超微血流成像及能量多普勒超声在类风湿关节炎临床缓解期中的应用研究

目的比较超微血流成像(SMI)和能量多普勒超声(PDUS)在类风湿关节炎(RA)临床缓解期监测关节滑膜血流中的临床应用价值。方法选取40例RA临床缓解期患者和20例健康志愿者,对其双侧腕关节、掌指关节及近端指指关节行超声检查,观察PDUS和SMI检测RA患者缓解情况,记录PDUS和SMI对关节滑膜内血流的显示和分级情况,比较两种检测方法对滑膜血流分级的一致性及显示率。结果 40例RA临床缓解期患者中,PDUS显示16例存在活动性滑膜炎,缓解率60.0%(24/40);SMI显示25例存在活动性滑膜炎,缓解率37.5%(15/40);两种检测方法比较差异有统计学意义(χ~2=4.053,P=0.044)。SMI和PDUS对20例健康志愿者关节滑膜血流的显示率均为0,对40例RA临床缓解期患者关节滑膜血流的显示率分别为12.72%和8.64%,差异有统计学意义(χ~2=7.718,P=0.005)。Kappa检验显示PDUS与SMI对关节滑膜血流分级一致性较好(Kappa=0.741,P<0.01)。结论在RA临床缓解期,SMI和PDUS可通过检测手腕关节滑膜血流提示病情、指导治疗,均有较好的临床应用价值;SMI较PDUS能更敏感地发现手腕关节滑膜中的血流信号。     

超微血流成像及能量多普勒超声在类风湿关节炎临床缓解期的应用价值

摘要：目的：探讨超微血流成像（SMI）及能量多普勒超声（PDUS）在类风湿关节炎（RA）临床缓解期的应用价值。方法：对40例RA临床缓解期患者和20例健康志愿者的双侧腕关节、掌指关节及近端指指关节进行超声检查,记录PDUS及SMI对增厚滑膜内血流分级结果,观察两种血流模式对滑膜血流的显示率和滑膜血流分级的差异。 结果:在40例RA临床缓解期患者中,PDUS和SMI显示的缓解率分别为60%和27.5%,两者的差异有统计学意义（P<0.05）;在20例健康志愿者中SMI和PDUS对滑膜血流的显示率为0,但在40例RA临床缓解期患者中,PDUS及SMI对滑膜血流的显示率分别为8.64%、12.8%,两种血流模式的血流信号显示率差异具有统计学意义（P<0.05）;PDUS与SMI对滑膜血流分级结果一致性较好（kappa=0.741）; SMI阳性患者继续强化治疗后,滑膜血流显示率明显下降。结论：在类风湿关节炎临床缓解期,SMI和PDUS都有一定的临床应用价值。但SMI比PDUS能够更敏感的发现手腕关节滑膜中的血流信号。     

超微血流成像技术评估类风湿关节炎患者手指关节亚临床炎

目的 探讨超微血流成像技术(SMI)评价类风湿关节炎(RA)患者手指关节亚临床活动性炎症反应的应用价值。方法 对临床缓解的30例RA患者480个手指关节(双手2~5指掌指关节和近节指间关节)滑膜区进行SMI检查,半定量评分系统对滑膜区血流进行分级,并与能量多普勒(PDUS)对比分析,比较两种检查结果的一致性。结果 临床缓解的30例患者中,PDUS和SMI显示的缓解率分别为56.67%(17/30)和26.67%(8/30),差异有统计学意义(P=0.035)。在480个受检关节中,PDUS对滑膜区血流信号的显示率为8.54%(41/480),SMI血流信号显示率为12.50%(60/480),差异有统计学意义(P<0.001)。PDUS与SMI对滑膜血流分级结果有高度一致性(Kappa=0.732,P<0.001)。结论 SMI技术可更敏感地显示临床缓解期RA患者手指关节滑膜区异常血流信号。     

高频超声及能量多普勒超声在类风湿关节炎中的应用

近几年,高频超声(HFUS)及能量多普勒超声(PDUS)技术在类风湿关节炎(RA)的诊疗中发挥重要作用,本文就HFUS及PDUS的成像特点、疗效评价,不同关节间HFUS检查的相关性,PDUS与RA滑膜病理学相关性及PDUS在RA达标治疗中的价值等方面的研究做一综述。     

