Spondyloarthritis (SpA) has extremely high social importance due to patient’s risk of early disability and a persistent decline in the quality of life. The last decade has brought important knowledge on its genetic mechanisms and pathophysiological aspects, as well as diagnosis and treatment. Axial spondyloarthritis (axSpA) is characterized by a pathological tissue response to immune and mechanical triggers, predominant lesion of the axial skeleton (spine, sacroiliac joints). It is divided into ankylosing spondylitis (AS) and non-radiological axSpA. Mechanical stress is proven to affect specific localization of inflammation and tissue damage in SpA. Areas of inflammation and erosion are limited to those having increased susceptibility and unique microanatomy. It is shown that a number of genes located outside the main histocompatibility complex significantly affect susceptibility to AS. A study of genes and polymorphisms not related to HLA-B27 revealed different pathogenesis mechanisms in various ethnic groups and formed a new understanding of AS pathogenesis and treatment. A family history of AS or anterior uveitis is useful to detect axSpA, as it is associated with the carrier of genetic marker HLA-B27. Researchers are strongly focused on studying AS patients» autoantibodies, where antibodies to CD74 are of the greatest diagnostic value. An imbalanced microbiome can trigger SpA development. Approximately 50 % of all SpA patients have microscopic signs of intestinal inflammation. The development and use of highly sensitive imaging methods in the future will lead to improved approaches for axSpA classification and more precise disease prognosis and therapeutic decisions. 18-fluorodeoxyglucose positron emission tomography is a sensitive method to determine syndesmophytes and sacroiliac joints in axSpA patients.

Objective: to analyze the incidence of falls and fractures in patients of older age groups, to identify a relationship with sarcopenia depending on gender and age in the study.

Materials and methods. 230 patients 65 years and older (average age 74.0 ± 6.5 years) who were observed at home were included in the study. Patients were divided into three age groups: 65–74 years old, 75–84 years old, 85 years old and older. Diagnosis of sarcopenia was consistent with the recommendations of EWGSOP (2010). Muscle mass was measured using dual-energy absorptiometry (DXA) based on the calculation of the AMM index (kg / m2 ). Muscle strength was measured using а grip strength, and physical performance was measured according to the results of a short set of tests of physical activity SPPB tests (short physical performance battery). Cases of falls and fractures were analyzed using a survey and medical documentation.

Results. 45.2 % of patients had falls within 12 months before the start of the study, in patients in the age group of 85 years and older the risk of falls is 1.50 higher (95 % confidence limit (CL) 1.24–1.83, p <0.001), compared with the age group younger than 75 years. Falling and non-falling patients had low values of muscle strength and physical performance (p <0.001). Sarcopenia was detected in 30 % of patients. Sarcopenic patients fell significantly more often than non-sarcopenic patients: 89.9 % (95 % CL: 81.5–95.9) and 26.1 % (95 % CL: 19.6–33.2), respectively (p <0.0001). The frequency of falls increased with age mainly in the group of sarcopenic patients (p <0.0001). 30 % of patients had fractures of any localization, 37.7 % of sarcopenic and 26.7 % of non-sarcopenic patients (p >0.05). There were no significant differences in the frequency of fractures in sarcopenic and non-sarcopenic patients in men and women (p >0.05). Fear of falls increased the risk of sarcopenia 3.02 (95 % CL: 1.79–5.11) times (p <0.0001).

Conclusion. Sarcopenia significantly increases the risk of falling. There were no differences in the number of fractures and their localization in sarcopenic and non-sarcopenic. Fear of falls is significantly higher in sarcopenic patients.

The aim to compare various sources of the pharmacotherapy safety information in the outpatient register.
Materials and methods. The original questionnaire included several questions for assessing information about patients’ knowledge of the concept of AEs of drug therapy, awareness of the possibility of drugs’ AEs, how often patients read the instructions for drugs and actions of patients in cases of AEs occurrence. Adverse events appearance were noted by the patients themselves in questionnaire and by doctors when completing the IRCs for the period from September 1. 2017 to May 31. 2018 are compared.
Results. Of the 162 patients who answered the questions in the original questionnaire, there were 80 women and 82 men. 112 patients were observed by doctors regularly (at least 1 time per year), 16 people visited doctors 1 time in 1–2 years, 14 people were with a doctor more than 2 years ago, in 18 patients information on the regularity of observation by doctors is not indicated were. According to the questionnaire, the majority of patients (145 (89.5 %)) were familiar with information about the possibility of developing side effects of drugs, and 125 (86.2 %) people received this information from their doctor, 19 (13.1 %) noted that the doctor did not inform them about this. Only 6 patients did not know anything about AE pharmacotherapy. As the questionnaire showed, most patients get acquainted with the instructions for the prescribed medications. Comparison of data from the IRCs and questionnaires revealed more frequent registration of AE by doctors; however, there was an incomplete coincidence of information about the presence of AE from different sources.
Conclusion. Using data from the retrospective-prospective registry with obtaining information about adverse events from doctors in combination with simultaneous patients questionare could get more complete information about safety of pharmacotherapy. At the same time solution to the problem of farmacotherapy safety lives in optimizing the doctor–patient relationship.

