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Spondyloarthritis (SpA) is a group of inflammatory rheumatic diseases that share some common genetic, clinical, serological, radiological, and prognostic features. Since the early 1960s, several classification criteria for SpA have been proposed, and some of them were also used for diagnostic purposes. The ASAS international group of experts established a set of classification criteria for SpA, dividing them into axial or peripheral, according to predominant involvement. The paradigmatic entity of axial SpA is ankylosing spondylitis, which is diagnosed in clinical practice with significant delay. Therefore the ASAS classification introduced the term “non-radiographic axial SpA”, which refers to changes in the sacroiliac joints seen on MRI, but not on radiograph. Although the ASAS classification has been widely accepted in the professional community, recently initiatives were raised suggesting changes and aiming at improvements. In this paper these objections are discussed, as well as the responses of experts who consider that these changes are not necessary.

In the etiology of non-malignant pain, a significant proportion is constituted by patients with pain originating in the musculoskeletal system. The use of strong opioids in the treatment of non-malignant pain is still controversial. Therefore, the aim of this study was to establish the efficacy and safety of oxycodone with a controlled release of the active substance (CR) in the treatment of patients with chronic, not well-controlled musculoskeletal pain. Here we present our preliminary results. In this prospective, open, single-center study conducted at a rheumatology center we enrolled consecutive patients with musculoskeletal pain due to a variety of musculoskeletal diseases (osteoarthritis, pain in the lower back, spondyloarthritis), who suffered from moderate to severe pain despite previous analgesic therapy (with NSAIDs, weak opioids, or a fixed combination of paracetamol and weak opioids). Patients were switched to therapy with oxycodone CR and followed for 14 days. The starting dose of oxycodone CR was 10 mg, and later the dose was adapted as necessary. The primary endpoint was to assess the effectiveness of oxycodone CR on pain intensity, and the secondary goal was to assess the efficiency on the general health of the patient (both on a horizontal visual analogue scale, VAS 0 = best, 10 = worst). Fifteen patients (12 women, 3 men), with a mean age of 61 ± 12 years and a diagnosis of osteoarthritis, pain in the lower back, or inflammatory arthritis, were included in the study. The duration of pain was 41 ± 12 months. The average intensity of pain before oxycodone CR treatment was 7.87 ± 2.28 (range 7-10), and at the end of the study it was 5.92 ± 2.43 (range 4-9) (p=0.069). General health was rated 7.27 ± 2.14 (range 3-10) before the start and 6.00 ± 1.53 (range 3-9) at the end of the study (p=0.028). In one patient the treatment was discontinued due to dizziness and nausea, and one patient voluntarily left the study because of fear and the subjective impression of no adequate pain control after 2 days of treatment. The oxycodone side-effect profile was as expected. Results of our preliminary study show that in patients with chronic non-malignant pain which is not well controlled by simple analgesics, NSAIDs, and weak opioids, treatment with oxycodone CR contributed to a significant reduction in the level of pain and improved the general health of the subjects.

Objective: Electrical stimulation of the vagus has proven effective in various inflammatory conditions in animal models. The aim of this study is to show the effect of vagal nerve neurostimulation on clinical and laboratory parameters in two patients with active rheumatoid arthritis (RA) and an inadequate response to methotrexate., Patients and Methods: The research was conducted as part of an international pilot study. Patients were implanted with the Cyberonics system for electrical stimulation of the vagus. After an initial in-clinic stimulation, the patients performed the stimulations at home for 42 days, when the device was inactivated. On day 56 the stimulations were reinitiated. The following parameters were evaluated: tender and swollen joint count, physician’s (PGA) and patient’s (PtGA) global score, intensity of pain, disease activity (DAS28), functional ability (HAQ), serum CRP level, and EULAR response., Results: In the period from the screening visit to the day 42 visit, both patients experienced an improvement of DAS28 (7.00 and 6.22 vs. 4.03 and 2.13), PGA (70 and 53 vs. 27 and 16), PtGA (48 and 43 vs. 15 and 14), tender joint count (26 and 28 vs. 4 and 0), swollen joint count (24 and 14 vs. 8 and 2), intensity of pain (72 and 87 vs 21 and 7), HAQ score (2.25 and 2.25 vs. 1.5 and 1.375), and CRP levels (23.8 and 5.58 vs. 13 and 4.61). After the device deactivation, DAS28 and VAS pain worsened in both patients., Conclusion: Vagal neural stimulation in the treatment of patients with active RA and an inadequate response to methotrexate is effective in reducing clinical symptoms and parameters of inflammation. Our results are in accordance with the results obtained in other centers. Research on a larger number of subjects is necessary for a better evaluation of the effect of this new approach to the treatment of patients with rheumatoid arthritis.

