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ЧАСТЬ 3. ПАТОГЕНЕТИЧЕСКИЕ АСПЕКТЫ В КЛИНИЧЕСКОЙ ПРАКТИКЕ
УДК:616-092.11
I.V. AKIZHANOVA MD, A.R. ARTYKBAYEVA
Department of radiology and functional diagnostics, Institute of postgraduate education, KazNMU after S.D. Asfendiyarov, Almaty, Kazakhstan
ULTRASOUND IMAGING OF VISUALIZATIONS PATHOMORPHOLOGICAL CHANGES IN JOINTS OF THE UPPER AND LOWER EXTREMITIES FOR PATIENTS WITH RHEUMATIC DISEASES
Nowadays a lot of researchers have published the musculoskeletal ultrasound results played an important role in management decisions about a formal rheumatoid arthritis diagnosis (RA), osteoarthritis, gout, psoriasis. Radiologic features usually not seen until 6-12 years after initial attack in some cases, butmusculoskeletal ultrasound helps early diagnosis in challenging cases. Ultrasound is more widely used than MRI is and also costs less,ultrasound is as well as due to the fact that this examine multiple joints, this examine also isn't need to inject contrast *1, 2+. But the part of researchers - rheumatologists said that a subsequent ultrasound exam was critical in their diagnostic process. The recently published EULAR Guidelines and research on ultrasound seems to clearly indicate the superiority of this advanced imaging test [3, 4], but the main disadvantage of the routine joint scans by ultrasound in patients with arthritis is that there are many ultrasonic technology protocols to study joints without accentuation of attention on the main points for detect pathognomonic aspects of inflammatory disorders, and what scan is more preferable in different rheumatic diseases [5].
Keywords: ultrasound, rheumatic diseases,rheumatoid arthritis, ultrasonic protocols, screening technology, joints
Aims & Objectives: The aim to optimize the musculoskeletal ultrasound of upper and lower extremities for rheumatologists, and to leads to faster diagnoses in different rheumatic diseases for quicker initiation of early treatment. Patients and Methods:Our own patented ultrasonic screening technology to study joints of the upper and lower extremities - "MSS -FAST - rheuma - 12 steps" was performed in 1455 patients at the age from 15 to 68 during the period from 2007 to 2013 .This patients were with early arthritis, they had inflammation of the different joints. Ultrasonography (US) of the musculoskeletal system (MSS) have done in B-mode on the multifunctional US-diagnostic high class system Voluson 730 PRO («Kretz» Austria) with a multi-frequency transducer 5-12 MHz and 10-12 MHz, on US-scanner SSI-I000 SonoScape Company (transducer L742), on US-scanner «S0N0ACE-8000 SE» «MEDISON» company. Application of portable SSI-I000 US-scanner (SonoScape Company) with applying transducer L742 made it possible to implement US of joint of patients who was "on the bed". A determination of sensitivity and specificity for all patients has not donein ourresearch report due to the fact that the momentary MRI more than 2-large joints of the extremities at the individual patients not routinely performed. The object of the study were periarticular tissues, capsule, synovium, synovial fluid, articular cartilage and subchondral bone of shoulder, elbow, wrist, metacarpophalangeal (MCP) joints, hip, knee, ankle, metatarsalphalangeal joints. In order to create comfortable conditions for the patient and to optimize the ultrasound examination this proposed protocol involves study of a patient in a caudal direction of "top-down", with the starts the scanning from the position of the patient sits on the bed, then the back, then to the abdomen. All scans of contralateral side are displayed on the double screen, on the first field - right sonogram scans, on the second field - left sonogram scans. First step (scan) - a longitudinal scan of the of shoulder joints for visualization subacromial space and subdeltoid bursa, at the beginning of examination a patient initially sits on the bed, arms down along the body. After that the transducer is moved distally.
Second step (scan) - a longitudinal scan of the olecranon for visualization of the olecranonbursa. The patient is lying on his back, his hands crossed on the epigastric area the transducer is located in projection of the olecranon. After that the transducer is moved distally again. Third step (scan) - a longitudinal scan of theradiocarpal joints (Fig. 1). In this area is fixedmost affordable changes, swelling with deformation area of the wrist joint, reflecting the manifestation of RA process. Then the transducer is moved distally again.
Fourth step (scan) - a longitudinal scan II metacarpophalangeal (MCP) joints to produce images of heads II metacarpal bones, the most presentable localization of the pathological process in RA.
