Prognostic factors in rheumatoid arthritis

Rheumatoid arthritis is a chronic, progressive, inflammatory joint disease, affecting primarily the small joints of the hands and feet symmetrically and characterized by joint destruction, progressive disability, and premature death. Rheumatoid arthritis shows a wide spectrum of clinical phenotypes from mild disease to severe arthritis. Aggressive disease implies a rapidly progressive course affecting most joints, with little or no response to drug therapy, and sometimes complicated by life-threatening extraarticular involvement. The eventual multiple joint destruction requires major surgery, and severe disability results in loss of occupation and dependence on others. Many prospective cohort studies have attempted to predict outcomes and develop prognostic markers, especially in early disease. Probably most useful are those factors that independent of disease activity, such as the presence of rheumatoid factor, the so-called shared epitope of HLA-DR. In addition, clinical indicators (e.g., higher affected joint counts, the presence of extra-articular features, subcutaneous nodules, considerable degree of physical disability at onset), laboratory variables (e.g., longstanding increased acute-phase response, decreased hemoglobin) are indicating a poor prognosis. Some sociodemographic markers, such as female sex and a lower level of formal education are associated with a poor prognosis. An ideal prognostic marker should be reliable, simple, accurate and independent of the stage and inflammatory activity of RA so that they can be used early of the disease. Patients with a poor outcome should be treated promptly and aggressively with disease-modifying antirheumatic drugs to limit or prevent further disease progression.     

Serologic markers of early rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune disease that affects symmetrically multiple joints. Recent therapeutic strategy has been focusing on the symptoms of the disease and the ways to prevent its progression as early as possible. Thus, early diagnosis is crucial since early therapy with disease-modifying anti-rheumatic drugs reduces the severity of joint damage. It is the early period of the development of the disease that a specific and sensitive serologic test is needed. The RA patient sera contains a lot of antibodies. Some of them are not specific for RA occurring also in other diseases, others are highly specific and detectable only in rheumatoid arthritis. Rheumatoid factor (RF) is a very sensitive but poorly specific marker which makes it rather an unsuitable antibody for rheumatoid arthritis. RA-specific antibodies can be very useful for early diagnosis and prognosis of the disease. Among the antibodies described in recent years the most promising candidates are the autoantibodies to antigens containing one or more than one citrulline residues (cyclic citrulline peptides, CCP) - the anti-CCP antibodies. They have been shown in recent research to play an important role in the diagnosis, prognosis and therapeutic approach to patients with RA. Their high specificity, the ability to diagnose RA early in its development and distinguish it from other nonerosive type of arthritis, make the anti-CCP a key serologic marker in the future.     

Predictors of outcome at two years in patients with rheumatoid arthritis.

The prognostic value of clinical and laboratory measures in 72 patients with rheumatoid arthritis (RA), seen initially within 18 months of disease onset, in predicting function outcome after a further two years was assessed. Limitation of wrist extension was associated with a slow disease onset, a high articular index and a high latex titre. A reduction in global functional capacity, as measured by the Stanford Health Assessment Questionnaire, was associated with a high initial articular index and a high latex titre. Neither outcome was associated with the initial level of acute phase reactants nor with patient or physician's initial assessment of disease activity. It is concluded, first, that factors predicting early disability outcome in RA are not identical to those associated with continuing disease activity; and secondly, that patients' and physicians' judgment of disease activity at diagnosis do not carry any prognostic value for functional outcome two years later.     

