Ultrasound imaging for the rheumatologist XXXVI. Sonographic assessment of the foot in gout patients. Ultrasound-detected musculoskeletal urate crystal deposition: which joints and what findings should be assessed for diagnosing gout? Diagnosis of gout by ultrasound. Ultrasonography shows disappearance of monosodium urate crystal deposition on hyaline cartilage after sustained normouricemia is achieved Association of baseline disease and patient characteristics with response to etoricoxib and indomethacin for acute gout* Development of a computed tomography method of scoring bone erosion in patients with gout: validation and clinical implications. Treatment of 60 cases of gouty arthritis with modified Simiao Tang. Ultrasound in gout: a useful tool for following urate-lowering therapy. Ultrasonography in early assessment of elderly patients with polymyalgic symptoms: a role in predicting diagnostic outcome? Numerical scoring systems for the anatomic evolution of osteoarthritis of the finger joints. 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) Treatment of chronic gout. Can we determine when urate stores are depleted enough to prevent attacks of gout? Minimally important differences of the gout impact scale in a randomized controlled trial. Biomarkers predict radiographic progression in early rheumatoid arthritis and perform well compared with traditional markers. Tailored approach to early psoriatic arthritis patients: clinical and ultrasonographic predictors for structural joint damage 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 Existing joint erosions increase the risk of joint space narrowing independently of clinical synovitis in patients with early rheumatoid arthritis
OBJECTIVES This study aims to investigate the relationship between clinical and US findings together with the prevalence and distribution of US findings indicative of monosodium urate ( MSU ) crystal deposition within the foot in patients with gout . METHODS A total of 50 patients with gout attending the in-patient and the out-patient clinics of the Rheumatology Departments were prospect ively enrolled in this multi-centre study . Multiplanar examination of the following 15 joints was performed : talo-navicular , navicular-cuneiform ( medial , intermediate and lateral ) , calcaneo-cuboid , medial , intermediate and lateral cuneiform-metatarsal , cuboid-4th metatarsal , cuboid-5th metatarsal and all five metatarsophalangeal ( MTP ) joints . RESULTS The following US findings were indicative of gout : enhancement of the superficial margin of the hyaline cartilage , intra-articular tophus , and extraarticular tophus . In 46 patients , a total of 1380 foot joints were investigated . In 1309 joints that were not clinical ly involved , US detected signs indicative of joint inflammation in 9 % ( 121/1309 ) . Talo-navicular joint and the first MTP joint were the joints in which the highest number of US findings were found at mid-foot and fore-foot , respectively . At MTP joint level , dorsal scans allowed the detection of a higher number of US findings indicative of joint inflammation , and MSU crystal deposits rather than on the volar plane . CONCLUSIONS This study demonstrated that US detected a higher number of inflamed foot joints than clinical examination , and that the first MTP and the talo-navicular joints were the anatomic sites with the highest prevalence of US signs of MSU crystal aggregates Objective The primary objective of this prospect i ve case-control study was to assess the diagnostic value of several intra-articular and periarticular ultrasound (US)-detected abnormalities in the upper and lower limbs in gout . The secondary objective was to test the concurrent validity of US abnormalities using as gold st and ard the microscopic demonstration of monosodium urate ( MSU ) crystals . Methods Ninety-one men with gout and 42 age-matched controls were prospect ively recruited . All patients with gout and controls underwent US assessment of several US abnormalities in 26 joints , six bursae , eight tendons , 20 tendon compartments , four ligaments , and 18 articular cartilages by experts in US blinded to the patients ’ group . Patients with gout and controls with US abnormalities were asked to undergo US-guided aspiration for microscopic identification of MSU crystals . Interobserver and intraobserver reliability of the US assessment was evaluated in a web-based exercise . Results The assessment of one joint ( ie , radiocarpal joint ) for hyperechoic aggregates ( HAGs ) , two tendons ( ie , patellar tendon and triceps tendon ) for HAGs and three articular cartilages ( ie , first metatarsal , talar and second metacarpal/femoral ) for double contour sign showed the best balance between sensitivity and specificity ( 84.6 % and 83.3 % , respectively ) . Intraobserver reliability was good ( mean κ 0.75 ) and interobserver reliability was moderate ( κ 0.52 ) . The aspirated material from HAGs was positive for MSU crystals in 77.6 % of patients with gout and negative in all controls . Conclusions Our results