Diagnosis of gout by ultrasound. Ultrasound imaging for the rheumatologist XXXVI. Sonographic assessment of the foot in gout patients. Ultrasonography shows disappearance of monosodium urate crystal deposition on hyaline cartilage after sustained normouricemia is achieved Existing joint erosions increase the risk of joint space narrowing independently of clinical synovitis in patients with early rheumatoid arthritis Association of baseline disease and patient characteristics with response to etoricoxib and indomethacin for acute gout* Relationship between structural joint damage and urate deposition in gout: a plain radiography and dual-energy CT study Improvements in early mortality and coagulopathy are sustained better in patients with blunt trauma after institution of a massive transfusion protocol in a civilian level I trauma center. Rilonacept in the treatment of acute gouty arthritis: a randomized, controlled clinical trial using indomethacin as the active comparator Comparison of triamcinolone acetonide with indomethacin in the treatment of acute gouty arthritis. Effect of alignment of the medial tibial plateau and x-ray beam on apparent progression of osteoarthritis in the standing anteroposterior knee radiograph. Chuanhu Anti-Gout Mixture versus Colchicine for Acute Gouty Arthritis: A Randomized, Double-Blind, Double-Dummy, Non-Inferiority Trial Goal-directed Hemostatic Resuscitation of Trauma-induced Coagulopathy: A Pragmatic Randomized Clinical Trial Comparing a Viscoelastic Assay to Conventional Coagulation Assays Lumiracoxib 400 mg once daily is comparable to indomethacin 50 mg three times daily for the treatment of acute flares of gout. 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) Osteosarcoma: a randomized, prospective trial of the addition of ifosfamide and/or muramyl tripeptide to cisplatin, doxorubicin, and high-dose methotrexate. Ultrasound in gout: a useful tool for following urate-lowering therapy. Effects of Discontinuation of Urate-Lowering Therapy: A Systematic Review Laser therapy and needling in myofascial trigger point deactivation. Effects of skim milk powder enriched with glycomacropeptide and G600 milk fat extract on frequency of gout flares: a proof-of-concept randomised controlled trial Minimally important differences of the gout impact scale in a randomized controlled trial. Osteosarcoma: the addition of muramyl tripeptide to chemotherapy improves overall survival--a report from the Children's Oncology Group. As compared to allopurinol, urate-lowering therapy with febuxostat has superior effects on oxidative stress and pulse wave velocity in patients with severe chronic tophaceous gout Colchicine for prophylaxis of acute flares when initiating allopurinol for chronic gouty arthritis.
OBJECTIVES To establish the usefulness of ultrasonography ( US ) for diagnosing gout and to determine whether there are sonographic features that are characteristic for gout but not for other arthropathies . METHODS We retrospectively compared joint images of gout patients with matching images from patients with other rheumatic conditions . Images of 37 joints of 23 patients with monosodium urate ( MSU ) crystal-proven gout were review ed . MSU crystals were identified in at least one joint in each patient . Our control group had 23 r and omly selected patients with 33 examined joints with rheumatic conditions other than gout . RESULTS Specific diagnostic features included a hyperechoic , irregular b and over the superficial margin of the articular cartilage described as a double contour sign in 92 % of gouty joints and in none of the controls ( P < 0.001 ) ; hypoechoic to hyperechoic , inhomogeneous material surrounded by a small anechoic rim , representing tophaceous material , was seen in all gouty metatarsophalangeal ( MTP ) joints , in all metacarpophalangeal ( MCP ) joints and in none of the controls ( P < 0.001 ) ; erosions adjacent to tophaceous material were seen in 65 % of MTP joints and in 25 % of MCP joints . One erosion was seen in a MTP joint in a control patient with psoriatic arthritis . CONCLUSIONS US can detect deposition of MSU crystals on cartilaginous surfaces ( P < 0.001 ) as well as tophaceous material and typical erosions . US may serve as a non-invasive means to diagnose gout OBJECTIVES This study aims to investigate the relationship between clinical and US findings together with the prevalence and distribution of US findings indicative of monosodium urate ( MSU ) crystal deposition within the foot in patients with gout . METHODS A total of 50 patients with gout attending the in-patient and the out-patient clinics of the Rheumatology Departments were prospect ively enrolled in this multi-centre study . Multiplanar examination of the following 15 joints was performed : talo-navicular , navicular-cuneiform ( medial , intermediate and lateral ) , calcaneo-cuboid , medial , intermediate and lateral cuneiform-metatarsal , cuboid-4th metatarsal , cuboid-5th metatarsal and all five metatarsophalangeal ( MTP ) joints . RESULTS The following US findings were indicative of gout : enhancement of the superficial margin of the hyaline cartilage , intra-articular tophus , and extraarticular tophus . In 46 patients , a total of 1380 foot joints were investigated . In 1309 joints that were