Pain is a cardinal symptom of rheumatic diseases and the most common reason for seeking medical help. Pain relief has many benefi cial eff ects and is necessary for the functional recovery. A variety of drugs are used for the treatment of pain in rheumatic diseases. Th ey usually include acetaminophen, nonsteroidal anti-rheumatic drugs, and opioids (mostly weak opioids). Antidepressants and anticonvulsants can be used in cases with a predominant neuropathic component. In this descriptive review we present up-to-date results of trials with systemic analgesic drugs in rheumatic diseases, including nerve growth factor inhibitors and symptomatic slow-acting drugs for osteoarthritis.

Golimumab is a human monoclonal antibody which inhibits tumor necrosis factor-alpha (TNF-α) and is approved for the treatment of inflammatory arthritides (rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis) when the conventional non-pharmacological and pharmacological therapies fail to cause remission or low disease activity. In this retrospective study there were included patients with rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis who were treated in Croatia with golimumab, from June 2011 to June 2013. included and these retrospective data are compared with similar data from clinical trials and other available databases. Standard variables of disease activity and functional ability were observed. Results demonstrated significant efficacy of golimumab regarding lowring the disease activity and imrpving functional ability in pateints with these inflammatory rherumatic disease. In conclusion, in this retrospective study during two years treatment golimumab showed efficacy in decreasing disease activity and imrpove functional ability in patiemts with rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis.

Diagnostic imaging methods aimed to detect osteoporosis range from the visual analysis of bone structure on plain skeletal radiographs to quantitative imaging techniques that enable accurate measurement of bone mineral density (BMD), such as quantitative computed tomography (QCT). According to the guidelines for diagnosis and treatment, dual X-ray absorptiometry (DXA) still represents the "gold standard" for diagnosis of osteoporosis and fracture risk prediction. This paper illustrates the current possibilities and recent advances the in application of bone densitometry.

Osteoanabolics are bone forming agents. The first approved osteoanabolic drug for the treatment of osteoporosis is teriparatide (TPTD). In the fracture prevention trial TPTD increased lumbar spine, total hip and femoral neck BMD is significantly greater compared with placebo, and it also prevents new fractures. Differently from the antiresorptive drugs, TPTD showed positive effects on various structural indices and microarchitecture using 2D histomorphometric analyses and 3D direct measurement. The insight into bone physiopathology and the better understanding of the core mechanisms involved in the development of osteoporosis led to the development of new compounds with therapeutic potential. Among them the most promising are Cathepsin K inhibitors and anti-sclerostin drugs.

Standardized approach to the patients with rheumatoid arthritis (RA) is one of the requirements of good clinical practice. Croatian Society for Rheumatology (HRD) of Croatian Medical Association (HLZ) updated the Proposed treatment of rheumatoid arthritis (RA) with biologic agents in line with recent findings in rheumatology for the last 3 years. By complying with the agreed standards of treatment we can avoid malpractice and irrational consumption, and to the most patients provide a greater chance for a favorable outcome.

Extra-articular rheumatism includes inflammatory and degenerative disorders of soft-tissues, most commonly tendons, enthesis and bursae. Although prevalent, this form of rheumatism is often a diagnostic problem. Exact and early diagnosis is based on history and clinical examination, with a help of diagnostic methods, especially diagnostic ultrasound. In this article are presented the most important entitites of localized extra-articular rheumatism.

Croatian Society for Rheumatology of Croatian Medical Association updated the proposal for the application of TNF-alpha inhibitors in adult patients with spondyloartritides (SpA) in accordance with the new classification of SpA and european recommendations for the treatment of SpA with biologic agents. In this way a standardized method of diagnosis, targeted treatment, monitoring and evaluating outcomes are proposed.

Gout is one of the most common forms of arthritis in the developed countries. Nevertheless, it is poorly managed mainly due to limited options in drug treatment, lack of widely accepted treatment strategies and underestimation of the importance of the disease. A significant proportion of especially elderly patients with gout are either unresponsive to or intolerant of the use of currently available medications. In the past decade we are witnessing the rise in gout prevalence and improvement in our understanding of its pathophysiology which both leaded to resurgence in scientist and clinician interest. Herewith are presented new medications for gout that act through different mechanism: anti-interleukin (IL)-1 drugs (anakinra, canakinumab, rilonacept) terminate the symptoms of acute gouty arthritis, febuxostat is a new selective xanthine oxidase inhibitor, poly(ethylene) glycol-uricase is a recently developed uricolytic as well as some new uricosuric agents. These innovatory drugs alongside with the concept of treat-to-target, with clear serum urate cut off, will help in the management of patients with gout.

