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Patent foramen ovale and hereditary thrombophilia are both known risk factors for ischemic stroke. Artery of Percheron is a rare anatomical variant in which vast areas of the midbrain and thalamus have a single source of blood supply. This case report presents a 45-years old female patient with bilateral thalamic stroke due to Percheron artery occlusion, with a combination of hereditary thrombophilia and patent foramen ovale as the risk factors. Modern approaches to the diagnosis and secondary prevention of this pathology are also discussed herein.

Behçet’s disease (BD) is systemic vasculitis of unknown etiology, which is more common in the countries located along the Great Silk Road. The disease is diagnosed if a patient has 4 key diagnostic signs: aphthous stomatitis, genital sores, and eye and skin lesions. Vascular diseases referred to as minor criteria for BD are characterized by the formation of aneurysms and thrombosis, predominantly in the venous bed. In venous disorders, a blood clot can form in any vessel, including caval, cerebral, pulmonary, and other veins. The paper describes two clinical cases of BD with intracardiac thrombosis. In one case, a 24-year-old male patient with a documented diagnosis of BD, echocardiography revealed a left ventricular spontaneous echo contrast phenomenon that disappeared due to immunosuppressive therapy. The other case was a 34-year-old female patient, in whom the diagnosis was based on the international disease criteria: aphthous stomatitis, skin lesions (pseudopustulosis, erythema nodosum), and genital sores. Computed tomographic angiography showed a 3.7×2.2-cm mass (thrombus) in the right atrium. In addition, blood clots were present in the hepatic and inferior vena cava. No abnormalities in the coagulation system were found in both cases.

Pulmonary arterial hypertension associated with systemic sclerosis (SSc-PAH) and idiopathic pulmonary arterial hypertension (IPAH) belong to group I in the clinical classification of PH, but there is evidence for significant differences in their survival due to current therapy. Objective: the objective of this report is to compare pts with (SSc-PAH) and (IPAH) based on data of Russian National Registry. Patients and methods: in the study we included 52 pts with IPAH and 50 with SSc-PAH. There were no differences in functional class (FC). Diagnosis was based on RHC. Results. At the moment of diagnosis average age of patients with SSc-PAH was 15 year higher (p

Aim. To determine N-terminal pro-brain natriuretic peptide (NT-proBNP) levels in patients with early rheumatoid arthritis (RA) before the use of disease-modifying antirheumatic drugs (DMARDs); to compare NT-proBNP values with traditional risk factors (TRF), cardiovascular diseases (CVD), inflammatory markers, and left ventricular (LV) diastolic dysfunction (DD). Subjects and methods. The investigation enrolled 74 patients with a valid RA diagnosis (the 2010 ACR/EULAR criteria), 56 (74%) women, median (Me) age, 54 years; disease duration, 7 months; seropositive for IgM rheumatoid factor (87%) and/or anti-cyclic citrullinated peptide antibodies (100%) with no history of the use of DMARDs and glucocorticosteroids. Duplex scanning and echographic findings were used to assess TRF for CVD and carotid artery atherosclerosis (CAA) in all the patients with early RA prior to therapy. An E/A ratio was used as a criterion for LVDD. Results. NT-proBNP concentrations in patients with early RA proved to be higher than those in the control group (p

Aim. To investigate the effect of sildenafil on the survival of patients with pulmonary arterial hypertension (PAH) associated with connective tissue diseases (CTD), who have been followed up at the Rheumatology Expert Center. Subjects and methods. A total of 16 patients (all women) with PAH associated with CTD, who had been admitted to the V.A.Nasonova Research Institute of Rheumatology in 2013—2015, were examined. PAH corresponded to Functional Class II in the majority of the patients. After the diagnosis was verified by catheterization of the right heart and pulmonary artery, all the patients reсeived original sildenafil (a phosphodiesterase type 5 inhibitor, a potent vasodilator, the efficiency of which was proven in patients with PAH) at a dose of 20 mg thrice daily. Survival rates and time to clinical deterioration were estimated during a prospective follow-up). Results. Three-year survival rates were 94% in the study group and 25% in the group of historical control (p

