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[Modern differential-therapeutic aspects of the drug therapy of chronic gout].

The present paper adopts a definite attitude to the differentiated therapy of the disturbances of the uric acid metabolism. This demands an exacter subdivision of the kind of the metabolic disturbance (types Ia, Ib, IIa, IIb, and III). On the basis of this classification in types an individually adapted therapy is possible. It might form the prerequisite of a still more effective meeting of the nephrogenic complications of the gout and of the reduction of the side effects of the necessary permanent therapy.

Allopurinol↗

Gout with superactive phosphoribosylpyrophosphate synthetase due to increased enzyme catalytic rate.

We have studied families C and A in which superactivity of PRPP synthetase (E.C. 2.7.6.1) is associated with gout and uric acid overproduction in affected hemizygous males. PRPP synthetase catalyzes synthesis of PRPP, a regulatory substrate in purine synthesis de novo. Activities of the enzyme in erythrocyte and fibroblast extracts from the male index cases, T.C. and R.A., were nearly threefold greater than normal at each Pi concentration tested. PRPP synthetase superactivity was accompanied by increased intracellular PRPP concentration and generation in erythrocytes and fibroblasts from these patients, and enhanced rates of PRPP-dependent purine synthesis reactions, including purine synthesis de novo, were demonstrable in their fibroblasts. These findings suggested that increased intracellular synthesis dut to enzyme superactivity underlay purine nucleotide and uric acid overproduction in these patients. Similar studies in cells from the sister of T.C. and the mother of R.A. showed increased values that were, however, intermediate between normal values and those of the affected males, indicating that these women are heterozygous carriers of the traits for enzyme superactivity. The enzymatic basis for increased PRPP synthetase activity in both families was investigated. Immunochemical studies in dialyzed erythrocyte lysates and highly purified erythrocyte enzyme preparations provided evidence for increased enzyme activity per molecule of immunoreactive enzyme. In addition, purified T.C. and R.A. PRPP synthetases showed 3.1- and 2.8-fold greater enzyme specific activities, respectively, than comparably purified normal enzymes. Kinetic constants of purified T.C. and R.A. PRPP synthetases for substrates, activators, and inhibitors were indistinguishable from normal, and increased maximal reaction velocity alone appeared to account for enzyme superactivity. Despite an apparently similar kinetic mechanism for superactivity, the diminished electrophoretic mobility of T.C. PRPP synthetase and increased thermal lability of R.A. PRPP synthetase suggested distinct structural alterations leading to enzyme superactivity in families C and A.

Adult↗

Management of gout and hyperuricemia.

The medical management of gout follows a logical course in eventually controlling the underlying hyperuricemia. Approached properly, it is one of the most gratifying rheumatic diseases for a physician to treat.

Allopurinol↗

Stimulation of synovial fibroblasts by calcium oxalate and monosodium urate monohydrate. A mechanism of connective tissue degradation in oxalosis and gout.

The responses of cultured rabbit synovial fibroblasts to amorphous and microcrystalline calcium oxalate were compared with responses to MSUM. Like urate crystals, crystalline calcium oxalate (but not amorphous oxalate) caused marked stimulation of secretion of latent collagenase and PGE2 after 3 days of culture without significant change in cell protein or gross cellular morphology. Collagenase rose from undetectable levels in control cultures to 32.4 +/- 6.0 and 27.4 +/- 7.9 U/mg of cell protein for crystalline calcium oxalate and MSUM, respectively. PGE2 rose from a control level of 0.24 +/- 0.14 to 19.47 +/- 5.15 and 23 +/- 4.84 micrograms/mg of cell protein for crystalline calcium oxalate and sodium urate compared to 1.22 +/- 0.48 microgram for amorphous calcium oxalate. Although the crystalline species studied caused LDH in the media to increase threefold, this was minimal. Cell stimulation by amorphous oxalate and the crystals did not correlate with membranolytic potential as measured with an erythrocyte lysis assay. Stimulation of resident synovial cells by crystalline calcium oxalate and sodium urate may contribute to the chronic inflammation and destruction of joint tissues that occurs in oxalosis and gout.