Musculoskeletal conditions are common throughout the world and their impact on individuals and society is enormous. The integrative and bio-psycho-socialy based model, the International Classification of Functioning, Disability and Health (ICF) is highly useful for structuring determinants of disability in these conditions. ICF encompasses health and health-related domains: body functions and structure, activity and participation and environmental factors. In clinical settings ICF is used for functional status assessment, goal setting and treatment planning and monitoring, as well as outcome measurement. In clinical practice the implementation of ICF is facilitated by the use of the ICF-based applications, such as ICF sheets or ICF Core Sets. In this article it is reported on the most important musculoskeletal conditions in rheumatology practice from the point of view of ICF and is complementary to the article by the same author that appeared in the previous issue of this journal.

Despite the advances in the pharmacological therapy non-pharmacologic methods and especially therapeutic exercise are a cornerstone in management of spondyloarthritides. In this review studies of various physical therapy programs in ankylosing spondylitis and other spondyloarthritides are addressed with emphasis on their benefits and potential indications as well as on limitations in clinical practice and in studying these treatments. Formal physical therapy under the supervision of a physical therapist has been shown to diminish pain and stiffness and to improve posture, mobility, function and quality of life. Apart form land exercises water therapy (including balneotherapy) may be beneficial and in most severe cases, inpatient rehabilitation may be indicated, too. Physicians should implement such non-pharmacological therapy as a part of a comprehensive management strategy. Even though data are not sufficient to determine which specific physical therapy programme should be recommended this review demonstrates that physical therapy is an effective form of intervention and remains an essential part of the management with the importance of emphasis on continued and regular exercise therapy.

Assessment of the impact of the rheumatic disease on the individual patient is necessary to evaluate the outcome of an intervention targeted at the disease process as well as at the restoration of the patient's functioning. The International Classification of Functioning, Disability and Health (ICF) is a comprehensive tool designed to record and organise a wide range of information about health and health related states, based on bio-psycho-social perspective. The ICF components, namely, body functions, body structures, and activities and participation are complemented by the contextual components, environmental factors and personal factors. All of them are in mutual interactions. The ICF contains lists of so-called ICF categories that describe the components of the integrative World Health Organisation model. It uses an alphanumerical model where categories are 'nested' so that broader categories are defined to include more detailed subcategories of the parent categories. Organized in such a way and with more than 1400 categories ICF covers virtually all the spectrum of problems encountered in patients with musculoskeletal conditions. The main practical tools of the ICF include ICF check lists, ICF core sets, ICF categorical profile and ICF assessment sheet. The ICF is likely to become the generally accepted conceptual framework and will be increasingly used in clinical practice to structure patient problems, particularly in multidisciplinary care and for rehabilitation purposes.

Rheumatoid arthritis is a chronic, inflammatory disease with the prevalence about 1%. Rheumatoid arthritis is characterized with synovitis, often evolve erosions of the joints, pain and functional deficit. Etiology is unknown, but the development of such autoimmune disease is due to genetic and environmental factors. Most of the patients with diagnosis of rheumatoid arthritis use nonbiologic disease modifying antirheumatic drugs. Advances in the undersstanding of the disease process have led to the development of biological agents to treat rheumatoid arthritis. With the use of biologic agents we wish to evolve the goal of therapy from that of symptomatiic relief to clinical remission. Biologic drugs have documented, fast and continuous efficacy with generaly well accepted safety profile. On behalf of Croatian Society for Rheumatology we propose recommendations for the biologic therapy in rheumatoid arthritis.

Osteoarthritis of the hip and the knee belongs to one of the most disabiliting conditions. Treatment goals for these patients include a reduction in pain, an improvement in joint mobility and to limit functional impairment. To properly manage osteoarthritis, both nonpharmacologic (non-interventional) and pharmacologic modalities may be employed, while minority of patients will require surgery. According to the available evidence for available therapies and experts' opinion here we present guidelines for the treatment of hip and the knee osteoarthritis in Croatia.

