Introduction. Nowadays it’s recommended to perform carotid endarterectomy (CEA) in up to 14 days after nondisabling stroke; the procedure is aimed at the prevention of recurrent stroke.

The objective of this research was the comparison of short-term and long-term (12 months) outcomes with early (in up to 30 days) and delayed (30-180 days) CEA in patients who suffered strokes of various severities.

Materials and methods. The research involved 88 patients who underwent CEA in the early stage (Group 1) and 88 patients who underwent CEA in their late period (Group 2). We assessed primary endpoints: ipsilateral stroke, myocardial infarction, 30-day Lethality, 30-day lethality after the surgery, any stroke or infarction (MACE). Secondary endpoints: the same parameters within 12 months after the surgery, post-surgery local or systemic complications, restenosis, changes in neurologic or cognitive status.

Results. In 30 days we observed ipsilateral strokes in 3 patients in Group 1 (3.4 percent), it was lethal in 1 patient (1.1 percent). 170 of 176 (96 percent) patients were followed up for 12 months. One lethal stroke was registered in the group of late interventions (1.1 percent). No statistically significant differences were observed between the outcomes in early and late treatment groups. The severity of disability (mRS) in patients of the early intervention group was significantly smaller at discharge and in 12 months after surgery.

Conclusion. The advisability of early CEA performance was proven by the absence of differences in post-surgery 30-day and longterm lethality as well as the progress of stroke or infarction with early or late CEA. In 12 months after the surgeries, significant improvement in neurologic status by mRS was only observed in the group of early interventions.

Introduction. Transient ischemic attacks can be a predictor of a more severe cardiovascular event, the risk of which depends on many factors that requires a personalized approach. Neuropsychological disorders (cognitive, emotional) have a significant impact on quality of life and social activity and are often underestimated in patients with TIA. Comprehensive medical rehabilitation with the inclusion of antithrombotic therapy and psychocorrection measures may reduce the risk of recurrent cardiovascular events in patients with TIA.

Purpose of the study: to substantiate the efficiency of complex medical and non-pharmacological rehabilitation in patients who underwent TIA by analyzing the characteristics of the main and leading concomitant diseases.

Materials and methods. The morbidity of 351 TIA patients was studied and analyzed. The average age of the examined patients was 58.6 ± 2.2 years, there were 64.9% of women and 35.1% of men. All patients received an individualized medical rehabilitation program for 12 months with correction of identified neuropsychological disorders. Depending on background and concomitant diseases the antiplatelet or anticoagulants therapy was differently administrated.

Results and dicussion. Psychological, cognitive, and physical disorders (based on subjective complaints) are common in patients with TIA. The prevalence of mental disorders in patients with TIA was 138.2 cases per 100 patients. The correction of cognitive impairment, depressive symptoms is associated with improved quality of life (p < 0.05). Repeated acute cerebrovascular events (TIA, ischemic stroke) were recorded during the first 6 months after TIA in 29 patients (10.4%) with severe stenosis of the brachiocephalic arteries, severe arterial hypertension and paroxysmal atrial fibrillation.

Conclusion. The importance of comprehensive medical and social rehabilitation of patients with TIA is determined. The participation of a psychotherapist as a member of a multidisciplinary team is necessary. A significant role of the secondary prevention of acute cerebrovascular events is assigned to rational antithrombotic therapy.

