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Monday, 23 May 2016

Most Common Disease of 50plus: The Clinical trials and Studies of Gout, a Common form of Musculo-Skeletal disorders(MSDs)

Kyle J. Norton (Scholar and Master of Nutrients, all right reserved)Health article writer and researcher; Over 10.000 articles and research papers have been written and published on line, including world wide health, ezine articles, article base, healthblogs, selfgrowth, best before it's news, the karate GB daily, etc.,.
Named TOP 50 MEDICAL ESSAYS FOR ARTISTS & AUTHORS TO READ by Disilgold.com Named 50 of the best health Tweeters Canada - Huffington Post
Nominated for shorty award over last 4 years
Some articles have been used as references in medical research, such as international journal Pharma and Bio science, ISSN 0975-6299.

Musculoskeletal disorders (MSDs) are medical condition mostly caused by work related occupations and working environment, affecting patients’ muscles, joints, tendons, ligaments and nerves and developing over time. According to a community sample of 73 females and 32 males aged 85 and over underwent a standardised examination at home, musculoskeletal pain was reported by 57% of those interviewed(*).

Types of Musculo-Skeletal disorders in elder

1. Osteoarthritis
2. Gout
3. Rheumatoid Arthritis
4. Polymalagia Arthritis
5. Cervical myleopathy and spinal canal stenosis
6. Osteoporosis
7. Low back pain
8. Fibromyalgia

                                                                  Gout

Gout mostly effected one joint is an acute and recurrent condition of arthritis as a result of uric acid building up in blood, inducing joint inflammation.

                                                  Symptoms

In the study carry out a cross-sectional survey on prevalence of musculoskeletal symptoms, rheumatoid arthritis (RA), ankylosing spondylitis (AS), and gout, Dr. Dai SM, and the research team at the Second Military Medical University, in the interviewe a total of 6584 adults (3394 women, 3190 men) with the response rate of 86.6%. showed that symptoms occurred more frequently in the following sites: knee 7.0% (95% CI 6.4-7.6%), lower back 5.6% (95% CI 5.0-6.2%), shoulder 4.7% (95% CI 4.2-5.2%), and neck 2.4% (95% CI 2.0-2.8%). Women complained of rheumatic symptoms more frequently than men. The standardized rates of RA, AS, gout, symptomaticknee osteoarthritis, and soft tissue rheumatism were 0.28% (95% CI 0.15-0.41%), 0.11% (95% CI 0.03-0.19%), 0.22% (95% CI 0.11-0.33%), 4.1% (95% CI 3.6-4.6%), and 3.4% (95% CI 3.0-3.8%), respectively(1a).
Most frequent symptoms of gout as a result of tophus(4), according to studies including
1. Warmth(1), pain(1), particular endpoint pain(2), swelling(1), erythema(1), and extreme tenderness(2)(called podagra. when it effects the big toe), according to the Cadence Physician Group/Orthopaedics(1)
2. Very red or purplish skin on the affect joint(5)
3. Reduced movement of affect joint and big toe, according ot the study by the Auckland University of Technology, walking shoes with good footwear characteristics can influence plantar pressure values and encourage a more efficient heel to toe gait pattern in people with gout(3).
4. Induced skin itching and peeling when the affect joint begins to heal(5)
5. Intractable back pain and fever if it a  spinal gout(6).

In fact, symptoms are quite noticeable, you may feel well when you go to bed but wake up during the night with intense pain in one or few joints and sometime with fever. The symptoms may go away in a few days, but can return from time to time. Chronic gout can cause lumps(4) below the skin around the affect areas.



                                         Causes and risk factors

A. Causes
The causes of gout is as the result of high levels of uric acid in the body that can lead to forming of crystals causes of inflammation due to your body can not get rid of uric acid or have made too much uric acid(4). Reduced intake of meats and seafood and foods containing higher levels of uric acid, such as alcoholic beverages, especially beer, and drinks sweetened with fruit sugar (fructose) may be necessary(7)(8).
According to the New York University School of Medicine/Langone Medical Center, the prevalence of gout and hyperuricemia has increased dramatically during the last several decades, to the point that gout is the most common inflammatory arthritis in the United States, affecting approximately 8 million Americans(9) and contributing to great numbers of hypertension, chronic kidney disease, and cardiovascular disease(9).


B. Risk factors
1. Improper diet
If you body can not get rid uric acid quickly, intake foods with high levels of purine such as Alcohol, Beverages, Beer, Anchovies, Smelt, Fish, Eggs, Herring, Mackerel, Sardine, Sweetbread, Liver, Kidney, etc., is at increased risk of gout(7)(8)(10). Several dietary factors increased the risk of incident gout, including meat intake, seafood intake, sugar sweetened soft drinks, and consumption of foods high in fructose(10).

2. Alcohol consumption
Dr. Singh JA and scientists at the Birmingham VA Medical Centre, indicated, of the 751 titles and abstracts, 53 studies met the criteria and were included in the review. Several risk factors were studied. Alcohol consumption increased the risk of incident gout, especially beer and hard liquor(10)(7).
 Others suggested that combined with their activities as urinate transporters and their strong associations with serum uric acid concentrations,

3. Medical conditions
Hypertension, renal insufficiency, hypertriglyceridemia, hypercholesterolemia, hyperuricemia, diabetes are associated to increased risk of gout(10). Patient with Chronic kidney disease are at higher risk of gout as a result of Serum uric acid control in gout was poor among patients without CKD and even worse among those with CKD(11). Distinct group differences by content of uric acid seem to arise from early onset of chronic renal failure in women.

4. Medication
Gout is also drug-related(21). Thiazide and loop diuretics users are at increased risk of gout(12)(10), according to Johns Hopkins University Bloomberg School of Public Health.

5. Race
Some ethnic groups are particularly susceptible to gout, probaby due to genetic predisposition(13)(14).
6. Age and sex  are associated to risk of the develop of gout(14)(15).

7. Genetics
GLUT9 and ABCG2 appeared to be important modulators of uric acid levels and likely of the risk of gout. Together with a growing list of environmental risk factors, these genetic data add considerably to our understanding of the pathogenesis of hyperuricemia and gout(16)(17)(19).

8. Family history 
Accoridng to the total of 543 cases of juvenile gout from the Ho-Ping Gout Database, and 5269 gouty cases with onset age of 40 to 50 years, family history is associated to increased risk of gout(18)(19)
9. Obesity, over weight, weight change
 Obesity and overweight are associated with a higher risk of incident gout and/or gout flare(10)(19).
Higher adiposity and weight gain are strong risk factors for gout in men, while weight loss is protective(5).

10. Menopause
Early menopause is associated with a higher risk of incident gout and/or gout flare(10). According to the16 years of follow-up (1 240 231 person-years), 1703 incident gout cases, conducted by the Taipei Municipal Hospital Gout Research Group, compared with premenopausal women, postmenopausal women had a higher risk of incident gout. Risk of gout is decreased among postmenopausal hormone users(22).

11. Recent surgery or trauma
According to Cleveland Clinic, risk of early postoperative gout is higher after bariatric surgery in comparison of patients undergoing other procedures(23)(24). There is a report of monoarticular gout following trauma in Medical College of Wisconsin literature(25).

                    Diseases associated with  Gout

According to the UK Gout Society,  diseases associated to gout may include

1. Hypertension
Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood. High blood pressure means raising pressure in your heart.If it stays high over time it can damage the body in many ways.

Dr, Gibson TJ said, "gout are associated with hypertension and chronic kidney disease is well established" and "(many medication such as Losartan may possess mild uricosuric properties and therefore has a role in treating hypertensive patients with gout"(26).
Western medication such as hydrochlorothiazide (HCTZ) and chlorthalidone (CTD), according to the University of Missouri, are effective used for treatment of hypertension in gout patients(27) with certain unwanted side effects.
Diet rich in fruits and vegetable and reduced intake of red meat, saturated fat and trans fat has shown to attenuated risk of hypertension(28). Recent study showed that celery(29) intake used conjunction with berries(30) and green tea(31) may be the potential drink for prevention and treatment of hypertension in patients with gout.
For more information visit: The Smoothies of celery, apple and green tea for prevention and treatment of Hypertension(32)


2. Renal insufficiency
Patients with gout are associated to chronic kidney disease has been well documented in epidemiological literature(26). The joint study led by the Keele University suggested, "Chronic kidney disease and nephrolithiasis are commonly found amongst patients with gout. Gout is independently associated with both chronic kidney disease and nephrolithiasis. Patients with gout should be actively screened for chronic kidney disease and its consequences"(33).
Dr. Krishnan E said, "Chronic kidney disease manifesting as reduced glomerular function or as presence of blood or protein in the urine increases the risk of incident gout"(34).
Chronic Kidney disease is defined as a condition of the progression loss of kidney function over period of many years. Stage of chronic kidney disease according to the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQ). 

In the review of literature from data base of PubMed, Brazil Nut(35)(36), Flax Seed(37) and Honey(38)(39) found effectively in treatment of renal insufficiency back by recent studies from some well known institutions  may serve as cornerstones of pharmaceutical target for further studies as well as a potential medication for treatment of Chronic Kidney disease in patient with gout. For more information, please visit The Impossible Smoothie of Brazil Nut, Flax Seed and Honey For Prevention and Treatment of Chronic Kidney disease(40).

3. Hypertriglyceridemia
Unhealthy diet such as typical American diet with high in saturated and trans fat and lower intake of vegetables and fruits has been found to associated to hypertriglyceridemia in epiodemilogical literature in data bases of PubMed(41)(42)(43), particular to hypertriglyceridemia in men(46).
In the searching of the association of hypertriglyceridemia in patients with gout, according to the Osaka University Medical School, there is a close correlation between the degree of uric acid production and triglyceride (TG) metabolism in 148 male subjects with primary gout(45).
Dr. Naito HK and Dr. Mackenzie AH. insisted, " diet and, possibly, defective clearance of triglycerides may be etiologic factors associated with the abnormal serum triacylglycerol (triglyceride) and lipoprotein concentrations in these individuals"(44).
According to the Korean National Health and Nutrition Examination Surveys (KNHANES) 2007-2009, supported the potential beneficial role of vegetables and fruits consumption to reduce blood triglyceride levels in Asian populations(47).
Furthermore, High-fat ketogenic diets, the only treatment available for Glut1 deficiency (Glut1D) as od today, according to joint study led by the Children's Hospital Aschaffenburg Alzenau after 3 years intake, showed a gradual increase of blood lipids, followed by rapid, severe asymptomatic hypertriglyceridemia (1,910 mg/dL)(48).

4. Hypercholesterolemia
Unhealthy diet such as typical American diet with high in satyrated and trans fat and lower intake of vegetables and fruits has been found to associated to Hypertriglyceridemia and Hypercholesterolemia in epidemiological literature in data bases of PubMed(41)(42)(43).
Dr. Tu FY and colleagues of some well known institutions in Taiwan, according to the data from the Taiwan national health insurance database for 2004 to 2006, showed that hypercholesterolemia, were the common comorbidities of gout(56).
Furthermore, the association of gout and hypercholesterolemia may be due to poor quality of  life style implications(59) such as alcohol intake(57) as well as dietary low in vegetables and fruits(58)
Recent studies suggested that avocado(49)(50), Almond(51)(52) and green tea(53)(54) may consist a therapeutic values used combination for reduced risk and treatment of high blood cholesterol in patients with gout. 

For more information of above effectiveness, please visit, The Smoothie of avocado, Almond and green tea for prevention and treatment of Hyperlipidemia(High blood Cholesterol)(55).


5. Hyperuricemia
Hyperuricemia, a condition with over expression of uric acid in the blood through liver most often found in patients with gout. According to Dr. Li YM. said, "It has been widely accepted that the increase in the level of uric acid significantly raises the risks of gout, cardiovascular disease, and type 2 diabetes."
It is acceptance epidemiological studies that high fruit and soybean products dietary intervention could be an effective alternative to a standard diet for achieving clinically important reductions in SUA for asymptomatic hyperuricemia patients(61). And major dietary patterns such as animal products and fried food are associated to risk of hyperuricemia(62).
According to the Chiang Mai University, green tea extract (GTE) also promoted hypouricemic and anti gout effects through modestly lowering serum uric acid (SUA) level and decreasing uric acid clearance(63). 
Reduced intake of food with rich purine, alcohol intake as well as controlling obesity and blood pressure, improving the status of lipid metabolic disorder together with programs as hypertension control etc.(64).

6. Diabetes
Diabetes is a condition caused by insufficient insulin entering the bloodstream to regulate the glucose. It is either caused by cells in pancreas dying off or receptor sites clogged up by fat and cholesterol. In some cases, diabetes is also caused by allergic reactions of cells in the immune system.
According to the University of Chicago, diabetic gout patients were older, more frequently female, and had longer gout duration(65).It is said that conventional treatment with 80 mg febuxostat may be more efficacious in female gout subjects with high rates of comorbidities in comparison of commonly prescribed doses of allopurinol(66).
Dr. Donath MY said, " an inflammatory process also seems to be involved in the development of cardiovascular, renal and ophthalmological complications of this disease. Interestingly, several other inflammatory diseases are associated with the metabolic syndrome(particular diabetes) such as psoriasis, gout and rheumatic arthritis"(67).

Recent studies back by renowned institution suggested that Cinnamon(69), Whole Food Papaya(70) and Green Tea(71) reduced Risk and Treatment of Diabetes through their effects in improved fasting blood glucose levels and glucose tolerance without altering the insulin secretion and in regulation of metabolism (carbohydrate, lipid, protein))-medicated glucose and lipid metabolism(68).

7.  Obesity
Obesity, one of the disease of metabolic syndrome is a medical condition of excess body fat accumulated overtime, while overweight is a condition of excess body weight relatively to the height.
According to the joint study led by the Catholic University of Korea, gout is a chronic inflammatory disease the development of which is associated with obesity-induced metabolic abnormalities(72). And General obesity in women may potentiate an sUA effect for gout development in the study of a total of 261,500 person-years conducted by the China Medical University(73).
Recent studies conducted by some renowned institutions suggested that green tea(75)(76), avocado and(77) blueberry(78)979) may be a potent drink for reduced weight and treatment of overweight and obese subjects.
People who are at increased risk of overweight due to family history, gene mutation, .....should drink at least one serving daily and overweight and obese people should drink the smoothie as much as they can depending to digestive toleration.
Change of life style and diet pattern are also recommended(74).

