Interview with Dr. Sci. (Med.) Andrey B. Danilov, Professor of Department of Nervous Diseases, I.M. Sechenov First Moscow State Medical University, Chairman of the Board of Experts of the Association of Interdisciplinary Medicine.

Interview with Natalya V. Chichasova, professor of the Department of Rheumatology, Russian Medical Academy of Continuous Professional Education (RMANPO), Member of the Presidium of the Board of the Association of Rheumatologists of Russia, Member of the Academic Council of the Federal State Budgetary Institution – V.A. Nasonova Research Institute of Rheumatology, Dr. Sci. (Med), Board Certified Physician.

Introduction. The quality of medical care is determined not only by the dynamics of functional recovery, but also depends on the patient satisfaction index, which is highly informative and should be used in in its assessment. Aim. To study and analyze the level of satisfaction of patients after ischemic stroke (IS) with the quality of MR services provided using the technology of multimodal correction of motor and cognitive disorders in the early recovery period.

Materials and methods. An anonymous survey was conducted of 186 patients with IS who underwent rehabilitation in inpatient and outpatient settings at the Moscow Research and Practice Center for Medical Rehabilitation, Restorative and Sports Medicine named after S.I. Spasokukotsky, using a specially designed questionnaire including 20 questions, as well as an analysis of medical and social factors affecting MR satisfaction.

Results. The majority of respondents (89.8%) were generally satisfied the results of MR, while more than half (65%) plan to undergo further MR using this technology. According to respondents, the favorable result of MR is influenced by the presence of relatives next to the patient (76.0%) and in 14.0% by the presence of a nurse, the availability of special training in rehabilitation of doctors and nursing staff (38%), awareness of the impact of rehabilitation measures for their existing functional disorders (94%). Almost three quarters of respondents noted that the individual regime of the rehabilitation program has the greatest impact on the successful outcome of rehabilitation (72.0%). At the same time, two thirds of specialists consider an important aspect to be the comprehensive work of all specialists engaged in MR (64.0%). The medical staff was highly appreciated by 44.1%, 34.9% and 21.0% highly. 36% of patients are highly satisfied with the results of MR, 42% are quite satisfied, and 16% of respondents gave an assessment of “average, normal”. Among the main reasons for dissatisfaction with MR are remoteness of residence from a medical organization, absence of relatives during the course of MR, the long duration of the MR course, lack of awareness information about the impact of multimodal correction technology on the restoration of impaired functions.

Conclusions. Based on the analysis of the overall patient satisfaction with the medical care provided by MR for stroke patients, using the technology of multimodal correction of motor and cognitive impairments, directions for improving the quality of medical services were identified.

Introduction. The high risk of recurrent ischemic events after non-cardioembolic ischemic stroke(IS), the prevalence of which is 25% of all strokes in the Russian Federation, determines the need to search for effective and safe secondary prevention strategies.

Аim. The study was to evaluate the efficacy and safety of a combination of ADP receptor inhibitors (dipyridamole) with acetylsalicylic acid in patients with ischemic stroke (IS) in the secondary prevention of noncardioembolic stroke.

Materials and methods. 229 patients in the early recovery period of noncardioembolic IS (139 women, 90 men), with an average age of 59.0 ± 5.7 years were included in the study. The duration of IS was 54.4 ± 6.1 days. All patients received a multimodal medical rehabilitation (MMR) program. Long-term double antiplatelet therapy with acetylsalicylic acid (ASA) 75 mg per day and dipyridamole at a daily dose of 225 mg divided into 3 doses were prescribed to all the patients. The neurological and neuropsychological status of the patient, quality of life and hemorheological parameters were assessed initially (T0), after MMR (T1, 6 weeks) and 12 months after IS(T2).

