Vol 81, No 6 (2009)

Aim. To study effects of the disease activity and comorbid chronic conditions on the incidence of mental disorders in patients with systemic lupus erythematosus (SLE) treated in the State Institute of Rheumatology, RAMS. Material and methods. A total of 115 patients with documented SLE (age 24-45 years, median 34 years, SLE duration 4-17, median 8 years) participated in the study. SLE activity was evaluated by SLEDAI scale, atherosclerosis - by ultrasonic arterial dopplerography, mental disorders - by psychological and psychic scales according to IDC-10. Results. Mental disorders were detected in 76 of 115 (66%) patients: anxiety and depression (83%), depression episodes (40%), maladaptation (24%), generalized anxiety (10%), dysthymia (9%). Manifest cognitive disorders were seen in 7% of examinees. SLE patients with and without mental disorders did not differ by age, gender, SLE duration and activity, cumulative doses of glucocorticoids and cytotoxic drugs, but differed by diagnosed atherosclerosis (23 and 8%, respectively). All SLE patients with the history of myocardial infarction had mental disorders. SLE patients with antiphospholipid syndrome had mental disorders in 85%, while controls - in 49%. Conclusion. Mental disorders are found frequently in SLE patients (66%). 83% of these disorders are anxiodepressive. Incidence of mental disorders in SLE patients do not correlate with age, gender, SLE duration and activity, doses of glucocorticoids and cytotoxic drugs, but correlate with comorbid diseases (atherosclerosis, myocardial infarction, acute cerebral attacks, antiphospholipid syndrome and Sjogren's syndrome.

Aim. To investigate the incidence of MALT-lymphoma in Sjogren's disease by means of biopsy of the enlarged parotid glands. Material and methods. The incisional parotid biopsy was performed in 57 primary Sjogren's syndrome (pSS) patients with existing parotid enlargement. The median age was 54 years (range 19-75 years). The median pSS duration was 7 years (range 1-30 years). The palpable parotid enlargement was defined as grade 1 and massive (visional) enlargement of the parotid glands was defined as grade 2. Histologic and immunohistochemical examinations for diagnosis of lymphoma were made. High resolution electrophoresis and immunofixation were performed for detection of monoclonal immunoglobulins in the serum and their free light chains in the urine. Results. Biopsy of he enlarged parotid glands identified MALT-lymphoma in 37 of 57 (64.9%) pSS patients. Of 37 pSS patients with parotid enlargement of grade 2, diagnosis of MALT-lymphoma was made in 89.2%. Of 20 pSS patients who had parotid enlargement of grade 1, MALT-lymphoma was diagnosed in 20%. In patients with grade 1 enlarged parotid glands MALT-lymphoma was identified only in cases with the presence of monoclonal immunoglobulins in the serum and their free light chains in the urine (3 of 4 patients) or in case of disseminated disease (lymphoma involved regional lymph nodes and soft tissues of the face) - 1 of 4 patients. In patients with grade 2 enlargement of parotid glands MALT-lymphoma located most frequently in affected parotid glands (69.6%). Conclusion. The incisional biopsy of enlarged parotid glands is necessary for detection of MALT lymphoma in pSS patients.

Aim. Cardiovascular risk determination in patients with rheumatoid arthritis (RA) on the basis of standard and new risk factors (RF). Material and methods. Incidence of standard cardiovascular RF was studied in 312 RA patients and 57 healthy controls. Overall coronary risk (OCR) and cardiovascular death risk (SCORE scale), coronary heart disease risk (Framingem scale) were analysed. In addition, such RF as severity of systemic inflammation, some hemostatic indices, arterial wall stiffness were assessed. Results. Arterial hypertension (AH) occurred in 63.5% and hypercholesterinemia in 57.7% patients. AH in RA males is detected significantly more often than in population while blood lipid composition is satisfactory because of high HDLP cholesterol. The Framingem index in RA patients is lower than in the controls (7.7 ± 5.4 and 9.4 ± 9.3%), mean SCORE was 2.16 ± 2.9% (17.3% patients had high SCORE), a high OCR was registered in 25.7%. High level of C-reactive protein, platelets (320 Ѕ 109/l), hyperfibrinogenemia were found in 70.2, 31.1% and 55.9% patients, respectively. RA is accompanied with high activity of Willebrand factor, a low level of antithrombin III, suppression of fibrinolysis in blood plasm (p < 0.05). This reflects high thrombogenic blood potential, high risk of thrombosis and related complications of coronary heart disease. Aortic pulse wave velocity over 12 m/s was recorded significantly more frequently in RA than in control patients (p < 0.001), RA females had high arterial rigidity both in the periphery and aorta. Conclusion. Cardiovascular risk indices based on standard RF cannot assess the risk in RA patients. Additional factors should be taken into consideration: severity of inflammation, hemostasis, arterial stiffness.