The aim of the study was to investigate the reliability and the validity of the Croatian version of the Bath Ankylosing Spondylitis Functional Index (BASFI) and Bath Ankylosing Spondylitis Disease Activity index (BASDAI) in patients with ankylosing spondylitis (AS). Patients with established diagnosis of AS participated in the study. Fifty-two and 48 patients were included for the evaluation of BASFI and BASDAI, respectively. For translation international translation steps were followed. For reliability patients recompleted both indices on the following day. To assess validity following parameters were obtained: spinal mobility in sagittal plane, chest expansion index, erythrocyte sedimentation rate, serum C-reactive protein, level of pain and patient's global health. Apart from descriptive statistics Spearman's rho coefficient was used. Correlation between BASFI and BASDAI score was 0.621. The mean BASFI scores on two occasions (within 24 hours) were 4.82 +/- 2.67 versus 4.88 +/- 2.52 (r = 0.961; p < 0.01), and for BASDAI scores were 5.46 +/- 2.30 versus 5.32 +/- 2.19, respectively (r = 0.959; p < 0.01). Stability index for both indices was 0.98. High correlation was found for each repeated question of BASFI and BASDAI. For both indices congruent validity demonstrated the best correlation with cervical and thoracic mobility. Also, the correlation was observed for BASFI with spinal mobility in lumbar region and with chest expansion index, and for BASDAI with the level of pain. Our findings indicate that Croatian version ofBASFI and BASDAI is reliable and valid. Therefore, it can be used in clinical research as well as in clinical practice.

Tumor-necrosis factor-alpha (TNFalpha) is a pro-inflammatory cytokine demonstrated to play an important role in the pathogenesis of rheumatoid arthritis (RA). Adalimumab is a recombinant human monoclonal antibody to TNFalpha. In the PREMIER study, when administered in combination with methotrexate (MTX), adalimumab demonstrated that 49% patients with early RA achieved remission. Adalimumab was effective in improving radiographic outcomes, too. At week 28, 52 and 104 of follow-up there was significantly less radiographic progression in combination group (adalimumab/MTX) than in each monotherapy group (adalimumab or MTX), with adalimumab showing better result than MTX. In a large open-label study with active RA, during adalimumab treatment 25% of patients experienced clinical remission and nearly half achieved minimal disease activity. Combining results from different clinical trials adalimumab has demonstrated up to seven years of efficacy among long-standing RA patients when used in combination with MTX. The percentage ofpatients achieving clinical remission continued to increase after two or more years of continuous treatment with combination therapy. In Health economic outcome study performed in parallel with PREMIER study there was a big reduction of days lost in the combination group (adalimumab/MTX) in comparison with MTX at year 1 and a difference maintained to year 2. The combination therapy was much more successful in maintaining quality of work than MTX. PROWD study, which was the first one to actually look at job loss as the primary outcome, showed that the combination of adalimumab and methotrexate has the ability to reduce job loss and work time lost when compared to just MTX. Adalimumab is the newest developed anti-TNFalpha, which not only demonstrated significant and sustained reduction in signs and symptoms and inhibition of radiographic progression, but has also improved functional status, quality of life and work productivity in patients with RA, with acceptable safety profile.

Osteoporosis is a disease characterized by loss of bone mass and the structural deterioration of bone tissue leading to increased bone fragility and fractures. Preventive measures for osteoporosis and osteoporotic fractures include adequate calcium and vitamine D intake, adequate physical activity and reduction of the risk factors can be influenced. Currently, measurement of bone mineral density using dual energy x-ray absorptiometry (DXA) is still the gold standard for the diagnosis of osteoporosis. Non-pharmacological therapy is the integral part of the management ofosteoporosis. Nitrogen-containing bisphosphonates in weekly or more prolonged (monthly) dosing intervals are now the firstline osteoporosis therapy. Oral bisphosphonates show, generally, similar efficacy on vertebral fractures risk reduction. There, might be some differences among bisphosphonates, regarding risk reduction of non-vertebral, hip and glucocortiocoid related fratures. On behalf of Croatian Society of Rheumatology of Croatian Medical Association we propose recommendations for the prevention, diagnosis and management ofpostmenopausal osteoporosis.

The diclofenac of rapid effect (Diclorapid) that has better gastric tolerability is presented.

Rheumatoid arthritis is a chronic, inflammatory disease with the prevalence about 1%. Rheumatoid arthritis is caracterized with synovitis, erosive changes of the joints, pain and functional deficit. Etiology is unknown. In the pathogenesis of rheumatoid arthritis the key role have proinflammatory citokines, particularly, tumour necrosis factor (TNFalpha). TNFalpha blockers have documented, fast and continuous efficacy with generally well accepted safety profile. Nowdays, TNFalpha antagonists are established drugs in early and late phase of rheumatoid arthritis. Prescription of TNFalpha antagonists is controlled, according local restrictions, regarding high costs of the therapy. On behalf of Croatian Society for Rheumatology we propose recommendations for the TNFalpha antagonist therapy in rheumatoid arthritis.

