Severity of hands and feet joint destruction is the most objective marker of rheumatoid arthritis (RA) progression determining functional disability. The main aim of RA treatment is suppression of joint destruction. Objective. To study dependence of joint erosions forming speed on disease modifying anti-rhcumatic drugs (DMARD) administration and RA activity. Material and methods. Retrospective analysis of 451 cases of RA treatment was performed. Erosions were counted according to modified Sharp method. Erosions forming speed was counted as ratio of erosion number increase to a year’s time space. Averaged disease activity was calculated as arithmetic mean for all DAS28 values obtained during disease course. Considering close relationship between disease activity and DMARD administration two-factor analysis was used. DMARD administration (>3 months) and mean activity of RA were considered as factors. Results. Variance analysis (ANOVA) with covariant showed that mean RA activity is a significant factor influencing erosions forming speed (F=12,5; p=4xl0 4). Character of DMARD, fact of its administration and disease duration did not significantly influence erosions forming speed considering disease activity covariant. Regression model with inclusion disease duration factor mean disease activity and DMARD administration at the moment of assessment allowed to explain 42% of dispersion (determination coefficient). Conclusion. Activity of RA is the main factor influencing erosions forming speed. Therapy not decreasing activity of RA does not change erosions forming speed

Objective. To develop the optimal mode of spine evaluation with magnetic resonance image (MRl) in pts with ankylosing spondylitis (AS) and to study relationship between MR! signs of spinal inflammatory lesions (IL), spondylitis duration and clinical features of AS activity. Material and methods. MRl was performed in 36 pts (22 male, 14 female) fulfilling the modified NY criteria of AS. Median age of pis was 26 years (range 19 - 55), Median AS duration - 8 years (range 1,8 - 24). 34 (97%) pts were HLA-B27 positive. 21 (64%) pts had high AS activity - median BASDAI 40 (range 10 - 77). 92% of pts had inflammatory spine pain (VAS>20 mm) and 61% of pts had night pain. Median inflammatory pain duration had been defined separately for every part of the spine assessed by MRl. Median duration of axial pain was 36 months (range: 1-240). MR-scanning (Magnetom Symphony, Siemens, 1.5 T) was performed inTl, T2 and T2-FS (fat signal suppression) modes. IL scoring was done only in 29 pts evaluated in both sagittal and axial planes. We used two scoring methods: 1) individual IL score of the each spine element (vertebral bodies, processes, arches, zygapophyseai, costovertebral and costotransverse joints, ligaments), and 2) separate IL scoring in the vertebral bodies and posterior spinal elements in order "yes/no”. Results. 50 MRl images of different parts of the spine (8 cervical, 30 thoracic and 12 lumbar) have been obtained in 36 pts. Spine IL were found in 35 pts. 26% of all IL were revealed in axial planes. 3 pts with short AS duration had IL only on axial slices (zygapophyseai lumbar joints, costotransverse joints, processes). IL were revealed more often in thoracic (average score: 7.1), than in lumbar (3.7) and cervical (2.1) spine. In most (26 from 29 pts, 90%) pts IL were found in painful parts of spine. There was no IL score difference between pts(n=12) with low (BASDAI <40) and high (BASDAI>40; n=17) AS activity. Me and range were 4 (1.8-10.3) and 6 (4-16), respectively; p=0.35. There was also no difference in percent of images with IL between pts with short (Me: 4 months, range: 1-18; n= 10) and prolonged (Me: 54 months, range: 24-180; n=16) duration of spondylitis (100% and 94% of images, respectively). However, pts with early spondylitis had significantly more IL in posterior spinal structures than in vertebral bodies (92.3% and 23.1% images, respectively; p<0,001). Conclusion. Inflammatory MRl lesions are frequently observed in pts with active AS, more often in thoracic spine, and independently of spondylitis duration. Inflammatory MRl lesions in early spondylitis are revealed more often in posterior structures of spine. These results show the necessity to obtain MRl scans for early diagnosis of AS not only in sagittal but also in axial plane.

