A new concept in spondyloarthritis (SpA) aimed to ease the diagnosis of the early stages of the disease differentiates axial SpA without radiological signs of sacroiliitis and ankylosing spondilitis (AS). However, such division of the entire nosological entity into two is illogical.  oreover, it contradicts International Statistical Classification of Diseases and Related Health Problems (ICD-10) and does not have a clinical proof (clinical data support), which was demonstrated in the work of E.E. Gubar et al. published in the present issue of the journal. Therefore it appears more reasonable to consider non-radiological axial SpA (with sacroiliitis confirmed by MRI) as an early stage of SpA.

Authors report new recommendations of All-Russian Public Organization «Association of Rheumatologists of Russia» (ARR) on treatment of rheumatoid arthritis (RA), which adapts contemporary concept accepted in the respective field of pharmacotherapy known as «Treat to Target». According to it, the main objective of RA pharmacotherapy is a remission (or low disease activity). To achieve it, disease modifying anti-rheumatic drugs (DMARD) should be administered to all RA patients as early as possible, with efficacy monitoring and therapy correction according to the disease activity. Special attention has been paid to the use of methotrexate (MTX) as
«the gold standard» of RA pharmacotherapy and the key component of «Treat to Target» strategy. Early MTX administration (including subcutaneous injections) should become an obligatory component of RA treatment at all stages of the disease. If MTX is not efficient or not well tolerated (including subcutaneous form of the drug) as monotherapy or combined with conventional DMARD, biological agents should be used. Those include TNFα inhibitors, antagonist of interleukin-6 receptor (Tocilizumab), anti-B-cell drugs (Rituximab) and agents blocking T-cell activation (Abatacept). Tofacitinib therapy (JAK inhibitor) is indicated in patients who are resistant to conventional DMARDs and biologics. All biologics and Tofacitinib are more effective in combination with MTX (or other DMARD).

Objective: to assess the efficacy and tolerability of Rituximab treatment in patients with serious immune inflammatory rheumatic diseases (IRD) like systemic lupus erythematosus (SLE), systemic sclerosis (SS), systemic vasculitis (SV), Sjogren syndrome (SjS), dermatomyositis/polymyositis (DM/PM).

Subjects and methods. The clinical efficacy has been analyzed in 229 patients with IRD: SLE (n=97), SV (n=50), SS (n=40), SjS (n=23) and DM/PM (n=19). Rituximab treatment was accompanied by administration of glucocorticoids and/or immunosuppressive drugs. Most patients demonstrated resistance to or low tolerability of standard therapy. Efficacy of treatment was analyzed in each group with the criteria relevant for each disease. To compare clinical response to the treatment between the groups we used gradations accepted by international registries: complete (good) response, partial response, no response. Average duration of monitoring comprised 72 (1–288) weeks after the first introduction of Rituximab. Average Rituximab dose administered to patients over the period of monitoring was low and varied from 1.6±0.84 in DM/PM to 3.1±1.75 in SV. About 80% of patients received one or two courses of Rituximab except for patients with SS (half of them received three and more courses).

Results. «Complete response» was observed in 50.6%, «partial response» – in 35% of patients. Rituximab courses provided positive dynamics in clinical scores and allowed to reduce supportive dose of glucocorticoids and to lower the dose or withdraw of immune-stimulating drugs. Multiple Rituximab courses provided stable and longlasting effect. Recurrences were observed less frequently, whereas efficacy of the therapy increased during a year and longer. Occurrence of adverse events and mortality rate were comparable to data of other national Rituximab registries.

Conclusion. The results of the study may prove administration of Rituximab in patients with resistance to standard therapy

Objective: to study clinical manifestations of axial spondyloarthritis (axSpA) fulfilling ASAS criteria and to evaluate Russian version of modified New York criteria for the diagnosis of AS in Russian patients.

Subjects and methods. Authors examined 73 patients aged 18–45 years suffering from inflammatory back pain for a period from 3 months to 5 years. BASDAI and ASDAS-CRP were used to assess activity, whereas BASFI – to evaluate functional status. Examination included: assessment of HLA-B27 rate, X-ray of pelvis and lumbar spine, ultrasonography of hip joints and calcaneal regions, magnetic-resonance imaging (MRI) of sacroiliac joints, lumbar spine and hip joints (if clinical signs of injury are present), densitometry of lumbar spine (LII–IV) and femoral neck.

