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WOS: 000393320300008 Gout is a disease cauising severe and sudden pain, tenderness, rash, edema and temperature rise in the joints. Although it appears generally in males, it can also be seen especially in postmenopausal women and it can rise in the joints except toe joint. It should be kept in mind for differential diagnosis and clinical approach in chronic hand arthritis. Sixty-one years old female patient admitted to our clinic with swelling and pain in the right second finger existing for several months. She had hypertension and was on 5 mg/day amlodipin and she was diagnosed with gout 9 years ago and was on colchicine 1 mg/day, allopruinol 300 mg/day. There were gray color changing, swelling, movement restriction and pain on 2. distal interphalengeal joint. Body mass index of the patient was 38 kg/m(2). Blood analyses values were normal and uric acid level was detected 6.2 mg/dL (normal 4.2-5.4 mg/dL). There were subchondral osteopenia, severe intraarticular narrowing and degenerative changes at X-ray examination. The medical treatment of patient was planned and she was consulted for surgery to orthopedics clinic. Uric acid crystals cumulate in joints and their environment in chronic gout patients. These accumulations are called tophus when they get together abundantly. They occur under the skin as swelling. Tophuses generally located at affected joints and their environment, on fingers, on elbows or external ear. Tophuses can damage joints. Although it appears generally in males, it can also be seen especially in postmenopausal obese women and it can rise in the joints except toe joint. It should be kept in mind for clinical approach, treatments and preventing unnecessary surgeries chronic gout arthritis.

Dorsal nasal gouty tophus are rare occurrences with limited documentation. Here we report a male patient who has a history of poorly controlled gouty arthritis. He had nasal obstruction with an enlarging mass over his left nasal ridge for the past three years. Image studies revealed a nasal bone defect underneath the nasal lesion. The firm mass was excised and confirmed to be of gouty origin. The nasal bone defect was repaired with a titanium mesh plate to prevent nasal depression. He has fully recovered with no more nasal obstruction or recurrence of nasal tophus. The case report illustrates a common illness, gout, with a rare clinical manifestation leading to a common symptom, nasal obstruction. It demonstrates the importance of a detailed history, a thorough physical examination and most important of all, an extensive differential diagnosis in our clinical practice. Keywords: Nose, Gouty tophus, Bone

©2016 Turkish League Against Rheumatism. All rights reserved. Gout is a clinical disorder resulting from urate crystal deposition.1 Tendinopathy and enthesopathy are extra-articular gout manifestations. The common sites involved in knee are the popliteus tendon, cruciate ligaments, and quadriceps tendon.2 Although patellar tendon has been mentioned as a possible involvement site, to our knowledge, only three case reports exist in the literature, two of which were reported in triathletes mimicking patellar tendonitis precipitated due to prolonged exercises.3-5 In this article, we report a 34-year-old male patient with eight years history of gout who presented with one week history of pain and swelling of extremities. He underwent excision of the olecranon bursae and biopsy from the tophus involving first toe three years ago. Recurrent gouty attacks were treated with nonsteroidal anti-inflammatory drugs, colchicines (1 mg/day), and analgesics. Serum uric acid level was 11.9 mg/dL, C-reactive protein was 18.2 mg/dL. Allopurinol had been discontinued due to elevated liver enzymes (alanine transaminase: 132 U/L; aspartate aminotransferase: 85 U/L). Physical examination demonstrated tophi overlying the toe, and tenderness over the caudal aspect of patella. The patellar tendon was slightly thickened on radiographs. Soft tissue tophus at the interphalangeal joint causing adjacent erosive changes, and swelling of olecranon bursae were seen (Figure 1). Magnetic resonance imaging showed fusiform mass-like thickening of the proximal patellar tendon, measuring 30x16 mm, with intermediate signal on T1 weighted and T2 weighted images. Edema of the tendon at insertion and patellar cortical irregularities not seen on radiograms were demonstrated (Figure 2).

Isolated intraosseous gouty invasion is a rare presentation of gout. Although most patients will have a history of gouty arthritis or hyperuricemia, others will have an insidious onset of local pain, tenderness without significant swelling, or inflammation. Surgical debridement is the mainstay of treatment for intraosseous tophus formation.

Fractures in the sesamoid bones may occur by direct trauma or repetitive overuse (stress fractures). Acute fracture of the hallucal sesamoids is seen most often with dislocation of the metatarsophalangeal joint after a high-energy injury1. A chronic stress fracture of the sesamoid bone is generally found in athletes and can be difficult to differentiate from other conditions that affect the hallucal sesamoids2. The optimal choice of treatment remains unclear3. In chronic tophaceous gout, urate deposition may occur in articular cartilage, subchondral membranes, joint capsules, and periarticular tissues. An isolated intraosseous tophaceous lesion in the hallucal sesamoids is rare4-7. We found only one previously published report describing a chronic stress fracture and nonunion of a hallucal sesamoid that was associated with tophaceous gout8. To our knowledge, there have been no previously published reports of an acute comminuted pathologic fracture of a hallucal sesamoid with a tophaceous deposit. We describe a rare case of an acute comminuted pathologic fracture with tophus of the fibular sesamoid in a young soldier with no history of gout or underlying systemic disorder. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A twenty-year-old soldier with no history of gout noted a painful disability of the right forefoot during a military march. The pain persisted for several days, and he was not able to bear weight in the standing position. He noted that he had experienced similar forefoot pain three years prior; he had also experienced similar symptoms several times before, but with less intensity. The pain increased during forced dorsiflexion of the …

Hyperuricemia and gout are associated with increased risk of cardiovascular disease and metabolic syndrome. The aim of this study was to evaluate the correlation of total tophus volumes, measured using dual-energy computed tomography, with cardiovascular risk and the presence of metabolic syndrome. Dual-energy computed tomography datasets from 91 patients with a diagnosis of gout were analyzed retrospectively. Patients who received urate lowering therapy were excluded to avoid the effect on tophus volume. The total volumes of tophaceous deposition were quantified using automated volume assessment software. The 10-year cardiovascular risk using the Framingham Risk Score and metabolic syndrome based on the Third Adult Treatment Panel criteria were estimated. Fifty-five and 36 patients with positive and negative dual-energy computed tomography results, respectively, were assessed. Patients with positive dual-energy computed tomography results showed significantly higher systolic blood pressure, diastolic blood pressure, fasting glucose, and higher prevalence of chronic kidney disease, compared with those with negative dual-energy computed tomography results. The total tophus volumes were significantly correlated with the Framingham Risk Score, and the number of metabolic syndrome components (r = 0.22 and p = 0.036 and r = 0.373 and p

OMERACT proposed a set of mandatory and discretionary domains to evaluate the effect of treatment in patients with gout. To determine the percentage of improvement and the effect size 6 and 12 months after starting a proper treatment in patients with gout from our cohort (GRESGO) based on the OMERACT proposal for chronic gout. GRESGO is a cohort of consecutive, new patients with gout attending either of two dedicated clinics. This report includes 141 patients evaluated at baseline and 6 months plus 101 of them completing a 12-month follow-up in 2012. Clinical data including the OMERACT domains for chronic gout were collected at baseline and every 6 months. Treatment was prescribed by their attending physician with the purpose of getting 6 mg/dL of seric uric acid (sUA). Most patients were males (96%) with inappropriate treatment (95%); 66% had tophi, 30% metabolic syndrome, and 32% low renal function. Mean dose of allopurinol at baseline and throughout the study went from 344 ± 168 mg/day to 453 ± 198 at 12 months. Most OMERACT domains and renal function improved significantly; 73% improved 20% from 6 to 12 months. Greater improvement was observed in the domains: flares, index tophus size, pain, general health assessment, and HAQ score, all of them associated to lower sUA values. Chronic gout patients improve significantly in most OMERACT domains when conventional and regular treatment is indicated. sUA 6 mg/dL is associated with greater improvement.

