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1、Rheumatoid Arthritis for Primary Care Physicians类风湿性关节炎Shenzhen China IPCEA Primary Care ProjectAugust 2013,William H. Stager, DO, MS, MPH, FAAFP, FAAMA, FAAO, FACOFP Clinical Professor, Dept. of Family Medicine, NSUCOM Clinical Associate Professor, Dept. of Family Medicine, LECOM 2013-2014 First Vi
2、ce President, FOMA 2006-2010 President, Florida Academy of Osteopathy 2006-2013 President, FOMA District 9 2008-2009 President, FSACOFP,Rheumatoid Arthritis: Introduction介绍,Rheumatoid arthritis (RA) is a symmetric, inflammatory, peripheral polyarthritis of unknown etiology. It typically leads to def
3、ormity through the stretching of tendons and ligaments and destruction of joints through the erosion of cartilage and bone. If it is untreated or unresponsive to therapy, inflammation and joint destruction lead to loss of physical function, inability to carry out daily tasks of living, and maintenan
4、ce of employment.类风湿性关节炎（RA）是对称的，炎症，病因不明的外周多发关节炎。它通常会通过拉伸肌腱、韧带导致畸形，侵蚀软骨和骨质来破坏关节。如果是未经处理的或无效的治疗，炎症和关节的破坏会导致生理功能丧失，不能正常进行日常生活和就业。Early recognition and treatment with disease-modifying antirheumatic drugs is important in achieving control of disease and prevention of joint injury and disability. Howeve
5、r, in patients with early disease, the joint manifestations are often difficult to distinguish from other forms of inflammatory polyarthritis. The more distinctive signs of RA, such as joint erosions, rheumatoid nodules, and other extraarticular manifestations, are seen primarily in patients with lo
6、ngstanding, poorly-controlled disease but are frequently absent on initial presentation.(1,2,3)早期识别和使用抗风湿药物治疗，是控制病情和防止关节损伤和残疾的要点。然而，在疾病早期的患者，关节的表现往往难以区分于其他形式的炎症性的多发关节炎。RA的更鲜明的标志，首先要看比如关节侵蚀，类风湿结节，和其他关节外的表现。,Rheumatoid Arthritis: Diagnosis诊断,Perform a thorough medical history, with particular attentio
7、n to joint pain, reported swelling, and the presence, location (peripheral joints rather than low back), and duration (at least 30 minutes) of morning stiffness. The absence of other conditions or symptoms suggesting an alternative diagnosis, such as psoriasis, inflammatory bowel disease, or a syste
8、mic rheumatic disease such as systemic lupus erythematosus (SLE), helps to exclude other disorders.需要详细的病史，特别要注意关节疼痛，和肿胀，以及其他表现，存在的部位（外周关节，而不是腰部），和持续时间（至少30分钟）晨僵。缺乏其他条件或症状提示是另一种诊断，有助于排除其他疾病，如银屑病，炎症性肠病，或全身性类风湿性疾病如系统性红斑狼疮（SLE）。A complete physical examination is indicated to assess for synovitis, inclu
9、ding the presence and distribution of swollen or tender joints and limited joint motion; extraarticular disease manifestations, such as rheumatoid nodules; and signs of diseases, such as systemic lupus erythematosus or psoriasis, included in the differential diagnosis.(1,2,3)评估滑膜炎需要一套完整的体检，包括关节肿胀和压痛
10、的存在和分布以及关节运动的限制；关节外疾病的表现，如类风湿结节；以及疾病的体征，包括鉴别诊断，如系统性红斑狼疮、银屑病。,Rheumatoid Arthritis: Diagnosis,Laboratory tests which support the diagnosis if positive and/or elevated:类风湿关节炎：诊断性的实验室检查，阳性和/或升高时支持诊断： Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) antibodies Perform both RF and anti-
11、CCP antibody testing when initially evaluating a patient with suspected RA.类风湿因子（RF）、抗环瓜氨酸肽（CCP）抗体 ：在评估疑似RA病人，进行RF和抗CCP抗体检测是必要的。The results of both tests are informative, since a positive result for either test increases overall diagnostic sensitivity, while the specificity is increased when both te
12、sts are positive.两个测试结果都是有用的，因为一个阳性的结果对整体诊断的的敏感度没有增加，当两个结果都是阳性时，特异性增加。 Despite this, both tests are negative on presentation in up to 50 percent of patients and remain negative during follow-up in 20 percent of patients with RA.尽管如此，多达50%的RA患者，两个检查均阴性，随访期间20%的RA患者是都是阴性的。 Erythrocyte sedimentation ra
13、te (ESR) and serum C-reactive protein (CRP) levels Both the ESR and CRP are typically elevated in RA. ESR和CRP的水平，类风湿性关节炎通常会升高。 Antinuclear antibody (ANA) testing A negative ANA helps exclude SLE and other systemic rheumatic diseases; the ANA may be positive in up to one-third of patients with RA. In
14、 patients with a positive ANA, anti-double stranded DNA and anti-Smith antibody testing should also be performed; these antibodies have high specificity for SLE.(1,2,3)抗核抗体（ANA）测试- ANA阴性帮助排除SLE和其他全身性风湿性疾病；约1/3的RA患者ANA是阳性。在ANA阳性的患者中，也应该进行抗双链DNA和抗Sm抗体测试；这些抗体对SLE有较高的特异性。,Rheumatoid Arthritis: Diagnosis
15、,Complete blood count (CBC) with differential and platelet count, tests of liver and kidney function, serum uric acid, and a urinalysis The CBC is often abnormal in RA, with anemia and thrombocytosis consistent with chronic inflammation. Liver and kidney testing abnormalities indicate a disorder oth
16、er than RA; if caused by comorbid conditions, they may affect therapeutic choices or drug dosing. Hyperuricemia may prompt additional efforts, including arthrocentesis and crystal search, to exclude gout; polyarticular gout can infrequently be mistaken for RA.全血细胞计数（CBC）和血小板计数，肝、肾功能试验，血清尿酸，尿分析-CBC在R
17、A经常是不正常的，伴有贫血和血小板增多症，需考虑为慢性炎症。肝肾功能异常表示RA以外的疾病；如果是并存的条件造成的，他们可能会影响治疗的选择或药物剂量。高尿酸血症可能需要更多的工作，包括关节穿刺、查找晶体，来排除痛风；多关节型痛风可以经常被误诊为类风湿性关节炎。Radiographs of the hands, wrists, and feet We obtain radiographs during the initial evaluation primarily as a baseline for monitoring disease progression. However, chara
18、cteristic joint erosions may be observed in patients presenting with symptoms for the first time and, hence, aid in diagnosis. Additionally, in patients with other disorders, such as psoriatic arthritis, spondyloarthropathy, gout, or chondrocalcinosis, radiographic changes more characteristic of these conditions may point to an alternative diagnosis.(1,2,3)手，手腕和脚的X光片，我们在初步评估时得到的x光片，是监测疾病进展情况的一个基础手段。然而，特征性的关节侵蚀可能在首次症状的患者上观察到，因此，有助于诊断。此外，在其他疾病的患者，如脊柱关节病，银屑病关节炎，痛风，或软骨钙化，X光片的改变具有更多这些疾病的特征则提示其他的诊断。,