The article systematizes information on the diagnosis and treatment of anxiety disorders, the frequency of which has increased significantly at the present time, in connection with the COVID-19 pandemic. The characteristic of stressful factors affecting the human psyche in the conditions of forced self-isolation and after it is given. Many people experience anxiety due to lockdown, social isolation, unemployment, and a high probability of illness and death. Uncertainty in the future, anxiety during the period of uncertainty caused by the spread of the “new coronavirus”, are a trigger for emotional exhaustion, suppress the immune system, which negatively affects the human nervous system and provokes an exacerbation of chronic ailments. The psychological consequences of a person’s stay in quarantine are considered. In the structure of mental health disorders associated with the COVID-19 epidemic, there is a large range of adaptation disorders: fear, frustration, a sense of hopelessness, expectation of threat, loneliness, social isolation and alienation. In the situation of COVID-19, there is often a depletion of mental resources and maladaptation, a disorder of adaptive reactions. Anxiety disorders occur in the form of adaptation disorders, generalized anxiety disorder, somatoform disorders, including panic attacks. Timely diagnosis of these disorders is possible not only by the psychiatric service, but also with the involvement of internists who possess screening diagnostic tools with automated conclusions (scales, mobile applications to smartphones, etc.). A brief review of domestic and foreign studies on the assessment of methods for the diagnosis and treatment of anxiety disorders is presented. Diagnostic methods and therapeutic tactics, the use of various traditional drugs in psychosomatic pathology are discussed. To correct the identified disorders, there is a choice of anti-anxiety drugs, including antidepressants (primarily selective serotonin reuptake inhibitors), tranquilizers, among which tofizopam occupies a worthy place.

The results of multicenter clinical trials show the broad potential of melatonin since discovery of this adaptogen to the present day. Melatonin is a neuropeptide that is synthesized mainly in the small brain gland, the pineal gland, and has a unique effect in humans and animals. Using melatonin, the pineal gland participates in the organization of circadian periodism and regulation of cyclic processes, acting as an intermediary between the pacemaker mechanism of the suprachiasmatic nuclei (SCN) and peripheral organs. The pineal gland and the SCN of the hypothalamus form part of the system of the so-called biological clock of the body, which plays a key role in the mechanisms of regulation of the biological clock via circadian rhythms and ageing. Initially, melatonin was only considered a hormone involved in the synchronization of the mechanisms of the circadian rhythm, but later it was found that, in addition to this hormonal function, it takes part in the regulation of the seasonal cycle in animals and humans.

At present, melatonin drugs have shown high efficacy and safety in various sleep-wake disorders regardless of their genesis, disorganization of circadian rhythms, stress adjustment disorders, rapid change of time zones, shift work and in complex therapy of patients with cerebrovascular diseases.

The article considers the multimodal capabilities of melatonin, including adaptogenic, biorhythmogenic, hypnotic, immunostimu-lating, antioxidant effects. The role of melatonin in the treatment of various central nervous system disorders, including neurodegenerative diseases, has been determined.

The review emphasizes the wide-ranging effects of melatonin and offers great opportunities for measuring melatonin as a biomarker for early detection and follow-up of various diseases.

Low back pain is one of the most common reasons for seeking medical attention. Musculoskeletal (nonspecific) pain is the most common (90%) cause of chronic pain. Depressive and anxiety disorders, sleep disorders, mainly in the form of insomnia, which negatively affect the course of the disease, are often encountered as comorbid disorders in patients with chronic musculoskeletal low back pain (CMLBP). When managing patients, it is effective to use an integrated approach: drug therapy, kinesitherapy and psychological methods. Kinesitherapy uses various types of exercise and walking; it is important that they are performed regularly under the supervision of a specialist, excluding excessive physical and static loads. Cognitive-behavioral therapy is the most effective psychological effect in CMLBP, which should be directed not only to pain, but also to insomnia, depression and anxiety disorders. Non-steroidal anti-inflammatory drugs (NSAIDs) are used as drugs for chronic pain. It is important to take into account the presence of risk factors, concomitant diseases, interactions with other drugs. The use of etoricoxib (Arcoxia) for chronic low back pain is discussed. The author presents his own experience in managing 71 patients (average age 55) with CMLBP using kinesitherapy, psychological methods, and NSAIDs. As a result of treatment after 3 months, a significant decrease in VAS was achieved from 8 (6-8) to 2 (0-4) points (p < 0.0001), the depression decreased from 7 (5-9) to 4 (3-6) points in HADS (p = 0.002), the anxiety from 7 (5-10) to 5 (3-7) points in HADS (p = 0.0003), a decrease in disabilities according to the Oswestry question-naire from 46 (34-57.77) to 11.11 (4.44-26) percent (p < 0.0001), increase in physical activity according to IPAQ-SF from 11 (7-16) to 23 (15-26 ) points (p = 0.0002), decrease insomnia according to ISI from 12 (7-15) to 6 (2-10) points (p < 0.001), improvement in sleep quality according to PSQI from 9 (7-13) points up to 4 (2-9) points (p < 0.001). The widespread introduction of complex treatment of patients with CMLBP is of great medical and social importance.