8. Heart diseases
Beside cancer, heart disease kills more than 2,000 Americans everyday. Approximately 60 million Americans have heart disease.  Most of heart diseases are caused by high blood pressure contributes to hardening of the arteries. High levels of bad cholesterol (LDL) build up in the arteries as a result of tuncontrolled diet with high levels of saturated fat and trans fat. According to study, risk of heart attached is increased in older women with gout(80).
In a total of 8,656,413 participants with a total of 1000 MI events included in the study conducted by Taizhou Municipal Hospital, patients with gout have an increased risk of myocardial infarction(81).
Recent studies conducted by some well known institutions suggested that the combination of Blueberry(82), Avocado(83) were found to have a potential effect for Reduced Risk and Treatment of Heart Disease. and recommended that People who are at increased of heart disease due to family history, obesity, gout.....should drink at least one serving daily and people with heart disease should drink no more than 4 servings a day, depending to digestive toleration.
Change of life style and diet pattern are also recommended(84).

9. Stroke 
Besides cancer and heart diseases, stroke is the third leading cause of death. Approximate 1/4 of all stroke victims die as a direct result of the stroke or it's complications. Stroke is caused by uncontrolled diet that is high in saturated and trans fats resulting in cholesterol build up in the arteries and high blood pressure. 
 In the review of all-England dataset included 202 033 hospital patients and all-England national linked dataset of hospital admissions and death records from 1999 to 2011, the University of Oxford, strongly confirmed that gout was associated with increased risk of stroke(85).
Dr. Grassi W and Dr. De Angelis R. in the analyzed clinical features of gout. found that gouty patients often have a medical history, including stroke, resulting with a poor overall quality of life(86).

This finding of the effectiveness of Green Tea(87) and coffee(88) and blueberry(89) phytochemicals in recent studies by some respectable institutions  may serve as cornerstones of pharmaceutical target for further studies in production of a potential medication for reduced risk treatment of stroke with little or no adverse effects.
If you need more information of above finding, please visit The incredible smoothie Green Tea, Coffee and Blueberry for reduced risk and treatment of Stroke(90)


11. Peripheral vascular(artery) disease 
Peripheral vascular disease is a condition of poor circulation of blood, affecting the  functions of heart and brain. Because of of its implication involving risk of myocardial infarction, stroke, and cardiovascular death and impaired quality of life, some researchers suggested of the importance in identified patients with PAD have become necessary(91). According to the a large cohort of primary care patients, patients with gout are associated to increase risk of vascular disease, particular in female patients with gout(92).
Dr. Baker JF and colleagues at the University of Pennsylvania said, " in multivariate model, a history of gout was associated with an odds ratio of 1.33. Serum uric acid level is independently associated with a higher (but statistically nonsignificant) risk of PAD"(93).
In the study involved classical risk factors and rheological profile of patients suffering from vascular disease of. 364 patients out of a total of 2,498 individuals suffered from vascular disease, the University of Saarland study insisted that patients with gout and metabolic syndrome are associated to elevated risk of peripheral vascular disease(94).

12. Psoriasis  
Psoriasis is an autoimmune diseases induced abnormal skin path with expression of redness, itchy, and scaly. According to the joint study led by the University of Trieste, the increased incidence of a large number of diseases which share an inflammatory origin probably due to the pro-inflammatory cytokine spillover from active psoriatic lesions leading to a large inflammation on distant tissues(95).
Methotrexate, a conventional medicine may be an effective therapy for extensive and severe forms of psoriasis if patients are selected carefully and monitored regularly in the dose of <15-20 mg/week(96) Dr. Haustein UF and Dr. Rytter M. insisted(96).
According to the joint study led by the Brigham and Women's Hospital and Harvard Medical School, Boston, individuals with psoriasis have increased blood levels of uric acid. In the documented 2217 incident cases of gout during follow-up. Psoriasis was associated with an increased risk of subsequent gout with a multivariate HR of 1.71(97).
Dr. Lai YC and Dr.Yew YW said, " A raised serum uric acid level may be a consequence of metabolic syndrome, which in turn is associated with psoriasis"(98).

Recent studies by some renowned institutions suggested that green tea(99) and grape(100) may be the next generation of ingredient extracted from natural sources for reduced risk and treatment of psoriasis.
If you need more information of the above smoothie, please visits, The Unbelievable Smoothie Green Tea and Grape for reduced risk and Treatment of Psoriasis(101).

                                           The complications



1. Tophi
Tophi is a forming of lumps building up around the joint due to chemical called uric acid. According to the University Hospital Southampton NHS Foundation Trust, tophi may be managed and treated by non-surgical and surgical procedures(102). 
Allopurinol, the conventional medication, allopurinol (100 to 600 mg daily) expressed low- to moderate-quality evidence indicating similar effects on withdrawals due to adverse events (AE) and serious adverse events (SAE). and incidence of acute gout attacks in randomised controlled trials (RCTs) or quasi-randomised controlled clinical trials (CCTs)(103). And benzbromarone is probably more successful than probenecid at achieving serum urate normalisation in people with gout(104).
According to the Hospital General Universitario de Alicante, diet supplements of vitamin C, has shown to the attenuated forming of lumps on joints but the study did not assess tophus regression, pain reduction or disability or health-related quality of life impact. The study reported no adverse events and no participant withdrawal due to adverse events(105).
Furthermore, there is good evidence from observational studies of an association between various lifestyle risk factors and gout development but the The Royal Melbourne Hospital, Parkville, Australia study did not include the expression of physical function, tophus regression and serum urate normalisation(106).

2. Kidney stone
Kidney stone is a composed of mineral salts formed in the kidneys. Men account for the 80% of those with kidney stones and are at risk of the forming between 30 and 40 years of age. About 75% of kidney stones are calcium stones.
Minimally surgical intervention depends on performing the least invasive technique with the highest success of stone removal, according to Harvard Medical School(107). Others suggests that flexible ureterorenoscopy may be the first-choice treatment for stones <2cm(108).
Dr. Ahmed MH and colleagues at the Milton Keynes Hospital NHS Foundation Trust, believe that Renal stone disease and gallstone disease are the widely prevalent renal stone disease and gallstone disease across the globe, are associated with a variety of diseases including gout(110).
In a total of 396 male patients with gout and 403 age- and sex- matched healthy controls included in this study conducted by the Affiliated Hospital of Qingdao University, risk of renal calculus is increased in patient carrying the TT genotype of CARD8 rs2043211 polymorphism with gout(109).

Recent study by some well known institution suggested that the combination of Green tea(111), Grape (112) and Sweet Potato(113) smoothie may hold a key in further studies in production of an effective natural ingredients for prevention and treatment of  kidney Stones  without inducing adverse effects.

If you need more information of the above smoothie, please visits, The Best Smoothie of Green tea, Grape and Sweet Potato for Prevention and Treatment of Kidney Stones caused by Medullary sponge kidney(114).

3. Joint damage
Acute gout or acute gouty arthritis can induce joint damage thoough deposit of uric acid crystals in joint spaces. Patients with gout are associated to complication of joint damage, according to the joint study led by University of Auckland, monosodium urate crystals are frequently present in joints affected by radiographic damage in gout(115).
Dr. Dalbeth N and professors at the University of Auckland in the review of joint damage in aptients with gout, suggested that intensive urate-lowering therapy plays a critical role in improvement in structural damage, particularly bone erosion(116).
MDHAQ (Multidimensional Health Assessment Questionnaire) scores for physical function (FN), pain, Patient Global Estimate (PATGL), and RAPID3 (Routine Assessment of Patient Index Data, a composite of these 3 measures) in the examination of patients with osteoarthritis, systemic lupus erythematosus, spondyloarthropathy, and gout, similarly to rheumatoid arthritis suggested an improvement scores in patients with 5 diagnoses, according to NYU Hospital for Joint Diseases,(117). 

4. Recurrent gout
Recurrent episodes of gout have shown to induce further damage to joints and other tissues from urate crystal deposition. Certain medication such as aspirin used on two consecutive days is associated with an increased risk of recurrent gout attacks(118). Purine-rich foods intake is associated to increased risk of recurrent gout after 2 days(119).
Consumption of beer, loop or thiazide diuretics, ciclosporin, tacrolimus, ethambutol, pyrazinomide, nicotinic acid, also are found stimulate the progression of recurrent gout, according to Dr. Robin Fox, GP(120). Other risk factors for recurrent gout include medical conditions such as Psoriasis Myeloproliferative disorders, Administration of cytotoxic drugs (tumour lysis syndrome), Inherited enzyme deficiencies and  Lead poisoning(occupations)(120).
Fortunately, in a study of 633 individuals with gout. cherry intake over a 2-day period was associated with a 35% lower risk of gout attacks. Cherry extract intake showed a similar inverse association(121). And according to the University of Maryland School of Medicine, "primary prevention of gout can be achieved through lifestyle changes including weight loss, restricting protein and calorie intake, limiting alcohol consumption, avoiding the use of diuretics in the treatment of hypertension, and avoiding occupational exposure to lead"(122).

5. Advanced gout
Untreated gout may cause even more deposits of urate crystals to form under the skin in nodules called tophi (TOE-fie), leading to advanced gout with tophi developed in several areas, including fingers, hands, feet, elbows,.......Occasionally,untreated gout can lead to advanced arthritic changes. and chronic discomfort of the hallux MTPJ, necessitating surgical intervention to help alleviate symptoms, according to Dr. Balutis E and Dr., Pino A.(123).Refractory gout in patients who have ongoing symptoms of active disease and cannot maintain a target serum urate less than 6 mg/dl were treated successfully with long-term pegloticase treatment, improvements in clinical status, in the form of flare and tophus reduction and maintained goal range urate-lowering responses during up to 2.5 years of additional treatment(124).

                                 The Diagnosis


According to the Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Feb. Report No.: 15(16)-EHC026-EF.AHRQ Comparative Effectiveness Reviews(125).
if you are experience SHARP pain in the joint with visual symptoms of collection of urate crystal deposit and other clinical signs and symptoms of gout, your doctor may order the below tests
1. Joint fluid test 
Withdraw fluid from affected joint to test for sign of urate crystal accumulation for confirmation of gout.

2. Blood test
Blood test is necessary to measure levels of uric acid for gout and creatinine for kidney function in your blood. According to the University of Auckland, measured blood test in people with gout has caused confusion about the details of urate measurement in suboptimal care(126), as the measurement may not be accurate as some some people with high levels of uric acid levels, have never experienced gout. And some people have signs and symptoms of gout, but don't have higher levels of uric acid in their blood(127).

3. X-ray imaging(125)
The aim of the test is to rule other causes of inflammation of joints. In case of negative or inconclusive, other tests such as ultrasound and dual energy CT scan to provide additional information in patients(128),


4. Ultrasound(125)
The aim is to detect any urate crystals deposit in a joint or in a tophus for confirmation of gout when X ray is inconclusive and negative(128). Dr. Codreanu C and Dr. Enache L said, "adding US to the clinical and serological features will significantly improve the sensitivity of proposed criteria. The ability of high resolution US to detect crystalline deposits of monosodium urate in joints and soft tissues is well recognized"(129)

5. Dual energy CT scan(125)
The aim of the test is to detect any any urate crystals deposit in a joint or in a tophus even without sign of acute inflammation. "Dual-energy computedtomography (CT) contributes over conventional single-energy CT,........ Particular emphasis will be placed on acute gout, bone marrow edema, acute renal colic, acute cardiovascular and neurovascular emergencies aswell as characterization of abdominal incidentalomas" according to the joint study led by the University of British Columbia.


                      The Misdiagnosis and delay diagnosis

According to the University of Kansas School of Medicine, out of 9,108 consecutive new patients seen in an outpatient rheumatology clinic, 155 (1.7%) diagnosed as having gout, 164 (1.8%) had been incorrectly diagnosed as having gout in the community(131).
"The main factors potentially contributing to delayed diagnosis after consultation included reported misdiagnosis, attacks in joints other than the first metatarsophalangeal joint, and female gender. The limitations in using serum uric acid (SUA) levels for diagnostic purposes were not always communicated effectively to patients, and led to uncertainty and lack of confidence in the accuracy of the diagnosis", the Keele University insisted(134).

1. Rheumatoid arthritis
In elderly, polyarticular gout may be misdiagnosed due to confusing clinical presentation of "diuretic gout" such as polyarticular onset, subacute symptoms. ......According to the Albert Einstein College of Medicine, misdiagnosis of rheumatoid arthritis can induce poor treatment of gout, affecting underlying conditions of renal insufficiency, and cardiac risks(132).

2. Elderly-onset gout (EOG)
Elderly-onset gout (EOG) is a condition of gout with onset at age 65 years or over, shared a relevant epidemiological, clinical and therapeutic differences from the typical middle-age form. According to the University of Ferrara,"EOG has recently been confirmed as the most common inflammatory arthropathy in older people, with important demographic implications and substantial impact on daily clinical practice. Despite the high prevalence, gout, in the elderly, often remains misdiagnosed or diagnosed late in its clinical course."(133).

3. Misdiagnosis due to confusing in classification
According to the Hospital Universitario Cruces, as a step-up disease, gout consists different stages: acute gout, intercritical gout, and chronic gout but in clinical practice, gout should be considered as a single disease with either or both acute (most commonly, episodes of acute inflammation) but not restricted to chronic synovitis in support the clinical manifestations and diagnosis of gout(135).

4. Recurrent gouty arthritis
There is a report of misdiagnosis of recurrent gouty arthritis associated with hyperuricemia and hyperlipidemia during adolescence. as steatohepatitis in a family with mild glycogen storage disease type 1a. National Chung Hsing University, due to the effect of result of misdiagnosis suggested that patients with mild glycogen storage disease should be considered in the adolescents with unexplained hyperuricemia and hyperlipidemia, despite the presence of normal blood glucose levels(136).

5. Chylous cysts of the neck or chest
According to the Geisinger Medical Center, there is a report of chylous cyst was misdiagnosed as recurrent chest wall gouty tophus due to form birefringent crystals upon drying(137).

6. Psoriatic arthritis
In the review of Forty-two patients with psoriatic arthritis who were referred to a tertiary medical center from 1983 to 1987, eight patients with foot and ankle involvement were diagnosed and treated for either gout or compression of a digital nerve due to failure to identify psoriatic skin lesions and the  associate foot and ankle symptoms with psoriatic arthritis.(138).


                             The Prevention and Management


The Do’s and Do not’s list
1. Coffee
Researchers found that long-term moderate coffee consumption is associated with a lower risk of incident gout, particular in women(139). According to the joint study led by the Naresuan University Hospital, there is an associations between vitamin C, alcohol,coffee, tea, milk and yogurt with uric acid and the risk of gout(140).
In Japanese men and women aged 49-76 years, "There were inverse associations of coffee consumption with serum UA concentrations and hyperuricemia in men regardless of adjustment for covariates" Said by Dr. Pham NM and colleagues at the Kyushu University(141).

2. Maintaining adequate fluid intake, particular at night
Dehydrate is associated with the increased risk of gout, particular at night time, epidemiological study suggested(142). Drinking water or skim milk can improve gout control, according to findings from two studies that highlight the important contribution of lifestyle factors on gout prevention and management(144), and recent use of diuretics is associated with a significantly increased risk for recurrent gouty arthritis(143).