Results. Mean age of patients was 28.3±6.4 years, mean duration of disease – 19.9±14.4 months. HLA-B27 was found in 94.5% of patients. Mean BASDAI value was 4.1±1.9; ASDAS – 2.7±1.3; BASFI – 2.6±2.1. Peripheral arthritis was observed in 65.8% of cases, coxitis – in 31.5%, calcaneal enthesitis – in 61.6%, dactylitis – in 19.2%, low bone mineral density – in 17.8%. MRI showed inflammatory changes of axial skeleton in 84.9% of patients, active sacroiliitis (SI) – in 72.6%. X-ray revealed definite SI in 49.3% of patients («classic» AS). According to MRI data, 30.1% of patients with active SI and without structural changes of sacroiliac joints had pre-radiological stage of AS (by Russian version of modified New York criteria). 74.0% of patients fulfilled both sets of ASAS criteria for axSpA, 5.5% – met only I criteria set, whereas 20.5% – only II criteria set. Three groups of patients were defined. The first included patients with radiologically proven SI, the second – with MRI-proven SI and the third – patients without SI. Significant difference between the groups was detected either by gender (number of males in groups I and II exceeded that in group III: p1–3=0.002, p2–=0.033) or by the rate of high activity according to ASDAS index (observed in groups I and II more frequently than in group III; p=0.02 in both cases) or by presence of inflammatory changes in spine in MRI scans (detected in 26% of patients of group III, not detected in patients of group II; p=0.05).

Conclusion. Half of patients with axSpA symptoms longer than 20 months already have structural changes in sacroiliac joints, so they can be diagnosed as «classic» AS. 80% of patients who had axSpA for less than 5 years match the description of AS provided by Russian version of modified New York criteria; one third of them has pre-radiological stage of disease. Number of males with radiologically proven SI and MRI-proven SI was larger than that of patients without SI. SI is often accompanied with high activity according to ASDAS. MRI showed that, inflammatory processes in spine may precede active SI. No clinical differences were revealed between patients with radiogically proven AS and pre-radiological stage of AS described by Russian version of modified New York criteria.

Objective: to study how clinical characteristics of ankylosing spondylitis (AS) affect working efficiency.

Subjects and methods. Authors examined 220 patients with AS (162 males and 58 females). Mean age was 35.1±9.5 years, mean age of the disease manifestation – 30.0±9.7 years. Median duration of AS was 73 [5; 396] months. Activity of the disease was high (BASDAI and ASDAS values 4.6±2.1 and 3.3±1.3 respectively). BASFI was increased to 4.1±2.6, HAQ – 0.98±0.64. Work productivity was assessed with WPAI (Work Productivity and Activity
Impairment) questionnaire by four aspects: absenteeism, presenteeism, general reduction in productivity (GRP) and activities of daily living (ADL).

Results. Among 220 patients with AS, 133 were employed (60%). Median value of absenteeism comprised 0 [0; 85] %, presenteeism – 40.3±24.4%, GRP – 59.1±32.9%. Mean ADL was 49.8±26.6% less than normal. Inverse correlation was observed between absenteeism and AS duration (R=-0.22). BASDAI correlated with WPAI aspects: absenteeism (R=0.21), presenteeism (R=0.70), GRP (R=0.37) and reduction in ADL (R=0.73). The strongest correlation detected was that between WPAI aspects (R>0.5) and the intensity of pain assessed by visual analogue scale. BASFI index showed moderate correlation – with GRP (R=0.30) and close – with presenteeism and reduction in ADL (R=0.56 and R=0.71 respectively) and did not correlatewith absenteeism.

Conclusion. AS activity was the main factor influencing work productivity. Presenteeism correlates with clinical characteristics
of AS considerably stronger than absenteeism. All WPAI aspects correlated with the disease activity and degree of functional impairment.

Uveitis is a common extraskeletal manifestation of ankylosing spondylitis (AS) occurring in 20–40% of patients. Most
authors underline a favorable prognosis for AS-associated uveitis.
Objective: to study features of clinical picture and progression of AS-associated uveitis and to estimate the occurrence of its complications.

