title: Epidemiology of gout and hyperuricemia. A long-term population study. Ultrasonography shows disappearance of monosodium urate crystal deposition on hyaline cartilage after sustained normouricemia is achieved Gout impacts on function and health-related quality of life beyond associated risk factors and medical conditions: results from the KING observational study of the Italian Society for Rheumatology (SIR) The effects of commercially available footwear on foot pain and disability in people with gout: a pilot study Development of a computed tomography method of scoring bone erosion in patients with gout: validation and clinical implications. Ultrasound-detected musculoskeletal urate crystal deposition: which joints and what findings should be assessed for diagnosing gout? Diagnosis of gout by ultrasound. Ultrasound imaging for the rheumatologist XXXVI. Sonographic assessment of the foot in gout patients. Ultrasound in gout: a useful tool for following urate-lowering therapy. Observations on spontaneous improvement in patients with podagra: implications for therapeutic trials of non-steroidal anti-inflammatory drugs. Relationship between structural joint damage and urate deposition in gout: a plain radiography and dual-energy CT study
abstract: T HE characteristics of a disease as it appears in the general population are likely to be quite different from its characteristics in a hospital population , since only patients who are severely afflicted or in whom complications have developed are likely to be found in the hospital population . Analysis of a hospital population , therefore , will give an exaggerated idea of the usual severity of the disease and of the frequency with which complications occur . A similar bias may be introduced when patients coming to the hospital with other complaints are used as controls , and an even greater bias introduced when autopsy series are used . This paper presents some observations of a forward-going study of an adult population sample in respect to the characteristics of hyperuricemia and gouty arthritis . The characteristics investigated include ( 1 ) the prevalence of hyperuricemia and its relationship to age ; ( 2 ) the prevalence of secondary hyperuricemia ; ( 3 ) the prevalence of gouty arthritis ; ( 4 ) the incidence of gouty arthritis and its relationship to age ; ( 5 ) the relationship of gouty arthritis to hyperuricemia and the risk of developing gouty arthritis for each uric acid level ; ( 6 ) the clinical features of gouty arthritis in this population ; and ( 7 ) the prevalence of complications related to gouty arthritis and to hyperuricemia . In the Town of Framingham , Massachusetts , a population was selected by r and om sampling for the studp of coronaryartery disease and hJ , pertension . This population has been described in detail elsewhere [ /--31 . A total of 5,127 subjects ( 2,283 men and 2,844 women ) , age thirtythrough fifty-nine , free of evidence of coronary heart disease on initial examination , were included in the sample ( hereinafter referred to as the population ) . The mean age on admission was forty-four . Biennial examination included history , physical examination , electrocardiogram , roentgenograms and various laboratory tests . The results of these examinations , transcripts of admission to the community hospital , and information obtained from physicians and hospitals outside the community formed the record of each subject . At the time of this report the population had been examined an average of seven times for a follow-up period of twelve years . A few subjects have died , moved away or have missed one or two examinations for various reasons . Some have had eight examinations . The current health status of approxiluately 95 per cent of the original 5,127 subjects is known and only 0.7 per cent are considered lost to follow-up [ J ] This study aim ed at determining whether lowering serum urate ( SU ) to less than 6 mg/dl in patients with gout affects ultrasonographic findings . Seven joints in five patients with monosodium urate ( MSU ) crystal proven gout and hyperuricemia were examined over time with serial ultrasonography . Four of the five patients were treated with urate lowering drugs ( ULDs ) ( allopurinol , n = 3 ; probenecid , n = 1 ) . One patient was treated with colchicine alone . Attention was given to changes in a hyperechoic , irregular coating of the hyaline cartilage in the examined