not clinical ly involved , US detected signs indicative of joint inflammation in 9 % ( 121/1309 ) . Talo-navicular joint and the first MTP joint were the joints in which the highest number of US findings were found at mid-foot and fore-foot , respectively . At MTP joint level , dorsal scans allowed the detection of a higher number of US findings indicative of joint inflammation , and MSU crystal deposits rather than on the volar plane . CONCLUSIONS This study demonstrated that US detected a higher number of inflamed foot joints than clinical examination , and that the first MTP and the talo-navicular joints were the anatomic sites with the highest prevalence of US signs of MSU crystal aggregates This study aim ed at determining whether lowering serum urate ( SU ) to less than 6 mg/dl in patients with gout affects ultrasonographic findings . Seven joints in five patients with monosodium urate ( MSU ) crystal proven gout and hyperuricemia were examined over time with serial ultrasonography . Four of the five patients were treated with urate lowering drugs ( ULDs ) ( allopurinol , n = 3 ; probenecid , n = 1 ) . One patient was treated with colchicine alone . Attention was given to changes in a hyperechoic , irregular coating of the hyaline cartilage in the examined joints ( double contour sign or “ urate icing ” ) . This coating was considered to represent precipitate of MSU crystals . Index joints included metacarpophalangeal ( MCP ) joints ( n = 2 ) , knee joints ( n = 3 ) , and first metatarsophalangeal ( MTP ) joints ( n = 2 ) . The interval between baseline and follow-up images ranged from 7 to 18 months . Serial SU levels were obtained during the follow-up period . During the follow-up period , three patients treated with ULD ( allopurinol , n = 2 ; probenecid , n = 1 ) achieved a SU level of < 6 mg/dl . In two patients , SU levels remained above 6 mg/dl ( treated with allopurinol , n = 1 ; treated with colchicine , n = 1 ) . At baseline , the double contour sign was seen in all patients . In those patients who achieved SU levels of < 6 ml/dl , this sign had disappeared at follow-up . Disappearance of the double contour sign was seen in two knee joints , two first MTP joints , and one MCP joint . In contrast , disappearance of the double contour sign was not seen in patients who maintained a SU level ≥7 mg/dl . In one patient treated with allopurinol  , SU levels improved from 13 to 7 mg/dl during the follow-up period . Decrease , but not resolution of the hyperechoic coating was seen in this patient . In the patient treated with colchicine alone , SU levels remained > 8 mg/dl , and no sonographic change was observed . In our patients , sonographic signs of deposition of MSU crystals on the surface of hyaline cartilage disappeared completely if sustained normouricemia was achieved . This is the first report showing that characteristic sonographic changes are influenced by ULDs once SU levels remain ≤6 mg/dl for 7 months or more . Sonographic changes of gout correlate with SU levels and may be a non-invasive means to track changes in the uric acid pool . Larger prospect i ve studies are needed to further assess these potentially important findings Introduction Clinical synovitis is often associated with damage to bone and cartilage . Previous data have suggested that joint erosions ( JE ) are more prevalent than joint space narrowing ( JSN ) and that the two processes are partly independent of each other . The objective of this study was to evaluate whether the presence of JE in an individual joint can lead to development of JSN and if existing JSN leads to new onset of JE , in the absence of synovitis . Methods The Prospect i ve Multi-Centre R and omised , Double-Blind , Active Comparator-Controlled , Parallel-Groups Study Comparing the Fully Human Monoclonal Anti-TNFα Antibody Adalimumab Given Every Second Week With Methotrexate Given Weekly and the Combination of Adalimumab and Methotrexate Administered Over 2 Years in Patients With Early Rheumatoid Arthritis ( PREMIER ) enrolled early rheumatoid arthritis ( RA ) patients who were r and omized to one of three treatments : methotrexate ( MTX ) , adalimumab ( ADA ) , or ADA + MTX .  All evaluable joints with JE and JSN measures at 26 and 52 weeks and synovitis assessment s from week 26 to 52 were included . Synovitis was assessed every 2–8 weeks by swollen joint counts between weeks 26 and 52 . Radiographs were taken at week 26 and 52 . Two readers , blinded to time and sequence , scored 14 bilateral joints individually for JE and JSN . Multivariate logistic modeling was used to characterize the dependence of JE/JSN onset at 52 weeks . Analyses were performed based on treatment arm and were also performed within individual joints . Results JE and swelling were independently and comparably associated with onset of JSN at week 52 . Assessment by individual joints indicated that existing JE , independent of swelling , was significantly associated with JSN onset in higher proportions of metatarsophalangeal ( MTP ; 7/10 ) than proximal interphalangeal ( PIP ; 1/8 ) or metacarpophalangeal ( MCP ; 1/10 ) joints . Treatment with ADA + MTX  prevents JE/JSN progression independently of its ability to suppress synovitis and limits JE/JSN onset and progression in joints with