Ankylosing spondylitis is a chronic, gradually progressive inflammatory disease characterized by lesions of the sacroiliac joints and / or spine, which can occur with simultaneous lesions of the enthesis and peripheral joints, leading to early disability and a decrease in the quality of life of patients, mainly young age. The international society for evaluation of spondylarthritis (ASAS) recommended a combination of nonpharmacological and pharmacological methods in the treatment and rehabilitation of patients with ankylosing spondylitis for the longest possible preservation of the quality of life of patients, which requires a multidisciplinary therapeutic approach.

Currently, in many European countries, the international classification of functioning, disability and health (IСF) is used as a universal approach to the assessment of human health. The IСF classifies the different areas of each patient’s life that are health-related and affect health, thus describing changes in their physical functioning and psychological well-being. It helps to introduce multidisciplinary, patient-centered, problem-oriented rehabilitation care into the real work of clinics.

The IСF shows a broader and more meaningful picture of the patient’s health, which allows the multidisciplinary team to consider the patient from different perspectives — biological, personal and social. Using the IСF in the process of complex therapy and rehabilitation of patients with ankylosing spondylitis, a multidisciplinary team can achieve a more complete coherence of views in the treatment of patients with ankylosing spondylitis, which is very important in achieving the success of therapy of this category of patients.

The issues of diuretic therapy in patients with chronic kidney disease, pharmacokinetics of diuretics, the problem of diuretic resistance, the tactics of using thiazides and loop diuretics in patients with various stages of chronic kidney disease, according to the recommendations of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative are discussed in the article. Particular attention is paid to the prescription of this group of drugs to patients with end stage renal disease, as well as those undergoing renal replacement therapy (hemodialysis).
Diuretics play an important role in the management of patients with chronic kidney disease with the development of hypertension and an increased extracellular fluid volume. In case of impaired renal function leading place is given to loop diuretics. Their combination with thiazide diuretics can increase the diuretic effect. The results of clinical trials assessing the effectiveness of the use of diuretics during decline of residual renal function are provided. It is reported about the effect of potassium-sparing diuretics on the incidence of cardiovascular complications, the development of hyperkalemia in patients undergoing dialysis treatment. The importance of continuation of intensive study about the possibility of antagonists of mineralocorticoid receptors usage, in particular the spironolactone, eplerenone, and finerenone in order to reduce cardiovascular complications and mortality, is indicated.

The article is devoted to the urgent problem of pediatrics and pediatric neurology, pre-hospital diagnosis of stroke in children. A review of domestic and foreign literature on the early diagnosis of stroke in children and adolescents, as well as epidemiological data on pediatric stroke, is presented. Particular attention is paid to the features of the symptoms of stroke and stroke-like conditions («stroke masks») in the pediatric population and the analysis of the main factors that influence errors in the early diagnosis of stroke in children and adolescents. Currently, in the diagnosis of ischemic stroke, its «masks» are found in 53.9 % of cases, with hemorrhagic stroke, in 36.3 %, and with transient ischemic attacks, in 9.8 % of cases. One of the most common diseases with which it is necessary to differentiate ischemic stroke in children is migraine. This problem is covered in academic writings that highlight the leading differential diagnostic criteria for migraine and stroke, and also represent a diagnostic algorithm. The clinical features of pediatric stroke, especially manifest symptoms, make it difficult to apply adult screening stroke scales in pediatrics. The article discusses the main scales for the early diagnosis of stroke in adults, and their potential application in pediatric practice. Currently accumulated experience in prehospital and early diagnosis of stroke in children determines the main directions of work to reduce the time of diagnosis of acute cerebrovascular accidents in children, followed by the introduction of reperfusion therapy in pediatric practice.

Cholelithiasis is one of the most common diseases of the digestive system, which affects all segments of the population. Currently, cholelithiasis is considered as a long, multi-stage process in which the period of stone formation is preceded by changes in metabolism and physical and chemical properties of bile. However, among the many contributing factors, insufficient attention is paid to the role of the infectious factor in the development of cholelithiasis. The analysis of the literature data showed that today there are various mechanisms for promoting ob development of cholelithiasis by excess enteral bacterial grouth. First, with excessive bacterial growth, duodeno-biliary reflux leads to infection of the biliary tract and the development of inflammation in the gallbladder. Substances that occur during the inflammatory process (proteins, mucus, exfoliated epithelium) are the matrix on which the gallstone is formed. Secondly, the role of dysbiosis in violation of enterohepatic circulation of bile acids is essential. The change in the ratio of conjugated and deconjugated bile acids contributes to the formation of lithogenic bile. Third, excessive bacterial growth leads to endotoxemia, which has a damaging effect on the metabolism of bile acids in the liver. Finally, in a certain dependence on the microbiota is the digestive and suction functions of the small intestine, but the participation of this channel in cholelithiasis requires further research.

