Rheumatic heart disease (RHD) is a preventable heart disease that remains endemic in developing countries. More than 30 million people in the world suffer from RHD, of which approximately 300,000 die every year, despite the fact that this disease is preventable and treatable. After a period of relative neglect of rheumatic heart diseases due to a decrease in the incidence in developed countries, interest in this problem has increased again over the past decade, due, apparent­ly, to an underestimation of its true prevalence due to the subclinical course of carditis. Research over the past two decades has demonstrated the advantage of diagnosing RHD with echocardiographic screening based on World Heart Federation echocardiographic criteria, which is 10 times greater than the clinical auscultatory picture only and it allows
early detection of it in patients, while prevention is to be more likely to be effective. Although understanding of the pathogenesis of the disease has advanced in recent years, key issues remain unresolved. Preventing or providing early treatment for streptococcal infections is the most important step in reducing the burden of this disease. The manage­ment of women with rheumatic heart disease before, during and after pregnancy remains a serious task requiring the efforts of a multidisciplinary team. In 2015, a civil society movement was launched aimed at raising awareness and supporting countries seeking to solve the RHD problem. In May 2018, the World Health Organization adopted a resolu­tion aimed at intensifying global and national efforts to prevent and combat acute rheumatic fever/RHD. Ultimately, a combination of treatment options, research and advocacy based on existing knowledge and science provides the best opportunity to cope with the burden of rheumatic heart disease. The article summarizes the latest achievements in the science of RHD and presents priorities for current actions and future research.

Introduction. Acute coronary artery disease is the leading cause of death in patients with chronic kidney disease (CKD). In addition, CKD itself is the initiator of acute coronary syndrome (ACS), the prevalence of which is greater, the more pronounced the impairment of kidney function and the more concomitant risk factors in the patient.

Aim. To study the predictive value of various laboratory and instrumental markers in identifying the risk of developing ACS in patients with CKD.

Materials and methods. A search was made for articles for the last 10 years in the databases: PubMed, Medline, Google Scholar and eLIBRARY by keywords in Russian and English, the articles were selected in accordance with the purpose of the study.

Results. ACS manifests itself in CKD patients with an atypical picture, and in 3 % of cases it is generally asymptomatic. The risk of death from cardiovascular complications increases in proportion to the deterioration of the glomerular  filtration rate (GFR). This progression also increases the risk of coronary artery calcification. At the same time, it was found that cystatin C is a more universal marker of a decrease in GFR than creatinine. Other laboratory markers that indicate the risk of ACS are inflammatory markers, albuminuria, troponins, natriuretic peptide.

Conclusion. So far as ACS is atypical or asymptomatic, in addition to troponins and traditional instrumental diagnostic methods, markers such as GFR, albuminuria, an increase in serum cystatin C, phosphate, fibroblast growth factor-23, interleukin-6, tumor necrosis factor-alpha, total parathyroid hormone, fibrinogen, natriuretic peptide can help in its prediction.

Aim. To evaluate the effectiveness of an integrated approach to the implementation of the outpatient stage of reha­bilitation of patients with chronic obstructive pulmonary disease (COPD) after outpatient treatment of moderate exa­cerbation.

Materials and methods. The analysis of the effectiveness of 100 programs of the outpatient stage of rehabilitation of COPD patients who have suffered an exacerbation of moderate severity with the inclusion of the stage of correction of risk factors, physical therapy and physiotherapy procedures was carried out. The effectiveness was evaluated with the determination of high-speed indicators, the severity of shortness of breath according to the modified Medical Re­search Council Scale (mMRC) questionnaire and the Borg's scale, the level of blood oxygen saturation, body mass index, the six-minute walk test and the BODE index (Body-mass index, airflow Obstruction, Dyspnea, and Exercise). In order to assess the impact of the outpatient stage of rehabilitation on the quality of life, in addition to using the MOS SF-36 questionnaire and COPD Assessment Test (CAT), tests were conducted to assess the global health status and quality of treatment by the patient and the doctor.

