[Etiopathogenetic factors of peripheral neuropathic pain in rheumatoid arthritis]. / Étiopatogeneticheskie faktory perifericheskoi neiropaticheskoi boli pri revmatoidnom artrite.

AIM: To determine a neuropathic component of pain and define its causes in patients with rheumatoid arthritis (RA). MATERIAL AND METHODS: One hundred and eighty-three patients with confirmed RA, mean age 46,5±11,7 years, RA duration from 3 month to 30 years, were studied. Rheumatology, neurological, using the DN4 questionnaire, examinations and stimulation electromyography were used. Results and сonclusion. Signs of neuropathic pain (NP) assessed with the DN4 were identified in 73 (43%) patients with RA. These patients were older, had longer RA duration as well as higher clinical stage of disease and reduced functional abilities. There were no correlation between NP and disease activity. Peripheral nervous system (PNS) lesions were seen in 96% patients with NP: sensory motor neuropathy (55%), tunnel syndrome (14%), mononeuropathy (19%) and their combinations (4%), cervical myelopathy (4%). PNS lesions is the main etiopathogenetic factor of peripheral NP in RA. This finding opens new perspectives for complex treatment, including group B vitamins, of chronic pain in RA.

[Ankylosing spondylitis and non-radiographic axial spondyloarthritis: Two stages of disease?] / Ankiloziruiushchii spondilit i nerentgenologicheskii aksial'nyi spondiloartrit: dve stadii odnoi bolezni?

AIM: To compare the clinical manifestations of ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nrAxSpA). SUBJECTS AND METHODS: A Moscow early spondyloarthritis cohort has now included 132 patients with axial spondyloarthritis, of whom 69 patients who have been followed up at least 12 months are to be involved in a preliminary analysis. The mean age at the time of inclusion in the study was 28.1±5.5 years; the mean disease duration was 24.7±15.8 months; 63 (91.3%) patients were HLA-B27 positive; 41 and 28 included patients were diagnosed with AS and nrAxSpA, respectively. RESULTS: Men were significantly more in the AS group than in the nrAxSpA group (58.5 and 32.1%, respectively; p=0.05). The patients of the two groups did not differ in main clinical parameters (the presence of arthritis and enthesitis), disease activity (BASDAI, ASDAS-CRP) and functional status (BASFI). All indicators of inflammatory activity decreased nearly 2-fold in both groups after 12 months of follow up. In 7 (25%) patients with nrAxSpA, radiologically detectable sacroiliitis (SI) developed over 12 months and the diagnosis of AS was verified. Among them, 2 (28.5%) patients had initially active SI detected by magnetic resonance imaging (MRI); 4 (57.1%) had chronic SI, and 1 (14.4%) had no pathological MRI changes. CONCLUSION: Due to the fact that the clinical manifestations of AS and nrAxSpA are comparable, it can be assumed that the latter is an early stage of AS.

[Differential diagnosis between mechanical and inflammatory lower back pain, therapy options]. / Differentsial'naia diagnostika vospalitel'noi i mekhanicheskoi boli v spine.

The article presents the differential diagnosis between mechanical and inflammatory lower back pain based on clinical and paraclinical evidence. The results of comparative studies of amtolmetinum guacilum (AMG) and celecoxib, as well the CORONA study of its efficacy and cardiovascular safety in ankylosing spondylitis, are also discussed.

[Central regulation of pain in patients with joint disease and approaches to therapy]. / Tsentral'naia reguliatsii boli u patsientov s zabolevaniem sustavov i podkhody k terapii.

The paper reviews investigations studies that have demonstrated that chronic pain syndrome is mixed in rheumatic diseases. The nervous system is involved in its pathogenesis with different frequency and different mechanisms. Under the influence of afferent pain impulses from damaged joints, there are changes in the excitability of spinal cord neurons, which is called central sensitization (CS). A number of patients have enhanced CS and clinical manifestations as neuropathic sensitive phenomena. The mixed model of the development of chronic pain in joint diseases and its presence along with nociceptive (inflammatory) and neuropathic pain components may explain the discrepancy between joint inflammatory and structural changes and pain intensity, the presence of distant pain and sensitive disorders in the areas outside the joint, and sometimes the efficiency of anti-inflammatory therapy. The presence of the neuropathic pain component serves as a rationale for combined therapy by adding centrally acting drugs, such as anticonvulsants.

[Use of nonsteroidal anti-inflammatory drugs in case of ankylosing spondylitis: long and persistently!].