One of the most prognostically unfavorable variants of glomerulopathy is focal segmental glomerulosclerosis (FSHC), which is detected by nephrobiopsy in 5-20% of patients with nephrotic syndrome (NS) and in 15% of adult patients with chronic glomerulonephritis. FSGS recurs in a transplanted kidney in 30-50% of patients. Among adult patients with FSH, men predominate. A poor prognosis of FSHC is explained by the heterogeneity of the disease and is exacerbated by a poor response to treatment. According to current data, FSGS is characterized by sclerosis of the mesangial matrix, hyalinosis, damage to capillaries, an increase in foam cells and their adhesion between the glomerular bundle and the Bowman capsule. In 2004, the following histological variants of FSGS were proposed: apical, perichillary, collaborating, cellular and classical. Each histological variant of FSGS differs in etiology, response to treatment, and prognosis. The clinical diagnosis of primary FSHC should be based on the exclusion of secondary causes of the disease. Focal sclerotic changes in the glomeruli can be caused by various factors and occur in various conditions, including the existing kidney pathology. According to international recommendations for the treatment of FSHS, one should focus on the amount of daily proteinuria. For patients with FSHS without pronounced proteinuria, the use of angiotensin converting enzyme inhibitors (ACE inhibitors) or angiotensin II receptor blockers (ARBs) is recommended. In FSGS and NS, immunosuppressive therapy is used along with ACE inhibitors or ARB II. For adult patients, glucocorticoids (HA) are prescribed daily in a single dose at a dose of 1 mg / kg per day, the maximum dose is 80 mg with a daily intake and 120 mg with an alternating regimen. Resistance to HA is detected in the absence of effect after 16 weeks. In the presence of contraindications or intolerance to HA, calcineurin inhibitors are used. The recommended initial dose of cyclosporine is 2 mg / kg / day, taken twice a day with a gradual increase to 3.5-4 mg / kg / day. The duration of therapy with satisfactory tolerance to cyclosporine is more than six months. After achieving complete remission, the dose of cyclosporin is gradually reduced by 0.5 mg / kg / day to the minimum effective dose (1.5-2 mg / kg / day) and such maintenance therapy is carried out for 1-2 years. A treatment option is possible using lower doses of HA and cyclosporine, or a combination of mycophenolate mofetil with a high dose of dexamethasone.

Objective To study the quality of life (QOL) and physical working capacity (PWC) in patients with pulmonary sarcoidosis. Materials and methods. Eighty patients with pulmonary sarcoidosis were examined (mean age 35 (39; 45) years), including 43 men (53.8 %) and 37 women (46.3 %). The duration of sarcoidosis was 3 (2; 4) years. Seventy-five percent of patients had pathologically proven sarcoidosis. All patients completed the SF-36 questionnaire; physical examination, chest computed tomography, spirometry and cardiopulmonary exercise testing (CPET) were conducted. PWC was determined according to the peak oxygen uptake (VO 2 peak) via CPET. Results. 29 (36,3%) patients had reduction of QOL (psychological and physical components of health). The most significant decrease of QOL was noted on the scale «general health» — 67 (47; 77) scores, «mental health» — 72 (54; 84) scores and «vitality» — 72.5 (50; 82.5) scores. Female patients (p=0.008) over 40 years of age (p=0.044) with clinically significant symptoms (p=0.012) and comorbidities (p=0.049) had a lower QOL. Patients with high or low QOL did not have differences in radiology stages, laboratory test results and lung function parameters. The female sex (OR 3.26, 95 % CI 1.15–9.23; p=0.026) and the clinical manifestations of sarcoidosis (OR 3.63, 95 % CI 1.06–15.47; p=0.041) were the independent factors of low QOL. Pulmonary sarcoidosis patients with exercise intolerance had the most significant reduction of the physical (p=0.037) and psychological components of health (p=0.033). Conclusion. Factors of QOL reduction in patients with sarcoidosis were female sex and clinically significant pulmonary sarcoidosis. In patients with low QOL, CPET can be used to determine the PWC and mechanisms of its reduction. The presented diagnostic algorithm will optimize the choice of therapy for patients with sarcoidosis.