Objective: to study the risk factors for acute renal injury, the dynamics of renal function and prognosis in patients with acute coronary syndrome with ST-segment elevation (STEACS) with contrast-induced nephropathy (CIN) after primary percutaneous coronary intervention (PCI).

Materials and methods. We studied 20 patients with STEACS, who developed СIN after PCI (follow-up group), and 98 patients with STEACS without СIN (comparison group). All patients were measured plasma creatinine level and glomerular filtration rate by the formula CKD-EPI before and 48 hours after PCI. CIN was detected with an increase in creatinine levels in the blood by more than 26.5 µmol / l from the baseline 48 hours after administration of radiopaque drug (RCP). Endpoints were evaluated at the hospital stage and within 12 months after PCI.

Results. CIN after PCI occurred in 16.9 % of patients with STEACS. Among patients with СIN, persons aged over 75 years (60 %), with diabetes mellitus (45 %), chronic kidney disease (75 %), postinfarction cardiosclerosis (50 %), chronic heart failure of functional class III–IV (80 %), developed acute heart failure T. Killip III–IV (90 %) were significantly more often observed. The left ventricular ejection fraction was lower in patients with СIN (p <0.05). The average increase in plasma creatinine 48 hours after PCI was higher in the follow-up group (p <0.05). In patients with СIN more often, than without СIN, three-vascular lesions of the coronary bed were detected (65 and 25.5 % respectively, p <0.001). The same trend was observed, when assessing the average number of coronary artery stenoses, the number of implanted stents and the volume of RCP used. Patients with СIN, than without СIN, were longer in hospital (12.1 ± 0.96 and 10.2 ± 1.11 days respectively, p <0.05) and more often needed re-hospitalization within 12 months after PCI (34 and 4.1 % respectively, p <0.05).

Summary. CIN in patients with STEACS after primary PCI was more likely to develop, if the following symptoms were present: age over 75 years, diabetes mellitus, chronic heart failure, post-infarction cardiosclerosis, chronic kidney disease, low ejection fraction of the left ventricle, initially high creatinine level, development of acute heart failure, trisovascular coronary lesion and multiple coronary stenting. The duration of hospital stay and the frequency of re-hospitalizations within a year after PCI significantly increased in patients in the CIN group.

Gout is a complex multifactorial disease associated with the deposition of crystals of sodium monourate in various tissues of the body and the emergence, in this regard, of chronic hyperuricemia, which is clinically manifested by acute recurrent arthritis and the formation of gouty nodes – tofus. Methods of treating gout can be divided into two groups: lifestyle modification / change in eating habits and pharmacotherapy. But, before drugs appeared, diet was the only way to treat the disease. Since ancient times, gout has been associated with excessive nutrition and excessive consumption of alcoholic beverages. In the Middle Ages, gout was often called the “disease of the kings”, explaining this, firstly, by constant plentiful meals without any measure, and therefore the kidneys of the “abusers” could not cope with the removal of a huge concentration of uric acid. And secondly, the high prevalence of this disease among male aristocrats. Ordinary people ate on a limited basis and could not afford food rich in purines, so they fell ill less often. However, in the last decade, wider knowledge has been gained about dietary factors associated with hyperuricemia and gout. Obesity, excessive consumption of red meat and excess alcohol have already been recognized as causative factors. Legumes and purine-rich vegetables have been justified after numerous studies. New risk factors have been described, such as fructose and sweetened drinks. Finally, protective factors such as low fat dairy products have been studied. Patients with gout are forced to follow a diet throughout their lives, and not only during periods of exacerbation, but now it has become easier to adhere to it, since the diet allowed for food has expanded significantly. Although most of the prerequisites for dietary recommendations have been assigned ratings of medium / low or very low quality, this article will provide the basis for changes in eating habits in patients with hyperuricemia and gout in accordance with large international studies.