Nonsteroidal anti-inflammatory drugs (NSAIDs) are extensively used in the treatment of rheumatic diseases to relieve pain and signs of inflammation. However, when treated for ankylosing spondylosis (AS), NSAIDS exert both symptomatic and structure-modifying effects, by slowing down the development of vertebral ankylosis. The effect of these drugs, which underlines the formation of syndesmophytes, may be associated with their anti-inflammatory activity and ability to suppress abnormal bone proliferation. There is convincing evidence to support the capacity of NSAIDs, when long and continuously used, to reduce the rates of X-ray progression of AS. So the continuous use of NSAIDs must be now considered to be a mandatory component of pharmacotherapy for this disease. Their use should be continued even after achieving a marked clinical improvement. At the same time, this situation requires that the development of adverse reactions as structural and functional diseases of the gastrointestinal tract and cardiovascular system be thoroughly controlled in this situation. The danger of these complications determines the need for a physician's attention, obligatory consideration of risk factors, and rational choice of the safest NSAIDs.

[The working classification and early diagnostics of ankylosing spondylitis].

A work classification of ankylosing spondylitis is presented including such novel concepts as the stage of the disease (instead of sacroiliitis), extra-axial and extra-skeletal manifestations. Modern approaches to the evaluation of disease activity are described Extensive explanations of these notions are presented together with the recommendations on formulation of diagnosis. The advent of new and more eficacious methods of visualization as well as more sensitive and specific criteria for inflammatory nature of back pain are considered The authors modified the traditional criteria for ankylosing spondylitis and developed their version to be verified in clinical practice in this country.

[Neurogenic mechanisms of chronic joint pain].

To study pathogenetic features of chronic joint pain, we examined 183 patients with rheumatoid arthritis (RA) and 80 patients with osteoarthrosis (OA). The presence of mixed pain syndrome was found. A neuropathic component of pain (NCP) was observed in some patients with nociceptive pain (43 and 30% with RA and OA, respectively). Patients with RA had tunnel syndromes (14%), polyneuropathies (55%), mononeuropathies (19%) and sensitive specific disorders, characteristic of NCP, which were localized in anatomic zones corresponding to affected nerves. No signs of the damage of the somatosensory nervous system were found in patients with OA. Neuropathic pain was concomitant to secondary hyperalgesia which covered the zones localized far from the affected joint that allowed to suggest the involvement of dysfunctional mechanisms in the pathogenesis of chronic pain in OA. The study opens new possibilities for pharmacotherapy.

[Some aspects of pathogenesis of ankylosing spondylitis].

Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease of the spine (spondylitis) and sacroiliac joints (sacroileitis) associated in many cases with inflammatory affection of the peripheral joints (arthritis), entesises (entesitis), eyes (uveitis), intestine (enteritis) and aortic root (aortitis). AS is considered now as a prototype of diseases from the group of seronegative spondyloarthritis. AS is a hereditary disease. Predisposition to AS (90%) is associated with genetic factors the key gene of which is HLA-B27. As pathogenesis of AS is not still verified, three hypotheses are considered basing on HLA-B27 biology. The role of environmental factors involved in AS development (tension in enteses and infection) are discussed.

[Prevalence of rheumatoid arthritis in Russia (according to epidemiological findings)].

AIM: To define the prevalence of rheumatoid arthritis (RA) from the data of an epidemiological study. SUBJECTS AND METHODS: During a questionnaire survey of 37057 adults of Russia, patients with complaints of articular swelling (n = 4975) were selected; of the latter a group (n = 3420) was randomly formed to be clinically examined by rheumatologists in order to detect RA. The 1987 ACR criteria were used for its diagnosis. RESULTS: According to the data of the questionnaire survey, RA was diagnosed in 159 (4.6%) of the 3420 patients with complaints of articular swelling. The prevalence of RA in Russia averaged 0.61%. Among the respondents who complained about articular swelling during the questionnaire survey, 258 (7.5%) respondents considered to have RA before rheumatological examination. While comparing the diagnoses reported by the respondents during the survey and the final diagnosis established by a specialist, RA was confirmed only in 61 (24%) patients. Out of all the identified patients with RA (n = 159), only 61 (38%) were aware of their diagnosis. In RA patients with less than one-year articular complaints (n = 24), 17% were familiar with their diagnosis; the diagnosis was first made in the others (n = 20). Among the patients with long-term articular complaints (n = 135), 42% were aware of their diagnosis. CONCLUSION: The epidemiological survey indicated that the number of patients with RA were twice higher than those given in the official statistics of the Russian Federation (671,000 versus 300,000, respectively). In outpatient practice, RA is correctly diagnosed only in 38% of cases. There is a significant hyperdiagnosis of this disease. The duration of articular complaints affects the establishment of the diagnosis of RA.