Fifth step (scan) - a longitudinal scan of the hip joint for the visualization of the bony rim, bony roof, cartilageroof, neck space, due to the frequent complaints of patients on pain in this area. Also this scan is included in this ultrasound screening to exclude clinicians' common misconceptions -accentuation of attention to the pain in the knee joint, which over a long period could be the only ones primarylatent coxarthrosissymptoms and also due to the considerable function (role) of the joints in the biomechanics of the lower extremities and the whole organism. Sixth step (scan) - a longitudinal projection of the knee (Fig. 2) - is investigated because there are frequent clinical manifestation in this area in patients with rheumatic diseases - arthritis, synovitis of the knee, also inclusion scanning of the knee at the ultrasound screening explained by the considerable function of these joints in the biomechanics of the lower extremities and the whole body. A transducer is located longitudinally, above the superior pole of the patella.
Seventh step (scan) - a transverse scan of the knee, the transducer is located above the superior pole of the patella, the visualization of articular cartilage and subchondral bone of femoral bone.
Eighth step (scan) - obliquely transverse scan of the knee for visualization of the medial meniscus of the right and left knee - to assessthe location and thedegreeof protrusion of
the medial meniscus, breach hyperechogenic contour of subchondral bone and parameniscus cysts are exposed. Ninth step (scan) - alongitudinal scan of the ankle joints. A transducer is transferred distally, this longitudinal scans performed along the median line of ankle joints. This projection is included in the screening due to the numerous clinical symptoms, swelling (edema) of area of ankle joints. This view allows quickly differentiate intra-articular effusion with swelling of area of ankle joints caused lymphostasis, venous insufficiency, or inflammation of the periarticular structures.
Tenth step (scan) - a longitudinal scanI metatarsophalangeal joints (Fig. 3). These scans are included in US-screening due to pathognomonic of joint involvement in gout. Depending on the stage visualized infringement subchondral bone contour head metatarsusbones varying degrees, hyperechoic inclusion in the periarticulartissues (tophus) of the Imetatarsophalangeal joint.The patient has to turn onto his abdomen.
Eleventh step (scan) - a longitudinal scan of the medial meniscus posterior horn of the knee.The transducer during the studyis set in the projection of the posterior horn of the medial meniscus. This projection is included due to the many-traumatic degenerative changes in the posterior horn of the medial meniscus in patients, as well as due to the fact that this localization reflects pathological process in the popliteal fossa just around the semimembranosus muscle. The presence of the structure echo negative irregular oval shape, with thin or thick capsule cysts in depending on the duration and severity of the pathological process in the popliteal region - Baker's cysts and the mouth of the
connecting joint cavity region should be carried out in this projection
Twelfth step (scan) - a longitudinal scan of the Achilles tendonis included in the screening due to the commonly observed Achill-bursitis in rheumatic patients. At the same echographic signs of Achilles tendinopathy diffuse thickening of the tendon and reduction itsover allechogenicity, and with psoriasis, Reiter's syndrome, or ankylosing spondylitis -an inflammatory tendinopathy - bulbo us thickening of the Achilles tendon.
Time of evaluation varied from 15 to 30 min and increased with the degree of the disease. According to the research, is made a determination about all findings during ultrasound screening, preliminary nosological form is established considering patterns and evaluation of the joints involved. Also allocated the area with the most expressed exudative components, subsequently scanning the area is to be used for monitoring rheumatic process the patient with therapy. Results: The most significant ultrasound patterns included the presence of a pathological effusion, intra-articular chondral bodies, tophi, erosion,
pathologicalhypervascularization. With RA the angiogenesis is considered a trigger pannus formation, the development of which leads to the erosion of the bone, therefore the identification of hypervascularpannus and detection of erosions are fundamentally important for statement of RA, and the degree of vascularization of the pannus or synovial hypertrophy in the dynamics may serve as an indicator of disease activity. A formal RA diagnosis was made owing toultrasound scoring systems ofultrasound patterns before laboratory issues in 41 patients - 2.8% from all patients.
¡H—•
Figure 1 - Third step (scan) a longitudinal scan of theradiocarpal joints
higure <d - sixtn step (scan; a longitudinal projection oîtne Knee A formal goal diagnosiswas made before laboratory issuesowing t o the visualization of fluid hyperechoic inclusion in the periarticular tissues (tophus) of the I metatarsophalangeal in 38 patients - 2,6% from all patients.
