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An integrated approach to the diagnosis of psoriasis arthritis
DOI: http://dx.doi.org/10.20534/ESR-17-1.2-77-79
Mirahmedova Khilola Tuhtasinovna, assistant professor of Tashkent Medical Academy Uzbekistan
E-mail: [email protected]
An integrated approach to the diagnosis of psoriasis arthritis
Abstract: Ultrasound is very informative to detect soft tissue changes of elements and determination of the activity of the inflammatory process. The symptoms of synovitis, enthesitis, tenosynovitis which are characteristic for the diagnosis of PsA were determined only by ultrasound. The use of complex clinical, laboratory and instrumental methods of investigation, reduces the time of diagnosis of early PsA and improves the prognosis of the disease due to the timely appointment of basic drugs. Given the prostate and security, ultrasound allows the monitoring of the disease and correction of therapy.
Keywords. Psoriasis arthritis, ultrasound, synovitis, enthesitis, tenosynovitis.
Diagnosis of psoriasis arthritis (PsA), especially at an early stage, the complexity is even for experts due to the high heterogeneity of clinical disease [1; 6; 8; 10].
Objective: improvement of the integrated approach to the early diagnosis of psoriatic arthritis.
Material and Methods: The study included 75 patients PsA who were treated at the Republican Rheumatology center (RRC) of the Rock. Of these, 36 (48%) men of 39 women (52%), aged from 20 to 65 years old The mean age was 45,4±14,5 years. The duration of PsA, on average equal to 9,5±2,7 years, but psoriasis 14,5±2,2 years. CASPAR criteria are widely used in rheumatological practice and are a tool for the detection of PsA [12]. PsA patients were divided into 2 groups: 1 group -33 patients with PsA disease duration up to 2 years (early PsA) and Group 2 -42 PsA patients with disease duration of more than 2 years. Patients underwent standard clinical examination of peripheral joints and enthesis. Counted articular index Richie and DAS. All patients included in the study, carried out a clinical examination on the index enthesis LEI. In addition, we evaluated the point of attachment of the plantar fascia (PF) to the heel bone on both sides. Patients underwent laboratory diagnosis of a number of indicators, including CRP, RF, ESR, HLA-B27, and radiation (X-ray, ultrasound of joints and enthesis). Radiological stage (R-phase) ofjoint damage was assessed by Shteynbrokeru. Sonography performed on a Mylab-40 apparatus (Esuobe, Italy) with a linear transducer with a frequency of 7.5-12 MHz. The obtained data were subjected to statistical processing on the PC Pentium-IV in programs designed in Excel package. Differences of mean values were considered significant at a significance level of P <0.05.
Results: he most important syndromes in the clinical picture of Pisa is a skin and joint, which define the basic content of the disease [1; 3]. In our material, the formation of PsA in 88% of patients took place against the background of already existing skin manifestations, 12% rash appeared after a long period from the beginning of the first symptoms ofjoint damage. Patients of the study group in the presence of PsA, observed all the characteristic clinical manifestations of the disease: arthritis was diagnosed in 100% dactylitis — 44%, enthesitis — at 40.0%, spondylitis — at 17.3%. Dactyl — a typical sign of PsA has clinical and diagnostic value [7; 11]. More than one third of patients (44%) was identified dactyls one or more fingers. It has prognostic value, often combined with rapid radiographic progression and destructive process. Mostly dactyls were characteristic of toes (26.6%) than the hands (10.6%), especially in patients with early PsA (36.3% and 12.1%, respectively). According to our data, signs of enthusiasts in the clinical examination of various localizations were detected in 40.0% of patients. Clinical examination localization enthesis by LEI index, depending on the duration ofthe disease showed that the clinical signs of enthesitis of the medial femoral condyle were more common in patients with a late and defeated the heel area (the place of attachment of the Achilles tendon and plantar fascia to the heel bone) — in patients with early PsA. Spondylitis arthritic forms of PSA with a primary lesion of the spine was observed in 17.4% of patients. Among them, in early arthritis in 10.7%. With increasing duration of disease incidence of this form it grew 22.3%. In 50.6% there was a combination of spondylitis with peripheral arthritis. Isolated spondylitis occurred only in 2% of patients. An important part in the diagnosis ofPsA is the use of instrumental methods [5; 9; 10]. Radiographic changes were observed in 73.3% of patients.
