The article covers the principles of comprehensive geriatric assessment — an interdisciplinary diagnostic procedure aimed at developing a plan of treatment, long-term monitoring and support of an elderly person. The components of a comprehensive geriatric assessment, including the determination of physical, functional, psychological and social status of the subject, are reflected. During the process of analyzing the patient’s physical status, the age-related features of the functioning of various organs and systems, knowledge of which is necessary for the development of a targeted geriatric care strategy, should be taken into account. Involution of the respiratory organs is characterized by a decrease in the respiratory surface, atrophic processes in the mucous and lymphoid tissues, and an increased risk of developing bronchoobstructive syndrome. Degenerative sclerotic changes in the cardiovascular system contribute to the development of circulatory failure, sinus node dysfunction, increased sensitivity to stress factors, orthostatic hypotension, etc. With age, the secretory function of the gastrointestinal tract decreases, and the functional ability of the liver is limited. Reducing the reserve capacity of the kidneys provokes the development of inflammatory processes and contributes to the dehydration of the body. In older people, the risk of developing diabetes, hypothyroidism and hyperparathyroidism increases. The growth of connective tissue in the blood-forming organs limits the functionality of the blood system. Age-related changes in the musculoskeletal system are characterized by a decrease in muscle mass and the development of osteoporosis. Drug therapy is also being analyzed, since polypharmacy in the elderly is associated with a particularly high risk of developing side effects of the drugs. Assessment of the functional status implies the determination of the self service ability and the degree of a person’s independence from the help of others by his/her ability to perform basic functions, activities in everyday life and instrumental activity. The psycho emotional status is judged by the emotional background of the patient and his/her cognitive functions. Social and household status is estimated by the living conditions of an elderly person. Based on the results of a comprehensive geriatric assessment, an individual management plan is drawn up, the implementation of which is possible with the combined efforts of the geriatrician and a team of medical specialists, relatives, and social workers.

The popularity of home canning contributes to a sufficiently high incidence of botulism worldwide. The canned products containing botulinum toxin do not change neither color, taste, nor smell of contents of canned food. The criteria for the severity of the course of botulism are considered a violation of swallowing liquid food and symptoms of difficulty breathing. A distinctive feature of the paralytic syndrome in botulism is its symmetry and the absence of a violation of sensitivity. The criteria of the severity of the course of botulism is considered a violation of swallowing liquid food and the severity of acute respiratory failure. The paper presents the features of the therapy of the patients with botulism in the intensive care unit. Clinical examples illustrate the difficulties in recognizing botulism at the early stage of the disease, which are due to the polymorphism of the clinical picture of botulism and the similarity of symptoms with other diseases. Most commonly, patients with botulism are diagnosed with acute intestinal infection or the neurological pathology. Patients are not hospitalized in a timely manner, which can affect the outcome of the disease. The ability to recognize botulism at the prehospital stage is necessary for all doctors.

Atrial fibrillation (AF) is one of the most common cardiac rhythm disorders. Its prevalence is about 1 % in the general population and exceeds 7 % in individuals older than 60 years of age. It is known that hyperactivation of the renin-angiotensin-aldosterone system plays a key role in structural and electrical myocardial remodeling in AF. Increased activity of the renin-angiotensin-aldosterone system causes inflammation, fibrosis and oxidative stress in cardiomyocytes. Last studies suggest that most of negative effects previously explained by angiotensin-2 may be particularly caused by excessive aldosterone activity. More data about extra-adrenal hormone production (in the myocardium, the vascular wall and even the brain) have appeared, and its receptors were found far beyond the kidneys — in cardiomyocytes, endothelial cells, fibroblasts, monocytes, and macrophages. It was also shown that aldosterone has a wide profile of pathogenic effects, one of which is the stimulation of atrial myocardial fibrosis as the structural basis for AF. The discovery of new features of aldosterone suggests that blockade of mineralocorticoid receptors may prevent or slow down atrial remodeling and thereby reduce the incidence of AF. The article presents data of the world literature and the results of own studies devoted to the use of mineralocorticoid receptor antagonists in patients with AF. Modern concepts of the role of aldosterone in the arrhythmia development and the main approaches of upstream-therapy are described. The possibilities of using eplerenone and spironolactone in primary and secondary prevention of AF are discussed.

