常规肌肉骨骼超声表现对自身抗体阴性的早期关节炎患者的诊断决策影响最大。

Routine musculoskeletal ultrasound findings impact diagnostic decisions maximally in autoantibody-seronegative early arthritis patients.

机构信息

Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.

Musculoskeletal Services Directorate, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.

出版信息

Rheumatology (Oxford). 2019 Jul 1;58(7):1268-1273. doi: 10.1093/rheumatology/kez008.

DOI:10.1093/rheumatology/kez008

PMID:30753709

Abstract

OBJECTIVE

The diagnostic value added by musculoskeletal ultrasound (MSUS) over standard clinical and laboratory parameters has proved difficult to quantify. The additive contribution to diagnostic classification of a pragmatic, 15 min MSUS protocol was appraised in a large, unselected cohort of early arthritis clinic attendees.

METHODS

Detailed baseline characteristics were recorded. Semi-quantitative MSUS scoring of the most symptomatic wrist, second/third MCPs and PIPs and second/fifth MTPs was recorded, along with the sonographer's scan impression (definitely inflammatory, possibly inflammatory or non-inflammatory). MSUS findings were available to rheumatologist diagnosticians during subsequent consultations. Persistent inflammatory arthritis (PIA) was classified only where patients were started on ≥1 DMARD. Multivariate and receiver operating characteristic (ROC) curve analyses were used to identify independent discriminators of PIA, and the added value of MSUS parameters.

RESULTS

Eight hundred and thirty-one patients were enrolled, of whom 31.3% acquired a PIA diagnosis. Swollen joint count, CRP, age and ACPA status were non-redundant clinical/laboratory predictors of a PIA diagnosis by consulting rheumatologists, with good discriminatory utility (area under the ROC curve, AUROC, 0.88). While the additive contribution of summed parameters from the seven-joint MSUS protocol to this model was statistically significant (P = 0.004), it was numerically small (ΔAUROC 0.02). However, the additive contribution to diagnostic outcome of sonographer's scan impression over clinical parameters alone became substantial in the sub-cohort of ACPA-negative patients, increasing the AUROC by 9% from 0.81 to 0.90 (P < 0.0001).

CONCLUSION

The clinical utility of a 15-min MSUS screen for diagnosing PIA requiring DMARDs is most evident among ACPA-negative patients attending an early arthritis clinic.

摘要

目的

肌肉骨骼超声（MSUS）在标准临床和实验室参数之上的诊断价值很难量化。在一个大型的、未经选择的早期关节炎诊所就诊者队列中，评估了一种实用的、15 分钟的 MSUS 方案对诊断分类的附加贡献。

方法

记录详细的基线特征。记录最有症状的腕关节、第二/第三掌指关节和近端指间关节以及第二/第五跖趾关节的半定量 MSUS 评分，以及超声医师的扫描印象（肯定是炎症性的、可能是炎症性的或非炎症性的）。在随后的会诊中，风湿病学家诊断医生可以获得 MSUS 检查结果。只有当患者开始使用≥1 种 DMARD 时，才会对持续性炎症性关节炎（PIA）进行分类。多变量和受试者工作特征（ROC）曲线分析用于识别 PIA 的独立鉴别指标，以及 MSUS 参数的附加价值。

结果

共纳入 831 例患者，其中 31.3%的患者诊断为 PIA。肿胀关节计数、CRP、年龄和 ACPA 状态是风湿病学家咨询时预测 PIA 诊断的非冗余临床/实验室预测因素，具有良好的鉴别能力（ROC 曲线下面积，AUROC，0.88）。虽然七个关节 MSUS 方案的参数总和对该模型的附加贡献具有统计学意义（P=0.004），但数值较小（ΔAUROC 为 0.02）。然而，在 ACPA 阴性患者亚组中，超声医师扫描印象对临床参数的附加诊断结果的贡献变得显著，将 AUROC 从 0.81 增加到 0.90（P<0.0001），增加了 9%。