia. The risk/benefit ratio of ULT is unclear. The risk of developing gout, estimated at 50%, must be weighed against the risk of cutaneous and cardiovascular side effects of xanthine oxidase inhibitors. The need for optimal comorbidity management, in contrast, is universally accepted. Medications for comorbidities that elevate urate levels should be discontinued and replaced with medications that have the opposite effect. Therapeutic lifestyle changes, weight loss as appropriate, and sufficient physical activity are useful for improving general health. Whether ULT has beneficial effects on comorbidities will be known only when well-powered interventional trials with relevant primary endpoints are available.