Vol 82, No 5 (2010)

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.

Aim. To assess the course and outcomes, functional and social status in long ill patients with juvenile arthritis (JA). Subjects and methods. The study included 213 patients aged 16 to 60 years (mean age 23.9 ± 6.5 years) with JA with its duration of 10 to 53 years (mean 17.4 ± 6.8 years). Ninety-seven patients were examined at the Institute of Rheumatology; the others filled in the social status and health assessment questionnaires (HAQ). Results. Polyarthritis and oligoarthritis were found in 72.9 and 17.7%, respectively; no articular changes were seen in 9.4%. Systemic signs were noted in 3.1%. A fourth of the patients developed uveitis. Articular functional limitations were minimal or absent (functional class (FC) I, II and HAQ = 0-1.0 score) in 71-81.2%; 18.8-29% needed assistance by other persons (FC III, IV and HAQ = 2.1-3.0 scores). The FC correlated with the clinico-laboratory indicators. Mild or moderate JA persisted in 87.8% of the patients. A third of the patients were found to have erosions; 31.9% presented with ankylosis; 27.8% had aseptic necrosis of predominantly the femoral head. The health status was appraised as good or very good, satisfactory, or bad by 43.3, 39.8, and 16.9% of the patients, respectively. 78.9% of the patients worked or studied; 48.2% graduated from or continued their education at the institute; 31.7% were married; 46 patients had children. Conclusion. In most adult patients with childhood-onset JA, the activity of the disease reduced; a good functional outcome was noted. The health status made it possible to obtain profession and to be adapted to routine life and social environment. The patients with the severer course and outcome of the disease with the formation of significant functional limitations needed treatment and further medical follow-up.

Aim. To estimate the frequency of relapses of thrombotic and hemorrhagic complications during moderately intensive therapy for antiphospholipid syndrome (APS) with warfarin with and without aspirin. Subjects and methods. Eighty-two patients diagnosed as having the antiphospholipid syndrome were examoned. Group 1 patients (n = 49) received warfarin alone as an antithrombotic drug; Group 2 patients (n = 33) had a combination therapy with warfarin plus aspirin. The efficiency of therapy was evaluated from the number and rate of recurrences of thromboses and transient ischemic attacks (TIA) and its safety was assessed from the frequency and number of hemorrhages during the study. The genetic variants of cytochrome P450 CYP2C9 were determined in 52 of the 82 patients; mutations in the gene for vitamin K epoxide reductase complex 1 (VCORC1) were revealed in 22 patients. Results. During the follow-up, antithrombotic therapy was ineffective in 18.4 and 36.6% of the Groups 1 and 2 patients, respectively (p = 0.07). The rate of poor outcomes (thromboses and TIA) was 7 and 14.8 cases per 100 person-years, respectively. The first six months of warfarin therapy proved to be most risky for thrombotic events to occur - this period was responsible for 37% of bleedings. Hemorrhagic complications of antithrombotic therapy developed in 46.9 and 60.6% of Groups 1 and 2 patients, respectively (p = 0.26). Major hemorrhages were observed more frequently in the combination (warfarin plus low-dose aspirin) therapy group than in the warfarin monotherapy group. Mutant cytochrome P450 gene variants (CYP2C9*2 and CYP2C9*3) were present in 38.5% of the patients; VCORC1 gene mutations were observed in 27.3%. The number of nasal and gingival hemorrhages was increased in patients with CYP2C9*3 and homozygous VCORC1 gene mutations. Conclusion. Moderately intensive warfarin therapy (international normalized ratio 2.0-3.0) could generally reduce the frequency of recurrent thrombotic events by at least 2-fold as compared with that before warfarin administration. The efficiency of using warfarin alone or in combination with aspirin in APS was found to be similar; and its safety was higher during monotherapy therefore it is undesirable to combine warfarin with antiaggregants in real clinical practice. The determination of CYP2C9 and VCORC1 genotypes in patients with APS before warfarin use allows excessive hypocoagulation and related hemorrhages to be avoided.