The degree of protrusion of the medial meniscus is perfect to detect the degree of the osteoarthritis in 989 patients -67% from all patients.
The visualization of fluid in the neck space at the longitudinal scan of the hip joint helped for early detecting aseptic necrosis of head femur in 18 patients with pain in the knees - 1,2% from all patients.
A longitudinal scan of the of shoulder joints detected abnormalities at these sites such of the rotator cuff tears in 6 patients - 0,41%from all patients. After that this patient were need for surgery for arthroscopic versus open repair, subacromion impingement was in 16 patients - 1,09%, bursitis was in 14 patients 0,96%, but more often we detected loss the rotator cuff subacromion ) interval in 568 patients- 39,03% from all patients . The visualization only of fluid in theretropatelar spice without other ultrasound patterns was in 160 patients -10,9% from all patients, but it was provided that an objective criteria report about the status the musculoskeletal system of this patient.
As a reference method for some patients was performed MRI of 796 joints: knee, hip, wrist, and the ultrasound
findings were confirmed in 784 cases (98,4%) from all performed MRI.
Conclusion: The different main criteria have been widely described in this protocol "MSS FAST - rheuma - 12 steps". This tool provides more comprehensive information about different arthritis, connective tissue diseases and RA. At suspicion on rheumatic disease protocol "MSS FAST -rheuma - 12 steps" has allowed the radiologist to focus on main ultrasound scans and patterns, pathognomonic for different rheumatic diseases and demonstrate ultrasound scoring systems of ultrasound patterns, not only ultrasound scoring systems of synovitis (GLOSS). The proposed ultrasound screening of joints and periarticular soft tissues of the musculoskeletal system allows to quickly visualize "control points" provide an objective criteria report about the status the musculoskeletal system of the patient, to determine the activity of the inflammatory process, to establish a differential diagnosis. The next stage of US may be stage the most carefully multiply scanning or monitoring of joints and periarticular soft tissuesor MRI.
REFERENCES
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2 Imaging in Rheumatology, Editors: Isenberg, David A.; Renton, Peter 1st Edition Copyright В©2003 Oxford University Press р.28-32.
3 J Rheumatology 2012;51:184-90.
3 J. Rheumatology 2010;37:1749-55.
j. Акижанова И.В Клинические потребности и ультразвуковые решение в диагностических ультразвуковых алгоритмах опорно-двигательного аппарата. // Сборник научных работ Международного 6-ого Невского радиологического форума.5-7 апреле 2013г г. - Сaнкт-Пeтербург. - С. 127-128.
И.В. АКИЖАНОВА, А.Р. АРТЫКБАЕВА
CsyneniK жэне функционалдын; диагностика кафедрасы, Дипломнан кейiнгi 6rniM беру Институты, С.Ж. Асфендияров атындагы 1^аз¥МУ
РЕВМАТИЗМД1К АУРУЛАРЫ БАР наукастардаГы аяК-Кол буындарыныН ПАТОМОРФОЛОГИЯЛЫК
а ЗГЕР1СТЕР1Н КЭ РСЕТУШ1Л1К
Тн шн: Ревматизмдт аурулары бар наукастардагы ае^ол буындарын скрининг-зерттеудщ патенттелген ультрадыбыстыщ б1ркезе4цт эдiсi - «FAST - rheuma-12 ^адам Т^А (^рек-1^имыл аппараты)». 2007 жылдан 2013 жылга дейiнгi кезе^це 15-тен 68-ге дейiнгi жастагы 1 455 нау^ас тексерiлдi. Жщ мса^ щ лпалардьщ жэне буындардыц ультрасонографиесы В-тэртiбiнде 512 МГц и 10-16 МГц мультижиЫк ^щ рылгысы бар Voluson 730 PRO («Kretz», Austria) кэ лемдi сканерлеу мн мкшдт бар жогары классты кэ п^ызметп УД-диагностикалы^ жн йесiнде, «SonoScape Company» фирмасыныц SSI-I000 УД-сканерiнде (L742 ^щ рылгы), «MEDISON» фирмасыныц «S0N0ACE-8000 SE»УД-сканерiнде жн ргiзiлдi.SSI-I000 протативт УД-сканерiн («SonoScape Company» фирмасы) L742 ^щ рылгысымен ^олдану «тэ сек» тэр^бшдеп нау^астардыц буындарын ультрадыбыстыщ зерттеу (УДЗ) жн ргiзудi ^амтамасыз етп. «FAST - rheuma- 12 ^адам ТКА(^рек-1^имыл аппараты)» хаттамасы ревматизмдiк ауруларга кн дiк туган жагдайда ае^ол буындарыныц жагдайы туралы критериалды есеп алуга жэне тн рлi ревматизмдт ауруларга патогномондыщ жэне ревматизмдiк н дерктщ белсендiлiгiн кэ рсететiн ультрадыбыстыщ белгiлерге радиолопъщ назарын тогыстыруга мн мюндт бердi.