Subjects and methods. Across-sectional study of 140 patients (98 males and 42 females) with AS, who had at least one uveitis attack over the period of disease and was followed up at V.A. Nasonova Research Institute of Rheumatology during 2008–2012. In addition to standard rheumatologic examination all patients were examined by ophthalmologist. Biomicroscopy, ophthalmoscopy, tonometry, computer-assisted perimetry, ultrasonography (B-scanning) of eyes and, if needed, fluorescein angiography and electrophysiological examination of retina were performed. Localization of uveitis, presence of complications affecting vision, total number of uveitis attacks by the moment of examination, mean number of uveitis attacks per year, correlation between the frequency of attacks and complications, presence of other extraskeletal manifestations and peripheral arthritis were assessed. The total number of uveitis attacks was defined from patients' interviews and respective medical documentation. Mean number of uveitis attacks was calculated as ratio of total number of uveitis attacks to the duration of disease for each patient. In the case of more than two attacks per year uveitis progression was considered
refractory.

Results.Mean duration of the disease was 17.7±11.03 years. In 19 patients (14%) AS manifested before and in 121 (86%) – after the age of 16 years. HLA-B27 was revealed in 135 (96%) patients, peripheral arthritis – in 43 (30%), whereas other extraskeletal manifestations – in 46 (32%). Early onset of uveitis in first 10 years of the disease was recorded in 81 (58%) patients, after10 years – in 21 (15%). Uveitis was the first clinical symptom of AS in 37 (26.4%) patients. 33 (24%) patients had more than 10 uveitis attacks during the disease, 17 (12%) – more than two attacks per year, whereas 18 (13%) had chronic uveitis. 118 (84%) had localized iridocyclitis, 12 (8%) – panuveitis, 2 (1%) – localized posterior uveitis. 122 (87%) patients had unilateral uveitis, 18 (13%) – bilateral, whereas 45 (36%) – alternating eye lesions (OD-OS). Uveitis complicated with vision impairment was observed in 41 (29%) patients: synechia in 26 (18%), vitreous degeneration – in 20 (14%), cataract – in 32 (23%), glaucoma – in 13 (9%), maculopathy – in 6 (4%), ribbon-like retinal degeneration – in 6 (4%), partial optic nerve atrophy – in 3 (2%). Authors revealed direct correlation between frequency of uveitis attacks and occurrence of synechia, cataract, glaucoma, vitreous degeneration.

Conclusion. AS-associated uveitis is predominantly characterized by unilateral iridocyclitis (84%) and the onset in the first 10 years of disease (84.4%); 25% of cases were remarkable for frequent relapses: more than two attacks per year and more than 10 during the period of disease. One third of patients demonstrated vision impairments, and its progression correlated with the frequency of uveitis attacks.

The main symptom of osteoarthritis (OA) is pain. Mechanisms of chronic pain in OA have not been fully investigated yet.
Objective: to study key mechanisms of chronic pain in patients with knee OA.

Subjects and methods. Authors examined 80 women aged 45–65 years, with chronic pain due to OA of the knee. Clinical rheumatologic and neurologic examinations, screening for neuropathic pain (PainDETECT and DN4 questionnaires), estimation of duration and intensity of pain, WOMAC assessment and evaluation of affective disorders (HADS questionnaire) were performed. X-ray and ultrasonography were used to assess destructive changes of the
knee.

Results. According to DN4 questionnaire, 25 (30%) patients scored 4 and more, i. e. had signs of neuropathic pain, whereas 55 (70%) did not (scored less than 4). Although neurologic examination did not reveal lesions of somatosensory system in neither of groups, assessment of the pain sensitivity showed hyperalgesia in 60% of cases. Patients with signs of neuropathic pain typically have secondary hyperalgesia propagating far from the damaged joint.

Conclusion. 30% of patients with osteoarthritis have pain of different intensity determined by nociceptive and neuropathic mechanisms. At the same time the absence of lesions of somatosensory system does not let us to consider the pain neuropathic and indicates that it has dysfunctional nature. Signs of neuropathic pain associated with secondary hyperalgesia may be a clinical symptom of central sensitization. Due to this fact, reasonable therapy of osteoarthritis-associated chronic pain should include, besides NSAIDs, central acting drugs for neuropathic pain treatment.