Modern treatment of rheumatoid arthritis

Modern treatment of rheumatoid arthritis. Rheumatoid arthritis is a chronic inflammatory disease of unknown etiology, which is characterised by pain, loss of capability to work, in severe cases the life expectancy is also reduced. The disease cannot be cured with current therapeutic possibilities, but complaints can be reduced, the destruction can be retarded. The treatment is more efficient in the early stage of the disease, but early diagnosis is difficult because of insidious onset and limited sensitivity of diagnostic methods. The complaints can be alleviated by nonsteroidal anti-inflammatory drugs and transient glucocorticoid treatment, but risk of continuous glucocorticoid therapy is significant. To prevent structural damage disease modifying antirheumatic drugs are used. Out of these methotrexate is the most effective and it is well tolerated. Destruction of the joints is the consequence of inflammation, so intensity of drug treatment must be adjusted to inflammatory activity. For monitoring in clinical practice the composite index disease activity score is recommended. To achieve the reduction of inflammatory activity the dosage of disease modifying drugs can be increased, they can be switched or combined, and continuous glucocorticoid treatment can be started. In cases refractory to conventional treatment it is possible to inhibit the activity of proinflammatory cytokines, which play a pivotal role in pathomechanism of rheumatoid arthritis. In synovitis limited to one joint intraarticular glucocorticoid injection can be given, in refractory cases synovectomy is indicated. Destruction of the joints can be partially corrected by exercise, orthoses and after all with surgery.     

The practice guideline 'Rheumatoid arthritis' (first revision) from the Dutch College of General Practitioners: a response from the perspective of general practice

In the revised guideline on rheumatoid arthritis of the Dutch College of General Practitioners, in contrast to the previous guideline, particular emphasis is given to an early diagnosis. Moreover, rapid and maximal suppression of the disease process is recommended to delay or prevent damage to the joints. This policy however does not take into account the lack of evidence with regard to improvement of prognostic disability parameters. A careful, individualized referral indication is necessary so as to reduce the chance that patients are referred and treated but later turn out not to have had rheumatoid arthritis.     

Management of Rheumatoid Arthritis

Rheumatoid arthritis is a progressive, disabling disease which can lead to long-term deformity and disability. Leflunomide is a disease-modifying antirheumatic drug (DMARD) approved to reduce signs and symptoms, inhibit structural damage and improve physical function in adults with active rheumatoid arthritis.In clinical trials in patients with active rheumatoid arthritis, leflunomide had a more rapid onset of action than methotrexate, sulfasalazine and placebo. In trials of 24 months’ duration, leflunomide was more effective than sulfasalazine and placebo and at least as effective as methotrexate in reducing rheumatoid arthritis disease activity (assessed using the American College of Rheumatology [ACR] criteria). In addition, leflunomide was as effective as sulfasalazine or methotrexate in decreasing the rate of radiological progression over 24 months. Over 12 months leflunomide was more effective than methotrexate and placebo in reducing the rate of structural damage. Data from a nonblind extension study suggests that the efficacy of leflunomide may be maintained when administered for periods up to 5 years.Leflunomide was significantly more effective than methotrexate, sulfasalazine and placebo in improving physical function measures among patients with active rheumatoid arthritis, and improved physical function was maintained after 2 years of treatment.Few well designed pharmacoeconomic analyses of leflunomide treatment in patients with rheumatoid arthritis exist. Economic studies to date show leflunomide to be either less cost effective or cost neutral compared to methotrexate. In addition, leflunomide has been shown to be a cost effective option compared with etanercept, infliximab and infliximab plus methotrexate.Leflunomide was generally well tolerated in clinical trials. Common adverse events associated with leflunomide treatment include diarrhea, respiratory infections, nausea and headache. Hematological and hepatotoxic adverse events are a concern, particularly in a setting of multiple risk factors such as concomitant hepatotoxins. Liver function monitoring should be adhered to in all patients receiving leflunomide and ACR guidelines should be followed in those receiving concomitant methotrexate.In conclusion, leflunomide is a DMARD which produces a rapid and sustained reduction in disease activity in patients with active rheumatoid arthritis. Leflunomide has a more rapid onset of action than sulfasalazine or methotrexate. Leflunomide is at least as effective as methotrexate and more effective than sulfasalazine in reducing disease activity after 24 months’ treatment. In addition, leflunomide is more effective than both of these agents in improving physical function and health-related quality of life. Thus it is predicted that leflunomide therapy may improve the long-term outcome of patients with rheumatoid arthritis and reduce the substantial burden imposed by the disease for patient, healthcare provider and payers. Consequently, leflunomide should be considered as an important treatment option for those patients with active rheumatoid arthritis including those intolerant to methotrexate.     

