| Abstract | Uvod: Reumatoidni artritis je sustavna upalna bolest koja se dominantno manifestira na sinoviji zglobova kao perzistirajući sinovitis. Ručni zglobovi zahvaćeni su praktički u svih bolesnika. Posljednjih godina ultrazvuk postaje važna metoda pregleda i praćenja pacijenata oboljelih od reumatskih bolesti. Omogućuje prikaz panusa, upalnih promjena sinovije, izljeva u zglobu, promjena u paraartikularnim strukturama i tetivama. Dopler omogućuje prikaz prokrvljenosti patološki promijenjenog zgloba, a od posebnog interesa je određivanje stupnja upalnih promjena i njihovo praćenje tijekom liječenja. ----- Cilj rada: Utvrditi konvencionalne ultrazvučne karakteristike promjena na ulnokarpalnim, metakarpofalangealnim i proksimalnim interfalangealnim zglobovima kod oboljelih od reumatoidnog artritisa u intervalu od minimalno šest mjeseci liječenja. Utvrditi pomoću obojenog doplera jačinu vaskularizacije, vrijednosti maksimalne sistoličke brzine, enddijastoličke brzine i indeksa otpora kod upalom zahvaćenih zglobova, te promjene nastale nakon minimalno šest mjeseci liječenja. Usporediti morfološke i doplerske nalaze s kliničkim nalazom aktivnosti bolesti DAS 28 (disease activity score), HAQ (health assessment questionnaire) skupnim skorom, kao i s vrijednostima upalnih parametara u serumu (RF, SE, CRP). ----- Ispitanici i metode: Analizirani su ultrazvučni i doplerski parametri 660 zglobova (ulnokarpalni, metakarpofalangealni i proksimalni interfalangealni) kod 30 bolesnika s reumatoidnim artritisom prije liječenja i 660 zglobova kod istih 30 bolesnika nakon minimalno šestomjesečnog liječenja. Bolesnici (21 žena i 9 muškaraca) su bili u dobnom rasponu od 17-79 godina (medijan dobi 53 godine). Obavljen je klasični klinički pregled, određen reumatoidni faktor, vrijednosti sedimentacije eritrocita i CRP-a u serumu. Određen je „score” aktivnosti bolesti (DAS 28) i ispunjen upitnik o mogućnosti svakodnevnog funkcioniranja – HAQ (Health Assessment Questionnaire). Učinjene su klasične RTG snimke. Učinjen je UZV pregled; konvencionalni UZV u B-prikazu, s procjenom erozija, zadebljanja sinovije, izljeva i ostale patologije, te pregled obojenim dupleks doplerom koji se sastojao od procjene vaskularizacije zglobova, mjerenja RI, PSV i EDV. Sve preglede vršila sam sama. U statističkoj obradi testirano je da li prikupljeni podaci imaju normalnu distribuciju Kolmogorov-Smirnovljevim testom. Pri normalnoj distribuciji korišteni su parametrijski statistički testovi, a pri distribuciji koja nije normalna korišteni su odgovarajući neparametrijski testovi. ----- Rezultati: Vrijednosti DAS 28 i SE su statistički značajno pale nakon liječenja (p<0.001, p=0,01), kao i vrijednost RF (p=0.015), te vrijednost HAQ (p=0.03). Uočena je statistički značajna korelacija između HAQ/DAS i indeksa otpora prije i nakon terapije u MCP I i MCP II zglobovima (p=0.004 do p=0.03). Statistički značajne razlike prije i nakon liječenja uočene su u vrijednostima indeksa otpora (RI) i EDV u oba ulnokarpalna zgloba, a u desnom UC zglobu i u stupnju vaskularizacije i PSV (p <0.001 do p <0.05). Statistički značajne razlike u stupnju vaskularizacije prije i nakon terapije uočene su i u desnom MCP III zglobu, u kojem je uočena i razlika u vrijednosti EDV i RI, u lijevom MCP III zglobu značajna je razlika EDV, u desnom MCP IV zglobu značajne su razlike u vrijednostima PSV i EDV, u MCP II zglobu desno značajna je razlika u vrijednosti PSV; sinovija je manje debljine nakon liječenja u MCP I, IV i V zglobovima lijevo, te u ulnokarpalnom zglobu. Za ulnokarpalne zglobove od doplerskih parametara najvišu razinu statističke značajnosti ima povišenje indeksa otpora. Na proksimalnim interfalangealnim zglobovima nisu uočene statistički značajne promjene, a u preko 50% zglobova inicijalno nisu ultrazvukom uočene značajnije patološke promjene niti u jednom aspektu. Izračun valjanosti dijagnostičkog postupka za različite granične vrijednosti indeksa otpora u skupini prije terapije pokazala je da je najbolji pokazatelj ustanovljen za graničnu vrijednost od RI < 0.40, za koju je izračunata osjetljivost i specifičnost od 100%. U skupini nakon terapije za graničnu vrijednost od RI ≥ 0.55 izračunata je osjetljivost od 100%, specifičnost od 87%, pozitivna prediktivna vrijednost od 94%, negativna prediktivna vrijednost od 100%, što znači da kod dijagnosticiranja bolesti RI < 0.40 praktički sigurno ukazuje na bolest, a nakon liječenja RI ≥ 0.55 ukazuje na povoljan terapijski odgovor. ----- Zaključci: Adekvatnim liječenjem dolazi do regresije promjena uočljivih konvencionalnim ultrazvukom i doplerom, što je najbolje uočljivo na ulnokarpalnim i metakarpofalangealnim zglobovima. Kod kliničkog poboljšanja dolazi do smanjenja vaskularizacije, povećava se indeks otpora, a smanjuje maksimalna sistolička i enddijastolička brzina protoka. Promjene doplerskih parametara mogle bi biti pokazatelj adekvatnosti terapije reumatoidnog artritisa. Granične vrijednosti RI od 0.40 prije liječenja i 0.55 nakon liječenja ukazuju na bolest, odnosno uspješno liječenje. Obojeni dopler ulnokarpalnih, te po mogućnosti metakarpoflangealnih zglobova treba rutinski koristiti u dijagnostici i procjeni uspješnosti liječenja bolesnika s reumatoidnim artritisom. |