One-third of patients attending a general practitioner’s office have some type of medical problem associated with pain. The most common types of acute pain in patients who consult a general practitioner are musculoskeletal pain in the neck and lower back with or without irradiation to the extremities and joint pain. The primary source of pain is very difficult to ascertain in the usual outpatient setting. However, therapeutic strategies do not directly depend on the primary source of pain, but are based on the pathogenetic mechanisms of pain. Acute nociceptive pain is often accompanied by inflammation, which is a key component of the transition of acute pain to the chronic phase, which should be taken into account when choosing therapeutic strategies. To date, the mechanisms associated with chronic pain are not fully understood due to their complex nature and the involvement of both peripheral and central mechanisms. In addition, complex interacting individual physical (age, female gender and overweight) and psychological factors also affect the transition from acute to chronic pain. The clinical management of acute pain requires an optimal balance between effective pain relief and the associated safety risks. Non-steroidal anti-inflammatory drugs are the most effective drugs for the relief of inflammatory pain. To achieve optimal results, a personalized approach is needed to ensure that the properties of the drugs best match the patient’s characteristics. Because of its multifactorial mechanism of analgesic action, nimesulide is an attractive therapeutic choice for the treatment of patients with acute pain.

Tolperizone is a central type of muscle relaxant that is widely used in clinical practice for the treatment of patients with acute and chronic nonspecific lower back pain(LBP), inflammatory and degenerative-dystrophic joint diseases, and is used in the treatment of myofascial pain syndrome (MPS).The Russian market widely used drug tolperizone, which is comparable in its clinical and anti-inflammatory activity with the original tolperizone, as well as with non-steroidal anti-inflammatory drugs (NSAIDs). Tolperizone is prescribed mainly in complex therapy, as well as as monotherapy.In some studies, based on the clinical efficacy of tolperizone (200 mg 3 times a day), it is concluded that tolperizone can be considered as a promising treatment for acute muscle spasm, without causing drowsiness. In the treatment of pain syndromes and osteoarthritis (OA) of various localization, the optimal dosage regimen of tolperizone is currently recommended: oral 150-300 mg per day for a course of 14 days, or according to a 2-stage scheme of administration, first intramuscularly 1.0 ml 2 times a day for 5 injections, then switching to oral administration of 150 mg 3 times a day; with MPS, a single local intramuscular injection of tolperizone is prescribed at the trigger point. The addition of tolperizone (150 mg/s) to the scheme of complex therapy allows to achieve an earlier clinical effect in OA of the hip and ankle joints, suppressing further progression of the disease. When included in the therapy regimen of tolperizone (150 mg/s, 14 days) OA of the ankle joint, with ultrasound examination, there is a statistically significant decrease in the signs of synovitis.

Lumbar pain (LP) is one of the most frequent causes of appeal to a doctor and temporary disability. LP is most often caused by the musculoskeletal (non-specific) pathologies, less often discogenic radiculopathy, lumbar stenosis or specific pathology. The diagnosis of acute (up to 4 weeks) of skeletal muscle pain and discogenic radiculopathy is based on clinical manifestations and the exclusion of specific pathology, and neuroimaging is not required if there are no symptoms of a dangerous disease. Conducting X-ray, computed tomography or magnetic resonanse tomography in patients with skeletal-muscular LP does not improve the prognosis of the disease, does not affect the development of complications and chronizing the process, and the cost of the examination, the patient’s concern and the frequency of surgical interventions are unreasonably increasing. A patient with acute nonspecific LP or discogenic radiculopathy should be informed about the benign nature of the disease, a favorable forecast, expediency to maintain physical and social activity, avoid bed regime. Therapeutic gymnastics is not recommended for acute LP, but it is joined by reducing pain, it is advisable to teach the patient to avoid excessive static and physical exertion for the prevention of relapses and chronic. To facilitate pain, unnecessary anti-inflammatory drugs can be used in minimally effective doses and a short course, muscle relaxants. The use of group vitamins in both additional analgesics during acute LP is discussed, the results of their own studies on the treatment of patients with acute pain in the back and discogenic lumbosacral radiculopathy are analyzed. It is noted, that patients with acute LP are relatively rarely informed by doctors about its favorable forecast, the possibilities of the natural regression of the hernia of the disk and neurological symptoms at discogenic LP and radiculopathy.