Associations between demographic and disease-related variables and disability over the first five years of inflammatory polyarthritis: a longitudinal analysis using generalized estimating equations

OBJECTIVES: To investigate whether the relationship between demographic and disease-related variables and disability is constant during the first five years of inflammatory polyarthritis (IP) and to identify the contribution from involvement of specific joint areas to overall disability. METHODS: 684 patients referred to the Norfolk Arthritis Register were followed for five years using the Health Assessment Questionnaire (HAQ). The relationship between disability and demographic and clinical variables was analyzed using a multi-level modelling approach. RESULTS: Female gender, older age at symptom onset (> or = 64 years), joint involvement at six specific sites, joint tenderness and the number of deformed joints were all independently associated with disability (HAQ > or = 1.00). Similar results were obtained using a more stringent cut-off (HAQ > or = 1.50) or when analysis was restricted to the 325 patients who satisfied the 1987 ARA list criteria for rheumatoid arthritis. CONCLUSION: Disability, as measured by the HAQ, was associated with a large number of independent factors over the first five years of disease.     

Management of Rheumatoid Arthritis

Rheumatoid arthritis is associated with substantial costs to both the individual and society; costs increase as disease severity worsens. Current thinking is that disease-modifying antirheumatic drug (DMARD) therapy should be started as soon as possible after the diagnosis of rheumatoid arthritis and that patients should be offered the most effective treatment available.Etanercept is a soluble dimeric fusion protein comprising two copies of the extracellular ligand-binding domain of the human p75 receptor for tumour necrosis factor-α (TNFα) linked to the constant portion of human immunoglobulin G1. TNFα is thought to play an important role in the pathophysiology of rheumatoid arthritis; by binding the cytokine, etanercept blocks its biologic effects.In a 12-month double-blind, randomized study involving patients with early active rheumatoid arthritis, administration of subcutaneous etanercept 25mg twice weekly was associated with a more rapid and significantly greater overall response (assessed using American College of Rheumatology criteria) than oral methotrexate. In addition, compared with methotrexate, etanercept was associated with more rapid slowing of radiographic progression and a more rapid improvement in measures of health-related quality of life. The efficacy of etanercept was maintained at 3 years’ follow-up.Etanercept, alone or in combination with methotrexate, also showed sustained efficacy in three double-blind, randomized, placebo-controlled studies of 3 to 6 months’ duration involving patients with active rheumatoid arthritis who had not responded adequately to previous treatment with DMARDs.Etanercept was generally well tolerated in clinical trials (the most commonly occurring adverse events included injection site reactions, infection, headache, nausea, rhinitis, dizziness, pharyngitis and cough).The high cost of etanercept relative to traditional DMARDs may be justified if it can be shown to reduce long-term outcomes associated with rheumatoid arthritis, thereby reducing disease costs.Conclusion: Etanercept is an important new treatment option in rheumatoid arthritis. It provides a rapid and sustained reduction in disease activity and inhibits the progression of structural damage in patients with early active rheumatoid arthritis, with good tolerability. The improvement in disease activity and slowing of joint damage seen with etanercept was more rapid than that seen with methotrexate. In addition, etanercept, alone or in combination with methotrexate, is effective in the treatment of patients with active rheumatoid arthritis who have not responded adequately to previous DMARD therapy. It is anticipated that etanercept may also improve the long-term outcome of patients with rheumatoid arthritis and reduce the substantial economic burden imposed by the disease; however, more long-term data are needed to establish this.     