Sedentary lifestyle, being a behavioral risk factor for chronic non-communicable diseases, is relevant for preventive medicine. A key role in the correction of behavioral risk factors for chronic non-communicable diseases is occupied by general medical practice, where the patient is continuously observed for many years. Increased physical activity reduces the risk of atherosclerosis, diseases of the musculoskeletal system, malignant tumors, has a positive effect on the psychological state of patients and reduces the overall morbidity and mortality. Increasing the reserves of the cardiorespiratory system of the body, physical activity improves the quality of life of patients and reduces the cost of medical care.

To effectively combat sedentary lifestyle, it is necessary to adequately motivate patients that can be achieved through routine counseling to enhance physical activity. The method of such consultation should take into account limited time of outpatient admission and all personal characteristics of patients (starting level of physical activity, health group and risk of disease).

The article presents a summary of modern scientific views in the field of increasing physical activity of patients, discusses current issues of counseling. The groups of patients with or without chronic diseases and the high risk of cardiovascular complications were discussed. The variant of rational outpatient counseling with the help of the algorithm of organization of physical activity mode, providing stratification of patients, planning, optimization and control of personal motor activity was presented. The proposed method of optimization of counseling successfully solves the problems of motivation, increase of physical activity and individual approach in outpatient practice.

Background: Numerous studies on the pathophysiological mechanisms of obstructive sleep apnea discover the relationship between obstructive sleep apnea and cardiovascular diseases, its contribution to the development of resistant hypertension and endothelial remodeling. Continuous Positive Airway Pressure (CPAP) is the only reasonable pathogenetic therapy in these patients. This treatment regimen implies the creation of a “pneumatic stent” with a given level of positive pressure on the inhalation and exhalation of the patient, allowing to stabilize the lumen of the upper respiratory tract and prevent the pharyngeal collapse. However, the effects and the required duration of CPAP of night sessions to achieve the target values of blood pressure and restore arterial stiffness in patients with severe obstructive sleep apnea with resistant hypertension remain poorly understood. Objective: to study the dynamics of blood pressure, arterial stiffness and endothelial dysfunction in patients with severe obstructive sleep apnea with resistant hypertension, depending on the duration of auto-adjusting CPAP (A-Flex therapy). Methods: the prospective single-center study enrolled 168 patients with obstructive sleep apnea with resistant hypertension (139 males, 46,6 ± 9,0 y. o.) with apnea-hypopnea index >30 events /hour. The night polygraphy study was performed to calculate AHI, oxygen desaturation index, mean nocturnal saturation (SpO2 ) according to the requirements of American Academy of Sleep Medicine. Endothelial function of blood vessels was assessed manually to peripheral arterial tone. The reactive hyperemia index and augmentation index was calculated. Blood pressure was monitored by office measurement, daily monitoring of blood pressure, and by individual patient diaries. Optimal level of CPAP-treatment was adjusted at home. Apnea-hypopnea index, the level of air leakage, average pressure and compliance to CPAP-therapy were established in accordance with international requirements. Results: In the group of patients, treated with night sessions of A-Flex > 6 h/night, significant dynamics was observed by the 6th month of treatment. That is, a decrease in RHI by -1.33 (95% CI from -2.25 to -0.41; P = 0.002), a decrease in AI by -12.4% (95% CI from -18.42 to -6.38; P = 0.001), a decrease in mean SBP (24 h) by -33.6 mm Hg (95% CI from -44.1 to -23.2; P = 0.002) and decrease in mean DBP (24 h) by -20.2 mm Hg (95% CI from -29.4 to -11.1; P = 0.001), with a decrease in rate of morning rise of SPB by -22.4 mm Hg/h (95% CI from -24.7 to -20.1; P = 0.002) and a decrease in rate of morning rise of DPB by -17.4 mm Hg/h (95% CI from -19.5 to -15.3; P = 0.003). The best target values were achieved by the 12th month of treatment: a decrease in RHI by -2.11 (95% CI from -2.57 to -1.65; P = 0.001), a decrease in AI by -28.5% (95% CI from -37.06 to -19.94; P = 0.002), a decrease in mean SBP (24 h) by -39.7 mm Hg (95% CI from -48.9 to -30.5; P = 0.001) and decrease in mean DBP (24 h) by -26.8 mm Hg (95% CI from -36.1 to -17.5; P = 0.001), with a decrease in rate of morning rise of SPB by -22.5 mm Hg/h (95% CI from -23.6 to -21.4; P = 0.001) and a decrease in rate of morning rise of DPB by -19.4 mm Hg/h (95% CI from -20.7 to -18.1; P = 0.002). Conclusions: in patients with severe obstructive sleep apnea and resistant hypertension only CPAP-therapy in the A-Flex mode > 6 h/night allows to achieve target blood pressure, restores endothelial function and arterial stiffness, therefore reducing the risks of cardiovascular complications.