existing damage . Conclusions Existing JE predisposes individual joints to development of JSN independently of synovitis in the same joint . Weight-bearing MTP joints with JE may be at increased risk for JSN when compared with MCPs and PIPs . Trial registration Clinical trials.gov NCT00195663 . Registered 13 September 2005 ABSTRACT Background and objective : Disease history and clinical features can influence treatment response in patients with acute gout . The purpose of this pooled subgroup analysis was to assess the association of baseline disease and patient characteristics with response to treatment in acute gout using data from two identical studies . Methods : Patients ≥ 18 years of age with onset of acute gout within 48 h associated with moderate , severe , or extreme pain involving less than four joints were eligible for inclusion in the primary studies , and were r and omized to etoricoxib 120 mg once daily ( N = 178 ) or indomethacin 50 mg three times daily ( N = 161 ) . The primary and secondary efficacy endpoints were analyzed using an analysis of covariance model to detect potential differential treatment responses across several subgroups : joint involvement ( mono-articular vs. oligo-articular ) , baseline pain severity ( moderate vs. severe ) , concomitant allopurinol and /or colchicine use ( users vs. nonusers ) , age ( < 45 , 45–55 , and > 55 years ) , gender , and race ( white or other ) . Results : Overall , etoricoxib and indomethacin demonstrated comparable efficacy across all subgroups . Compared with patients with oligo-articular disease , those with mono-articular disease had significantly greater improvements in patient assessment of pain , patient global assessment of response to therapy ( PGART ) , investigator global assessment of response to therapy ( IGART ) , and study joint tenderness ( p < 0.001 for all ) . Greater improvements were seen in patient assessment of pain ( p < 0.001 ) and study joint tenderness ( p < 0.05 ) for severe/extreme baseline pain compared with moderate baseline pain . Concomitant use of colchicine and /or allopurinol was associated with significantly worse IGART ( p < 0.05 ) . Conclusions : This pooled subgroup analysis demonstrated significantly greater response of acute gout to either etoricoxib or indomethacin among those with monoarticular disease , severe/extreme baseline pain , and non-use of colchicine and /or allopurinol . These results should be interpreted in the context of a pooled subgroup analysis with a limited sample size , and with the underst and ing that associations identified in such analyses do not define causation . Despite limitations , the results provide insights into the types of patients more likely to respond better to anti-inflammatory medication , and reiterate the importance of earlier effective control of the disease Objectives The aim of this work was to examine the relationship between joint damage and monosodium urate ( MSU ) crystal deposition in gout . Methods Plain radiographs and dual-energy CT ( DECT ) scans of the feet were prospect ively obtained from 92 people with tophaceous gout . Subcutaneous tophus count was recorded . The ten metatarsophalangeal joints were scored on plain radiography for Sharp – van der Heijde erosion and joint space narrowing ( JSN ) scores , and presence of spur , osteophyte , periosteal new bone and sclerosis ( 920 total joints ) . DECT scans were analysed for the presence of MSU crystal deposition at the same joints . Results  DECT MSU crystal deposition was more frequently observed in joints with erosion ( OR ( 95 % CI ) 8.5 ( 5.5 to 13.1 ) ) , JSN ( 4.2 ( 2.7 to 6.7 % ) ) , spur ( 7.9 ( 4.9 to 12.8 ) ) , osteophyte ( 3.9 ( 2.5 to 6.0 ) ) , periosteal new bone ( 7.0 ( 4.0 to 12.2 ) ) and sclerosis ( 6.9 ( 4.6 to 10.2 ) ) , p<0.0001 for all . A strong linear relationship was observed in the frequency of joints affected by MSU crystals with radiographic erosion score ( p<0.0001 ) . The number of joints at each site with MSU crystal deposition correlated with all features of radiographic joint damage ( r>0.88 , p<0.05 for all ) . In linear regression models , the relationship between MSU crystal deposition and all radiographic changes except JSN and osteophytes persisted after adjusting for subcutaneous tophus count , serum urate concentration and disease duration . Conclusions MSU crystals are frequently present in joints affected by radiographic damage in gout . These findings support the concept that MSU crystals interact with articular tissues to influence the development of structural joint damage in this disease INTRODUCTION Transfusion practice s across the country are changing with aggressive use of plasma ( fresh-frozen plasma [ FFP ] ) and platelets during massive transfusion with current military recommendations to use component therapy at a 1:1:1 ratio of packed red blood cells to FFP to platelets . METHODS A massive transfusion protocol ( MTP ) was design ed to achieve a packed red blood cell : FFP : platelet ratio of 1:1:1 We prospect ively gathered demographic , transfusion , and patient outcome data during the first year of the MTP and compared this with a similar cohort of injured patients ( pre-MTP ) receiving > or = 10 red blood cell ( RBC ) in the first 24 hours of hospitalization before instituting the MTP .  