3. Weight reduction
Obesity cause cause pressure to the joint. Obesity is not only a risk factor for incident gout but is associated with an earlier age at gout onset(147). According to the a total of 543 cases of juvenile gout from the Ho-Ping Gout Database and 5269 gouty cases with onset age of 40 to 50 years, family history of overweight and hereditary background are significantly associated to increased risk of juvenile gout(145).
Dr. Lee J and the research team at the The Catholic University of Korea, said," Gout is a chronic inflammatory disease the development of which is associated with obesity-induced metabolic abnormalities."(146).
In deed, women with early- and mid-adult life obesity, high mid-adult life waist-to-hip ratios, and adulthood high weight gain, experience a greater incidence of gout, according to Johns Hopkins University School of Medicine(148).

4. Dietary and life style pattern changes
a. Reduce alcohol
Alcohol intake is strongly associated with an increased risk of gout. This risk varies substantially according to type of alcoholic beverage: beer confers a larger risk than spirits, whereas moderate wine drinking does not increase the risk(150). The association between excessive alcohol consumption and risk of gout has been suspected since ancient times which was confirmed by the study by the Harvard Medical School, Boston(149).
Unfortunate to alcohol drinker, regardless of type of alcoholic beverage, episodic alcohol consumption,was associated with an increased risk of recurrent gout attacks, including potentially with moderate amounts(151).

b. Reduce intake of foods with high levels of purine, such as sardines, herring, kidney and sweetbreads, shrimp, etc.(152). According to the Third National Health and Nutrition Examination Survey, in the review of the data from 14,809 participants (6,932 men and 7,877 women) ages 20 years and older for the years 1988-1994, higher levels of meat and seafood consumption are associated with higher serum levels of uric acid(153) and sugar-sweetened soft drink consumption is associated with serum uric acid levels and frequency of hyperuricemia(154).

c. Diet with foods to prevent gout
Dairy products, vegetables, nuts, legumes, fruits (less sugary ones), and whole grains are healthy choices for the comorbidities of gout and may also help prevent gout by reducing insulin resistance(156). Coffee and vitamin C(155) supplementation could be considered as preventive measures as these can lower urate levels, as well as the risk of gout and some of its comorbidities(156).
Diet with foods such as cherries and strawberries to prevent gout(157), as  evidence of the impact of strawberry intake on gout has been report(157).

5. Reduce intake of medications which can cause gout and recurrent gout by reviewing them with your doctor, as certain medicine such as Thiazide and loop diuretics(158).

6. Exercise
Regular physical exercise is associated to reduce risk of gout(159).
“Exercises to relieve gout should be done steady and cautiously as to avoid further irritation to the joints. The best exercises for gout are range of motion types: strength training, stretching and building endurance. Yoga is an exercise that incorporates all four; however, there are other exercises that can be done individually also” According to the article of How to Exercise If You Have Gout(160).


                         The top anti inflammatory Foods


The top 5 anti inflammatory foods in reduced risk of over expression of pro inflammatory cytokine are always important to prevent the early onset and patient with gout as well as the expression of cardiovascular and renal risks(190).
2.1. Garlic 
Inflammation plays an important roles in the early onset of uric acid involved the develop of gout. Dr. Perez-Ruiz F and Dr, Becker MA suggested, inflammation may provide a mechanistic explanation, related to some important chronic co-morbidities remains uncertain(189).
According to the joint study led by the Instituto de Neurobiología, alliin, a garlic (Allium sativum) compound inhibited the exprssion of LPS-induced inflammation(186) in 3T3-L1 adipocytes(187), involved decreasing serum levels of glucose, insulin, triglycerides, and uric acid, as well as insulin resistance, and cytokine levels(187).
Dr. Percival Ssaid, "Garlic contains numerous compounds that have the potential to influence immunity. Immune cells, especially innate immune cells, are responsible for the inflammation necessary to kill pathogens. Two innate lymphocytes, γδ-T and natural killer (NK) cells, appear to be susceptible to diet modification"(188).

2.2. Turmeric
Turmeric with the similar property as garlic in enhancing immune system fighting against inflammation caused by either free radicals and foreign invasion(191). Recent study suggested, IL-1β inhibited by turmeric(195) is a potent proinflammatory cytokine of the innate immune system involved in host defense against infection. may increase production of IL-1β which plays a pathogenic role in various inflammatory diseases, such as rheumatoid arthritis, gout(194).
In animal with gout study, there was a positive correlation between intra-articular macrophage migration inhibitory factor involved in increased synovial fluid of patients with acute gout and IL-1β concentration(196).
According to the joint study led by the Federal University of Technology and China Pharmaceutical University, turmeric (Curcuma longa) exhibited effects on enzyme activities of purinergic and cholinergic systems as well as inflammatory cytokine levels(192). including including interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α)(192) through inhibiting the xanthine oxidase (XOD) activity related to amelioration of urinary uric acid (Uur) level(193).

2.3. Green Tea
Green tea, a precious drink in traditional Chinese culture has been served exceptional in socialization for more than 4000 thousand years. Due to its commercial values and health effects, green tea now was cultivated all over the world in suitable climate. According to the Naresuan University Hospital, dietary of green tea is associated to attenuate risk of  of yugout(197), through its effect on lower SUA level and decreases uric acid clearance via significantly elevated serum antioxidant capacity(198).
Dr. L'Allemain G said, in the study of the effect of Epigallo catechin-O-gallate (EGCG), the most active epicatechin in green tea, "although no direct molecular target has been so far elucidated for EGCG, the multi-potentialities of this molecule, along with its broad bioavailability, render it very attractive as a putative curative drug for various diseases such as dermatosis, gout, atherosclerosis and cancer" and "Its anti-oxidant properties could explain its antagonistic action in some inflammatory processes"(199)

2.4. Shiitake mushroom
Shiitake mushroom is an edible mushroom, genus Lentinula, belongings to family Marasmiaceae, native to East Asia and widely cultivated for consumption for its health benefits and commercial purpose in many Asian countries. According to the joint study led by the University of Florida, intake of Shiitake mushroom improved immunity, through cell proliferation and activation and increased sIgA production, reduced inflammation via cytokine and serum CRP levels(200). Dr. Urano W and colleagues at the Tokyo Women's Medical University said, "Decrease in SUA during acute gouty arthritis is associated with increased urinary excretion of uric acid; an inflammatory process may play a role in the mechanism"(201).
The effect of Shiitake mushroom on Interleukin-6 (IL-6), a monokine with a number of biological activities, are intimately related to inflammatory responses in ameliorated serum uric acid (SUA) and increased uric acid excretion(201)(202).

2.5. Onion
Onion is a plants in the genus Allium, belongings to the family Alliaceae, a close relation of garlic. It is often called the "king of vegetables" because of its pungent taste and found in a large number of recipes and preparations spanning almost the totality of the world's cultures. According to the Universidad Nacional de Cuyo, garlic (G) and onion (O) exhibited anti-inflammatory properties through antioxidant in attenuated oxidative stress(203) as well as (poly)phenols altered cytokine release, in protection against age-related inflammation and chronic diseases, including gout(204).
In fact, Quercetin, a flavonoid found in high levels in onions lowers blood uric acid in humans in 4 weeks, in dose dependent-manner, according to a randomised, double-blinded, placebo-controlled, cross-over trial.(205).

2.6. Ginger
Ginger is the genus Zingiber, belongings to the family Zingiberaceae, native to Tamil, used in traditional and Chinese medicine to treat dyspepsia, gastroparesis, constipation, edema, difficult urination, colic, etc. According to the VIT University, Trikatu, a herbal compound including ginger exhibited significant analgesic, anti-pyretic and anti-inflammatory effect against gout through precipitation of monosodium urate crystals in the joints(206).
Dr. Sabina EP and professors also at the VIT University, in the evaluation of 6-Shogaol isolated active principle from ginger suggested that application of 6-Shogaol attenuated the increased significantly the levels of lysosomal enzymes, lipid peroxidation, and inflammatory mediator tumour necrosis factor-alpha and paw volume and improved the activities of anti-oxidant status in monosodium urate crystal-induced mice(207).


               The Top immune enhancers

Enhancing immunity has shown to reduced risk of inflammatory diseases(218). The University of Calgary study insisted "Uric acid crystals [monosodium urate (MSU)] have emerged as an important factor for both gouty arthritis and immune regulation. This simple crystalline structure appears to activate innate host defense mechanisms in multiple ways and triggers robust inflammation and immune activation"(219)


1. Omega 3 fatty acids
Omega-3 fatty acids, phytochemincals in the class of Lipids, found abundantly in dark-green leafy vegetables, grains, legumes, nuts, etc. play an impotant role in reduced risk of weaken immunity inducing inflammatory diseases, including gout(220). Dr. Simopoulos AP said, "omega-3 polyunsaturated fatty acids (PUFA) which possess the most potent immunomodulatory activities," and "Animal experiments and clinical intervention studies indicate that omega-3 fatty acids have anti-inflammatory properties and, therefore, might be useful in the management of inflammatory and autoimmune diseases."(221).
Omega 3 fatty acid for prevention of hyperlipidemia(223) may also be effective in reduced metabolic syndrome including hypertension, hyperuricemia, hyperinsulinemia......., according to the St. Thomas' Hospital, (222).


2. Selenium
Selenium is one of most powerful antioxidant, played an important role in enhancing immune system fighting against forming of free radicals and foreign invasion, epidemiological evidences suggested.
In the follow up of serum selenium (Se) concentrations in 117 hemodialysis patients (HPs) during a 2-year longitudinal study, the University of Granada found that dyslipidemia and hyperuricemia found have a  negative correlation between the serum Se and uric acid levels(224).
The observation of total antioxidant capacity, including selenium was significantly higher in non-responders and well correlated with hyperuricemia(225).

3. Zinc
Zinc may plays an important role for the development of osteoarthritis, according to Randers Regional Hospital, patient with osteoarthritis are found to have significantly higher serum zinc concentrations and lower urine zinc concentrations in comparison to patient with osteoporosis(226).
In Gout, Zinc stimulates insulin action and insulin receptor tyrosine kinase activity in patient with type II diabetes reducing the risk of Insulin resistance induced the complication of hyperuricaemia(227).
Furthermore, according to the Universidade Federal de São Paulo, zince supplement decreased insulin resistance, anthropometric and diet parameters, leptin and insulin concentration, zinc concentration in the plasma and urine, lipid metabolism and fasting plasma glucose, affecting the hyperuricaemia levels in type II diabetes(228).


4. Vitamin B2
Vitamin B2, awater soluble, also known as riboflavin has a chemical compound formula of C17H20N4O6. Like many other vitamin B complexes, it plays an important role in providing energy to our body by the metabolism of fat, carbohydrates and protein. According to the joint study led by National Cancer Center, vitamin B2 levels were significantly lower in the hyperuricemia subjects than in the controls, in the study of 28,589 people who participated in a health examination between 2008 and 2011(229) due to higher alcohol intake and lower vegetable and dairy product intake.
 Australian Diabetes, Obesity and Lifestyle Study 1999/00 (n=9734, age 25-91) and Tromsø Study 4 1994/95 (n = 3031, age 25-69).suggested, " lower levels of SUA were found in subjects with higher consumption of carbohydrates, calcium and vitamin B2, while higher fat intake was associated with higher SUA"(230).

5. Vitamin B6
Vitamin B6 is water soluble and a member of vitamin B complex, played an important role in amino acids metabolism for to maintaining the proper function in our body. Vitamin B6 deficiency may be associated to risk of hyperglycaemia and hyperuricaemia(231). In deed, according to the  Universidad Complutense de Madrid, consumption of Cereals, vegetables, legumes and fruit, together with milk and eggs, constituted the most important ingredients of the diet in a closed community showed to reduced risk of deficiencies of iron, magnesium, zinc, vitamin B(6) and vitamin D in induction of hyperuricaemia, the main cause of gout(232).




                                           The diet

Dietary consumption and life style  plays an important role in association to risk and attenuated risk and progression of gout(208)..
1. Green tea
Green tea containing more amount of antioxidants than any drinks or food with the same volume, is the leaves of Camellia sinensis, undergone minimal oxidation during processing, originated from China. Regular intake of green tea has shown to reduced levels of uric acid by epidemiological and research studies and literature(210)
Recent study suggested that green tea exhibited anti SUA level and induced decreases uric acid clearance in a study comprised 1-week control, 2-week interventional, and 1-week follow-up periods conducted by the Chiang Mai University(209).


2. Coffee
Coffee is a brewed drink prepared from roasted coffee beans from the Coffee plant. The third national health and nutrition examination survey. using data from 14,758 participants ages >/=20 years in (1988-1994) support the effectiveness of drinking coffee >/=6 cups daily in ameliorated risk of gout in comparison to green tea. The study also said, "The inverse association with coffee appears to be via components of coffee other than caffeine"(211).
According to a system review by the joint study led by the Ajou University School of Medicine, moderate coffee intake might be advocated for primary prevention of hyperuricemia and gout in both genders(212).
Dr. Pham NM and colleagues at the Kyushu University said, " There were inverse associations of coffee consumption with serum UA concentrations and hyperuricemia in men regardless of adjustment for covariates. Women showed a statistically significant, but weaker, inverse association betweencoffee and serum UA levels after allowance for the confounding factors"(213).

3. Yogurt
Yogurt, a product of dairy used widely in Western world as a healthy foods for enhancing the digestive system is a dairy product made from milk. According to Dr. Towiwat and , Li ZG in the review of dietary effect of yogurt insisted that yogurt expressed anti uric acid and reduced risk of gout in regular consumption(214).
Dr Schlesinger said, " Non-fat milk and low-fat yogurt have a variety of health benefits and dairy products may have clinically meaningful antihyperuricaemic effects"(215) and "Dairy consumption was inversely associated with the serum uric acid level." Harvard Medical School, showed(216).

4. Milk
The diary product produced from cow drunk by millions of the world population may also have a positive effect on gout(216). According to the 3-month randomised double-blind controlled trial of milk products for prevention of gout flares, consumption of SMP/GMP/G600 daily over the 3-month period, showed greater improvements in pain and fractional excretion of uric acid, particular in tender joint count(217).