Impaired cutaneous cell-mediated immunity in newly diagnosed rheumatoid arthritis

BACKGROUND: Rheumatoid arthritis is characterized by an impaired immune response and a defective cutaneous cell-mediated immunity has been reported. This study was realised in order to determine the characteristics of cutaneous cell-mediated immunity in patients affected by recent-onset and untreated rheumatoid arthritis. METHODS: Forty-eight patients affected by newly diagnosed rheumatoid arthritis were studied by skin testing with seven common recall antigens. The skin tests were performed before the administration of disease modifying anti-rheumatic drugs (methotrexate, cyclosporine-A, hydroxychloroquine) and were repeated after four months of therapy. RESULTS: 43.75% of the RA patients (21 out of 48) were defined as anergic compared with 2% of the normal control subjects and the rate of depression of cutaneous cell-mediated immunity was not related either with the markers of disease activity or with the clinical assessment. The impaired cutaneous cell-mediated immunity shows a slight improvement after methotrexate therapy, while cyclosporine-A and hydroxychloroquine were not able to achieve the same result. CONCLUSIONS: Rheumatoid arthritis shows a defective cutaneous cell-mediated immunity when the patients are studied in the early phase of the disease and before a second-line of therapy with disease modifying anti-rheumatic drugs. The anergy does not correlate either with the disease activity or with the short-term response to treatment. The prognostic significance of these data remains uncertain.     

Early recognition of rheumatoid arthritis

Target to treat within the first 12 weeks. The rheumatoid arthritis (RA) disease process may be modulated best in the very early phase of the disease, therefore the period of the first 12 weeks of the disease is called the "window of opportunity". Patients in whom treatment is started within 12 weeks of onset of symptoms develop less severe joint damage and have a better chance of remission. At present only 31% of Dutch new RA patients are assessed by a rheumatologist within 12 weeks of symptom onset. Arthritis is identified by joint palpation; in order to detect subtle arthritis of minor joints, experience in carrying out this joint examination is required. In order to distinguish patients with early RA from other patients with recent onset arthritis, several prediction models have been developed. Early recognition of arthritis and RA is mandatory for early treatment of RA and improvement of the prospects of RA patients.     

全身型儿童类风湿关节炎21例预后因素分析

目的:探讨全身型儿童类风湿关节炎临床特点与预后因素,以提高对全身型儿童类风湿关节炎的认识。方法:对21例全身型儿童类风湿关节炎患儿进行统计,并分析相关资料。结果:甲氨蝶呤的治疗对全身型儿童类风湿关节炎完全缓解有重要意义;多关节炎者和类风湿因子,C反应蛋白,血小板的增高,不利于疾病的缓解;年龄小的患儿和女性患儿远期致残率较高。结论:全身型儿童类风湿关节炎的预后差,有较高的致死致残率,在病情反复发作5年的患儿,均发生了破坏性的关节病变。应及早诊断,及早治疗,包括甲氨蝶呤在内的联合方案,缩短肾上腺糖皮质激素的疗程和减少其剂量,监测各种感染的发生,以改善其预后。     