RESULTS One hundred sixteen MTP activations occurred . Twelve non-trauma patients and 31 who did not receive 10 RBC ( 15 deaths , 16 early bleeding controls ) were excluded . Seventy-three MTP patients were compared with 84 patients with pre-MTP who had similar demographics and injury severity score ( 29 vs. 29 , p = 0.99 ) . MTP patients received an average of 23.7 RBC and 15.6 FFP transfusions compared with 22.8 RBC ( p = 0.67 ) and 7.6 FFP ( p < 0.001 ) transfusions in pre-MTP patients . Early crystalloid usage dropped from 9.4 L ( pre-MTP ) to 6.9 L ( MTP ) ( p = 0.006 ) . Overall patient mortality was markedly improved at 24 hours , from 36 % in the pre-MTP group to 17 % in the MTP group ( p = 0.008 ) and at 30 days ( 34 % mortality MTP group vs. 55 % mortality in pre-MTP group , p = 0.04 ) . Blunt trauma survival improvements were more marked and more sustained than victims of penetrating trauma . Early deaths from coagulopathic bleeding occurred in 4 of 13 patients in the MTP group vs. 21 of 31 patients in the pre-MTP group ( p = 0.023 ) . CONCLUSIONS In the civilian setting , aggressive use of FFP and platelets drastically reduces 24-hour mortality and early coagulopathy in patients with trauma . Reduction in 30 day mortality was only seen after blunt trauma in this small subset Introduction In phase-3 clinical trials , the interleukin ( IL-1 ) blocker , rilonacept ( IL-1 Trap ) , demonstrated efficacy for gout flare prevention during initiation of urate-lowering therapy . This trial evaluated rilonacept added to a st and ard-of-care , indomethacin , for treatment of acute gout flares . Methods Adults , aged 18 - 70 years , with gout presenting within 48 hours of flare onset and having at least moderate pain as well as swelling and tenderness in the index joint were r and omized to subcutaneous ( SC  ) rilonacept 320 mg at baseline plus oral indomethacin 50 mg TID for 3 days followed by 25 mg TID for up to 9 days ( n = 74 ) ; SC placebo at baseline plus oral indomethacin as above ( n = 76 ) ; or SC rilonacept 320 mg at baseline plus oral placebo ( n = 75 ) . The primary efficacy endpoint was change in pain in the index joint ( patient-reported using a Likert scale ( 0 = none ; 4 = extreme ) ) from baseline to the average of values at 24 , 48 and 72 hours ( composite time point ) for rilonacept plus indomethacin versus indomethacin alone . Comparison of rilonacept monotherapy with indomethacin monotherapy was dependent on demonstration of significance for the primary endpoint . Safety evaluation included clinical laboratory and adverse event ( AE ) assessment s. Results Patient characteristics were comparable among the groups ; the population was predominantly male ( 94.1 % ) , white ( 75.7 % ) , with mean ± SD age of 50.3 ± 10.6 years . All treatment groups reported within-group pain reductions from baseline ( P < 0.0001 ) . Although primary endpoint pain reduction was greater with rilonacept plus indomethacin ( -1.55 ± 0.92 ) relative to indomethacin alone ( -1.40 ± 0.96 ) , the difference was not statistically significant ( P = 0.33 ) , so formal comparison between monotherapy groups was not performed . Pain reduction over the 72-hour period with rilonacept alone ( -0.69 ± 0.97 ) was less than that in the other groups , but pain reduction was similar among groups at 72 hours . Treatment with rilonacept was well-tolerated with no reported serious AEs related to rilonacept . Across all groups , the most frequent AEs were headache and dizziness . Conclusions Although generally well-tolerated , rilonacept in combination with indomethacin and rilonacept alone did not provide additional pain relief over 72 hours relative to indomethacin alone in patients with acute gout flare . Trial registration Clinical Trials.gov registration number NCT00855920 Twenty-seven patients presenting within 5 days of the onset of crystalline proven acute gout were prospect ively treated with either indomethacin 50 mg tid or triamcinolone acetonide 60 mg intramuscularly . Patients with contraindications to therapy with indomethacin  received triamcinolone acetonide . They were followed for 30 days . Resolution of all symptoms occurred at an average of 8 days for the indomethacin patients and 7 days in the triamcinolone patients . No side effects or episodes of rebound gout attacks occurred with the triamcinolone acetonide therapy . It is as safe and effective as indomethacin in the treatment of acute gout , and is particularly useful in patients with contraindications to therapy with nonsteroidal antiinflammatory drugs OBJECTIVE Previous studies of knee osteoarthritis ( OA ) have yielded variable estimates of the rate of joint space narrowing ( JSN ) in the st and ing anteroposterior ( AP ) radiograph , due largely to longitudinal changes in the alignment of the medial tibial plateau ( MTP ) and x-ray beam . To characterize this bias , we examined serial radiographs  of subjects with knee OA in population -based and clinical OA cohorts from 3 locations in the United States and the United Kingdom . METHODS Radiographic features of knee OA ( e.g. ,  osteophytosis , JSN ) and MTP alignment in 428 OA knees were evaluated by consensus of 2 readers . Alignment was considered satisfactory if the anterior and