Epilepsy is a common chronic neurological disease. The problems of people with epilepsy go well beyond epileptic seizures. Comorbidities in epilepsy are very common and often cause more problems to the patients than the seizures themselves. Although seizures are the most prominent clinical presentation of epilepsy, people with epilepsy are exposed to risk of not only seizures, but also of many health problems. Both children and adults with epilepsy often complain of memory impairment. It is commonly believed that cognitive dysfunction in epilepsy is multifactorial. The components that deteriorate cognitive functions include active seizures and especially generalized tonic-clonic seizures, traumatic brain injuries, structural epilepsy, and drug therapy. Cognitive dysfunction is very often present as far back as during the onset of epilepsy. The cognitive dysfunction detected in patients with epilepsy depend on the localization of the epileptic focus, the frequency and type of epileptic seizures, and changes in the interictal electroencephalogram. Seizures can be controlled with antiepileptic drugs in most patients with epilepsy. Therapy of cognitive dysfunction in patients with epilepsy presents significant difficulties, as there is no evidence of the efficacy of various drugs in cognitive disorders. The article presents a new Russian antiepileptic drug based on phenosanic acid as part of combination therapy in patients with partial epileptic seizures with or without secondary generalization, which can improve cognitive functions in patients with epilepsy.

The number of cases of alcoholism in Russia is gradually decreasing, but still significantly affects the overall health indicators of the population. One of its frequent complications is alcoholic polyneuropathy. The article deals with the pathogenetic mechanisms of the occurrence and development of the disease, its forms, classification, and clinical picture. The damage to the nervous system in patients with alcoholism depends on the frequency of alcohol consumption, the dose, the type of drinks that were consumed, malnutrition, genetic predisposition and individual characteristics that determine the level of alcohol dehydrogenase and aldehyde dehydrogenase. In the clinical picture, a toxic form of alcoholic polyneuropathy is currently distinguished, associated with the direct effect of toxic alcohol metabolites on somatic and autonomic nerve fibers, thiamine deficiency, resulting from a deficiency of B vitamins, and mixed forms. According to the rate of development of clinical manifestations, there are acute forms of alcoholic polyneuropathy (thiamine deficiency) and chronic forms (toxic). The article discusses the possibilities of diagnostics using modern instrumental and laboratory methods of research, primarily electroneuromyography. With the help of this method of investigation, in alcoholic polyneuropathy, signs of axonal damage are most often detected, and in the thiamine-deficient form, it is possible to determine signs of secondary demyelination. The authors emphasize the importance of differential diagnosis with other pathologies. The article highlights the current understanding of the main therapeutic strategies, treatment options for patients with alcoholic polyneuropathy. Therapy of patients suffering from alcoholic polyneuropathy includes refusal of alcohol abuse, normalization of nutrition, medication. For drug therapy, B vitamins and antioxidants are used. The drug with a recognized antioxidant effect is alpha-lipoic acid. A clinical case was analyzed on the basis of our own clinical observation of a mixed form of alcoholic polyneuropathy.

Spasticity is one of the most frequent movement disorders and its development is associated with such CNS lesions as stroke, multiple sclerosis, cerebral palsy, craniocerebral and spinal injuries, CNS tumors, neurodegenerative diseases. Post-stroke spasticity develops in about 40% of patients, and about 15% of patients have severe and disabling spasticity. According to statistics, after TBI, about 75% of patients develop spasticity, and half of them require treatment.