In the past decade treatment strategies for patients with rheumatoid arthritis have changed dramatically. Patients are being treated earlier and more aggressively than in the past, and far more therapeutic options are available, which has increased the complexity of the management of patients with rheumatoid arthritis. The processes have had an influence on the outcome of patients with RA and on the way they are being evaluated. Disease course should regularly be evaluated with both process (i.e. erythrocyte sedimentation rate, joint counts) and outcome measures (i.e. radiological progression). For the evaluation of interventions, 'core sets' of valid measures to assess disease activity and outcome and specific criteria for improvement should be used. "Tight control" of patients with rheumatoid arthritis will enable us to adjust the therapy and to achieve the ultimate goals, remission and less disability.

Rheumatoid arthritis is a chronic, inflammatory disease with the prevalence about 1%. Rheumatoid arthritis is characterized with synovitis, erosive changes of the joints, pain and functional deficit. Etiology of the disease is unknown. In the pathogenesis of rheumatoid arthritis the key role have proinflammatory citokines, particularly, tumour necrosis factor (TNFalpha). TNFalpha blockers have documented, fast and continuous efficacy with generaly well accepted safety profile. Nowadays, TNFalpha antagonists are established drugs in early and late phase of rheumatoid arthritis. Prescription of TNFalpha antagonists is controlled, according local restrictions, regarding high costs of the therapy. On behalf of the Croatian Society for Rheumatology we propose recommendations for the TNFalpha antagonist therapy in rheumatoid arthritis.

Persistence and adherence are major determinants of optimal results in the treatment of osteoporosis. In order to improve the efficacy of antiresorptive drugs, fewer demands on patients and better adherence were obtained with less frequent dosing schedule. Once-weekly and once-monthly oral bisphophonates showed equivalency with once daily medications. Comparison of persistence and adherence between weekly and monthly bisphosphonate regimens revealed conflicting results. In Croatia, persistence and adherence of weekly alendronate seem to be better than in other countries. In the light of compliance problems there is a need to assure adequate intake of vitamin D, because it is essential for prevention and treatment of osteoporosis and osteoporotic fractures. Vitamin D has other beneficial effects, particularly on neuromuscular performances. A high prevalence of vitamin D inadequacy was seen across all geographic regions. Weekly alendronate and vitamin D in one tablet provides proven fracture prevention at the spine and hip, and assure that patients receive a weekly dose of vitamin D.

Non-pharmacological treatment is important in management of musculoskeletal pain. Therapeutic modalities such as superficial heat or cold agents, therapeutic ultrasound, laser and/or electric currents have been used extensively for various musculoskeletal diseases and conditions. They have many advantages over other pain-modifying interventions. However, relatively few high-quality research studies have been performed to elucidate mechanisms underlying their analgesic properties and there are insufficient controlled efficacy findings supporting the use of various physical agents in the management of pain conditions. The cornerstones of non-pharmacological management of chronic musculoskeletal pain are education, exercise and cognitive-behavioural therapy, ideally in combination through the multidisciplinary treatments programs based on biopsychosocial model of pain. From the available evidence it can not be concluded whether an indivudual patient with chronic pain should be referred to cognitive-behavioural treatment programs or active conservative treatment. There is a need for further studies to clarify the type and manner of non-pharmacological treatments, their intensity, duration and progression according to patient-specific outcomes.

The aims of management in seronegative spondiloarthritides are to control pain and inflammation, maintain optimal mobility of spine and peripheral joints, restoration and preservation of functional ability, prevent contractures and deformities. Non-steroidal anti-inflammatory drugs are the basis of drug treatment. Numerous non-steroidal anti-inflammatory drugs have been shown to reduce pain and inflammation. Apart from non-steroidal anti-inflammatory drugs, in order to control the pain pure analgesics and weak opioids are the most often used drugs. In this paper is discussed use of these drugs in patients with seronegative spondyloarthritides.

