Dual antiplatelet therapy (acetylsalicylic acid and platelet P2Y12 receptor antagonist) is a standard component of treatment of any type of acute coronary syndrome, independently of perfusion and the chosen treatment strategy. Due to certain limitations of clopidogrel as the 2nd component of dual antiplatelet therapy in patients with acute coronary syndrome and percutaneous coronary intervention, the possibility of using prasugrel or ticagrelor should be considered first. Their effectiveness is higher than clopidogrel’s, as was demonstrated in large clinical trials. As a result, prasugrel and ticagrelor were included in all major international and Russian guidelines on treatment of this category of patients with the same class and level of evidence. Currently, there’re no data from any finished large randomized clinical trials of sufficient statistical power directly comparing the effectiveness and safety of prasugrel and ticagrelor. Therefore, careful analysis of the accumulated data on the safety and effectiveness of each drug including meta-analyses and registries is necessary for providing the best care for every individual patient.

Objective: to evaluate the safety and effectiveness of vaccination with trivalent split virion influenza vaccine in patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS), estimate the effect of vaccination on rheumatoid disorder (RD) activity and influenza and influenzalike illnesses morbidity.

Materials and methods. The study included 86 patients (58 females and 28 males aged 22–82 years) with RDs (52 patients with RA and 34 patients with AS), as well as 40 subjects without RD (control group). At the time of study inclusion, all patients were receiving drug therapy. Duration of RD varied from 2 months to 46 years. The Vaxigrip vaccine containing the currents trains of the flu virus for 2016–2017 season or 2017–2018 season was administered subcutaneously as 1 dose (0.5 ml) with continuing antirheumatic therapy. The main control stages were visits 1, 3, and 6 months after vaccination. During the visits, standard clinical and labtests, clinical examination with disease activity evaluation were performed.

Results. In 98 patients, vaccination tolerability was high, no post vaccination reactions were observed. In 20 cases, pain, swelling, and hyperemia of the skin 2 cm in diameter at the point of vaccination were observed; in 8 cases, low-grade fever, myalgia, discomfort, headache were observed. No RD flares or development of new autoimmune disorders were diagnosed during the follow-up period. No cases of influenza or influenza-like illnesses were registered during the follow-up period.

Conclusion. The obtained data demonstrate high tolerability, clinical effectiveness of trivalent split virion influenza vaccine in patients with RA and AS.

 Objective: to compare the level of modified low-density lipoproteins (mLDL) in patients with diabetes mellitus type 2 (DM2) and without DM2; to identify the factors affecting mLDL сontent.

Materials and methods. The study involved 64 patients; they were divided into 2 groups. The main group included 32 patients with DM2 (15 men and 17 women, median age – 65 years), the control group 2 included 32 patients without DM2 (15 men and 17 women, median age – 60.5 years). All patients (100 %) had arterial hypertension. Both groups were generally comparable in the main clinical and laboratory characteristics. Mann–Whitney test, Spearman correlation coefficient were used for statistical data processing.

Results. In patients with DM2 mLDL level was significantly higher (р <0.001) and correlated with blood glucose concentration (p = 0.021), glycated hemoglobin values (p <0.001) and body-weight index (p = 0.007). In patients without DM2 mLDL level correlated with bodyweight index (p <0.001). No correlation between mLDL level and standard LDL content was found in patients with DM2 and in patients without DM2 (p = 0.714 and p = 0.758 respectively).

Conclusion. DM2 is significantly associated with an increased mLDL level that is affected by parameters of carbohydrate metabolism and body-weight index. In persons without hyperlipidemia mLDL level increases in case of hyperglycemia.

Objective: to evaluate vasopressin (VP) concentration in patients with varying severity of chronic heart failure (CHF), intensity of clinical symptoms, and decreased level of left ventricular ejection fraction (LVEF).

