Analysis of the official statistics of the Ministry of Health of the Russian Federation for the year 2011 indicates a growing incidence of diseases of the musculoskeletal system in adult population of Russia as compared to 2010. A total of 16,277 thousand of adult patients with this pathology were registered in 2011 (13958.4 per 100 thousand population), 3,673 thousand of them were newly diagnosed (3149.9 per 100 thousand). The distribution of the major rheumatic diseases over eight federal districts was studied. Significant differences in the overall and primary morbidity were observed in the federal regions.

In our previous publication, we reported the main provisions of the new EULAR recommendations (2013) and discussed some debating points of RA pharmacotherapy that require further research. The purpose of this article is to review the present-day knowledge concerning the use of methotrexate (MT), since according to the EULAR recommendations, “MT should be considered as the main component of the strategy of the first-line treatment of active RA”. In the context of EULAR recommendations, special priority was given to the discussion of MT administration in patients with early inflammatory (undifferentiated) arthritis (UDA) and early RA, efficacy of MT monotherapy and combined therapy, including, along with MT, the standard basic anti-rheumatic drugs (DMARDs) and genetically engineered biological drugs (GEBDs), the role of MT in the induction and maintenance of remission, including remission without treatment with GEBDs. A conclusion was drawn that administration of MT is required in all patients with early RA and probably in patients with UDA in case of high risk of the disease transformation into RA. Early administration of the subcutaneous form of MT improves the efficacy of RA treatment and should be a mandatory component of the intensive RA treatment strategies, regardless of the use of glucocorticoids and other standard DMARDs and GEBDs. In patients with high disease activity, who require administration of high dose of MT or different schemes of combined treatment, it is advisable to begin the treatment with the injectable form of MT rather than tablet one.

The course of uveitis in patients with ankylosing spondylitis (AS) does not always correlate with inflammation in the axial skeleton and peripheral joints. Effect of tumor necrosis factor α (TNFα) inhibitors on uveitis has been insufficiently studied yet, unlike their effect on the peripheral joints and spine.
Objective. To compare the frequency of uveitis attacks in patients with AS during treatment with TNFα inhibitors and the conventional anti-inflammatory therapy.
Materials and Methods. The study included 48 patients with AS and recurrent uveitis treated with TNFα inhibitors: 25 – infliximab, 15 – adalimumab, 9 – etanercept; 7 patients received two or more drugs sequentially. Median [25th, 75th percentiles] of the treatment duration was 3 [3.5; 5] years. The duration of treatment since the first attack of uveitis until administration of TNFα inhibitors was 5 [5; 9.7] years. Eighteen patients received only nonsteroidal anti-inflammatory drugs (NSAIDs), 30 patients received NSAIDs and basic anti-inflammatory drugs (DMARDs), including sulfasalazine (n = 23), methotrexate (n = 4), and cyclosporine (n = 4).
Results. The median number of uveitis exacerbations during the standard anti-inflammatory therapy was 1 [0.4; 3] per year; during treatment with TNFα inhibitors – 0 [0; 0.5] per year (p = 0.0007). In 19 of 48 patients (40%), no
exacerbations of uveitis were registered during therapy with these drugs. The frequency of uveitis attacks in patients treated with infliximab decreased from 1 [0.2; 2.75] to 0.1 [0; 0.8] episodes per year (p = 0.002), adalimumab – from
1.75 [1; 4.5] to 0 [0; 0.07] (p = 0.04), etanercept – from 0.95 [0.5; 1.75] to 0 [0; 0.07] (p = 0.001).
Conclusion. Administration of TNFα inhibitors significantly reduces the frequency of uveitis attacks in patients with AS.