Osteoporosis is chronic bone disorder that require persistent treatment. Bone fracture is the final outcome of OP and early diagnosis, active prevention, treatment and improvement of the patient adherence to treatment are needed. Ibandronate is a potent, nitrogen-containing bisphosphonate specifically developed for once-monthly oral and three-monthly administration with the same anti-resorptive efficacy. Ibandronate reduce vertebral fracture risk 50-60%, increase spine and hip BMD, 6% and 3%, significantly decrease biochemical markers of bone turn-over without histomorphometric changes of bone. There is strong patient preference for once-monthly regimen and the favourable impact on therapeutic adherence. Intravenous ibandronate formulation is indicated for all patients who are unable to take oral medicine. Adverse events are infrequent, short duration and reversibile.

Osteoporosis represents a major and increasing public health problem with the aging of population. Major clinical consequences and economic burden of the disease are fractures. Many risk factors are associated with the fractures including low bone mass, hormonal disorders, personal and family history of fractures, low body weight, use of certain drugs (e.g. glucocorticoids), cigarette smoking, elevated intake of alchohol, low physical activity, insufficient level of vitamin D and low intake of calcium. This epidemiological review describes frequency, importance of risk factors and impact of osteoporosis and osteoporotic fractures. Objective measures of bone mineral density along with clinical assessment of risk factors can help identify patients who will benefit from prevention and intervention efforts and eventually reduce the morbidity and mortality associated with osteoporosis-related fractures.

The purpose was to determine the efficacy of therapeutic ultrasound in patients with chronic low back pain. Thirty-one patients, age 38-77, with low back pain lasting more than three months and the intensity of pain on visual analogue scale at least 50 mm, are randomly divided in two groups. Ultrasound is applied on the lumbar paravertebral muscle in 16 patients and in 15 patients the machine was not switched on. All patients also underwent kinesitherapy. Pharmacological treatment was not changed during the research (except the possibility of using paracetamol as the "rescue drug"). Following parameters were measured at the beginning and at the end of the research: pain intensity on the visual analogue scale/mm, modified Schober measure/cm, patient's and physician's global assessment of treatment efficacy (1-5 scale). The intensity of pain in the ultrasound group before the treatment was 82,7+/-14,0 and after the treatment 79,8+/-12,2 (p<0,05). The intensity of pain in the placebo group before the treatment was 81,7+/-12,1 and at the end of the treatment 78,9+/-12,1 (p>0,05). The value of the modified Schober measure for the ultrasound group were 5,7+0,8 cm vs. 5,8+/-0,9 cm (p>0,05) and in the placebo group were 5,4+/-0,9 cm vs. 5,6+/-1,0 cm (p>0,05). There was no significant statistical difference between ultrasound and placebo group regarding the efficacy of the treatment (patients p>0,05, physicians p>0,05). Therapeutic ultrasound was effective in decreasing the pain intensity in this research, but showed no improvement regarding the functional ability of the lumbar spine in patients with chronic low back pain.

Low-back pain is a major health and social problem. The approach to patients with low-back pain is complex and multidisciplinary, and drugs take the important place. In this rewiev we discuss knowledge about the role of non-opioid analgetics, nonsteroidal anti-inflammatory drugs and weak opioids in the treatament of low-back pain.

Reducing pain is a major goal in treating patients with arthritis. Oral controlled-release opioid products enable patients to better maintain pain control due to convenient dosing intervals and sustained blood concentration. Oxycodone is a strong opioid that has proved to be efficacious in analgesic studies of persistent moderate to severe pain in patients with degenerative and inflammatory rheumatic diseases. Beyond significant pain control and better physical function, controlled-release oxycodone improved coping with pain in patients with osteoarthritis.

Recently, many studies showed need to administer vitamin D in treatment of osteoporosis. Vitamin D deficiency was proved in postmenopausal women with osteoporosis. Effects of vitamin D resulted in lower risk of fractures and falls, as well as improvement of neuromuscular performances. In more than ten years of practice and several short- and long-term clinical studies alendronate lowered the risk of vertebral and extravertebral fractures, improved BMD of all measured sites in postmenopausal women and men with osteoporosis. Positive results of alendronate were demonstrated in different entities like persons of various ages and grades of lower BMD or patients with glucocorticoid-induced osteoporosis. Combination of vitamin D with efficacious antiresorptive drug alendronate maintains all pharmacological features and proves clinical effects of lx weekly alendronate, partly eliminating need for vitamin D supplementation.

After the withdrawall of rofecoxib from worldwide market, there is ongoing debate whether gastrointestinal safety of COX-2 inhibition compared to non-selective NSAID-s may come at the cost of increased cardiovascular events. In this paper the relevant data regarding mechanisms, effects and side effects of selected COX-2 inhibitors are presented. Possible class effect is disscused and proposed alternative therapies.

