The Clinician

Although smoking cessation is the most cost-effective approach to prevention and treatment of cardiovascular disease, the number of smokers does not decrease. Currently, the possibility of using new forms of nicotine delivery – electronic cigarettes (ECs) and electronic heated tobacco products (HTPs) – to quit is being discussed. The majority of specialized societies are opposed to the use of ECs and HTPs for this purpose, but a number of studies have demonstrated their effectiveness. Our aim was to provide a descriptive review of the literature on the possibility of using ECs and HTPs as additional tools for smoking cessation. The 2025 Cochrane review found that ECs with nicotine are more effective for smoking cessation than nicotine replacement therapy, nicotine-free ECs, and behavioral therapy. According to the 2022 Cochrane review on the use of HTPs for smoking cessation, there was less exposure to toxins/carcinogens while using HTPs compared to conventional smoking. Finally, the 2023 systematic review of randomized clinical trials of the effects of HTPs on the cardiovascular system demonstrated a significant reduction in biomarkers involved in inflammation, oxidative stress, lipid metabolism, and endothelial dysfunction. The use of ECs may be feasible in patients who are not ready to quit and not interested in pharmacological smoking cessation support, as mentioned in the 2018 ACC Expert Consensus Decision Pathway on Tobacco Cessation Treatment. The potential for the use of ECs for smoking cessation is also mentioned in the 2023 American Heart Association/American College of Cardiology Guideline for the Management of Patients with Chronic Coronary Disease and in the 2024 European Society of Cardiology Guidelines for the Management of Chronic Coronary Syndromes. At the same time, none of the new forms of nicotine delivery should be considered completely safe and recommended for long-term use, especially in adolescents, young adults, pregnant women, as well as in nonsmoking adults.

Background. The 6-minute walk test (6MWT) is used to assess physical performance (PP) in cardiac rehabilitation. PP in the 6MWT in patients with rheumatoid arthritis (RA) is poorly studied.

Aim. To assess results of comprehensive rehabilitation including aerobic activity in patients with RA using 6MWT, to determine PP factors and dynamics affecting 6MWT parameters.

Material and methods. 6MWT was performed in 127 patients with RA, out of exacerbation, aged 33–81 years, before and 2 weeks after comphehensive rehabilitation with moderate aerobic exercise on Kardiomed 700 cardio-machines. 79.5 % of patients had arterial hypertension, 74 % had overweight or obesity. The dynamics of RA activity according to the Disease Activity Score 28 (DAS-28), rheumatoid factor in blood serum, pain intensity according to the visual analogue scale, vital signs index per the Health Assessment Questionnaire – Disability Index (HAQ-DI), hand compression strength, and daily blood pressure monitoring were studied. ROC analysis was used to determine factors that allow prediction of the results of 6MWT.

Results. The median distance in 6MWT initially was 400 m (IQR (interquartile range) 340–480 m), after 2 weeks of rehabilitation it increased to 430 m (IQR 386–510 m; p <0.01) but remained below the required value 473.9 m (IQR 431.5–529.9 m; p <0.01).

The distance in the 6MWT positively correlated with the strength of the left arm (p = 0.02) and negatively with age (p = 0.02), HAQ-DI (p = 0.01), mean pulse (p = 0.01) and systolic blood pressure at night (p = 0.02), overall health (p = 0.02) and pain intensity (p = 0.01). An increase in the distance after rehabilitation was accompanied by a decrease in the tender and swollen joint counts, improvement of overall health per the DAS-28 assessment, decrease in pain, increase in the compression force of the hands, increase in HAQ-DI, and decrease in systolic and diastolic blood pressure during the daytime. According to ROC analysis, 6MWT before and after rehabilitation depended on age (less than or more than 61 years), body mass index (less than or more than 27 kg / m²), and duration of RA less than or more than 1 year).

Conclusion. The PP in patients with RA out of exacerbation and in the absence of serious comorbid diseases is moderately reduced and increases after 2 weeks of rehabilitation with moderate-intensity aerobic exercises, accompanied by improvement in joint syndrome indicators, increased vital activity, and decreased blood pressure. The 6MWT is an additional tool for assessing the functional state of patients with RA. The 6MWT distance varies depending on age, body mass index, and the duration of RA, which should be taken into account when predicting the results of rehabilitation and evaluating its effectiveness.

Aim. To evaluate the outcomes of using various biologic disease-modifying antirheumatic drugs (bDMARDs) / targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs) in patients with difficult-to-treat (DtT) rheumatoid arthritis (RA).

Material and methods. A retrospective analysis of medical records of 1145 patients with confirmed RA diagnosis was conducted. Patients with follow-up duration of less than 6 months, those who did not receive basic therapy, and patients with subsequent diagnosis change were excluded. In the selected group (121 patients), DtT patients were identified. These were RA patients who received recommended treatment with conventional disease-modifying antirheumatic drugs (DMARDs) and whose therapy with two classes of bDMARDs / anti-cytokine drugs failed to achieve low disease activity/ remission or was discontinued due to adverse events.

A treatment episode with a targeted drug was considered successful if it resulted in at least low disease activity and treatment duration exceeded 6 months. Unsuccessful episodes were defined as those lasting 6 months or less, or those failing to achieve low disease activity or remission. Episodes that could not be classified as successful or unsuccessful were excluded from the analysis. More than 400 quantitative and categorical indicators were analyzed in each subgroup.