The objective: To assess the prevalence of diastolic dysfunction in patients with hypertension and preserved left ventricular ejection fraction under pharmacological correction (monotherapy) with angiotensin converting enzyme inhibitors, angiotensin II receptor blockers and β-blockers. Materials and methods: 82 patients (58 women and 24 men) with stage 2 hypertension were examined. The diastolic function was assessed via echocardiography in accordance with the European Association of Cardiovascular Imaging guidelines (2017). Echocardiography was performed before the onset of the treatment and 6 months after its onset. The treatment onset was considered to start after a 2-week period of elimination of previously used pharmacological substance and 2 weeks of assessing tolerability, dose and regimen adjustment. Results: For all selected drugs, target values of blood pressure were achieved, and no adverse effects were identified. The average values of the left atrial volume index before and after the treatment course did not show significant differences. In the majority of the examined patients, this parameter did not exceed the threshold value of 34 ml/m2 . Values exceeding the specified threshold were observed in Group 1 in 4 patients, in Group 2 in 3 patients and in Group 3 in 8 patients. According to the Tissue Doppler echocardiography results on the velocity of myocardial motion at the early diastolic filling, which was measured at the level of the lateral segments of mitral valve and the interventricular septum, positive, but unreliable changes were observed in the Groups of bisoprolol and valsartan, and no changes — in the Group of perindopril. According to the traditional criteria, diastolic dysfunction was observed in 80 % of patients, while according to the criteria of the European Association of Cardiovascular Imaging (2017) — in 21 % of patients. Conclusion: The same efficacy of all three drugs is observed in terms of achieving target blood pressure values. The most pronounced effect on the morphometric parameters of the left atrium and intracardiac hemodynamics is shown in the Groups of bisoprolol and valsartan.

Diabetes mellitus holds one of the leading positions among the current problems of modern medicine. Despite the obvious success in studying diabetes in the last decades, its prevalence has become pandemic. In spite of the use of modern methods of therapy, a rather high frequency of diabetes mellitus complications from various organs and systems, the pathological changes in which largely determine the course of the disease and patient’s quality of life remains. Issues of eating disorders and their correction play an important role in the complex therapy of patients with diabetes mellitus. Objective: determination of the characteristics and relationship of eating disorders with gastroenterological symptoms and glucose levels in patients with chronic gastritis in type 2 diabetes. Materials and methods: dynamic study of the eating behavior and quality of life in 66 patients with chronic gastritis in type 2 diabetes mellitus was conducted using GSRS, SF-36 and DEBQ questionnaires. The level of glucose on an empty stomach and after eating was also measured, the frequency of self-measurement of glucose level and the presence of diabetes mellitus complications were determined. Results: the identified correlation relationships suggest that gastrointestinal symptoms characteristic of chronic gastritis with type 2 diabetes mellitus worsen the physical and psychological components of health, which provokes a breakdown and a violation of the diet in this category of patients. Conclusion: chronic gastritis in patients with type 2 diabetes mellitus aggravates the prognosis of diabetes and exacerbates eating disorders, which requires observation of an endocrinologist, as well as a gastroenterologist and psychotherapist in the management of such patients.