7关节超声评分评估类风湿关节炎病情进展

目的 探讨7关节超声评分（US7）在评估RA病情进展中的临床意义。方法 根据28关节疾病活动度（DAS28），将198例RA患者分为轻度活动期组（n=55）、中度活动期组（n=83）和重度活动期组（n=60），对严重侧腕关节，第2、3掌指关节，近端指间关节和第2、5跖趾关节行灰阶超声（GSUS）和能量多普勒超声（PDUS）检查及US7，比较3组间评分差异，分析其与病情严重程度的相关性，并采用Logistic回归分析寻找RA病情进展的预测因子。结果 随病情严重程度增加，DAS28、GSUS滑膜炎、PDUS滑膜炎、GSUS肌腱腱鞘炎、PDUS肌腱腱鞘炎及US7总分均显著增加（P均<0.001），且后5项指标与RA严重程度均呈正相关（P均<0.001）。US7系统中，PDUS滑膜炎是轻-中度活动期的独立预测因子，其与GSUS肌腱腱鞘炎均为中-重度活动期的独立预测因子（P均<0.05）。结论 US7与RA进展存在相关性；PDUS滑膜炎是鉴别RA严重程度的有效指标。     

类风湿性关节炎手部小关节病变的声像图表现

目的探讨高频超声在类风湿性关节炎(RA)手部小关节病变检查中的应用价值。方法应用高频超声对23例类风湿性关节炎患者(RA组)的230个掌指关节及184个近端指间关节行双侧对比扫查,检测滑膜厚度、血流供应,观察关节腔、骨面及关节周围软组织情况,并与20例健康志愿者(对照组)双侧相应关节扫查结果对比。结果超声图像可清晰显示RA组指关节积液303个(303/414,73.19%);关节滑膜增生264个(264/414,63.77%);彩色多普勒血流成像及能量多普勒超声均可显示RA组患者病变指关节滑膜血管过度增生,显示率分别为31个(31/303,10.23%),76个(76/303,25.08%);且能量多普勒超声的显示率明显高于彩色多普勒血流成像(P0.01)。结论高频超声可清晰显示手部关节腔积液、关节滑膜增生及关节内血管增生,为临床诊治RA提供重要依据。     

超声对类风湿性肩关节炎的早期诊断价值

目的探讨超声在类风湿性关节炎(RA)肩关节病变中的早期诊断价值。方法应用高频超声(HFUS)对40例RA患者(RA组)的60侧病变肩关节进行扫查,观察肩关节腔腋囊侧及后隐窝侧、肩峰下滑囊、肱二头肌长头肌腱鞘4个区域内滑膜厚度、积液深度;观察肱骨头(大结节、前内侧及后外侧)骨表面侵蚀及肩袖损伤;利用能量多普勒超声(PDUS)观察病变区域滑膜血流情况,并与20名健康志愿者(对照组)40侧肩关节扫查结果进行对比。结果超声检出RA组5种病变类型:关节积液、滑膜增生、血管过度形成、肩袖撕裂以及骨质侵蚀,检出率分别为42.50%(102/240)、39.58%(95/240)、20.83%(50/240)、31.67%(19/60)和36.11%(65/180);对照组肩关节腔内未见积液,滑膜未见增生,未见血流信号。与对照组比较,RA组滑膜明显增厚(P<0.01)。结论 HFUS和PDUS可检出类风湿性肩关节炎引起的多种病变,有助于早期诊断。     

超声在早期类风湿性关节炎的临床研究

目的 探讨手部小关节的彩色多普勒超声成像在早期类风湿性关节炎诊断中的临床价值.方法 对38例患者(共836个关节)及20例健康志愿者(共440个关节)采用高频探头进行双手腕关节、掌指关节及近端指间关节超声检查.并随机选取5例患者行核磁对照.结果 38例患者中34例273个关节滑膜增厚;30例112个关节关节腔积液;12例25个关节探及滑膜血管翳;5例5个关节伴有关节周围渗出;3例11个关节可见骨破坏.滑膜增厚发生最多,双手共22个关节中,有19个关节滑膜厚度与健康组比较差异有统计学意义.结论 彩色多普勒超声诊断早期类风湿性关节炎手部小关节滑膜病变为临床提供诊断依据.     