[Statistics on rheumatic conditions in the Russian Federation in early 2000es].

The analysis of rheumatic disease morbidity in the Russian Federation in early XXI century is presented.

[Low back pain in general medical practice].

AIM: To characterize prevalence and features of low back pain (LBP) in Moscow outpatients. MATERIAL AND METHODS: The questionnaire designed in the Rheumatology Institute of Russian Medical Academy was used in the trial performed for a month with participation of 1300 Moscow outpatients aged 18 to 50 years. RESULTS: LBP is a frequent cause of consulting a physician in an outpatient practice. Most of the outpatients complained of acute and subacute moderate or severe LBP. This pain often caused disability. Of diagnostic tools most frequent was x-ray investigation of the spine. CONCLUSION: Spinal osteochondrosis is the most frequent diagnosis made in LBP outpatients. Detectability of threat marks in LBP patients is not more than 10%.

[Incidence rates of articular pain in urban and rural population of Russia (preliminary data)].

AIM: Screening of the population sample for articular pain and swelling. MATERIAL AND METHODS: A screening questionnaire for detection of arthritides and arthralgias was filled in for each adult rural and urban citizen aged over 18 years from 15 RF regions. Rural population was covered with a complete examination, urban one was examined by formation of a representative sample from general population. The screening covered a total of 31424 persons, mean age of whom was 47.6 +/- 17.6 years. Among them 14001 lived in the cities and 17423 in the villages. 61% respondents were women. RESULTS: Prevalence of arthralgias in the population reaches 46%. While the symptoms alleviated with time in 8%, they became chronic in the rest. The articular complaints rate in the population is sex-related and depends on the age. In persons under 20 years arthralgia occurs in 9%. Urban citizens have articular pains more frequently than rural population--43 and 33%, respectively. CONCLUSION: Pilot results of the screening program demonstrate prevalence of arthralgias in Russia and the importance of joint pathology problem in Russia.

[Causes of death in patients with rheumatic diseases in Moscow].

AIM: To study causes of death of rheumatic patients in Moscow. MATERIAL AND METHODS: Autopsy protocols for 1999-2002 were analysed for two pathoanatomic departments of Moscow. RESULTS: Rheumatic diseases were detected in 165 cases (2.0% of overall number of autopsies in these departments). Rheumatic heart disease (RHD) was stated in 99 (60.0%) cases, rheumatic fever relapse (RFR) in 4 (2.4%), rheumatoid arthritis (RA) in 28 (17.0%), systemic lupus erythematosus (SLE) in 8 (4.8%), systemic sclerosis (SS) in 3 (1.8%), ankylosing spondilarthritis (AS) in 2 (1.2%), systemic vasculitis (SV) in 2 (1.2%), osteoarthrosis in 11 (7.3%), gout in 3 (1.8%), polymyositis in 1 (0.6%). RHD patients died of decompensated circulation (DC) (54%), acute heart failure (AHF) (14%), thromboembolism (TE) (6%), other causes (26%). RF patients died of TE (n = 2), DC (n = 1), AHF (n = 1). Out of 28 RA patients, 5 patients died of secondary amyloidosis, 3 of DC, 7 of AHF, 1 of TE, 5 of infectious complications, 7 of other causes. SLE patients died of uremia (n = 2), acute adrenal failure (n = 1), infectious complications (n = 2), AHF (n = 2), brain edema (n = 1). CONCLUSION: Among rheumatic diseases, rheumatic heart valve disease was most severe as it caused the highest mortality. Cardiovascular pathology caused death in most of the rheumatic patients.

[The causes of death of patients with rheumatic diseases in Moscow]. / Prichiny smerti bol'nykh s revmaticheskimi zabolevaniiami v Moskve.

