本文選題：關(guān)節(jié)病型銀屑病 + 銀屑病性關(guān)節(jié)炎PsA　； 參考：《安徽醫(yī)科大學(xué)》2017年碩士論文

【摘要】：研究背景和目的關(guān)節(jié)病型銀屑病亦稱(chēng)銀屑病性關(guān)節(jié)炎(Psoriatic arthritis,PsA),屬于脊柱關(guān)節(jié)病(spondyloarthropathy,SpA)的一個(gè)亞型。PsA是一種臨床異質(zhì)性較強(qiáng)的系統(tǒng)性、免疫性、炎癥性疾病,臨床表現(xiàn)復(fù)雜多樣,包括一組炎癥性改變:如銀屑病紅斑鱗屑皮損、指(趾)甲病變、關(guān)節(jié)滑膜炎、附著點(diǎn)炎、潰瘍性結(jié)腸炎、虹膜睫狀體炎等。PsA以銀屑病皮損和關(guān)節(jié)炎癥為主要臨床特征,皮損可表現(xiàn)為尋常型、紅皮病型、膿皰型,其關(guān)節(jié)損傷常導(dǎo)致關(guān)節(jié)及其周?chē)浗M織疼痛、腫脹,僵硬、運(yùn)動(dòng)障礙,病程遷延、反復(fù)發(fā)作,甚至呈進(jìn)行性加重,出現(xiàn)關(guān)節(jié)永久性損傷而殘毀,嚴(yán)重影響了患者的社會(huì)交往和生活質(zhì)量,給患者造成極大的心身痛苦。本研究通過(guò)分析Ps A的臨床特征及實(shí)驗(yàn)室指標(biāo)變化的意義,加深對(duì)PsA病因病機(jī)的認(rèn)識(shí),為制定出符合中國(guó)國(guó)情的PsA分型分級(jí)標(biāo)準(zhǔn)提供理論依據(jù),同時(shí)為有效防治PsA及其系統(tǒng)損害、改善其預(yù)后等積累經(jīng)驗(yàn)。方法根據(jù)PsA的CASPAR診斷標(biāo)準(zhǔn)篩選2013年7月至2015年12月于空軍總醫(yī)院皮膚科就診的121例PsA患者,對(duì)其基線(xiàn)時(shí)病史、體格檢查及相關(guān)實(shí)驗(yàn)室檢查的資料進(jìn)行統(tǒng)計(jì)分析,并與58例尋常型銀屑病患者和70例正常健康者進(jìn)行對(duì)照。利用SPSS17.0統(tǒng)計(jì)軟件,計(jì)量資料的比較采用t檢驗(yàn)、單因素方差分析、LSD法、Kruskal-Wallis檢驗(yàn)、Wilcoxon符號(hào)秩和檢驗(yàn),計(jì)數(shù)資料的比較采用c2檢驗(yàn),指標(biāo)間相關(guān)性采用Spearman相關(guān)性分析法。結(jié)果1、發(fā)病情況:121例PsA患者,男69例,女52例,男女之比為1.33:1,平均年齡(41.29±12.42)歲。銀屑病皮損初發(fā)病年齡平均(27.51±11.95)歲,關(guān)節(jié)炎初發(fā)病年齡平均(36.70±11.95)歲。以皮損首發(fā)者100例(82.64%),以關(guān)節(jié)炎首發(fā)者6例(4.96%),皮損和關(guān)節(jié)炎同時(shí)出現(xiàn)者15例(12.40%)。2、psa皮膚損害:(1)皮損分型:皮損為尋常型者112例(92.56%),膿皰型者5例(4.13%),紅皮病型者4例(3.31%);(2)皮損分期:進(jìn)展期者89例(73.55%),靜止期者21例(17.36%),消退期者11例(9.10%);(3)皮損嚴(yán)重程度:pasi評(píng)分0.30~50.10分,平均11.80(13.30)分。輕度者(0pasi10)51例(42.15%),中度者(10≤pasi30)60例(49.59%),重度者(pasi≥309例(7.44%)。3、psa關(guān)節(jié)損傷:(1)外周型101例(83.47%),累及的關(guān)節(jié)中以手部第Ⅲ指近端指間關(guān)節(jié)受累最為多見(jiàn);中軸型20例(16.53%),最常累及足部第Ⅲ趾近端趾間關(guān)節(jié)。(2)單純附著點(diǎn)炎8例(6.61%),最常累及足跟;單純滑膜炎15例(12.40%),最常累及膝關(guān)節(jié);附著點(diǎn)炎合并滑膜炎98例(80.99%),最易累及手近端指間關(guān)節(jié),并以第Ⅲ指近端指間關(guān)節(jié)受累最為常見(jiàn)。4、psa皮膚與關(guān)節(jié)損害的關(guān)系:外周型和中軸型psa在銀屑病皮損分型上差異有高度統(tǒng)計(jì)學(xué)意義(p=0.001),而在皮損分期(p=0.608)方面無(wú)差異。中軸型psa患者中,膿皰型和紅皮病型發(fā)生率高于外周型。5、系統(tǒng)損害特征:psa易合并尿酸、糖、脂代謝和造血系統(tǒng)功能異常,且后兩者異常特點(diǎn)與pv不同。(1)尿酸水平:psa患者ua明顯高于正常,差異有統(tǒng)計(jì)學(xué)意義(p0.05);(2)糖代謝:psa患者fbs明顯高于正常及尋常型,差異均有統(tǒng)計(jì)學(xué)意義(p0.05);(3)脂代謝:psa患者tg、apoaⅠ、apob100明顯升高,差異均有統(tǒng)計(jì)學(xué)意義(p0.05);hdl-c明顯下降,差異亦有高度統(tǒng)計(jì)學(xué)意義(p=0.000)。pv患者tc、ldl-c、hdl-c、apob100明顯下降,差異有統(tǒng)計(jì)學(xué)意義(p0.05)。(4)造血系統(tǒng)功能:psa患者rdw明顯下降,差異有高度統(tǒng)計(jì)學(xué)意義(p=0.000);mcv、mch、mchc與正常對(duì)照相比無(wú)差異(p0.05)。pv患者rdw明顯下降,mcv、mch、mchc明顯升高,差異均有高度統(tǒng)計(jì)學(xué)意義(p=0.000)。psa患者plt明顯高于正常對(duì)照及尋常型,差異均有高度統(tǒng)計(jì)學(xué)意義(p=0.000);mpv明顯低于正常,但較尋常型高,差異均有統(tǒng)計(jì)學(xué)意義(p0.05)。psa患者wbc、neut明顯高于正常及尋常型,差異均有高度統(tǒng)計(jì)學(xué)意義(p0.01)。