Background Ultrasonography (US) and dual-energy computed tomography (DECT) can assess urate burden in gout. The objective of this study was to compare the quantification of urate deposition provided by US to the one provided by DECT. Methods Patients with a diagnosis of gout were prospectively recruited to undergo quantification of urate deposition using US and DECT. US examination for tophi and the double contour (DC) sign was performed on the knees and feet and corresponding DECT scans provided volumes of tophi and of overall urate deposition. The primary endpoint was the intra-class correlation coefficient (ICC) of the volume of the index tophus measured by US and DECT and its 95% confidence interval (CI 95%). Results Of the 64 patients included, 34 presented with at least one tophus on US. DECT inter-reader agreement for urate deposition was perfect with an ICC of 1 (1–1) and good for the measurement of the index tophus with an ICC of 0.69 (0.47–0.83). The ICC for the measurement of the index tophus between the two techniques was poor with a value of 0.45 (0.1–0.71). The average ratio between the index tophi volume as assessed by DECT and US was 0.65. The number of DC-positive joints did not correlate with DECT volume of overall deposits (Spearman correlation coefficient of 0.23). Conclusions DECT measurements of tophi give smaller volumes to the same tophi measured with US, and US signs of urate deposition in joints do not correlate with overall DECT volumes of extra-articular deposition. Electronic supplementary material The online version of this article (doi:10.1186/s13075-017-1381-2) contains supplementary material, which is available to authorized users.

Objective.To investigate the frequency and distribution of characteristics of the Achilles tendon (AT) in people with tophaceous gout using musculoskeletal ultrasound (US).Methods.Twenty-four participants with tophaceous gout and 24 age- and sex-matched controls without gout or other arthritis were recruited. All participants underwent a greyscale and power Doppler US examination. The AT was divided into 3 anatomical zones (insertion, pre-insertional, and proximal to the mid-section). The following US characteristics were assessed: tophus, tendon echogenicity, tendon vascularity, tendon morphology, entheseal characteristics, bursal morphology, and calcaneal bone profile.Results.The majority of the participants with tophaceous gout were middle-aged men (n = 22, 92%) predominately of European ethnicity (n = 14, 58%). Tophus deposition was observed in 73% (n = 35) of tendons in those with gout and in none of the controls (p < 0.01). Intratendinous hyperechoic spots (p < 0.01) and intratendinous power Doppler signal (p < 0.01) were more frequent in participants with gout compared to controls. High prevalence of entheseal calcifications, calcaneal bone cortex irregularities, and calcaneal enthesophytes were observed in both gout participants and controls, without differences between groups. Intratendinous structural damage was rare. Hyperechoic spots were significantly more common at the insertion compared to the zone proximal to the mid-section (p < 0.01), but between-zone differences were not observed for other features.Conclusion.US features of urate deposition, tophus, and vascularization are present throughout the AT in patients with tophaceous gout. Despite crystal deposition, intratendinous structural changes are infrequent. Many characteristics observed in the AT in people with tophaceous gout, particularly at the calcaneal enthesis, are not disease-specific.

Background Preliminary criteria for remission in gout patients have recently been proposed. These include serum urate, acute flares, tophus, pain and patient global assessment. 1 These preliminary criteria were based on consensus exercises and have not yet been tested in a large clinical trial database of chronic gout patients. Because of the availability of clinical results from subjects with chronic refractory gout treated with pegloticase (8 mg every 2 weeks), a mammalian recombinant uricase conjugated to polyethylene glycol that is approved in the US for treatment of adult patients with chronic gout refractory to oral urate lowering therapy 2 , the utility of these proposed criteria could be assessed. Objectives To test the utility of the preliminary criteria to discern a complete response (CR) in subjects with chronic refractory gout treated with pegloticase (8 mg every 2 weeks). Methods Data from two randomized clinical trials (RCT) evaluating the impact of pegloticase therapy in subjects with chronic refractory gout were examined. 2 Of this group of subjects, 42% had persistently lowered serum urate and 58% did not meet the urate-lowering endpoint of this RCT. Initially, individual patient data was reviewed to establish the frequency with which subjects, who were responders to pegloticase, met the proposed remission criteria. Mixed modeling was then employed on data from these subjects to determine the components of the model that best correlated with time of maximum benefit. Results Of 34 pegloticase responders, 25 (73.5%) met the published criteria 1 of remission. However, pain assessment was often an outlier; data obtained by visual analogue scale and Medical Outcomes Study Short Form-36 questionnaire often differed. Mixed modeling was, therefore, carried out using the data obtained from the subjects meeting criteria for remission to determine the components that best correlated with time to maximum benefit. Other clinical outcome measures assessed in the clinical trial were also analyzed. Besides serum urate levels in the mixed modeling analysis, the components of response that best correlated with time of maximum benefit included assessment of tophi (analyzed photographically), number of swollen joints, number of tender joints and patient global assessment. Using these criteria, 25 of the responders (73.5%) and 29.4% of the entire pegloticase-treated population met criteria for a CR. The median time to reach a CR was 252 days (range: 126–966 days). Of interest, when a decrease in serum urate was omitted, 6 (12.2%) of the pegloticase nonresponders also met criteria for a CR. Patients receiving placebo did not achieve the composite outcome measure considered as CR. Conclusions These results have defined criteria for achieving CR in individuals with chronic refractory gout treated with pegloticase and suggest that most individuals who persistently lowered their serum urate levels while on pegloticase reached criteria for CR in a median of 8.4 months. This composite CR definition can serve as an evidence-based target aiding the design and endpoints of future clinical trials. References deLautour H, Taylor WJ, Adebajo A, et al. Arthritis Care Res. 2016;68:667–672. Sundy JS, Baraf HSB, Yood RA, et al. JAMA. 2011;306:711–720. Disclosure of Interest N. Schlesinger Grant/research support from: AstraZeneca, Consultant for: Pfizer, AstraZeneca, Proteothera, Celgene, Horizon, P. Khanna Grant/research support from: AstraZeneca, Consultant for: Horizon, Ironwood, Selecta Bio, A. Yeo Consultant for: Horizon Pharma, P. Lipsky Consultant for: AstraZeneca, Celgene, EMD Serono, GSK, Horizon Pharma, Janssen, Medimmune, Pfizer, Roche, Sanofi, UCB

Background Gout is a chronic, progressive, inflammatory disease characterised by elevated serum uric acid (sUA) levels. sUA levels above its saturation point result in the deposition of monosodium urate crystals, which lead to gout flares and tophi (1). Multiple studies support the use of sUA levels as a marker for clinical improvements; hence the therapeutic goal is to lower sUA levels ( Objectives To conduct a systematic review to identify studies reporting the effect of sUA levels on the incidence of gout flares and tophus status in adult patients with gout/hyperuricaemia, with a focus on publications reporting a correlation between the parameters. Methods Publications were identified by interrogating electronic databases; Medline & MEDLINE In-Process, EMBASE and the Cochrane Library (accessed 6 Sept 2016). Eligibility criteria included adult patients with a diagnosis of acute/chronic gout or hyperuricemia, with no restriction on publication date, study design or geography. Results In total, 59 studies met the pre-defined inclusion criteria and were reviewed; of these, 17 reported the relationship between sUA levels and flares (n=12) and/or tophus status (n=11). Two studies were multinational (North America), and 15 were single country (US [n=10]; Spain [n=2]; New Zealand [n=1]; Germany [n=1]; Japan [n=1]). The majority of studies had a follow-up period of ≤1 year, with one reporting 10 years9 follow-up. All 12 studies evaluating flares reported that achieving sUA levels ≤6 mg/dL was associated with a decreased risk of gout flares, compared with sUA levels >6 mg/dL (p 6 mg/dL (p Conclusions Maintenance of sUA levels 5 years) are warranted, this review further supports that decreases in sUA levels are a marker for clinical improvements. References Keenan R, et al. Etiology and pathogenesis of hyperuricemia and gout. Elsevier Saunders. 2013;94:1533–53. Richette P, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis. 2016:annrheumdis-2016–209707. Shoji A, et al. A retrospective study of the relationship between serum urate level and recurrent attacks of gouty arthritis: evidence for reduction of recurrent gouty arthritis with antihyperuricemic therapy. Arthritis Care Res. 2004;51(3):321–5. Disclosure of Interest S. Mitchell: None declared, L. Manounah: None declared, H. Liedgens Employee of: Grunenthal GmbH, E. Johannes Employee of: Grunenthal GmbH

