Vol 87, No 5 (2015)

In the past decade, investigators’ undeniable and justified interest has not been fading in comorbidities in the presence of rheumatic diseases. The terms «comorbidity» and «multimorbidity» are frequently and not always consciously used as interinterchangeable, confusing the terminology and accordingly the elaboration of strategies for further researches. The concepts «co-occurring disease» and «multimodality» are not mutually exclusive or contradictory, but these should be considered from another point of view than «comorbidity». The problem of multimorbid disease is the rule rather than the exception for clinicians treating primarily «typical» rheumatic patients. Recent researches could outline a few key areas for further study of the concept of multimorbidity in rheumatologic practice, which will be able to turn the international research community from rheumatic disease to the patient as a whole.

Aim. To estimate the rate of diastolic dysfunction (DD) of the left and right ventricles (LV and RV) in patients with early rheumatoid arthritis (RA) before using disease-modifying antirheumatic drugs (DMARDs) therapy and to investigate its association with traditional risk factors (TRFs) for cardiovascular diseases (CVD) and inflammatory markers. Subjects and methods. The investigation enrolled 74 patients with a valid diagnosis of RA, including 56 (74%) women (median age, 54 years; disease duration, 7 months); the patients who were seropositive for rheumatoid factor (RF) (87%) and/or anti-cyclic citrullinated peptide (anti-CCP) antibodies (100%) who had not been on DMARDs or glucocorticosteroids. TRFs for CVD and carotid artery atherosclerosis were assessed from duplex scanning data and echocardiography was performed in all the patients with early RA before starting the therapy. The ratio of the maximum blood flow velocity during early diastolic filling (E) to that during atrial systole (A) was used as a criterion for LVDD and RVDD. There were 3 types of impaired ventricular filling: 1) E/A <1; 2) E/A = 1—2; 3) E/A >2. Results. LVDD and RVDD were detected in 35 (48%) and 17 (23%) patients, respectively. RVDD was recorded only in conjunction with LVDD. Among LVDD and RVDD, the former was prevalent. All the patients with early RA were divided into 3 groups: 1) patients with LVDD and RVDD; 2) those with LVDD; 3) those without ventricular DD. All the three groups were matched for the level of DAS28, anti-CCP antibodies, and RF. The incidence of arterial hypertension, dyslipidemia, and abdominal obesity was higher in the patients of Groups 1 and 2 than in those of Group 3. There was a progressive decrease in high-density lipoprotein (HDL) cholesterol concentrations and increases in triglyceride (TG) levels and atherogenic index from Group 3 to Group 1, with the concentrations of total cholesterol and low-density lipoprotein cholesterol being similar in the 3 groups. Coronary heart disease was recorded more frequently in Group 2 than in Group 3. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) proved to be also significantly higher in the patients with DD than in those without DD. Correlations were found between LV E/A and ESR, CRP, HDL cholesterol, TG, RV E/A and ESR, DAS28, TG. Conclusion. The patients with early-stage RA were found to have high incidence rates of LVDD and RVDD, which is related to the high prevalence of CVD, the high spread of TRF for CVD, and the high activity of an inflammatory process.

Aim. To study the clinical features of early- and extended-stage microscopic polyangiitis (MPA) and its outcomes on the basis of a long-term follow-up in a rheumatologist’s practice. Subjects and methods. The clinical features of early- and extended-stage MPA were studied in detail and the premorbid background and possible precipitating factors were analyzed in 70 patients with MPA and the proven hyperproduction of antineutrophil cytoplasmic antibodies (anti-proteinase-3 (anti-PR3) antibodies in 55% and anti-myeloperoxidase (anti-MPO) antibodies in 45%) who had been followed up for more than a year. Results. There is evidence for the nosological unity of the two immunological types of MPA associated with anti-PR-3 or anti-MPO antibodies. MPA has been demonstrated to be an aggressive, polysyndromic disease prone to recurrences (52%), the typical manifestation of which is glomerulonephritis (94%) that is rapidly progressive in every four cases and accompanied by hemorrhagic alveolitis (69%) and involvement of other organs. ENT organs and lungs have been noted to be commonly involved in early-stage MPA, which was observed in 61% of the patients in the premorbid period, and to become the first manifestation of MPA (63%) concurrent with body temperature rises (64%), arthralgia or arthritis (41%). Respiratory tract involvement in MPA may be asymptomatic. Anti-PR-3-associated MPA may manifest itself more aggressively and in the first 2 years it is characterized by a poorer prognosis than of anti-MPO-associated MPA (survival rates, 82 and 94%, respectively; p=0.04). With time, the differences were levelled off; recurrences in the patients with anti-PR-3 and anti-MPO develop equally frequently and proceed showing the similar clinical picture; the survival curves converge by age 3. Anti-MPO-associated MPA is characterized by the highest rate of lung involvement in the clinical phase of the disease (61%) and by a propensity to develop hemorrhagic alveolitis, diffuse interstitial (22%) or circumscribed pulmonary fibrosis in the outcome. Conclusion. The findings emphasize how important to diagnose MPA early and to prescribe long-term active treatment using the entire current arsenal of medications as soon as possible until severe injury to organs and systems develops. To specify regularities in the development of MPA may be of value for the better diagnosis of the disease and the further elaboration of optimal treatment policy.