6、psa病情評(píng)估指標(biāo):(1)psa皮損評(píng)估指標(biāo):esr(r=0.19,p=0.045)、crp(r=0.251,p=0.007)和hs-crp(r=0.247,p=0.049)三項(xiàng)炎癥性指標(biāo)與psa患者皮損的pasi評(píng)分均呈正相關(guān),ua與pasi評(píng)分亦呈正相關(guān)(r=0.217,p=0.018);(2)psa關(guān)節(jié)損傷評(píng)估指標(biāo):il-6與壓痛關(guān)節(jié)數(shù)(r=0.314,p=0.001)、壓痛關(guān)節(jié)評(píng)分(r=0.332,p=0.001)、腫脹關(guān)節(jié)數(shù)(r=0.264,p=0.006)和腫脹關(guān)節(jié)評(píng)分(r=0.292,p=0.003)等均呈正相關(guān),hs-crp與壓痛關(guān)節(jié)數(shù)(r=0.391,p=0.002)、壓痛關(guān)節(jié)評(píng)分(r=0.403,p=0.001)、腫脹關(guān)節(jié)數(shù)(r=0.225,p=0.078)和腫脹關(guān)節(jié)評(píng)分(r=0.212,p=0.098)等均呈正相關(guān),crp與壓痛關(guān)節(jié)數(shù)(r=0.287,p=0.002)、壓痛關(guān)節(jié)評(píng)分(r=0.260,p=0.006)、腫脹關(guān)節(jié)數(shù)(r=0.196,p=0.040)等均呈正相關(guān),hdl-c與關(guān)節(jié)壓痛程度呈負(fù)相關(guān)(壓痛關(guān)節(jié)數(shù):r=-0.232,p=0.014;壓痛關(guān)節(jié)評(píng)分:r=-0.218,p=0.021)。小結(jié)(1)大多數(shù)psa患者的銀屑病皮損先于關(guān)節(jié)損傷出現(xiàn),且皮損分型以尋常型為主,皮損分期以進(jìn)展期主,皮損嚴(yán)重程度以輕、中度為主;(2)psa的關(guān)節(jié)損傷主要累及外周動(dòng)關(guān)節(jié),以附著點(diǎn)炎合并滑膜炎為主,最常累及近端指間關(guān)節(jié);(3)中軸型psa患者中,膿皰型和紅皮病型發(fā)生率高于外周型;(4)psa易合并尿酸、糖、脂等代謝異常,且后兩者異常特點(diǎn)與pv不同。psa患者ua明顯高于正常,但低于尋常型,psa患者fbs明顯高于正常及尋常型。psa患者tg、apoaⅠ、apob100明顯升高,hdl-c明顯下降;(5)psa易伴發(fā)造血系統(tǒng)功能異常,psa合并的貧血類(lèi)型為正細(xì)胞均一性貧血;psa外周血中plt、wbc、neut明顯升高,mpv明顯減小;(6)esr、crp和hs-crp三項(xiàng)炎癥性指標(biāo)和尿酸水平可在一定程度上反映psa患者皮損炎癥活動(dòng)程度;(7)IL-6、hs-CRP、CRP和HDL-C可作為評(píng)估PsA關(guān)節(jié)炎癥活動(dòng)度的參考指標(biāo)。深入了解PsA的臨床特征和實(shí)驗(yàn)室指標(biāo)變化的臨床意義,對(duì)于PsA的早期診斷、評(píng)估以及規(guī)范化防治具有重要指導(dǎo)意義。
[Abstract]:Background and objective psoriasis, also known as Psoriatic arthritis (PsA), is a subtype of spondyloarthropathy (spondyloarthropathy, SpA), a subtype of.PsA that is a highly heterogeneous, systemic, immune, inflammatory disease with complex clinical manifestations, including a group of inflammatory changes, such as psoriasis red Skin lesions, finger (toe) lesions, joint synovitis, attachment point inflammation, ulcerative colitis, iritis and ciliary body inflammation are the main clinical features of psoriasis and joint inflammation. The skin lesions can be characterized by vulgaris, erythrodermic, pustular, and joint injuries often causing pain, swelling, stiffness, and dyskinesia in the joints and their surrounding soft tissues. The course of the disease was prolonged, repeated attacks, even progressive aggravation, and the permanent injury of the joints was damaged and damaged, which seriously affected the social communication and quality of life of the patients, and caused great mental and physical pain for the patients. This study was made through the analysis of the clinical features of Ps A and the significance of the changes in the laboratory indexes to deepen the understanding of the etiology and pathogenesis of PsA. In accordance with the national conditions of China, the PsA classification and classification standards provide the theoretical basis, at the same time, to effectively prevent and control PsA and its systemic damage and improve its prognosis. Methods according to the CASPAR diagnostic criteria of PsA, 121 cases of PsA patients who were diagnosed in Department of Dermatology of General Hospital of the Air Force PLA from July 2013 to December 2015 were selected. The data of laboratory examination were statistically analyzed and compared with 