joints ( double contour sign or “ urate icing ” ) . This coating was considered to represent precipitate of MSU crystals . Index joints included metacarpophalangeal ( MCP ) joints ( n = 2 ) , knee joints ( n = 3 ) , and first metatarsophalangeal ( MTP ) joints ( n = 2 ) . The interval between baseline and follow-up images ranged from 7 to 18 months . Serial SU levels were obtained during the follow-up period . During the follow-up period , three patients treated with ULD ( allopurinol , n = 2 ; probenecid , n = 1 ) achieved a SU level of < 6 mg/dl . In two patients , SU levels remained above 6 mg/dl ( treated with allopurinol , n = 1 ; treated with colchicine , n = 1 ) . At baseline , the double contour sign was seen in all patients . In those patients who achieved SU levels of < 6 ml/dl , this sign had disappeared at follow-up . Disappearance of the double contour sign was seen in two knee joints , two first MTP joints , and one MCP joint . In contrast , disappearance of the double contour sign was not seen in patients who maintained a SU level ≥7 mg/dl . In one patient treated with allopurinol  , SU levels improved from 13 to 7 mg/dl during the follow-up period . Decrease , but not resolution of the hyperechoic coating was seen in this patient . In the patient treated with colchicine alone , SU levels remained > 8 mg/dl , and no sonographic change was observed . In our patients , sonographic signs of deposition of MSU crystals on the surface of hyaline cartilage disappeared completely if sustained normouricemia was achieved . This is the first report showing that characteristic sonographic changes are influenced by ULDs once SU levels remain ≤6 mg/dl for 7 months or more . Sonographic changes of gout correlate with SU levels and may be a non-invasive means to track changes in the uric acid pool . Larger prospect i ve studies are needed to further assess these potentially important findings Introduction Gout is the most prevalent arthritis and significantly impacts on function and quality of life . Given that gout associates with disabling comorbid conditions , it is not clear whether such a complex of diseases accounts for the increased disability or if gout may play a role by itself . This study aims to evaluate the specific influence of gout and disease-related features on functional disability and health-related quality of life ( HRQoL ) in patients with gout followed in rheumatology clinics . Methods A r and om sample of patients was drawn from clinical registries of 30 rheumatology clinics across Italy . Sociodemographic , general health and gout-specific variables were collected . Functional disability and HRQoL were assessed by the  health assessment question naire ( HAQ )  and the Physical and Mental Component Summary scores ( PCS and MCS ) of the Short Form-36 ( SF-36 ) . Crude and adjusted ordinal logistic and linear regression models were applied to investigate the specific contribution of different variables on HAQ and SF-36 scores . Results are presented as odds ratio ( OR ) or mean difference ( MD ) and 95 % confidence intervals . Results Out of 446 patients with gout , 90 % were males with a mean age of 63.9 years and median disease duration of 3.8 years ; the majority of patients were overweight or obese , and with several comorbidities ; 21.1 % showed at least moderate disability ; the PCS score was significantly lower than expected age- and gender-matched sample s in the general population , while MCS score was not . After adjusting for potential sociodemographic and general-health confounders , gout-specific variables significantly impacted on HAQ , including polyarticular involvement OR 3.82 ( 1.63 , 8.95 ) , presence of tophi OR 1.92 ( 1.07 , 3.43 ) and recent attacks OR 2.20 ( 1.27 , 3.81 ) . Consistent results were found for PCS . The impairment of PCS compared to the general population was limited to patients with features of chronic gout . MCS was only affected by recent attacks ( MD -2.72 [ -4.58 , -0.86 ] ) and  corticosteroid  treatment ( -3.39 [ -5.30,-1.48 ] ) . Conclusions The data from the KING study confirm that gout impacts on disability and provide evidence for an independent association of gout and gout-related features with functional outcome and HRQoL. This result supports the need to improve specific treatment in gout Background There is limited evidence on non-pharmacological interventions for gout . The aim of the study was to determine