The lack of reliable data on rheumatic diseases (RD) incidence in the Republic of Tajikistan, discrepancy in statistical figures and growing rate of registered advanced cases became an impetus to analyzing hospital incidence of rheumatic diseases within the largest republican medical institution.
Objective: to present the pattern, incidence and clinical picture of RD in patients who was undergoing hospital treatment in the Department of Rheumatology of National Medical Healthcare Center (NMHC) of the Republic of Tajikistan (Dushanbe).

Subjects and methods. The present article provides data of retrospective analysis of medical records of 4716 patients hospitalized to the Department of Rheumatology of NMHC during 2005–2010. All patients were divided into two groups on a provisional basis: patients with inflammatory RD (n=2872) and those with non-inflammatory or metabolic RD (n=1844).

Results. Authors established that leading cases among inflammatory rheumatic diseases are rheumatoid (n=1481) and reactive (n=598) arthritis, whereas among non-inflammatory and metabolic RD – osteoarthritis (n=1243) and gout (n=157). Continuing growth of newly registered RD can be proven by the fact that over 5 years the number of callings increased from 729 to 1032 per year. At this, women were diagnosed with RD more often than men (66 and 34% of cases respectively). Mean age of RD patients was 41.05±11.79 years, what shows that the part of the country population which is characterized by the highest work productivity is affected. Patients with RD also had comorbid cardiovascular pathology, metabolic syndrome and gastropathies.

Conclusion. Rheumatoid and reactive arthritis are the most frequent RD of inflammatory origin, whereas osteoarthritis is one of the most frequent reasons of hospitalization. RD affects the most productive part of population. Besides, RD is gender-selective as in all considered age groups women were most affected. The most frequent comorbid diseases in patients with RD are cardiovascular diseases, metabolic syndrome and gastropathies.

Objective: to study results of arthrodesis of the first metatarsophalangeal joint (I MPT joint) in patients with rheumatoid
arthritis (RA) and hallux valgus, assess methods of arthrodesis fixation, reveal complications and analyze longterm results.

Subjects and methods. Authors observed 86 patients with RA, female : male ratio 3.2:1, mean age was 53.8±9.5 years (from 18 to 75 years); 80 from them had seropositive and 6 – seronegative RA. 72 patients had low, and 14 –moderate activity of the disease. II stage of RA was revealed in 31.4%, III – in 62.8%, IV – in 5.8%; 52.3% of  patients had I and 47.7% – II functional class. All patients  ad hallux valgus as a component of typical deformation of the forefoot – digitis V rheumaticus (DVR). Standard global reconstructive operation (SGRO) and its modification (MGRO) were used. Both techniques included arthrodesis of the I MTP joint where fusion of bones was fixed with Kirschner wire and compression clamps in groups A and B respectively. Results of surgical treatment
were assessed separately for I and II–V toes. The present work provides solely the results of the I MTP joint arthrodesis.

Results. Assessment of the I MTP joint with hallux valgus before and 2.3±1.5 years after operation based on AOFAS comprised 35.51±8.16/82.32±6.09 in the group A and 39.93±6.65/82.26±5,59 in the group B. Inefficiency of arthrodesis of the I MTP joint was observed in 3 patients from the group B (2.15%). Before operation, 3 from 141 feet had hallux valgus of the II stage (21–40°); III (41–60°) and IV (>60°) stages of hallux valgus were recorded in 90 and
48 feet respectively. Following 2.3 years after arthrodesis normal I MTP joints (10–11°) were observed in 131 feet whereas, that of the II stage of hallux valgus (12–20°) – in 10 feet.

Conclusion. High efficacy of arthrodesis of the I MTP joint in patients with RA and hallux valgus and, subsequently, low failure rate (2.15%) were achieved as a result of appropriate techniques of arthrodesis fixation. Positive long-term results (according to AOFAS questionnaire) in 2.3 years after the operation were recorded in 97.8% of cases.

Objective: to compare the efficacy and safety of intra-articular therapy with Rusvisk (hyaluronic acid product) and Ostenil in early stages of knee osteoarthritis.