Spasticity worsens walking, complicates hygiene, dressing, complicates rehabilitation measures, and reduces the quality of life of patients and his family members. In recent years, this movement disorder has been actively studied, new data have appeared on the pathophysiology of spastic paresis and encouraging data on improving function in patients receiving botulinum toxin injections as part of multidisciplinary rehabilitation.

The article presents data from the latest systematic reviews on the effectiveness of various rehabilitation technologies for the treatment of spasticity.

The use of botulinum neurotoxin for the treatment of spastic paresis of the upper and lower extremities is the preferred method of complex multidisciplinary rehabilitation of patients with spasticity and has the highest level of evidence.

Currently, there is no doubt that botulinum toxin should be used as early as possible in patients with an emerging pathological movement pattern, which can contribute to pattern change and muscle length maintenance. But the question remains: which rehabilitation technology is most effective for enhancing and prolonging the action of botulinum neurotoxin. To date, there is no clear answer to this question.

The COVID-19 pandemic was announced in 2020, and many professional medical societies had to review their algorithms for the management of high-risk patients. In addition to risk factors such as overweight, age over 65 years, cardiovascular disease, diabetes mellitus, and bronchial asthma, other chronic diseases should also be emphasized, taking into account possible immunosuppressive therapy. This publication presents two clinical cases of COVID-19 infection in patients with multiple sclerosis treated with ocrelizumab. During the course of the disease, both patients developed a cytokine storm and were treated with IL-6 blockers. Both cases ended with recovery and a subsequent return to anti-B-cell therapy. Given the mechanism of action of ocrelizumab, there are higher risks of infectious complications, including with COVID-19, but mortality is not higher than the population average. The information published to date may serve as a reason to consider the use of extended dosing intervals to minimize the possible risks of COVID-19 infection, which are probably highest in the first months after infusion.

The article discusses various options for the management of patients with rheumatoid arthritis (RA) in accordance with modern foreign and domestic recommendations. Data on the possibility of achieving an effect on the background of monotherapy with methotrexate (MT) are presented and options for more active therapy are discussed. The authors compare the effectiveness of sequential change of basic anti-inflammatory drugs (DMARDs), sequential addition of DMARDs to MT, treatment with a triple combination of DMARDs with an inadequate response to MT or in the debut of therapy, combination of DMARDs and biological drugs. According to the study data, in cohorts of patients with equal clinical effectiveness of the triple combination of DMARDs and the combination of DMARDs with biological drugs, however, the severity of the progression of destruction in the joints of the hands and feet is less when using biological agents. It was noted that the evaluation of the effectiveness of the double / triple combination of DMARDs was carried out in open observational studies, which has less evidence value than randomized controlled double-blind placebo-controlled trials (RCTs) for the assessment of biological drugs. Despite the importance of implementing biological drugs in clinical practice, their high cost limits their use by patients. Registration in the Russian Federation of the first biosimilar of etanercept (ETN) - the drug Erelzi is important for the treatment of patients with RA. The article describes the advantages of original ETN (tumor necrosis factor ainhibitor - iFNO a) over other iFNO a, which are monoclonal antibodies to this cytokine. The article presents data on the equivalence of the ETN biosimilar registered in the Russian Federation (Erelzi) with the original ETN in terms of clinical efficacy, safety and immunogenicity. The comparability of drugs in terms of the frequency of adverse events was demonstrated. It is shown that switching from the original ETN to its biosimilar allows you to maintain the effect, not accompanied by an increase in the frequency of intolerance or immunogenicity. It is indicated that Erelzi is registered in the Russian Federation for the treatment of RA, various variants of axial spondylitis, psoriatic arthritis, psoriasis and juvenile idiopathic arthritis.