Background It has been suggested that the velocity of resolution of tophi in persons with chronic tophaceous gout is related to the serum urate levels.1 However, few subjects with a persistent serum urate less than 4.0 mg/dL were studied. Pegloticase is a recombinant uricase conjugated to polyethylene glycol approved in the US for treatment of patients with chronic refractory gout. It profoundly decreases serum uric acid in responders to Objectives To assess the velocity of tophus resolution in subjects treated with pegloticase for chronic refractory gout. Methods This analysis used results from two randomized controlled trials (RCTs) of 6 months duration.2,3 For tophus measurements, serial standardized digital photographs were analyzed by a blinded reader using computer-assisted quantitative measurement software. Subjects were defined as responders and nonresponders based upon maintenance of a serum urate Results During the 6 months of the RCTs, a total of 952 tophus measurements were analyzed in 87 subjects, including 341 in 30 responders; 361 in 36 nonresponders receiving pegloticase infusions; and 250 in 21 subjects receiving placebo infusions. Mean serum urate levels in these subjects were 10.1, 0.3 and 0.3 mg/dL at baseline, 3 months and 6 months in responders; 10.7, 8.9 and 9.6 mg/dL in nonresponders; and 10.2, 9.8 and 9.7 mg/dL in placebo treated patients, respectively. At baseline, the mean tophus area in responders was 581.6 +/- 742.7 mm2 (mean ± SD; n=90 tophi); in nonresponders it was 676.5+/-1416.6 mm2 (n=93 tophi); and in placebo treated subjects it was 672.9+/-1039.5 mm2 (n=66 tophi). By regression analysis, the velocity of tophus resolution over the 6 months of treatment was 50.1 mm2/month in responders; 14.0 mm2/month in nonresponders; and 13.9 mm2/month in placebo treated patients (responders versus nonresponders or responders vs placebo treated subjects (p=0.001)). In responders, the mean time to total tophus resolution was estimated to be 347 days (11.5 months, with a range of 5.6–36.4 months). During the 6 month treatment period, the area under the curve (AUC) of multiple serum urate measurements in responders was 6,067.9+/-6,781.6 mg/dL hr compared with 34,647.4+/-8,586.7 and 42,451.1+/-6,396.1 mg/dL·hr in nonresponders and placebo treated subjects, respectively (p Conclusions Pegloticase treatment causes a rapid resolution of tophi in responders as predicted from the profound and persistent serum urate lowering associated with this therapy. References Perez-Ruiz F et al, Arthritis Rheum 2002; 47:356–60. Sundy JS, et al. JAMA. 2011;306:711–720. Becker MA, et al. Ann Rheum Dis. 2013;72:1469–1474. Disclosure of Interest B. Mandell Grant/research support from: Horizon, Consultant for: Horizon, Ironwood, A. Yeo Consultant for: Horizon Pharma, P. Lipsky Consultant for: AstraZeneca, Celgene, EMD Serono, GSK, Horizon Pharma, Janssen, Medimmune, Pfizer, Roche, Sanofi, UCB

Background The recent ACR/EULAR classification (1) classify gout in patients with at least 8 out of maximum 23 points, but presence of monosodium urate crystals in a symptomatic joint/tophus alone is sufficient for gout classification without need for further scoring. It is not known how in crystal-proven patients with increased serum urate (sUA) the whole range of classification points distribute. Objectives To determine the distribution along the spectrum of ACR/EULAR criteria in crystal-proven patients with insufficiently treated sUA levels, and if disease factors in gout are associated with high classification scores. Methods Baseline data from a prospective observational study were used from patients with crystal-proven gout who presented after a recent gout flare. Included patients had at baseline insufficiently treated sUA level (>360 μmol/L [>6 mg/dl]). Demographic, clinical data and sUA levels were collected from September 2015 to December 2016 in one rheumatology department. Ultrasound of joints was assessed with one total score for double contour sign, tophus, and aggregates in several joints and tendons/entheses. The score for ACR/EULAR criteria for gout was calculated. Results 89 patients were included, with baseline mean (SD) age 56.0 (14.8) years, 92% males, 88% Caucasians, disease duration 7.9 (7.3) years, presence of palpable tophi 19%, ultrasound score 19.9 (13.8), serum urate 486 (90) μmol/L, creatinine 78 (18) ml/min, creatinine clearance 78 (18) ml/min, ESR 14 (14) mm/h, body mass index 29.4 (4.9) kg/m2, comorbidity score [SCQ] 3.5 (3.2), and physical function [HAQ] 0.34 (0.51). All patients satisfied clearly the scoring arm of the classification criteria with a median (range) 19 (11 – 23) of 23 possible points (Figure 1). Patients with a median and higher score above the median (≥19 points) vs. lower score reported more gout flares during the last 12 months (p Conclusions As expected, patients seen in the clinic with crystal-proven gout and at least slightly increased sUA also satisfy the scoring arm of the new classification criteria for gout, supporting their clinical use. Patients with classification points above the median had more flares in the preceding year, and a higher urate burden assessed by ultrasound, but did not have other indicators for a more severe disease. References Neogi T et al. Ann Rheum Dis 2015;74:1789–98. Disclosure of Interest T. Uhlig: None declared, L. F. Karoliussen: None declared, E. A. Haavardsholm: None declared, T. K. Kvien Consultant for: Fees for speaking and/or consulting from AbbVie, Biogen, BMS, Boehringer Ingelheim, Celltrion, Eli Lilly, Epirus, Janssen, Merck-Serono, MSD, Mundipharma, Novartis, Oktal, Orion Pharma, Hospira/Pfizer, Roche, Sandoz and UCB, H. B. Hammer: None declared