Diagnosis of lesions of the spine and sacroiliac joints may be helpful in discrimination between early psoriatic arthritis (ePsA) and early rheumatoid arthritis (eRA).
Objective. To assess the significance of inflammatory back pain (IBP), HLA-B27, and active sacroiliitis (ASI) confirmed by magnetic resonance imaging (MRI) for differential diagnosis of polyarticular ePsA and eRA.
Materials and Methods. The study included 29 patients with ePsA (13 males and 16 females, mean age 36.52 ± 11.27 years, average duration of the disease 13.03 ± 9.77 months) and 25 patients with eRA (7 males and 18 females, mean age 52.68 ± 14.7 years, average duration of the disease 4.0 ± 1.72 months). Presence of IBP (according to the ASAS criteria) and HLA-B27 were assessed (in 27 patients with PsA and in 20 patients with RA); ASI signs were assessed based on the MRI data (bone marrow edema/osteitis). DAS, DAS28, M ± SD, Fisher's exact test, t-test, χ2, the Yule coefficients of association (Q: level from -1 to +1) and Phi were calculated; differences were considered to be statistically significant at p <0.05.
Results. In patients with ePsA, ASI was detected by MRI significantly more frequently than in patients with eRA (41.4% and 12% of cases respectively, p < 0.016). No correlation between the presence of ASI and DAS28 was observed in both groups. In the ePsA group, IBP was detected in 17 patients (58.6%); it was long-term in 10 (58.8%) of the patients and episodic – in 7 (41.2%) patients. Back pain with mechanical rhythm was observed in 3 (12%) patients with eRA. HLA-B27 was detected in 9 (33.3%) of 27 patients with ePsA and in 3 (15%) of 20 patients with eRA (p < 0.014). In patients with ePsA, a very high level of association between ASI and IBP (Q = 0.91, Phi = 0.56; p < 0.003) and a high level of association between ASI and HLA-B27 (Q = 0.75, Phi = 0.56; p < 0.039) were detected. MRI showed no association between the presence of HLA-B27 and ASI signs in patients with RA.
Conclusions. ASI is detected by MRI significantly more often in patients with ePsA; however, it can also be observed in patients with eRA. In patients with ePsA, ASI is closely associated with IBP and HLA-B27; this fact can be used for
differential diagnosis of polyarticular ePsA and eRA. The activity level of peripheral arthritis does not affect detectability of ASI by MRI in patients with ePsA.

Objective. To develop a structured training program for patients with rheumatoid arthritis (RA) to self-monitor disease activity and to assess effectiveness of this program.
Material and Methods. The study included 60 patients with definite diagnosis of RA according to the ACR/EULAR 2010 diagnostic criteria (52 females and 8 males, mean age 58.8 ± 10.4 years, the median duration of RA was 5 [2.75;
12] years). Patients were trained using the original method Structured Program of Training Patients with RA to Self-Monitor Disease Activity during the first visit and one month later (second visit). Skill acquisition was controlled by
estimating the number of painful (NPJ) and swollen (NSJ) joints in parallel by a physician and the patient during the second visit and 2 months after the first visit (the third visit). Statistical significance was analyzed using the McNemar’s test (differences are considered to be significant when p <0.05).
Results. Absolute coincidence of NSJ as assessed in parallel by a physician and the patient was observed in 26 (43%) cases during the second visit and 41 (68%) cases during the third visit (p = 0.018). Results of NPJ assessment by a
physician and the patient coincided in 20 (33%) cases during the second visit and 36 (60%) cases during the third visit (p = 0.003).
Conclusion. The structured program allows RA patients to correctly determine the painfullness of joints in 60% of cases and joint swelling in 68 % of cases, which is important for self-control of the disease activity.

Diseases of the musculoskeletal system (DMSS) are a topical social, medical, and economic problem. They are widespread and account for about 10% of the overall morbidity and primary disability of population, about 5% of primary morbidity, and about 0.1% of mortality. The reliable statistics are important to analyze the situation and make necessary adjustments to the organization of medical care.
Objective. To examine the accuracy of the data on morbidity and mortality from DMSS in the Tula region.
Materials and Methods. Data from statistical reports, reference documents, and databases of Tula region residents (including those who died in 2000–2011) were used.
Results. The inequality in growth rates of general and primary morbidity were revealed, which is indicative of incorrect coding and underestimation of DMSS in medical organizations of the Tula region.A comprehensive phased statistical study was carried out to assess validity of the mortality data, including the following: verification of databases for errors using an automated system; control of postmortal diagnosis quality using the four-digit subcategory code in accordance with the WHO recommendations; analysis according to the initial and multiple causes of death. Underestimation of mortality from rheumatoid arthritis by about 25% was revealed. Attention was paid to the implementation and use of automated systems.