58 cases of psoriasis vulgaris and 70 normal healthy persons. Using SPSS17.0 statistical software, the comparison of measurement data was compared with t test, single factor variance analysis, LSD method, Kruskal-Wallis test, Wilcoxon sign rank sum test, and comparison of count data using C2 test and index. Correlation used Spearman correlation analysis. Results 1, incidence of disease: 121 cases of PsA patients, 69 men and 52 women, the ratio of men and women was 1.33:1, the average age was (41.29 + 12.42) years old. The average age of onset of psoriasis was (27.51 + 11.95) years (27.51 + 11.95) years, and the average age of arthritis was (36.70 + 11.95) years old. The first onset of skin lesions was 100 (82.64%), with arthritis first first. 6 cases (4.96%), skin lesions and arthritis in 15 cases (12.40%).2, PSA skin damage: (1) skin lesions of 112 cases (92.56%), 5 cases of pustular type (4.13%), 4 cases of red skin type, 4 cases (3.31%); (2) stage of lesion, 89 cases (73.55%), stationary phase Degree: PASI score 0.30~50.10 score, average 11.80 (13.30) points. Mild (0pasi10) 51 cases (42.15%), moderate (10 < pasi30) 60 cases (49.59%), severe (PASI > 309 cases (7.44%).3, PSA joint damage: (1) peripheral 101 cases (83.47%), involved in the third finger proximal interphalangeal joint involvement in the most common; middle axis 20 cases (16.53%), the most often tired. The interphalangeal joint of the third toe of the foot. (2) 8 cases of simple attachment point inflammation (6.61%), the most often involved in the heel; 15 cases of simple synovitis (12.40%), the most often tiring and knee joint; adherent point inflammation and 98 cases (80.99%), the most likely to involve the proximal interphalangeal joint of the hand, and the most common.4, PSA skin and joint damage with the proximal interphalangeal joints of the third finger. The difference in psoriatic skin lesions was highly statistically significant (p=0.001) in peripheral and middle type PSA (p=0.001), but there was no difference in skin lesion staging (p=0.608). The incidence of pustular and erythroderma type was higher than that of peripheral.5 in patients with middle axis type PSA. The characteristics of systemic damage were: PSA was easy to combine with uric acid, sugar, lipid metabolism and hematopoietic system dysfunction, and two The abnormal characteristics were different from that of PV. (1) uric acid level: PSA patient UA was significantly higher than normal, the difference was statistically significant (P0.05); (2) glucose metabolism: PSA patients were significantly higher than normal and normal type, the difference was statistically significant (P0.05); (3) lipid metabolism: TG, ApoA I, apoB100 significantly increased in PSA patients, the difference was statistically significant (P0.05); obviously lower The difference also had a high statistical significance (p=0.000).Pv patients TC, LDL-C, HDL-C, apoB100 significantly decreased, the difference was statistically significant (P0.05). (4) the function of the hematopoietic system: RDW