Results. In patients of the clinical observation group with mandatory inclusion of lifestyle modification (complete cessation of smoking and the use of alternative methods of nicotine delivery), 4 weeks after the beginning of the out­patient stage of pulmonary rehabilitation, there was a tendency to increase the maximum volumetric flow rate (MOS) at the level of 50 (p = 0.078) and 75 % (p₁ = 0.061, p₂ = 0.085) from the forced vital capacity of the lungs, the severity of dyspnea on the mMRC scale decreased by 18.6 % (p = 0.03); exercise tolerance improved - by 10.2 % on the Borg's scale (p < 0.01), by 4.9 % on the six-minute walk test (p < 0.01); the BODE (Body-mass index, airflow Obstruction, Dyspnea, and Exercise) index decreased by 31.7 % (p < 0.01). In both subgroups of the clinical observation group, there was a statistically significant improvement in quality of life indicators characterizing the state of physical health: physical functioning, role functioning and the total level of physical health; as well as indicators characterizing mental health indicators: vitality and social functioning (at p < 0.05)

Conclusion. The effectiveness of an integrated approach to the implementation of the outpatient stage of rehabilitation of COPD patients who have suffered an exacerbation of moderate severity, with the inclusion of mandatory lifestyle modification (smoking cessation and the use of alternative techniques), physiotherapeutic methods of treatment (me­dicinal electrophoresis on the chest area) and methods of physical rehabilitation. Pulmonary rehabilitation of COPD patients with mandatory correction of risk factors, both during remission and during exacerbation, should be carried out in a planned form within the framework of primary health care to the population, primarily determining the quality of life of patients.

The purpose of the study. Demonstration of differential diagnostic search for the causes of acute kidney injury (AKI) in a young man.

Materials and methods. Clinical observation of a patient with Takayasu arteritis (TAK).

Results. The presented clinical observation describes the late diagnosis of TAK at the stage of severe ischemic lesions of the internal organs (myocardial infarction, cerebral infarction, occlusion of the lumen of the arteries of the left lower limb with the development of gangrene, occlusion of the renal arteries with the outcome of left kidney shrive­ling). Most likely, thrombotic occlusion of the right renal arteries caused the development of severe AKI. During the examination, the diagnosis of TAK was made, other possible nosologies were excluded. Taking into account the late diagnosis of the disease, the minimal severity of the inflammatory process, the high risk of complications, therapy with glucocorticoids in a small dose, anticoagulants was carried out. Against this background, recovery of intrarenal blood flow and diuresis was noted, but high rates of azotemia remained, requiring continued dialysis. After 3 months, the loss of renal functions was detected.

Conclusions. The development of vascular lesions of internal organs with signs of critical ischemia (heart, brain, vessels of the lower extremities, kidneys, etc.) in young patients, dictates the need for a differential diagnostic search for the cause, first of all, the exclusion of the systemic process (systemic vasculitis, antiphospholipid syndrome, diffuse con­nective tissue diseases). It is important to accumulate experience in managing patients with TAK in order to timely diagnose, start therapy early and prevent the development of irreversible lesions of internal organs.

Aim. To present a clinical case of late diagnosis of granulomatosis with polyangiitis (GPA), which for a long time was interpreted as a pulmonary form of tuberculosis with the passage of anti-tuberculosis therapy without effect, which led to severe structural changes and resection of the lungs and deformation of the bones of the facial skeleton.