High-Frame-Rate Power Doppler Ultrasound Is More Sensitive than Conventional Power Doppler in Detecting Rheumatic Vascularisation

Early recognition of joint inflammation will increase treatment efficacy in rheumatoid arthritis (RA). Yet, conventional power Doppler (PD) ultrasound might not be sufficiently sensitive to detect minor inflammation. We investigated the sensitivity of high-frame rate Doppler, combined with singular value decomposition technique, to suppress tissue signals, for microvascular flow in a flow phantom setup and in a proof-of-principle study in healthy controls and in RA patients with different disease activities. In the flow phantom, minimal detectable flow velocity was a factor 3 lower with high-frame-rate PD than with conventional PD ultrasound. In the proof-of-principle study we detected a positive PD signal in all volunteers, diseased or healthy, with high-frame-rate PD ultrasound. We saw a gradual increase in PD signal in RA patients depending on disease activity. In conclusion, high-frame rate Doppler is more sensitive in detecting vascularisation than conventional PD ultrasound.     

高频超声在类风湿性膝关节炎诊断中的应用

目的：探讨高频超声检查在类风湿性关节炎膝关节病变诊断中的价值。方法：应用高频发声及彩色多普勒技术研究了３２例类风湿性关节炎患者６４个膝关节二维志趣超声图像及彩色多普勒血流改变并与Ｘ线检查进行比较。结果：（１）关节囊积液６２个（９６．８７％）,间距２．９￣２５．６ｍｍ;（２）６１个关节囊滑膜增厚（９５．３１％）;厚度２．２￣１６．９ｍｍ,腔面毛糙不平,部分可见绒毛状突起;（３）滑膜血管增生,４７个关     

类风湿关节炎跖趾关节病变的超声表现

目的 了解类风湿关节炎(RA)患者跖趾关节病变的超声表现.方法 RA患者65例,健康志愿者20例,分别利用高频超声检查跖趾关节,观察二维声像图及彩色多普勒血流显像情况.结果 RA患者跖趾关节病变的超声表现主要为:滑膜炎,部分可见血流信号;关节腔积液;骨质破坏;肌腱病变.结论 超声检查可以观察到RA患者跖趾关节的病理改变,且有明确的声像图表现,在判断病情变化和随访中有较高的应用价值.     

B-flow及超声造影在类风湿关节炎手腕小关节滑膜血流显像中的应用

目的探讨彩色多普勒、B-flow及超声造影在类风湿性关节炎手腕小关节滑膜血流显像的价值。方法采用GE Logiq S8 18 M马球棍形线阵探头检查240例类风湿性关节炎患者腕关节、掌指关节及近端指间关节,应用彩色多普勒检查滑膜血流信号并按Szkudlarek半定量法分为0~3级。对250个滑膜血流信号1级及以上的关节,应用频谱多普勒测量滑膜血管翳阻力指数（RI）并与半定量法作相关性分析。应用B-flow检查滑膜血流信号并与彩色多普勒比较两种技术对滑膜血流显示率的差异。对90个彩色多普勒显示滑膜无血流的类风湿性关节炎关节行超声造影,并与B-flow比较两种技术对滑膜血流检出率的差异。结果240例类风湿性关节炎滑膜均为不均匀低回声。其中200例类风湿性关节炎关节滑膜可探及血流信号（1级82例、2级72例、3级46例）。随着血流分级的增加,RI逐渐减低,血流分级与RI呈负相关。彩色多普勒与B-flow对类风湿性关节炎关节滑膜血流信号的显示率分别为154/250及206/250,差异有统计学意义（P<0.05）。90个彩色多普勒显示滑膜无血流的类风湿性关节炎关节,B-flow与超声造影的血流显示率为56/90与74/90,差异有统计学意义（P<0.05）。结论B-flow与超声造影较彩色多普勒对类风湿性关节炎关节滑膜血流显示率高,尤以超声造影明显,滑膜血管翳RI可有效评估类风湿性关节炎活动性,对类风湿性关节炎早期诊断及治疗用药,甚至治疗终点的决定有重要指导意义。     