 Materials and methods. In total, 120 patients (44 males, 76 females) with CHF of varying genesis (mean age 72.12 ± 10.18 years) and 30 clinically healthy individuals (18 males, 12 females) as a control group (mean age 33.4 ± 6.23 years) were examined. All patients underwent comprehensive clinical and instrumental examination in accordance with the standards for patients with CHF. The VP level was determined using ELISA. Statistical analysis was performed using the IBM SPSS Statistics v. 23 software.

Results. The patients with CHF had significantly higher blood VP levels compared to the control group (72.91 ± 53.9 pg/ml versus 6.6 ± 3.2 pg/ml respectively; p <0.01). At the same time, patients with stage III CHF had significantly lower VP levels than patients with stages IIВ and IIА (35.61 ± 21.53 pg/ml versus 71.67 ± 48.31 pg/ml and 86.73 ± 59.78 pg/ml respectively; p<0.01). A similar picture was observed for the functional classes (FC). For instance, for CHF FC II and III, the VP level was 91.93 ± 67.13 pg/ml and 77.95 ± 54.01 pg/ml respectively, while for FC IV it decreased to 50.49 ± 28.18 pg/ml (p <0.01). The VP concentration in patients who subsequently perished was significantly lower than in patients who survived (48.79 ± 26.30 pg/ml versus 79.72 ± 57.73 pg/ml; p = 0.012). Moreover, in patients with LVEF <50 %, the VP level was significantly lower than in patients with LVEF >50 % (59.43 ± 42.51 pg/ml versus 86.43 ± 62.46 pg/ml respectively; p <0.05).

Conclusion. The observed significant differences in VP in patients with stage III and IV CFH can indicate depletion of neurohumoral mediators in this patient category. However, a correlation between the VP level and the level of LVEF decrease can indicate a significant difference in the role of VP in CHF pathogenesis in patients with preserved and decreased LVEF. This observation requires further research.

Objective: to analyze and present a clinical case of late diagnosis of Takayasu’s arteritis in a young female patient with long-term arterial hypertension.

Materials and methods. The female patient G., born in 1989, had noted elevated arterial pressure (AP) of 150/90 mm Hg since she was 14. At 21 the following diagnosis was stated: Fibro-muscular dysplasia, stenosis of the left renal artery. Stenosis of the celiac trunk. Aneurisms of the branches of the superior mesenteric artery; prosthesis of the left renal artery was performed. Since the beginning of 2016, the patient has noted elevated AP of 200/110 mm Hg despite continuing hypotensive therapy. Diagnosis of Nonspecific aortoarteritis was proposed in May of 2017. Methylprednisolone therapy was administered: 250 mg No. 2 intravenously, Prednisolone: 25 mg a day orally. Due to signs of decreased blood flow to the left kidney, in August of 2017 extracorporeal repeat prosthesis of the left renal artery, bypass of the right middle renal artery with reversed autovein were performed.

Results. During examination in October of 2017, the patient complained of weakness, frequent elevated AP of 200/110 mm Hg. In blood test: hemoglobin 106 g/l, erythrocyte sedimentation rate 38 mm/h, C-reactive protein 25 mg/l. A heterozygous mutation in the methylenetetrahydropholate reductase, a heterozygous mutation in the factor V gene (G1691A) were identified. Homocysteine level was normal, infection and oncological pathology were excluded. The following diagnosis was made: Takayasu»s arteritis type IV affecting the aorta and its branches, moderate activity. Occlusion of the celiac trunk. Aneurisms of the branches of the superior mesenteric artery. Critical stenosis of the left renal artery. Thrombosis of the aorto-renal prosthesis. Hypoplasia of the left kidney. Prednisolone 50 mg a day, metoprolol 50 mg a day, valsartan 160 mg a day, acetylsalicylic acid 100 mg a day were prescribed.

Conclusion. The presented clinical observation shows the importance of comprehensive examination of young patients complaining of elevated AP for many years. Due to untimely diagnosis and absence of pathogenetic therapy, the patient suffered negative consequences of surgical treatment.

Objective: to analyse and provide a description of the clinical case of a giant parathyroid adenoma, to show the fetures of clinical course, diagnosis, the results of surgical treatment and tactics of conducting in the postoperative period.