Aim. To study the clinical and hemodynamic characteristics of a group of patients with Functional Class (FC) IV pulmonary arterial hypertension (PAH) developing in the presence of diffuse connective tissue diseases (DCTD) and to evaluate the efficacy of intravenous iloprost. Subjects and methods. The study enrolled 59 patients with PAN-DCTD, including 7 who had FC IV and 8 who developed this condition during a follow-up. The diagnosis of PAH was based on pulmonary artery catheterization findings. FC IV was diagnosed using the conventional New York Heart Association classification. All the patients received PAH-specific therapy (bosentan, sildenafil); the patients with FC IV had combined therapy; 4 patients were treated with intravenous iloprost calculated with reference to 0.5—2.5 ng/kg/min for 15 days. In addition to the patients with FC IV, 3 patients with unstable FC III were given iloprost. Besides targeted therapy, all the patients received standard treatment, including diuretics, and ionotropic therapy. Results. Evaluation of hemodynamics in patients with different FCs revealed the most important differences in right atrial pressure, cardiac output, cardiac index, and pulmonary vascular resistance. A linear relationship was seen between the level of this indicator and FC, the closest correlation being for hemodynamic parameters characterizing right ventricular systolic function. There were no changes in mean pulmonary artery pressure; only the patients with FC IV were found to have its slight elevation (from 52±15 to 55±11 mm Hg). Pulmonary artery wedge pressure remained unchanged regardless of FC. Intravenous iloprost was noted to have an obvious positive effect on both clinical and hemodynamic parameters. Catheterization verified improvement in 6 out of the 7 patients; no hemodynamic changes were found in 1 patient during 15-day therapy. Conclusion. The patients with FC IV PAH-DCTD have clinical and hemodynamic features responsible for a fatal prognosis. The results of using intravenous iloprost in patients with decompensated PAH associated with scleroderma systematica convince to use its PAH-specific tablets in cases of verified clinical deterioration when taking its dosage form.

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 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 describe hemodynamic and clinical changes in patients with elevated mean pulmonary artery pressure (MPAP) >30 mm Hg during exercise and the impact of bosentan therapy on stress-induced pulmonary hypertension (SIPH). Subjects and methods. The study included 19 patients with systemic sclerosis (SDS) in whom possible causes of pulmonary hypertension (PH) (lung and left heart injuries and thromboembolism) were excluded. All the patients underwent pulmonary artery catheterization at rest and during exercise. The hemodynamic (right atrial pressure (RAP), systolic and diastolic pressure, MPAP, pulmonary artery wedge pressure (PAWP), cardiac output (CO) by a thermodilution technique), clinical (demographic, immunological, and instrumental) parameters were analyzed and the risk of pulmonary arterial hypertension (PAH) was also calculated; 5 patients with SIPH received 16-week bosentan therapy according to the conventional regimen. Results. Ten of the 19 patients were at increased risk for PAH in accordance with the DETECT scale, but no signs of PH at resting catheterization were found in anybody. In 5 patients, MPAP, was in the range from 21 to 24 mm Hg; in 9 (47%) patients were found to have SIPH, a median MPAP of 35 (32; 41) mm Hg. Seven patients had no diagnostic changes during exercise; 3 patients could not perform an exercise test. There were correlations between MPAP and DETECT risk scores (p

Pulmonary hypertension (PH) is a group of diseases characterized by progressive increases in pulmonary vascular resistance and pulmonary artery pressure, which results in right ventricular heart failure and sudden death. Based on the current version of the guidelines for PH diagnosis and treatment, adopted by the experts of the European Society of Cardiology and the European Respiratory Society in 2009, and on the data of Russian and foreign clinical trials, the Russian experts elaborated clinical guidelines for PH in 2013. The latter consider the current classifications of PH, the specific features of its pathogenesis, and its diagnostic algorithm. The section dealing with drugs for maintenance therapy discusses data on the use of oral anticoagulants, diuretics, cardiac glycosides, and oxygen therapy. PH-specific therapy includes calcium antagonists, prostanoids, endothelin receptor antagonists, and phosphodiesterase type 5 inhibitors. Surgical procedures for PH involve atrial septostomy, thromboendartectomy, and lung or heart-lung transplantation. A treatment algorithm is proposed for PH patients. The current medicinal approaches using specific therapy agents and their combinations offer new promises for the effective treatment of patients with PH and improve its prognosis.

