本文選題：血友病 + 關(guān)節(jié)病變��； 參考：《南方醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的:以磁共振成像為參照,探討常規(guī)超聲對血友病關(guān)節(jié)病變的評估價值,并在此基礎(chǔ)上進(jìn)一步探討超聲造影對血友病關(guān)節(jié)病變的評價作用以及超聲檢查結(jié)果與患者臨床檢查指標(biāo)的相關(guān)性,以期對臨床診斷、療效隨訪以及治療方案選擇提供參考依據(jù)。方法:1.對42例血友病患者的關(guān)節(jié)進(jìn)行超聲和磁共振成像檢查(Magnetic Resonance Imaging,MRI),以MRI為參照,比較超聲與MRI對關(guān)節(jié)病變檢出的一致性;比較超聲與MRI評分的差異以及一致性;比較超聲檢查操作者間的一致性以及操作者自身的重測穩(wěn)定性。2.于入組時對75例血友病患者的75個關(guān)節(jié)進(jìn)行常規(guī)超聲檢查及評分,評分項目包括關(guān)節(jié)積液/積血、滑膜增生、含鐵血黃素沉積、軟骨破壞、骨質(zhì)破壞、彩色多普勒血流顯像半定量評分;并對其中45例患者的45個關(guān)節(jié)進(jìn)行超聲造影檢查及評分,評分為超聲造影半定量評分。患者入組后開始進(jìn)行規(guī)律預(yù)防治療并進(jìn)行為期4個月的隨訪,記錄患者隨訪期間關(guān)節(jié)出血次數(shù),根據(jù)隨訪期間有無關(guān)節(jié)出血將患者分為關(guān)節(jié)有出血組與關(guān)節(jié)無出血組。記錄患者臨床資料,包括年齡、身高、體重、最低凝血因子水平、初次替代治療年齡、初次預(yù)防治療年齡。比較血友病患者關(guān)節(jié)常規(guī)超聲評分與臨床資料的相關(guān)性;比較灰階超聲模式下和超聲造影模式下測得滑膜厚度的差異;比較關(guān)節(jié)有出血組與關(guān)節(jié)無出血組滑膜厚度的差異以及超聲檢查各項評分的差異;比較超聲檢查各項評分與隨訪期間關(guān)節(jié)出血次數(shù)的相關(guān)性。結(jié)果:超聲對血友病關(guān)節(jié)積液/積血、滑膜增生、含鐵血黃素沉積、軟骨破壞、骨質(zhì)破壞以及關(guān)節(jié)面下骨囊腫的診斷敏感性為82.9%、97.0%、97.0%、90.0%、70.9%、14.0%;特異性為 94.1%、100.0%、100.0%、92.0%、94.7%、100.0%;假陽性率為 5.9%、0.0%、0.0%、8.0%、10.5%、100.0%;假陰性率為 17.0%、3.0%、3.0%、10.0%、29.0%、86.0%;符合率為 88.0%、97.3%、97.3%、90.7%、76.0%、42.7%。常規(guī)超聲與MRI檢出早期軟組織病變以及軟骨破壞的一致性優(yōu)秀(k=0.761～0.885,P=0.000),檢出骨質(zhì)破壞的一致性中等(k=0.498,P=0.000),檢出關(guān)節(jié)面下骨囊腫的一致性差(k=0.098,P=0.050)。常規(guī)超聲與MRI對早期軟組織病變以及軟骨破壞的評分差異無統(tǒng)計學(xué)意義(P0.05～0.75),MRI對骨質(zhì)破壞的評分較高,差異有統(tǒng)計學(xué)意義(P=0.03)。常規(guī)超聲與MRI對早期軟組織病變以及軟骨破壞評分一致性為好至優(yōu)秀(k=0.635～0.833,P=0.000),對晚期骨質(zhì)破壞評分一致性為差(k=0.145,P=0.009)。對早期軟組織病變和軟骨破壞,操作者間的一致性和操作者自身重測穩(wěn)定性均為好至優(yōu)秀(k=0.676～0.885,P=0.000),對晚期骨質(zhì)破壞,操作者間的一致性和自身重測穩(wěn)定性均為中等(k=0.421～0.589,P=0.000)。除了關(guān)節(jié)積液/積血的評分以外,血友病患者年齡、身體質(zhì)量指數(shù)(Body Mass Index,BMI)、初次替代治療年齡以及初次預(yù)防治療年齡與關(guān)節(jié)超聲檢查各項目評分呈正相關(guān)(r=0.19～0.67,P0.05);除關(guān)節(jié)積液/積血外,最低凝血因子濃度與關(guān)節(jié)超聲檢查各項目評分呈負(fù)相關(guān)(r=-0.304～-0.444,P=0.000)。超聲造影模式下測得的滑膜厚度較灰階超聲模式下更厚,厚度分別約0.53±0.29cm、0.39±0.16cm,兩者差異有統(tǒng)計學(xué)意義(P=0.012)。隨訪期間關(guān)節(jié)有出血組在CEUS模式下和灰階超聲模式下測得的滑膜厚度均較關(guān)節(jié)無出血組厚,厚分別約 0.62±0.31cm、0.33±0.11cm vs 0.44±0.16cm、0.30±0.12cm,差異有統(tǒng)計學(xué)意義(P =0.000;P =0.021);在6個沒有彩色多普勒血流顯像的關(guān)節(jié)滑膜中有3個可見造影增強信號。關(guān)節(jié)有出血組超聲檢查各項評分均較關(guān)節(jié)無出血組高,評分分別為0.38±0.75cm～6.86±3.49cm vs 0.10±0.42cm～4.42±3.86cm,兩組差異有統(tǒng)計學(xué)意義(P=0.000～0.029);入組時超聲檢查各項目評分與隨訪期間關(guān)節(jié)出血次數(shù)呈正相關(guān)(r=0.17～0.63,P=0.000～0.030),其中CEUS評分相關(guān)性最高。結(jié)論:超聲檢查在血友病關(guān)節(jié)病變尤其是在關(guān)節(jié)早期軟組織病變和關(guān)節(jié)軟骨病變的評估中具有重要價值。超聲檢查各項目評分與患者臨床檢查指標(biāo)存在相關(guān)性,結(jié)合超聲檢查結(jié)果能夠更準(zhǔn)確反應(yīng)患者病情變化,指導(dǎo)臨床治療。血友病患者關(guān)節(jié)病變與臨床出血風(fēng)險密切相關(guān),超聲造影(CEUS)較常規(guī)超聲能更清晰準(zhǔn)確地評估滑膜增生程度及新生血管化程度,與出血風(fēng)險相關(guān)性最高,對指導(dǎo)臨床治療具有重要意義。
