الفهرس 
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Abstract
Gout is one of the most common arthritis in adults which is caused by the accumulation of MSU crystals within the joints and is associated with elevated uric acid in the blood or hyperuricemia. Humans lack the enzyme uricase, which converts uric acid into a more soluble end-product, leading to higher levels of serum uric acid. Hyperuricemia may be attributable to either an overproduction of uric acid from purine metabolism or an underexcretion of uric acid by the renal system [1,2]. Hyperuricaemia itself is typically undetected until occurance of gout or its commonly associated comorbidities. It reduces the quality of life in patients. The prevalence of asymptomatic MSU deposition has previously been examined in extremely hyperuricaemic individuals which was estimated to be between 10% and 20% world wide.[3] Hyperuricemia and gout may also be associated with vascular diseases including cardiovascular diseases such as hypertension, CAD, AF, and HF, in addition to CKD. Recently, a high incidence of clinical atherosclerotic complications, independent of known risk factors, has been reported in gout patients which supports the association between inflammation and atherosclerosis[4,5].In chronic gout, the combination of persistent systemic and joint inflammation and hyperuricemia may potentiate or synergize vascular disease development. It has been proposed that urate crystal material in vessel walls may cause the release of inflammatory cytokines, acute phase reactants that are known to promote vascular damage. Additionally, hyperuricemia may be associated with metabolic syndrome including obesity, diabetes and insulin resistance, and hyperlipidemia[6,7]. Musculoskeletal Ultrasound has recently been introduced as a promising new imaging modality for gout, which will provide an early, non invasive diagnostic tool. Crystalline material reflects US waves more strongly than the surrounding tissues, such as hyaline cartilage or synovial fluid which enables the distinction of MSU crystals deposition from the less echogenic surrounding soft tissues, and MSU crystals are found to be in the cartilage, tendon sheaths, synovial fluid, and subcutaneous tissue. Ultrasound detects deposition of MSU crystals on cartilaginous surfaces, as well as tophaceous material and typical erosions[8]. Power Doppler Imaging has the sensitivity for the detection of flow and is particularly useful for small vessels and those with low-velocity flow. The aim of this work was ultrasonographic evaluation of articular, extraarticular, and vascular changes in gout and AHU participants. The participants were divided into two groups: This study included 60 patients with gout and 60 participants with AHU who had been recruited from the outpatient clinic at the Academic Rheumatology, Nottingham hospitals, University of Nottingham. The United Kingdom. All the participants gave their written informed consent to participate in this study. Each participant had a special file with a code number. All investigations and results of the research have been only be used for scientific purposes with the assurance of patient privacy. Inclusion criteria: group 1: Patients with gout (N.=60): Patients with primary gout fulfilled ” 2015 Gout classification criteria: an American College of Rheumatology/European League against Rheumatism collaborative initiative”.[70], which had been collected from the Nottingham city hospital Rheumatology Unit. group 2: Participants with asymptomatic hyperuricemia (N.=60): Hyperuricemia was defined as uric acid above 7mg/dL in men and above 6 mg/dL in women,and the partcipants had been collected from the Nottingham city hospital clinics while doing routine check-up. The two groups were matched in their demographic data, in group 1 patients’ age ranged from 33-85 years with a mean of 59.63+10.16 and there were 9 female and 51 male patients. In group II, patients’ age ranged from 35-75 years with a mean of 57.33+10.08 years and there were 5 female patients and 55 male patients. Exclusion criteria: Patients with a history of any inflammatory arthritis; such as rheumatoid arthritis, reactive arthritis, psoriatic arthritis, spondylarthritis, or other autoimmune diseases or infectious musculoskeletal diseases ,in addition to, history of trauma to the affected joint. Patients with secondary gout caused by myeloproliferative disease, malignancy, radiotherapy, chemotherapy. Patients with a history of cervical radiotherapy, carotid artery intervention or surgery, and carotid artery trauma. Patients with severe heart and kidney diseases, blood infections, vasculitis, and other infectious diseases. Patients with