The Correlation Study On Rheumatoid Arthritis Syndrome Differentiation And Joint High Frequency Ultrasound Performance

Background and ObjectiveRheumatoid arthritis (rheumatoid arthritis, RA) is a chronic and systemic autoimmune disease,the main clinical manifestation of which is Joint pain, swelling, stiffness, deformation. The basic lesion is synovitis,synovitis show the synovial effusion, synovial hyperplasia, the formation of pannus, then gradually involved tendon, ligament, cartilage and bone cortical,cause the structure damage. And the metacarpophalangeal joint, proximal interphalangeal joint, wrist, knee, ankle joint are common in the clinical.Diagnosising unclear or failing to control inflammation of active period can obviously aggravate the disease progress,there is a high disability rate,so it is important to promote early diagnosis and early treatment. Now the magnetic resonance image is an advanced imaging technology which can identify the lesion of rheumatoid arthritis prior to the typical performance in conventional X-ray examination. MRI can detect the lesions the X-ray plain film even CT cannot display,it is known as the gold standard for detecting synovitis, but it is limited for rheumatoid arthritis due to the expensive price. With the rapid development of ultrasound imaging, the technology is widely used to diagnose and treat diseases of the musculoskeletal system. The most obvious advantage of this technology is that there is no Ionizing radiation, repetitive operation,and ti is easily used by the "bedside". Studies have found that high frequency ultrasound and power doppler ultrasound can be comparaed with MRI in the differential value for inflammatory and destructive changes of small joint. Some well-known scholars have metaphored the musculoskeletal ultrasound as the Stethoscope of rheumatologists.Most RA patients need long-term oral non-steroidal anti-inflammatory drugs(NASIDS), slow acting antirheumatic drugs (SAARD), glucocorticoids and biological agents and other drugs for treatment, however, the application of those western medicine are restricted due to their high cost, and side effects.Clinical practices have improved that chinese medicine has its unique advantage in the treatment of RA,because it can definitely improve the effect of Western Medicine and reduce adverse effct. Since the promulgation of TCM Therapy and clinical path for RA by state administration of traditional chinese medicine in recent years, its guidance cover most chinese hospital as well as chinese and western integrated hospital.In Traditional medicine. RA is called as "wangbi", the criteria of diagnostic efficacy on syndrome was published by State administration of TCM in October11,1994. It point out that "wangbi" is a disease associated with the invasion of wind-cold damp pathogen Stagnation of Qi and blood, easily causes pain、swelling and Morning stiffness gradually develop In the small joints of the fingers and wrist,could pose a serious risk of arthrentasis、Joint stiffness,and even a high disability rate if not control at the active period.so it is important that the inflammation of RA patients in active stage is controled. Patients with active rheumatoid arthritis could have repeated episodes due to the pathogen of wind cold dampness,and it can be divided into two main types by syndrome differentiation of traditional Chinese medicine with cold dampness syndrome (cold pain in limb, localized swelling, inconvenient flexion, joint spasm, localized chills, pain serious in the cold while reduction in the heat, The skin is not red, fat tongue, pale tongue, white slippery or white greasy moss, pulse string corrosion or heavy tight) and damp heat syndrome (joint pain, touching hot, thirst without desire to drink, annoyed and uneasy, fever or not, red tongue, yellow greasy moss, number or moisten slippery number).The local Performance of joint is also the important differentiation basis.besides systemic manifestations, tongue condition and pulse condition in the process of clinically syndrome differentiation.Many objective studies were investigated for the different traditional Chinese medicine(TCM) syndromes in inflammation and immune indexes from the blood in the past, there was no attendtion to research the relationship between local changes of joints and TCM syndromes. Although these lab indexes such as erythrocyte sedimentation rate, C reactive protein,rheumatoid factor, anti-cyclic citrullinated peptide antibodies inflammation and immune response,but it cannot directly explain specific lesions of affected joints.Especially when there have been cartilage destruction, bone erosion, laboratory indexes are very limited.There were few researchers that revealed the difference of RA TCM syndromes by single knee or wrist ultrasound in the past,but it was difficult to reach a consensus because of a small number of joints, less prominent joints, inconsistent results