whether a footwear intervention can reduce foot pain and musculoskeletal disability in people with gout . Methods Thirty-six people with gout participated in a prospect i ve intervention study over 8 weeks . Participants selected one of 4 pairs of shoes and thereafter wore the shoes for 8 weeks . The primary outcome was foot pain using a 100 mm visual analogue scale . Secondary outcomes related to function and disability were also analysed . Results The Cardio Zip shoe was selected by 58 % of participants . Compared with baseline , overall scores for all shoes at 8-weeks demonstrated a decrease in foot pain ( p = 0.03 ) , general pain ( p = 0.012 ) , Health Assessment Question naire (HAQ)-II ( p = 0.016 ) and Leeds Foot Impact Scale ( LFIS ) impairment subscale ( p = 0.03 ) . No significant differences were observed in other patient reported outcomes including patient global assessment , LFIS activity subscale , and Lower Limb Task Question naire subscales ( all p > 0.10 ) . We observed significant improvements between baseline measurements using the participants ’ own shoes and the Cardio Zip for foot pain ( p = 0.002 ) , general pain ( p = 0.001 ) , HAQ-II ( p = 0.002 ) and LFIS impairment subscale ( p = 0.004 ) after 8 weeks . The other three shoes did not improve pain or disability . Conclusions Footwear with good cushioning , and motion control may reduce foot pain and disability in people with gout OBJECTIVES To develop a method of scoring bone erosion in the feet of patients with gout using CT as an outcome measure for chronic gout studies , consistent with the components of the OMERACT filter . METHODS Clinical assessment , plain radiographs and CT scans of both feet were obtained from 25 patients with chronic gout .  CT scans were scored for bone erosion using a semi-quantitative method based on the Rheumatoid Arthritis MRI Scoring System ( RAMRIS ) .  CT bone erosion was assessed at 22 bones in each foot ( total 1100 bones ) by two independent radiologists . A number of different models were assessed to determine the optimal CT scoring system for bone erosion , incorporating the frequency of involvement and inter-reader reliability for individual bones . RESULTS An optimal model was identified with low number of bones required for scoring ( seven bones/foot ) , inclusion of bones over the entire foot , high reliability and ability to capture a high proportion of disease . This model included the following bones in each foot : first metatarsal ( MT ) head , second to fourth MT base , cuboid , middle cuneiform and distal tibia ( range 0 - 140 ) . Scores from this model correlated with plain radiographic damage scores ( r = 0.86 , P < 0.0001 ) and disease duration ( r = 0.42 , P < 0.05 ) . Scores were higher in those with clinical ly apparent tophaceous disease than in those without tophi ( P < 0.0001 ) . CONCLUSIONS We have developed a preliminary method of assessing bone erosion in gout using conventional CT . Further testing of this method is now required , ideally in prospect i ve studies to allow analysis of the sensitivity to change of the measure Objective The primary objective of this prospect i ve case-control study was to assess the diagnostic value of several intra-articular and periarticular ultrasound (US)-detected abnormalities in the upper and lower limbs in gout . The secondary objective was to test the concurrent validity of US abnormalities using as gold st and ard the microscopic demonstration of monosodium urate ( MSU ) crystals . Methods Ninety-one men with gout and 42 age-matched controls were prospect ively recruited . All patients with gout and controls underwent US assessment of several US abnormalities in 26 joints , six bursae , eight tendons , 20 tendon compartments , four ligaments , and 18 articular cartilages by experts in US blinded to the patients ’ group . Patients with gout and controls with US abnormalities were asked to undergo US-guided aspiration for microscopic identification of MSU crystals . Interobserver and intraobserver reliability of the US assessment was evaluated in a web-based exercise . Results The assessment of one joint ( ie , radiocarpal joint ) for hyperechoic aggregates ( HAGs ) , two tendons ( ie , patellar tendon and triceps tendon ) for HAGs and three articular cartilages ( ie , first metatarsal , talar and second metacarpal/femoral ) for double contour sign showed the best balance between sensitivity and specificity ( 84.6 % and 83.3 % , respectively ) . Intraobserver reliability was good ( mean κ 0.75 ) and interobserver reliability was moderate ( κ 0.52 ) . The aspirated material from HAGs was positive for MSU crystals in 77.6 % of patients with gout and negative in all controls . Conclusions Our results suggest that US bilateral assessment of one joint , three articular cartilages and two tendons may be valid for diagnosing gout with acceptable sensitivity and specificity OBJECTIVES To establish the usefulness of ultrasonography ( US ) for diagnosing gout and to determine whether there are sonographic features that are characteristic for gout but not for other arthropathies . METHODS We retrospectively compared joint images of gout patients with matching images from patients with other rheumatic conditions . Images of 37 joints of 23 patients with monosodium urate ( MSU ) crystal-proven gout were review ed . MSU crystals were identified in at least one joint in each patient . Our control group had 23 r and omly selected patients with 33 examined joints with rheumatic conditions other than gout . RESULTS Specific diagnostic features included a hyperechoic , irregular b and over the superficial margin of the articular cartilage described as a double contour sign in 92 % of gouty joints and in none of the controls ( P < 0.001 ) ; hypoechoic to hyperechoic , inhomogeneous material surrounded by a small anechoic rim , representing tophaceous material , was seen in all gouty metatarsophalangeal ( MTP ) joints , in all metacarpophalangeal ( MCP ) joints and in none of the controls ( P < 0.001 ) ; erosions adjacent to tophaceous material were seen in 65 % of MTP joints and in 25 % of MCP joints . One erosion was seen in a MTP joint in a control patient with psoriatic arthritis . CONCLUSIONS US can detect deposition of MSU crystals on cartilaginous surfaces ( P < 0.001 ) as well as tophaceous material and typical erosions . US may serve as a non-invasive means to diagnose gout OBJECTIVES This study aims to investigate the relationship between clinical and US findings together with the prevalence and distribution of US findings indicative of monosodium urate ( MSU ) crystal deposition within the foot in patients with gout . METHODS A total of 50 patients with gout attending the in-patient and the out-patient clinics of the Rheumatology Departments were prospect ively enrolled in this multi-centre study . Multiplanar examination of the following 15 joints was performed : talo-navicular , navicular-cuneiform ( medial , intermediate and lateral ) , calcaneo-cuboid , medial , intermediate and lateral cuneiform-metatarsal , cuboid-4th metatarsal , cuboid-5th metatarsal and all five metatarsophalangeal ( MTP ) joints . RESULTS The following US findings were indicative of gout : enhancement of the superficial margin of the hyaline cartilage , intra-articular tophus , and extraarticular tophus . In 46 patients , a total of 1380 foot joints were investigated . In 1309 joints that were not clinical ly involved , US detected signs indicative of joint inflammation in 9 % ( 121/1309 ) . Talo-navicular joint and the first MTP joint were the joints in which the highest number of US findings were found at mid-foot and fore-foot , respectively . At MTP joint level , dorsal scans allowed the detection of a higher number of US findings indicative of joint inflammation , and MSU crystal deposits rather than on the volar plane . CONCLUSIONS This study demonstrated that US detected a higher number of inflamed foot joints than clinical examination , and that the first MTP and the talo-navicular joints were the anatomic sites with the highest prevalence of US signs of MSU crystal aggregates OBJECTIVE We aim ed to determine the ability of ultrasonography ( US ) to show decrease or disappearance of urate deposits in gouty patients requiring urate-lowering therapy ( ULT ) . METHODS To be included in this prospect i ve single-centre study , patients needed toexhibit ( 1 ) proven gout by monosodic urate ( MSU ) crystals in synovial fluid and ( 2 ) US- evidence d urate deposits ( double contour [ DC ] sign and /or tophi ) before starting ULT ( allopurinol [ n=4 ] , febuxostat [ n=12 ] ) . At baseline and after six months of ULT , one trained ultrasonographer assessed the knee and first metatarsophalangeal ( MTP1s ) joints . Serum uric-acid ( SUA ) level was assessed at baseline and at three and six months after ULT initiation . Correlation between US findings and achievement of SUA level objective ( < 360μmol/L ) was estimated by the kappa coefficient ( κ ) . RESULTS We studied 16 patients ( all males , mean age 61.0±18.3 years ) . The mean disease duration was 7.1±6.2 years . Tophi were found at clinical examination in 56 % of patients . Baseline SUA levels were 688±153μmol/L. At baseline , US revealed tophi or a DC sign among 62.5 to 75 % of patients in knees and 87.5 % in MTP1s . After six months of ULT , none of the four patients , not achieving the SUA level objective , had disappearance of US features . Among the remaining 12 patients , US features ( tophi or DC sign ) disappeared or decreased in all but one with a stable DC sign in one MTP1 . The correlation between the whole US examination and SUA level was excellent ( κ=0.875 ) . CONCLUSIONS US could show disappearance of urate deposits after ULT and appears to be well correlated with efficacy of ULT 1 The natural history of acute gouty arthritis was studied in 11 volunteers with podagra . 2 Two patients withdrew from the study on day 4 because of severe persistent pain . Of the remaining patients all showed some improvement in pain by day 5 and in swelling by day 7 . Tenderness improved in seven patients by day 7 but two continued to experience the same amount of discomfort as at trial entry . In spite of these improvements only three patients noted resolution of their pain during the study period . 3 These data indicate that while the majority of patients show spontaneous improvement , resolution is unlikely over a period of 7 days without the use of effective non-steroidal anti-inflammatory medication . 4 Documentation of the natural history of the acute gouty attack may assist clinical investigators in interpreting the results of uncontrolled evaluations of non-steroidal anti-inflammatory drugs Objectives The aim of this work was to examine the relationship between joint damage and monosodium urate ( MSU ) crystal deposition in gout . Methods Plain radiographs and dual-energy CT ( DECT ) scans of the feet were prospect ively obtained from 92 people with tophaceous gout . Subcutaneous tophus count was recorded . The ten metatarsophalangeal joints were scored on plain radiography for Sharp – van der Heijde erosion and joint space narrowing ( JSN ) scores , and presence of spur , osteophyte , periosteal new bone and sclerosis ( 920 total joints ) . DECT scans were analysed for the presence of MSU crystal deposition at the same joints . Results  DECT MSU crystal deposition was more frequently observed in joints with erosion ( OR ( 95 % CI ) 8.5 ( 5.5 to 13.1 ) ) , JSN ( 4.2 ( 2.7 to 6.7 % ) ) , spur ( 7.9 ( 4.9 to 12.8 ) ) , osteophyte ( 3.9 ( 2.5 to 6.0 ) ) , periosteal new bone ( 7.0 ( 4.0 to 12.2 ) ) and sclerosis ( 6.9 ( 4.6 to 10.2 ) ) , p<0.0001 for all . A strong linear relationship was observed in the frequency of joints affected by MSU crystals with radiographic erosion score ( p<0.0001 ) . The number of joints at each site with MSU crystal deposition correlated with all features of radiographic joint damage ( r>0.88 , p<0.05 for all ) . In linear regression models , the relationship between MSU crystal deposition and all radiographic changes except JSN and osteophytes persisted after adjusting for subcutaneous tophus count , serum urate concentration and disease duration . Conclusions MSU crystals are frequently present in joints affected by radiographic damage in gout . These findings support the concept that MSU crystals interact with articular tissues to influence the development of structural joint damage in this disease
target: 1st MTP pain was a prominent feature in people with gout .
  Imaging features were common at the 1st MTP including the double contour sign , tophi and erosions .
  Conclusions 1st MTP acute arthritis is highly prevalent in people with gout and has a substantial impact on patient-reported pain and disability .
  Gout affects the structure and function of the 1st MTP .
  Microscopic and imaging studies have demonstrated crystal deposition and joint damage at the 1st MTP in people with gout
background: Background The aim of this review was to qualitatively synthesis e studies that have investigated characteristics of the  first metatarsophalangeal joint ( 1st MTP )  in gout and to undertake a meta- analysis to estimate the average prevalence of acute 1st MTP arthritis across studies in people with gout .