Aim. To study characteristics of neurohumoral regulation of blood pressure (BP) in patients with systemic diseases of the connective tissue and hemorrhagic vasculitis (HV). Material and methods. The trial included 45 patients with systemic lupus erythematosus (SLE), 25 patients with scleroderma systematica (SS), 30 HV patients and 30 healthy controls. The following parameters were estimated: activity of plasmic renin, aldosteron concentration in plasma, catecholamines (noradrenaline and adrenalin), serum level of endotheline-1, number of desquamated endotheliocytes by J. Hladovec (1978) with use of Goryaev's camera. A BP 24-h profile was obtained by the standard method with the device Kardiotekhnika 4000 AD. Renal function was assessed by blood creatinine (Reberg's test). Results. Contribution of different factors to pathogenesis of arterial hypertension (AH) in rheumatic conditions was different. SLE activity enhancement was associated with renal dysfunction and growth of plasmic renin leading to AH resultant from activation of the renin-angiotensin-aldosteron system (RAAS), sympathico-adrenal system (SAS) and suspended by endothelial dysfunction. AH in SS patients presented with SAS activation, endothelial dysfunction and moderate pathology of the kidneys. HV activation provoked renal and endothelial dysfunction, SAS activation leading to development of AH. Conclusion. In rheumatic diseases AH develops with activation of SAS, RAAS, endothelial and renal dysfunction.

Aim. To evaluate clinical significance of heart rate variability (HRV) in patients with psoriatic arthritis (PsA). Material and methods. HRV was investigated by means of time-domain analysis of 24 h ECG ambulatory recording in 113 PsA (70 female) patients < 55 years old and 65 age-matched healthy subjects. We assessed the presence of standard cardiovascular risk factors, performed carotid and femoral ultrasound with measurement of intima-medial thickness (IMT) in PsA patients. Inflammatory markers (CRP, fibrinogen) were detected in all the patients. Results. Significantly lower values of HRV parameters adjusted by Mean NN (SDNNn%, SDNNIN%) were detected in PsA men and women when compared to the control group. There was a significant negative correlation between HRV and disease duration, PsA activity (DAS4, Ritchi index), swollen and tender joint counts, femoral IMT, CRP in PsA males (p < 0.05). SDNNin% was lower in PsA male smokers than in non-smokers (p = 0.03). There was a significant negative correlation between HRV and age, systolic blood pressure, dyslipidemia, body mass index, carotid IMT, CRP, fibrinogen in PsA women. Conclusion. Reduced HRV reflects sympatho-vagal imbalance in PsA patients associated with the disease duration and activity, smoking, femoral IMT, markers of inflammation (CRP) in males; with standard cardiovascular risk factors, fibrinogen, CRP, carotid IMT in women, and may be identified as a risk factor for cardiovascular morbidity and mortality in further studies.

Aim. To study autonomous regulation of cardiac activity in patients with alkylosing spondylitis(AS) according to heart rate variability. Material and methods. A total of 51 male patients aged 35.4 ± 7.3 years with verified AS participated in the trial. Patients with manifest cardiovascular pathology, disturbances of cardiac rhythm or conduction were not included. All the patients were screened for basic cardiovascular risk factors. AS activity was studied with a clinical index BASDAI and acute phase indices. HRV was analysed by 5-min at rest ECG fragments. The control group consisted of 23 healthy males at the age 35.7 ± 11.5 years matched by basic cardiovascular risk factors with AS patients. Results. Basic time and frequency HRV parameters were much lower in AS patients than in healthy controls. A significant negative correlation was found between HRV parameters and acute phase parameters (ESR, C-reactive protein, fibrinogen) evidencing for a significant impact of persistent systemic inflammation on autonomic regulation of cardiac activity consisting in regress of parasympathic and/or enhancement of sympathetic activity and leading to reduction of HRV in AS patients. Conclusion. AS patients have abnormal autonomic regulation of cardiac activity manifesting with subnormal HRV. This is closely related with the activity of systemic inflammation. Reduced HRV may be one of the factors of a high cardiovascular risk in AS patients.

Aim. To study damage to the heart, kidneys and vessels in patients with arterial hypertension (AH) of different severity with and without metabolic syndrome. Material and methods. The trial enrolled 303 patients with AH of the first-third degree aged 25-70 years (mean age 52 ± 18 years), 110 males and 193 females. The patients were matched by sex and age. All the patients were divided into two groups: group 1 (n = 151) without metabolic syndrome (MS) and group 2 (n = 152) with MS. The following parameters were studied: lipid spectrum, blood glucose, glomerular filtration rate, MAU, data of 24-h blood pressure monitoring, echocardiography, Doppler ultrasonography of the brachiocephalic arteries. Results. Early AH was accompanied with diastolic LV myocardial dysfunction, subnormal glomerular filtration rate and the presence of MAU. In AH of the second degree there was LV remodeling. In AH of the third degree left ventricular myocardial mass (LVMM) and thickness of intima-medial complex (TIM) were increased. Close correlations were found between the disturbance of diastolic function and MAU, thickness of interventricular septum and thickness of the inferior wall and LVMM index with MAU. Less manifest correlation existed between diastolic dysfunction and TIM, thickness of the interventricular septum and thickness of the inferior wall and TIM. Conclusion. The presence of metabolic syndrome contributes to earlier and more serious damage of the target organs in patients with arterial hypertension.

Causes of vertebrogenic back pain are described. Differential diagnosis in this condition is important as visceral pathology may underlie the pain syndrome. Algorithm of the patient examination is given. Paraclinic examination is important but in diagnosis clinical examination is of key value. Pharmacological and non-pharmacological treatment approaches are considered

General pathophysiological mechanisms of inflammation are reviewed on the models of atherosclerosis, calcinating aortic stenosis, cardiac failure and osteoporosis widely encountered at old age.