Blepharospasm (BS) is one of the diseases characterized exclusively by involuntary face movements (facial hyperkinesis). Typical clinical manifestations include squinting or increased blinking. Among frequent patients’ complains at the disease onset are unpleasant irritations, a foreign body sensation, itching, dry eyes, and frequent blinking. Dynamism is a typical BS feature: 1) it increases during emotional stress, in stressful situations, during fatigue, eye strain (reading), in bright light; 2) disappears while sleeping; 3) decreases after waking up; 4) «corrective gestures», such as touching skin of the eyelids, paraorbital regions and glabellar region, wearing glasses, chewing or absorbing sweets, other arbitrary movements, affect BS. Botulinum therapy (botulinum toxin type A (BtA) injections, in particular using Relatox, the effectiveness of which has been demonstrated in clinical studies) is considered the «gold standard» in BS treatment. BtA is injected mainly into the orbicular muscle of eye, superficially, into the upper, lower eyelids and outer eye corner. The clinical effect occurs quickly, already in the first week after injection and lasts 3 months or more. Cases of botulinum therapy inefficiency in treating BS and other facial hyperkinesis are extremely rare.

The article describes BS main clinical aspects, BtA injection schemes as well as adverse events during the therapy. Electromyography is not mandatory to assess BtA effectiveness in BS treatment, but it is necessary in cases of inefficient therapy, adverse events or the therapy complications. It is particularly important to strictly comply with recommended BtA doses, and that the drug is injected by a certified specialist only. Botulinum therapy for BS patients is a highly effective and, in most cases, the only treatment with a good safety profile.

The aim to demonstrate that subclinical atherosclerosis and vascular rigidity in a postmenopausal patient without clinical sings of cardiovascular disease and osteoporosis are connected with a decreased bone mass.
Materials and methods. Patient O., 64 years old, was examined at the National Medical Research Center for Preventive Medicine within the program “Comprehensive assessment of total risks and early preclinical markers of osteoporosis and atherosclerosis complications”. No complaints during the examination were revealed. Laboratory tests were performed to evaluate blood lipids level, calcium-phosphorus metabolism, determine marker of bone resorption – CTX (β-crosslaps), measure levels of vitamin D and parathyroid hormone. Instrumental examinations included dual-energy x-ray absorptiometry of the spine and femoral neck, carotid ultrasound, applanation tonometry, multispiral computed tomography of coronary arteries with calcium score determination.
Results. During outpatient examination, densitometry revealed decreased bone mineral density in the lumbar spine and in the femoral neck, corresponding to osteoporosis, carotid ultrasound identified atherosclerotic plaques, multispiral computed tomography of coronary arteries – coronary calcification, applanation tonometry – increased aortic stiffness.
Conclusion. The clinical case is an example of early-detected preclinical signs of atherosclerosis and osteoporosis, as well as an increased risk of cardiovascular complications. Due to the high frequency of subclinical atherosclerosis, vessel wall state should be examined in women at the beginning of postmenopause. Signs of vascular stiffness and subclinical atherosclerosis give occasion to assess risk of fractures using the FRAX ® calculator and, if necessary, to diagnose bone mass loss using X-ray densitometry. Proposed algorithm can contribute to the early detection of cardiovascular diseases and at the same time improve fracture risk assessment.

Objective. To demonstrate the possibility of having a spondyloarthritic mask of osteomalacia in patients of both sexes.

Materials and methods. Two clinical cases of osteomalacia occurring under the mask of spondyloarthritis in patients treated at the Clinical Rheumatology Hospital of Saint-Petersburg, Russia, as well as similar cases described in the literature, were analyzed.

Results. In the cases described, patients were diagnosed with a disease from the group of spondyloarthritis based on a number of individual symptoms, such as pain in the lower back and stiffness, as well as instrumental examination data. At the same time, with in-depth evaluation, the pain in the lower back did not did not met to the inflammatory pain ASAS criteria, and there were also no signs of general laboratory activity of the disease. The conventional therapy for spondyloarthritis was ineffective. With the re-evaluation of clinical, laboratory and instrumental data, the diagnosis was changed to osteomalacia. Appointment of adequate therapy with vitamin D after a review of the diagnosis resulted in both a regression of clinical symptoms and an improvement in laboratory parameters.

Conclusions. If the patient has pain in the lower back, especially without clear signs of inflammatory, no signs of general laboratory activity, further examination is necessary to clarify possible osteomalacia. Spondyloarthritis should be only diagnosed in cases with the secondary nature of symptoms excluded.

