风湿

超声无炎症表现的关节痛

作者:van der Ven M 翻译:北医三院赵金霞 来源:中国风湿病公众论坛 日期:2017-10-12
导读

         超声无炎症表现的关节痛患者一般不会发展为关节炎

关键字:  关节痛 | 超声 

        摘要:

        背景:为了降低类风湿关节炎的疾病负担,对于具有类风湿关节炎危险因素的患者应该尽可能早识别,尤其是还未出现临床明显的滑膜炎阶段。迄今为止,确定发展为炎性关节炎的患者的确很困难,但最近应用超声的研究显示了早期检测是可行的。本研究的目的在于应用超声检测关节痛患者初次就诊时的亚临床滑膜炎,确定哪些患者会在1年内发展为炎性关节炎。

        方法:本研究为多中心的队列研究,具有至少两个关节(包括手,足或肩关节)疼痛而无临床关节炎的患者,至少随访1年。症状持续时间小于1年,并且无法用其他疾病解释。分别于基线,6个月和12个月收集体格检查,实验室和诊断数据。基线时,我们共检查26个关节的超声影像(双掌指关节2-5,近端指间关节2-5,腕关节,跖趾关节2-5)。根据灰阶超声(GS:0-3)和能量多普勒(PD:0-3)进行半定量评分。超声滑膜炎定义为GS≥2 和/或PD≥1。炎性关节炎定义为临床软组织肿胀。以敏感性和特异性来评价超声对于发展为炎性关节炎的诊断价值。应用单因素logistic 回归分析来分析自变量与发生炎性关节炎的相关性。多因素logistic回归分析中,选择最强变量(p<0.157)。估算自变量的缺失值。

        结果:共纳入196例患者,159例完成了12个月的随访。31例(16%)患者发展为炎性关节炎,其中59%在基线时显示超声下滑膜炎。超声滑膜炎的敏感性和特异性分别为59% 和 68%。如果无关节显示有超声下滑膜炎,其阴性预测值为89%。多因素logistic回归分析显示年龄(OR 1.1),晨僵时间>30分钟(OR 3.3)和PD信号(OR 3.4)与炎性关节炎发生相关。

        结论:基线时候具有PD信号,晨僵时间>30分钟和年龄是发展为炎性关节炎的独立危险因素。关于超声在早期关节痛患者发生炎性关节炎的诊断价值,超声下无滑膜炎表现对炎性关节炎具有很好的排除诊断价值。

        附原文:Abstract BACKGROUND:Todecrease the burden of disease ofrheumatoid arthritis(RA), patientsat risk for RA need to be identified as early as possible, preferably when noclinically apparent synovitis can be detected. Up to now, it has been fairlydifficult to identify those patients with arthralgia who developinflammatoryarthritis(IA), but recent studiesusingultrasound(US) suggest that earlier detection is possible. Weaimed to identify patients with arthralgia developing IA within 1yearusing US to detect subclinical synovitis at first consultation.METHODS:In amulti-centre cohort study, we followed patients with arthralgia with at leasttwo painful joints of the hands, feet or shoulders without clinical synovitisover 1year. Symptom duration was<1year, and symptoms were notexplained by other conditions. At baseline and at 6 and 12months, datawere collected for physical examinations, laboratory values and diagnoses. Atbaseline, we examined 26 joints ultrasonographically (bilateral metacarpophalangealjoints 2-5, proximal interphalangeal joints 2-5, wrist and metatarsophalangealjoints 2-5). Scoring was done semi-quantitatively on greyscale (GS; 0-3) andpower Doppler (PD; 0-3) images. US synovitis was defined as GS≥2 and/or PD≥1. IA was defined as clinical softtissue swelling. Sensitivity and specificity were used to assessthediagnosticvalue of US for the development of IA. Univariatelogistic regression was used to analyse the association between independentvariables and the incidence of IA. For multivariate logistic regression, thestrongest variables (p<0.157) were selected. Missing values for independentvariables were imputed.RESULTS:A total of 196 patients were included, and 159completed 12months of follow-up. Thirty-one (16%) patients developed IA,of whom 59% showed US synovitis at baseline. The sensitivity and specificity ofUS synovitis were 59% and 68%, respectively. If no joints were positive on US,negative predictive value was 89%. In the multivariate logistic regression, age(OR 1.1), the presence of morning stiffness for>30minutes (OR 3.3) and PD signal(OR 3.4) were associated with incident IA.CONCLUSIONS:The presence of PDsignal, morning stiffness for>30minutes and age at baseline were independentlyassociated with the development of IA. Regarding the value of US inthediagnosticworkup of patients with early arthralgia at risk forIA, US did perform well in ruling out IA in patients who did not have USsynovitis.

        引自:van der Ven M,van der Veer-Meerkerk M,Ten Cate DF,Rasappu N,Kok MR,Csakvari D,Hazes JMW,Gerards AH,Luime JJ.Absence ofultrasoundinflammation in patientspresenting with arthralgia rules out the development ofarthritis. ArthritisResTher. 2017 ;19(1):202. doi: 10.1186/s13075-017-1405-y.

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