The shrinking toe sign in gout.

OBJECTIVE: To describe the frequency, clinical presentation and understand the pathophysiology of toe shortenings during urate-lowering treatment (ULT) of gout, a feature we called the shrinking toe sign. METHODS: Sequential foot photographs and radiographs of 1141 consecutive gouty patients followed-up for at least 6 months under ULT were retrospectively scrutinized. Features from patients with toe shortenings were extracted from anonymized files. Tophi adjacent to the shortening sites were semi quantified on foot photographs and toe shortenings were measured on radiographs with the Corel draw software (Corel corporation, Canada). Measurement concordance was assessed by concordance correlation coefficients (CCC) and correlation between tophus scores and toe shortenings was analyzed by using linear model with a patient random effect. 97 patients who did not develop toe shortening during ULT were analyzed as controls. RESULTS: Shrinking toes were observed in 10 patients (0.9%) with tophaceous gout at joints with baseline destructive arthropathy. The first and second toes and metatarsophalangeal joints were predominantly involved. The sign was observed after serum urate had been lowered below the 300 and 360 µmol/l targets, in 8 and 2 patients, respectively. Measured shortenings (CCC: 0.99) correlated (p < 10-4) with decreases in tophus score (CCC: 0.91). Sequential radiograph analysis revealed that toe shortening was mainly due to lytic bone collapse during articular tophus dissolution. Comparison with controls showed that the sign developed in severe gout and in joints with more severe erosion score at baseline. CONCLUSION: The shrinking toe appears as rare feature of severe tophaceous gout, triggered by dissolution of bone-replacing tophi. Our findings reinforce the need to treat gout early, before destruction of bone scaffold by extensive tophi, as MSU crystal dissolution by ULT may further weaken these areas and induce their collapse.

A cross-sectional study of 502 patients found a diffuse hyperechoic kidney medulla pattern in patients with severe gout.

We have previously shown that ultrasonography can detect hyperechogenic crystal deposits in the kidney medulla of patients with gout. In this cross-sectional study we investigated the frequency and clinical correlates of hyperechogenic kidney medulla in 502 consecutive primary consultants for gout (ACR/EULAR criteria) at the Vien Gut medical center in Ho Chi Minh City, Vietnam. None of these patients received urate-lowering drugs. Kidney medulla echogenicity on B-mode ultrasonography was compared to that of the kidney cortex. Overall, 36% patients showed a hyperechoic pattern of Malpighi pyramids. On univariate analysis, the pattern was significantly associated with age, estimated gout duration, steroid-dependency, clinical tophi, urate arthropathy, double contour thickness at the scanned joints, coronary heart disease, arterial hypertension, hyperuricemia, proteinuria, leukocyturia, and decreased estimated glomerular filtration rate. On multivariable analysis, the hyperechoic pattern was associated with estimated disease duration, clinical tophi, urate arthropathy, double contour thickness and decreased estimated glomerular filtration rate. No hyperechoic pattern was observed in 515 consecutive consultants without gout. Thus, hyperechoic kidney medulla was frequently demonstrated in Vietnamese patients with tophaceous gout and associated with features of tubulointerstitial nephritis. This finding revives the hypothesis of microcrystalline nephropathy of gout, predominantly seen in untreated gouty patients, which could be an important target for urate-lowering therapy.

Prevalence and Clinical Profile of Undiagnosed Diabetes Mellitus: Data from a Tertiary Hospital.

BACKGROUND: The prevalence of diabetes mellitus in Vietnam is relatively low compared to other Asian countries, but it is accelerating with the economic and cultural transition. This study aimed to estimate the current prevalence and clinical profile of undiagnosed diabetes mellitus in a tertiary hospital in the south of Vietnam. METHODS: A cross-sectional investigation was conducted to recruit 1, 250 participants, who were at least 18 year-old and randomly sampled from Cho Ray Hospital, Ho Chi Minh City, Vietnam. Fasting plasma glucose concentration and HbA1c were measured for each individual. The American Diabetes Association criteria were used to diagnose diabetes. Demographic data and other clinical characteristics of diabetes were also documented, including age, sex, residence, educational status, weight, height, waist and hip circumferences, blood pressure, familial history of diabetes, and lipid profile. RESULTS: The prevalence of undiagnosed diabetes mellitus was 7.5% in the population studied. Age, waist circumference, waist-hip ratio, body mass index, and hypertension, as well as dyslipidaemia were well-correlated with the diabetes rate. CONCLUSION: The prevalence of undiagnosed diabetes mellitus is increasing far more than expected. Newly diagnosed diabetic patients usually presented with multiple comorbidities, including overweight/ obesity, hypertension, and dyslipidaemia.