Objective. To assess melatonin (ML) efficacy for correction of sleep disturbances, its influence on clinical symptoms and laboratory activity measures as well as cortisol level in pts with rheumatoid arthritis (RA) Material and methods. Blind randomized placebo controlled study was performed. 38 women with RA fulfilling ACR criteria and disease duration not exceeding a year were included. Pts of the main group (n=19) received melatonin (Melaxen, Unifarm, USA) 3 mg I hour before sleep, control group pts (n= 19) received placebo. All pts received nonsteroidal anti-inflammatory drugs and disease modifying anti-rheumatic drugs. Clinico-laboratory measures of inflammatory activity, sleepless symptoms score, plasma cortisol and urine 6-sulphotoximelanotonin (6-STM) levels with immuno-enzyme assay were evaluated. Results. To the end of study sleep quality improved and morning stiffness significantly decreased in the main group pts in comparison with placebo group. 20% decrease of morning stiffness was achieved in 90% of ML group and 44% of placebo group pts. Other clinical features of RA including DAS28 changes did not significantly differ between groups. Treatment with ML also induced endocrine status changes in RA pts: decrease of plasma cortisol and significant increase of urine 6-STM levels. Endocrine measures did not change in placebo group. Conclusion. ML efficacy in the treatment of sleep disturbances in pts with RA was confirmed. Decrease of cortisol blood level in such pts probably connected with shift of its peak to earlier hours providing decrease of morning stiffness.

Objective. To assess significance of arthrosonography in diagnosis of in knee joint changes in patients with early rheumatoid arthritis (RA). Material and methods. 44 patients with early RA aged 19 to 73 years were examined. 29,5% of pts had early RA without primary osteoarthritis (OA), 70,5% had early RA with primary OA. Ultrasonography of knee joints was performed with Diasonics (USA, 1997) by the linear sensor with frequency of 7 MHz. The protocol of ultrasonic examination of knee joints was filled for each pt. Results. Clinical signs of of knee joint synovitis have been revealed in 61,5% of pts with early RA without primary OA, and in 80,6% of pts with early RA with primary OA, ultrasonic - in 100% of pts. Intraarticular knee joint effusion resulted in increase of suprapatellar bursa and lateral recesses size. Extraarticular inflammation was frequently shown by thickening of semymemranous muscles tendons, especially in pts with the early RA with primary OA (p<0,005). Degenerative changes in the group of pts with primary OA were more expressed in early RA and usually accompanied by non-uniform decrease of cartilage thickness and occurrence of osteophytes while cartilage in pts with early RA without primary OA had normal thickness or thickening because of swelling, and osteophytes were absent. Conclusion. Prevalence of knee joint intraarticular and extraarticular inflammatory changes over degenerate changes (symmetric thickening of the synovium, primary increase of the sizes of suprapatellar bursa and lateral recesses because of effusion, thickening of tendons of knee joints at the normal or increased thickness of cartilage because of inflammation) can be considered sonographic sign of early RA. In pts with early RA coincided with primary OA these changes were usually found in combination with non-uniform decrease of cartilage thickness. In case of cartilage inflammatory edema, detection of osteophytes allows to confirm presence of OA in pts with early RA.

Introduction. Adalimumab (Humira) is a monoclonal anti-TNFa antibody fully identical to human antibodies, a member of group of TNFa blockers which are now the main biological drugs for the treatment of rheumatoid arthritis (RA). Till recently adalimumab was little known in Russia. Material and methods. 24 pts (2 male and 22 female) were included in an open 24-week clinical study of adalimumab in active RA. Mean duration of the disease was 6,4 years. 5 pts had early RA. In all pts DAS28 was higher than 5,1. All pts earlier received main traditional DMARDs (methotrexate, leflunomide, sulfasalazine) and steroids without significant improvement. All pts were treated on an outpatient basis. Adalimumab 40 mg was injected subcutaneously with 2 weeks intervals during 24 weeks. Results. 22 from 24 pts (91,7%) completed full course of treatment with adalimumab. All outcome measures (pt self assessment on VAS, DAS28,HAQ, CRP) showed fast and sustained improvement. Good effect according to EULAR criteria was achieved in 8 (33,4%), moderate — in 14 (58,3%) pts and 2 pts (8,3%) did not respond to the treatment. Effect did not depend on age, previous treatment, comorbid diseases and disease duration. During follow up period serious adverse events and tuberculosis did not appear in this group of pts. Conclusion. Adalimumab is a highly effective biological drug from the group of TNFa blockers which is particularly useful for the treatment of RA resistant to conventional therapy on an outpatient basis.

Rituximab in the treatment of nodal B- cell marginal zone lymphoma, primary Sjogren’s syndrome and autoimmune hepatitis A case of nodal B- cell marginal zone lymphoma, primary Sjogren’s syndrome and autoimmune hepatitis treated with rituximab is presented.