posterior margins of the MTP were superimposed within 1 mm . Readers were blinded to subject identity , and films were read in r and om order . The minimum medial joint space width was also measured manually ( st and ard error of repeated measurements 0.20 mm ) in serial knee images . RESULTS Only 14 % of serial radiographs exhibited alignment of the MTP in both images . In OA knees with satisfactory alignment in both images , the mean rate of JSN over 2 - 3 years ( 0.26 mm/year ) was significantly larger ( P = 0.004 ) than that in OA knees with misalignment in 1 or both radiographs and was 86 % more rapid than the mean JSN in all OA knees . Moreover , the within-group st and ard deviation of JSN was significantly smaller among knees with reproduced alignment of the MTP than in knees in which misalignment occurred in 1 or both images ( P = 0.006 ) . CONCLUSION Poor st and ardization of knee positioning in serial st and ing AP radiographs in previous studies of OA progression has obscured the rate and variability of articular cartilage loss in subjects with knee OA . True JSN ( i.e. , JSN that is not attributable to longitudinal changes in the alignment of the MTP with the x-ray beam in serial radiographic examinations ) may occur more rapidly , and with less between-subject variability , than that previously thought to be characteristic of knee OA Background The Chuanhu anti-gout mixture has been used for many years in the treatment of gout in Chinese Traditional Medicine , and current methods for treatments for acute gouty arthritis have been either less effective or have had serious side effects . Methods In this 12-week , double-blind , double-dummy , non-inferiority study , outpatient individuals with newly diagnosed acute gouty arthritis were r and omly assigned to receive Chuanhu anti-gout mixture or colchicine . Both the study investigators and the participants were masked to the treatment assignments . The primary outcome was the recurrence rate of acute gouty arthritis , and the secondary outcomes were changes in white blood cells ( WHC ) and C-reactive protein ( CRP ) . This trial is registered at IS RCT N.org as trial IS RCT N65219941 . Results A total of 176 patients were r and omly assigned to receive either the Chuanhu anti-gout mixture or Colchicine . The overall recurrence rates in the Chuanhu anti-gout mixture group ( CH group ) and the Colchicine group ( Col group ) were 12.50 % vs 14.77 % ( difference -2.22 % , 95 % confidence interval ( 95 % CI ) : -10.78%~6.23 % ) , meeting the predefined non-inferiority criterion of 15 % , as did the data for WHC and CRP . The incidence of adverse events ( mainly diarrhea ) was less in the Col group than in the CH group ( 2.27 % vs 28.41 % , 95 % CI 0.01~0.26 ) . In addition , changes in blood uric acid , alanine aminotransferase , aspartate aminotransferase and creatinine in the CH group were significantly larger compared to those in the Col group ( P<0.05 ) . Conclusions The Chuanhu anti-gout mixture was non-inferior to colchicine for the treatment of acute gouty arthritis . The study suggested that the Chuanhu anti-gout mixture can be considered an alternative choice for the treatment of acute gouty arthritis because of its lower incidence of adverse events and its protection of kidney and renal function Background : Massive transfusion protocol s ( MTPs ) have become st and ard of care in the management of bleeding injured patients , yet strategies to guide them vary widely . We conducted a pragmatic , r and omized clinical trial ( RCT ) to test the hypothesis that an MTP goal directed by the viscoelastic assay thrombelastography ( TEG ) improves survival compared with an MTP guided by conventional coagulation assays ( CCA ) . Methods : This RCT enrolled injured patients from an academic level-1 trauma center meeting criteria for MTP activation . Upon MTP activation , patients were r and omized to be managed either by an MTP goal directed by TEG or by CCA ( ie , international normalized ratio , fibrinogen , platelet count ) . Primary outcome was 28-day survival . Results : One hundred eleven patients were included in an intent-to-treat analysis ( TEG = 56 , CCA = 55 ) . Survival in the TEG group was significantly higher than the CCA group ( log-rank P = 0.032 , Wilcoxon P = 0.027 ) ; 20 deaths in the CCA group ( 36.4 % ) compared with 11 in the TEG group ( 19.6 % ) ( P = 0.049 ) . Most deaths occurred within the first 6 hours from arrival ( 21.8 % CCA group vs 7.1 % TEG group ) ( P = 0.032 ) . CCA patients required similar number of red blood cell units as the TEG patients [ CCA : 5.0 ( 2–11 ) , TEG : 4.5 ( 2–8 ) ] ( P = 0.317 ) , but more plasma units [ CCA : 2.0 ( 0–4 ) , TEG : 0.0 ( 0–3 ) ] ( P = 0.022 ) , and more platelets units [ CCA : 0.0 ( 0–1 ) , TEG : 0.0 ( 0–0 ) ] ( P = 0.041 ) in the first 2 hours of resuscitation . Conclusions : Utilization of a goal -directed , TEG-guided MTP to resuscitate severely injured patients improves survival compared with an MTP guided by CCA and utilizes less plasma and platelet transfusions during the early phase of resuscitation OBJECTIVES To demonstrate non-inferiority of lumiracoxib 400 mg once daily ( o.d . ) compared with indomethacin 50 mg three times daily ( t.i.d . ) in the treatment of acute gout , and to