Animals↗

An approach to hyperuricemia and gout.

Arthrocentesis and patient and family histories make gout relatively easy to diagnose. The next step is to distinguish between primary and secondary hyperuricemia. Hyperuricemia results from either impaired renal excretion or excessive production of uric acid--or both. Determining the cause guides the choice of therapy.

Allopurinol↗

Surgery for tophaceous gout.

Cases of tophaceous gout amenable to surgical management may be encountered in a podiatric practice. This paper reviews the indications for surgery, the pathology, the principles of surgical technique, the preoperative and postoperative management, and presents a case report.

Aged↗

Coexistent gout and hypertrophic osteoarthropathy in patients with cyanotic heart disease.

We describe 2 adult patients with cyanotic congenital heart disease whom, as a complication of their cardiopathy, had 2 different rheumatic syndromes: gout and hypertrophic osteoarthropathy. The coexistence of these arthropathies in the same patient, to our knowledge, has not been previously reported. We discuss the possible pathogenic mechanisms that may link these syndromes to cyanotic heart disease.

Adult↗

Mechanisms of vascular damage in gout and oxalosis: crystal induced, granulocyte mediated, endothelial injury.

Immune triggered granulocyte (PMN)-endothelial interactions have been implicated in the pathogenesis of vascular diseases. While hyperuricemia and gout are associated with an increased risk of atherogenesis, we studied the modulation by monosodium-urate (MSU) crystals of PMN-endothelial interactions in vitro. The relationship between calcium oxalate (COX) crystals - implicated in the vasculitis of primary oxalosis - and immunologically mediated endothelial injury was also explored. Both MSU- and COX-crystal treated sera stimulate PMN to adhere to and induce significant 51Cr-release from endothelial cells in vitro. Platelets significantly increase crystal-triggered PMN endothelial cell adherence and 51Cr-release. This platelet augmenting effect depends on the release of platelet constituents (e.g. serotonin). Microcrystalline material present in vessel walls, thus may cause C-activation and may trigger PMN and platelets to damage endothelium in vitro and in vivo. These findings may have relevance to the understanding of the accelerated atherogenesis of hyperuricemia and the fulminant vasculitis of oxalosis or ethylene glycol poisoning.

Blood Physiological Phenomena↗

Sartorial ridge gout.

A 54-year-old man presented with acute swelling and pain in the posteromedial aspect of the knee not involving the joint itself. Aspiration of the soft tissue swelling produced viscous fluid in which multiple, negatively birefringent crystals were noted on compensated polarized microscopy. The first described case of acute gout involving the sartorial ridge, this case underlines the need for examining aspirated fluid from soft tissue as well as from joints for crystals.

Acute Disease↗

Human hypoxanthine-guanine phosphoribosyltransferase. Structural alteration in a dysfunctional enzyme variant (HPRTMunich) isolated from a patient with gout.

HPRTMunich is a mutant form of human hypoxanthine-guanine phosphoribosyltransferase that was isolated from a patient who presented with gout and a partial deficiency of enzyme activity. Profound abnormalities in the catalytic function of HPRTMunich are responsible for the deficiency of enzyme activity in vivo. Tryptic peptides of HPRTMunich were mapped by reverse phase high pressure liquid chromatography in an attempt to define the precise abnormality in its primary structure. Sequence analysis of aberrant peptides localized the structural alteration in HPRTMunich to residue 103. Several additional findings suggest that the mutation in this variant is most likely a serine to arginine substitution at residue 103. This amino acid substitution lies within the putative hypoxanthine-binding site of human hypoxanthine-guanine phosphoribosyltransferase possibly explaining its selective effect on intrinsic enzyme activity and binding of hypoxanthine.