Timeliness of the topic: Pulmonary arterial hypertension(PAH), associated with systemic rheumaticdiseases(SRD),in particular with diffuse scleroderma, is a progressive disorder characterized by adverse outcomeespecially in lack of adequate treatment. Sildenafil 20 mg relaxes blood vessels and shows antiproliferative effect in patients with SRD.The aim of this paperis to study efficiency and safety of sildenafil in patients with PAH, associated with systemic rheumatic diseases.Material and methods:we have been monitoring the 16-week therapyin 14 patients with PAH, associatedwith systemic scleroderma (12 patients) and systemic lupus erythematosus (2 patients). The efficiency was assessed by the dynamics of clinico-laboratorial indices, central hemodynamics were evaluated using the right heart catheterization before the study and after 16 weeks of treatment.Results:We marked thatthe walkeddistancehad been increased by 31 meterinsix-minute walking testduring the therapy;we also saw the improvement of thefunctional classin 29% of patients.The significant improvement achieved in evaluating the hemodynamic parameters.A significant reduction of mean pulmonary arterial pressure was determined from 50.4 ± 9.2 mm Hg to 40.7 ± 10.2 mm. (p = 0.002), the pulmonary vascular resistance fell from 9.5 ± 5.9 to 6.4 ± 3.7 Wood units(p = 0.05),as well assome of the other indicators decreased.Right atrial pressurefell from8.3 ± 5.5 mm Hg. to 6.5 ± 3.1 mm Hg,we noticedthe stabilizationof left ventricle systolic function indices, thus,cardiac indexin all 14 patients,participatingin our study,had not been undergoingsignificant changes (3.1 ± 0.9 l/min/m2at the beginning of the study and 3.1 ± 0.7 l/min/m 2after 16 weeks of the therapy).The risk level, using scale register REVEAL, significantly decreased frommoderate high (9.0 ± 2.0)to medium (8.2 ± 1.9), (p = 0.04).There were no serious adverse events during the 16-week treatment using sildenafil. Three patients showed predisposition to hypotension, but, the blood pressuredecreased within the normal rangesin total group. Skin changes characterized bydermahemia ("blush") were observed in 4 patients and did not significantly impact on the general well-being of patients.Conclusion: Thus, Sildenafil 20 mgshowedefficiency and safety and could be used in treatment patients with PAH, associated with SRD.

AIM: To evaluate the short-term efficacy of the nonselective endothelin receptor antagonist bosentan in the treatment of pulmonary hypertension (PH) associated with diffuse connective tissue diseases (CTD), as well as its effect on survival in both monotherapy and in combination with other PH-specific agents/MATERIAL AND METHODS: The study included 20 CDT-associated PH patients who had been hospitalized in 2009-2013. All the patients had valid diagnoses of scleroderma systematica (SDS) (n=18) or systemic lupus erythematosus (SLE) (n=2). Bosentan was given in an initial dose of 62.5 mg/day twice for 4 weeks, then 125 mg/day twice/RESULTS: Eighteen patents completed therapy at 16 weeks. One patient with Functional Class (FC) IV PH associated with SDS died after 10 weeks of treatment because of PH progression; bosentan was discontinued in another patient following 4 weeks because of the enhanced activity of transaminases. The patients who had completed the investigation showed a significant FC decrease (from 2.9±1.0 to 2.4±1.0 following 16 weeks; р=0.03), an increase in 6-minute walking distance (from 298±140 to 375±94 m; р

Objective: to study the efficiency and tolerance of rituximab (RTM) treatment in patients with scleroderma systematica (SDS) with interstitial lung injury (ILI).Subjects and methods. The trial included 27 patients (26 women and 1 man) (mean age 45.7±13.0 years), with diffuse (n=13) and circumscribed (n = 14) forms and a disease duration of > 5 years in 63%. All the patients underwent chestcomputed tomography; examination of external respiratory function, including forced vital capacity (FVC) and diffusing capacity of the lung (DCL), as well as echocardiographic study. The efficiency of the treatment was evaluated from changes in FVC, skin score, and disease activity index. The indicators were compared prior to the treatment and one year after the first administration of RTM. The latter was injected with premedication (125–500 mg of methylprednisolone intravenously) 500–1000 mg per administration. The mean dose of RTM was low and amounted to 1.3 g per year.Results. As estimated by the physician, good, satisfactory, no effects were seen in 81.5, 14.8, and 3.7% of the patients, respectively. There was a significant increase in mean FVC one year after the first administration of RTM and a reduction in the total activity of the disease, including skin syndrome. DCL was substantially unchanged in the entire group. In the diffuse and circumscribed forms of the disease, FVC increased significantly and to the same extent. A clinically significant increase in FVC (by 11%) was achieved in patients with a disease duration of ≤5 years and mild lung injury. In people with a more than 5-year disease duration, FVC was initially decreased to a greater extent and the treatment-induced increase was only 3.7%. A significant and permanent decline in peripheral blood B lymphocytes was noted when both the standard dose (2 g) of RTM and its lower doses (0.5–1 g) were administered. RTM treatment was well tolerated, but complicated by mild intercurrent infections in 11% of cases within the first 2 months after RTM administration.Conclusion. The findings substantiate the indications for RTM use primarily in the early stage of the disease. The admittedly low doses of RTM have an inadequate effect if the disease is long-lasting. Further study of dosage regimensfor RTM is required within the framework of controlled trials.