Adalimumab for Rheumatoid Arthritis

Third-party payors and national health systems require evidence that new medications for rheumatoid arthritis are cost effective. To determine cost effectiveness, one must consider the cost of a given therapy versus the long-term cost of the disease, with and without therapy. The direct and indirect costs of rheumatoid arthritis over the course of the disease, including the considerable costs related to hospitalization and disability, have been quantified. Resource utilization and treatment costs are high for patients with rheumatoid arthritis, and there is a strong link between functional disability and direct cost of care.Traditional disease-modifying antirheumatic drugs (DMARDs) [such as methotrexate and gold] have limited long-term effects in improving lives and avoiding costs for patients with rheumatoid arthritis. Tumor necrosis factor (TNF) antagonists, the newest class of rheumatoid arthritis drug therapies, significantly improve patient outcomes, including reducing the signs and symptoms of rheumatoid arthritis, improving physical function and health-related quality of life, and inhibiting radiographie damage. Failing to treat rheumatoid arthritis effectively is very costly; effective treatment includes early, aggressive therapy. As a result, the National Health Service in the UK, other societal decision-makers, and third-party payors have recommended the use of TNF antagonists, in many instances, for the treatment of rheumatoid arthritis.The TNF antagonists — infliximab, etanercept, and the most recently approved, adalimumab — address the limitations of traditional DMARDs, thus setting a new therapeutic standard for rheumatoid arthritis. Data from three key studies (Anti-TNF Research Program of the Monoclonal Antibody Adalimumab in Rheumatoid Arthritis, DE019 and DE011) indicate that adalimumab provides a rapid, sustainable, predictable, and significantly greater reduction in the signs and symptoms of rheumatoid arthritis than traditional DMARDs. Adalimumab yields significantly less structural joint damage as measured by the total Sharp scores and scores on its two major components: joint erosions and joint space narrowing. It also improves physical function (as measured by the Health Assessment Questionnaire Disability Index) and health utility (as measured by the Health Utilities Index Mark 3).In conclusion, rheumatoid arthritis and other musculoskeletal diseases are costly, but an upfront investment in highly effective therapies may provide long-term cost savings compared with traditional therapies. The immediate, out-of-pocket costs of TNF antagonists are greater than traditional DMARDs, but with the potential to significantly improve response rates, inhibit structural joint damage, and improve disability and health utility, TNF antagonists have the potential to be more cost effective over the long run. TNF antagonists can be valuable for patients in need and therefore appropriate for reimbursement by national health systems and third-party payors.     

High incidence and prevalence of rheumatoid arthritis in Pima Indians

A longitudinal epidemiologic study has been conducted to estimate the incidence and prevalence of rheumatoid arthritis in an American Indian population, the Pima and Papago Indians of Arizona. Clinical, serologic, and radiologic data were collected during biennial examinations of subjects aged 20 years or more during the period 1967-1986. Rheumatoid arthritis was diagnosed by criteria for the active and the inactive disease. Age-adjusted to the 1980 US population at least 20 years of age, the prevalence of classical and definite rheumatoid arthritis in 1984 was 5.3% (3.23% in males and 6.95% in females), a rate appreciably higher than that reported in studies in Rochester, Minnesota, and in Hiroshima and Nagasaki, Japan. Among Pimas, during the study period, 70 incident cases of rheumatoid arthritis occurred. The age-adjusted incidence rate was 42.2 cases per 10,000 person-years (29.7 in males and 51.8 in females), 10.3 times as high as the age-adjusted rate in Rochester (4.1/10,000 person-years), and 5.7 times as high as in Japan (7.4/10,000 person-years). Rates generally increased with age. No secular trend was found. On the basis of both prevalence and incidence data, this study confirms that rheumatoid arthritis does not have uniform occurrence in different populations. This has to be taken into account in the search for the factors related to the differences in risk of disease.     

Nonpharmacological interventions for rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease characterised by persistent inflammation of synovial joints, often leading to joint destruction and disability. The major goals of treatment are to relieve pain, reduce inflammation, slow down or stop joint damage, prevent disability, and preserve or improve the patient's sense of wellbeing and ability to function.     

Atherogenic lipid profiles and its management in patients with rheumatoid arthritis

Cardiovascular morbidity and mortality are enhanced in rheumatoid arthritis, which might be due to an increased prevalence of cardiovascular risk factors such as dyslipidemia. The dyslipidemia observed in RA appears to be dependent on disease activity, ie, a higher disease activity is associated with lower total cholesterol levels and even more depressed high density lipoprotein levels, leading to a higher (ie, unfavorable) atherogenic index. It appears that this dyslipidemia is already present long before the clinical onset of rheumatoid arthritis. Antirheumatic drug treatment with disease modifying antirheumatic drugs as well TNF-blocking agents has, in general, favorable, albeit moderate, effects on the lipid profile. Therefore, it is unlikely that the observed beneficial effects of antirheumatic drug treatment on cardiovascular morbidity and cardiovascular mortality in rheumatoid arthritis is mediated through effects on the lipid metabolism. Management of dyslipidemia in rheumatoid arthritis should be part of a general cardiovascular risk management. Hence, in addition to the assessment of the lipid profile, other cardiovascular risk factors should be determined and appropriate treatment installed when indicated. Lower treatment thresholds should be considered in view of the enhanced cardiovascular risk in rheumatoid arthritis and guidelines should be developed based on epidemiological data.     