早期类风湿性关节炎腕关节病变超声与MRI对比研究

目的 探讨超声与MRI在诊断早期类风湿性关节炎腕关节病变中的作用和价值.方法 对31例临床诊断为类风湿性关节炎的患者进行腕关节超声和MRI检查,比较2种影像学方法对病变的检出能力.结果 31例RA患者62个腕关节中超声显示滑膜炎62个,关节积液42个,肌腱腱鞘炎38个,骨侵蚀24个;MRI显示滑膜炎62个,关节积液43个,肌腱腱鞘炎41个,骨侵蚀35个,同时还显示骨髓水肿16个.对早期RA腕关节滑膜炎、关节积液、肌腱腱鞘炎的检出,2种检查方法之间差异无统计学意义(P>0.05);对骨侵蚀的检出,2种检查方法之间差异有统计学意义(P<0.05).结论 对临床疑诊的类风湿性关节炎患者首选超声检查,若超声表现不典型者再行MRI检查.     

基于APP的教考结合自主学习模式在小关节超声培训中的应用

目的探讨基于APP的教考结合自主学习模式在小关节超声培训中的应用价值。 方法13名超声医师通过APP中设置的电子课程自主学习“小关节超声评分”，随后进入APP超声图文考核平台，对140个类风湿关节炎手部小关节［第2/3掌指关节（MCP2/3）、腕关节及第2/3远端指间关节（PIP2/3）］以选择题方式进行自主评分，采用超声诊断符合率及组内相关系数（ICC）对培训效果进行分析。 结果在小关节有无滑膜炎、腱鞘炎及骨侵蚀判断方面，观察者间一致性中等~极好（ICC=0.49~0.97），且超声诊断符合率较好（76.4%~90.4%），而滑膜炎能量多普勒超声（PDUS）较灰阶超声评分培训效果好（75.7%/0.88 vs 45.2%/0.65）。其中MCP2滑膜炎PDUS及骨侵蚀培训效果最好（80.8%/0.77、88.5%/0.95）。MCP2/3滑膜炎灰阶超声评分一致性良好，但超声误判较高（0.63、0.75；44.4%、46.2%）。腕关节骨侵蚀及PIP2/3滑膜炎灰阶超声评分一致性较差、超声诊断符合率较低（27.4%~53.8%/0.14~0.37）。腕关节滑膜炎灰阶超声评分、PIP2/3及MCP3骨侵蚀判断超声诊断符合率高，但一致性差（74.40%~81.2%；0.24~0.38）。MCP2与MCP3关节，PIP2与PIP3关节整体超声培训效果相似（71.8%/0.83 vs 64.7%/0.83；58.1%/0.60 vs 59.3%/0.45）。 结论基于APP的自主学习及考核可作为关节超声的有效教学及考核手段，在精细分析考核结果的基础上，针对误判率较高、一致性较差的病变类型进行图像规范化、诊断标准化的递进强化培训，将有助于进一步优化教学效果并提高超声医师临床诊断能力。     

MRI对早期类风湿性关节炎手、腕部关节的诊断价值

目的 研究早期类风湿性关节炎（RA）手、腕部关节的MRI对早期RA的诊断及临床价值。方法 对40例早期RA患者行双手掌指关节及腕关节X线平片检查和MR扫描。对X线和MRI发现的骨侵蚀病灶分别进行计数，并对滑膜炎进行分级评分。同时搜集患者的临床资料包括症状、体征、实验室化验指标。统计并分析X线和MRI征象与临床检查之间的关系。结果 MRI见26例49只腕关节有184处明确的骨侵蚀改变，X线平片仅发现11例14只腕关节21处有骨侵蚀征象。21例患者掌指关节有32处MRI骨侵蚀改变，X线仅发现6处骨侵蚀征象。X线和MRI对早期RA患者的骨侵蚀病灶的检出上的差异有统计学意义。MRI所见40例RA患者均出现滑膜炎性改变，其中31例见明显强化，9例未见明显强化。对明显强化的滑膜炎进行分级评分，腕关节得分为2.5，掌指关节为2.8。腕关节滑膜强化组、无强化组与患者的临床检查的差异性有统计学意义，同时腕关节滑膜炎分级与骨侵蚀征象有较高相关性（r=0.91，P〈0.01）。另外，MRI还可显示早期RA的骨髓水肿、关节积液、肌腱炎等征象。结论 MRI能显示早期RA手腕部关节的病理改变，对骨侵蚀的检出明显优于传统X线检查。MRI可以对早期RA的滑膜炎进行半定量化分级评分，为早期RA滑膜炎的深入研究提供新的平台。早期滑膜炎、骨侵蚀病变对评价RA的活动性及预测疾病进程、预后方面有重要价值。     