The study was held in order to analyze the main causes of death in cases of rheumatic diseases (RD) in Moscow. The authors studied the pathology records of autopsies performed in 1999-2002 in two pathology departments of Moscow clinics. Cases with RD were selected. The study found 165 cases of RD, which constituted 2% of all autopsies performed in these departments. There were 99 cases (60%) of rheumatic heart disease (RHD), 4 cases (2.4%) of rheumatic fever (RF) relapse, 28 cases (17%) of rheumatoid arthritis (RA), 8 cases (4.8%) of systemic lupus erythematosus (SLE), 3 cases (1.8%) of scleroderma systematica (SS), 2 cases (1.2%) of ankylosing spondylitis (AS), 2 cases (1.2%) of systemic vasculitis (SPV), 11 cases (7.3%) of osteoarthrosis, 3 cases (1.8%) of gout, 1 case (0.6%) of polymyositis. The death of patients with RHD had been caused by hemodynamic decompensation (HD) in 54% of the cases, acute cardiovascular collapse (ACC) in 14% of the cases, 6% of the patients had died from thromboembolism (TE) and 26%--from other conditions (intoxication, uremia, brain and lung edema etc). The death of patients with RF was caused by TE in 2 cases, by HD in 1 case and by ACC in 1 case. Secondary amyloidosis resulting in chronic renal failure and uremia occurred in 5 out of 28 cases of RA, HD--in 3, ACC--in 7, TE--in 1, infectious complications--in 5, other complications--in 7 cases. Patients with SLE died from various conditions: uremia in 2 cases, acute adrenal failure in 1 case, infectious complications in 2, ACC--in 2, brain edema--in 1 case. The complications of SS were uremia and intoxication. ACC was the cause of death in cases of gout and SS. The majority of RD cases were patients with RHD. The main cause of death in RD was cardiovascular disorders.

[Markov model of decision making for basic therapy of rheumatoid arthritis: oder of monotherapy and expenses for drug therapy]. / Markovskaia model' priniatiia reshenii pri naznachenii bazisnoi terapii revmatoidnogo artrita: posledovatel'nost' monoterapii i zatraty na lekarstvennuiu terapiiu.

AIM: To design Markov's model of decision making to study the role of order in the use of most usable basic antirheumatic drugs (methotrexate-MT, parenteral gold--PG and sulfasalasine--SS) in terms of the course duration and cost. MATERIAL AND METHODS: The model was based on metaanalysis made in 2000. The program TreeAge 3.0 was used. The prices for the drugs were taken as mean about Moscow for 2002 and prices presented by ACR for 2002. RESULTS: The sequence MT-PG-SS had the advantage over the other sequences in that less number of patients stopped treatment after 5 and 10 years of therapy. Mean cost of the drugs per patient is the lowest (for five years) if MT is prescribed first. In longer treatment SS-MT-PG is more cost-effective. CONCLUSION: It is feasible to design Markov's models for making decision on optimal therapy of rheumatoid arthritis both in terms of cost and clinical response.

[Statistic-mapping modeling of rheumatic diseases prevalence among population of different regions of Russia]. / Statisticheski-kartograficheskoe modelirovanie rasprostranennosti revmaticheskikh boleznei sredi naseleniia razlichnykh regionov Rossiiskoi Federatsii.

AIM: To assess feasibility of the method of mapping modeling for spacial featuring of rheumatic diseases (RD) morbidity statistics for population of Russia. MATERIAL AND METHODS: Population morbidity statistics for 78 administrative units of the Russian Federation (1993-2000) were processed. Statistic-mapping modeling employed weighted mean interpolation i.e. mathematic prediction of the sign value depending on its magnitude in basic points. RESULTS: Mapped images of RD prevalence, prevalence/primary morbidity values and number of documented cases/number of rheumatologists demonstrate special distribution of the signs studied about the RF territory. The estimation of mean, minimal, maximal values and dispersion of each sign established dynamic trends in the markers for the period under study(increased area with RD prevalence above 95/1000 from 15.9 to 44.5%; increased mean ratio prevalence/morbidity from 2.8 to 3.2 and decreased ratio of patients/rheumatologists from 10882 to 9031). Regions with minimal and maximal values are shown. CONCLUSION: Statistic-mapping modeling demonstrates spacial distribution of the markers, reveals the relations between them.

[Russian society and patients with rheumatic diseases]. / Problema revmaticheskikh zabolevanii v Rossii s pozitsii obshchestva i patsienta.

The morbidity, primary morbidity, temporary incapacity for work and disablement due to rheumatoid diseases registered among Russia's population in the recent 3 years are described on the basis of an analysis of Russian statistics. Issues related with mortality, caused by rheumatic diseases, the related expenses and influence on patients' life quality are under discussion. A conclusion is made on a high social-and-medical importance of the above category of diseases as viewed from the standpoint of society (state), patient and his or her family.