Subjects and methods. The follow-up included 66 patients (34 women and 32 men) who took NSAIDs for emergent low back pain. Results. The findings may suggest that etoricoxib-based therapy is highly effective and relatively safe for the management of acute nonspecific backache in patients with comorbidity. The important feature is the established tendency towards BP destabilization in patients with chronic cerebrovascular diseases treated with NSAIDs (diclofenac, meloxicam, to a lesser extent, nimesulide). After completion of drug intake for 14 days or longer, acute cerebral circulatory disorder and acute cerebrovascular event developed within 4.5 months in 3 and 2 patients, respectively. Conclusion. Thus, the spectrum of possible adverse cardiovascular effects of NSAIDs is rather broad. It is advisable to identify two major groups of NSAID-associated complications: 1) destabilized hypertension; 2) cardiovascular and cerebrovascular events.

Aim. To analyze overall and new-onset osteoarthritis (OA) morbidity among the adult population in the Republic of Kazakhstan in 2011—2012. Subjects and methods. The data of annual statistical reports «On Population Health and Public Health System» (Form No. 12) in 2011—2012 were analyzed. The indicators in the Republic of Kazakhstan were taken from the statistical collected articles «Population Health in the Republic of Kazakhstan and Activities of Healthcare Facilities». Results. A comparative analysis of the indicators revealed a rising trend in overall morbidity by 1%, including in the incidence of musculoskeletal diseases (MSD) by 3% (the increase rate per 100,000 population was 2%). An analysis of the incidence of MSD per 100,000 population in some regions of the Republic of Kazakhstan showed an upward trend in the Almaty Region: the incidence increased among the women and the 18 or more year olds by 23 and 16%, respectively. Among the adults (aged 18 years or older) and women, the number of patients with a newly diagnosed coxarthrosis (CA) increased by 43 and 18%, respectively; the number of those with gonarthrosis (GA) rose by 36 and 33%, respectively. The people older than 60 years of age and women showed 122 and 82% rises in the number of patients with a newly diagnosed CA; there were 78% increment rates in the patients with GA and 68% in the women. Conclusion. In the Republic of Kazakhstan, there was a high incidence of OA in both the people aged 18 years or older with newly diagnosed CA, GA and the people over 60 years of age, in women in particular.

Aim. To evaluate endothelial function (EF) and to estimate the level of a serum apoptosis marker (caspase-8) in patients with metabolic syndrome (MS) and in those with non-alcoholic fatty liver disease (NAFLD). Subjects and methods. The investigation enrolled 76 patients: 43 with MS (out of them, 72.1% were found to have NAFLD) and 33 without MS and NAFLD. All the patients underwent evaluation of EF by photoplethysmography; the level of caspase-8 as one of the apoptosis markers was studied in all. Results. Increased arterial stiffness was more common in a group of patients with MS. Systolic duration was higher in these patients (p<0.05). In these patients, an occlusion test revealed the significantly more marked signs of endothelial dysfunction (ED), which correlated with some cardiovascular diseases (CVD), and hepatic steatosis (p<0.05). The mean level of caspase-8 was significantly higher in the group of MS patients (p<0.05). There was a positive correlation between caspase-8 levels and hepatic and pancreatic steatosis, obesity, aortic atherosclerosis, type 2 diabetes mellitus, and gastroesophageal reflux disease (p<0.05). Conclusion. The study group of MS patients (among whom, there was a preponderance of those with NAFLD) had, firstly, higher arterial stiffness more frequently (as evidenced by photoplethysmography), secondly, longer systolic duration, which may be a risk factor for CVD; thirdly, more pronounced ED. Fourthly, according to the data of a study of caspase-8 levels, its indicator may serve as a prognostic marker for the development of CVD and NAFLD. It was, fifthly, shown that the administration of statins might reduce the degree of apoptosis.

The paper describes a case of primary hepatic diffuse large B-cell lymphoma in a 52-year-old woman with a 27-year history of Sjögren’s disease. It gives the data available in the literature on the etiology, diagnosis, and morphological characteristics of primary hepatic lymphoma and touches upon the issues of differential diagnosis.

A new nomenclature of systemic vasculitides (SV) and current approaches to their treatment have necessitated the discussion of some debatable questions on this condition. The paper gives the data of examining 325 patients with different forms of SV, followed up in the Interregional Consulting Center for SV patients, and the results of testing the American College of Rheumatology classification criteria for SV and the authors’ criteria, by taking into account the International Chapel Hill Consensus Conference, USA (1994 and 2011) guidelines for CV nomenclature. It discusses the etiological factors and pathogenetic components of SV, morphological aspects, and relationships between the local and systemic forms of SV. The findings were compared with the data available in the literature. It is concluded that differentially diagnostic criteria for CV should be elaborated to specify the stage of the disease, the activity and use of adapted therapy regimens.

In patients with chronic inflammatory diseases, including rheumatic ones, the risk of fractures exceeds that in the population. Chronic inflammation is one of the most discussed and most important pathogenic factors of reduced bone mineral density (BMD), its worse quality and increased fracture risk. The chronic inflammatory process contributes to the imbalance of bone remodeling toward bone resorption. The use of biological agents in patients with rheumatic and other autoimmune diseases effectively suppresses systemic inflammation and increases BMD. However, the effect of the biological agents in lessening the risk of fractures remains unproven.

Animal Helicobacter species other than Helicobacter pylori are also able to cause human gastritis, gastric ulcers, and MALT lymphomas. Animal Helicobacter species are presented with typical spiral fastidious microorganisms colonizing the gastric mucosa of different animals. Bacteria initially received their provisional name Helicobacter heilmannii, and out of them at least five species colonizing the gastric mucosa of pigs, cats, and dogs were isolated later on. A high proportion of these diseases are shown to be zoonotic. Transmission of pathogens occurs by contact. The factors of bacterial pathogenicity remain little studied.