Antibiotic prophylaxis of hematogenous bacterial arthritis]

The outcome of bacterial arthritis is generally poor: the mortality is 10-15% and there is loss of joint function in 25-50% of the survivors. Adverse prognostic factors are advanced age, a pre-existent joint disease and an infection of a prosthetic joint. The incidence of bacterial arthritis is low: 2-6 per 100,000 persons per year. Risk factors are advanced age, a joint disease--especially rheumatoid arthritis--diabetes mellitus and presence of a prosthetic joint. Situations that can lead to bacterial arthritis are mainly skin infections of the feet and only rarely invasive medical or dental procedures. Because of the severity of the disease, antibiotic prophylaxis of haematogenous bacterial arthritis in patients with prosthetic joints is advocated in guidelines. However, because of the rarity of the disease it is unclear whether the advantages of prophylaxis outweigh the disadvantages of the large-scale use of antibiotics, such as side effects, costs and increased resistance of bacteria. In a decision analysis of a large group of patients with joint diseases, antibiotic treatment of skin infections appeared to be (cost-)effective in the prevention of haematogenous bacterial arthritis, mainly in high-risk patients. On the other hand, prophylaxis around medical or dental procedures was not (cost-)effective, except possibly in a small group of patients with increased risk.     

General practitioners' knowledge of functional and social factors in patients with rheumatoid arthritis

The care of people with chronic physical disease is an important part of the work of general practitioners (GPs). Knowledge of social and functional factors, and good teamwork with other health and social care professionals, are necessary to provide high quality general practice care. This study investigated functional disability, social situation and the involvement of health and social care professionals in patients with rheumatoid arthritis, and their GPs' knowledge of these factors. Questionnaires were sent to all patients aged 15-74 with rheumatoid arthritis in two general practices, and similar questionnaires were given to their GPs. Functional disability was assessed using the health assessment questionnaire (HAQ), on a scale of 0-3. The GP consultation rate for patients with rheumatoid arthritis in the previous year was 6.9 compared to 3.7 for all patients in the practices, and increased with increasing disability. Sixty-five per cent of patients had a moderate (HAQ > 1 but 2) disabiltiy. There was an average difference between patient and GP scores for functional disability on the HAQ of 0.49 (95% confidence interval 0.36-0.62), with GPs scoring lower than patients and the difference increased with increasing disability. Seventy-one per cent of patients had seen a rheumatologist or orthopaedic surgeon in the previous year, but there was little involvement by other members of the primary health care team (PHCT). General practitioners had good levels of knowledge of their patients' employment status and who they lived with, but poor knowledge of most of the welfare benefits they were receiving, and of other health and social care professionals involved. It is concluded that GPs see their patients with rheumatoid arthritis frequently, but are often lacking the knowledge about their patients to provide high quality care. They often only know about aspects of their patients' care in which they are directly involved. Ways are suggested for how this situation could be improved.     