Objective: to study the association of ultrasound (US) remission criteria with the clinical and laboratory indicators of inflammatory activity, functional status, and X-ray changes in patients with rheumatoid arthritis (RA) during tocilizumab (TCZ) therapy.Subjects and methods. The trial included 36 patients with RA (meeting the 1987 American College of Rheumatology (ACR) criteria) who had received TCZ for 6 months. The authors made a clinical and laboratory assessment of RA activity (DAS28-CRP, and SDAI), functional impairments (HAQ index) and US verification of wrist joint synovitis (a Voluson-i device, GE, 4-13-MHz linear transducer) at baseline and 6 months after therapy. No signs of grey-scale (B-mode) and power Doppler (PD) synovitis (B = 0; PD = 0) or minimal B-mode synovitis, and not more one PD hypervascular signal (В ≤1; PD ≤1) were arbitrarily taken as US remission criteria. Destruction changes were evaluated by hand and foot X-ray using the Sharp method modified by van der Heijde (SHS).Results. After 6 months of therapy, about 80% of the patients in clinical remission retained moderate or significant synovitis, as evidenced by US studies. There were no clinical differences in clinical activity indices and functional impairments between the patients who were and were not in US remission (p > 0.05). The 12-month follow-up SHS score was significantly higher with the preservation of 6-month therapy signs of B-mode synovitis and PD hypervascularization (of not more than one signal) than that in US remission (p < 0.05). There was no relationship of X-ray progression to the clinical and functional statuses (p > 0.05).Conclusion. Subclinical synovitis is observed even in clinical remission of RA. Destruction progression is significantlyrelated to synovitis persistence, as shown by ultrasonography.

The diagnosis of enthesitis can help in differentiating early psoriatic arthritis (ePsA) from early rheumatoid arthritis (eRA).Objective. To estimate the diagnostic value of detecting enthesitis during clinical examination and ultrasound in ePsA and eRA.Subjects and methods. The trial included 36 patients with ePsA and 33 with eRA. Entheses were evaluated using the Leeds Enthesitis Index (LEI): lateral humeral epicondyle and medial femoral condyle (MFC), Achilles tendon insertion site (ATAP), and plantar fascia (PF) point on the right and on the left. Enthesitis (on ultrasound) presented with thickening, reduced echo density, and vascularization at Doppler energy imaging. DAS, DAS28, SDAI, CDAI, M±SD, Me [25th, 75th percentile], t-test, Fisher's exact test, χ2test, U test, and Spearman correlation coefficients (R) were calculated; the value p < 0.05 was considered statistically significant.Results. Clinical examination revealed enthesitis in 41.6% of the patients with ePsA and in 39.4% of those with eRA (p >0.05). No significant differences were found between ePsA and eRA according to LEI (0.5 [0; 2] and 1 [0; 2] and to LEI+PF (1 [0; 2] and 1 [0; 2], respectively). Enthesitis of MFC and PF was significantly more frequently detected in ePsA than in eRA – 12 (33.3%)/2 (6.1%) and 10 (27.8%)/2 (6.1%) patients, respectively. In eRA versus ePsA, enthesitis of MFC was more frequently found (16 (48.4%) and 8 (22.2%) patients), respectively. Ultrasound revealed no significant differences between the groups in enthesitis. In ePsA, there was a significant correlation between DAS, DAS28, SDAI, CDAI, LEI, and LEI+PF.Conclusion. Enthesis ultrasound cannot differentiate ePsA from eRA. Clinical examination more frequently detects enthesitis in the knee joints in eRA and in the calcaneal region in ePsA.