Objective. To compare efficacy of different glucocorticoid (GC) medication forms in protracted and chronic gout arthritis. Material and methods. 59 pts with tophaceous gout (crystal-verified diagnosis) and arthritis of three and more joints lasting more than a months in spite of treatment with sufficient doses of nonsteroidal anti-inflammatory drugs were included. Median age of pts was 56 [48;63], median disease duration — 15,2 years [7,4;20], median swollen joint count at the examination — 8 [5; 11]. The patients were randomized into 2 groups. Methylprednisolone (MP) 500 mg/day iv during 2 days and placebo im once was administered in one of them, betamethasone (BM) 7 mg im once and placebo iv twice — in the other. Results. Number of pts with full resolution of arthritis, recurrent exacerbation, insufficient arthritis resolution or clinically insignificant response was comparable in both groups. More rapid decrease of pain at moving was achieved during the first 2-3 days after GC administration in pts with full resolution of arthritis (p=0,03) in group receiving MP in comparison with BM. At day 14 joint damage measures did not differ between groups. Conclusion. Efficacy of short-term glucocorticoid administration does not depend on mode of administration and GC medication form (methylprednisolone 500 mg/day iv during 2 days or betamethasone 7 mg im once.

Objective. To study functional status, character of functional disturbances and possibilities of their correction in children of early age with juvenile arthritis (JA). Material and methods. 42 pts with oligoarticular (at presentation) variant of JA with onset before 4 years of age admitted to pediatric department of the Institute of rheumatology of RAMS were included. Mean age of children at the disease onset was 22,4+10 months (from 9 to 46 months), mean disease duration at the first hospitalization — 9,5±5,5 months. Functional status and daily activities limitations (decrease of moving capacity and hand performance) were assessed at the beginning of the disease, at admission to the institute and at discharge after drug and rehabilitation treatment. Results. At the disease onset 40 pts (95,2%) had knee joint damage (one sided in 28 — 66,6%). 30 from these 40 pts (75%) had flexion deformity and daily activities limitations and two pts had anlde joint damage. 12 pts (28,6%) received courses of nonsteroidal anti-inflammatory drugs (NSA1D) and 5 pts (11,9%) — disease modifying anti-rheumatic drugs (DMARD) before admission. All pts had active joint syndrome at admission. Daily activities limitations were present in 41 pts (97,6%). DMARD were prescribed to 41 pts (with glucocorticoids (GC) in 12 cases). Intra-articular injections of GC were performed in 15 pts. Individual exercise therapy (passive joint movement) was applied in all pts, postural treatment — in 41 (97,6%). One pt received exercise therapy in a group. Splints were done for 6 pts. Stepped correction in plaster was performed in 4 from them. In all pts after treatment arthritis subsided and functional status improved. In 18 (42,8%) from them function of damaged joint was fully restored and in 19 (45,2%) — improved. After several stages of hospital treatment deformation was corrected and function restored in 4 (9,5%) pts Conclusion. Клее joints are frequently involved in children of early age with oligoarticular variant of JA. Pain contractures and moving disturbances appear already at the onset of the disease. Appropriate and timely drug and rehabilitation treatment allow correcting joint deformity and preventing disability of these pts.

Objective. To analyze nimesulid efficacy and safety in children with reactive and juvenile chronic arthritis. Material and methods. 108 children aged 1,5 to 18 years receiving niomesulid (Doctor Reddi’s Laboratories Ltd, India) from 3,0 to 5,0 mg/kg/day as the main anti-inflammatory drug were included. Results. Duration of continuous treatment with nimesulid varied from 10 days in reactive arthritis to 1 year in juvenile chronic arthritis. Efficacy of the drug was quite comparable with other NSAID in 99,1% of pts with joint diseases. Adverse events appeared in 5,4% of cases (mainly gastrointestinal damage). Allergic skin rush was seen only during suspension administration. Nimesulid monotherapy did not induce hepatotoxic effect. Conclusion. Nimesulid can be recommended as anti-inflammatory drug in children with reactive and juvenile chronic arthritis. The drug has sufficient anti-inflammatory effect and minimum adverse events during long term administration and in combination with disease modifying anti-rheumatic drugs. Age restriction for nimesulid administration can be decreased to 1,5 years.