Background Gout is due to monosodium urate (MSU) crystal deposition after chronic hyperuricemia. Although MSU crystal deposition can occur in every joint and peri-articular structure, spine involvement is scarcely reported. Dual energy computed tomography (DECT) is a performant tool to assess urate deposits, especially in deep structures such as intervertebral discs and apophyseal joints. Objectives to describe spinal DECT features of urate monosodium deposits compared to peripheral joint DECT. Methods Patient with gout diagnosis (MSU crystal identification by polarized microscopy or fulfilling “Nijmegen9s criteria” (1)) who had undergone DECT were included from November 2012 to June 2016. Images were analyzed by a trained musculoskeletal radiologist. For each DECT, clinical and biochemical characteristics of each patient were collected retrospectively. Results 22 patients (men 77%), mean age 62.5 years and mean BMI 28.4 kg/m2 were included. Mean gout duration was 108.0±114.4 months, mean of last available serum uric acid level was 520±193 μmol/l, and 15 patients had at least one clinical tophus. Mean estimated glomerular filtration rate (MDRD formula) was 47±27 ml/min/1.73 m2. One patient was on hemodialysis and one had received kidney transplant. A total of 39 DECT has been performed: 28 of peripheral joints and 11 of the spine (9 lumbar, 1 sacroiliac and 1 cervical). Spinal DECT were done in 10 patients to explore recurrent inflammatory pain (n=3 lumbar, 1 cervical and 1 buttock) or mechanical back pain (n=2 lumbar). 4 spinal DECT were performed in asymptomatic patients with extended peripheral tophi. Spinal MSU crystal deposits were disclosed by DECT in 83% (5/6) and 25% (1/4) of symptomatic and asymptomatic patients, respectively. In all painful patients, MSU crystal deposition was considered as a likely explanation of spinal symptoms. MSU crystal depositions was identified in apophyseal joints (n=5), cervical intervertebral disc (n=1) and yellow or interspinous ligaments (n=4). All involved apophyseal joints were eroded (figure 1). No vertebral bone erosion was observed. Calcification of spinal tophus was observed in 4 patients. DECT identified peripheral deposits in 15/18 (83.3%) patients. In peripheral DECT, bone erosions were observed in 71.4% and joint effusion in 32.1% of DECT positive peripheral joints. MSU crystal depositions were observed in tendons, cartilages or synovial membranes in 82.1% of positive DECT joints and in soft tissues in 64.3% of positive patients. MSU crystal deposits were calcified in 7 cases. Conclusions MSU crystal depositions at the spine are present in 60% of patients in this retrospective DECT study. DECT can represent a performing imaging procedure for their detection in symptomatic patients. Further studies are needed to assess the clinical utility of DECT of the spine in gout. References Janssens HJ, Fransen J, van de Lisdonk EH, et al. A diagnostic rule for acute gouty arthritis in primary care without joint fluid analysis. Arch Intern Med 2010;170:1120–6. Disclosure of Interest None declared

Background From rheumatologist point of view (secondary care) there is a serious concern about suboptimal treatment of gout patients in primary care with warnings for worse prognostic consequences.(1) Some refer even to a “state of suboptimal gout care” promoted by “substantial gaps between rheumatologists and primary care providers” in their approaches to gout care:(2) the strategy of “treating-to-target” (to lower serum uric acid (SUA) levels Objectives To quantify the occurrence of flares and the use of ULT, in primary care patients with gout, and to analyze patient characteristics related to low or high flare frequency. Methods A retrospective cohort study (setting one Dutch primary care center with an integrated medical praxis and pharmacy). Electronic medical records of ca. 5800 enlisted patients were used to select all patients with gout, to analyze their ULT use, and to assess flare frequency in a 2-year time window (2014–2015). Flare was defined as each pharmacy delivery of an anti-inflammatory drug or pain killer linked to a morbidity code for gout. Associations were studied between high or low flare frequency and patient characteristics by univariate logistic regression. Results Of 173 included patients (prevalence 3%; mean age 66.4 yr; 75.7% men) 38.7% used ULT persistently during the 2-year time-window. Median time after initial diagnosis was 8.0 yr (IQR 3.0–14.5). Mean total numbers of flares in two years was 2.7 (SD: 4.7), median 1.0 (IQR: 0.0–4.0). Of the patients not receiving ULT (n=106, 61.3%) 41.5% had never, 25.5% one or two, and 6.6% more than six flares during two years. No associations were found between patient characteristics (e.g. age, time after initial diagnosis, crystal diagnosis, ULT use, cardiovascular co-morbidity, diuretic use) to differentiate patients with “no-or-1-flare” and “2-or-more-flares” per two years. Conclusions Occurrence of flares in this stringently observed primary care cohort of patients with gout was very low, even if most patients did not use prophylactic ULT. Only 6.6% of patients experienced >6 flares in two years. Patients, in particular those not using ULT and with a low flare frequency (the majority), may reflect individuals with a distinctive (moderate) disease activity. They probably do not fulfill the general accepted advancing course of gout with ongoing and increasing flare frequency, MSU deposition, tophus formation, and joint damage. Immediate lifelong ULT for them may not be automatically indicated. Our study shows that suboptimal gout management in the perception of rheumatologists (secondary care) does not lead to an abundant number of gout flares in primary care patients. This urges to caution when recommendations based upon secondary care guide lines are advised for primary care patients with gout. References Doherty M, et al. Ann Rheum Dis 2012;71:1765–70. Dalbeth N, et al. Arthritis Rheumatol 2017;69:22–34. McLean RM, et al. Ann Intern Med 2017;166:73–4. Morillon MB, et al. BMJ Open 2016;6:e012026. Disclosure of Interest None declared

Background Primary gout is a metabolic disease occurred in male and post-menopause female in most cases. Though the ultrasound features of gout had been discovered for several years, no reports illuminated whether there would be difference presentations between different genders in the joints. Objectives We employed ultrasound instead of dual-energy CT to explore more refined pathological manifestations of primary gout in different genders. Methods All cases were confirmed as gout fulfilling 1997 ACR classification criteria. All cases excluded secondary gout induced by drug, tumor, hypertension, diabetes mellitus, renal failure. Ultrasound was performed during chronic stage of gout but not at acute attack. The process was done by 2 observers blinded to each other, blood tests. Final diagnosis was determined by the third US expert if the 2 observers got the different conclusion. Bilateral toes, dorsal feet, ankle, knee, wrist, fingers, elbow, and shoulder were detected to find 6 features of gout suggested by OMERCT: tophus, “snow storm”-like effusion, cloudy synovium in grey scale, double-contour sign, bone erosion and Power Doppler (PD) signal. Each above positive presentations in each above range would get 1 point and the sum scores would be ranged from 0 to 84. Serum uric acid (UA) was recorded too. Results 1) 23 female and 139 male were recruited in the program. The female-male ratio was 1:6. Mean age and disease duration of the female subjects were elder than male ones (female:male=57.2±14.1: 44.7±14.7 years old) with longer disease duration to confim the diagnosis (female:male = 10.9:1.2 months). The average serum UA level in female was lower than male group (female:male = 413.8±162.1umol/L, 515.5±156.9umol/L, sig 2) The intra-observer reliability from 20% samples random seclection showed an overall agreement of 80%, 92%, 96%, 87%, 80%, 73% for tophus, “snow storm”-like effusion, cloudy synovium in grey scale, positive double-contour sign, bone erosion and PD signal with kappa value of 0.78, 0. 92, 0.95, 0.86, 0.79, 0.72, respectively. 3) The difference showed female gout had higher frequency of tophus, bone erosion and lower frequency of effusion while the other indexes were equal:topus scores (female:male=87%:,74.1%), cloudy synovium grey scale scores (female:male=65.2%:62.6%), effusion scores (female:male=17.4%,31.7%), bone erosion scores (female:male=30.4%,16.5%), power dopplar scores (female:male=34.8%,41%), positive double-contour signs (60.9%:59.9%. The top 2 affected ranges were ankle (female:male=69.6%:55.3%), knee (female:mlae=60.9%:54.0%). Furthermore, female gout had more frequently occurred not in the less typical ranges such as fingers (female:male=34.7%:19.4%), elbow (8.7%:2.7%), which might be the cause for delayed diagnosis. Conclusions Though the level of serum UA was lower, Female gout had its unique ultrasound features with more tophus, bone erosion and less effusion compared to male gout. The less typical ranges were recommended for US examinations. Disclosure of Interest None declared

Background The foot and ankle represent a common site for tophi in people with gout, yet it is unclear whether the presence of tophi is related to impaired muscle function. This study aimed to determine the association between foot and ankle tophi and muscle force in people with gout. Methods Participants with gout were stratified into two groups based on the presence of clinically-evident tophi affecting the foot or ankle on physical examination. Isometric muscle force for plantarflexion, dorsiflexion, inversion and eversion was measured using static dynamometry. Mixed-models regression was used to determine the difference in muscle force between the two groups while adjusting for age, disease duration and foot pain. This model was also used to determine the difference in muscle force between presence and absence of tophi at specific locations within the foot and ankle. In addition, Pearson’s correlations were used to determine the association between total foot tophus count and muscle force. Results Fifty-seven participants were included (22 with foot or ankle tophi and 35 without foot or ankle tophi). Foot and ankle tophi were most often seen at the Achilles tendon. After adjusting for age, disease duration and foot pain, participants with tophi had significantly reduced muscle force during plantarflexion (P 0.05). Conclusion In people with gout, clinically-evident foot or ankle tophi are associated with muscle force deficits during foot plantarflexion, dorsiflexion, inversion and eversion, which persist despite adjusting for age, disease duration and foot pain. Tophi at the Achilles tendon, which associate with force deficits, may contribute to reduced muscular activation and consequent disuse muscle atrophy.