Objective: to estimate the value of simplified ultrasound (US) indices of synovitis in the most commonly involved joints of the dominant hand, which are studied using the grey scale mode while monitoring the efficiency of tocilizumab (TCZ) therapy in patients with rheumatoid arthritis (RA). Subjects and methods. Forty-six patients with RA confirmed by the 1987 American College of Rheumatology (ACR) criteria who had been ineffectively treated received TCZ infusions for 6 months. The patients were stratified into two groups: 1) 11 patients with early (2-year) RA (PRA). Disease activity and therapy efficiency were determined by DAS28-CRP, SDAI, and US study of the dominant hand joints most commonly involved in the pathological process. Results. The evaluation of TCZ therapy from the simplified US indices reflected synovitis regression in the dominant hand joints of patients with ERA. The highly significant correlations between the changes in US parameters and RA activity the indices ^US-wrist/iDAS28-CRP: r = 0.75; p = 0.01; ΔUS-S8/ΔDAS28-CRP and ΔUS-S5/ΔSDAI: r = 0.65; p < 0.05) confirm the validity of the above changes. No reduction in the joint indices was observed in the patients with PRA. Conclusion. The simplified grey-scale US indices of synovitis in the joints of the dominant hand (including one wrist joint) is an accessible noninvasive method for evaluating the efficiency of the therapy performed in patients with ERA.

Objective: to estimate the contribution of arthrosonography to the diagnosis of metatarsophalangeal joint (MTPJ) injury and to reveal predictors for functional impairments in patients with rheumatoid arthritis (RA). Subjects and methods. The investigation enrolled 50 patients with the RA diagnosis meeting to the American College of Rheumatology 1987 criteria. According to disease duration, the patients were divided into two groups: 1) 9 patients with an early RA history of less than 2 years (ERA); 2) 41 patients with a RA history of over 2 years (LRA). All the patients underwent clinical joint evaluation, laboratory and instrumental examination, including joint X-ray and ultrasonography (USG). Results. An inflammatory process in the foot joints is significantly more frequently detected on ultrasound than clinically (p < 0.0001). The detection rate of erosions, as evidenced by USG, was significantly higher than that by X-ray, in ERA in particular (p = 0.01). Comparison analysis of patients with low and high HAQ scores showed the relationship between functional status, age, pain degree, and inflammatory process in the fifth MTPJ, as shown by USG. There were no associations with disease duration, traditional clinical and laboratory parameters of RA activity, and erosive changes in the feet. Conclusion. Joint USG in daily clinical practice makes it possible to objectively evaluate pathological changes in the feet and the probability of work disability due to RA.

Objective: to estimate the informative value and reproducibility of ultrasound study (USS) in interstitial lung disease (ILD) in patients with scleroderma systematica (SDS) and to compare ultrasound lung comet (ULC) scores with the data of multislice spiral computed tomography (MSCT) of the lung and its function tests. Subjects and methods. Forty patients with SSD and ILD were examined. According to the extent of lung injury, the patients were divided into two groups: 1) 12 patients with significantly pronounced changes (>20% lung involvement, as evidenced by MSCT); 2) 28 patients with just noticeable changes (

Objective: to define the significance of ultrasonography (USG) in the diagnosis of early destructive changes in the hand joints and the rates of rheumatoid arthritis (RA) progression in patients at different ages of disease onset. Subjects and methods. 100 patients with a valid RA diagnosis (American College of Rheumatology (ACR) 1987 criteria were examined. They were divided into 2 groups: 1) 11 patients with an early RA history of less than 2 years (ERA); 2) 35 patients with a RA history of over 2 years (LRA). Hand USG (Voluson-i GE; a 4-13-MHz linear probe; gray scale mode) was carried out at baseline and after 6-month follow-up. A sonographic index (US-Er-10) based on the bilateral evaluation of 5 articular areas, such as wrinkles, second-to-third metacarpophalangeal (MCP) and second-to-third proximal interphalangeal (PIP) joints, was proposed to evaluate the progression of destruction. According to US-Er-10 changes, the rates of development of the destructive process were arbitrarily separated into three categories: 1) slow progression rate; 2) moderate progression rate; 3) a rapidly progressive course. The X-ray parameters of structural progression were estimated at 12-month follow-up, by employing the Sharp method modified by van der Heide (SHS). Results. The USG versus X-ray detection rate of erosions was significantly higher in both ERA and LRA (p < 0.05). The ERA patients who had fallen ill after 55 years of age were found to have more significant baseline and final destructive changes according to a total SHS score (p < 0.05) and US-Er-10 index (p < 0.005) than those with RA onset at a younger age. In the ERA patients in whom US-Er-10 increased by three points or more at 6-month follow-up, the rates of X-ray progression at 12 months were significantly higher than those with less pronounced negative changes in this index (Δ total SHS score of 13.5 [3-23] and 0 [0-0], respectively; p < 0.05). The LRA group displayed no statistically relationships between the USG rate of erosion progression and the time course of X-ray changes and laboratory evidence. Conclusion. Hand USG reveals early erosive joint changes significantly more frequently than X-ray study and the high progression rate of destruction according to USG and the disease with onset after 55 years of age are associated with its severer course and poor prognosis in patients with ERA.