and other reasons.So this research investigate the effect of joint ultrasound on the identification of TCM syndromes of RA by observe synovitis, tenosynovitis, bone erosions, Synovial blood flow of many easily involved large and small joints of rheumatoid arthritis patients who are different types of syndrome of active period as well as remission.In addition to make correlation analysis between laboratory indexes and disease activity. To provide objective basis for TCM syndrome of RA.Materials and Methods83patients of RA in active stage are divided into damp heat syndrome group (referred to as the damp heat group) and cold dampness syndrome (referred to as the cold dampness group) according to the different traditional Chinese medicine(TCM) syndromes,20patients of RA in remission are compared (referred to as the remission group).Those patients all come our hospital from2013April to2013September outpatient and inpatient. High frequency ultrasound and power doppler ultrasound technology are used to make comparative observation by scores in synovitis, tenosynovitis, synovial blood flow and bone erosion of three groups of patients, and a total of24joints for each person have been done including metacarpophalangeal (MCP) joints and proximal interphalangeal (PIP) joints from second to fifth, wrist joints, knee joints, the second and the fifth metatarsophalangeal (MTP) joints.At the same time the laboratory indexes and disease activity are recorded of three groups of patients including erythrocyte sedimentation rate(ESR),C-reactive protein(CRP) and immunoglobulin (globin,G), immunoglobulin G (Immuno-globulinQIgG), immunoglobulin A (Immuno-globulinA, IgA), immunoglobulin M (Immuno-globulinM, IgM), Anti-CCP and RF titer, disease activity score (DAS28score).It is be analyzed that correlation among ultrasound performance, laboratory indexes and disease activity. At the same time it is analyzed that there is or not disease activity of ultrasonic aspect for those patients who be in remission.Result3groups of laboratory indexes, DAS28score comparison There is no statistical difference in G,IgG, IgA,IgM between the three groups (P>0.05). Compared with the remission group, the ESR, CRP, Anti-CCP, DAS28score and the positive rate of RF of damp heat group show statistical difference (P<0.05, P<0.01). Only the DAS28score of cold dampness group show statistical difference (P<0.05). Compared with cold dampness group, the ESR, CRP, Anti-CCP, DAS28score and the positive rate of RF of damp heat group show statistical difference (P<0.05, P<0.01).3groups of ultrasound indexes comparison Compared with the remission group,the synovitis, tenosynovitis, synovial blood flow and bone erosion of damp heat group are significantly increased (P<0.01), The synovitis, synovial blood flow of cold dampness group also show statistical difference (P<0.05). Compared with cold dampness group, the four ultrasound indexs of damp heat group show statistical difference (P<0.05, P<0.01).The correlation analysis of ESR, CRP, DAS28score and ultrasound indexes of damp heat group The ESR of damp heat group is positively correlated with the synovitis, synovial blood flow and bone erosion (r=0.444,0.397,0.486, P<0.05).The CRP of damp heat group is positively correlated with the synovitis, synovial blood flow (r=0.378,0.270, P<0.05).The DAS28score of damp heat group is also positively correlated with the synovitis, synovial blood flow(r=0.304,0.351, P<0.05). But the correlation coefficient is less than0.5. There is no correlation among the ESR, CRP, DAS28score of cold dampness group and remission group with every ultrasound index.All the patients of damp heat group and cold dampness group show the disease activity of ultrasound. But the patients who are in remission have nearly40%disease activity of ultrasound.Conclusion 1.Globulin and immunoglobulin indexes possibly can not as the objective basis of different traditional Chinese medicine(TCM) syndromes of RA patients.2.Whether ultrasound indexes or inflammation indexes, disease activity can fully describe that the clinical response of RA patients who are damp heat syndrome are the most sensitive, the local performance ystemic manifestations almost occur the same period. Inflammatory response of active period rapidly spread from the local region to whole body.3.Compared with cold dampness syndrome, the RA patients of damp heat syndrome have lighter degree of inflammation, the illness progresses slowly, there is a time window in this aspect that synovitis,synovial pannus formation the tendon inflammation, bone destruction.4.Ultrasound evaluation and the evaluation of ESR,CRP,DAS28possibly are two different evaluation system in RA traditional Chinese medicine syndrome,two do not influence each other.5.The RA patients of remission can not exclude the possibility of potential inflammation, ultrasound is expected to become the key of target therapy for the RA patients.