                      The Phytochemicals to prevent Gout


1. Quercetin and Rutin

Quercetin is a plant pigments belongings to the group of flavonoids and its conjugate rutin is a quercetin-3-O-rutinoside and sophorin, according to Dr. Zhu JX and research team at the School of Life Sciences, Nanjing University expressed inhibition of enzyme activities in mouse liver in relation to their absorption and metabolism, and their potential application to treat gout and hyperuricemia(161). Dr. Shi Y and Dr. Williamson G said" quercetin treatment, plasma uric acid concentrations were significantly lowered by -26·5 µmol/l (95 % CI, -7·6, -45·5; P=0·008), without affecting fasting glucose, urinary excretion of uric acid or blood pressure" in a randomised, double-blinded, placebo-controlled, cross-over trial(162). The antioxidant also exerted a strong anti-inflammatory effect that may be useful for the treatment of acute gouty arthritis, TianJin University of Traditional Chinese Medicine(163)

2. Morin
Morin (3,5,7,2′,4′-pentahydroxyflavone), a phytochemical found in the twigs of Morus alba L. documented in traditional Chinese medicinal literature to treat conditions akin to gout, was demonstrated to exert potent inhibitory action on urate uptake in rat renal brush-border membrane vesicles(164). In the study of Ramulus Mori, the branch of Morus alba, is widely used in traditional Chinese medicine prescriptions to treat gout and hyperuricemia, researchers at the Nanjing University suggested that the effectiveness of the herbal medicine in treating gout, probably due to the presence of antioxidants, including morin(165).
According to the Nanchang University, luteolin exhibited a stronger synergistic effect with kaempferol than did morin at the lower concentration(166).

3. Other phytochemicals
13 flavonoids  including myricetin, kaempferol, icariin, apigenin, luteolin, baicalin, silibinin, naringenin, formonoetin, genistein, puerarin, daidzin and naringin dihydrochalcone selected to investigate for their hypouricemic action in mice, also significantly reduced liver uric acid level in hyperuricemic animals(167).

3.1. Myricetin
Myricetin is one of the flavonoid class of polyphenolic compounds, found abundantly in fruits and vegetables, including berries.
According to Dr. Li Y and colleagues, Myricetin and luteolin expressed binding to the xanthine oxidase and cyclooxygenase-2 in attenuate the complex pathogenesis of gout, a metabolic disease(168). The Sri Ramakrishna Institute of Paramedical Sciences study also exhibited the protective effect of asepigallocatechin, acacatechin, myricetin, naringenin, daidzein and glycitein in reduced the expression of in gout patients(169).
In support of the effectiveness of flavonoids for treatment of gout, Universidad Nacional de Asunción insisted that quercitrin, quercetin, myricitrin and myricetin strongly displayed the xanthine oxidase inhibitory action against the over expression of gout(170).

3.2 Kaempferol
Kaempferol is one of the flavonoid class of polyphenolic compounds, found abundantly in fruits and vegetable with formula C15H10O6. According to the Nanchang University, the phytochemical catalyze xanthine to generate uric acid and cause hyperuricemia and gout, through it direct interference of site of Xanthine oxidase (XO), a key enzyme in purine catabolism(171).
Dr. Ahmad NS and colleagues at the National University of Sciences and Technology suggested that kaempferol-3-O-beta-d-glucopyranoside isolated from Pistacia integerrima leaves, exhibited dose dependent UA lowering effect in hyperuricemic mice(172).

3.3 Icariin 
Icariin, a flavonol glycoside, type of flavonoid is a 8-prenyl derivative of kaempferol 3,7-O-diglucoside. According to the Nanjing University, icariin exhibited anti hyperuricemic and over expression of gout effects through inhibition on the liver xanthine oxidase (XOD) activities(167).

3.4. Apigenin 
Apigenin, a natural product belonging to the flavone class, remarkedly lowered serum uric acid levels in potassium oxonate induced hyperuricemic mouse, according to the study by the Beijing Institute of Pharmacology & Toxicology(173). Apigenin-7-O-β-D-glucoside, derivative of apigenin isolated from Olea europaea leaf (Ph.Eur.) extract, exhibited strongly the anti-gout property through expression of inhibitory effects on xanthine oxidase (XO)(174).

3.5. Luteolin
According to Dr. Li Y and colleagues, Myricetin and luteolin expressed binding to the xanthine oxidase and cyclooxygenase-2 in attenuate the complex pathogenesis of gout, a metabolic disease(168).

                                                            The Antioxidants

 Dr. Choi HK in the study of dietary risk factors for rheumatic diseases said, "Because diet is an unavoidable universal exposure for people, even a small effect that can be achieved by dietary manipulation may produce a large impact on the population's health" and "A recent prospective study investigated several purported dietary factors for gout and confirmed some of the long-standing suspicions (red meats, seafood, beer, and liquor), exonerated others (total protein, wine, and purine-rich vegetables), and also identified potentially new protective factors (dairy products)"(185).

1. The Free radical scavengers
1.1. Vitamin A
Vitamin A, a bi-polar molecule formed by bonds between carbon and hydrogen, is a fat soluble vitamin, which can not be stored in the live, converted from beta-carotene, a powerful antioxidant.
According to the Arthritis Research Centre of Canada, Vancouver, the finding of vitamin A and its derivative in reduced risk and treatment has been controversial as vitamin A supplementation and food fortification may contribute to the high frequency of hyperuricemia in the US population, whereas β-carotene intake may be beneficial against hyperuricemia(175) by using data from 14,349 participants ages ≥20 years in the Third National Health and Nutrition Examination Survey (1988-1994),
Dr. Ford ES and Dr. Choi HK, in the differentaition of the concentrations of uric acid with concentrations of vitamin A and beta-carotene among adults in the United States, said, "Concentrations of uric acid were significantly and positively associated with concentrations of vitamin A and inversely with concentrations of beta-carotene"(176), of that support the evaluation of the Vancouver finding.
In fact, there are several lines of indirect evidence implicate vitamin A intoxication, associated mainly with impaired renal function involved the inhibition of enzyme xanthine oxidase in ameliorated the conversion of xanthine to uric acid and vitamin A intoxication(177).

1.2. Vitamin C
Vitamin C, also known as L-ascorbate is a water soluble vitamin with a chemical structure formula of C6H6O6. The vitamin cannot be stored in the body for more than 24 hours. Oral administration of vitamin C is associated to reduced risk of levels of serum uric acid (sUA) in chronic gout patients(178).
In fact, epidemiological evidence(180) has shown an support of the question of lifestyle and diet involved in significant role in gout and serum uric acid level which had been raised 2500 years ago, particular over intake of vitamin C(179).
A pilot randomized controlled trial involved patients with gout and an SU level >0.36 mmoles/liter (6 mg/dl), researchers at the University of Otago suggested that modest dosage of vitamin C (500 mg/day) for 8 weeks had no clinically significant urate-lowering effects in patients with gout of which differ from the findings in healthy control subjects with hyperuricemia(181) and contradicted to the study conducted by Johns Hopkins Bloomberg School of Public Health (vitamin C supplementation significantly lowered SUA, in reduced hyperuricemia or prevent incident and recurrent gout)(182).


1.3. Vitamin D
Vitamin D is a fat-soluble secosteroids found in small amount in few foods, including salmon, mackerel, sardines and tuna. The vitamin plays an important role in modulation of cellular proliferation, apoptosis induction, tumor growth suppression and promotion in absorption of minerals, including calcium, iron, magnesium, phosphate and zinc.
According to the The Affiliated Hospital of the Medical College, lower serum 25(OH)D levels is found to associated to patients with gout involved the attenuation of regulating immune system  in fighting against the inflammatory parameters(182)(183).
In fact, Dr. Takahashi S and colleagues at the Hyogo College of Medicine said, in the study of serum of concentrations of 1,25(OH)2-vitamin D3 in patients with gout, "The administration of uric acid lowering agent to the patients for 1 year caused a significant increase in their serum 1,25(OH)2-vitamin D3 concentration which was associated with a significant decrease in their serum uric acid concentration"(184).



                                              Treatments

A. In conventional medicine perspective
A.1. Acetaminophen
Acetaminophen is an analgesic drug used by conventional medicine for treatment of headaches, arthritis, etc., as well as reducing fever, often as an alternative to aspirin without causing gastrointestinal adverse effecta. Acetaminophen such as Tylenol can help to relive the pain of Gout.
b. Side effects if overdose, are not limit to
b.1. Nausea and vomiting
b.2. Appetite loss
b.3. Sweating
b.4. Diarrhea
b.5. Irritability
b.6. Abdominal pain
b.7. Etc.
The University of Adelaide, in a double-blind, placebo-controlled trial, showed that application of acetaminophen was associated with adverse effects of suppression of serum neutralizing antibody response and increased nasal symptoms and signs(233) and hepatic  damage(234) and toxicity(234).
Dr. Bhargava VO and Dr. Hirate J., said, " the relative contribution of the gastrointestinal tract and liver to the oral first-pass effect of acetaminophen may be dose-dependent"(235).

A.2. The study of Gout–what are the treatment options? indicated that The options available for the treatment of acute gout (236)are

1. NSAIDs
a. NSAIDs, also known as nonsteroidal anti-inflammatory agents/analgesics are commonly prescribed to control gout attacks in patients with hyperuricaemia.
Colchicine, due to economic affordable to many patients has been prescribed for treatment of gout with less adverse effects such as better tolerated, especially in patients with peptic ulcer, gastrointestinal bleeding or dyspepsia or who are taking anticoagulants(237), in acute gout patients.
According to the joint study led by the Lanzhou University in review of researched articles from 1983 until August 2014 suggested, beside "pain relief as the primary outcome, Tenderness, swelling, patients' global assessments of response to treatment, and investigators' global assessments of response to treatment were reported as the secondary outcomes"(238) with certain adverse effects depending to types of medicine and dose manner.

b. Side effects are not limit to
Dr. Bjarnason I, and the research team at King’s College School of Medicine and Dentistry, in the study of Side effects of nonsteroidal anti-inflammatory drugs on the small and large intestine in humans, suggested "Ingested NSAIDs may cause a nonspecific colitis (in particular, fenemates), and many patients with collagenous colitis are taking NSAIDs. Large intestinal ulcers, bleeding, and perforation are occasionally due to NSAIDs. NSAIDs may cause relapse of classic inflammatory bowel disease and contribute to serious complications of diverticular disease (fistula and perforation)" and
"NSAIDs may occasionally cause small intestinal perforation, ulcers, and strictures requiring surgery. NSAIDs, however, frequently cause small intestinal inflammation, and the associated complications of blood loss and protein loss may lead to difficult management problems"  and "The pathogenesis of NSAID enteropathy is a multistage process involving specific biochemical and subcellular organelle damage followed by a relatively nonspecific tissue reaction. The various possible treatments of NSAID-induced enteropathy (sulphasalazine, misoprostol, metronidazole) have yet to undergo rigorous trials"(239).
Dr. Davies NM and colleagues at the University of Sydney insisted, Non-steroidal anti-inflammatory drugs (NSAIDs) may also cause damage distal to the duodenum, through involving specific biochemical and subcellular organelle damage followed by inflammatory tissue reaction(240).
Furthermore, Dr. Davies NM said, "Because NSAIDS are widely prescribed and some are available without a prescription, heightened awareness of these toxicologic manifestations throughout the GI tract may reduce morbidity"(241).


2. Colchicine
a. Colchicine, used for a long period in gout, was approved for the first time in 2009 by the FDA for the prophylaxis and the treatment of acute attack, on the basis of a pivotal trial that showed the efficacy in the very short term – that is 24 h of a well-tolerated, low-dose regimen of Colcrys (colchicine, URL Pharma, Philadelphia, USA) to reduce pain in patients with acute gout – when given early(242). Use of medication should monitor through tapering, high-sensitivity CRP monitoring, bleeding risk and contraindications to ASA/NSAID therapy(244).
The main function of the medicine is to block the inflammatory processes and result in its utility for treating and preventing acute gout flare. Colchicine may also be used for treatment of other chronic inflammatory diseases involved the over expression of these molecular pathways(245).

b. Side effects are not limit to
1. Diarrhea
2. Dizziness
3. Flushing
4. Hair loss
5. Headache
6. Loss of appetite
7. Nausea; sore gums
8. Stomach pain
9. Vomiting
10. Etc.
According to the review of the research paper of "Thiocolchicoside: review of adverse effects" liver injury, pancreatitis, seizures, blood cell disorders, severe cutaneous disorders, rhabdomyolysis and reproductive disorders have been found in gout patients with the use of the medication(243).Long term usage of the medication also exhibited central nervous system (CNS) adverse effects(244).


3. Corticosteroids
Corticosteroids, also known as terpod hormone, are an anti-inflammatory medicine prescribed for a wide range of conditions in reduced inflammation and suppressed the immune system.a. According to study, systemic corticosteroids could be used in severe poly articular flares(246). Anti-IL1 should provide a therapeutic alternative for severe cortico dependent gout with tophus(246). To prevent acute flares and reduce tophus volume, uric acid serum level should be reduced and maintained below 60mg/L (360μmol/L). The medicine is also considered as one of most frequent prescription for treatment of gout patients(247).


b. Side effects are not limit to
b.1. Stomach irritation
b.2. Rapid heartbeat
b.3. Nausea
b.4. Insomnia
b.5. A metallic taste in the mouth
b.6. Etc.

According to the University of Alberta, application of glucocorticoids has shown to induce pressure in the cardiovascular system include dyslipidemia and hypertension(249) as well as exhibiting certain psychiatric symptoms, including depression(250) and psychiatric complications such as psychosis, mania, hypomania, depression, apathy, anxiety, panic, depersonalization, delirium, confusion, hallucinations, delusions, paranoia, cognitive impairment and dementia(251).
Dr. Mitra R said, "Glucocorticoid (GC) exposure is the most common etiology of drug-induced (secondary) osteoporosis." and "GC stimulates osteoclast-mediated bone resorption and reduces osteoblast-mediated bone formation, which results in increased overall net bone resorption'(248).

4. Corticotrophin(Acortan, ACTH, Acthar, Acton, Cortigel, Trofocortina)
Acortan, ACTH, Acthar, Acton, Cortigel, Trofocortina are synthetic version of adrenocorticotropic hormone (ACTH), also known as corticotropin produced and secreted by the anterior pituitary gland used for treatment of gout in convention medicine with some success.the study of Dr. Alexander B. Gutman and Dr. Yü, M.D suggested,  ACTH effected a very rapid and satisfactory response in the local and systemic manifestations of acute gout in seven of eleven cases treated, including one patient refractory to colchicine(252).
According to the University of Patras Medical School, ACTH injection. is effective and safe for the treatment of gout in hospitalized patients in replacement of problematicnon-steroidal anti-inflammatory drugs, steroids or colchicine in this patient population(253) for its better in management of gout and control of hyuperuricemia(254).

b. Side effects are not limit to
In the study of 162 children with infantile spasms were treated with ACTH at the Children’s Hospital, Helsinki, and at the Aurora Hospital, Helsinki, during 1960–76. In a large proportion (37%) of the children the treatment caused pronounced side effects, and the mortality was 4.9%.(255), such as hypertension, osteoporosis, hypokalaemic alkalosis, and other marked electrolyte disturbances.