The international recommendations «Treat to target» (T2T) underline the greatest importance of treatment strategy for the success of treating rheumatoid arthritis (RA). Evaluation of the efficiency of this approach obviously requires special strategic studies with an adaptive design, which substantially differ from classical randomized clinical trials and are much closer to clinical practice. To date, there are only single publications on the practical application of the T2T recommendations, there is a problem in the choice of effectiveness criteria and there are a number of other important problems associated with the introduction of these recommendations. The Russian study REMARCA is to answer these questions. Its design focuses on the practical adaptation of the T2T strategy to treat patients with earlyand extended-stage active RA who have poor prognostic factors, by using subcutaneous methotrexate and genetically engineered biological agents (GEBA). Preliminary analysis shows that therapy according to the REMARCA protocol is successful in the majority of patients. The high rate of low RA activity and remission has been achieved during subcutaneous methotrexate monotherapy. The patients who need GEBA to be incorporated may be initially more resistant to therapy. The patients with early RA have better chances of successful T2T therapy than those with extended-stage RA.

Objective: to estimate the time course of changes in the ultrasound signs of wrist joint synovitis in patients with rheumatoid arthritis (RA) during tocilizumab (TCZ) treatment and to determine whether the progression of joint X-ray changes can be predicted by ultrasonography (USG). Subjects and methods. The investigation enrolled 46 patients with the diagnosis of RA that met the American College of Rheumatology 1987 criteria. All the patients were given TCZ during insufficiently effective previous therapy (median DAS28 was 6.7 [range 5.9—7.2]). They were divided into 2 groups: 1) early RA (ERA) with a disease history of less than 2 years (n = 11); 2) RA with a history of over 2 years (n = 35). Hand USG (Voluson-i GE, USA) with a 4—13-MHz linear probe using an energy Doppler (ED) was carried out before and 6 months after therapy. Structural changes were evaluated by hand and foot X-ray study (before and at 12-month follow-up) according to the Sharp method modified by van der Heide. Results. Dynamic evaluation of the ultrasound signs of inflammation indicated a significant reduction in the magnitude of synovitis in accordance with the gray-scale data in both groups and only in the patients with ERA in the ED mode. There was a clear association of the annual increment in joint X-ray changes with the result of estimation of the magnitude of synovitis according to the ED data (r = 0.669; p < 0.01). Conclusion. Wrist joint sonography allows evaluation of the efficiency of the performed therapy in patients with RA and the presence of moderate or severe synovitis, as evidenced by ED, is a predictor for the progression of joint destruction.

AIM: To estimate the prevalence of plasminogen activator inhibitor type 1 (PAI-1) gene polymorphism in patients with antiphospholipid syndrome (APS) and its implication in vascular disorders/MATERIAL AND METHODS: The investigation enrolled 138 patients: 103 with APS, including 47 with systemic lupus erythematosus (SLE) + APS and 56 with primary APS (PAPS), 15 with SLE without APS, 20 with idiopathic thrombosis (IT), a control group (30 apparently healthy individuals). Thrombosis at various sites was recorded in 91 (88%) of the 103 patients with APS. The authors analyzed both the presence of thrombotic events in all the groups and the number of cases of thrombosis in each patient. Antiphospholipid antibodies, such as lupus anticoagulant, anticardiolipin antibodies, and anti-Β2-glycoprotein type 1 antibodies, were studied in all the patients. To diagnose a genotype in patients by the code encoding for PAI-1, DNA isolated from peripheral blood by standard methods was used and further investigated by real-time polymerase chain reaction/RESULTS: Out of 91 patients with APS and thrombosis, 27 (30%) had the 4G/4G genotype, which corresponded to homozygous mutation in the PAI-1 gene, 50 (55%) had the 4G/5G genotype (heterozygous mutation), and 14 (15%) had the 5G/5G (a normal genotype). The PAI-1 4G/5G genotype was present in 22 (70%) of 31 patients with SLE + APS and lower limb deep vein thrombosis versus 17 (47%) of 36 patients with PAPS (odds ratio (OR) 2.73; 95% confidence interval (CI), 0.89 to 8.59; р=0.08) and in 9 (90%) of 10 patients with SLE + APS and pulmonary artery thromboembolism versus 8 (40%) of 20 patients with PAPS (OR 13,5; 95% CI, 1.23 to 344.98; р=0,02). The incidence of thrombosis per 100 person-years was higher in the PAI-1 4G/4G and 4G/5G groups: 35.4 and 28.1 cases per 100 person-years, respectively. Thromboses were least often in the group of patients with the PAI-1 5G/5G genotype (18.6)/CONCLUSION: The prevalence of the PAI-1 5G/5G genotype in patients with APS and thrombosis was significantly lower than in those with SLE without APS or thrombosis. The 4G/5G polymorphism in APS in the presence of SLE was associated with venous thromboembolisms whereas in PAPS there was no relationship between the PAI-1 genotype, a history of thrombosis, and its localization.

