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The Clinician

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Vol 10, No 1 (2016)
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https://doi.org/10.17650/1818-8338-2016-10-1

ORIGINAL INVESTIGATIONS

12-16 1649
Abstract

Objective: to establish features of a chronic pain syndrome disorders in patients with rheumatoid arthritis, to reveal correlation with psychoemotional disorders and to develop the differential approach to maintaining patients.
Materials and methods. 101 patients at the age of 60.6 ± 11.8 years, 92 % of women, with reliable rheumatoid arthritis (American College of Rheumatology – ACR, 1987), were examined. The visual analog scale was used for an assessment of pain strength at the moment; the Van Korff’s questionnaire – for determination of pain strength at the moment and retrospectively for the last half a year with an assessment of disadaptation level and disability, ranging of a chronic pain syndrome on classes; the McGill Pain Questionnaire – for the characteristic of touchsensitive and emotional components of pain. Neuropathic pain was revealed by DN4 questionnaire. Anxiety and depression were determined by the Hospital Anxiety and Depression Scale (HADS). Fibromyalgia diagnosed by criteria of ACR, (1990).
Results. Pain estimated by various scales and questionnaires varied from moderated to intensive. According to Van Korff’s questionnaire it was characterized by average level of disadaptation and easy disability that corresponded to the second class of chronic pain. The Rank pain index of the McGill Pain Questionnaire touch scale testified that pain was described by a smaller number of definitions on a touch scale than on emotional. This indicates a moderate impact of pain syndrome on a state of mind. Neuropathic pain is diagnosed for 37.3 % of patients with tunnel syndrome, mononeuritis and touch polyneuropathy. The secondary fibromyalgia is revealed for 2 % of patients with early rheumatoid arthritis of high activity. According to HADS anxiety and depression was revealed for 58 and 59 % of patients correspondingly. This demanded psychotherapeutic consultation and additional correction. We proposed the algorithm of diagnostic and medical tactics for rheumatoid arthritis patients with a chronic pain syndrome in therapeutic practice based on pain strength gradation, assessment of chronic pain syndrome variations, definition of anxiety and depression signs. All this allows to validate consultation of medical specialists and to differentiate treatment.
Conclusions. The integrated approach to diagnostics of a chronic pain syndrome for rheumatoid arthritis allows to estimate pain strengths in dynamics of disease development, to reveal existence of pain variations, anxiety and depression. It enables usage of patient maintenance tactics and increases efficiency of treatment in therapeutic practice. 

17-21 833
Abstract

Objective: to determine the dynamics of the extra-articular pain after primary hip replacement.
Materials and methods. A total of 1286 patients undergoing primary total hip arthroplasty. Among the patients were women, mean age was 56.6 ± 13.9 years. In a clinical study of patients using differential diagnostic table extra-articular pain, visual analogue scale of pain, with instrumental examination – X-ray data, and sonographic densitometry study.
Results. The incidence of the disease state is 42.7 %. Risk factors for decompensation classified muscles that stabilize the hip joint (r = 0.78), shortening of the operated limb more than 3 cm (r = 0.72). The most intense pain is fixed from the 3rd to the 6th month after the surgery. The least pronounced dynamics of reduction in pain severity observed in patients with dysplastic coxarthrosis and diseases arising on a background of systemic pathology.
Conclusion. Extra-articular pain occurs more than a third of patients after primary prosthesis. According to the etiology is often vertebrogenic and adaptive pain. From the 3rd to the 6th month, in connection with the formation of a new dynamic stereotype of gait is highest probability of occurrence and/or enhance the intensity of the pain, which are reduced to 12th month after surgery.