5. Intra-articular corticosteroids
a. Intraarticular steroid injections are injected directly into an affected joint to improve joint function in patinet with gout. According to the study led by the Flexion Therapeutics, Inc., intra-articular corticosteroids porduced by the company significantly improved histological scores with no adverse effect on the HPA axis, through reduced pathophysiology of multiple joint diseases such as osteoarthritis (OA), RA and gout(256).
Unfortunately, Dr. Wechalekar MD and colleagues at the Repatriation GeneralHospital, suggested, "There is presently no evidence from randomised trials to support the use of intra-articular glucocorticoid treatment in acute gout. Evidence suggests intra-articular glucocorticoids may be a safe and effective treatment in osteoarthritis and rheumatoid arthritis"(257).
b. Side effects are not limit to(258)
b.1. Infection
b.2. Facial flushing
b.3. Local skin atrophy and depigmentation
b.4. Crystalline synovitis
b.5. Allergic reaction
b.6. Uterine haemorrhage
b.7. Etc.




In herbal medicine perspective
1. Artichoke
Apricot tree is classified with the family of the plum belongings to the family Rosaceae with yellow to orange color, often tinged red on the side exposed to the sun.
According to the University of Florida, Artichoke (Cynara scolymus L.) leaves historically used for the treatment of hyperuricemia and gout. In our study the leaves also inhibited the xanthine oxidase (XO) through the efficacy of caffeic acid derivatives and flavones(259) but not  luteolin, and luteolin 7-O-glucoside in animal study(259).
Dr. Caton SJ and colleagues at the joint study led by the University of Leeds, said, "Repeated exposure is known to enhance intake of a novel vegetable in early life but individual differences in response to familiarisation have emerged from recent studies"(260) learning to love artichoke may reduce risk of gout in aging process.
In fact, University of Tokushima study of caffeic acid insisted, The phenolic compounds ameliorated xanthine oxidase (XO) which which is related to several diseases, e.g. gout(262), through its antioxidant activity when comparison to the conventional allopurinol(261).
Further more the flavones found in artichoke exhibited anti xanthine oxidase and/or α-glucosidase effects by remarkedly lowered serum uric acid levels in potassium oxonate induced hyperuricemic mouse(263)

2. Green tea
Green tea contains more amount of antioxidants than any drinks or food with the same volume, and is the leaves of Camellia sinensis, undergone minimal oxidation during processing, originated from China. Epidemiological evidence showed that green green tea process anti cancers and anti progression of numbers of diseases(264), including gout(265)(266)
Epigallo catechin-O-gallate (EGCG), along with its broad bioavailability is considered very attractive as a putative curative drug for various diseases such as dermatosis, gout, atherosclerosis and cancer, through green tea anti-oxidant properties and antagonistic action in some inflammatory(267). processes.
Quercetin, another green tea main component of antioxidant also displays lowered plasma uric acid concentrations significantly, equivalence to in approximately 100 g red onions, for 4 weeks in healthy males(268).
Dr. Jatuworapruk K and colleagues at the Chiang Mai University, insisted," Green tea extract may modestly lower SUA level and decreases uric acid clearance. Green tea extract also significantly elevated serum antioxidant capacity with a positive dosage effect. The effect of GTE on SUA in healthy individuals was short term. The effects of GTE on urate handling in patients with hyperuricemia or gout need to be determined"(269).



3. Alfalfa
Alfalfa is a flowering plant in the genus Medicago, belongings to the family Fabaceae, cultivated all over the world as hay for cattle feeding. The leaves, sprouts, and seeds has been used in traditional medicine over thousands of year to treat high cholesterol, asthma, osteoarthritis, rheumatoid arthritis, diabetes, enhance digestive system, bleeding disorder, kidney and urinary tract infection, etc.

In the article by By jeffwend, the author wrote that Alfalfa can help to increase uric acid levels in the urine which can help reduce the amount of uric acid available to crystallize(270), probably due to the effectiveness of ethyl acetate extracts isolated from the herb in ameliorated production of pro-inflammatory cytokines and alleviate acute inflammatory hazards(271).
Dr. Ferrari FC and colleagues at the Universidade Federal de Ouro Preto, in the investigation of Leaves infusion of Pimenta pseudocaryophyllus (Gomes) Landrum, expressed the inhibition of ethyl acetate extracts in anti-hyperuricemic effects through uricosuric effects and inhibition of xanthine oxidase throughits anti-inflammatory property(272).
The Universidade other study also insisted, "The ethyl acetate, methanolic and aqueous extracts of Sparattosperma leucanthum showed significant results on evaluated models and therefore may be important agents for the treatment of gouty arthritis and hyperuricemia"(273).


4. Devil’s claw
Devil's claw also known as wood spider, is a plant of genus Harpagophytum in the family of Pedaliaceae, native to South Africa,  used as herb in traditional and herbal medicine to treat fever, rheumatoid arthritis, skin, gallbladder, pancreas, stomach and kidneys conditions, etc.Harpagoside, a Glycoside, the chemical, principle extracted from the Devil’s Claw root, contributes the natural anti-inflammatory properties and used as a Gout remedy and other painful disorders of the musculoskeletal system(274). The major phytochemical harpagoside, as a major iridoid glycoside, exhibited anti-inflammatory and COX inhibitory activity against rheumatism, gout, palsy and amenorrhea(276), according to the National Institute of Pharmaceutical Education and Research.

According to the University of KwaZulu-Natal, Harpagophytum procumbens root may be very effective used in the management and/or control of painful, arthritic and other inflammatory conditions, as well as for adult-onset, type-2 diabetes mellitus as the roots is used exclusive in some communities of South Africa(275).
Furthermore, phytochemical phenylpropanoid glycoside acteoside found in the herb(277) also ameliorated the levels of serum uric acid and hyperuricemic in mice through expression of inhibited mouse liver xanthine dehydrogenase XDH and xanthine oxidase XO activity(278), the Second Military Medical University suggested.

5. Purple Sweet Potato
Sweet potato is a large, starchy, sweet tasting tuberous roots vegetable, genus Ipomoea, belongings to the family Convolvulaceae. Its young leaves can be made into a delicious dish in Chinese foods. Some species of batatas are actually poisonous.
Anthocyanin extracts from purple sweet potato in comparison with conventional medicine allopurinol, on serum uric acid levels in hyperuricemic mice, reduced the serum uric acid concentration to 4.10 ± 0.04 mg/dLa single oral dose of 100 mg/kg(279).
Dr. Zhang ZC and colleagues at the Huazhong Agricultural University said, "APSPE could not only inhibit the XO activity in mouse liver, but also reduce the serum uric acid level in hyperuricemic mice and affect the expression of mRNA levels of related renal transporters, such as mURAT1, mGLUT9, mOAT1 and mOCTN2"(280).


In Traditional Chinese medicine perspective

A. Treatment according to TCM assistant in the article of "Chinese herbal formula(s) can treat or relief Gout"(27), in Chinese medicine, gout is a condition of a joint painful wind syndrome caused by
1.  Formula for Damp-Heat induced gout
1.1. Painful obstruction due to the containment of Damp-Heat in the channels of that can lead to acute articular rheumatism, acute attack of gout, arthritis, hot joints, joint pain, tremors, dark urine, etc.
1.2. Chinese Herbal Formula Xuan Bi Tang used to clear and damp-Heat, unblock the Channels, eliminate painful obstruction, etc. Ingredients include
a. Guang Fang Ji (Radix Aristolochiae Fangchi, Aristolochia Root, Stephania) – 15g. -expels damp heat in upper jiao, expels superficial swellings, induces urination
b. Xing Ren (Semen Pruni Armeniacae, Apricot Seed) – 15g. -regulates lung Qi and water metabolism
c. Yi Yi Ren (Semen Coicis Lachryma Jobi) – 15g. -tonify spleen, clear dampness, relieve painful obstructions
d. Can Sha (Excrementum Bombycis Mori, Silkworm Feces) – 9g. -tonify spleen, clear dampness, relieve painful obstructions
e. Ban Xia (Rhizoma Pinelliae Tematae, Pinellia Rhizome) – 9g. -dries dampness, transforms tubidity
f. Lian Qiao (Fructus Forsythiae Suspensae, Forsythia Fruit) – 9g. -clears superficial heat
g. Zhi Zi (Fructus Gardeniae Jasminoidis, Cape Jasmine Fruit, Gardenia) – 9g. -clear heat, drains dampness, induces urination
h. Hua Shi (Talcum, Talcum) – 15g. -clear heat, drains dampness, induces urination
i. Chi Xiao Dou (Semen Phaseoli Calcarati) – 9g. -clears heat, drains dampness, induces urination(281)

2. Recurrent Wind-Cold-Damp
2.1. Recurrent Wind-Cold-Damp painful obstruction in which localized constraint generates Heat of that can lead to acute attack of gout, arthritis, difficulty in movement, joint pain, edema of lower extremities, painful lower limbs, rheumatism;, swelling of joints, etc.
2.2. Chinese herbal formula Gui Zhi Shao Yao Zhi Mu Tang used to disperses Damp and Wind, unblocks the Channels. moves Yang, etc.
a. Gui Zhi (Ramulus Cinnamomi Cassiae, Cinnamon, Cassia Twig) – 12g. -warms and unblocks channels
b. Ma Huang (Herba Ephedrae, Ephedra Stem, ma-huang) – 6g. -unblocks channels, relieves superficial swellings
c. Fu Zi (Radix lateralis Aconiti Carmichaeli, Szechuan Aconite Root, Aconite) – 6g. -warms channels, relieves pain
d. Zhi Mu (Rhizoma Anemarrhenae Asphodeloidis, Anemarrhena Rhizome) – 12g. -clear heat from the joints, nourish yin
e. Shaoyao (Radix Paeoniae , Peony Root) – 9g. -clear heat, nourish yin
f. Bai Zhu (Rhizoma Atractyloids Macrocephaelae, Atractylodes White Rhizome) – 15g. -harmonizes ying and wei Qi levels (Bai Shao)
g. Fang Feng (Radix ledebouriellae, Ledebouriella Root, Siler) – 12g. -expels wind and dampness
h. Sheng Jiang (Rhizoma Zingiberis officinalis Recens, Fresh Ginger Rhizome) – 15g. -promotes Qi circulation
i. Gan Cao (Radix Glycyrrhizae uralensis, Licorice Root) – 6g. -harmonizes other herbs within formula, regulates middle jiao(282).

3. Wind-Damp, Phlegm and Blood stasis

3.1. Wind-Damp, Phlegm and Blood stasis lead to acute attack of gout. arthritis, difficulty in movement, joint pain, edema of lower extremities, swelling of joints;, chills, etc.
3.2. Chinese herbal formula Shu Feng Huo Xue Tang used to disperses Damp and Wind, eliminates Blood stasis
a. Gui Zhi (Cinnamon twig, cassia twig) 2.5g
b. Qiang Huo (Notopterygium root, chiang-huo) 2.5g
c. Bai Zhi (Angelica root) 2.5g
d. Huang Bai (amur cork tree bark, phellodendron bark) 2.5g
e. Wei Ling Xian (Chinese clematis root, clematis) 2.5g
f. Cang Zhu (Atractylodes rhizome) 2.5g
g. Chuan Xiong (Sichuan lovage root, cnidium, Chuanxiong root) 2.5g
h. Hong Hua (Safflower flower, Carthamus) 1g
i. Gan Jiang (Dried ginger rhizome) 1g
j. Dang Gui (Chinese angelica root) 2.5g
k. Dan Nan Xing (P Arisaematis cum Fel Bovis) 2.5g
l. Han Fang Ji (Stephania root) 2.5g(283)

B. Other research and studied formulas
1. Modified Simiaowan (MSW)
Modified Simiaowan (MSW), a TCM formula is widely used as a clinically medication formula for its efficiency in treating gouty diseases. According to the joint study led by the Nanjing University of Chinese Medicine, the formula targeted related pathways involving gouty diseases through inhibited pro inflammatory cytokines and uric acid synthetase or transporters, via heat-clearing and dampness-eliminating herbs in MSW physicochemical properties(284).
Dr. Shi L and colleagues said, "MSW could significantly prevent the paw swelling and neutrophil infiltration induced by intra-articular MSU injection in rats. MSW also showed potent analgesic effects at (5.0, 10, and 20 g/kg body weight) in acetic acid-induced mice depending on the dosage" in 
gouty arthritis mice(285).

2. Shuang-Qi gout capsule
Shuang-Qi gout capsule is another formula used widely in traditional Chinese medicine for treatment of of joint pain, inflammation and gout arthritis. According to the China Pharmaceutical University, application of the formula effectively inhibit the inflammation, analgesia, through the modulation of emission of pro-inflammatory cytokines and the curative effect is dose dependent manner(286).
Dr. Kodithuwakku ND and colleagues at the joint study led by the China Pharmaceutical University said, "SQ could effectively regulate the main renal transporters denoted its denote probable antihyperuricemic mechanism of SQ and its dose dependent uricosuric effect. In addition, SQ attenuated the deleterious effects of hyperuricemia with renal dysfunction"(287).

3. Modified Simiao Decoction
Modified Simiao Decoction(MSD), containing 4 herbs is also one of common used formula in traditional Cjinese medicine for treatment of gouty arthritis. According to the Huazhong University of Science and Technology, the formula attenuated successfully the accumulation of monosodium urate (MSU) crystals in the joints(289), through expression of crystals-induced inflammation through its target of reduced over reaction of proinflammatory cytokines, such as of IL-1 β and TNF α secretion(288).
Dr. Hua J and colleagues at the The Second People Hospital of Xihu District said, "MSD processes uricosuric and nephroprotective actions by regulating renal urate transporters and enhancing antioxidant enzymes activities to improve renal dysfunction in hyperuricemic mice"(290).

In fact, in the review of  a total of 120 cases of gouty arthritis randomly divided into the treatment group and control group with 60 cases in each group study, researchers indicated the effectiveness of the decoction in treatment of gout as the formula significantly improved the symptoms and signs of gouty arthritis and decrease the levels of UA and CRP(291).

4. Ermiao wan
The herbal formula is widely used as anti-gouty syndrome of damp and heat in traditional Chinese medicine. According to the Nanjing University of Traditional Chinese Medicine, the effects of the herbal medicine may be due to the ingredients of alkaloids, flavonoids, organic acids which has shown to associate with reduced risk of gout arthritis(292)(293)(294).
Dr. Kong LD and colleagues at the Nanjing University, said, "atractylodis rhizomes assisted and enhanced the effect of phellodendri cortex on reduction of serum uric acid level in hyperuricemic mice, and hypouricemic effects of Ermiao wan and phellodendri cortex may be achieved by other mechanism partly instead of the XDH and XO inhibition."(295).