[Abstract]:Objective: To evaluate the value of conventional ultrasound in the assessment of hemophilia joint lesions, and on the basis of this, the evaluation of ultrasonography on hemophilia joint lesions and the correlation between the results of ultrasound examination and the clinical examination index of patients were further discussed in order to make a clinical diagnosis, follow-up of curative effect and the choice of treatment options. Methods: 1. cases of 42 patients with hemophilia were examined by ultrasound and magnetic resonance imaging (Magnetic Resonance Imaging, MRI). The consistency of ultrasonic and MRI in detection of joint lesions was compared with MRI, and the difference between ultrasound and MRI scores and the uniformity were compared, and the consistency between the ultrasonic examination operators and the operation were compared. The author's own retest stability.2. was performed on 75 joints of 75 patients with hemophilia by routine ultrasound examination and score. The score included joint effusion / blood accumulation, synovial hyperplasia, hemoflavin deposition, cartilage destruction, bone destruction, and color Doppler flow imaging, and 45 joints in 45 of the patients. A half quantitative score of ultrasound contrast was performed by ultrasound contrast examination and score. After the patients entered the group, regular prophylaxis and follow-up were conducted for 4 months to record the number of joint bleeding during the follow-up period, and the patients were divided into joint bleeding group and joint without bleeding group. Data, including age, height, weight, the level of the lowest coagulation factor, primary replacement age, primary prophylaxis age. Comparison of the correlation between routine ultrasound score and clinical data in hemophilia patients; comparison of the difference in the thickness of the synovial membrane under the gray scale ultrasound model and the ultrasound contrast model; compared with the joint bleeding group and the joints. The difference in the thickness of the synovial membrane in the bleeding group and the differences in the scores of the ultrasound examination; the correlation between the scores of the ultrasound examination and the number of joint bleeding during the follow-up. Results: the diagnostic sensitivity of ultrasound to hemophilia joint effusion / haemorrhage, synovial hyperplasia, hemoflavin deposition, cartilage destruction, bone destruction, and subarticular cyst of the articular surface 82.9%, 97%, 97%, 90%, 70.9%, 14%, and the specificity of 94.1%, 100%, 100%, 92%, 94.7%, 100%; the false positive rate is the false negative rate; the coincidence rate is 42.7%. conventional ultrasound and MRI detection of early soft tissue lesions and cartilage destruction Good consistency (k=0.761 to 0.885, P=0.000), the consistency of bone destruction was moderate (k=0.498, P=0.000), and the consistency of the subarticular subarticular cysts was poor (k=0.098, P=0.050). There was no significant difference between conventional ultrasound and MRI on early soft tissue lesions and cartilage destruction (P0.05 ~ 0.75), and MRI had a higher score on bone destruction. The difference was statistically significant (P=0.03). The consistency of conventional ultrasound and MRI on early soft tissue lesion and cartilage damage score was good (k=0.635 to 0.833, P=0.000), and the consistency of the late bone destruction score was poor (k=0.145, P=0.009). The consistency