| Abstract (english) | Introduction: Rheumatoid arthritis is systemic inflammatory disease that has dominant manifestations on joints synovia, as persistent synovitis. Hand joints are affected in almost all patients. Over the last years ultrasound has become important imaging modality for diagnosis and follow-up of patients suffering from rheumatic diseases. Ultrasound enables demonstration of pannus, inflammatory changes of synovia, joint effusions, paraarticular changes and tendons. Doppler enables demonstration of vascularization of pathologically altered joint. Evaluation of the degree of inflammatory changes and their follow-up during the treatment is of the particular interest. ----- Aim of the study: To determine B-mode ultrasound features of changes on ulnocarpal, metacarpophalangeal and proximal interphalangeal joints in patients with rheumatoid arthritis in at least six month interval of treatment. To demonstrate by color Doppler the degree of vascularization, the value of peak systolic velocity, enddiastolic velocity and resistance index in affected joints, and changes after at least six months of treatment. To compare morphologic and Doppler findings with the clinical disease activity score DAS 28, health assessment questionnaire (HAQ), and values of serum inflammatory parameters (RF, ESR, CRP). ----- Examinees and methods: B-mode US and color Doppler features were analyzed of 660 joints (UC, MCP and PIP) in 30 patients with rheumatoid arthritis before therapy and in same 660 joints after the therapy, lasting minimally six months. Patients (21 women, 9 men) were in the age-range of 17-79 years (median age 53 years). Clinical examination was performed, RF determined, as well as ESR and CRP value in serum. The „disease activity score-DAS 28” was determined, and questionnaire about daily activities filled - HAQ (Health Assessment Questionnaire). Conventional X-rays were performed, as well as US exam: conventional B-mode ultrasound with evaluation of erosions, synovial thickening, effusion and other pathologies, and color duplex Doppler that evaluated the degree of vascularization of joints, and RI, PSV and EDVs were measured. All examinations were performed by the author exclusively. The statistical analyses consisted of tests for normal distribution; parametric tests were used when the distribution was normal, while non-parametric tests were used in the case of distribution that was not normal. ----- Results: Values of DAS 28 and ESR have statistically significantly decreased after the therapy (p<0.001, p=0.01), as well as RF value (p=0.015), and HAQ value (P=0.03). Significant correlation was determined between HAQ/DAS and resistance index (RI) before and after therapy in MCP I and MCP II joints (p=0.004 to p=0.03). Significant differences were observed before and after therapy in RI values (RI) and EDV in both ulnocarpal joints, while in the right UC joint significant difference was also observed in the degree of vascularization and PSV value (p <0.001 to p <0.05). Significant differences in the degree of vascularization before and after therapy were observed in the right MCP III joint, as well as in values of EDV and RI; in the left MCP III joint significant was the difference in EDV, in the right MCP IV joint differences in PSV and EDV were significant, in the right MCP II joint differences in PSV were significant; synovial thickening was decreased after therapy in left MCP I, IV and V joints, as well as in the UC joints. Among the Doppler parameters in UC joints, the highest degree of statistical significance was observed for the differences in RI values before and after the treatment. Significant differences were not observed in proximal interphalangeal joints at all, and in more than 50% of these joints there were no initial pathological changes visible by ultrasound in any aspect. The calculation of the value of diagnostic procedure for various cut-off values of resistance index (RI) in the group before therapy has shown that cut-off value of RI < 0.40 has the sensitivity and specificity of 100%. In the group after the therapy for the cut-off value of RI ≥ 0.55 the sensitivity of 100%, specificity of 87%, positive predictive value of 94%, and negative predictive value of 100% was observed, meaning that in the time of initial diagnosis RI < 0.40 indicates the disease, while after therapy RI ≥ 0.55 indicates the good therapeutic response. ----- Conclusion: Adequate therapy of rheumatoid arthritis results in the regression of changes visible by conventional ultrasound and Doppler, which is best assessed in ulnocarpal and metacarpophalangeal joints. In patients that have clinical improvement after therapy, decreased vascularization is observed by Doppler, accompanied by elevation of the resistance index and decrease of the peak systolic and end-diastolic velocity. Doppler parameters may indicate the efficacy of therapy of rheumatoid arthritis. The cut-off values of RI of 0.40 before the treatment and 0.55 after the treatment indicate the presence of the disease, and the efficacy of treatment, respectively. Color Doppler of ulnocarpal, and metacarpophalangeal joints should be routinely used in ultrasound diagnosis and evaluation of therapeutic response of patients with rheumatoid arthritis. |