New classification divides medications on five classes by influence on comorbid diseases and conditions and rates drug’s effects as favourable (A), possible (B), neutral (C), undesirable (D), and unfavourable (X). Class A includes drugs used in treatment of comorbid disease, class B embraced drugs with positive influence, class C includes drugs without significant influence or contradictory influence, class D consist of drugs with possible nonsevere adverse effects, and class X includes drugs with severe adverse effects. The more universal drug classification according to influence on comorbid diseases can include and unite other classifications. Classification may help unify marks of positive and negative influences drugs on comorbidity and help practitioners in selection of effective and safe treatment.

The combination of chronic obstructive pulmonary disease and cardiovascular disease is an urgent public health problem, that determines more severe disease progression, worse prognosis for the patient. The aim of the work was to evaluate the status of the cardiovascular system performing a pulse wave contour analysis in patients with chronic obstructive pulmonary disease depending on the severity of bronchial obstruction. Material and Methods. Applanation tonometry was performed in 60 patients (56 men, age 63.5 [IQR 59; 70] years) with chronic obstructive pulmonary disease to assess central hemodynamic parameters. The severity of obstructive disorders was determined by spirometry after taking bronchodilator. Results. In case of progression of bronchial obstruction, a decrease in parameters characterizing coronary blood flow was detected, mainly determined by an increase in heart rate and by a decrease in the duration of diastole. In addition, higher values of augmentation pressure, corrected by heart rate of 75 bpm, pulse pressure, central pulse height at the point of maximum rise of direct pulse wave were determined in patients with more severe bronchial obstruction. These parameters indicate higher values of arterial stiffness in this group of patients. Conclusion. In patients with chronic obstructive pulmonary disease and high values of bronchial obstruction there is an imbalance in the ratio of myocardial load and actual blood supply, and increased arterial stiffness with impaired aortic damping function, that contributes to the development of cardiovascular disease in this group of patients. These factors may explain high prevalence of cardiovascular disease in this group of patients.

The article demonstrates a clinical case of a disease that occurs mainly in older age groups — ankylosing spinal hyperostosis (AHP) or Forestier disease. The rarity and lack of knowledge of AHP and the associated lack of alertness in relation to this disease makes its diagnostic a difficult task. The disease is more common in older people, which requires differential diagnosis with degenerative changes of the vertebrae. AHP is a low-symptom disease. Clinical symptoms are determined not so much by hyperostosis of the ligaments and tendons by themselves, but by the development of reactive inflammation of these structures during the process of ossification, overloading of still moving segments of the spine adjacent to ankylosed vertebrae. Of particular importance for this disease is the defeat of the anterior longitudinal ligament, the continuity of its ossification for at least four vertebrae (in contrast to trauma, tumors). Important is absence or low severity of ankylosis of the arched joints, sacroiliitis, characteristic of ankylosing spondylitis. The absence or weak severity of degenerative changes in the intervertebral discs detected in osteochondrosis matters. The presence of laboratory and clinical signs of inflammation, damage to other organs and systems is not typical to this pathology. At present time we have no treatment standards for AHP, which also makes the choice of patient management tactics complicated.

The insufficient amount of information about this disease makes wider coverage of the pathology necessary in order to improve diagnostic skills, prescribing timely and complete treatment.

The article presents the clinical features and treatment options for autoimmune thrombocytopenic purpura associated with autoimmune hemolytic anemia in the context of Fisher-Evans syndrome. Patient P. was admitted to the emergency department by an ambulance team with a direct diagnosis of acute pancreatitis. Leading clinical syndromes were hemorrhagic and anemic syndromes. A physical examination also revealed a strip-formed hemorrhagic rash in the area of inguinal folds, the anterior surface of the thighs and lower legs. During the differential diagnostic search, the diagnosis of Fisher-Evans syndrome was established. Initial oral and pulse therapy with prednisone was not effective. The patient received platelet transfusions regularly. When eltrombopag was included in therapy, there was an improvement in the patient’s condition, as well as a tendency to increase the level of platelets. On the 35th day, the patient was discharged from the hospital.

We examined various clinical variants of thrombocytopenia, I meet in real clinical practice.