Table 1. - Radiographic changes in the musculoskeletal system in patients with PsA
Symptoms of PsA Early, n=33 Late, n=42
KOA-BO % KOA-BO %
Periarticular osteoporosis 5 15,1 7 16,6
Narrowing gaps interarticular 6 18,1 21 50,0***
Cystoid enlightenment, erosion 6 18,1 29 69,0***
Bone proliferation 2 6,0 12 28,5***
Bone ankylosis, subluxation 0 0 8 19,0***
Note: * - the differences regarding these significant group of early (*** - P <0,001)
X-ray analysis of the data flow depending on the duration showed that periarticular osteoporosis recorded with the same frequency in individuals with a disease duration of up to 2, and more than 2 years, 15.1% and 16.6%, respectively (table 1). In patients with early PsA cysts and erosion occurred in 18.1% ofpatients. Multiple bone erosion in the joints subluxation occurs most frequently in 69% of patients with late PsA. In patients with PsA duration up
to 2 years, bone proliferation occurs in 6.0% of patients, in patients with PsA late in 28.5% of patients. In our study, the frequency of radiographic abnormalities was 36.3% in patients with early and 92.8% in patients with PsA late.
To assess early PsA used ultrasound joints and enthesis. Ultrasound joints and enthesis was conducted in 50 patients. The appearance of liquid in the joints occurred in 90% of patients. Diffuse
Section 8. Medical science
thickening of the synovium was determined in 92% of patients in all groups studied joints. In 16% of patients with PsA determined roughness, heterogeneity in the cortical bone of the articular surfaces epimetaphysis, more frequently in patients with a disease duration of 5 years or more, and in some cases, changes were observed normal ehostruktury. Erosion and bone defects that are visible in both the longitudinal and transverse scan were found in 8% of patients with high activity of inflammation that we observed in the head of the metatarsal
and metacarpal bone. A characteristic feature of the early PsA is also enthesitis — inflammation at the site of attachment of tendons and ligaments to bone [2; 4]. In 36% of patients with PsA was observed early subclinical damage enthesis (for US only). Tenosynovitis of the flexor finger was the most frequent lesion with PsA and was found in 66% of cases. These changes affected the tendon-fold teley fingers and wrist extensors. Analysis of the incidence of ultrasound signs with PsA according to the duration of the disease is presented in table 2.
Table 2. - The frequency of the ultrasonic symptoms depending on the stage of the disease
Ultrasound signs Early, n=32 Late, n=18
авс % авс %
The thickening of the synovial mebrane 29 90,6 17 94,4
The presence of liquid 30 93,8 15 83,3
Enthesitis 18 56,2 7 38,8
Tenosynovitis 24 75,0 9 50,0
Reducing the thickness of the cartilage 28 87,5 16 88,8
Erosion 1 3,1 3 16,6
Bone proliferation 2 6,3 8 44,4**
Note: * - the difference relative to the first group of data are significant (** - P <0,01)
The thickening of the synovial membrane, the presence of fluid, reducing cartilage thickness was observed equally in patients with early and late PsA. Statistically significant differences were in relation to the incidence of erosion, marginal osteophytes growths that significantly more defined group of patients with a disease duration of more than 2 years. The defeat of the tendon and ligaments as enthesopathies and tenosynovitis was determined by ultrasonography in patients with early PsA in 1.4 times more likely. The defeat of the synovial membrane, hyaline cartilage does not depend on the duration of the disease, but reflect the activity of the disease, the involvement of the tendon and ligaments were more frequent in patients with early PsA. The appearance of bone proliferation was typical for patients with late PsA.
Thus, the most common change of the joints according to the US have been increasing the amount of synovial fluid, synovial proliferation, enthesitis, tenosynovitis of flexor tendons of fingers,
blurred and uneven joint surfaces. Ultrasound reveals numerous pathological changes in the investigated group of patients at an early stage (in some cases, from 3 to 6 months): synovitis — at 90.6%, enthesitis — at 56.2%, tenosinovit- 75%. Ultrasound reveals flexor tenosynovitis of fingers and feet was significantly (p <0,05) more frequently than it can be done with the help of X-ray diffraction method and clinical examination.
Conclusion. For timely diagnosis and adequate treatment of PsA is necessary to know peculiarities of the clinical picture and accounting characteristics of the course of the disease, using the existing diagnostic criteria. X-ray diagnosis of rheumatic diseases, which include PsA remains one of the main diagnostic methods. However, radiographic methods to identify signs of PsA can only be in 2-3 years or more after onset of the disease. These results suggest that one of the ways to improve the early diagnosis of PsA is the use of ultrasound joints of the hands and feet.