Vertebral fractures in osteoporosis (OP) patients are accompanied by a decrease in quality of life (QoL) and functional limitations. Physical activity is often recommended for such patients to reduce pain, improve QoL, and functional
status.
Objective. To assess the impact of exercises on QOL, functional performance, and balance in patients with osteoporotic vertebral fractures.
Material and Methods. The study included 78 women with vertebral fractures and chronic back pain (40 patients in the study group and 38 patients in the control group). The average age of patients in the study group was 70.7 ± 8.1 years; in the control – 67.6 ± 7.0 years (p = 0.35). The studied parameters did not significantly differ for two groups at the beginning of the study. In the study group, physical exercises were conducted for 40 minutes twice a week during 12 months. Patients in the control group were recommended to follow the same physical activity as it was prior to the study. Evaluation of the studied parameters at study baseline and 12 months later was carried out using the QUALEFFO-41 questionnaire, a computer system for disequilibrium diagnostics and the «Stand up and walk» test.
Results. After 12 months, a statistically significant improvement in QoL was observed among patients of the study group, both in the total score (41.2) compared with the control (57.3, p<0.0001), and in values of all domains, as well as results of the «Rise from a sitting position» and «Chasse step» balance tests. After 12 months, the study group showed a statistically significant reduction of time required to execute the «Stand up and walk» test from 12.1 ± 3.8 to 10.8 ± 2.5 s (p = 0.028), while no changes were observed in the control group (11.1 ± 3.4 and 11.1 ± 2.8 s respectively). Exercises improve QoL, functional activity and balance in patients with osteoporotic vertebral fractures.

The lecture provides information about the etiology and pathogenesis of antiphospholipid syndrome (APS) and genetic susceptibility to its development. The most recent international diagnostic criteria for APS and its variants have been reported. This syndrome can affect multiple organ systems depending on localization of thrombosis; therefore, nowadays the problem of APS is multidisciplinary. Clinical manifestations of APS are rather general (thrombosis of different localization); thus, the diagnosis can be verified only in the case of presence of antiphospholipid antibodies. The differential diagnosis of APS is discussed.

Rheumatoid arthritis (RA) is a heterogeneous disease. The pathogenesis of this disease is based on a complex combination of genetically determined and acquired defects of the regulatory mechanisms that limit the pathological activation of the immune system in response to potentially pathogenic stimuli and often to physiologic stimuli. Modern antirheumatic drugs can effectively suppress the inflammatory process and largely deter the disease progression. However, their potential can be fully used only provided that the appropriate treatment strategy is applied, with regular monitoring of disease activity being the key component in the management of RA patients. Quantitative assessment of the patient's status allows one to develop standardized indications for antirheumatic therapy. Application of clinical indices for assessment of the disease activity does not guarantee complete objectivity of the results. Diagnostic indices based on multivariate analysis of biomarkers are being elaborated. Accumulation of the data on features of protein profile in RA patients gave grounds for elaborating an index to determine disease activity. This index is based on measuring concentration of biomarkers associated both with clinical indices and their components (multibiomarker disease activity, MBDA) – VECTRA DA. MBDA is currently the only clinically proven laboratory index that can be used to monitor RA activity and to predict the progression degree of destructive joint disease and therapy effectiveness.