serious diseases of other systems affecting the investigation and patients who refuse to sign informed consent. All participants were subjected to the following assessment: • Full medical history taking. • Thorough clinical examination with joint scores using VAS for pain. • Functional assessment using LEFS • Laboratory assessment using the following: o Complete Blood Count (CBC). o C – Reactive Protein (CRP). o Erythrocyte Sedimentation Rate (ESR) o Serum uric acid (SUA). o Serum Creatinine. o Estimated glomerular filtration rate (eGFR) o Total cholesterol (TC) o Total glyceride (TG) - All the participants underwent sonographic examination at the ultrasound unit in the Academic Rheumatology Department at Nottingham city hospital, Nottingham, UK. - The following anatomical areas were bilaterally scanned in both axes (longitudinal and transverse): • Knee joints and patellar tendons insertion, • Ankle and Achilles tendons. • First MTPJs, • Wrist joints. • Elbow joints and triceps tendons • Bilateral examination of the carotid artery for measurement of IMT. The results of this study are summarized as the following: 1. There was an insignificant difference between the two groups as regards demographic data with disease duration ranging from 2-to 15 years in gout patients, and the number of flares from the onset of disease ranging from 1-to 10. 2. Hypertension , knee osteoarthritis and hyperlipidemia were the most prevalent comorbidities in all participants. While diabetes was more prevalent in gout patients than AHU group with significant differences between both groups. On the other hand, smoking and drinking habits are more frequent in gout patients with significant differences between both groups. 3. Antihypertensive and anti- triglycerides were taken by most of our participants in both groups, especially gout patients. Urate lowering agents were taken by (38.3%) of gout patients. 4. The 1st MTP joint was the most affected one in both groups by clinical examination. Additionally, all laboratory findings and LEFS scores were higher in gout patients than AHU participants with significant differences between the two groups according to the laboratory findings. 5. The articular and extra-articular ultrasonographic findings in form of tophi and/or aggregates (86.7%) followed by DCS (78.3%) were the most observed ultrasonographic findings and in gout group, respectively, while, subclnical synovitis (40%) was the highest ultrasonographic finding detected by US in AHU participnats. Moreover, bone erosion was (65% versus 20%), and tendinopathy or calcification at any joint was (73.3% versus 20%).Moreover,icreased CIMT was found in (76.7% versus 47.7%) in gout and AHU partcipants,respectively.Additionally, carotid plaques were found in (43.3%) versus (23.3%) of the examined participants in both groups with significant differences between both groups in all ultrasonographic parameters. 6. Serum uric acid was significantly correlated with the presence of hypertension and there was a negative linear relationship between the level of SUA and the increase in LEFS score ,which was being a protective factor that may reflect low urate deposition (DCS, tophi, aggregates) and erosions detected by ultrasound..Additionally, there was a significant correlation between higher SUA levels in gout patients and all laboratory findings and BMI. Comparatively, SUA levels showed a significant correlation with BMI, ESR,CRP,TC, eGFR, and serum creatinine in the participants with AHU. 7. Age of the participants,disease duration, higher level of serum uric acid were being strong risk factors for presence of tophi and/or aggregates and DCS ,while higher level of serum creatinine and lower eGFR in gout patient were found to be more risk factors for tophi and/or aggregates detected by US in gout patients. Addirionally, presence of carotid plaque was found to be significantly associated with tophi detected by US. Furthermore,Erosions detectd by ultrasound in gout patients were found to be associated with longer disease duration. 8. Age of the paricipants, higher BMI and level of serum uric acid was a effective risk factor for development of US pathological findings as tophi and/or aggregates ,and DCS. 9. Age of the partcipants,higher level of serum uric acid,TC ,BMI and presence of hypertension were being strong risk factors for developing subclnical atherosclerosis in both groups,in addition to longer disease duration in gout group. 10. Presence of carotid plaque was signficantly associated with tophi detected by US in the gout group only, while the presence of increased carotid intima thickness was not correlated with any of the ultrasonographic findings detected in both groups.