between the early soft tissue and cartilage, the consistency between the operators and the operator's self retest The stability was good to excellent (k=0.676 ~ 0.885, P=0.000). For advanced bone destruction, the consistency between the operators and the self retest stability were moderate (k=0.421 to 0.589, P=0.000). In addition to the score of joint effusion / blood accumulation, the age of hemophilia, the body mass index (Body Mass Index, BMI), the initial replacement treatment age and the initial stage of treatment. There was a positive correlation between the age of the secondary prophylaxis and the scores of the joint ultrasound examination (r=0.19 ~ 0.67, P0.05). Except for the joint effusion / accumulation of blood, the minimum coagulation factor concentration was negatively correlated with the scores of each item (r=-0.304 ~ -0.444, P=0.000). The thickness of the synovial membrane under the mode of contrast ultrasound was thicker than that of the gray scale ultrasound model. The difference was 0.53 + 0.29cm, 0.39 + 0.16cm, and the difference was statistically significant (P=0.012). The thickness of the synovial membrane in the joint hemorrhagic group under the CEUS mode and the gray scale ultrasound mode were both 0.62 + 0.31cm, 0.33 + 0.11cm vs 0.44 + 0.16cm and 0.30 + 0.12cm respectively. The difference was statistically significant (P =0.000; P) 21); in 6 joint synovium without color Doppler flow imaging, there were 3 visible contrast enhancement signals. The scores of ultrasonic examination in the joint bleeding group were higher than those in the joint without bleeding group, and the scores were 0.38 + 0.75cm to 6.86 + 3.49cm vs 0.10 + 0.42cm to 4.42 + 3.86cm respectively. The difference between the two groups was statistically significant (P=0.000 ~ 0.029). The score of each item was positively correlated with the number of joint bleeding during the follow-up period (r=0.17 to 0.63, P=0.000 to 0.030), and the correlation of CEUS score was the highest. Conclusion: ultrasonography has important value in the assessment of hemophilia joint lesions, especially in the assessment of early joint soft tissue lesions and articular cartilage lesions. There is a correlation between the clinical examination indexes and the ultrasound examination results, which can reflect the patient's change more accurately and guide the clinical treatment. The joint lesions of the hemophilia patients are closely related to the risk of clinical bleeding. Contrast enhanced ultrasound (CEUS) can more clearly and accurately assess the degree of synovial hyperplasia and the degree of neovascularization, and the bleeding wind than the conventional ultrasound. The highest risk correlation is of great significance for guiding clinical treatment.
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R445.1;R554.1

【參考文獻(xiàn)】

相關(guān)期刊論文 前2條

1 何雯雯;吳心怡;陳振萍;甄英姿;張寧寧;王巖;張紀(jì)水;唐凌;鄭杰;于國霞;李剛;吳潤暉;;學(xué)齡前期重型及中間型血友病119例患兒2年臨床出血隨訪結(jié)果分析[J];中華實用兒科臨床雜志;2014年15期

2 何雯雯;吳潤暉;吳心怡;甄英姿;蘇雁;張紀(jì)水;趙磊;張寧寧;曹琪;;129例學(xué)齡前重型及中間型血友病患兒臨床分析[J];中華血液學(xué)雜志;2012年05期

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本文編號：1959612