Matrix metalloproteinases (MMPs) are a group of over 20 proteolytic enzymes responsible for cleavage of protein components of the extracellular matrix. Three types of MMPs play an important role in the development of joint damage in patients with rheumatoid arthritis (RA): collagenases (MMP1, 8 and 13), stromelysins (MMP3), and gelatinases (MMP9). MMP3 is considered to be one of the key mediators of joint damage. Increased serum level of MMP is not specific for RA and may be registered in other rheumatic diseases (osteoarthritis, psoriatic arthritis, gout, ankylosing spondylitis, systemic lupus erythematosus); however, monitoring of the level of MMP is of particular clinical importance in patients with RA. MMP3 serum level may be a useful marker of disease activity. Several studies have shown a correlation of MMP3 concentration with clinical and laboratorial parameters of inflammatory activity (ESR and C-reactive protein – CRP) in RA patients. The elevated level of MMP3 is associated with radiological changes in joints and can also be a predictor of severe destructive lesions in RA patients. Evaluation of the MMP3 level can also be useful for monitoring the therapy effectiveness using both standard disease-modifying antirheumatic drugs (DMARDs) and genetically engineered biological drugs (GEBD). Thus, evaluation of MMP3 concentration is useful for assessing disease activity and efficacy of treatment with DMARDs and GEBD, as well as for predicting the severity of destructive changes in joints.

The article reports one of the most affordable rehabilitation methods, i.e. occupational therapy. The issues related to the history of occupational therapy as a treatment method, its application in rheumatology and promising directions
of development are covered.

This article reports a clinical case of administration of canakinumab (Ilaris®), an interleukin-1β inhibitor, in a patient with chronic tophacaceous gout resistant to therapy with nonsteroidal anti-inflammatory drugs, glucocorticoids, and
colchicine. The results show a good and long-term clinical effect of the drug, which includes reduction of the number of painful and swollen joints and the absence of exacerbations during trial of the therapy of hyperuricemia.

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by inflammatory and destructive joint damage and extra-articular manifestations involving various organs and systems in the pathological process. One of systemic manifestations of RA is cutaneous rheumatoid vasculitis (RV). Factors predisposing to the development of RV in RA patients include male gender, high titers of rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) antibodies, antineutrophil cytoplasmic antibodies, and presence of other extra-articular manifestations. RV may develop due to immune complex deposition on the vascular walls. RV activity correlates with high level of RF, anti-CCP and anti-nuclear antibodies. The typical signs of RV include peripheral gangrene, mononeuritis multiplex, as well as scleritis, pericarditis and lung damage. However, skin lesions, such as periungual infarction (digital arteritis), capillaritis, livedo reticularis, and chronic leg ulcers, are more common signs. Development of RV worsens the prognosis of the disease. The 5-year survival rate of RV patients was 28–40% until the principle of early administration of basic anti-inflammatory drugs was implemented. RV is not an independent disease; in most cases, RV alone does not impose a threat to a patient and requires no treatment. Special treatment of cutaneous vasculitis is required in case of venous ulcers only. The article discusses the pathogenesis issues and strategies of RV treatment in RA patients.

Lung damage, along with the pathology of the upper respiratory tract and kidneys, constitute the classic triad of Wegener's granulomatosis with polyangiitis (GPA). The special features of pulmonary pathology in this disease include the possibility of asymptomatic course. A case of asymptomatic lung damage in a patient with GPA has been reported. Despite clear signs of drug-induced clinical and laboratory remission, routine computed tomography (CT) revealed
progressive changes in lung parenchyma as multiple foci with destruction, which regressed after treatment with cyclophosphamide. The importance of instrumental examination, including CT of the chest at the onset of GPA and during the subsequent follow-up, was emphasized.

The article presents a rare case of pulmonary manifestation of seropositive protracted rheumatoid arthritis in the form of bronchocentric granulomatosis. The algorithm for diagnosis is described in details in the context of the known literature on pulmonary manifestations as a complication of rheumatoid arthritis and morphology of bronchocentric granulomatosis.

The article presents a brief review of the proceedings of the IX European Forum on antiphospholipid antibodies held in May 2013 in Krakow (Poland). The aim of the Forum is to coordinate multicenter projects focused on antiphospholipid antibodies (aPL), both clinical and fundamental research, based on cooperation between the European countries. The main purpose is to stimulate research into all aspects of aPL, to facilitate the exchange of information between institutions, and to involve many centers in different countries into scientific research on this issue. The issues of standardization of the diagnostic criteria for antiphospholipid syndrome (APS), primarily serological markers (their specificity, sensitivity and correlation with clinical manifestations), as well as non-criterial manifestations of APS, were considered at the meeting. In addition, the therapy problems were discussed.