compare the safety and tolerability of these treatments . METHODS In this 1-week , multicentre , r and omized , double-blind , double-dummy , active-controlled , parallel-group study , patients with a clinical diagnosis of gout , an acute attack of gout in four or more joints within the 48 h prior to evaluation , and at least moderate pain intensity in the target joint were r and omized to treatment with lumiracoxib 400 mg o.d . ( n = 118 ) or indomethacin 50 mg t.i.d . ( n = 117 ) . The primary efficacy endpoint was the mean change in pain intensity from baseline over days 2 - 5 , assessed on a 5-point Likert scale , where non-inferiority could be cl aim ed if the lower limit of the confidence interval ( CI ) was greater than -0.5 . The patient 's and physician 's global assessment of response to treatment , and physician 's assessment of tenderness , swelling and erythema of the study joint were also assessed . RESULTS The estimated difference between treatments for the change from baseline in pain intensity over days 2 - 5 was -0.004 ( 95 % CI -0.207 to 0.199 , P > 0.05 ) , indicating that lumiracoxib 400 mg o.d . had comparable efficacy to indomethacin 50 mg t.i.d . for the primary efficacy variable . There was no significant difference between treatments in any of the secondary efficacy variables . Adverse events were reported by 10.2 % of patients treated with lumiracoxib and 22.2 % of those receiving indomethacin . CONCLUSIONS Lumiracoxib is as effective as indomethacin for treatment of acute gout and may have a better safety and tolerability profile 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 PURPOSE To determine whether the addition of ifosfamide and /or muramyl tripeptide ( MTP ) encapsulated in liposomes to cisplatin , doxorubicin , and high-dose methotrexate ( HDMTX ) could improve the probability for event-free survival ( EFS ) in newly diagnosed patients with osteosarcoma ( OS ) . PATIENTS AND METHODS Six hundred seventy-seven patients with OS without clinical ly detectable metastatic disease were treated with one of four prospect ively r and omized treatments . All patients received identical cumulative doses of cisplatin , doxorubicin , and HDMTX and underwent definitive surgical resection of the primary tumor . Patients were r and omly assigned to receive or not to receive ifosfamide and /or MTP in a 2 double dagger 2 factorial design . The primary end point for analysis was EFS . RESULTS Patients treated with the st and ard arm of therapy had a 3-year EFS of 71 % . We could not analyze the results by factorial design because we observed an interaction between the addition of ifosfamide and the addition of MTP . The addition of MTP to st and ard chemotherapy achieved a 3-year EFS rate of 68 % . The addition of ifosfamide to st and ard chemotherapy achieved a 3-year EFS rate of 61 % . The addition of both ifosfamide and MTP result ed in a 3-year EFS rate of 78 % . CONCLUSION The addition of ifosfamide in this dose schedule to st and ard chemotherapy did not enhance EFS . The addition of MTP to chemotherapy might improve EFS , but additional clinical and laboratory investigation will be necessary to explain the interaction between ifosfamide and MTP 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 Background Urate-lowering therapy ( ULT ) is associated with low rates of adherence , leading to a potential risk of relapse of gouty arthritis , tophi , or urolithiasis . Our main aim was to identify the recurrence of gouty arthritis , tophi , or urolithiasis after discontinuation of ULT . Secondary aims included an assessment of ULT re introduction rates and factors associated with relapse . Methods We conducted a systematic literature review of clinical studies investigating the effect of discontinuing any ULT ( allopurinol , febuxostat , probenecid , sulfinpyrazone , benzbromarone ) in adults on long-term therapy . We search ed The Cochrane Central Register of Controlled Trials , MEDLINE , EMBASE , Science Citation Index , and Clinical Trials.gov from inception to March 2016 . Conference abstract s of the ACR/ARHP and EULAR annual conferences were h and - search ed . Study quality was assessed using the first eight items of the method ological index for non-r and omized studies ( MINORS ) tool . The review protocol is registered with PROSPERO ( CRD42016042048 ) . Results A total of 4640 articles were identified , eight of which were ultimately included . Most of these studies pre date d 2000 . MINORS scores ranged from 5 to 10 out of a possible 16 . Mean follow-up duration after discontinuation ranged from 12 to 96 months . Five studies focused on discontinuation of ULT in gouty arthritis and tophi , two in urolithiasis , and one in asymptomatic hyperuricemia . Relapse rates were high in gout ( 36—81 % ) and lower in urolithiasis ( 15 % ) . Relapses occurred 1–4.5 years after ULT discontinuation . In one study , a low serum urate level before and after ULT discontinuation was associated with lower gout recurrence . Discussion Relapse of gout is common although delayed after discontinuation of ULT . Short-term prognosis after ULT discontinuation appears favorable if the serum urate level was low before ULT discontinuation . The results of this review are limited by the paucity of existing studies