Evaluation of finger joint synovial vascularity in patients with rheumatoid arthritis using contrast-enhanced ultrasound with water immersion and a stabilized probe

PURPOSE.: To assess synovial microvascularity in finger joints with rheumatoid arthritis (RA) by contrast-enhanced ultrasound (CEUS), distinguishing between cases of active disease and those in remission; to standardize the technique for software analysis. METHODS.: Fifty-two finger joints of RA patients (26 with active disease and 26 in remission) were immersed in water and examined by CEUS using a fixed probe. Signal intensity curves were calculated with the software. RESULTS.: Contrast enhancement was detectable in all 26 patients with active RA (100%), but not in 25 of 26 patients in remission (96%); one of the latter patients (4%) showed minimal enhancement. The method's sensitivity and specificity in distinguishing active disease from remission were 100% and 96%. The grades of synovial enhancement correlated with clinical disease activity and software flow parameters. The peak contrast levels correlated with clinical activity, a peak of 9% representing the cutoff between remission and active disease. CONCLUSIONS.: CEUS with a fixed probe on finger joints immersed in water detected synovial vascularization in RA, producing results suitable for standardized software analysis and avoiding artifacts.     

滑膜炎超声影像在评估早期类风湿性关节炎中的诊断价值

[目的]探讨超声检查滑膜炎影像证据应用于2010ACR/EULAR类风湿关节炎(RA)分类标准对评估RA早期诊断的价值.[方法]严格选取54例疑似RA的早期患者,所有患者进行38关节超声检查[GSUS≥1及PDUS(+)]和临床体格检查,分别统计受累关节的数目和部位,将上述三种方法统计的受累关节结果应用于2010ACR/EULAR分类标准评分,统计评分结果.同时对患者进行ACR1987分类标准进行评分.依据《2010ACR/EULAR分类标准联合倡议》以患者使用DMARDs治疗或(和)风湿专科医生判断为RA作为诊断RA的"金标准",计算不同分类标准的敏感性和特异性等指标.比较不同分类标准(方法)间的差异.[结果]54例中以上述标准最终诊断RA37例,符合2010ACR/EULARGSUS≥1标准39例,符合2010ACR/EULARPDUS(+)标准21例,符合2010ACR/EULAR临床体检标准27例,符合ACR1987标准18例.超声不同评估标准GSUS≥1,PDUS(+)与临床体检对"受累关节"检出率比较,GSUS≥1全部关节检出率,PDUS(+)跖趾关节检出率,GSUS≥1总检出率高于临床体检,差异具有统计学意义(P<0.05).2010ACR/EULAR超声不同标准敏感性均高于2010ACR/EULAR临床体检标准及ACR1987标准;其中以2010GSUS≥1敏感性最高,ACR1987最低;特异性PDUS(+)最高,2010GSUS≥1最低;诊断符合率2010GSUS≥1最高,ACR1987最低;约登指数最高为PDUS(+),Kappa值最高为2010GSUS≥1;诊断可靠性(AUC)以2010PDUS(+)最高.[结论]超声不同评估标准能够在多个关节检出临床体检无法发现的亚临床滑膜炎,其中GSUS≥1全部关节、PDUS(+)跖趾关节检出率较高.超声不同评估标准提供关节受累证据应用于2010ACR/EULAR分类标准后该标准诊断效能均高于ACR1987标准及2010ACR/EULAR临床体检标准,诊断效能以2010PDUS(+)提供关节受累证据较高.     