Osteoarthritis (OA) is a widespread disease of synovial joints, the treatment of which determines a significant number of tactical and strategic directions. Currently, there is experience in the local use of so-called synovial fluid (SF) prostheses, which are viscoelastic substances that improve the cushioning properties of the native intra-articular environment. The overwhelming majority of viscoelastic additives are represented by hyaluronic acid (HA) derivatives, a natural component of SF, whose biological role consists in maintaining the rheological properties of fluid and the presence of anti-inflammatory, anti-nociceptive and chondro-protective properties. In the development of HA drugs, the main goals are the sustained and controlled release of therapeutic doses of the drug, taking into account the choice of carrier, drug molecule and target articular tissue. Assessing the quality and physiological feasibility of introducing a particular viscoelastic drug into the joint involves determining the so-called crossover frequency - the point of intersection of the viscosity modulus G’ and the elastic modulus G” (G’/G”), which reflects changes in the viscoelastic properties of the SF with increasing load frequency when transitioning from walking to running. Physiological range of frequencies out of the majority of investigated medical products corresponds to a single one, among which there are also variants of domestic production. Numerous studies of local application of some HA drugs in patients with OA confirm their effectiveness and safety, in particular, reduction of pain syndrome, reduction of the need for nonsteroidal anti-inflammatory drugs, improvement of the quality of life. However, unfortunately, most HA drugs available on the market have not undergone full-fledged clinical trials, so there is a need to study the comparative effectiveness of drugs of this group approved for use and determine their place in the treatment of OA with different variants of the course.

In accordance with current views on the pathogenesis of the new coronavirus infection, some antirheumatic drugs are considered as therapeutic agents for suppressing the hyperinflammatory response in severe COVID-19. The review presents literature data on the efficacy and safety of certain basic anti-inflammatory and genetically engineered drugs in patients with COVID-19. Hydroxychloroquine is not indicated for the treatment of SARS-CoV-2 infection of any severity due to the lack of therapeutic benefits, the likelihood of a worse prognosis in more severe patients and the development of adverse reactions, especially when used concomitantly with azithromycin. The use of systemic glucocorticoids (GC) in patients with COVID-19 who require oxygen support leads to a decrease in mortality and an improvement in the prognosis of the disease. However, the optimal time of administration, dose and duration of HA administration remain the subject of further research. Despite the encouraging data, it is too early to draw final conclusions about the feasibility of using tocilizumab in COVID-19, since no randomized clinical trials have demonstrated a clear advantage of the drug in terms of reducing mortality. The use of anakinra does not reduce the need for noninvasive / invasive lung ventilation or the mortality of patients with COVID-19. Two drugs from the group of tumor necrosis factor inhibitors - infliximab and adalimumabare currently being considered as possible treatment options for COVID-19. The use of a combination of baricitinib and remdesivir for the treatment of COVID-19 patients requiring oxygen support has been approved. New RCTs are needed to study the effectiveness of other anti-rheumatic drugs in COVID-19.

The article is devoted to an urgent issue - rheumatoid arthritis (RA). The symptoms of arthritis appear in women during menopause. Literature data show that it is often during period of poor reproductive function that the disease first manifests itself in women. RA significantly affects the prognosis of women’s life expectancy and quality. The clinical and pathogenetic relationships between autoimmune diseases (one of which is RA) and the features of menopause remain poorly understood and require research. Basically, papers devoted to the problem present epidemiological studies and the study of the relationships between sex hormones levels and inflammatory mediators that are specific to RA.

A literature review on the features of the onset and course of rheumatoid arthritis in menopausal women is presented. The most accepted in the literature explanations characterizing the relationship between changes during menopause and RA are arguments about the protective effect of estrogens on the cells of the musculoskeletal system and the ability of estrogens to influence the intensity of inflammation (systemic inflammation of low intensity associated with age). In the case of the development of rheumatoid arthritis in old age, higher levels of IL-6 and lower TNFa are revealed. This fact gives rise to the choice of basic therapy in favor of a humanized monoclonal antibody to the human interleukin-6 receptor - tocilizumab.

The review may be of interest to both practising rheumatologists, neurologists, and gynecologists and general practitioners.