and their low quality . Further comparative studies should consider larger primary care population s and discontinuation of febuxostat The aim of this study was to evaluate different approaches to deactivating myofascial trigger points ( MTPs ) . Twenty-one women with bilateral MTPs in the masseter muscle were r and omly divided into three groups : laser therapy , needle treatment and control . Treatment effectiveness was evaluated after four sessions with intervals ranging between 48 and 72 h. Quantitative and qualitative methods were used to measure pain perception/sensation . The Wilcoxon test based on results expressed on a visual analog scale ( VAS ) demonstrated a significant ( P < 0.05 ) decrease in pain only in the laser and needle treatments groups , although a significant increase in the pressure pain threshold was evident only for needling with anesthetic injection ( P = 0.0469 ) , and laser therapy at a dose of 4 J/cm² ( P = 0.0156 ) . Based on these results , it was concluded that four sessions of needling with 2 % lidocaine injection with intervals between 48 and 72 h without a vasoconstrictor , or laser therapy at a dose of 4 J/cm² , are effective for deactivation of MTPs Objectives Previous laboratory studies have identified two dairy fractions , glycomacropeptide ( GMP ) and G600 milk fat extract ( G600 ) , with anti-inflammatory effects in models of acute gout . The aim of this proof-of-concept clinical trial was to test the hypothesis that daily intake of skim milk powder ( SMP ) enriched with GMP and G600 can prevent gout flares . Methods This was a 3-month r and omised double-blind controlled trial of milk products for prevention of gout flares . One hundred and twenty patients with recurrent gout flares were r and omised to one of three arms : lactose powder control , SMP control and SMP enriched with GMP and G600 ( SMP/GMP/G600 ) . The primary end point was change in the frequency of gout flares using a daily flare diary measured monthly for 3 months . Results The frequency of gout flares reduced in all three groups over the 3-month study period compared with baseline . Over the 3-month study period there was a significantly greater reduction in gout flares in the SMP/GMP/G600 group ( analysis of covariance pgroup=0.031 , Tukey post hoc test compared with lactose control , p=0.044 ) . Following treatment with SMP/GMP/G600 over the 3-month period , greater improvements were also observed in pain and fractional excretion of uric acid , with trends to greater improvement in tender joint count . Similar adverse event rates and discontinuation rates were observed between the three groups . Conclusions This is the first reported controlled trial of dietary intervention in patients with gout , and suggests that SMP enriched with GMP and G600 may reduce the frequency of gout flares OBJECTIVE The Gout Impact  Scale ( GIS ) is a gout-specific quality of life instrument that assesses impact of gout during an attack and impact of overall gout . The GIS has five scales and each is scored from 0 to 100 ( worse health ) . Our objective was to assess minimally important differences ( MIDs ) for the GIS administered in a r and omized controlled trial ( RCT ) assessing rilonacept vs placebo for prevention of gout flares during initiation of allopurinol therapy . METHODS Trial subjects ( n = 83 ) included those with two or more gout flares ( self-reported ) in the past year . Of these , 73 had data for Weeks 8 vs 4 and formed the MID analysis group and were analysed irrespective of the treatment assignment . Subjects completed the GIS and seven patient-reported anchors . Subjects with a one-step change ( e.g. from very poor to poor ) were considered as the MID group for each anchor . The mean change in GIS scores and effect size ( ES ) was calculated for each anchor 's MID group . The average of these created the overall summary MID statistics for each GIS . An ES of 0.2 - 0.5 was considered to represent MID estimates . Results . Trial subjects ( n = 73 ) were males ( 96.0 % ) , White ( 90.4 % ) , with mean age of 50.5 years and serum uric acid of 9.0 mg/dl . The mean change score for the MID improvement group for scales ranged from -5.24 to -7.61 ( 0 - 100 scale ) . The ES for the MID improvement group for the four scales ranged from 0.22 to 0.38 . CONCLUSION The MID estimates for GIS scales are between 5 and 8 points ( 0 - 100 scale ) . This information can aid in interpreting the GIS results in future gout RCTs . Trial Registration . Clinical trials.gov , www . clinical trials.gov , NCT00610363 PURPOSE To compare three-drug chemotherapy with cisplatin , doxorubicin , and methotrexate with four-drug chemotherapy with cisplatin , doxorubicin , methotrexate , and ifosfamide for the treatment of osteosarcoma . To determine whether the addition of muramyl tripeptide ( MTP ) to chemotherapy enhances event-free survival ( EFS ) and overall survival in newly diagnosed patients with osteosarcoma . PATIENTS AND METHODS Six hundred sixty-two patients with osteosarcoma without clinical ly detectable metastatic disease and whose disease was considered resectable received one of four prospect ively r and omized treatments . All patients received identical cumulative doses of cisplatin , doxorubicin , and methotrexate and