Objective — to evaluate potential input of different factors in the development of left ventricular hypertrophy (LVH) in patients with gout. Material and methods. 57 male patients with gout were included into the study. Echocardiography was performed in M- and B-modes and left ventricular myocardial mass index (LVMMI) was calculated for each patient. LVH was defined as LVMMI >115 g/m 2. Results. LVH was detected in 23 (40,4%) out of 57 patients. LVH was associated with advanced age, arterial hypertension, obesity, hyperuricemia and increased C-reactive protein levels.

Aim. To study survival of patients with a natural course of pulmonary arterial hypertension (PAH) associated with systemic sclerosis (SS). Material and methods. Twenty SD patients with PAH and 71 SS patients free of PAH were followed up for 10 years (1998-2008) when therapy with specific pulmonary vasodilators was not available. Survival curves for both groups were plotted by Kaplan-Mayer method. Results. One-, 3and 5-year survival were 85, 25 and 5%, respectively, in the SS-PAH group and 99, 82 and 77% in the SS group, respectively. The differences were significant (р < 0,001). Survival median in the group SS-PAH was 32 months. Conclusion. The above evidence is comparable to the results obtained earlier and demonstrate a fatal outcome of the disease in the absence of therapy with specific pulmonary vasodilators.

Aim. To evaluate tocilizumab (TLZ) effects on blood lipids composition and severity of carotid arteries (CA) atherosclerosis in rheumatoid arthritis (RA) patients after 24 week TLZ treatment. Material and methods. Before and 24 weeks after TLZ treatment 43 RA patients (33 women and 10 men) were examined by DAS 28 index, for blood serum concentration of cholesterol, triglycerides (TG), LPHD and LPLD cholesterol. The drug was injected intravenously in drops in a dose 8 mg/kg each 4 weeks. Results. A 24 week TLZ treatment produced satisfactory and good anti-inflammatory effects in RA patients. Hypoalphalipoproteinemia incidence and atherogenicity index (AI) reduced 3 and 5 times, respectively (p < 0.05). Elevated levels of cholesterol, TG, LDPL cholesterol occurred with the same frequency before and after TLZ treatment. Cholesterol rose by 11.6%, LPHD cholesterol by 48.9%, TG lowered by 7%, AI by 31.9% (p

Aim. To estimate a relationship between the intima-media thickness (TIM), cardiovascular risk (CVR) factors, and the level of C-reactive protein (CRP) in gouty patients. Subjects and methods. Eighty-nine patients at an interattack interval were examined. The patients' mean age was 46.0 ± 11.4 years; the duration of the disease was 5.2 (3.0; 8.9) years. The traditional CVR factors were analyzed. Carotid ultrasound scanning was performed to detect vascular atherosclerotic lesion. The serum CRP concentration was measured by a highly sensitive immunonefelometric assay. Results. According to the TIM, the patients were divided into 2 groups: 1) 37 patients with signs of carotid atherosclerotic lesion (TIM l 0.9 mm); 2) 52 patients with a TIM of less than 0.9 mm. The ages at the moment of examination and at the onset of the disease, the duration of the disease, as well as systolic blood pressure, and the risk of myocardial ischemia were greater in Group 1 than those in Group 2. In patients with atherosclerosis, the concentration of CRP was statistically significantly higher than that in patients without this condition. Conclusion. By complementing the classical CVR factors, CRP may be a predictor of cardiovaskular diseases and their complications in patients with gout at an interattack interval.

Scleroderma systematica (SDS) is a disease in which vascular diseases underlie the pathogenesis and presented by diverse clinical manifestations. Raynaud's syndrome and digital ulceration are the most common symptom of the diseases, which influences the quality of life in patients and requires continuous drug therapy. The paper discusses the recent European guidelines for the management of this manifestation of SDS. The proposed recommendations cannot unfortunately be realized in full measure now due to the unavailability of some drugs. The authors give their clinical experience with therapy for the vascular manifestations of SDS.