Colchicine is a drug that has been known for several millennia, since the days of Ancient Egypt, but has been successfully used to treat gout to this day. The action of colchicine is based on microtubule damage, mitosis suppression, as well as the ability to inhibit the activation of NLRP3 inflammasoma by monosodium urate crystals and block the release of interleu-kina (IL)-1p - key cytokine in the development of gout inflammation. However, the mechanism of action of colchicine is still not fully understood.

Colchicine should be considered as the optimal drug not only for relieving an acute attack of arthritis in gout, but also as the best method for preventing attacks of gouty arthritis when choosing urate-lowering therapy. Recent studies have confirmed the good efficacy and safety profile of the drug when used correctly in patients with gout. Currently, it is recommended to use low doses of the drug (1-1.5 mg per day to relieve an acute attack of arthritis and 0.5-1.0 mg to prevent attacks when initiating uratelowering therapy). At the same time, according to the results of recent studies on the effectiveness, low doses are not inferior to high doses, but when low doses are used, the frequency of undesirable effects is much less. Unlike non-steroidal anti-inflammatory drugs and glucocorticoids, the drug does not have a negative effect on the cardiovascular system and can be used in patients with diabetes mellitus. This allows the drug to be used for a long time, which is especially important, since it is recommended to prevent arthritis attacks for at least 6 months from the start of taking urate-lowering drugs. This avoids the exacerbation of arthritis in most patients and significantly reduces their frequency. In addition, in the light of the accumulating data on the effect of the drug on the cardiovascular system of the drug, in conjunction with the high safety profile, other points of application should be considered where both anti-inflammatory and cardioprotective properties of colchicine can be used.

Amidst the growing coronavirus infection (COVID-19) pandemic, there is increasing evidence of the development of neurological complications of this disease and, especially, acute cerebrovascular accidents, and what is more, an increase in incidence rates of strokes is noted in the patients under the age of 50, who did not have risk factors for cerebrovascular diseases. The article examines several potential mechanisms that determine the relationships between ischemic stroke and COVID-19. A clinical case of the development of ischemic stroke in the vertebrobasilar system affected by the coronavirus infection is presented. The causal relationship between coronavirus infection and vascular catastrophe is discussed. In the described case, COVID-19 contributed to the decompensation of the patient’s associated risk factors. A feature of the described case is the delayed development of a rare motor disorder in the form of Holmes tremor and combined speech disorders (dysarthria and aftereffects of motor aphasia) in the patient. Holmes tremor is an unusual type of tremor characterized by a combination of rest, postural, and action tremors that predominantly affects the proximal limbs. This symptom is named after the British neurologist Gordon Holmes, who described a series of cases of an unusual variant of tremulous hyperkinesis in 1904. The article discusses the pathogenesis issues of the development of this condition and provides clinical criteria for Holmes tremor. This is a rather rare symptom, there are no data on large studies of this disorder in the literature, and it is mainly described in small series of clinical cases. The efficacy of Akatinol Memantine in the treatment of post-stroke speech disorders is discussed, and the rationale for prescribing this drug in the management of patients with post-stroke speech disorders is presented.

A clinical case of a patient with chronic nonspecific low back pain and comorbid chronic insomnia is described, and a modern approach to the management of this patient category is shown. So-called yellow flags - factors that contribute to the central sensitization of pain - lead to chronicity of LBP. In the presented clinical case we identified the most common "yellow flags”: insomnia, pain catastrophizing, restrictive ”pain” behavior, anxiety. In practice, they often ignore the aforementioned factors, determine only the presence of back pain and prescribe analgesic therapy, which does not allow for an effective result.

Insomnia is prevalent among patients with LBP, occurring in 47-64% of cases. With the COVID-19 pandemic among the population, the incidence of insomnia, anxiety and depression has increased. To date, the identification and treatment of these disorders is particularly relevant in the management of patients with chronic nonspecific LBP.