Results. Motor and coordination indicators of patients as well as the cognitive and emotional parameters were significantly (p < 0,05) improved due to MMR technology. These were confirmed by the dynamics of the corresponding scales. The prescribed double antiplatelet therapy did not cause significant adverse events and worsening of the patients’ well-being both during the MMR process and during the observation period. The combination of ASA with dipyridamole was well tolerated. At the end of the study, recurrent IS, myocardial infarctions, and fatal bleeding were not recorded. In 5.2% patients with severe risks of cardiovascular complications there was occurred TIA. The effectiveness of the dual antiplatelet therapy was confirmed by a decrease in the level of platelet aggregation (p < 0,05).

Conclusions. The high effectiveness of secondary prevention of IS with a combination of ASA and dipyridamole with good tolerability and safety in patients after IS has been shown.

Introduction. Cognitive stimulation therapy (CST) used worldwide to treat cognitive impairment has recently attracted interest of Russian medical and scientific minds. However, when applied to Russian-speaking patients with dementia, CST requires adaptation. Aim. To evaluate the effectiveness and safety of the Russian-language version of CST for Russian-speaking patients with Alzheimer’s disease at the stage of moderate dementia.

Materials and мethods. 8 participants involved into the trial were residents of social care center ZILANT diagnosed as dementia patients with Alzheimer’s, aged 76 ± 10.8 years, with the median MMSE score identified 17 ± 5.0. Before implementing the main course of CST developed by E. Spector et al we translated and localized it for Russian patients. The patients undergoing CST were assessed for the state of cognitive functions, everyday activity, mental symptoms, as well as enjoyment and involvement. One of the recruited patients was excluded due to restlessness and anxiety.

Results. Seven patients had significantly improved on ADAS-Cog scale (p = 0.002), Lowton&Brody and ADCS-ADL. The NPI scale indicated a reduction in symptoms of delirium and apathy which contributed to a reduction in antipsychotic dosages and a corresponding decrease in caregiver’s distress. The most striking indicator of CST effectiveness was improvements in the patient’s mood and satisfaction, which we view significant in everyday life and as an indicator of CST safety.

Conclusion. The Russian-language version of CST proved effective and safe for moderate dementia patients with Alzheimer’s and can be recommended for implementing in clinical practice. This opens up prospects for studying CST as part of various drug strategies in treatment of dementia of various origins.

Migraine is one of the most common primary headache disorders. Nowadays, there is an increase in the prevalence of migraine. It causes a significant reduction in the Quality of Life of those affected. There are two major approaches to treating migraines: attack management and prevention. The concept of primary prophylactic therapy of migraine has developed rapidly. In addition to standard medication, there are increasing data indicating the usefulness and feasibility of non-drug treatments, such as TES (transcranial electrical stimulation). Both cathodal and anodal stimulation have been shown to be effective in migraine treatment: after a course of TES, the number of days per month with headache decreased, the duration and intensity of migraine attacks decreased, and some studies reported a reduction in the number of medications used. O1/O2 (1–2 mA) for cathodal stimulation and F3/F4 (1–2 mA) for anodal stimulation were the most frequently stimulated cortical areas. The average duration of each session was 20 minutes. The length of TES sessions varied from study to study. TES has shown efficacy and safety in treating various forms of migraine. Using this non-invasive method to prevent attacks may be one of the directions for personalizing migraine treatment.

Chest pain of a non-cardiac nature is one of the extremely significant problems of clinical medicine, which is associated with the widespread prevalence of this condition and the high healthcare costs for diagnosing and treating such patients. Along with neurological, gastroenterological and pulmonological diseases, mental disorders make a major contribution to the formation of chest pain. Moreover, the formation of pain in the chest area can be associated not only with such well-known psychopathological conditions as depression and anxiety disorders, but also with the pathology of the somatoform circle. This review presents data on the frequency of chest pain associated with mental disorders (pain as a symptom of a mental disorder, mental disorders as a consequence of a previous episode of chest pain, etc.), the nature of the relationship between pain symptoms and mental disorders, as well as the clinical picture somatoform disorders manifesting in the form of thoracalgia. Information is summarized on approaches to diagnosing mental disorders in patients with chest pain and the possibilities for their psychopharmacotherapy and psychotherapy. When discussing psychopharmacotherapy, emphasis is placed on the possibilities of using the atypical tranquilizer tofisopam in this category of patients, and a brief description of its effectiveness and safety is given. To illustrate the main points of the review, a clinical case of a patient with chest pain of non-cardiac origin, which manifested itself after a traumatic event, which in turn provoked a myocardial infarction, is also presented. Positive dynamics with subsequent recovery during therapy with tofisopam are described.