Background Peripheral neuropathies (PN), are peripheral nervous system disorders associated to several causes. According to distribution are classified as: Local (mononeuropathy [MNP]) or Systemic (Multiple mononeuropathy [MNPM] and polyneuropathy [PNP]). PN in gout has been scarcely described. Previous reports only consider MNP of median nerve at the wrist and MNP of the ulnar nerve at the elbow, due to tophus compression. Objectives To describe the frequency and characteristics of PN in patients with gout and its association to gout related variables, co-morbidity and treatment. Methods Consecutive patients from GRESGO, a cohort of 450 gout (ARA/CGD/ACR-EULAR) patients seen for the first time at Rheumatology department and treated according to published guidelines for gout. Variables included: demographic, clinical, biochemical data, HAQ and 3 questionnaires for PN (DN4, LANSS and MNSI) previously translated and validated in our country. We performed Nerve Conduction Studies (NCS) following AAME guidelines (Include:Sensory action potential [sural, ulnar and median nerves], Compound muscle action potential [peroneal, tibial, median and ulnar nerves] and late F-wave [tibial and ulnar nerves]). This protocol was approved by the local IRB and the patients signed an informed consent. Statistical analysis: Student9s t test, Mann–Whitney U test and X2. Results We included 162 gout patients, 98% males, 72% tophaceous gout, 48% severe tophaceous gout (STG), mean age 49.4±12 years, 14±10 years of disease duration, educational level 8±4 years, BMI 27.9±4.6kg/m2. According to questionnaires: 56% DN4, 45% MNSI and 36% LANSS could be classified as PN. Sixty five percent had abnormal NCS: MNP: 52%, most of them (58%) neuropraxia. PNP 35% and 13% MNPM in them, axonal damage was reported in 88%. MNP localization: Median nerve/carpal tunnel (89%); peroneal nerve/fibula head (7.4%); ulnar nerve/elbow (1.8%) and tibial nerve/ankle (1.8%). For associated factors, Gout+Local PN (L-PN) patients were compared with Gout without PN as well as Gout+Systemic PN (S-PN) (see table). Hypertriglyceridemia and dyslipidemia were significantly more frequent among L-PN patients; in other hand, frequency of tophi, STG and mean HAQ values were significantly more frequent in S-PN patients, there were no significant differences among other clinical data associated with gout itself. Conclusions PN is common among gout patients, PN could be diagnosed by questionnaires (particularly DN4) and NCS in 65%. L-PN (median nerve most of them) explain 52% of the cases, in 48% S-PN was found, in these group PNP is more frequent. Hypertriglyceridemia is associated with L-PN and STG to S-PN. The role of uric acid and/or crystals needs to be evaluated. Disclosure of Interest None declared

Background Gout is due to monosodium urate (MSU) deposition in joints and soft tissues. Ultrasonography (US) and dual-energy CT (DECT) have been shown to be effective in detecting MSU deposits. Both techniques can examine tophi size. DECT is effective to identify soft-tissue MSU deposits and US can show joint deposition with the double contour (DC) sign. It is unknown if these two techniques provide the same quantification of the extent of urate deposition on a given patient. Objectives The main objective of this study is to compare the tophus size measured by US and by DECT. The secondary objective is to evaluate the correlation between the prevalence of the US DC sign and the global volume of urate deposits measured by DECT. Methods This prospective cross-sectional study included patients fulfilling the 2015 ACR/EUALR criteria for gout. Patients underwent US and DECT examinations of their knees and feet. The largest US tophi was selected as the index tophus. US examination of the DC sign was performed on the femoro-patellar joints, talo-crural joints and 1st metatarsophalangeal joints. Total volume of urate deposits of knees and feet was measured by DECT. The primary endpoint was the intra-class correlation coefficient (ICC) of the volume of the index tophus measured by US and DECT [CI 95%]. Results A total of 64 patients were included in the study, of which 35 patients presented with at least one US tophus. Patients were in average 64.5±16.3 years old, 84.4% were male, had an average ACR/EULAR score of 13.6±2.5, and disease duration was 12±14.7 years. Overall, 44 patients (68.8%) were currently taking urate lowering therapy and 22 patients (34.4%) had clinical tophi. Out of the 35 US selected largest tophi, 6 tophi were not seen in DECT. Of the tophi identified with both techniques, 21 were localized in the feet and 8 in the knees. The ICC of the tophus volume assessment by US and DECT was 0.45 [0.12–0.69]. The average volume of the largest US tophi was 2.7±6.5 cm3 and 1.5±3.3cm3 when measured by DECT. If the index tophus was localized in the knee, the ICC was 0.36 [0–0.82] and was 0.68 [0.37–0.86] if the tophus was in the foot. The Spearman correlation coefficient between the DECT urate volume and the number of joints with a positive DC sign was 0.15. Conclusions US and DECT do not provide the same assessment of tophus size. The correlation is improved when considering tophi localized in the feet. The number of joints with positive DC sign does not correlate to the volume of urate deposition in the soft tissues measured by DECT. Disclosure of Interest None declared

Background Hyperuricemia is associated with worsened outcomes in patients with heart failure (HF). However, little is known about the association between gout and HF. Objectives To assess the impact of gout control on the rate of hospitalization for acute HF in a prevalent gout population. Methods This retrospective database analysis used data from the Clinical Practice Research Datalink-Hospital Episode Statistics (UK) from Jan 1, 2009 to Dec 31, 2011. Patients were required to have evidence of “prevalent established gout” (ie, treated with urate-lowering therapy [ULT] or eligible for ULT based on ACR guidelines) between Jan 1, 2009 and Dec 31, 2009 and be aged ≥18 on index date (Jan 1, 2010). Follow-up extended from Jan 1, 2010 to Dec 31, 2011. HF rate was calculated as the percentage of eligible patients having ≥1 HF-related hospitalization over the course of the calendar year. In each calendar year, patients were considered to have controlled gout if they had no elevated serum uric acid (sUA; ≥6 mg/dL), no diagnosis of tophus, and no flare documented. Uncontrolled gout was defined as ≥1 elevated sUA or 1 tophus diagnosis during the year. In this analysis patients with no documented sUA were considered not evaluable. To mitigate the limited availability of sUA data, a sensitivity analysis was conducted using an alternate definition of control status: if sUA was available, controlled was defined as no elevated sUA, no flare, and no tophi and uncontrolled was defined as ≥1 elevated sUA, tophus, or flare; if sUA was unavailable, controlled was defined as medication possession ratio (MPR)>80% and uncontrolled defined as 0% Results A total of 29,758 eligible gout patients were identified. Within the subset of patients with available sUA (4762 in 2010 and 4385 in 2011), the HF rate was consistently lower in patients whose gout was controlled in the ongoing year (adjusted OR: 0.253 in 2010 [P=0.032]; 0.268 in 2011 [P=0.019]). The sensitivity analysis conducted using MPR as a proxy for control in a larger population (26,999 patients in 2010 and 26,176 patients in 2011) yielded similar results (OR: 0.387 in 2010 [P Conclusions This study suggests that patients with controlled gout have a lower risk of being hospitalized for HF. Further studies would be required to validate this finding on larger samples. Acknowledgements This study was sponsored by Ardea Biosciences/AstraZeneca. Disclosure of Interest R. Morlock Consultant for: AstraZeneca, Ironwood, Ardea Biosciences, P. Chevalier Employee of: QuintilesIMS, A. Klein Employee of: AstraZeneca