Burden of major musculoskeletal conditions

Musculoskeletal conditions are a major burden on individuals, health systems, and social care systems, with indirect costs being predominant. This burden has been recognized by the United Nations and WHO, by endorsing the Bone and Joint Decade 2000-2010. This paper describes the burden of four major musculoskeletal conditions: osteoarthritis, rheumatoid arthritis, osteoporosis, and low back pain. Osteoarthritis, which is characterized by loss of joint cartilage that leads to pain and loss of function primarily in the knees and hips, affects 9.6% of men and 18% of women aged > 60 years. Increases in life expectancy and ageing populations are expected to make osteoarthritis the fourth leading cause of disability by the year 2020. Joint replacement surgery, where available, provides effective relief. Rheumatoid arthritis is an inflammatory condition that usually affects multiple joints. It affects 0.3-1.0% of the general population and is more prevalent among women and in developed countries. Persistent inflammation leads to joint destruction, but the disease can be controlled with drugs. The incidence may be on the decline, but the increase in the number of older people in some regions makes it difficult to estimate future prevalence. Osteoporosis, which is characterized by low bone mass and microarchitectural deterioration, is a major risk factor for fractures of the hip, vertebrae, and distal forearm. Hip fracture is the most detrimental fracture, being associated with 20% mortality and 50% permanent loss in function. Low back pain is the most prevalent of musculoskeletal conditions; it affects nearly everyone at some point in time and about 4-33% of the population at any given point. Cultural factors greatly influence the prevalence and prognosis of low back pain.     

葡萄糖-6-磷酸异构酶与抗环瓜氨酸肽抗体对类风湿关节炎诊断意义的比较研究

目的比较葡萄糖-6-磷酸异构酶（glucose-6-phosphate isome-rase,GPI）和抗环瓜氨酸肽（anti-cycliccitrullinated peptide,anti-CCP）抗体对类风湿关节炎（rheumatoid arthritis,RA）的诊断意义。方法收集未经治疗的128例RA患者（RA组）、117例其他风湿病人（非RA组）、74例健康人（正常对照组）血清,采用酶联免疫吸附法（ELISA）检测GPI、抗CCP抗体,采用速率散射比浊法检测RF、C反应蛋白（CRP）、补体（C3、C4）、免疫球蛋白（IgA、IgG、IgM）,采用魏氏法测红细胞沉降率（血沉,ESR）。结果⑴GPI、抗CCP抗体诊断RA的特异性（分别为91.09%、94.14%）、敏感性（分别为75.0%、75.8%）差异均无统计学意义（P〉0.05）,但二者特异性与RF（78.53%）比差异有统计学意义（P〈0.01）。⑵GPI、抗CCP抗体分别与RF联合检测,两个指标均为阳性诊断RA的特异性（分别为94.24%、95.81%）差异无统计学意义（P〉0.05）,与单独检测RF比差异有统计学意义（P〈0.01）;两个指标任一阳性诊断RA的敏感性（分别为85.16%、85.94%）差异无统计学意义（P〉0.05）,与单独检测GPI或抗CCP抗体比差异有统计学意义（P〈0.05）。⑶GPI阳性的RA患者关节炎部位数、CRP、ESR水平明显高于GPI阴性RA患者,且差异有统计学意义（P〈0.05）。结论 GPI诊断RA具有与抗CCP抗体相似的特异性和敏感性。与RF联合检测可提高诊断RA的特异性和敏感性。此外,GPI还可作为RA活动性指标。     

Intraarticular rheumatoid nodule detection in the knee joint using ultrasonography

Rheumatoid nodules represent a classic diagnostic sign of rheumatoid arthritis. They can be found in 20-25% of patients and are localized to the extensor surface of the proximal ulna and other friction areas such as the back of the head, the sacrum, the digits and the Achilles tendon. They can also develop in some internal organs such as the lungs, kidneys and the heart. Rheumatoid nodules are a characteristic extra-articular feature of RA. Intraarticular rheumatoid nodules are rare and their detection is a diagnostic challenge. There are few reports in the medical literature on their ultrasonographic detection. We report our results from a retrospective study on 9 patients (5 with gait problems and 4 - asymptomatic) with intraarticular rheumatoid nodules in the knee joint. Ultrasonography was most important in their detection. The diagnosis was confirmed histologically in two of our patients following surgical removal of the nodules.