5. Combined Therapy of  gout with TCM and Western Medicine
The Shanghai University of Traditional Chinese Medicine, in the investigated the combined therapy of traditional and Western medicine for treatment of gout suggested, the combination therapy of traditional Chinese and Western medicines for treatment of gout based on the stage of disease not only showed a significant control of the symptoms of gouty arthritis, improve joint function, and the BUA level during the intermissio, but also prevented recurrence and relieve the adverse effects(296).
Dr. Zhou L and researchers at the Jinhua Municipal Hospital of TCM said, "acupuncture combined with infrared irradiation achieves superior efficacy on acute gouty arthritis as compared with oral medication of Indomethachin and the therapy provides a significant effect on analgesia and does not bring the damage of liver function"(297).

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(77) The modulating effect of Persea americana fruit extract on the level of expression of fatty acid synthase complex, lipoprotein lipase, fibroblast growth factor-21 and leptin--A biochemical study in rats subjected to experimental hyperlipidemia and obesity by Monika P1, Geetha A2.(PubMed)
(78) Blueberry peel extracts inhibit adipogenesis in 3T3-L1 cells and reduce high-fat diet-induced obesity by Song Y1, Park HJ, Kang SN, Jang SH, Lee SJ, Ko YG, Kim GS, Cho JH.(PubMed)
(79) Blueberry and mulberry juice prevent obesity development in C57BL/6 mice by Wu T1, Tang Q, Gao Z, Yu Z, Song H, Zheng X, Chen W.(PubMed)
(80) Gout raises heart-attack risk in older women. Take steps to prevent this unexpected consequence.[No authors listed](PubMed)
(81) Gout and Risk of Myocardial Infarction: A Systematic Review and Meta-Analysis of Cohort Studies by Liu SC1, Xia L2, Zhang J1, Lu XH3, Hu DK1, Zhang HT4, Li HJ5.(PubMed)
(82) Blueberry Anthocyanins-Enriched Extracts Attenuate Cyclophosphamide-Induced Cardiac Injury. by Liu Y1, Tan D2, Shi L1, Liu X1, Zhang Y1, Tong C1, Song D2, Hou M1.(PubMed)
(83) Cardiovascular effects of Persea americana Mill (Lauraceae) (avocado) aqueous leaf extract in experimental animals by Ojewole JA1, Kamadyaapa DR, Gondwe MM, Moodley K, Musabayane CT.(PubMed)
(84) The Curable and Delicious smoothie of Blueberry, Avocado for Reduced Risk and Treatment of Heart Disease by Kyle J. Norton
(85) Gout as a risk factor for myocardial infarction and stroke in England: evidence from record linkage studies by Seminog OO1, Goldacre MJ.(PubMed)
(86) Clinical features of gout by Grassi W1, De Angelis R.(PubMed)
(87) The impact of green tea and coffee consumption on the reduced risk of stroke incidence in Japanese population: the Japan public health center-based study cohort by Kokubo Y1, Iso H, Saito I, Yamagishi K, Yatsuya H, Ishihara J, Inoue M, Tsugane S.(PubMed)
(88) Coffee and tea consumption and risk of stroke subtypes in male smokers by Larsson SC1, Männistö S, Virtanen MJ, Kontto J, Albanes D, Virtamo J.(PubMed)
(89) Diets containing blueberry extract lower blood pressure in spontaneously hypertensive stroke-prone rats by Shaughnessy KS1, Boswall IA, Scanlan AP, Gottschall-Pass KT, Sweeney MI.(PubMed)
(90) The incredible smoothie Green Tea, Coffee and Blueberry for reduced risk and treatment of Stroke by Kyle J. Norton
(91) Peripheral Artery Disease: Evolving Role of Exercise, Medical Therapy, and Endovascular Options by Olin JW1, White CJ2, Armstrong EJ3, Kadian-Dodov D4, Hiatt WR5(PubMed)
(92) Increased risk of vascular disease associated with gout: a retrospective, matched cohort study in the UK clinical practice research datalink by Clarson LE1, Hider SL1, Belcher J1, Heneghan C2, Roddy E1, Mallen CD1.(PubMed)
(93) Serum uric acid level and risk for peripheral arterial disease: analysis of data from the multiple risk factor intervention trial by Baker JF1, Schumacher HR, Krishnan E.(PubMed)
(94) Prevalence, risk factors and rheological profile of arterial vascular disease; first results of the Aachen study by Kiesewetter H1, Jung F, Kotitschke G, Nüttgens HP, Witt R, Winkelhog C, Ladwig KH, Waterloh E, Roebruck P, Schneider R, et al.(PubMed)
(95) Increased airway inflammation in patients with psoriasis by Damiani G1, Radaeli A2, Olivini A2, Calvara-Pinton P3, Malerba M2.(PubMed)
(96) Methotrexate in psoriasis: 26 years' experience with low-dose long-term treatment by Haustein UF1, Rytter M.(PubMed)
(97) Psoriasis, psoriatic arthritis and risk of gout in US men and women by Merola JF1, Wu S2, Han J3, Choi HK4, Qureshi AA5.(PubMed)
(98) Psoriasis and uric acid: a population-based cross-sectional study by Lai YC1, Yew YW2.(PubMed)
(99) Green tea protects against psoralen plus ultraviolet A-induced photochemical damage to skin by Zhao JF1, Zhang YJ, Jin XH, Athar M, Santella RM, Bickers DR, Wang ZY.(PubMed)
(100) Resveratrol ameliorates imiquimod-induced psoriasis-like skin inflammation in mice by Kjær TN1, Thorsen K2, Jessen N2, Stenderup K3, Pedersen SB1.(PubMed)
(101) The Unbelievable Smoothie Green Tea and Grape for reduced risk and Treatment of Psoriasis by Kyle J. Norton