Тн йiндi сэ здер: ревматизмдш аурулар, ультрасонографие, скрининг зерттеу, буындар.
И.В. АКИЖАНОВА, А.Р. АРТЫКБАЕВА
Кафедра лучевой и функциональной диагностики, Институт последипломного образования,
КазНМУ им. С.Д. Асфендиярова
ВИЗУАЛИЗАЦИЯ ПАТОМОРФОЛОГИЧЕСКИХ ИЗМЕНЕНИЙ СУСТАВОВ ВЕРХНИХ И НИЖНИХ КОНЕЧНОСТЕЙ У ПАЦИЕНТОВ С РЕВМАТИЧЕСКИМИ ЗАБОЛЕВАНИЯМИ
Резюме: Запатентованная ультразвуковае одномоментнае методика скрининг- исследование суставов верхних и нижних конечностей у пациентов с ревматическими заболеваниеми - «FAST - rheuma- 12 шагов ОДА(опорно-двигательный аппарат». За период с 2007г. по 2013г. обследовано 1455 пациентов в возрасте от 15 до 68 лет. Ультрасонография метких тканей и суставов проводили в В-режиме на многофункциональной УЗ-диагностической системе высокого класса с возможностями объемного сканирование Voluson 730 PRO («Kretz» Austria) с мультичастотным датчиком 5-12 МГц и 10-16 МГц, на УЗ-сканере SSI-I000 фирма SonoScapeCompany (датчик L742), на УЗ-сканере «S0N0ACE-8000 SE» фирмы «MEDISON». Применение портативного УЗ-сканера SSI-I000 (фирма SonoScapeCompany) с применением датчика L742 обеспечивало провести УЗИ суставов пациентам, находещимсе на постельном режиме - «на койке». Протокол «FAST - rheuma- 12 шагов ОДА» при подозрении на ревматические заболевание позволил получить критериальный отчет о состоении суставов верхних и нижних конечностей и сфокусировать внимание радиолога на ультразвуковых признаках, патогномоничных дле различных ревматических заболеваний и демонстрируящих активность воспалительного ревматического процесса. Ключевые слова: ревматические заболевание, ультрасонографие, скрининг исследование, суставы.
УДК: 618.145:616-007.61:577.175.64+577.175.632+577.171.6
Л.Л. АЛИЕВ, Е.П. КОВАЛЕНКО, А.В. КУБЫШКИН, С.В. ЛИТВИНОВА, О.В. КАРАПЕТЯН, О.Е. ШУВАЛОВ
Государственное учреждение «Крымский государственный медицинский университет имени С.И. Георгиевского»,
г. Симферополь, Украина
ПАТОГЕНЕТИЧЕСКОЕ ЗНАЧЕНИЕ АССОЦИИРОВАННОГО ВОСПАЛЕНИЯ ПРИ ГИПЕРПЛАЗИИ ЭНДОМЕТРИЯ
В проведенном исследовании выявлен повышенный уровень эстрогенов и прогестерона в внутриматочных смывах при гиперплазиях эндометрия с абсолютным или относительным преобладанием эстрогенов. Наиболее выраженный дисбаланс отмечен при простой гиперплазии. Параллельно было показано изменение активности неспецифических протеиназ и их ингибиторов в маточных смывах при разных типах гиперплазии у женщин. Развитие дисбаланса в состоянии местных неспецифических протеиназ и их ингибиторов, проявляющееся ростом трипсино- и эластазоподобной активностей и уменьшением локальной секреции кислотостабильных ингибиторов протеиназ, наряду с повышением уровня эстрогенов, является важным фактором формирования гиперплазии эндометрия. Кроме того, обнаруженное повышение локального уровня провоспалительных цитокинов (IL-1.fi, 6, TNF-a), а также экспрессии CD45 у женщин с различными типами гиперплазией эндометрия может быть интерпретировано как