decreased significantly in PSA patients, and the difference was statistically significant (p=0.000); MCV, MCH, and normal The difference both showed high statistical significance (p=0.000).Psa patients PLT was significantly higher than normal control and normal type, the difference was statistically significant (p=0.000), MPV was significantly lower than normal, but higher than normal, the difference was statistically significant (P0.05).Psa patients WBC, neut significantly higher than normal and vulgaris, the difference was highly statistically significant (P0.01).6, PSA evaluation index: (1) the index of PSA skin lesion assessment: ESR (r=0.19, p=0.045), CRP (r=0.251, p=0.007) and hs-CRP (r=0.247, and hs-CRP) were positively correlated with the severity score of the patients' skin lesions. .314, p=0.001), r=0.332 (p=0.001), swelling joint number (r=0.264, p=0.006) and swelling joint score (r=0.292, p=0.003) were all positive correlation, hs-CRP and pressure joint number (r=0.391, p=0.002), pain joint score, swelling joint score, swelling joint score and so on are all positive CRP was correlated with the number of r=0.287 (p=0.002), r=0.260 (p=0.002), r=0.260 (p=0.006), the number of swelling joints (r=0.196, p=0.040) and so on. HDL-C had a negative correlation with the degree of joint pressure pain (the number of pain joints: r=-0.232, p=0.014; r=-0.218, p=0.021). (1) most of the patients with psoriasis were prior to the joints. The damage occurred, and the lesions were mainly typed in the ordinary type, the lesions were mainly in the progressive stage, and the severity of the lesions was mainly mild and moderate; (2) the joint injury of PSA was mainly involved in the peripheral joints, mainly with adherent point inflammation and synovitis, and most often involved the proximal interphalangeal joints; (3) the incidence of pustular and erythroderma type in the middle axis type PSA patients was higher than that of the outside. (4) PSA was easy to merge with uric acid, sugar, fat and other metabolic abnormalities, and the abnormal characteristics of the latter two were significantly higher than that of normal PV in.Psa patients, but the FBS in PSA patients was significantly higher than that of normal and normal.Psa patients TG, ApoA I, apoB100 significantly increased, HDL-C obviously decreased; (5) anemia associated with the anemia of the combined anemia class. The PLT, WBC, neut and MPV decreased obviously in the peripheral blood of PSA; (6) the three inflammatory indices and uric acid levels of ESR, CRP and hs-CRP can reflect the degree of inflammatory activity in patients with PSA; (7) IL-6, hs-CRP, CRP, and may be used as a reference for evaluating the degree of inflammatory activity. The clinical significance and clinical significance of changes in laboratory parameters are of great significance for early diagnosis, evaluation and standardized prevention and treatment of PsA.

【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R758.63

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