(102) Interventions for tophi in gout by Sriranganathan MK1, Vinik O, Bombardier C, Edwards CJ.(PubMed)
(103) Allopurinol for chronic gout by Seth R1, Kydd AS, Buchbinder R, Bombardier C, Edwards CJ.(PubMed)
(104) Uricosuric medications for chronic gout by Kydd AS1, Seth R, Buchbinder R, Edwards CJ, Bombardier C.(PubMed)
(105) Dietary supplements for chronic gout by Andrés M1, Sivera F, Falzon L, Buchbinder R, Carmona L.(PubMed)
(106) Lifestyle interventions for chronic gout by Moi JH1, Sriranganathan MK, Edwards CJ, Buchbinder R.(PubMed)
(107) Minimally invasive surgical treatment for kidney stone disease by Rodríguez D1, Sacco DE2.(PubMed)
(108) Current practice in Latin America of flexible ureterorenoscopy with laser for treating kidney stones responses on a Latin American questionnaire[Article in English, Spanish] by Manzo BO1, Bertacchi M2, Lozada E3, Rasguido A4, Aleman E5, Cabrera M6, Rodríguez A7, Manzo G3, Sánchez H3, Blasco J8.(PubMed)
(109) CARD8 rs2043211 polymorphism is associated with gout in a Chinese male population by Chen Y1, Ren X, Li C, Xing S, Fu Z, Yuan Y, Wang R, Wang Y, Lv W.(PubMed)
(110) The association between renal stone disease and cholesterol gallstones: the easy to believe and not hard to retrieve theory of the metabolic syndrome by Ahmed MH1, Barakat S, Almobarak AO.(PubMed)
(111) Effects of green tea on urinary stone formation: an in vivo and in vitro study by Jeong BC1, Kim BS, Kim JI, Kim HH.(PubMed)
(112) 1,2,3,4,6-Penta-O-galloyl-beta-D-glucose reduces renal crystallization and oxidative stress in a hyperoxaluric rat model by Lee HJ1, Jeong SJ, Lee HJ, Lee EO, Bae H, Lieske JC, Kim SH.(PubMed)
(113) Vitamin E therapy prevents hyperoxaluria-induced calcium oxalate crystal deposition in the kidney by improving renal tissue antioxidant status by Thamilselvan S1, Menon M.(PubMed)
(114) The Best Smoothie of Green tea, Grape and Sweet Potato for Prevention and Treatment of Kidney Stones caused by Medullary sponge kidney by Kyle J. Norton
(115) Relationship between structural joint damage and urate deposition in gout: a plain radiography and dual-energy CT study by Dalbeth N1, Aati O1, Kalluru R1, Gamble GD1, Horne A1, Doyle AJ2, McQueen FM3.(PubMed)
(116) Exploratory study of radiographic change in patients with tophaceous gout treated with intensive urate-lowering therapy by Dalbeth N1, Doyle AJ, McQueen FM, Sundy J, Baraf HS.(PubMed)
(117) MDHAQ/RAPID3 to recognize improvement over 2 months in usual care of patients with osteoarthritis, systemic lupus erythematosus, spondyloarthropathy, and gout, as well as rheumatoid arthritis by Castrejón I1, Bergman MJ, Pincus T.(PubMed)
(118) Low-dose aspirin use and recurrent gout attacks by Zhang Y1, Neogi T, Chen C, Chaisson C, Hunter DJ, Choi H.(PubMed)
(119) Purine-rich foods intake and recurrent gout attacks by Zhang Y1, Chen C, Choi H, Chaisson C, Hunter D, Niu J, Neogi T.(PubMed)
(120) Management of recurrent gout by Robin Fox, GP1(PMC)
(121) Cherry consumption and decreased risk of recurrent gout attacks by Zhang Y1, Neogi T, Chen C, Chaisson C, Hunter DJ, Choi HK.(PubMed)
(122) Prevention and management of gout by Star VL1, Hochberg MC.(PubMed)
(123) Gout Causing Isolated Sesamoid Destruction Mimicking a Neoplastic Process by Balutis E1, Pino A.(PubMed)
(124) Long-term safety of pegloticase in chronic gout refractory to conventional treatment by Becker MA1, Baraf HS, Yood RA, Dillon A, Vázquez-Mellado J, Ottery FD, Khanna D, Sundy JS.(PubMed)
(125) Diagnosis of Gout [Internet].Editors Newberry SJ, FitzGerald J, Maglione MA, O'Hanlon CE, Han D, Booth M, Motala A, Tariq A, Dudley W, Shanman R, Shekelle PG.(PubMed)
(126) Urate testing in gout: why, when and how by Dalbeth N1, Winnard D, Gow PJ, Boswell DR, Te Karu L, Lindsay K, Arroll B, Stamp LK.(PubMed)
(127) Tests and diagnosis By Mayo Clinic Staff(127)
(128) Diagnostic imaging of gout: comparison of high-resolution US versus conventional X-ray by Rettenbacher T1, Ennemoser S, Weirich H, Ulmer H, Hartig F, Klotz W, Herold M.(PubMed)
(129) Is ultrasound changing the way we understand rheumatology? Including ultrasound examination in the classification criteria of polymyalgia rheumatica and gout by Codreanu C1, Enache L2.(PubMed)
(130) Dual-Energy Computed Tomography: Advantages in the Acute Setting by McLaughlin PD1, Mallinson P2, Lourenco P2, Nicolaou S2.(PubMed)
(131) The misdiagnosis of gout and hyperuricemia by Wolfe F1, Cathey MA.(PubMed)
(132) Misdiagnosis of rheumatoid arthritis in an elderly woman with gout by Sewell KL1, Petrucci R, Keiser HD.(PubMed)
(133) Elderly-onset gout: a review. by De Leonardis F1, Govoni M, Colina M, Bruschi M, Trotta F.(PubMed)
(134) Mapping patients' experiences from initial symptoms to gout diagnosis: a qualitative exploration. by Liddle J1, Roddy E1, Mallen CD1, Hider SL1, Prinjha S2, Ziebland S2, Richardson JC1.(PubMed)
(135) Clinical manifestations and diagnosis of gout by Perez-Ruiz F1, Castillo E2, Chinchilla SP2, Herrero-Beites AM3.(PubMed)
(136) Misdiagnosis as steatohepatitis in a family with mild glycogen storage disease type 1a by Shieh JJ1, Lu YH, Huang SW, Huang YH, Sun CH, Chiou HJ, Liu C, Lo MY, Lin CY, Niu DM.(PubMed)
(137) Misdiagnosis of a chylous cyst as chest wall gouty tophus: a case of true pseudogout by Adhikesavan LG1, Ayoub WT, Schumacher HR.(PubMed)
(138) Psoriatic arthritis of the foot and ankle: analysis of joint involvement and diagnostic errors by Hammerschlag WA1, Rice JR, Caldwell DS, Goldner JL.(PubMed)
(139) Coffee consumption and risk of incident gout in women: the Nurses' Health Study by Choi HK1, Curhan G.(PubMed)
(140) The association of vitamin C, alcohol, coffee, tea, milk and yogurt with uric acid and gout by Towiwat P1, Li ZG2.(PubMed)
(141) The relation of coffee consumption to serum uric Acid in Japanese men and women aged 49-76 years by Pham NM1, Yoshida D, Morita M, Yin G, Toyomura K, Ohnaka K, Takayanagi R, Kono S.(PubMed)
(142) Nocturnal Risk of Gout Attacks by Hyon K. Choi, MD, DrPH,1 Jingbo Niu, MD, DSc,1 Tuhina Neogi, MD, PhD, FRCPC,1 Clara A. Chen, MHS,1 Christine Chaisson, MPH,1 David Hunter, MBBS, PhD,2 and Yuqing Zhang, DSc1(PMC)
(143) Recent diuretic use and the risk of recurrent gout attacks: the online case-crossover gout study by Hunter DJ1, York M, Chaisson CE, Woods R, Niu J, Zhang Y.(PubMed)
(144) Water, Skim Milk Consumption May Improve Gout Control By: AMY ROTHMAN SCHONFELD JANUARY 1, 2010,(Eheumatology News)
(145) Juvenile gout in Taiwan associated with family history and overweight by Chen SY1, Shen ML.(PubMed)
(146) Visceral fat obesity is highly associated with primary gout in a metabolically obese but normal weighted population: a case control study by Lee J1, Lee JY2, Lee JH3, Jung SM4, Suh YS5, Koh JH6, Kwok SK7, Ju JH8, Park KS9, Park SH10.(PubMed)
(147) Obesity and younger age at gout onset in a community-based cohort by DeMarco MA1, Maynard JW, Huizinga MM, Baer AN, Köttgen A, Gelber AC, Coresh J.(PubMed)
(148) Incident gout in women and association with obesity in the Atherosclerosis Risk in Communities (ARIC) Study by Maynard JW1, McAdams DeMarco MA, Baer AN, Köttgen A, Folsom AR, Coresh J, Gelber AC.(PubMed)
(149) Alcohol intake and risk of incident gout in men: a prospective study by Choi HK1, Atkinson K, Karlson EW, Willett W, Curhan G.(PubMed)
(150) Alcohol intake and risk of incident gout in men: a prospective study by Choi HK1, Atkinson K, Karlson EW, Willett W, Curhan G.(PubMed)
(151) Alcohol quantity and type on risk of recurrent gout attacks: an internet-based case-crossover study by Neogi T1, Chen C2, Niu J3, Chaisson C2, Hunter DJ4, Zhang Y3.(PubMed)
(152) Purine-rich foods, dairy and protein intake, and the risk of gout in men by Choi HK1, Atkinson K, Karlson EW, Willett W, Curhan G.(PubMed)
(153) Intake of purine-rich foods, protein, and dairy products and relationship to serum levels of uric acid: the Third National Health and Nutrition Examination Survey by Choi HK1, Liu S, Curhan G.(PubMed)
(154) Sugar-sweetened soft drinks, diet soft drinks, and serum uric acid level: the Third National Health and Nutrition Examination Survey by Choi JW1, Ford ES, Gao X, Choi HK.(PubMed)
(155) A prescription for lifestyle change in patients with hyperuricemia and gout by Choi HK1.(PubMed)
(156) A prescription for lifestyle change in patients with hyperuricemia and gout by Choi HK1.(PubMed)
(157) Impact of strawberries on human health: insight into marginally discussed bioactive compounds for the Mediterranean diet by Tulipani S1, Mezzetti B, Battino M.(PubMed)
(158) Use of diuretics and risk of incident gout: a population-based case-control study by Bruderer S1, Bodmer M, Jick SS, Meier CR.(PubMed)
(158) Recent diuretic use and the risk of recurrent gout attacks: the online case-crossover gout study. by Hunter DJ1, York M, Chaisson CE, Woods R, Niu J, Zhang Y.(PubMed)
(159) Effects of diet, physical activity and performance, and body weight on incident gout in ostensibly healthy, vigorously active men by Paul T Williams(PubMed)
(160) How to Exercise If You Have Gout by Sequoia
(161) Effects of Biota orientalis extract and its flavonoid constituents, quercetin and rutin on serum uric acid levels in oxonate-induced mice and xanthine dehydrogenase and xanthine oxidase activities in mouse liver by Zhu JX1, Wang Y, Kong LD, Yang C, Zhang X.(PubMed)
(162) Quercetin lowers plasma uric acid in pre-hyperuricaemic males: a randomised, double-blinded, placebo-controlled, cross-over trial by Shi Y1, Williamson G1.(PubMed)
(163) Therapeutic properties of quercetin on monosodium urate crystal-induced inflammation in rat by Huang J1, Zhu M, Tao Y, Wang S, Chen J, Sun W, Li S.(PubMed)
(164) The dual actions of morin (3,5,7,2',4'-pentahydroxyflavone) as a hypouricemic agent: uricosuric effect and xanthine oxidase inhibitory activity by Yu Z1, Fong WP, Cheng CH.(PubMed)
(165) Uricosuric and nephroprotective properties of Ramulus Mori ethanol extract in hyperuricemic mice by Shi YW1, Wang CP, Wang X, Zhang YL, Liu L, Wang RW, Ye JF, Hu LS, Kong LD.(PubMed)
(166) Novel insights into the inhibitory mechanism of kaempferol on xanthine oxidase by Wang Y1, Zhang G, Pan J, Gong D.(PubMed)
(167) Hypouricemic action of selected flavonoids in mice: structure-activity relationships by Mo SF1, Zhou F, Lv YZ, Hu QH, Zhang DM, Kong LD.(PubMed)
(168) Virtual and in vitro bioassay screening of phytochemical inhibitors from flavonoids and isoflavones against xanthine oxidase and cyclooxygenase-2 for gout treatment by Li Y, Frenz CM, Li Z, Chen M, Wang Y, Li F, Luo C, Sun J, bohlin L, Li Z, Yang H, Wang C.(PubMed)
(169) Virtual Screening Analysis and In-vitro Xanthine Oxidase Inhibitory Activity of Some Commercially Available Flavonoids by Umamaheswari M1, Madeswaran A, Asokkumar K.(PubMed)
(170) Preliminary pharmacological studies on Eugenia uniflora leaves: xanthine oxidase inhibitory activity by Schmeda-Hirschmann G1, Theoduloz C, Franco L, Ferro E, de Arias AR.(PubMed)
(171) Novel insights into the inhibitory mechanism of kaempferol on xanthine oxidase by Wang Y1, Zhang G, Pan J, Gong D.(PubMed)
(172) Pharmacological basis for use of Pistacia integerrima leaves in hyperuricemia and gout by Ahmad NS1, Farman M, Najmi MH, Mian KB, Hasan A.(PubMed)
(173) Discovery of xanthine oxidase inhibitors and/or α-glucosidase inhibitors by carboxyalkyl derivatization based on the flavonoid of apigenin by Su ZR1, Fan SY1, Shi WG1, Zhong BH2.(PubMed)
(174) Olea europaea leaf (Ph.Eur.) extract as well as several of its isolated phenolics inhibit the gout-related enzyme xanthine oxidase by Flemmig J1, Kuchta K, Arnhold J, Rauwald HW.(PubMed)
(175) Independent association of serum retinol and β-carotene levels with hyperuricemia: A national population study by Choi WJ1, Ford ES, Curhan G, Rankin JI, Choi HK(PubMed)
(176) Associations between concentrations of uric acid with concentrations of vitamin A and beta-carotene among adults in the United States by Ford ES1, Choi HK.(PubMed)
(177) Gout and vitamin A intoxication: is there a connection? by Mawson AR1, Onor GI.(PubMed)
(178) Dietary supplements for chronic gout by Andrés M1, Sivera F, Falzon L, Buchbinder R, Carmona L.(PubMed)
(179) The association of vitamin C, alcohol, coffee, tea, milk and yogurt with uric acid and gout by Towiwat P1, Li ZG2.(PubMed)
(180) Epidemiology of gout by Roddy E1, Choi HK2.(PubMed)
(181) Clinically insignificant effect of supplemental vitamin C on serum urate in patients with gout: a pilot randomized controlled trial by Stamp LK1, O'Donnell JL, Frampton C, Drake JM, Zhang M, Chapman PT.(PubMed)
(182) Effect of oral vitamin C supplementation on serum uric acid: a meta-analysis of randomized controlled trials by Juraschek SP1, Miller ER 3rd, Gelber AC.(PubMed)
(182) Polymorphisms in the vitamin D receptor and risk of gout in Chinese Han male population by Liu SG1, Li YY, Sun RX, Wang JL, Li XD, Han L, Chu N, Li CG.(PubMed)
(183) Serum vitamin D and C-reactive protein levels are independently associated with diastolic dysfunction by Akin F1, Ayça B, Köse N, Celik O, Yilmaz Y, Akin MN, Arinc H, Ozkok A, Covic A, Kanbay M.(PubMed)
(184) Decreased serum concentrations of 1,25(OH)2-vitamin D3 in patients with gout by Takahashi S1, Yamamoto T, Moriwaki Y, Tsutsumi Z, Yamakita J, Higashino K.(PubMed)
(185) Dietary risk factors for rheumatic diseases by Choi HK1.(PubMed)
(186) Purified aged garlic extract modulates allergic airway inflammation in BALB/c mice by Zare A1, Farzaneh P, Pourpak Z, Zahedi F, Moin M, Shahabi S, Hassan ZM.(PubMed)
(187) Alliin, a garlic (Allium sativum) compound, prevents LPS-induced inflammation in 3T3-L1 adipocytes by Quintero-Fabián S1, Ortuño-Sahagún D2, Vázquez-Carrera M3, López-Roa RI4.(PubMed)
(188) Aged Garlic Extract Modifies Human Immunity by Percival SS1.(PubMed)
(189) Inflammation: a possible mechanism for a causative role of hyperuricemia/gout in cardiovascular disease by Perez-Ruiz F1, Becker MA2.(PubMed)
(190) Detrimental role of hyperuricemia on the cardio-reno-vascular system by Stack A1, Manolis AJ2, Ritz E3.(PubMed)
(191) Safety and anti-inflammatory activity of curcumin: a component of tumeric (Curcuma longa) by Chainani-Wu N1.(PubMed)
(192) Effect of Ginger and Turmeric Rhizomes on Inflammatory Cytokines Levels and Enzyme Activities of Cholinergic and Purinergic Systems in Hypertensive Rats by Akinyemi AJ1, Thomé GR2, Morsch VM2, Bottari NB2, Baldissarelli J2, de Oliveira LS2, Goularte JF3, Belló-Klein A3, Duarte T4, Duarte M4, Boligon AA5,Athayde ML5, Akindahunsi AA1, Oboh G1, Schetinger MR2.(PubMed)
(193) Study on the anti-gout activity of chlorogenic acid: improvement on hyperuricemia and gouty inflammation by Meng ZQ1, Tang ZH, Yan YX, Guo CR, Cao L, Ding G, Huang WZ, Wang ZZ, Wang KD, Xiao W, Yang ZL.(PubMed)
(194) Phosphocholine-Modified Macromolecules and Canonical Nicotinic Agonists Inhibit ATP-Induced IL-1β Release by Hecker A1, Küllmar M1, Wilker S1, Richter K2, Zakrzewicz A1, Atanasova S1, Mathes V1, Timm T3, Lerner S1, Klein J4, Kaufmann A5, Bauer S5, Padberg W1,Kummer W6, Janciauskiene S7, Fronius M8, Schweda EK9, Lochnit G3, Grau V10.(PubMed)
(195) Anti-inflammatory effect of curcumin on mast cell-mediated allergic responses in ovalbumin-induced allergic rhinitis mouse by Zhang N1, Li H1, Jia J2, He M3.(PubMed)
(196) Macrophage migration inhibitory factor drives neutrophil accumulation by facilitating IL-1β production in a murine model of acute gout by Galvão I1, Dias AC1, Tavares LD2, Rodrigues IP1, Queiroz-Junior CM3, Costa VV2, Reis AC3, Ribeiro RD4, Louzada-Junior P4, Souza DG2, Leng L5, Bucala R5, Sousa LP6, Bozza MT7, Teixeira MM8, Amaral FA9.(PubMed)
(197) The association of vitamin C, alcohol, coffee, tea, milk and yogurt with uric acid and gout by Towiwat P1, Li ZG2(PubMed)
(198) Effects of green tea extract on serum uric acid and urate clearance in healthy individuals by Jatuworapruk K1, Srichairatanakool S, Ounjaijean S, Kasitanon N, Wangkaew S, Louthrenoo W.(PubMed)
(199) [Multiple actions of EGCG, the main component of green tea].[Article in French] by L'Allemain G1.(PubMed)
(200) Consuming Lentinula edodes (Shiitake) Mushrooms Daily Improves Human Immunity: A Randomized Dietary Intervention in Healthy Young Adults by Dai X1, Stanilka JM1, Rowe CA1, Esteves EA2, Nieves C Jr1, Spaiser SJ1, Christman MC3, Langkamp-Henken B1, Percival SS1.(PubMed)
(201) The inflammatory process in the mechanism of decreased serum uric acid concentrations during acute gouty arthritis by Urano W1, Yamanaka H, Tsutani H, Nakajima H, Matsuda Y, Taniguchi A, Hara M, Kamatani N.(PubMed)
(202) Interleukin-6 (IL-6) in synovial fluid and serum of patients with rheumatic diseases by Swaak AJ1, van Rooyen A, Nieuwenhuis E, Aarden LA.(PubMed)
(203) Garlic and onion attenuates vascular inflammation and oxidative stress in fructose-fed rats by Vazquez-Prieto MA1, Rodriguez Lanzi C, Lembo C, Galmarini CR, Miatello RM.(PubMed)
(204) Quercetin lowers plasma uric acid in pre-hyperuricaemic males: a randomised, double-blinded, placebo-controlled, cross-over trial by Shi Y1, Williamson G1.(PubMed)
(206) Trikatu, a herbal compound that suppresses monosodium urate crystal-induced inflammation in rats, an experimental model for acute gouty arthritis by Murunikkara V1, Rasool M.(PubMed)
(207) 6-Shogaol inhibits monosodium urate crystal-induced inflammation--an in vivo and in vitro study by Sabina EP1, Rasool M, Mathew L, Ezilrani P, Indu H.(PubMed)
(208) Management of gout in the real world: current practice versus guideline recommendations by Doghramji PP1, Fermer S2, Wood R3, Morlock R4, Baumgartner S5.(PubMed)
(209) Effects of green tea extract on serum uric acid and urate clearance in healthy individuals by Jatuworapruk K1, Srichairatanakool S, Ounjaijean S, Kasitanon N, Wangkaew S, Louthrenoo W.(PubMed)
(210) The association of vitamin C, alcohol, coffee, tea, milk and yogurt with uric acid and gout by Towiwat P1, Li ZG2.(PubMed)
(211) Coffee, tea, and caffeine consumption and serum uric acid level: the third national health and nutrition examination survey by Choi HK1, Curhan G.(PubMed)
(212) Effects of coffee consumption on serum uric acid: systematic review and meta-analysis by Park KY1, Kim HJ2, Ahn HS2, Kim SH1, Park EJ1, Yim SY3, Jun JB4.(PubMed)
(213) The relation of coffee consumption to serum uric Acid in Japanese men and women aged 49-76 years by Pham NM1, Yoshida D, Morita M, Yin G, Toyomura K, Ohnaka K, Takayanagi R, Kono S.(PubMed)
(214) The association of vitamin C, alcohol, coffee, tea, milk and yogurt with uric acid and gout by Towiwat P1, Li ZG2.(PubMed)
(215) Dietary factors and hyperuricaemia by Schlesinger N1.(PubMed)
(216) Intake of purine-rich foods, protein, and dairy products and relationship to serum levels of uric acid: the Third National Health and Nutrition Examination Survey by Choi HK1, Liu S, Curhan G.(PubMed)
(217) Effects of skim milk powder enriched with glycomacropeptide and G600 milk fat extract on frequency of goutflares: a proof-of-concept randomised controlled trial by Dalbeth N1, Ames R, Gamble GD, Horne A, Wong S, Kuhn-Sherlock B, MacGibbon A, McQueen FM, Reid IR, Palmano K.(PubMed)
(218) Immunity, inflammation, and cancer by Grivennikov SI1, Greten FR, Karin M.(PubMed)
(219) Monosodium urate crystals in inflammation and immunity by Shi Y1, Mucsi AD, Ng G.(PubMed)
(220) Omega 3 polyunsaturated fatty acids, inflammation and immunity by Calder PC1.(PubMed)
(221) Omega-3 fatty acids in inflammation and autoimmune diseases by Simopoulos AP1.(PubMed)
(222) Drug treatment of combined hyperlipidemia by Wierzbicki AS1, Mikhailidis DP, Wray R.(PubMed)
(223) An omega-3 polyunsaturated fatty acid concentrate increases plasma high-density lipoprotein 2 cholesterol and paraoxonase levels in patients with familial combined hyperlipidemia by Calabresi L1, Villa B, Canavesi M, Sirtori CR, James RW, Bernini F, Franceschini G.(PubMed)
(224) Altered serum selenium and uric acid levels and dyslipidemia in hemodialysis patients could be associated with enhanced cardiovascular risk by Martí del Moral L1, Agil A, Navarro-Alarcón M, López-Ga de la Serrana H, Palomares-Bayo M, Oliveras-López MJ.(PubMed)
(225) Urinary nitrite/nitrate concentrations and total antioxidant capacity in patients with chronic hepatitis C in therapy with interferon and ribavirin by Stanzial AM1, Benoni G, Cuzzolin L, Gabrielli GB, Pasino M, Perfetti P, Corrocher R.(PubMed)
(226) Differences in zinc status between patients with osteoarthritis and osteoporosis by Ovesen J1, Møller-Madsen B, Nielsen PT, Christensen PH, Simonsen O, Hoeck HC, Laursen MB, Thomsen JS.(PubMed)
(227) Zinc supplementation for the prevention of type 2 diabetes mellitus in adults with insulin resistance by El Dib R1, Gameiro OL, Ogata MS, Módolo NS, Braz LG, Jorge EC, do Nascimento P Jr, Beletate V.(PubMed)
(228) Zinc supplementation for the prevention of type 2 diabetes mellitus by Beletate V1, El Dib RP, Atallah AN.(PubMed)
(229) Comparison of nutrient intake and diet quality between hyperuricemia subjects and controls in Korea by Ryu KA1, Kang HH1, Kim SY1, Yoo MK1, Kim JS2, Lee CH3, Wie GA1.(PubMed)
(230) Cross-sectional analysis of nutrition and serum uric acid in two Caucasian cohorts: the AusDiab Study and the Tromsø study by Zykova SN1, Storhaug HM2, Toft I3,4, Chadban SJ5,6, Jenssen TG7,8, White SL9.(PubMed)
(231) Anthropometry, lipid- and vitamin status of 215 health-conscious Thai elderly by Pongpaew P1, Tungtrongchitr R, Lertchavanakul A, Vudhivai N, Supawan V, Vudhikes S, Prayurahong B, Tawprasert S, Kwanbunjan K, Migasena P, et al.(PubMed)
(232) Nutritional assessment, health markers and lipoprotein profile in postmenopausal women belonging to a closed community by Sánchez-Muniz FJ1, Carbajal A, Ródenas S, Méndez MT, Bastida S, Raposo R, Ruiz T.(PubMed)