suggest that US bilateral assessment of one joint , three articular cartilages and two tendons may be valid for diagnosing gout with acceptable sensitivity and specificity OBJECTIVES To establish the usefulness of ultrasonography ( US ) for diagnosing gout and to determine whether there are sonographic features that are characteristic for gout but not for other arthropathies . METHODS We retrospectively compared joint images of gout patients with matching images from patients with other rheumatic conditions . Images of 37 joints of 23 patients with monosodium urate ( MSU ) crystal-proven gout were review ed . MSU crystals were identified in at least one joint in each patient . Our control group had 23 r and omly selected patients with 33 examined joints with rheumatic conditions other than gout . RESULTS Specific diagnostic features included a hyperechoic , irregular b and over the superficial margin of the articular cartilage described as a double contour sign in 92 % of gouty joints and in none of the controls ( P < 0.001 ) ; hypoechoic to hyperechoic , inhomogeneous material surrounded by a small anechoic rim , representing tophaceous material , was seen in all gouty metatarsophalangeal ( MTP ) joints , in all metacarpophalangeal ( MCP ) joints and in none of the controls ( P < 0.001 ) ; erosions adjacent to tophaceous material were seen in 65 % of MTP joints and in 25 % of MCP joints . One erosion was seen in a MTP joint in a control patient with psoriatic arthritis . CONCLUSIONS US can detect deposition of MSU crystals on cartilaginous surfaces ( P < 0.001 ) as well as tophaceous material and typical erosions . US may serve as a non-invasive means to diagnose gout 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 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 To develop a method of scoring bone erosion in the feet of patients with gout using CT as an outcome measure for chronic gout studies , consistent with the components of the OMERACT filter . METHODS Clinical assessment , plain radiographs and CT scans of both feet were obtained from 25 patients with chronic gout .  CT scans were scored for bone erosion using a semi-quantitative method based on the Rheumatoid Arthritis MRI Scoring System ( RAMRIS ) .  CT bone erosion was assessed at 22 bones in each foot ( total 1100 bones ) by two independent radiologists . A number of different models were assessed to determine the optimal CT scoring system for bone erosion , incorporating the frequency of involvement and inter-reader reliability for individual bones . RESULTS An optimal model was identified with low number of bones required for scoring ( seven bones/foot ) , inclusion of bones over the entire foot , high reliability and ability to capture a high proportion of disease . This model included the following bones in each foot : first metatarsal ( MT ) head , second to fourth MT base , cuboid , middle cuneiform and distal tibia ( range 0 - 140 ) . Scores from this model correlated with plain radiographic damage scores ( r = 0.86 , P < 0.0001 ) and disease duration ( r = 0.42 , P < 0.05 ) . Scores were higher in those with clinical ly apparent tophaceous disease than in those without tophi ( P < 0.0001 ) . CONCLUSIONS We have developed a preliminary method of assessing bone erosion in gout using conventional CT . Further testing of this method is now required , ideally in prospect i ve studies to allow analysis of the sensitivity to change of the measure OBJECTIVE To observe the clinical effect of a modified Simiao Tang ( Modified Decoction of Four Wonderful Drugs ) for gouty arthritis and its influence on uric acid in blood . METHODS 120 cases of gouty arthritis were r and omly divided into the treatment group and control group with 60 cases in each group . Modified Simiao Tang ( MST ) was orally administered to the patients in the treatment group and allopurinol tablet was orally administered to the patients in the control group . The clinical effects of two groups were evaluated after one-week treatment and uric acid ( UA ) and C-reactive protein ( CRP ) levels in blood were determined after 1-month treatment . RESULTS The total effective rate in the treatment group was significantly higher than in the control group , 86.7 % vs. 68.3 % ( P < 0.01 ) . And the treatment group was also significantly better than the control group in decreasing UA and CRP ( P < 0.05 or P < 0.01 ) . CONCLUSIONS MST can significantly improve the symptoms and signs of gouty arthritis and decrease the levels of UA and CRP . It is good for gouty arthritis 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 Objective : To study the usefulness of ultrasonography ( US ) in predicting the diagnostic outcome in patients with polymyalgic symptoms . Methods : Sixty-one elderly patients with polymyalgic syndrome were recruited in a secondary care setting and followed up in a prospect i ve way . Clinical , laboratory , and US data obtained at onset were re-evaluated after 1 year when diagnostic outcome was defined . Results : A diagnostic shift was observed in 