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QT interval dispersion in patients with Q-wave myocardial infarction
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DOI: http://dx.doi.org/10.20534/ESR-17-1.2-79-81
Mullabaeva Guzal Uchkunovna, Kurbanov Ravshan Davletovich Republican Specialized Center of Cardiology E-mail: [email protected]
QT interval dispersion in patients with Q-wave myocardial infarction
Abstract: The article provides information on 252 patients with Q-MI (Q-wave myocardial infraction). Evaluation of correlation of QT interval dispersion revealed a significant correlation between its elongation and signs of unfavorable course of disease (anterior localization, left ventricular aneurysm, systolic dysfunction). There were no significant differences of QT interval dispersion in patients with ventricular arrhythmias of high gradations.
Keywords: QT interval dispersion, Q-wave myocardial infarction, ventricular arrhythmias.
Sudden cardiac death (SCD) is one of the most urgent problems in modern cardiology. This is exactly the variant of lethal outcome that occurs most frequently in cases of ischemic heart disease (IHD), especially in patients who endured myocardial infarction (MI). From 6 to 10% of patients die during the first year after MI, and half of them die unexpectedly [1]. A lot of studies have shown that the main electrophysiological cause of SCD is thought to be malignant ventricular arrhythmias (MVA). In the 70s-90s of XX century the studies were published that demonstrated an important prognostic role of VA in SCD [2; 3; 4].
It was suggested that QT dispersion (QTd) may reflect inho-mogeneity of repolarization processes and, thus, a tendency towards development of arrhythmias [4; 5]. A number of studies revealed a connection between the increase of QTd and the emergence of VA in patients with IHD [5, 6]. In general, literature data show that the increased QTd is connected with a higher risk both for sudden death and total mortality [5; 7]. However, some researchers challenge the prognostic significance of QTd [1; 7; 8]. Thus, the duration of QT interval and its dispersion continue to take up an uncertain position in the prediction of outcomes in patients with MI.
The objective of the study: to assess the relationship between predictors of SCD in patients with Q-wave MI and QTd.
Materials and methods: the study included 252 male patients with Q-wave MI (middle age). Exclusion criteria were as follows: female gender, presence of MI in anamnesis, complete block of left bundle branch, patients older than 70 years, presence of congenital
Table 1. - QT interval dispersion in patients with
During the study of QTd on the 10th-14th day in patients with Q-wave MI of different localization we revealed significant dif-
QT abnormalities. The analysis of QTd was performed according to ECG records on the 12th-14th day of the disease. QT-interval was measured from the beginning of Q-wave to the end of T-wave in no less than 3 consecutive ventricular complexes. QTd was calculated as the difference between maximum and minimum values of the interval in 12 deflections. For characterization of VA we used the gradational classification of B. Lown and M. Wolf (1971) and the prognostic classification ofJ. Bigger (1982). Hourly qualitative and quantitative evaluation of VA was conducted in accordance with Lown-Wolf's grading system. According to J. Bigger's classification, after the old MI, potentially dangerous ventricular arrhythmias (PDVA) included VA>10 per hour, paired VA and group VA.
Statistical data analysis was performed using standard statistical methods with the help of the application software package SPSS 12.0. Data evaluation was performed using parametric and non-parametric methods. Data are presented as M±o (M — average value, o — standard deviation) in normal distribution, and as Me (25; 75) (Me — median value, 25th and 75th percentiles) in non-normal distribution. Differences were considered to be significant at p<0.05.
Results and their discussion:
On average, this indicator in the group amounted to 82.6±13,2 ms (Me 82,9; IQR 73,3-91,8), i. e. the 25th percentile corresponded to 73.3 ms, the 50th percentile — 82,9 ms and the 75th percentile — 82,9 ms.
We studied the features of QTd in patients depending on the clinical course of Q-wave MI.
Q-wave MI on the 10th-14th day of the disease
ferences of QTd values in anterior and posterior localization of MI, what is explained by more common myocardial damage of
Indicators QT dispersion, ms Reliability
Anterior wall, n=141 92,2±15,3 0,00001
Posterior wall, n=111 70,8±17,4
Ejection fraction <50%, n=136 98,3±30,2 0,00001
Ejection fraction >50%, n=116 78,6±10,1
Presence of aneurysm, n=72 95,1±11,3 0,00001
Absence of aneurysm, n=180 73,5±29,4
Left ventricular diastolic dysfunction, n=137 90,0±30,7 0,00001
Without left ventricular diastolic dysfunction, n=115 78,6±9,8
Heart failure of more than II class according to NYHA, n=100 93,9±25,9 0,00001
Absence of heart failure, n=152 68,7±10,4