The pathophysiology of asthenia is very complex and is associated with chronic kidney disease, heart failure, chronic obstructive pulmonary disease, sarcopenia, bacterial and viral pathogens, micronutrient nutritional imbalances, hypothyroidism, etc. Asthenia can occur with excessive (for a given patient) physical, mental or mental stress and adaptation disorders or be iatrogenic in nature (in particular, due to taking medications that contribute to increased loss of vitamins and microelements), incl. due to unwanted drug interactions. The complex nature of the pathophysiology of asthenia necessitates the use of a differentiated approach aimed at eliminating the main cause of asthenia in a given patient. If asthenia is associated primarily with disorders of energy metabolism, then the pathophysiological treatment is the use of nutrients that support intracellular synthesis - such as citrulline, citrulline malate, the main mechanisms of action of which are supporting the urea cycle, increasing the excretion of ammonium ions, reducing the concentration lactate in the blood. The paper presents the results of a comparative pharmacoinformatic and chemoreactomic analysis of citrulline, citrulline malate (CM), carnitine, sulbutiamine and meldonium. The profile of pharmacological effects of citrulline/CM was significantly different from the profiles of other molecules. For citrulline/CM, cholinergic, antidepressant, and lipid-modifying effects have been identified and an antiasthenic effect has been suggested when used in the treatment of Duchenne muscular dystrophy and for disorders of carbohydrate metabolism. Unlike other molecules, CM and carnitine do not contribute to the loss of vitamins and minerals. Inhibition of the CM serotonin 5HT3A receptor may improve vestibulation because blockers of 5-HT3 receptors concentrated in neurons of the vestibular apparatus, improves tests of balance and walking in an experiment in mice. A positive dose-dependent effect of citrulline and CM on the lifespan of a number of model organisms has been shown. Chemoreactomic analysis of molecular receptor proteins indicated new molecular mechanisms of the antiasthenic action of CM: inhibition of serotonin receptors, calcium sensor protein receptors, chemokine receptors, lipopolysaccharides (toll receptors), nociceptin, glutamate, orexin, purines and prostanoids, biosynthesis of NF-kB and TNFα.

Introduction. Autism spectrum disorders and attention deficit hyperactivity disorder are among the most significant and widespread mental disorders that manifest in childhood and adolescence. Their etiology and pathogenesis have not been studied enough and most likely a complex of factors leads to their formation. Among other things, data are accumulating on the role of various hazards and diseases of the mother, which increase the risk of neuropsychiatric disorders in offspring. These include genitourinary infections, whose contribution to the development of autism spectrum disorders and attention deficit hyperactivity disorder has not yet been systematically studied.

Aim. To establish the contribution of maternal genitourinary infections to the formation of autism spectrum disorders and attention deficit hyperactivity disorder in children.

Materials and methods. An electronic search was conducted in the Scopus and Pubmed databases to obtain relevant literature by August 2022. The search strategy included a combination of keywords and MESH terms: urogenital infections, and autism, and autism spectrum disorders, and attention deficit hyperactivity disorder, and maternal infections.

Results. On this topic 10 papers have been identified in the available literature – 6 on autism spectrum disorders and 4 on attention deficit hyperactivity disorder. In all the papers on attention deficit hyperactivity disorder included in the analysis, an association between genitourinary infections and neuropsychiatric disorders was revealed. In the case of autism spectrum disorders, the data obtained were more contradictory. The heterogeneity of the available data (different designs, different deficits and approaches to the diagnosis of genitourinary infections) did not allow for a meta-analysis.