Objective: to describe the clinical case of a patient with ankylosing spondylitis (AS) with an assessment of the functioning of his body taking into account the clinical situation, environmental factors and personal factors from the standpoint of the international classification of functioning, life and health limitations.
Materials and methods. The patient, 26 years old, was hospitalized in the Department of therapy with complaints of periodic aching pain in the lumbar and cervical spine at rest; aching pain in the ankle and knee joints when moving; heel pain when walking; morning stiffness in the spine lasting 30 minutes; weight loss to 11 kg. over the past year. The patient was evaluated laboratory parameters, electrocardiography, echocardiographic examination, ultrasound examination of hepatobiliary zone and kidneys, radiography of pelvic bones, lumbar spine, ankle, knee, foot joints, magnetic resonance imaging of sacroiliac joints.
Results. During the examination, a clinical diagnosis was established: as. Formed rehabilitation diagnosis: b280.3, b710.2, b780.1, b130.1, b134.0, b455.3, s760.1, s740.0, s750.1, d230.2, d410.3, d450.3, d850.1, d760.1, d920.2, d475.2, which fixed the patient has intense pain, moderate violations of mobility in the spine, a short morning stiffness, mild depression, severe fatigue; minor violations in the structure of the lumbar spine, knee and ankle joints and joints of the foot; moderate difficulties in maintaining activity during the day, expressed functional disorders, expressed difficulties in walking, minor difficulties in performing paid work, minor difficulties in spending time with family and friends, moderate difficulties in recreation and leisure, moderate difficulties in driving.
Conclusion. This clinical case demonstrates the possibility of using ICF in clinical practice on the model of a patient with as, which allows a comprehensive look at the patient and quantify the condition of the patient, to form a common language for the work of a multidisciplinary team to determine the further stage of rehabilitation of patients.

The aim of the work is to describe the clinical case of formation, diagnosis and treatment of the acquired form of blood clotting factor VIII deficiency – of acquired hemophilia A.
Material and methods. Patient R., 71 years, from April 2018, was found an acute hemorrhagic syndrome in the hematomic type of large hematomas manifested submandibular region, neck, chest, right breast, pubic and inguinal regions on the right, the anterior-medial surface of the left femur, anterior surface of left tibia. Standard laboratory tests, computed tomography of soft tissues of the neck, lungs, abdomen; coagulogram; blood clotting factors; inhibitor of factor VIII were evaluated in dynamics during the patient’s stay in the hospital; platelet aggregation function.
Results. Typical gematomny type of bleeding, prolongation of coagulation indicators, the presence of the inhibitor factor VIII (7,0 BAA), the decrease in factor VIII (2 %) allowed diagnosis of acquired hemophilia A. Anti-inhibitory coagulant complex, fresh frozen plasma was successfully used for treatment. The patient is under observation in the regional Hematology center. The hematomas were not renewed.
Conclusion. Our clinical observation demonstrates the features of the course, the algorithm of diagnosis and management of patients with of acquired hemophilia A.

Objective: description of a clinical case of the development of longitudinally spread transverse myelitis in a young woman suffering from nonHodgkin’s lymphoma (follicular, 1 degree, IIIA stage, complete remission from February 2017). This is a rare, significant case in clinical practice for both residents and neurologists, and the case is under discussion. It requires certain scientific studies in the search for specific antionkoneural antibodies or a more detailed study of the already known. It is necessary to introduce these studies into laboratory practice in Russia, which would help to accelerate the diagnosis of paraneoplastic myelitis.

Materials and methods. Patient B., 30 years old, has been suffering non-Hodgkin’s lymphoma since February 2016 (follicular, I degree, IIIA stage, complete remission from February 2017), receives infusions of Rituximab with a dose of 600 mg once in 2 months, the subacute developed pronounced lower spastic paraparesis. In November 2018, suddenly, against the background of complete well-being, weakness and numbness of the legs appeared. The patient asked for help at the Center for Multiple Sclerosis on 11.17.2018, then she was hospitalized and examined. Patient B. received a pulse therapy with methylprednisolone 1000 mg intravenously № 5. Discharged with positive dynamics with a diagnosis of Demyelinating CNS disease, unspecified. Acute protracted transverse myelitis (LETM), EDSS = 3.5 points. On December 13, due to the increase in spacity and leg weakness, she was urgently hospitalized in the neurological department of the Clinical Hospital.

Results. After the completion of laboratory and instrumental examination, the condition was regardedby us as paraneoplastic myelitis. Relapse of lymphoma was ruled out. The treatment was carried out: pulse therapy with methylprednisolone, Plasmapheresis and intravenous administration of IgG (Privigen) with a distinct positive dynamics.

Conclusion. This clinical observation allowed us to become more familiar with paraneoplastic syndromes and, in particular, with paraneoplastic myelitis. In the clinical situation previously described, we encountered a number of features: longitudinally extensive transverse myelitis developed without relapse of lymphoma, progressed rapidly, there was no response to treatment (glucocorticosteroids, plasmapheresis, Rituximab). All these signs and MRI data of the cervical and thoracic spine (a symmetric hyper-intensive signal from level CII to level ThXI, mainly involving the central spinal cord T2 MRI mode) testified in favor of the paraneoplastic etiology of longitudinally extensive transverse myelitis.