22-28 3903
Abstract

Objective: to study the clinical, laboratory, and radiographic characteristics of early-stage sarcoidosis in a cohort of patients referred to a rheumatology center.
Materials and methods. The investigation enrolled 125 patients (104 women and 21 men; mean age 42 ± 12 years) with the clinical and X-ray signs of Löfgren’s syndrome. All the patients were referred to a rheumatology center with diagnosed erythema nodosum (EN). The median disease duration was 1 (0.5–2.0) month. All the patients underwent comprehensive clinical examination and laboratory and instrumental studies of biochemical and immunological parameters, chest X-ray or computed tomography (CT), as well as postmortem examinations of skin and subcutaneous fat biopsy specimens were done in 15 cases.
Results. EN was located on the lower leg mostly on its anterior surface (97 %), hip (35 %), upper limbs (25 %), and trunk (3 %). There was a symmetric pattern of eruptions in 50 % of the patients. Nodules fused into a conglomerate in 48 %. More than 50 % injury of the shin surface (68 %) was directly related to the number of nodules (p < 0.001; r = 0.60) and the level of C-reactive protein (p = 0.006; r = 0.38). There was a direct relationship of the number of nodules to the duration of EN (p = 0.04; r = 0.20) and their trend of fusion (p < 0.001; r = 0.39). The signs of joint injury were found in 106 (85 %) patients. The predictors of the CT frosted glass phenomenon were male sex (odds ratio (OR) 6.5; confidence interval (CI) 1.2–35.0; p = 0.026) and the presence of nodular conglomerates (OR 4.8; CI 1.4–16.1; p = 0.01). EN did not recur and articular syndrome virtually completely regressed in 90% of the patients during one-year follow-up.
Conclusion. Patients with acute sarcoidosis require that physicians of different specialties, including rheumatologists, should coordinate their actions to determine the volume of further examination and to use adequate treatment. 

29-35 1284
Abstract

Objective: to estimate a trend in the frequency of using drugs with their proven effect on disease outcome in patients with chronic coronary heart disease (CHD) in 2004–2014 within the CHD PROGNOSIS registry.
Materials and methods. The investigation included data from the CHD PROGNOSIS registry on 303 patients with verified CHD during the 2004–2007 reference hospitalization at the National Research Center for Preventive Medicine, who made a control visit 4 years later, and those on 125 patients who had come following 7 years.
Results. There was a low frequency of prescribing the drugs that were able to improve prognosis in patients with stable CHD prior to the 2004–2007 reference hospitalization with an increase at discharge and with a further reduction during outpatient treatment. 7.6 and 86.5% of the patients took statins; 68 and 96 % received disaggregants; 24.8 and 94 % used β-adrenoblockers (β-AB), and 19 and 83 % had angiotensin-converting enzyme (ACE) inhibitors before hospitalization and at discharge, respectively (p < 0.001). Four and seven years after discharge, there were reductions in the frequency of using statins to 67 and 70 %, disaggregants to 80 and 90 %, β-AB to 80 and 75 %, and ACE inhibitors to 66 and 65 %, respectively (p < 0.01). At the same time, the above-mentioned drugs were taken by 15 and 69 % of patients on admission and at discharge, respectively (p < 0.001), by 41 and 35 % after 4 and 7 years (p < 0.01). In 2004 to 2014, most drugs were used at low and moderate doses with a gradual increase in the share of generics.
Conclusion. The therapy in patients with stable CHD was characterized by a low frequency of using the drugs with their proven effect on prognosis prior to the 2004–2007 reference hospitalization with an increase and a decrease in the frequency of their use on discharge and after 4 and 7 years. During 10 years, β-AB, ACE inhibitors/angiotensin II receptor antagonists, and statins were used mainly at low and moderate doses. Moreover, there was a gradual rise in the share of generics, in the use of statins in particular. 