Conclusions. Genitourinary infections play a pathogenetic role in the formation of attention deficit hyperactivity disorder, while the effect of genitourinary infections on the development of autism spectrum disorders seems less unambiguous. It is necessary to continue work in this area with a more unified design to form practical recommendations for the prevention of neuropsychiatric disorders.

Asthenic disorders are a pressing problem for modern medicine. The lack of specificity of this disease makes it difficult to make a nosological diagnosis, since these disorders occur not only in somatic pathologies and infections, but also in various neurological and mental diseases. Attempts at systematization taking into account clinical variability did not lead to a single paradigm, since they did not reflect all possible variants of disorders. In ICD-10, conditions, the main manifestation of which is asthenia, are considered under various headings: Neurasthenia – F48.0; Organic emotionally labile (asthenic) disorder - F06.6; Other specified neurotic disorders – F48.8; Fatigue syndrome after a viral infection – G93.3; Condition after COVID-19 - U09.9; Overwork (burnout syndrome) – Z73.0; somatoform disorders – F45. Currently, there is no single concept in the treatment strategy for patients. With these disorders, the number of active receptors in the brain is reduced, the response to medications is reduced, even the addition of energy correctors does not fully stimulate the restructuring of the functional state of the central nervous system only with specific effects on neurotransmitter systems. Correction of the functional state of the central nervous system through nonspecific effects is necessary. Phenylpiracetam is the first drug with a neuromodulatory effect. The antiasthenic effect of the drug appears after a single use, prolonged action has its advantages for increasing the effectiveness of therapy, which allows reducing the pharmacological burden on the patient and thereby reduce the risk of developing polypharmacy.

Introduction. Acute dorsalgia is a common reason to seek outpatient medical care in Russia. The clinical picture usually includes muscular-tonic and pain syndromes. The most common form of dorsalgia by localization is acute lumbar pain (lumbodynia).

Aim. To evaluate the effectiveness of Spascuprel®, Traumeel S in the complex treatment of patients with acute lumbar pain in real-world clinical practice.

Materials and methods. We conducted a non-interventional, prospective, observational study of 110 outpatients aged 26 to 65 years. Patients received a standard on-demand therapy with nonsteroidal anti-inflammatory drugs (NSAIDs). In addition, Group 1 received Spascuprel® and Traumeel® C, and Group 2 received centrally acting muscle relaxants. The effectiveness of  treatment was assessed using the visual analogue scale (VAS) of pain intensity and the limitations of various activities in daily living were measured using the Roland – Morris questionnaire. Consideration was given to the exacerbation duration, the need for additional intake of NSAIDs, and the number of cases of pain exacerbation within 60 days from the start of participation in the observational study.

Results. Under treatment, pain intensity showed statistically significant decreases in VAS scores (from 61.0 to 35.5 scores out of 100 according to VAS by Day 7 and to 19.5 scores by Day 14 of treatment in Group 1, from 61.2 to 41.1 and to 25.8 scores in Group 2, respectively (p < 0.05)). A more rapid decrease was observed in VAS pain intensity score from baseline in Group 1. Over 2-month observation period, group 1 had less exacerbations (p < 0.05) and fewer cases of need for additional intake of NSAIDs (p < 0.05). The frequency and severity of adverse events did not differ between two groups.

Conclusion. A more rapid decrease in VAS pain intensity scores and reduction in the need for NSAIDs were noted in the group of patients with acute dorsalgia who used Traumeel® C and Spascuprel® in addition to standard NSAID therapy.