 Materials and methods. Patient S., aged 60, with a 10-year history of severe osteoporosis with fractures, urolithiasis, hypertension, low back pain, was consulted by a rheumatologist. In respect that there was the combination of severe osteoporosis with nephrolithiasis and elevated serum calcium level, the patient was directed to a consultation with the endocrinologist and was hospitalized in the city endocrinology department.

Results. When examining in the endocrinology department, violations of phosphorus-calcium metabolism, an increase in parathyroid hormone, characteristic of hyperparathyroidism of bone skeleton changes were revealed. Based on the results of ultrasound and magnetic resonance imaging of the neck, neoplasm of the lower parathyroid gland was revealed on the left side. A puncture biopsy and surgical treatment was performed. A dense tumor of dark color, 45 × 30 × 20 mm in size, was removed, according to a histological study – a mixed-cell adenoma with cellular polymorphism. The early postoperative period was complicated by the development of hypoparathyroidism that was corrected by taking calcium and cholecalciferol preparations. In the future, the condition stabilized, a partial regression of the symptoms of hyperparathyroidism was observed.

Objective: to analyse and describe clinical cases of Still’s disease in adults and peculiarities of therapy in patient with a monocyclic course of the disease who had at the beginning of the observation a high systemic account (12) and in patient with a recurrent course of the disease with a positive result for 25 and 10 years of a dynamic observation.

Materials and methods. Patient L., a female, 35 years old, was taken to the therapeutic department of the clinic with fever of 38–39 °С, chills and sweating, resistant not itching rash, lymphadenopathy, signs of myocarditis, loss of 20 kg of weight, exudative pleurisy, pronounced orthopnea with respiration rate of 40–48, tachycardia up to 130 beats per minute, myalgia, hepatosplenomegaly and abdominal pains. In past medical history for 2 months of the disease the patient was examined, and the sings of disease progression were present. The clinical constellation in patient L. allowed us to formulate a diagnosis of Still»s disease. Some investigations were conducted repeatedly to track the changes. The following therapy by Indomethacin in a daily dose of 150–200 mg/day for 1 year and for 6 months in combination with D-penicillamine in a dose of 450 mg/day induced remission. Till the end of 2016 the disease recurrence was not revealed. In another patient B., a male of 57 years old, the disease manifested with sub-febrile temperature, pain in a testicular area, thrombocytosis, and the symptoms increased in 2 weeks and included resistant febrile temperature, lymphadenopathy, changes of laboratory tests, signs of nephropathy and encephalitis. The patient was examined to exclude oncology.

Results. Still’s disease was diagnosed and the following therapy was administrated: diclofenac and methotrexate for 4 years with episodes of disease recurrence in case of decreasing the doses of the medications, but in future the therapy managed to cancel, and there was no recurrence observed.

The problem of the association of infective endocarditis (IE) and oncological diseases has been discussed for more than 60 years, and is now becoming increasingly relevant because of observed increasing of number IE in elderly patients. The review of the literature presents both data on the incidence of oncological diseases diagnosed with IE and in the long-term follow-up of patients after IE, as well as current estimates of IE incidence in cancer patients, obtained in large population-based studies. The highest risk of IE development was found in patients with tumors of the colon and rectum, and the predominant etiological role of Streptococcus bovis/gallolyticus was proved in such cases. The frequency of concomitant oncological diseases is higher in elderly patients with IE. On the other hand, it is obvious that IE can be considered as a marker of latent oncological pathology, especially gastrointestinal tumors, malignant blood diseases and lymphoproliferative diseases that are most often detected during the period of active IE and in the first 1–2 years later. Therefore, mandatory colonoscopy is recommended for patients with IE caused by Streptococcus bovis/gallolyticus during the period of IE and annually in subsequent years, even if initially the colonoscopy did not reveal pathology. In elderly IE patients we should also be aware of the high likelihood of concomitant oncological pathology and carry out appropriate oncological search. Antimicrobial prophylaxis of IE in patients with gastrointestinal cancer remains unresolved.