Subjects and methods. 50 patients with II–III stage of the knee osteoarthritis were included in the randomized double blinded controlled study. They had pain at movement of more than 40 mm by visual analogue scale (VAS) and Lequesne index of 4–12. All patients received a course of three intra-articular injections with products of hyaluronic acid at the interval of 7 days. Rusvisk (molecular weight 3500 kDa) was administered to 25 patients, whereas other 25 received Ostenil (molecular weight 1200–1400 kDa). In 1, 2, 3 weeks after the first injection following criteria were registered: changes of WOMAC index, pain at movement and at rest by VAS, general assessment of therapy efficacy by doctor and patient, assessment of efficacy according to OMERACTOARSI.

Results. In three weeks after the first injection a significant decrease of pain at movement (by 69% in Rusvisk group and by 55% in Ostenil group) and of WOMAC index (by 63% in Rusvsik group and by 60% in Ostenil group) was achieved in both groups without any differences between them. Significant decrease of pain at rest was observed at all visits only in Rusvisk group. When assessing the general efficacy, patients found more advantagesin the  domestic product, whereas the therapist did not see the differences between groups. Response to the therapy by OMERACT-OARSI criteria was observed in 88% of patients in Rusvisk group and in 64% in Ostenil group. Short-term pain in the site of injection was mentioned by 64% of patients from Rusvisk group and by 72% from Ostenil group.

Conclusion. Intra-articular therapy with the products of hyaluronic acid «Rusvisk», «Ostenil» provides comparable decrease of pain and improvement of functional parameters in patients with knee osteoarthritis.

The present work is devoted to mechanisms of action of cytokines BAFF/BLyS and APRIL in immune inflammatory rheumatic diseases; correlation between the level of this cytokines and activity of rheumatic arthritis and systemic lupus erythematosus (SLE); impact of the biologic agents on the level of BAFF/BLyS and APRIL at RA and SLE.

The present review is devoted to the problem of progression of the knee osteoarthritis. It has been shown that the most important predictors of the disease progression are female gender, strong knee pain, synovitis,
deformation of joints, high body mass index, previous traumas, high bone mineral density of the axial skeleton and subchondral parts of femur and tibia, bone marrow edema. Despite numerous studies conducted in order to reveal risk factors of knee osteoarthritis, results remain controversial and require further investigation.

The present review is devoted to the risk factors of osteoporosis progression in patients with rheumatoid arthritis (RA), both relevant and irrelevant to the main disease. It is assumed that the most important predictors of the bone mineral density decrease is severe course of RA, significant functional disability (according to HAQ), glucocorticoid therapy, elderly age, low body mass index and menopause. However, despite the vast amount of studies, results on the risk factors of osteoporosis remain ambiguous and require further investigation.

It is assumed that juvenile idiopathic arthritis (JIA), as many other rheumatic diseases, is in close pathogenic connection with metabolic disorders and early atherosclerosis. However, the prevalence of metabolic syndrome and its components both in healthy Finno-Ugrian children and teens and JIA patients is unknown.

Objective of the present work was to study the prevalence of metabolic disorders in children with JIA, living in the Republic of Mordovia.

Subjects and methods. Authors have examined 82 children (among them 44 girls) with JIA aged 10–18 years. Results. Full complex of metabolic syndrome symptoms was revealed in 36.6% of patients, most of which had arthritis. Dyslipidaemia, obesity and arterial hypertension were recorded most frequently and correlated with activity of the disease and the dose of systemic glucocorticoids.

Conclusion. JIA is associated with high prevalence of metabolic disorders which only partially (arterial hypertension and carbohydrate metabolism disorders) are connected with glucocorticoid therapy and mainly determined by the high inflammatory activity of the disease.

The case of a giant-cell arteritis is presented. First clinical signs of the disease were fewer and development of infarction in the basin of the left vertebral artery. Magnetic resonance angiography showed its prolonged diminution. Laboratory results were remarkable for the high rate of erythrocyte sedimentation and the increase of C-reactive protein (CRP) concentration. Physical examination revealed acrotism in temporal arteries. Diagnosis was proven by biopsy results which included giant multinucleate cells. Authors discuss problems of diagnosis of the disease, the role of radiological methods (angio-ultrasonography, magnetic resonance and computed tomography aided angiography, positron-emission tomography) and the necessity to pay particular attention to the elderly patients with high rate of erythrocyte sedimentation and the increased CRP concentration.