36-42 1203
Abstract

Objective: to analyze the risk factors (RFs) of osteoporosis (OP), the risk of OP-related fractures, the specific features of osteopenic syndrome in patients with chronic non-infectious diseases (CNID) (coronary heart disease (CHD), hypertension, chronic obstructive pulmonary disease (COPD), and asthma).
Materials and methods. The investigation enrolled 377 patients (mean age 55.3 ± 1.6 years) with CNID and 221 persons (mean age, 53.2 ± 1.3 years) who formed a control group. According to the nosological entity, the patients were divided as follows: Group 1 included 84 patients with CHD and hypertension; Group 2 comprised 99 hypertensive patients; Group 3 consisted of 70 patients with COPD; and Group 4 included 124 asthmatic patients. The examinees of all the groups were matched for age, gender, and body mass index. The investigation excluded patients with functional class IV chronic heart failure, continuous atrial fibrillation, heart valve disease, or myocardial noncoronarogenic diseases and those with other diseases and conditions that could have an independent impact on bone metabolism. Prior to the examination, the patients had received no specific therapy for the prevention and treatment of OP. RFs for OP were assessed using the one-minute test recommended by the International OP Foundation (2008); 10-year risk for OP-related fractures were calculated applying the FRAX computer program in accordance with the guidelines of the International OP Association and the World Health Organization (WHO, 2008). To investigate bone mineral density (BMD), bioenergy X-ray densitometry of the lumbar spine and proximal femur was carried out by means of a Lunar DPX apparatus (USA). The results were assessed using the t-test in standard deviations (SD) from the peak bone mass according to the WHO guidelines.
Results. The RFs of OP were more frequently recorded in the patients with CNID than in the healthy individuals. RFs, such as smoking, low physical activity, and low-energy fractures, were most common in the patients with cardiovascular disease or COPD. The frequent use of glucocorticoid therapy was also an important RF in the patients with COPD. CHID considerably increased the risk of fractures in the succeeding 10 years after disease onset. The high risk of fractures, those of the proximal femur in particular, provides a rationale for the need for timely antiosteoporotic therapy in the majority of patients with CNID. The performed investigation demonstrated that the BMD values in the patients with CNID corresponded, on the average, to the osteopenia criteria; the lowest BMD values were recorded in the patients with COPD and associated cardiovascular disease. The severe course of osteopenic syndrome (a BMD decrease that was diagnostically significant for OP concurrent with fractures was observed in one-third of patients with CNID. The patients with cardiovascular disease or COPD showed a high incidence and degree of OP, which allows these diseases to be considered as a RF for decreased BMD. The long-term uncontrolled course of disease, the degree of organ and functional disorders in the patients with CNID, and concomitant use of glucocorticoid therapy contribute to a reduction in BMD.
Conclusion. RFs for OP were identified in the majority of patients with CNID. The high risk of fractures due to an obvious BMD decrease in patients with CNID requires timely diagnosis, treatment, and prevention of osteopenia.

CONFERENCES, SYMPOSIUMS, MEETINGS

CASE REPORT

43-47 1013
Abstract

Objective: to describe a case of the total development of alopecia in a female patient with psoriatic arthritis during treatment with a tumor necrosis factor-αlpha (TNF-α) inhibitor.
Materials and methods. Patient I., aged 36 years has been followed up at the Kazan’ Center of Rheumatic Diseases and Osteoporosis since 1998. At approximately the same time, the patient noted the appearance of skin eruptions behind the ears, on the skin of the scalp. She was examined by a dermatologist who diagnosed psoriasis. In 2005, she was admitted to Kazan’ Rheumatology Center, City Clinical Hospital Seven, for the development of obvious synovitis of the knee joint and for the inefficiency of therapy with nonsteroidal anti-inflammatory drugs and diagnosed with psoriatic arthritis. During the prescribed therapy with methotrexate 10 mg/week, evident menstrual irregularities were observed in the patient who stopped using the drug herself. The second pregnancy occurred in 2008. Articular syndrome progression and eruptive psoriasis were recorded in the lactation period. After lactation cessation in 2009, she was hospitalized again. Her examination revealed high laboratory activity (erythrocyte sedimentation rate, as high as 40 mm/hr); magnetic resonance imaging of the knee joints showed the signs of bilateral synovitis; lumbar spine radiography exhibited grade II sacroiliitis. Leflunomide 20 mg/day was recommended as a basic drug. In 2012, the patient used leflunomide, her condition worsened; joint pain progressed; new joints were involved into the process, and cutaneous manifestations were aggravated. To verify a diagnosis and to choose therapy, the patient was referred to a consultation at the Moscow Research Institute of Rheumatology.
Results. In connection with the high activity of the disease and with no response to the performed therapy, it was recommended to initiate therapy with biologics, such as infliximab, the drug of choice. Seven infliximab injections were well tolerated: the patient reported lower intensity of joint pains and regression of the skin manifestations of psoriasis. In 2013, after the eighth infliximab injection the patient sought medical advice because of complaints about an obvious exacerbation of psoriasis affecting the trunk, upper and lower extremities, and the development of total alopecia within a week. Discontinuation of cytostatics and biologics was recommended; whether ustekinumab therapy should be used was considered.
Conclusion. Practical interest in this clinical case is due to the development of a rare (3.3 %) adverse event in the patient with psoriatic arthritis – hair loss (total development of alopecia) during treatment with a TNF-α inhibitor. 