32 polymyalgic patients ( 52 % ) . Calcium pyrophosphate deposition disease ( CPDD ) was diagnosed in nine patients , elderly-onset rheumatoid arthritis ( EORA ) in 18 , and elderly-onset spondyloarthritis ( EOSpA ) in five . In polymyalgia rheumatica ( PMR ) patients US demonstrated synovitis in 90 % of cases , in both proximal ( 90 % ) and peripheral joints ( 41 % ) . The best predictive US model for the definitive diagnosis of PMR comprised : the presence of subacromial-subdeltoid bursitis [ odds ratio ( OR ) 5.603 , p = 0.003 ] , low frequency of wrist ( OR 0.074 , p < 0.001 ) , metacarpophalangeal ( OR 0.052 , p < 0.001 ) , and metatarsophalangeal effusion/synovitis ( OR 0.107 , p < 0.027 ) , low frequency of knee menisci chondrocalcinosis ( OR 0.091 , p = 0.013 ) , tendinous calcaneal calcifications ( OR 0.078 , p = 0.006 ) , and Achilles enthesitis ( OR 0.107 , p = 0.027 ) , and low power Doppler US ( PDUS ) scores at wrist ( OR 0.052 , p < 0.001 ) . Conclusions : US and PDUS can be useful in distinguishing , at onset of disease , pure PMR from other diseases mimicking this condition OBJECTIVE To assess and score the progression of  osteoarthritis ( OA ) of the distal and proximal interphalangeal ( DIP and PIP ) and metacarpophalangeal ( MCP ) joints . METHODS Forty-six patients with OA of the finger joints were followed up for 3 years ; 36 of them were followed up for 5 years . Posteroanterior radiographs of the h and s were obtained at the start of this prospect i ve study and at yearly intervals . The scoring systems used were based on the increased incidence of OA during consecutive years in previously normal joints , the radiologic progression of anatomic lesions in the affected finger joints , and the consecutive pathologic phases recognized in the course of the disease . RESULTS Significant increases both in the numbers of affected DIP , PIP and MCP joints per subject and in the anatomic progression of the disease ( changes in osteophyte growth , loss of joint space , and subchondral cysts or sclerosis ) in the different finger joints of each patient were recorded during the 3 and 5 years of followup . In approximately 40 % of the patients , the classic picture of OA was complicated by erosive changes , which preceded a period in which repair phenomena in the " eroded " finger joints led to the generation of a new subchondral plate covered by cartilaginous tissue . Huge osteophytes were then responsible for the nodular aspect of the affected finger joints . CONCLUSION OA of the finger joints is progressive in nature and passes through predictable phases . The recognition of and the attribution of a score to these respective phases made assessing the progression of OA less time-consuming and led to the same conclusions as when the anatomic progression was scored 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 OBJECTIVE To determine if lowering of serum uric acid ( SUA ) concentrations below 6 mg/dl or longer duration of lowered SUA will result in depletion of urate crystals from the knee joints and prevent further attacks of gout . METHODS A prospect i ve study was initiated 10 years ago at Philadelphia VA Medical Center to attempt to maintain SUA levels of patients with crystal proven gout at < 6.0 mg/dl . We recalled all 57 patients who were available during 1999 . Patients were divided into 2 groups : Group A , with SUA still > 6 mg/dl , and Group B , with SUA < or = 6 mg/dl . A knee joint aspirate was requested from all asymptomatic Group B patients and many in Group A. Aspirates were examined by polarized light microscopy for identification of crystals . RESULTS There were no differences between the groups in age , sex , duration of gout , or serum creatinine . Group A ( n = 38 ) had a mean of 6 attacks of gout for the recent year , those with tophi having the most frequent attacks . Among the 16 patients in this group who agreed to knee aspiration , monosodium urate ( MSU ) crystals were found in 14 , although they were asymptomatic at the time . Nineteen patients ( Group B ) were able to maintain serum urate levels < or = 6 mg/dl for > 12 months . Nearly half of them had no attack of gout for 2 or more years , with a mean of 1 attack in the last year for the whole group . Three patients in whom tophi were found did not have major flares of gout within the past year . Knee joint aspiration was done on 16 asymptomatic patients . Seven ( 44 % ) still had MSU crystals present in their knees . Patients in this group who were taking prophylactic colchicine did not differ with respect to the character of synovial fluid from those who had discontinued it for up to several years , although the frequency of attacks was less in those who continued colchicine . CONCLUSION A majority of patients were able to deplete urate crystal stores in their knee joint fluids when their SUA levels were kept to < or = 6 mg/dl for several years . The mechanisms for persistence in some patients , and whether such crystals have clinical implication s , are not known . Patients with chronic gout need