Low back pain (LBP) is a major public health problem globally. As life expectancy increases, the number of people with LBP will further increase in the coming decades. LBP is the leading cause of work productivity and activity impairment worldwide, therefore training of neurologists, primary care physicians, and general practitioners for timely and accurate diagnosis of LBP, as well as effective treatment of patients with LBP is an economically and socially significant challenge for medical practice. The clinical case describes the successful management of a female patient with LBP. It provides a modern, clear and effective approach to the diagnosis and treatment of musculoskeletal LBP. The typical comorbid disorders and factors that contribute to the pain syndrome chronicity are presented. The female patient was treated using a complex approach that included disease awareness conversations, kinesiotherapy, and pharmacotherapy in the form of a 10-day nonsteroidal anti-inflammatory drug (NSAID) course. Nimesil (nimesulide) with proven efficacy and safety in the treatment of musculoskeletal pain has become a drug of choice. It should be noted that nimesulide was prescribed to the patient from the first days of treatment concurrently with the beginning of a training course in kinesiology. The patient experienced a rapid pain relief while taking pharmacotherapy, which played an important role in supporting adherence to recommendations for increasing physical activity and taking training courses in kinesiology. The patient reported a significant decrease in pain on Day 10. After 1.5-month treatment, the pain regressed and she returned to her normal daily activities. The presented approach to therapy allows to provide LBP patients with a relatively fast pain relief, and the 6-month follow up period demonstrated sustainability of the therapeutic effect achieved.

Low back pain is one of the most common causes of seeking medical care, loss of ability to work, and is a heavy socio-economic burden for the country. In the vast majority of cases, the pain syndrome is musculoskeletal, associated with pathology of joints, muscles and ligaments and is benign in nature. Discogenic compression-ischemic radiculopathy is less common, but this pathology is associated with a wide range of issues in differential diagnosis and correct treatment tactics for patients. This article provides an overview of modern clinical guidelines for the diagnosis and treatment of discogenic radiculopathies. The diagnosis of discogenic radiculopathy is clinical. MRI of the spine is performed to exclude secondary causes of nerve root compression if treatment is ineffective. An important direction in the treatment of radiculopathy is non-drug treatment, which includes informing the patient about the benign nature of the disease, the possibility of spontaneous regression of a disc herniation, therapeutic exercises, maintaining the maximum tolerated amount of physical activity, social and professional activity Treatment of back pain is associated with an increased risk of side effects of non-steroidal anti-inflammatory drugs, which patients often use uncontrollably. The issue of safe relief of pain syndromes remains relevant. This can be achieved using a combination of non-steroidal anti-inflammatory drugs and high-dose B vitamins. B vitamins also have a neurotrophic effect, which allows the restoration of impaired neurological functions.

The need to follow an integrated approach when prescribing treatment for patients suffering from osteoarthritis (OA) is beyond doubt. It is clear that success depends on the implementation of recommendations for both lifestyle modification and the introduction of pharmacological agents with different compositions and mechanisms of action aimed at reducing pain, stiffness, inflammation, normalizing joint function, and preventing cartilage destruction. The arsenal of such drugs is increasing, and the evidence base of effectiveness and safety is being enriched. Considering the heterogeneity of OA patients seeking help in terms of gender, age, body mass index, financial wealth, comorbidity, clinical manifestations of the disease, radiological stage of the disease and its duration, experience of previous treatment, a reasonable and agreed upon choice with the patient not only of the drug is relevant, but also the method of administration. The article provides a clinical example of a justified and coordinated choice of treatment for a patient with a generalized form of OA, synovitis of the knee joint, suffering from obesity, depression, low adherence to treatment using the example of prescribing a chondroprotector, the active component of which is a bioactive extract from small sea fish. The treatment effect was confirmed by clinical and instrumental assessment methods over time.