This article is an attempt at a theoretical substantiation of the proposition that scientific knowledge is naturally communicative. The peculiarities of the scientific language and experimental activity are analyzed in the article. The author pays special attention to the problem how it becomes possible to develop mutual understanding among the scientists.

Pulmonary hypertension (PH) associated with scleroderma systematica (SDS) is a menacing manifestation of this systemic disease of connective tissue, in which a rapid progression results in very poor outcomes. In SDS, PH is more frequently observed with the prolonged disease, circumscribed skin lesion, develops after a long benign course, and is one of the common causes of death. The early stage of PH can be identified by instrumental and not always accessible studies. The stage of clinical manifestations, which is frequently manifested only by dyspnea, requires a differential diagnosis from a wide range of conditions both caused by and concurrent with SDS. The need for differential diagnosis stems from the varying course and prognosis of the disease, as well as treatment policy.

Aim. To define clinical features of systemic sclerosis (SS) in age and sex aspects. Material and methods. The study covered 100 patients aged 15 to 83 years with SS (24 males and 76 females) lasting for 1-15 years (mean 6.2 ± 4.1 years). Groups of females and males, with disease onset age under 50 years (32 years) and over 50 years were compared. Results. Males had a prevalent diffuse clinical form ofSS with advanced skin syndrome, primarily indurative alterations, marked disturbances of microcirculation, abnormal heart rhythm and conduction, interstitial pulmonary fibrosis with development of pulmonary hypertension. The patients with late SS onset are characterized by development of visceral pathology within the first 3 years of the disease. Conclusion. In making SS diagnosis and in the disease treatment it is necessary to consider the patients ' sex and age, peculiarities of the debute, clinical picture, course and prognosis.

Остеопороз приобретает размеры эпидемии, охватывая все слои населения и понижая качество жизни пациентов. Одним из модифицируемых факторов риска развития этого заболевания является низкая физическая активность. Цель: определить влияние скандинавской ходьбы (СХ) на качество жизни пациентов с постменопаузальным осте-опорозом (ПМОП). Материал и методы. В исследовании приняли участие 48 женщин c установленным диагнозом постменопаузальный остеопороз, получающих терапию бисфосфонатами в сочетании с препаратами кальция и витамина D. Основная группа представлена 28 женщинами 62,8±8,9 лет (здесь и далее M±S), с длительностью менопаузы 6,1±7,9 лет, посещающими занятия СХ продолжительностью 60 минут 2 раза в неделю. Группу контроля составили 20 пациенток 61,3±9,5 лет, с длительностью менопаузы 5,9±6,8лет, не занимающиеся СХ (ЛФК произвольно). Критериями исключения стали заболевания и состояния, являющиеся противопоказанием для групповых занятий СХ. Занятие СХ, состоящее из разминки, основной тренировочной части и заминки, проводилось на уровне 55-70% от максимальной возрастной частоты сердечных сокращений (ЧССмакс), вычисляемых по специальным формулам. Качество жизни (КЖ) оценивали с помощью русскоязычного варианта опросника QUALEFFO-41 (Quality of life questionnaire of the European Foundation for Osteoporosis), разработанного Европейским фондом остеопороза (European Foundation for Osteoporosis) для исследования качества жизни у больных остеопорозом с компрессионным переломом позвонка. Опросник состоит из 7 доменов (А - боль, Б - физическая активность, В - работа по дому, Г - подвижность, Д - отдых и социальная активность, Ж - эмоциональное состояние), позволяющих получить общую оценку качества жизни. Чем ниже количество баллов, тем выше качество жизни. Качество жизни оценивалось в начале исследования и через 3 месяца. Результаты. По результатам опросника QUALEFFO-41 в начале исследования общий балл в обеих группах составил 61,5±3,8, КЖ было «неудовлетворительным» у 67,8% обследованных основной группы и 65,0% контрольной группы (средний балл 71,2±1,7), «удовлетворительным» у 32,2% и 35,0% соответственно (средний балл 43,3±2,4). При повторном тестировании через 3 месяца были получены следующие данные: в основной группе «неудовлетворительное» качество жизни констатировали 10,7% пациенток основной группы (средний балл 71,2±2,1) и 30,0% в контрольной группе (средний балл 72,2±1,9) (р