(233) Adverse effects of aspirin, acetaminophen, and ibuprofen on immune function, viral shedding, and clinical status in rhinovirus-infected volunteers by Graham NM1, Burrell CJ, Douglas RM, Debelle P, Davies L.(PubMed)
(234) Hepatic differentiation of human adipose tissue-derived mesenchymal stem cells and adverse effects of arsanilic acid and acetaminophen during in vitro hepatic developmental stage by Kwon MJ1, Kang SJ, Park YI, Yang YH, Bang SI, Park YH, So B, Cho MH, Kang HG.(PubMed)
(235) Gastrointestinal, liver, and lung extraction ratio of acetaminophen in the rat after high dose administration by Bhargava VO1, Hirate J.(PubMed)
(236) Gout--what are the treatment options? by Schlesinger N1, Dalbeth N, Perez-Ruiz F.(PubMed)
(237) Preventing acute gout when starting allopurinol therapy. Colchicine or NSAIDs? by Kot TV1, Day RO, Brooks PM.(PubMed)
(238) Efficacy and safety of etoricoxib compared with NSAIDs in acute gout: a systematic review and a meta-analysis by Zhang S1, Zhang Y1, Liu P1, Zhang W1, Ma JL1, Wang J2,3.(PubMed)
(239) Side effects of nonsteroidal anti-inflammatory drugs on the small and large intestine in humans by Bjarnason I1, Hayllar J, MacPherson AJ, Russell AS.(PubMed)
(240) Detection and prevention of NSAID-induced enteropathy by Davies NM1, Saleh JY, Skjodt NM.(PubMed)
(241) Toxicity of nonsteroidal anti-inflammatory drugs in the large intestine by Davies NM1.(PubMed)
(242) Effects of adrenocorticotropic hormone (ACTH) in gout, Author links open the overlay panel. Numbers correspond to the affiliation list which can be exposed by using the show more link by Alexander B. Gutman, M.D. 1, T.F. Yü, M.D.(Science direct)
(243) Thiocolchicoside: review of adverse effects by [No authors listed](PubMed)
(244) Non-Steroidal Anti-Inflammatory Drugs and Aspirin Therapy for the Treatment of Acute and Recurrent Idiopathic Pericarditis by Schwier N1, Tran N2.(PubMed)
(245) Mechanism of action of colchicine in the treatment of gout by Dalbeth N1, Lauterio TJ2, Wolfe HR3.(PubMed)
(246) [Treatment of gout].[Article in French]by Dubost JJ1, Mathieu S, Soubrier M.(PubMed)
(247) Dual-Energy CT in Patients with Suspected Gouty Arthritis:: Effects on Treatment Regimen and Clinical Outcome by Metzger SC1, Koehm M2, Wichmann JL1, Buettner S3, Scholtz JE1, Beeres M1, Kerl JM1, Albrecht MH1, Hammerstingl R1, Vogl TJ1, Bauer RW4.(PubMed)
(248) Adverse effects of corticosteroids on bone metabolism: a review. by Mitra R1.(PubMed)
(249) Adverse effects of corticosteroids on the cardiovascular system by Sholter DE1, Armstrong PW.(PubMed)
(250) Psychiatric adverse effects of corticosteroids by Warrington TP1, Bostwick JM.(PubMed)
(251) Psychiatric complications of treatment with corticosteroids: review with case report by Kenna HA1, Poon AW, de los Angeles CP, Koran LM.(PubMed)
(252 Effects of adrenocorticotropic hormone (ACTH) in gout(Research Gate)
(253) ACTH as first line treatment for acute gout in 181 hospitalized patients by Daoussis D1, Antonopoulos I, Yiannopoulos G, Andonopoulos AP.(PubMed)
(254) Update on the management of hyperuricemia and gout by Pillinger MH1, Keenan RT.(PubMed)
(255) ACTH therapy in infantile spasms: side effects by R Riikonen and M Donner(PMC)
(256) Sustained efficacy of a single intra-articular dose of FX006 in a rat model of repeated localized knee arthritis by Kumar A1, Bendele AM2, Blanks RC3, Bodick N4.(PubMed)
(257) Intra-articular glucocorticoids for acute gout by Wechalekar MD1, Vinik O, Schlesinger N, Buchbinder R.(PubMed)
(258) Intraarticular cortisone injection for osteoarthritis of the hip. Is it effective? Is it safe? by David W. Kruse(PMC)
(259) Flavonoids of Cynara scolymus possess potent xanthinoxidase inhibitory activity in vitro but are devoid of hypouricemic effects in rats after oral application by Sarawek S1, Feistel B, Pischel I, Butterweck V.(PubMed)
(260) Learning to eat vegetables in early life: the role of timing, age and individual eating traits by Caton SJ1, Blundell P2, Ahern SM2, Nekitsing C2, Olsen A3, Møller P3, Hausner H3, Remy E4, Nicklaus S4, Chabanet C4, Issanchou S4, Hetherington MM2.(PubMed)
(261) Identification of a potent xanthine oxidase inhibitor from oxidation of caffeic acid by Masuda T1, Shingai Y2, Takahashi C2, Inai M2, Miura Y2, Honda S2, Masuda A3.(PubMed)
(262) Structure-activity relationship of caffeic acid analogues on xanthine oxidase inhibition by Chan WS1, Wen PC, Chiang HC.(PubMed)
(263) Discovery of xanthine oxidase inhibitors and/or α-glucosidase inhibitors by carboxyalkyl derivatization based on the flavonoid of apigenin by Su ZR1, Fan SY1, Shi WG1, Zhong BH2.(PubMed)
(264) #Healthy #Foods - Green tea - Leaves of Camellia sinensis by Kyle J. Norton
(265) Quercetin lowers plasma uric acid in pre-hyperuricaemic males: a randomised, double-blinded, placebo-controlled, cross-over trial by Shi Y1, Williamson G1.(PubMed)
(266) The association of vitamin C, alcohol, coffee, tea, milk and yogurt with uric acid and gout by Towiwat P1, Li ZG2.(PubMed)
(267) [Multiple actions of EGCG, the main component of green tea].[Article in French] by L'Allemain G1.(PubMed)
(268) Quercetin lowers plasma uric acid in pre-hyperuricaemic males: a randomised, double-blinded, placebo-controlled, cross-over trial by Shi Y1, Williamson G1.(PubMed)
(269) Effects of green tea extract on serum uric acid and urate clearance in healthy individuals. by Jatuworapruk K1, Srichairatanakool S, Ounjaijean S, Kasitanon N, Wangkaew S, Louthrenoo W.(PubMed)
(270) Alfalfa For Gout, Updated on August 24, 2012(Treat and prevent gout with Alfalfa Tablets)
(271) Ethyl acetate extracts of alfalfa (Medicago sativa L.) sprouts inhibit lipopolysaccharide-induced inflammation in vitro and in vivo by Hong YH1, Chao WW, Chen ML, Lin BF.(PubMed)
(272) Effects of Pimenta pseudocaryophyllus extracts on gout: Anti-inflammatory activity and anti-hyperuricemic effect through xantine oxidase and uricosuric action by Ferrari FC1, Lemos Lima Rde C1, Schimith Ferraz Filha Z1, Barros CH1, de Paula Michel Araújo MC1, Antunes Saúde-Guimarães D2.(PubMed)
(273) Effects of extracts of leaves from Sparattosperma leucanthum on hyperuricemia and gouty arthritis by Lemos Lima Rde C1, Ferrari FC1, de Souza MR1, de Sá Pereira BM1, de Paula CA1, Saúde-Guimarães DA2.(PubMed)
(274) Devils Claw as a Natural Remedy for Gout By: Betty Roberts
(275) Analgesic, antiinflammatory and antidiabetic properties of Harpagophytum procumbens DC (Pedaliaceae) secondary root aqueous extract by Mahomed IM1, Ojewole JA.(PubMed)
(276) Anti-inflammatory effect of Ajuga bracteosa Wall Ex Benth. mediated through cyclooxygenase (COX) inhibition by Gautam R1, Jachak SM, Saklani A.(PubMed)
(277) New and known iridoid- and phenylethanoid glycosides from Harpagophytum procumbens and their in vitro inhibition of human leukocyte elastase by Boje K1, Lechtenberg M, Nahrstedt A.(PubMed)
(278) Hypouricemic effects of phenylpropanoid glycosides acteoside of Scrophularia ningpoensis on serum uric acid levels in potassium oxonate-pretreated Mice by Huang CG1, Shang YJ, Zhang J, Zhang JR, Li WJ, Jiao BH.(PubMed)
(279) Hypouricemic effects of anthocyanin extracts of purple sweet potato on potassium oxonate-induced hyperuricemia in mice by Hwa KS1, Chung DM, Chung YC, Chun HK.(PubMed)


(280) Effects of anthocyanins from purple sweet potato (Ipomoea batatas L. cultivar Eshu No. 8) on the serum uric acid level and xanthine oxidase activity in hyperuricemic mice by Zhang ZC1, Su GH, Luo CL, Pang YL, Wang L, Li X, Wen JH, Zhang JL.(PubMed)
(281) TCM assistant
(282) Xuan Bi Tang(American Dragon)
(283) Gui Zhi Shao Yao Zhi Mu Tang(American Dragon)
(284) Shu Feng Huo Xue Tang by (Root down US)
(284) A network pharmacology approach to determine active ingredients and rationality of herb combinations of Modified-Simiaowan for treatment of gout.by Zhao F1, Guochun L2, Yang Y3, Shi L1, Xu L1, Yin L4.(PubMed)
(285) Suppressive effect of modified Simiaowan on experimental gouty arthritis: an in vivo and in vitro study by Shi L1, Xu L, Yang Y, Song H, Pan H, Yin L(PubMed)
(286) Anti-inflammatory and antinociceptive effects of Chinese medicine SQ gout capsules and its modulation of pro-inflammatory cytokines focusing on gout arthritis by Kodithuwakku ND1, Pan M, Zhu YL, Zhang YY, Feng YD, Fang WR, Li YM.(PubMed)
(287) The molecular insight into the antihyperuricemic and renoprotective effect of Shuang Qi gout capsule in mice by Kodithuwakku ND1, Feng YD2, Zhang YY1, Pan M3, Fang WR4, Li YM5.(PubMed)
(288) Effects of Modified Simiao Decoction on IL-1 β and TNF α Secretion in Monocytic THP-1 Cells with Monosodium Urate Crystals-Induced Inflammation by Liu YF1, Tu SH1, Chen Z1, Wang Y1, Hu YH1, Dong H1.(PubMed)
(289) Monosodium urate crystals trigger Nrf2- and heme oxygenase-1-dependent inflammation in THP-1 cells by Jhang JJ1, Cheng YT1, Ho CY1, Yen GC2.(PubMed)
(290) Anti-hyperuricemic and nephroprotective effects of Modified Simiao Decoction in hyperuricemic mice by Hua J1, Huang P, Zhu CM, Yuan X, Yu CH.(PubMed)
(291) Treatment of 60 cases of gouty arthritis with modified Simiao Tang by Qiu R1, Shen R, Lin D, Chen Y, Ye H.(PubMed)
(292) [Fingerprint comparison of effective parts of Ermiao wan categorized formula in anti-gouty syndrome of damp and heat].[Article in Chinese] by Li X1, Yin L, Duan JA, Ding AW.(PubMed)
(293) In vitro Xanthine Oxidase Inhibitory Studies of Lippia nodiflora and Isolated Flavonoids and Phenylethanoid Glycosides as Potential Uric Acid-lowering Agents by Cheng LC, Murugaiyah V, Chan KL.(PubMed)
(294) Flavonoids and phenylethanoid glycosides from Lippia nodiflora as promising antihyperuricemic agents and elucidation of their mechanism of action by Cheng LC1, Murugaiyah V2, Chan KL3.(PubMed)
(295) A Chinese herbal medicine Ermiao wan reduces serum uric acid level and inhibits liver xanthine dehydrogenase and xanthine oxidase in mice by Kong LD1, Yang C, Ge F, Wang HD, Guo YS.(PubMed)
(296) [Stage-based treatment of gouty arthritis by combination therapy of traditional Chinese and Western medicines: a randomized controlled trial].[Article in Chinese] by Wang YF1, Li BH, Zhang M, Xu WB, Zhou R, Zhou M.(PubMed)
(297) [Comparative observation of the efficacy on acute gouty arthritis between acupuncture combined with infrared irradiation and western medicine].[Article in Chinese] by Zhou L1, Xu QF, Zhang WS.(PubMed)