Two clinical cases of tofacitinib use in the management of rheumatoid arthritis (RA) patients by a rheumatologist at the outpatient stage within the framework of the “Treatment to Target” strategy are presented. The first clinical case describes the case history of a female patient (age 48 years, RA duration 20 years), which demonstrates the difficulties in selecting pathogenetic therapy for late-stage RA. Consecutively prescribed four synthetic baseline anti-inflammatory drugs (methotrexate, sulfasalazine, cyclophosphamide, leflunomide) and two genetically engineered biological drugs (infliximab, rituximab) failed to achieve remission of the disease in the patient. Decrease in disease activity was noted after connection of the third biological drug – etanercept, treatment with which had to be interrupted due to pregnancy planning. The return to the combined treatment after childbirth did not lead to repeated “success”. A positive result was achieved 12 weeks after tofacitinib at a dose of 10 mg/day, which provided a decrease in RA activity to moderate and complete withdrawal of glucocorticoids. Given the incomplete clinical effect, tofacitinib dose was increased to 20 mg/day by the outpatient rheumatologist, which resulted in achieving low RA activity persisting for 5 years. The second case demonstrates the effectiveness of tofacitinib inclusion in the RA treatment regimen as a “second-line” drug. A patient (age 46 years, RA duration 10 years) with long-term drug (methotrexate 25 mg/week) clinical and laboratory remission of RA after an upper respiratory tract infection developed an exacerbation of the disease. Despite three-component therapy with baseline anti-inflammatory drugs, the patient had persistence of high RA activity, which led to the revision of pathogenetic therapy – tofacitinib at a dose of 10 mg/day with clinical effect of the drug after 4 weeks. The achieved clinical and laboratory remission of the disease has been maintained for two years. In outpatient practice tofacitinib can be an effective tool for optimizing RA treatment.

The article discusses the historical aspects of the study of aseptic necrosis, as well as the issues of therapy and early diagnosis of aseptic necrosis of the femoral head. The authors raise the issues of pathogenesis and discuss the factors influencing its development. So it is believed that the leading factors are excessive alcohol consumption, deep-sea diving and some autoimmune diseases. Attention is also paid to the long-term consequences of COVID-19 infection, in which significant complications from the musculoskeletal system are observed, including aseptic necrosis of the femoral head. The consequences of infection can be triggered both by the inflammatory process itself and as a high risk of complications during glucocorticosteroid therapy. The article focuses on the clinic of aseptic necrosis of the femoral head and its difference from the clinic of osteoarthritis. As well as the importance of early diagnosis of aseptic necrosis of the femoral head. The article discusses the issues of drug therapy, indications for it and the choice of drugs. The article provides a clinical example that demonstrates the importance of careful collection of complaints and anamnesis in a young patient with atypical hip pain, as well as the effectiveness of prescribed therapy according to clinical recommendations. A specific example demonstrates not only the importance of using magnetic resonance imaging in the diagnosis of aseptic necrosis of the femoral head, but also the effectiveness and safety of therapy. The possible synergism and pleiotropic effects of the prescribed therapy are also discussed. The emphasis is on the importance of further research to develop indications and criteria for the effectiveness of therapy for aseptic necrosis of the femoral head.

The article provides a review of the literature on the pathology of the periarticular structure of the enthesis - the site of attachment of a tendon or ligament to the bone. The anatomical and functional features of the fibrocartilaginous enthesis are presented in detail from the position of the “enthesis organ”, which includes the enthesis and the adjacent synovial membrane, bursae and adipose tissue. The issues of the occurrence of degenerative changes against the background of mechanical stress and inflammatory rheumatic pathological processes in the above structural and functional anatomical unit are analyzed. The anatomical zones whose entheses are most often affected are given. The terminology of degenerative and inflammatory lesions of the enthesis is considered, including from the standpoint of ICD-10 codes. The advantages and disadvantages of modern terms are discussed, current concepts corresponding to the etiology of the pathological process are proposed: degenerative-dystrophic or traumatic enthesopathy and inflammatory enthesitis. This division of concepts is aimed at adopting the correct diagnostic and treatment tactics for a doctor of any specialization. The differential diagnosis of these nosologies and approaches to conservative treatment are considered. The possibilities of local injection therapy for enthesitis and enthesopathies, the use of  anti-inflammatory and reparative techniques are discussed in detail. Based on our own clinical experience, the features of the treatment of various enthesopathies with glucocorticoids, autologous plasma, microinductive collagen, linear hyaluronates and polynucleotides are considered. Issues of priority methods in different clinical situations and the possibility of prolonging the therapeutic effect, as well as a combination of local and non-drug methods, were discussed. The tactics for ineffective local treatment, methods for correcting therapy and the choice of a leading specialist for various pathologies are discussed.