48-51 956
Abstract

Objective: to describe effective treatment in a patient with stent thromboses and a left ventricular (LV) thrombus resistant to therapy with the novel anticoagulants clopidogrel and prasugrel.
Materials and methods. Patient P.V., aged 53 years, was admitted to the Department of Cardiology with complaints of dyspnea, lower limb edema, general weakness, palpitation, reduced urine output, and elevated body temperature. His medical history showed myocardial infarction experienced three times, coronary stenting using 3 drug-eluting stents, and stent thromboses. Echocardiography (EchoCG) revealed a mobile thrombus with a total area of 11 cm2 in the area of chronic LV aneurysm.
Results. According to the data of EchoCG conducted over time, there was a decrease in thrombus sizes to 3.06 cm2 during rivaroxaban therapy, their subsequent increase up to 9.25 cm2 after anticoagulant therapy that was discontinued without permission, and final lysis of a LV thrombus following the intake of rivaroxaban 20 mg/day during one month.
Conclusion. LV thrombus lysis in the rivaroxaban-treated patient with post-infarction cardiosclerosis and stent thromboses resistant to therapy with clopidogrel and prasugrel was described in this case.

52-56 936
Abstract

Objective: to describe the results of the joint monitoring and diversified treatment of oncologists and dermatologists those patient with multiple recurrent melanoma who received over a long period a targeted anti-cancer therapy, which was complicated by side-effect as widespread acneform rush, resistant to traditional treatment.
Patient A., born in 1988, was followed up and got a treatment more than 2 years in oncology out-patient clinic diagnosed with “Melanoma of the front surface of the left leg T2bN0M0 IIA”. Subsequently, the patient was verified metastasis in the inginal lymph nodes, in the soft tissues of the hips, to liver. Acute adverse reaction has developed in a short time after getting the anti-tumor target therapy as generalized acneform rush and itching of the skin. Skin symptoms accompanied by pronounced psychological and emotional stress, therefore, dermatologists have been invited to provide additional medical assistance to this patient. Due to the fact that subsequent traditional anti-acne algorithms of topical and oral treatment was not such effective, there was made a decision to use an alternative supporting external therapy, which did not have similar examples of usage previously.

Results. External application of tacrolimus ointment in combination with other drugs and then as a mono-therapy, allows us in a rather short period achieve a stable and pronounced regression of skin pathological lesions, to return to the previously cancelled initial drug dose of the anti-tumor target therapy, to change significantly components of the patient’s quality of life.
Conclusion. The search for additional and alternative treatment approaches for similar patients, as in our case, remains relevant for specialists and patients themselves. This case is an example of alternative approach to the tacrolimus topical application in patient with drug-mediated acneform rush.

EDITORIAL

10-11 1066
Abstract

The paper considers different pathophysiological types of pain syndrome. It gives the definition of chronic pain and discusses methods for the objective evaluation of pain. The paper underlines that the choice of optimal therapeutic tactics for pain syndrome should be based not only on the evaluation of pain intensity, but also on its clinical pathogenetic type.



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ISSN 1818-8338 (Print)
ISSN 2412-8775 (Online)