Correlation between upper limb functional ability and structural hand impairment in an early rheumatoid population

OBJECTIVE: To explore the relationship in individuals with early rheumatoid arthritis (RA) between self-report upper limb function, therapist-assessed upper limb function and therapist-assessed measures of structural impairment (handgrip, active hand motion and metacarpophalangeal (MCP) joint ulnar deviation). DESIGN: Thirty-six patients with early RA were recruited across seven outpatient occupational therapy departments. OUTCOME MEASURES: Upper limb functional activity and ability was measured using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and the Grip Ability Test (GAT). Upper limb impairment was assessed by bilateral power handgrip using the MIE Digital Grip Analyser, goniometry measures of bilateral metacarpophalangeal (MCP) joint ulnar deviation and bilateral active motion of the wrist. RESULTS: Strong correlations (> 0.7) were seen between the self-report DASH questionnaire and the therapist-rated GAT assessment. Bilateral power handgrips were also strongly correlated with both functional assessments. Dominant ulnar deviation at the MCP joints demonstrated a weak correlation (0.3-0.4) with both self-report and therapist-rated functional ability and a weak to moderate. (0.1-0.5) correlation on the nondominant side. CONCLUSION: In this early RA population handgrip strength is an accurate indicator of upper limb ability. Ulnar deviation at the MCP joints shows only a weak to moderate association with upper limb functional activity and ability. Although the DASH and the GAT were strongly correlated, the DASH was a more discriminating measure than the GAT in assessing upper limb ability in this sample population.     

An AA-amyloidosis course in patients with rheumatoid arthritis

AIM: To characterize renal amyloidosis in patients with rheumatoid arthritis and stages of amyloid nephropathy. MATERIAL AND METHODS: The trial covered 30 patients (6 males and 24 females) with documented rheumatoid arthritis (RA) complicated with secondary AA-amyloidosis. Amyloidosis diagnosis was confirmed in all the patients morphologically, the samples were studied with the peroxidase immunohistochemical method using specific monoclonal antibodies to SAA. Clinical manifestations of RA were assessed by the disease activity, functional impairment of the joints, x-ray alterations, extraarticular signs of RA, etc. All the patients were examined clinically, total blood count and biochemical tests were made. RESULTS: In 23 (77%) of 30 examinees with RA, proteinuria as the first clinical symptom of AA-amyloidosis emerged with the first 15 years of RA. RA of the second-third degree of activity were diagnosed in 25 (83%) patients, 21 (70%) patients had apparent destructive changes in the joints (x-ray stage III-IV). Severe functional insufficiency of the joints was observed in 25 (83%) patients, deformation of the joints - in 27 (90%) patients. Clinically, renal amyloidosis was characterized by change of stages - from moderate proteinuria to nephrotic syndrome and renal failure. Prognosis of amyloid nephropathy in RA depends on duration of the proteinuric stage: if this stage is short (3 years maximum), the prognosis is worse than in its long duration. CONCLUSION: RA ranks first among causes of secondary AA-amyloidosis. Development of AA-amyloidosis in RA patients is most probable in the first 15 years of the course of the articular process. Amyloidosis is more frequent in patients with severe clinical manifestations of RA.     

Joint Mobilization of the Hands of Patients With Rheumatoid Arthritis: Results From an Assessor-Blinded,Randomized Crossover Trial

ObjectiveThe purpose of this study was to assess the clinical feasibility and effectiveness of manual mobilization of the hands of patients with rheumatoid arthritis (RA).MethodsA total of 320 individual hand joints were evaluated after recruiting an experimental research group of 12 participants with RA and, for clinical comparability, 8 participants with hand osteoarthritis (OA). One hand per participant was randomized to receive weekly low-grade (I-II) Kaltenborn manual mobilization, using passive sustained stretch of the metacarpophalangeal (MCP) joints II to V by licensed manual therapists. After 2 weeks, the randomized treated hand was crossed over to control (untreated) during weeks 3 to 4 and vice versa. Final assessment was at 2 months, which was 1 month after the last treatment at week 4. Primary hand outcomes included pain by visual analog scale, tender or swollen joint count, and presence of Doppler signal or synovial fluid and radiographic joint space by musculoskeletal ultrasound.ResultsIn the RA group, both the initially randomized treated hand and the contralateral hand improved significantly from baseline to crossover to follow-up at 2 months (pain outcomes and Doppler signal, P < .050; synovial fluid and MCP joint space, P ≤ .001). Hand pain and MCP joint space also improved significantly in OA. There were no dropouts or reported adverse events in either the RA or OA group.ConclusionIn this study, manual mobilization of the hands of patients with RA was shown to be feasible, safe, and effective to integrate into specialized healthcare.