Cardiovascular disease is one of the major causes of death throughout the world. Early detection of target organ damage is important for more successful prevention of cardiovascular diseases and improvement of patient outcomes. One of these target organs is the vascular wall, and its damage consists in loss of elastic properties and increase in stiffness. Many studies have shown that the increasing stiffness of the vascular wall is an independent predictor of cardiovascular risk. Objective: To evaluate parameters of the ambulatory arterial stiffness monitoring in patients with bronchial asthma. Materials and methods. The study enrolled 119 patients with asthma. The group of control included 30 practically healthy volunteers comparable by gender and age with the patients of the main group. Each patient underwent ambulatory blood pressure and arterial stiffness monitoring using BPLab MnSDP-2 device (Petr Telegin, Russia). Results: In patients with asthma higher values of augmentation index, arterial stiffness index and pulse wave velocity in the aorta in comparison with patients of the control group, as well as violation of the 24-hour profile of arterial stiffness were noted. Conclusion. Patients with asthma demonstrated significantly increased arterial stiffness in comparison with control group.

Sarcoidosis is an inflammatory disease characterized by the formation of non-caseating granulomas in various organs and tissues. The clinical signs of sarcoidosis are determined by the number of affected organs, the degree of their structural and functional impairment, and the severity of inflammatory symptoms. The article presents a clinical observation of one of the forms of sarcoidosis — Lofgren’s syndrome, which is characterized by a triad of intrathoracic lymphadenopathy, acute arthritis and erythema nodosum. The diagnosis was confirmed histologically. Under the prescribed treatment, signs of acute inflammation reversed and the patient’s state improved. The authors emphasize that they do not recommend widespread use of systemic glucocorticosteroids in patients with this disease, since their use may be associated with a relapsing course.

The article presents a clinical case of an onset of antiphospholipid syndrome in a patient with systemic lupus erythematosus and ischemic stroke. Systemic lupus erythematosus is a non-modifiable risk factor for ischemic stroke.

Pheochromocytoma is a tumor of chromaffin tissue that produces a large amount of biologically active substances (adrenaline, noradrenaline, dopamine), clinically manifested by hypertension and various metabolic disorders. Quite often the diagnosis is made only after autopsy. One of the reasons for late diagnosis is a great number of different clinical masks of the disease. Usually pheochromocytoma is suspected in patients with paroxysmal hypertension. We present a 37-year-old pregnant female (week 8 of pregnancy) with pheochromocytoma and permanent hypertension and sustained elevation of blood pressure up to 220/150 mm Hg. Her only complaint was vision disorder that started 3 months ago. Also, she noted a weight loss of 4 kg over the last 6 months. Retinopathy, left ventricle hypertrophy, tumor of right adrenal gland and glucose level disorders were revealed. Pregnancy was terminated for medical reasons. The patient took combination of doxazosin 0.4 mg, metoprolol 100 mg and moxonidin 0.4 mg per day and blood pressure was normalized to 130/90 mm Hg. Due to hypertension and tumor of right adrenal gland that are accompanied by retinopathy and metabolic disorders, pheochromocytoma was suspected. Contrast-enhanced computed tomography confirmed the tumor (60×73×70 mm) of right adrenal gland. Urinary normetanephrine level was 5.5 times higher than the norm. Magnetic resonance angiography of cerebral vessels was done because of malignant hypertension and family history (the patient’s sister had died of cerebral hemorrhage). Fusiform aneurysm of right internal carotid artery was revealed. The patient underwent laparoscopic resection of right adrenal gland. Histologic examination: pronounced cellular and nuclear polymorphism, invasion of tumor cells into a fibrous capsule, which does not exclude the malignant nature of pheochromocytoma. Follow-up period lasted for 8 months and was characterized by normalization of blood pressure, glucose level and weight gain of 3.5 kg. Computed tomography of retroperitoneal space and normal urinary metanephrine tests revealed no recurrent pheochromocytoma.