The patient was treated, which included non-drug and drug methods and complied with Russian and foreign clinical guidelines on the therapy of chronic nonspecific LBP and on the therapy of chronic insomnia. Non-drug treatment consisted of educational talks, recommendations on daily activity and sleep hygiene, cognitive-behavioral therapy, mindfulness, relaxation, and therapeutic gymnastics. The listed methods were aimed at reducing pain catastrophizing, physical and social activation of the patient. The nonsteroidal anti-inflammatory drug dexketoprofen was used as pharmacotherapy according to a step-by-step regimen. After 5 days of therapy pain relief was observed, after 3 months of therapy back pain regressed, sleep normalized, mood improved. This therapeutic approach showed its effectiveness and safety in the treatment of chronic nonspecific LBP and comorbid chronic insomnia.

Intoduction. Currently, for the treatment of patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA), basic anti-inflammatory drugs and biological drugs are widely used to effectively control the activity of the disease. However, the use of these drugs is associated with an increased risk of developing comorbid infections, some of which can be prevented by vaccination. Objective. To evaluate the immunogenicity, safety, and clinical efficacy of the 23-valent pneumococcal polysaccharide vaccine (PPV-23) in patients with RA and SpA.

Materials and methods. The study included 122 patients: 79 - with RA, 43-with SpA. Most patients had a history of two or more cases of lower respiratory tract infections, 2 patients reported a monthly exacerbation of chronic sinusitis, one patient reported the development of otitis media every 2-3 months. At the time of inclusion in the study, most patients received immunosuppressive therapy. PPV-23 was administered in an amount of 1 dose (0.5 ml) subcutaneously against the background of anti-rheumatic therapy. The level of antibodies to pneumococcal capsular polysaccharide was determined using the EIA PCP IgG kit (TestLine Clin-ical Diagnostics s.r.o., Czech Republic) before vaccination, 1, 3 and 12 months after vaccination. In addition, the tolerance of PPV-23, the frequency of pneumonia, and the effect on the activity of RA and SpA were evaluated (according to the dynamics of DAS28 and BASDAI).

Results. At 1, 3, and 12 months after vaccination, the concentration of antibodies to pneumococcal capsular polysaccharide was significantly higher than the baseline values, which indicates sufficient immunogenicity of PPV-23. There was no negative effect of vaccination on the activity of the underlying disease and the occurrence of new autoimmune disorders. In the majority of patients (67% - RA, 81.4% - SpA), the tolerance of the vaccine was good. During the follow-up period, none of the patients developed pneumonia. Patients suffering from frequent sinusitis and otitis media reported the absence of these infections after vaccination.

Conclusion. Preliminary results of the study indicate sufficient immunogenicity, safety, and clinical efficacy of PPV-23 in patients with RA and SpA.

Introduction. Early diagnosis of cardiac autonomic neuropathy is the basis for the risk of heart disease and premature death in patients with type 2 diabetes mellitus (type 2 diabetes). All patients with type 2 diabetes and prediabetes should undergo annual screening, including history taking and neurophysiologic evaluation, for early diabetic autonomic neuropathy. This article describes a modern diagnostic technique based on changes in heart rate variability, which allows early detection of damage to the parasympathetic nervous system and timely prescribing disease-modifying treatment in patients with type 2 diabetes.

Materials and methods. The study included 50 patients with type 2 diabetes (cf. Age 56.5 ± 13.5 years) and 30 healthy subjects (cf. Age 58 ± 10 years), matched by sex and age. according to the NSC questionnaire, the severity of neurological deficit - according to the NIS-LL scale, neuropathic pain syndrome - according to the TSS scale.

Results. In the study group of patients with type 2 diabetes, severe CAN was detected in 13.3%, moderate CAN in 40% of patients, in 46.6% of patients, CAN was not detected. In the group of healthy volunteers, disorders of the autonomic nervous system of moderate were detected in 3.3%, in the remaining 96.7% of autonomic disorders were not accepted.

Conclusion. The results of pulse oximetric tests with deep breathing are comparable to the results of the QAT device Case-4 (p < 0.001). The method of pulse oximetric diagnostics is more practical to use in comparison with the hardware QAT.