Osteoarthritis (OA), the most common joint disease, coexists with obesity in most of the world’s population. According to the forecast of the World Health Organization, the number of patients with these diseases is expected to increase, which represents a serious medical and social problem due to increased disability, the need for surgical treatment, an increase in comorbid diseases, treatment complications and mortality in this group of patients. OA and obesity have common pathogenetic mechanisms, and the development of one disease increases the risk of developing the other, which can become the beginning of a vicious circle. In recent years, obesity is considered not only as a biomechanical factor (excessive load on the joint, destruction of articular cartilage), but also as a cause of metabolic syndrome and systemic inflammatory effects. Inflammatory cytokines, especially IL-1β and TNF-α, drive catabolic pathways and promote the progression of OA. There is compelling evidence that weight loss reduces pain and joint inflammation and improves prognosis in patients with OA. The review presents data on the prevalence of OA and obesity, the role of immune disorders in these diseases, and indicates methods of pharmacological and non-pharmacological treatment of OA. General principles and specific updated recommendations of the European League Against Rheumatism for non-drug treatment of OA of the hip and knee joints are outlined, and recommendations for weight loss through dietary interventions and exercise are formulated.

Acute or chronic stress, as well as high anxiety condition constitute risk factors leading to the development and progression of many common chronic diseases, including cardiovascular, endocrinological, pulmonary, oncological diseases, etc. A particular feature of these conditions co-occurring with chronic diseases is their significant impact on the motivational aspect of medication compliance, including non-pharmaceutical treatments and a healthy lifestyle, which can increase manyfold the risk for complicated course of chronic somatic disease. On the one hand, the urgent need to identify and manage anxiety and stress disorders in the outpatient practice is caused by high incidence rates of these disorders in patients with chronic pathologies, deteriorated quality of life and increased adverse outcomes, and on the other hand, by inadequate awareness of the options available for safe and efficient correction of these disorders. Therapeutic approaches to the management of high anxiety conditions, in particular those under chronic stress, include both pharmaceutical and non-pharmaceutical treatments, but their efficiency, availability and safety are often not interchangeable. This review article presents the most common variants of anxiety disorders combined with chronic somatic diseases in outpatient practice. A safe and effective option to combat symptoms of stress and high anxiety using modern herbal medicines with anti-anxiety, sedative and antispasmodic effects that can be regarded as alternatives to conventional anxiolytics is considered.

Fatigue is an extremely disabling symptom both in healthy people and in various diseases. Physical fatigue is characterized by limitations in physical functioning, while mental/cognitive fatigue involves difficulties in concentrating and performing cognitive tasks. Mental and physical fatigue exist in both pathological and physiological fatigue. Fatigue is primarily an adaptive physiological process. It is a signal to have a rest and helps conserve energy to prevent injury, which can be useful after intense work, or when the body’s defenses need to be redistributed, for example, during infectious disease. It is important to distinguish between fatigue or tiredness and chronic fatigue syndrome in clinical practice. Chronic fatigue syndrome has multisystem manifestations and affects millions of people globally. Although the exact aetiology of chronic fatigue syndrome is uncertain, the studies point to neurological, immunological, autonomic and energy disorders. The main sings of chronic fatigue syndrome are debilitating fatigue that is worsened by activity, poor exercise tolerance, unrefreshing sleep and cognitive impairment. Reduced information processing speed is the most common cognitive impairment in chronic fatigue syndrome. Other manifestations include decreased reaction time, working memory, and attention. These symptoms must persist for at least 3–6 months for a diagnosis to be made. As there are no specific tests for chronic fatigue syndrome, a diagnosis can be established on the basis of a medical history and physical examination.

Although there are no standards-based methods specific to chronic fatigue syndrome, clinicians can reduce the severity of symptoms using pharmacological and non-pharmacological treatment approaches that have proved their efficacy in clinical practice. In particular, nootropics are widely used in asthenic conditions and chronic fatigue syndrome. Fonturacetam is a nootropic drug that directly activates brain integration activities, promotes memory consolidation, and improves concentration and mental activity.