Materials and methods. Patient S., 31 y. o., was hospitalized in the rheumatology department with complaints of bloody discharge from the nose with the formation of crusts, hearing loss on both sides, weakness, nose deformity. From the anamnesis: in 2012, a cough with mucous sputum appeared. During examination at the Center for Combating Tuberculosis, on the basis of multiple rounded foci of both lungs, despite a negative diaskin test and the absence of mycobacterium tuberculosis in the sputum analysis, infiltrative tuberculosis was diagnosed. For two years, combined therapy with anti-tuberculosis drugs was carried out. In 2013, a staged combined resection of the left lung was performed; in 2014, a resection of the lower lobe of the right lung was performed. In 2015, nasal discharge increased, large crusts began to stand out, followed by bleeding, and a change in the shape of the nose was observed. In 2016, due to hearing loss in the left ear, he turned to an otorhinolaryngologist, diagnosed with ulcerative necrotic rhinitis, perforation of the nasal septum. Antibiotic therapy - no effect. Blood tests revealed positive antibodies to proteinase-3. In March 2017, he was hospitalized in the rheumatology department.

Results. There were CT signs of fibrotic changes in the lungs with calcifications, areas of compaction of the “frosted glass” type in the upper lobes of the lungs. Laboratory examination revealed positive antibodies to proteinase-3, decreased glomerular filtration and tubular reabsorption. Analysis of the biopsy material from the lung and nasal mucosa revealed morphological signs of granulomatosis with polyangiitis. For the first time in 5 years, granulomatosis with polyangiitis was diagnosed, generalized form, chronic course, moderate activity, with damage to the upper respiratory tract (pansinusitis, rhinitis, chronic bilateral adhesive otitis media), lungs (nonspecific interstitial pneumonia), kidneys (microhematuria, proteinuria), joints (arthralgia). The activity index according to the Birmingham BVAS scale is 16 points, the VDI organ damage index is 6 points. In a retrospective analysis, tuberculosis was not confirmed. Therapy with prednisolone, cyclophosphamide (endoxan), biseptol was carried out, against which the patient's condition improved significantly.

Conclusion. The presented clinical case demonstrates the difficulties of differential diagnosis of GPA with other granulomatous processes. Late diagnosis led to damage to vital organs: lungs, kidneys, deformity of the back of the nose, which, most likely, could have been avoided in case of timely diagnosis and early initiation of adequate therapy. As a result of an erroneous diagnosis at the onset of the disease, the patient underwent unjustified resection of both lungs twice. Timely diagnosis of the granulomatous process with the involvement of several pathologists as experts, including those with a torpid course of pulmonary tuberculosis, significantly improves the prognosis of patients and avoids fatal complications.

Musculoskeletal pain syndromes are one of the most common causes of temporary disability, they are often associated with a significant decrease in the quality of life of patients. Due to the peculiarities of biomechanics (significant phy­sical exertion experienced throughout life, a large volume of movements in various directions), the lumbar spine is especially vulnerable, the lesion of which is often associated with the development of lumbar pain (PB). The mechanisms of formation of PB are diverse, however, as a rule, inflammation is the basis of the pain syndrome. The results of modern studies have convincingly demonstrated the presence of imaging and biochemical markers of the inflammatory process in the area of altered spinal structures, in particular, in intervertebral discs and arch-process joints. There are reasons to believe that it is the focus of inflammation that can be the source of pain, although in the future the role of the active inflammatory process may become less important, and other mechanisms are involved in maintaining pain and other clinical manifestations. In this regard, drugs should be chosen for the treatment of patients with PB, depending on the predominant action - analgesic or anti-inflammatory. In the article, along with the main mechanisms of the occurrence and persistence of PB, modern approaches to the treatment of such patients are considered. The undoubted validity of the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for the treatment of patients with PB is noted. Their most significant clinical effects are noted, which may be useful in the treatment of patients with PB. The features of side effects associated with the use of NSAIDs, including those from the gastrointestinal tract and the cardiovascu­lar system, are considered. Information is provided on the results of studies devoted to the study of the efficacy and safety of dexketoprofen (Dexonal®, Binnopharm Group) in the treatment of patients with PB. The undoubted positive properties of the drug are noted (rapid development of action with a powerful analgesic effect and a favorable safety profile) Dexonal®.