serum urate concentrations to be kept low to prevent further attacks 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 OBJECTIVE To evaluate the performance of biochemical and traditional markers in predicting radiographic progression in rheumatoid arthritis ( RA ) . METHODS One hundred thirty-two patients with early RA were treated with nonbiologic therapies for 2 years and studied longitudinally . Genomic DNA was analyzed for presence of the shared epitope . Levels of matrix metalloproteinases ( matrix metalloproteinase 1 [ MMP-1 ] , MMP-13 , and MMP-3 ) , tissue inhibitor of metalloproteinases 1 ( TIMP-1 ) , and cartilage oligomeric matrix protein ( COMP ) were assessed in serially obtained serum sample s. The presence of pyridinoline ( Pyr ) , deoxypyridinoline , glycosylated Pyr ( Glc-Gal-Pyr ) , and C-telopeptide of type II collagen ( CTX-II ) was assessed in urine sample s. Radiographs obtained at entry and at 2 years were evaluated using the modified Larsen score . RESULTS Baseline and 2-year radiographs were available from 118 patients .  Larsen scores worsened during the 2 years in 50 patients , while 68 patients had no radiographic progression . Levels of a variety of biochemical markers , i.e. , MMP-3 , CTX-II , COMP , TIMP-1 , Pyr , and Glc-Gal-Pyr , correlated significantly with radiographic progression at entry and longitudinally as assessed by area under the curve ( AUC ) . By multivariate analysis , a model including MMP-3 and CTX-II was identified as providing the best prediction of radiographic progression at entry ( predictive accuracy by receiver operating characteristic [ ROC ] AUC = 0.76 [ 95 % confidence interval 0.66 - 0.85 ] ) , while a combination of MMP-3 , CTX-II , and swollen joint count formed the best longitudinal AUC model ( predictive accuracy by ROC AUC = 0.81 [ 95 % confidence interval 0.73 - 0.89 ] ) . Patient-reported measures ( Health Assessment Question naire , pain scores ) were of limited use . In a subset of 50 patients who were treated with methotrexate ( MTX )  during the followup period , median serum MMP-3 levels decreased after the initiation of MTX therapy ( P = 0.0003 ) . CONCLUSION These results indicate that biochemical markers are useful predictors of radiographic progression in RA and that serum MMP-3 levels decrease significantly with MTX therapy . Multivariate models that include MMP-3 and CTX-II perform better than existing traditional markers in predicting radiographic outcome in RA This study aims to identify the clinical predictors of arthritis in patients with psoriasis and to evaluate the use of musculoskeletal ultrasonography ( US ) as a predictor for inflammatory structural progression in psoriatic patients .  Measures of association ( odds ratio ( OR ) ) were tested , in a prospect i ve , cohort 1-year follow-up study , between structural deterioration and the presence of baseline inflammation , or its persistence . One hundred twenty-six psoriatic patients were prospect ively evaluated both clinical ly and by US at 0 , 6 , and 12 months for synovitis/ joint damage , enthesitis , and onychopathy . X-ray was performed at 0 and 12 months . One hundred twelve sex and age-matched pasoriatic patients without histories of musculoskeletal symptoms were included as control group .  Structural deterioration was observed in 47 % of the 5,292 evaluated joints . Clinical variables associated with arthritis risk : BMI > 25 ( OR = 1.7 ) , body surface area ( OR = 1.13 ) , family history ( OR = 5.72 ) and nail involvement ( OR = 2.25 ) . BMI > 30 was significantly correlated ( P < 0.01 ) with shorter time for the onset of arthritis . Baseline synovial score/PD score ≥ 2 was associated with increased risk of structural progression : OR = 1.98 versus 2.61 versus 2.66 ( P < 0.001 ) for the clinical versus US-gray scale ( GS ) versus US-power Doppler ( PD ) evaluation , respectively . An increased probability for structural progression in the presence of enthesitis was observed ( OR = 2.79 and 3.50 ) for both US-GS and US-PD , whereas OR was 2.46 for clinical examination . Onychopathy was associated with structural joint damage ( OR = 2.30 ) . In multivariate logistic regression analysis , persistent of synovitis/enthesitis at 6 months of therapy was predictive of subsequent structural progression . Family history of psoriatic arthritis , large BMI ( > 25 ) , high percentage of psoriatic body surface area , and nail involvement were significantly associated with early onset psoriatic arthritis . Baseline GS score of ≥2 , PD score of ≥2 , presence of enthesitis , enhanced vascularity at enthesitis , higher GUESS score , and onychopathy , all at base line as well as persistent synovitis and enthesitis at 6 months are predictors of progressive early psoriatic arthritis . Regular ultrasonographic monitoring of these patients is m and atory to assess the progression of their arthritis status 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 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
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 .