Amino Acid Sequence↗

[Gout - a surgical problem].

The incidence of gout has increased in recent years. For effective treatment an interdisciplinary approach is necessary. Medical therapy can be effectively supported by surgical removal of the tophi. This way normalisation of the uric-acid-pool can be achieved more quickly without additional harmful effects on the kidneys. Especially in the area of the hand surgical extirpation of the tophi can be gratifying, though it may be a difficult task. Severe restrictions in function of the hand can be corrected. This is demonstrated by the case of a 56 year old patient.

Allopurinol↗

[Principles of treatment of gout and hyperuricemia].

Gout can be considered to be a group of diseases that are typified by acute arthritis, tophi and kidney stones. The acute attacks of arthritis should be treated with standard anti-inflammatory agents and the patient should receive maintenance therapy after the second acute attack. The dangers of asymptomatic hyperuricaemia are acute arthritis and uric acid kidney stones. Patients should be treated when the serum uric acid level is greater than 0,54 mmol/l or if the urinary uric acid excretion is greater than 4,2 mmol/l/24 h.

Acute Disease↗

[Treatment of acute gout attacks with tolmetin (author's transl)].

In an open trial 15 patients with acute gout attacks were treated with Tolmetin. A statistically significant improvement of several pain values measured as well as subsidence of swellings and redness were observed. By summing up the scores "good" and "moderate", the joint judgement of physician and patients established a 90% success of treatment with regard to efficacy and tolerability. During Tolmetin treatment a statistically significant decrease of mean uric acid levels could be seen.

Acute Disease↗

Classic gout in Hageman factor (Factor XII) deficiency.

A 62-year-old man with a typical history of gout was admitted to the hospital with left-sided hemiplegia. His serum uric acid level was 10.3 mg/dL, his partial thromboplastin time was 198 s, and his Hageman factor (factor XII) coagulant activity and antigen were less than 1% of normal. Aspiration of synovial fluid from his inflamed knee disclosed urate crystals and abundant leukocytes but an absence of Hageman factor antigen. The presence of acute gouty arthritis in a patient with Hageman trait challenges the role of Hageman factor in the pathogenesis of gouty arthropathy.

Extremities↗

[Pseudotumorous gout in a 34-year-old man].

We report the case history of a young man, who suffered from atypical gout. The most prominent clinical findings were several tumor-like tophi. One of these located close to the right knee joint and impeding the joint motion had to be surgically removed.

Adult↗

Demonstration of chemotactic factor in human gout: further characterization of occurrence and structure.

The early events in gout are not clear. In the present studies a chemotactic factor having a molecular weight of 8,400 has been identified in human gouty synovial fluid. Washed crystals from a tophus were shown to generate chemotactic activity when added to polymorphonuclear leukocytes. Amino acid analysis demonstrated this chemotactic factor to be relatively rich in glycine, serine, aspartic acid, glutamic acid and alanine. Evidence from canine experiments suggest that chemotactic activity may also be produced by synovial lining cells. The amount of chemotactic activity that can be demonstrated diminishes over time in joints repeatedly injected with urate crystals.

Animals↗

[Xeroradiography in comparison to roentgen studies in gout, hyperuricemia and dyspurinia].

In 24 patients with gout and in 15 patients with clinical oligo- and polyarthritic syndromes associated with hyperuricemia and dyspurinia xeroradiographic examinations of the clinically affected joints and soft tissues were carried out. In 32 cases comparisons were made with the classic x-ray examinations. In most cases the findings correlated, particularly the rarifaction of the bone structure including cystic changes of fingers and toes. In advanced cases, particularly in the hallux, erosions occurred and at the same time the changes in the soft tissues were recorded. Cystic changes in the larger bones were better estimated by the classical x-ray examinations. The soft tissues are shown better xeroradiographically. Xeroradiography has the advantage that it can record the structure of bones and soft tissue at the same time.

Adult↗