Results. The analysis included 262 treatment episodes, of which 90 (34.4 %) were classified as successful. The mean duration of successful treatment episodes was 28.5 months (interquartile range 13.0–56.75), while unsuccessful episodes lasted 13,0 months (interquartile range 9.0–25.0). No significant association was found between non-response to various drugs / drug classes and the likelihood of success in subsequent treatment.

The highest success rates were observed for: levilimab – 66.7 %, tocilizumab – 54.3 %, abatacept – 44.0 %, tofacitinib – 40.0 %. Patients who received bDMARD therapy within ≤6 months after diagnosis had significantly lower treatment success rates (26.2 % versus 53.2 %; p <0.008 taking into account Bonferroni’s correction). In this group, tocilizumab and levilimab showed the highest success rates (51.6 %).

Conclusion. No clear associations were found between the likelihood of success with bDMARD / tsDMARD use and previous unsuccessful use of other drug classes, except for abatacept. In non-responders to abatacept, success was primarily achieved with interleukin 6 inhibitors (except sarilumab) and etanercept (55.6 % and 75.0 %, respectively). The use of TNF inhibitors in DtT patients is relatively less promising after other classes have been used. The exception is etanercept, which proved to be quite effective in non-responders to any drug class. Overweight can be an important factor in inefficacy of some bDMARD / anti-cytokine drugs and can serve as a reason for dose increase in this patient cohort.

Aim. To demonstrate comprehensive approach to management of a patient with chronic pain syndrome and postherpetic neuralgia alongside recurrent herpes virus infection taking into account modern therapeutic capabilities.

Material and methods. Female patient A., 47 years, with intense neuropathic pain syndrome on the left in the thoracic spine (up to score 7–8 on the visual analogue scale) and sleep disruption due to pain developed after hypothermia. Had a history of herpes zoster, received a full course of antiviral therapy. Comprehensive clinical, laboratory and instrumental diagnostics were performed, in the Th₅–Th₇ segments on the left characteristic eruptions, areas of hyperpathia, allodynia and hyperesthesia were verified. The patient took the recommended gabapentin 1500 mg / day with positive but insufficient effect: significant burning and intense itching continued, and laennec (human placenta hydrolysate) was prescribed per the following scheme: 4 mL intramuscularly every other day – N.5; 4 mL intramuscularly 3 times a week – N.10; 4 mL intramuscularly 2 times a week – N.10.

Results. Stringent clinical effect of the therapy was achieved after 2 months: shooting pains and intense itching are absent, burning sensation appears rarely and is not bothersome; sleep normalized completely.

Conclusion. Modern management of postherpetic neuralgia requires comprehensive approach which should include, apart from symptomatic treatment of neuropathic pain syndrome, medications with immunomodulating and anesthetic effects allowing to not only treat current disease episode but also to prevent its future recurrence.

Osteoarthritis (OA) is one of the most common chronic diseases and is frequently associated with comorbid conditions, primarily cardiovascular diseases, metabolic disorders, and other musculoskeletal diseases. Patients with OA have a moderately increased risk of cardiovascular events (myocardial infarction, stroke, thromboembolic complications) which is related both to traditional risk factors and comorbidity clustering, as well as to specific features of the therapy used, primarily the administration of nonsteroidal anti-inflammatory drugs. Nonsteroidal anti-inflammatory drugs remain a key tool for pain control in OA, but their use is associated with a risk of gastrointestinal, cardiovascular, renal, and hepatotoxic complications, as well as a number of other adverse events, which is of particular importance in elderly and comorbid patients. Current clinical guidelines emphasize the need for individualized risk stratification, selection of a drug based on its safety profile, possible use of gastroprotection, and administration of the lowest effective dose for the shortest possible duration of therapy. Nimesulide, a moderately selective cyclooxygenase-2 inhibitor, has demonstrated analgesic efficacy and a favorable benefit – risk profile in OA patients with moderate risk of gastrointestinal complications and low to moderate cardiovascular risk. Thus, successful management of comorbid patients with OA is based on comprehensive risk assessment, personalized therapy selection, and careful monitoring for potential adverse effects.

Currently, comprehensive medical care for combat veterans on the part of primary care doctors is an important problem. To improve the unified teaching strategy in medical universities for preparation of highly qualified specialists, the main questions of the training process of students studying the general medicine specialty are discussed. The article presents points of view of psychiatrists, psychologists, internal medicine doctors, ophthalmologists, dermatologists, and proposals on optimization of continuity of teaching how to manage patients with post-traumatic stress disorder and how to improve communication skills of future doctors during caring for patients with this acute emotional disorder. To improve preparedness of medical students to apply knowledge in clinical practice, the experts focus on the classical manifestations of post-traumatic stress disorder and psychosomatic disorders, teaching systemic approach to patients’ needs with focus on communication during outpatient appointments, discussion of combat stress target organs. During comprehensive discussion, the experts concluded that it is necessary to strengthen interactions between clinical and scientific departments of medical universities to study the role of stress in stepwise development of long-term consequences of stress-induced somatic pathology, to increase attention to details in communication between doctors and patients with post-traumatic stress disorder, to introduce problems of outpatient observation of combat veterans into the summer working practice of 5th year students training in general medicine. Regular updates of the training materials will help to better understand the problem of post-traumatic stress disorder and prepare graduates for performing qualified and rounded medical services to combat veterans.