Aim. To estimate the distribution of HLA Class I (A, B) antigens in patients with Behcet's disease (BD) and the association of HLA-B5 antigen with the clinical manifestations of the disease in different ethnic and population groups in relation to gender. Subjects and methods. The study covered 93 patients (68 males, 25 females) from the representatives of 24 ethnicities with the verified disease. HLA Class I antigens were typed by the microlymphocytotoxic technique, by applying an antileukocytic serum kit (GISANS, Saint Petersburg). Results. In patients with BD, the prevalence of HLA-B5 antigen proved to be significantly higher than that in the controls (72.0 and 21%, respectively) and to be similar in patients of different ethnicities living in the Caucasus and Transcaucasus (80-83%) while the number of HLA-B5 antigen-positive patients with BD was thrice less in the Russian population than in other BD patients (p < 0.01). There was a significant correlation of HLA-B5 antigen with ocular lesion (retinal angiitis) predominantly in male patients with BD. Conclusion. The prevalence of HLA-B5 antigen was higher in patients with BD than in the population-based control. The diagnostic value of this antigen is not so great, for example, in the Russian population of patients with BD. The presence of HLA-B5 antigen in the phenotype of male patients with BD may be regarded as a prognostically poor marker of development of eye diseases.

Aim. To provide rationale for early basic therapy in patients with gonarthrosis. Subjects and methods. Three hundred and eight female and male patients with early stages of gonarthrosis and 50 healthy individuals were examined. Clinical, X-ray, and arthrosonographic studies were performed; the levels of interleukin (IL) 1β, IL-1B receptor antagonist, and IL-6 were measured and quality of life was assessed. Results. The findings have led to the conclusion that the early stages of gonarthrosis are characterized by significant clinical symptomatology and lower femur condylar cartilage height; synovitis is frequently revealed by arthrosonography; there is IL-1β hyperproduction; the quality of life in the patients is worse than that in the healthy individuals from the control group. Conclusion. Therapy aimed at alleviating the symptoms of gonarthrosis and local inflammation and reducing the rate of articular cartilage degradation and X-ray progression of the disease should be initiated at the earliest, including pre-X-ray, stages of the pathological process.

Aim. To estimate the bone mineral density (BMD) in end-stage lung disease (ESLD) and to determine risk factors for reduced BMD and correlations between lung functional parameters and pretransplantation bone mass. Materials and methods. Sixty-five case histories were retrospectively analyzed in patients with ESLD who were to undergo lung transplantation. BMD in the lumbar spine (LS) and femoral neck (FN) was estimated by dual-energy X-ray absorptiometry. External respiratory function was investigated; gasometry and six-minute walk test (SMWT) were carried out. Results. Osteopenic syndrome was recorded in 89% of the patients. Normal LS and FN BMD was found only in 7 (11%) patients. T-scores (in both LII-LIV and FN) were directly related to the body mass index. There was a direct correlation of BMD with forced expiratory volume in one second and an inverse correction with arterial blood pCO2. There was no significant relationship between the results of SMWT and BMD in both LII-LIV. Conclusion. Osteoporosis is a common severe systemic manifestation in patients with ESLD.

Rheumatoid arthritis (RA) is a chronic autoimmune disease that is characterized by a systemic inflammatory and destructive joint lesion that is manifested by the involvement of various organs and systems into the pathological process. Whether the variants of the course and outcomes of RA may be predicted early is the most important inadequately studied problem. HLA-DRB1* genotypes affect disease severity; however, different alleles encoding the identical amino acid sequence have a varying association with the disease and their combinations can differently increase the risk of RA. Total epitope (SE) is associated not only with the risk of RA as a whole, but also with the development of the severe course of the disease to a greater extent. A number of studies have demonstrated that if a patient has concurrently antibodies to cyclic citrullinated peptide (CCP) and rheumatoid factor, as well as HLA-DRB1 alleles, the likelihood of rapid X-ray progression is 10 times greater than that in a patient without these markers. The paper considers the course of early RA depending on the combined determination of immunological and immunogenetic markers (SE and CCP antibodies). Each of them makes a substantial contribution to the development of a destructive process in early RA, which necessitates the assessment of a combination of the factors.