Osteoarthritis (OA) is the most common form of arthritis and the most common indication for total hip and total knee replacement. It is an ageing-disorder which mostly affects distal interphalangeal joints, proximal interphalangeal joints, trapezo-metacarpal joints of the thumbs, knees and hips. Risk factors for the development and/or progression of OA identified in epidemiological studies can be broadly divided into systemic factors that increase the susceptibility to the disease and local biomechanical factors that influence the development of OA at the particular joint. It is estimated that costs associated with OA exceed 2% of the gross national product in developed countries. When it involves the hip and/or knee, OA accounts for more functional limitations and physical disability than any other chronic disease among adults.

The comparison of standard high frequency (ST-TENS) and acupuncture-like TENS (AL-TENS) in patients with rheumatoid arthritis is presented. Thirty-three patients (26 women and 7 men) with rheumatoid arthritis (according to modified ACR criteria), and with the duration of the disease 10.7 +/- 8.8 years are investigated. Each subject received ST-TENS (75 Hz) at the selected joint and AL-TENS (4 Hz) at the contralateral joint respectively. No significant difference between left and right side in pre-treatment pain was the main criterion for selecting the treated joint. Treatment was performed during 12 days. The initiation, duration, level of hypolgesia (according to Ritchie's pain assessment scale and VAS), patients' global assessment and possible reduction of dosage of analgetics/antirheumatics were measured. There was a significant reduction in pain level on ST-TENS site (48.6%), and on AL-TENS site (40.8%), measured on VAS. Results of Ritchie's index showed significant difference before and after application (for each type of TENS P < 0.05). There was no statistical difference between both types of TENS regarding the reduction of pain level, as well as the initiation of analgesic effect, whilst it was noted a slightly longer, although statistically not significant, hypoalgesic effect of AL-TENS. Patients' global assessment also did not differ relating to ST-TENS and AL-TENS, as well as their opinion on possible dosage reduction of analgetics/antirheumatics. Side effects for both types of TENS were negligible. The findings showed that ST-TENS and AL-TENS provided hypoalgesic effect in the similar degree in patients with long-standing rheumatoid arthritis.

Physical activity is associated with increased bone mass and reduced risk of hip fracture. However, scarce are data from population samples concerning the effect of level of physical and sport activity on the risk of osteoporotic vertebral deformity. The aim of the study was to determine the amount of physical and sport activity and to relate it to occurrence of vertebral deformity in older population. In total 425 subjects (269 women and 156 men) age 50 and above, were recruited from a population frame sample, as a random sample of city of Zagreb. An interviewer-administered questionnaire was used to get information about level of physical and sport activity in three different age periods (15-24 years, 25-49 years and 50 years and above), and the amount of time spent walking or cycling each day. Lateral thoracolumbar radiographs were taken using standardised procedure. Radiographs were evaluated morphometrically and the presence of vertebral deformity was defined according to method of McCloskey and al., with an alternative approach for defining normal values using iterative algorithm described by Melton and al. Vertebral deformities were found in 50 (11.8%) subjects. Men were more involved in sports activities in all three life periods, and had heavier overall physical activity from 15-24 years. Although results suggest possible decreased risk for vertebral deformity with stronger physical activity in the first life period, no significant association was found between physical or sport activity and vertebral deformities, even when possible confounding factors were taken in account. Current walking or cycling, adjusted for possible confounders, did not change the risk for vertebral deformities, too. Various confounding factor, different from those taken in account for this study or inadequately large sample for sport activity could have influence the results. We conclude that men are more physically active in younger age, and overall do more sports. Warning is the fact that appreciable proportion of men and women do not do any sport activity. We could not confirm that level of physical or sport activity, as well as regular walking or cycling was significantly important for occurrence of vertebral deformities. Prospective studies are needed in order to understand better the epidemiology and the role of possible risk factors of osteoporotic vertebral deformities in our population, which can help us in planning programs of prevention.

The subcutaneous rheumatoid nodules (RN) have been recognized by the American Rheumatism Association, both in 1958 and in 1987, as one of the diagnostic criteria (ARA criteria) among other rheumatoid arthritis (RA) symptoms. The aim of this research has been both to provide the incidence of occurrence of RN in patients with RA in Croatia and to determine its significance in making the RA diagnose. The test group comprised 233 patients (182 women and 51 men) with RA, their average age being 48.3 years in the range of 18 to 77. Both the anamnesis and the clinical examination have determined the occurrence of RN in 54 (23.2%) of 233 patients. The range of occurrences was more evident in men (31.4%) than in women (20.8%), though this difference was statistically irrelevant. The most common localization of benign rheumatoid nodules was the exterior side of elbow and PIP hand joints. The obtained results prove that the incidence of RN in our tested patients with RA can be compared with those of the earlier researches done in Croatia (18.1% Jajić, Vlak; 20-25% Jajić), as well as with those obtained in the western European countries (20% Doherty, George; 25% Ziff; 20-25% Miehle; 21% Wolf et al.).