Background Ultrasonography (US) has demonstrated its ability to detect urate deposition in gouty patients. Some US features have been suggested to be specific such as tophus and the double contour (DC) sign. In contrast to the usefulness of US for diagnosis, data are lacking on its role in follow-up of gout deposition after initiation of urate-lowering therapy (ULT). Objectives We aimed to determine the ability of US to show disappearance of urate deposits in gouty patients requiring ULT. Methods We performed a 6-month multicentre prospective study. To be included in the study, patients needed to have: i) a proven gout (identification of monosodic urate crystal in synovial fluid analysis or tophus aspiration), ii) presence of US features of gout (tophus and/or DC sign) at knee and/or first metatarsophalangeal joints (MTP1s). Serum uric-acid (SUA) level was assessed at baseline, M3 and M6. US evaluations were performed at baseline, M3 and M6 after starting ULT, by one local rheumatologist, blinded to SUA levels and clinical data. The primary outcome was the decrease (absolute value and percentage of decrease) of US tophus after 6 months of ULT, according to the final SUA levels. The secondary outcome was the mean percentage of joint sites with DC sign disappearance. Three stages of SUA levels were defined (high SUA levels: >360 μmol/l, low SUA: 300 -360 μmol/l, very low SUA: Results A total of 79 gouty patients (mean ± SD age 61.8±14 years, 91% of males) were included. The mean disease duration was 6.3±6.1 years. Tophi were found at clinical exam in 29% of patients. Baseline SUA levels were 530±97 μmol/l. At least one US tophus and DC sign were found in 74 (93.7%) and 68 (86.1%) of patients, respectively. Allopurinol and febuxostat was started in 26 (33%) and 53 (67%) patients, respectively. A total of 67 patients were completers at 6 months. Among those M6 completers, 39 and 18 patients achieved a very low and low SUA levels, respectively. The 10 remaining patients maintained high SUA levels. Comparison of US features of gout modifications between the 3 groups of final SUA levels revealed a higher decrease of US tophus size and higher proportion of DC sign dissolution among patients with lowest SUA levels (Table 1). Additionally, final M6 SUA levels was associated with: decrease size of tophus (r=0.5093 [0.3012; 0.6711], P Conclusions US is able to detect decrease or disappearance of US urate deposits after ULT. Additionally, the decrease of US deposits is strongly correlated with lowest SUA levels. These data suggest that US could be useful for ULT management in gouty patients. Disclosure of Interest None declared

Background Tophus burden (TB) was proposed by OMERACT as mandatory domain for chronic gout studies. Image methods although useful, frequently are not available in daily clinical practice. Objectives To evaluate TB clinically in a cohort of gout patients during 3 years follow-up. Methods We analyzed baseline and follow-up data (6, 12, 18, 20, 24, 30 and 36 months) of patients with gout (ARA/CGD/ACR-EULAR) from the GRESGO cohort; this analysis includes the patients with ≥1 clinical nodule(s) considered as tophi in the baseline visit. Index tophi size (ITS) was considered as the longer axis of the bigger tophi. TB evaluations: 1) Tophi number (T); 2) ITSt (cm) measured with tape; 3) ITSca (cm), measured with caliper; 4) ITSco, measured with compass. 5) Index tophi hardness (ITh) or consistency, by VAS (0: very soft-10 hard as a rock). This protocol was approved by the local IRB and patients signed and informed consent for their participation. All the patients received treatment for gout and associated diseases according to published guides and available drugs. The evaluations were done by the same group of physicians (Rheumatologists and Residents). Variables: TB measures, demographic, clinical and biochemical variables. HAQ and EUROQoL and VAS for pain and general health. Inter/intraobserver variability were evaluated. Statistical analysis: t test, X2, r, kappa, Friedman and multiple correlation. Results 298 patients; 97%males, 203 (68%) tophaceous gout, age, age at onset and duration of the disease were: 46.4±12.7 32.4±12.4 and 14.7±9.3 years respectively. Available ULT: Allopurinol and probenecid, colchicine as prophylaxis. Mean allopurinol dose prescribed at baseline visit was 346.9±154 mg/d and 550±205 mg/d 3 years later.TB values (see table). Index tophi size had r>0.93 among the 3 evaluations (ITSt, ITSca, ITSco) and r Conclusions In our cohort, ITSt was the best measure for TB evaluation, the 3 ITS measures had a good correlation between them and less with ITh or consistency. Patients with tophaceous gout, improved significantly with allopurinol and probenecid during 3 years follow-up in TB (ITSt) as well according to the other OMERACT proposed domains for chronic gout. Disclosure of Interest None declared

Background Acute gout is usually associated with a decrease in serum uric acid (SUA) level but the mechanism responsible for this phenomenon remains unclear. Objectives We aimed to investigate relationships between changes in SUA level, urinary excretion of uric acid and biochemical markers during gout attack. Methods SUA, eGFR (estimated glomerular filtration rate), serum CRP level and urinary excretion of UA, expressed as fractional excretion of UA (FeUA), from 35 ULT (urate-lowering therapy)-free and diuretic-free gout patients were prospectively measured during acute gout attack (Tc) and intercritical (Tic) phase. In 11 patients, data were available after achievement of SUA target (Tt) ( Results There were 32 men, mean age 57.9 years, mean body mass index 28.6 kg/m2, and mean waist circumference 104 cm. Overall 17.1% had type 2 diabetes, 37.1% dyslipidemia, 54.3% hypertension, 34.4% obesity, 74.3% abdominal obesity and 51.4% chronic kidney disease (CKD, 31.4% CKD 2 and 20% CKD 3–5). Gout duration was 3.9±6.7 years, 28.6% of patients had tophus and 31.4% gout arthropathy. SUA, eGFR and FeUA values were similar between Tc and Tic phases: SUA: 504.9±79.9 and 507.6±89.7 μmol/l; eGFR: 78.1±28.8 and 81.4±33.8 ml/min/1.73m2; FeUA: 4.90±2.3 and 4.45±3.3%, respectively. Moreover, the FeUA values were identical between Tt, Tic and Tc in 11 patients who achieved SUA target (296.0±37.8 μmol/l) under ULT. CRP levels were higher at Tc (44.8±69.4 mg/dL) than Tic (5.2±3.3 mg/dl) and Tt (4.6±1.2 mg/dl). While mean SUA levels were similar between Tc and Tic, SUA levels were lower in Tc than Tic in 21 patients (mean difference: 56.9±33.7 μmol/l) (figure1). In contrast, 14 patients had a SUA level higher in Tc than in Tic (mean difference: 78.6±71.5 μmol/L) (figure 1). SUA variations between Tc and Tic were not correlated with FeUA modifications in these two groups (p=0.15). Similarly, SUA and FeUA variations were not correlated with CRP variations between Tc and Tic (p=0.29 and p=0.30, respectively). Conclusions SUA levels during gout attack can be either higher or lower than SUA during intercritical phase. These variations are linked neither to inflammation level nor to FeUA. It would be interesting to assess the intestinal excretion of uric acid, xanthine oxidase activity and diet intake during these different gout phases. Disclosure of Interest None declared