underwent definitive surgical resection of primary tumor . Patients were r and omly assigned to receive or not to receive ifosfamide and /or MTP in a 2 x 2 factorial design . The primary end points for analysis were EFS and overall survival . RESULTS In the current analysis , there was no evidence of interaction , and we were able to examine each intervention separately . The chemotherapy regimens result ed in similar EFS and overall survival . There was a trend toward better EFS with the addition of MTP ( P = .08 ) . The addition of MTP to chemotherapy improved 6-year overall survival from 70 % to 78 % ( P = .03 ) . The hazard ratio for overall survival with the addition of MTP was 0.71 ( 95 % CI , 0.52 to 0.96 ) . CONCLUSION The addition of ifosfamide to cisplatin , doxorubicin , and methotrexate did not enhance EFS or overall survival for patients with osteosarcoma . The addition of MTP to chemotherapy result ed in a statistically significant improvement in overall survival and a trend toward better EFS Abstract We prospect ively evaluated whether an effective 12-month uric acid-lowering therapy ( ULT ) with the available xanthine oxidase ( XO ) inhibitors allopurinol and febuxostat in patients with chronic tophaceous gout has an impact on oxidative stress and /or vascular function . Patients with chronic tophaceous gout who did not receive active ULT were included . After clinical evaluation , serum uric acid levels ( SUA ) and markers of oxidative stress were measured , and carotid – femoral pulse wave velocity ( cfPWV ) was assessed . Patients were then treated with allopurinol ( n = 9 ) or with febuxostat ( n = 8) to target a SUA level ≤360 μmol/L. After 1 year treatment , the SUA levels , markers of oxidative stress and the cfPWV were measured again . Baseline characteristics of both groups showed no significant differences except a higher prevalence of moderate impairment of renal function ( estimated glomerular filtration rate < 60 ml/min ) in the febuxostat group . Uric acid lowering with either inhibitors of XO result ed in almost equally effective reduction in SUA levels . The both treatment groups did not differ in their baseline cfPWV ( allopurinol group : 14.1 ± 3.4 m/s , febuxostat group : 13.7 ± 2.7 m/s , p = 0.80 ) . However , after 1 year of therapy , we observed a significant cfPWV increase in the allopurinol group ( 16.8 ± 4.3 m/s , p = 0.001 as compared to baseline ) , but not in the febuxostat patients ( 13.3 ± 2.3 m/s , p = 0.55 ) . Both febuxostat and allopurinol effectively lower SUA levels in patients with severe gout . However , we observed that febuxostat also appeared to be beneficial in preventing further arterial stiffening . Since cardiovascular events are an important issue in treating patients with gout , this unexpected finding may have important implication s and should be further investigated in r and omized controlled trials OBJECTIVE The use of colchicine to prevent acute gout flares during initiation of allopurinol therapy is widely practice d despite lack of proven benefit . We investigated if colchicine administration during initiation of allopurinol for chronic gouty arthritis reduces the frequency and /or severity of acute gout flares . METHODS Patients starting allopurinol for crystal-proven chronic gouty arthritis were r and omized to receive colchicine 0.6 mg po bid or placebo in a r and omized , prospect i ve , double blind , placebo controlled trial . Subjects were followed for evidence of acute gout flares and remained on study drug for 3 months beyond attaining a serum urate concentration < 6.5 mg/dl . Treatment arms were analyzed regarding frequency of flares , likelihood of any flare or multiple flares , severity of flares on the visual analog scale ( VAS ) , and length of flares in days . RESULTS Forty-three subjects were studied . Subjects treated with colchicine experienced fewer total flares ( 0.52 vs 2.91 , p = 0.008 ) , fewer flares from 0 to 3 months ( 0.57 vs 1.91 , p = 0.022 ) , fewer flares 3 - 6 months ( 0 vs 1.05 , p = 0.033 ) , less severe flares as reported on VAS ( 3.64 vs 5.08 , p = 0.018 ) , and fewer recurrent gout flares ( p = 0.001 ) . Colchicine was well tolerated . CONCLUSION Colchicine prophylaxis during initiation of allopurinol for chronic gouty arthritis reduces the frequency and severity of acute flares , and reduces the likelihood of recurrent flares . Treating patients with colchicine during initiation of allopurinol therapy for 6 months is supported by our data
1st MTP pain was a prominent feature in people with gout .
Imaging features were common at the 1st MTP including the double contour sign , tophi and erosions .
Conclusions 1st MTP acute arthritis is highly prevalent in people with gout and has a substantial impact on patient-reported pain and disability .
Gout affects the structure and function of the 1st MTP .
Microscopic and imaging studies have demonstrated crystal deposition and joint damage at the 1st MTP in people with gout
Background The aim of this review was to qualitatively synthesis e studies that have investigated characteristics of the  first metatarsophalangeal joint ( 1st MTP )  in gout and to undertake a meta- analysis to estimate the average prevalence of acute 1st MTP arthritis across studies in people with gout .