The aim of the study was to establish the employment and working ability for patients with ankylosing spondylitis. The study was performed using a questionnaire mailed to 185 patients with verified diagnosis of ankylosing spondylitis who were treated at the Department of Rheumatology of the University Hospital "Sestre milosrdnice" in Zagreb in the last 5 years. The questionnaire included a few categories of questions and here we analysed those referring the working abilities. The answers were obtained from 92 patients. We took in account the data for 79 patients who fall into the age group of working population (men to 65 yrs, women to 60 yrs.). In that group there were 50 men and 29 women. Twenty-six patients have a full time job, 7 patients have a part-time job, one changed the job and 45 of them are retired. The difference of working abilities was observed regarding to the physical requirement for the job (P < 0.05) and the duration of the disease (P < 0.05). Among the patients who are retired majority stated that ankylosing spondylitis was the cause of their retirement. As for the patients who still work (N = 34), 14 of them were not on sick-leave the last year at all, 2 of them were absent up to one week, 10 patients were absent from 1 to 4 weeks, 3 patients were on sick-leave from 1 to 3 months, and 5 of them more than 3 months. Statistically significant difference was observed in sick-leave rate regarding to the physical requirements for the job (P < 0.01), but not regarding to the duration of the disease (P > 0.05). The results of our study suggest that ankylosing spondylitis reduce the working ability especially for patients who have a hard job. There is an imperative to maintain the working abilities of patients with ankylosing spondylitis as long as possible.

The aim of the study was to establish some clinical features of ankylosing spondylitis in an epidemiological study using a mailed questionnaire. The questionnaire was sent to 185 patients with ankylosing spondylitis who were treated at the Department for Physical Medicine, Rehabilitation and Rheumatology. The answers were obtained from 92 patients (49.7%). In the studied cohort there were 60 men and 32 women. The average age of all patients were 51.6 +/- 11.8 yrs. In most of the patients (69 or 75%) the duration of ankylosing spondylitis is more than 15 years. The diagnosis of ankylosing spondylitis was established on average 6.5 years after the beginning of symptoms. Patients suffering from ankylosing spondylitis more than 15 years reported that the worst period of the disease was the starting 10 years. The main symptoms of the disease are stiffness and pain. The aggravation of pain occurs with enhanced physical activity as well as with prolonged rest--Painful swelling of one or more joints of 3 weeks duration had 63.7%, and more than 3 weeks duration 40.7% patients. There was no difference in occurrence of painful swelling extravertebral joints regarding to duration of the disease (P > 0.05). The most often affected joints were hips and shoulders. Eyes inflammation was reported by 63 patients, and unspecified enterocolitis had 16 patients.

In 30 patients (20 males and 10 females) wih psoriatic arthritis chloroquine was administered in a dosage of 250 mg daily per os. After 12 months of monitoring decreased number of swollen and painfully tender joints were found as well as shortening in duration of morning stiffness. As for laboratory parameters lowering of the average values of ESR and alpha-2 globulins were found whilst there were no changes of ceruloplasmin, haptoglobin and CRP. Worsening of skin lesions was observed in only 2 patients (6.5%). These results suggest that synthetic antimalarials (chloroquine) can be successfully used in the treatment of psoriatic arthritis with special care.

The aim of the study was to establish age and sex distribution, seasonal variations, and mode, of onset in a sample of patients with rheumatoid arthritis. One hundred eighty nine patients (146 women and 43 men), whose age ranged from 18 to 77 yrs. (mean age 49.1, SD 12.93) were included in the survey. In majority of patients the disease started between 31-50 years, whereas in the age group from 21-30 it occurred more frequent in women, and in the age group from 51-60 in men. The onset of rheumatoid arthritis was in almost equal proportions acute or insidious, regardless sex. No difference was found concerning onset of the disease and seasonal variations. However there was a statistically significant correlation between mode of the onset and seasonal variations (P < 0.05). Rheumatoid arthritis started abruptly more often in springtime, and more insidiously in autumn, whereas in summer and winter there was an equal number of patients with acute or insidious onset of the disease.