Background The first metatatarsophalangeal joint (1st MTP joint) is a common location for sonographic evidence of urate deposition in people with gout and asymptomatic hyperuricaemia. However, it is unclear whether these are related to clinically-assessed pain and function. This study aimed to determine the association between ultrasound features and clinical characteristics of the 1st MTP joint in people with gout, asymptomatic hyperuricaemia and age- and sex-matched normouricaemic individuals. Methods Twenty-three people with gout, 29 with asymptomatic hyperuricaemia and 34 with normouricaemia participated in a cross-sectional study. No participant had clinical evidence of acute inflammatory arthritis at the time of assessment. Four sonographic features at the 1st MTP joint were analysed: double contour sign, tophus, bone erosion and synovitis. Clinical characteristics included in the analysis were 1st MTP joint pain, overall foot pain and disability, 1st MTP joint temperature, 1st MTP joint range of motion and gait velocity. Statistical analyses adjusted for the diagnostic group of the participant. Results After accounting for the diagnostic group, double contour sign was associated with higher foot pain and disability scores (P

The objective of this study is to analyze clinical characteristics associated with the formation of subcutaneous tophi among Chinese gout patients. It was a retrospective outpatient cohort study. Five thousand six hundred ninety-three gout patients treated at the Affiliated Hospital of Qingdao University from March 2011 to February 2016 were included and divided into the tophus group and non-tophus group according to the presence of megascopic tophus. Relevant clinical information and biochemical parameters were analyzed to identify potential risk factors for the incidence of subcutaneous tophi. There are significant difference (P

The aim of our study was to compare the overall accuracy of ultrasonography (US), with at least one sign positive (double contour, tophus, aggregates), and dual-energy CT in the diagnosis of gouty arthritis. PubMed, Web of Science, EI, Elsevier, Wiley Online Library and Cochrane library were systematically searched for studies on the diagnostic performance of dual-energy CT (DECT) and ultrasound (US) from 2005 to February 2016. After study selection, data and quality assessment, the sensitivity (SEN), specificity (SPE), diagnostic odds rate (DOR), positive likelihood ratio (PLR), negative likelihood ratio (NLR) and summary receiver operating contraction racteristic (SROC) curves were calculated. Eleven publications met our inclusion criteria. Of these, six studies were included in the dual-energy CT group, six studies in the US group, and one study compared dual-energy CT and US. The pooled SEN, SPE, DOR, PLR, NLR and SROC of US with at least one sign positive, were 93%, 73%, 37.94, 3.39, 0.11 and 92%, respectively; and of DECT the values were 88%, 85%, 38.70, 5.12, 0.16, 93% and respectively. Based on current evidence, both US and DECT can be used for diagnosis of gouty arthritis, but there are some differences between them regarding diagnostic sensitivity and specificity.

An uncommon case of spinal gouty tophus was diagnosed in a 74-year-old man who presented in the emergency department with sudden onset of acute paraplegia. The patient underwent laminectomy and nodule removal for neurodecompression. After surgery, the patient demonstrated good functional recovery and returned to baseline performance status. Intraspinal tophi are rare. Image study may show irrelevant findings. In patients with gout, the differential diagnosis should include tophi. In the present case, imaging did not reveal much inflammatory change, but severe symptoms were observed, and a definite preoperative diagnosis was difficult. In cases with neurological compromise, timely neurosurgical decompression leads to good outcomes, as in the present case.

BackgroundTophus burden is currently measured using physical examination and imaging methods. The aim of this study was to develop a patient-reported outcome (PRO) tool to assess tophus burden in people with gout.MethodsThe responses from interviews with 25 people with tophaceous gout were used to generate items for a preliminary PRO tool. Following cognitive testing of each item, a preliminary 34-item questionnaire was administered to 103 people with tophaceous gout. Rasch analysis generated a 20-item Tophus Impact Questionnaire (TIQ-20). Test-retest reproducibility and construct validity of the TIQ-20 were assessed.ResultsThe TIQ-20 responses fit the Rasch model and demonstrated unidimensionality, adequate precision, absence of differential item functioning and adequate person separation index. The TIQ-20 included items related to pain, activity limitation, footwear modification, participation, psychological impact and healthcare use due to tophi. In the 103 patients with tophaceous gout, floor effects were observed in 4.9% and ceiling effects in 1%. The TIQ-20 test-retest intraclass correlation coefficient was 0.76 (95% CI 0.61 to 0.85). All predicted correlations for construct validity testing were observed, including weak correlation with serum urate concentrations (r0.50).ConclusionsWe have developed a tophus-specific PRO in patients with tophaceous gout. The TIQ-20 demonstrates acceptable psychometric properties. Initial results show internal, face and construct validity, reproducibility and feasibility. Further research is required to determine responsiveness to change.

Die Differenzialdiagnose einer unklaren Polyarthritis im Alter umfasst u. a. Autoimmunerkrankungen, Kristallablagerungserkrankungen oder infektassoziierte Polyarthritiden. Bei klinischem Verdacht auf eine Gicht sollte durch Harnsäurekristallnachweis in der Synovialflüssigkeit oder im Tophus idealerweise bestätigt werden. Wenn eine Arthrozentese nicht realisierbar ist, können nicht-invasive hochspezifische Untersuchungen, wie der hochauflösenden muskuloskelettale Ultraschall oder eine DECT-Untersuchung hilfreich sein.

Item does not contain fulltext BACKGROUND: Although there has been major progress in gout imaging, no gout classification criteria currently include advanced imaging techniques. OBJECTIVE: To examine the usefulness of imaging modalities in the classification of gout when compared to monosodium urate (MSU) crystal confirmation as the gold standard, in order to inform development of new gout classification criteria. METHODS: We systematically reviewed the published literature concerning the diagnostic performance of plain film radiography, MRI, ultrasound (US), conventional CT and dual energy CT (DECT). Only studies with MSU crystal confirmation as the gold standard were included. When more than one study examined the same imaging feature, the data were pooled and summary test characteristics were calculated. RESULTS: 11 studies (9 manuscripts and 2 meeting abstracts) satisfied the inclusion criteria. All were set in secondary care, with mean gout disease duration of at least 7 years. Three features were examined in more than one study: the double contour sign (DCS) on US, tophus on US, and MSU crystal deposition on DECT. The pooled (95% CI) sensitivity and specificity of US DCS were 0.83 (0.72 to 0.91) and 0.76 (0.68 to 0.83), respectively; of US tophus, were 0.65 (0.34 to 0.87) and 0.80 (0.38 to 0.96), respectively; and of DECT, were 0.87 (0.79 to 0.93) and 0.84 (0.75 to 0.90), respectively. CONCLUSIONS: US and DECT show promise for gout classification but the few studies to date have mostly been in patients with longstanding, established disease. The contribution of imaging over clinical features for gout classification criteria requires further examination.

To examine the role of matrix proteins in the formation of gouty tophus, we analyzed the crystalline components and matrix proteins in a gouty tophus from a patient with recurrent gout. Micro-area X-ray diffraction analysis and infrared spectroscopy indicated that the tophus was composed of monosodium urate monohydrate. Proteomic analysis identified 134 proteins from the tophus as matrix proteins. Many proteins relevant to inflammation and host defense were identified, and immunoglobulin was detected in all four extracted fractions (KCl, formic acid, guanidine-HCl, and ethylenediaminetetraacetic acid) and from many spots throughout a broad molecular weight range after electrophoresis. It is thought that the process of biological defense including the immunity has occurred in the gouty tophus.

Objectives To compare dual-energy CT images (DECT) directly with gold standard histology. Methods A 85-year-old woman with chronic recurrent gouty arthritis and macroscopically visible tophi was assessed with DECT-scans of her feet. When she died 7 days later, three tophi in different regions and in different tissues of her left foot were processed for histological examination. Results Of the selected tophi, two were almost completely missed by the color-coding DECT sequences. The tophi remained in most of their volume below the detection threshold value of 150 HU (default value). Conclusions It could be demonstrated that DECT only highlights the dense tophi (corresponding of approximately 15–20 vol% urate in the tophus). Less dense tophi, despite considerable size, will be missed in the color-coded images.

Item does not contain fulltext Crystal arthritides such as gout can be detected by ultrasonography (US). This study reveals the performance of joint US (double contour sign (DCS), tophus (T), hyperechoic spots cq. "snow storm" (SS)) for diagnosing gout and calcium pyrophosphate dihydrate crystal deposition disease (CPPD) in patients with acute mono- or oligoarthritis (MOA). The gold standard is the presence of monosodium urate (MSU)/CPPD crystals. Fifty-four Dutch patients had an acute MOA. US was performed on the following six joints maximum: the arthritic joint, the contra lateral side, metatarsophalangeal (MTP)-1, and knees bilaterally in case of arthritis in one of these joints. In case of wrist/PIP/MCP-arthritis, the knees and MTP-1 were scanned. These were examined for DCS, T, SS, and intercartilage rim (CPPD). Synovial fluid was aspirated from the affected joint for MSU proof. Twenty-six of the 54 (48 %) patients with MOA had MSU-proven gout. Sensitivity of DCS and any US abnormality (DCS, T, SS) was 77 and 96 %, respectively. The positive likelihood ratio (LR+) for DCS and any ultrasonographic abnormality (USabn) was 3.08 and 2.99, respectively, and the LR- was 0.31 and 0.06, respectively. In MSU-proven gout patients where the affected joint is not MTP-1, MTP-1 still showed USabn in 42 % of the patients. None of the CPPD patients had an intercartilage rim. In dedicated hands, ultrasonography deserves a place early in a screening algorithm of MOA patients, particularly if specificity is high enough to make punctures abundant or when microscopy is not available. In 86 % of the MSU-proven gout patients, the DCS is not present in another joint other than the affected or MTP-1 joint.

Rationale: 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 rare case with a tophaceous tendonitis on the flexor hallucis longus (FHL) tendon with tarsal tunnel syndrome (TTS). This is the first surgical case of TTS by gouty tophi in FHL. Patient Concerns: A 55-year-old woman presented with a 6-month history of mild discomfort at the right foot, which gradually worsened in the past 3 weeks. The patient visited our outpatient clinic due to persistent and aggravating foot pain and swelling around the tarsal tunnel. Diagnosis: The patient was diagnosed with hyperuricemia and diabetes mellitus with chronic kidney disease, and did not receive regular antigout treatments. Paresthesia was found along the distribution of medial and plantar nerve and tinel test was positive on tarsal tunnel. Biochemical examination showed she had raised serum uric acid (10.6 mg/dL) and decreased estimated glomerular filtration rate (69 mL/min/1.73 m2). Conventional radiography examination showed negative pathology except soft tissue swelling. Magnetic resonance imaging revealed a fusiform mass within the FHL tendon and fluid collection around tarsal tunnel. Interventions: Surgical exploration was performed to remove the mass. Inflammation fluid exploded out from FHL tendon sheath, which was later proven to have infiltration of monosodium urate crystal. Superficial dissection revealed a white chalky mass and posterior tibial nerve was significantly compressed by the tophus mass. Outcomes: The mass was removed and the symptoms were relieved at immediate postoperative period. Lessons: A tophaceous tendonitis on FHL tendon can cause TTS and surgical decompression of the gout lesion can reduce the symptoms.

The aim of this study was to measure the urate volume within tophus and bone erosion volume using dual-energy computed tomography in patients with tophaceous gout. Furthermore, our study aims to quantitatively analyze the relationship between monosodium urate (MSU) crystal deposition and bone erosion according to the anatomic location of urate deposition.Seventy-seven subjects with chronic gout were positively identified for the presence of urate deposition. Only 27 subjects identified for the presence of urate in contact with bone erosion were included in this study. The urate volumes and associated erosion volumes were measured. The relationships between urate within tophus and bone erosion were separately analyzed according to the anatomic location of urate deposition.Twenty-seven subjects were all male (100%) with a median (interquartile range, IQR) age of 52 (45-61) years. From all the subjects, 103 tophi depositions were identified in contact with bone erosion, including 58/103 tophi that contained an intraosseous component and 45/103 nonintraosseous tophi. Tophi containing intraosseous components were larger than nonintraosseous tophi (urate volume: median [IQR] 45.64 [4.79-250.89] mm vs 19.32 [6.97-46.71] mm, P = .035) and caused greater bone erosion (erosion volume: 249.03 [147.08-845.33] mm vs 69.07 [32.88-111.24] mm, P < .001). Almost all erosion volumes were larger than urate volumes in nonperiarticular tophi, in contrast to most erosion volumes, which were less than urate volumes in the tophi that contained a periarticular component (odds ratio, 95% confidence interval: 74.00, 14.70-372.60; P < .001). Urate volume and erosion volume demonstrated positive correlations in intraosseous tophi, intraosseous-intra-articular-periarticular tophi, and intraosseous-intra-articular tophi (rs = 0.761, rs = 0.695, rs = 0.629, respectively, P < .05).MSU crystal deposition shows a promoting effect on the development of bone erosions in varying degrees, associated with the location of MSU crystals deposited in the joints. The intraosseous tophi contribute the most to bone erosions, followed by intra-articular tophi, and periarticular tophi.

Objective Tophi are strongly associated with structural damage in gout, and urate-lowering therapy reduces tophus size. Pegloticase leads to dramatic reductions in serum urate and subcutaneous tophi in treatment responders. The aim of this analysis was to examine whether profound urate lowering can alter radiographic findings in gout. Methods Serial plain radiographs of the hands and feet were obtained from 8 patients with tophaceous gout treated with pegloticase. Radiographs were scored for erosion and joint space narrowing (JSN) according to the gout-modified Sharp/van der Heijde method. Scorers were blinded to each other's scores and to the clinical characteristics of the patients (including the clinical response to pegloticase). A detailed qualitative site-by-site analysis was undertaken to define additional changes observed from baseline. Results All patients experienced a profound urate-lowering response (serum urate level

Spinal involvement is uncommon during gout and may raise diagnostic challenges. We describe five cases seen at a single center. Methods We retrospectively reviewed the medical charts of the five patients with spinal gout seen over a 3-year period. Results There were four men and one woman with an age range of 52 to 87 years. One patient presented with acute neck pain and visualization by imaging studies of a discovertebral tophus, another had febrile arthritis of a lumbar facet joint, and a third presented with a synovial cyst in a lumbar facet joint. The remaining two patients had acute febrile discitis confirmed by magnetic resonance imaging, at the cervical spine and lumbar spine, respectively. Laboratory tests showed systemic inflammation in four patients and marked serum uric acid elevation in two patients. Only three patients reported a previous history of peripheral acute gout attacks. Specimens of the spinal lesions were obtained in three patients and consistently showed monosodium urate crystals with tissue inflammation or a tophus. The outcome was rapidly favorable, either with colchicine therapy alone in four patients or after surgical resection of a facet joint cyst (during surgery to stabilize the lumbar spine) in the remaining patient. The patient with neck pain due to a tophus experienced nerve root pain at the acute phase. No other neurological manifestations were recorded. Conclusion These case reports illustrate the diagnostic challenges raised by spinal involvement due to gout. The spinal lesions can be inaugural, as seen in two of our five patients.